The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial JOHN KRAUSS, PT, PhD, OCS, FAAOMPT', DOUG CREIGHTON, DPT, OCS, FAAOMPT', JONATHAN D. ELY PT, MS, FAAOMFT-, JOANNA PODLEWSKA-ELY PT, MS. FAAOMPT' P ainful, restricted cervical mobility is seen and treated daily in physical therapy clinics and it accounts for up to 25% of the patient population seen in outpatient orthopedic practice'. Ac- cording to Keisey-, 40% to 50% of the general population will experience me- chanical neck pain. Injury and degenera- tive changes affecting the interverfebral disc may account for excessive transla- tion between two adjacent vertebrae dur- ing active cervical motion'^ This exces- sive translation can cause considerable strain on the annulus fibrosis, increase load on the cervical facet joints, and re- sult in pain during active cervical mo- tion^-. Aprill and Bogduk reported that the occurrence of cervical facet joint pain ABSTRACT: 'lhis study examined theefTectof translatoric spinal nianipitlation (TSM) on cervical pain and cervical active motion restriction when applied lo upper thoracic (T1-T4) segments. Active cervical rotation range of motion v/as measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of conve- nience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were ran- domly assigned to the experimental group and ten were assigned to the control grt)up. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. Tbe experimental group received TSM to hypomobile upper thoracic segments. The control group received no inter- vention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differ- ences in cervical rotation and pain. Significance was accepted at p - 0.05. SigEiificant changes that exceeded the MDC^_ were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD} in right rotation of 8.23° (7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cer- vical rotation showed significant improvement during right rotation for patients experienc- ing pain during bilateral rotation only (p-.O5). Tliis study supports the hypothesis that spi- nal manipulation applied to the upper thoracic spine (Tl -T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for pa- tients experiencing pain during bilateral cervical rotation. KEYWORDS: Manipulation, Pain, Range of Motion. Thoracic Spine. Translatoric Spinal Manipulation can be as high as 64%'\ Provocation dis- cography has shown a relationship be- tween radiographic appearance of an ab- normal cervical disc and the pain provocation results at that cervical spinal motion segment'' . There is a clinical and biomechanical concept that suggests that a hypomobile spinal motion segment{s) may produce or perpetuate a symptomatic response from an adjacent hypermobile spinal mo- tion segmenf^ Cervical-fhoracic and up- per thoracic mobility restrictions have been associated with neck pain. Accord- ing to Norlander et al, reduced mobility at the cervical-thoracic junction has been shown to be a risk factor for neck pain'*'". This relationship was further explored by Feniandez-de-la-Pefias et al", who iden- tified upper thoracic (UT) joint dysfunc- tions in patients experiencing cervical whiplash (69%) and mechanical neck pain (13%). Upper thoracic joint dysfunction has been defined as a temporary reduction of mobility in one or more planes in the first four thoracic segments'-. A number of different passive intervertebral move- ment techniques have been developed to evaluate for excessive or limited passive segmenfal motion. Antero-posterior (A- P) joint play testing is an examination fechnicjue that uses linear motion lo eval- uate the amount of segmental transla- tion". Other passive segmental motion tests use angular motion such as flexion 'Associate Professor, Program in Physical Therapy, School of Health Sciences, Oakland University. Rochester. MI. ^Owner, Pro Staff Physical Therapy. Lexington, MI, 'Physical Tlierapist, Port Huron Hospital Sport and Spine, Port Huron, MI. Address all correspondence and requests for reprints to: Dr. John R. Krauss, [email protected]THEJOURNALOFMANUAL&MANIPULATIVETHERAPY • VOLUME 16 • NUMBERTWO [93]
Transcript
The Immediate Effects of Upper Thoracic TranslatoricSpinal Manipulation on Cervical Pain
and Range of Motion: A Randomized Clinical TrialJOHN KRAUSS, PT, PhD, OCS, FAAOMPT', DOUG CREIGHTON, DPT, OCS, FAAOMPT',
JONATHAN D . ELY PT, MS, FAAOMFT-, JOANNA PODLEWSKA-ELY PT, MS. FAAOMPT'
Painful, restricted cervical mobilityis seen and treated daily in physicaltherapy clinics and it accounts for
up to 25% of the patient population seenin outpatient orthopedic practice'. Ac-cording to Keisey-, 40% to 50% of thegeneral population will experience me-chanical neck pain. Injury and degenera-tive changes affecting the interverfebral
