Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Subject Index

Abstract

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.     

Resolution of whiplash-associated allodynia following cervicothoracic thrust and non-thrust manipulation

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.     

Resolution of whiplash-associated allodynia following cervicothoracic thrust and non-thrust manipulation

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.     

The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.KEYWORDS: Manipulation, Manual Therapy, Shoulder Pain, Thoracic SpineRegional interdependence, as described by Wainner and col-leagues^1,2, “refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient''s primary complaint”. This model suggests that many musculoskeletal disorders may respond more favorably to a regional examination and treatment approach that, in addition to localized treatment, encourages physical therapists to examine and treat distant dysfunctions that may be influencing the patient''s symptoms. Although the specific mechanism (whether neurophysiologic, biomechanical, or other) has yet to be elucidated, several high-quality clinical trials have demonstrated the effective use of this regional examination and treatment approach in achieving positive functional outcomes for patients with a variety of musculoskeletal disorders^3–10.Three of these studies^3–5 have investigated the effects of including cervicothoracic spine and rib manual physical therapy into an overall treatment approach for patients with shoulder pain. Winters et al⁵ found that manipulative therapy applied throughout the shoulder girdle was more effective than physiotherapy in reducing the duration of shoulder pain in a subgroup of 58 patients whose shoulder pain was attributed to dysfunctions within the cervical spine, upper thoracic spine, or upper ribs. Bang and Deyle³ reported improved outcomes in strength, function, and pain when manual physical therapy techniques for the shoulder, cervical spine, and thoracic spine were added to an exercise program for patients with shoulder impingement syndrome. In a more recent clinical trial, Bergman et al⁴ assessed the added benefit of applying cervicothoracic and rib manipulations and mobilizations to a standardized treatment regimen of anti-inflammatory and analgesic medications, corticosteroid injections, and physical therapy (exercises, massage, and modalities) for patients with shoulder pain and dysfunction. The addition of manipulative therapy to this usual medical care resulted in significant improvements in short- and long-term recovery rates and symptom severity for these subjects.Although the overall treatment effect of manual physical therapy has been demonstrated in these studies, the relative contribution of specific manipulative techniques applied to the cervical spine, thoracic spine, and/or ribs towards the improvement in functional outcomes for patients with shoulder pain cannot be determined. The purpose of this preliminary study is to report the immediate effects of thoracic and rib manipulation on subjects with primary complaints of shoulder pain. Exploratory studies of this nature are needed to help define the potential interdependence between anatomic regions such as the thoracic spine, upper ribs, and shoulder.     

Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial

Mechanical neck pain is a common occurrence in the general population resulting in a considerable economic burden. Often physical therapists will incorporate manual therapies directed at the cervical spine including joint mobilization and manipulation into the management of patients with cervical pain. Although the effectiveness of mobilization and manipulation of the cervical spine has been well documented, the small inherent risks associated with these techniques has led clinicians to frequently utilize manipulation directed at the thoracic spine in this patient population. It is hypothesized that thoracic spine manipulation may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the magnitude of risk associated with the cervical technique. The purpose of this randomized clinical trial was to investigate the immediate effects of thoracic spine manipulation on perceived pain levels in patients presenting with neck pain. The results suggest that thoracic spine manipulation results in immediate analgesic effects in patients with mechanical neck pain. Further studies are needed to determine the effects of thoracic spine manipulation in patients with neck pain on long-term outcomes including function and disability.     

Effect of sternoclavicular joint mobilization on pain and function in a patient with massive supraspinatus tear

Massive irreparable rotator cuff tears can be difficult to treat conservatively, especially when the patient has multiple comorbidities. Although there is evidence to support interventions aimed at the spine, there is paucity in the literature describing interventions to the sternoclavicular joint (SCJ) in individuals with rotator cuff pathology. A 57-year-old female with multiple comorbidities and a body mass index of 59 was referred to physical therapy with a 4-month history of right shoulder pain, significant functional limitations, and magnetic resonance imaging (MRI), demonstrating a full-thickness supraspinatus tear. She presented initially with active shoulder flexion range of motion (ROM) 0–80°, numeric pain rating scale (NPRS) 7/10, and QuickDASH 65.9%. After six physical therapy sessions, the patient had plateaued with improvements in pain and ROM. SCJ mobilizations at visit 7 immediately improved pain, active ROM, and subjective reports of function. The patient was discharged after 13 visits with increased active shoulder flexion ROM to 0–170°, NPRS 1/10, QuickDASH 31.8%, and Global Rating of Change (GROC) +5. This case highlights the successful conservative treatment of an individual with an irreparable rotator cuff tear and numerous comorbidities by using a multimodal approach including SCJ mobilizations.     

