Manual Therapy 16 (2011) 141e147

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effectiveness of thoracic manipulation on patients with chronic mechanical

neck pain e A randomized controlled trial
Herman Mun Cheung Lau a, Thomas Tai Wing Chiu a, *, Tai-Hing Lam b
a
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
b
Department of Community Medicine, The University of Hong Kong, Hong Kong

a r t i c l e i n f o a b s t r a c t

Article history: The aim of our study was to assess the effectiveness of thoracic manipulation (TM) on patients with
Received 21 October 2009 chronic neck pain. 120 patients aged between 18 and 55 were randomly allocated into two groups: an
Received in revised form experimental group which received TM and a control group without the manipulative procedure. Both
20 July 2010
groups received infrared radiation therapy (IRR) and a standard set of educational material. TM and IRR
Accepted 9 August 2010
were given twice weekly for 8 sessions. Outcome measures included craniovertebral angle (CV angle),
neck pain (Numeric Pain Rating Scale; NPRS), neck disability (Northwick Park Neck Disability Ques-
Keywords:
tionnaire; NPQ), health-related quality of life status (SF36 Questionnaire) and neck mobility. These
Spinal manipulation
Thoracic spine
outcome measures were assessed immediately after 8 sessions of treatment, 3-months and at a 6-month
Neck pain follow-up. Patients that received TM showed signicantly greater improvement in pain intensity
(p 0.043), CV angle (p 0.049), NPQ (p 0.018), neck exion (p 0.005), and the Physical Component
Score (PCS) of the SF36 Questionnaire (p 0.002) than the control group immediately post-intervention.
All these improvements were maintained at the 6-month follow-ups. This study shows that TM was
effective in reducing neck pain, improving dysfunction and neck posture and neck range of motion
(ROM) for patients with chronic mechanical neck pain up to a half-year post-treatment.
2010 Elsevier Ltd. All rights reserved.

1. Introduction be a primary contributor to neck pain (Flynn et al., 2007). Flynn

Neck pain is a common musculoskeletal disorder in the general
population. In Saskatchewan, Canada, Cote et al. (2000) reported
that the age-standardized lifetime prevalence of neck pain was
66.7%. In a telephone survey performed in Hong Kong, Chiu and
Leung (2006) reported that the lifetime prevalence of neck pain
was 65.4% and the 12-month prevalence was 53.6% (41.0% in male,
59.0% in female). Neck pain is costly in terms of treatment, indi-
vidual suffering, and time lost to work absentee (Rempel et al.,
1992).
Growing evidence has conrmed that the use of manipulation
with exercise or the use of mobilization with exercise in treating
neck pain has better clinical outcomes than other major and
common modalities (Greenman, 1996; Gross et al., 2002; Flynn
et al., 2007).
Owing to the intrinsic biomechanical linkage with the cervical
spine, disturbances in the biomechanics of the thoracic spine could
* Corresponding author. Tel.: 852 27666709; fax: 23308656.
E-mail address: rstchiu@polyu.edu.hk (T.T. Wing Chiu).
et al. (2007) reported that with the use of thoracic manipulation
(TM), there was immediate improvement in neck pain. However
the lack of comparative group in this trial renders the cause-and-
effect relationship inconclusive (Flynn et al., 2007). Many clinicians
have intuitively adopted the use of TM to treat neck pain patients,
although there is a lack of scientic evidence. Cleland et al. (2005)
reported that thoracic spine is the area that is most often
manipulated.
There are studies investigating the effect of TM in treating acute
and subacute mechanical neck pain (Cleland et al., 2005, 2007a,b;
Fernandez-de-las-Penas et al., 2007; Gonzalez-Iglesias et al.,
2009a,b), but to date, no studies have investigated the effect in
patients with chronic neck pain. In a randomized controlled trial,
Cleland et al. (2005) demonstrated an immediate analgesic effect in
patients with mechanical neck pain. However the study was
limited to a short-term follow-up and the effects on disability and
physical impairments e.g. cervical range of motion (ROM) was not
evaluated (Cleland et al., 2005).
In contrast, Parkin-Smith and Penter (1998) demonstrated that
the combination of cervical and TM did not result in any signicant
benet than cervical manipulation alone. Another trial comparing
the effect of TM and instructed exercise in the management of neck-