disc may account for excessive transla-tion between two adjacent vertebrae dur-ing active cervical motion'^ This exces-sive translation can cause considerablestrain on the annulus fibrosis, increaseload on the cervical facet joints, and re-sult in pain during active cervical mo-tion^-. Aprill and Bogduk reported thatthe occurrence of cervical facet joint pain
ABSTRACT: 'lhis study examined theefTectof translatoric spinal nianipitlation (TSM) oncervical pain and cervical active motion restriction when applied lo upper thoracic (T1-T4)segments. Active cervical rotation range of motion v/as measured re- and post-interventionwith a cervical inclinometer (CROM), and cervical pain status was monitored before andafter manipulation with a Faces Pain Scale. Study participants included a sample of conve-nience that included 32 patients referred to physical therapy with complaints of pain in themid-cervical region and restricted active cervical rotation. Twenty-two patients were ran-domly assigned to the experimental group and ten were assigned to the control grt)up. Pre-and post-intervention cervical range of motion and pain scale measurements were taken bya physical therapist assistant who was blinded to group assignment. Tbe experimental groupreceived TSM to hypomobile upper thoracic segments. The control group received no inter-vention. Paired t-tests were used to analyze within-group changes in cervical rotation andpain, and a 2-way repeated-measure ANOVA was used to analyze between-group differ-ences in cervical rotation and pain. Significance was accepted at p - 0.05. SigEiificant changesthat exceeded the MDC _ were detected for cervical rotation both within group and betweengroups with the TSM group demonstrating increased mean (SD} in right rotation of 8.23°(7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cer-vical rotation showed significant improvement during right rotation for patients experienc-ing pain during bilateral rotation only (p-.O5). Tliis study supports the hypothesis that spi-nal manipulation applied to the upper thoracic spine (Tl -T4 motion segments) significantlyincreases cervical rotation ROM and may reduce cervical pain at end range rotation for pa-tients experiencing pain during bilateral cervical rotation.
KEYWORDS: Manipulation, Pain, Range of Motion. Thoracic Spine. Translatoric SpinalManipulation
can be as high as 64%'\ Provocation dis-cography has shown a relationship be-tween radiographic appearance of an ab-normal cervical disc and the painprovocation results at that cervical spinalmotion segment'' .
There is a clinical and biomechanicalconcept that suggests that a hypomobilespinal motion segment{s) may produceor perpetuate a symptomatic responsefrom an adjacent hypermobile spinal mo-tion segmenf^ Cervical-fhoracic and up-per thoracic mobility restrictions havebeen associated with neck pain. Accord-ing to Norlander et al, reduced mobilityat the cervical-thoracic junction has beenshown to be a risk factor for neck pain'*'".This relationship was further explored byFeniandez-de-la-Pefias et al", who iden-tified upper thoracic (UT) joint dysfunc-tions in patients experiencing cervicalwhiplash (69%) and mechanical neckpain (13%).
Upper thoracic joint dysfunction hasbeen defined as a temporary reduction ofmobility in one or more planes in the firstfour thoracic segments'-. A number ofdifferent passive intervertebral move-ment techniques have been developed toevaluate for excessive or limited passivesegmenfal motion. Antero-posterior (A-P) joint play testing is an examinationfechnicjue that uses linear motion lo eval-uate the amount of segmental transla-tion". Other passive segmental motiontests use angular motion such as flexion
'Associate Professor, Program in Physical Therapy, School of Health Sciences, Oakland University. Rochester. MI. ^Owner, Pro Staff PhysicalTherapy. Lexington, MI, 'Physical Tlierapist, Port Huron Hospital Sport and Spine, Port Huron, MI.Address all correspondence and requests for reprints to: Dr. John R. Krauss, [email protected]
THE IMMEDIATE EFFECTS OF UPPER THORACIC TRANSlATORiC SPINAL MANIPULATION ON CERVICAL PAIN AND RANGE OF MOTION
and extension in order to determine ifpassive movement impairment is pres-ent at a segment"" ' \ Studies have ques-tioned the reliability of passive segmen-tal mobility testing in the thoracicspine"'''. This may in part be due to er-rors in nominal palpation; however,from a treatment perspective, identifica-tion of exact nominal level may not beessential as long as the segment treatedis correctly identified as hypomobile'".
