Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Non-specific chronic neck pain is a prevalent musculoskeletal dysfunction commonly described as pain in the lateral or posterior aspect of the neck. Neck pain acquires the label of chronicity when the duration of painful symptoms last longer than 12 weeks. Non-specific chronic neck pain (NCNP) has generated a substantial socioeconomic burden, as the number of prevalent cases of neck pain worldwide was estimated to be 288.7 million in 2015. The recurrence, progression, and underlying mechanisms for non-specific chronic neck pain are not well understood in the available evidence-based literature. However, many clinicians have theorized that NCNP may be associated with a deficiency in the proprioceptive abilities of the neck muscles; these muscles play a decisive role in the cervical joint position and motor control of the head.

There have been numerous studies conducted to evaluate the clinical efficacy of manual therapy and therapeutic exercise on patients with non-specific chronic neck pain. However, few research articles have appraised the time of action along with duration of effects for both manual therapy and therapeutic exercise. Manual therapy is known to reduce inflammatory biomarkers and alter activity in the pain processing centers of the brain, whereas therapeutic exercise assists with proper motor pattern reorganization along with structural adaptations to increase muscular strength. The aim of this randomized controlled trial was to compare the effects of these two different treatments for patients with NCNP in different stages of follow-up appointments.

Inclusion criteria for the study required participants between the ages of 18 and 50, with current neck pain that has continued for the past 12 weeks. Participants could only receive their assigned treatment of either manual therapy or therapeutic exercise and were prohibited from combining their assigned treatments with pharmacological adjuncts. A total of 65 participants completed the randomized controlled trial with 22 participants in the manual therapy group, 23 participants in the therapeutic exercise group, and 20 participants in the control group (sham treatment). There were numerous major outcomes analyzed in this study: pain levels using the Visual Analog Scale (VAS), pain pressure threshold (PPT), and level of neck disability utilizing the Neck Disability Index (NDI).

The treatment for the manual therapy group consisted of high thrust manipulation to the upper thoracic spine, mobilization of the upper cervical spine, and providing gentle distraction force to inhibit overactive suboccipital muscles of the neck. The treatment for the therapeutic exercise group consisted of exercises that focused on increased motor recruitment of the deep cervical neck flexor muscles. This therapeutic exercise group then progressed to isometric co-contraction exercises of the deep and superficial neck flexors, finally ending with eccentric motor recruitment of necks flexors and extensors in the final stage of their protocol. Patients assigned to the control group received treatment 1 (manual therapy) or 2 (therapeutic exercise) after completing the study.

The results of this study showed clear clinical efficacy for the therapeutic exercise and manual therapy treatment groups in comparison to the control group for patients with non-specific chronic neck pain. The researchers found that the level of neck disability in patients, measured through the Neck Disability Index (NDI), was more immediately reduced in the therapeutic exercise group compared to the manual therapy group. However, the manual therapy group created a more immediate reduction in patient’s painful symptoms measured through the VAS pain scale and pain pressure threshold.

Clinical Application:

Therapeutic exercise may help to reduce cervical disability in the short term before manual therapy, whereas manual therapy may help reduce pain perception in the short term before therapeutic exercise. This trend should be taken into consideration when crafting a treatment plan for patients with NCNP. However, an evidence-based, multimodal approach combining manual therapy, therapeutic exercise, and pain education could be the best therapeutic weapon for subjects with nonspecific chronic neck pain.


Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial. Trials. 2020;21(1):682. Published 2020 Jul 28. doi:10.1186/s13063-020-04610-w

Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Dry needling is an innovative treatment technique utilized by various healthcare practitioners such as physical therapists, physicians, and chiropractors. Dry needling is implemented by inserting needles into painful areas of muscle perceived to have motor abnormalities in an attempt to restore normal muscle function and alleviate higher levels of pain. These painful areas of muscle are more commonly referred to as myofascial trigger points by clinicians.

There is a growing body of new evidence and research that reinforces the clinical effectiveness of dry needling for various musculoskeletal conditions such as low back pain. However, there have been limited studies that evaluate the effect of dry needling on soft tissue stiffness after its application. This randomized controlled trial utilized ultrasound shear-wave elastography (SWE), technology that quantifies soft tissue elasticity by sending sound waves into the desired soft tissue area. Vibrations move faster through the areas of soft tissue that are more stiff and less elastic. The primary aim of this study is to compare the effects of dry needling and sham dry needling (control group), on lumbar muscle stiffness in individuals with low back pain.

