Thoracic spine manipulation and long-term neck pain caused by mechanical means.  JPR Dove Medical Press


The pain of the neck is typical condition that is becoming more prevalent among the general population, and the majority of people suffer from it at least once during their lives. 1 The patterns of movement and everyday activities can have an significant impact on economy and participation of people. 2,3 The 1-year incidence of neck pain has been found to be between 16.7 percent and 75.1 percent. 4 According to the Global Burden of Disease 2010 study, neck pain came in at 4th in terms of disability, as measured by years of disability (YLDs) and 21st in terms overall burden. And in 2015, neck pain was identified as the most significant cause of disability in the majority of nations. 5,6

The most commonly used classification for neck pain is that of mechanical neck discomfort. 7 Although the definition may differ between different research studies and studies, the term “mechanical neck pain” is often described as pain within the neck spine or cervicothoracic joint that can be triggered and/or intensified by palpation and/or cervical motion of cervical muscles. 7-10 Recently in the last few years, researchers from the Cochrane Collaboration (2015) recommended classifying patients according to symptom duration in three categories: chronic (<6 weeks) or subacute (6-12 weeks) or chronic (>12 weeks). 11 Subacute, acute, or chronic phases are based on time and are useful in categorizing medical conditions. A guideline for clinical practice on neck pain states that the time-based stages aid in making treatment decisions based on irritation of the neck’s tissues ailments. 12

The management of neck pain can be accomplished using a variety of method of treatment, such as medication, manual therapy and exercises. Manual therapies help to reduce the quality of life and reduce pain in people who suffer from neck discomfort. 13,14 The inherent biomechanical linkage between the thoracic region with the cervical spine as well as the disturbances to how the body’s biomechanics work on the spine may be the primary cause of the neck’s suffering. 15 Thoracic manipulation on its own or in conjunction with other physiotherapy treatments has been employed to alleviate cervical spine pain, and improve the function of the cervical spine, and increase the mobility (CROM). 10,16

Evidence is beginning to appear for the use of thoracic spine manipulative thrust as a method of the treatment of neck pain that is not specific and severe mechanical neck discomfort. 7,10,17-19 The impact of these interventions on people suffering from chronic neck pain has not been consistent and, for instance, pain relief was obtained in studies that evaluated the thoracic manipulation on its own or in conjunction with the groups of control or comparison. 20-24 However there were no statistically significant differences could be observed in the intergroup or intragroup analyses of the placebo and experimental groups in the severity of neck pain either in the immediate or the short-term post-intervention tests. The study comparing cervical manipulation with the thoracic manipulation didn’t show any statistically significant interaction between time and group in chronic neck pain. 25-27 Hence the principal goal for this article is to analyze the current evidence regarding the efficacy of thoracic manipulation to reduce neck disability and pain in patients with chronic neck pain.

Materials and Methods

Protocol and Registration

This systematic review and meta-analysis were registered in the PROSPERO database as (CRD42020204983) accessed at and conducted according to the PRISMA guidelines.28

Eligibility Criteria

Criteria for Inclusion

Randomized control studies are available as full texts and on the English languages, which were completed in the past decade (2010-2020). It was decided to utilize 2010 as the year of cut-off since a search performed by the authors could not find any significant literature in this area prior to the year. Study studies that focused on participants suffering from just chronic neck pain caused by mechanical means and who were older than 18 years old that evaluated the effectiveness of thoracic manipulatives versus other methods of treatment were included.

Exclusion Criteria

Studies that weren’t matched to the purpose in this study, including poor quality of PEDro score of less than 4/10, and studies that evaluated two techniques for thoracic manipulation, without describing the participant’s the duration of their symptoms or chronic neck pain. Also, studies that did not reveal the results of interest were not included in this review.

Study Type

Every published random controlled study (RCT) in full-text version that investigated the effects of thoracic manipulation on people suffering from chronic neck pain was considered.


The participants were adult with more than 18 years of age and both genders (male or female) suffering from a persistent mechanical neck pain.


The procedure of interest was the technique of thoracic manipulative (TM). The technique can be administered repeatedly to one spinal region or different spinal regions within one session or several sessions. Co-interventions can also be performed in the treatment session, when they are also included in the control group. This allows for different results in the effect of treatment to be attributed to the inclusion to TM in the group that was experimental.


The research should compare the thoracic spine thrust manipulation with other non-thrust treatment or mobilization technique, exercise without intervention or placebo.


