Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial.The prevalence of neck pain in the general population has been reported to be 15% for men and 23% for women, with nearly half of these individuals experiencing constant unremitting symptoms. (1) It has been estimated that as many as 70% of individuals report experiencing neck pain at some point in their lifetimes, and at a 5-year follow-up, 78% of men and 85% of women report full recovery. (2,3) The economic burden associated with neck pain is immense, and nearly one third of people who experience a first-time onset of neck pain will continue to report health care utilization for their neck pain at a 5-year follow-up. (4) Additionally, nearly 25% of all visits in outpatient physical therapist practice are made by people with a primary report of neck pain. (5) Physical therapists use several interventions and modalities Modalities The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors. in the management of neck pain, including joint mobilization/manipulation (nonthrust and thrust), therapeutic exercise, and traction. (6) However, robust evidence to support the use of many of the aforementioned management strategies is lacking. (7-11) The Philadelphia Panel evidence-based clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. concluded that there is insufficient evidence insufficient evidence n. a finding (decision) by a trial judge or an appeals court that the prosecution in a criminal case or a plaintiff in a lawsuit has not proved the case because the attorney did not present enough convincing evidence. for the use of many commonly used interventions for people with neck pain. (8) Perhaps this finding is at least partially responsible for the lack of clinical improvement observed in people with neck pain compared with people with low back or lower-extremity pain. (12) Recently, evidence has begun to emerge for the use of manual therapy, specifically, thrust mobilization/ manipulation procedures, directed at the thoracic thoracic /tho·rac·ic/ (thah-ras´ik) pectoral; pertaining to the thorax (chest). tho·rac·ic adj. Of, relating to, or situated in or near the thorax. spine in people with mechanical neck pain. In a randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. , Cleland et al (13) demonstrated that people who received thoracic spine thrust mobilization/ manipulation experienced immediate and significant (P<.001) reductions in pain, as measured with a visual analog scale, compared with people who received a placebo mobilization/manipulation; the between-group difference was 11.3 mm (95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI]=6.9-15.7). It was also demonstrated that people with whiplash-associated disorders who received thoracic spine thrust mobilization/ manipulation experienced a significantly greater (P<.003) reduction in pain than those who did not receive thoracic spine thrust mobilization/ manipulation. (14) There is little evidence supporting a theoretical rationale as to why manual physical therapy techniques directed at the thoracic spine may be beneficial in reducing pain and improving function in people with neck pain. Additionally, all studies to date that have investigated the effects of treatments targeting the thoracic spine have incorporated only thrust mobilization/ manipulation procedures. Thus, it is not known whether non-thrust mobilization/manipulation procedures will result in similar outcomes or whether thrust mobilization/manipulation is essential in the recovery process for people with neck pain. The main purpose of this study was to compare the short-term effectiveness of thrust mobilization/manipulation with that of nonthrust mobilization/manipulation directed at the thoracic spine in patients with mechanical neck pain. We also sought to compare the frequencies, durations, and types of side effects Side effects Effects of a proposed project on other parts of the firm. between people receiving thrust mobilization/manipulation and those receiving non-thrust mobilization/manipulation. Method Subjects Consecutive patients, who were referred over a 13-month period (June 2005 to July 2006) for physical therapy at 1 of 5 outpatient orthopedic physical therapy clinics (Rehabilitation Services, Concord Hospital, Concord, NH; Newton-Wellesley Hospital, Newton, Mass; Centennial Physical Therapy, Colorado Springs Colorado Springs, city (1990 pop. 281,140), seat of El Paso co., central Colo., on Monument and Fountain creeks, at the foot of Pikes Peak; inc. 1886. It is a year-round resort and a booming military, technological, and commercial city. , Colo; Groves Physical Therapy, St Paul, Minn; and Sharp HealthCare Sharp HealthCare is a not-for-profit integrated regional health care delivery system located in San Diego. Sharp includes four acute care hospitals, three specialty hospitals, three affiliated medical groups and a health plan. , San Diego San Diego (săn dēā`gō), city (1990 pop. 1,110,549), seat of San Diego co., S Calif., on San Diego Bay; inc. 1850. San Diego includes the unincorporated communities of La Jolla and Spring Valley. Coronado is across the bay. , Calif) by their primary care physicians because of a complaint of mechanical neck pain, were screened for eligibility criteria. Inclusion criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. required subjects to be between the ages of 18 and 60 years and to have a primary complaint of neck pain with or without unilateral upper-extremity symptoms and a baseline Neck Disability Index neck disability index, n in chiropractic medicine, parameter used to monitor the progression of a patient throughout the treatment period. Specifically, this questionnaire evaluates changes in a patient's function and measures a self-evaluated disability (NDI NDI National Death Index, see there ) score of 10% or greater. Exclusion criteria exclusion criteria AIDS Donor exclusion criteria, see there were: identification of any medical signs suggestive of suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. a nonmusculoskeletal etiology of symptoms, a history of a whiplash injury whiplash injury n. A hyperextension-hyperflexion injury to the cervical spine caused by an abrupt jerking