There were several outcomes assessed at the end of this randomized controlled trial: self-reported pain using the numerical pain rating scale (NPRS), LBP-related disability using the Oswestry Disability Index (ODI), self-reported changes using the Global Rating of Change, as well as lumbopelvic active range of motion. The participants in this study were currently experiencing low back pain between the ages of 18 and 65. Current low back pain for the participants was defined as pain between the 12th rib and the buttocks region as well as an ODI score of at least 10%.

Following the baseline evaluation and outcome assessment, 60 participants were randomized to either receive dry needling or sham dry needling. Therefore, there were 30 participants in the dry needling group and 30 participants in the sham treatment group. Treatment was performed by an experienced physical therapist trained in dry needling and blinded to all outcomes. Treatment was applied to a total of four sites on both the lumbar multifidi and erector spinae, muscles of the low back region. During each insertion of the needle, a ‘pistoning’ (in and out motion) technique was used in an attempt to elicit a local twitch response. Each participant was instructed to perform a double knee-to-chest maneuver 6 times for 5–10 seconds to alleviate residual soreness.

The results of the study showed that the resting erector spinae muscle stiffness was lower in individuals that received dry needling than in those that received sham dry needling 1 week after treatment. Additionally, individuals that received dry needling reported statistically larger overall improvements using the Global Rating of Change scale, as well as statistically significant improvements in pain levels utilizing the numerical pain rating scale (NPRS). No serious adverse events were reported throughout the course of this randomized controlled trial.

 Clinical Application:

Dry needling can be utilized as an effective intervention for individuals with low back pain to attenuate muscular stiffness in the low back region, as well as provide improvements in pain levels. Dry needling can be a useful intervention to help reduce the activity of myofascial trigger points, decrease hypersensitivity of taut bands in skeletal muscle, as well as restore normal muscle function during routine functional activities.


Koppenhaver SL, Weaver AM, Randall TL, et al. Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography. J Man Manip Ther. 2022;30(3):154-164.

Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Patellofemoral pain syndrome (PFPS) is a chronic musculoskeletal condition characterized by persistent anterior knee pain. This condition is sometimes referred to as “runner’s knee” because it is common in individuals who participate in sports or recreational activities. However, patellofemoral pain syndrome can also occur in nonathletes as the increased pain levels and stiffness can make it difficult to climb up stairs, kneel down, and other activities of daily living.

Often times, a multimodal approach is utilized to treat individuals with PFPS. However, there is very little evidence to support the idea that the current multimodal approach for treatment of PFPS leads to successful clinical outcomes. A research study by Brown et al. on patients with PFPS, showed that only 46% of patients’ knees were pain-free at discharge. Based on the failures of the current multimodal treatment approach, there has been a strong recommendation from the International Patellofemoral Pain Research Retreats to clinically subgroup patients with PFPS and deliver targeted treatments. This prospective crossover intervention categorized patients with PFPS into 3 subgroups to assess whether targeted treatments would show clinical benefits over a multimodal approach.

The participants for this study were between the ages of 18 and 40, attending a physical therapy outpatient clinic at a university hospital with a clinical diagnosis of PFP. Various assessment tools were utilized to categorize the patients with PFPS: quadriceps and hip abductor muscle strength in the form of manual muscle tests, patella glide test, quadriceps length, gastrocnemius length, and the foot posture index. Based on these PFPS criteria, the participants were classified into 1 of 3 subgroups: strong, weak and tight, or weak and pronated feet.

All 61 patients in this crossover intervention study were given 6 weeks of multimodal treatment. The multimodal treatment included thermotherapy (heat application), transcutaneous electrical neural stimulation (TENS), stretching, as well as hip and knee strengthening. 21 patients responded positively to this treatment approach but 40 patients were non-responders to this approach. The 40 PFPS non-responders were then given an additional 6 weeks of targeted treatment based upon one of the three subgroups they were classified within. The intervention program for the “strong” subgroup was targeted at improving neuromuscular control and coordination ability using proprioceptive exercises. In the “weak and tight” subgroup, the exercise program consisted of closed kinetic chain (CKC) muscle strengthening and stretching and weight management advice. Lastly, the “weak and pronated foot” subgroup had an intervention program that included CKC strengthening exercises and foot orthoses.

