Journal of Bodywork & Movement Therapies xxx (2016) 1e6

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Hypoalgesic effects of three different manual therapy techniques on

cervical spine and psychological interaction: A randomized clinical
trial
Jose Luis Alonso-Perez a, Almudena Lopez-Lopez b, Roy La Touche c, Sergio Lerma-Lara c,
~ e e, *,
Emilio Suarez b, Javier Rojas b, Mark D. Bishop d, Jorge Hugo Villafan
 Ferna
Josue ndez-Carnero f, g, h

a
Department of Physiotherapy, Universidad Europea de Madrid, Spain
b
Department of Psychology, Universidad Rey Juan Carlos, Alcorco n, Madrid, Spain
c noma de Madrid, Spain
Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle, Universidad Auto
d
Department of Physical Therapy, University of Florida, USA
e
IRCCS Don Gnocchi Foundation, Milan, Italy
f
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorco n, Madrid, Spain
g n y tratamiento del dolor (I-dol), Avenida de Atenas s/
Grupo de Excelencia Investigadora, URJC-Banco de Santander:Grupo Multidisciplinar en investigacio
n, 28922 Madrid, Spain
n, Alcorco
h
Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The purpose of this study was to evaluate the extent to which psychological factors interact
Received 10 July 2016 with a particular manual therapy (MT) technique to induce hypoalgesia in healthy subjects.
Received in revised form Methods: Seventy-five healthy volunteers (36 female, 39 males), were recruited in this double-blind,
16 November 2016
controlled and parallel study. Subjects were randomly assigned to receive: High velocity low ampli-
Accepted 12 December 2016
tude technique (HVLA), joint mobilization, or Cervical Lateral glide mobilization (CLGM). Pressure pain
threshold (PPT) over C7 unilaterally, trapezius muscle and lateral epicondyle bilaterally, were measured
Keywords:
prior to single technique MT was applied and immediately after to applied MT. Pain catastrophizing,
Manual therapy
Pressure pain threshold
depression, anxiety and kinesiophobia were evaluated before treatment.
Psychological interaction Results: The results indicate that hypoalgesia was observed in all groups after treatment in the neck and
elbow region (P < 0.05), but mobilization induces more hypoalgesic effects. Catastrophizing interacted
with change over time in PPT, for changes in C7 and in manipulation group.
Conclusions: All the MT techniques studied produced local and segmental hypoalgesic effects, supporting
the results of previous studies studying the individual interventions. Interaction between catastrophizing
and HVLA technique suggest that whether catastrophizing level is low or medium, the chance of success
is high, but high levels of catastrophizing may result in poor outcome after HVLA intervention.
Trial registration: ClinicalTrials.gov Registration Number: NCT02782585.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction musculoskeletal pain disorders (Bertozzi et al., 2015b; Castaldo

Neck pain represents one of the more common and frequent
* Corresponding author. Reg. Generala 11/16, Piossasco, 10045, TO, Italy.
E-mail addresses: jolualpe79@hotmail.com (J.L. Alonso-Perez), almudena.
lopez@urjc.es (A. Lopez-Lopez), roylatouche@yahoo.es (R. La Touche), slermalara@
yahoo.es (S. Lerma-Lara), emiponfe@hotmail.com (E. Suarez), jorgeriotercero@
yahoo.com.ar (J. Rojas), bish@phhp.ufl.edu (M.D. Bishop), mail@villafane.it
~ e), josuefernandezcarnero@gmail.com (J. Fern
(J.H. Villafan andez-Carnero).
et al., 2014; Vicenzino et al., 1998) and the economic costs are
increasing (Bertozzi et al., 2013; Borghouts et al., 1998, 1999; Isgro
et al., 2014; Negrini et al., 2013). A recent systematic review has
suggested that joint-biased manual therapies (MT) (i.e. joint
manipulation and mobilization) have immediate or short-term
pain relief effectiveness for mechanical neck pain treatment
(Gross et al., 2010), but the superiority of one MT over another has
not been demonstrated.
MT techniques applied to the cervical region have effects over

