Effectiveness of Thoracic Manipulation - Literature review Example

EFFECTIVENESS OF THORACIC MANIPULATION By Location Introduction Any damage, injury or disorder pertaining to the tissues or joints in the back or lower and upper limbs is referred to as a musculoskeletal disorder. This may be the result of awkward postures, sudden or repeated exertion of force, repeated strain as well as vibrations. Low back pain and neck pain are the most common musculoskeletal disorders globally, with 30-50% of the adult population experiencing neck pain associated disorders. Neck pain is caused by a number of disorders that range from straining of the neck muscles to having a hernianated cervical spine. If the neck pain is not specific and is exacerbated by movements of the neck, the condition is referred to as mechanical neck pain. However, there exist difficulties in differentiating pains from the neck, upper back and shoulders (Vernon et al. 2007, p. 218). With studies showing that neck pain has a significant negative impact on mental health which reduces productivity a lot of research has been conducted to develop treatments for the reduction of the disorder (Daffner et al. 2003, p. 2031). One such mode of treatment is thoracic manipulation. This is the low amplitude or high velocity movement (thrust) of any segment of the thoracic spine (Walser, Meserve and Boucher 2009, 237). Since 2004, increased literature concerned with the thoracic manipulation’s effectiveness on treatment of musculoskeletal conditions through different techniques has been published. The literature evidences that manipulation of the thoracic spine improves the motion range and reduces pain among patients with MNDs (Lau, Wing Chiu and Lam 2011, p. 141). With the procedure associated with lesser risks of vertebral artery injuries as compared to manipulations of the cervical spine, researchers have argued that it is a viable alternative to the latter (Cleland et al. 2005, p. 128; Fernandez-de-las-Penas et al. 2007, p. 16). This paper seeks to examine literature on TSM in order to establish the effectiveness of the therapy and show whether there exists significant differences between application of TSM alone and combining it with other intervention methods. The larger part of the TSM research focused on the effects of the therapy on the body regions around the thoracic spine. This regional interdependence concept relied on the idea that reduced upper thoracic segments’ movements relate to the pains in the neck and shoulders (Walser, Meserve and Boucher 2009, 237). This is illustrated by the fact that reduction of the pain or general neck disorder by TSM is not a direct effect of the manipulation because the reduction in mechanical stress and therefore pain is the result of the normalizing of the upper and cervical regions’ biomechanics (Lau, Wing Chiu and Lam 2011, p. 141).The neuropsychological impacts associated with TSM like hypoalgesia are also caused by this interdependence. This means that the concept may be utilized in examining the effectiveness of the therapy. Studies of the effectiveness of TSM alone There is a lot of literature pertaining to studies of the utilization of TSM in treatment of neck pains and disorders. The studies integrated into this review utilized TSM therapy in the treatment of the neck disorders with subjects exhibiting reduction in pain and increased mobility with some showing short-term disability reduction. However, the studies conducted were mainly short term and research on the long term effects of the therapy is necessary. Krauss et al. (2008, p. 94) conducted a fair study where a TSM method was used to treat neck disorders. The study rated pain at end range instead of when subjects rested. Since cervical rotation was associated with pain the assessment took an approach that indirectly analysed the effect of activities. The study found that the application of TSM methods in subjects with neck pains resulted in significant reductions in pain during left and right cervical rotations in the end range. There were significant changes exhibited in bilateral cervical rotations (Krauss et al. 2008, p. 97). This enabled the subjects to show improvements in the performance of aforementioned activities. Another high quality study by (Suvarnnato et al. 2013, p. 868) investigated the thoracic manipulation effects on 39 patients with chronic mechanical neck pain. The patients got assigned to thoracic manipulation therapies and thoracic mobilization of single level randomly with their responses taken immediately after the procedures and 24 hours later. The researchers then measured the pain ratings using a visual analog scale as well as the subject’s cervical range of motion in all directions. The findings showed that both of the techniques resulted in a decrease in pain and increased cervical motion ranges significantly at the 24 hour follow up. The two techniques however, did not exhibit significant differences at rest at the follow up time. Even if the study was of high quality utilizing a scale and two techniques as well as control experiments to provide clear differences, there are some key components worth noting. First is the fact that the follow up period was only 24 hours after treatment. This means that the results only apply for a short term basis. It is possible that after the 24 hours, the findings would