Pain during activity measured using a visual analog scale (VAS) was the primary outcome measure of this study. The perception of recovery scale (PRS) was also utilized where patients rated themselves from “worse than ever” to “completely recovered” on a 7-point scale. The results of the study showed that 72.5% (29 patients) of the 40 PFPS non-responders demonstrated recovery after targeted treatment approaches. Recovery was measured through improved pain intensity (VAS) scores at rest and during activity, as well as significantly improved PRS scores. The findings of this intervention study suggest that targeted interventions based on subgroups provide a more effective treatment strategy for patients with PFPS.

Clinical Application:

Patients with PFPS who do not respond positively to the current multimodal treatment approach may benefit from a more targeted treatment. Targeted subgroups used to classify PFPS patients as “strong,” “weak and tight,” or “weak and pronated foot” provide a blueprint for targeted interventions that can improve clinical outcomes. Below is a graphic that outlines the targeted interventions for each subgroup:


Yosmaoğlu HB, Selfe J, Sonmezer E, et al. Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?. Sports Health. 2020;12(2):170-180. doi:10.1177/1941738119883272

Brown J. Physiotherapists knowledge of patellofemoral pain syndrome. Br J Ther Rehabil. 2000;7:346-353.

Using a Validated Algorithm to Judge the Appropriateness of Total Knee Arthroplasty in the United States: A Multi-Center Longitudinal Cohort Study

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Utilization of total knee arthroplasty (TKA) procedures in the United States has skyrocketed in recent years. According to Cram et. al (2012), the annual volume of TKA surgeries among Medicare beneficiaries increased 161.5% between 1991 and 2010. In this research article, Cram and his colleagues proposed that this dramatic advancement in TKA surgeries could be due to the fact that the TKA procedure is highly reliant on subjective criteria, therefore lending itself to potential over-utilization. Determining whether a TKA surgery is advisable for a patient requires evidence-based appropriateness criteria; however, these specific criteria have never formally been developed for patients undergoing TKAs. The aim of this cohort study is to determine if the current TKA appropriateness criteria is valid and accurately predicts whether a patient should opt for a TKA surgery.

As previously mentioned, there has been no formal appropriateness criteria for TKA procedures in the United States. The most commonly recommended and studied approach is the RAND/UCLA method developed by Escobar and his colleagues in Spain. Escobar et. al constructed their TKA appropriateness algorithm based on several variables: symptom behavior, age, extent of radiographic arthritis, prior medical history, knee joint mobility and stability, and functional status. These researchers in Spain then tested their algorithm against 775 TKA patients and determined their appropriateness based on their specialized criterion. The purpose of this cohort study was to modify Escobar’s system for US TKA patients and analyze its validity in determining whether a patient is a good candidate for a TKA procedure.

For the cohort study, 216 subject data sets were derived from 4,796 possible patients enrolled in the Osteoarthritis Initiative (OAI). In order to assess severity of knee arthritis for each patient, the KL radiographic grading system was utilized: 1 indicated mild (1 to 33%) narrowing, 2 indicated moderate (34–66%) narrowing and 3 indicated severe (67 to 100%) narrowing. The WOMAC Physical Function scale evaluates the functional status of each patient and how their symptoms impact their function:0 = none, 1=mild impairment, 2= moderate impairment, 3=severe impairment, 4=extreme impairment. Additionally, patients were categorized as limited when they had either less than 0° to 90° of knee motion or greater than 5 millimeters of medial or lateral gapping during stress testing.

The results of the cohort study were based on the modifications of Escobar’s appropriateness algorithm. Of 175 subjects with complete data sets, 77 were classified as appropriate TKA surgeries. The majority of patients that were deemed appropriate for TKA surgeries had intense or severe symptoms that impacted functional status, KL arthritis scores of 4 (severe knee joint narrowing), and were greater than 55 years of age. Many patients struggle with the ultimate decision of undergoing a TKA surgery so the researchers of this cohort study wanted to provide evidence-based criteria for patients to aid in their choice.

