Table of Contents    
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 93-96  

Effectiveness of thoracic spine manipulation in conjunction with cranial base release technique on pain and range of motion in patients with mechanical neck pain

Department of Physiotherapy, Lovely Professional University, Phagwara, Punjab, India

Date of Submission16-Mar-2020
Date of Decision13-Apr-2020
Date of Acceptance30-May-2020
Date of Web Publication27-Jan-2021

Correspondence Address:
Ramesh Chandra Patra
Lovely Professional University, Phagwara, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsbm.JNSBM_60_20

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Background: Pain originates from the neck and may radiate to the shoulder or base of the cranium and is often aggravated by anxiety, depression, soft-tissue strain, occupational activities, and poor posture. In this study, we evaluated the efficiency of thoracic spine manipulation along with cranial base release technique to improve motion and alleviate pain in individuals suffering from mechanical neck pain. Materials and Methods: We recruited 60 individuals (male: 31 and female: 29) who were suffering from mechanical neck pain. The participants were randomly distributed into Groups A and B. Patients of Group A underwent conventional physiotherapy treatment, whereas patients of Group B patients underwent thoracic spine manipulation and cranial base release. Baseline range of motion and pain were evaluated before starting the treatment, and postintervention measures were obtained after the weeks of intervention. Results: All participants completed 2 weeks of treatment. Group A had shown better outcome in all the parameters than Group B. We observed that the pain and cervical range of motions of Group B patients were statistically significantly different from those of Group A patients (P < 0.05). Conclusions: Thoracic spine manipulation in conjunction with cranial base release technique is more effective in the management of pain and cervical range of motion compared to the conventional physiotherapy treatment.

Keywords: Cranial base release, manipulation, mechanical neck pain, pain, range of motion

How to cite this article:
Patra RC, Kanungo B, Nazir S, Abraham A. Effectiveness of thoracic spine manipulation in conjunction with cranial base release technique on pain and range of motion in patients with mechanical neck pain. J Nat Sc Biol Med 2021;12:93-6

How to cite this URL:
Patra RC, Kanungo B, Nazir S, Abraham A. Effectiveness of thoracic spine manipulation in conjunction with cranial base release technique on pain and range of motion in patients with mechanical neck pain. J Nat Sc Biol Med [serial online] 2021 [cited 2021 Jul 29];12:93-6. Available from:

   Introduction Top

In terms of general well-being, neck pain poses a significant public health issue. The most common type of neck pain is mechanical neck pain, in which the pain is confined to the posterior portion of the neck and can be exacerbated by the motion of the neck or continuous posture.[1] Nonspecific neck pain generally occurs due to long-term physiological excessive loads or poor posture.[2],[3] The annual prevalence rate of neck pain is more than 30%, whereas its lifetime prevalence is 22%–70%.

General shoulder or neck pain with the mechanical features could also be referred to as mechanical neck pain, which could be triggered by sustained postures of the neck, neck stiffness, or cervical muscle palpation.[4] According to the Global Burden of the Disease study, people with acute neck pain, which does not radiate to the extremities, present with features such as difficulty in turning their head and lifting objects, feeling tired, and experiencing disturbed sleep.[5] The pathology of mechanical neck pain is not yet completely clear; however, it may involve several structures such as ligaments, muscles, neural tissue, intervertebral discs, zygapophyseal joints, and uncovertebral joints.[6]

Neck pain can be treated using the several agents such as anesthetics, muscle relaxants, analgesics, corticosteroids, nonsteroidal anti-inflammatory drugs, or opioids.[7] Nonpharmacological therapies used in pain management include physical therapy modalities (electrical stimulation, ultrasound, superficial heat, and cryotherapy), exercise, patient education and psychological intervention, and mobilization and manipulative techniques.[8],[9]

Thoracic spine manipulation and cranial base release are a hands-on technique involving manual therapeutics with a profound effect on the spinal disorders. The region of fifth to seventh (T5–T7) thoracic vertebrae harbors the roundest and the narrowest portion of the spinal canal[10] and exhibits the high level of neural tension.[11] Improvement in T5–T7 area mobility facilitates better translation movement, which could decrease both neural tissue and dural ligament tensions.[12] On the other hand, suboccipital muscle inhibition technique stimulates the autonomic nervous system (parasympathetic system), which triggers muscle relaxation.[13] It also enhances β-endorphin secretion, which reduces pain perception.[14]

Till date, no studies have examined the alleviation of chronic mechanical neck pain using thoracic spine manipulation along with the cranial base release technique. Our current hypothesis was that thoracic spine manipulation along with cranial base release technique could help in enhancing the range of motion and alleviating neck pain in patients with mechanical neck pain.

   Materials and Methods Top

This randomized clinical trial was conducted from June 2019 to January 2020 at the Outpatient Department, Department of Physiotherapy, Lovely Professional University, Chaheru, Phagwara, Punjab, India. The Institutional Ethics Committee approval was obtained before recruiting the patients (LPU/IEC/2019/01/05) for the proposed study. The study was conducted for the master of physiotherapy dissertation, and the Clinical Trial Registration (CTRI) was not done.

