PT Critically Appraised Topics

Document Type

Critically Appraised Topic

Publication Date


Clinical Scenario

The patient who led me to pursue this question was a 27 year old female suffering from neck pain, headaches, thoracic outlet syndrome, and carpal tunnel syndrome. She was referred to physical therapy by her doctor for a cervical strain evaluation and treatment. Her primary impairments were decreased cervical active range of motion (AROM) with pain at end ranges, headaches, and increased muscle tension. She woke up with neck symptoms approximately one month ago and simply attributed it to an awkward sleeping position and stress. She sought relief via massage twice and was waiting for it to resolve with time. She is now seeking physical therapy since her symptoms were not improving and began interfering with function.

Clinical Question

Is thoracic spine manipulation in addition to standard care more effective in the treatment of adults with insidious onset neck pain than standard care alone?

Clinical Bottom Line

Based on the results of the studies by Gonzalez-Iglesias et al. and Krauss et al., the use of thoracic thrust manipulation is an effective treatment for decreasing pain and increasing cervical range of motion in adults with acute mechanical neck pain. Both studies were randomized controlled trials with PEDro scores of 9/10 and 8/10, respectively. Only the study by Krauss et al. had limited internal validity due to lack of subject blinding. Results cannot be generalized to any patients with whiplash or complications such as cervical surgery or radiculopathy due to the exclusion criteria in both studies. Both studies demonstrated increased cervical range of motion in the manipulation group but not the non-manipulation group immediately after treatment (Krauss et al., 2008) and at a two-week follow-up (Gonzalez-Iglesias et al., 2009). Regarding pain outcomes, there was some discrepancy. Gonzalez-Iglesias and colleagues demonstrated decreased pain greater than the minimum clinically important difference (MCID), but Krauss and colleagues did not demonstrate any decrease in pain. The study by Gonzalez-Iglesias et al. had the higher PEDro score, larger sample size, and longer term analysis. Thus, it can be concluded that thoracic thrust manipulation as performed in the study by Gonzalez-Iglesias et al. results in a clinically significant decrease in pain and increase in cervical ROM in adults with acute mechanical neck pain. More research is needed to determine the amount of training required to perform thoracic thrust manipulations effectively. It would also be interesting to determine if thoracic manipulations are effective for patients who have had whiplash but are no longer in the acute phase and have had imaging to rule out serious pathology.