TESIS DOCTORAL

FISIOTERAPIA EN LA CERVICALGIA CRÓNICA. MANIPULACIÓN

VERTEBRAL Y KINESIOTAPING.

DEPARTAMENTO DE FISIOTERAPIA

UNIVERSIDAD DE GRANADA

Manuel Saavedra Hernández

2012

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Editor: Editorial de la Universidad de Granada
Autor: Manuel Saavedra Hernández
D.L.: GR 2905-2012
ISBN: 978-84-9028-228-1
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A mis padres,

A mis tres hijas y mi mujer

que es mi sol de media noche,

A Pablo y A mi abuela.

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INDICE

Resumen..........................................................................................................................1

Abreviaturas....................................................................................................................2

Introducción....................................................................................................................3

Bibliografía.....................................................................................................................4

Objetivos.........................................................................................................................5

Material y Métodos.........................................................................................................6

Resultados y Discusión...................................................................................................7

1. Predictors for Identifying Patients with Mechanical Neck Pain

Who Are Likely to Achieve Short-Term Success with Manipulative
Interventions Directed at Cervical Thoracic Spine. (ArtículoI)…...............................12

2. Short-Term Effects of Kinesiotaping versus Cervical Thrust

Manipulation In Patients with Mechanical Neck Pain: a Randomized
Clinical Trial. (Artículo II)…........................................................................................13

3. Short-Term Effects of Spinal thrust Joint Manipulation in Patients

with Chronic Mechanical Neck Pain: A Randomized Clinical Trial.
(Artículo III)..................................................................................................................14

4. Pain Intensity, Physical Impairment and Pain-Related Fear to

Function in Patients with chronic Mechanical Cervical Pain.(Artículo IV).................16

Conclusiones................................................................................................................23

Agradecimientos…......................................................................................................24

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RESUMEN:

El dolor de columna vertebral y más concretamente el dolor cervical, representa una de

las causas más frecuentes de consulta en los centros de fisioterapia. La cervicalgia, es
definida como dolor en columna cervical, aunque algunos autores lo describen también,
como dolor localizado entre el occipucio y la tercera vertebra dorsal. El dolor cervical
puede involucrar una o varias estructuras neurovasculares y musculoesqueléticas,
pudiéndose presentar con o sin irradiación hacia los brazos (braquialgias) o la cabeza
(cefaleas). La cervicalgia puede ser debida a trastornos estáticos y funcionales, a
enfermedades de tipo inflamatorio, traumático, tumoral, infeccioso, o bien a desordenes
de origen psicosomático. Un gran número de autores coincide en que el origen de las
cervicalgias es fundamentalmente mecánico.

En este trabajo de investigación, el tamaño muestral ha estado constituido por 243

sujetos con dolor mecánico cervical, con una edad comprendida entre 18 y 60 años. Las
variables de medida registradas han sido el diagrama corporal de localización de
síntomas, escala numérica de rango de dolor, índice numérico de discapacidad, escala
de kinesiofobia de Tampa, rango de movimiento cervical, rotación activa torácica,
movilidad articular y respuesta sintomática a la movilización, examen específico de
dolor cervical y radiculopatía, y cambio de rango global. Los sujetos de estudio fueron
sometidos a distintos procedimientos de intervención en fisioterapia; técnicas de
manipulación espinal dirigidas al segmento medio cervical, charnela cérvico-dorsal y
dorsales altas; y vendaje neuromuscular (Kinesio Taping).

El vendaje neuromuscular y los procedimientos de terapia manipulativa han mostrado

resultados similares en la reducción del dolor y en el aumento del rango de movilidad.
Sin embargo, los sujetos que recibieron la técnica combinada de terapia manipulativa de
columna cervical media y charnela cérvico-dorsal, han mostrado una mayor reducción
de la discapacidad, con respecto al grupo de Kinesio Taping. Asimismo, los pacientes
que recibieron terapia manipulativa combinada dirigida a dorsales altas, charnela
cérvico-dorsal y cervical media, han mostrado una mayor reducción de la discapacidad,

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en comparación con el grupo de pacientes al que se le administró un único
procedimiento manipulativo a nivel cervical medio.

En la regla de predicción clínica, se han identificado diversos factores potenciales de

pronóstico terapéutico en la mejora de la cervicalgia mecánica, entre los que se
incluyen, un rango de extensión cervical inferior a 46º, una intensidad del dolor de 4.5
en la escala numérica de rango de dolor, hipomovilidad en la vértebra T1, test
neurodinámico de miembro superior negativo y pertenecer al sexo femenino.

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ABREVIATURAS.

ANOVA= Análisis de la Varianza de un Factor.

BMJ= British Medical Journal.

C1= Primera vértebra cervical.

C2= Segunda vértebra cervical.

C3= Tercera vértebra cervical.

C5= Quinta vértebra cervical.

C6= Sexta vértebra cervical.

C7= Séptima vértebra cervical.

CROM= Cervical Range of Motion (Rango de Movimiento Cervical).

EMG= Electromiograma.

Fig= Figura.

LRs= Likelihood ratios.

M= Media.

MCID= Minimal Clinically Important Difference (Diferencia Mínima Clínicamente

Importante).

MDC= Minimal Detectable Change (Mínimo Cambio Detectable).

NDI= Neck Disability Index (Índice de Discapacidad Cervical).

nº= Número.

NPRS= Numeric Pain Rating Scale (Escala de Rango Numérico del Dolor).

QTF= The Quebec Task Force on Spinal Disorders.

RHB= Rehabilitación.

ROM= Range of Motion (Rango de Movimiento).

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RPC= Regla de Predicción Clínica.

SD= Standard Derivation (Derivación Estándard).

SEM= Standard Error of Measurement (Medida de error Estándard).

SPSS= Statistical Product for Service Solutions.

T1= Primera vértebra dorsal.

T2= Segunda vértebra dorsal.

T3= Tercera vértebra dorsal.

T4= Cuarta vértebra dorsal.

T9= Novena vértebra dorsal.

TENS= Estimulación Eléctrica Transcutánea.

TJM= Thrust Joint Manipulation (Manipulación Articular de alta Velocidad).

TSK= Tampa Scale for Kinesiophobia (Escala de Kinesiofobia de Tampa).

ULTT= Upper Limb Tension Test (Test Neurodinámico de Miembro Superior).

VBI= Vertebrobasilar Insufficiency (Insuficiencia Vértebrobasilar).

y= Years (Años).

α= Alfa.

χ2= Chi-cuadrado.

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INTRODUCCIÓN.

1. Concepto de dolor mecánico cervical.

El dolor de columna vertebral y más concretamente el dolor cervical, representa

una de las causas más frecuentes de consulta en los centros de fisioterapia, por lo que
consideramos de capital importancia, el abordaje desde el punto de vista científico de
esta patología, con el fin de ofrecer una atención sanitaria de máxima calidad. 1

Siendo imprecisa como es la definición de cervicalgia, debido a su

heterogeneidad desde el punto de vista biológico, etiológico, fisiopatológico y
psicológico,1,2,3,4 nos remitimos a su significado etimológico como “algia cervical”,
siendo por tanto un síntoma5 definido como dolor en la columna cervical por la mayoría
de los autores.6 Aunque, también es definida por otros autores como un dolor localizado
entre el occipucio y la tercera vértebra dorsal.7

El dolor cervical puede involucrar a una o varias estructuras neurovasculares y

musculoesqueléticas como nervios, ganglios, raíces nerviosas, articulaciones
uncovertebrales, articulaciones intervertebrales, discos, huesos, periostio, músculos y
ligamentos;1 pudiéndose presentar con o sin irradiación hacia los brazos o la cabeza,
produciendo en ocasiones braquialgias o cefaleas de origen cervical 1,8,9,10
respectivamente. Igualmente, es causa a su vez de vértigo con origen cervicogénico, 1,11,12
por lo que es un proceso en el que, además de la lesión que se produce a nivel de las
distintas estructuras implicadas en esta patología, hay que sumarle la alteración
emocional que podría conllevar el dolor cervical.2,3,4

La cervicalgia puede ser debida a trastornos estáticos y funcionales, a

enfermedades de tipo inflamatorio, traumático, tumoral, infeccioso, o bien a desordenes
de origen psicosomático.3,13 Un gran número de autores coincide en que el origen de las
cervicalgias es fundamentalmente mecánico, ocasionado por posturas mantenidas de
cabeza y/o brazos, por sostener o cargar pesos de forma estática, realizar movimientos
repetitivos de la columna cervical o los miembros superiores, y también por no realizar
pausas o descansos en el trabajo.14-18

2. Prevalencia y coste económico de la cervicalgia.

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 El dolor mecánico cervical representa, para cualquier país, un importante
problema de salud.19 Ha sido evidenciado que tanto la prevalencia como la duración del
dolor cervical, es igual de importante que el dolor lumbar. 20,21 Aproximadamente, el
54% de los individuos han experimentado dolor cervical en los últimos seis meses, 22 y
la incidencia de esta patología puede verse incrementada en el tiempo. 23,24 El dolor
mecánico cervical tiene una prevalencia puntual comprendida entre el 9’5% y el 35%, 25-
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, con una prevalencia a lo largo de la vida del 70%. 25 En el periodo de un año su
rango, según los estudios más recientes, oscila entre el 16.7% y 75,1 %, con una media
del 37.2%.20 Un número importante de estos pacientes se recupera antes de las seis
semanas.25-28

El dolor cervical produce a menudo una discapacidad importante, originando

una pérdida de las horas de trabajo y un coste económico a los sistemas sanitarios,22,25,29-
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traduciéndose por tanto, en unos costes socioeconómicos elevados.33,34 Aunque la
cervicalgia no supone para la vida una amenaza, si conlleva un detrimento de la calidad
de ésta, que en reiteradas ocasiones, produce trastornos importantes de salud, generando
dolor, déficit funcional, cefaleas, restricción de movimiento, síndromes vertiginosos,
nauseas y/o vómitos, etc., con el consiguiente incremento de gasto sanitario y
absentismo laboral.4,35 El coste económico asociado al tratamiento de fisioterapia,
farmacológico, ausencias en el trabajo, indemnizaciones, etc., en el paciente con
cervicalgia es muy elevado, estando en segundo lugar, precedido por el dolor lumbar, en
gastos de compensación a los trabajadores en EEUU.36 En España, las derivaciones al
servicio de fisioterapia por cervicalgia, ocupan el 10% del total de todas las demandas
sanitarias.37 Sin embargo, en países como Canadá este porcentaje se eleva al 30%, y al
15% en Gran Bretaña.39

Aproximadamente el 44 % de los pacientes que han padecido dolor cervical, van

a desarrollar síntomas crónicos30, y muchos continuarán presentando discapacidad
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moderada a largo plazo. Aproximadamente, más de la mitad de estos pacientes, los
cuales han padecido dolor cervical como resultado de un latigazo cervical, continuarán
sufriendo sintomatología dolorosa durante más de 17 años, después de haber
experimentado el traumatismo.41 Existe un incremento del riesgo de dolor cervical
crónico, un aumento de la severidad de los síntomas, y los episodios de dolor anteriores
en individuos que se encuentran en el grupo de edad comprendido entre los 45 y los 59
30,42
años.
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 La fisioterapia es a menudo, la primera aproximación terapéutica que reciben los
pacientes con cervicalgia mecánica, suponiendo aproximadamente el 25% de todos los
pacientes que solicitan los servicios de fisioterapia.43 Jette et al 43
documentaron que
los pacientes con dolor cervical, suponen aproximadamente el 25% de todos los
pacientes que recibieron fisioterapia clínica.

El coste directo que ocasiona la cervicalgia al sistema sanitario, más

concretamente, en la consulta de Atención Primaria, supone el 2% del coste total. 4, 44, 45
Incrementándose las cifras hasta alcanzar en algunos centros un 12%, si consideramos
las pruebas diagnósticas, gasto farmacéutico y visitas al especialista. 4,44 También es
importante considerar los costes indirectos, como es el absentismo laboral y la
discapacidad ocasionados por esta patología, los cuales según diversos estudios,
generan mayores gastos que los resultantes de costes directos. 35, 46-48
En un estudio
económico realizado en Holanda en el año 1996, sobre los costes indirectos que produce
la cervicalgia, se obtuvieron los siguientes resultados: Del total de los 686,2 millones
del gasto sanitario en pacientes con cervicalgia, el 77% fueron costes indirectos. 29 Las
personas diagnosticadas de esguince cervical postraumático, y que por ello son
indemnizadas en la sociedad occidental, muestran una prevalencia de 300 casos por
cada 100.000 habitantes.47- 49

3. Abordaje terapéutico de la cervicalgia mecánica.

La intervención más comúnmente prescrita para el tratamiento de dolor

cervical, por la medicina general, son los analgésicos. 16, 50 A pesar de la gran incidencia
de la cervicalgia, hay un gran déficit de evidencia científica sobre las técnicas y
protocolos a seguir en el abordaje terapéutico, desde el punto de vista de la
fisioterapia.51 Las directrices más recientes para el tratamiento del dolor cervical las
encontramos en The Quebec Task Force on Spinal Disorders (QTF)52 y the British
Medical Journal (BMJ) 53 guidelines.

El tratamiento del dolor cervical mecánico muestra una gran paradoja en los
múltiples enfoques, escuelas y variedades terapéuticas, siendo aún escasas las grandes
revisiones que cumplan los parámetros de calidad de la Medicina Basada en la
Evidencia, y que justifiquen de manera definitiva el empleo de una u otra técnica. 54,55

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Tipo de Intervención Aguda Crónica
Ejercicio/reeducación neuromuscular ND A,I
Estimulación Eléctrica ID ID
Ultrasonidos Terapéutico ND C,I
TENS C,I ID
Tracción C,I C,II
Intervenciones RHB Combinadas ND ID
Termoterapia ND ND
EMG Biofeedback ND ND
Masaje ND ID
TENS: Estimulación Eléctrica Transcutánea; RHB: Rehabilitación; EMG:
Electromiograma; ND: No Datos; ID: Datos Insuficientes; A: Beneficio Demostrado; C:
No Beneficio Demostrado; Nivel I: Evidencia Obtenida a partir de Estudios Controlados
Randomizados; Nivel II: Evidencia Obtenida a partir de Ensayos Clínicos Controlados.
Extraído de: Philadelphia Panel Evidence-Based Guidelines on Selected Rehabilitation
Interventions for Neck Pain.56

4. Evidencia para la utilización de la manipulación vertebral en pacientes con

dolor mecánico cervical.

La intervención mediante terapia manual es una estrategia de tratamiento

utilizada para el abordaje de la cervicalgia. 57 La Guía para la Practica de la Fisioterapia
(Guide to Physical Therapist Practice)57 utiliza el término “movilización-manipulación”
para referirse a las técnicas de terapia manual que conllevan un continuo movimiento
pasivo de las articulaciones y tejidos blandos relacionados, y que son aplicadas a
diferentes velocidades y amplitudes, incluyendo las de baja y alta velocidad. En
concreto, el término “manipulación” en este tratado, se refiere específicamente a
aquellas técnicas que son ejecutadas con alta velocidad y baja amplitud (thrust),
mientras que la movilización hace referencia, a las técnicas que son desarrolladas a baja
velocidad mediante un movimiento pasivo de una articulación.

Aproximadamente, el 37% de los terapeutas con una experiencia desarrollada en

terapia manual, utilizan técnicas de manipulación y/o movilización en pacientes con
dolor cervical, en su práctica clínica.58 La efectividad de este tipo de intervenciones en
pacientes con dolor cervical y cefaleas de origen cervicogénico, está siendo

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recientemente respaldada por un numeroso incremento de estudios de elevada calidad,
a través de ensayos clínicos randomizados 59-65 y revisiones sistemáticas 1, 51, 66-68, en los
cuales se demuestra la efectividad de la terapia manual como terapéutica en el abordaje
de la cervicalgia y cefaleas. Sin embargo, las guías de la práctica clínica sobre el
tratamiento del dolor cervical, raras veces sitúan la manipulación espinal como un
tratamiento recomendado en este tipo de problemas 69. No obstante, su utilización en el
contexto clínico es cada vez más demandado por los pacientes, debido a sus potentes
efectos analgésicos inmediatos observados en la práctica clínica habitual.

La aplicación de la terapia manual dirigida directamente sobre el raquis cervical,

puede tener un cierto riesgo potencial. El riesgo de complicaciones se asocia con la
insuficiencia de la arteria vertebral, y ha sido estimado como extremadamente bajo
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(aproximadamente en 6 de cada 10 millones de sujetos; 0.00006%). Sin embargo, los
estudios realizados hasta la fecha, han fracasado en la posibilidad de desarrollar
procedimientos de test de screening, que sean capaces de identificar los pacientes con
riesgo de sufrir este tipo de eventualidades antes del tratamiento. 71 Por lo tanto, se
considera, que la manipulación cervical, puede tener algún tipo de riesgo. 71-76 Ante esta
riesgo potencial, sería conveniente establecer la posibilidad de realizar manipulaciones a
distancia del foco lesional, que puedan producir mejoras en el raquis cervical de forma
más segura; o bien, estudiar la efectividad real de la manipulación cervical para valorar
su relación con el riesgo asumible tras la adecuada realización de los tests clínicos
discriminativos. Así por ejemplo, en una encuesta realizada en Canadá a profesionales
de la fisioterapia, el 88% de los encuestados, estaban de acuerdo en que se deberían
realizar todos los test de screening disponibles, previamente a la manipulación de la
columna cervical.58

Expertos clínicos han sugerido que en pacientes con dolor cervical, se debe
incluir el examen y tratamiento de la columna dorsal. 77-80 Debido a la relación
biomecánica existente entre la columna cervical y la dorsal, probablemente las
alteraciones en la movilidad articular en esta última, puedan servir como un elemento
81-83
contribuyente al desarrollo de alteraciones cervicales. Se ha demostrado que la
manipulación y la movilización de las articulaciones a distancia sobre los pacientes con
dolor cervical, pueden dar como resultado un efecto analgésico inmediato.84-87 Por estas
razones, se sugiere, que incorporar la manipulación torácica, así como, las

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movilizaciones del segmento cervical, a la manipulación de la columna cervical, puedan
ser intervenciones que tengan un efecto terapéutico.88

Sin embargo, de forma similar a como ocurre en el dolor lumbar, el dolor

cervical mecánico, es un problema de etiología heterogénea, pudiendo ser éste
originado por problemas a nivel articular, discal, neurológico, ligamentario y
muscular.89-101 Incluso en poblaciones consideradas como un grupo homogéneo, por
ejemplo, pacientes sin antecedentes traumáticos con dolor no agudo cervical, existen
diferencias considerables en cuanto a los exámenes derivados de la exploración
clínica.102 Los procedimientos de examen clínico estandarizados, han mostrado poco
éxito en identificar las causas patoanatómicas de los síntomas en este tipo de pacientes
con dolor cervical mecánico.95, 103, 104
Debido a la variabilidad que existe en la
presentación clínica en cuanto a la etiología del dolor cervical, parece evidente, que no
todos los pacientes con dolor cervical mecánico, van a responder de manera positiva a la
manipulación de columna cervical, charnela cérvico-dorsal y torácica. No obstante, es
esencial identificar y clasificar a aquel subgrupo de pacientes homogéneos con dolor
cervical mecánico, que son susceptibles de responder a las manipulaciones previamente
mencionadas.

Actualmente, se está estableciendo una tendencia a la utilización de la

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manipulación de la columna dorsal, en el abordaje del dolor cervical. Pho y Godges
utilizaron un tratamiento multimodal en el abordaje de un paciente que presentaba
alteraciones asociadas con latigazo cervical. El inicio de los síntomas fue bastante
agudo, y no permitió el tratamiento de forma directa sobre el cuello, de manera que los
autores decidieron focalizar el tratamiento en la columna torácica. Como resultado de
este estudio, el paciente experimentó un total retorno a la actividad funcional, por lo que
los autores concluyeron que, la columna torácica alta puede ser el origen de los
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síntomas en algunos pacientes con dolor cervical. Parkin-Smith et al compararon la
efectividad de los tratamientos consistente en manipulación de la columna dirigida al
segmento cervical y al torácico en un grupo de pacientes con dolor mecánico cervical.
Los pacientes fueron randomizados en dos grupos, recibiendo 6 sesiones de terapia
manipulativa durante un periodo de 3 semanas. El resultado del estudio demostró que
ambas manipulaciones, cervical y columna dorsal alta, con respecto a la intervención
exclusiva sobre la columna cervical, no mostró un beneficio suplementario sobre la
discapacidad. Sin embargo, el estudio exhibió una pobre potencia estadística sugiriendo

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que, posiblemente existió un error metodológico que podría justificar la falta de
resultados. En definitiva, se informó que algunos de los pacientes recibieron masaje del
tejido blando y por tanto no sabemos si las variables añadidas podrían haber afectado a
los resultados de estos pacientes.

En línea con los estudios liderados por Flynn 86 y Cleland,87 y más recientemente
por Fernández de las Peñas,107 centrados en los efectos inmediatos de la manipulación
de la columna torácica en pacientes con dolor cervical mecánico, se ha demostrado que
en un grupo de pacientes con alteraciones asociadas a latigazos cervical, tratados
mediante manipulación de la columna torácica, se produce una mejora clínica en la
reducción de dolor, valorada mediante escala visual analógica, en comparación con
aquellos sujetos, que no fueron tratados mediante manipulación torácica.

Una encuesta administrada a clínicos que practican terapia manual mostraron

que la columna torácica es la región de la columna más manipulada a pesar del hecho de
que muchos pacientes manifiestan dolor cervical. 108 Sin embargo, el mecanismo preciso
por el cual la manipulación de la columna torácica mejora el dolor cervical, así como,
el grupo de pacientes más proclives a la mejora clínica, no está todavía muy
demostrado.

4.1. Fundamentos biomecánicos para el tratamiento a distancia de la cervicalgia

crónica.