Individuals diagnosed with mechanical neck pain due to continuous posture and movement, in the absence of a detectable etiology (infection and inflammation), were recruited for the study. Patients who presented with a history of surgery or cervical spine injury, headaches or facial pain, vertebral malignancy, dizzy spells, cervical radiculopathy, bone infections, vertebral-basilar insufficiency, neurological deficit, and/or hypermobility spine were excluded from the study. We recruited sixty patients for this study. All the participants received both verbal and written information about the study in their local language and then provided their informed consent. The participants were grouped randomly (lottery method) into Groups A and B (each containing thirty patients). Patients of Group A underwent conventional physiotherapy, whereas Group B participants were subjected to thoracic thrust manipulation with cranial base release. The patients of both groups were advised to do an active range of motions of the neck (daily two times morning and evening, ten repetitions) and undergo postural education. Three participants (two from Group A and one from Group B) discontinued the treatment because of their personal problem. Pretest pain was evaluated by the Numerical Pain Rating Scale, and range of motion was assessed using a Goniometer. The intervention duration was 2 weeks, and then, posttest readings were recorded again after the intervention [Figure 1].
Figure 1: Summary of study protocol

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Thoracic spine manipulation

The patient was in the prone position with the arms by the side. Contact zone was transverse process of the vertebrae, and therapists used the pisiform of both the hands. One hand was placed on the transverse process on the side to be adjusted (i.e., right transverse process), and the other hand was placed on the side of left transverse process one level above or below the segment to be adjusted. The therapist was in the standing position with the feet spread apart facing the head of the patient. The therapist stood as tall as possible and then applied a downward and caudal force from one hand and a downward and cephalic force from the other hand. Thrust was applied simultaneously with a downward and cephalic vector at T4 transverse process and a downward and caudal vector at the T5 transverse process. Sub-occipital release: the patient was laid in the supine position. Therapist sat just behind the patient's head and then placed both hands under the head of the patient and made contact with sub-occipital muscles. Then, the therapist applied an upward pressure toward the ceiling for nearly 4 min until the tissues and the muscles relaxed. During the intervention, the patients were advised to close their eyes.

Data analysis

SPSS 16 Statistical Package for the Social Sciences was used for the statistical analyses. Data from the experimental and control groups were compared using the unpaired and paired t-tests. Descriptive analysis was done for the demographic variables [Table 1]. Unpaired t-test was used for the analyses between different groups. The comparisons within the same group were done using the paired t-test. P < 0.05 defined significant values.
Table 1: Patients' demographic data (mean±standard deviation)

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   Results Top

Sixty-seven participants were initially selected for the study, out of which seven participants did not meet the inclusion criteria and were excluded. Later, three more patients (one from the experimental group and two from the control group) were excluded. Therefore, 57 participants (control: 28, experimental: 29) were analyzed through the paired and unpaired t-tests. A summary of study protocol is shown in [Figure 1]. The demographic data of the patients in the two groups did not differ significantly [Table 1]. For both groups, pain intensity reduced, while range of motion improved [Table 2]. A more significant difference in the improvement of range of motion and pain reduction was observed between the two groups [Table 3].
Table 2: Comparison within the groups

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Table 3: Comparison between the groups

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   Discussion Top

This randomized clinical trial was aimed at determining the efficiency of thoracic spine manipulation in conjunction with cranial base release technique to manage cervical range of motion and pain in individuals with mechanical neck pain. Our results supported the hypothesis that the above-mentioned approach facilitated the better management of such patients compared to the conventional physiotherapy treatment.

It has been previously reported that thoracic spine manipulation primarily affects the biomechanical and neurophysiological (either segmental or central) mechanisms.[12]

Another report showed that thoracic spine manipulation alleviated neck pain by affecting the biomechanical connection between thoracic and cervical spine. It is also possible that thrust manipulation has inherent qualities that can stimulate mechanoreceptors and sympathetic nervous system.[15]

In addition, several biomechanical changes have been hypothesized to be produced by vertebral movement during the spinal manipulation. Previous literature has shown that spinal manipulation introduces a mechanical force in the vertebral column. The manipulation alters segmental biomechanics through decrease in the distortion of annulus fibrosus or release of adhesions and/or trapped meniscoids.[12],[16],[17] In the innervated paraspinal tissues, the normalization of a buckled segment, or release of the discal material, segmental adhesions, or trapped meniscoids could lead to decreased nociceptive input from receptive nerve endings.

On the other hand, suboccipital release refers to a soft-tissue manual therapy technique that reduces the tension of muscle as well as the dura. Previous literature has revealed an association between dura mater and the suboccipital muscle, especially the rectus capitus posterior minor muscle. In addition, the dura and the posterior aspect of the bodies of the lumbar and thoracic vertebrae and the posterior longitudinal ligament are attached.[18],[19] Therefore, changes in the dural tension can affect the spinal mechanics and mobility and reduce the pain.[20] The application of cranial base release with thoracic spine manipulation might provide the maximum effect on the mechanical neck pain-related manifestations.

   Conclusions Top

Thoracic spine manipulation in conjunction with cranial base release technique could facilitate the better management of pain and cervical range of motion compared to the conventional physiotherapy treatment.


The authors would like to express heartfelt thanks to the Department of Physiotherapy, LPU, and fellow colleagues who participated in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Kashyap R, Iqbal A, Alghadir AH. Controlled intervention to compare the efficacies of manual pressure release and the muscle energy technique for treating mechanical neck pain due to upper trapezius trigger points. J Pain Res 2018;11:3151-60.  Back to cited text no. 3
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Colloca CJ, Keller TS, Gunzburg R. Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy. J Manipulative Physiol Ther 2004;27:1-5.  Back to cited text no. 17
Rueda VG, de Celis CL, López ME, Uribarren AC, Tomás SC, García CH. Effectiveness of a specific manual approach to the suboccipital region in patients with chronic mechanical neck pain and rotation deficit in the upper cervical spine: Study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2017;18:384.  Back to cited text no. 18
Palomeque-Del-Cerro L, Arráez-Aybar LA, Rodríguez-Blanco C, Guzmán-García R, Menendez-Aparicio M, Oliva-Pascual-Vaca Á. A systematic review of the soft-tissue connections between neck muscles and Dura mater: The myodural bridge. Spine (Phila Pa 1976) 2017;42:49-54.  Back to cited text no. 19
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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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