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Manipulative treatment in neck pain

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Manual Therapy, Posturology & Rehabilitation Journal. ISSN 2236-5435. Copyright © 2016. This is an Open Access article
distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-
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Effect of manipulative treatment in patients with mechanical
neck pain: a systematic review
Jossandra Cássia de Maria Alves Teles1,3, Daniel Nunes de Oliveira1,3, Antônia Vitória Silva Mota1,3,
Patrícia Xavier Lima Gomes2,3, Francisco Fleury Uchôa Santos-Júnior1,2, 3.
ABSTRACT
Introduction: The neck pain especially of mechanical origin (related to the joints of the spine) interfere in health and qualit y of life
of individual widely affecting the population. Objective: Analyze through a systematic review the effectiveness of manipulation as a
therapeutic tool in neck pain. Method: The search was performed using the following databases: Scientific Electronic Library Online
(SCIELO), Virtual Health Library (BIREME), PubMed (MEDLINE) and Google Scholar with the descriptors “Cer vical manipulation”, as well
as associated with the word “joint, in the last 14 years (2001 to 2015). The search resulted in 446 ar ticles of which 49 were selected for
reading the full text, but only 10 articles contemplated the methodological criteria. There were included studies that approach about
the neck pain, using manipulation associated with physiotherapy techniques. Reviews, master and doctoral thesis and Completion
of Course Work were excluded, as well as studies involving animals. Results: The articles included in this study were submitted to
methodological quality analysis of the PEDro scale, in which all items have average higher than or equal to six. The sample size ranges
from 6 to 96 subjec ts with age between 18 and 65 years old. Regarding the gender of patients the prevalence was 35.71% for males and
64.28% for females, being this one predominant in the studies included in the research. The majority of the evaluated articles proved
to be favorable to cervical manipulation with improvement of pain in 48.9% of patients in primary care and about 75% decreased in
6 months, as well as improvement of functional limitation. Conclusions: The cervical manipulation proved to be an important and
effec tive technique in the treatment of mechani cal neck pain, because it can mi nimize the painful condition and restor e range of motion.
Keywords: Spinal manipulation, Physiotherapy, Osteopathic Medicine.
Corresponding author: Name: Francisco Fleury Uchoa Santos-Junior Telephone: +55 (85) 3201-2400 Address: Rua Av Aguanambi, N° 251, CEP 60055-400,
Fatima, Fortaleza – Ceara E-mail: dreuryjr@gmail.com
1 Faculdade Mauricio de Nassau (UNINASSAU), Fortaleza (CE), Brazil.
2 Centro Universitário Estácio do Ceará (Estácio), Faculdade Mauricio de Nassau, Fortaleza (CE), Brazil.
3 “Mouvement” research group, Fortaleza (CE), Brazil.
Financial support: There was no nancial support for this study.
Submission date 15 May 2016; Acceptance date 5 August 2016; Publication online date 22 August 2016
http://dx.doi.org/10.17784/mtprehabjournal.2016.14.318
INTRODUCTION
Neck pain is a musculoskeletal problem that compromises
the health, the quality of life of individuals (1) and widely aects
the populaon and can be acute or chronic. According to the
World Health Organizaon (WHO), 50% of adults suer from
neck pain at some point in their lives. (2) Among the most
common condions t the whiplash injury, cervical muscle
spasm, dysfuncons with impairment of the upper limbs and
mechanical derangements. (3)
The origin of neck pain is mulfactorial and may be related
to repeve movements, lack of breaks at work, stac jobs
keeping the head and/or arms in the same posion for too
long. (4-5) Regarding the clinical features of the paents, they
can report pain associated or not to a strength decit in the
exor and extensor muscles of the cervical region, (6) limited
range of moon and increase in muscle fagability. (7) Neck
pain can be related to sudden or abrupt movements, long stay
in a forced posion, stress or trauma, and can be dened as
a pain on the back of the neck and upper shoulder blade or
upper dorsal, which is not accompanied by characterisc signs
of the radiculopathy. (8, 9, 10)
One of the neck pain treatment ways is through techniques
related to physiotherapy, for example: in cases of mechanical
neck pain, the Positional Release Therapy (PRT), which
aims at the harmonizaon of the musculoskeletal system,
approaching passively origin and muscle inseron with specic
placement of body segments, with the nality of reduce the
pain, normalize the myofascial tension, relax the periarcular
ssues and improve the circulaon. (11) Therefore, manipulaon
of the spine can be set as a manual applicaon technique of
a physical impulse performed in a short period of me, that
is, high speed and low amplitude. These movements and
applied forces are generated to cause vertebral displacement
within physiological limits of movement modifying the local
stress. (12) The objecve of the present study is to analyze the
eecveness of manipulaon as a therapeuc tool in neck
pain.
