Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation

[Purpose] The purpose of this study was to conduct cervical stability training and upper thoracic manipulation for patients with chronic neck pain and then investigate the changes of cervical proprioception and pain. [Subjects and Methods] Subjects were 30 workers with mechanical neck pain, who were randomly divided into an upper thoracic manipulation group and a cervical stability training group. Upper thoracic manipulation after cervical stability training was conducted for the upper thoracic manipulation group, and only stability training was conducted for the cervical stability training group. The intervention period was six weeks, and consisted of three sessions a week, each of which lasted for 30 minutes. For proprioception measurement, an electro-goniometer was used to measure reposition sense before and after the intervention. The visual analogue scale was used to assess pain. [Results] After the intervention, the error angle was significantly smaller in flexion and right left side-bending, and pain was significantly reduced in the upper thoracic manipulation group. According to the post intervention comparison of the two groups, there were significant differences in the proprioception and pain values. [Conclusion] Conducting both cervical stability training and upper thoracic manipulation for patients with chronic neck pain was more helpful for the improvement of proprioception and pain than cervical stability training alone.     

A comparison of two non-thrust mobilization techniques applied to the C7 segment in patients with restricted and painful cervical rotation

Objectives:

Cervical mobilization and manipulation have been shown to improve cervical range of motion and pain. Rotatory thrust manipulation applied to the lower cervical segments is associated with controversy and the potential for eliciting adverse reactions (AR). The purpose of this clinical trial was to describe two translatory non-thrust mobilization techniques and evaluate their effect on cervical pain, motion restriction, and whether any adverse effects were reported when applied to the C7 segment.

Methods:

This trial included 30 participants with painful and restricted cervical rotation. Participants were randomly assigned to receive one of the two mobilization techniques. Active cervical rotation and pain intensity measurements were recorded pre- and post-intervention. Within group comparisons were determined using the Wilcoxon signed-rank test and between group comparisons were analyzed using the Mann–Whitney U test. Significance was set at P = 0.05.

Results:

Thirty participants were evaluated immediately after one of the two mobilization techniques was applied. There was a statistically significant difference (improvement) for active cervical rotation after application of the C7 facet distraction technique for both right (P = 0.022) and left (P = 0.022) rotation. Statistically significant improvement was also found for the C7 facet gliding technique for both right (P = 0.022) and left rotation (P = 0.020). Pain reduction was statistically significant for both right and left rotation after application of both techniques. Both mobilization techniques produced similar positive effects and one was not statistically superior to the other.

Discussion:

A single application of both C7 mobilization techniques improved active cervical rotation, reduced perceived pain, and did not produce any AR in 30 patients with neck pain and movement limitation. These two non-thrust techniques may offer clinicians an additional safe and effective manual intervention for patients with limited and painful cervical rotation. A more robust experimental design is recommended to further examine these and similar cervical translatory mobilization techniques.     

Lumbopelvic manipulation in patients with patellofemoral pain syndrome

Objectives:

A recent clinical prediction rule (CPR) identified characteristics that may predict an immediate reduction in pain following lumbopelvic manipulation in patients with patellofemoral pain syndrome. The purpose of this single-arm cohort study was to replicate the proposed CPR in a different population and investigate changes in self-reported pain, hip range of motion, strength, and function immediately following lumbopelvic manipulation.

Methods:

Forty-four subjects (63·6% female; mean age 27·4 years) met inclusion criteria. Hip internal rotation range of motion, lower extremity strength using a handheld dynamometer, and single/triple hop tests were assessed prior to and immediately following a spinal manipulation. A global rating of change questionnaire was administered after testing and telephonically at 1 week. Paired t-tests compared pre- and post-manipulation range of motion, strength, and hop test limb symmetry indices (α = 0·05).

Results:

Fifty-seven percent of subjects had a successful outcome measured by the numerical pain rating scale immediately following manipulation. Twenty-five of subjects experienced a successful outcome as measured by the global rating of change questionnaire at 1 week. No single individual or combination of predictor variables predicted a positive outcome immediately following the lumbopelvic manipulation (+likelihood ratio 0·7 with three of five predictor variables present). Statistically significant differences (P<0·05) were found in hip extension and abduction strength and hip internal rotation symmetry post-manipulation, but do not appear to be clinically meaningful.

