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.     

Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial

BACKGROUND AND PURPOSE: Evidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups. SUBJECTS: The subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain. METHODS: For all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group x time interaction. RESULTS: Sixty patients with a mean age of 43.3 years (SD=12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI]=5.3-14.7), and in pain, with a between-group difference of 2.0 (95% CI=1.4-2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups. DISCUSSION AND CONCLUSION: The results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.     

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.     

Multimodal management of lateral epicondylalgia in rock climbers: a prospective case series

Objective

The purpose of this prospective case series was to describe the outcomes of a set of rock climbers with lateral epicondylalgia (LE) treated with manual therapy directed at the cervical spine, elbow, and wrist as well as trigger point (TrP) dry needling and kinesio tape.

Methods

Nine consecutive rock climbers presenting to physical therapy with a diagnosis of LE were included. At baseline, all patients completed the Patient-Rated Tennis Elbow Evaluation and underwent pain pressure threshold testing over the extensor carpi radialis, extensor carpi brevis, brachioradialis, and supinator muscles at baseline, after the third visit (week 3), and at 2-month follow-up. Treatment included manipulation of the cervical spine, mobilization with movement directed at the elbow, manipulation of the wrist, TrP dry needling, and kinesio tape.

Results

Of the 9 subjects who participated in this study, 3 were women (33%), and the mean duration of symptoms was 3 weeks, with an SD of 1.7 weeks (median, 2 weeks; range, 1-6 weeks). There was an improvement in all outcome measures at both the final visit and 2-month follow-up period.

Conclusions

This group of rock climbers with LE who were conservatively managed with a treatment approach consisting of cervical spine manipulation, mobilization directed at the elbow and wrist, and TrP dry needling as well as kinesio tape exhibited clinical improvement.     

Uneventful upper cervical manipulation in the presence of a damaged vertebral artery

OBJECTIVE: To discuss a case in which a patient with a previously injured vertebral artery underwent manipulation in the upper cervical spine without alteration of her symptom pattern. The literature concerning the relative safety of specific upper cervical manipulative techniques is reviewed. CLINICAL FEATURES: A 42-year-old woman had a 3-week history of unilateral suboccipital pain that she related to a sudden twisting of her head and neck that occurred while she was putting sheets of drywall on top of her car. Subsequent examination by a neurologist 2 weeks later was unremarkable, and a tension-type headache was diagnosed. Approximately 10 days later (3 weeks after injury), a single high-velocity upper-cervical manipulation (incorporating slight rotation and full lateral flexion) was performed with no change in her symptom pattern. Two weeks after that, the patient had development of a lateral medullary syndrome (also known as Wallenberg syndrome) after she briefly extended and rotated her upper cervical spine while painting a ceiling. INTERVENTION AND OUTCOME: The patient was treated with anticoagulant therapy, and the lateral medullary infarct healed without incident. The spinocerebellar and subtle motor symptoms also resolved, but the ipsilateral suboccipital headache and the loss of temperature sensation associated with the spinothalamic tract lesion were still present 9 months later. CONCLUSION: This case report demonstrates that vigorous manipulation of the upper cervical spine is possible without injuring an already damaged vertebral artery. It is suggested that the line of drive used during the single manipulation, almost pure lateral flexion with slight rotation, was responsible for the apparent innocuous response. Guidelines for the evaluation and management of vertebral artery dissection are reviewed. Because it is currently impossible to identify patients at risk of having a dissected vertebral artery with standard in-office examination procedures, rotational manipulation of the upper cervical spine should be abandoned by all practitioners, and schools should remove such techniques from their curriculums.     

Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education

BACKGROUND AND PURPOSE: To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. SUBJECTS: This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. METHODS: Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. RESULTS: Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio=5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. DISCUSSION AND CONCLUSION: The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.     

Chiropractic care of a 47-year-old woman with chronic Bell's palsy: a case study

OBJECTIVE: The purpose of this case study is to describe the effect of chiropractic care on a patient with chronic Bell's palsy. CLINICAL FEATURES: A 47-year-old woman with medically diagnosed Bell's palsy presented for chiropractic care. She had experienced right sinus pressure and congestion, lack of facial tone on the right, and intermittent tingling of the right side of her face. INTERVENTIONS AND OUTCOMES: The patient received high-velocity, low-amplitude chiropractic manipulation (adjustments) to the cervical and thoracic spine, interferential muscle stimulation, and hydroculation on the trapezius muscles bilaterally. Reduction in symptoms occurred following the initial visit and continued over the next 9 weeks of care. After the course of a year of chiropractic care, the patient reached 90% improvement. CONCLUSIONS: For this patient, chiropractic care reduced Bell's palsy symptoms.     