1356-689X/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2010.08.003
142 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147
shoulder pain revealed that there was a statistically signicant
reduction in the level of perceived worst pain after 12-months
follow-up (Savolainen et al., 2004).
As there is a lack of general consensus on the efcacy of TM for
patients with neck pain, a well designed trial studying the clinical
effects of TM in treating mechanical neck pain with substantial
period of follow-up is necessary.
2. Methodology
2.1. Subjects
A sample of 120 patients with a diagnosis of chronic mechanical
neck pain by a primary care physician were recruited from an
outpatient clinic of the Prince of Wales Hospital and randomly
allocated to a TM group (Group A) and a control group (Group B).
Patients whose age ranged between 18 and 55 with a diagnosis of
mechanical neck pain for more than 3 months were recruited.
Patients who had one or more of the following conditions such
as: contraindication to manipulation (Gonzalez-Iglesias et al.,
2009a,b), history of whiplash or cervical surgery, diagnosis of
bromyalgia syndrome (Wolfe et al., 1990), having undergone
spinal manipulative therapy in the previous 2 months or loss of
standing balance were excluded from the current study. Explana-
tion and informed consent were obtained from each subject. This
study was approved by the ethical review board of the university.
2.2. Randomization
Patients were randomly allocated to the TM group or the control
group by using computer-generated minimization method (Jenson,
1991) taking into account of their age, gender, and degree of
disability resulting from neck pain. A computer program for
randomization was installed in a notebook computer. After a senior
physiotherapist keyed in the patients particulars, the program
automatically allocated the grouping of the patient according to the
minimization theory that yielded the smallest imbalance between
the two groups. The computer-based randomization also helps
establish allocation concealment, which is an essential part of
a randomized trial. The senior physiotherapist then notied the
physiotherapist in-charge for the group allocation of individual
patient through a sealed envelope in the patients bed-notes.
2.3. Outcome measures
For the baseline examination and the subsequent follow-ups,
each subject reported his/her intensity of neck pain by the verbal
Numeric Pain Rating Scale (NPRS) (Jensen et al., 1986) (scale: 0 no
paine10 worst pain), which was the primary outcome, and
completed two sets of questionnaires [Northwick Park Question-
naire (NPQ) (Chiu et al., 2001) and SF36 health-related quality of life
questionnaire (SF36)] as subjective measurements. For objective
measurements, subjects cervical ROM was measured by the Han-
oun Multi-Cervical Unit (MCRU) (Chiu and Lo, 2002). The cranio-
vertebral (CV) angle of these subjects was also measured by an
Electronic Head Posture Instrument (EHPI) (Lau et al., 2009).
2.4. Sample size calculation
The rationale for calculating the sample size was as follows:
From a related study (Chiu et al., 2001) (N 90) using the same
questionnaire (NPQ), it was found that the mean and standard
deviation of the neck pain score were 13.99 and 5.823, respectively.
Assuming that the TM group would improve by 50% and the control
group would improve by 25%. Assuming a 0.5 correlation between
the pre- and post-measurement, and the standard deviations in the
pre- and post-intervention measurement would be about the same,
the standard deviation for their difference would be about the same
as that of the original measurement (or smaller if the correlation is
higher). Using 5% alpha, 90% power, 2-sided alternative test on the
difference between pre- and post-measurement, it was estimated
that 60 subjects should be required for each group.
2.5. Study design
Group A received TM including 8 sessions (2/week) of infrared
radiation therapy (IRR) for 15 min over the painful site. TM (ante-
rioreposterior approach in supine lying) (Gibbons and Tehan,
2000) was given and the level of TM was determined according
to clinical assessment (which includes movement analysis and
palpation) by an experienced physiotherapist who had post-grad-
uate training in spinal manipulative therapy and with at least 5
