[ RESEARCH REPORT ]

JAVIER GONZÁLEZ-IGLESIAS, PT¹š9;I7H<;HDÜD:;P#:;#B7I#F;y7I" PT, PhD²

@EI>K77$9B;B7D:" PT, PhD³šC7H?7:;BHEI7H?E=KJ?xHH;P#L;=7"PT¹

Thoracic Spine Manipulation for the

Management of Patients With Neck Pain:
A Randomized Clinical Trial

N
eck pain is a considerable py program and an electro/thermal ther- course of 6 visits. The results of a 1-week
economic burden and apy program plus thoracic spine thrust follow-up demonstrated that the group
manipulation in a group of patients with receiving thrust manipulation experi-
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.

may result in substantial

d i s a b i l i t y. 1 , 4 - 6 , 1 6 , 2 8 , 3 1
Therefore, the importance of
identifying the most appropriate
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
mechanical neck pain.25 Three thrust enced significantly greater and clinically
manipulations were delivered during the meaningful improvements in cervical
T:;I?=D0 Randomized clinical trial. ing greater improvements in the manipulation

management strategies for TE8@;9J?L;I0 To investigate if patients with group for all the outcome measures. Patients re-
patients with neck pain should mechanical neck pain receiving thoracic spine ceiving thoracic manipulation experienced greater
thrust manipulation would experience superior improvements in pain at the fifth (final) treatment
remain a priority for researchers. session and at the 2-week and 4-week follow-up
outcomes compared to a group not receiving
Physical therapy is often the first
treatment approach for patients
with mechanical neck pain,
and these patients account for
approximately 25% of all physical
Journal of Orthopaedic & Sports Physical Therapy®
therapy visits.27 Manual therapy
thrust manipulation. periods (P.001), with pain improvement scores
T879A=HEKD:0 Evidence has begun to emerge
in the manipulation group of 16.8 mm and 26.5
mm greater than those in the comparison group
in support of thoracic thrust manipulation as an in-
at the 2- and 4-week follow-up periods, respec-
tervention in the management of mechanical neck
tively. The experimental group also experienced
pain. However, to make a strong recommendation
significantly greater improvements in disability
for a clinical technique it is necessary to have
with a between-group difference of 8.8 points
multiple studies with convergent findings.
(95% confidence interval [CI]: 7.5, 10.1; P.001)
is a treatment commonly used TC;J>E:I7D:C;7IKH;I0 Forty-five pa-
at the fifth visit and 8.0 points (95% CI: 5.8, 10.2;
tients (21 females) were randomly assigned to 1 of
in the management of neck pain. 2 groups: a control group, which received electro/
There is growing evidence demonstrat-
ing the benefits of thoracic spine thrust
manipulation in the management of pa-
tients with neck pain.13-15,18,19,21,25 The ma-
jority of studies on the effects of thoracic
manipulation in patients with mechani-
cal neck pain have been limited to imme-
diate outcomes,13-15 2-day outcomes,14 or
1-week outcomes.25 Another study lacked
a comparison group,19 which precluded
inferences about a cause-and-effect rela-
tionship. We have recently completed a
thermal therapy for 5 treatment sessions, and
the experimental group, which received the same
electro/thermal therapy program in addition to a
thoracic spine thrust manipulation once a week
for 3 consecutive weeks. Mixed-model analyses
of variance (ANOVAs) were used to examine the
effects of treatment on pain (100-mm visual
analogue scale), disability (100-point disability
scale), and cervical range of motion, with group
as the between-subjects variable and time as the
within-subjects variable. The primary analysis was
the group-by-time interaction for pain.
TH;IKBJI0 The group-by-time interaction effects
for the ANOVA models were statistically significant
P.001) at the 2-week follow-up.
T9ED9BKI?EDI0 The results of our study
suggest that thoracic spine thrust manipulation
results in superior clinical benefits that persist
beyond the 1-month follow-up period for patients
with acute neck pain. Future studies should
continue to investigate the effects of thoracic
spine thrust manipulation, as compared to other
physical therapy interventions, in a population with
mechanical neck pain.
TB;L;BE<;L?:;D9;0 Therapy, level 1b.
J Orthop Sports Phys Ther 2009;39(1):20-27.
doi:10.2519/jospt.2009.2914
TA;OMEH:I0 cervical spine, clinical trial,
randomized clinical trial comparing the for pain, mobility, and disability (P.05), indicat- manual therapy, mobilization, thrust manipulation
effectiveness of an electro/thermal thera-

1
Clinical Consultant, Centro de Fisioterapia Integral, Candas, Asturias, Spain. 2 Professor and Clinical Researcher, Department of Physical Therapy, Occupational Therapy,
Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. 3 Professor, Department of Physical Therapy, Franklin Pierce University, Concord,
NH; Clinical Researcher and Physical Therapist, Rehabilitation Services, Concord Hospital, NH; Professor, Faculty, Manual Therapy Fellowship Program, Regis University, Denver,
CO. The protocol for this study was approved by The Human Research Committee of the Escuela de Osteopatía de Madrid. Address correspondence to Dr César Fernández de
las Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, 89 57 Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain. E-mail: cesar.fernandez@urjc.es