have been different. Therefore the findings and recommendations are not valid for interventions meant for long term results. The fact that only 39 subjects participated in the means restricts the generalization of the findings to be applicable for the wider population or neck pains disorders. The researchers could have conducted the study on a larger number of subjects drawn from different demographics and with a diverse range of conditions causing neck pains to make it more concrete. Finally, there is the issue that the whole study based its procedures on Butler’s (1991, p. 45) findings that showed the T6 vertebral level served as the most rigid component contributing to the nervous system mobility. This saw the mobilization and manipulation being conducted on the level as a technique of improving chronic neck pain symptoms. The study did not therefore consider the possibility that the T6 was not the cause of the pain. This means that if a subject’s condition stemmed from injury at another vertebral level, the result of the manipulation may be defective. Cleland and colleagues also conducted a number of high quality studies on the issue. In the 2007 study of “Short term effects of thrust versus non thrust, they used TSM therapy as treatment offered to patients with neck pain conditions ranging from acute to sub-acute (Cleland et al. 2007, p. 432). The aim of the study was to test whether the manipulation of parts of the thoracic spine by thrusting them resulted in mechaMND symptoms reduction at a lesser cost of fewer complications. As in the other studies, the procedure resulted in a significant reduction in the symptoms. The results also showed a significant reduction in disability. This showed that treatment of mechanical neck pain subjects with multilevel TSM facilitates an immediate neck function and symptom improvement. Although the results were similar to those of other studies and portray TSM to be effective, they were only short term. This serves as a limitation as it does not show that the therapy is an effective guarantee for complete treatment of the conditions. Critical evaluation The three studies illustrate TSM as a viable method of intervening in cases of MNDs since it reduced symptoms and disability. However, this does not show the effectiveness of the techniques. We therefore need to review TSM literature and determine the effectiveness of the treatment. Although there are lots of articles and books talking about TSMs, no existing literature clearly defines the biomechanical and neuropsychological processes associated with the manipulation as there is no definitive knowledge of the effects. However, there are several hypotheses seeking to explain these neuropsychological effects. Pickar (2002, p. 365) argues that the current research and evidence on the issue shows that the manipulation creates an inhibition of pain or muscle relaxation reflex through the modification of the proprioceptive group I and II mechanoreceptors’ discharge. This facilitates the processing of sensory in the spinal cord and improved control of the reflexes of skeletal muscles improving mobility. An additional hypothesis is that the noradrenergic and serotogernic receptors utilize descending inhibitory pathways in mediation of analgesic responses by manipulating the spine (Skyba et al. 2003, p. 163). This causes the reduction in pain in regions that are distant from the manipulation. However, electromyographical studies suggested that the manipulation facilitates activation of muscles next to the site of manipulation (Suter et al. 1994, p. 126). The theory is that the activation that causes the effect starts from the articular mechanoreceptors of type II found in the spine (Suter et al. 1994, p. 126). Although it is not clear which is the correct mechanism, evidence shows that TSM procedures do indeed work to some extent. A review of literature by (Cross et al. 2011, p. 339) illustrated that a procedure of thrust TSM in patients suffering from sub-acute or acute mechanical neck pains increased their CROM and reduced pain. The review showed that the effects occurred immediately in 6 random tests with the effects remaining for up to six months. It also showed that the growing literature assessing TSM mostly consisted of researches and investigations conducted on subjects who had been mechanical neck pain patients for a period of 3 months or less (González-Iglesias et al. 2009, p. 307). This showed the exclusion of chronic neck disorder patients that make up a humongous burden. The interpretation is that TSM practical application as a treatment regime may lack validity for treatment of the chronic neck disorders. This has seen the integration of the technique in clinical practice in a manner that can described as cautionary. Another issue with the studies advocating for incorporation of TSM on its own as a neck disorder treatment is the technique used. According to Butler’s (1991, p. 45), T6 level is the most rigid component of the nervous system mobility, making it the best level to manipulate. Relying on this information, the (Suvarnnato et al. 2013, p. 867) study puts its subjects through manipulation of the T6 level, regardless of the condition or disk causing the disorder. The results showed that the manipulation was successful in improving the symptoms. The interpretation of this is that TSM does not