Clinical Application:

The patient population that are most likely to be deemed appropriate for TKA surgeries are those with intense/severe symptoms that impact functional status, KL arthritis scores of 4 (severe knee joint narrowing shown on radiographic images), and greater than 55 years of age. Other important variables that must be considered before a TKA procedure include psychological readiness for the surgery and the recommendations of all members of the patient’s healthcare team.


Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012; 308(12):1227–36.

Escobar A, Quintana JM, Arostegui I, Azkarate J, Guenaga JI, Arenaza JC, et al. Development of explicit criteria for total knee replacement. Int J Technol Assess Health Care. 2003; 19(1):57–70.

Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66(8):2134-2143.

Foam Rolling vs. Proprioceptive Neuromuscular Facilitation Stretching in the Hamstring Flexibility of the Amateur Athletes: Control Trials

Reviewed by Austin Mowrey PT, DPT


Hamstring injuries are common in many sports that require repetitive acceleration and deceleration, including football, soccer, and basketball. There is also a correlation between hamstring mobility and pelvic, knee and low back pain. The aim of this study was to compare foam rolling and proprioceptive neuromuscular facilitation (PNF) to address hamstring mobility deficits.  

Methods and Interventions:  

This study consisted of 80 subjects over 18 years old with no history of hypermobility, hamstring injuries in the past 6 months, a diagnosed orthopedic problems or surgery in the lower limb, back pain or spine surgery, and systemic and neurological disorders. The sample consisted of 53 men and 27 women with an average age of 22.82 years. Subjects were randomly assigned to receive PNF treatment or foam rolling treatment. Hamstring mobility was assessed using a modified sit-and-reach test before interventions, during interventions and 2 minutes after interventions. The subject’s discomfort was also measured using the BORG RPE scale at the end of the intervention.  

The PNF group consisted of 29 men and 11 women with an average age of 22.48. The PNF stretching protocol was performed with each participant in a long sitting position on a plinth. The participant was asked to perform a maximal isometric hamstring muscle contraction for 5 seconds followed by 5 seconds if relaxation and 20 seconds of stretching (30 seconds total). Each participant underwent four repetitions of the PNF stretching in which hamstring length was recorded at baseline, at the end of first repetition, and at the end of the protocol.  

The foam roll group consisted of 24 men and 16 women with an average age of 22.50. For the foam rolling protocol, each participant assumed the long sitting position on a firm and even surface by placing their arms backward and transferring their weight to their palms. The foam roller was placed bilaterally under their hamstrings and slowly moved back forth from the ischial tuberosity and the popliteal fossa for two minutes. Hamstring length was recorded at baseline, 30 seconds from the start of the intervention and at the end of the protocol.  


Baseline measurements of hamstring flexibility demonstrated no significant differences between each group, but both groups had statistically significant increase in hamstring flexibility during the interventions and after the intervention. The PNF group demonstrated a 56% total gain of hamstring mobility after the first bout of PNF stretching and the rest during the last three bouts. The foam roll group demonstrated 47% of the total gain after 30 seconds of foam rolling and the rest during the last 90 seconds. When comparing PNF stretching vs foam rolling for hamstring mobility, PNF stretching demonstrated statistically significant results during and after the interventions. There were no statistically significant results when comparing the participants’ perceived exertion between groups or with increased effort and flexibility gained.  


The PNF group and foam rolling both experienced statistically significant increase in flexibility in their hamstrings during and after both interventions. When comparing the two groups, the PNF group had significant increase in hamstring flexibility compared to the foam rolling group, but both groups had similar sensation of perceived exertion.  

Take Home Message: 

It is important for clinicians to consider patients’ needs, body size, demographics and goals when deciding on the appropriate intervention. This study concludes that PNF stretching and foam rolling are both effective to improve hamstring flexibility, but PNF is more effective for the population studied. Further research should be performed to assess the duration of the physiological changes noted in this study.  


Pérez-Bellmunt A, Casasayas-Cos O, Ragazzi P, Rodríguez-Sanz J, Hidalgo-García C, Canet-Vintró M, Caballero-Martínez I, Pacheco L, López-de-Celis C. Foam Rolling vs. Proprioceptive Neuromuscular Facilitation Stretching in the Hamstring Flexibility of Amateur Athletes: Control Trials. International Journal of Environmental Research and Public Health. 2023; 20(2):1439.