Short-Term Effects of Thrust Versus Nonthrust Mobilization/Manipulation Directed at the Thoracic Spine in Patients With Neck Pain: A Randomized Clinical Trial

Short-Term Effects of Thrust VersusNonthrust Mobilization/ManipulationDirected at the Thoracic Spine inPatients With Neck Pain:A Randomized Clinical TrialJoshua A Cleland, Paul Glynn, Julie M Whitman, Sarah L Eberhart,Cameron MacDonald, John D Childs

Background and PurposeEvidence supports the use of manual physical therapy interventions directed at the thoracic spinein patients with neck pain. The purpose of this study was to compare the effectiveness of thoracicspine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in pa-tients with a primary complaint of mechanical neck pain. The authors also sought to compare thefrequencies, durations, and types of side effects between the groups.

SubjectsThe subjects in this study were 60 patients who were 18 to 60 years of age and had a primarycomplaint of neck pain.

MethodsFor all subjects, a standardized history and a physical examination were obtained. Self-reportoutcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric PainRating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evalua-tion, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrustmobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial exami-nation, and they again completed the NDI and the NPRS, as well as the Global Rating of Change(GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis ofvariance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipula-tion) as the between-subjects variable and time (baseline and 48 hours) as the within-subjectvariable. Separate ANOVAs were performed for each dependent variable: disability (NDI) andpain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group � timeinteraction.

ResultsSixty patients with a mean age of 43.3 years (SD�12.7) (55% female) satisfied the eligibilitycriteria and agreed to participate in the study. Subjects who received thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of10% (95% confidence interval [CI]�5.3–14.7), and in pain, with a between-group difference of2.0 (95% CI�1.4–2.7). Subjects in the thrust mobilization/manipulation group exhibitedsignificantly higher scores on the GROC Scale at the time of follow-up. No differences in thefrequencies, durations, and types of side effects existed between the groups.

Discussion and ConclusionThe results suggest that thoracic spine thrust mobilization/manipulation results in significantlygreater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.

JA Cleland, PT, DPT, PhD, OCS,FAAOMPT, is Assistant Professor,Department of Physical Therapy,Franklin Pierce College, 5 ChenellDr, Concord, NH 03301 (USA); Re-search Coordinator, RehabilitationServices, Concord Hospital, Con-cord, NH; and Faculty, ManualPhysical Therapy Fellowship Pro-gram, Regis University, Denver,Colo. Address all correspondenceto Dr Cleland at: [email protected].

P Glynn, PT, DPT, OCS,FAAOMPT, is Physical TherapyClinical Specialist, Newton-Wellesley Hospital, Newton, Mass,and Fellow, Manual Physical Ther-apy Fellowship Program, RegisUniversity.

JM Whitman, PT, DSc, OCS,FAAOMPT, is Assistant Faculty,Department of Physical Therapy,and Faculty, Manual PhysicalTherapy Fellowship Program, Re-gis University.

SL Eberhart, PT, MPT, is PhysicalTherapist and Clinical II, Rehabili-tation Services, Concord Hospital.

C MacDonald, PT, DPT, GCS,OCS, FAAOMPT, is Physical Ther-apist, Centennial Physical Ther-apy, Colorado Sport and SpineCenters, Colorado Springs, Colo.

JD Childs, PT, PhD, MBA, OCS,FAAOMPT, is Assistant Professorand Director of Research, DoctoralProgram in Physical Therapy, USArmy–Baylor University, San Anto-nio, Tex.

[Cleland JA, Glynn P, Whitman JM,et al. Short-term effects of thrustversus nonthrust mobilization/manipulation directed at the tho-racic spine in patients with neckpain: a randomized clinical trial.Phys Ther. 2007;87:431–440.]