Regional interdependence and manual therapy directed at the thoracic spine

Abstract

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.     

Short-term effect of myofascial trigger point dry-needling in patients with Adhesive Capsulitis

BackgroundAdhesive Capsulitis (AC) is a common disabling musculoskeletal pain condition of unknown etiology related to the shoulder joint. Literature reported the restricted range of motion (ROM) and pain could be the result of myofascial trigger points (MTrPs) in the muscles of the shoulder girdle. Hence, the objective of this study was to assess the short-term effectiveness of MTrP dry needling (DN) in improving ROM, pain, pressure pain threshold (PPT), and physical disability among patients having AC.MethodsIn a single group pre-post experimental study design, a total of 70 clinically diagnosed patients (both male & female, age group between 40 and 65 years) with AC were recruited from three multi-specialty hospitals. The informed consent forms were received from each patient before participating in the study. Each patient received DN for the MTrPs of shoulder girdle muscles for alternative six days. In addition to DN, each patient had received conventional physiotherapy for continuous twelve days which includes electrotherapy modalities and exercises. The pain intensity (visual analog scale), shoulder ROM (Goniometer), disability (shoulder pain and disability index) and PPT (Algometer) were the outcome measures assessed at the baseline and twelfth day of the intervention.ResultsThere was a statistically significant (p < 0.05) improvement in shoulder ROM, pain intensity, shoulder disability, and PPT at the end of the twelve days of intervention as compared to baseline assessment.ConclusionMTrPs-DN techniques may improve the pain, ROM, disability and PPT along with conventional physiotherapy management among patients with AC.     

Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: a randomized controlled trial

Hsieh L-F, Hsu W-C, Lin Y-J, Chang H-L, Chen C-C, Huang V. Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: a randomized controlled trial.ObjectiveTo compare the efficacy of intra-articular hyaluronic acid (HA) injections plus physical therapy (PT) with that of PT alone for the treatment of adhesive capsulitis (AC) of the shoulder.DesignProspective, randomized controlled trial.SettingRehabilitation and orthopedics department of a private teaching hospital.ParticipantsPatients (N=70) with AC of the shoulder were randomly placed into either of the following treatment groups: group 1, HA injections with PT (HAPT group); or group 2, PT alone (PT group).InterventionsThe patients in group 1 received intra-articular glenohumeral joint injections of HA, 20mg, once per week for 3 consecutive weeks and also participated in a PT program for 3 months. The patients in group 2 received PT alone.Main Outcome MeasuresActive and passive range of motion (ROM) of the affected shoulder, pain, disability, and quality of life.ResultsBoth groups experienced improvements in terms of pain, disability, and quality of life after the treatments; furthermore, the active and passive ROM improved linearly with increasing treatment duration. When the groups were compared, no significant group effect was found for any of the outcome measurements.ConclusionsIntra-articular HA injections did not produce added benefits for patients with AC of the shoulder who were already receiving PT. Thus, the use of intra-articular HA injections for patients with AC of the shoulder should be carefully assessed to reduce unnecessary medical expenditures.     

The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders

There is little known about the specific manual therapy techniques used to treat painfully limited shoulders and their effects on range of movement (ROM) and pressure pain threshold (PPT). The objective of this study was to investigate the initial effects of a Mulligan's mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and PPT in participants with anterior shoulder pain. A repeated measures, double-blind randomized-controlled trial with a crossover design was conducted with 24 subjects (11 males and 13 females). ROM and PPT were measured before and after the application of MWM, sham and control conditions. Significant and clinically meaningful improvements in both ROM (15.3%, F (2,46)=16.31 P=0.00) and PPT (20.2%, F(2,46)=3.44, P=0.04) occurred immediately after post treatment. The results indicate that this specific manual therapy treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement. Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.     