movement of the head, either in a backward or forward direction. within 6 weeks of the examination, a diagnosis of cervical spinal stenosis Spinal Stenosis Definition Spinal stenosis is any narrowing of the spinal canal that causes compression of the spinal nerve cord. Spinal stenosis causes pain and may cause loss of some body functions. , evidence of any central nervous system involvement, signs consistent with nerve root compression (at least 2 of the following had to be diminished for nerve root involvement to be considered: myotomal strength, sensation, or reflexes), previous cervicothoracic surgery, or pending legal action. All subjects reviewed and signed a consent form approved by the respective institutional review board before participation. Therapists Twelve physical therapists (mean age=36 years, SD=6.4) participated in the examination and treatment of all subjects in this study. All therapists underwent a standardized training regimen, which included studying a manual of standard procedures with the operational definitions of each examination and intervention technique used in this study. All participating therapists underwent training provided by a current Fellow in the Manual Physical Therapy Fellowship Program, Regis University Campuses Regis University has several campuses throughout the state of Colorado. The main campus is located in northwest Denver at 50th and Lowell Boulevard. Other sites include: Aurora, Longmont, Colorado Springs, Denver Tech Center, Fort Collins and Interlocken at Broomfield. , Denver, Colo. During this training session, all participating therapists were required to demonstrate the examination and intervention techniques to ensure that all study procedures were performed in a standardized fashion. Participating therapists had a mean of 9.7 years (SD=6.8, range=1-19) of clinical experience. Examination Procedures All subjects provided demographic information and completed several self-report measures, and a standardized history and a physical examination were obtained (baseline). Self-report measures included a body diagram, (15) the Numeric Pain Rating Scale (NPRS NPRS Network Performance Reporting System ), (16) the NDI, (17) and the Fear-Avoidance Beliefs Questionnaire (FABQ FABQ Fear Avoidance Beliefs Questionnaire ). The FABQ was used to quantify a subject's fear-avoidance beliefs about physical activity as well as work. (18) The FABQ consists of work (FABQW) and physical activity (FABQPA) subscales, each of which has been shown to exhibit a high level of test-retest reliability test-retest reliability Psychology A measure of the ability of a psychologic testing instrument to yield the same result for a single Pt at 2 different test periods, which are closely spaced so that any variation detected reflects reliability of the instrument . (19) The FABQW subscale has been shown to exhibit predictive validity In psychometrics, predictive validity is the extent to which a scale predicts scores on some criterion measure. For example, the validity of a cognitive test for job performance is the correlation between test scores and, for example, supervisor performance ratings. in the identification of people who have low back pain and who are likely to respond to spinal mobilization/manipulation. (20,21) Additionally, lower scores on a modified FABQ (FABQPA and FABQW) have been shown to be predictive for people who have neck pain and who likely will benefit from spinal mobilization/manipulation applied to the thoracic spine and rib cage rib cage n. The enclosing structure formed by the ribs and the bones to which they are attached. . (22) For this study, the FABQ was modified by replacement of the word "back" with the word "neck." (22) The standardized history and the physical examination were obtained in a fashion identical to that described by Cleland et al. (22) Outcomes The primary outcome measure used in this study was the subjects' perceived level of disability as a result of their neck pain, as captured with the NDI. (17) The NDI contains 10 items--7 related to activities of daily living, 2 related to pain, and 1 related to concentration. (23) Each item is scored from 0 to 5, and the total score is expressed as a percentage, with higher scores corresponding to greater disability. The NDI has been demonstrated to be a reliable and valid outcome measure for people with neck pain (24-26) and has been used widely in clinical trials of people with neck pain. (17,27-29) Westaway et al (30) identified the minimal detectable change (MDC (1) (Mobile Daughter Card) See riser card. (2) See Meta Data Coalition. ) on the NDI as 5 points, and Stratford et al (26) also identified the MDC to be 5 points for a group of people with neck pain. In both of these studies, the investigators reported the MDC on a 50-point scale; we calculated the NDI as a percentage of 100, which would translate to an MDC of 10%. Although these investigators reported that a change of 5 points (or 10%) must be observed to be certain that the change in scores is greater than measurement error, no values for the minimal clinically important difference have been reported in the literature for people with mechanical neck pain. (26,31) Secondary outcome measures included pain and a subject Global Rating of Change (GROC GROC Great Recordings of the Century GROC Gang/Rock County Task Force (Wisconsin) ) Scale. The NPRS was used to capture a subject's level of pain. Subjects were asked to indicate the intensity of current, best, and worst levels of pain over the preceding 24 hours by using an 11-point scale ranging from 0 ("no pain") to 10 ("worst pain imaginable"). (32) The average of the 3 ratings was used to represent a subject's level of pain over the preceding 24 hours. The minimal clinically important difference for the NPRS has been reported to be 2 points. (33) At the time of follow-up, subjects completed the GROC Scale. (34) They were asked to rate their overall perception of improvement since beginning the interventions on a scale ranging from -7 ("a very great deal worse") to 0 ("about the same") to +7 Ca very great deal better"). It has been suggested (34) that scores on the GROC Scale of between [+ or -] 3 and [+ or -] 1 represent small changes, scores of [+ or -] 4 and [+ or -] 5 represent moderate changes, and scores of [+ or -] 6 and [+ or -] 7 represent large changes. (34) Randomization randomization (ranˈ·d  ·m