Repeated Applications of Thoracic Spine Thrust Manipulation do not Lead to Tolerance in Patients Presenting with Acute Mechanical Neck Pain: A Secondary Analysis

It has been demonstrated that patients receiving mobilization techniques do not exhibit tolerance to repeated applications. However, this phenomenon has not been investigated for thoracic manipulation. Our aim was to determine if patients receiving thoracic thrust manipulation exhibit tolerance to repeated applications in acute mechanical neck pain. Forty-five patients were randomly assigned to two groups. The control group received electro- and thermotherapy for 5 sessions, and the experimental group received the same program and also received a thoracic thrust manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain and cervical mobility. Within-session change scores for pain and mobility during treatment sessions #1, 3, and 5 were examined with a one-way repeated measured ANOVA. A 2-way ANOVA with session as within-subject variable and group as between-subject variable was used to compare change scores for each visit between groups to ascertain if there were significant between-group differences in within-session changes for the experimental versus the control group. The ANOVA showed that for either group the 3 within-session change scores were not significantly different (P > 0.1). The 2-way ANOVA revealed significant differences between groups for both pain and neck mobility in within-session change scores (all, P < 0.001). Change scores in each session were superior in the experimental group as compared to those in the control group. The results suggest that patients receiving thoracic manipulation do not exhibit tolerance to repeated applications with regard to pain and mobility measures in acute mechanical neck pain. Further studies should investigate the dose-response relationship of thoracic thrust manipulation in this population.KEYWORDS: Neck Pain, Thoracic Thrust Manipulation, ToleranceNeck pain is a significant problem in society. The incidence rate for self-reported neck pain in the general population has been reported to be between 146 and 213 per 1,000 patient years¹. The reported point prevalence of neck pain varies between 9.5–35%^2,3. The 12-month prevalence for neck pain ranges from 30–50%, and the 12-month prevalence of activity-limiting pain is reported to be between 1.7% and 11.5%¹. Nearly half of patients with neck pain will go on to develop chronic symptoms⁴, and many will continue to exhibit moderate disability at long-term follow-up⁵. In the United States, neck pain accounts for almost 1% of all visits to primary care physicians⁶. After lumbar spine-related diagnoses at 19%, cervical spine diagnoses were the second most common reason for referral at 16% in a US study on outpatient physical therapy⁷. Similarly, the economic burden associated with the management of neck pain patients is second only to low back pain in annual workers'' compensation costs in the United States⁸.In the majority of patients with neck pain, no patho-anatomic diagnosis can be provided resulting in a diagnostic label of non-specific or mechanical neck pain for many patients. Childs et al⁹ have proposed a treatment-based classification system to further differentiate among this likely heterogeneous group of patients. In this classification, manual therapy to the cervical and thoracic spine, particularly thrust and non-thrust manipulation, is the main treatment intervention proposed for management of the mobility subgroup. There is growing evidence supporting the use of thoracic thrust manipulation in the management of this subgroup of patients with mechanical neck pain with multiple studies showing noted improvements in pain, range of motion, and function^10–13.However, the design of previous studies^10–13 has varied in that the researchers have used different numbers of manipulations. This makes it difficult for clinicians to determine how many applications of thrust manipulation are likely to maximize patient outcomes. In this context, one issue we need to consider is whether repeated application of thoracic manipulation leads to tolerance. Tolerance is defined here as a decrease in the effect size or magnitude of the intervention over time, as measured within sessions. Tolerance should affect the number of interventions provided. In the context of thoracic manipulation for patients with mechanical neck pain, tolerance to thoracic manipulation would logically decrease the number of manipulations that are applied and that are required for the demonstrated positive study outcomes.Paungmali et al¹⁴ studied tolerance to repeated applications of a manual non-thrust technique directed at the elbow region. They showed that the technique had a hypoalgesic effect measured as an increase in pressure pain threshold levels at each session that was of similar magnitude to the first time the technique was administered, suggesting that non-thrust techniques do not cause tolerance to repeated applications. It should be noted that this study did not include a control group so the possibility of consistent improvements in their cohort could have potentially been related to a placebo effect. Irrespective, this phenomenon of cumulative tolerance has yet to be investigated with regards to thrust techniques. Studying thrust in addition to non-thrust techniques is relevant, since non-thrust and thrust interventions stimulate different axial sensory beds¹⁵. Also, thoracic spine manipulation was shown to result in significantly greater short-term reductions in pain and disability than thoracic non-thrust manipulation in neck pain patients¹⁶. From a clinical perspective, one could argue that it is necessary to investigate the tolerance aspect not only with regard to neurophysiological measures, such as pressure pain thresholds, but also with regard to clinically relevant outcomes, such as pain and mobility.We recently conducted a randomized clinical controlled trial comparing the effectiveness of an electro- and thermotherapy program alone or in combination with thoracic spine thrust manipulation in patients with acute neck pain¹⁷. This paper presents a secondary analysis of data related to the tolerance aspect of the thoracic spine thrust manipulation. The purpose of this paper is to analyze whether repeated application of thoracic manipulation causes tolerance with regard to pain and mobility outcomes in patients with acute neck pain. We hypothesized that repeated application of thoracic spine manipulation would not lead to tolerance to repeated applications both with regard to pain and neck mobility outcomes.     