Norlander et al81-83 informaron de la relación existente entre la articulación

cérvico-dorsal y el dolor en región cervical y hombro, además del dolor referido a
columna dorsal alta, justificando de este modo el nexo biomecánico existente entre la
columna cervical y dorsal alta, así como, el vínculo existente entre la cintura escapular y
la columna dorsal. En un estudio inicial, Norlander et al 81 evaluaron la movilidad de la
unión cervicotorácica e investigaron si la hipomovilidad estaba correlacionada con los
síntomas cervicales y de hombro; determinando que la presencia de hipomovilidad en la
unión cervicotoracica estaba directamente correlacionada con la presencia de dolor
cervical. Es por ello, que los sujetos que presentaban movilidad reducida, exhibieron un
incremento significativo de su Odds Ratio (2,7) en la presencia del dolor cervical
durante al menos 7 días en los últimos 12 meses, comparándolos con los individuos

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asintomáticos. En un estudio de seguimiento,82 se demostró que en el mismo grupo de
pacientes del estudio inicial81, el riesgo relativo de experimentar dolor en los dos años
siguientes al estudio, oscilaba entre el 2,7 y 3,3 en aquellos casos donde existía una
hipomovilidad de la región cervicotorácica. Los autores sugirieron que la hipomovilidad
de la unión cervicotorácica, podría ser posiblemente, una variable predictiva para la
identificación de pacientes que son capaces de desarrollar dolor cervical en el futuro.

En un estudio transversal sobre 281 trabajadores industriales, Norlander et al 83

demostraron que la hipomovilidad del segmento C7-T1 está directamente relacionada
con los síntomas en el dolor cervical y de hombro. La movilidad reducida de la unión
cervicotorácica, explicó el 14% del dolor cervical de esta población. Los autores
concluyeron que el ajuste de la movilidad a nivel de C7-T1 y de T1-T2, podría
estimular los mecanorreceptores localizados en las articulaciones cigoapofisarias, las
cuales pueden dar como resultado la aparición del dolor cervical. Asimismo, se ha
mostrado que la reducción de la movilidad en la unión cervicotorácica, podría estar
provocada o relacionada con una postura inadecuada. Según el estudio de Griegel-
Morris et al.109, una postura inadecuada está directamente relacionada con el dolor
cervical.

Esta restricción de movilidad junto con la alteración postural prolongada en el

tiempo, pueden dar como resultado, la degeneración de la columna torácica superior y
columna cervical.110 En el estudio de Arane et al, 110 identificaron una correlación entre la
degeneración discal del segmento torácico superior y el dolor cervical en un 13,4% de
los pacientes con dolor cervical, identificado a través de resonancia magnética. Quizá la
restauración de la movilidad de estos segmentos a través del uso de técnicas
manipulativas de alta velocidad, puede ser un método efectivo en la restauración de la
movilidad segmentaria, reduciéndose así, la estimulación de los mecanorreceptores, y
dando como resultado la reducción del dolor.

Las membranas sinoviales inervadas por terminaciones nerviosas nociceptivas,

las cuales podrían llegar a ser pinzadas por las articulaciones cigoapofisarias, podría ser
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una superficie potencialmente capaz de dar como resultado dolor cervical . También
es probable, que los discos meniscales fibroadiposos atrapados a nivel de estas
articulaciones puedan dar como resultado la aparición del síndrome doloroso. 98
Considerando que las articulaciones cigoapofisarias de los segmentos cervical y

20
torácicos pueden ser potenciales fuentes de dolor hacia la región de la columna cervical,
es posible que la manipulación de estos niveles, permita la liberación de este espacio,
facilitando una mejor funcionalidad, y originando como resultado una reducción del
dolor cervical.112

4.2 Zona de Transición C6-C7, C7-T1 y T1-T2.

En un análisis morfológico de la región cervicotorácica, se rebeló que los

platillos superiores de C6 e inferiores de T4 exhibían características morfológicas
similares.113 En análisis radiográfico se reveló que el ápex de la curvatura
cervicotorácica es la vértebra T3 para la población joven, esto va cambiando
progresivamente conforme se van cumpliendo los años y trasladándose el ápex de la
curva progresivamente hacia C7-T1.114 Quizá esto está relacionado con un incremento
de espesor de los cuerpos vertebrales durante el proceso de envejecimiento. 115 Arana et
al110 en un estudio con 166 pacientes, investigaron las relaciones entre la degeneración
de los discos en la columna torácica superior y el dolor cervical. Los resultados
revelaron que los cambios degenerativos a nivel de los segmentos T1-T4 están
significativamente relacionados con la presencia de dolor cervical.110

La posición de la columna cervicotorácica, puede dar como resultado

alteraciones de la distribución homogénea de carga en estas dos regiones vertebrales, y
por lo tanto, la biomecánica del movimiento estará alterada, dando lugar a la producción
de síntomas dolorosos a consecuencia de la disfunción de la columna cervical y
torácica.116 Por lo tanto, es esencial observar que la cifosis torácica superior presente
algún tipo de desviación, la cual podría ser un contribuyente fundamental para los
pacientes con dolor cervical mecánico. 117 De hecho un número importante de autores 80,

118, 119
han sugerido que tratando la columna torácica y cervicotorácica en pacientes con
dolor cervical mecánico, se podrían conseguir mejorías terapéuticas importantes.
Considerando la íntima relación entre la columna cervical y la columna torácica
superior, es posible que la manipulación dirigida directamente a la columna dorsal
superior y charnela cérvico-dorsal podría mejorar directamente los síntomas asociados
con dolor cervical mecánico. Por tanto, la relación C7-T1-T4 parece ser una
fundamentación razonable para el tratamiento de los pacientes con dolor cervical, que
sufren alteraciones de la movilidad en la columna cervicotorácica, pudiendo ser esta

21
región un contribuyente fundamental para las alteraciones musculoesqueléticas
cervicales.80 Diferentes estudios120 han investigado la contribución que tienen los
patrones de dolor referido desde las articulaciones cigoapofisarias cervicales,
demostrando que estas articulaciones están claramente relacionadas con el dolor
cervical.

4.3. Influencias neurofisiológicas para la fundamentación del uso de la

manipulación vertebral en la cervicalgia crónica.

Las articulaciones cigoapofisarias presentan una rica inervación y presencia de

mecanoreceptores.111,121,122 La manipulación de la columna puede estimular estos
mecanoreceptores dando como resultado, alteraciones en las aferencias sensoriales a
nivel medular. Existen distintas teorías que afirman que la manipulación de la columna
puede también alterar los patrones sensoriales producidos por los mecanoreceptores
dentro de los tejidos inervados en una de estas articulaciones cigoapofisarias. 123
Asimismo, existe la posibilidad de que la manipulación espinal, pueda disminuir el
dolor a través de la inhibición de la nocicepción proveniente de los distintos receptores
articulares cervicales.

Un importante número de estudios85,124-127 han tenido como objetivo evaluar la

actividad del sistema nervioso simpático, en un intento de cuantificar los efectos
fisiológicos de la manipulación espinal (técnicas de movilización y manipulación).
Muchos de estos estudios127 han demostrado que la manipulación espinal produce una
respuesta simpático-excitativa, estadísticamente significativa, cuando se compara con
un placebo o un grupo control. Todos los estudios mencionados anteriormente,
utilizaron la conductancia de la piel como medida de la activación periférica del sistema
nervioso simpático. Algunos de estos estudios, 124 han demostrado que la movilización-
manipulación de la columna, va acompañada de un efecto hipoalgésico, con una
magnitud suficiente como para producir cambios estadísticamente significativos al ser
comparados con grupo placebo o control. Vicenzino et al 85 realizaron un estudio para
118
evaluar los efectos de la movilización cervical usando el procedimiento de Maitland
sobre el umbral doloroso a la presión y la conductancia de la piel, en pacientes con
epicondilitis. Los resultados demostraron que no solo hubo un incremento en la
respuesta simpático-excitatoria e hipoalgésica, sino también, una correlación positiva

22
entre estas variables, lo cual plantea la posibilidad de una relación entre ambos efectos
de la terapia manual, cuya dirección causa-efecto deberá ser estudiada en futuros
estudios. Aunque la terapia manual genera estos resultados, su génesis y relación no
están claramente establecidas. Se han desarrollado diferentes marcos teóricos, teniendo
como referencia la posible acción sobre el sistema de control central encefálicos 58,59
que pudieran producir una estimulación de mecanismos inhibitorios descendentes.85,128-
130

4.4. Efectos neuromusculares de la terapia manual.

4.4.1 Inhibición muscular.

Un inadecuado hábito postural puede incrementar la cifosis torácica y la lordosis

cervical, pudiendo ser esto un factor contribuyente fundamental para el dolor cervical.
Griegel y Morris109 han demostrado que las anormalidades de las posturas a nivel
cervical y torácico, están asociadas con un incremento de las incidencias en el dolor de
columna lumbar alto, dolor cervical y cefaleas. Se teoriza que un habito postural
inadecuado puede estar asociado con un patrón de desequilibrio muscular específico, en
el que los músculos posturales llegan a estar acortados y tensos, mientras que los
músculos fásicos (músculos encargados del movimiento) están alargados o
inhibidos.131,132 Distintos estudios han demostrado que la manipulación espinal produce
como resultado un cambio inmediato en la actividad electromiográfica, con el
consiguiente incremento en la activación muscular a nivel de músculo trapecio,
musculatura espinal, músculo longísimo y musculatura intertransversa en individuos
asintomáticos.133,134 Se podrían establecer indicios de que las mejoras en el dolor cervical
después de la manipulación de la columna cervical y torácica, pueden estar parcialmente
atribuidas a cambios en los tejidos blandos, y de manera similar, al fenómeno observado
en la columna lumbar. Se ha documentado en la literatura, que un habito postural
inadecuado, a menudo produce dolor, desequilibrio muscular y restricciones en el
movimiento,22,23 estando demostrada la relación existente entre unos inadecuados
hábitos posturales y una disminución de la actividad muscular en trapecios. 135 Quizá el
músculo trapecio esté débil o inhibido en pacientes con dolor cervical, por lo tanto, la
manipulación de la columna cervical y torácica puede mejorar este desajuste y
contribuir a una remisión del dolor y mejora funcional.

23
 Janda132,136 describió un síndrome, denominado “síndrome cruzado superior”, en
el que los pacientes presentan una anteriorización crónica de la cabeza, dando como
resultado un acortamiento de los músculos pectoral mayor y menor, trapecio superior,
elevador de la escápula y del músculo esternocleidomastoideo. Estas restricciones de la
flexibilidad, están comúnmente asociadas a la combinación de la debilidad de los
músculos trapecio medio e inferior, serrato anterior, romboides y de los músculos
flexores cervicales profundos.24,132,136

Griegel-Morris et al109 demostraron que la severidad de la anteriorización

postural de la cabeza y el incremento de la cifosis torácica, están directamente
relacionadas con la incidencia de dolor interescapular. Raine y Twomey137 sugirieron
que estos déficit posturales podían dar como resultado una incongruencia en las
superficies articulares de las vértebras, conllevando a su vez, una distribución
inadecuada de las fuerzas a este nivel. El estrés postural crónico de estas articulaciones,
inhibe a la musculatura periarticular, dando como resultado que los músculos
antagonistas estén acortados y tensos.137

Se ha propuesto que la inhibición muscular puede darse como resultado de una

inflamación o lesión articular.138,139 La inhibición se define como la incapacidad para
producir un reclutamiento de las unidades motoras de un determinado grupo muscular
funcional, para que este pueda dar como resultado una contracción máxima
voluntaria.140-142 Algunos autores143-145 ponen de manifiesto la existencia de varios
patrones de inhibición muscular en pacientes con dolor lumbar. Grabiner et al 145
demostraron que los pacientes con dolor lumbar exhiben una reducción significativa de
la funcionalidad en la excitabilidad paraespinal, cuando se comparan con un grupo de
controles asintomáticos. Hodges y Richardson 144 demostraron un retraso significativo
en la contracción del músculo transverso abdominal durante los movimientos de la
extremidad superior en un grupo de pacientes con dolor lumbar. Hides et al 143
demostraron que existe una inhibición del segmento del músculo multífido en los
pacientes con dolor lumbar. Los autores de estos tres artículos mencionados
previamente, pronosticaron que, un determinado número de factores contribuyentes, que
incluirían la inflamación, dolor, estiramiento ligamentoso o irritación de los tejidos
capsulares y músculo-esqueléticos, puede haber causado la inhibición muscular.

24
 Varios estudios han demostrado que la inhibición muscular que ocurre en los
músculos cuádriceps e isquiotibiales, puede ser producida por una articulación en
disfunción, en individuos que presentan artrosis incipiente de la rodilla, incluso sin que
exista la presencia de dolor o inflamación articular. 139,146 La patología articular, en
ausencia de dolor, puede potencialmente inhibir la actividad muscular, dando como
resultado una reducción de la fuerza del músculo. 138 Un mecanismo neurofisiológico
posible, para esta inhibición muscular, es la aferencia anormal de los receptores
articulares que están sensibilizados en la articulación disfuncional, produciendo una
inhibición de los músculos que cruzan dicha articulación. 139 La idea de que la inhibición
muscular de origen articular puede impedir significativamente la restauración de la
fuerza muscular y la recuperación funcional, debería ser reconocida, dentro del ámbito
clínico.

Varios estudios140,141,147 han investigado los efectos sobre la musculatura de las

extremidades, utilizando técnicas manipulativas espinales. Suter et al 140,141 demostraron
que la disfunción sacroilíaca está directamente relacionada con la inhibición de la
musculatura del músculo cuádriceps. Los autores pensaron, que este hecho pudo ser
debido a que la musculatura pertenecía al mismo segmento metamérico de la
articulación sacroilíaca (L2 – S2), también suplementados por la inervación del
cuádriceps (nervio femoral). La manipulación de la articulación sacroilíaca de estos
pacientes da como resultado una reducción significativa de la inhibición muscular
inmediatamente después de la aplicación de la técnica. En un ensayo randomizado,
Cibulka et al147 demostraron que los sujetos con alteraciones de la musculatura
isquiotibial, tenían relación directa con la disfunción sacroilíaca.

De manera especifica con la temática de este trabajo y en relación con los

cambios descritos previamente en diferentes estructuras musculoesquleticas, a menudo
envueltas en la aparición de dolor musculoesquelético; Suter y McMorldan 142
demostraron que la musculatura del bíceps branquial esta inhibida cuando existe dolor
cervical crónico. La inhibición fue reducida significativamente inmediatamente después
de la manipulación cervical a nivel de C5-C6-C7.142 Muchos autores han teorizado, que
la manipulación de la columna aplicada en forma de técnicas de alta velocidad y baja
amplitud, puede activar los mecanoreceptores alrededor de la articulación manipulada.
Estos cambios en el input sensorial pueden dar como resultado la restauración de la

25
funcionalidad de los músculos, pudiendo ser medida a través de la reducción de la
inhibición y el incremento de la fuerza.146

Quizá uno de los elementos de mayor relevancia de este trabajo, sean los estudios 149-151
en los que se han demostrado los efectos beneficiosos de la movilización de las
articulaciones en la fuerza de los músculos, estando en consonancia con estos autores,
en que las técnicas de movilización dirigidas a la disfunción de las estructuras
articulares, pueden servir para facilitar el proceso de rehabilitación.

Se cree que las movilizaciones de las articulaciones modifican el patrón de

activación de los mecanoreceptores, dando como resultado una reducción de la
inhibición neural, facilitando la activación de la musculatura implicada en la aparición
de estos síntomas, y consecuentemente, incrementando la posibilidad de reclutamiento y
por tanto de fuerza muscular en la región manipulada. 150,151 Una articulación
disfuncional, produce una información aferente que da lugar a una inhibición muscular
de origen articular, esta inhibición muscular da lugar a una reducción de la descarga
motora en los músculos que cruzan la articulación. 139 Sin embargo, incluso ante la
ausencia de dolor, dicha inhibición de origen articular, puede dar como resultado una
debilidad muscular.138 Se cree que el incremento en la fuerza puede estar relacionada
por una reducción de la inhibición de origen articular ocasionada por los impulsos
aferentes, desencadenados por la manipulación de las articulaciones que se encuentran
en disfunción. Se entiende que esta inhibición muscular artrogénica puede impedir
significativamente la restauración de la fuerza muscular, por lo cual, esto tiene que ser
considerado, con el fin de conseguir una rehabilitación efectiva de los pacientes. 138,138
Clínicamente esto podría sugerir que el método más efectivo para conseguir una mejora
de la fuerza, consistiría en eliminar la inhibición muscular de origen articular mediante
la manipulación, y posteriormente, llevar a cabo la instalación de un programa de
mejora del control motor y desarrollo de la fuerza en la región afectada.

4.4.2. Sobre el control motor en la unión Cervicotorácica.

Aunque el mecanismo exacto por el cual la manipulación reduce el espasmo e

incrementa la fuerza, aún no ha sido clarificado, los investigadores han informado que
existen cambios en la actividad eléctrica muscular,152 y una reducción del espasmo

26
muscular reflejo.153 A través de la manipulación, podemos producir un impacto en la
musculatura que esta relacionada directamente con estas áreas, o que tiene también un
punto de origen en la región a manipular. Está contrastado y estudiado, que existe un
número de músculos que están unidos a los segmentos cervical y torácico. 154 También
está clarificado que en ambos grupos de pacientes con dolor cervical crónico y trastorno
asociado a latigazo cervical, muchos de estos músculos exhiben una reducción de la
fuerza y resistencia.155-163

Es posible que el desequilibrio muscular pueda dar como resultado una

alteración postural,136 produciendo un estrés excesivo sobre la columna cervical, el cual
puede afectar a estructuras relacionadas directamente con el dolor cervical.

Por tanto, la manipulación espinal es un procedimiento fisioterapéutico con un

amplio marco conceptual, y con una corta pero densa trayectoria, como foco de interés
en la investigación en Fisioterapia. A la vista de todos sus posibles mecanismos de
acción dentro de la cervicalgia crónica, sería interesante evaluar el perfil de los
pacientes que se verían especialmente beneficiados con la aplicación de la manipulación
vertebral. La obtención de dicho perfil reduciría la aplicación indiscriminada de
recursos terapéuticos en estos síntomas discapacitantes, facilitando la disminución del
coste sanitario derivado del tratamiento de la cervicalgia.

27
5. Reglas de predicción clínica en Fisioterapia (RPC).

Los terapeutas que utilizan frecuentemente la manipulación de columna cervical,

dorso-cervical y dorsal como parte de sus tratamientos, tienen la noción de que algunos
pacientes con este tipo de dolor en la región cervical, responden de forma drástica y
rápida, mientras que otros experimentan poca o ninguna mejoría. Los cambios que los
terapeutas están apreciando en la respuesta a estas técnicas, es muy dependiente de las
características individuales de cada paciente. Ningún sistema de clasificación es, en
última instancia, una prueba diagnóstica. Cada proceso diagnóstico está compuesto por
muchos procedimientos diagnósticos individuales, diseñados para obtener una fiabilidad
y reproductividad, asignando así, una etiqueta diagnóstica a cada paciente, con el
objetivo de mejorar el proceso decisorio en lo que concierne a la determinación de la
intervención más eficaz. Existen guías de práctica clínica para el tratamiento de
pacientes con dolor cervical, que se basan en los resultados de las reglas de predicción
168
clínica, y existen pocas evidencias que den soporte al uso de la manipulación
cervical, cervico-dorsal y torácica, en los pacientes con dolor cervical. Sin embargo, la
guía de prácticas clínicas y los resultados de los ensayos clínicos randomizados, están
diseñados para mejorar la toma de decisiones de un grupo de pacientes con dolor
169
cervical. Los terapeutas obviamente, no tratan grupos de pacientes, por lo tanto, las
guías de prácticas clínicas y los resultados derivados de los ensayos clínicos
randomizados, no son los sistemas ideales para ayudar al clínico en la práctica diaria,
para decidir si un determinado paciente con un dolor específico de cuello puede
beneficiarse de una intervención concreta.

La RPC es una herramienta que puede ser utilizada por el clínico para resolver
este tipo de dilemas.170,171 La propuesta de una RPC es mejorar la seguridad del terapeuta
a la hora de predecir y diagnosticar los resultados derivados de una determinada
intervención.170,171 Existen varias RPC como por ejemplo: mejora de la fiabilidad en el
diagnóstico de las fracturas de tobillo en individuos con lesiones agudas de tobillo, 172 la
predicción de probabilidad de muerte dentro de los cuatro años para individuos con
enfermedad coronaria,173 y la determinación de cuando una radiografía cervical es
174
necesaria para los pacientes que han experimentado un traumatismo cervical. El
proceso para el desarrollo y valoración de una RPC ha sido descrito en distintas
170,171
referencias bibliográficas. Aunque las RPC han sido desarrolladas para mejorar la
fiabilidad de ciertos diagnósticos, la importancia de parte de este estudio en el que

28
desarrollamos una RPC con el objetivo de predecir el resultado de un tratamiento
determinado, es original por nuestra parte. El desarrollo de una RPC utiliza propiedades
diagnósticas de sensibilidad, especificidad, valor predictivo positivo y valor predictivo
negativo, bajo la base de los pacientes individuales. Por lo tanto su interpretación estará
aplicada y dirigida a los individuos, no a los grupos de pacientes.

170,171
El primer paso en el desarrollo de una RPC es la creación de una regla.
Esto requiere que el investigador examine la capacidad de múltiples factores, derivados
de la historia y el examen clínico para predecir un resultado de interés. El resultado de
interés sirve como la referencia estándar o “Gold Standard” por el cual se considera un
éxito el tratamiento. Todos los posibles factores que se puedan creer relacionados con el
resultado de interés, deberán ser incluidos como potenciales factores predictivos. Estos
factores predictivos pueden ser seleccionados desde la literatura, por la experiencia
previa experimentada en el trabajo, o bien desde la experiencia de investigadores
clínicos. Una vez que se establecen las variables predictoras, los sujetos son expuestos
al tratamiento de interés, posteriormente son evaluados según si el resultado es éxito o,
por el contrario, no éxito, comparándolo con el estándar de referencia, basado éste en la
puntuación predeterminada de corte, y que es clínicamente relevante. Aunque otras
técnicas podrían ser útiles, la regresión logística, es el elemento estadístico comúnmente
utilizado para la determinación de las variables predictivas de mayor potencia, y para
maximizar la fiabilidad de este valor predictivo.170,171

La RPC ha demostrado un gran potencial para obtener relevancia clínica dentro

de la práctica, siendo una herramienta que está basada en la evidencia, y sirve a los
clínicos en la identificación de subgrupos relevantes de pacientes. Sin la capacidad de
asociar determinadas intervenciones a determinados grupos de pacientes, los clínicos no
tendrán un aporte basado en la evidencia, en su proceso de toma de decisiones. El
desarrollo de una RPC para predecir de forma efectiva, que pacientes experimentarán
una mayor mejora clínica en el dolor y la función a través de la manipulación de
columna cervical, charnela cérvico-dorsal y columna dorsal, puede ser en sí misma
bastante útil para los terapeutas en el proceso de toma de decisiones. Si los pacientes
que se benefician de las manipulaciones, pueden ser identificados de manera sencilla a
través de la historia y el examen físico, los fisioterapeutas podrán utilizar las
manipulaciones de columna cervical, charnela cérvico-dorsal y columna dorsal con una
mayor probabilidad de éxito en este tipo de pacientes. El criterio de la RPC puede ser

29
utilizado en el futuro en ensayos clínicos, mejorando así la capacidad de las
investigaciones clínicas, durante los estudios que valoren la respuesta de los pacientes
con dolor cervical. Por lo tanto, uno de los objetivos principales de este trabajo de tesis
doctoral consiste en la propuesta una RPC para identificar pacientes con dolor cervical
sean capaces de experimentar una mejora sustancial en un periodo corto de tiempo.