After the baseline examination baseline examination Clinical practice A physical exam which is part of an initial Pt-physician contact, and designed to assess a Pt's eligibility for enrollment in a clinical trial and produce requisite baseline data. , subjects were randomly assigned to receive thrust or nonthrust mobilization/ manipulation directed at the upper thoracic spine .and the middle thoracic spine. Concealed allocation was performed by use of a computer-generated randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. table of numbers created before the beginning of the study. Individual, sequentially numbered index cards with the random assignments were prepared. The index cards were folded and placed in sealed opaque envelopes. A second therapist who was unaware of the baseline examination findings opened the envelopes and proceeded with the interventions according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the group assignments. All subjects received the interventions on the day of the initial examination. Interventions Nonthrust mobilization/manipulation group. Subjects who were randomly assigned to receive nonthrust mobilization/manipulation were positioned in the prone position Word history The word prone, meaning "naturally inclined to something, apt, liable,", is recorded in English since 1382; the meaning "lying face-down" is first recorded in 1578 but is also referred to as "laying down" or "going prone". . The clinician performed one 30-second bout of grade Ill or IV central posterior-anterior nonthrust mobilization/manipulation at the T1 spinous process spinous process n. 1. See sphenoidal spine. 2. The dorsal projection from the center of a vertebral arch. spinous process as described by Maitland et al. (35) After the 30-second bout, the therapist proceeded to T2 and performed the same technique. This process was continued sequentially in a caudal caudal /cau·dal/ (kaw´d'l) 1. pertaining to a cauda. 2. situated more toward the cauda, or tail, than some specified reference point; toward the inferior (in humans) or posterior (in animals) end of the body. direction to T6, for an overall intervention time of approximately 3 minutes (Fig. 1). [FIGURE 1 OMITTED] Subjects then were instructed in a general cervical mobility exercise as originally described by Erhard. (36) To perform this exercise, each subject was instructed to place the fingers over the manubrium manubrium /ma·nu·bri·um/ (mah-noo´bre-um) pl. manu´bria [L.] a handle-like structure or part, such as the manubrium of the sternum. and to start in a position with the chin placed directly on the fingers. Next, the subject was asked to rotate the head and neck to one side as far as possible and return to the starting position. The subject was instructed to perform this maneuver alternately to both sides within pain tolerance Pain tolerance is the amount of pain that a person can withstand before breaking down emotionally and/or physically. Pain tolerance is distinct from a pain threshold. The minimum stimulus necessary to produce pain is the pain threshold. . The subject was asked to start by using 5 fingers and then to progress to 4, 3, and 2 fingers and finally to 1 finger as mobility improved. The subject was instructed to perform this exercise within pain tolerance for 10 repetitions to each side, 3 or 4 times per day, each day during participation in the study. Additionally, subjects were instructed to maintain their usual activities within the limits of pain and to avoid activities that aggravated ag·gra·vate tr.v. ag·gra·vat·ed, ag·gra·vat·ing, ag·gra·vates 1. To make worse or more troublesome. 2. To rouse to exasperation or anger; provoke. See Synonyms at annoy. symptoms. Subjects also were instructed to maintain their current medication regimens throughout the course of the study and to avoid any other cointerventions. Thrust mobilization/manipulation group. Subjects in this group received thrust mobilization/manipulation targeting the upper thoracic spine and thrust mobilization/manipulation targeting the middle thoracic spine. The upper thoracic spine procedure was administered first and was performed with the subject in the supine position The supine position is a position of the body; lying down with the face up, as opposed to the prone position, which is face down. Using terms defined in the anatomical position, the posterior is down and anterior is up. . The clinician was instructed to target between segments T1 and T4 with this technique. Because thrust mobilization/manipulation of the thoracic spine reportedly lacks spatial sensitivity, (37) we did not capture the exact segments targeted for each subject. The subject was instructed to clasp CLASP - Computer Language for AeronauticS and Programming his or her hands across the base of the neck. The subject's arms then were pulled downward to create spinal flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. down to the upper thoracic spine. The therapist's manipulative hand was used to stabilize the inferior vertebra vertebra /ver·te·bra/ (ver´te-brah) pl. ver´tebrae [L.] any of the 33 bones of the vertebral (spinal) column, comprising 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae . of the targeted motion segment, and his or her body applied force through the subject's arms to produce a high-velocity, low-amplitude thrust high-velocity, low-amplitude thrust, n.pr a direct method of osteopathic treatment that employs careful patient positioning in concert with the practitioner's short, quick thrusts (high velocity) applied over short distances (low amplitude) across areas (Fig. 2). If a pop occurred, then the therapist moved on to the next procedure. If not, the subject was repositioned, and the technique was performed again. This procedure was performed for a maximum of 2 attempts. [FIGURE 2 OMITTED] The subject remained in the supine position, and the treating therapist performed a middle thoracic spine thrust mobilization/manipulation. The clinician was instructed to target