Management of atypical infant colic – a pain syndrome of infancy – and the emotional stress associated with it: Why treat a benign disorder?

Objective

To present one case study in which the complete resolution of atypical infantile colic – a pain syndrome of infancy – and associated symptoms and emotional stress was achieved when the patient underwent chiropractic treatment.

Design

A case report.

Setting

Private chiropractic practice.

Subjects

This case involved a 4-month-old male infant presenting with excessive crying and associated head malposition, disturbed feeding and sleeping patterns, all of which started one-and-a-half months previously. Upper cervical, mid thoracic and cranial dysfunction as well as suboccipital musculature hypertonicity was recorded in this case.

Methods

The infant received diversified low-force chiropractic manipulation to the upper cervical spine and low-pulsed impulses to the thoracic spine. Additionally, soft tissue stretching to the restricted cervical and trunk musculature and light touch cranial manipulative therapy was given to the infant. Treatment was provided over a 4-week period, twice weekly and included supportive care (advice about emotional disturbances and coping mechanisms in times of overwhelming feelings were given to the parents).

Results

Complete resolution of all presenting symptoms was achieved in this instance.

Discussion

This case suggests a possible association between the development of cranial and spinal segmental dysfunction, muscular imbalance and consequential manifestation of symptoms of a pain syndrome of infancy. It also illustrates chiropractic treatment restoring correct spinal and cranial motion, with an associated resolution of symptoms. Finally, it emphasizes the importance of offering help for distressed caregivers.     

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.     

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.     

Immediate Changes in Neck Pain Intensity and Widespread Pressure Pain Sensitivity in Patients With Bilateral Chronic Mechanical Neck Pain: A Randomized Controlled Trial of Thoracic Thrust Manipulation vs Non–Thrust Mobilization

Objective

The purpose of this study was to compare the effects of thoracic thrust manipulation vs thoracic non–thrust mobilization in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity and neck pain intensity.

Methods

Fifty-two patients (58% were female) were randomly assigned to a thoracic spine thrust manipulation group or of thoracic non–thrust mobilization group. Pressure pain thresholds (PPTs) over C5-C6 zygapophyseal joint, second metacarpal, and tibialis anterior muscle and neck pain intensity (11-point Numerical Pain Rate Scale) were collected at baseline and 10 minutes after the intervention by an assessor blinded to group allocation. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome. The primary analysis was the group * time interaction.

Results

No significant interactions were found with the mixed-model ANOVAs for any PPT (C5-C6: P > .252; second metacarpal: P > .452; tibialis anterior: P > .273): both groups exhibited similar increases in PPT (all, P < .01), but within-group and between-group effect sizes were small (standardized mean score difference [SMD] < 0.22). The ANOVA found that patients receiving thoracic spine thrust manipulation experienced a greater decrease in neck pain (between-group mean difference: 1.4; 95% confidence interval, 0.8-2.1) than did those receiving thoracic spine non–thrust mobilization (P < .001). Within-group effect sizes were large for both groups (SMD > 2.1), and between-group effect size was also large (SMD = 1.3) in favor of the manipulative group.

Conclusions

The results of this randomized clinical trial suggest that thoracic thrust manipulation and non–thrust mobilization induce similar changes in widespread PPT in individuals with mechanical neck pain; however, the changes were clinically small. We also found that thoracic thrust manipulation was more effective than thoracic non–thrust mobilization for decreasing intensity of neck pain for patients with bilateral chronic mechanical neck pain.     

The effect of direction specific thoracic spine manipulation on the cervical spine: a randomized controlled trial

Objectives: To determine the difference on neck outcomes with directional manipulation to the thoracic spine. There is evidence that thoracic spine manipulation is effective in treating patients with neck pain. However, there is no research that determines if the assessment of directional hypomobility and the selection of thrust direction offer improved outcomes.

