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. 2023 Jul 2;32(2):159–165. doi: 10.1080/10669817.2023.2230010

Spinal displacement during thoracic manipulative therapy in mechanical neck pain patients: an observational study

Phak Niamsuwan 1, Duangporn Suriyaamarit 1, Adit Chiradejnant 1,✉
PMCID: PMC10956907  PMID: 37393578

ABSTRACT

Introduction

Thoracic manipulative therapy (TMT) is recommended for treating patients with mechanical neck pain (MNP). However, there are multiple proposed recommendations for the mechanism for neck pain reduction.

Objective

To investigate displacement of the cervicothoracic spine during the application of TMT in patients with MNP.

Methods

Thirty-five male patients with MNP were recruited. Displacements of C3, C5, C7, T2, T4 and T6 were measured using a motion capture system while a therapist applied a grade III central posteroanterior TMT (cpa-TMT) to T6.

Results

Mean (SD) displacement ranged from 2.2 (0.62) to 5.5 (1.1) mm. A significant decrease in neck pain intensity at rest was found after the application of the cpa-TMT (mean difference 17 mm, p < 0.001). A downward trend in spinal displacement was noted, with the largest and smallest displacement occurring at T6 and C3, respectively. Correlations between the displacement of T6 and adjacent spinal levels were moderate to high (Pearson’s r range 0.70–0.90, p < 0.001). It was showed that cpa-TMT applied to T6 produced the PA displacement toward the upper cervical spine.

Conclusion

TMT produces spinal segmental displacements toward the upper cervical spine in MNP patients. These segmental displacements would activate the alleviation effect at both the spinal and supraspinal levels resulting in neck pain reduction. These findings would provide supporting evidence for the use of TMT in neck pain reduction.

KEYWORDS: Spinal manipulative therapy, Mechanical neck pain, Manual therapy, Spinal mobilization, Spinal manipulation

Introduction

Neck pain is a common musculoskeletal disorder that is increasing worldwide in the general population [1,2]. It has been reported that 30%–50% of adults experience neck pain at least once per year [1]. Neck pain is commonly diagnosed in two broad categories: mechanical neck pain (MNP), when the source of the symptoms originates from mechanical dysfunction of various structures surrounding the cervical spine [3], and non-mechanical neck pain, when the symptoms are caused by specific pathologies, such as a tumor, metabolic bone disease or spinal fracture [4]. MNP is also defined as pain in the region between the occiput and the third thoracic vertebra that is exacerbated by neck movements or sustained neck postures [5,6].

Spinal manipulative therapy (SMT) is commonly used by chiropractors, physiotherapists, and medical practitioners in the treatment of MNP [7,8]. Growing evidence has shown that performing SMT techniques on patients with MNP can result in neck pain reduction and improvement in cervical range of motion [9–11]. Additionally, SMT has been found to be more beneficial than other treatments, such as electrotherapy and acupuncture, in the treatment of MNP [12]. Although SMT has been reported to be beneficial in MNP treatment [10,11], the application of thrust manipulation or non-thrust mobilization to the cervical spine has been associated with several adverse effects related to cervical arterial dysfunction including vertigo, dysarthria, visual deficits, and soreness in the application area [13]. In order to avoid such effects, thoracic manipulative therapy (TMT) has been recommended as an alternative approach to treat MNP [1].

A number of studies have investigated the effectiveness of TMT in the treatment of MNP [9–11]. TMT has been shown to be effective in alleviating and improving cervical range of motion [9–11]. Due to limited evidence regarding the mechanism by which TMT alters range of motion, it remains unclear how TMT changes mechanical properties and improves range of motion. In addition, evidence is conflicting regarding the amount of force required during TMT to alter mechanical properties [14,15]. It has been noted that the amount of force applied to live participants [14] was significantly less than that applied to a cadaveric specimen [15]. In addition, the results of previous studies should be interpreted with care due to differences in comparing subjects. It has also been reported that manipulative therapy affects muscle activity [16], and it is unclear whether there is a link between muscle activity and range of motion.