© 2007 American Physical TherapyAssociation

Research Report

April 2007 Volume 87 Number 4 Physical Therapy f 431

The prevalence of neck pain inthe general population hasbeen reported to be 15% for

men and 23% for women, with nearlyhalf of these individuals experiencingconstant unremitting symptoms.1 Ithas been estimated that as many as70% of individuals report experienc-ing neck pain at some point in theirlifetimes, and at a 5-year follow-up,78% of men and 85% of women reportfull recovery.2,3 The economic burdenassociated with neck pain is immense,and nearly one third of people whoexperience a first-time onset of neckpain will continue to report healthcare utilization for their neck pain at a5-year follow-up.4 Additionally, nearly25% of all visits in outpatient physicaltherapist practice are made by peoplewith a primary report of neck pain.5

Physical therapists use several in-terventions and modalities in themanagement of neck pain, includ-ing joint mobilization/manipulation(nonthrust and thrust), therapeuticexercise, and traction.6 However, ro-bust evidence to support the use ofmany of the aforementioned man-agement strategies is lacking.7–11 ThePhiladelphia Panel evidence-basedclinical practice guidelines con-cluded that there is insufficient evi-dence for the use of many commonlyused interventions for people withneck pain.8 Perhaps this finding is atleast partially responsible for thelack of clinical improvement ob-served in people with neck paincompared with people with lowback or lower-extremity pain.12

Recently, evidence has begun toemerge for the use of manual ther-apy, specifically, thrust mobilization/manipulation procedures, directed atthe thoracic spine in people with me-chanical neck pain. In a randomizedcontrolled trial, Cleland et al13 dem-onstrated that people who receivedthoracic spine thrust mobilization/manipulation experienced immediateand significant (P�.001) reductions

in pain, as measured with a visual an-alog scale, compared with peoplewho received a placebo mobilization/manipulation; the between-group dif-ference was 11.3 mm (95% confidenceinterval [CI]: 6.9–15.7). It was also dem-onstrated that people with whiplash-associated disorders who receivedthoracic spine thrust mobilization/manipulation experienced a signifi-cantly greater (P�.003) reduction inpain than those who did not receivethoracic spine thrust mobilization/manipulation.14

There is little evidence supporting atheoretical rationale as to why manualphysical therapy techniques directedat the thoracic spine may be beneficialin reducing pain and improving func-tion in people with neck pain. Addi-tionally, all studies to date that haveinvestigated the effects of treatmentstargeting the thoracic spine have in-corporated only thrust mobilization/manipulation procedures. Thus, itis not known whether non-thrustmobilization/manipulation procedureswill result in similar outcomes orwhether thrust mobilization/manipula-tion is essential in the recovery processfor people with neck pain. The mainpurpose of this study was to comparethe short-term effectiveness of thrustmobilization/manipulation with thatof nonthrust mobilization/manipu-lation directed at the thoracic spinein patients with mechanical neckpain. We also sought to comparethe frequencies, durations, and typesof side effects between people re-ceiving thrust mobilization/manipu-lation and those receiving non-thrustmobilization/manipulation.

MethodSubjectsConsecutive patients, who were re-ferred over a 13-month period (June2005 to July 2006) for physical ther-apy at 1 of 5 outpatient orthopedicphysical therapy clinics (Rehabilita-tion Services, Concord Hospital,Concord, NH; Newton-Wellesley

Hospital, Newton, Mass; CentennialPhysical Therapy, Colorado Springs,Colo; Groves Physical Therapy, StPaul, Minn; and Sharp HealthCare,San Diego, Calif) by their primarycare physicians because of a com-plaint of mechanical neck pain, werescreened for eligibility criteria. Inclu-sion criteria required subjects to bebetween the ages of 18 and 60 yearsand to have a primary complaint ofneck pain with or without unilateralupper-extremity symptoms and abaseline Neck Disability Index (NDI)score of 10% or greater.

Exclusion criteria were: identifica-tion of any medical signs suggestiveof a nonmusculoskeletal etiology ofsymptoms, a history of a whiplashinjury within 6 weeks of the exami-nation, a diagnosis of cervical spinalstenosis, evidence of any central ner-vous system involvement, signs con-sistent with nerve root compression(at least 2 of the following had to bediminished for nerve root involve-ment to be considered: myotomalstrength, sensation, or reflexes), pre-vious cervicothoracic surgery, orpending legal action. All subjects re-viewed and signed a consent form ap-proved by the respective institutionalreview board before participation.