http://dx.doi.org/10.1016/j.jbmt.2016.12.005
1360-8592/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alonso-Perez, J.L., et al., Hypoalgesic effects of three different manual therapy techniques on cervical spine and
psychological interaction: A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/
j.jbmt.2016.12.005
2 J.L. Alonso-Perez et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e6
both local (neck) and distant regions (elbow) in both asymptomatic
(Fernandez-de-Las-Penas et al., 2008; Fernandez-de-las-Penas
et al., 2007) and symptomatic populations (Bertozzi et al., 2013;
Coppieters et al., 2003; Sterling et al., 2001; Vicenzino, 1995;
Vicenzino et al., 1996). Neurophysiological mechanisms are hy-
pothesized to explain the results, with effects originating from
peripheral mechanisms, spinal cord and supraspinal mechanisms
(George et al., 2006; Wright, 1995).
There is also an increasing interest in the study of the role of
psychological variables in the treatment success in neck pain
(Bertozzi et al., 2015a; Gorka et al., 2016). Psychological variables,
such as anxiety catastrophizing or kinesiophobia are related to poor
prognosis in the development of pain outcomes and disability in
neck pain, with the Fear-Avoidance Model of pain (Vlaeyen et al.,
1995) being one of the most tested (Howell et al., 2012). The role
of psychological variables in neck pain have also been studied in
relation to their interaction with treatment outcomes. A study in
physiotherapy practice reported that high kinesiophobia, high
catastrophizing and high somatization were predictors of non-
recovery in patients with neck, shoulder and arm pain (Karels
et al., 2007). Cai and coworkers proposed a clinical prediction
rule to identify neck pain patients who were likely to benefit from
mechanical cervical traction treatment in which fear avoidance
beliefs played an important role (Cai et al., 2011). Hill et al., (2007)
reported that catastrophizing and anxiety were independent pre-
dictors of longer term (6 months) treatment outcomes in patients
with neck pain treated by physical therapy. Furthermore, Verhagen
et al., (2010) recently found that increased catastrophizing at
baseline increased the chance of recovery after treatment with
manual therapy compared to exercise therapy in neck pain patients.
In contrast, George et al., (2006), based on correlational analyses,
did not find any association between level of fear of pain and
anxiety and the immediate effects of spinal manipulation in
healthy, asymptomatic subjects. Therefore, we can hypothesize that
some psychological factors might influence manual therapy out-
comes in neck pain patients, but it is unclear whether the same
factors influence outcomes in people without chronic neck pain.
Although many studies have demonstrated the hypoalgesic ef-
fects of cervical manipulations and mobilization over cervical spine
in pain-free subjects (Fernandez-de-Las-Penas et al., 2008;
Fernandez-de-las-Penas et al., 2007; George et al., 2006; Vice-
nzino et al., 1999), none have demonstrated whether one manual
therapy technique is better than other, and also whether the
hypoalgesic effects could be induced in subjects without pain.
Moreover, it is necessary to investigate the influence of psycho-
logical factors on the hypoalgesic effects of the different techniques,
in pain-free subjects, who do not have any pain processing mech-
anism involved in the treated regions.
Therefore our goal with this paper was to evaluate extent to
which psychological factors interact with a particular MT technique
to induce hypoalgesia in healthy subjects.
2. Methods
2.1. Study design
We conducted a double-blind, controlled trial with healthy
subjects. Informed consent was obtained from all participants and
procedures were conducted according to the Declaration of Hel-
sinki. The protocol was approved by the Local Ethical Committee
(number A07e12.12) and was registered with ClinicalTrials.gov
(NCT02782585). The study has been registered at Trial registra-
tion Current Controlled Trials website. The present document was
prepared according to CONSORT publishing guidelines (Johnson
and Green, 2009).
Please cite this article in press as: Alonso-Perez, J.L., et al., Hypoalgesic effects of three different manual therapy techniques on cervical spine and
psychological interaction: A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/
j.jbmt.2016.12.005
2.2. Subjects
This sample was comprised of subjects with no history of neck
or back pain (Pillastrini et al., 2016) over the last 3 months and
without any previous experience with MT, who responded to study
advertisements placed in the University, from October 2010 and
June 2011. Subjects were verbally screened for history of neck or
back pain and current use of pain relievers. The subjects were
examined by an independent researcher before participating in the
study to rule out any signs or symptoms originating from the cer-