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Manipulative treatment in neck pain MTP&RehabJournal 2016, 14: 318
METHOD
Eligibility Criteria
The study included arcles that approached manipulaon
of the cervical spine with the use of high speed and low
amplitude techniques related to range of moon disorders.
In this study were excluded clinical trials that did not report
diseases involving cervical joint, the ones that had absence
of clinical trials randomized without amounts of group of
parcipants, as well as reviews, master and doctoral thesis,
compleon of course work and studies involving animals.
Search strategy and selection of the study
The search was performed using the following electronic
databases in the last 14 years (2001 to 2015): Scienc Electronic
Library Online (SCIELO), Virtual Health Library (BIREME),
PubMed (MEDLINE) and Google Scholar. The researches were
realized between March and May 2015 and comprehend the
following descriptors: “Cervical manipulation” isolated or
associated with the word joint. The arcles were repossessed
in English and Portuguese.
Data extraction
Initially in Figure 1, by placing the descriptors in the
databases were found 446 articles, in which: Scientific
Electronic Library Online (SCIELO) with n=274; PubMed
(MEDLINE) with n=21; LILACS with n=19; Virtual Health Library
(BIREME) with n=26; Google Scholar with n=106. Shortly aer
a thorough reading of the abstracts of the studies, 436 were
excluded because they did not include the established
methodological criteria. In total were read 10 papers in full.
The overall quality of the articles was analyzed according
to the evaluation items of the Physiotherapy Evidence
Database-PEDro scale.
Figure 1. Flowchart of the studies included in the research.
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Teles JCMA et al.
MTP&RehabJournal 2016, 14: 318
This scale has 11 items for assessment of PEDro table and
for beer classicaon of arcles was applied specic result,
according to the table criteria. Each sased item (except the
rst) contributes one point to the total score of the scale.
The nal score is obtained by the sum of all posive responses,
and those that have average equal or higher than ve on the
scale were considered of high methodological quality.
Following are described the aspects analyzed by PEDro
table as criteria to be followed to evaluate the studies.
1. The eligibility criteria were specified. 2. The subjects
were randomly allocated to groups (a crossover study, the
subjects were placed randomly into groups according to
the treatment received). 3. The allocaon of subjects was
secret. 4. Inially, the groups were similar in regard to most
important prognosc indicators. 5. All subjects parcipated
in the study blindly. 6. The therapy was administered blindly
by all therapists. 7. All assessors who measured at least one
key outcome did it blindly. 8. Measurements of at least one
key outcome were obtained in more than 85% of the subjects
inially distributed between the groups. 9. All subjects who
presented measurements of results received the treatment or
control condion as allocated, or when this was not the case,
the analysis was made for at least one of the key outcome by
“intent treatment”. 10. The results of stascal comparisons
intergroup were described for at least one key outcome.
11. The study presents both precision measures as variability
measures for at least one key outcome.
RESULTS
The table 1 presents the main data as author and year,
objecve of the study, intervenon, results and outcome.
The sample size ranges from 6 to 96 subjects with age between
18 and 65 years old. Regarding the gender of paents the
prevalence was 35.71% for males and 64.28% for females,
being this one predominant in the studies included in the
research.
In Table 2 contains information about methodological
quality using the PEDro scale, which can be evidenced that all
the items included in this study underwent this legimacy, and
according to the classicaon all of them had average higher
or equal to six, in which 33.3% of these score six, 41.62% score
seven and 24.97% score eight. Therefore, all items had a good
methodological quality.
Table 1. Main characteriscs of the studies as author and year of the arcle, objecves, intervenon, results and outcome.
Author/year Objecve Intervenon Results Outcome
Kamonsekiet al 2012 [13] Determine the immediate
inuence of high-velocity
low-amplitude technique
(HVLA) applied to the upper
cervical spine in acve mouth
opening.