20 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
 range of motion, pain, and function.25
The study design did not investigate if
the clinical benefits lasted beyond the
1-week time frame. However, the results
of the study25 suggest that the addition of
thoracic spine thrust manipulation to a
multimodal treatment program is more
effective than an electro/thermal therapy
program alone.
Recently developed clinical guidelines
for the management of neck pain made a
recommendation for the use of thoracic
thrust manipulation based on weak evi-
dence.8 It is important to further enhance
the scientific evidence for the use of phys-
ical therapy interventions to allow clini-
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.
cians to more easily apply the principles
of evidence-based practice into patient
management. Therefore, the purposes of
this clinical trial were to utilize a similar
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
design to our previous trial25 in a differ-
ent cohort of patients with neck pain,
and to investigate if the group receiving
thoracic spine thrust manipulation would
experience superior outcomes in regard
to cervical range of motion, pain, and
disability. Additionally, we sought to in-
vestigate if changes would be maintained
at a 2-week (pain, disability, and cervi-
Journal of Orthopaedic & Sports Physical Therapy®
cal range of motion) and 4-week (pain)
follow-up period.
C;J>E:I
FWj_[dji
9
onsecutive patients with me-
chanical neck pain of less than 1
month in duration, referred by
their primary care physician to a physical
therapist between September 2007 and
February 2008 were screened for eligibil-
ity. Mechanical neck pain was defined as
generalized neck and/or shoulder pain
with symptoms provoked by neck pos-
tures, neck movement, or palpation of the
cervical musculature. Exclusion criteria
included the following: (1) contraindica-
tion to manipulation, (2) history of whip-
lash or cervical surgery, (3) diagnosis of
cervical radiculopathy or myelopathy, (4)
diagnosis of fibromyalgia syndrome,35 (5)
having undergone spinal manipulative
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | 21
therapy in the previous 2 months, or (6)
less than 18 or greater than 45 years of
age. The medical history for each patient
was solicited from their primary care
physician to assess the presence of any
exclusion criteria or “red flags” (infec-
tion, osteoporosis). The research project
was approved by The Human Research
Committee of the Escuela de Osteopatía
de Madrid. All subjects signed an in-
formed consent prior to participation in
the study.
FheY[Zkh[
Patients completed numerous self-report
measures and received a standardized
history and physical examination by an
experienced manual therapist. Demo-
graphic data included age, gender, past
medical history, and location, nature, and
onset of symptoms.
EkjYec[C[Wikh[i
We used self-reported pain at the 4-week
follow-up as the primary outcome meas-
ure in this trial. A visual analog scale
(VAS) was used to record the patient’s
level of pain at baseline, immediately af-
ter the final treatment session (fifth visit),
and at the 2-week and 4-week follow-up
periods. The VAS is a 100-mm line, with a
“0” at one end representing “no pain” and
“100” at the other end representing “the
worst pain imaginable.” Patients placed a
mark along the line corresponding to the
intensity of their symptoms, which was
scored to the nearest millimeter. The VAS
has been shown to be a reliable and valid
instrument for measuring pain intensity.2
The VAS was also selected as an outcome
measure based on its ability to detect im-
mediate changes in pain that exhibit a
minimal clinically important difference
(MCID) between 9 and 11 mm.3,22
Cervical range of motion was assessed
with the patient sitting comfortably on a
chair with both feet flat on the floor, hips
and knees positioned at 90° angles, and
buttocks positioned against the back of
the chair. The goniometer was placed on
the top of the head. Once the goniometer
was set in the neutral position, the pa-
tient was asked to move the head as far
as possible in a standard fashion: flexion,
extension, right lateral flexion, left lateral
flexion, right rotation, and left rotation.
Three trials were recorded for each di-
rection of movement, and the mean was
employed in the analysis. This method
of assessment has been previously de-
scribed.17 Reliability testing of these spe-
cific methods of measuring cervical range
of motion yielded intraclass correlation
coefficients ranging from 0.66 to 0.78.12
The cervical range-of-motion data were
collected at baseline, after the fifth treat-
ment (final physical therapy visit), and at
the 2-week follow-up period.
The Spanish version of the Northwick
Neck Pain Questionnaire (NPQ) was
used to assess subjects’ perceived level of
disability as a result of their neck pain.24
The NPQ is a self-administered question-
naire that includes 9 sections regarding
typical daily activities: intensity, sleeping,
numbness, duration, reading or televi-
sion, carrying, work, social, and driving.
Each section is scored on a scale from
0 to 4, with 4 representing the greatest
disability, and the total score is obtained
by summing the scores for the 9 sec-
tions (possible score, 0-36).30 The NPQ
was collected at baseline, after the fifth
treatment (final physical therapy visit),
and at the 2-week follow-up period. All
outcome measures were collected by a
therapist who was blind to the patient’s
group assignment.
7bbeYWj_ed
Following the baseline examination, pa-
tients were randomly assigned to receive
an electro/thermal therapy program
with or without thoracic spine thrust
manipulation. Concealed allocation was
performed using a computer-generated
randomized table of numbers created pri-
or to the start of data collection by a re-
searcher not involved in the recruitment
and treatment of patients. Individual,
sequentially numbered index cards with
the random assignment were prepared.
The index cards were folded and placed
in sealed, opaque envelopes. A second
 [ RESEARCH REPORT ]
Patients with neck pain
screened for eligibility criteria
(n = 60)

