Research Review By Dr. Ceara Higgins©

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Date Posted:

August 2019

Study Title:

Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients with Cervical Radiculopathy: A Randomized Controlled Trial

Authors:

Young IA, Pozzi F, Dunning J, et al.

Author's Affiliations:

CORA Physical Therapy, Savannah, Georgia; American Academy of Manipulative Therapy, Montgomery, Alabama; University of Florida, Gainesville, Florida; Alabama Physical Therapy and Acupuncture, Montgomery, Alabama; Center for Physical Therapy and Sports Medicine, PC, Richmond, Virginia; University of Southern California, Los Angeles, California – all in USA.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2019; 49(5): 299-309.

Background Information:

Previous research has demonstrated both immediate and short-term improvements in cervical spine range of motion (ROM) and pain after thoracic spine manipulation (4), as well as better outcomes in neck pain patients when compared with (low-velocity) mobilization of the thoracic spine (3). This (in general) supports the use of thoracic manipulation in patients with cervical spine pain – a useful clinical approach employed by many clinicians. However, there is a lack of evidence surrounding the use of thoracic spine manipulation in individuals with neck and arm pain related to cervical radiculopathy. This treatment could be valuable in the early phases of treatment when patients with cervical radiculopathy may not tolerate cervical manipulation well.

Cervical radiculopathy is generally associated with cervical disc pathology or other space-occupying lesions which result in nerve root inflammation, impingement, or both (6); and can present with or without neck pain and with a wide variety of upper extremity symptoms. Common treatment for this condition includes manual therapy (mobilization/manipulation of the cervical and thoracic spine, neurodynamic techniques, and soft tissue mobilization), exercise (strengthening of the deep neck flexors and scapular-thoracic region), and cervical traction (manual, mechanical, and/or home traction) (6).

This study aimed to assess the immediate and short-term effects of a single session of thoracic manipulation in patients with cervical radiculopathy compared with a sham thoracic manipulation. Primary outcomes included neck and upper extremity pain and patient-perceived changes in neck and upper extremity symptoms. Secondary outcomes included neck disability, active cervical spine ROM, deep neck flexor muscle endurance, upper extremity numbness and tingling, and symptom distribution.

Pertinent Results:

No increases in neck, arm, or hand symptoms were reported either immediately after treatment or at the 48-72-hour follow-up, and no participants reported soreness lasting more than 3 hours after treatment. Audible cavitations were elicited in 100% of the manipulation group and 0% of the sham group. 90% of participants in the manipulation group believed they had received the active treatment, compared to 57% in the sham manipulation group.

Participants in the manipulation group reported significantly less neck pain at both follow-up points when compared to the sham group, with an average reduction on the NPRS of 1.9 points for the manipulation group, and only 0.1 points for the sham group immediately following treatment. However, this did not meet the MCID. At the 48-72-hour follow-up the manipulation group showed an average reduction in the NPRS score for neck pain of 2.4 points, which exceeded the MCID. Differences on the NPRS between groups for upper extremity pain did not meet MCID with a reduction of 1.5 points immediately following treatment and 1.7 points at the 48-72-hour follow-up for the manipulation group. These changes may still be clinically meaningful, as patients in the manipulation group were significantly more likely to report at least a moderate change on the GROC for upper extremity pain.

The manipulation group also showed greater decreases in both neck and upper extremity pain and these changes were associated with large effect sizes. A significantly greater percentage of participants in the manipulation group reported at least moderate improvement (a GROC score of +4 or greater) for both neck and upper extremity symptoms.

The manipulation group showed a greater increase in deep neck flexor muscle endurance from baseline to 48-72 hours with an average between group difference of 7.8 seconds. This did not exceed the MCID, however, so these results should be interpreted with caution as it is possible that individuals with cervical radiculopathy may have shorter average times on the deep neck flexor endurance test when compared to patients with neck pain or healthy controls (5). The improvements seen may also be a result of pain inhibition rather than actual improvements in endurance.

