Pragmatically applied cervical and thoracic nonthrust manipulation versus thrust manipulation for patients with mechanical neck pain: a multicenter randomized clinical trial

Key points

1. 01No between-group differences were found on neck disability, pain, function, or deep cervical flexion endurance at any time point
2. 02Both groups improved significantly over time on all primary and secondary outcomes
3. 03The number of treatment visits and total duration of care were similar between groups
4. 04Minor side effects occurred equally in both groups (13 patients each), and no serious adverse events were reported
5. 05Clinician preference for one technique over the other did not alter patient outcomes

How it was conducted

Design

Multicenter randomized clinical trial (Level 1b)

Participants

103 adults with mechanical neck pain, NDI at least 20%, NPRS at least 2/10, from 7 clinics across 6 US states

Groups

Non-thrust manipulation (NTM, n=55) vs thrust manipulation (TM, n=48), both applied pragmatically to the most symptomatic cervical and thoracic level

Primary outcome

Neck Disability Index (NDI) at baseline, visit 2, and discharge

Secondary outcomes

PSFS, NPRS (24-hour average), deep cervical flexion endurance (DCF), GROC, number of visits, duration of care

Analysis

Two-way repeated-measures ANCOVA with clinical equipoise as a covariate

What they found

• No significant between-group difference on NDI (P=.67), PSFS (P=.26), NPRS (P=.25), or DCF (P=.98)
• No significant between-group difference for GROC (P=.77), number of visits (P=.21), or duration of care (P=.61)
• Significant within-subject improvement over time for NDI (difference estimate 17.39; 95% CI 4.5-20.1; P<.001)
• Significant within-subject improvement over time for PSFS (difference estimate 3.1; 95% CI 0.695-3.62; P<.001)
• Significant within-subject improvement over time for NPRS (difference estimate 3.00; 95% CI 0.769-3.45; P<.001)
• Significant within-subject improvement over time for DCF (difference estimate 22.14; 95% CI 2.6-29.0; P<.001)
• 25% of patients (26/103) reported at least one minor side effect; equal distribution across both groups (13 NTM, 13 TM)
• NTM applied to cervical spine lasted on average 4.36 +/- 2.3 minutes (range 1-8 min); thoracic NTM averaged 2.9 +/- 1.9 minutes (range 0.5-10 min)

Limitations

• No long-term follow-up beyond discharge; durability of outcomes is unknown
• Treating clinicians and patients could not be blinded to group allocation, introducing potential performance bias
• Convenience sample rather than a random sample; generalizability may be limited
• Symptom duration was not stratified, so whether acute vs. chronic presentations respond differently is unclear

Why it matters

For patients

Patients with mechanical neck pain can expect similar pain relief and functional recovery whether their therapist uses hands-on thrust or gentler oscillatory techniques, as long as the treatment is tailored to their specific symptoms.

For clinicians

Clinicians can apply either thrust or non-thrust manipulation based on patient preference, tolerance, or contraindications without compromising outcomes when using a pragmatic, patient-specific approach targeting the symptomatic spinal level.

For readers

The equivalence of NTM and TM in a pragmatic multi-site RCT suggests that technique selection criteria beyond patient safety and preference may not meaningfully influence short-term neck pain outcomes.