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Kasey Miller DPT, COMT  - Foot and Ankle Differential Diagnosis - Short Case Studies
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Young IA, Pozzi F, Dunning J, Linkonis, Michener LA. (2019). Journal of Orthopaedic & Sports Physical Therapy; 49(5): 299–309

Article Summary: by Kellie Stringer SPT, Missouri State University, Springfield, MO. 

The goal of this multicenter, randomized controlled trial is to assess the immediate and short-term effects that one session of thoracic manipulation has in patients with cervical radiculopathy, compared to a sham thoracic manipulation. Many studies have presented supportive evidence for the use of thoracic spine manipulation in patients with neck pain.  However, until now no study has explored the immediate or short-term effects of thoracic manipulation on related impairments and outcomes in patients with cervical radiculopathy.

In this study, forty-three participants with cervical radiculopathy were randomly assigned to receive either thoracic spine manipulation (n=22) or a sham manipulation (n=21). The manipulation group was given a supine high-velocity, low-amplitude (HVLA) thrust directed bilaterally to the upper thoracic (C7-T3) and mid-thoracic (T4-T9) spine. The sham manipulation group was placed in an identical setup position as the active manipulation group, except for the therapist’s hand positioning. An open hand (fingers extended) placement was used and no HVLA thrust manipulation was delivered.

The outcomes were measured at baseline, immediately after treatment, and at a follow-up 48 to 72 hours after the initial treatment. The numeric pain-rating scale (NPRS) and the global rating of change (GROC) were used to measure the primary outcomes, which included neck and upper extremity pain and the patient-perceived changes in neck and upper extremity symptoms, respectively. Secondary outcomes included neck disability on the Neck Disability Index (NDI), cervical spine impairments (active ROM and deep neck flexor muscle endurance), and centralization of symptoms.

Immediately after treatment, the manipulation group reported significantly less neck pain with an average reduction of 1.9 points in the NPRS score, compared to 0.1 points in the sham group (P<.01). At 48 to 72 hours after treatment, the manipulation group had an average reduction of 2.4 points in the NPRS score, and 50% of these participants reported at least a moderate positive improvement with a GROC score of +4 or greater in neck and upper extremity symptoms (P<.01). No between group differences in the upper extremity were found immediately after treatment (P=.34) or 48 to 72 hours after treatment (P=.18). 55% of the patients in the manipulation group reported greater centralization of symptoms versus 5% in the sham group (P<.01) immediately after treatment, with 64% of the patients in the manipulation group reporting centralization of symptoms at follow-up versus 5% in the sham group (P<.01). There was also a significant group-by-time interactions found for the NDI (P<.01), deep neck flexor endurance test (P<.01), active cervical ROM (P<.01).

The study concluded that patients with cervical radiculopathy who received one session of upper and mid-thoracic thrust manipulation had improvements in neck pain, patient-rated disability, and cervical impairments (active ROM and deep neck flexor endurance) immediately and 48 to 72 hours following treatment, compared to those treated with sham manipulation. A greater amount of the patients who received manipulation also reported at least moderate positive change in their neck and upper extremity symptoms up to 48 to 72 hours following the initial treatment. 

Personal Commentary:

Cervical radiculopathy is a condition resulting from nerve root compression or irritation. This condition is most often attributed to a lesion of the nerve root secondary to cervical disc derangement or spondylosis (Wainner & Gill, 2000). Patient’s commonly present with neck and arm pain and may have accompanying motor or sensory deficits in the areas innervated by the affected nerve root. This condition is typically managed by physical therapists using a multimodal treatment approach including manual therapy (mobilization/manipulation), exercise, and cervical traction (Cross, Kuenze, Grindstaff, & Hertel, 2011). Some patients with cervical radiculopathy may be unable to tolerate cervical manual interventions, and thoracic manipulation may be another viable option.

I found interest in this particular topic when I reviewed the literature and found that the evidence supported thoracic manipulation to be effective in short-term improvements in pain and disability in patients with neck pain (Cleland et al., 2007). The findings in this article show that thoracic manipulation may be an early treatment option for patients with cervical radiculopathy. Although the long-term effects are unknown, thoracic manipulation was found to improve the immediate and short-term effects of pain, disability, cervical ROM, and endurance in patients with cervical radiculopathy. 

The authors in this study mentioned that the sham manipulation may not have been an adequate control, and therefore a limitation. At the 48 to 72-hour follow-up time, 90% of the participants in the manipulation group believed they received the active treatment compared to those in the sham manipulation (57%, P= .01). It is important to acknowledge this disparity because of the influence it could play in patient expectations. The authors also mentioned that an audible cavitation was expected for a successful manipulation, and that a second would be performed if there was no audible. The authors did not specify if they had to perform more than one manipulation on any of the participants in the active manipulation group. However, they did specify that audible cavitations were recorded in 100% of the manipulation group compared to 0% that were recorded in the sham manipulation group. According to Sillevis and Cleland (2011), the presence of joint sounds does not contribute to reducing pain in patients with chronic neck pain following thrust manipulations (Sillevis & Cleland, 2011). However, sounds that accompany the manipulative treatments may result in a placebo effect, potentially influencing the overall results (Sillevis & Cleland, 2011). If a second manipulation attempt was required in order to get an audible, it makes me consider the effect placebo may have had on the results. 

Thoracic spine manipulation as an intervention depends on appropriate clinical decision making and the realization that this technique is not a “fix-all” for patients with cervical radiculopathy. It should be emphasized that the literature supports the short-term effects of thoracic manipulation, but the importance of other interventions as well as an individualized treatment plan should not be minimized. 

References:

  1. Cleland, J. A., Glynn, P., Whitman, J. M., Eberhart, S. L., Macdonald, C., & Childs, J. D. (2007). Short-Term Effects of Thrust Versus Nonthrust Mobilization/Manipulation Directed at the Thoracic Spine in Patients With Neck Pain: A Randomized Clinical Trial. Physical Therapy87(4), 431–440. doi: 10.2522/ptj.20060217

 

  1. Cross, K. M., Kuenze, C., Grindstaff, T., & Hertel, J. (2011). Thoracic Spine Thrust Manipulation Improves Pain, Range of Motion, and Self-Reported Function in Patients With Mechanical Neck Pain: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy41(9), 633–642. doi: 10.2519/jospt.2011.3670

 

  1. Sillevis, R., & Cleland, J. (2011). Immediate Effects of the Audible Pop From a Thoracic Spine Thrust Manipulation on the Autonomic Nervous System and Pain: A Secondary Analysis of a Randomized Clinical Trial. Journal of Manipulative and Physiological Therapeutics34(1), 37–45. doi: 10.1016/j.jmpt.2010.11.007

      4. Wainner, M. R. S., & Gill, L. H. (2000). Diagnosis and Nonoperative Management of Cervical Radiculopathy. Journal of Orthopaedic & Sports Physical Therapy30(12), 728–744. doi: 10.2519/jospt.2000.30.12.728