vical spine. The exclusion criteria consisted of any history of
musculoskeletal or rheumatologic conditions, any kind of spinal
surgery, dizziness, previous trauma to the cervical spine, and
neurologic signs and symptoms. A physiotherapist with more than
12 years of experience in diagnosing and treating patients with
musculoskeletal disorders was responsible for the selection of the
study sample.
All eligible subjects signed written informed consent before
they entered the study. All the eligible subjects who agreed to
participate in the present study were randomly assigned an
experimental group or the control group. Randomization was per-
formed with closed envelope method using computer generated
random-sequence table (GraphPad Software, Inc CA 92037, USA).
2.3. Procedure
The participants in three groups were treated by a physiother-
apist with more than 10 years of clinical experience in the man-
agement of musculoskeletal disease. The physical therapist was
blinded to all data. All outcomes were collected by an external
observer blinded to the treatment allocation of the participants.
The variables were measured at baseline and after intervention.
Each of the randomly assigned interventions was applied for a
standard 5-min period to minimize variation in hypoalgesic effect
due to differences related to re-assessment time and treatment
dosage. Participants received High velocity, low amplitude (HVLA)
or Cervical Lateral glide mobilization (CLGM) or Unilateral Posterior
to Anterior mobilization. Subjects were given an explanation about
the three different techniques. PPT measures were collected again
5 min after intervention was administered. Subjects were asked to
notify the assessor if the experienced any pain.
2.4. Intervention
Each of the techniques used in this study were employed
because they have demonstrated a capacity to produce hypoalgesia
in the neck in previous studies.
2.4.1. High velocity, low amplitude (HVLA)
This technique was performed with subject in supine position.
The technique was applied at C5-C6 vertebral level, because this
level has been chosen in other studies (Fernandez-de-las-Penas
et al., 2007). The cervical spine was placed in a neutral position.
The index finger of the therapist applied a contact over the
posterolateral aspect of the zygapophiseal joint of C5. The therapist
cradled the subject's head with the other hand. Gentle ipsilateral
side flexion and contralateral rotation to the targeted side were
introduced until slight tension was perceived in the tissues at the
contact point. The HVLA manipulation was directed upward and
medially in the direction of the subject's contralateral eye. The
therapist monitored for any cavitation or ‘popping sound’ accom-
panying the manipulations. If an audible sound was not heard
during the first manipulative attempt, the procedure was repeated
in the second time (Gorrell et al., 2016).
 J.L. Alonso-Perez et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e6
2.4.2. Cervical Lateral glide mobilization (CLGM)
CLGM was applied to the right side at the C5-C6 spinal level in
supine, for 3 sets of 2 min with 1 min rest between sets of CLGM to
the right side at a grade III. The upper limb of the right side of
subjects was maintained in rest, with the arm along the trunk and
the hand over the abdominal wall. The right hand of the treating
therapist was positioned over the scapula region, to depress the
scapula while the left hand cradled the the occiput and neck above
C5-C6 and the left hand produced a passive lateral movement of the
occipital and neck region (Lopez-Lopez et al., 2015).
2.4.3. Unilateral Posterior to Anterior mobilization
The third group received a passive cervical mobilization that
involved a grade III oscillatory unilateral posteroanterior mobili-
zation to the right articular pillar of C5/C6 segment as described
Maitland, (2005) at a frequency of 2 Hz (Chiu and Wright, 1996). All
the subjects were positioned in prone position as the protocol
described by Sterling et al., (2001) for 3 sets of 2 min with 1 min rest
between sets.
2.5. Outcomes and measurements
Data on pain threshold, anxiety, depression, kinesiophobia and
catastrophizing were recorded at the admission and soon after the
treatment through the administration of mechanical pressure pain
thresholds (PPTs) using an algometer (Walton et al., 2011) and self-
report psychological questionnaires: State subscale (STAI-E) of the
Spanish version (Bermúdez, 1978) of State-Trait Anxiety Inventory
(STAI) (Spielberger et al., 1970), the level of depressive symptom-
atology was measured by the Spanish version (Sanz et al., 2003) of
the Beck depression Inventory (BDI-II) (Beck and Brown, 1996), the
Tampa Scale for Kinesiophobia (TSK), developed by Miller (Miller
et al., 1991) and to evaluate the subject's propensity to cata-
strophize about pain, we used the Spanish version (García Campayo
et al., 2008) of the Pain Catastrophizing Scale (PCS) (Sullivan et al.,
1995).