between segments T5 and T8 with this technique. The subject was instructed to clasp his or her hands to the opposite shoulder. The subject's arms were pulled downward to create spinal flexion down to the targeted motion segment. The therapist's manipulative hand was used to stabilize the inferior vertebra of the motion segment, and his or her body was used to apply force through the subject's arms to produce a high-velocity, low-amplitude thrust (Fig. 3). If no pop was heard on the first attempt, then the therapist repositioned the subject and performed the mobilization/manipulation again. A maximum of 2 attempts were made. A similar amount of time was required to complete the thrust mobilization/manipulation and nonthrust mobilization/manipulation techniques (approximately 3 minutes), minimizing the potential for an attention effect. [FIGURE 3 OMITTED] Subjects assigned to the thrust mobilization/manipulation group also received instructions in the same general cervical exercise program as those assigned to the nonthrust mobilization/manipulation group and were instructed to maintain their usual activities within the limits of pain and to avoid activities that aggravated symptoms. Subjects in this group also received instructions to maintain their current medication regimens throughout the course of the study and to avoid any other cointerventions. Follow-up All subjects were scheduled for follow-up within 2 to 4 days of the initial examination and intervention session. At the time of follow-up, subjects again completed the NDI and the NPRS, as well as the GROC Scale. Additionally, subjects completed a questionnaire regarding any side effects that they may have experienced since the initial intervention session. The questionnaire was modified from that used by Cagnie et a1 (38) and included questions regarding commonly described side effects associated with the use of manual physical therapy techniques, such as stiffness, headaches, muscle spasm muscle spasm n. Persistent increased tension and shortness in a muscle or group of muscles that cannot be released voluntarily. muscle spasm, n , fatigue, or radiating ra·di·ate v. ra·di·at·ed, ra·di·at·ing, ra·di·ates v.intr. 1. To send out rays or waves. 2. To issue or emerge in rays or waves: Heat radiated from the stove. discomfort. Subjects also could mark "other" and then identify any other unusual side effects that they had experienced since the initial intervention session. If the subjects indicated that they had experienced any side effects, then they were asked to report the time of onset (categorized as [less than or equal to] 24 hours or >24 hours), the duration (categorized as [less than or equal to] 24 hours or >24 hours), and the severity (scored on a scale of 1-4, where 1=light to 4=severe) of the symptoms. Sample Size Determination The sample size and power calculations were performed with Sample Power statistical software, version 10.1. * The calculations were based on detecting a 10% difference in the NDI at follow-up, assuming a standard deviation In statistics, the average amount a number varies from the average number in a series of numbers. (statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. of 13%, a 2-tailed test, an alpha level of .05, and a desired power of 80%. These assumptions generated a sample size of 30 subjects per group. Data Analysis Key baseline demographic variables, including current medication usage and scores on the self-report measures, were compared between the groups by use of independent t tests for continuous data and chi-square tests of independence for categorical data categorical data data relating to category such as qualitative data, e.g. dog, cat, female. It may be nominal when a name is used, e.g. location, breed, or ordinal when a range of categories is used, e.g. calf, yearling, cow. (Tab. 1). The primary aim (effects of interventions on disability and pain) was examined by use of a 2-way repeated-measures analysis of variance (ANOVA anova see analysis of variance. ANOVA Analysis of variance, see there ), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and follow-up) as the within-subject variable. Separate ANOVAs were performed with disability (NDI) and pain (NPRS) as the dependent variables. For each ANOVA, the hypothesis of interest was the 2-way interaction (group x time). An independent t test was used to determine differences in the GROC Scale scores between the groups at follow-up. We used intention-to-treat analysis with subjects analyzed in the group to which they were allocated. Data analysis was performed with the SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. , version 13.0, statistical software package. * The proportion of subjects reporting side effects in each group was analyzed by use of a chi-square test. Additionally, the number of side effects experienced by subjects in each group was calculated. Chi-square tests also were used to determine whether a difference existed between the groups for the proportion of subjects experiencing an onset of symptoms within 24 hours of the interventions, for whether the symptoms diminished within 24 hours of onset, and for the severity of the reported symptoms. We also calculated the odds ratio and the corresponding 95% CI for experiencing a side effect associated with the interventions. Results A total of 104 consecutive patients were screened for possible study eligibility. Sixty patients, with a mean age of 43.3 years (SD=12.7) (55% female), satisfied the eligibility criteria, agreed to participate, and were randomly assigned to the thrust (n = 30) and nonthrust (n = 30) mobilization/manipulation groups. The reasons for ineligibility are shown in Figure 4, which is a flow diagram of subject recruitment and retention. All 60 participants returned for the follow-up visits and were included in the analysis. [FIGURE 4 OMITTED] Baseline characteristics for the groups were similar for all variables (P>.05), with the exception of the number of subjects receiving workers' compensation workers' compensation, payment by employers for some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. (9 in the thrust mobilization/ manipulation group and 3 in the nonthrust