5.1 Manipulación espinal de la columna cervical y de la charnela Cérvico-dorsal.

La Guía para la Práctica de la Fisioterapia, 57 identifica, que la manipulación y la

movilización son intervenciones apropiadas para el tratamiento de los pacientes con
alteraciones de la columna vertebral, y evidencian que diferentes ensayos clínicos
randomizados y revisiones sistemáticas, garantizan la efectividad de esta intervención
para pacientes con dolor cervical.30,51,67,70,71,175,176

Varios estudios han demostrado la eficacia de la manipulación cervical 59,64,68 y

torácica62,63 para el tratamiento del dolor cervical; existiendo controversia en relación a
la efectividad con respecto a la utilización de otras técnicas de fisioterapia 57. Estos
desacuerdos pueden ser atribuidos a la heterogeneidad del dolor mecánico cervical, por
lo que en la práctica clínica no todos los pacientes se pueden beneficiar de la misma
intervención terapéutica. 65

6. Vendaje Neuromuscular con KinesioTaping ®

Algunos pacientes no pueden recibir procedimientos basados en la manipulación

vertebral de alta velocidad por presentar alguna de las contraindicaciones que estas
tienen, por lo que es importante el tener alternativas terapéuticas que puedan ser
aplicadas en estos pacientes con dolor cervical, y que no conlleven riesgo potencial para
su salud.

Una técnica que está en auge y muy utilizada en los últimos tiempos por la
fisioterapia para el tratamiento del dolor es el KinesioTaping ®, siendo el campo de las
lesiones deportivas donde está teniendo un mayor éxito de aplicación. 177 Dentro de los
beneficios obtenidos se encuentran la mejora del dolor, disminución o aumento del tono
muscular, mejora del sistema linfático y arterio-venoso, todo ello en función de la forma

30
de aplicación.177-182 El KinesioTaping ® es una técnica desarrollada en los años 70,
compuesta por un material adhesivo flexible y que se diferencia de la cinta clásica en
sus características físicas. Es muy fino y puede ser estirado hasta el 120-140 % de su
original182 longitud que lo hace más elástico que la cinta convencional.

Es cierto que su eficacia no esta muy estudiada desde el punto de vista científico.
Unos artículos publicados nos proporcionan pruebas preliminares de que el Kinesio
Taping ® puede ser beneficioso en el tratamiento del dolor agudo de la rótula, 180
tobillo,179 tronco,178 y dolor miofascial.183 Más recientemente ensayos clínicos aleatorios
han demostrado que el Kinesio Taping ® puede ser eficaz para el tratamiento de
hombro184 y el latigazo cervical185 mejorando el rango de movimiento y el dolor. En
pacientes con dolor de hombro, el Kinesio Taping ® mejoró inmediatamente el rango de
movimiento activo, pero no hubo cambios en el dolor. 184 Sin embargo, hasta el
momento ningún estudio evaluó los efectos del Kinesio Taping ® en pacientes con el
dolor mecánico cervical.

7. Planteamiento del Problema.

La cervicalgia crónica de origen mecánico es un problema de salud altamente

prevalente en nuestra sociedad cuyo coste sociosanitario no es asumible en la actual
situación económica. El paciente con cervicalgia crónica sufre un proceso autolimitado
de discapacidad y pérdida de función que le anima a la demanda de cuidados por parte
del fisioterapeuta para favorecer la rápida reincorporación laboral, así como, la
eliminación de los síntomas para una mejora de su calidad de vida.

La fisioterapia presenta un amplio arsenal terapéutico frente a la cervicalgia

crónica que ha sido utilizado sin el adecuado refrendo de la investigación, empleando a
veces diferentes procedimientos para aliviar los síntomas sin conocer realmente la
supremacía de uno sobre otros, o la especificidad terapéutica ante determinado tipo de
pacientes.

Las nuevas tendencias en la Fisioterapia necesitan de la aparición de estudios

que puedan manifestar las posibles diferencias entre distintos procedimientos
terapéuticos como la manipulación espinal o el Kinesio Taping. La evolución de una
disciplina joven como la fisioterapia exige de la puesta en marcha de estudios de

31
efectividad interna en aquellos casos donde el procedimiento haya sido implantado de
forma empírica en la práctica clínica, como es el caso del kinesio Taping. En el caso de
procedimientos de amplia trayectoria como la manipulación espinal, se hacen necesarios
estudios de eficacia comparativa con el objeto de dilucidar cual es el procedimiento con
mayor potencia terapéutica ante un problema de salud específico como la cervicalgia
mecánica crónica. Finalmente, el desarrollo de una RPC sobre manipulación espinal
puede facilitar la labor del fisioterapeuta asumiendo el uso de este procedimiento en
aquellos pacientes especialmente proclives a mejorar con esta maniobra terapéutica, de
forma que la fisioterapia pueda optimizar su capacidad y reducir su ineficacia,
especialmente en patologías de un alto interés social como la cervicalgia crónica.

32
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51
OBJETIVOS.

GENERAL

Analizar la eficacia de la terapia manipulativa y el kinesio taping en la cervicalgia

crónica del origen mecánico.

ESPECIFICOS:

 Desarrollar una regla de predicción clínica, basada en un grupo de signos y

síntomas derivados de la historia y del examen físico, e identificar aquellos
pacientes con dolor mecánico cervical capaces de beneficiarse de un
protocolo de manipulación de la columna cervico-dorsal.

 Conocer la eficacia comparativa sobre el dolor mecánico cervical crónico

mediante la manipulación aislada cervical respecto a la manipulación
combinada cervico-dorsal sobre el rango de movimiento articular y el dolor
percibido por el paciente.

 Comparar la eficacia de la técnica de Kinesio taping® y manipulación

cervical semidirecta a nivel de C3 y C7-T1, sobre el rango de movimiento
articular de la columna cervical, así como, los cambios en la sintomatología
dolorosa en un grupo de pacientes con cervicalgia crónica.

 Evaluar las relaciones entre intensidad de dolor, desequilibrio funcional y

conductas de evitación al movimiento relacionadas con el dolor mecánico
cervical crónico mediante terapia manipulativa espinal y kinesio taping.

52
MATERIAL Y MÉTODOS.

En las tablas 1, 2, 3 y 4 se muestra el Material y los Métodos utilizados en los diferentes

artículos que constituyen la presente memoria de Tesis.

Tabla 1. Tabla resumen del material y métodos utilizados en el artículo I.

ARTÍCULO DISEÑO SUJETOS INTERVENCIÓN VARIABLES METODO

DEL
ESTUDIO

I. Predictors for Estudio 81 sujetos con dolor Manipulación 103 Variables:

Identifying Patients with Prospectivo mecánico cervical. Espinal (Thrust):
- Diagrama Corporal de - Cuestionario del
Mechanical Neck Pain Simple. - Técnica Localizacion de Dolor McGill.
who are Likely to Manipulativa en Síntomas.
Achieve Short-term Columna Cervical - 11 Puntos de la
Alta, Charnela - Escala Numérica de Escala (NPRS).
Success with Rango de Dolor.
Cérvico-Dorsal y
Manipulative Columna Cervical - Cuestionario
Interventions Directed Media. - Índice Numérico de Discapacidad
Discapacidad. Cervical (NDI).
at the Cervical and
- Periodo entre
Thoracic Spine. sesiones: 2-4 días. - Escala de - Versión Reducida
Kinesiofobia de Tampa de la Escala de
(TSK). Kinesiofobia de
Tampa (TSK-11).
- Historia Clínica:
naturaleza del dolor, - Cuestionario con 6
factores agravantes y Dominios.
factores que mejoran el
dolor, examen físico, - Goniómetro
test neurológicos y Estándar.
examen postural.
- Examen Bilateral.
- Rango de Movimiento
Cervical . - Test de Spring C2-
T9.
- Rotación Activa
Torácica. - Test de Distracción
Cervical, Test de
- Movilidad Articular y Spurling y Test
Respuesta Sintomática Neurodinámico de
en Movilidad Articular Miembro Superior.

- Examen Específico de - Cuestionario para

Dolor Cervical y Cambio de Rango
Radiculopatía. Global (GROC).

- Cambio de Rango
Global.

53
Tabla 2. Tabla resumen del material y métodos utilizados en el artículo II.

ARTÍCULO DISEÑO DEL SUJETOS INTERVENCIÓN VARIABLES METODO

ESTUDIO

II. Short-term effects of Ensayo Clínico 80 sujetos con dolor Manipulación Espinal 4 Variables:
kinesio Taping Versus Randomizado. mecánico cervical: (Thrust):
Cervical Thrust - Escala - 11 Puntos
Manipulacion in - Grupo Técnicas de - Técnica de Thrust en Numérica de de la Escala
Patients with Manipulación Columna Cervical Rango de (NPRS).
Mechanical Neck Pain: Espinal (n= 40). Media y Charnela Dolor.
A Randomized Clinical Cérvico- Dorsal. - Cuestionario
Trial. – Grupo Kinesio - Índice Discapacidad
Taping (n= 40). - Vendaje Numérico de Cervical
Neuromuscular Discapacidad. (NDI).
(Kinesio Taping):
Técnica de Aplicación - Diagrama - Cuestionario
en “Y” sobre Corporal de del Dolor
musculatura extensora Localizacion McGill.
cervical (T1- C1), y de Síntomas.
segunda tira de forma - Goniómetro
perpendicular en - Rango de Estándar.
región C3-C6. Movimiento
Cervical
(CROM).

54
Tabla 3. Tabla resumen del material y métodos utilizados en el artículo III.

ARTÍCULO DISEÑO DEL SUJETOS INTERVENCIÓN VARIABLES METODO

ESTUDIO

III. Short-term Ensayo Clínico 82 sujetos con Dolor Manipulación 3 Variables:

Effects of Spinal Randomizado. Mecánico Cervical: Espinal (Thrust):
- Escala - 11 Puntos de la Escala
Thrust Joint - Una Intervención - Técnica de Thrust Numérica de (NPRS).
Manipulation in Manipulativa Cervical en Columna Rango de
Patients with (n=41). Cervical Media. Dolor. - Cuestionario
Discapacidad Cervical
Chronic Mechanical (NDI).
- Tres Intervenciones - Técnica de Thrust - Índice
Neck Pain: A Manipulativas Espinales en Columna Numérico de
Randomized Clinical (n=41). Torácica Alta, Discapacidad. - Goniómetro Estándar.

Trial. Charnela Cérvico-

Dorsal y Cervical - Rango de
Media. Movimiento
Cervical
(CROM).

55
Tabla 4. Tabla resumen del material y métodos utilizados en el artículo IV.

ARTÍCULO DISEÑO DEL SUJETOS INTERVENCIÓN VARIABLES METODO

ESTUDIO

IV. Pain Intensity, Estudio 120 Sujetos con Dolor Sin Intervención 4 Variables:
physical impairment Mecánico Cervical (35
and pain-related fear Descrptivo Hombres y 85 Mujeres). - Variables - Cuestionario de 5
to function in patient Demográficas. Dimesiones.
with chronic
mechanical cervical - Intensidad del - 11 Puntos de la Escala
pain. Dolor. (NPRS).

- Escala de - Versión Reducida de

Kinesiofobia de la Escala de
Tampa (TSK). Kinesiofobia de Tampa
(TSK-11).

- Goniómetro Estándar.
- Rango de
Movimiento - Cuestionario
(ROM). Discapacidad Cervical
(NDI).
- Índice
Numérico de
Discapacidad.

56
RESULTADOS Y DISCUSIÓN

En los siguientes artículos publicados y/o sometidos se exponen tanto los resultados
como la discusión de los mismos.

57
 I. Predictors for Identifying Patients with Mechanical Neck Pain
Who Are Likely to Achieve Short-Term Success with Manipulative
Interventions Directed at Cervical Thoracic Spine.

Autores: Saavedra-Hernández M, Castro-Sánchez AM, Fernández-de-las-Peñas C,

Cleland J, Ortega-Santiago R, Arroyo-Morales M. J Manipulative Phys. 2011;
34(3)144-52.

58
ORIGINAL ARTICLES

PREDICTORS FOR IDENTIFYING PATIENTS WITH

MECHANICAL NECK PAIN WHO ARE LIKELY TO
ACHIEVE SHORT-TERM SUCCESS WITH
MANIPULATIVE INTERVENTIONS DIRECTED AT THE
CERVICAL AND THORACIC SPINE
Manuel Ssavedra-Hernández, PT,a Adelaida M. Castro-Sánchez, PT,
PhD,a César Fernández-de-las-Peñas, PT, DO, PhD,b Joshua A. Cleland,
PT, PhD,c Ricardo Ortega-Santiago, PT, MSc,b and Manuel Arroyo-
Morales, MD, PT, PhDd

ABSTRACT

Objective: The purpose of this study was to identify the prognostic factors for individuals with mechanical neck
pain likely to experience improvements in both pain and disability after the application of an intervention including
cervical and thoracic spine thrust manipulations.
Methods: Patients presenting with mechanical neck pain participated in a prospective single-arm trial. Participants
underwent a standardized examination and then received a series of thrust manipulations directed toward the cervical,
cervicothoracic, and thoracic spine. Participants were classified as having achieved a successful outcome at the second
and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise
logistic regression model to determine the most accurate set of variables for the prediction of treatment success.
Results: Data from 81 subjects were included in the analysis, of which 50 experienced a successful outcome
(61.7%). Five variables including pain intensity greater than 4.5 points; cervical extension less than 46°; presence of
hypomobility at T1; a negative upper limb tension test and female sex were identified. If 4 of 5 variables were present
(likelihood ratio, +1.9), the likelihood of success increased from 61.7% to 75.4%.
Conclusions: This study identified several prognostic clinical factors that can potentially identify, a priori, patients
with neck pain who are likely to experience a rapid response to the application of an intervention including both
cervical and thoracic spine manipulations. However, no combination of the variables was able to dramatically increase
the posttest probability. (J Manipulative Physiol Ther 2011;34:144-152)
Key Indexing Terms: Neck Pain; Manipulation; Cervical Spine; Thoracic Spine

a
Professor, Department of Nursing and Physical Therapy,
Universidad de Almería, Spain. 144
b
Professor, Department of Physical Therapy, Occupational
Therapy, Physical Medicine and Rehabilitation, Universidad
Rey Juan Carlos, Alcorcón, Spain.
c
Professor, Department of Physical Therapy, Franklin Pierce
University, Concord, NH.
d
Professor, Department of Physical Therapy. Health Sciences
School, Universidad Granada, Spain.
Submit request for reprints to: César Fernández-de-las-Peñas
PT, DO, PhD, Facultad de Ciencias de la Salud, Universidad
Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón,
Madrid, Spain (e-mail: cesar.fernandez@urjc.es).
Paper submitted November 2, 2010; in revised form February
2, 2011; accepted February 10, 2011.
0161-4754/$36.00
Copyright © 2011 by National University of Health Sciences.
doi:10.1016/j.jmpt.2011.02.011
 care problem in any country. It has been
reported that the lifetime and point prevalence
of neck pain
is almost as high as the prevalence of low back pain.1,2
The 1-year prevalence for neck pain has been reported to
range from 16.7% to 75.1%, with a mean of 37.2%. 1

M
echanical neck pain represents a significant
Neck pain continues to be a source of significant health
care expenditures.3
Spinal manipulation is a manual therapy technique
often used by different therapists for the management of
neck pain patients.4 Although several studies have
demonstrated the effectiveness of cervical5-7 and
thoracic8,9 manipulation for the management of neck
pain, there continue to remain controversy in relation to
their effectiveness over other interventions.4
Inconsistencies may be attributable to the fact that
mechanical neck pain is a heterogeneous pain
Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 3 Ssavedra-Hernández et al 145
Cervical and Thoracic Manipulation in Neck Pain

condition, and it is commonly seen in clinical practice that ulative therapy; or (6) evidence of any central nervous
not all patients with mechanical neck pain benefit from system involvement, or signs consistent with nerve root
the same intervention.10 compression. All subjects read and signed a consent form,
Recently, there have been a number of studies and this study was approved by the ethics board of the
identifying the prognostic variables to guide interventions Universidad de Granada.
for the management of low back pain, 11 tension-type
headache,12 ankle sprains,13 cervicogenic headache,14 and Examination Procedures
shoulder pain.15 Two of these studies purported to identify
The examination procedures were conducted in the
predictors for identifying patients with neck pain who will
identical fashion to a previous clinical prediction rule
benefit from either cervical16,17 or thoracic18 spine
derivation study for patients with neck pain. 18 Patients
manipulation. Six predictors including Neck Disability
provided demographic and clinical information and com-
Index (NDI) less than 11.5 points, bilateral symptoms, not
pleted different self-report measures at baseline, which
performing sedentary work more than 4.5 hours a day,
included a body diagram to assess the distribution of
feeling better moving the neck, neck extension does not
symptoms,21 a numeric pain rating scale (NPRS) for
aggravate the symptoms, and no diagnosis of
assessing the intensity of the pain, 22 NDI,23 and the
radiculopathy were identified for success cervical
Tampa Scale for Kinesiophobia (TSK).24
manipulation.16 Six variables were also identified for
Patients recorded the location of the symptoms on the
success of thoracic thrust manipulation; however, it has
body diagram to determine the most distal extent of their
recently been demonstrated that these variables were
symptoms. The body diagram has shown to be a reliable
simply spurious findings and did not predict prognosis. 19
method to localize the patient's pain symptoms.25 The
Furthermore, the results of this study suggest that patients
NPRS (range: 0, no pain; 10, maximum pain) was used to
with mechanical neck pain who do not exhibit
assess the mean spontaneous neck pain intensity. In fact,
contraindications should receive thoracic manipulation.
NPRS has shown to be reliable and valid for pain
However, simply using just cervical or thoracic
assessment.26
manipulation may not be representative of usual clinical
The NDI consist of 10 questions measured on a 6-point
practice, because therapists usually apply different
scale (0, no disability; 5, full disability). 23 The numeric
manipulative interventions for the management of neck
score for each item is summed for a total score varying
pain. Therefore, it would be of clinical utility to have
from 0 to 50, where higher scores reflect greater disability.
guidance in selecting patients with neck pain who may
The NDI has demonstrated to be a reliable and valid self-
experience improved outcomes after interventions includ-
assessment of disability in patients with neck pain. 27
ing cervical and thoracic spine manipulations. However, it
Finally, we used the 11-item TSK that assesses fear of
is not known if patients who are likely to have a favorable
movement or of injury or reinjury.24 Individuals rate each
outcome can be predicted in this patient population. Thus,
item on a 4-point Likert scale, with scoring alternatives
the purpose of the current study was to identify the
ranging from “strongly disagree” to “strongly agree.”
prognostic factors for patients with mechanical neck pain
Test-retest reliability is high.24
likely to experience improvements in both pain and
The clinical history included questions regarding the
disability after the application of an intervention including
onset, nature and location of symptoms, aggravating and
cervical and thoracic spine thrust manipulations.
relieving factors, and history of neck pain. The physical
examination began with a neurologic screen followed by
METHODS an assessment of the posture as previously described. 18
The clinician next measured the cervical range of motion
We conducted a prospective single-arm study of and symptoms response28 with a cervical range of motion
consecutive patients presenting with mechanical neck pain goniometer, which has shown intratester reliability between
who were referred for therapy at one clinical site in 0.87 and 0.96 in individuals with neck pain. 29 Symptom
Almeria, Spain. Inclusion criteria required patients to be response (no pain, increase, or decrease of pain) during
between the ages of 18 and 60 years, with a primary active rotation of the thoracic spine was also recorded. 30
complaint of mechanical neck pain with or without upper- The presence of joint mobility (normal, hypomobile, or
extremity symptoms. Mechanical neck pain was defined hypermobile) and symptoms response (pain or no pain)
as general- ized neck and/or shoulder pain provoked by were recorded for segmental mobility testing of the
neck postures, neck movement, or palpation of the neck cervical spine and for spring testing of the cervical and
muscles. Exclusion criteria were as follows: (1) any thoracic spine (C2-T9).31 The examination culminated
contraindication to spinal manipulation: positive with differ- ent tests performed in the examination of
extension-rotation test, infection, osteoporosis, or individuals with neck pain and cervical radiculopathy 32:
nystagmus; (2) history of cervical surgery or whiplash the Spurling test, the Neck Distraction Test, and Upper
injury; (3) medical diagnosis of cervical radiculopathy or Limb Neurodynamic Test. For the Upper Limb
myelopathy; (4) diagnosis of fibromyalgia20; (5) previous Neurodynamic Test, any of the following constitute a
treatment with spinal manip- positive test: (1) symptom
146 Ssavedra-Hernández et al Journal of Manipulative and Physiological Therapeutics
Cervical and Thoracic Manipulation in Neck Pain March/April 2011

reproduction, (2) a difference less than 10° in between

limbs in elbow extension at the end of the test, and (3) an
increase in symptoms with contralateral cervical side
bending or decrease symptoms with ipsilateral side
bending.32 A total of 103 clinical variables were collected
during the examination. This clinical examination has
been previously used in different studies attempting to
identify potential predictors of prognosis.15,18

Spinal Manipulation Intervention

Because treatment outcome served as the reference
criterion,33 all patients received, on each session, 3 thrust
manipulation techniques targeted at the midcervical spine,
cervicothoracic junction, and upper thoracic spine region.
Because we wanted to mimic the commonly clinical
practice for the management of patients with neck pain,
clinicians choose the level of spinal thrust manipulation in
the cervical and thoracic spine based on the clinical
findings. The clinical finding criteria for application of
spinal manipulation were the presence of hypomobility
(abnormal end-feel and increased tissue resistance) com-
bined with pain provocation during the test. The 3
techniques took less than 5 minutes and were conducted
as follows34:

1. Upper thoracic spine “distraction” manipulation:

patients were supine with the arms crossed over the
chest and hands passed over the shoulders. The therapist
placed their upper chest at the level of the patient's Fig 1. Upper thoracic spine “distraction” manipulation.
middle thoracic spine and grasped the patient's
elbows. Gentle flexion of the thoracic spine was
The index finger of the therapist applied contact over
introduced until slight tension was felt in the tissues
the posterior-lateral aspect of the zygapophyseal
at the contact point. Then, a distraction thrust mani-
joint of C3. The therapist cradled the patient's head
pulation in an upward direction was applied (Fig 1).
with the other hand. Gentle ipsilateral side flexion
If no popping sound was heard on the first attempt,
and contralateral rotation to the targeted side is
the therapist repositioned the patient, and performed
introduced until slight tension was perceived in the
a second manipulation. A maximum of 2 attempts
tissues at the contact point (Fig 3). A high-velocity
were performed on each patient.
low-amplitude thrust manipulation was directed
2. Cervicothoracic junction manipulation: this technique
upward and medially in the direction of the subject's
was applied bilaterally. Here we describe the
contralateral eye. Again, a maximum of 2 attempts
procedure for a right C7-T1 manipulation; that is,
were performed.
the contact was on the right side of the
cervicothoracic junction. The patient was prone with
the head and neck rotated to the left. The therapist The first treatment was always performed on the day of
stands on the left side of the patient facing cephalic. the initial examination, and the patients were scheduled
The therapist's right hand makes contact with the for a follow-up visit within 2 to 4 days. At the start of the
thumb on the right side of the spinous process of T1. second session, subjects completed the Global Rating of
The therapist's left hand supports the head of the Change (GROC), NDI, and NPRS and were judged to
patient. The head/neck is gently laterally flexed to have a successful or nonsuccessful outcome (see the
the right, until slight tension is palpated in the following section). If the subject did not meet the threshold
tissues. A high-velocity low- amplitude thrust was for success at the second visit, a second treatment session
applied toward the subjects' left side (Fig 2). Again, was applied, and a second follow-up visit was scheduled.
a maximum of 2 attempts were performed for each At the third visit, they again completed the GROC, NDI,
side. and NPRS and were categorized accordingly. After the
3. Midcervical spine manipulation: the subject was third visit, their participation in the study was complete,
supine with the cervical spine in a neutral position. and treatment was administered at the discretion of their
therapist.
Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 3 Ssavedra-Hernández et al 147
Cervical and Thoracic Manipulation in Neck Pain

Fig 2. Cervicothoracic junction manipulation. Fig 3. Midcervical spine manipulation.