2.6. Data analysis
Data were analyzed using SPSS version 21.0 (SPSS Inc, Chicago,
IL, USA). Group data were summarized as means and standard
deviations. The Kolmogorov-Smirnov test confirmed the normality
of the distribution of the data. Prior to the analyses, we recoded all
psychological variables in levels of severity, following clinical
criteria (in case of depression), or using 50 and/or 75 percentiles in
the rest of the variables. The mean values of the 3 PPT measures in
each site were calculated. Then, we tested the interaction between
the intervention technique (group; HVLA, mobilization and CLGM)
and changes in PPT from pre to post-intervention (change from
baseline). In addition, we tested the interaction between psycho-
logical variables and changes in PPT in each treatment condition. To
do that, we carried out analysis of variance (ANOVA), using pre-post
change as a within-subject factor, and group and psychological
variables as between-subjects factors. In addition, for measures in
trapezius and lateral epicondyle, we added side (ipsilateral,
contralateral to the side of the intervention) as within-subject
factor.
2.7. Sample size
The sample size and power calculations were performed using
online software from the MGH biostatistics center (Boston, MA,
USA). The calculations were based on detecting a 1.5 kg difference
with the Algometer, assuming a standard deviation of 1.7 kg, 2
tailed test, and an alpha level equal to 0.05. This has been
Please cite this article in press as: Alonso-Perez, J.L., et al., Hypoalgesic effects of three different manual therapy techniques on cervical spine and
psychological interaction: A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/
j.jbmt.2016.12.005
3
previously demonstrated measuring the trapezius muscle in pa-
tients with neck pain (Walton et al., 2011). This generated a sample
size of 14 patients per group. Allowing for a conservative dropout
rate of 20%, we planned to recruit at least 50 patients into the study.
This sample size yielded 80% power to detect a statistically signif-
icant change in the pressure pain threshold scores.
3. Results
Screening identified 74 consecutive subjects (mean ± SD age:
29.3 ± 9.4 years; 48.6% female) who met the eligibility criteria and
agreed to participate, and were randomized to the HVLA (n ¼ 25) or
CLGM (n ¼ 24) or Unilateral Posterior to Anterior mobilization
(n ¼ 25) group, as presented in Fig. 1. The reasons for ineligibility
were: did not meet the inclusion criteria (n ¼ 5), declined to
participate (n ¼ 3) and other reasons (n ¼ 1).
The baseline characteristics of the participants in each group are
presented in Table 1.
3.1. Response to treatment
3.1.1. PPT over cervical process C7
The intraexaminer repeatability of PPT readings for the C7
spinous process was 0.98 and the SEM was 0.27 kg/cm2.
PPT revealed a significant effect of pre-post difference
(F[1.0] ¼ 7.70, p ¼ 0.007) for PPT over C7. The post hoc analysis
revealed significant within group differences for the manipulation
group (p ¼ 0.02). The results of ANCOVA test showed that pre-post
change from baseline  group interaction remained significant
(F[1.0] ¼ 3.70, p ¼ 0.03) once catastrophizing was added as a co-
variate, as well as the manipulation group maintained a greater
increase in PPT over C7 than mobilization and CLGM techniques
(F[1.0] ¼ 9.11; p ¼ 0.004) (see Table 2).
3.1.2. PPT over trapezious muscle (TM)
The intra-examiner repeatability of PPT readings for the upper
trapezius muscle was 0.98 for the right side and 0.96 for the left
side, respectively and the SEM was 0.25 and 0.30 kg/cm2 for the
right and left respectively.
Regarding the results of the PPT over TM right and left
demonstrated a significant pre-post factor (F[1.0] ¼ 38.146 and
F[1.0] ¼ 23.443, all, p < 0.001, respectively). The post hoc analysis
revealed significant within group differences for the all groups (all,
P < 0.001) right and (all, P < 0.02) left.
3.1.3. PPT over epicondyle region
The intra-examiner repeatability of PPT readings for the lateral
epicondyle was 0.98 for the right side and 0.98 for the left side and
the SEM was 0.28 and 0.34 kg/cm2 for the right and the left side
respectively.
Outcomes for PPT over epicondyle region demonstrated a sig-
nificant pre-post factor (F[1.0] ¼ 11.10, p < 0.001). The post hoc
analysis revealed significant differences between the sessions for
the all groups (all, P < 0.03).
No significant psychological main effect or interactions were
noted.
4. Discussion
Our study directly compared the immediate hypoalgesic effects
of three MT techniques previously shown to cause hypoalgesia. The
results support that all the MT techniques studied produced local
and segmental hypoalgesic effects and these outcomes are similar
to the results of previous studies (Sterling et al., 2001; Vicenzino
et al., 1996, 1998; Villafane et al., 2013a, Villafane et al. 2013b).
4 J.L. Alonso-Perez et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e6