Excluded (n = 15):
1 oncomitant migraine (n = 5)
1 revious whiplash (n = 5)
1 hronic neck pain (n = 5)

Baseline measurements (n = 45)

Outcome measures: pain, range-
<?=KH;'$Thoracic spine thrust manipulation. of-motion, disability
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.

therapist, blinded to the baseline ex-

amination findings, opened the envelope Randomized (n = 45)
and proceeded with treatment according
to the group assignment. All patients re-
Allocated to electro/thermal Allocated to electro/thermal
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ceived the first treatment on the day of

the initial examination. therapy intervention with therapy intervention without
thoracic spine manipulation (n= 23) thrust manipulation (n = 22)
Jh[Wjc[dj
Individuals in both study groups received
5 treatment sessions of a standard electro/
Loss to follow-up (n = 0) Loss to follow-up (n = 0)
thermal therapy program over a 3-week
period. All patients attended the first visit
on a Monday, the second visit on the fol-
Fifth visit (n = 23) Fifth visit (n = 22)
Journal of Orthopaedic & Sports Physical Therapy®

lowing Thursday, the third visit on the

Outcome measures: pain, Outcome measures: pain,
following Monday, and so on. Patients in
range-of-motion, disability range-of-motion, disability
the experimental group received thoracic
thrust manipulation on the 3 consecutive
Mondays (first, third, and fifth visits). Pa-
2-week follow-up (n = 23) 2-week follow-up (n = 22)
tients were blinded to the treatment group,
Outcome measures: pain, Outcome measures: pain,
without revealing that the inclusion of a range-of-motion, disability range-of-motion, disability
specific intervention (thoracic thrust ma-
nipulation) was truly being evaluated. All
the treatments were applied by the same
4-week follow-up (n = 23) 4-week follow-up (n = 22)
therapist to all the participants.
Outcome measure: pain Outcome measure: pain

;b[Yjhe%J^[hcWbJ^[hWfoFhe]hWc
The standardized program included the
application of superficial thermal and
electrotherapy as follows: an infrared
lamp (250 W) located 50 cm from the
patients’ neck was applied for 15 min-
utes. After superficial thermal therapy,
transcutaneous electrical nerve stimula-
tion (Uniphy Phyaction 782; Uniphy BV,
Son, The Netherlands) at a frequency
of 100 Hz (250-microsecond pulses)
<?=KH;($Flow diagram of subjects throughout the course of the study.
was applied for 20 minutes using two 4 tion on 3 consecutive Mondays (first,
 6-cm electrodes placed bilaterally on third, and fifth visits). The patient was
each side of the spinous process of the C7 seated with arms crossed over the chest
vertebra.11,25 and hands passed over the shoulders (1
hand on the opposite shoulder and 1 hand
J^ehWY_YJ^hkijCWd_fkbWj_ed along rib cage). The therapist placed his
Patients in the experimental group re- upper chest at the level of the patient’s
ceived a seated “distraction” manipula- middle thoracic spine and grasped the

22 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
 patient’s elbows. Gentle flexion of the
thoracic spine was introduced until slight J78B;' Baseline Demographics for Both Groups*
tension was felt in the tissues at the con-
tact point between the therapist’s chest 9^WhWYj[h_ij_Yi 9edjheb=hekf ;nf[h_c[djWb=hekf
and patient’s back. Then, a distraction Gender (male/female) 12/10 12/11
thrust manipulation was applied in an Age (y) 35  6 34  4
upward direction23 (<?=KH;'). During the Duration of symptoms (d) 18.7  3.9 19.5  4.5
manipulation, the therapist listened for a Neck pain† 52.7  5.5 54.7  8.2
cracking or popping sound. If no popping Disability‡ 27.0  3.1 27.9  3.0
was heard on the first attempt, the thera- Cervical range of motion (deg)
pist repositioned the patient, and per- Flexion 44.4  5.1 45.2  4.6
formed a second thrust manipulation. A Extension 58.8  5.8 59.4  8.2
maximum of 2 attempts were performed Right lateral flexion 39.4  4.7 38.2  5.2
on each participant. This procedure was Left lateral flexion 40.2  4.8 39.2  4.6
the same employed in previous studies Right rotation 56.1  6.6 55.4  7.3
addressing the effectiveness of thoracic
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.

Left rotation 57.6  5.4 58.2  6.4

spine thrust manipulation in patients
with neck pain.13-15,25
IWcfb[I_p[:[j[hc_dWj_ed
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
* Data are mean  SD except for gender. No difference between groups for all variables (P.30).
†
Measured with a 0- to 100-mm visual analogue scale (0, no pain; 100, worst pain imaginable).
‡
Measured with the Northwick Neck Pain Questionnaire (score range, 0-36, with higher scores indicat-
ing greater disability).