Determination of Success corner represented the value with the best diagnostic
The perceived improvement level was used as a accuracy, and this point was selected as the cutoff defining
reference criterion for establishing a successful outcome. a positive test.38 Sensitivity, specificity, and positive and
Patients self-perceived improvement was assessed using a negative likelihood ratios (LRs) were calculated for
GROC, which consists of a 15-point scale ranging from potential predictor variables. If there was an empty cell in
−7 (a very great deal worse) to +7 (a very great deal the 2 × 2 contingency table, a value of 0.5 was added to
better).35 Descriptors of worsening or improving were each cell to allow for calculations as described by
assigned with values ranging from −1 to −7 and +1 to Wainner et al.32 All potential predictor variables were
+7, respectively.36 It has been reported that scores of +4 entered into a stepwise logistic regression model to
and +5 are indicative of moderate changes in patient determine the most accurate set of predictor variables for
status, whereas scores of +6 and +7 indicate large changes treatment success. A significance level of P b .10 was
in the status of the patient. Therefore, in the current study, required for removal from the equation to minimize the
we consider responders those patients who reported a likelihood of excluding potentially helpful variables.38 The
GROC of a score of +5 or greater (“a very great deal variables retained in the regression model were obtained
better,” “a great deal better,” or “quite a bit better”). We set as the most optimal cluster for predicting individuals with
+5 as threshold for success because this score represents mechanical neck pain who are likely to have a successful
clinically meaningful improvements, and because of the outcome. The Hosmer- Lemeshow summary goodness-of-
short duration of this study, it would be likely that the fit statistic was used to assess the fit of the model to the
clinical outcome would be attributable to the treatment data and tested the hypothesis that the model fit the data. 39
rather than the passage of time. All the analyses were performed with SPSS version 14.0
software (SPSS, Chicago, IL).
Data Analysis
Participants were dichotomized as either responders or
nonresponders based on the treatment response at either RESULTS
the time of the second or third visit as indicated by a score Between September 2009 and March 2010, 100
of +5 or greater on the GROC. Variables from self-report patients with a primary report of neck pain were screened
measures, the history, and clinical examination were for eligibility criteria. Eighty-one individuals (81%)
tested for univariate relationship with the reference satisfied the criteria for the study and agreed to
criteria using χ2 tests for categorical variables and participate. The number of patients screened, reasons for
independent t tests for continuous variables at the follow- ineligibility, and dropout can be seen in Figure 4. Patient
up. Any of the 103 variables with a significance level of P demographics and initial baseline variables from the
b .10 were retained as potential prediction variables.37 For history and self-report measures for the entire sample as
continuous variables with a significant univariate well as for both the responders and nonresponders groups
relationship, sensitivity and specificity values were can be found in Table 1. Categorical variables from the
calculated for all possible cutoff points and then plotted as clinical examination with a significant difference (P b .01)
a receiver operator characteristic curve. The point on the between responders
curve nearest the upper left-hand
148 Ssavedra-Hernández et al Journal of Manipulative and Physiological Therapeutics
Cervical and Thoracic Manipulation in Neck Pain March/April 2011

100 patients screened for Not eligible Contraindication to manipulation (n = 3)

eligibility criteria (n = 17) Previous whiplash (n = 7)
Previous treatment (n = 7)

Eligible (n = 83) Decline to participate (n = 2)

Agree to participate, sign

informed consent form,
and received treatment
(n = 81)

Responders (n = 50)

Immediate follow-up
(n = 81) Non-Responders (n = 31)

Fig 4. Flow diagram of subject recruitment and retention throughout the course of the study.

Table 1. Demographics, baseline self-report variables, and baseline characteristics of subjects

Variable All subjects (n = 81) Responders (n = 50) Nonresponders (n = 31) Significance
Age (y), mean (SD) 39.4 (9.2) 38.9 (4.1) 40.1 (9.0) .58 a
Sex: female, n (%) 55 (70) 38 (76) 17 (55) .08 ab, c
Duration of symptoms (d), median (SD) 1703.2 (1726.5) 1610.3 (1571.9) 1904.9 (1960.0) .47
NPRS, mean (SD) 4.8 (1.7) 5.2 (1.6) 4.3 (1.8) .03 a, c
NDI, mean (SD) 14.2 (5.2) 15.0 (4.9) 13.1 (5.4) .095 a, c
TSK, mean (SD) 24.2 (7.2) 24.7 (7.3) 23.4 (7.2) .44 a
Cervical range of motion:
Flexion degrees, mean (SD) 53.4 (10.5) 54.5 (10.9) 51.5 (9.8) .21 a
Extension degrees, mean (SD) 49.0 (10.2) 47.2 (10.1) 51.5 (9.9) .066 a, c
Side-bending right degrees, mean (SD) 37.7 (7.3) 37.9 (7.1) 37.3 (7.6) .71 a
Side-bending left degrees, mean (SD) 38.8 (5.7) 39.1 (6.0) 38.1 (5.0) .47 a
Rotation right degrees mean (SD) 69.5 (11.2) 69.8 (11.3) 68.4 (10.7) .59 a
Rotation left degrees, mean (SD) 71.2 (11.5) 70.9 (10.4) 71.1 (12.1) .95 a
a
χ2 tests.
b
Independent samples t tests.
c
A cutoff of +5 of the GROC was used to categorize “improved.”

and nonresponders are summarized in Table 2. Fifty change score, 12.4%;

patients (61.7%) were categorized as responders, and the
remaining 31 (38%) as nonresponders. Thirty-three
subjects (40.2%) were classified as having a successful
outcome after the first session, and the remaining 17
(21.5%) were classified as having a successful outcome
after 2 sessions. The analysis of the change scores
revealed that the responder group exhibited significantly
greater improve- ments (P b .001) in pain (NPRS
change score, 3.1; 95% confidence interval [CI], 2.4-
3.8) and disability (NDI change score, 43.7%; 95%
CI, 31.8-55.70) as compared with the nonresponder
group (NPRS change score, 1.1; 95% CI, 0.8-1.9; NDI
95% CI, 2.3-23.2). tension test (ULTT), and female sex (P b .001, Nagelkerke
 Eight potential variables for predicting prognosis at
the follow-up were identified and entered into the
logistic regression (Table 3). The cutoff for continuous
variables as identified by the receiver operator
characteristic curves were pain intensity greater than
4.5 points and cervical extension less than 46°.
Sensitivity, specificity, and positive LR (and 95% CI) for
all 8 variables can be found in Table 3. The positive LR
ranged from 1.4 to 2.7, with the strongest predictor being
the presence of hypomobility at T1 vertebra. Of these 8
variables, 5 were retained in the final regression
model for predicting outcome: pain intensity greater
than 4.5 points; cervical extension less than 46°;
presence of hypomobility at T1; a negative upper
limb

95% CI, 2.3-23.2). tension test (ULTT), and female sex (P b .001, Nagelkerke
Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 3 Ssavedra-Hernández et al 149
Cervical and Thoracic Manipulation in Neck Pain

Table 2. Categorical variables from the baseline clinical examination with a significant difference (P b .10) between responders
and nonresponders
Variable All subjects (n = 81) Responders (n = 50) Nonresponders (n = 31) Significance (χ2)
Shoulder protraction (%) 66 (81.4) 44 (88) 22 (71) .08
Atlanto-axial joint mobility hypomobile (%) 25 (30.9) 19 (37.3) 6 (19.4) .09
Hypomobility T1 (%) 16 (19.7) 13 (26) 3 (9.7) .09
Sex: female (%) 55 (67.9) 38 (76) 17 (54.8) .08
ULTT negative (%) 46 (56.8) 33 (66) 13 (41.9) .04

Table 3. Accuracy statistics with 95% CIs for individual predictor variables
Variable Sensitivity (95% CI) Specificity (95% CI) Positive LR (95% CI) Probability of success (%)
Pain N4.5 0.66 (0.51-0.78) 0.55 (0.36-0.72) 1.4 (0.95-2.6) 69.3
Extension range of motion less than 46 0.44 (0.30-0.59) 0.74 (0.55-0.87) 1.7 (0.87-3.3) 73.3
Hypomobility T1 0.26 (0.15-0.41) 0.90 (0.73-0.97) 2.7 (0.83-8.7) 81.3
ULTT negative 0.66 (0.51-0.78) 0.58 (0.39-0.75) 1.6 (0.99-2.5) 72
Sex: female 0.77 (0.63-0.88) 0.43 (0.26-0.62) 1.4 (0.97-1.9) 69.3
Pain with mobility testing of Atlanto-axial joint 0.38 (0.25-0.53) 0.81 (0.62-0.92) 2.0 (0.88-4.4) 76.3
Neck disability N13 0.60 (0.45-0.73) 0.55 (0.36-0.72) 1.3 (0.85-2.1) 67.7
Shoulder protraction 0.88 (0.75-0.95) 0.29 (0.15-0.48) 1.2 (0.97-1.6) 65.9
The probability of success is calculated using the positive LRs and assumes a pretest probability of 61.7%.

Table 4. Combination of predictor variables and associated accuracy statistics with 95% CIs
• Pain greater than 4.5
• Extension range of motion less than 46
• Hypomobility T1
• ULTT negative
• Sex: female
No. of predictor variables present Satisfied Did Not Satisfy Sensitivity Specificity Positive LR Probability of success (%)
5+ 1 80 0.29 (0.03-0.13) 0.98 (0.91-0.99) 1.9 (0.08-44.8) 75.37 a
4+ 6 75 0.12 (0.05-0.25) 0.94 (0.77-0.99) 1.9 (0.40-8.6) 75.4
3+ 26 55 0.52 (0.38-0.66) 0.65 (0.45-0.80) 1.5 (0.85-2.5) 70.7
2+ 42 39 0.84 (0.70-0.92) 0.29 (0.15-0.48) 1.2 (0.92-1.5) 66
1+ 48 33 0.96 (0.85-0.99) 0.16 (0.06-0.34) 1.1 (0.97-1.3) 63.9
The probability of success is calculated using the positive LRs and assumes a pretest probability of 61.7%. Accuracy statistics with 95% CIs for individual
variables for predicting success.
a
Added 0.05 to each cell of the 2 × 2 table to account for an empty cell according to the guidelines of Wainner et al.39

R2 = 0.38). The results of the Hosmer-Lemeshow test 1.9 (95% CI, 0.40-8.6), and the posttest probability was
indicated that the model adequately fit the data (P = .38). 75.4%. If all the variables were present, we needed to add 0.5 to
These 5 variables were used to form a combination of each cell in the 2 × 2 table, which resulted in a LR+ of 1.9
predictors for identifying patients with mechanical neck
pain likely to benefit from spinal manipulation.
Sensitivity, specificity, and positive LR (and 95% CI)
were calculated for the numbers of variables present
(Table 4).
The pretest probability for a favorable outcome was
61.7%. If 1 of the 5 variables was present, the posttest
pro- bability was 63.9% (LR+, 1.1; 95% CI, 0.97-1.3). If 2
of the 5 variables were present, then the posttest probability
increased to 66% (LR+, 1.2; 95% CI, 0.92-1.5). If 3
variables were
present, the posttest probability was 70.7% (LR+, 1.5;
95% CI, 0.85-2.5). If 4 of 5 variables were present, the
LR+ was
and a posttest probability of 75.4%. of success.
DISCUSSION
We have attempted to identify prognostic clinical
factors that may potentially identify, a priori, patients
with mechanical neck pain who are likely to
experience a rapid response after the application of a
therapy intervention including cervical and thoracic
spine thrust manipulations. Five variables including
pain intensity greater than 4.5 points, cervical
extension less than 46°, hypomobility at T1 vertebra, a
negative ULTT, and female sex were identified. If 4
of 5 variables were present (LR+, 1.9), the likelihood
of success increased from 61.7% to 75.4%. If all the
variables were present, the +LR was 1.9 and the
posttest probability remained consistent at 75.4%.
Although we identified variables that may have
plausibly been predicted, no parsimonious sub- set of
them could substantially raise the posttest probability

and a posttest probability of 75.4%. of success.

150 Ssavedra-Hernández et al Journal of Manipulative and Physiological Therapeutics
Cervical and Thoracic Manipulation in Neck Pain March/April 2011

The identified variables posed at least a degree of face suggested for widespread clinical application. In fact, it has
validity. The high pain score may have fallen out as a been stated that single-arm clinical prediction rules are
predictor because it could plausibly be that those folks vulnerable to a regression effect, where the variables
who have a more severe pain may have room for entered into the logistic regression may have
quicker improvements with the appropriate intervention or
sponta- neous recovery, or it could simply be that patients
with a higher intensity of pain are more likely to
recover.40 Restricted cervical extension would
theoretically make sense as patients with neck pain
often exhibit impaired biomechanics of the
cervicothoracic (C7-T1) region.41-43 This would also
lend credibility for the hypomobility identified at T1,
which has historically been used as a method to
identify patients who should receive thrust
manipulation.31 In addition, we cannot exclude the
neurophysiologic mechanisms of spinal manipulation.44
In fact, it has been reported that C7-T1 manipulation
induced hypoalgesic effects, that is, an increase in
pressure pain thresholds in the cervical spine in healthy
subjects.45 A negative ULTT suggests that the patients
in this study likely present without neurogenic symptoms,
which may render them more likely to recover rapidly
then a group with neck and arm pain. This coincides
with the study by Tseng et al,16 who found that patients
without cervical radiculopathy had a better outcome with
cervical spine thrust manipulation. The reason why the
female sex was identified as a prognostic variable
remains a bit elusive. It has been demonstrated that sex
in itself is not a predictive factor of outcome46; however, it
has been also shown in other studies in patients with
whiplash associated disorders that male sex was a
predictor of
poor expectations for recovery.47
We did not identify a subset of factors likely to identify
prognosis in this study; it might be that this subgroup of
patients cannot easily be identified. This would be in
agreement with the study of Cleland et al 19 that demon-
strated that the previously identified predictor variables
could not be identified. Given the rapid improvement
associated with manipulative techniques in the
management of patients with neck pain, we also agree that
given the minute risks and the obvious benefit, manual
techniques are likely beneficial for most patients with
neck pain.19

Limitations
There are some limitations to the current study. First,
the absence of a control group does not allow for
inferences to be made regarding cause and effect, so it
cannot be deter- mined if the rule predicted response to
treatment or simply identified patients with a good
prognosis. Future random- ized clinical trials are required
to validate the variables in the rule before it can be
resulted in overfitting of the model, which can lead to
spurious findings).48 However, in the development stages
of a possible clinical prediction rule, it is important and
necessary to include all potential predictor variables.
Nevertheless, as is the case with all statistical modeling,
the results presented here will require validation, which
can include performing the study on an independent
sample of patients.49 Therefore, these results should be
considered as a temporary and exploratory first analysis.
Second, we should recognize that we collected only
data for short-term outcomes and after 1 or 2 sessions of
treatment. Therefore, we do not know whether the
patients classified as responders were still doing well at a
longer- term follow-up, and if some patients classified as
nonresponders can be classified as having a successful
outcome with consecutive treatment sessions. Finally, it
is possible that our sample was small. Methods for
calculating sample size for multivariate analyses suggest
that studies need at least 50 subjects for the first
independent variable and 8 for each of the subsequent
ones, which would give a greater sample size of that one
included in the current study. Future studies are now
needed to elucidate these questions.

CONCLUSIONS
We have identified several potential prognostic
clinical factors including pain intensity greater than 4.5
points, cervical extension less than 46°, hypomobility of
T1 vertebra, a negative ULTT, and female sex that may
poten- tially identify, a priori, patients with mechanical
neck pain who are likely to have an overall good
prognosis. However, no combination of the variables
was able to dramatically increase the posttest
probability. Therefore, we would recommend the use of
manual therapy techniques in this pain patient population
considering the small inherent risks and likelihood of
benefit. Future studies should compare the effects of
thoracic and cervical spine manipulation in a patient
population with mechanical neck pain.
Practical Applications
• The current study identified several prognostic
clinical factors including pain intensity greater
than 4.5 points, cervical extension less than 46°,
hypomobility of T1 vertebra, a negative ULTT,
and female sex that may potentially identify
patients with mechanical neck pain who are likely
to experience a rapid and positive response to the
application of cervical and thoracic spine thrust
manipulations.
• If 4 of 5 variables were present (LR+, 1.9), the
likelihood of success increased from 61.7% to
86.3%.
• Future studies are necessary to examine the
validity of the predictive value of the prognostic
factors identified in this study.

resulted in overfitting of the model, which can lead to

Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 3 Ssavedra-Hernández et al 151
Cervical and Thoracic Manipulation in Neck Pain

FUNDING SOURCES AND POTENTIAL CONFLICTS OF therapy management of cervicogenic headache. Cephalalgia
INTEREST
No funding sources or conflicts of interest were
reported for this study.

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 II. Short-Term Effects of Kinesiotaping versus Cervical Thrust
Manipulation In Patients with Mechanical Neck Pain: a Randomized
Clinical Trial.

Autores: Saavedra-Hernández M, Castro-Sánchez AM, Arroyo-Morales M, Cleland J,

Lara-Palomo I, Fernández-de-las-Peñas C. JOSPT 2012. En prensa.

68
 Journal of Orthopaedic & Sports Physical Therapy

SHORT-TERM EFFECTS OF KINESIOTAPING VERSUS

CERVICAL THRUST MANIPULATION IN PATIENTS WITH
MECHANICAL NECK PAIN: A RANDOMIZED CLINICAL TRIAL

Review Copy
Journal: Journal of Orthopaedic & Sports Physical Therapy
Manuscript ID:
Manuscript Categories:
Draft
Research Report
Key Words: Cervical spine, neck pain, manipulation, clinical trial, Kinesiotaping

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Page 1 of 25 Journal of Orthopaedic & Sports Physical Therapy

TITLE PAGE

TITLE

SHORT-TERM EFFECTS OF KINESIOTAPING VERSUS CERVICAL THRUST

MANIPULATION IN PATIENTS WITH MECHANICAL NECK PAIN: A
RANDOMIZED CLINICAL TRIAL

AUTHORS

Manuel Saavedra-Hernández1 PT, MSc; Adelaida M. Castro-Sánchez 1 PT, PhD;

2 3,4,5
Manuel Arroyo-Morales MD, PT, PhD; Joshua A. Cleland PT, PhD; Inmaculada C.

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1 6,7
Lara-Palomo PT; César Fernández-de-las-Peñas PT, PhD

AFILIATIONS

1. Department of Nursing and Physical Therapy, Universidad de Almería, Spain

2. Department of Physical Therapy. Health Sciences School, Universidad Granada,
Spain
3. Department of Physical Therapy, Franklin Pierce University, Concord, NH,
USA
4. Physical Therapist, Rehabilitation Services, Concord Hospital, NH, USA
5. Faculty, Manual Therapy Fellowship Program, Regis University, Denver,
Colorado, USA
6. Department of Physical Therapy, Occupational Therapy, Physical Medicine and
Rehabilitation of Universidad Rey Juan Carlos, Alcorcón, Spain
7. Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorcón, Spain

Address for reprint requests / corresponding author.