mobilization/manipulation group; P=.045) (Tab. 1). Sixty-seven percent of subjects in the thrust mobilization/manipulation group at tended their follow-up visits at 2 days, 20% attended at 3 days, and 13% attended at 4 days. Sixty percent of subjects in the nonthrust mobilization/ manipulation group attended their follow-up visits at 2 days, 30% attended at 3 days, and 10% attended at 4 days. Additionally, the 95% CI for the difference in time to follow-up between the groups crossed 0 (-0.36 to 0.90). The overall 2-way group x time interaction for the repeated-measures ANOVA was statistically significant for disability (P<.001) and pain (P<.001). The intercept graph for the NDI and scores of intervention time is shown in Figure 5. Subjects receiving thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% CI=5.3-14.7), and pain, with a between-group difference of 2% (95% CI=1.4-2.7) (Tab. 2). Subjects in the thrust mobilization/manipulation group exhibited significantly (P<.01) higher scores on the GROC Scale at the time of follow-up, with a mean difference between the groups of 1.5 points (95% CI=0.48-2.5). [FIGURE 5 OMITTED] There was no significant difference (P=.78) between the numbers of side effects experienced by subjects in the nonthrust and thrust mobilization/manipulation groups (9 and 10, respectively). The odds ratio for experiencing a reported side effect for subjects receiving thrust mobilization/manipulation was 1.17 (95% CI=0.39-3.47). The specific reported side effects for subjects in the nonthrust mobilization/manipulation group included an aggravation Any circumstances surrounding the commission of a crime that increase its seriousness or add to its injurious consequences. Such circumstances are not essential elements of the crime but go above and beyond them. of symptoms (n=2), muscle spasm (n=1), neck stiffness (n=2), headache (n=2), and radiating symptoms (n=2). Subjects in the thrust mobilization/manipulation group experienced the following side effects: aggravation of symptoms (n=8), muscle spasm (n=1), and headache (n=l). There was no difference in the onset of side effects between the groups, with 90% of all subjects (8 in the nonthrust mobilization/manipulation group and 9 in the thrust mobilization/manipulation group) reporting that the symptoms began within 24 hours of the interventions (P=.74). All subjects in both groups who reported experiencing a side effect noted that the symptoms lasted 24 hours or less. The severity of the complaints was not significantly different between the groups (P=.67) and was reportedly mild (7 subjects in the nonthrust mobilization/manipulation group and 8 subjects in the thrust mobilization/manipulation group) to moderate (2 subjects in the nonthrust mobilization/manipulation group and 2 subjects in the thrust mobilization/manipulation group). No serious complications were reported by any subjects in the study. Discussion and Conclusion The results of the present study demonstrate that the differences between the groups in change scores for disability and pain exceeded the boundaries of measurement error. Fifty percent of subjects in the thrust mobilization/manipulation group reached the cutoff on the GROC Scale, indicating a moderate change in status (scores of greater than or equal to +4), whereas only 10% of subjects in the nonthrust mobilization/manipulation group reached this cutoff. Additionally, the difference between the groups in changes in disability was 10% or approximately one third of the initial disability. Considering the moderate effect size between the interventions and the negligible disparity in associated risks, the differences demonstrate that, compared with thoracic spine nonthrust mobilization/manipulation, thoracic spine thrust mobilization/ manipulation results in short-term reductions in pain and disability in people with neck pain. We recognize that a variety of mobilization/manipulation techniques are used by physical therapists as well as other health care professionals. (39) However, to improve the generalizability of the findings to clinical practice, we standardized the treatment program to a few techniques that have been well documented in the literature. (13,14,40,41) In addition, the clinicians did not use intersegmental mobility assessments to directly target a specific segmental segmental /seg·men·tal/ (seg-men´t'l) 1. pertaining to or forming a segment or a product of division, especially into serially arranged or nearly equal parts. 2. undergoing segmentation. restriction during our interventions. (35,42,43) Regardless of the clinical presentation, the subjects received specific nonthrust or thrust mobilization/manipulation directed at consistent segments across all subjects because of the inherent lack of evidence to support decision making based on biomechanical theoretical constructs. Compared with other studies investigating the prevalence of side effects associated with thrust mobilization/ manipulation directed at the entire spine, the present study demonstrated lower rates for both thrust and nonthrust mobilization/manipulation procedures. (38,44) Senstad et al (44) reported that, in 4,700 subjects, a variety of side effects occurred after mobilization/ manipulation for 55% of the treatments. The most common side effect was local discomfort and was experienced with over one half of the treatments. Although the authors did not report the side effects associated with the area of the spine treated, they concluded that these reactions were benign and should be considered normal events. More recently, Cagnie et al (38) identified that 60% of subjects receiving mobilization/manipulation of the spine experienced a number of side effects, including headache (20%), stiffness (19%), dizziness (4%), and nausea (3%). Although the types of associated side effects experienced by subjects in our study were similar to those in the studies of Senstad et al (44) and Cagnie et al, (38) the rates were significantly lower. Senstad et al (44) and Cagnie et al (38) investigated side effects associated with thrust mobilization/ manipulation directed at the entire spine; our study included techniques directed only at the thoracic spine. Perhaps techniques