The sample size and power calculations

were performed using Tamaño de la
Muestra, Version 1.1. The calculations
were based on detecting differences of
11.3 mm on a 100-mm VAS, assuming
a standard deviation of 6.9 (data taken
from Cleland et al14), a 2-tailed t test, an
alpha level of .05, and a desired power
of 80%. The estimated desired sample
Journal of Orthopaedic & Sports Physical Therapy®
pairwise comparisons were performed
to examine differences from baseline
to each time point between groups to
investigate if any between-group differ-
ences in change scores were statistically
significant. Separate 2  3 mixed-model
ANOVAs were done with cervical range
of motion (flexion, extension, rotation,
the electro/thermal therapy program
(n = 22) or the electro/thermal therapy
program with thoracic thrust manipula-
tion (n = 23). The reasons for ineligibility
can be found in <?=KH;(, which provides
a flow diagram of patient recruitment
and retention. Baseline characteristics
between the groups were similar for all

size was calculated to be 20 subjects per
group.
IjWj_ij_YWb7dWboi_i
Data were analyzed with SPSS, Version
14.0 (SPSS, Inc, Chicago, IL). Key base-
and lateral-flexion) and disability as the
dependent variable with group (control
or experimental) as the between-subjects
variable, and time (baseline, fifth visit,
2-week follow-up) as the within-subjects
variable. Again, the hypothesis of interest
variables (P.05) (J78B;').
FW_d
The overall group-by-time interaction
for the 2 × 4 mixed-model ANOVA was
statistically significant for pain as the de-
line demographic variables, including
current medication usage and scores on
the self-report measures, were compared
between groups using independent t tests
for continuous data and chi-square tests
was the group-by-time interaction at an
a priori alpha-level of .05. Additionally,
planned pairwise comparisons were per-
formed to examine differences from base-
line to each time point between groups, to
pendent variable (P.001). Planned pair-
wise comparisons indicated that patients
receiving thoracic spine thrust manipu-
lation experienced greater improvements
in pain at the fifth visit and at the 2-week
of independence for categorical data. A
2  4 mixed-model analysis of variance
(ANOVA) was used to examine the ef-
fects of treatment on pain, with group
(control, experimental) as the between-
subjects variable, and time (baseline,
fifth visit, 2-week follow-up, and 4-week
follow-up) as the within-subjects vari-
able. The hypothesis of interest was the
group-by-time interaction at an a priori
alpha level of .05. Additionally, if a signif-
icant interaction was identified, planned
journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | 23
further investigate if any between-group
differences in change scores were statisti-
cally significant.
H;IKBJI
S
ixty consecutive patients were
screened for possible eligibility
criteria. Forty-five patients (47%
female; mean  SD age, 34  5 years)
satisfied the eligibility criteria, agreed to
participate, and were randomized into
and 4-week follow-up periods (P.001
for all comparisons). Between-group
difference for the fifth visit and 2-week
follow-up period can be seen in J78B;I(
7D:).
At the 4-week follow-up period, the
thoracic manipulation group showed a
mean  SD pain score of 21.5  10.6, with
a mean within-group change score com-
pared to baseline of 33.2 (95% confidence
interval [CI]: 29.5, 36.9). The mean 
SD pain score of the comparison group
 [ RESEARCH REPORT ]
Baseline, Final Treatment Session, and Change Scores for Neck Pain,
J78B;(
Cervical Range of Motion, and Disability*

   M_j^_d#=hekf 8[jm[[d#=hekf:_÷[h[dY[
C[Wikh[i 8Wi[b_d[ ;dZe\Jh[Wjc[dj 9^Wd][IYeh[i _d9^Wd][IYeh[i
Pain (mm)† 26.5 (22.9, 30.2)
Electro/thermal program 52.7  5.5 44.7  5.5 7.9 (5.2, 10.7)
Thrust manipulation 54.7  8.2 20.2  7.8 34.5 (31.8, 36.9)
Cervical flexion (deg) 12.0 (10.1, 14.0)
Electro/thermal program 44.4  5.1 44.8  4.2 0.4 (–0.9, 1.8)
Thrust manipulation 45.2  4.6 57.6  5.0 12.4 (10.9, 14.0)
Cervical extension (deg) 11.4 (9.7, 13.2)
Electro/thermal program 58.8  5.8 59.0  4.6 0.2 (–1.5, 1.2)
Thrust manipulation 59.4  8.2 71.1  7.3 11.6 (10.3, 13.6)
Cervical right rotation (deg) 12.4 (10.0, 14.4)
Electro/thermal program 56.1  6.6 54.7  5.7 –1.4 (–3.1, 0.5)
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.