César Fernández de las Peñas Telephone number: + 34 91 488 88 84

Facultad de Ciencias de la Salud
Universidad Rey Juan Carlos Fax number: + 34 91 488 89 57
Avenida de Atenas s/n
28922 Alcorcón, Madrid
SPAIN
Email address: cesar.fernandez@urjc.es

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Abstract

Design: Randomized clinical trial.

Objective: To compare the effectiveness of cervical spine thrust manipulation and

Kinesiotaping® applied to the neck on self-reported disability and cervical range of

motion in individuals with mechanical neck pain.

Background: The effectiveness of cervical manipulation has received considerable

attention in the literature. However, since some patients cannot tolerate cervical thrust

manipulations, alterative therapeutic options should be investigated.

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Methods and measures: Eighty patients (36 females) were randomly assigned to 1 of 2

groups: the manipulative group received 2 cervical thrust manipulations, whereas the

tape group received Kinesiotaping® applied to the neck. Neck pain (11-point numeric

pain rating scale), disability (Neck Disability Index), and cervical range of motion were

collected at baseline and one week after the intervention by an assessor blinded to the

treatment allocation of the patients. Mixed-model ANOVAs were used to examine the

effects of the treatment on each outcome variable with group as the between subject

variable, and time as the within subjects variable. The primary analysis was the Group *

Time interaction.

Results: No significant Group * Time interactions were found for the 2X2 mixed model

ANOVA for pain (F=1.892; P=0.447) or disability (F=0.115; P=0.736). The Group *

Time interaction for the 2X2 mixed ANOVA was statistically significant for right (F =

7.317, P=0.008) and left (F=9.525, P=0.003) rotation, but not for flexion (F=0.944; P=

0.334), extension (F=0.122; P=0.728), right (F=0.220; P=0.650) and left (F=0.389, P=

0.535) lateral-flexion: patients receiving the cervical thrust manipulation experienced

greater increase in cervical rotation than those receiving the Kinesio Tape application (P

< 0.01).

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Conclusions: Patients with mechanical neck pain receiving cervical thrust manipulation

or an application of Kinesiotaping® exhibited similar reductions in neck pain and

disability and similar changes in active cervical range of motion. Changes in neck pain

surpassed the minimal clinically important difference (MCID), whereas changes in

disability were slightly inferior to the MCID. Changes in cervical range of motion were

small and not clinically meaningful since they did not surpass the MCID.

Level of Evidence: Therapy, Level 1b

Key Words: Cervical spine, neck pain, manipulation, clinical trial, Kinesiotaping

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SHORT-TERM EFFECTS OF KINESIOTAPING VERSUS CERVICAL

THRUST MANIPULATION IN PATIENTS WITH MECHANICAL NECK
PAIN: A RANDOMIZED CLINICAL TRIAL

INTRODUCTION

Mechanical neck pain is a significant societal burden and may include symptoms

in the neck and upper extremity. It has been reported the lifetime and point prevalence

of neck pain is almost as high as the low back pain.25 A systematic review found that

the 1-year prevalence for neck pain symptoms ranging between 16.7% and 75.1%

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(mean: 37.2%).13 Additionally, mechanical neck pain results in substantial disability and

5,10,23
costs.

Determining the most appropriate interventions for individuals with neck pain

continues to remain a priority for researchers. Physical therapy is usually the first

management approach for patients with mechanical idiopathic insidious neck pain with

manual therapy often being a preferred intervention.7

Although a number of randomized controlled trials exists in support of manual

6,12,19,26,30
therapy directed at the cervical spine in patients with neck pain. However, a

recent Cochrane review concluded that only low quality evidence suggests that cervical

manipulation provides greater short-term pain relief compared to a control group.18

Additionally, some individuals with mechanical neck pain may not tolerate or be

appropriate candidates for the application of cervical thrust manipulation. Hence,

alternative therapeutic strategies should be considered.

Another intervention used clinically in the management of patients with neck pain

is KinesioTaping®. KinesioTaping® was a technique developed in the 70s.21 The

adhesive pliable material is used in Kinesio Tape® differs from the classical tape in its

physical characteristics. It is a thin and can be stretched up to 120-140% of its original

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length making it more elastic than conventional tape. 22 Although `physical therapists

regularly use KinesioTaping® in clinical practice, particularly with sport injuries, 36

scientific evidence investigating its effectiveness is limited. A few published case

reports provide preliminary evidence that Kinesiotaping® may be beneficial in treating

29 28 35 16
acute patellar dislocations, ankle, trunk, and myofascial pain. More recently, 2

randomized clinical trials have demonstrated that Kinesiotaping® may be effective for

32 17
the treatment of shoulder pain and acute whiplash injury. In patients with shoulder

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pain, Kinesiotaping® immediately improved pain-free active shoulder range of motion

but did not change pain or disability.32 In individuals with acute whiplash, the

application of Kinesiotaping® slighted improved pain and cervical range of motion.17

However, to date no study evaluated the effects of Kinesiotaping® in patients with

mechanical neck pain. The purpose of this randomized controlled trial was to examine

the effects Kinesiotaping® versus cervical thrust manipulation on neck pain, self-

reported disability and cervical range of motion in patients with mechanical neck pain.

METHODS

Participants

Participants were patients with primary complaint of mechanical idiopathic neck

pain who refereed for physical therapy at a private clinic in Almeria-Spain. Mechanical

neck pain was defined as generalized neck or shoulder pain provoked by neck postures,

neck movement or palpation of the neck musculature. Exclusion criteria included the

following: 1) contraindication to neck manipulation; 2) history of whiplash; 3) history

of cervical surgery; 4) diagnosis of cervical radiculopathy or myelopathy; 5) diagnosis

of fibromyalgia; 6) having previously undergone spinal manipulative therapy or Kinesio

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Tape applications; 7) any tape allergy; or 8) less than 18 or greater than 45 years of age.

Informed consent was obtained from each patient before entering the study, which was

performed in accordance with the Helsinki Declaration. The study was approved by the

ethics and research committee of the University of Almeria.

Study Protocol

Patients provided demographic and clinical information and completed a number

of self-report measures at baseline, which included a numeric pain rating scale (NPRS)

for assessing the intensity of the pain,20 the Neck Disability Index (NDI) to measure

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self-perceived disability,
33
and a body diagram to assess the distribution of pain.
34
Once

patients completed the self-report measures they underwent cervical range of motion

(CROM) testing. They were also screened for any signs of Vertebrobasilar Insufficiency

(VBI), such as nystagmus, gait disturbances and Horner’s syndrome. Patients also

underwent screening for upper cervical spine ligamentous instability.8

The NPRS (range: 0, no pain; 10, maximum pain) was used to assess neck pain

intensity. The NPRS has shown to be reliable and valid tool for the assessment of

pain.20 The minimal detectable change (MDC) and minimal clinically important

difference (MCID) for the NPRS have been reported as 1.3 and 2.1 points, respectively 9

The NDI consists of 10 questions addressing functional activities such as personal

care, lifting, reading, work, driving, sleeping, and recreational activities, as well as pain

intensity, concentration, and headache. 33 There are 6 potential responses for each item,

ranging from no disability (0) to total disability (5). The NDI is scored from 0 to 50,

with higher scores indicating greater disability. MacDermid et al recently concluded that

the MDC and the MCID for the NDI were 5 and 7 points out of 50, respectively.24

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Cervical range of motion (CROM) testing was assessed with the patient sitting

comfortably on a chair, with both feet flat on the floor, hips and knees at 90º of flexion,

and buttocks positioned against the back of the chair. A CROM goniometer was placed

on the top of the head, and patients were asked to move the head as far as possible

without any pain in a standard fashion: flexion, extension, right lateral flexion, left

lateral flexion, right rotation, and left rotation. The CROM goniometer has been shown

to exhibit intra-tester reliability between 0.87 and 0.96 in subjects with neck pain. 15 A

recent study reported that the standard error of measurement (SEM) across the six

1
6.5º.
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cervical movements ranged from 1.6º to 2.8º, whereas the MDC ranged from 3.6º to

All outcomes were collected at baseline and 7 days after the intervention by an

assessor blinded to the treatment allocation of the patients. Patients were blinded to their

treatment allocation, as they were naïve to what intervention the other group would

receive.

Allocation

Following the baseline examination, patients were randomly assigned to receive

KinesioTaping® (tape group) or manipulative interventions directed at the cervical

spine (manipulative group). Concealed allocation was performed using a computer-

generated randomized table of numbers created prior to the start of data collection by a

researcher not involved in either recruitment or treatment of the patients. Individually,

sequentially numbered index cards with the random assignment were prepared. The

index cards were folded and placed in sealed opaque envelopes. A second therapist,

blinded to baseline examination findings, opened the envelope and proceeded with

treatment according to the group assignment. All patients received the intervention on

the day of the initial examination.

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KinesioTaping® Application

The tape [Kinesio Tex, Kinesiotaping®, USA] used in this study was waterproof,

porous, and adhesive. Tape with a width of 5cm and a thickness of 0.5mm was used.

Patients in this group received the standardized Kinesio Tape application (Fig 1). For

the application the patients were seated. The first layer was a blue Y-strip placed over

the posterior cervical extensor cervical muscles and applied from the insertion to origin

with paper-off tension. The paper-off tension tape is manufactured and applied to its
21,22
paper backing with approximately 15% to 25% stretch. Patients were sitting for the

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application of the Kinesio Tape. Each tail of the first (blue) strip (Y-strip, 2-tailed) was

applied with the patients’ neck in a position of cervical contra-lateral side bending and

rotation. The tape was first placed from the dorsal region (T1-T2) to the upper-cervical

region (C1-C2). The overlying strip (black) was a space-tape (opening) placed

perpendicular to the Y-strip over the mid cervical region (C3-C6) with the patients’

cervical spine in flexion to apply tension to the posterior structures. This application has
17
been also used in a previous study.

Manipulative Interventions

The manipulative group received 2 thrust manipulation interventions directed at

the mid-cervical spine and cervico-thoracic junction. For the mid-cervical spine thrust

manipulation, the subject was supine with the cervical spine in a neutral position. The

index finger of the clinician applied a contact over the posterior-lateral aspect of the

zygapophyseal joint of C3. The therapist cradled the patient's head with the other hand.

Gentle ipsi-lateral cervical side-flexion and contra-lateral rotation was introduced until

slight tension was perceived in the tissues at the contact point (Fig. 2). A high-velocity

low-amplitude thrust manipulation was directed upward and medially in the direction of

the subject’s contra-lateral eye.27 The cervico-thoracic junction thrust manipulation was

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applied bilaterally. We describe here the procedure for a left C7-T1 manipulation, that

is, the contact was on the right side of the C7-T1 junction. The patient was prone with

the head and neck rotated to the left. The therapist stood on the left side of the patient

facing cephalic. The therapist’s right hand made contact with the thumb on the right

side of the spinous process of T1. The therapist’s left hand supported the head of the

patient. The head and neck was gently laterally-flexed to the right, until slight tension is

palpated in the tissues. A high-velocity low-amplitude thrust was applied toward the

subjects’ left side (Fig. 3). These 2 manipulative procedures were selected as they are

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commonly used in clinical practice in patients with neck pain.

Statistical Analysis

Data were analyzed with SPSS© version 18.0 and it was conducted following

intention-to-treat analysis. When post-intervention data were missing, baseline scores

were used. Baseline demographic and clinical variables were examined between both

groups using independent Student t-tests for continuous data and 2 tests of

independence for categorical data. Separate 2X2 mixed model ANOVAs were used to

examined the effects of treatment on pain, self-reported disability and cervical range of

motion (flexion, extension, rotation, or lateral-flexion) as the dependent variables, with

group (tape or manipulative) as the between subjects variable and time (baseline, 1-

week follow-up) as the within subjects variable. The hypothesis of interest was the

Group * Time interaction at an a priori alpha-level equal to 0.05.

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RESULTS

Ninety-three consecutive patients were screened for eligibility criteria. Eighty

patients (mean ± SD age: 45 ± 10 year; 46.5% female) satisfied the eligibility criteria,

agreed to participate, and were randomized into Kinesio Tape (n=40) or manipulative

(n=40) group. The reasons for ineligibility are found in Figure 4, which provides a flow

diagram of patient recruitment and retention. Baseline features between the groups were

similar for all variables (Table 1).

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The 2X2 mixed model ANOVA did not find a statistically significant Group *

Time interaction for neck pain (F = 1.892; P = 0.447) or NDI (F=0.115; P=0.736) as the

dependent variable: both groups experienced similar decreases in neck pain and NDI.

Table 2 shows baseline, post-intervention, within-group and between-group differences

with associated 95% CI for pain and self-reported disability.

The Group * Time interaction for the 2X2 mixed ANOVA was statistically

significant for right (F = 7.317, P = 0.008) and left (F = 9.525, P = 0.003) rotation, but

not for flexion (F = 0.944; P = 0.334), extension (F = 0.122; P = 0.728), right (F =

0.220; P = 0.650) and left (F = 0.389, P = 0.535) lateral-flexion: patients receiving the

manipulative thrust experienced greater increase in cervical rotation than those patients

receiving the Kinesio Tape application (P < 0.01). Table 2 summarizes baseline, post-

intervention, within-group and between-group differences with associated 95% CI for

cervical range of motion.

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DISCUSSION

The results of the current study demonstrated the application of Kinesio Tape

and cervical thrust manipulation was equally effective for reducing pain and disability.

Additionally both experienced similar improvements in CROM flexion, extension and

both directions in lateral-flexion in patients with mechanical neck pain. In addition,

individuals who received cervical thrust manipulation exhibited greater increase in

cervical rotation than those receiving Kinesio Tape.

The decrease on neck pain in both groups was statistically significant for NPRS,

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and surpassed the MCID which has been reported to be 2.1 points on a NPRS.9 Previous

studies have reported that cervical thrust manipulation is effective for reducing pain and

6,12,19,26,30
disability in individuals with mechanical neck pain, but this is the first study

demonstrating that Kinesiotaping® was also effective for reducing pain and also

disability in patients with mechanical neck pain. The current results are similar to those

previously identified in patients with acute whiplash,17 although the reduction in neck

pain was greater in the current study. Thelen et al also found that Kinesiotaping®

improved pain-free shoulder range of motion in patients with shoulder pain, but it had

no effect on spontaneous pain or function.32 It is important to note that the current study

also demonstrated that either cervical thrust manipulation or Kinesiotaping® were able

to reduce self-reported disability (NDI). However, changes observed were lower that the

reported MCID of 7 points.24 It is possible that consecutive applications of either

Kinesiotaping® or cervical manipulation would result in greater changes.

The current study also identified that patients receiving either intervention

exhibited small increases in cervical range of motion. This is in agreement with

previous published studies showing an improvement in mobility after the application of

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16,17,28,29,32,35 6,12,19,26,30
Kinesiotaping® or cervical manipulation. Changes in cervical

rotation were greater in the manipulative group, but these differences were relatively

small. Additionally, change improvements in cervical range of motion did not surpass

the MDC which ranged between 3.6º-6.5º.1 It is possible that greater changes in cervical

range of motion are observed from multiple applications of each intervention over a

longer period of time.

The current study has reported that Kinesiotaping® was as effective as cervical

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thrust manipulation for decreasing pain and disability in individuals presenting with

mechanical neck pain. One possible mechanism by which Kinesiotaping® induced

these changes could be related to the neural feedback provided to the patients which can

facilitate their ability to move the cervical spine with a reduced mechanical irritation on

the soft tissues. In addition, the tape may have created tension in soft tissues structures

providing an afferent stimuli, facilitating a pain inhibitory mechanism, thereby reducing

the pain levels of the patients.

Historically, it has been believed that the mechanisms of spinal manipulation

have been primarily biomechanical in nature but recently it has been purported that the

-4
mechanisms may be neurophysiological in origin.2 In fact, it was demonstrated that

spinal thrust manipulation results in decreases in inflammatory cytokine31 and an

increase in endorphins.11 Further it has been also demonstrated that cervical spine thrust

manipulation increases pain pressure thresholds to a greater magnitude than a sham and

control group.14 It is also possible that spinal manipulation results in a decrease in

thermal pain sensitivity.4 The exact mechanism as to how spinal thrust manipulation

exerts its effects remains to be elucidated.

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There are a number of limitations in the current study that should be recognized.

First, we used a sample of convenience from 1 clinic, which may not be representative

of the entire population of individuals with mechanical neck pain. Second, we

investigated the short-term effects of cervical thrust manipulation and Kinesiotaping®

application. Therefore, we cannot make inferences that the benefits would be

maintained in the long term. . In addition, therapists usually use a multi-modal approach

to the management of patients with mechanical neck pain and would not solely use

cervical manipulation or Kinesiotaping® as an isolated intervention. We suggest that

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future studies investigate if the inclusion of either procedure enhances outcomes when

added to interventions with already proven effective such as active exercise.

CONCLUSION

Patients with mechanical neck pain receiving a cervical thrust manipulation or an

application of Kinesiotaping® exhibited similar reduction in neck pain and disability

and similar changes in active cervical range of motion. Changes in neck pain surpassed

the MCID, whereas changes in disability were slightly inferior to the MCID. Finally,

changes in cervical range of motion were small and not clinically meaningful since they

did not surpass the MCD.

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KEY POINTS

Findings: The application of Kinesio Tape or cervical thrust manipulation was equally

effective for reducing pain and disability and for increasing cervical range of motion in

patients with mechanical neck pain.

Implications: This study provides evidence for the application of cervical thrust

manipulation and Kinesiotaping® in the management of patients with mechanical neck

pain.
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Caution: Changes in cervical range of motion were small and not clinically meaningful.

Also, the generalizability of the results should be interpreted with caution as all patients

were treated by the same therapist.

Legend of Figures

Figure 1: Kinesio Taping® Application

Figure 2: Mid-cervical spine manipulation

Figure 3: Cervico-thoracic junction manipulation

Figure 4: Flow diagram of subjects throughout the course of the study

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(abstract). J Orthop Sports Phys Ther 2001; 31: A37

29. Osterhues DJ. The use of Kinesiotaping in the management of traumatic patella

dislocation: A case study. Physiother Theor Pract 2004; 20: 267-170

30. Puentedura EJ, Landers MR, Cleland JA, Mintken PE, Huijbregts P, Fernández-

de-las-Peñas C. Thoracic spine manipulation versus cervical spine thrust

manipulation in patients with acute neck pain: a randomized clinical trial. J

Orthop Sports Phys Ther 2011; 41: 208-220

31. Teodorczyk-Injeyan JA, Injeyan HS, Ruegg R. Spinal manipulative therapy

reduces inflammatory cytokines but not substance P production in normal

subjects. J Manipulative Physiol Ther 2006; 29: 14-21.

JOSPT, 1111 N. Fairfax St., Suite 100, Alexandria, VA 22314, ph. 877-766-3450 18
Page 19 of 25 Journal of Orthopaedic & Sports Physical Therapy

32. Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for

shoulder pain: a randomized, double-blinded, clinical trial. J Orthop Phys Ther

2008; 38: 389-395

33. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity.

J Manipulative Physiol Ther 1991; 14: 409-415

34. Werneke MW, Hart DL, Cook D. A descriptive study of the centralization

phenomenon: a prospective analysis. Spine 1999; 24: 676-683

35. Yoshida A, Kahanov L. The effect of Kinesiotaping on lower trunk range of

Review Copy
motions. Res Sports Med 2007; 15: 103-112

36. Zajt-Kwiatkowska J, Rajkowska-Labon E, Skrobot W, Bakula S, Szamotulska J.

Application of kinesio taping for treatment of sport injuries. Research Year-

Book 2007; 13: 130-134

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 Journal of Orthopaedic & Sports Physical Therapy Page 20 of 25

Table 1: Baseline demographics for both groups*

Manipulative Group Kinesio Tape Group P values

Gender (Male / Female)

Age (years)
Duration of symptoms (months)
Review Copy 19/17
44 ± 10
75 ± 18
21/19
46 ± 9
82 ± 19
0.906
0.312
0.479
Neck pain** 5.0 ± 1.9 5.2 ± 1.4 0.456
Neck Disability Index*** 22.5 ± 4.3 21.4 ± 2.3 0.151
Cervical range of motion (degrees)
Flexion 56.0 ± 10.7 55.8 ± 7.8 0.955
Extension 56.9 ± 12.9 53.1 ± 19.9 0.333
Right lateral-flexion 39.0 ± 8.6 39.0 ± 8.4 0.978
Left lateral-flexion 39.6 ± 7.5 38.9 ± 6.4 0.653
Right rotation 70.6 ± 12.3 71.3 ± 12.6 0.809
Left rotation 71.1 ± 13.7 76.0 ± 12.7 0.108

* Data are mean SD except for gender.

