Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial
Abstract
:1. Introduction
- Patients with mechanical neck pain often experience reduction in neck mobility [6,7]. When reduction in neck mobility affects the upper cervical spine, a relevant reduction in the overall cervical range of motion may be expected. The cervical range of motion deficit could be especially present in the transverse plane, since around 60% of the cervical movement occurs in the upper cervical spine [8]. Several studies have analyzed the effect of myofascial [9] or articular [10,11,12,13] techniques to increase the reduced upper cervical spine-range of motion. These studies have shown an increase in the flexion–rotation test, a test measuring upper cervical spine range of motion in the transverse plane. In order to promote safety in the management of the upper cervical spine, the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) recommends avoiding techniques which use maximal end range cervical rotation and extension [14].
2. Material and Methods
2.1. Study Design
2.2. Subjects and Sample Size
2.3. Randomization and Allocation
3. Measurements
- The primary outcome measures reported were neck disability and cervical mobility. Active cervical range of motion was measured in all planes for global cervical mobility and in the sagittal plane for upper cervical spine. Flexion–rotation test was measured to assess passive upper cervical spine range of motion in the transverse plane. Demographic variables were also registered (Table 1).
- For the active mobility testing, patients were asked to sit upright and move their head as far as they could without pain [25]. For the passive upper cervical spine mobility testing, a flexion–rotation test was performed according to Hall et al. [21]. The direction of the flexion–rotation test with less movement was considered the “flexion–rotation test to the more restricted side” and vice versa. The CROM device (Plastimo Airguide, Buffalo Groove, IL, USA) is a reliable and valid method for measuring active and passive cervical mobility [26]. Two measurements of each movement were performed, and the mean value was used for further analysis. The minimal detectable change in active range of motion is between 5°–10° [27,28] and in flexion–rotation between 4.7°–7° [29] using the CROM device.
- Measurements were performed at baseline (T0), at the end of the treatment (T1), and at three-months follow-up (T2). A researcher with 17 years of experience and specifically trained performed the measurements. This researcher was blinded to the allocation group of each patient.