Discussion:

The previously identified CPR was not able to be replicated and no clinically meaningful changes in range of motion, strength, or function were apparent. Future research should focus on a comprehensive impairment-based treatment approach in patients with patellofemoral pain syndrome.     

Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial

Thoracic spine manipulation has been shown to be effective for the management of neck pain. The purpose of this study was to investigate the immediate effect of a T3–T4 spinal thrust manipulation on autonomic nervous system activity in subjects with chronic cervical pain. An additional aim was to determine if the manipulation resulted in an immediate pain relief in patients with chronic neck pain when compared to a placebo intervention. One hundred subjects with chronic neck pain were randomly assigned to receive either a thoracic thrust manipulation or a placebo intervention. The Friedman’s test was used to evaluate the change in pupil diameter within both groups. The Wilcoxen signed-ranks test was used to explore pupil changes over time and to make paired comparisons of the pupil change between the groups. The Mann–Whitney U test was used to compare the change in pain perception for the chronic cervical pain group subjects receiving either the thrust manipulation or the placebo intervention. The results demonstrated that manipulation did not result in a change in sympathetic activity. Additionally, there was no significant difference in the subject’s pain perception (P = 0.961) when comparing the effects of the thrust manipulation to the placebo intervention within this group of subjects with chronic neck pain. The clinical impression of this study is that manipulation of the thoracic spine may not be effective in immediately reducing pain in patients with chronic neck pain.     

Ultrasound analysis of the vertebral artery during non-thrust cervical translatoric spinal manipulation

Objective

Cervical translatoric spinal manipulation (TSM) techniques have been suggested as a safer alternative to cervical thrust rotatory techniques. The objective of this study was to determine the effect of three C5–C6 non-thrust TSM techniques on vertebral artery (VA) lumen diameter (LD) and two blood flow velocity parameters. The two-tailed research hypothesis was that the TSM techniques would result in a significant change (increase or decrease) in blood flow velocity and arterial LD at the C5–C6 intertransverse portion of the VA.

Methods

In a sample of 30 subjects representative of a clinical population, color-coded duplex Doppler diagnostic ultrasound imaging was used to collect data on LD, peak systolic velocity (PSV), and end diastolic velocity with the cervical spine positioned in neutral and in three different manipulation positions. Pair-wise mean differences between measurements at baseline (neutral position) and in all three manipulation positions were analyzed using two-tailed paired t-tests with alpha set at 0·05.

Results

Of the 18 paired comparisons, there were four statistically significant differences between measurements in the neutral position and a manipulation position, three concerning LD and one PSV.

Discussion

The three significant differences in LD ranged from 4·6 to 3·2% and were not associated with changes in blood flow velocity. The one significant change in PSV was only 6·6 cm/s. A value that still greatly exceeded the end diastolic velocity. No subject experienced symptoms associated with VA compromise. This study has provided evidence for the safety of the three lower cervical non-thrust TSM techniques on the current population studied. Further study is required on thrust versus non-thrust TSM techniques and on levels other than C5–C6.     

Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases

Objective

This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxial osteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy.

Clinical Features

A retrospective case review of 10 patients who were diagnosed with either degenerative or posttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographic presentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedic services. All 10 patients selected for this series were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatment period. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physical examination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to a mean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment was improved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinical improvement was described as “good” or “excellent” in about 80% of patients. Clinical improvements in pain and range of motion were seen in 80% and 90% of patients, respectively.

Conclusion

Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.     

3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients

Objective

The purpose of this study was to investigate the influence of thoracic high-velocity low-amplitude thrust (HVLAT) manipulation on quantitative and qualitative 3-dimensional cervical spine kinematic patterns in a subgroup of patients with acute neck pain.

Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial

Objectives

The purpose of this study was to compare the effects of a cervical vs thoracic spine manipulation on pressure pain threshold (PPT) and pain-free grip strength in patients with lateral epicondylalgia (LE).