The primary outcomes that were examined in this systematic review included disability and pain. In all the studies, pain was assessed by using or using the Numeric Pain Rating Scale (NPRS which ranges from 0-10 points) as well as the Visual Analog Scale (VAS; 100mm – 0-100mm) as well as Disability was measured with one of using the Neck Disability Index (NDI; 100% – 0%)) as well as the Northwick Park Pain Questionnaire (NPQ (0-100 percent).

Search Strategy

Starting in June 2020, researchers thoroughly conducted a search of relevant articles to this meta-analysis, using the databases on electronic devices comprising PubMed, CINAHL, Cochrane Library and PEDro databases. The search was limited to RCT and was written in the English languages, and was conducted between 2010 and 2020. The following keywords were used or keywords together: (thoracic manipulation, thoracic thrust manipulation, neck pain manipulation thrust, cervical or chronic neck discomfort that was filtered using RCTs, full-text human participants, and duration of 10 years) (Table 1).

Table 1. Table 1 Literature Search Strategy

The aim of the method of searching was to locate the potential RCTs that evaluated the importance of the thoracic spine manipulative techniques in treatment of patients with CMNP. They (GS, GGG and TT) thoroughly searched for articles that are relevant to the meta-analysis. When the computerized search had been completed the reference lists of the articles were analyzed for by authors (GS as well as GG) to find other related articles. The authors (GS, GT and TT) looked over every title and abstract to determine eligibility for the study at first. Full-text articles were then reviewed in accordance with a specific inclusion criteria by (GS as well as GG).

The Selection of Studies

We applied the established inclusion criteria to identify relevant full-text studies. The article was used for evaluation analysis, data extraction and evaluation in accordance with the guidelines for eligibility.

Quality Assessment

The quality of the methodological aspects of the articles selected were evaluated using the eleven-item Physiotherapy Evidence Database (PEDro) scale (Table 2). 29 PEDro scale is a valid tool for assessing the quality of the methodology used in rehabilitation and physical therapy studies. The two authors (GS as well as GG) with a background as physiotherapy experts and more experienced using the instrument independently assessed each article after which the differences were was resolved by discussions until there was a consensus. The study was deemed to be “high” quality if it had a PEDro score was 7 or more, “fair” quality if the score was 5-6 is achieved, as well as “poor” quality when the score was lower than. 30

Table 2. Qualitative of Articles (PEDro Scale)

To evaluate the total evidence base and to assess the overall body of evidence, it was decided to use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was used in all studies. There are five domains that are utilized to determine the GRADE system, which include the risk of bias inconsistent findings, indirectness of evidence imprecision, as well as the possibility of reporting the bias. 11,31 Randomized controlled trials start with a high-quality classification of evidence but could be graded down when one or more of the mentioned domains exist. 31

Data Extraction

2 Investigators (GS as well as GB) extracted data by using a pre-designed method of data extraction. We extracted information such as size of the sample, age, outcomes and interventions that were performed (including manipulative techniques, approaches and frequency of treatment) as well as the treatment provided to the comparator group as well as follow-up times and the results. The mean difference (MD) and normal deviation (SD) was determined for the outcomes identified. The similarities and variations of the findings were analyzed and discussed.


Data analysis was carried out with RevMan 5.3. The post-intervention scores as well as Standard deviations (SD) were entered in the analysis. In all meta-analyses, a random-effects model using an the inverse variance method was employed to calculate weighted mean difference and 95 percent confidence intervals. If there was multi-group data We chose the most more common and clinically relevant comparison. Heterogeneity of trials was measured by using I 2 as the I 2. statistic. This II 2. statistic reveals the proportion of variation in the estimations that is due to heterogeneity, not the error in sampling (chance) lower than 40% indicates that heterogeneity wasn’t a major factor higher than 75% indicates significant heterogeneity. Values between 40% and 75% suggest moderate-to-substantial heterogeneity.32 The pooled data for each outcome were reported as weighted mean differences with a 95% confidence interval (CI).


Study Selection

Literature searches were conducted using various databases. In the initial search, 745 articles were discovered from one database. After removing duplicates the remaining 312 articles were found. Of the 24 full-text papers, 16 were excluded according to the criteria for eligibility. Eight RCTs that met the review’s objectives could be included as part of the meta-analysis. PRISMA flow diagrams were utilized to demonstrate the process of searching and to identify the relevant studies (Figure 1.).

Figure 1. preferred reporting items for Meta-analysis and systematic reviews (PRISMA) diagram for the study choice.