4. Intervention
- In the inhibitory suboccipital technique, patients were positioned in supine. The therapist was sitting with their forearms resting on the head-end of the table, metacarpophalangeal joints of middle and ring finger flexed 90°, and applying ventral pressure in the suboccipital area with the patient’s head resting in the therapist’s hands [18]. The applied pressure was adjusted according to the therapist´s perception (Figure 2).
5. Statistical Analysis
6. Results
7. Neck Disability Index
8. Global Active Cervical Range of Motion
9. Upper Cervical Range of Motion
10. Discussion
11. Limitations
12. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Variables | IST Group (n = 26) | UCTM Group (n = 26) | Control Group (n = 26) |
---|---|---|---|
Age in years (mean ± SD) | 59.31 ± 12.41 | 58.92 ± 11.75 | 61.65 ± 15.77 |
Sex (n and %) | |||
Man | 5 (19.2%) | 5 (19.2%) | 4 (15.4%) |
Woman | 21 (80.8%) | 21 (80.8%) | 22 (84.6%) |
Work activity (n and %) | |||
Active | 12 (46.2%) | 11 (42.3%) | 9 (34.6%) |
Not working | 14 (53.8%) | 15 (57.7%) | 17 (65.4%) |
Work with manual loads (n and %) | |||
Yes | 7 (26.9%) | 8 (30.8%) | 3 (11.5%) |
No | 17 (65.4%) | 13 (50%) | 21 (80.8%) |
Varied | 2 (7.7%) | 5 (19.2%) | 2 (7.7%) |
Analgesic medication (n and %) | |||
Yes | 16 (61.5%) | 10 (38.5%) | 15 (57.7%) |
No | 10 (38.5%) | 16 (61.5%) | 11 (42.3%) |
FRT Restricted Side (n and %) | |||
Right | 15 (57.7%) | 19 (73.1) | 18 (69.2%) |
Left | 11 (42.3%) | 7 (26.9) | 8 (30.8%) |
Duration of symptoms in months (mean ± SD) | 25.73 ± 25.21 | 24.88 ± 23.78 | 19.81 ± 19.25 |
Global Cervical Spine ROM (°) (mean ± SD) | |||
Flexion | 55.50 ± 12.04 | 60.29 ± 14.62 | 59.42 ± 9.67 |
Extension | 34.86 ± 8.46 | 40.44 ± 8.01 | 39.56 ± 9.63 |
Lateral Flexion (Right) | 26.38 ± 6.65 | 29.33 ± 9.97 | 26.65 ± 6.77 |
Lateral Flexion (Left) | 26.31 ± 7.88 | 30.19 ± 8.62 | 28.56 ± 7.80 |
Rotation (Right) | 45.56 ± 8.54 | 50.48 ± 11.46 | 49.83 ± 8.08 |
Rotation (Left) | 46.19 ± 12.78 | 53.48 ± 12.79 | 50.83 ± 12.55 |
Upper Cervical Spine ROM (°) (mean ± SD) | |||
Flexion | 10.54 ± 5.28 | 11.94 ± 4.58 | 12.42 ± 5.60 |
Extension | 9.96 ± 4.36 | 10.35 ± 4.38 | 11.61 ± 4.28 |
FRT More restricted | 23.92 ± 6.44 | 25.52 ± 7.65 | 25.35 ± 6.38 |
FRT Less restricted | 36.04 ± 7.28 | 38.23 ± 6.14 | 37.19 ± 7.04 |
Neck Disability Index (n and %) | |||