years of clinical experience in the management of neck pain
patients with manual procedures (Appendix 1). A standard set of
educational materials illustrating the simple pathology of neck pain
and general advice on neck care was also given. Neck exercises
prescribed in the educational pamphlet mainly involve active neck
mobilization, isometric neck muscle contraction for stabilization,
stretching of upper trapezius and scalene muscles and postural
correction exercise. For the mobilization exercises, subjects were
instructed to perform 10 repetitions of movement in exion,
extension, side exion and rotation. For the isometric muscle
contractions, subjects were instructed to sustain a contraction in
exion, extension, side exion and rotation for 5 s and repeat this
for 10 repetitions. For the stretching exercise, subjects were
instructed to hold a stretched position for 5e8 s for 10 repetitions.
All exercises were to be performed daily.
Group B was the control group and received 8 sessions (2/week)
of the same IRR treatment together with the same set of educa-
tional materials. IRR was suitable as a control intervention as it
gives only supercial heating (almost all energy is absorbed at
a depth of 2.5 mm) and the effect is not long lasting (Chiu et al.,
2005).
All subjects were evaluated and assessed at baseline, immedi-
ately after 8 sessions of treatment, at 3-months and at a 6-month
follow-up by a blinded assessor.
2.6. Data analysis
Data was analysed with the SPSS package (Version 16.0). The TM
group was compared with the control group at the baseline by
independent t-tests. After the intervention, statistical analysis for
the difference (i.e. difference between the pre- and post-
measurement) of all outcome measures in both groups were
compared by using repeated-measures analysis of variance
(ANOVA). The mean difference and their standard deviation were
calculated. Moreover, repeated-measures ANOVA was used to
investigate whether there was any change after the intervention in
each group. Paired t-tests with Bonferroni adjustment were adop-
ted for the post-hoc analysis. Between-group effect size was
calculated using Partial Eta squared. A p value of less than 0.05 was
considered statistically signicant.
2.7. Missing data
Some subjects did not return for the follow-up assessments. All
of these subjects were contacted again by phone to identify the
reason and to determine the treatment effect. The present study
adopted the following methods to impute the missing data: (1) For
those subjects who failed to attend the follow-up because of
 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147
dissatisfaction of the intervention effect or worsening of symptoms
after treatment, a mean percentage of worsening of symptoms was
calculated from all the observed subjects of both groups whose
condition had become worse and the missing data was replaced by
the product of the mean percentage and the baseline measurement.
(2) For those subjects whose condition was improving but they
could not attend because of time constraints, a mean percentage of
improvement was calculated from all the observed subjects of both
groups whose condition had been better, and the missing value was
replaced by the product of the mean percentage and the baseline
measurement. (3) For those subjects whose treatment effect was
unknown, the baseline value was used for imputation.
3. Results
3.1. Baseline descriptive statistics
A total of 120 patients (60 in each group with 30 male and 30
female) were recruited and followed up in the study from June
2007 to June 2009. There was no signicant difference in gender
between the control and the TM group. [t (118) 0.000; p 1]. The
age range of the patients was between 18 and 55 with a mean age of
43.78 (SD 9.25) and 44.17 (SD 9.27) in the control and the TM
group respectively. There was no signicant difference in age
between the two groups [t (118) 0.227; p 0.821]. All patients
completed the 4 week, 8 sessions of treatment, and they all
completed most of the follow-up evaluations up to 6-months post-
treatment. No discomfort or any other adverse conditions were
reported after the TM or other treatment procedures. The partici-
pants ow of follow-up evaluation from immediately post-treat-