A number of recent studies have ex-plored the interaction between high-ve-locity manipulation of the thoracic spineand cervical pain. These studies haveused outcome measures such as theNeck Disability Index (NDI), the VisualAnalog Scale (VAS), the Numeric PainRating Scale (NPRS), and the GlobalRating of Change (GROC) Scale'" -. Thegeneral findings of these studies are thathigh-velocity manipulation applied tothe UT spine reduces subjective com-plaints of neck pain and disability. Thisoutcome appears to occur regardlessof how many cavitations occur andhow segmentally specific the cavitationsare -'--".
Another method of measuring im-provement in cervical spine functionfollowing the application of high-veloc-ity thoracic manipulation is through theuse of goniometric or inclinometer mea-surements. Two studies have been iden-tified that directly examine this outcome.Cleland et aP^ examined the relationshipbetween the audible pop and manipula-tion and changes in cervical range ofmotion (ROM). They concluded that thenumber and location of cavitations didnot seem to impact improvements incervical ROM. Using a case series de-sign, Fernandez-de-la-Penas et ap-' ex-amined the effects of thoracic manipula-tion on cervical ROM and found a trendtowards significance in ROM changespost manipulation. No controlled ran-domized studies were identified that ex-amined the effects of thoracic manipula-tion on cervical ROM as measured by aninclinometer.
The 9-point Faces Pain Scale (FPS)developed by Bieri et aP^ uses nine dif-ferent faces depicting various severitiesof pain. This scale was first validated foruse in children and adolescents and waslater validated for use with mature pop-
ulations (>55 years of age)'"'". In regardsto patient preference, the FPS has beenshown to be of greater preference thanthe NPRS by mature adults'". In addi-tion, there is cross-cultural evidence tothe usefulness of the FPS'^
Translatoric Spinal Manipulation(TSM) co-developed by Evjenth andKaltenborn is a manipulative approachthat uses short straight-lined high- andlow-velocity movements directed paral-lel to or at a right angle to the spinal jointsurfaces. Techniques that are part of thismanipulative approach are well de-scribed by Krauss, Evjenth, and Creigh-ton '', who theorized that short straight-lined movementsare an effective methodof restoring joint motion with minimalrisk of symptom exacerbation. Thisstudy sought to determine if TSM wouldhave an effect on cervical pain (mea-sured by the FPS) and cervical ROM(measured by an inclinometer) whenapplied to hypomobile segments foundin the upper thoracic region-".
Methods
Subjects
A convenience sample of 32 patients ad-mitted to three ditferent outpatientphysical therapy clinics with a diagnosisof cervical pain voluntarily participatedin the study. Patients between 19 and 50years old presenting with complaints ofnon-traumatic posterior mid-cervicalpain of an insidious onset in the regionof the fourth to seventh cervical verte-bral levels and aggravated with activecervical rotation were invited to partici-pate. Patients with symptoms originat-ing from the thoracic spine, systemicdisease or autoimmune disease affectingthe musculoskeletal system, positive ra-dicular signs, myelopathy, or previoussurgery to the cervical spine were ex-cluded from the study. The study wasapproved by the Oakland University In-stitutional Review and Ethics Board inRochester, Michigan.