directed at the thoracic spine result in fewer side effects than techniques directed at the cervical or lumbar spine Lumbar spine The segment of the human spine above the pelvis that is involved in low back pain. There are five vertebrae, or bones, in the lumbar spine. Mentioned in: Low Back Pain ; however, this hypothesis requires further investigation. Additionally, it should be recognized that the sample size calculations in the present study were not based on identifying differences in side effects between the groups; therefore, it is possible that the present study did not have adequate power to detect such disparities. Although we cannot make direct generalizations about the effectiveness of other thrust mobilization/ manipulation techniques in people with neck pain, evidence suggests that the specific technique used may not influence patient-centered outcomes. (29,45,46) One substantial limitation of the present study is the failure to collect long-term follow-up data. Participation in the present study ended after the follow-up session, which occurred between 2 and 4 days after the baseline examination and intervention session. Although the differences between the groups were noted at the short-term follow-up session, the data cannot be used to ascertain the outcomes for subjects in either group at any time period longer than 2 to 4 days. The implications of this finding should be recognized clearly when the results of the present study are applied to clinical practice. Future studies should seek to investigate the long-term benefits of thoracic spine thrust and nonthrust mobilization/ manipulation. Because we used a standardized treatment program, the results cannot be generalized to other mobilization/ manipulation techniques. In addition, it should be recognized that another potential limiting factor A factor or condition that, either temporarily or permanently, impedes mission accomplishment. Illustrative examples are transportation network deficiencies, lack of in-place facilities, malpositioned forces or materiel, extreme climatic conditions, distance, transit or overflight rights, of the present study was the inability to keep the subject or clinician unaware of the interventions being delivered. Future clinical trials should investigate the effectiveness of different thrust and nonthrust mobilization/manipulation procedures directed at the thoracic spine for people with neck pain and should compare thrust mobilization/ manipulation techniques directed at the thoracic spine in combination with exercise and manual physical therapy techniques directed at the cervical spine cervical spine Clinical anatomy The region of the vertebral column encompassing C1 through C7 for people with neck pain. Dr Cleland, Dr Whitman, and Dr Childs provided writing and data analysis. Dr Cleland, Dr Glynn, Ms Eberhart, and Dr MacDonald provided data collection, subjects, and facilities/equipment. Dr Cleland provided project management, fund procurement, and clerical support. Dr Cleland, Dr Glynn, and Dr MacDonald provided institutional liaisons. The authors thank the American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in of Orthopaedic Manual Physical Therapists and Steens Physical USA for providing funding for this project. These organizations played no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. The authors also thank the following therapists for assisting with data collection: Tracy Carter, Sheryl Cheney, John Groves Major John Groves, Essex Rifles, was the first Crown Equerry in the Royal Household, being appointed in 1854. He died in office in 1859. Major Groves held the concurrent office of Superintendent of the Royal Mews. , John Gray, Tim Mondale, Jessica Palmer Jessica Palmer, born in Chicago Illinois in 1953, writes science fiction, fantasy, mystery and horror. She also has written nonfiction under the name of Jessica Dawn Palmer. All told, she has 10 novels, 2 novellas, and 12 textbooks to her credit. , Suzanne Stoke, and Noel Squires. This study was approved by the institutional review boards of the Medical Education and Research Institute of Colorado, Colorado Springs, Colo; Regis University, Denver, Colo; Sharp HealthCare, San Diego, Calif; and Concord Hospital, Concord, NH. Preliminary results of this study (45 subjects) were presented at the 12th Annual Conference of the American Academy of Orthopaedic Manual Physical Therapists; October 19-22, 2006; Charlotte, NC. The American Academy of Orthopaedic Manual Physical Therapists and Steens Physical USA provided funding for this project. This article was received August 4, 2006, and was accepted December 15, 2006. DOI (Digital Object Identifier) A method of applying a persistent name to documents, publications and other resources on the Internet rather than using a URL, which can change over time. : 10.2522/ptj.20060217 References (1) Gummesson C, Isacsson SO, Isacsson AH, et al. The transition of reported pain in different body regions: a one-year follow-up study. BMC (BMC Software, Inc., Houston, TX, www.bmc.com) A leading supplier of software that supports and improves the availability, performance, and recovery of applications in complex computing environments. Musculoskelet Disord. 2006;7:17. 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(21) Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients likely to benefit from spinal manipulation: a validation study. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 2004; 141:920-928. (22) Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87:9-23. (23) Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy cervical radiculopathy Neurology Irritation of nerve roots of the neck due to a herniation or prolapse of a intervertebral disk from its normal position, which impinge on nearby nerves resulting in pain and neurologic Sx. 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Lying on the back; having the face upward. 2. cervical rotatory ro·ta·to·ry adj. 1. Of, relating to, causing, or characterized by rotation. 