Hello,
Reading through this paper and it brought up some thoughts with regards to the use of manual therapies to treat acute and chronic non-specific neck pain that I was hoping to share and get some feedback/discussion.
Maybe I am generalizing, but like many clinicians who are consumers of BBM and ClinicalAthlete content, I tend to shy away from manual therapies with the rationale that I run the risk of removing a patient’s internal locus of control and fostering dependency on myself as a provider, instead relying on exercise and education as my primary means of intervention.
This review provides solid evidence against passive modalities for the treatment of acute and chronic neck pain (electrical stimulation, laser therapy, acupuncture to name a few). But that’s not what I wanted to talk about.
What caught my eye was the use of manual therapies to treat neck pain. The authors did report that thoracic manipulation may provide a clinically important benefit in numeric pain rating, disability and perception of recovery for patients with acute neck pain compared to those who received an HEP and cervical non-thrust mobilizations (citing this study).
For chronic neck pain, they cited this study which showed no additional benefits in pain, disability, perception of benefit, or measures of ROM and strength when adding cervical and thoracic manipulation to a high dose exercise program.
Now, are these findings compelling enough for me to change my practice and approach for these patients? Probably not. That said, it does challenge my bias against manual therapies. Does the specific technique matter? No. Is the mechanism by which it has benefit likely placebo induced? Sure, the argument can be made that there is a placebo component to everything we do. Does that matter? I would think so, especially if one is supplying false or unhelpful narratives along with the treatment.
The biggest question I have that I hope for a helpful dialogue is: Do you or do you not provide manual therapies for patients who match these respective categories? Whether the answer is yes or no, what is the reasoning behind it?
Thanks!
First off, I appreciate your well thought out post, others feel free to chime in as well, but I will tell you my opinion on these studies and why they don’t move the needle for me
The first study the authors state this conclusion In the results “thoracic manipulation offers short-term benefits for pain” but has no other benefits noted for manipulation and states there are no long term difference, but still finished with the conclusion that manipulation is beneficial (only short term) I’m having trouble opening he article on my phone but I assume it’s cites the second study or the cleland work
The second study masaracchio/cleland study is a common one cited favoring thoracic manipulation, however if you read the method the researchers followed up after 2 treatments one week later with outcome measures forms. For me that is an example of someone a poor study that adds nothing even though its classified as a level 1 study since it’s an RCT
The third study concludes themselves “Supervised strengthening exercise with and without spinal manipulation performed similarly”
If A=A+B why do B? (Manipulation). We already know the placebo risks and that manipulation adds nothing else from multiple studies so why include it in my treatment? I would actually argue this article is actually a good argument proving not to do a manipulation
a 2019 meta analysis by Masarrchio (again) concluded thoracic spinal manipulation is no better than placebo thoracic spine manipulation, and while they only compared it against other manual therapy interventions to judge effectiveness (did not compare to exercise control - flawed design) and even they still concluded that the current research on thoracic spinal manipulation only shows short term benefits with no long term differences noted with weak to moderate evidence at best
Again just my thoughts, but none of these papers would do anything to change my treatment or approach, but I always enjoy looking at any new ideas and thanks for posting, others feel free to chime in as well
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@Keith_Kahil Thanks for the reply. I just pulled that 2019 meta analysis. Excited to read through it!
The first study the authors state this conclusion In the results “thoracic manipulation offers short-term benefits for pain” but has no other benefits noted for manipulation and states there are no long term difference, but still finished with the conclusion that manipulation is beneficial (only short term) I’m having trouble opening he article on my phone but assume it’s cites the second study or there cleland work
Correct, this is a systematic review which cited the Masaracchio study.
The second study masaracchio/cleland study is a common one cited favoring thoracic manipulation, however if you read the method the researchers followed up after 2 treatments one week later with outcome measures forms. For me that is an example of someone a poor study that adds nothing even though its classified as a level 1 study since it’s an RCT
This is a huge flaw of the study IMO. The authors justified it by saying they did so to minimize attrition rate. But really, giving an NDI a week apart would almost never happen in a clinical scenario. Merely to play devil’s advocate, could a clinician not justify the use of thoracic manipulation for acute neck pain for the reason that it may provide short term belief, regardless of the mechanism of action? And if there is no harmful or false narrative coupled with it, and the patient goes home happy, really what’s the harm?
Having said that (and to argue against my own counterpoint lol) I would have a hard time getting behind that argument, as I am not so sure that it would be more effective than just providing reassurance to someone and fostering independence. Anecdotal disclaimer here, but FWIW colleagues I have worked with in the past who would rely heavily on manipulations as part of their treatments did tend to have patients return a substantial portion of the time for a “tune up…” :shrug:
You both sound like you’d enjoy this article:
https://thesports.physio/2019/03/07/abandoning-manual-therapy/
I most likely agree with both of you on the use of manual therapy. I’ve been trained in the osteopathic, Maitland, Mulligan manual therapy applications. Actually taught mobilization and manipulation as a teaching assistant and to clinicians early on. Came out of school cracking folks daily thinking I was the reason for their success (I wasn’t). The manual therapy I find most effective includes a nice hand shake, a hands on physical examination (not to palpate for asymmetries, but folks appreciate someone willing to push on a painful area to feel validated) and the occasional movement of the painful region (again not in the dogmatic manual therapists line of thinking, more like PROM or just having a hand on a knee while they move it).
If you’ve never been through the research process, try not to fault the researchers in their research. It is a very challenging, complicated, red tape loaded, financially and time consuming process. Not only that, the articles you cite are done in clinical environments. I see how difficult it is on a weekly basis where I work to collect clean data and uphold the research methods.
In many cases each research article is intentionally leading into another question. So while the initial research may not be so clinically useful, the long term may bear some importance.
For example:
Patient: Patient with neck pain
Intervention: Thoracic manipulation
Comparison: Wait list
Outcome: 4 week NPRS
Next study may use thoracic manipulation vs sham/placebo
Next study may use TM vs exercise
Next study may use TM vs cervical manipulation
These may allow the researchers to track the outcomes into 6, 12 and 24 months, where we may get a more accurate representation of the effectiveness in the clinical environment.
Thanks for the article, I’ll take a look at it, I think it’s clear all 3 of us are on the same page in regards to manual therapy.
I’ve been out of PT about 9 years and participated in research during and after school and you are right on @Matthew_Rupiper_PT - Research is a huge pain and tied in red tape if you want to get it published somewhere (which everyone does) That being said I don’t need to read your study with a one week follow up that then gets cited as evidence to use a technique by other authors
-Agree with you 100%; providing reassurance and independence is the goal for our patients here
Cue @Michael_Ray to unload on somebody due to the body as car reference here