Methods: A total of 69 patients with cervical spine pain were randomly assigned to receive either a manipulation that was consistent with their thoracic spine motion loss (matched) or opposite their motion loss (unmatched). The patient was given care consistent with the orthopedic section guidelines for neck pain and the physical therapist’s clinical reasoning. Baseline outcome measures (NPRS, NDI, GROC) were taken and reassessed two days and two weeks after treatment.

Results: Both groups had positive results when pain, neck disability index, and global rating of change were assessed. There was no difference between the matched and unmatched groups.

Discussion: Directional manipulation of hypomobile thoracic spine segments may not be required to improved outcomes in patients with neck pain. Future studies should assess a variety of factors when determining the best available treatment, including manual therapy procedures, exercise, and patient selection.

Level of Evidence: 1b.     

Immediate improvement in the cranio-cervical flexion test associated with MDT-based interventions: a case report

The patient in this case study presented with constant idiopathic neck pain and left lower scapular pain (greater than 3 months) and was treated based on the principles of Mechanical Diagnosis and Therapy (MDT). Retraction exercises produced centralization of the lower scapular pain to the upper part of the scapula at the initial visit. At the first visit, the performance level on the Cranio-Cervical Flexion Test (CCFT) was ≤20 mmHg before the treatment. At the conclusion of the treatment during which centralization occurred, the CCFT level improved to 24 mmHg. At the second visit, all symptoms were abolished and cervical range of motion (ROM) was fully restored by performing repeated extension in lying from a retracted position with clinician’s traction. The CCFT levels before and immediately after the treatment were 24 and 26 mmHg, respectively. At the third visit (1 week after the initial visit), he noted that all daily activities could be performed without pain. The CCFT level was maintained at 26mmHg. The patient in this study showed immediate improvement in the CCFT through the treatments based on MDT. This suggests a possible link between MDT interventions and motor control of the cervical spine and a need to further investigate this relationship.     

Effects of Maitland's manual mobilization on the thoracic spine

The goal of manual therapy is to decrease pain and to increase function of the spine and peripheral joints. The method introduced by Maitland is widely used in manual medicine. However, no objective changes in the mobility of the thoracic spine after performing manual mobilization have been published in the literature. The aim of this study is to reveal possible changes in the segmental mobility of the thoracic spine after posterior-anterior manipulations without thrust in comparison with a control group. In addition, significant changes within the treatment group were examined. Thirty-six volunteers were randomized into an intervention (16) and a control group (20). The intervention group was treated two times a week for three weeks. The control group received no treatment. The mobility was objectively measured by using Medimouse. No significant difference in the mobility of the thoracic spine could be shown within the intervention group and in comparison with the control group.     

Use of Multifidus Isometric for a Patient with Acute Neck Pain: A Case Report

Abstract

The purpose of this case report is to describe how a simple isometric technique was effective in treating a patient with complaints of acute neck pain. The patient was a 35-year-old female who complained of an acute onset of right cervical pain. She exhibited a significant increase in range of motion (approximately 50 degrees of right rotation) and a 50% reduction in pain level after one treatment. After two treatments, full pain-free cervical range of motion and function was restored. The report suggests that the technique can significantly increase cervical range of motion and decrease pain in one treatment session. Thrust and nonthrust manipulation techniques have been found to be effective in treating neck pain. Nonthrust techniques, however, appear to lessen the risk to the patient. The multifidus isometric is a safe, nonthrust manual therapy technique that can be effective in reducing pain and increasing range of motion in some cases of acute cervical dysfunction in as little as one treatment session.     

Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals

Abstract

This case report describes the effectiveness of thrust manipulation to the elbow and carpals in the management of a patient referred with a medical diagnosis of cubital tunnel syndrome (CuTS). The patient was a 45-year-old woman with a 6-week history of right medial elbow pain, ulnar wrist pain, and intermittent paresthesia in the ulnar nerve distribution. Upon initial assessment, she presented with a positive elbow flexion test and upper limb neurodynamic test with ulnar nerve bias. A biomechanical assessment of the elbow and carpals revealed a loss of lateral glide of the humerus on the ulna and a loss of palmar glide of the triquetral on the hamate. After the patient received two thrust manipulations of the elbow and one thrust manipulation of the carpals over the course of four sessions, her pain and paresthesia were resolved. This case demonstrates that the use of thrust manipulation to the elbow and carpals may be an effective approach in the management of insidious onset CuTS. This patient was successfully treated with thrust manipulation when joint dysfunction of the elbow and wrist were appropriately identified. This case report may shed light on the examination and management of insidious onset CuTS.