It has been established that manipulative therapy would be able to result in an alleviating effect at both the spinal and supraspinal levels known as neurophysiological mechanism [17], which has been supported in a number of studies [18,19]. The alleviating effect should occur when there is overlap between the symptomatic area and the region of neural innervation, called the dermatome, myotome, and sclerotome. In studies investigating the effectiveness of TMT in patients with MNP, it has been noted that TMT can reduce neck pain, and these studies have used the concept of the neurophysiological mechanism to explain their findings [10,11]. However, considering the difference between the symptomatic area and the treated area, this explanation may be inappropriate. There is some evidence that displacement of cervical spine levels occurs during TMT [20]. Based on this finding, TMT would induce cervical spine displacement, and this displacement would activate the neurophysiological mechanism, resulting in a reduction in neck pain. However, this study was conducted on only healthy subjects without a history of neck pain. Different findings may be observed in subjects presenting with neck pain, as MNP often leads to increased spinal stiffness, causing cervicothoracic displacement to be different than that found in healthy subjects. The aim of this study was to investigate displacement of the cervicothoracic spine during the application of TMT in patients with MNP.

Methods

A descriptive observational study was conducted to determine cervicothoracic spinal displacement during central posteroanterior TMT (cpa-TMT) in patients with MNP. The study was conducted at the Health Science Service Unit, Faculty of Allied Health Sciences, Chulalongkorn University, Thailand.The study was conducted at the Health Science Service Unit, Faculty of Allied Health Sciences, Chulalongkorn University, Thailand. All participants gave written consent prior to data collection. Ethical consideration was approved by the Research Ethics Review Committee for Research Involving Human Research Participants, Chulalongkorn University (COA No. 026/2021). Additionally, this study was registered with the Thai Clinical Trails Registry (TCTR20210428002).

Participants

Patients with MNP who presented for treatment of neck pain were asked if they wished to participate in this study. To be eligible for this study, the MNP patients must have had the following characteristics: (1) male aged 18 to 55 years old, (2) neck pain at rest of more than 20 on a 0–100 mm visual analog scale (VAS) [21] and (3) self-reported disability of more than 4 points on a scale of 50 points using the Thai version of the Neck Disability Index (NDI-TH) [22]. The NDI-TH has been reported to be highly reliable in investigating functional limitation and disability, with an intraclass correlation coefficient (ICC) of 0.74–0.91 [22]. The current study recruited only male in order to exclude the effect of the change in hormonal level during the menstrual cycle [23–25]. Patients were excluded if they had the following characteristics: (1) a history of trauma or surgery to the cervicothoracic spine and (2) any contraindications to TMT, such as malignancy, inflammatory diseases, infectious diseases, and fracture affecting the cervicothoracic spine [7].

Three physiotherapists participated in this study. The first therapist was responsible for identifying the C3, C5, C7, T2, T4, and T6 spinous processes of the cervicothoracic spine and collecting the displacement data during cpa-TMT. To ensure that a standardized protocol was employed during data collection, the researcher practiced identifying the spinous processes with an experienced physiotherapist (the second therapist), who had a Master of Physiotherapy (Manipulative Physiotherapy) degree and experiences for more than 20 years in treating patients with spinal problems. Briefly, anatomical landmarks were used as reference points in the following manner: C2, T3, and T7 were identified by palpating below the external occipital protuberance at midline, palpating parallel to the superior angle of the scapula, and palpating parallel to the inferior angle of the scapula, respectively [26]. The agreement between the first and second therapists in identifying the spinal levels was found to be excellent, with Kappa values of 1.00.

The third therapist, who completed a Master of Science program in Manipulative Physical Therapy and trained the use of Maitland mobilization techniques for two years, was responsible for applying grade III cpa-TMT to T6 of all participants. The grading system has been defined and the application of the technique has been described elsewhere [27]. As described by Maitland, grade III was defined as a large amplitude movement performed into firm resistance or up to the limit of the available range [27]. During the cpa-TMT technique, the participant was asked to lie in a prone position. The therapist stood at the participant’s side and placed their pisiform on the spinous process of T6. Grade III cpa-TMT was then performed as a set of oscillatory movements. The force range and frequency employed in this study were similar to those noted in a previous study [20]. To ensure the third therapist applied grade III cpa-TMT [20], the therapist practiced performing cpa-TMT with a force of 111.3 N, with ranging between 84.9 and 156.9 N, and a frequency of 0.8 Hz measured by a bathroom scale and metronome, respectively. The intra-rater reliability of the application of cpa-TMT was investigated, with an ICC(3,1) of 0.89–0.95 calculated.