TherapistsTwelve physical therapists (meanage�36 years, SD�6.4) participatedin the examination and treatment ofall subjects in this study. All thera-pists underwent a standardized train-ing regimen, which included study-ing a manual of standard procedureswith the operational definitions ofeach examination and interventiontechnique used in this study. Allparticipating therapists underwenttraining provided by a current Fel-low in the Manual Physical TherapyFellowship Program, Regis Univer-sity, Denver, Colo. During this train-ing session, all participating thera-pists were required to demonstratethe examination and intervention

Thrust Versus Nonthrust Mobilization/Manipulation at the Thoracic Spine for Neck Pain

432 f Physical Therapy Volume 87 Number 4 April 2007

techniques to ensure that all studyprocedures were performed in a stan-dardized fashion. Participating thera-pists had a mean of 9.7 years (SD�6.8,range�1–19) of clinical experience.

Examination ProceduresAll subjects provided demographic in-formation and completed several self-report measures, and a standardizedhistory and a physical examination wereobtained (baseline). Self-report mea-sures included a body diagram,15 theNumeric Pain Rating Scale (NPRS),16

the NDI,17 and the Fear-Avoidance Be-liefs Questionnaire (FABQ). The FABQwas used to quantify a subject’s fear-avoidance beliefs about physical ac-tivity as well as work.18 The FABQ con-sists of work (FABQW) and physicalactivity (FABQPA) subscales, each ofwhich has been shown to exhibit ahigh level of test-retest reliability.19

The FABQW subscale has been shownto exhibit predictive validity in the iden-tification of people who have low backpain and who are likely to respond tospinal mobilization/manipulation.20,21

Additionally, lower scores on a modi-fied FABQ (FABQPA and FABQW)have been shown to be predictivefor people who have neck pain andwho likely will benefit from spinalmobilization/manipulation applied tothe thoracic spine and rib cage.22 Forthis study, the FABQ was modified byreplacement of the word “back” withthe word “neck.”22 The standardizedhistory and the physical examinationwere obtained in a fashion identical tothat described by Cleland et al.22

OutcomesThe primary outcome measure usedin this study was the subjects’ per-ceived level of disability as a result oftheir neck pain, as captured with theNDI.17 The NDI contains 10 items—7 related to activities of daily living, 2related to pain, and 1 related to con-centration.23 Each item is scoredfrom 0 to 5, and the total score is ex-pressed as a percentage, with higherscores corresponding to greater dis-

ability. The NDI has been demon-strated to be a reliable and valid out-come measure for people with neckpain24–26 and has been used widelyin clinical trials of people with neckpain.17,27–29

Westaway et al30 identified the mini-mal detectable change (MDC) on theNDI as 5 points, and Stratford et al26

also identified the MDC to be 5 pointsfor a group of people with neck pain.In both of these studies, the investiga-tors reported the MDC on a 50-pointscale; we calculated the NDI as a per-centage of 100, which would trans-late to an MDC of 10%. Although theseinvestigators reported that a change of5 points (or 10%) must be observed tobe certain that the change in scores isgreater than measurement error, novalues for the minimal clinically impor-tant difference have been reported inthe literature for people with mechan-ical neck pain.26,31

Secondary outcome measures in-cluded pain and a subject Global Rat-ing of Change (GROC) Scale. TheNPRS was used to capture a subject’slevel of pain. Subjects were asked toindicate the intensity of current, best,and worst levels of pain over the pre-ceding 24 hours by using an 11-pointscale ranging from 0 (“no pain”) to 10(“worst pain imaginable”).32 Theaverage of the 3 ratings was used torepresent a subject’s level of pain overthe preceding 24 hours. The minimalclinically important difference for theNPRS has been reported to be 2points.33

At the time of follow-up, subjectscompleted the GROC Scale.34 Theywere asked to rate their overall per-ception of improvement since begin-ning the interventions on a scaleranging from �7 (“a very great dealworse”) to 0 (“about the same”) to�7 (“a very great deal better”). It hasbeen suggested34 that scores on theGROC Scale of between �3 and �1represent small changes, scores of

�4 and �5 represent moderatechanges, and scores of �6 and �7represent large changes.34

RandomizationAfter the baseline examination, sub-jects were randomly assigned to re-ceive thrust or nonthrust mobilization/manipulation directed at the upperthoracic spine and the middle tho-racic spine. Concealed allocation wasperformed by use of a computer-generated randomized table of num-bers created before the beginning ofthe study. Individual, sequentially num-bered index cards with the randomassignments were prepared. The in-dex cards were folded and placed insealed opaque envelopes. A secondtherapist who was unaware of thebaseline examination findings openedthe envelopes and proceeded with theinterventions according to the groupassignments. All subjects received theinterventions on the day of the initialexamination.