No Disability | 3 (11.5%) | 2 (7.7%) | 1 (3.8%) |
Mild Disability | 10 (28.5%) | 14 (53.8%) | 17 (65.4%) |
Moderate Disability | 12 (46.2%) | 8 (30.8%) | 7 (26.9%) |
Severe Disability | 1 (3.8%) | 1 (3.8%) | 1 (3.8%) |
Complete Disability | 0 (0%) | 1 (3.8%) | 0 (0%) |
T0 | T1 | T2 | ||||
---|---|---|---|---|---|---|
Baseline | End of Treatment | 3 Months Post-Treatment | ||||
n (%) | n (%) | p and r Value | n (%) | p and r Value | ||
No Disability | Control | 1 (3.8%) | 6 (23.1%) | p < 0.122 r = 0.23 | 9 (34.6%) | p < 0.063 r = 0.24 |
IST | 3 (11.5%) | 7 (26.9%) | 7 (26.9%) | |||
UCTM | 2 (7.7%) | 12 (46.2%) | 15 (57.7%) | |||
Mild Disability | Control | 17 (65.4%) | 14 (53.8%) | 13 (50%) | ||
IST | 10 (28.5%) | 15 (57.7%) | 17 (65.4%) | |||
UCTM | 14 (53.8%) | 13 (50%) | 11 (42.3%) | |||
Moderate Disability | Control | 7 (26.9%) | 5 (19.2%) | 4 (15.4%) | ||
IST | 12 (46.2%) | 4 (15.4%) | 2 (7.7%) | |||
UCTM | 8 (30.8%) | 1 (3.8%) | 0 (0%) | |||
Severe Disability | Control | 1 (3.8%) | 1 (3.8%) | 0 (0%) | ||
IST | 1 (3.8%) | 0 (0%) | 0 (0%) | |||
UCTM | 1 (3.8%) | 0 (0%) | 0 (0%) | |||
Complete Disability | Control | 0 (0%) | 0 (0%) | 0 (0%) | ||
IST | 0 (0%) | 0 (0%) | 0 (0%) | |||
UCTM | 1 (3.8%) | 0 (0%) | 0 (0%) |
T1 | T2 | ||||||
---|---|---|---|---|---|---|---|
Mean (95% CI) | p-Value | ES | Mean (95% CI) | p-Value | ES | ||
IST vs. UCTM | Flexion GCS | −4.44 (−12.20/3.31) | 0.494 | 0.04 | 2.26 (−6.14/10368) | 1.000 | 0.17 |
Extension GCS | −3.96 (−10.67/2.74) | 0.457 | 0.35 | 2.40 (−4.29/9.09) | 1.000 | 0.27 | |
Right SB | −2.27 (−6.33/5.79) | 1.000 | 0.03 | 1.52 (−4.37/7.41) | 1.000 | 0.18 | |
Left SB | −1.03 (−6.38/4.31) | 1.000 | 0.13 | 0.23 (−0.55/1.01) | 1.000 | 0.17 | |
Right Rotation GCS | 1.00 (−6.74/8.74) | 1.000 | 0.08 | −0.23 (−7.73/7.27) | 1.000 | 0.02 | |
Left Rotation GCS | −1.08 (−8.92/6.77) | 1.000 | 0.09 | 1.94 (−5.02/8.90) | 1.000 | 0.21 | |
Flexion UCS | 1.06 (−3.11/5.22) | 0.874 | 0.17 | −0.25 (−5.12/4.62) | 1.000 | 0.03 | |
Extension UCS | −1.06 (−4.85/2.74) | 1.000 | 0.20 | 0.33 (−3.55/4.20) | 1.000 | 0.06 | |
FRT More restricted | −2.02 (−6.86/2.82) | 0.931 | 0.30 | −4.69 (−9.88/0.49) | 0.089 | 0.66 | |
FRT Less restricted | 3.02 (−2.32/8.36) | 0.512 | 0.37 | −2.44 (−8.59/3.70) | 1.000 | 0.27 | |
IST vs. Control | Flexion GCS | −1.48 (−9.23/6.27) | 1.000 | 0.13 | 1.57 (−6.83/9.99) | 1.000 | 0.13 |
Extension GCS | 1.90 (−4.81/8.61) | 1.000 | 0.18 | 6.13 (−0.55/12.82) | 0.083 | 0.60 | |
Right SB | 2.15 (−3.90/8.21) | 1.000 | 0.27 | 0.94 (−4.94/6.83) | 1.000 | 0.12 | |