Procedures
Patient examinations were performed atthree different outpatient physical ther-apy clinics by three orthopedic manual
physical therapists (OMPTs) trained at atwo-year certificate program at OaklandUniversity (Rochester, MI). The averagenumber of years in clinical practicefor the treating therapists was 12.3. Du-ring the examinations, patients werescreened for the presence of mechanicalneck pain during the performance ofactive cervical rotation. Diagnostic cri-teria for mechanical neck pain have beenput forth by Van Schalkwyk and Parkin-Smith™". Their criteria include neckpain without neurologic or vasculardeficit, unilateral or bilateral neck pain,discomfort with joint challenge/pres-sure, and restriction of movement of amotion segment(s) identified by staticor motion palpation. Neck pain wasrated at the end of active left and rightrotation using a 9-point Faces Pain Scale(FPS). Stuppy'' reported that the FPS isreliable (r = .70, p < .001), valid (whencorrelated with the NPRS r = .95, p <.001) and differentiates between moreand less pain. Active cervical right andleft rotation were measured with a cer-vical range of motion inclinometer/compass system (CROM) (PerformanceAttainment Associates, St. Paul, MN ).Youdas et al" reported intraclass corre-lation coefficient values (ICC) for lefirotation (ICC = .90) and right rotation(ICC = .93) to be highly reliable whenrepeated by the same physical therapist.Between-tester reliability for activerange of motion measurements of neckrotation with the CROM device rangedfrom good (ICC = .82) for left rotationto high for right rotation (ICC = ,92)".
To reduce the likelihood that pa-tient complaints of neck pain were ofthoracic origin, symptoms were local-ized to the mid-cervical region by per-forming rotational symptom localiza-tion as described by Evjenth'^ Forexample, if active rotation to the rightincreased the patient's cervical pain, theclinician would have the patient rotatehis or her neck to the right until the painincreased. Then the patient would slowlyrotate the bead/neck to the left until thecervical pain slightly decreased. Tliiscervical position was then maintainedby the clinicians chest and non-testinghand. At this point the clinician wouldpassively rotate individual cervical ver-tebra to the right beginning at the C7
FIGURE 1. Symptom localization of the cervical spine.
THE IMMEDIATE EFFECTS OF UPPER THORACIC TRANSLATORIC SPINAL MANIPULATION ON CERVICAL PAIN AND RANGE OF MOTION
level. The manual contact for the exami-nation technique was the posterior por-tion of the lamina on the left side and theright side of the spinous process. Whensimilar symptoms were provoked ascompared with the patient's active cervi-cal right rotation, the cranial vertebra ofthe involved symptomatic segment wasconsidered to have been identified (Fig-ure I). Jull et al showed that manualdiagnosis by a trained manipulative ther-apist can be as accurate as radiologicallycontrolled diagnostic blocks in the diag-nosis of cervical zygapophysial syn-dromes". The symptomatic cervical mo-tion segment(s) found with symptomlocalization testing was then recorded.
A-P joint play testing was used toidentify UT segmental motion restric-tion^ This was performed with the pa-tient seated on the treatment table withthe arms folded across the chest. The cli-nician palpated with the index finger atthe interspinous space of the segment tobe tested. The remainder or proximalportion of the palpating hand providedstabilization caudal to the segment be-ing tested. The clinicians movement armwrapped around the patient's trunkand under the patients crossed armsallowing for contact on the anterior por-tion of the rib cage and opposite upperextremity. A-P translation was producedby the clinican's arm and chest move-ment"" (Figure 2). All subjects exam-ined presented with one or more levelsof restricted A-P translation. The hypo-mobile UT motion segment(s) was re-ct)rded tor each patient by the examin-ing OMPT.
The patient was then informed ofthe study and given detailed instructionsregarding the study timeline and partic-ipant responsibilities in addition to aninformed consent form to review andsign prior to participating in the study.The patient was not treated on the day ofthe initial examination nor was he or shegiven a home exercise program or seenby another practitioner prior to his orher first return visit. The first return visitwas scheduled one to two days after theinitial examination.
When the patient returned for thesecond visit, he or she was randomly as-signed to either the experimental group(EG) or control group (CG). Random-
FIGURE 2. AP joint piay ot the thoracic spine in sitting.
FIGURE 3. Translatoricspinal manipulation of thethoracic spine.
ization was performed via the use of anumbered and sealed envelope contain-ing a slip of paper indicating group as-signment as either EG or CG. The enve-lope was given to the treatment OMPTupon participant arrival. Envelope num-bers were recorded by the OMPT on alldata collection forms and on a mastersheet containing both envelope num-
bers and group assignment. This mastersheet was then stored in a locked con-tainer maintained at each data collec-tion site.