Physical Therapy (92)

J eanine Yip Menck, Susan Mais Requejo, Kornelia Kulig: Thoracic spine dysfunction in upper extremity complex regional pain syndrome type 1. (University of Southern California, Los Angeles, CA) J Orthop Sports Phys Ther 2000;30:401–409. The objective of this case study was to demonstrate the importance of assessment and treatment of the thoracic spine in the management of a patient with signs and symptoms of upper extremity complex regional pain syndrome type I. The patient was a 38‐year‐old woman who suffered a traumatic injury to her left hand. Five months after the injury, she presented with severe pain, immobility of the left arm, and associated dystrophic changes. She was unable to work and needed help in some activities of daily living. The patient was treated for 3 months in 36 visits. Initial treatment consisted of cutaneous desensitization, edema management, and gentle therapeutic exercises. However, further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. Joint manipulation of the T3 and T4 segments was implemented. The patient's status was monitored. Immediately after the vertebral manipulation, there was significant increase in the left hand's skin temperature and a decrease in hyperhydrosis as measured by palpation. Shoulder range of motion increased from 135º to 175° and the patient reported reduced pain. The decrease in the patient's dystrophic and allodynic symptoms permitted further progress in functional reeducation. The patient was discharged with full return to independence and initiation of a vocational training program. Conclude that the assessment and treatment of the thoracic spine should be considered in patients with upper extremity complex regional pain syndrome type I. Comment by Karen Crawford, RPT. This is a study demonstrating the importance of assessment of the thoracic spine to manage patients with signs and symptoms of upper extremity complex regional pain syndrome type I (CRPS‐I). The patient was a 38‐year‐old female with traumatic injury to the left hand. The purpose of this study is to determine the relation between distal symptoms of CRPS‐I and the thoracic spine and to describe the use of thoracic spine manipulation in the management of patients with CRPS‐I in the upper extremity. CRPS‐I in the upper extremity often exhibits postural deviations associated with protective positioning of the arm. It emanates as trunk motion during upper activities and may present with decreased thoracic intervertebral mobility. This study believes that the evaluation and treatment in areas proximal to a patient's symptoms in CRPS‐I may be necessary. Hypomobility secondary to abnormal posturing and anatomical proximity of the sympathetic ganglions to the thoracic spine may contribute to the link between upper quadrant CRPS‐I and thoracic joint dysfunction. In the study, a 38‐year‐old, left‐hand dominant, female who sustained trauma to her left wrist and hand while at work was seen in physical therapy for a total of 36 visits. Initial treatment consisted of desensitization, edema management, and general therapeutic exercises. Further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. At that time, joint manipulation of T3 and T4 segments was implemented. The patient's status was monitored and range of motion, strength, temperature, and skin moisture were measured. The patient reported minimal changes in her status, and 1 month into treatments, she hit her left hand on a door and consequently discontinued therapy because of increased pain. Five months after the initial injury, patient was reevaluated. She then received physical therapy 3 times per week for 12 weeks and was discharged with significant improved functional status. At the initial examination, the diagnosis of CRPS‐I was based on the IASP Committee on Taxonomy. The initial treatment objective was pain management and edema control. The long‐term goal was return to a functional status. Initial treatment consisted of gentle active and passive wrist and finger range of motion and tubagrip for edema management. A home program desensitization was implemented. The patient's active participation in therapy was limited secondary to her willingness to move her left arm. Treatment 2 included evaluation and manipulation of the upper thoracic spine. Her clinician used her manipulating hand as a fulcrum by placing it under the supine patient at the level of thoracic joint dysfunction. A thrust was delivered through the patient's folded arms as she exhaled and there as an audible click. There was an immediate normalization of skin temperature, color, as well as significantly decreased allodynic response to light touch along the left arm and the left upper thoracic vertebral column. Segmental thoracic mobility was immediately improved and there was immediate increase in shoulder flexion after this treatment. This reduction of signs and symptoms of CRPS‐I made it possible to proceed with functional rehabilitation. Manipulation of the thoracic spine may have resulted in improvements in distal upper extremity pain, skin color, and temperature in a patient with CRPS‐I. One explanation is that disuse of the arm and abnormal posturing may contribute to thoracic hypomobility. The anatomic proximity of the sympathetic chain to the dysfunctional thoracic joints may predispose the ganglions to mechanical pressure. Therefore, it is concluded that the evaluation and treatment of areas proximal to the patient's symptoms are necessary. It is difficult to identify the mechanism responsible for changing distal symptoms after thoracic manipulation. The immediate increase in shoulder flexion after manipulation is likely due to mechanical change in the tissue. In conclusion, this study describes a link between the thoracic spine and distal symptoms in patients with CRPS‐I. Thoracic joint manipulation appeared to improve spinal mobility, and also appeared to relieve distal and autonomic symptoms. These improvements allowed for functional rehabilitation of the effected arm. Therefore, it is the opinion of the study that the mobility of the thoracic spine should be evaluated for patients with autonomic dysfunction diagnosed with CRPS‐I. The research also indicates a need for further research to define the relationship between neurogenic symptoms and musculoskeletal pathology.     