2. Occurring or proceeding in alternation or succession. manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study. J Manipulative Physiol Ther. 2000;23:324-331. (30) Westaway M, Stratford PW, Binkley JM. The Patient-Specific Functional Scale: validation of its use in persons with neck dysfunction. J Orthop Sports Phys Ther. 1998;27:331-338. (31) Hoving JL, de Vet HC, Koes BW, et al. Manual therapy, physical therapy, or continued care by the general practitioner general practitioner n. Abbr. GP A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. for patients with neck pain: long-term results from a pragmatic randomized clinical trial. Clin J Pain. 2006;22:370-377. (32) Jensen MP, Karoly p, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27: 117-126. (33) Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005; 30:1331-1334. (34) Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10:407-415. (35) Maitland G, Hengeveld E, Banks K, English K. Maitland's Vertebral ver·te·bral adj. 1. Of, relating to, or of the nature of a vertebra. 2. Having or consisting of vertebrae. 3. Having a spinal column. Manipulation. 6th ed. Oxford, United Kingdom: Butterworth-Heinemann; 2000. (36) Erhard RE. The Spinal Exercise Handbook: A Home Exercise Manual for a Managed Care Environment. Pittsburgh, Pa: Laurel Concepts; 1998. (37) Ross JK, Bereznick DE, McGill SM. Determining cavitation cavitation Formation of vapour bubbles within a liquid at low-pressure regions that occur in places where the liquid has been accelerated to high velocities, as in the operation of centrifugal pumps, water turbines, and marine propellers. location during lumbar lumbar /lum·bar/ (lum´bar) pertaining to the loins. lum·bar adj. Of, near, or situated in the part of the back and sides between the lowest ribs and the pelvis. and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29:1452-1457. (38) Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther. 2004;9:151-156. (39) van de Veen EA, de Vet HCW HCW Health care worker, see there , Pool JJM JJM John Jackson Miller (comic book writer) , et al. Variance in manual treatment of nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. low back pain between orthomanual physicians, manual therapists, and chiropractors. J Manipulative Physiol Ther. 2005;28:108-116. (40) Liebler EJ, Tufano Coors L, Douris P, et al. The effect of thoracic spine mobilization on lower trapezius tra·pe·zi·us n. A muscle with origin from the superior nuchal line, the external occipital protuberance, the nuchal ligament, the spinous processes of the seventh cervical and thoracic vertebrae, with insertion into the lateral third of the posterior strength testing strength testing, n assessment procedure to determine the contractile strength of a muscle. . Journal of Manual and Manipulative Therapy. 2001;9:207-212. (41) Pho C, Godges J. Management of whiplash-associated disorder addressing thoracic and cervical spine impairments: a case report. J Orthop Sports Phys Ther. 2004;34:511-519. (42) Paris SV, Loubert PV. Foundations of Clinical Orthopaedics. 2nd ed. St Augustine, Fla: Institute Press; 1997. (43) Kaltenborn F. The Spine: Basic Evaluation and Mobilization Techniques. 3rd ed. Minneapolis, Minn: Orthopaedic Physical Therapy Products; 1993. (44) Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy Spinal manipulative therapy (SMT) is the generic term commonly given to a group of manually applied therapeutic interventions. [1] These interventions are usually applied with the aim of inducing intervertebral movement by directing forces to vertebrae, and include spinal . Spine. 1997;22:435-440. (45) Cleland JA, Fritz JM, Whitman JM, et al. The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: a case series. J Orthop Sports Phys Ther. 2006;36:209-214. (46) Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapist selected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: a randomised controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. . Aust J Physiother. 2003;49:233-241. * SPSS Inc, 233 S Wacker Wacker may refer to:
JA Cleland, PT, DPT, PhD, OCS OCS - Object Compatibility Standard , FAAOMPT, is Assistant Professor, Department of Physical Therapy, Franklin Pierce College In 2006 the Library won a national Excellence award. Academics Pierce College offers associate's degrees, mainly in the arts and sciences. There are also certificate programs in early childhood education, social services, dental hygienist, and others. , 5 Chenell Dr, Concord, NH 03301 (USA); Research Coordinator, Rehabilitation Services, Concord Hospital, Concord, NH; and Faculty, Manual Physical Therapy Fellowship Program, Regis University, Denver, Colo. Address all correspondence to Dr Cleland at: joshcleland@ comcast.net. P Glynn, PT, DPT, OCS, FAAOMPT, is Physical Therapy Clinical Specialist, Newton-Wellesley Hospital, Newton, Mass, and Fellow, Manual Physical Therapy Fellowship Program, Regis University. JM Whitman, PT, DSc, OCS, FAAOMPT, is Assistant Faculty, Department of Physical Therapy, and Faculty, Manual Physical Therapy Fellowship Program, Regis University. SL Eberhart, PT, MPT MPT Maryland Public Television MPT Modern Portfolio Theory (investing) MPT Ministry of Posts and Telecommunications MPT Message-Passing Toolkit MPT Master of Physical Therapy MPT Mitochondrial Permeability Transition , is Physical Therapist and Clinical II, Rehabilitation Services, Concord Hospital. C MacDonald, PT, DPT, GCS GCS Glasgow Coma Scale GCS Guilford County Schools (North Carolina) GCS Ground Control Station GCS Grand Central Station GCS Ground Control System GCS Ground Combat Systems GCS Group Communication Systems , OCS, FAAOMPT, is Physical Therapist, Centennial Physical Therapy, Colorado Sport and Spine Centers, Colorado Springs, Colo. JD Childs, PT, PhD, MBA MBA abbr. Master of Business Administration Noun 1. MBA - a master's degree in business Master in Business, Master in Business Administration , OCS, FAAOMPT, is Assistant Professor and Director of Research, Doctoral Program in Physical Therapy, US Army-Baylor University, San Antonio San Antonio (săn ăntō`nēō, əntōn`), city (1990 pop. 935,933), seat of Bexar co., S central Tex., at the source of the San Antonio River; inc. 1837. , Tex. [Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus nonthrust mobilization/ manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007;87:431-440.]