InterventionsNonthrust mobilization/manipu-lation group. Subjects who wererandomly assigned to receive non-thrust mobilization/manipulation werepositioned in the prone position. Theclinician performed one 30-secondbout of grade III or IV central posterior-anterior nonthrust mobilization/ma-nipulation at the T1 spinous process asdescribed by Maitland et al.35 After the30-second bout, the therapist pro-ceeded to T2 and performed the sametechnique. This process was contin-ued sequentially in a caudal directionto T6, for an overall intervention timeof approximately 3 minutes (Fig. 1).

Subjects then were instructed in a gen-eral cervical mobility exercise as orig-inally described by Erhard.36 To per-form this exercise, each subject wasinstructed to place the fingers over themanubrium and to start in a positionwith the chin placed directly on thefingers. Next, the subject was asked torotate the head and neck to one side as



far as possible and return to the start-ing position. The subject was in-structed to perform this maneuver al-ternately to both sides within paintolerance. The subject was asked tostart by using 5 fingers and then toprogress to 4, 3, and 2 fingers andfinally to 1 finger as mobility im-proved. The subject was instructed toperform this exercise within pain tol-erance for 10 repetitions to each side,3 or 4 times per day, each day duringparticipation in the study. Addition-ally, subjects were instructed to main-tain their usual activities within thelimits of pain and to avoid activitiesthat aggravated symptoms. Subjectsalso were instructed to maintain theircurrent medication regimens through-

out the course of the study and toavoid any other cointerventions.

Thrust mobilization/manipulationgroup. Subjects in this group re-ceived thrust mobilization/manipulationtargeting the upper thoracic spine andthrust mobilization/manipulation tar-geting the middle thoracic spine. Theupper thoracic spine procedure wasadministered first and was performedwith the subject in the supine posi-tion. The clinician was instructed totarget between segments T1 and T4with this technique. Because thrustmobilization/manipulation of the tho-racic spine reportedly lacks spatial sen-sitivity,37 we did not capture the exactsegments targeted for each subject.The subject was instructed to clasp his

or her hands across the base of theneck. The subject’s arms then werepulled downward to create spinal flex-ion down to the upper thoracic spine.The therapist’s manipulative hand wasused to stabilize the inferior vertebraof the targeted motion segment, andhis or her body applied force throughthe subject’s arms to produce a high-velocity, low-amplitude thrust (Fig. 2).If a pop occurred, then the therapistmoved on to the next procedure. Ifnot, the subject was repositioned, andthe technique was performed again.This procedure was performed for amaximum of 2 attempts.

The subject remained in the supineposition, and the treating therapistperformed a middle thoracic spinethrust mobilization/manipulation. Theclinician was instructed to target be-tween segments T5 and T8 withthis technique. The subject was in-structed to clasp his or her hands tothe opposite shoulder. The subject’sarms were pulled downward to cre-ate spinal flexion down to the tar-geted motion segment. The thera-pist’s manipulative hand was usedto stabilize the inferior vertebra ofthe motion segment, and his or herbody was used to apply forcethrough the subject’s arms to pro-duce a high-velocity, low-amplitudethrust (Fig. 3). If no pop was heardon the first attempt, then the thera-pist repositioned the subject andperformed the mobilization/manipu-lation again. A maximum of 2 at-tempts were made. A similar amountof time was required to completethe thrust mobilization/manipulationand nonthrust mobilization/manipu-lation techniques (approximately 3minutes), minimizing the potentialfor an attention effect.

Subjects assigned to the thrustmobilization/manipulation group alsoreceived instructions in the samegeneral cervical exercise program asthose assigned to the nonthrustmobilization/manipulation group and

Figure 1.Nonthrust mobilization/manipulation technique used in this study.