Thrust manipulation 55.4  7.3 66.5  7.1 11.1 (9.1, 12.3)

Cervical left rotation (deg) 11.2 (9.0, 13.1)
Electro/thermal program 57.6  5.4 57.2  4.3 –0.4 (–2.1, 1.2)
Thrust manipulation 58.2  6.4 69.1  5.2 10.8 (9.3, 12.4)
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Cervical right lateral flexion (deg) 9.3 (7.9, 11.7)

Electro/thermal program 39.4  4.7 39.9  3.5 0.4 (–1.2, 2.2)
Thrust manipulation 38.2  5.2 48.0  4.7 9.7 (9.1, 11.6)
Cervical left lateral flexion (deg) 10.7 (8.5, 13.2)
Electro/thermal program 40.2  4.8 39.4  3.1 –0.8 (–2.4, 0.9)
Thrust manipulation 39.2  4.6 49.1  4.6 10.0 (8.3, 11.7)
Disability (n points)‡ 8.8 (7.5, 10.1)
Electro/thermal program 27.0  3.1 23.1  3.2 3.9 (3.2, 4.6)
Thrust manipulation 27.9  3.0 15.2  3.9 12.7 (11.5, 13.8)
Journal of Orthopaedic & Sports Physical Therapy®

* Values are expressed as mean  SD for baseline and final treatment, and as mean (95% confidence interval) for within- and between-group change scores.
†
Measured with a 0- to 100-mm visual analogue scale (0, no pain; 100, worst pain imaginable).
‡
Measured with the Northwick Neck Pain Questionnaire (score range, 0-36, with higher scores indicating greater disability).

was 42.2  7.7, with a mean within-group ment at visit 5 and the 2-week follow- :?I9KII?ED
change score compared to baseline of 10.4 up measurements.
(95% CI: 6.8, 14.1). Hence, the between-

J
he results of our study further
group difference in change in pain scores :_iWX_b_jo substantiate the findings of others
at the 4-week follow-up period was 22.8 The overall group-by-time interaction who have reported that thoracic
(95% CI: 17.7, 27.8; P.001). for the 2  3 mixed-model ANOVA spine thrust manipulation can result in
was statistically significant for disability improvements in pain, cervical range of
9[hl_YWbHWd][e\Cej_ed (P.001). Planned pairwise compari- motion, and disability in a patient popu-
The overall group-by-time interaction sons demonstrated that the experimental lation with mechanical neck pain.19,25 The
for the 2  3 mixed-model ANOVA group experienced significantly greater results of our analysis indicated a signifi-
was statistically significant (P.05) improvements in disability, with a be- cant group-by-time interaction for pain,
for all directions of the cervical range tween-group difference of 8.8 points suggesting greater improvements in the
of motion. Individuals in the thoracic (95% CI: 7.5, 10.1; P.001) at the fifth manipulation group. The pairwise com-
manipulation group demonstrated a visit and 8.0 points (95% CI: 5.8, 10.2; parisons revealed significant between-
greater improvement in cervical range
of motion than those in the nonthrust
group. J78B;I ( 7D: ) summarize be-
tween-group differences and associated
95% CIs for the immediate posttreat-
P.001) at the 2-week follow-up. J78B;I
( 7D: ) summarize between-group dif-
ferences and associated 95% CIs for the
immediate posttreatment and 2-week
follow-up measurements.
group mean difference change scores
surpassing the MCID at the fifth visit
and the 2-week and 4-week follow-up
periods. Additionally, the relatively nar-
row confidence intervals provide greater

24 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
 Baseline, 2-Week Follow-up, and Change Scores for Neck Pain,
J78B;)
Cervical Range of Motion, and Disability*

   M_j^_d#=hekf 8[jm[[d#=hekf:_÷[h[dY[
C[Wikh[i 8Wi[b_d[ (#M[[a<ebbem#kf 9^Wd][IYeh[i _d9^Wd][IYeh[i
Pain (mm)† 16.8 (11.7, 21.8)
Electro/thermal program 52.7  5.5 41.2  6.1 11.5 (8.5, 14.4)
Thrust manipulation 54.7  8.2 26.4  11.8 28.3 (24.1, 32.4)
Cervical flexion (deg) 8.1 (4.8, 11.4)
Electro/thermal program 44.4  5.1 47.5  5.0 3.1 (0.6, 5.5)
Thrust manipulation 45.2  4.6 56.3  5.4 11.2 (8.8, 13.5)
Cervical extension (deg) 7.1 (4.8, 10.1)
Electro/thermal program 58.8  5.8 58.2  5.7 –0.6 (–2.2, 0.9)
Thrust manipulation 59.4  8.2 65.8  5.6 6.4 (4.3, 9.1)
Cervical right rotation (deg) 12.0 (9.2, 14.7)
Electro/thermal program 56.1  6.6 51.8  5.1 –4.3 (–6.3, –2.1)
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.

Thrust manipulation 55.4  7.3 63.3  5.3 7.8 (5.4, 9.7)

Cervical left rotation (deg) 8.4 (5.0, 10.9)
Electro/thermal program 57.6  5.4 55.4  5.2 –2.1 (–4.1, –0.5)
Thrust manipulation 58.2  6.4 64.6  4.6 6.4 (3.9, 8.3)
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Cervical right lateral flexion (deg) 8.7 (7.4, 14.0)

Electro/thermal program 39.4  4.7 40.3  3.1 0.8 (–0.4, 1.9)
Thrust manipulation 38.2  5.2 47.7  5.6 9.5 (8.4, 11.5)
Cervical left lateral flexion (deg) 5.9 (3.4, 8.4)
Electro/thermal program 40.2  4.8 41.9  3.3 1.7 (0.2, 3.2)
Thrust manipulation 39.2  4.6 46.7  4.5 7.6 (5.6, 9.7)
Disability (n points)‡ 8.0 (5.8, 10.2)
Electro/thermal program 27.0  3.1 21.8  3.3 5.1 (3.6, 6.7)
Thrust manipulation 27.9  3.0 14.7  2.8 13.2 (11.5, 14.9)
Journal of Orthopaedic & Sports Physical Therapy®