Methods

A single-blind randomized clinical trial was completed with 18 participants with LE. Each subject attended 1 experimental session. Participants were randomized to receive either a cervical or thoracic spine manipulation. Pressure pain threshold over the lateral epicondyle of both elbows pain-free grip strength on the affected arm and maximum grip force on the unaffected side were assessed preintervention and 5 minutes postintervention by an examiner blind to group assignment. A 3-way analysis of variance with time and side as within-subject variable and intervention as between-subject variable was used to evaluate changes in PPT and pain-free grip.

Results

The analysis of variance detected a significant interaction between group and time (F = 31.7, P < .000) for PPT levels. Post hoc testing revealed that the cervical spine manipulation produced a greater increase of PPT in both sides compared with thoracic spine manipulation (P < .001). For pain-free grip strength, no interaction between group and time (F = .66, P = .42) existed.

Conclusions

Cervical spine manipulation produced greater changes in PPT than thoracic spine manipulation in patients with LE. No differences between groups were identified for pain-free grip. Future studies with larger sample sizes are required to further examine the effects of manipulation on mechanisms of pain and motor control in upper extremity conditions.     

Inclusion of thoracic spine thrust manipulation into an electro-therapy/thermal program for the management of patients with acute mechanical neck pain: a randomized clinical trial

Our aim was to examine the effects of a seated thoracic spine distraction thrust manipulation included in an electrotherapy/thermal program on pain, disability, and cervical range of motion in patients with acute neck pain. This randomized controlled trial included 45 patients (20 males, 25 females) between 23 and 44 years of age presenting with acute neck pain. Patients were randomly divided into 2 groups: an experimental group which received a thoracic manipulation, and a control group which did not receive the manipulative procedure. Both groups received an electrotherapy program consisting of 6 sessions of TENS (frequency 100Hz; 20min), superficial thermo-therapy (15min) and soft tissue massage. The experimental group also received a thoracic manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain (numerical pain rate scale; NPRS), level of disability (Northwick Park Neck Pain Questionnaire; NPQ) and neck mobility. These outcomes were assessed at baseline and 1 week after discharge. A 2-way repeated-measures ANOVA with group as between-subject variable and time as within-subject variable was used. Patients receiving thoracic manipulation experienced greater reductions in both neck pain, with between-group difference of 2.3 (95% CI 2-2.7) points on a 11-NPRS, and perceived disability with between-group differences 8.5 (95% CI 7.2-9.8) points. Further, patients receiving thoracic manipulation experienced greater increases in all cervical motions with between-group differences of 10.6 degrees (95% CI 8.8-12.5 degrees) for flexion; 9.9 degrees (95% CI 8.1-11.7 degrees) for extension; 9.5 degrees (95% CI 7.6-11.4 degrees) for right lateral-flexion; 8 degrees (95% CI 6.2-9.8 degrees) for left lateral-flexion; 9.6 degrees (95% CI 7.7-11.6 degrees) for right rotation; and 8.4 degrees (95% CI 6.5-10.3 degrees) for left rotation. We found that the inclusion of a thoracic manipulation into an electrotherapy/thermal program was effective in reducing neck pain and disability, and in increasing active cervical mobility in patients with acute neck pain.     

A preliminary study comparing the use of cervical/upper thoracic mobilization and manipulation for individuals with mechanical neck pain

Objectives:Neck pain is routinely managed using manual therapy (MT) to the cervical and thoracic spines. While both mobilizations and manipulations to these areas have been shown to reduce neck pain, increase cervical range of motion, and reduce disability, the most effective option remains elusive. The purpose of this preliminary trial was to compare the pragmatic use of cervical and thoracic mobilizations vs. manipulation for mechanical neck pain.Methods:This trial included 20 patients with mechanical neck pain. Each patient was randomized to receive either mobilization or manipulation to both the cervical and thoracic spines during their plan of care. Within-group analyses were made with Wilcoxon signed-rank tests and between-group analyses were made with Mann–Whitney U.Results:There were no between-group differences for any of the dependent variables including cervical active range of motion (CAROM) (P = 0.18), deep cervical flexion (DCF) endurance (P = 0.06), numerical pain rating scale (NPRS) (P = 0.26), the neck disability index (NDI, P = 0.33), patient-specific functional scale (PSFS, P = 0.20), or the global rating of change (GROC) scale (P = 0.94). Within-group results were significant for all outcome variables (P<0.001) from initial evaluation to discharge for both groups.Discussion:These findings were consistent with other trials previously conducted that applied the MT techniques in a pragmatic fashion, but varied from previous trials where the treatment was standardized. A larger experimental study is necessary to further examine the differences between mobilization and manipulation for neck pain.     