Figure 2.Upper thoracic spine thrust mobilization/manipulation technique used in this study.



were instructed to maintain their usualactivities within the limits of pain andto avoid activities that aggravatedsymptoms. Subjects in this group alsoreceived instructions to maintain theircurrent medication regimens through-out the course of the study and toavoid any other cointerventions.

Follow-upAll subjects were scheduled forfollow-up within 2 to 4 days of theinitial examination and interventionsession. At the time of follow-up,subjects again completed the NDIand the NPRS, as well as the GROCScale. Additionally, subjects com-pleted a questionnaire regarding anyside effects that they may have expe-rienced since the initial interventionsession. The questionnaire was mod-ified from that used by Cagnie et al38

and included questions regardingcommonly described side effects as-sociated with the use of manualphysical therapy techniques, such asstiffness, headaches, muscle spasm,fatigue, or radiating discomfort. Sub-jects also could mark “other” andthen identify any other unusual sideeffects that they had experiencedsince the initial intervention session.If the subjects indicated that theyhad experienced any side effects,then they were asked to report thetime of onset (categorized as �24hours or �24 hours), the duration(categorized as �24 hours or �24hours), and the severity (scored on ascale of 1–4, where 1�light to 4�severe) of the symptoms.

Sample Size DeterminationThe sample size and power calcula-tions were performed with SamplePower statistical software, version10.1.* The calculations were basedon detecting a 10% difference in theNDI at follow-up, assuming a stan-dard deviation of 13%, a 2-tailed test,an alpha level of .05, and a desired

power of 80%. These assumptionsgenerated a sample size of 30 sub-jects per group.

Data AnalysisKey baseline demographic variables,including current medication usageand scores on the self-report mea-sures, were compared between thegroups by use of independent t testsfor continuous data and chi-squaretests of independence for categoricaldata (Tab. 1). The primary aim (ef-fects of interventions on disabilityand pain) was examined by use ofa 2-way repeated-measures analysisof variance (ANOVA), with inter-vention group (thrust versus non-thrust mobilization/manipulation)as the between-subjects variable andtime (baseline and follow-up) as thewithin-subject variable. SeparateANOVAs were performed with dis-ability (NDI) and pain (NPRS) asthe dependent variables. For eachANOVA, the hypothesis of interestwas the 2-way interaction (group �time). An independent t test was usedto determine differences in the GROCScale scores between the groups atfollow-up. We used intention-to-treatanalysis with subjects analyzed in thegroup to which they were allocated.Data analysis was performed with theSPSS, version 13.0, statistical softwarepackage.*

The proportion of subjects reportingside effects in each group was ana-lyzed by use of a chi-square test. Ad-ditionally, the number of side effectsexperienced by subjects in eachgroup was calculated. Chi-squaretests also were used to determinewhether a difference existed be-tween the groups for the proportionof subjects experiencing an onset ofsymptoms within 24 hours of theinterventions, for whether the symp-toms diminished within 24 hours ofonset, and for the severity of the re-ported symptoms. We also calcu-lated the odds ratio and the corre-sponding 95% CI for experiencinga side effect associated with theinterventions.

ResultsA total of 104 consecutive patientswere screened for possible study el-igibility. Sixty patients, with a meanage of 43.3 years (SD�12.7) (55%female), satisfied the eligibility cri-teria, agreed to participate, andwere randomly assigned to thethrust (n�30) and nonthrust (n�30)mobilization/manipulation groups.The reasons for ineligibility areshown in Figure 4, which is a flowdiagram of subject recruitment andretention. All 60 participants re-turned for the follow-up visits andwere included in the analysis.

* SPSS Inc, 233 S Wacker Dr, Chicago, IL60606.

Figure 3.Middle thoracic spine thrust manipulation technique used in this study.