Outcome measures

Demographic data were collected at baseline, including age, height, weight, body mass index, neck pain intensity at rest, and disability. The primary outcome was displacement of the cervicothoracic spine at C3, C5, C7, T2, T4, and T6. Displacement was measured using a modified instrumented couch (Tension S Cell, Mettler Toledo, Bangkok, Thailand) with a motion capture system (Basler scA640, Basler AG, Ahrensburg, Germany) [28]. This equipment was used to measure the force applied and displacement produced by the therapist during cpa-TMT. It has been shown to be highly reliable in measuring force and displacement, with an ICC(2,1) of 0.99–1.00 and ICC(3,1) of 1.00, respectively. The average percentage error of the couch in measuring applied force and the motion capture system in measuring distance has been reported to be less than 1.2% and 0%, respectively. The amount of force applied to the couch surface was synchronized with the distance obtained from the motion capture system in real-time. The motion capture system measured spinal displacement through markers mounted with adhesive tape on the spinous processes of C3, C5, C7, T2, and T4. The radial styloid process of the therapist’s hand was considered the marker of T6 because the spinous process of T6 was the point of force application during cpa-TMT.

Procedure

The patients with MNP who met the inclusion criteria were provided with an in-depth explanation of the procedure. The patients who agreed to participate were then asked to give written consent and are hereby called participants. The participants were asked to answer screening questionnaires that included demographic data, pain intensity using the VAS, and NDI-TH. The participants were asked to lie in a standardized prone position with their heads resting over a breathing hole and their arms by their sides. The cushions of the couch were replaced by a rigid wooden surface to ensure that the measured displacement was solely from the participant’s displacement [29].

The first therapist identified the spinous processes of C3, C5, C7, T2, T4, and T6. All marked spinous processes except for T6 had bead markers measuring 7 millimeters in diameter attached to them using adhesive tape. The third therapist then collected data and practiced the application of force on each participant. After completion of the practice, the participants were instructed to breathe normally and were asked to give a signal when they were ready to hold their breath at the end of normal expiration to ensure the data collection was performed based on the standardized protocol [29]. After the signal was given, the third therapist applied grade III cpa-TMT to T6 for 30 seconds and the first therapist collected the force and spinal displacement data. All data were kept for analysis. Finally, the participants were asked to report their neck pain intensity immediately after the application of cpa-TMT.

Data analysis

A sample size calculation was performed by using the correlation sample size formula and considering the correlation between the displacement of T6 and the adjacent spinal levels reported in the previous study on healthy subjects (r range 0.54–0.83) [20,30]. The lowest correlation coefficient was selected as this study expected to find the minimum correlation in MNP patients. A correlation coefficient of 0.54 was considered for a statistical power of 90% and a two-tailed alpha of 0.05. Given these parameters, a sample size was calculated to be 32 participants. Therefore, a total of 35 participants was then recruited in this study.

Prior to analysis, the force/time data and displacement/time data were exported and plotted using Microsoft Excel. After the graphs were plotted, the third to fifth cycles of force and displacement were identified for further analysis by using the Contemplas templo motion analysis software [29]. Descriptive statistics were used to investigate the mean, standard deviation (SD), minimum, and maximum for the participants’ demographic data, neck pain intensity, and spinal displacement.

