STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. BACKGROUND: Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain. METHODS: Patients completed the Neck Disability Index, the numeric pain rating scale, the flexion-rotation test for measurement of C1-2 passive rotation range of motion, and the craniocervical flexion test for measurement of deep cervical flexor motor performance. Following the baseline evaluation, patients were randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines. Patients were reexamined 48-hours after the initial examination and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance (ANOVA). RESULTS: One hundred seven patients satisfied the eligibility criteria, agreed to participate, and were randomized into the HVLA thrust manipulation (n = 56) and nonthrust mobilization (n = 51) groups. The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly (P<.001) greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly (P<.001) greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization. The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up, using the global rating of change and Neck Disability Index cut scores, respectively. CONCLUSION: The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2012;42(1):5-18, Epub 30 September 2011. doi:10.2519/jospt.2012.3894

KEY WORDS: high-velocity low-amplitude thrust, mobilization, neck pain, spinal manipulation

STUDY DESIGN: Case series. BACKGROUND: Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period. CASE DESCRIPTION: Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks. OUTCOMES: Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least “moderately better.” At 6 weeks, 6 of 10 patients had a successful (mean ± SD) DASH outcome score (initial, 33.9 ± 16.2; 6 weeks, 8.1 ± 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 ± 14; 12 weeks, 8.3 ± 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients). DISCUSSION: A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):474-493. doi:10.2519/jospt.2010.3223

KEY WORDS: manipulation, pain, rotator cuff, shoulder, supraspinatus