** Measured with a 11-point numerical pain rate scale (0, no pain; 10, worst pain imaginable)
*** Range of score is 0-50 with higher scores meaning greater disability

20

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Page 21 of 25 Journal of Orthopaedic & Sports Physical Therapy

Table 2: Baseline, 7-days post-treatment, and change scores for neck pain, disability, and cervical range of motion
Outcome Group Baseline 7-days post-treatment Within Group Change Scores Between-Group Change Scores
Pain (0-10 points)
Kinesio Tape 5.2 ± 1.4 2.7 ± 1.2 -2.5 (-2.9, -2.0) 0.2 (0.0, 0.5)
Manipulative 5.0 ± 1.9 2.7 ± 1.6 -2.3 (-3.0, -1.1)
Neck Disability Index (0-50 points)

Review
Kinesio Tape 21.4 ± 2.3 15.4 ± 1.8 -6.0 (-6.8, -5.2) 0.3 (-1.3, 1.9)
Manipulative 22.5 ± 4.3 16.8 ± 3.9 -5.7 (-7.2, -4.1)
Cervical Flexion (deg)
Kinesio Tape 55.8 ± 7.8 58.6 ± 9.5 2.8 (0.1, 5.5) 2.0 (-2.1, 6.0)
Manipulative 56.0 ± 10.7 56.8 ± 7.6 0.8 (-4.0, 2.4)
Cervical Extension (deg)
Kinesio Tape 53.1 ± 19.9 57.0 ± 15.2 3.9 (2.6, 10.3) 1.4 (-6.8, 9.7)

Copy
Manipulative 56.9 ± 12.9 62.2 ± 9.9 5.3 (2.0, 8.6)
Cervical Right Lateral Flexion (deg)
Kinesio Tape 39.0 ± 8.4 43.9 ± 7.6 4.9 (2.2, 7.6) 1.4 (-6.7, 9.8)
Manipulative 39.0 ± 8.6 45.3 ± 7.7 6.3 (4.1, 8.5)
Cervical Left Lateral Flexion (deg)
Kinesio Tape 38.9 ± 6.4 42.8 ± 6.6 3.9 (1.9, 4.7) 0.9 (-2.1, 4.0)
Manipulative 39.6 ± 7.5 42.6 ± 7.2 3.0 (0.4, 5.4)
Cervical Right Rotation (deg)
Kinesio Tape 71.3 ± 12.6 72.0 ± 12.5 0.7 (-3.1, 4.6) 6.8 (1.8, 11.7)*
Manipulative 70.6 ± 12.3 78.1 ± 9.8 7.5 (4.3, 10.7)
Cervical Left Rotation (deg)
Kinesio Tape 76.0 ± 12.7 76.8 ± 10.4 0.7 (-2.4, 3.9) 7.0 (2.5, 11,5)*
Manipulative 71.1 ± 13.7 78.8 ± 9.6 7.7 (4.3, 11.1)

Values are expressed as mean ± standard deviation for Baseline and immediate post-treatment means and as mean (95% confidence interval) for
within- and between-group change scores / * Significant Group * Time interaction (ANOVA, P < 0.01)

21

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 Journal of Orthopaedic & Sports Physical Therapy Page 22 of 25

Review Copy

254x338mm (72 x 72 DPI)

JOSPT, 1111 N. Fairfax St., Suite 100, Alexandria, VA 22314, ph. 877-766-3450
Page 23 of 25 Journal of Orthopaedic & Sports Physical Therapy

Review

Copy
365x274mm (180 x 180 DPI)

JOSPT, 1111 N. Fairfax St., Suite 100, Alexandria, VA 22314, ph. 877-766-3450
 Journal of Orthopaedic & Sports Physical Therapy Page 24 of 25

Review

Copy
365x274mm (180 x 180 DPI)

JOSPT, 1111 N. Fairfax St., Suite 100, Alexandria, VA 22314, ph. 877-766-3450
Page 25 of 25 Journal of Orthopaedic & Sports Physical Therapy

Figure 4: Flow diagram of patients throughout the course of the study

Patients with mechanical neck pain screened

for eligibility criteria (n=93)

Excluded (n=13):
Fibromyalgia (n=3)
Positive extension-rotation test (n=3)
Osteoporosis (n=3)
Previous cervical surgery (n=2)
Previous whiplash (n=1)

Review
Baseline Measurements (n=80)
Previous cervical manipulation (n=1)

Pain
Range of Motion
Disability

Allocated to KinesioTaping®
Copy
Randomized (n=80)

Allocated to cervical thrust manipulation

(n=40) (n=40)

7 days post- intervention (n=40) 7 days post- intervention (n=36)

Pain Pain
Range of Motion Range of Motion
Disability Disability

Lost follow-up (n=4)

Family problems (n=2)
Other health problems (n=2)

JOSPT, 1111 N. Fairfax St., Suite 100, Alexandria, VA 22314, ph. 877-766-3450
 IV. Pain Intensity, Physical Impairment and Pain-Related Fear to
Function in Patients with chronic Mechanical Cervical Pain.

Autores: Saavedra-Hernández, Castro-Sánchez AM, Cuesta-Vargas AI, Cleland J,

Fernández-de-las-Peñas C, Arroyo-Morales M. Amercian Journal Physical Medicne &
Rehabilitation. En Revisión.

119
 Clinical Rehabilitation

SHORT-TERM EFFECTS OF SPINAL THRUST JOINT

MANIPULATION IN PATIENTS WITH CHRONIC MECHANICAL
NECK PAIN: A RANDOMIZED CLINICAL TRIAL

For
Journal: Clinical Rehabilitation

Manuscript ID: CRE-2012-2228

Manuscript Type: Original Article

Peer
Keywords: manipulation, Neck pain, pain, Disability

Objective: To compare the effects of an isolated application of cervical

spine joint manipulation (TJM) vs. the application of cervical, cervico-
thoracic junction and thoracic spine TJM on neck pain, disability and
cervical range of motion (CROM) in chronic mechanical neck pain. Design:
Randomized clinical trial. Setting: Clinical practice. Participants: Eighty-two
patients (41 females) with chronic mechanical neck pain. Interventions:
Patients were randomly assigned to a cervical spine TJM group or a clinical

Review
manipulative group who received 3 mid-cervical, cervico-thoracic, and
thoracic TJM. Measurements: Neck pain intensity (11-point numeric pain
rating scale), self-reported disability (Neck Disability Index), and CROM
were collected at baseline and one week after the intervention by an
assessor blinded to the treatment allocation of the patients. Results: A
Abstract: significant Group*Time interaction for NDI (P=0.022), but not for neck pain
(P=0.612) was found: patients in the clinical manipulative group exhibited
greater reduction in disability than those who received the cervical spine
TJM, whereas both groups experienced similar decrease in neck pain.
Patients in both groups experienced similar increases in CROM (P>0.40).
No effect of gender was observed (P>0.299). Conclusions: The application
of cervical TJM alone is equally effective for reducing neck pain and for
improving CROM than the application of cervical TJM combined with
cervico-thoracic and thoracic TJM in mechanical neck pain. The reduction of
disability was greater in patients receiving clinical combination of spinal
TJM. Changes in neck pain and disability surpassed the minimal clinically
important difference, but the changes in CROM were not clinically
meaningful.

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Page 1 of 22 Clinical Rehabilitation

1
2
3 SHORT-TERM EFFECTS OF SPINAL THRUST JOINT MANIPULATION IN
4 PATIENTS WITH CHRONIC MECHANICAL NECK PAIN: A RANDOMIZED
5 CLINICAL TRIAL
6
7
8 ABSTRACT
9
10 Objective: To compare the effects of an isolated application of cervical spine joint
11
12 manipulation (TJM) vs. the application of cervical, cervico-thoracic junction and thoracic spine
13
14 TJM on neck pain, disability and cervical range of motion (CROM) in chronic mechanical neck
15
16 pain. Design: Randomized clinical trial. Setting: Clinical practice. Participants: Eighty-two

For Peer Review

17
18 patients (41 females) with chronic mechanical neck pain. Interventions: Patients were
19
20 randomly assigned to a cervical spine TJM group or a clinical manipulative group who received
21
22 3 mid-cervical, cervico-thoracic, and thoracic TJM. Measurements: Neck pain intensity (11-
23
24 point numeric pain rating scale), self-reported disability (Neck Disability Index), and CROM
25
26 were collected at baseline and one week after the intervention by an assessor blinded to the
27
28 treatment allocation of the patients. Results: A significant Group*Time interaction for NDI
29
30
(P=0.022), but not for neck pain (P=0.612) was found: patients in the clinical manipulative
31
32
group exhibited greater reduction in disability than those who received the cervical spine TJM,
33
34
whereas both groups experienced similar decrease in neck pain. Patients in both groups
35
36
37 experienced similar increases in CROM (P>0.40). No effect of gender was observed (P>0.299).
38
39 Conclusions: The application of cervical TJM alone is equally effective for reducing neck pain
40
and for improving CROM than the application of cervical TJM combined with cervico-thoracic
41
42
43 and thoracic TJM in mechanical neck pain. The reduction of disability was greater in patients
44
45 receiving clinical combination of spinal TJM. Changes in neck pain and disability surpassed the
46
47 minimal clinically important difference, but the changes in CROM were not clinically
48
49 meaningful.
50
51
52
53 Key Words: Cervical spine, neck pain, manipulation, clinical trial.
54
55
56
57
58
59
60
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 Clinical Rehabilitation Page 2 of 22

1
2
3 SHORT-TERM EFFECTS OF SPINAL THRUST JOINT MANIPULATION IN
4 PATIENTS WITH CHRONIC MECHANICAL NECK PAIN: A RANDOMIZED
5 CLINICAL TRIAL
6
7
8 ABSTRACT
9
10 Objective: To compare the effects of an isolated application of cervical spine joint
11
12 manipulation (TJM) vs. the application of cervical, cervico-thoracic junction and thoracic spine
13
14 TJM on neck pain, disability and cervical range of motion (CROM) in chronic mechanical neck
15
16 pain. Design: Randomized clinical trial. Setting: Clinical practice. Participants: Eighty-two

For Peer Review

17
18 patients (41 females) with chronic mechanical neck pain. Interventions: Patients were
19
20 randomly assigned to a cervical spine TJM group or a clinical manipulative group who received
21
22 3 mid-cervical, cervico-thoracic, and thoracic TJM. Measurements: Neck pain intensity (11-
23
24 point numeric pain rating scale), self-reported disability (Neck Disability Index), and CROM
25
26 were collected at baseline and one week after the intervention by an assessor blinded to the
27
28 treatment allocation of the patients. Results: A significant Group*Time interaction for NDI
29
30
(P=0.022), but not for neck pain (P=0.612) was found: patients in the clinical manipulative
31
32
group exhibited greater reduction in disability than those who received the cervical spine TJM,
33
34
whereas both groups experienced similar decrease in neck pain. Patients in both groups
35
36
experienced similar increases in CROM (P>0.40). No effect of gender was observed (P>0.299).
37
38
Conclusions: The application of cervical TJM alone is equally effective for reducing neck pain
39
40
41 and for improving CROM than the application of cervical TJM combined with cervico-thoracic
42
43 and thoracic TJM in mechanical neck pain. The reduction of disability was greater in patients
44
45 receiving clinical combination of spinal TJM. Changes in neck pain and disability surpassed the
46
47 minimal clinically important difference, but the changes in CROM were not clinically
48
49 meaningful.
50
51
52
53 Key Words: Cervical spine, neck pain, manipulation, clinical trial.
54
55
56
57
58
59
60 1
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Page 3 of 22 Clinical Rehabilitation

1
2
3 INTRODUCTION
4
5 Mechanical neck pain constitutes a significant societal burden since it results in
6
7 substantial disability and costs (1,2). It has been reported that the prevalence of neck pain is
8
9 almost as high as low back pain (3). The 1-year prevalence for neck pain has been reported to
10
11 range between 16.7% and 75.1% (37.2%) (4).
12
13 Physical therapy is the first management approach for patients with insidious
14
15 mechanical neck pain with manual therapy often being a preferred intervention (5). In fact, a
16

For Peer Review

17 common clinical approach for therapists is to incorporate manual therapy interventions directed
18
19 to the cervical spine into the management of individuals with neck pain. These manual therapy
20
21 techniques include passive joint non-thrust mobilization and thrust joint manipulation (TJM).
22
23 Although a number of randomized controlled clinical trials supports the application of
24
25 either cervical (6-9) or thoracic (10-13) spine TJM in individuals with mechanical neck pain;
26
27 recent reviews have concluded that low quality evidence exists for the use of cervical (14) or
28
29 thoracic (15) thrust interventions in isolation. Further, preliminary studies have developed
30
31
clinical prediction rules to identify subgroups of patients with neck pain who were more likely
32
33
to benefit from thoracic (16) or cervical (17) TJM. Nevertheless, patients fulfilling one of these
34
35
rules, e.g. thoracic spine TJM can also benefit from the other intervention, that is, cervical spine
36
37
38 TJM (18).
39
40 One of the main limitations of previous studies is that simply using just cervical or thoracic
41
42 spine TJM may not be representative of usual clinical practice, as therapists usually apply
43
44 different manipulative interventions at different levels for the management of patients with
45
46 mechanical neck pain (19). We do not know if the application of different spinal TJM would
47
48 increase the effect of the application of only one intervention. Therefore, the purpose of this
49
50 randomized controlled trial was to compare the effects of an isolated application of cervical
51
52 spine TJM vs. the application of a clinical combination of cervical, cervico-thoracic and
53
54 thoracic spine TJM on neck pain, disability and cervical range of motion (CROM) in
55 individuals
56 with chronic mechanical neck pain.
57
58
59
60 2
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 Clinical Rehabilitation Page 4 of 22

1
2
3 METHODS
4
5 Participants
6
7 A randomized single blind clinical trial was conducted. Patients with a primary complaint
8
9 of bilateral chronic mechanical neck pain who were referred for physical therapy at a private
10
11 clinic in Almeria (Spain) were recruited for this study. Mechanical neck pain was defined as
12
13 neck pain provoked by neck postures, cervical movement or manual palpation of the neck
14
15 musculature. Patients were screened for any signs of Vertebrobasilar Insufficiency (VBI), e.g.,
16

For Peer Review

17 nystagmus, gait disturbances, Horner’s syndrome, and underwent screening for upper cervical
18
19 spine ligamentous instability through Sharp-Purser test, alar ligament stress test, and transverse
20
21 ligament tests. Exclusion criteria included the following: 1) contraindication to cervical TJM
22
23 (e.g. fracture, osteoporosis, positive extension-rotation test, any symptom of Vertebrobasilar
24
25 Insufficiency; 2) history of whiplash; 3) history of cervical spine surgery; 4) diagnosis of
26
27 cervical radiculopathy or myelopathy; 5) diagnosis of fibromyalgia syndrome; 6) having
28
29 previously undergone spinal manipulative therapy; or, 7) less than 18 or greater than 55 years of
30
31
age. Informed consent was obtained from each patient before entering the study, which was
32
33
conducted in accordance with the Helsinki Declaration. The study was approved by the ethics
34
35
and research committee of the University of Almeria.
36
37
38 Study Protocol
39
40 Patients provided demographic and clinical information and completed a number of
41
42 self-report measures at baseline, which included a numeric pain rating scale (NPRS) for
43
44 assessing the intensity of the pain (20), the Neck Disability Index (NDI) to measure self-
45
46 perceived disability (21), and a body diagram to assess the distribution of pain (22). Once
47
48 patients completed the self-report measures, cervical range of motion (CROM) testing was
49
50 assessed. The NPRS (range: 0, no pain; 10, maximum pain) was used to assess the intensity of
51
52 neck pain at rest. The minimal detectable change (MDC) and the minimal clinically important
53
54 difference (MCID) for the NPRS in individuals with neck pain have been reported to be 1.3
55 and
56 2.1 points, respectively (23). The NDI consists of 10 questions addressing functional activities
57
58 (personal care, lifting, reading, work, driving, sleeping, and recreational activities) as well as
59
60 3
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Page 5 of 22 Clinical Rehabilitation

1
2
3 pain intensity, concentration, and headache (21). There are 6 potential responses for each
4
5 question, ranging from no disability (0) to total disability (5). The NDI is scored from 0 to 50,
6
7 with higher scores indicating greater disability. The MDC and the MCID for the NDI have been
8
9 estimated on 5 and 7 points out of 50, respectively (24). Cervical range of motion (CROM)
10
11 testing was assessed with the patient sitting following previous guidelines (25,26). Patients were
12
13 asked to move their head as far as possible without pain in a standardized manner: flexion,
14
15 extension, right and left lateral flexion, right and left rotation. It has been reported that the
16

For Peer Review

17 standard error of measurement (SEM) across the 6 cervical movements ranged from 1.6º to 2.8º,
18
19 whereas the MDC ranged from 3.6º to 6.5º (27).
20
21 All outcomes were collected at baseline and 7 days after the intervention by an assessor
22
23 blinded to the treatment allocation of the patients.
24
25 Allocation
26
27 Following the baseline examination, patients were randomly assigned to receive only
28
29 cervical TJM (cervical manipulative group) or several manipulative interventions (clinical
30
31
manipulative group). Concealed allocation was performed using a computer-generated
32
33
randomized table of numbers created prior to the start of data collection by a researcher not
34
35
involved in either recruitment or treatment of the patients. Sequentially numbered index cards
36
37
38 with the random assignment were prepared. The index cards were folded and placed in sealed
39
40 opaque envelopes. A second therapist, blinded to baseline examination findings, opened the
41
42 envelope and proceeded with treatment according to the group assignment.
43
44 Manipulative Interventions
45
46 As we wanted to mimic common clinical practice for the management of patients with
47
48 mechanical neck pain, clinicians chose which levels of the spine to manipulate in the cervical,
49
50 cervico-thoracic or thoracic spine based on the following clinical findings: presence of
51
52 hypomobility (abnormal end-feel and increased tissue resistance) combined with pain
53
54 provocation during the test. All treatments were applied by 2 experienced therapists with a 5-
55
56 year certification in spinal manipulative therapy after completion of their physical therapy
57
58 degree and more than 10 years of clinical experience with patients. In the cervical manipulative
59
60 4
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 Clinical Rehabilitation Page 6 of 22

1
2
3 group, patients received only the cervical spine TJM, and in the clinical manipulation group,
4
5 they received 3 TJM techniques targeted at the cervical spine, cervico-thoracic junction and
6
7 upper thoracic spine region. All patients received the intervention on the day of their initial
8
9 examination. The techniques took less than 5min and were conducted as follows (28):
10
11 A) Upper thoracic spine manipulation: patients were supine with the arms crossed over the
12
13 chest and hands placed over the shoulders. The therapist placed their chest at the level of the
14
15 patient’s middle thoracic spine and grasped the patient’s elbows. Flexion of the thoracic spine
16

For Peer Review

17 was introduced until slight tension was felt in the tissues at the contact point. A distraction TJM
18
19 in an upward direction was applied (Fig. 1). If no popping sound was heard on the first attempt,
20
21 the therapist repositioned the patient, and performed a second manipulation. A maximum of 2
22
23 attempts were allowed on each patient.
24
25 B) Cervico-thoracic junction manipulation: this technique was applied bilaterally. Here we
26
27 describe the procedure for a right C7-T1 TJM, that is, the contact was on the left side of the
28
29 cervico-thoracic junction. The patient was prone with the head and neck rotated to the right. The
30
31
therapist stood on the right side of the patient facing in a cephalic direction. The therapist’s left
32
33
hand makes contact with the thumb on the left side of the spinous process of T1. The therapist’s
34
35
right hand supports the head of the patient. The head/neck is gently laterally-flexed to the left,
36
37
38 until slight tension is palpated in the tissues. A high-velocity low-amplitude thrust was applied
39
40 toward the patients’ right side (Fig. 2). Again, a maximum of 2 attempts were allowed for each
41
42 side.
43
44 C) Mid-cervical spine manipulation: the subject was supine with the cervical spine in a neutral
45
46 position. The index finger of the therapist applied a contact over the posterior-lateral aspect of
47
48 the zygapophyseal joint of C3. The therapist cradled the patient's head with the other hand.
49
50 Ipsilateral side-flexion and contralateral rotation to the targeted side was introduced until slight
51
52 tension was perceived in the tissues at the contact point (Fig. 3). A high-velocity low-
53 amplitude
54 thrust manipulation was directed upward and medially in the direction of the patient’s
55
56 contralateral eye. Similarly, a maximum of 2 attempts were allowed to obtain
57 cavitation.
58
59
60 5
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Page 7 of 22 Clinical Rehabilitation

1
2
3 Treatment Side Effects
4
5 Patients were asked to report any adverse event that they experienced after the
6
7 intervention and during a one week follow-up. In this study, an adverse event was defined as
8
9 sequelae of medium-term in duration with any symptom perceived as distressing and
10
11 unacceptable to the patient and required further treatment.
12
13 Statistical Analysis
14
15 Data were analyzed with SPSS© version 18.0 and it was conducted following intention-
16

For Peer Review

17 to-treat analysis. When post-intervention data were missing, baseline scores were used. Baseline
18
19 demographic and clinical variables were examined between groups using independent Student t-
20
21 tests for continuous data and 2 tests of independence for categorical data. Separate mixed-
22
23
model ANCOVA were used to examine the effects of treatment on neck pain and self-reported
24
25
disability as dependent variables, with group as the between-subjects variable, time as within-
26
27
subjects variable and gender as covariate. A 3x2 mixed-model ANCOVA was used to evaluate
28
29
the differences in cervical range of motion for lateral-flexion and rotation motion with side and
30
31
32 time as the within-subjects variable, group as the between-subjects variable and gender as
33
34 covariate. Finally, a 2x2 ANCOVA with group as the between-subjects variable, time as within-
35
36 subjects variable and gender as covariate was again used to evaluate the differences in
37
38 flexion/extension. The hypothesis of interest was the Group * Time interaction at an a priori
39
40 alpha-level equal to 0.05.
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 6
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 Clinical Rehabilitation Page 8 of 22

1
2
3 RESULTS
4
5 Ninety consecutive individuals were screened for eligibility criteria. Eighty-two
6
7 patients (mean ± SD age: 45 ± 9 year; 50% female) satisfied the eligibility criteria, agreed to
8
9 participate, and were randomized into cervical manipulative (n=41) or clinical manipulative
10
11 (n=41) group. Reasons for ineligibility can be found in Figure 4, which provides a flow
12
13 diagram of patient recruitment and retention. Baseline features between both groups were
14
15 similar for all variables at the beginning of the study (Table 1).
16

For Peer Review

17 The mixed model ANCOVA revealed a statistically significant Group * Time
18
19 interaction for NDI (F = 5.450; P = 0.022), but not for neck pain (F = 0.259; P = 0.612) as
20
21 dependent variables: patients who received the clinical combination of spinal TJM exhibited
22
23 greater reduction in disability than those who received only the cervical spine TJM whereas
24
25 both groups experienced similar decreases in neck pain. No effect of gender for NDI (F = 0.355;
26
27 P = 0.553) or neck pain (F = 0.219; P = 0.641) was found. Table 2 shows data at baseline, post-
28
29 intervention, within-group and between-group differences with associated 95% CI for neck pain
30
31
and self-reported disability.
32
33
The 3X2 mixed ANCOVA did not find significant Group * Time interaction for
34
35
cervical flexion (F = 0.697, P = 0.406), extension (F = 0.275, P = 0.602), lateral-flexion (F =
36
37
38 0.485; P = 0.487) or rotation (F = 0.297; P = 0.587) range of motion: patients in both groups
39
40 experienced similar increases in cervical range of motion. Again, no effect of gender was
41
42 observed for any cervical range of motion: flexion: F = 0.468, P = 0.496; extension: F= 1.004,
43
44 P= 0.299; lateral-flexion: F = 0.474, P = 0.493; rotation: F = 0.283, P = 0.596. Table 2
45
46 summarizes baseline, post-intervention, within-group and between-group differences with
47
48 associated 95% CI for cervical range of
49 motion.
50 In this study, 2 patients reported a minor side effects: 1 patient (2.5%) who received
51 the
52 cervical thrust manipulation experienced an increased neck pain the day after the intervention,
53
54 and 1 patient (2.5%) who received the clinical combination of spine thrust manipulation
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56 exhibited increased neck fatigue after the treatment. These minor post-treatment symptoms
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58 resolved spontaneously within 24 hours of onset.
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5 DISCUSSION
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7 Our results showed that the application of cervical TJM alone was equally effective in
8
9 reducing neck pain and improving CROM as the application of cervical TJM combined with
10
11 cervico-thoracic junction and thoracic TJM in patients with chronic mechanical neck pain. In
12
13 addition, those patients receiving the clinical combination of spinal TJM exhibited greater
14
15 reduction of self-reported disability than those receiving the cervical spine TJM alone.
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For Peer Review