Left SB | 3.50 (−1.85/8.85) | 0.340 | 0.44 | 0.35 (−0.41/1.14) | 0.762 | 0.28 | |
Right Rotation GCS | 3.48 (−4.26/11.22) | 0.824 | 0.29 | 3.54 (−3.96/11.04) | 0.755 | 0.33 | |
Left Rotation GCS | −1.11 (−8.96/6.73) | 1.000 | 0.10 | 4.56 (−2.40/11.52) | 0.399 | 0.42 | |
Flexion UCS | 1.81 (−2.36/5.97) | 1.000 | 0.30 | 3.19 (−1.68/8.06) | 0.338 | 0.41 | |
Extension UCS | 1.75 (−2.05/5.56) | 0.788 | 0.33 | 3.04 (−0.84/6.92) | 0.176 | 0.53 | |
FRT More restricted | 4.65 (−0.19/9.49) | 0.064 | 0.60 | 1.96 (−3.22/7.14) | 1.000 | 0.25 | |
FRT Less restricted | 5.84 (0.50/11.19) | 0.027 | 0.81 | 1.90 (−4.24/8.05) | 1.000 | 0.19 | |
UCTM vs. Control | Flexion GCS | 2.96 (−4.79/10.71) | 1.000 | 0.20 | −0.69 (−9.10/7.72) | 1.000 | 0.06 |
Extension GCS | 5.86 (−0.84/12.58) | 0.107 | 0.19 | 3.73 (−2.95/10.42) | 0.529 | 0.36 | |
Right SB | 2.42 (−3.63/8.48) | 0.992 | 0.25 | −0.57 (−6.46/5.31) | 1.000 | 0.06 | |
Left SB | 4.54 (−0.81/9.89) | 0.123 | 0.57 | 0.13 (−0.64/0.91) | 1.000 | 0.27 | |
Right Rotation GCS | 2.48 (−5.26/10.22) | 1.000 | 0.25 | 3.77 (−3.73/11.27) | 0.667 | 0.37 | |
Left Rotation GCS | -0.04 (−7.88/7.81) | 1.000 | 0.00 | 2.61 (−4.34/9.57) | 1.000 | 0.32 | |
Flexion UCS | 0.75 (−3.41/4.91) | 1.000 | 0.12 | 3.44 (−1.43/8.31) | 0.263 | 0.53 | |
Extension UCS | 2.80 (−0.99/6.60) | 0.223 | 0.47 | 2.71 (−1.16/6.59) | 0.273 | 0.47 | |
FRT More restricted | 6.67 (1.83/11.51) | 0.004 | 0.99 | 6.65 (1.47/11.84) | 0.007 | 0.84 | |
FRT Less restricted | 2.83 (−2.52/8.17) | 0.597 | 0.34 | 4.34 (−1.80/10.49) | 0.262 | 0.53 |
T0 | T1 | T2 | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Baseline | End of Treatment | Difference Between Baseline | 3 Months Post-Treatment | Difference Between Baseline | ||||||||
Mean ± SD | Mean ± SD | Mean ± SD | (95% CI) | p-Value | ES | Mean ± SD | Mean ± SD | (95% CI) | p-Value | ES | ||
Control Group | Flexion GCS | 59.42 ± 9.67 | 58.96 ± 7.69 | −0.46 ± 7.91 | −4.44/−3.52 | 1.000 | 0.05 | 61.85 ± 8.96 | 2.42 ± 10.59 | −2.91/7.75 | 0.764 | 0.26 |
Extension GCS | 39.56 ± 9.63 | 37.37 ± 8.72 | −2.19 ± 10.20 | −7.33/2.94 | 0.851 | 0.24 | 38.27 ± 10.30 | −1.29 ± 11.69 | −7.17/4.59 | 1.000 | 0.13 | |
Right SB | 26.65 ± 6.77 | 28.29 ± 7.41 | 1.63 ± 8.92 | −1.97/5.24 | 1.000 | 0.23 | 30.23 ± 7.65 | 3.58 ± 9.46 | −0.24/7.40 | 0.196 | 0.50 | |
Left SB | 28.56 ± 7.80 | 29.33 ± 8.48 | 0.77 ± 7.98 | −3.24/4.78 | 1.000 | 0.09 | 28.56 ± 7.80 | 0.00 ± 0.00 | 0.00/0.00 | 1.000 | 0.00 | |