Baseline characteristics for the groupswere similar for all variables (P�.05),with the exception of the number ofsubjects receiving workers’ compen-sation (9 in the thrust mobilization/

manipulation group and 3 in thenonthrust mobilization/manipulationgroup; P�.045) (Tab. 1). Sixty-sevenpercent of subjects in the thrustmobilization/manipulation group at-

tended their follow-up visits at 2 days,20% attended at 3 days, and 13% at-tended at 4 days. Sixty percent of sub-jects in the nonthrust mobilization/manipulation group attended their

Table 1.Demographics, Outcome Measures, and Selected Physical Impairments at Baseline

Variablea Nonthrust Mobilization/Manipulation Group(n�30)

Thrust Mobilization/Manipulation Group(n�30)

P

Age, X (SD) 42.7 (13.9) 43.8 (11.5) .75b

Women 15 (50) 18 (60) .29c

Duration of symptoms, d, X (SD) 56.1 (27.6) 54.9 (46.0) .90b

NPRS, X (SD) 4.5 (2.1) 5.3 (1.4) .086b

NDI, X (SD) 29.6 (12.6) 33.5 (11.2) .20b

FABQPA, X (SD) 11.2 (5.0) 11.5 (4.9) .82b

FABQW, X (SD) 12.3 (10.6) 12.5 (10.7) .93b

Symptoms distal to shoulder 6 (20) 4 (13) .73c

Mode of onset—traumatic 11 (37) 11 (37) 1.0c

Previous history of neck pain 11 (37) 8 (27) .29c

Receiving workers’ compensation 3 (10) 9 (30) .045c

Taking medications at start of study 17 (57) 12 (40) .30c

Symptoms aggravated by:

Turning right 21 (70) 23 (77) .39c

Turning left 21 (70) 15 (50) .25c

Looking up 19 (63) 21 (70) .39c

Looking down 18 (60) 16 (53) .45c

Driving 22 (73) 19 (63) .29c

Cervical range of motion,degrees, X (SD)

Flexion 51.1 (12.8) 6.4 (13.2) .17b

Extension 38.8 (13.9) 44 (14.9) .17b

Side bending right 32.4 (12.7) 33.2 (13.1) .80b

Side bending left 30.6 (10.7) 40.0 (34.3) .16b

Rotation right 59.1 (11.8) 59.1 (12.2) .98b

Rotation left 61.1 (12.6) 63.6 (11.4) .43b

Medication usage

Total 16 (53) 12 (40) .30b

NSAIDs 9 (30) 8 (27) .98b

Pain medications 4 (13) 2 (7) .67b

Muscle relaxants 3 (10) 2 (7) .98b

a Data are reported as number (percentage) of subjects, unless otherwise indicated. FABQPA�Fear-Avoidance Beliefs Questionnaire physical activity subscale(range�0–24), FABQW�Fear-Avoidance Beliefs Questionnaire work subscale (range�0–42), NDI�Neck Disability Index (range�0%–100%),NPRS�Numeric Pain Rating Scale (range�0–10), NSAIDs�nonsteroidal anti-inflammatory drugs.b As determined by independent sample t tests.c As determined by chi-square tests.



follow-up visits at 2 days, 30% at-tended at 3 days, and 10% attended at4 days. Additionally, the 95% CI forthe difference in time to follow-up be-tween the groups crossed 0 (�0.36 to0.90).

The overall 2-way group � time in-teraction for the repeated-measuresANOVA was statistically significantfor disability (P�.001) and pain(P�.001). The intercept graph forthe NDI and scores of interventiontime is shown in Figure 5. Subjectsreceiving thrust mobilization/manip-

ulation experienced greater reduc-tions in disability, with a between-group difference of 10% (95% CI�5.3–14.7), and pain, with a between-groupdifference of 2% (95% CI�1.4–2.7)(Tab. 2). Subjects in the thrust mobili-zation/manipulation group exhibitedsignificantly (P�.01) higher scores onthe GROC Scale at the time of follow-up, with a mean difference betweenthe groups of 1.5 points (95%CI�0.48–2.5).