ment till the 6-month follow-up is illustrated in Fig. 1.
3.2. Baseline measurement
There was no signicant difference in any of the parameters
between the control and the TM group at the baseline measure-
ment. The p value ranges from 0.11 to 0.91 (Table 1).
3.3. Post-treatment measurements
The mean values, 95% CI and standard deviation of all parame-
ters in both the control and treatment group and the 95% CI of
between-group comparison and the interaction effect between
time and groups are listed in Tables 2e4 respectively.
3.4. Northwick Park Neck Disability Questionnaire (NPQ)
Both groups demonstrated a decrease in NPQ immediately post
treatment which remained decreased up to 6-months post-treat-
ment. The TM group showed a signicantly greater decrease in NPQ
compared to the control group from immediately post-intervention
up to the 6-month follow-up (p 0.018, 0.004 and 0.007 respec-
tively). Details of NPQ in both groups during the entire study are
shown in Tables 2e4.
3.5. CV angle
The CV angle was increased in both groups right after treatment
and up to the 6-month post-treatment period. A statistically
signicant difference was detected up to 6-months post-treatment
(p 0.049, 0.031 and 0.012 respectively). Details of the CV angle in
both groups throughout the study are shown in Tables 2e4.
143
3.6. Numeric Pain Rating Scale (NPRS)
Patients in the TM group showed a signicantly greater reduc-
tion in pain than that of the control group from immediate post-
treatment (p 0.043) to the 6-month follow-up (p 0.002 and
p 0.001 respectively). Details of the NPRS in both groups
throughout the study are shown in Tables 2e4.
3.7. Cervical ROM
3.7.1. Flexion
Flexion increased in both groups immediately after 4 weeks of
treatments and continued to increase 6-months post-treatment (p
values are 0.005, <0.001 and <0.001 respectively).
3.7.2. Extension (E), left side exion (LSF) and right side exion
(RSF)
Both groups showed improvement in E, LSF and RSF immedi-
ately after the 4-week intervention and up to the 6-month follow-
up. Yet the improvement shown in the TM group became signi-
cantly better than that of the control group from the 3-month
follow-up onwards up to 6 months (p values for E from 3-month to
6-month follow-up are 0.001 and 0.001 respectively; p values for
LSF are 0.007 and 0.003 and p values for RSF are 0.041 and 0.011
respectively). Details of changes in E, LSF and RSF in both groups are
listed in Tables 2e4.
3.7.3. Left rotation (LR) and right rotation (RR)
LR and RR improved in both groups immediately after treatment
and was maintained at 6 months. Although statistically not
signicant, the TM group showed a greater increase than the
control group. Details of the cervical ROM in both groups during the
entire study are shown in Tables 2e4.
3.7.4. SF36 e PCS and Mental Component Score (MCS)
There was an increase in PCS and MCS 6-months post-treat-
ment. The TM group showed a greater increase than the control
group in PCS and MCS. However, only the difference shown in PCS
was statistically signicant throughout the study (p values 0.002,
<0.001 and <0.001 respectively at different follow-up assess-
ments). Details of changes in PCS and MCS in both groups during
the entire study are shown in Tables 2e4.
4. Discussion
4.1. Subjects/populations selected for the study
Patients in the present study came from one of the largest
typical physiotherapy outpatient departments in Hong Kong, thus
the population should be a reasonably representative sample of
patients with chronic mechanical neck pain. In addition, their dis-
played pain intensity and disability were comparable to those of
typical patients with chronic mechanical neck problems listed in
many previous studies (Ylinen et al., 2003; Chiu et al., 2005). Hence,
the results of the present study could be generalized to patients
with chronic mechanical neck pain.
4.2. Change in NPQ
Improvement in NPQ was signicantly better in the TM group
than that of the control group up to 6 months. A randomized
clinical trial by Gonzalez-Iglesias et al. (2009a,b) also demonstrated
that TM in patients with acute mechanical neck pain showed
a greater improvement in perceived neck disability (NPQ) with
a between-group difference of 8.5 points where the current study
144 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147

