Dataset Information

Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis.

ABSTRACT:

Objective

To investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP).

Data sources

Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018.

Study selection

Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria.

Study appraisal and synthesis methods

Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0-100%; 0 = no disability).

Results

Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up.

Limitations

The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence.

Conclusions

TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability.

Trial registration

PROSPERO CRD42017068287.

SUBMITTER: Masaracchio M

PROVIDER: S-EPMC6373960 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundComplex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.ObjectivesWe aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.Design and data sourcesA systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.ResultsOut of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.ConclusionsThe analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.

Project description:BACKGROUND:Mobilization and manipulation therapies are widely used by patients with chronic nonspecific neck pain; however, questions remain around efficacy, dosing, and safety, as well as how these approaches compare to other therapies. OBJECTIVES:Based on published trials, to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic nonspecific neck pain. STUDY DESIGN:A systematic literature review and meta-analysis. METHODS:We identified studies published between January 2000 and September 2017, by searching multiple electronic databases, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation and/or mobilization therapies to sham, no treatment, each other, and other active therapies, or when combined as multimodal therapeutic approaches. We assessed risk of bias by using the Scottish Intercollegiate Guidelines Network criteria. When possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation was applied to determine the confidence in effect estimates. This project was funded by the National Center for Complementary and Integrative Health under award number U19AT007912 and ultimately used to inform an appropriateness panel. RESULTS:A total of 47 randomized trials (47 unique trials in 53 publications) were included in the systematic review. These studies were rated as having low risk of bias and included a total of 4,460 patients with nonspecific chronic neck pain who were being treated by a practitioner using various types of manipulation and/or mobilization interventions. A total of 37 trials were categorized as unimodal approaches and involved thrust or nonthrust compared with sham, no treatment, or other active comparators. Of these, only 6 trials with similar intervention styles, comparators, and outcome measures/timepoints were pooled for meta-analysis at 1, 3, and 6 months, showing a small effect in favor of thrust plus exercise compared to an exercise regimen alone for a reduction in pain and disability. Multimodal approaches appeared to be effective at reducing pain and improving function from the 10 studies evaluated. Health-related quality of life was seldom reported. Some 22/47 studies did not report or mention adverse events. Of the 25 that did, either no or minor events occurred. LIMITATIONS:The current evidence is heterogeneous, and sample sizes are generally small. CONCLUSIONS:Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions. It appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. The studies comparing to no treatment or sham were mostly testing the effect of a single dose, which may or may not be helpful to inform practice. According to the published trials reviewed, manipulation and mobilization appear safe. However, given the low rate of serious adverse events, other types of studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for nonspecific chronic neck pain. KEY WORDS:Chronic neck pain, nonspecific, chiropractic, manipulation, mobilization, systematic review, meta-analysis, appropriateness.

Project description:BackgroundThe thoracic area has mainly been neglected in research compared to the lumbar and cervical regions. No clinical practice guidelines (CPGs) for non-specific thoracic spine pain (TSP) have been compiled. Therefore, it can be argued that the absence of specific CPGs raises questions about the management of non-specific TSP. Hence, this study aimed at determining the management of non-specific TSP among physiotherapists in Italy.MethodsA web cross-sectional survey investigating physiotherapists' management of non-specific TSP was conducted. The survey instrument was divided into three sections. The first section obtained participants' characteristics. The second section determined participants' agreement with 29 statements regarding the clinical management of non-specific TSP utilising a five-point Likert scale. Participants who partially or completely agreed (scores 4-5) were considered to agree with the statements. A ≥ 70% of agreement with a statement was considered as consensus according to previous literature. The third section asked the participants to indicate how often they adopted several treatments to manage non-specific TSP with a 5-point scale (always - often - sometimes - rarely - never). The frequencies of answers were calculated, and a visual representation through a bar chart was reported. The online version of the survey instrument was delivered through the newsletter of the Italian Association of Physiotherapists and the postgraduate master's degree in Rheumatic and Musculoskeletal Rehabilitation of the University of Genova (Genova, Italy).ResultsIn total, 424 physiotherapists (mean age (SD): 35.1 years (10.5); 50% female) completed the survey. In the second section, physiotherapists achieved consensus for 22/29 statements. Those statements addressed the importance of psychosocial factors, exercise, education, and manual therapy techniques in managing non-specific TSP. In the third section, 79.7% of participants indicated they would always adopt a multimodal treatment (education, therapeutic exercise, manual therapy), followed by education and information (72.9%), therapeutic exercise (62.0%), soft tissue manual therapy (27.1%), and manual therapy (16.5%).ConclusionsStudy participants considered fundamentally using a multimodal programme based on education, exercise and manual therapy to manage non-specific TSP. This approach aligns with the CPGs for other chronic musculoskeletal pain than non-specific TSP.

