[ RESEARCH REPORT ] IAN A. YOUNG, PT, DSc, OCS, SCS1,2 • FEDERICO POZZI, PT, PhD3 • JAMES DUNNING, DPT, FAAOMPT2,4 RICHARD LINKONIS, PT, DPT5 • LORI A. MICHENER, PT, PhD, ATC6 Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial ecent evidence supports the use of high-velocity, low-amplitude reported following manipulation of thrust manipulation to the thoracic spine in patients with neck the thoracic spine.11 Moreover, thoracic pain.3,6,8,11,20,42,43 Immediate and short-term improvements in manipulation has demonstrated bet- pain and cervical spine range of motion (ROM) have been ter outcomes compared to mobilization R (nonthrust) in patients with neck pain.8,32 Current evidence supports the use of tho- UUBACKGROUND: Thoracic spine thrust manipu- 48-to-72-hour follow-up, the manipulation group had racic manipulation in patients with neck lation has been shown to improve patient-rated lower neck pain (P<.01), better cervical ROM (P<.01), pain, but there is a paucity of evidence for outcomes for individuals with neck pain. However, lower disability (P<.01), and better deep neck flexor its use in patients with neck and arm pain there is limited evidence of its effectiveness in endurance (P = .02) compared to the sham manipu- related to cervical radiculopathy. A single patients with cervical radiculopathy. lation group. The manipulation group had moderate to large effect-size changes over time. No between- case report has suggested that thoracic UUOBJECTIVES: To compare the immediate and short-term effects of thoracic manipulation to group differences for upper extremity pain were found manipulation may be useful in the treat- those of a sham thoracic manipulation in patients immediately following the intervention (P = .34) and ment of cervical radiculopathy, noting with cervical radiculopathy. at 48 to 72 hours after the intervention (P = .18). At a decrease in upper extremity radicular 48 to 72 hours after treatment, a greater proportion METHODS: In this multicenter randomized con- symptoms following a single dose of tho- UU of participants in the manipulation group reported trolled trial, participants with cervical radiculopathy racic manipulation.12 Thoracic manipu- improvement (global rating of change scale score of were randomized to receive either manipulation (n 4 or greater) in neck and upper extremity symptoms lation may be a viable treatment option = 22) or sham manipulation (n = 21) of the thoracic in the early phases of treatment, when spine. Outcomes were measured at baseline, im- (P<.01), centralization of symptoms (P<.01), and mediately after treatment, and at a follow-up 48 to beliefs about receiving an active manipulation (P = cervical manual interventions may not 72 hours after manipulation. A repeated-measures .01) compared to the sham manipulation group. be tolerated well by patients with cervi- analysis of variance was used to analyze neck and cal radiculopathy.12 UUCONCLUSION: One session of thoracic manipu- upper extremity pain (numeric pain-rating scale), lation resulted in improvements in pain, disability, Cervical radiculopathy is most com- disability (Neck Disability Index), cervical range of cervical ROM, and deep neck flexor endurance in monly associated with a cervical disc motion (ROM), and endurance (deep neck flexor patients with cervical radiculopathy. Patients treated derangement or other space-occupying endurance test). The chi-square test was used to with manipulation were more likely to report at least Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Select Medical Department of Education on May 2, 2019. For personal use only. No other uses without permission. Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. lesion, resulting in nerve root inflamma- analyze changes in neck and upper extremity pain, moderate change in their neck and upper extremity centralization of symptoms, and beliefs about 30 symptoms up to 48 to 72 hours following treatment. tion, impingement, or both. Patients receiving the active manipulation treatment using a can present with or without neck pain LEVEL OF EVIDENCE: Therapy, level 2. global rating of change scale. UU and with a multitude of upper extrem- J Orthop Sports Phys Ther 2019;49(5):299-309. RESULTS: Neck and upper extremity pain, cervical UU doi:10.2519/jospt.2019.8150 ity symptoms. Physical therapy manage- ROM, disability, and deep neck flexor endurance all ment of cervical radiculopathy includes showed significant interactions between group and UUKEY WORDS: clinical trial, neck pain, radicu- time (P<.01). Immediately after treatment and at the lopathy, thoracic spine, thrust manipulation manual therapy, exercise, and cervical traction.3,7,9,30,39,42 Manual therapy may 1CORA Physical Therapy, Savannah, GA. 2American Academy of Manipulative Therapy, Montgomery, AL. 3Department of Physical Therapy, University of Florida, Gainesville, FL. 4Alabama Physical Therapy and Acupuncture, Montgomery, AL. 5Center for Physical Therapy and Sports Medicine, PC, Richmond, VA. 6Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. The Office of Research at Virginia Commonwealth University provided Institutional Review Board approval of this study (HM13804). This randomized controlled trial was registered with ClinicalTrials.gov (NCT01495728). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Ian Young, 22 West Oglethorpe Avenue, Savannah, GA 31401. E-mail: [email protected] Copyright ©2019 Journal of Orthopaedic & Sports Physical Therapy® UU journal of orthopaedic & sports physical therapy | volume 49 | number 5 | may 2019 | 299 [ RESEARCH REPORT ] consist of mobilization/manipulation endurance compared to those receiving for their current condition, and none re- to the cervical and thoracic spine, neu- sham manipulation. Further, we hypoth- ported having received these manipula- rodynamic techniques, and soft tissue esized that a greater proportion of partic- tions for their current episode of cervical mobilization.12,27,42 Exercise involves ipants in the manipulation group would radiculopathy. strengthening the deep neck flexor report at least moderate improvement in muscles and scapular-thoracic region.9,42 neck and upper extremity symptoms, as Procedures Traction includes manual, mechanical, well as centralization of symptoms, com- Before participating in the study, all par- and home traction options.4,17,42 Stud- pared to those in the sham manipulation ticipants signed an informed-consent ies indicate that a multimodal approach group. form, and the rights of participants were using these interventions has resulted protected. The study protocol was ap- in improved outcomes4,8,9,31,42 and can METHODS proved by the Institutional Review Board be predictive of a successful outcome at Virginia Commonwealth University in this patient population.7 The use of a Participants Office of Research (HM13804). The pro- standardized multimodal treatment of onsecutive patients with uni- tocol was registered on ClinicalTrials.gov manual therapy and exercise has resulted lateral upper extremity pain, par- (NCT01495728). Each participant under- in improvements in pain and disability.42 Cesthesia, or numbness, with or went standardized data collection, which Unfortunately, multimodal treatment without neck pain, were recruited for included patient-reported outcomes and studies are unable to establish the iso- this multicenter randomized controlled impairment measures. The data-collec- lated intervention effects of thoracic ma- trial at 6 orthopaedic physical therapy tion procedures were performed at base- nipulation on symptoms, impairments, clinics in Georgia, Virginia, and Califor- line, immediately after treatment, and 48 and function. Moreover, a 2016 system- nia between September 2011 and July to 72 hours after treatment. The evaluat- atic review35 reported a lack of evidence 2014. Inclusion criteria were being 18 to ing physical therapist collected baseline for the effectiveness of thoracic manipu- 65 years of age, having a Neck Disabil- outcomes and performed the manipu- lation as a single-mode intervention in ity Index (NDI) score of 10/50 points or lation and sham manipulation, while patients with cervical radiculopathy. greater, and having a clinical diagnosis another clinician blinded to group allo- This same systematic review35 suggests of cervical radiculopathy, as defined by cation collected all follow-up outcomes. a need for more evidence to support the Wainner and Gill38 (positive scores on 3 Randomization Following the baseline use of thoracic manipulation as a treat- of 4 clinical tests: Spurling’s test, upper- examination, participants were randomly ment option in this patient population. limb neurodynamic test/median nerve assigned to receive manipulation or sham Further research is needed to justify the bias, cervical distraction test, and cervi- manipulation to the upper and mid tho- use of thoracic manipulation and to un- cal rotation toward the symptomatic side racic spine. Numbered, sequential, sealed derstand its short-term effects on related of less than 60°). When 3 of these 4 tests opaque envelopes containing group allo- impairments and outcomes in patients are positive, the