Enrollment
Assessed for elgibility (n=198)

Excluded (n=78)
Eligible but refused to particiate (n=12)
Not meeting inclusion criteria (n=66)

Randomised
(n=120)
Allocation

(Manipulation Group) (Control Group)

Allocated to intervention (n=60) Allocated to intervention (n=60)
Received allocated intervention (n=60) Received allocated intervention (n=60)
Did not receive allocated intervention (n=0) Did not receive allocated intervention (n=0)

Discontinued follow up (n=0) Discontinued follow up (n=0)

Assessment

Not enough time to attend =0 Not enough time to attend =0

Baseline

Dissatisfied with treatment effect =0 Dissatisfied with treatment effect =0

Worsening of symptoms=0 Worsening of symptoms =0
Other reason =0 Other reason =0

Discontinued follow up (n=3) Discontinued follow up (n=6)

Not enough time to attend =2 Not enough time to attend =1
Immediate
follow up

Dissatisfied with treatment effect=1 Dissatisfied with treatment effect =2

Worsening of symptoms =0 Worsening of symptoms=2
Other reason =0 Other reason =1
Drop out rate=5% of the manipulation group Drop out rate=10% of the control group

Discontinued follow up (n=5) Discontinued follow up (n=11)

Not enough time to attend =2 Not enough time to attend =3
3 months
follow up

Dissatisfied with treatment effect =1 Dissatisfied with treatment effect =3

Worsening of symptoms=1 Worsening of symptoms =4
Post

Other reason= 1 Other reason= 1

Drop out rate=8.33% of the manipulation group Drop out rate=18.33% of the control group

Discontinued follow up (n=6) Discontinued follow up (n=11)

Not enough time to attend =3 Not enough time to attend =2
6 months
f o ll o w u p

Dissatisfied with treatment effect=1 Dissatisfied with treatment effect =4

Worsening of symptoms =1 Worsening of symptoms =4
P os t

Other reason =1 Other reason =1

Drop out rate=10% of the manipulation group Drop out rate=18.33% of the control group

Analyzed (n=60) Analyzed (n=60)

Analysis

Excluded from analysis by intention to treat (n=0) Excluded from analysis by intention to treat (n=0)

Fig. 1. Participant ow and follow-up evaluation.

showed similar results of 6.0e8.9 points. However, their study
terminated at 1 week post-treatment with no longer follow-up
evaluation.
4.3. Changes in CV angle
The TM group showed a signicantly better improvement
than the control group up to 6-months post-treatment. However,
the control group failed to demonstrate any signicant change to
the CV angle for the rest of the study after completion of
treatment.
To the best of the authors knowledge, the current study
is the rst to investigate the effect of TM on the CV angle. This
study provides evidence that TM could lead to an improvement
in head posture as a result of the signicant increase in the
CV angle.
 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147 145

Table 1 4.4. Changes in NPRS

Baseline characteristics of patients.

Intervention Control P* Both groups showed improvement in NPRS after completion of

