The Immediate Effects of Thoracic Transverse Mobilization in Patients With Primary Complaint of Mechanical Neck Pain: A Pilot Study
Condition: Mechanical Neck Pain
MeSH terms: Neck Pain
Study type: Interventional

Summary: 
      The purpose of this study was to explore the immediate effects of transversrse vertebral
      pressures (TVP) to the thoracic spine on cervical range of motion and pain in subjects with
      neck pain,
    

Detailed description: 
      Recruitment was by convenience sampling via referrals from local physical therapists and
      flyers posted on a university campus. Participants were assigned to either a transverse
      vertebral pressures mobilization group or a control group. Inclusion criteria for the
      mobilization group were 1) ages 18 to 60, and 2) mechanical neck pain defined as pain
      exacerbated by movement. Among the exclusion criteria were unexplained night pain,
      unexplained weight loss, numbness and tingling in the arms and/or legs, balance or
      coordination problems, morning stiffness lasting greater than one hour, a history of whiplash
      injury within six weeks of treatment, diagnosis of osteoporosis, symptoms suggestive of nerve
      root compression, prior cervical or thoracic spine surgery, or a pending legal action.
      Inclusion criteria for the control group were 1) ages 18 to 60, and 2) asymptomatic neck and
      thoracic regions over the previous six years by subject report. The latter group was labeled
      "control" in the sense that it allowed blinding of the rater rather than in the sense of a
      sham treatment group. The project was approved by the University of Puget Sound Institutional
      Review Board, and written informed consent was obtained from all the subjects.

      Outcome Measures Outcomes of interest were active neck motion, pressure pain threshold (PPT)
      and report of pain. For active range of motion, a single bubble inclinometer (MIE
      Inclinometer, Medical Research Ltd, London, UK) was used to measure flexion, extension, and
      side-flexion with the subjects seated. Since measurement of rotation by inclinometer would
      introduce a change from the sitting position, a universal goniometer was chosen to measure
      rotation. De Koning et al conducted a systematic review of seated inclinometry for
      quantifying active cervical ROM. Interrater intraclass correlation coefficients (ICCs) for
      flexion, extension and lateral flexion varied from 0.81 to 0.94 for healthy subjects and from
      0.68 to 0.86 for those with neck pain. Among patients with mechanical neck pain, ICCs for
      cervical rotation using the universal goniometer in sitting have been reported as 0.77 to the
      right and 0.57 to the left.12 In order to consider a motion to have changed, we required
      statistical significance at ≤ 0.01 and a difference in degrees of ≥5. Before commencing the
      study, one researcher participated in a training session followed by intra-rater reliability
      testing for all ROM measurements.

      PPT, the minimum pressure that induces pain, was measured at the right lateral epicondyle
      using a hand-held digital algometer (Model FPX 25, Wagner Instruments, Greenwich CT.) Three
      measurements were taken separated by 10 second intervals, and the mean of these trials was
      used for analysis. Good to excellent reproducibility, intra-rater and inter-rater
      reliabilities for PPT have been reported.13-15 However, Prushansky et al reported a
      significant difference between raters which prompted the recommendation that PPT measurement
      should be performed by the same rater when utilized as an outcome measure. We followed this
      recommendation.

      An 11-point numerical pain rating scale (NPRS) was used to assess pain before and after the
      intervention. Cleland et al reported the psychometric properties of the NPRS specific to neck
      pain in a cohort of 137 patients. Test-retest reliability was moderate (ICC=.76; CI,
      .51-.87). The minimum clinically important difference for neck pain in his study was a change
      of 1.3 points. In our study, we selected a requirement of a 1.5-point change for clinical
      importance.

      Study Protocol After determining eligibility, baseline ROM and PPT scores were taken by one
      blinded rater, and subjects completed an NPRS. The mobilization group was treated with
      non-thrust transverse vertebral pressures as described by Maitland. The patient lay prone
      with arms to the side and in a "forehead rest position". Pressures were applied to spinal
      levels T1 through T4. The spinous process of T1 was identified by first locating C6 using the
      cervical extension method17 and then counting caudally. The researcher stood at the level of
      the vertebra to be mobilized on one side of the subject. The pad of the researcher's
      non-dominant thumb was placed in contact with the lateral aspect of the spinous process of
      T1, while the dominant thumb was placed on the dorsal side of the other thumb. Pressure was
      applied to the spinous process to produce small amplitude, low velocity oscillation into
      resistance to the end-range of the vertebra (Grades IV to IV+). This procedure was performed
      for 30 seconds, then sequentially applied to the next caudal level through T4. The same
      pattern of application was used on the subject's contralateral side. The entire procedure was
      repeated once again for a total of 8 minutes. This was followed by a repeat of the outcome
      measurements. The control group received no treatment. Each control subject assumed the same
      prone position for 8 minutes as was used with the mobilization group and outcome measurements
      were repeated. The researcher performing the outcome measurements was blinded to group
      assignment. All subjects were clothed such that no localized residual evidence of thoracic
      manual contact was visible.

      Statistical Analyses Data were analyzed with SPSS, Version 14.0 (SPSS, Inc, Chicago IL). We
      compared pre-intervention data between the transverse mobilization group and the control
      group utilizing independent t-tests for ROM and PPT, and the Mann-Whitney test for NPRS
      scores. We compared pre and post session measurements within each group utilizing paired
      t-tests for ROM and PPT, and the Wilcoxon signed-ranks test for NPRS scores.
    

Intervention name(s): Transverse vertebral pressures
Intervention type(s): Other
Intervention description(s): Graded transverse mobilization directed to the thoracic spine
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: neck pain; transverse vertebral pressures; thoracic mobilization