Global and regional kinematics of the cervical spine during upper cervical spine manipulation: A reliability analysis of 3D motion data

Studies reporting spine kinematics during cervical manipulation are usually related to continuous global head–trunk motion or discrete angular displacements for pre-positioning. To date, segmental data analyzing continuous kinematics of cervical manipulation is lacking. The objective of this study was to investigate upper cervical spine (UCS) manipulation in vitro. This paper reports an inter- and intra-rater reliability analysis of kinematics during high velocity low amplitude manipulation of the UCS. Integration of kinematics into specific-subject 3D models has been processed as well for providing anatomical motion representation during thrust manipulation.Three unembalmed specimens were included in the study. Restricted dissection was realized to attach technical clusters to each bone of interest (skull, C₁–C₄ and sternum). During manipulation, bone motion data was computed using an optoelectronic system. The reliability of manipulation kinematics was assessed for three experimented practitioners performing two trials of 3 repetitions on two separate days.During UCS manipulation, average global head–trunk motion ROM (±SD) were 14 ± 5°, 35 ± 7° and 14 ± 8° for lateral bending, axial rotation and flexion-extension, respectively. For regional ROM (C₀–C₂), amplitudes were 10 ± 5°, 30 ± 5° and 16 ± 4° for the same respective motions. Concerning the reliability, mean RMS ranged from 1° to 4° and from 3° to 6° for intra- and inter-rater comparisons, respectively.The present results confirm the limited angular displacement during manipulation either for global head–trunk or for UCS motion components, especially for axial rotation. Additionally, kinematics variability was low confirming intra- and inter-practitioners consistency of UCS manipulation achievement.     

The Effects of Thoracic Manipulation Versus Mobilization for Chronic Neck Pain: a Randomized Controlled Trial Pilot Study

[Purpose] To investigate effects of thoracic manipulation versus mobilization on chronic neck pain. [Methods] Thirty-nine chronic neck pain subjects were randomly assigned to single level thoracic manipulation, single level thoracic mobilization, or a control group. The cervical range of motion (CROM) and pain ratings (using a visual analog scale: VAS) were measured before, immediately after and at a 24-hour follow-up. [Results] Thoracic manipulation significantly decreased VAS pain ratings and increased CROM in all directions in immediate and 24-hour follow-ups. The thoracic mobilization group significantly increased in CROM in most directions at immediate follow-up and right and left rotational directions at the 24-hour follow-up. Comparisons between groups revealed the CROM for the manipulation group to increase significantly more than for control subjects in most directions at immediate follow-up and flexion, left lateral flexion and left rotation at the 24-hour follow-up. The CROM for the thoracic mobilization group significantly increased in comparison to the control group in flexion at immediate follow-up and in flexion and left rotation at the 24-hour follow-up. [Conclusion] The study demonstrated reductions in VAS pain ratings and increases in CROM at immediate and 24-hour follow-ups from both single level thoracic spine manipulation and thoracic mobilization in chronic neck pain.Key words: Single level thoracic manipulation, Single level thoracic mobilization, Chronic neck pain     

Immediate Effects of Thoracic Spinal Manipulation on Pulmonary Function in Stroke Patients: A Preliminary Study

Objectives

The purpose of this study was to investigate the immediate effects of thoracic spinal manipulation (TSM) on pulmonary function in stroke patients.