n 60 60 a 4-week intervention up to the 6-month follow-up. In addition, the
Age (yr) improvement shown (reduction in NPRS) in the TM group was better
Mean/SD 44.17/9.27 43.78/9.25 0.82 than the reduction in NPRS in the control group throughout the
Range 18e55 19e55
entire study period. Hence TM was shown to have a positive inu-
Gender (n)
Male 30 30 1.00a ence in NPRS reduction with an effect lasting up to 6-months post-
Female 30 30 treatment. It is important to note that between-group differences for
NPQ pain achieved by the thoracic spine thrust manipulation group in this
Mean/SD 39.15/15.00 41.86/11.66 0.27 present study was not only statistically signicant but also clinically
Range 9.38e84.38 18.75e71.88
CV
meaningful as the improvement exceeded the clinically important
Mean/SD 44.27/7.00 43.09/6.02 0.32 benet (15%) as suggested by the Philadelphia Panel (2001)
Range 9.38e55.20 28.10e55.40 (decrease in NPRS ranged from 34.4% to 40.6% in the TM group).
NPRS In a prospective study on the efcacy of different treatments for
Mean/SD 5.02/1.83 5.05/1.48 0.91
chronic mechanical neck pain patients (Muller and Giles, 2005),
Range 1e10 2e8
F results showed that TM signicantly decreased mean NPRS from 6 to
Mean/SD 48.99/10.32 47.94/8.83 0.55 2.3 (reduction of 3.7) whereas the present study showed an average
Range 26.77e66.17 24.76e65.10 reduction of 1.20 in NPRS. However, the total treatment sessions
E were 9 weeks as compared with only 4 weeks in the current study.
Mean/SD 47.30/9.33 45.39/10.60 0.30
Range 24.40e66.36 25.32e67.07
In an RCT study comparing the short-term effect of a single TM
LSF and mobilization in patients with neck pain by Cleland et al.
Mean/SD 33.20/8.48 32.21/6.97 0.48 (2007a,b), the results showed similar ndings as the present
Range 14.57e53.30 11.77e49.63 study with a signicantly greater reduction in NPRS by TM than
RSF
mobilization 2e4 days after the intervention.
Mean/SD 34.00/9.82 33.48/8.32 0.75
Range 15.73e53.57 11.03e50.02
LR
4.5. Changes in cervical ROM
Mean/SD 54.57/13.88 53.16/13.14 0.57
Range 27.10e75.00 14.30e81.80
RR Except for rotation, improvement in cervical ROM was signi-
Mean/SD 56.16/12.91 55.58/14.64 0.82 cantly better in the TM group at 3-months and 6-months post-
Range 34.77e76.37 15.37e80.32 treatment. Moreover, exion ROM was signicantly greater
MCS
Mean/SD 43.92/10.14 46.28/10.52 0.21
immediately post-treatment in the TM group.
Range 19.18e65.17 16.91e70.87 A case study on the effect of TM on neck pain and ROM
PCS (Fernandez-de-las-Penas et al., 2007) showed there was a signi-
Mean/SD 38.35/10.36 35.35/9.75 0.11 cant decrease in neck pain and a trend toward an increase in
Range 9.11e54.98 10.00e51.59
cervical ROM after a single TM. In a randomized controlled trial on
*P values of comparison of baseline characteristics using independent T-test. the treatment of mechanical neck disorders, cervical ROM
MCS Mental Component Score; PCS Physical Component Score;
improvement was better immediately following a single high
NPQ Northwick Park Neck Disability Questionnaire; CV Craniovertebral angle;
NPRS Numeric Pain Rating Scale; F Flexion; E Extension; LSF Left Side
velocity, low-amplitude manipulation than following regular
Flexion; RSF Right Side Flexion; LR Left Rotation; RR Right Rotation. physiotherapy treatment (Martinez-Segura et al., 2006). Yet both
a
As determined by chi square test for independence. studies were only evaluating the immediate effect (with 48 h) and
there was no comparison with a control.
Similar results were demonstrated by Flynn et al. (2007). They
reported that TM resulted in an immediate increase in cervical ROM
in patients with primary neck dysfunction. However, owing to the

Table 2
Results at post-treatment immediate follow-up.

Outcome Control Intervention P value for Between-group

Measures interaction comparison by
Mean (95%Cl) SD Mean (95%Cl) SD
effect between ANOVA (95%CI)
time and group
NPQ 36.01 (32.11e40.71) 13.47 27.15 (22.60e30.78) 16.84 0.016* 28.58e34.52*
CV 44.25 (42.91e45.81) 5.87 47.24 (45.80e48.56) 4.52 0.032* 44.77e46.77*
NPRS 4.37 (3.89e4.93) 1.75 3.14 (2.49e3.47) 1.99 0.001* 3.33e4.05*
F 48.74 (46.85e51.40) 7.89 56.26 (54.79e59.12) 8.77 0.000* 51.47e54.61*
E 49.19 (47.21e51.74) 8.64 52.21 (50.31e54.63) 7.51 0.873 49.41e52.54
LSF 35.36 (32.96e38.26) 10.22 39.34 (36.95e42.00) 7.91 0.043* 35.71e39.37
RSF 36.45 (33.89e38.63) 8.34 40.27 (38.06e42.58) 8.14 0.038* 36.65e39.93
LR 57.18 (54.76e61.13) 11.1 62.08 (59.18e65.24) 11.3 0.084 57.88e62.27
RR 57.84 (54.03e61.86) 13.66 62.46 (59.02e66.48) 13.33 0.012* 57.65e63.06
MCS 46.16 (43.80e49.43) 10.03 45.08 (42.88e48.24) 10.17 0.349 44.14e48.03
PCS 36.01 (32.98e37.90) 6.98 41.73 (39.45e44.14) 10.13 0.436 36.92e40.32*