Description of Studies

The studies that were included in this meta-analysis are all clinical trials that were randomized to study the impact of TSM on neck pain and impairment in patients suffering from CMNP as compared to other treatments. There were 385 participants that ranged of 30 to 120 participants were involved in the eight research studies. 20-26 All of the studies comprised female and male participants within an age range of 18-60, with the exception of one study 27 where all study participants were females aged 18 to 60 suffering from chronic neck pain. Each study included participants suffering from CMNP who were randomly assigned to or the TSM group or a control group. The time to follow-up varied across studies from the initial to six months after intervention. The majority of studies examined the impact of pain (NPRS as well as VAS) as well as three studies evaluated disabilities (NDI). A comparison of thoracic manipulations was performed using the placebo 22-25, 27, the thoracic spine mobilization cervical manipulation, 21 cervical manipulation 26, and other co-interventions, such as infrared therapy, craniocervical deep-flexor exercise, and cervical stabilization exercises. 20,23,24 The outcomes of these studies were analyzed, synthesized and discussed at the conclusion of the review and a summary of the included studies is provided in Table 3.

Table 3. Specifications of the Studies

Methodological Evaluation of Quality

The articles were then evaluated on their quality using the PEDro scale, and then tabled in Table 2. The scores of the articles ranged from 4 up to 8 with an average scores that was 6.63/10 (SD=+-1.3) which indicates that the quality of the research included was moderate or fair. Five studies 20-21, 25-27 were identified as being of high quality, with two articles 22-23 with “fair” quality and one study 24, in “poor” of poor quality. None of the research studies blinded the therapists or clinicians who were treating them however only one study 27 did not meet the standard for blinding subjects, as it is widely known that blinding is difficult for the patient and is not possible to blind the healthcare provider when performing manual therapies.

A formal grade of evidence was performed with GRADEpro software. GRADEpro software to give an overall evidence level for the use of thoracic manipulations in the treatment of CMNP. The individual levels varied from low to high, and the overall proof (certainty) in the study was moderate to low. The data is available in Table 4 and Table 5.

Table 4 GRADE Evidence Profile of Articles Individually

Table 5 GRADE Overall Evidence Profile

Synthesis of Results

In this review, we present evidence about the efficacy of TSM to lessen the severity of pain and improve neck mobility in patients suffering from chronic neck discomfort. A few of the articles evaluate thoracic thrust manipulative with non-thrust techniques, manipulating cervical thrusts as well as with groups that are not in intervention. The results of these studies are reviewed and summarized. The significance of the statistical analysis was determined using an value of p-value <0.05 or 95 percent confidence interval.

Pain Intensity

Pain intensity was accessed in all eight studies with outcome measures of (VAS and NPRS).20-27 Pain relief was attained in most of the studies.20-24 Between-group differences for pain achieved by the thoracic spine thrust manipulation group were not only statistically significant but also clinically meaningful decrease in NPRS ranged from 34.4% to 40.6% in the TM group in immediate post-treatment, which was maintained for the 3 and 6-month follow-up similarly, patients receiving thoracic spine thrust manipulation experienced a greater decrease in neck pain between-group mean difference: 1.4; 95% CI (0.8-2.1) than did those receiving thoracic spine non-thrust mobilization within 10-minute post-intervention.20,21

The study which examined the immediate effects of the single level thoracic maneuver (STM) and multi-level Thoracic Manipulation (MTM) for chronic neck pain demonstrated that pain levels at rest significantly decreased following MTM1.96 (95 percent 95% CI (1.04-2.95) as well as 2.35 (95 percent C.I. (1.44-3.71) for one week and 24 hours for a period of one week and 24 hours, and. 22 A study that examined the effects of the thoracic manipulative (TM) along with deep craniocervical muscle (DCF) instruction on intensity of pain for the subjects revealed that reduction in pain intensity was greater in the group that received of TM and DCF instruction (MD as well as SD =-3.8+-0.6) as compared to the group who received DCF training on its own following a 10-week following-up. 23 According to the post-intervention analysis with the upper-thoracic manipulation as well as cervical stability training and the cervical stability training group There were significant differences in scores of pain. 24