Pearson’s correlation coefficient was used to investigate the correlation between the amount of displacement of T6 and the displacement of adjacent spinous processes. The correlation coefficient value was interpreted as follows: a value less than 0.3 indicated no correlation, 0.31–0.5 indicated a low correlation, 0.51–0.70 indicated a moderate correlation, 0.71–0.90 indicated a high correlation and greater than 0.90 indicated an excellent correlation [31]. Neck pain intensity at baseline and after cpa-TMT were compared using a paired t-test. The change in pain intensity score was also calculated by subtracting the after cpa-TMT score from the baseline score. SPSS version 28 for windows was used for all analyses with a p-value of < 0.05 indicating statistical significance.

Results

Characteristics of the participants

Thirty-five male participants were recruited. Participants’ demographic data are presented in Table 1. A significant decrease in neck pain intensity at rest after the application of cpa-TMT was observed (p < 0.001). Additionally, the mean (SD) of force applied and frequency of cpa-TMT were 112.3 (12.08) N ranged between 87.3 and 139.3 N, and 0.81 (0.1), and 0.81 (0.07) Hz, respectively.

Table 1.

Participants’ characteristics.

Characteristics Participants (n = 35)
Age (yr), mean (SD); min to max 25 (4.5); 20 to 35
Weight (kg), mean (SD); min to max 69 (16); 47 to 115
Height (m), mean (SD); min to max 1.7 (.07); 1.6 to 1.9
BMI (kg/m2), mean (SD); min to max 22 (4.1); 17 to 33
Duration of pain (days), mean (SD); min to max 362 (358); 7 to 1460
Neck pain intensity (mm), mean (SD); min to max  
 Baseline 53 (17); 25 to 85
 After the CPA-TMT 36 (16) ; 10 to 71
 Mean of change score of pain intensity 17 (8.2)* ; 5.2 to 34
NDI-TH score, mean (SD) min to max 10 (4.3); 5 to 21
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Note: *p < 0.001, analysis using paired t-test.

Displacements of the cervicothoracic spine

Table 2 presents the mean (SD) and minimum–maximum (Min–Max) displacement of each spinal level. Figure 1 illustrates the displacement (mean [SD]) of the marked spinous processes. Table 3 shows the correlation coefficients (r) between the displacement of T6 and the adjacent spinous processes, with r ranging between 0.70 and 0.90 (p < 0.001).

Table 2.

Mean (SD) and minimum-maximum of spinal displacement.

Spinal
level		 Spinal displacement (mm)
Mean (SD) min-max
C3 2.2 (0.62) 1.2–3.5
C5 2.5 (0.66) 1.5–3.8
C7 2.7 (0.67) 1.7–4.1
T2 3.1 (0.80) 1.7–4.8
T4 3.6 (1.0) 1.9–5.8
T6 5.5 (1.1) 3.2–8.3
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Figure 1.

Figure 1.

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Mean (SD) of spinal displacement. The upper and lower bars represent the standard deviations.

Table 3.

Correlation coefficients between the displacement of T6 and the displacement of adjacent spines.

Displacement of T6 T4 T2 C7 C5 C3
Correlation coefficient (r) 0.90 0.88 0.81 0.73 0.70
p-value <0.001 <0.001 <0.001 <0.001 <0.001
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Discussion

The results of this study indicated that cpa-TMT produced cervicothoracic spinal displacement in patients with MNP, with the mean displacement ranging from 2.2 to 5.5 mm (Table 2). The highest and lowest displacements were noted at T6 and C3, respectively (Figure 1). Additionally, the displacement at T6 was highly correlated with the displacement at adjacent spinal levels (p<0.001; Table 3).

The displacement measured in the current study was less than that noted in the previous study [20]. This may be due to increased joint stiffness in subjects presenting with spinal pain, as it has been reported that spinal stiffness in subjects with MNP is greater than that of asymptomatic subjects [32]. Even though the displacement values were small, the displacements obtained in this study were greater than the standard error of measurement of the first therapist in measuring the spinal displacements. Additionally, the decreasing spinal displacement from lower to higher spinal levels in the patients with MNP was similar to what was observed in healthy subjects [20]. These findings indicate that cpa-TMT produces spinal displacement in the cervical spine in subjects with MNP.