Immediately after treatment, the manipulation group showed greater active cervical flexion (average difference of 10.8°), extension (average difference of 10°), rotation to the symptomatic side (average difference of 14.2°), and asymptomatic side (average difference of 9.2°). At the 48-72 hour follow-up, the manipulation group showed greater active cervical flexion (average difference of 13.7°), extension (average difference of 11.1°), rotation to the symptomatic side (average difference of 13.9°) and asymptomatic side (average difference of 11.4°), lateral flexion to the symptomatic side (average difference of 8.6°), and deep neck flexor endurance (average difference of 6.3 seconds). The manipulation group also showed lower NDI scores at the 48-72-hour follow-up (average difference of -7.8 points) but this difference did not reach MCID. Finally, a greater percentage of the manipulation group versus the sham group reported centralization of symptoms immediately (55% versus 5%) and at the 48-72-hour follow-up (64% versus 5%).

Clinical Application & Conclusions:

Patients receiving a single session of thoracic manipulation showed greater improvements in neck pain, neck-related patient-rated disability, cervical ROM, and deep neck flexor endurance, both immediately and 48-72 hours after treatment, when compared to patients receiving a single session of sham manipulation. Patients in the manipulation group were also more likely to report at least a moderate improvement in their neck and upper extremity symptoms and centralization of their symptoms.

Patients in the manipulation group showed greater increases in active cervical ROM from baseline to the 48-72-hour follow-up in flexion, extension, rotation to both the symptomatic and asymptomatic sides and lateral flexion to the symptomatic side. The increases seen in rotation and lateral flexion to the symptomatic side are of particular interest, as the diagnostic criteria for cervical radiculopathy used in this study included a positive Spurling test (lateral flexion to the symptomatic side with overpressure) and restricted rotation to the symptomatic side (less than 60°).

This study suggests thoracic manipulation may be useful for treating cervical radiculopathy, as it can provide at least short-term benefits. More research is needed to assess how long these effects can last and also the potential impact of more regular treatment (at least more than one!).

Study Methods:

Patients with unilateral upper extremity pain, paresthesia, or numbness with or without neck pain were recruited from 6 physical therapy clinics in Georgia, Virginia, and California.

Inclusion criteria were as follows:
  • Individuals 18 to 65 years of age
  • Neck Disability Index (NDI) score of 10/50 or greater
  • Clinical diagnosis of cervical radiculopathy as defined by Wainner and Gill (7). This includes positive results on 3 of these 4 clinical tests: Spurling’s test, upper limb neurodynamic test/median nerve bias, cervical distraction test, and cervical rotation toward the symptomatic side of less than 60°
Exclusion criteria:
  • History of previous cervical or thoracic spine surgery
  • Bilateral upper extremity symptoms
  • Signs or symptoms of upper motor neuron disorder
  • Medical red flags
  • Use of medication or cervical steroidal injection within the past 2 weeks
All participants were asked about prior experience with cervical or thoracic thrust manipulation, with none receiving either treatment for their current episode of radiculopathy.

Data collection was performed at baseline, immediately after treatment, and at 48 to 72 hours after treatment. Participants were randomly assigned to either the manipulation or sham manipulation group and were blinded to their group assignment. At follow-up 48-72 hours after treatment, participants were asked to identify which group they thought they had been assigned to in order to assess blinding.

Six physical therapists were involved in the study and performed baseline assessments and the interventions. The majority (83%) were men and they had an average of 8 years of experience. All were provided with training and a standardized instruction manual for examination, treatment, blinding, and data collection procedures. Participants in the manipulation group received supine, high-velocity, low-amplitude thrust manipulation bilaterally to the upper thoracic (C7-T3) and mid-thoracic (T4-T9) spine (‘anterior’ adjustments). In cases where there was no audible cavitation, a second attempt was made. Manipulations were considered successful when an audible cavitation was achieved. Participants in the sham manipulation group were placed in an identical position to those in the manipulation group, but the contact hand over the vertebrae was left open, with the fingers extended. Participants were instructed to inhale and then exhale, but no thrust manipulation was applied.