need focus on the specific condition or vertebral level as manipulating the T6 will result in improvements (Ross, Bereznick and McGill 2004, p. 156).. This contrasts with the Cleland et al. (2005, p. 132) study that revealed that there exist variations in locations of specific thoracic manipulation. At the same time, the review by Cross et al. (2011, p. 335) showed that a majority of the investigative literature on the issue utilized techniques of spine or seated thrust manipulation. The fact that most of the results indicated improvements of symptoms creates the question of which method is suitable to utilize in TSM treatments? The paradox is furthered by the fact that none of the studies explained a clinical reason that comprehensively covers the reason for choosing the method. Thus the question of whether every technique yields the same effect, or are the improvements caused by the placebo effect? The placebo effect is such that when a person is told about the potential benefits of a treatment, the brain creates a perception that stimulates the body to respond positively to the treatment (Lærum 2005, p. 5). When a study candidate is informed of the possible benefits of the TSM treatment, the expectations are expected to develop placebo analgesia from the procedure (Price et al. 1999, p. 149). This means that the treatment may not be successful if the patient is not informed of the possible benefits. This means that the effectiveness of the TSM relies on providing information on the potential benefits to the patient and the development of placebo analgesia. Thoracic manipulation with other interventions Thoracic spine manipulation is a treatment regime that is applicable on its own as an intervention for neck pains. However, there exist other regimes that can serve as substitutes for TSM as well as being applied alongside TSM. These include therapeutic exercises and soft tissue mobilization (Costello 2008, p .129). Ever since researchers claimed that thoracic manipulation could be applied to intervene in neck pain disorders, there has been an unending debate concerning the application of TSM on its own. Protagonists claim that the procedure is viable on its own while the antagonists argue that it needs the support of other intervention methods to make it effective. The effect is the conducting of research and creation of literature focusing on the effects combining manipulation and other intervention methods in the dealing with the neck pain disorder. Gross A.R. is one of those researchers who has greatly contributed to the debate through a number of studies. The “conservative management of mechanical neck disorders: a systematic review” is a study that was conducted by Gross and colleagues. It aims to establish whether conservative treatments of neck pains were successful through the updating of 11 randomized controlled trials’ systematic reviews (Gross et al. 2007, p. 102). The study involved the selection of studies, data abstraction and methodological quality assessment by two independent authors from computerized databases. They then calculated the studies’ relative risks as well as standardized mean differences with pooled effect sizes being calculated in cases where heterogeneity lacked. In total a number of 88 unique RCTs were studied with 59% meeting the threshold of acceptable mean methodological quality. The findings showed that the exercise plus manipulation technique had higher levels of pain reduction [ pooled SMD -0.85 (95% Cl -1.20, -0.50)], positive global perceived effect and improvement of function (CROM) as compared to the control which involved manipulation or mobilization techniques only for subjects with chronic or sub-acute MND (Gross et al. 2007, p. 102). Many of the treatments, however exhibited short term effects with the figures showing that direct neck stretching and strengthening had moderate long term benefits. The interpretation is that regime comprising of thoracic manipulations and therapeutic exercises had a higher rate of improvements of the symptoms of MNDs. However, the benefits extracted from this combination were not long term, although the effects were immediate (Gross et al. 2007, p. 102). The fact that the study was based on information from other researches enabled it to have good generality as it was able to integrate information concerning a wide range of people. However, this aspect of the study also proved to be its limitation as the reliance on other people’s findings may result in the invalidity of findings if the data was erroneous. Although the team conducted a quality assessment of the information, it does not guarantee the eligibility of the information. Michael Costello has also presented research on the issue. The research is based on a case report for a 41-year-old male who worked as an equipment operator referred to physical therapy after a diagnosis of neck pain (Costello 2008, p .129). The patient complained of a burning sensation in the neck accompanied by an ache in the left arm which aggravated after working. He wanted to reduce the pain and improve his neck’s mobility. Before treatment he filled out a self report that included a numeric pain rating scale for measuring pain intensity. On a scale of 0 to 10, he rated an average of 4.66. The disability level created by the pain was also measured using a patient-specific functional