However, the results of the study, which compared left and right cervical manipulation with the thoracic manipulation, did not show any statistically significant time-to-group interaction in neck pain. The three groups experienced an identical reduction in neck pain following the treatment. 26 Similarly the study that was carried out to examine the effect of thoracic manipulative versus mobilization on neck pain that is chronic during the follow-up period of 24 hours showed VAS ratings were significantly reduced across both treatments. But, there was no significantly different in pain at rest for the three groups for 24 hours following the procedure. 25 In the study that was conducted to determine the short- and immediate results of the upper and thoracic spine manipulation on the intensity of pain and myoelectric activity of muscles of the sternocleidomastoid in women who suffer from constant neck pain there were no statistically significant difference was observed between the intergroup and intragroup studies of the placebo and experimental groups in the severity of neck pain during the short or immediate post-intervention tests. 27

In this meta-analysis and systematic review of the short-term or immediate effects of thoracic manipulatives on the intensity of pain in patients suffering from constant mechanical discomfort was studied by combining data from eight studies that utilized self-reported VAS and NPRS. The meta-analysis of five research studies 22-25,27 which included a total of 151 participants who measured the intensity of pain using VAS (0-100mm) found an important effect (MD -12.46 (95% percent CI: -17.29, -7.64; I 2 = 52%, p 0.001) (Figure 2.) and a analysis of the meta-analysis results of three research studies that examined 20,21,26 which measured pain using the PNRS (0-10 points) showed a significant difference (MD -0.85 (95 %) C.I. -1.60, -0.10; I 2 = 61 percent and p = 0.03) immediately following the procedure (Figure 3).).

Figure 2. A meta-analysis of the effects of Thoracic spine manipulative (TSM) to relieve pain using a visual analogue scale (VAS).

3. A meta-analysis of the effects of the thoracic spine manipulative (TSM) to relieve pain using the Numeric Pain Rating Scale (NPRS).

Neck Disabilities

The neck-related disability was studied through three research studies 20,22, 23 which included 183 participants. The results of a study that compared experimental groups who received TM as well as an untreated control group that did not undergo the manipulative process revealed that the TM group to have a significant decrease in neck impairment compared to the control group. There was a between-group variation that was 6-8.9 percent. 20 Similarly as in the study that looked at the effects on the neck from single-level (STM) and multi-level manipulatives of the thorax (MTM) for CMNP,, the neck impairment in the MTM and MTM groups was significantly reduced by 8-12 points compared to the control group during one week and after 24 hours. 22 The NDI in a group receiving the thoracic manipulatives in conjunction with deep craniocervical flexion exercises was reduced by a decrease of 5.9 points compared to those who received just flexion training in the deep part of the craniocervical area. 23

In this meta-analysis and systematic review of the short-term or immediate impact of thoracic manipulations on neck impairment in patients suffering from constant mechanical pain studied by pooling the data from these three studies. A meta-analysis of three research studies 20,22,23 which totaled 383 participants measured neck disability showed an important effect (MD -6.46 with 95% C.I. -10.43-2.50 2 = 57%, p = 0.001). 2. = 57 percent (p = 0.001) immediately following the treatment (Figure 4).).

Figure 4. A meta-analysis of the impact of Thoracic spine manipulative (TSM) upon neck disabilities.


This meta-analysis and systematic review assessed the impact of TSM on patients suffering from chronic neck pain. At the time of writing, to the best of our information it’s a preliminary systematic review study that evaluates the impact of TSM on patients suffering from chronic neck pain. This systematic review comprises eight recent RCTs completed within 10 years that have a mean PEDro score with a fair quality of evidence and the GRADE evidence level was found to be low to high for the individual studies as well as moderate to low overall evidence from the review.

The review offers evidence that the thoracic manipulation on its own or in conjunction with other treatments have produced an immediate and immediate effect to reduce neck pain and disability in patients suffering from chronic neck pain. The summation of the pooled effects in this study favors either the Thoracic manipulation or experimental group with an effective magnitude of -0.85 and-12.46 for studies that evaluated the degree of pain using VAS and PNRS measurements and VAS measurements, respectively. In the same way, the summation result on neck impairment was -6.46 in the favor of the Thoracic manipulation group. This result is in line with the findings of earlier research studies on thoracic manipulations for neck pain.17-19 TSM can be more beneficial than cervical mobilization and conventional care in the short-term however it is not as effective as manipulating the cervical spine or Thoracic spine manipulation to reduce disabilities and pain among those suffering from mechanical neck pain (MNP)17 and nonspecific neck pain.18 A similar systematic review that compared the thoracic manipulation with mobilization showed that there was a substantial amount of evidence supporting the short-term advantages of thoracic manipulation when treating patients suffering from cervical mechanical pain.19 This could be a proof of the inherent biomechanical linkage between the thoracic region with the cervical spine and the disturbances in how the body’s biomechanics work on the spine may be the primary reason for neck pain.15