Project description:Background and aimsThoracic spine manipulation (TSM) increases the thoracic spine's range of motion (ROM), effectively reducing pain intensity and disability in patients with mechanical neck pain. We aimed to determine the effect of TSM on neck pain intensity and functional impairment in patients classified under the "mobility" category in Childs' classification.MethodsIn this randomized controlled trial, patients with mechanical neck pain who met the inclusion criteria were randomly assigned to either the TSM (n = 21) or sham manipulation (n = 20) group. The primary outcomes were pain during neck rotation and subjective improvement assessed using the Numerical Pain Rating Scale (NPRS) and Global Rating of Change (GROC), respectively. The secondary outcomes were NPRS at rest, disability (assessed using the Neck Disability Index [NDI]), and ROM of the cervical and thoracic spine rotation. Outcome measurements were performed at baseline, immediately after treatment, 1 week after treatment, and at the 4-week follow-up. Linear mixed models were used to analyze the NPRS, NDI, and ROM. The GROC was analyzed using a chi-square test for the percentage recording ≥+4; the means of each group were compared using an unpaired t-test.ResultsThe NPRS with neck rotation, neck and thoracic ROM, and NDI showed significant interactions between the groups. The NPRS with neck rotation was significantly lower in the TSM group than in the sham group at all time points after the treatment (p < 0.001). There was no difference between the groups in the proportion showing moderate (≥+4) improvement according to the GROC; however, there was a significant difference in the mean values (p = 0.013).ConclusionIncorporating TSM into treatment protocols may improve clinical outcomes in patients with neck pain, potentially leading to better pain management and functional recovery. Therefore, physiotherapists should consider TSM as a viable and effective intervention to improve patient outcomes in neck pain rehabilitation.

Project description:BACKGROUND CONTEXT:Spinal manipulation (SM) is a common treatment for neck and back pain, theorized to mechanically affect the spine leading to therapeutic mechanical changes. The link between specific mechanical effects and clinical improvement is not well supported. SM's therapeutic action may instead be partially mediated within the central nervous system. PURPOSE:To introduce brain-based models of pain for spinal pain and manual therapy research, characterize the distributed central mechanisms of SM, and advance the preliminary validation of brain-based models as potential clinical biomarkers of pain. STUDY DESIGN:Secondary analysis of two functional magnetic resonance imaging studies investigating the effect of thoracic SM on pain-related brain activity: A non-controlled, non-blinded study in healthy volunteers (Study 1, n?=?10, 5 females, and mean age?=?31.2?±?10.0 years) and a randomized controlled study in participants with acute to subacute neck pain (Study 2, n?=?24, 16 females, mean age?=?38.0?±?15.1 years). METHODS:Functional magnetic resonance imaging was performed during noxious mechanical stimulation of the right index finger cuticle pre- and post-intervention. The effect of SM on pain-related activity was studied within brain regions defined by the Neurologic Pain Signature (NPS) that are predictive of physical pain. RESULTS:In Study 1, evoked mechanical pain (p < 0.001) and NPS activation (p?=?0.010) decreased following SM, and the changes in evoked pain and NPS activation were correlated (rRM2?=?0.418, p?=?0.016). Activation within the NPS subregions of the dorsal anterior cingulate cortex (dACC, p?=?0.012) and right secondary somatosensory cortex/operculum (rS2_Op, p?=?0.045) also decreased following SM, and evoked pain was correlated with dACC activity (rRM2?=?0.477, p?=?0.019). In Study 2, neck pain (p?=?0.046) and NPS (p?=?0.033) activation decreased following verum but not sham SM. Associations between evoked pain, neck pain, and NPS activation, were not significant and less clear, possibly due to inadequate power, methodological limitations, or other confounding factors. CONCLUSIONS:The findings provide preliminary evidence that SM may alter the processing of pain-related brain activity within specific pain-related brain regions and support the use of brain-based models as clinical biomarkers of pain.