scale where he scored 3. A medical screen showed that he did not have any red flags allowing physiotherapy. A physical examination to determine the CROM was conducted with diagnosis being cervical radiculopathy as he met 3 out of 4 variables identified in (Fritz et al. 2007, p. 1623). The physiotherapist opted to take the patient through a regime that thoracic spine thrust manipulation, mobilization of soft tissue and therapeutic exercise. This was because the TSM that was the first step of intervention did not relieve the pain in all regions necessitating the application of the mobilization (Costello 2008, p .129). The exercises that the patient was recommended to do at home were to result in the longevity of the effects. The effect was that the pain rating reduced to 4.66/10 to 0/10 after just three visits. This shows that the combination of the different alternatives is the best effective method of handling neck pain disorders. The fact that the TSM on its own failed to alleviate all the pain shows that application on its own is not as effective as a combination of different alternatives. In the study, the application of TSM on its own served as the control experiment as it showed how it fairs on its own. However, this case study report is limited by the fact that it solely relies on the perception of the patient to determine the levels of development. If the patient had used pain killers, the values of the findings would have been distorted. Critical analysis Although these two studies have utilized different methods to provide understanding on the issue of multimodal treatment of neck pains, they have both showed that the package is better suited to offer treatment in comparison to TSM on its own. However, both of the studies involve the incorporation of TSM as a treatment for MNDs as well as other pathology that cannot be compared with mechanical neck disorders. This does not mean that the treatment regime is less effective for MNDs. In the Gross case, the findings showed that subjects had a preference for a multimodal package because it was better in pain reduction and mobility improvement (Gross et al. 2007, p. 102). Although the TSM users also claim it has a good reputation for treatment of neck pain related conditions, the reduced numbers show that it is not the best choice. Even Cleland reports that a multimodal package for treating the neck pains indicates potential positive outcomes (Cleland et al. 2007, p. 439). This is supported by the evidence provided by the (Costello 2008, p .129) case where the administration of a multimodal package resulted in the significant improvement of symptoms in just three visits. Sarig-Bahat after reviewing a number of articles came to the conclusion that chronic neck pain patients may benefit from dynamic strength and proprioceptive exercises for the neck and shoulders (Sarig-Bahat 2003, p. 18). If the therapist had decided to continue with the TSM package, the patient would be a recurring visitor for a while. Nevertheless, there Costello case has one important factor that needs consideration. Although the patient is suffering from mechanical neck pain, he also has complications in his shoulder and left arm. One may argue that the ineffectiveness of the TSM applied for the treatment was the result of the occurrence of other injuries. This means that if he had only suffered from MND, a TSM regime would have been effective. But the effects of the treatment regime also affected the MND directly (Costello 2008, p .129). This means that the regime is the most effective for the disorder and the argument lacks validity. However, it is necessary to conduct further research on the issue of the effects of the different regimes as the patients dramatic recovery could be the result of one of the interventions, their mix or the history of the patient. Conclusion Neck pains and neck associated disorders are some of the most common musculoskeletal disorders. They occur in different magnitude depending on the cause and are known to cause mental illnesses and reduce productivity. There are a number of methods to counter the neck pains including thoracic manipulation. It involves the thrusting of a point in the spine. There is a large literature base that focuses on this topic with some of them arguing that the effectiveness of this procedure enables it to be administered on its own. However, to properly understand and prove this argument we need to examine studies on the topic. The studies in this paper have shown that the TSM methods are effective in treating neck pains associated disorders. However, the discussion has also shown that the techniques are somewhat lacking and not fully effective. Other studies have shown that the combination of the technique with other methods yields better results at faster speeds. Hence it is correct to conclude that there exists a significant difference in the effects of application of TSM on its own and with a combination of alternative intervention methods. 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Walser, R, Meserve, B and Boucher, T 2009, The Effectiveness of Thoracic Spine Manipulation for the Management of Musculoskeletal Conditions: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. The Journal of Manual & Manipulative Therapy, Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813505/ [25 Nov. 2014]. Read More