*P < 0.05.
MCS Mental Component Score; PCS Physical Component Score; NPQ Northwick Park Neck Disability Questionnaire; CV Craniovertebral angle; NPRS Numeric Pain
Rating Scale; F Flexion; E Extension; LSF Left Side Flexion; RSF Right Side Flexion; LR Left Rotation; RR Right Rotation.
146 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147

Table 3
Results at 3-months follow-up.

Outcome Control Intervention P value for Between-group

Measures interaction comparison by
Mean (95%Cl) SD Mean (95%Cl) SD
effect between ANOVA (95%CI)
time and group
NPQ 35.40 (31.12e39.69) 14.4 27.84 (23.40e31.57) 15.8 0.114 28.49e34.40*
CV 43.58 (42.28e44.87) 4.74 46.43 (45.16e47.63) 4.37 0.034* 44.09e45.88*
NPRS 4.41 (3.89e4.93) 2.02 3.29 (2.74e3.74) 1.70 0.002* 3.46e4.19*
F 47.89 (45.54e50.24) 8.72 55.52 (53.56e58.04) 8.10 0.000* 50.22e53.47*
E 47.16 (44.93e49.39) 8.89 53.56 (51.73e55.98) 7.11 0.129 48.97e52.05*
LSF 37.05 (34.85e39.25) 7.04 43.22 (41.45e45.64) 8.62 0.001* 38.78e41.82*
RSF 36.38 (34.46e38.30) 5.77 40.72 (39.05e42.70) 7.57 0.004* 37.30e39.95*
LR 57.84 (54.68e61.00) 9.77 61.35 (58.81e64.84) 12.69 0.104 57.65e62.02
RR 54.58 (50.96e58.19) 13.01 60.81 (57.70e64.59) 12.65 0.001* 55.36e60.36
MCS 46.76 (43.52e50.00) 12.07 45.85 (42.85e49.02) 10.76 0.317 44.11e48.59
PCS 34.34 (31.91e36.76) 8.67 41.44 (39.25e43.87) 8.43 0.715 36.27e39.62*

*P < 0.05.
MCS Mental Component Score; PCS Physical Component Score; NPQ Northwick Park Neck Disability Questionnaire; CV Craniovertebral angle; NPRS Numeric Pain
Rating Scale; F Flexion; E Extension; LSF Left Side Flexion; RSF Right Side Flexion; LR Left Rotation; RR Right Rotation.

lack of comparison group in the study, no conclusion about the
cause-and-effect relationship could be drawn. In addition, only
the short-term positive effect was investigated in their study while
the present study showed improvement in cervical ROM up to
6-months post-treatment.
More importantly, the signicant improvement in cervical ROM
after TM in the present study gives good support to the biome-
chanical implications associated with thoracic spine manipulation
in patients with neck pain. Our results suggest that TM could help
restore normal biomechanics to the cervical-thoracic motion
segment, leading to a decrease in mechanical stress to the cervical
spine and thus improve neck pain.
4.7. Adverse effects from the present study
The types of benign, self-limiting adverse events from TM have
been prospectively and systemically described in different studies
(Leboeuf-Yde et al., 1997; Sentad et al., 1997; Barrett and Breen,
2000; Cagnie et al., 2004; Hurwitz et al., 2004; Rubinstein et al.,
2007). Generally, those events are mild to moderate in intensity,
have little to no inuence on activities of daily living, and sponta-
neous recovery, typically lasting not more than a few days
(Rubinstein, 2008). However, no adverse effect was reported from
the TM group throughout the entire study period (up to 6-months
post-treatment) in the present study.