Table 1.
Demographics, Outcome Measures, and
Selected Physical Impairments at Baseline
Variable (a) Nonthrust Thrust P
Mobilization/ Mobilization/
Manipulation Manipulation
Group (n = 30) Group (n = 30)
Age, [bar.X] (SD) 42.7 (13.9) 43.8 (11.5) .75 (b)
Women 15 (50) 18 (60) .29 (b)
Duration of symptoms,
d, [bar.X] (SD) 56.1 (27.6) 54.9 (46.0) .90 (b)
NPRS, [bar.X] (SD) 4.5 (2.10) 5.3 (1.4) .086 (b)
NDI, [bar.X] (SD) 29.6 (12.6) 33.5 (11.2) .20 (b)
FABQPA, [bar.X] (SD) 11.2 (5.0) 11.5 (4.9) .82 (b)
FABQW, [bar.X] (SD) 12.3 (10.6) 12.5 (10.7) .93 (b)
Symptoms distal to
shoulder 6 (20) 4 (13) .73 (c)
Mode of onset--traumatic 11 (37) 11 (37) 1.0 (c)
Previous history of neck
pain 11 (37) 8 (27) .29 (c)
Receiving workers'
compensation 3 (10) 9 (30) .045 (c)
Taking medications
at start of study 17 (57) 12 (40) .30 (c)
Symptoms aggravated by:
Turning right 21 (70) 23 (77) .39 (c)
Turning left 21 (70) 15 (50) .25 (c)
Looking up 19 (63) 21 (70) .39 (c)
Looking down 18 (60) 16 (53) .45 (c)
Driving 22 (73) 19 (63) .29 (c)
Cervical range of motion,
degrees, [bar.X] (SD)
Flexion 51.1 (12.8) 6.4 (13.2) .17 (b)
Extension 38.8 (13.9) 44 (14.9) .17 (b)
Side bending right 32.4 (12.7) 33.2 (13.1) .80 (b)
Side bending left 30.6 (10.7) 40.0 (34.3) .16 (b)
Rotation right 59.1 (11.8) 59.1 (12.2) .98 (b)
Rotation left 61.1 (12.6) 63.6 (11.4) .43 (b)
Medication usage
Total 16 (53) 12 (40) .30 (b)
NSAIDs 9 (30) 8 (27) .98 (b)
Pain medications 4 (13 2 (7) .67 (b)
Muscle relaxants 3 (10) 2 (7) .98 (b)
(a) Data are reported as number (percentage) of subjects, unless
otherwise indicated. FABQPA = fear-Avoidance Beliefs Questionnaire
physical activity subscale (range = 0-24), FABQW = Fear-Avoidance
Beliefs Questionnaire work subscale (range = 0-42), NDI = Neck
Disability Index (range = 0%-100%), NPRS = Numeric Pain Rating
Scale (range = 0-10), NSAIDs = nonsteroidal anti-inflammatory drugs.
(b) As determined by independent sample t tests.
(c) As determined by chi-square tests.
Table 2.
Baseline, Final, and Change Scores for the Neck Disability Index and
the Numeric Pain Rating Scale
Measure Group (n) [bar.X] (SD)
Baseline Final
Neck Nonthrust 29.6 (12.6) 24.0 (13.4)
Disability mobilization/
Index manipulation (30) y
Thrust 33.5 (11.2) 18.0 (10.9)
mobilization/
manipulation (30)
Numeric Pain Nonthrust 4.5 (2.1) 3.9 (2.2)
Rating mobilization/
Scale manipulation (30)
Thrust 5.3 (1.4) 2.7 (1.4)
mobilization/
manipulation (30)
Measure Group (n) Between-Group
Change Score, %,
Within-Group [bar.X] (95%
Change Score Confidence Interval)
Neck Nonthrust 5.5 (8.8) 10.03 (5.3-14.7)
Disability mobilization/
Index manipulation (30)
Thrust 15.5 (9.3)
mobilization/
manipulation (30)
Numeric Pain Nonthrust 0.54 (l.07) 2.03 (1.4-2.7)
Rating mobilization/
Scale manipulation (30)
Thrust 2.6 (1.5)
mobilization/
manipulation (30)
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