17 This randomized clinical trial further supports the effectiveness of spinal TJM for
18
19 decreasing neck pain in individuals with mechanical neck pain which agrees with previous
20
21 studies (6-15). In fact, the decrease in neck pain intensity in both groups was statistically
22
23 significant and the mean decrease surpassed the MCID which has been reported to be 2.1 points
24
25 (23). Nevertheless, the lower bound estimates for the 95% confidence intervals fall above the
26
27 previously reported MCID of 2.1 in both groups so this assumption should be considered with
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29 caution since the reduction of neck pain in several patients maybe lower. Further both groups
30
31
also exhibited similar small increases in CROM; however, most change improvements in
32
33
CROM did not surpass the MDC which ranged between 3.6º and 6.5º (27). It is probable that
34
35
changes in CROM may be greater and more clinically meaningful after multiple spinal TJM
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37
38 over a longer period of time. In fact, a recent study has demonstrated that consecutive
39
40 application of lumbar spine TJM induces better long-term outcomes in patients with chronic low
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42 back pain (29).
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44 We also found that patients receiving the 3 spinal TJM exhibited greater reduction in
45
46 self-reported disability than those receiving the cervical spine TJM alone. In fact, mean
47 changes
48 and their confidence intervals observed in the clinical manipulative group surpassed the MCID
49
50 of 7 points established for NDI (27), whereas changes in the cervical spine group did not
51
52 surpass the MCID. It is possible that the application of thoracic and cervico-thoracic junction
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54 TJM in addition to the cervical spine TJM have a cumulative effect on outcomes. It is also
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56 possible that consecutive applications of spinal TJM would induce greater reduction in
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58 disability.
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3 While a complete review of the neuro-physiological mechanisms of spinal TJM is
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5 beyond the scope of this study, some aspects should be considered. It has been historically
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7 believed that the mechanisms of spinal TJM should be primarily biomechanical in nature, but it
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9 has been recently demonstrated that these mechanisms may also be neurophysiological in origin
10
11 (30,31). For instance, it has been shown that spinal manipulation decreases inflammatory
12
13 cytokines (32) and increases in endorphins (33). Further it has been also demonstrated that
14
15 cervical spine (34) or cervico-thoracic junction (35) TJM increases pain pressure thresholds to a
16

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17 greater magnitude than sham and control groups. These neurophysiological effects may be
18
19 involved in the decrease in neck pain and disability found in the current study after the
20
21 application of spinal TJM. Nevertheless, the fact that patients receiving the clinical combination
22
23 of spinal TJM exhibited similar decreases in neck pain than those receiving only the cervical
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25 TJM suggests that the inclusion of a greater number of TJM does not increase the short-term
26
27 effect on pain. We found that patients receiving a greater number of TJM (clinical manipulative
28
29 group) only demonstrated better outcomes on disability.
30
31
There are a number of limitations that should be considered with respect to our study.
32
33
First, we used a sample of convenience from only one clinic, which may not be representative of
34
35
the general population of patients with chronic mechanical neck pain. Future studies should
36
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38 investigate the effects of spinal TJM including patients with both acute and chronic neck pain
39
40 and treated by different clinicians. Second, we investigated the short-term effects of spinal TJM.
41
42 We cannot infer that the benefits observed would be maintained in the long term. As it has been
43
44 pointed out, it is plausible that consecutive applications induce greater effects (29). Third,
45
46 management of patients with mechanical neck pain usually involves a multi-modal approach
47
48 and not only the use of spinal TJM as isolated interventions. We would recommend that future
49
50 studies investigate if the inclusion of spinal TJM enhances outcomes when added to
51
52 interventions which have already been proven effective, such as active exercise (36).
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5 CONCLUSION
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7 We found that the application of cervical TJM alone was equally effective in reducing
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9 neck pain and in improving CROM when compared to the application of cervical TJM
10
11 combined with cervico-thoracic junction and thoracic TJM in patients with chronic mechanical
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13 neck pain. We also found that the reduction of disability was greater in those patients receiving
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15 the clinical combination of spinal TJM. Changes in neck pain and disability surpassed the
16

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17 MCID, whereas changes in CROM were not clinically meaningful since they did not surpass the
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19 MCID.
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23
24
25 CLINICAL MESSAGES
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27
28
This randomized controlled trial investigated changes in pain and disability outcomes in patients
29
30
with mechanical neck pain who received a cervical spine manipulation alone or in combination
31
32
33 with C7-T1 and thoracic spine thrust manipulation.
34
35
36
This study found that the application of cervical manipulation alone is equally effective for
37
38
39 reducing neck pain and for improving cervical range of motion than the application of cervical
40
41 combined with cervico-thoracic junction and thoracic spine thrust manipulation in chronic
42
43 mechanical neck pain. The reduction of disability was greater in patients receiving clinical
44
45 combination of spinal thrust manipulation
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3 REFERENCES
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5 1. Borghouts JA, Koes BW, Vondeling H et al. Cost-of-illness of neck pain in The
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9 2. Cote P, Cassidy J, Carroll L. The factors associated with neck pain and its related
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13 3. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan
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15 SD. Expenditures and health status among adults with back and neck problems. JAMA
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17 2008; 299: 656-664
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19 4. Fejer R, Ohm-Kyvik K, Hartvigsen J. The prevalence of neck pain in the world
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42 Rodríguez-Blanco C. Immediate effects on neck pain and active range of motion
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48 8. Evans R, Bronfort G, Nelson B, Goldsmith CH. Two-year follow-up of a randomized
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3 pain: non-invasive interventions: results of the Bone and Joint Decade 2000-2010 Task
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9 Palomeque-del-Cerro L, Méndez-Sánchez R. Inclusion of thoracic thrust manipulation
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13 neck pain: A randomized clinical trial. Man Ther 2009; 14: 306-313
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15 11. González-Iglesias J, Fernández-de-las Peñas C, Cleland J, Gutiérrez-Vega M. Thoracic
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19 clinical trial. J Orthop Sports Phys Ther 2009; 39: 20-27
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21 12. Krauss J, Creighton D, Ely JD, Podlewska-Ely J. The immediate effects of upper
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25 randomized clinical trial. J Man Manip Ther 2008; 16: 93-99
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27 13. Lau HM, Wing Chiu TT, Lam TH. The effectiveness of thoracic manipulation on
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29 patients with chronic mechanical neck pain: a randomized controlled trial. Man Ther
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38 Man Ther 2010; 15: 315-333
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40 15. Cross KM, Kuenze C, Grindastaff TL, Hertel J. Thoracic spine thrust manipulation
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42 improves pain, range of motion, and self-reported function in patients with mechanical
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44 neck pain: a systematic review. J Orthop Sports Phys Ther 2011; 41: 633-42.
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46 16. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinical
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48 prediction rule for guiding treatment of a subgroup of patients with neck pain: use of
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50 thoracic spine manipulation, exercise, and patient education. Phys Ther 2007; 87: 9-23.
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52 17. Tseng YL, Wang WT, Chen WY, Hou TJ, Chen TC, Lieu FK. Predictors for the
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54 immediate responders to cervical manipulation in patients with neck pain. Man Ther
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3 18. Puentedura EJ, Landers MR, Cleland JA, Mintken PE, Huijbregts P, Fernández-de-las-
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5 Peñas C. Thoracic spine manipulation versus cervical spine thrust manipulation in
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7 patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther
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9 2011; 41: 208-220
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11 19. Fernández-de-las-Peñas C, Cleland JA, Glynn P. Spinal manipulative therapy: from
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13 research to clinical practice. Crit Rev Phys Rehabil Med 2008; 20 : 39-53
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15 20. Jensen MP, Turner JA, Romano JM, Fisher L. Comparative reliability and validity of
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For Peer Review

17 chronic pain intensity measures. Pain 1999; 83: 157-162
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19 21. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J
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21 Manipulative Physiol Ther 1991; 14: 409-415
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23 22. Werneke MW, Hart DL, Cook D. A descriptive study of the centralization phenomenon:
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25 a prospective analysis. Spine 1999; 24: 676-683
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27 23. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability
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29 Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Arch Phys
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Med Rehabil 2008; 89: 69-74
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24. Macdemid JC, Walton DM, Avery S, Blanchard A, Etruw E, Mcalpine C, Goldsmith
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38 Orthop Sports Phys Ther 2009; 39: 400-417
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40 25. De-la-Llave-Rincón AI, Fernández-de-las-Peñas C, Palacios-Ceña D, Cleland JA.
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42 Increased forward head posture and restricted cervical range of motion in patients with
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44 carpal tunnel syndrome. J Orthop Sports Phys Ther 2009; 39: 658-64
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46 26. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Forward head
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48 posture and neck mobility in chronic tension-type headache: a blinded, controlled study.
49
50 Cephalalgia 2006; 26: 314-9
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52 27. Audette I, Dumas JP, Côté JN, De Serres SJ. Validity and between-day reliability of
53 the
54 cervical range of motion (CROM) device. J Orthop Sports Phys Ther 2010; 40: 318-23
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28.
3 Mintken PE, DeRosa C, Little T, Smith B. AAOMPT clinical guidelines: A model for
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5 standardizing manipulation terminology in physical therapy practice. J Orthop Sports
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7 Phys Ther 2008; 38: A1-6.
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9 29. Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic
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11 nonspecific low back pain result in better long-term outcome? Spine 2011; 36: 1427-37
12
30. Bialosky JE, Bishop MD, Price DD et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive
13
14
model. ManTher 2009; 14: 531-8.
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16

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17 31. Bialosky JE, George SZ, Bishop MD. How spinal manipulative therapy works: why ask
18
19 why? J Orthop Sports Phys Ther 2008; 38:293-5.
20
21 32. Teodorczyk-Injeyan JA, Injeyan HS, Ruegg R. Spinal manipulative therapy reduces
22
23 inflammatory cytokines but not substance P production in normal subjects. J
24
25 Manipulative Physiol Ther 2006; 29: 14-21
26
27 33. Degenhardt BF, Darmani NA, Johnson JC et al. Role of osteopathic manipulative
28
29 treatment in altering pain biomarkers: a pilot study. J Am Osteopath Assoc 2007; 107:
30
31
387-400.
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33
34. Fernandez-de-las-Penas C, Perez-de-Heredia M, Brea-Rivero M et al. Immediate effects
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35
on pressure pain threshold following a single cervical spine manipulation in healthy
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38 subjects. J Orthop Sports Phys Ther 2007; 37: 325-9
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40 35. Fernández-de-las-Peñas C, Alonso-Blanco C, Cleland JA, Rodríguez-Blanco C,
41
42 Alburquerque-Sendín F. Changes in pressure pain thresholds over C5-C6
43
44 zygapophyseal joint following a cervico-thoracic junction manipulation in healthy
45
46 subjects. J Manipulative Physiol Ther 2008; 31: 332-7
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48 36. Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for neck pain: A
49
50 systematic review. Man Ther 20120; 15: 334-354.
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5 Legend of Figures
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7 Figure 1: Upper thoracic spine manipulation
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9 Figure 2: Cervico-thoracic junction manipulation
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11 Figure 3: Mid-cervical spine manipulation
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13 Figure 4: Flow diagram of subjects throughout the course of the study
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Table 1: Baseline demographics for both groups*
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12 Clinical Manipulative Group Cervical Manipulative Group P values
13 (n=41) (n=41)
14 Gender (Male / Female) 21/20 20/21 0.906
15
16 Age (years) 45 ± 8 44 ± 9 0.812
17 83 ± 7 77 ± 7 0.684
Duration of symptoms (months)
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19 Neck pain** 4.9 ± 1.1 4.8 ± 1.5 0.903
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21 Neck Disability Index*** 22.2 ± 11.6 23.7 ± 4.1 0.392
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Cervical range of motion (degrees)
23
24 Flexion 54.4 ± 11.0 55.6 ± 10.7 0.608
25
26 Extension 56.0 ± 7.6 56.8 ± 8.7 0.711
27 37.9 ± 5.3 39.1 ± 8.6 0.426
Right lateral-flexion
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29 Left lateral-flexion 38.5 ± 5.4 39.7 ± 7.6 0.409
30
31 Right rotation 68.0 ± 10.8 70.6 ± 12.4 0.423
32 71.2 ± 11.6 71.4 ± 13.7 0.951
Left rotation
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36 * Data are mean SD except for gender.
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6 Table 2: Baseline, 7-days post-treatment, and change scores for neck pain, disability, and cervical range of motion
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8 Outcome Group Baseline 7-days post-treatment Within Group Change Scores Between-Group Change Scores
9 Pain (0-10 points)
10 Clinical Manipulative 4.9 ± 1.1 2.7 ± 1.5 -2.2 (-2.8, -1.8) 0.1 (0.0, 0.3)

For
11 Cervical Manipulative 4.8 ± 1.5 2.7 ± 1.3 -2.1 (-3.5, -1.4)
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Neck Disability Index (0-50 points)
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14 Clinical Manipulative 22.2 ± 11.6 11.6 ± 8.9 -10.6 (-13.1, -7.9) 3.7 (1.5, 6.8)*
15 Cervical Manipulative 23.7 ± 4.1 16.8 ± 3.9 -6.9 (-8.3, -5.3)

Peer
16 Cervical Flexion (deg)
17 Clinical Manipulative 54.4 ± 11.0 56.8 ± 9.0 2.4 (1.2, 4.3) 0.5 (-2.3, 2.5)
18 Cervical Manipulative 55.6 ± 10.7 57.5 ± 7.8 1.9 (0.5, 3.6)
19 Cervical Extension (deg)
20 Clinical Manipulative 56.0 ± 7.6 60.0 ± 10.8 4.0 (2.1, 6.3) 1.8 (-2.8, 4.8)
21 Cervical Manipulative 56.8 ± 8.7 62.6 ± 9.4 5.8 (2.0, 8.2)

Review
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Cervical Right Lateral Flexion (deg)
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24 Clinical Manipulative 37.9 ± 5.3 41.4 ± 9.7 3.5 (1.1, 6.0) 2.7 (1.1, 5.9)
25 Cervical Manipulative 39.1 ± 8.6 45.3 ± 7.8 6.2 (3.8, 8.5)
26 Cervical Left Lateral Flexion (deg)
27 Clinical Manipulative 38.5 ± 5.4 40.2 ± 8.3 1.7 (0.5, 2.9) 0.6 (-2.3, 3.7)
28 Cervical Manipulative 39.7 ± 7.6 42.0 ± 6.9 2.3 (0.2, 4.5)
29 Cervical Right Rotation (deg)
30 Clinical Manipulative 68.0 ± 10.8 75.4 ± 12.3 7.4 (2.9, 9.7) 0.5 (-4.4, 5.3)
31 Cervical Manipulative 70.6 ± 12.4 77.5 ± 10.0 6.9 (3.7, 10.2)
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Cervical Left Rotation (deg)
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Clinical Manipulative 71.2 ± 11.6 76.3 ± 11.9 5.1 (2.1, 7.8) 2.5 (-1.8, 6.7)
35 Cervical Manipulative 71.4 ± 13.7 79.0 ± 9.7 7.6 (4.1, 11.1)
36
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38 Values are expressed as mean ± standard deviation for Baseline and immediate post-treatment means and as mean (95%
39 confidence interval) for within- and between-group change scores / * Significant Group * Time interaction (ANOVA, P < 0.05)
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 IV. Pain Intensity, Physical Impairment and Pain-Related Fear to
Function in Patients with chronic Mechanical Cervical Pain.

Autores: Saavedra-Hernández, Castro-Sánchez AM, Cuesta-Vargas AI, Cleland J,

Fernández-de-las-Peñas C, Arroyo-Morales M. Amercian Journal Physical Medicne &
Rehabilitation. En Revisión.

119
 1 The Contribution of Previous Episodes of Pain, Pain Intensity, Physical

2 Impairment and Pan-Related Fear to Disability in Patients with Chronic

3 Mechanical Neck Pain

4 Authors:

5 Manuel Saavedra-Hernández1 MsC; Adelaida M. Castro-Sánchez1 PhD; Antonio I. Cuesta-

6 Vargas 2 PhD; Joshua A Cleland3 PT, PhD; César Fernández-de-las-Peñas4 PT, PhD; Manuel

7 Arroyo-Morales5 PT, PhD.

8 Affiliations:

9 (1)Department of Physical Therapy, Universidad of Almería, Spain (Dr. Saavedra-

10 Hernández; Dr. Castro-Sánchez)

11 (2)Department of Physical Therapy, Universidad of Málaga, Spain (Dr. Cuesta-Vargas)

12 (3)Department of Physical Therapy, Franklin Pierce University, Concord, NH, USA (Dr.

13 Cleland)

14 (4)Department of Physical Therapy, Occupational Therapy and Rehabilitation, University

15 Rey Juan Carlos, Alcorcón, Spain (Dr. Fernández-de-las-Peñas)

16 (5)Department of Physical Therapy, School of Health Sciences, University of Granada,

17 Granada, Spain (Dr. Arroyo-Morales),

18

19 Correspondence: Manuel Arroyo Morales, PhD, Departamento de Fisioterapia, Universidad

20 de Granada, Avda. Madrid s/n, 18014, Granada, Spain, e-mail: marroyo@ugr.es

21

22 Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest

23 have been reported by the authors or by any individuals in control of the content of this

24 article.

25 No conflicts of interest
1
26 The Contribution of Previous Episodes of Pain, Pain Intensity, Physical

27 Impairment and Pan-Related Fear to Disability in Patients with Chronic

28 Mechanical Neck Pain

29

30 ABSTRACT

31 Objective: The influence of physical and psychosocial variables on self-rated disability in

32 patients with chronic mechanical neck pain has not been fully determined. This study

33 examined the relationship between pain, physical impairment, and pain-related fear to

34 disability in individuals with chronic mechanical neck pain.

35 Design: A cross-sectional was conducted. One hundred-twenty (n=120) subjects (35 male, 85

36 female; age: 39 years) with chronic mechanical neck pain were prospectively recruited.

37 Demographic information, duration of symptoms, pain intensity, pain-related fear and

38 cervical range of motion (ROM) were collected. Self-reported disability was measured with

39 the Neck Disability Index (NDI). Correlation and regression analysis were performed to

40 determine the association between the variables and to determine the proportions of explained

41 variance in disability.

42 Results: Significant positive correlations between disability and prior history of neck pain

43 (r=0.59; P<0.001), disability and pain intensity (r=0.22, P=0.01), and disability and

44 kinesiophobia (r=0.21, P=0.02) were found. Further, a significant negative correlation

45 between disability and cervical extension ROM (r =-0.19, P=0.04) was also observed.

46 Stepwise regression analyses revealed that previous neck pain episodes, the intensity of neck

47 pain, kinesiophobia and cervical extension ROM were significant predictors of disability

48 (r2=0.452; r2 adjusted=0.433; F=22.91; P<0.001).

2
49 Conclusions: This study found that previous episodes of neck symptoms, pain intensity,

50 pain-related fear and cervical extension ROM explained 45% of the variability of self-report

51 disability. Longitudinal studies will help to determine the clinical implications of these

52 findings.

53 Keywords: neck pain; disability; range of motion; kinesiophobia.

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72 The Contribution of Previous Episodes of Pain, Pain Intensity, Physical
73 Impairment and Pan-Related Fear to Disability in Patients with Chronic
74 Mechanical Neck Pain
75

76 INTRODUCTION

77 Neck pain is a common problem which most people experience at some point in their

78 life. Most cases appear to run a chronic-episodic course.1 Neck pain and its related disability

79 have a huge impact on individuals, their families, communities, health-care systems, and

80 economy.2,3 The point prevalence of neck pain in the general population in high-income

81 countries has been reported to be 27.2% in females and 17.4% in males, while in low- and

82 middle-income countries the mean has been shown to be 17.5%.1 Neck pain results in severe

83 disability in 5 % of affected people.4 A better understanding of physical and psychological

84 impairments associated with neck-related disability can potentially assist clinicians in

85 determining adequate therapeutic programs in this group of patients.

86 Previous research has shown that different demographic and socioeconomic factors

87 such as gender or age have prognostic value in patients with neck pain.4 It is also plausible

88 that clinical characteristics of neck pain, e.g., intensity, duration of symptoms, or number of

89 previous episodes have also an influence in the prognosis for patients with neck pain.5-7 The

90 potential influence of these factors warrants further investigation.

91 The fear avoidance model explains that avoidance of pain and painful activities

92 because of fear leads to physical and psychological consequences in patients with pain.8

93 Research has demonstrated that the fear avoidance model can be applied to patients with neck

94 pain.9,10 Chronic pain could produce a hipervigilance which perpetuates a vicious cycle.11

95 Howell et al.12 have recently examined the fear avoidance model in a cohort of individuals

96 with neck pain. In that study, self-rated disability in patients with chronic neck pain was

97 found to be correlated with fear-avoidance beliefs and with impairment measures-ranges of

4
 98 motion in the cervical spine. However, the small sample size (n=35) does not allow for

99 determining a definitive model relative to the potential implications of these variables in

100 neck-related disability.

101 It has been reported that neck pain has also been associated with an alteration in spinal

102 movements including reduced rotation, extension and retraction as compared to healthy

103 people.13 Decrease in cervical rotation has been confirmed in a group of female office

104 workers with neck pain.14 Other studies had added different outcomes and aspects of cervical

105 mobility15 or increased coupling motion.16 A negative correlation between a reduction in

106 cervical range of motion and disability has been proposed.13 However, the contribution of

107 decreased cervical range of motion in neck-related disability has not been previously studied.

