Effectiveness of Thoracic Spine Manipulation on the Management of Neck Pain: A Systematic Review and Meta-Analysis of Randomized Control Trials

Figures & data

Table 1 The Literature Search Strategy

Data Base	Search Strategy
PubMed	“chronic neck pain” OR “mechanical neck pain” OR “cervical pain” AND “spinal manipulation” OR “TSM” OR “thrust manipulation” OR “high-velocity thrust manipulation” OR “thoracic vertebrae” AND “clinical trial” OR “randomized” OR “placebo” OR “RCT”AND “humans”.
CINAHL	“neck pain” OR “cervical pain” AND “thoracic spinal manipulation” OR “thrust manipulation” OR “high-velocity thrust manipulation” AND “thoracic vertebrae” AND “Clinical trial” OR “randomized” OR “placebo” OR “RCT”.
Cochrane Library	“Mechanical neck pain” OR “cervical pain” OR “neck pain” AND “thoracic spinal manipulation” OR “thrust manipulation” OR “high-velocity thrust manipulation” OR “thoracic manipulation” AND “Clinical trial” OR “randomized” OR “RCT”.
PEDro	“Mechanical neck pain” OR “neck pain” AND “thoracic manipulation” AND “clinical trial OR” “RCT”

Table 2 Quality of Articles (PEDro Scale)

PEDro criteria	Lau et al^Citation20	Martínez et al^Citation26	Suvarnnato et al^Citation25	Salom-M et al^Citation21	Puntumetakul et al^Citation22	Pires et al^Citation27	Yang et al^Citation24	Lee and Kim^Citation23
1. Eligibility*	Yes	Yes	No	Yes	No	Yes	Yes	No
2. Randomization	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
3. Concealed allocation	Yes	Yes	Yes	Yes	No	Yes	No	No
4. Baseline comparability	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
5. Blind subject	No	No	No	No	No	Yes	No	No
6. Blind therapist	No	No	No	No	No	No	No	No
7. Blind assessor	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
8. Adequate follow-up	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
9. Intention-to-treat analysis	Yes	No	No	No	No	No	No	No
10. Between-group comparisons	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
11. Point estimate variability	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Total score	8/10	7/10	7/10	7/10	6/10	8/10	4/10	6/10
Study quality	High	High	High	High	Fair	High	Poor	Fair

Note: *Criterion 1; is not used to calculate the total PEDro score.

Figure 1 Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) flow diagram of study selection.