* Values are expressed as mean  SD for baseline and 2-week follow-up, and as mean (95% confidence interval) for within- and between-group change scores.
†
Measured with a 0- to 100-mm visual analogue scale (0, no pain; 100, worst pain imaginable).
‡
Measured with the Northwick Neck Pain Questionnaire (score range, 0-36, with higher scores indicating greater disability).

assurance when making clinical decisions
regarding the treatment effect identified
in this study.32 It should also be noted
that even the lower bound estimates for
the 95% CIs fall above the previously re-
ported MCID of 9 to 113,22 and provide
further certainty about the value of tho-
racic manipulation in the management
of patients with neck pain. These results
also suggest that the difference between
groups for pain scores remains beyond
the 1- and 2-week follow-up periods.
The difference in cervical range-of-
motion change scores between groups
at the time of discharge from therapy
ranged between 10° and 12° and was
remarkably similar to the differences
reported in our previous trial with a
different group of patients.25 Again, the
relatively narrow confidence intervals in-
dicate the precision of the results.32 While
no MCID has been reported for cervical
range of motion, we feel that the magni-
tude of these changes is clinically impor-
tant, as the point estimates, and the lower
bound estimate of the 95% CI exceeded
the previously reported standard error
of measure in a population with neck
pain.12 Although statistically significant,
the differences in cervical range of mo-
tion between groups were smaller when
measured at the 2-week follow-up. It is
unclear if significant differences would
still exist with a longer follow-up.
We also found that the changes in dis-
ability scores obtained with this study
were nearly identical to those obtained in
our previous clinical trial25 and supported
the inclusion of thoracic spine thrust ma-
nipulation for the treatment of mechani-
cal neck pain. The current study reports
the longest follow-up period to date for
this intervention in the clinical popula-
tion, which suggests that the clinical ben-
efits of thrust manipulation may persist
beyond the 2-week and 4 week follow-up
periods. Future studies should examine if
these clinical benefits continue to exist at
6- or 12-month follow-up periods. How-
ever, the fact that this study demonstrat-
ed similar findings to our previous trial25
suggests that clinicians should consider
incorporating thoracic spine thrust ma-
nipulation in the management of patients
with mechanical neck pain.
There exist a few limitations to the
current study. One clinician performed

journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | 25
 [ RESEARCH REPORT
all the manipulations, which somewhat
limits the generalizability of the results.
We only collected changes in disabil-
ity up to the 2-week follow-up period. It
would have been beneficial to see if these
benefits remain at 1-month, similar to
the improvements in pain. Additionally,
there exists a multitude of thoracic spine
thrust manipulation techniques, and we
cannot make any conclusions about the
clinical benefits of other techniques that
were not used in this study. The particu-
lar technique selected might not be as
critical as identifying the proper patient
who is likely to benefit from thrust tech-
niques.9,10,20 However, this hypothesis re-
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.
]
clinical benefits of thoracic spine thrust
manipulation (pain reduction) persisted
at the 1-month follow-up period. Future
studies should continue to investigate the
effects of thoracic spine thrust manipu-
lation in a population with mechanical
neck pain, as compared to other physical
therapy interventions, and include long-
term follow-up periods. T
A;OFE?DJI
<?D:?D=I0 Patients with mechanical
neck pain who received thoracic spine
thrust manipulation experienced greater
improvements in pain, cervical range
of motion, and disability than those
of a postal survey in a county of Sweden. Pain.
1989;37:215-222.
7. Brosseau L, Tugwell P, Wells GA. Philadelphia
Panel evidence-based clinical practice guide-
lines on selected rehabilitation interventions for
neck pain. Phys Ther. 2001;81:1701-1717.
8. Childs JD, Cleland JA, Elliott JM, et al. Neck
pain: clinical practice guidelines linked to the
international classification of functioning,
disability, and health from the Orthopaedic
Section of the American Physical Therapy
Association. J Orthop Sports Phys Ther.
2008;38:A1-A34. http://dx.doi.org/10.2519/
jospt.2008.0303
9. Chiradejnant A, Latimer J, Maher C, Stepkovitch
N. Does the choice of spinal level treated dur-
ing posteroanterior (PA) mobilisation affect
treatment outcome? Physiother Theor Pract.
2002;18:165-174.
10. Chiradejnant A, Maher CG, Latimer J, Stepko-

vitch N. Efficacy of "therapist-selected" versus

quires further investigation. We also used
an electro/thermal therapy program in
this study, which doesn’t necessarily re-
flect common physical therapist practice.
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
treated with an electro/thermal therapy
program alone. Greater improvement
persisted at the maximum follow-up of
2 weeks for range of motion and dis-
11.
"randomly selected" mobilisation techniques for
the treatment of low back pain: a randomised
controlled trial. Aust J Physiother. 2003;49:233-
241.
Chiu TT, Hui-Chan CW, Chein G. A random-