When the adjacent spinal levels were displaced during the application of cpa-TMT to T6, this would result in oscillatory movements of each spinal level toward the upper cervical spine. The oscillatory movements occurred in cervical spines, this would activate the neurophysiological mechanism resulting in neck pain reduction [17]. This is supported by a significant decrease in neck pain intensity reported after the application of cpa-TMT (p <0.001; Table 1). However, the mean change in pain intensity score found in the current study (17 mm) was less than the minimum clinically important difference reported in a previous study (20 mm) [21]. This may be due to the current study only employing one set of cpa-TMT to investigate the displacement of the adjacent spinal levels; different findings might be noted if 2–4 sets of oscillations were applied during cpa-TMT [7].

The results of the current study provide important insight into a plausible mechanism of neck pain reduction after the application of cpa-TMT [33–36]. Based on these findings, it would be able to claim that the TMT applied to the thoracic spine would be able to produce segmental oscillatory movements of the spines toward the upper cervical spine. This would activate the neurophysiological mechanism both the spinal and supraspinal levels resulting in neck pain reduction. However, these results should be interpreted with care, as the current study did not evaluate the change in sympathoexcitation parameters, such as skin temperature, skin conductance, and pain pressure threshold, to confirm these findings. Future studies are indicated to investigate the effectiveness of cpa-TMT on MNP reduction. Caution is needed to exercise in order to generalize the results of this study as follow. First, the participants recruited in this study were all males with age range between 20–35 years old, different findings might be noted if a study investigating in different age group and gender. The reason of recruiting only male in the current study because it has been noted that hormonal level fluctuates in female during menstrual cycle noting to affect joints stiffness [23–25,29]. Additionally, the noted displacements in the current study would include the soft tissue compression especially at the application area (T6). This would be the case that the greatest displacement was noted being 5.5 (1.1) mm at T6 and dramatically reduced being 3.6 (1.0) mm at the adjacent spinal level T4. In order to exclude the compressibility of the soft tissue, a further study is also indicated to use imaging to note displacement during the application of cpa-TMT.

Conclusion

The cpa-TMT produces spinal displacement up to the upper cervical spine in patients with MNP. These segmental displacements would activate the alleviation effect at both the spinal and supraspinal levels resulting in neck pain reduction. These findings would provide evidence of the mechanism of cpa-TMT on neck pain reduction.

Acknowledgements

The Scholarship from the Graduate School, Chulalongkorn University to commemorate the 72nd anniversary of his Majesty King Bhumibol Aduladej and the 90th Anniversary of Chulalongkorn University Fund (Ratchadaphiseksomphot Endowment Fund) are gratefully acknowledged.

Biographies

Phak Niamsuwan is a post graduate student at Physical Therapy Department, Faculty of Allied Health Sciences, Chulalongkorn University, Thailand. He graduated from Chulalongkorn University with a Bachelor’s Degree in Physical Therapy (2nd class honors). His research interests involve the use of spinal manipulative therapy in management of musculoskeletal problems.

Duangporn Suriyaamarit is an Assistant Professor at Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Thailand with a Bachelor’s Degree in Physical Therapy (1st class honors), Master’s and Doctoral degrees in Physical Therapy. Her teach responsibilities are not only within entry level program but also postgraduate program. Her research currently focuses on pediatric physical therapy, biomechanics, motor control, clinical reasoning, evidence-based practice and pain.

Adit Chiradejnant is an Assistant Professor at Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Thailand with a Bachelor’s Degree in Physical Therapy, Master of Physiotherapy (Manip. Physio., University of South Australia) and Doctoral degree in Physical Therapy (University of Sydney). His teach responsibilities include both entry level and postgraduate program. Dr. Chiradejnant’s research interests include further understanding of the mechanisms of manipulative therapy, manipulative therapy in orthopedics, pain, motor control, clinical reasoning and evidence-based practice. Dr. Chiradejnant is also an advanced practitioner in the treatment of patients with spinal disorders and also runs his private practice (Saladaeng Physiotherapy clinic) in Bangkok, Thailand.

Funding Statement

This work was partially supported by the Master of Science Program in Physical Therapy, Chulalongkorn University.

Disclosure statement

No potential conflict of interest was reported by the authors.

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