Immediately after treatment and at the 48-72-hour follow-up, patients were asked about any adverse effects following manipulation and asked to contact the investigator if they experienced any soreness lasting for more than 3 hours. Participants were told to resume their normal daily activities until their next visit, with no home exercises nor advice given.

Primary outcomes included self-reported pain in the neck and upper extremity using a numeric pain-rating scale (NPRS) and perceived improvement on the global rating of change scale (GROC). Secondary outcomes included disability as measured on the NDI, cervical ROM, deep neck flexor muscle endurance, and numbness, tingling, and distribution of symptoms. NPRS, cervical ROM, and deep neck flexor muscle endurance data were collected at baseline, immediately after manipulation, and at 48-72-hour follow-up. GROC was collected at both follow-ups and the NDI was collected at baseline and at the 48-72-hour follow-up.

The NPRS used an 11-point scale asking patients to rate their pain from 0 (no pain) to 10 (worst pain imaginable), with neck pain and upper extremity pain assessed separately. The minimal clinically important difference (MCID) was set at 2.2 points. The GROC used a 15-point scale where participants rated their perception of change after treatment from -7 (a very great deal worse) to 0 (about the same) to +7 (a very great deal better), with neck pain and upper extremity pain assessed separately. A change of +4 was used to indicate moderate positive improvement. The NDI included a 10-item questionnaire to measure the impact of neck symptoms on functional activities. Each item was scored from 0-5 for a total score ranging from 0-50 with higher scores indicating higher disability. For patients with cervical radiculopathy a MCID of 8.5 has been shown.

Active cervical ROM (flexion, extension, rotation, and lateral flexion) was assessed using a goniometer with minimal detectable changes ranging from 9.6° to 18.8° for flexion, 7° to 13° for extension, 5.9° to 10° for right lateral flexion, 9.1° to 19° for left lateral flexion, 7.6° to 13.9° for right rotation, and 6.4° to 6.7° for left rotation (2). The deep neck flexor muscle endurance test was performed as described by Harris et al (5) and used their MCID of 16.2 seconds for patients with neck pain (5). Distribution of tingling, numbness, and other symptoms associated with cervical radiculopathy was assessed before and after treatment. Patients were educated about their symptoms and symptom centralization using a body diagram and written instructions and asked to confirm their understanding. Centralization was recorded as either “yes” or “no”.

Study Strengths / Weaknesses:

Strengths:
  • Use of the Wainer and Gill (7) criteria for a diagnosis of cervical radiculopathy has shown a specificity of 0.94 and a positive likelihood ratio of 6.1 – so it is likely all participants had true cervical radiculopathy.
Weaknesses:
  • The significantly higher percentage of participants who believed they had received active treatment in the manipulation group may indicate that the blinding procedure was not as successful as hoped.
  • The use of a very short-term follow-up is not ideal, as there is some speculation on the clinical significance of immediate treatment effects (an with many studies, it would be nicer to have longer-term follow-ups).
  • The sham manipulation procedure used may not have been an adequate control, as evidenced by the greater proportion of patients in the manipulation group who believed they were receiving the active treatment. This may have influenced the between group outcomes due to differing patient expectations (1).

Additional References:

  1. Bishop MD, Mintken P, Bialosky JE, et al. Factors shaping expectations for complete relief from symptoms during rehabilitation for patients with spine pain. Physiother Theory Pract 2019; 35: 70-79.
  2. Cleland JA, Childs JD, Fritz JM, et al. Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil 2006; 87: 1388-1395.
  3. 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.
  4. Cross KM, Kuenze C, Grindstaff TL, et al. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review. J Orthop Sports Phys Ther 2011; 41: 633-642.
  5. Harris KD, Heer DM, Roy TC, et al. Reliability of a measurement of neck flexor muscle endurance. Phys Ther 2005; 85: 1349-1355.
  6. Radhakrishnan K, Litchy WJ, O’Fallon WM, et al. Epidemiology of cervical radiculopathy. A population-based study from Rochester. Minnesota 1976 through 1990. Brain 1994; 117 pt 2: 325-335.
  7. Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther 2000; 30: 728-744.