It has been reported that the evidence
for treatment of neck pain by different
forms of electrotherapy is either lacking
or conflicting.7,29 Hence it is possible that
other treatment strategies used by physi-
cal therapists might result in the same, if
not better, outcomes that occurred with
the thoracic spine thrust technique used
in this study.
Journal of Orthopaedic & Sports Physical Therapy®
ability, and the maximum follow-up of 4
weeks for pain.
?CFB?97J?EDI0 The results of this study
support the use of thoracic spine thrust
manipulation in the management of pa-
tients with mechanical neck pain.
97KJ?ED0 We used a relatively small
sample and all patients were treated by
1 therapist. Hence, the generalizability
ized clinical trial of TENS and exercise for
patients with chronic neck pain. Clin Rehabil.
2005;19:850-860.
12. Cleland JA, Childs JD, Fritz JM, Whitman
JM. Interrater reliability of the history and
physical examination in patients with me-
chanical neck pain. Arch Phys Med Rehabil.
2006;87:1388-1395. http://dx.doi.org/10.1016/j.
apmr.2006.06.011
13. Cleland JA, Childs JD, Fritz JM, Whitman JM,
Eberhart SL. Development of a clinical predic-

Future studies should investigate the
long-term outcomes (6-months to 1-year
follow-up) of thoracic spine thrust ma-
nipulation for the management of me-
chanical neck pain with patients treated
by numerous clinicians. Studies should
also continue to investigate the effects
of spine thrust manipulations compared
to other physical therapy interventions
for the management of mechanical neck
pain.
9ED9BKI?ED
of the results should be interpreted with
caution.
H;<;H;D9;I
1. Andersson HI, Ejlertsson G, Leden I, Rosenberg
C. Chronic pain in a geographically defined
general population: studies of differences in age,
gender, social class, and pain localization. Clin J
Pain. 1993;9:174-182.
2. Bijur PE, Silver W, Gallagher EJ. Reliability of the
visual analog scale for measurement of acute
pain. Acad Emerg Med. 2001;8:1153-1157.
3. Bird SB, Dickson EW. Clinically significant
changes in pain along the visual analog scale.
Ann Emerg Med. 2001;38:639-643. http://
tion rule for guiding treatment of a subgroup
of patients with neck pain: use of thoracic
spine manipulation, exercise, and patient edu-
cation. Phys Ther. 2007;87:9-23. http://dx.doi.
org/10.2522/ptj.20060155
14. Cleland JA, Childs JD, McRae M, Palmer JA,
Stowell T. Immediate effects of thoracic manipu-
lation in patients with neck pain: a randomized
clinical trial. Man Ther. 2005;10:127-135. http://
dx.doi.org/10.1016/j.math.2004.08.005
15. Cleland JA, Glynn P, Whitman JM, Eberhart
SL, MacDonald C, Childs JD. Short-term ef-
fects 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. http://dx.doi.
org/10.2522/ptj.20060217
16. Cote P, Cassidy JD, Carroll L. The factors

F
atients with mechanical neck
pain who received thoracic spine
thrust manipulation experienced
greater improvements in pain, cervical
range of motion, and disability at the
fifth treatment session and at the 2-week
follow-up, compared to those who re-
ceived a program of electro/thermal
therapy interventions. Additionally, the
dx.doi.org/10.1067/mem.2001.118012
4. Borghouts JA, Koes BW, Bouter LM. The
clinical course and prognostic factors of non-
specific neck pain: a systematic review. Pain.
1998;77:1-13.
5. Borghouts JA, Koes BW, Vondeling H, Bouter LM.
Cost-of-illness of neck pain in The Netherlands
in 1996. Pain. 1999;80:629-636.
6. Brattberg G, Thorslund M, Wikman A. The preva-
lence of pain in a general population. The results
associated with neck pain and its related dis-
ability in the Saskatchewan population. Spine.
2000;25:1109-1117.
17. Fernandez-de-las-Penas C, Alonso-Blanco
C, Cuadrado ML, Pareja JA. Forward head
posture and neck mobility in chronic tension-
type headache: a blinded, controlled study.
Cephalalgia. 2006;26:314-319. http://dx.doi.
org/10.1111/j.1468-2982.2005.01042.x
18. Fernández-de-las-Peñas C, Fernandez-Carnero