Three physical therapist assistants(PTAs), one at each outpatient clinic,collected the data for this study. EachPTA was trained in the use ot the CROMand was blinded to group assignment. In
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THE IMMEDIATE EFFECTS OF UPPER THORACIC TRANSLATORIC SPINAL MANIPULATION ON CERVICAL PAIN AND RANGE OF MOTION
an enclosed treatment booth, the PTArecorded CROM measurements for ac-tive left and right rotation and pain levelat end range of active cervical rotation inboth directions using a FPS. This pro-cess was performed for both the EG andCG. The PTA recording the measure-ments then left the hooth.
The OMPT then entered the boothand performed a bilateral translatoricfacet joint traction manipulation to thehypomobile UT intervertebral seg-ments''* (Figure 3). This TSM techniqueis a short, passive linear movement per-formed in a dorsal direction approxi-mately perpendicular to the plane ofthefacet joints and approximately parallel tothe plane of the UT intervertebral disc(IVD) joints at each level"''. The CG rece-ived no intervention to minimize non-specific effects of sham treatment andremained seated on the treatment tahlefor approximately the amount ot time itwould take for the TSM to be performed.The OMPT left the hooth, and the assi-stant who originally measured cervicalrotation with the CROM and collectedthe pain data on the FPS returned to thebooth and recorded these values in thesame manner as above. Patient partici-pation in this study was then concluded.
The effect ofthe TSM interventionon ROM and pain was analyzed using apaired f-test to analyze within-group
differences and a 2-way repeated-mea-sure analysis of variance (ANOVA) withintervention group (TSM versus con-trol) as the between-subjects variableand the time (baseline and follow-up) asthe within-subject variable. SeparateANOVAs were performed with ROMand pain (FPS) as the dependent vari-ables. For each ANOVA, the hypothesisof interest was the 2-way interaction(group X time). Data analysis was per-formed using SPSS 15.0. Statistical sig-nificance was accepted at the 0.05% levelof confidence. Further, analysis of theminimal detectable change at a 95%confidence interval was calculated usingthe formula MDC95 = 1.96 x V2 xSEM'^''- with SEM = SD X V(l-ICC)^
Results
Thirty-two subjects participated in thestudy, 6 males and 26 females with 22 inthe EG and U) in the CG. Three maleswere distributed to each group and 7 fe-males were distributed to the CG withthe remaining 19 distributed to the EG.The mean age (SD) of participants was34.2 years (9.56) for the CG and 35(10.51) for the EG. Descriptive statisticsin terms of age, initial rotation, and ini-tial FPS for both groups are listed inTable 1. Ofthe 32 participants, 10 hadpain with bilateral rotation, 11 had pain
with left rotation only, and 11 had painwith right rotation only. Levene's statis-tic revealed no violation in normalityand homogeneity of variance betweengroups for age, gender, rotation, FPS,and direction of symptoms. No candi-dates refused to participate in the study.
A paired f-test analysis revealed nosignificant within-group change in leftand right rotation in the CG (p = .52 and.90, respectively). Paired ^test analysisrevealedsignificantwithin-groupchangein left and right rotation in the EG (p <0.01 and < 0.01, respectively) (Tahle 2).The 2-way group x time interaction forthe repeated-measures ANOVA was sta-tistically significant for right rotation(p=.002) and left rotation (p=.OOl). Sub-jects in the TSM group experiencedgreater ROM with a mean (SD) increasein cervical right rotation of 8.23 (7.41)and left rotation of 7.09° (5.83°). TheMCD^^ was calculated using the be-tween-tester ICC reported hy Youdas etal and was .82 for left rotation and .92for right rotation. Based on these calcu-lations {Table 3), the changes in motiondetected within this study (7.09° for leftrotation and 8.23° for right rotation) ex-ceeded the MDC^. of 6.82° for left rota-tion and 5.79° for right rotation.
To analyze the effects of pain duringleft and right rotation, subjects weregrouped according to which direction
TABLE 1. Between-group comparisons for age and baseline ROM (in degrees) and FPS.
Age
Initial Left RotationROM
Inilial Right RotationitOM
Initial Pain withLeft Rotation
Initial Pain withiiighl Rotation
TSM - ExperimtTilal Group.