Effectiveness of Scapular Stabilization Versus Non-Stabilization Stretching on Shoulder Range of Motion,a Randomized Clinical Trial

BackgroundPrevious research has demonstrated the benefits of both stabilization and non-stabilization of the scapula during stretching in individuals with posterior shoulder tightness, but limited evidence exists in patients with shoulder pain.Hypothesis/PurposeThe aim of this study was to determine the effect of stabilized scapular stretching on patients with shoulder pain. The primary hypothesis of this study is that stabilized scapular stretching will improve glenohumeral motion and pain compared to non-stabilized stretch program. A secondary hypothesis of this study is that stabilized scapular stretching will produce greater improvement in function compared to the non-stabilized stretching program.Study DesignRandomized Clinical TrialMethodsSixteen patients with sub-acromial pain associated with tendinopathy and associated pathologies presenting to physical therapy were randomized into two groups (stabilized or non-stabilized scapular stretching). Baseline pain and range of motion were measured prior to and following each treatment session for three visits that occurred over the course five to seventeen days depending on the patients availability. The dependent measurements were stabilized horizontal adduction, stabilized internal rotation, stabilized shoulder flexion, non-stabilized shoulder flexion, and current pain level.ResultsPatients in the scapular stabilization stretching group increased horizontal adduction 40° (CI₉₅ 31, 48°) compared to the non-stabilization stretching group increase of 8° (CI₉₅ 0, 17°) over the course of the three treatments (p<0.001). Similarly, the stabilized stretching group increased internal rotation 48° (CI₉₅ 26, 69°) compared to the non-stabilized stretching group increase of 26° (CI₉₅ 4, 48°) (p=0.001). Pain decreased in the stabilized stretching group by 1.4 points (CI₉₅ -0.4, 3.2) but increased slightly in non-stabilized group by -0.5 points (CI₉₅ -2.3, 1.3) which was not a clinically meaningful change. (p=0.03)ConclusionStabilized scapular stretching was more effective than non-stabilized stretching at gaining shoulder mobility in patients with shoulder pain. Benefits were immediate and sustained between treatment sessions. Stretching interventions improved range of motion but had limited effect on shoulder pain.Level of Evidence2     

Effect of adding stretching to standardized procedures on cervical range of motion,pain, and disability in patients with non-specific mechanical neck pain: A randomized clinical trial

Objectiveto investigate the benefit of adding stretching exercises to cervical joint mobilization and active rotation exercises for patients with non-specific mechanical neck pain.MethodsThirty-eight subjects with non-specific mechanical neck pain were randomly assigned to a standard procedure group (passive cervical mobilization and active cervical rotation range of motion exercise) or a combined procedure (passive cervical mobilization, active cervical rotation range of motion exercises, and stretching procedures). Mixed factorial analysis of variance was used to compare changes between groups over time in active cervical range of motion, Numeric Pain Rating Scale, Neck Disability Index, Global Rating of Change, and Pressure Pain Threshold.ResultsThere was a significant change in mean active range of motion in all directions, Pressure Pain Threshold, perceived pain, disability levels, and global rating of change over time (p < 0.001). There was a significant group by time interaction in mean active range of motion during extension (p = 0.01), right rotation (p = 0.004), right and left lateral flexion (p = 0.05, and p = 0.02 respectively). However, there was no significant group by time interaction in mean active range of motion during flexion, left rotation, pain intensity (p = 0.09), right and left pressure pain threshold (p = 0.30, 0.47, respectively), and disability (p = 0.07).ConclusionsBoth study groups improved significantly in all subjective and objective outcome measures. However, data from this study suggest that adding stretching to the standard procedures may be more effective than the standard procedure alone at improving cervical extension, right rotation, and lateral flexion active range of motion, but not pain and disability.     

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.     