High-velocity low-amplitude
technique (HVLA).
In intragroup analysis:
there were no signicant
dierences from the control
group. In experimental
group: amplitude of mouth
opening was signicantly
higher post-intervenon when
compared to pre-intervenon
me.
This study showed that
HVLA applied in the upper
cervical region promoted
immediate improvement
in mouth opening, because
the range was greater aer
performing the technique
in the experimental group
compared to the control
group.
Barbosa et al 2012 [14] Check the eecveness of
spinal manipulaon by full-
scanning technique in the
correcon of head protrusion
and the relief of neck pain
and headaches, as well as the
electrical acvity of the upper
trapezius muscle before and
aer the protocol.
Full-scanning technique Pain analysis: the ten paents
who completed treatment
achieved signicant results in
pain analysis in the studied
groups, with a group with very
signicant results.
The biophotogrammetry
analysis has indicated
signicant dierences in the
groups.
The results suggest that the
full-scanning technique was
relevant to pain reducon
between the inial and
nal moments as well as for
angular reducon occurred
in biophotogrametrics
data, with consequent
improvement of cervical
and head posioning of the
studied volunteers.
Stelleet al 2013 [15] Check if the osteopathic
manipulaon through
the rhythmic arculatory
technique generates increase
of cervical rotaon amplitude
measured by eximetry.
Osteopathic manipulaon
with the cervical rhythmic
arculatory technique.
There was a signicant
increase of range of moon in
all cases.
There was a signicant
increase of range of moon
in all cases. The OM-CRAT
(Osteopathic Manipulaon
with Cervical Rhythmic
Arculatory Technique),
proved to be eecve in
cervical rotaon amplitude
gain and may serve as a
treatment for diseases that
are related to vertebral
hypomolity, as neck pain
and cervical osteoarthris.
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Manipulative treatment in neck pain MTP&RehabJournal 2016, 14: 318
Author/year Objecve Intervenon Results Outcome
Stelleet al 2014 [16] Check if osteopathic
manipulaon with cervical
rhythmic arculatory
technique generates abnormal
oscillaons of the blood
ow velocity or risks to the
circulaon of the internal,
vertebral, basilar and carod
arteries.
Cervical rhythmic
arculatory technique.
It is possible to say that
OM-CRAT in sliding and in
rotaon generated no risk to
the movement of the arteries,
osteopathic manipulave
treatment or vertebral
manipulaon did not cause
injury or undue stress on the
vertebral and carod arteries.
There was only a discrete
increase of the ow velocity in
the intracranial arteries aer
OM-CRAT.
There is no signicant
oscillaon in ow velocity
in the vertebral arteries
(intracranial and extracranial -
bilateral), internal carod and
basilar (bilateral) with OM-
TARC, which allows to provide
security in the cervical
manipulave treatment
without the risk of vascular
complicaons.
Camargo et al 2012 [17] Determine the immediate
eects of C5/C6 (Ashmore)
manipulaon technique on
the bilateral EMG acvity
of the middle deltoid
muscle during resng and
contracons.
Ashmore technique Cervical manipulaon to
C5/C6 level with rotaon to
the le in the sing posion
was able to change the
behavior of muscle acvity
during contracons of 30” in
paents with neck pain. These
changes were of a reduced
size eect and was lacking
uniformity with regard to the
periods of beginning and end
of the contracon.
The Ashmore C5-C6 technique
reduced signicantly the
bilateral EMG acvity of
middle deltoids for 30”
of isometric contracon,
increasing muscle recruitment
and fague resistance
compared with the electrical
acvity in the control group
subjects.
Leaveret al 2010 [18] Determining whether neck
manipulaon or mobilizaon
is most eecve for pain.
Technique of high speed
manual therapy, low-
amplitude impulse
techniques.
Technique of low-speed
manual therapy, passive
oscillang movement.
There were no stascally
signicant dierences
between groups of
manipulaon and mobilizaon
in the secondary outcomes
of pain, disability, funcon,
global perceived eect or
health-related quality of life at
any point of me.
Nearly half of the parcipants
of the study did not fully
recovered from the episode
of neck pain, however there
has been rapid and signicant
improvement in pain scores in
both groups.
Vargas et al 2014 [19] Invesgate the real-me
feedback eect on the
performance of CSM (cervical
spine manipulaon).