26 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy
 J, Plaza Fernández A, Lomas-Vega R, Miango-
larra-Page JC. Dorsal manipulation in whiplash
injury treatment: a randomized controlled trial.
J Whiplash Relat Disord. 2004;3:55-72. http://
dx.doi.org/10.1300/J180v03n02_05
19. Fernandez-de-las-Penas C, Palomeque-del-
Cerro L, Rodriguez-Blanco C, Gomez-Conesa
A, Miangolarra-Page JC. Changes in neck
pain and active range of motion after a single
thoracic spine manipulation in subjects
presenting with mechanical neck pain: a
case series. J Manipulative Physiol Ther.
2007;30:312-320. http://dx.doi.org/10.1016/j.
jmpt.2007.03.007
20. Flynn TW. There's more than one way to ma-
nipulate a spine. J Orthop Sports Phys Ther.
2006;36:198-199. http://dx.doi.org/10.2519/
jospt.2006.0105
21. Flynn TW, Wainner RS, Whitman JM. Immediate
effects of thoracic spine manipulation on cervi-
Downloaded from www.jospt.org at on May 23, 2020. For personal use only. No other uses without permission.
ish version of the Northwick Park Neck Pain
Questionnaire: reliability and validity. Clin Exp
Rheumatol. 2001;19:41-46.
25. Gonzalez-Iglesias J, Fernandez-de-Las-
Penas C, Cleland JA, Alburquerque-Sendin F,
Palomeque-Del-Cerro L, Mendez-Sanchez R.
Inclusion of thoracic spine thrust manipulation
into an electro-therapy/thermal program for
the management of patients with acute me-
chanical neck pain: a randomized clinical trial.
Man Ther. 2008;http://dx.doi.org/10.1016/j.
math.2008.04.006
26. Gore DR, Sepic SB, Gardner GM, Murray MP.
Neck pain: a long-term follow-up of 205 pa-
tients. Spine. 1987;12:1-5.
27. Jette AM, Smith K, Haley SM, Davis KD. Physical
therapy episodes of care for patients with low
back pain. Phys Ther. 1994;74:101-110; discus-
sion 110-105.
28. Korthals-de Bos IB, Hoving JL, van Tulder MW,
neck pain and disability. Br J Rheumatol.
1994;33:469-474.
31. Makela M, Heliovaara M, Sievers K, Impivaara O,
Knekt P, Aromaa A. Prevalence, determinants,
and consequences of chronic neck pain in Fin-
land. Am J Epidemiol. 1991;134:1356-1367.
32. Noteboom JT, Allison SC, Cleland JA, Whitman
JM. A primer on selected aspects of evidence-
based practice to questions of treatment. Part
2: interpreting results, application to clinical
practice, and self-evaluation. J Orthop Sports
Phys Ther. 2008;38:485-501. http://dx.doi.
org/10.2519/jospt.2008.2725
33. Nygren A, Berglund A, von Koch M. Neck-and-
shoulder pain, an increasing problem. Strategies
for using insurance material to follow trends.
Scand J Rehabil Med Suppl. 1995;32:107-112.
34. Rempel DM, Harrison RJ, Barnhart S. Work-re-

lated cumulative trauma disorders of the upper

cal range of motion and pain [abstract]. J Man
Manip Ther. 2001;9:164-171.
22. Gallagher EJ, Liebman M, Bijur PE. Prospective
validation of clinically important changes in pain
severity measured on a visual analog scale. Ann
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
et al. Cost effectiveness of physiotherapy,
manual therapy, and general practitioner care
for neck pain: economic evaluation alongside a
randomised controlled trial. BMJ. 2003;326:911.
http://dx.doi.org/10.1136/bmj.326.7395.911
extremity. JAMA. 1992;267:838-842.
35. Wolfe F, Smythe HA, Yunus MB, et al. The Ameri-
can College of Rheumatology 1990 Criteria for
the Classification of Fibromyalgia. Report of

Emerg Med. 2001;38:633-638. http://dx.doi. 29. Kroeling P, Gross A, Houghton PE. Electro- the Multicenter Criteria Committee. Arthritis
org/10.1067/mem.2001.118863 therapy for neck disorders. Cochrane Database Rheum. 1990;33:160-172.
23. Gibbons P, Tehan P. Manipulation of the Spine, Syst Rev. 2005;CD004251. http://dx.doi.
Thorax and Pelvis: An Osteopathic Perspective. org/10.1002/14651858.CD004251.pub3

@
Edinburgh, UK: Churchill Livingston; 2002. 30. Leak AM, Cooper J, Dyer S, Williams KA,
24. Gonzalez T, Balsa A, Sainz de Murieta J, Turner-Stokes L, Frank AO. The Northwick Park
CEH;?D<EHC7J?ED
Zamorano E, Gonzalez I, Martin-Mola E. Span- Neck Pain Questionnaire, devised to measure WWW.JOSPT.ORG
Journal of Orthopaedic & Sports Physical Therapy®

GO GREEN By Opting Out of the Print Journal

JOSPT subscribers and APTA members of the Orthopaedic and Sports
Physical Therapy Sections can help the environment by “opting out” of
receiving the Journal in print each month as follows. If you are:

· A JOSPT subscriber: Email your request to jospt@jospt.org or call the

Journal office toll-free at 1-877-766-3450 and provide your name and
subscriber number.
· An APTA Orthopaedic or Sports Section member: Go to www.apta.org
and update your preferences in the My Profile area of myAPTA.
Select “myAPTA” from the horizontal navigation menu (you’ll be asked
to login, if you haven’t already done so), then proceed to “My Profile.”
Click on the “Email & Publications” tab, choose your “opt out”
preferences and save.

Subscribers and members alike will continue to have access to JOSPT

online and can retrieve current and archived issues anytime and anywhere
you have Internet access.

journal of orthopaedic & sports physical therapy | volume 39 | number 1 | january 2009 | 27