ControlTSM Group
ControlTSM Group
ControlTSM Group
ControlTSM Group
ControlTSM Group
Mean
34.2034.95
54.8058.95
55.8060.41
2.503.73
2.802.75
StandardDeviation
9.55510.513
12.65614.669
11.08415.271
2.8382.707
1.8892.671
StandardError
3.0212.241
4.0023.128
3.5053.256
.898
.577
.597
.570
95% ConfidenceInterval for Mean
LowerBound
27.3730.29
45.7552.45
47.8753.64
.472.53
1.451.57
UpperBound
41.0339.62
63.8565.46
63.7367.18
4.534.93
4,153.93
Min
1916
3017
3522
00
00
Max
5052
7078
7085
79
58
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THE IMMEDIATE EFFECTS OF UPPER THORACIC TRANSLATORS SPINAL MANIPULATION ON CERVICAL PAIN AND RANGE OF MOTION
TA B LE 2. Within-group comparisons of changes in cervical rotation
Control Group Left RotationTSMGroup Left Rotation
Control Group Right Rotation•I'SMGroup Right Rotation
Mean
-0.67.09
-0,18.23
Standard Deviation
3,665,83
2.337.41
(in degrees).
95% ConfidenceInterval ofthe Difference
Lower
-2.024.52
-1.574.94
Upper
3.229,68
1,7711.51
t
,5295.71
.1365.21
df
921
921
Sig. (2-tailed)
.626•<o.oi
.895•< 0.01
' Significant at a .05 level. TSM = Experimental Group,
TA B LE 3. Within-group comparisons of changes in pain reported during cervical rotation (measured using a 9-pointFaces Pain Scale).
Pain with RightRotation Only
Control Group Right Rotation'ISM Group Right Rotation
Pain with LeftRotation Only
Control Group Left RotationTSM Group Left Rotation
Pain duringBilateral Rotation
Control Group Right RotationTSM (iroup Right RotationControl Group Left RotationTSM Group Left Rotation
Mean
-.1001.50
.667
.688
-.5001.38-.5001.63
Standard Deviation
.2242.88
1.161.03
.7071.09.707
1.62
95% ConfidenceInterval of the Difference
Lower
-.378-1.52
-2.20-.176
-6.85.461
-6.85.270
Upper
.1784.52
3.541.55
5.852.295.852.98
t
-1.001.28
1.001.88
- !3.56
-12.84
df
45
27
1717
Sig. {2-tailed)
.37
.26
.42
.10
.50
*.O1.50
•.03
• Significant at a .05 level. TSM = Experimental Group.
provoked the pain (right, left, or bilat-eral). Paired (-test analysis for patientsexperiencing pain during right rotationonly (N = 5 for the CG and N = 6 for theEG) revealed no significant within-group difference for the EG or CG (p =.258 and .374, respectively) (Table 4). Nosignificant between-group differences
were noted upon repeated-measureANOVA for patients experiencing painwith right rotation only (p = .25).
Paired (-test analysis for patientsexperiencing pain during left rotationonly (N = 3 for the CG and N = 8 for theEG) revealed no significant witbin-group difference for the EG or CG (p
.10 and .42, respectively). No significantbetween-group differences were notedupon repeated-measure ANOVA for pa-tients experiencing pain with left rota-tion only (p = .98).
Paired /-test analysis for patientsexperiencing pain during bilateral rota-tion (N - 2 for tbe CG and N = 8 for the
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THE IMMEDIATE EFFECTS OF UPPER THORACIC TRANSLATORIC SPINAL MANIPULATION ON CERVICAL PAIN AND RANGE OF MOTION
TABLE 4. Reliability and responsiveness of inclinometer measurement ofcervical active range of motion in rotation.
ICC SD SEM MDC95
Right rotationLeft rotation
.92
.827.415.83
2.092.47
5.796.82
lCC=Intractass correlation coefficient; SD=Standard deviation; SKM^Standard t-rror of measurement;MDC95 =minimal detectable change at 95% confidence.
EG) revealed sigtiificant within-groupdilTerence for the EG during right andleft rotation (p = .01 and .03, respec-tively). No significant within-group dif-ference was revealed during paired f-testanalysis for the CG during right and leftrotation (p = .50 and .50, respectively).For this subgroup, a repeated-measureANOVA revealed significant between-group differences in pain during rightrotation (p = .05) but not during left ro-tation (p = .25). The EG's mean (SD)decrease in pain during right cervicalrotation was 1.38(1.1) and during leftrotation it was 1.63(1.6).