Cervical spine Manipulaon
Technique (CSMT).
There were signicant
dierences in angular velocity
of rotaon. The results
also showed no signicant
dierence in pre-manipulator
posion, impulse
displacement or lateral exion
of angular velocity.
Suggest that the feeding in
real-me feedback derived
from an inera sensor can be
used for key-variable amounts
associated with the important
CSM and can assist in the
development of impulse
speed.
Gong 2013 [20] Idenfy the eects of cervical
joint manipulaon at the joint
posion sense (JPS) of normal
adults.
Cervical joint manipulaon
at the joint posion sense
(JPS).
Test group results revealed
stascally signicant
dierences in exion and
extension, but the control
group showed no signicant
dierences in any of the
variables.
Combined of massage and
cervical joint manipulaon is
more eecve in increasing
the range of moon.
Hernandez et al 2012 [21] Examine the eects of Kinesio
taping against cervical spine
manipulaon in pain neck
intensity, disability and
cervical range of moon in
paents with mechanical neck
pain.
Manipulave technique
of high-speed and
low-amplitude.
Kinesio
Taping.
Paents who received impulse
manipulaon experienced
a greater increase in the
cervical moon rotaon range
than those who received the
applicaon kinesio tape.
Paents with mechanical
neck pain receiving a cervical
impulse manipulaon or a
KinesioTaping applicaon
showed reducon in neck
pain and disability and
changes in cervical range
of moon over a period of
7 days.
Table 1. Connued...
5
Teles JCMA et al.
MTP&RehabJournal 2016, 14: 318
Author/year Objecve Intervenon Results Outcome
Puenteduraet al 2011 [22] The dierences in the result of
cervical thrust manipulaon
compared to chest thrust
manipulaon to treat paents
with cervical pain showed that
the treatment of the thoracic
spine demonstrated benets
and involves less risk.
Thrust manipulaon The study shows that paents
with mechanical neck pain in
the cervical group compared
with the thoracic group
showed signicant and greater
improvement in all outcome
measures.
It was found that paents
who were treated with a
combinaon of cervical spine
manipulaon and exercises
showed signicantly greater
improvement in pain and
disability compared to those
treated with thoracic spine
manipulaon and exercises.
Kolberg et al 2015 [23] The aim of this study was to
invesgate the parameters
of oxidave stress in paents
with chronic neck pain or
back pain aer 5 weeks
of treatment with high-
speed and low-amplitude
manipulaon (HVLA) of the
spine.
High-velocity low-amplitude
manipulaon (HVLA).
The study showed treatment
by spine manipulaon twice a
week for 5 weeks. In subjects
with unspecic chronic neck
pain increased SOD and GPx
acvies, without signicant
changes. And metabolites
acvity in systemic blood were
almost unchanged aer 6
sessions of HVLA manipulaon
in men with neck pain.
This study showed that SOD
and GPx acvity in paents
with nonspecic cervical
chronic pain or back pain
increased aer 10 sessions
of HVLA manipulaon of the
spine. This study supported
the hypothesis that the
eects of HVLA manipulaon
of the spine on the oxidave
stress depend on the
me and the frequency of
treatment.
Hurwitzet al 2002 [24] To evaluate the relave
ecacy of approaches of
treang pain in the neck
approaches commonly used
by chiropractors.
High-Velocity Low-
Amplitude manipulaon.
Stretching, exibility or
strengthening exercises
and advice on ergonomics
and modicaons in the
workplace.
Manipulaon and mobilizaon
with or without heat, with
or without electrical muscle
smulaon produced similar
improvements in the intensity
of pain and disability aer 6
months.
The results suggest that
cervical mobilizaon of
the spine is as eecve as
manipulaon in reducing
neck pain and disability
among paents of
chiropracc. Furthermore,
was showed that no heat or
electrical muscle smulaon,
alone or in combinaon with
manipulaon or mobilizaon,
signicantly improves the
clinical results, although
heat may provide short-term
benets for some paents.
Table 1. Connued...
Table 2. Analysis of the arcles according to the Physiotherapy Evidence Database – PEDro table scores.