There was no significant difference(P�.78) between the numbers of

side effects experienced by subjectsin the nonthrust and thrust mobiliza-tion/manipulation groups (9 and 10,respectively). The odds ratio for ex-periencing a reported side effect forsubjects receiving thrust mobiliza-tion/manipulation was 1.17 (95%CI�0.39–3.47). The specific re-ported side effects for subjects inthe nonthrust mobilization/manipu-lation group included an aggravationof symptoms (n�2), muscle spasm(n�1), neck stiffness (n�2), head-ache (n�2), and radiating symptoms(n�2). Subjects in the thrust mobili-

Figure 4.Flow diagram of subject recruitment and retention.



zation/manipulation group experi-enced the following side effects: ag-gravation of symptoms (n�8),muscle spasm (n�1), and headache(n�1).

There was no difference in the onsetof side effects between the groups,with 90% of all subjects (8 in thenonthrust mobilization/manipulationgroup and 9 in the thrust mobiliza-tion/manipulation group) reportingthat the symptoms began within 24hours of the interventions (P�.74).All subjects in both groups who re-ported experiencing a side effect

noted that the symptoms lasted 24hours or less. The severity of thecomplaints was not significantly dif-ferent between the groups (P�.67)and was reportedly mild (7 subjectsin the nonthrust mobilization/ma-nipulation group and 8 subjects inthe thrust mobilization/manipula-tion group) to moderate (2 subjectsin the nonthrust mobilization/ma-nipulation group and 2 subjects inthe thrust mobilization/manipulationgroup). No serious complicationswere reported by any subjects in thestudy.

Discussion and ConclusionThe results of the present study dem-onstrate that the differences be-tween the groups in change scoresfor disability and pain exceeded theboundaries of measurement error.Fifty percent of subjects in the thrustmobilization/manipulation groupreached the cutoff on the GROCScale, indicating a moderate changein status (scores of greater than orequal to �4), whereas only 10% ofsubjects in the nonthrust mobiliza-tion/manipulation group reachedthis cutoff. Additionally, the differ-ence between the groups in changesin disability was 10% or approxi-mately one third of the initial disabil-ity. Considering the moderate effectsize between the interventions andthe negligible disparity in associatedrisks, the differences demonstratethat, compared with thoracic spinenonthrust mobilization/manipulation,thoracic spine thrust mobilization/manipulation results in short-term re-ductions in pain and disability inpeople with neck pain.

We recognize that a variety ofmobilization/manipulation techniquesare used by physical therapists as wellas other health care professionals.39

However, to improve the generaliz-ability of the findings to clinical prac-tice, we standardized the treatmentprogram to a few techniques that have

Table 2.Baseline, Final, and Change Scores for the Neck Disability Index and the Numeric Pain Rating Scale

Measure Group (n) X (SD) Between-GroupChange Score, %, X(95% Confidence Interval)

Baseline Final Within-GroupChange Score

Neck Disability Index Nonthrust mobilization/manipulation (30)

29.6 (12.6) 24.0 (13.4) 5.5 (8.8) 10.03 (5.3–14.7)

Thrust mobilization/manipulation (30)

33.5 (11.2) 18.0 (10.9) 15.5 (9.3)

Numeric Pain Rating Scale Nonthrust mobilization/manipulation (30)

4.5 (2.1) 3.9 (2.2) 0.54 (1.07) 2.03 (1.4–2.7)

Thrust mobilization/manipulation (30)

5.3 (1.4) 2.7 (1.4) 2.6 (1.5)

Figure 5.Intercept graph for Neck Disability Index scores of intervention time (P�.001).



been well documented in the litera-ture.13,14,40,41 In addition, the clini-cians did not use intersegmental mo-bility assessments to directly target aspecific segmental restriction duringour interventions.35,42,43 Regardless ofthe clinical presentation, the subjectsreceived specific nonthrust or thrustmobilization/manipulation directed atconsistent segments across all subjectsbecause of the inherent lack of evidenceto support decision making based onbiomechanical theoretical constructs.

Compared with other studies investi-gating the prevalence of side effectsassociated with thrust mobilization/manipulation directed at the entirespine, the present study demonstratedlower rates for both thrust and non-thrust mobilization/manipulation pro-cedures.38,44 Senstad et al44 reportedthat, in 4,700 subjects, a variety of sideeffects occurred after mobilization/manipulation for 55% of the treat-ments. The most common side effectwas local discomfort and was experi-enced with over one half of the treat-ments. Although the authors did notreport the side effects associated withthe area of the spine treated, they con-cluded that these reactions were be-nign and should be considered normalevents. More recently, Cagnie et al38

identified that 60% of subjects receiv-ing mobilization/manipulation of thespine experienced a number of sideeffects, including headache (20%), stiff-ness (19%), dizziness (4%), and nausea(3%).