The effect of thoracic spine mobilization and stabilization exercise on the muscular strength and flexibility of the trunk of chronic low back pain patients

[Purpose] To investigate whether thoracic spine mobilization added to stabilization exercises increases the muscular strength and range of motion of the thoracic vertebrae of chronic low-back pain patients. [Subjects] This study enrolled 20 patients with chronic low back pain, who were divided into two groups. Ten subjects were randomly selected for the stabilization exercise group and the remaining 10 subjects received thoracic spine mobilization in addition to performing the stabilization exercises. [Methods] The patients performed stabilization exercises and received thoracic spine mobilization for 12 weeks. The range of motion and isometric muscular strength of the vertebrae of all subjects were measured before and after the intervention. [Results] In the comparison of muscular strength before and after the intervention, the change in muscular strength of the trunk flexors in the stabilization exercise group was 16.0±7.4 Nm, and that of the thoracic spine mobilization group was 34.2±7.6 Nm, a significant difference in each group. In the post-intervention intergroup comparison, the muscular strength of trunk flexors in the stabilization exercise group was 111.1±16.9 Nm, while that of the thoracic spine mobilization group was 125.9±11.3 Nm, a significant difference. Also, the muscular strength of the trunk extensors in the stabilization exercise group was 148.9±31.8 Nm, while that of the thoracic spine mobilization group was 182.9±37.2 Nm, a significant difference. The thoracic spine flexion in the stabilization exercise group was 29.8±9 degrees, while that of the thoracic spine mobilization group was 38.7±6.9 degrees, a significant difference. However, there was no significant difference in lumbar flexion values between the two groups. [Conclusion] Thoracic spine mobilization added to a stabilization exercise increased the muscular strength of patients with chronic low back pain.Key words: Isometric muscle strength, Lumbar stabilization exercise, Thoracic spine mobilization exercise     

Single door laminoplasty plus posterior fusion for posterior atlantoaxial dislocation with congenital malformation: A case report and review of literature

BACKGROUNDPosterior atlantoaxial dislocation (PAD) is a rare type of upper cervical spine disease. We sought to describe a unreported case of old PAD with os odontoideum (OO) and atlas hypoplasia (AH) and our unique treatment approach consisting of C1 single door laminoplasty with C1-3 posterior fixation and fusion.CASE SUMMARYA 70-year-old male patient who suffered from progressive aggravating numbness and limb weakness for 4 years without trauma, was diagnosed with old PAD with OO and AH. The patient underwent closed reduction and C1 single door laminoplasty with C1-3 posterior fixation and fusion instead of C1 laminectomy with occipitocervical fusion. During the 3-year follow-up, he was able to walk by himself instead of using a wheelchair and with a ± 25° range of head rotation as well as a ± 10° range of flexion-extension. Three-year follow-up images showed satisfactory reduction and fusion.CONCLUSIONC1 single door laminoplasty with cervical fusion in PAD combined with spinal cord compression could be a suitable and effective surgical option. Compared with laminectomy and occipitocervical fusion, it retains more cervical range of motion, has a smaller incision and provides an adequate bone grafting space for atlantoaxial fusion.     

The Audible Pop from Thoracic Spine Thrust Manipulation and Its Relation to Short-Term Outcomes in Patients with Neck Pain