Table 3 Characteristics of the Included Studies

Study	Participants	Outcome Measures	Intervention	Comparison	Follow-Up	Result
Lau et al, 2011^Citation20	n =120 Age=18–55 Patients with chronic mechanical pain	NPRS,	TM (anteroposterior approach in supine lying) including 8 sessions (2/week) of infrared radiation therapy (IRR) for 15 min over the painful site.	Received 8 sessions (2/week) of the same IRR and the same set of educational materials.	Immediately, 3-months and at a 6-month	TM showed significantly greater improvement in pain intensity by decrease in NPRS ranged from 34.4% to 40.6% in the TM group, Between-group comparison by ANOVANPRS (95% CI: 3.33–4.05) and NPQ (95% CI: 28.58–34.52 than the control group immediately post-intervention.
Martínez et al, 2012^Citation26	n = 90 Age = 18–65 Patients with bilateral chronic mechanical pain	NPRS	A high-velocity, end-range, AP thrust applied through the elbows to the upper thoracic spine on the mid-thoracic spine in cervicothoracic flexion was applied	Allocated to cervical manipulation on the right and left side,	10 minutes	No significant interactions were found with the mixed-model analyses of covariance for neck pain intensity with in group mean difference and 95% CI=2.8 (2.2, 3.3)
Suvarnnato et al, 2013^Citation25	n =39 Age =18–60 patients with chronic mechanical neck pain	VAS	Single-level thoracic manipulation; thoracic manipulation (screw thrust technique) at both zygapophyseal joints of T6-T7.	Sham (Control group; Hand placement without compressive pressure on the joints for a total of 2 minutes).	Immediate and 24 hours	Thoracic manipulation significantly decreased VAS pain ratings with Means (SD) from 45.08(18.87) during pretest to 37.46 (19.57) immediate and 35.92(19.77) 24- hour follow-ups
Salom-M et al, 2014^Citation21	n=52 Age =18–60 Patients with chronic mechanical neck pain	NPRS	Middle thoracic spine thrust manipulation. high-velocity, end-range, AP thrust applied through the elbows to the mid-thoracic spine	20-second bouts of grades III to IV of central PA non–thrust mobilization from T3 to T6 spinous process	Immediate, 01 week	Patients receiving thoracic spine thrust manipulation experienced a greater decrease in neck pain (between-group mean difference: 1.4; 95% CI, 0.8–2.1) than did those receiving non–thrust mobilization (P=0.001). Within-group effect sizes were large for both groups (SMD=2.1), and the between-group effect size was also large (SMD = 1.3) in favor of the manipulative group.
Puntumetakul et al, 2015^Citation22	n =48 Age =18–59 Patients with chronic mechanical pain	VAS, and (NDI-TH)	Multiple-level thoracic manipulation (MTM)sides of the respective zygapophyseal joint	Sham (The therapist’s hands were placed without any treatment).	24-hour and 1-week	Neck disability significantly improved 10.38 and 95% CI (4.21–14.81) and 1-week 12.38 (5.85–16.71). Pain levels in the MTM groups decreased compared with the control group with a 24-hour MD 1.96 and 95% CI (1.04, 2.95), and 1-week follow-up 2.53(1.44, 3.71)
Pires, et al, 2015^Citation27	n=32 Age =18–39	VAS	Upper thoracic spine manipulation, immediately below the first thoracic vertebra (T1), lasted 2 minutes	Placebo group were placed in the same position, except that the therapist’s hand was open and not in the pistol grip, lasted 2 minutes	Immediate and 48–72 hours	No statistically significant differences were found for pain intensity analyzed in the intergroup comparisons in VAS mean and 95% CI of 0.18 (−1.52 to 1.89); P = 0.64.
Yang et al, 2015^Citation24	n=30 Age= not stated Patients with chronic mechanical neck pain	VAS	Upper thoracic manipulation after cervical stability training. The intervention consisted of three sessions a week, each of which lasted for 30 minutes.	Stability training was conducted for the cervical stability training group. The intervention consisted of three sessions a week, each lasted for 30 minutes	6 weeks	The posttest mean (SD) result showed pain decreased in Manipulation group 1.93 (0.70) and control group 3.40 (0.74)
Lee and Kim, 2016^Citation23	n =46 Age = 18–60 Patients with neck pain	VAS, K-NDI	TM + Craniocervical deep flexor exercise; 35 minutes a day, 3 days a week for 10 weeks.	Craniocervical deep flexor exercise; 35 minutes a day, 3 days a week for 10 weeks	10 weeks	Pain intensity significantly decreased in the group TM combined with DCF training mean difference and SD (−3.8±0.6), and NDI (−21.0±3.6) than DCF only.

Table 4 GRADE Evidence Profile of Individual Articles

Study	Risk of Bias	Inconsistency	Indirectness	Imprecision	Publication Bias	Quality
Lau et al, 2011^Citation20	Pain (follow-up 6 months; measured with PNRS)
	No serious	No serious	No serious	No serious	Undetected	High
	Neck disability (follow-up 0–6 months; measured with NDI)
	No serious	No serious	No serious	No serious	Undetected	High
Martínez et al, 2012^Citation26	Pain (follow-up 1 day; measured with: NPRS)
	Serious^a	No serious	No serious	No serious	Undetected	Moderate
Suvarnnato et al, 2013^Citation25	Pain (follow-up 24 hours; measured with VAS)
	No serious	No serious	No serious	Serious^d	Undetected	Moderate
Salom-M et al, 2014^Citation21	Pain (follow-up 0–1 weeks; measured with NPRS)
	Serious^a	No serious	No serious	No serious	Undetected	Moderate
Puntumetakul et al, 2015^Citation22	Pain (follow-up 1 week; measured with VAS)
	Serious^a	Serious^b	No serious	No serious	Undetected	Low
	Neck disability (follow-up 1 week; measured with NDI)
	Serious^a	Serious^b	No serious	Serious^d	Undetected	Low
Pires, et al, 2015^Citation27	Pain (follow-up 72 hours; measured with VAS)
	No serious	No serious	No serious	No serious	Undetected	High
Yang et al, 2015^Citation24	Pain (follow-up 6 weeks; measured with VAS)
	Serious^a,b	Serious^c	No serious	No serious	Undetected	Low
Lee and Kim, 2016^Citation23	Pain (follow-up 10 weeks; measured with VAS)
	Serious^a,b	Serious	No serious	No serious^c	Undetected	Low
	Neck disability (follow-up mean 10 weeks; measured with NDI)
	Serious^a,b	Serious	No serious	Serious^c,d	Undetected	Low

Notes: ^aPerformance bias (therapist and participant not blinded). ^bAttrition, and selection bias. ^cStudies contained small sample sizes. ^dStudies have wide confidence intervals.