ENRROLMENT
Assessed for eligibility
(n=83)

Excluded (n= 8)
Not meet the inclusion criteria
(n=5)
Decline to parƟcipate (n=2)
Other reasons (n=1)

Randomized

Allocated intervenƟon Allocated intervenƟon Allocated intervenƟon

ALLOCATION

(n=25) (n=25) (n=25). Received allocated

Received allocated of HVLA Received allocated of of CLGM (n=25).
(n=25). mobilisaƟon (n=25). Did not receive allocated
Did not receive allocated Did not receive allocated intervenƟon (n=0)
intervenƟon (n=0) intervenƟon (n=0)
ANALYSIS

Analyzed (n=25) Analyzed (n=25) Analyzed (n=24)

Excluded from Excluded from Excluded from analysis
analysis (n=0) analysis (n=0) (Declined, n=1)

Fig. 1. Flow diagram.

Table 1
Demographics characteristics.

Characteristic Manipulation group Mobilization group Cervical lateral glide group P

N¼(25) N¼(25) N¼(24)

Age 30.5 ± 11.3 30.2 ± 11.1 29.0 ± 8.2 0.8

Weight (kg) 69.33 ± 15.6 66.1 ± 12.0 73.0 ± 10.9 0.2
Height (cm) 170 ± 0.8 170 ± 1.0 173 ± 1.0 0.2
Gender (M/F, Female %) 11/13 (52%) 10/15 (60%) 17/8 (32%) 0.7
BDI, (0e63) 4.5 ± 5.6 2.4 ± 2.9 4.2 ± 4.5 0.2
STAI, (0e120) 10.5 ± 6.9 8.8 ± 0.8 12.2 ± 1.6 0.2
TSK, (17e68) 18.4 ± 11.0 14.6 ± 9.7 15.8 ± 11.2 0.4
PCS, (0e52) 9.6 ± 8.4 5.1 ± 5.8 5.8 ± 6.9 0.1
Pressure pain threshold (kg/cm2)
C7 4.3 ± 1.8 4.4 ± 1.8 4.9 ± 2.5 0.5
Trapezius muscle (right side) 4.2 ± 1.3 4.6 ± 2.0 4.9 ± 1.9 0.4
Trapezius muscle (left side) 4.0 ± 1.2 4.7 ± 2.0 4.9 ± 1.7 0.1
Epicondyle (right side) 4.7 ± 2.4 4.4 ± 1.9 4.7 ± 2.4 0.4
Epicondyle (left side) 4.4 ± 1.4 5.1 ± 2.3 5.4 ± 2.4 0.3

BDI: Beck depression Inventory, STAI: State-Trait Anxiety Inventory, TSK: Tampa Scale for Kinesiophobia, PCS: Pain Catastrophizing Scale.

Table 2
Within pre-post values of all groups for each outcome measure.

Manipulation group Mobilization group Cervical lateral glide group Partial eta-square P-value

Pre-intervention Post-intervention Pre-intervention Post-intervention Pre-intervention Post-intervention

PPT_ C7 4.3 ± 1.8 5.0 ± 1.9 4.4 ± 1.7 4.2 ± 1.6 4.9 ± 2.4 5.2 ± 2.5 0.0 0.047
PPT_ TM_R 4.2 ± 1.2 4.8 ± 1.6 4.6 ± 1.9 5.3 ± 2.3 4.9 ± 1.9 5.4 ± 2.1 0.4 0.001
PPT_ TM_L 4.0 ± 1.2 4.8 ± 1.5 4.7 ± 1.9 5.3 ± 2.4 4.9 ± 1.7 5.4 ± 2.2 0.4 0.001
PPT_EP_R 4.0 ± 1.4 4.6 ± 1.5 4.4 ± 1.9 4.8 ± 2.3 4.7 ± 2.4 5.1 ± 2.5 0.2 0.001
PPT_EP_L 5.0 ± 2.2 4.8 ± 1.5 5.1 ± 2.3 5.5 ± 2.4 5.4 ± 2.4 5.4 ± 2.6 0.2 0.001

Values are expressed as mean ± standard deviation (confidence interval).

PPT_ C7 ¼ Pressure Pain Threshold over C7; PPT_TM_ R ¼ Pressure Pain Threshold over Trapezious right; PPT_TM_ L ¼ Pressure Pain Threshold over Trapezious left;
PPT_EP_R ¼ Pressure Pain Threshold over Lateral epicondyle right side; PPT_EP_L ¼ Pressure Pain Threshold over Lateral epicondyle left side.