108 Pain-related fear and reduced cervical range of motion are potentially modifiable risk

109 factors for the development of chronic disability in patients with neck pain. For this reason,

110 the purpose of the current study was to examine the relationship of pain-related fear, pain

111 intensity and cervical range of motion to disability-related chronic mechanical neck pain in

112 an outpatient orthopedic rehabilitation population.

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123 METHODS

124 Participants

125 A cross-sectional design was used in the current study. One hundred and twenty-two

126 patients from the Cervical Pain Clinic Study at University of Almeria participated. Eligible

127 participants had to present with a report of neck and shoulder pain provoked by neck

128 postures, neck movement, or palpation of the neck musculature. Exclusion criteria were as

129 follows: 1, history of cervical surgery or whiplash injury; 2, medical diagnosis of cervical

130 radiculopathy or myelopathy; 3, diagnosis of fibromyalgia; 4, evidence of central nervous

131 system involvement and signs consistent with nerve root compression. All subjects read and

132 signed a consent form, and this study was approved by the ethics board of the Universidad de

133 Almería.

134 Data collection

135 Eligible participants were first contacted by telephone, and those who agreed to

136 participate were scheduled for initial testing appointment. Upon arrival they received a

137 complete explanation of the study protocol and signed the consent form. Demographic and

138 clinical characteristics were self-reported. If clinical and self-reported data were not

139 consistent, we gave precedence to the clinical data.

140 Measurements

141 The NPRS (range, 0: no pain; 10: maximum pain) was used to assess the mean

142 spontaneous neck pain intensity. The NPRS has been shown to be a reliable and valid method

143 for pain assessment.17

144 The NDI consist of 10 questions measured on a 6-point scale (0: no disability; 5: full

145 disability).18 The numeric score for each item is summed for a total score varying from 0 to

146 50, where higher scores reflect greater disability. The NDI has demonstrated to be a reliable

147 and valid self-assessment of disability in individuals with neck pain.19

6
148 Finally, we used the 11-item TSK that assesses fear of movement or of injury or

149 reinjury.20 Individuals rate each item on a 4-point Likert scale, with scoring alternatives

150 ranging from “strongly disagree” to “strongly agree.” Test-retest reliability for the TSK has

151 been shown to be high.20

152 The clinical history included questions regarding the onset, nature and location of the

153 symptoms, aggravating and relieving factors, and previous history of neck pain. A physical

154 therapist with more than fifteen year of experience in the management of patients with neck

155 pain assessed the cervical range of motion with a cervical range of motion goniometer

156 (CROM) which has shown to exhibit intra-tester reliability between 0.87 and 0.96 in

157 individuals with neck pain.21

158 Statistical Analysis

159 Means and standard deviations were calculated to describe the sample. Pearson

160 product Correlation coefficients were calculated to determine relationships between the

161 dependent measure (disability) and the following independent variables: age, gender,

162 previous episodes, days from symptoms onset, perceived pain, kinesiophobia, cervical range

163 of motion (ROM) and body mass index. Similar analyses were used to examine relationships

164 between independent variables to check for multicollinearity and shared variance between the

165 measures.

166 A regression model was used to determine the independent variables that contributed

167 significantly to variance in self-rated disability. A hierarchical regression analysis examined

168 the proportions of explained variance in NDI score. To analyze the unique contribution of

169 pain-related fear to function beyond demographics, intensity of pain, and impairment

170 measures, independent variables were entered into the regression model in 4 steps. Presence

171 of previous episodes variable was entered into the model at the first step, followed by pain

172 intensity (step 2) and extension ROM (step 3). Finally, kinesiophobia (TSK-11 score) was
7
173 added in the forth step. Changes in R2 were reported after each step of the regression model to

174 determine the influence of some additional variables. Last, variables that significantly

175 contributed to neck disability were selected for inclusion in a parsimonious final regression

176 model. The significance criterion of the critical F value for entry into the regression equation

177 was set at P < 0.05. All analyses were performed using IBM SPSS Statistics 19.0.

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198 RESULTS

199 Demographic data and mean impairment and outcome measure scores are listed in

200 Table 1. Thirty five males and eighty -five females were included in the study. Mean age of

201 the sample was 39 years (range, 19-59 years). Symptom onset was higher than or equal to 3

202 months for 97 individuals (80.8%). Seventy-three (63.3%) patients presented between 1 to 3

203 previous neck pain episodes and twenty-eight (23.3%) patients presented more than 10

204 previous episodes of neck pain.

205 Correlational Analyses

206 Significant positive correlations between disability and prior history of neck pain

207 (r=0.59; p<0.001), disability and pain (r=0.22, P=0.01), disability and kinesiophobia (r =0.21,

208 P=0.02) were identified: the higher number of previous neck pain episodes, the higher

209 intensity of pain or the higher kinesiophobia, the greater the self-rated disability.

210 Furthermore, a significant negative correlation between disability and extension cervical

211 ROM (r=- 0.19, P=0.04) was also found: the lower the cervical extension, the greater the

212 disability.

213 In addition, significant correlations existed among the independent variables (r = -

214 0.19< r < 0.59; Table 2), but none were considered to be multicollinear (defined as r > 0.80);

215 therefore, each one variable was included in regression analyses.

216 Regression Analyses

217 Stepwise regression analyses revealed that previous neck pain episodes, intensity of

218 neck pain, kinesiophobia and cervical extension ROM were significant predictors of

219 disability, and when combined, they explained 43.3% of the variance in self-perceived

220 disability scores (r2=0.452; r2 adjusted=0.433; F=22.91; P<0.001) (Table 3).

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222
9
223 DISCUSSION

224 The objective of the current study was to investigate the relationships between

225 disability and clinical characteristics including cervical range of motion, pain intensity and

226 kinesiophobia in patients suffering from chronic mechanical neck pain. Our sample of

227 participants exhibited a moderate intensity of pain22 and disability, 18

a low level of

228 kinesiophobia23 and reduced range of motion in flexion, extension and side bending of the

229 cervical spine.24 In our sample, 98.3% of patients with neck pain patients reported moderate

230 disability following criteria previously reported by Vernon et al.18 Similar levels of disability

231 have been reported in a previous study.25

232 We found significant low to moderate positive associations between disability,

233 presence of previous episodes of neck pain, the intensity of current neck pain, and also

234 kinesiophobia and a negative association between disability and cervical extension. In fact,

235 results from the regression analyses showed that presence of previous neck pain episodes;

236 pain intensity, kinesiophobia and cervical extension ROM were significant predictors of

237 neck-pain disability. We found that age, sex, and duration of symptoms do not influence

238 neck-related disability which agree with studies conducted in patients with chronic whiplash

239 associated disorders26 and neck pain.25

240 Our findings also support an association between the presence of previous pain

241 episodes and neck pain disability.27-30 Furthermore, Bot et al. identified that patients who at

242 baseline reported a previous episode of neck pain were significantly more likely to still be

243 experiencing pain at a 3 month and 12 month follow-up period.30 We also found that cervical

244 range of motion may also influence neck disability similarly to the findings of others.31,32 It is

245 plausible that a history of repeated episodes of neck pain and reduced cervical range of

246 motion could be indicative of a lack of recovery from previous bouts of neck pain as well as

10
247 the persistent nature of mechanical neck pain. Methods to prevent patients with this clinical

248 presentation from progressing to chronicity require further attention in the literature.

249 Our results further support that fear-avoidance attitudes play an important role in

250 current self-ratings of neck-pain disability in patients with chronic mechanical neck pain

251 which is similar to the findings in patients with whiplash.26,32 This suggests that it may be

252 essential for clinicians to understand the importance of these psychosocial issues when

253 managing patients with both acute and chronic neck pain.33 It is possible that if fear-

254 avoidance attitudes are identified in the acute stage and managed accordingly, it could

255 prevent the development of chronic symptoms. However, this hypothesis required further

256 investigation.

257 The results of the current study indirectly suggest that the biopsychosocial model

258 which recognizes that individuals exhibit a combination of somatic and psychological factors

259 influenced by social context, may be beneficial in the management of patients with neck-

260 related disability.34,35 The identification of patients at risk for prolonged disability may allow

261 for appropriate management strategies and potentially enhanced the outcomes. Clinicians

262 need to develop multimodal therapeutic strategies combining therapeutic exercise directed at

263 musculoskeletal impairments, e.g., reduced range of motion, and cognitive educational

264 programs to reduce the influence of exaggerated pain perception to determine the

265 effectiveness of preventing prolonged neck-pain disability.

266 There are a number of limitations that should be recognized. First, we used a cross-

267 sectional design. In fact, because of the sample size, the number of independent variables

268 included in the regression analysis was limited to reduce the like hood of type II error.

269 Further, due to the cross-sectional study design, a cause and effect relationships between

270 those variables associated with prolonged disability cannot be inferred. Second, since all

271 patients were outpatient orthopedic rehabilitation population, extrapolation of the current
11
272 results to the general population should be considered with caution. Finally, other potential

273 variables, such as sleep disturbances, 36 were not included in this study.

274

275 In summary, the current study examined the influence of cervical range of motion,

276 as well as the role of pain related-fear and different clinical variables on self-reported

277 disability in individuals with chronic mechanical neck pain. Previous episodes of symptoms,

278 pain intensity, pain related fear and cervical extension range of motion explained 45% of the

279 variability of self-report disability. Future longitudinal studies will help to determine the

280 clinical implications of these findings.

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390

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 Table 1: Demographics and Baseline Variable Scores

Mean (95% CI) SD

Age (years) 39.3 (37.7 - 40.9) 8.8
Body mass Index (Kg*m-2) 24.5 (23.7 - 25.2) 4.0
Numerical Pain Rat Scale (NPRS, 0.10) 5.3 (5.0 - 5.6) 1.9
Tampa Scale of Kinesiophobia (TSK-11, 11-44) 24.3 (22.9 - 25.6) 7.3
Neck Disability Index (NDI, 0-50) 16.5 (15.4 - 17.5) 5.3
ROM Neck flexion (º) 54.1 (52.3- 55.9) 9.8
ROM Neck extension (º) 49.8 (47.2 - 52.4) 14.2
ROM Neck right side flexion (º) 38.1 (36.7 - 39.5) 7.6
ROM Neck left side flexion (º) 38.8 (37.7 - 39.9) 5.9
ROM Neck right rotation (º) 69.9 (67.8-72.1) 11.7
ROM Neck left rotation (º) 72.7 (70.5-74.9) 12.1

ROM: range of motion

1
 Table 2: Pearson-Product Moment Correlation Matrix for Study Variable

Variable NDI NPRS TSK ROM ROM ROM ROM ROM ROM Gender Age BMI Previous Cronicity
Flexion Extension Side right Side left Rotation Rotation episodes
right Left
NDI 1.00 0.218* 0.209* 0.001 ‐0.182* ‐0.045 ‐0.073 ‐0.118 0.017 0.019 0.114 0.021 0.588** 0.115
NPRS 0.218* ‐‐ 0.187* 0.177 0.014 0.075 0.115 0.026 0.040 0.091 0.030 ‐0.091 0.029 ‐0.145
TSK 0.209* 0.187* ‐‐ ‐0.001 0.011 0.048 0.040 ‐0.021 ‐0.065 ‐0.101 0.094 ‐0.064 0.043 ‐0.113

ROM 0.001 0.117 ‐0.001 ‐‐ 0.133 0.418** 0.290** 0.259** 0.309** 0.012 ‐0.033 ‐0.086 0.081 0.109
Flexion
ROM ‐0.182* 0.014 0.011 0.133 ‐‐ 0.409** 0.466** 0.209* 0.171 0.015 0.013 ‐0.080 0.051 0.007
Extension
ROM ‐0.045 0.075 0.048 0.418* 0.409** ‐‐ 0.498** 0.367** 0.357** ‐0.021 ‐0.136 ‐0.067 0.054 ‐0.011
Side Right
ROM ‐0.073 0.115 0.040 0.290* 0.466** 0.498** ‐‐ 0.271** 0.298** ‐0.023 ‐0.115 0.006 ‐0.043 ‐0.073
Side Left
ROM ‐0.118 0.026 ‐0.021 0.259* 0.209* 0.367** 0.271** ‐‐ 0.621** 0.073 ‐0.209* ‐0.073 0.022 0.080
Rotation
Right
ROM 0.017 0.040 ‐0.065 0.309* 0.171 0.357** 0.298** 0.621** ‐‐ 0.113 ‐0.055 ‐0.011 0.162 0.231*
Rotation
Left
Gender 0.019 0.091 ‐0.101 0.012 0.015 ‐0.021 ‐0.023 0.073 0.113 ‐‐ 0.066 ‐0.155 ‐0.042 0.148
Age 0.114 0.030 0.094 ‐0.033 0.013 ‐0.136 ‐0.115 ‐0.209* ‐0.055 0.066 ‐‐ 0.370** 0.050 ‐0.040
BMI ‐0.006 ‐0.145 ‐0.151 0.080 ‐0.156 ‐0.009 0.006 0.073 ‐0.011 ‐0.155 0.370** ‐‐ 0.065 0.015
Previous 0.588* 0.029 0.043 0.081 0.051 0.054 ‐0.043 0.022 0.162 ‐0.042 0.050 0.065 ‐‐ 0.245**
Episodes
Chronicity 0.115 ‐0.145 ‐0.113 0.109 0.007 ‐0.011 ‐0.011 0.080 0.231* 0.148 ‐0.040 0.015 0.245** ‐‐

* P < 0.05; ** P < 0.01

2
 Table 3: Summary of Stepwise Regression Analyses to Determine Predictors of Disability, r 2= 43.3 %

Independent Variable β 95% CI t P

Intercept 10.18 5.86, 14.50 4.67 <0.001
Previous neck pain episodes* 2.39 1.83,2.96 8.28 <0.001
Perceived Pain 0.65 0.18, 1.13 2.75 0.007
Tampa Scale of Kinesiophobia 0.10 -0.01, 0.21 1.96 0.048
Extension Cervical Range of Motion - 0.08 -0.13, -0.02 -2.90 0.004

* Previous neck pain episodes coded as: (0) not previous episodes, (1) 1-3 prior episodes, (2) 3-10 episodes, (4) more than 4 episodes.

3
CONCLUSIONES
I. La regla de predicción clínica para el dolor mecánico cervical susceptible de mejora

mediante técnica de manipulación espinal aplicada en nivel medio cervical, charnela

cérvico-dorsal y dorsales altas, ha identificado cinco variables potencialmente predictoras

de éxito terapéutico, como son hipomovilidad en T1, test neurodinámico de miembro

superior negativo, extensión cervical inferior a 46º, una valoración de 4,5 puntos en la

escala NPRS, y pertenecer al sexo femenino.

II. Los pacientes con dolor mecánico cervical que recibieron manipulación espinal a nivel

cervical-medio y en charnela cérvico-dorsal, exhibieron similares resultados en rango de

movilidad cervical, reducción de la intensidad del dolor y discapacidad, respecto del grupo

que recibió Kinesio Taping. Los cambios en el dolor cervical fueron superiores al rango

establecido como diferencia clínica mínimamente importante. Sin embargo, los cambios

obtenidos en la discapacidad fueron ligeramente inferiores a los establecidos como

diferencias mínimas clínicamente importantes.

III. La aplicación de una manipulación espinal a nivel cervical medio fue igualmente

efectiva en la reducción del dolor cervical y en el aumento del rango del movimiento,

comparado con la aplicación combinada de técnicas de manipulación espinal dirigidas al

segmento cervicotorácico. Sin embargo, la mejora de la discapacidad fue mayor en los

pacientes que recibieron la técnica combinada de manipulación espinal en el segmento

cervicotorácico.

139
IV. La discapacidad percibida en el paciente con dolor mecánico cervical está relacionada

con haber padecido episodios previos de dolor, miedo al dolor, episodio actual de dolor

intenso y dolor en el rango de movimiento de extensión cervical.

V. En definitiva podemos concluir que la terapia manipulativa espinal y el kinesio taping

son procedimientos terapéuticos efectivos para el dolor mecánico cervical, debido a que se

obtienen resultados similares en la reducción de la intensidad del dolor percibida por el

paciente, y en los cambios producidos en el rango de movimiento; obteniendo como

salvedad, una mejora en la discapacidad mediante la técnica combinada de manipulaciones

espinales cérvico-dorsales.

140
AGRADECIMIENTOS

Nunca imaginé que me resultara tan difícil transformar en unas cuantas palabras este
profundo sentimiento de agradecimiento a tantas personas que han garantizado que este
sueño se cumpla.

Una vez que me enfrento a esta situación y echo un vistazo hacia atrás, me es imposible
evitar una sonrisa que nace desde lo más profundo de mí. No paran de aparecer caras y
momentos vividos, circunstancias que me han conducido a este preciso instante y que
me hacen pronunciar constantemente: GRACIAS.

Ha sido un proyecto muy importante para mí, que ha visto la luz gracias al esfuerzo de
gente también muy especial cuyo amor, entusiasmo, energía y pericia, han hecho
posible que esto sea una realidad.

Vuestro apoyo, compromiso y sentido del éxito, me conmueve de veras. Vuestra leal
confianza y voluntad de abrirme vuestra mente y vuestro corazón, me ha aportado la
fuerza necesaria para no rendirme nunca.

Gracias por aportar tanta positividad a mi vida.

A mi director Manuel Arroyo, por ser una fuente de inspiración constante para mí. Por
tu incansable y continuado esfuerzo que siempre me conducen hacia la grandeza. Por
ser un ejemplo vivo de integridad y superación. Por ir siempre por delante allanando el
camino. Por tu gratuidad y generosidad conmigo (nunca olvidaré la mañana de los
sellos). Gracias por ayudarme a alcanzar mis retos y ser mi amigo.

A mi directora Adelaida Castro, gracias por tu valiosa e inagotable ayuda (han sido
tantas horas, y… a qué horas), Por tu compromiso y dedicación, Por tu disciplina y
orden. Por garantizar el conocimiento necesario para que esto sea lo que es. Gracias por
tu entrega.

A mi director César Fernández, gracias por brindar tus conocimientos, por hacerlo todo
más fácil, por el apoyo e impulso que le has dado a este trabajo. Gracias porque tus
directrices han hecho esto posible.

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A mi mujer, si hay alguien que ha hecho esta tesis, ha sido Eva. Cuanto apoyo
emocional, cuanto apoyo…, siempre animándome a seguir, siempre alimentando mis
sueños, aguantando el “me tengo que ir” , nadie más que tú sabe lo que esto cuesta, los
desánimos, el no merece la pena, pero tu ahí, dale que dale. A cuántas cosas has
renunciado y no se notaba, siempre mirándome a mí. Siempre juntos, mi vida.

A mis tres hijas, Eva, Beatriz y Miriam, que son las estrellas que iluminan mi alma. Sois
mis verdaderas maestras y la gran motivación que me ayuda cada día a ser un poquito
mejor, a superar el miedo y a romper mis propios límites.

A mis padres, que me lo han dado todo, las raíces para ser quien soy, el coraje para
mirar siempre de frente a la vida, el alma limpia de quien hace las cosas honestamente,
el espíritu de incansable sacrificio, el amor que me hace creer en la misericordia de
Dios, la sencillez y la humildad de quien lo da todo sin esperar nada a cambio. A ti
mamá, a ti papá, gracias por estar siempre a mi lado, gracias por darme la vida. Me
siento orgulloso de ser vuestro hijo.

A mi hermano Ventura, mi compañero de tantas batallas. Gracias por estar siempre ahí
conmigo, incansable, apoyándome incondicionalmente, sin preguntas, nunca pusiste una
pega a mis ausencias. Gracias por ser mi hermano.

A mi hermano Paco, porque a pesar de nuestras distancias y silencios, sé que tu amor y

admiración son de verdad. Gracias por tu generosidad conmigo; sé que cuando te
necesito, acudes sin vacilar. Gracias por ese corazón tan grande que escondes ahí
dentro. Siempre serás mi hermano mayor.

A Antonio Montes, tu fuerza de voluntad y tu tesón han sido un ejemplo para mí.
Gracias por sentirte tan orgulloso de mí (aunque nunca lo dices).

A mi prima Ana, porque con tu alegría y tu amor me hacías sentirme fuerte, me llevaba
a mirar siempre hacia delante. Gracias por quererme.

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A toda mi familia, cuñados y sobrinos, por tantos buenos momentos, por tantas
experiencias vividas, por ayudarme en la vida, por compartir conmigo todo tipo de
vivencias.

A todos mis amigos, por la inmensa suerte de encontraros en mi camino. Qué

afortunado me hacéis sentir. Gracias por vuestro ánimo y entusiasmo y tantos momentos
vividos, que siempre me inspiran a caminar erguido cada día.

A los que no están y que han formado una parte de mi historia. Ejemplos de vida.
Gracias por vuestra Luz espiritual que guía mis pasos y hace que pueda cumplir este y
tantos sueños.

A Nuria, agradecer tu ayuda en esos largos días de toma de datos y echar esas
carcajadas que hacían más fácil las sesiones clínicas. Gracias.

A todos mis compañeros de trabajo, siempre habéis pensado que estaba un poco loco,
no tenéis razón, estoy bastante loco. Gracias por tantas experiencias vitales vividas con
vosotros, por el apoyo clínico con los pacientes, por vuestra amistad a pesar de ser a
veces vuestro jefe.

A los pacientes, en realidad sois el verdadero sentido de toda mi vida profesional, sois el
mejor agradecimiento que se me puede dar, hacéis que ame mi profesión, hacéis que no
entienda otra forma de vida, que me emocione con lo que pasa en los tratamientos, que
me sorprenda con los resultados, alucino con el ser humano, me enseñáis todos los días,
sois el alma del sanador. Gracias por vuestra confianza.

Gracias a mis maestros, desde la infancia hasta hoy, tengo recuerdos muy especiales,
que me hacen también amar la enseñanza, porque aprendes más que enseñas, ojalá un
día alguien se acuerde de mí como yo me acuerdo de vosotros.

A los compañeros de la Universidad de Almería y a su personal de administración por

su ánimo, cooperación y ayuda.

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Gracias a todos por creer en mí.

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