Clinicians routinely consider the success of a thrust manipulation technique based on the presence or absence of an audible pop despite the lack of evidence suggesting that this pop is associated with improved outcomes. The purpose of this study was to determine the relationship between the number of audible pops with thoracic spinal manipulation and improvement in pain and function in patients with mechanical neck pain. In this prospective cohort study, 78 patients referred to physical therapy with mechanical neck pain underwent a standardized examination and thoracic spine manipulation treatment protocol. All patients were treated with a total of 6 thrust manipulation techniques directed to the thoracic spine followed by a basic cervical range of motion exercise. The treating clinician recorded the presence or absence of a pop during each manipulation. Outcomes were assessed at a 2–4 day follow-up with an 11-point numeric pain rating (NPRS), the Neck Disability Index, the patient Global Rating of Change (GROC), and measurements of cervical range of motion (CROM). The relationship between the number of pops and change scores for pain, disability, and CROM was first examined using Pearson correlation coefficients. Individuals were then categorized as having received ≤3 or >3 pops. Repeated measures analyses of variance were used to examine whether achievement of >3 pops resulted in improved outcome. Seventy-eight patients with a mean age of 42 (SD 11.3) years participated in the study. Pearson correlation coefficients revealed no significant correlation existed between the number of pops and outcomes with the exception of 3 of the 6 CROM measurements, which were inversely related. There was no significant interaction for group X time for any of the dependent measures (P>0.05). The odds ratio for patients experiencing dramatic improvement was in favor of the group experiencing ≤3 pops but this was not clinically meaningful (1.3: 95% CI 0.46, 3.7). The results of this analysis provide preliminary evidence for the hypothesis that there is no relationship between the number of audible pops during thoracic spine thrust manipulation and clinically meaningful improvements in pain, disability, or CROM in patients with mechanical neck pain. Additionally, a greater number of audible pops experienced was not associated with a dramatic improvement with manipulation treatment.Key Words: Cavitation, Manipulation, Neck Pain, Audible Pop, Thoracic SpineThe prevalence of neck pain is high, with nearly 70% of individuals experiencing neck pain at some point in their life and with 15–22% of individuals continuing to experience symptoms 5 years after onset^1,2. This results in a substantial economic burden as nearly 1/3 of patients who experience a first-time onset of neck pain will report continued healthcare utilization for their neck pain at a 10-year follow-up³. Additionally, nearly 25% of all visits in outpatient physical therapy practice consists of patients with a primary report of neck pain⁴.Physical therapists utilize a number of interventions in the management of neck pain including joint manipulation (non-thrust and thrust), therapeutic exercise, traction, and a variety of modalities⁵. Recently, evidence has begun to emerge for the use of manual therapy, specifically thrust procedures, directed to the thoracic spine in patients with mechanical neck pain^6–9. Clinicians often believe that an audible pop associated with a thrust manipulation is a criterion for determining the success of the technique¹⁰. However, ultimately the success of an intervention should be based on whether it is associated with improvements in patient-centered outcomes¹¹.Recently Flynn, Fritz, et al¹² reported on a series of 71 patients with non-radicular low back pain (LBP) who received lumbopelvic thrust manipulation. Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac region manipulative technique, and the presence or absence of an audible pop was noted. Similar to the operational definition of an audible pop used in this study, the number of actual pops that may have occurred during one thrust manipulation was not recorded but only whether an audible sound was perceived during one particular manipulation. The subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), in pain as measured by the Numeric Pain Rating Scale (NPRS), and in Oswestry (OSW) scores. There were no between-group differences for flexion ROM, NPRS, and OSW scores (P>0.05). The odds ratio (1.2; 95% CI: 0.38–4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms following the manipulation¹². Based on the data, the authors concluded that there was no relationship between an audible pop during sacroiliac region manipulation and improvement in ROM, pain, or disability in individuals with non-radicular low back pain¹².In a follow-up study, Flynn, Childs, et al¹³ examined whether the occurrence of a manipulative pop during lumbopelvic region manipulation was related to the outcome of the intervention over a 4-week period of time rather than the 48-hour follow-up in the earlier study. Seventy patients were randomly assigned to receive thrust manipulation during the first two sessions. Therapists recorded whether the patient or therapist heard either a single or multiple audible pops. Again similar to the operational definition of an audible pop used in this study, the number of actual pops that may have occurred during one thrust manipulation was not recorded. Outcome was assessed with an 11-point NPRS, the OSW, and measurement of lumbopelvic flexion ROM. No differences were detected at baseline or at any follow-up period in the level of pain, the OSW score, or lumbopelvic ROM based on whether a pop was achieved (P>0.05). The odds ratios and 95% confidence intervals for achieving a successful outcome at each of the follow-up periods all approximated a value of 1, suggesting no improvement in the odds of successful outcome among patients in whom an audible pop occurred. The results supported the previous findings that the audible pop was unrelated to changes in patient-centered outcomes for patients with LBP¹³.While previous studies provide evidence that an audible pop accompanying lumbopelvic thrust manipulation is not associated with improved patient-centered outcomes, this has yet to be examined in other spinal regions. Therefore, the purpose of this study was to examine the relationship between the audible pop and patient-centered outcomes in a cohort of patients with neck pain treated with thoracic spine thrust manipulation.