Although the types of associated sideeffects experienced by subjects inour study were similar to those in thestudies of Senstad et al44 and Cagnieet al,38 the rates were significantlylower. Senstad et al44 and Cagnieet al38 investigated side effects as-sociated with thrust mobilization/manipulation directed at the entirespine; our study included techniquesdirected only at the thoracic spine.Perhaps techniques directed at thethoracic spine result in fewer side

effects than techniques directed atthe cervical or lumbar spine; how-ever, this hypothesis requires furtherinvestigation. Additionally, it shouldbe recognized that the sample sizecalculations in the present study werenot based on identifying differences inside effects between the groups; there-fore, it is possible that the presentstudy did not have adequate power todetect such disparities.

Although we cannot make directgeneralizations about the effective-ness of other thrust mobilization/manipulation techniques in peoplewith neck pain, evidence suggeststhat the specific technique used maynot influence patient-centered out-comes.29,45,46 One substantial lim-itation of the present study is thefailure to collect long-term follow-updata. Participation in the presentstudy ended after the follow-up ses-sion, which occurred between 2 and4 days after the baseline examina-tion and intervention session. Althoughthe differences between the groupswere noted at the short-term follow-up session, the data cannot be used toascertain the outcomes for subjects ineither group at any time period longerthan 2 to 4 days. The implications ofthis finding should be recognizedclearly when the results of the presentstudy are applied to clinical practice.Future studies should seek to investi-gate the long-term benefits of thoracicspine thrust and nonthrust mobilization/manipulation.

Because we used a standardized treat-ment program, the results cannot begeneralized to other mobilization/manipulation techniques. In addition,it should be recognized that anotherpotential limiting factor of the presentstudy was the inability to keep thesubject or clinician unaware of the in-terventions being delivered. Futureclinical trials should investigate the ef-fectiveness of different thrust andnonthrust mobilization/manipulationprocedures directed at the thoracic

spine for people with neck pain andshould compare thrust mobilization/manipulation techniques directed atthe thoracic spine in combinationwith exercise and manual physicaltherapy techniques directed at the cer-vical spine for people with neck pain.

Dr Cleland, Dr Whitman, and Dr Childs pro-vided writing and data analysis. Dr Cleland,Dr Glynn, Ms Eberhart, and Dr MacDonaldprovided data collection, subjects, andfacilities/equipment. Dr Cleland providedproject management, fund procurement,and clerical support. Dr Cleland, Dr Glynn,and Dr MacDonald provided institutionalliaisons. The authors thank the AmericanAcademy of Orthopaedic Manual PhysicalTherapists and Steens Physical USA for pro-viding funding for this project. These orga-nizations played no role in the design, con-duct, or reporting of the study or in thedecision to submit the manuscript for publi-cation. The authors also thank the followingtherapists for assisting with data collection:Tracy Carter, Sheryl Cheney, John Groves,John Gray, Tim Mondale, Jessica Palmer, Su-zanne Stoke, and Noel Squires.

This study was approved by the institutionalreview boards of the Medical Education andResearch Institute of Colorado, ColoradoSprings, Colo; Regis University, Denver,Colo; Sharp HealthCare, San Diego, Calif;and Concord Hospital, Concord, NH.

Preliminary results of this study (45 subjects)were presented at the 12th Annual Confer-ence of the American Academy of Orthopae-dic Manual Physical Therapists; October 19–22, 2006; Charlotte, NC.

The American Academy of OrthopaedicManual Physical Therapists and Steens Phys-ical USA provided funding for this project.

This article was received August 4, 2006, andwas accepted December 15, 2006.

DOI: 10.2522/ptj.20060217

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Short-Term Effects of Thrust Versus Nonthrust Mobilization/Manipulation Directed at the Thoracic Spine in Patients With Neck Pain: A Randomized Clinical Trial

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