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RESEARCH COMMENTARY
Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)


 
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Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

December 14, 2017

RESEARCH COMMENTARY

Robert J Fluegel, PT, COMT
MAPS Faculty, 
Fellow in Training,
MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT 
Fellowship Program Director

Nonspecific mechanical neck pain (NSMNP) affects an estimated 50% of the population, and appears most prevalent in middle age (Celenay et. al. (2016)). It is no surprise that mechanical neck pain can have a substantial effect upon the patient’s daily life. Numerous structures, mechanisms, and anatomical regions have been found to be dysfunctional in NSMNP patients, including: over-activity of global muscles with under-activity of local control muscles, and restricted mobility in the cervical and thoracic spine and the scapula.

This Research Commentary discusses a recently published Randomized Clinical Trial (RCT) that compared stabilization exercises with and without the addition of manual therapy to the treatment of patients with NSMNP. The 2016 paper “A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients with Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial” by Celenay, Akbayrak and Kaya (2016) can be found here: http://www.jospt.org/doi/full/10.2519/jospt.2016.5979

Level of Evidence: Randomized Clinical Trial

Methods:  

102 patients diagnosed with NSMNP were randomly assigned to stabilization (51) or stabilization plus manual therapy (51).


Interventions:

1) Stabilization Exercises: All patients performed the same exercises listed below, while the physical therapist progressed them through their program.

  • The cervical stabilization exercises utilized in this RCT consisted of cervical bracing exercises in various positions that then progressed to include extremity movements to challenge the cervical bracing, dynamic isometric exercises using Theraband® of various resistance, and functional activities utilizing unstable surfaces, resistance bands and exercise balls to challenge the patient’s ability to maintain ideal cervical alignment. 

  • The scapula stabilization exercises consisted of the following exercises utilizing Theraband®: Scapula adduction with shoulder external rotation, eccentric scapula retraction, scapula retraction with shoulder extension, Brügger’s exercises, forward punch and dynamic hug.

2) Manual Therapy: The manual therapy group received the following interventions in addition to the stabilization exercises that are listed above:

  • bridging technique for cervical spine
  • cervical manual traction
  • generalized, non-segmental specific:
    -passive physiological cervical rotation in traction,
    -passive accessory anterior/posterior cervical glide in traction,
    -cervical side glide
  • scapula superior/inferior and rotational gliding as well as scapula distraction.


Outcome Measures

The primary outcome measure utilized was the Neck Disability Index (NDI). Secondary outcome measures included: Visual Analog Scale (VAS) for resting pain, pain with activity and night pain, Pressure Pain Threshold (PPT) of the upper trapezius bilaterally, cervical active range of motion in all planes (AROM), and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Patients participated in the study 3 times a week for 4 weeks (12 visits).


Results

The group that received manual therapy and stabilization exercises for their NSMNP experienced a significantly greater (p=0.03) decrease in NDI scores, indicative of a reduced disability (an improved condition). This group also experienced a greater improvement in night pain, cervical rotation AROM, and quality of life (MCS and PCS components of the SF-36).


Conclusion/Discussion

The Celenay, et. al (2016) paper demonstrated that the addition of manual therapy to a stabilization exercise program is superior to a stabilization exercise program alone.

The Celenay, et. al. (2016) study adds to the body of evidence supporting the superior effectiveness of manual therapy alone or in augmenting the effect of other physical therapy interventions for a variety of neuromusculoskeletal (NMS) conditions. 

Previous MAPS research commentaries have highlighted some of these studies, including Abbott et. al. (2013), which compared exercise interventions vs. manual therapy vs. a combination of manual therapy and exercise vs. usual care in the management of Hip and Knee osteoarthritis (OA). The authors concluded that,  “manual therapy was superior to exercise therapy and usual care for patients with OA.” Read more in the MAPS 2/28/2014 Research Commentary: http://ozpt.com/research_commentary_item.php?id=26&wh=hist

The lack of evidence for the effectiveness of exercise alone for acute mechanical neck pain was also previously discussed in the 4/21/2015 MAPS Research Commentary which highlights a Cochrane Systematic Review (SR) Gross, et.al. (2015): http://www.ozpt.com/research_commentary_item.php?id=41&wh=hist

Furthermore, Bang and Deyle (2000) concluded, “Manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial is better than exercise alone for increasing strength, decreasing pain, and improving function in patients with shoulder impingement syndrome.”


TAKE HOME MESSAGES:

1) Manual therapy in addition to stabilization exercises was found to be superior to stabilization alone in non-specific mechanical neck pain (NSMNP) (Celenay et al (2016))

2) NO evidence has been found to date for the effectiveness of ANY exercises for Acute Neck Pain. (Gross et al 2015)

3) Manual therapy is superior to exercises and usual care for Hip and Knee OA (Abbott et al (2013))

4) Manual therapy combined with supervised exercise is SUPERIOR to exercise alone in the management of shoulder impingement syndrome. (Bang and Deyle (2000)).

5) Therefore, manual therapy has an important role to play, in isolation, and in combination with exercise, in the management of numerous neuromusculoskeletal (NMS) conditions.


Happy Holidays, Cheers and Enjoy,

Robert J. Fluegel and Chris R. Showalter 

© Maitland Australian Physiotherapy Seminars
Not to be reproduced, copied or retransmitted in any manner without author's express written permission
Directing others to the MAPS website (www.ozpt.com) is permissible.

References:

  1. Abbott JH1, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, Baxter GD, Theis JC, Campbell AJ; MOA Trial team (2013). Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness http://www.oarsijournal.com/article/S1063-4584%2813%2900003-4/abstract

  2. Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. The Journal of Orthopaedic and Sports Physical Therapy, 30(3), 126–137. https://www.ncbi.nlm.nih.gov/pubmed/10721508

  3. Celenay, ST et al. A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization exercises Alone in Patients with Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial J Orthop Sports Phys Ther. 2016;46 (2): 44-55 https://www.ncbi.nlm.nih.gov/pubmed/26755405

  4. Gross, A., Kay, T. M., Paquin, J.-P., Blanchette, S., Lalonde, P., Christie, T., … Cervical Overview Group. (2015). Exercises for mechanical neck disorders. The Cochrane Database of Systematic Reviews, 1, CD004250. https://doi.org/10.1002/14651858.CD004250.pub5


 

View the Complete List of Research Commentaries

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Historical List
2017
December 14, 2017
Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

October 03, 2017
Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients

August 11, 2017
Posterior-Anterior (PA) non-thrust mobilization IS SUPERIOR to Prone Press-ups in the treatment of non-specific low back pain (NSLBP)

June 15, 2017
Can isolating the VMO assist with rehabilitation of Patello-Femoral Pain Syndrome?

April 26, 2017
Trunk Reposition Error (TRE) is common in patients following acute stroke, but does inpatient stroke rehabilitation improve TRE?

March 16, 2017
Is Your Patient a Victim of “VOMIT” or “BARF”?

February 01, 2017
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January 04, 2017
Where is the Clinical Reasoning?

View the Complete List of Research Commentaries

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