Right Rotation GCS | 49.83 ± 8.08 | 50.31 ± 8.61 | 0.48 ± 9.56 | −3.38/4.34 | 1.000 | 0.06 | 51.85 ± 8.05 | 2.02 ± 8.46 | −1.40/5.43 | 0.704 | 0.02 | |
Left Rotation GCS | 50.83 ± 12.55 | 51.94 ± 10.57 | 1.12 ± 11.04 | −4.43/6.67 | 1.000 | 0.10 | 52.37 ± 13.01 | 1.54 ± 9.86 | −3.42/6.49 | 1.000 | 0.12 | |
Flexion UCS | 12.42 ± 5.60 | 12.56 ± 5.09 | 0.13 ± 6.22 | −2.38/2.65 | 1.000 | 0.03 | 9.75 ± 3.31 | −2.67 ± 7.14 | −5.56/0.21 | 0.203 | 0.58 | |
Extension UCS | 11.61 ± 4.28 | 11.79 ± 5.16 | 0.17 ± 5.99 | −2.25/2.59 | 1.000 | 0.04 | 10.56 ± 4.13 | −1.06 ± 5.89 | −3.44/1.32 | 1.000 | 0.25 | |
FRT More Restricted | 25.35 ± 6.38 | 29.79 ± 5.76 | 4.44 ± 7.71 | 0.56/8.32 | 0.021 | 0.73 | 31.77 ± 6.07 | 6.42 ± 8.56 | 2.11/10.74 | 0.017 | 1.03 | |
FRT Less restricted | 37.19 ± 7.04 | 31.71 ± 4.64 | −5.48 ± 7.32 | −9.16/−1.80 | 0.002 | 0.92 | 32.63 ± 7.37 | −4.56 8.97 | −9.07/−0.04 | 0.047 | 0.63 | |
IST Group | Flexion GCS | 55.50 ± 12.04 | 53.56 ± 11.84 | −1.94 ± 13.40 | −7.36/3.47 | 1.000 | 0.16 | 59.50 ± 8.83 | 4.00 ± 13.47 | −1.44/9.44 | 0.427 | 0.38 |
Extension GCS | 34.86 ± 8.46 | 34.58 ± 11.49 | −0.29 ± 10.66 | −5.65/5.08 | 1.000 | 0.03 | 39.71 ± 10.36 | 4.85 ± 8.51 | 0.56/9.13 | 0.023 | 0.51 | |
Right SB | 26.38 ± 6.65 | 30.17 ± 8.10 | 3.79 ± 6.60 | 0.47/7.11 | 0.022 | 0.51 | 30.90 ± 8.59 | 4.52 ± 5.99 | 1.50/7.53 | 0.002 | 0.54 | |
Left SB | 26.31 ± 7.88 | 30.58 ± 8.21 | 4.27 ±7.80 | 0.34/8.19 | 0.030 | 0.53 | 26.67 ± 8.63 | 0.37 ± 1.86 | −0.57/1.30 | 0.981 | 0.04 | |
Right Rotation GCS | 45.56 ± 8.54 | 49.52 ± 13.00 | 3.96 ± 14.16 | −1.76/9.68 | 0.498 | 0.36 | 51.12 ± 11.82 | 5.56 ± 12.55 | 0.49/10.63 | 0.099 | 0.54 | |
Left Rotation GCS | 46.19 ± 12.78 | 46.19 ± 12.50 | 0.00 ± 10.25 | −5.16/5.16 | 1.000 | 0.00 | 52.29 ± 11.24 | 6.10 ± 11.85 | 0.13/12.06 | 0.044 | 0.51 | |
Flexion UCS | 10.54 ± 5.28 | 12.48 ± 6.20 | 1.94 ± 5.84 | −0.42/4.30 | 0.307 | 0.34 | 11.06 ± 7.25 | 0.52 ± 8.30 | −2.83/3.87 | 1.000 | 0.08 | |
Extension UCS | 9.96 ± 4.36 | 11.88 ± 4.44 | 1.92 ± 4.66 | −0.04/3.81 | 0.137 | 0.44 | 11.94 ± 5.13 | 1.98 ± 5.66 | −0.31/4.27 | 0.270 | 0.42 | |
FRT More Restricted | 23.92 ± 6.44 | 33.02 ± 8.60 | 9.10 ± 7.82 | −13.03/−5.16 | 0.001 | 1.20 | 32.31 ± 7.32 | 8.38 ± 7.01 | 4.86/11.91 | 0.001 | 1.22 | |
FRT Less restricted | 36.04 ± 7.28 | 36.40 ± 7.92 | 0.37 ± 7.03 | −3.17/3.90 | 1.000 | 0.05 | 33.38 ± 10.54 | −2.65 ± 10.53 | −7.95/2.64 | 0.631 | 0.29 | |
UCTM Group | Flexion GCS | 60.29 ± 14.62 | 62.79 ± 12.68 | 2.50 ±12.20 | −2.43/7.43 | 0.918 | 0.18 | 62.02 ± 11.61 | 1.73 ± 12.90 | −3.48/6.94 | 1.000 | 0.13 |