悬吊运动疗法结合手法治疗肩关节周围炎的疗效

目的观察悬吊运动疗法（SET）结合手法治疗肩关节周围炎的疗效。方法将2009-04—2011-04于本院就诊的60例肩关节周围炎患者随机分成两组,观察组和对照组各30例。观察组采用SET技术结合手法治疗,对照组采用手法治疗结合磁振热治疗,疗程4周,治疗前后进行VAS评分,ROM测量评分。结果观察组经治疗后,肩部活动度（屈、伸、外展、内旋、外旋）改善程度明显好于对照组,两组疗效比较差异有统计学意义。结论 SET对肩关节周围炎有着较好的治疗效果,能够明显缓解疼痛症状,具有确切的治疗作用。     

Immediate effects of thoracic spine self-mobilization in patients with mechanical neck pain: A randomized controlled trial

ObjectivesTo investigate the immediate effects of thoracic spine self-mobilization in patients with mechanical neck pain.Study designRandomized, controlled trial.BackgroundThoracic spine self-mobilization is performed after thoracic spine thrust manipulation to augment and maintain its effects. To the best of our knowledge, no study has investigated the effects of thoracic spine self-mobilization alone in individuals with mechanical neck pain. The purpose of this randomized, controlled trial was to evaluate the immediate effects of thoracic spine self-mobilization alone without any other intervention on disability, pain, and cervical range of motion in patients with mechanical neck pain.MethodsFifty-two patients (39 females and 13 males) with mechanical neck pain were randomly allocated to either a thoracic spine self-mobilization group that was performing a thoracic spine active flexion and extension activity using two tennis balls fixed by athletic tape or a placebo thoracic spine self-mobilization group. Outcome measures were collected at pre-intervention and immediately after intervention, including the Neck Disability Index, visual analogue scale, and active cervical range of motion (ROM). The immediate effect of the intervention was analyzed using two-way repeated measures analysis of variance (ANOVA). If interactions were found, a simple main effect test was performed to compare the pre-post intra-group results.ResultsThe results of two-way repeated measures ANOVA indicated that the main effect of time was significant (p < 0.05) for all measurement outcomes. The main effect of group was not significant for all measurement outcomes (p > 0.05). The group × time interactions for cervical flexion active ROM (p = 0.005) and cervical extension active ROM (p = 0.036) were significant. The tests of simple main effect in cervical flexion active ROM (p < 0.0001) and cervical extension active ROM (p < 0.0001) showed a significant difference before and after intervention in the thoracic spine self-mobilization group.ConclusionPatients with mechanical neck pain who carried out thoracic spine self-mobilization showed increases in active cervical flexion and extension ROM.     

Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain?

Physiotherapists often use within-session changes to provide a guide for refining treatment application. This study tested the validity of within-session changes as predictors of between-session changes for patients with neck pain receiving manual therapy treatment. A total of 70 pairs of treatments from 29 patients with sub-acute non-specific neck pain receiving manual therapy were assessed to determine the relationship between within-session and between-session changes in range of motion (ROM), pain intensity, and centralisation. Measurements were taken of ROM of the more limited direction on each axis of flexion, extension, lateral-flexion and rotation, and pain (intensity and location) before and after treatment. The same measurements were repeated before the following treatment. Regression analysis demonstrated that within-session change accounted for 26% to 48% of the variability in between-session change for ROM and six per cent for pain intensity. The proportion of the within-session change for ROM maintained between sessions ranged from 42% to 63% (95% CI 25% to 88%). The odds ratios for within-session improved/not improved categorisation to predict between-session category for ROM ranged from 2.5 (95% CI 0.6 to 4.3) to 21.3 (95% CI 10.1 to 96.1), for pain intensity 4.5 (95% CI 1.2 to 14.4) and for pain centralisation 9.2 (95% CI 2.2 to 38.7) indicating greater likelihood of between-session improvement after within-session improvement. The between-session results for most patients (71% to 83%) could be classified correctly by their within-session category. The results support the use of within-session changes in ROM, centralisation, and possibly pain intensity as predictors of between-session changes for musculoskeletal disorders of the cervical spine.