The review was conducted using those suffering from chronic neck pain. The research included in the review compares the treatment or thoracic manipulation with sham methods or placebo 22,25,27 the thoracic spine mobilization 21, as well as cervical manipulative. 26 Co-interventions such as infrared therapy and educational materials as well as exercises to strengthen the cervical deep flexor and cervical stability training Twenty-23 and 24 were also included in the treatment sessions since these were also included in the comparative group that demonstrates the different in the treatment effects that can be due to the inclusion of TM within the experimental group. But, regardless of different interventions that were compared, the findings of the review suggest that treatments that include the thoracic spine thrust manipulation show greater effect on outcomes measurements. Incorporating TM in the group of experimenters and co-interventions within both groups may result in important clinical differences in the reduction of the level of neck disability and pain between the participants.

There is moderate variation among the studies that were included in the form of three studies that have I two = 52 percent, 57%, and 61 percent. This could be due to the fact that most of the studies included examined various control strategies as well as different doses and methods of intervention. one of the reasons for this the heterogeneity could be a huge variation in the size of the sample that ranges from 26 for the Suvamnato study to 25, up to 120 for study Lau research. 20 Though this variation in sample size may question the general effectiveness of meta-analysis the articles included were of a acceptable in terms of methodological excellence and moderately backed by evidence. The authors consider meta-analysis to be useful in determining the overall effect of TSM since it’s relevant and could aid in the decision-making process for the treatment of patients suffering from MNP.

The research studies discussed the various the thoracic spine thrust manipulation methods. The precise location to where the thrust manipulation was performed also differed among studies as four RCTs tried to offer the thrust manipulation in some or all of the generic places of the mid-thoracic as well as the upper thoracic spine when a patient is in a the supine line with elbow flexed anteriorly. thrust manipulation. 20,21,23,26 A study that extrapolated the decision to determine the best place to apply the thoracic spine manipulating thrust, and acknowledged that the method does not specifically target particular segment of the vertebrae. 33 In contrast to the suggested medical method, Suvernato et al attempted to manipulate only a single segment, which was found to be insufficiently mobile in joint mobility tests. 25 Puntamutakul and co. studied the single as well as multiple manipulations of the thoracic spine comparison with the control group, in which the hand of the therapist was placed with no treatments. 22 Nevertheless the outcomes of the current studies didn’t appear to be affected by the particular technique or the reason for its the use.

The intervals between follow-up for all of the studies that were included within this study were brief. The literature currently has individual reports on the effectiveness of treatment immediately following intervention within the first 24 hours. One study evaluated the immediate post-intervention outcomes after 3 months, followed by 6 months follow-up. 20 Although different follow-up intervals were included however, the long-term outcome has not been documented.

Relevance for clinical Practice

The meta-analysis and review found that thoracic manipulation has the immediate and short-term effects to reduce neck pain and impairment in patients suffering from chronic neck pain. Therefore, physiotherapists and clinicians are able to utilize the techniques of high-velocity and low-amplitude (HVLA) Thoracic thrust manipulation as a method of treatment to lessen neck disability in patients suffering from chronic neck pain.

Impacts on Future Research

The next step is to determine the most efficient method of the thoracic thrust to treat each type in neck pain (acute chronic, subacute mechanical, and not mechanical). Its long-term impact is correlated is enhanced by a longer time-frame for follow-up and to review of research studies focusing on the impact of the thoracic spine manipulations as a singular technique.

Strengths and Limitations

The review was a success because it complied with PRISMA guidelines, which are registered in PROSPERO Quality of evidence for the studies evaluated with PEDRo and GRADE as well as all of the included papers are newly published RCTs. However, despite its strengths, this review could have some drawbacks. The inclusion of low to fair quality evidence articles, the possibility of limitation on the search engine and the selection of English language articles , as it may result in the risk of missing publications published in other languages. Inconsistency among the studies included was one of the major issues, and could be caused by the review. not particular to the time frame for follow-up of the papers.


The thorough review, as well as the meta-analysis suggest that the thoracic spine thrust manipulation can reduce neck-related pain and disability for all adults suffering from chronic neck pain, when in comparison to other treatments. While the results of this review prove the clinical benefits of TSM in reducing pain, physicians must be aware of these findings because the level of evidence is minimal to medium.

Ethics Approval

A patient’s consent or ethical approval was not necessary as the current study was an analysis of published research.


The authors do not report any conflicts of interest in the study.


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