Discussion
The results from this study support thehypothesis that high-velocity manipula-tion of the thoracic spine may increasecervical spine rotation. All subjects inthe EG demonstrated an increase inpost-intervention active cervical rota-tion that exceeded the MCD,,_. Twelve ofthe twenty-two subjects in the EG dem-onstrated a range of active motion im-provement between 10' to 30 .
Pain levels perceived during post-intervention cervical rotation showedstatistically significant improvementduring right rotation for patients expe-riencing symptoms during bilateral ro-tation only. While this is in contrast totlie findings of other studies that de-tected significant reductions in pain fol-lowing thoracic manipulation, it shouldbe noted that tbese studies examinedpain at rest and not at end-range rota-tion. The only study that attempted toexamine changes in end-range pain useda case series design and did not detectsignificant end-range pain reductions^\
While there was a statistically sig-nificant decrease in pain during rightrotation, there remains a question re-
garding the clinical significance of thisfinding as there is no information re-garding the minimally clinically impor-tant difference (MCID) for the FPS. hshould be noted that post-interventionevaluation of pain level was taken at theend of any new or additional gains in ac-tive cervical rotation. As described inthe introduction, symptom localizationtesting was used to implicate the cervicalspine as the source of the patients' pain.It is our belief that treatment of the tho-racic spine may improve the movementavaiiabie in the cervical spine during ro-tation; however, it may not necessarilyreduce the reactivity of the cervicalsource of neck symptoms. Therefore, re-gardless of the increase in range, thepainful cervical source may be provokedat end range of rotation, hi our opinion,if the post-intervention pain rating hadbeen taken at the same point in tbe rangeof movement pre-intervention insteadof the end of the new ROM gained post-intervention, there would likely havebeen a greater decrease in pain thannoted in this study.
The limitations for this study in-clude the use of the FPS as opposed tothe numeric pain rating scale (NPRS).Ghilds'' has demonstrated that clini-cians could be confident that a 2-pointchange on the NPRS represents clini-cally meaningful change that exceedsthe bounds of measurement error. Thistype of analysis has not been performedfor the FPS. A second limitation relatesto a sample that was limited in number,age range, and gender (consisting pre-dominantly of females). Tiie number ofparticipants was particularly problema-tic when the groups were analyzed forcbanges in pain based on tbe directionof symptoms and resulting in smallnumbers of participants per group. Ad-ditional limitations of this study include
the lack of baseline demographics speci-fically in terms of acuity or chronicity ofsymptoms. Lastly, we cannot rule outany placebo effect that may have occureddue to manual contact being applied tothe manipulation group only.
Future research could explore theutility of the FPS for this type of researchin addition to establishing an MGID forthe scale. While a 9-point FPS was usedin this study, a new II-point FPS hasbeen shown to be valid and reliable andmore directly comparable to the NPRS,and it may also be a useful alternative totbe NPRS when applied to populationsof various educational and culturalbackgrounds'**. Future research couldincorporate a comparison between TSMversus a placebo treatment or a differentform of research-based manipulationapplied to hypomobile UT segments.Also, changes in rotation as a result ofUT manipulation could be analyzed andcompared between subjects with pain-dominant cervical motion limitationversus stiffness-dominant cervical mo-tion limitation. Lastly, future studiesshould directly compare UT manipula-tion for cervical pain and motion im-pairment versus manipulation ol symp-tomatic cervical segments.
Conclusion
There are numerous orthopedic manualphysical therapy treatment stratagiesthat can be used to assist patients in themanagement of painful movement im-pairments affecting their cervical spine.This study demonstrated that applica-tion of TSM to the UT segments mayalso be a useful treatment option forthe managment of the same. Gervicalrotation range of motion improved inall subjects following the application otthis form of manipulation to the UTsegments. No patient reported any in-crease in cervical symptoms post-manipulation.
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THE JOURNAL OF MANUAL & MANIPULATIVE THERAPY • VOLUME 16 • NUMBER 2 [99]
