Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. Randomized controlled trial

Abstract

Background: Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction.

Purpose: To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction.

Methods: Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0-10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise.

Results: The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range: 0.003-0.000).

Conclusion: Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

Keywords: Manipulation; Neck pain; Physical therapy; Physiotherapy; Training.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021 Rodríguez-Sanz et al.

Figures

Figure 1. (A) Deep neck flexor. Subjects were instructed to “gently nod their head as though they were saying yes”. The physical therapist identified the target level that the subject could hold steadily for 10 s without use of the superficial neck flexor muscles using the craniocervical flexion test. Contribution from the superficial muscles was monitored using observation and palpation. Training was started at the target level the subject was able to achieve with a correct craniocervical flexion. The subjects were taught to perform a slow and controlled craniocervical flexion action. For each target level, the contraction lasted for 10 s, and the subject trained until able to perform 10 repetitions. At this stage, the exercise moved to the next target level16. (B) Deep neck extensors. The patient tucked their chin towards their chest slightly, and maintaining their chin in this position while gently extending their neck20. (C) Craniocervical flexion. Subjects were instructed to initiate the movement with a deep neck flexor contraction. Then they flexed the whole cervical column by lifting the head off the table7. (D) Extensors with resistance. The exercise is performed in a way similar to exercise “B” adding an external resistance to increase the intensity of the exercise20.

Figure 2. (Aa) C0-1 Traction manipulation in the resting position. Patient was in supine with neck in neutral position. The therapist gently cupped the patient’s chin with their hand while their arm was cradled around the head. The other hand placed the radial side of the index finger under the mastoid process and aligned the forearm in the line of drive pointing cranially. Then the therapist applied a cranial thrust41,20,8. (Bb) C1-2 Traction manipulation in the resting position. The same handling procedure was performed but the grip was relocated in the atlas vertebrae41,20,8. (Cc) C2-3 Traction manipulation in the resting position. The same handling procedure was performed but the grip was relocated in C3 vertebrae41,20,8. (Dd) C0-1 Dorsal mobilization. Patient was positioned in supine, with neck in neutral position. The therapist placed a hand dorsally at the level of the vertebral arch of C1 with the metacarpophalangeal and radial border of the index finger. The other hand was placed posteriorly under the occiput, with the shoulder positioned anteriorly on the patient’s forehead. The mobilization force was directed dorsally from the shoulder until the therapist felt a marked resistance, and then slightly more pressure was applied to perform a stretching mobilization46,34,40.

Figure 3. CONSORT.

(Consolidated standards of reporting trial) flow diagram.

Figure 4. Neck disability index outcomes.

Figure 5. Pain intensity NPRS means (0–10).