Study Criteria 1 2 3 4 5 6 7 8 9 10 11 Total quality Methodological quality
Kamonseki et al 2012 [13] + + + + +- - + - - - 6/11 High
Barbosa et al 2012 [14] + ++ + - + - - + - + 7/11 High
Stelleet et al 2013 [15] + - - + + + - + - + + 7/11 High
Stelleet al 2014 [16] + - + - + +- + - - + 6/11 High
Camargo et al, 2012 [17] + ++ + - + + - + - + 8/11 High
Leaver et al, 2010 [18] + ++ + - + + - + - + 8/11 High
Vargas; Williams. 2014 [19] + - + - + +- + - - + 6/11 High
Wontae Gong, 2013 [20] + - + - + + - + - + + 7/11 High
Hernández et al 2013 [21] - + - + + + - + - + - 6/11 High
Kolberg et al 2015 [22] + + + - -- - + + + + 7/11 High
Of the arcles analyzed 85% were observed performing
a type of manipulaon and/or cervical technique, showing
posive results such as decrease of pain and proper posture
at the me of intervenon to the end of the study. In 40% of
subjects analyzed were seen that cervical joint manipulaon
in a single session revealed signicant posive dierences
in exion and extension. In 48.9% of the parcipants in the
studies showed pain reducon in primary care and about
6
Manipulative treatment in neck pain MTP&RehabJournal 2016, 14: 318
75% had reducons in 6 months. It was seen in the studies
that 85.71% had the presence of high intensity pain at the
inial moment of the research, taking into consideraon the
improvement in pain during the sessions.
Of the observed articles, various manipulations were
performed such as: Positional Release Therapy (PRT),
Osteopathic Manipulaon (OM), osteopathic manipulaon
with cervical rhythmic arculatory technique, low-amplitude
impulse techniques applied to the cervical spine, these
manipulations and techniques have significant results for
decrease in pain, resulng in the improvement of the posture,
cervical and head posioning of the evaluated.
It was observed that 92.8% of subjects treated with cervical
manipulaon along with another technique presented with
considerable sasfacon, i.e., the combinaon of manipulaon
of the cervical spine and exercises techniques resulted in
signicant improvement in the pain and disability compared
with those treated only with manipulation or a type of
technique.
DISCUSSION
In this systematic review, it was found that the joint
manipulaon promotes posive results such as reducing pain,
range of moon and quality of life in paents with mechanical
cervicalgia. (23) The method of study of the manipulaon has
provided more detailed crically on this techniques, seng
it to one of the best indicaons of treatment for mechanical
neck pain. (24)
It may be emphasized that all arcles included in this study
were considered of good methodological quality according
to the PEDro scale thus underlining the importance of the
quality of clinical studies used to perform this review. Lacerda
et al (2011), highlighted the importance of this quality in
evidence-based medicine because it contributes to search for
more judicious pracces, by meeng, recognion and crical
analysis of the knowledge produced. (25)
The manipulaon of the cervical aer 4 to 6 treatment
sessions, being highlighted the Gonstead techniques,
high-speed low-amplitude (HVLA) and full-scanning promoted
pain relief in paents with mechanical neck pain. Haavik et al
(2012), demonstrated that manipulaon may help treat pain
through a mechanism which can contribute to changes that
alter corcal plascity inuenced in motor control. (26)
In the study of Bronfort et al (2001), was showed that
the manipulaon technique associated with stretching and
isometric strengthening obtained beer result than ulized
only the manipulaon, during this study was observed that
there was an improvement in disability and an increase in
neck range of moon, showing that such combinaon therapy
has more eecve and lasng results leading to an improved
quality of life. (27)
Cervical manipulaon, besides relieving the pain, makes
the paent return to daily acvies, improving funconal
ability. The use of cervical manipulaon for the treatment of
mechanical neck pain, disability and increased range of moon,
promotes posive results reducing the pain symptoms and
increasing the amplitude neck movement. (28-29)
CONCLUSION
The joint manipulation proved a significant tool for
the treatment of mechanical neck pain, minimizing pain
symptoms and reestablishing the range of moon. However,
further studies should be encouraged in order to improve the
treatment of mechanical neck pain, because of the diversity
of manipulave techniques.
AUTHOR’S CONTRIBUTION
JCMAT: Arcle wring; DNO and AVSM: Search strategy and analysis of arcles;
PXLG and FFUSJ: Experimental design, arcle wring.
CONFLICTS OF INTEREST
The authors declare that they have no conicts of interest.
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