Extension GCS | 40.44 ± 8.01 | 44.12 ± 9.72 | 3.67 ± 8.66 | −0.69/8.03 | 0.121 | 0.41 | 42.88 ± 6.28 | 2.44 ± 9.06 | −2.12/7.00 | 0.545 | 0.34 | |
Right SB | 29.33 ± 9.97 | 33.38 ± 8.07 | 4.06 ± 10.75 | −0.28/8.40 | 0.197 | 0.45 | 32.33 ± 9.35 | 3.00 ± 10.01 | −2.03/8.03 | 0.417 | 0.31 | |
Left SB | 30.19 ± 8.62 | 35.50 ± 10.59 | 5.31 ± 7.84 | 1.36/9.25 | 0.006 | 0.55 | 30.33 ± 8.81 | 0.13 ± 0.69 | −0.21/0.48 | 0.981 | 0.02 | |
Right Rotation GCS | 50.48 ± 11.46 | 53.44 ± 11.63 | 2.96 ± 9.90 | −1.04/6.96 | 0.420 | 0.26 | 56.27 ± 9.82 | 5.79 ± 11.71 | 1.06/10.52 | 0.055 | 0.54 | |
Left Rotation GCS | 53.48 ± 12.79 | 54.56 ± 14.63 | 1.08 ± 13.18 | −5.53/7.07 | 1.000 | 0.08 | 57.63 ± 10.93 | 4.15 ± 8.79 | −0.27/8.58 | 0.071 | 0.32 | |
Flexion UCS | 11.94 ± 4.58 | 12.83 ± 4.27 | 0.88 ± 6.32 | −1.67/3.44 | 1.000 | 0.20 | 12.71 ± 3.95 | 0.77 ± 5.88 | −1.60/3.14 | 1.000 | 0.18 | |
Extension UCS | 10.35 ± 4.38 | 13.33 ± 5.02 | 2.98 ± 6.02 | 0.55/5.41 | 0.055 | 0.63 | 12.00 ± 4.00 | 1.65 ± 5.57 | −0.59/3.90 | 0.427 | 0.39 | |
FRT More Restricted | 25.52 ± 7.65 | 36.63 ± 6.54 | 11.12 ± 5.65 | 8.27/13.95 | 0.001 | 1.56 | 38.60 ± 5.19 | 13.08 ± 7.25 | 9.42/10.73 | 0.001 | 2.00 | |
FRT Less restricted | 38.23 ± 6.14 | 35.58 ± 7.32 | −2.65 ± 9.09 | −7.23/1.92 | 0.448 | 0.39 | 38.02 ± 5.53 | −0.21 ± 7.37 | −3.92/3.50 | 1.000 | 0.04 |
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González-Rueda, V.; Hidalgo-García, C.; Rodríguez-Sanz, J.; Bueno-Gracia, E.; Pérez-Bellmunt, A.; Rodríguez-Rubio, P.R.; López-de-Celis, C. Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2020, 17, 8334. https://doi.org/10.3390/ijerph17228334
González-Rueda V, Hidalgo-García C, Rodríguez-Sanz J, Bueno-Gracia E, Pérez-Bellmunt A, Rodríguez-Rubio PR, López-de-Celis C. Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial. International Journal of Environmental Research and Public Health. 2020; 17(22):8334. https://doi.org/10.3390/ijerph17228334
Chicago/Turabian StyleGonzález-Rueda, Vanessa, César Hidalgo-García, Jacobo Rodríguez-Sanz, Elena Bueno-Gracia, Albert Pérez-Bellmunt, Pere Ramón Rodríguez-Rubio, and Carlos López-de-Celis. 2020. "Does Upper Cervical Manual Therapy Provide Additional Benefit in Disability and Mobility over a Physiotherapy Primary Care Program for Chronic Cervicalgia? A Randomized Controlled Trial" International Journal of Environmental Research and Public Health 17, no. 22: 8334. https://doi.org/10.3390/ijerph17228334