Table 5 GRADE Overall Evidence Profile

Participants (Studies) Follow-Up	Risk of Bias	Inconsistency	Indirectness	Imprecision	Publication Bias	The Overall Quality of Evidence
Pain (measured with NPRS)
232 (5 studies) 0–6 months	No serious risk of bias	Serious^a	No serious indirectness	No serious imprecision	Undetected	MODERATE^a due to inconsistency
Pain (measured with VAS)
89 (3 studies) 0–6 months	Serious^b	Serious inconsistency^a,c,d	No serious indirectness	Serious^c	Undetected	LOW^a,b,c,d due to risk of bias, imprecision
Disability (measured with NDI)
183 (3 studies) 0–6 months	No serious risk of bias	Serious^a	No serious indirectness	Serious^e	Undetected	LOW^a,e due to inconsistency, imprecision

Notes: ^aDosage of the intervention varied across studies. ^bStudies demonstrated the risk of bias associated with performance, attrition, and selection bias. ^cStudies contained small sample sizes. ^dDosage of the intervention varied across studies. ^eStudies have wide confidence intervals.

Figure 2 A meta-analysis on the effect of thoracic spine manipulation (TSM) for pain using visual analog scale (VAS).

Figure 3 A meta-analysis on the effect of thoracic spine manipulation (TSM) for pain using numeric pain rating scale (NPRS).

Figure 4 A meta-analysis on the effect of thoracic spine manipulation (TSM) on neck disability.

Lau HMC, Chiu TTW, Lam T-H. The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain–a randomized controlled trial. Man Ther. 2011;16(2):141–147. doi:10.1016/j.math.2010.08.003

 PubMed Web of Science ®Google Scholar

Martínez-Segura R, de-la-Llave-Rincón AI, Ortega-Santiago R, et al. Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2012;42(9):806–814. doi:10.2519/jospt.2012.4151

 PubMed Web of Science ®Google Scholar

Suvarnnato T, Puntumetakul R, Kaber D, et al. The effects of thoracic manipulation versus mobilization for chronic neck pain: a randomized controlled trial pilot study. J Phys Ther Sci. 2013;25(7):865–871. doi:10.1589/jpts.25.865

 PubMed Web of Science ®Google Scholar

Salom-Moreno J, Ortega-Santiago R, Cleland JA, et al. 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. J Manipulative Physiol Ther. 2014;37(5):312–319. doi:10.1016/j.jmpt.2014.03.003

 PubMed Web of Science ®Google Scholar

Puntumetakul R, Suvarnnato T, Werasirirat P, et al. Acute effects of single and multiple level thoracic manipulations on chronic mechanical neck pain: a randomized controlled trial. Neuropsychiatr Dis Treat. 2015;11:137. doi:10.2147/NDT.S69579

 PubMed Web of Science ®Google Scholar

Pires PF, Packer AC, Dibai-Filho AV, et al. Immediate and short-term effects of upper thoracic manipulation on myoelectric activity of sternocleidomastoid muscles in young women with chronic neck pain: a randomized blind clinical trial. J Manipulative Physiol Ther. 2015;38(8):555–563. doi:10.1016/j.jmpt.2015.06.016

 PubMed Web of Science ®Google Scholar

Yang J, Lee B, Kim C. Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation. J Phys Ther Sci. 2015;27(3):795–798. doi:10.1589/jpts.27.795

 PubMedGoogle Scholar

Lee K-W, Kim W-H. Effect of thoracic manipulation and deep craniocervical flexor training on pain, mobility, strength, and disability of the neck of patients with chronic nonspecific neck pain: a randomized clinical trial. J Phys Ther Sci. 2016;28(1):175–180. doi:10.1589/jpts.28.175

 PubMedGoogle Scholar