4.6. Changes in MCS, PCS (SF36) 4.8. Limitations of present study

Although a statistically signicant result was shown only in the
PCS domain, the TM group had improvement in the health-related
quality of life in both MCS and PCS.
Results reported by Muller and Giles (2005) showed that spinal
manipulation signicantly improved neck disability and SF36 after
a 1-year follow-up. However, the total treatment sessions were
9 weeks as compared with only 4 weeks in the present study. In
addition, cervical manipulation instead of TM was performed in
their study.
As the present study only recruited patients with chronic non-
specic neck pain, the results of the study may not apply to patients
with acute neck pain conditions such as whiplash injury. In addi-
tion, the sample size of the present study did not allow subgroup
analysis of the effects of TM on patients of different genders or age
groups. Furthermore, the time spent in the TM in the treatment
group was higher than the control group. The cost effectiveness of
the TM for treating neck pain needs to be evaluated in future
studies.

Table 4
Results at 6-months follow-up.

Outcome Control Intervention P value for Between-group

Measures interaction comparison by
Mean (95%Cl) SD Mean (95%Cl) SD
effect between ANOVA (95%CI)
time and group
NPQ 34.80 (30.35e39.25) 15.34 28.77 (24.53e33.01) 16.03 0.085 28.71e34.86*
CV 43.49 (42.18e44.80) 4.54 46.62 (45.38e47.87) 4.69 0.067 44.15e45.96*
NPRS 4.24 (3.69e4.80) 2.12 2.98 (2.46e3.51) 1.76 0.004* 3.23e3.99*
F 49.72 (47.06e52.37) 9.52 54.56 (52.03e57.09) 9.24 0.000* 50.30e53.97*
E 49.30 (46.85e51.76) 9.23 53.10 (50.76e55.44) 8.12 0.114 49.50e52.90*
LSF 37.30 (34.46e40.15) 7.71 42.30 (39.59e45.01) 11.76 0.003* 37.84e41.77*
RSF 34.93 (32.28e37.59) 7.57 40.39 (37.87e42.92) 10.73 0.002* 35.83e39.50*
LR 56.09 (52.39e59.79) 12.62 58.37 (58.84e61.90) 13.45 0.148 54.67e59.79
RR 53.08 (49.80e56.36) 11.62 60.20 (57.08e63.33) 11.54 0.004* 54.38e58.91
MCS 46.55 (43.60e49.49) 10.24 45.35 (42.55e48.16) 10.54 0.514 43.91e47.99
PCS 35.67 (33.11e38.22) 9.63 41.24 (38.81e43.67) 8.40 0.600 36.69e40.21*

*P < 0.05.
MCS Mental Component Score; PCS Physical Component Score; NPQ Northwick Park Neck Disability Questionnaire; CV Craniovertebral angle; NPRS Numeric Pain
Rating Scale; F Flexion; E Extension; LSF Left Side Flexion; RSF Right Side Flexion; LR Left Rotation; RR Right Rotation.
 H.M.C. Lau et al. / Manual Therapy 16 (2011) 141e147
5. Conclusion
The effect of TM was shown to be positive in reducing neck pain,
improving dysfunction and neck posture, and neck ROM up to half
a year post-treatment. In treating patients with chronic mechanical
neck pain, TM could be a choice for effective management.
Appendix 1. Procedure of TM
1. The subject lay supine with the arms crossed over the chest and
hands passed around the shoulder with the thoracic spine was
in neutral position.
2. The hand of the therapist contacted with a neutral hand posi-
tion over the spinous process of the selected thoracic level
(inferior vertebra of the motion segment).
3. The other hand stabilized the head, neck, and upper thoracic
spine of the subject.
4. Gently, exion of the thoracic spine was introduced until slight
tension was palpated in the tissues at the therapists contact
point.
5. Then, a high velocity, low-amplitude technique downward
toward the couch and in a cephalad direction was applied
(Fig. 1).
6. A cracking or popping sound accompanied all manipulations.
7. If no popping sound was heard on the rst attempt, the ther-
apist repositioned the subject, and the therapist performed
a second manipulation over the same selected thoracic level(s).
8. A maximum of 2 attempts was performed on each subject at
each session.
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