Please cite this article in press as: Alonso-Perez, J.L., et al., Hypoalgesic effects of three different manual therapy techniques on cervical spine and
psychological interaction: A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/
j.jbmt.2016.12.005
 J.L. Alonso-Perez et al. / Journal of Bodywork & Movement Therapies xxx (2016) 1e6
For example, the results from the CLGM technique used in our
study agreed with Vicenzino et al., (1996) who demonstrated
hypoalgesic effects in the elbow region in healthy subjects and also
in patients with lateral epicondilalgia and the results of for Post-
eroanterior (PA) mobilization results agree with previous studies in
which unilateral grade III mobilization has a superior effects the
contact or control conditions in patients with neck pain (Sterling
et al., 2001). In addition, other studies with healthy subjects have
demonstrated that HVLA technique increased the PPT in the neck
and in the elbow in pain free subjects (Fernandez-Carnero et al.,
2008).
Our results extend these findings showing that local hypoalgesia
over the cervical spine was greater for the HVLA when compared
with the unilateral PA mobilization or CLGM techniques.
The hypothesis often used to explain the hypoalgesic effects of
MT is that MT engages the endogenous pain inhibitory system
(EPIS). This hypothesis is supported by animal studies that have
demonstrated the EPIS to be activate by stimulation (electrical and
chemical) of different parts of periaqueductal grey substance
(Lovick, 1991). Animal studies (Skyba et al., 2003) have demon-
strated that the mobilization to the knee produces a hypoalgesic
effect due descending serotoninergic or noradrenergic inhibitory
mechanism via cortocospinal projection from the periaqueductal
grey matter (PAG). Therefore manual therapy applied to the cervical
spine may produce a sensory input which activates the endogenous
pain inhibitory system. We speculate that if, in line with the model
proposed by Bialosky et al., (2009), MT serves as the mechanical
stimulus to trigger the neurophysiological processes related to
hypoalgesia, the greater forces applied to the tissues during HVLA
scales the magnitude of response to that stimulus. Further work
should test this hypothesis by systematically grading the force and
amplitude of MT (Reed et al., 2013). However, it should be noted
that there may be other local mechanisms that could mediate the
hypoalgesia evoked by manual therapy, Pickart et al(Pickar and
Wheeler, 2001). describes that manual therapy in the spine in-
fluences the proprioceptive primary afferent neurons of the para-
spinal structures, this factor could alter the processing of pain at the
spinal cord level affecting motor control. Theory of pain gate con-
trol could explain the hypoalgesic effect of manual therapy since
these techniques could activate low threshold Ab fibers, which
inhibit the nociceptive entry of afferent fibers Ad and C in the spinal
cord (Abraira and Ginty, 2013).
In the current study, we also obtained hypoalgesic effects
distant from the segment to which it was applied supporting
conjecture that MT has a supramedular effect. Additional support
comes from our finding of the interaction of hypoalgesic effects and
Catastrophizing indicating a supraspinal influence on hypoalgesia
resulting from MT.
Prior studies of immediate hypoalgesia have used psychological
factors to establish that randomization to treatment assignment
did not result in baseline group differences in factors known to
influence the intensity of pain reports (e.g. George et al., 2006). In
contrast, our study aimed to identify the extent to which psycho-
logical factors might interact or explain the hypoalgesia experi-
enced after MT. Our data showed that only catastrophizing
interacted with change in PPT over time, and this interaction was
exclusive for changes at C7 in the HVLA group.
This interaction has implications for clinical settings suggesting
that we should evaluate pain catastrophizing level using HVLA in-
terventions to treat patients with neck pain. If the patient's cata-
strophizing level is low or medium, the chance of getting success is
high. Alternatively, patients with high catastrophizing may not
report local hypoalgesia after HVLA intervention. We speculate that
participants with elevated Catastrophizing, especially rumination
and helplessness, may focus on the local sensations of pain in the
Please cite this article in press as: Alonso-Perez, J.L., et al., Hypoalgesic effects of three different manual therapy techniques on cervical spine and
psychological interaction: A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/
j.jbmt.2016.12.005
5
neck to a greater extent than others. Due to manipulation group
showing an apparent higher level of catastrophizing, we might
wonder whether the interaction of group with catastrophizing is
simply due to baseline differences, but the results of ANOVA carried
out to test differences in base line, showed no significant differ-
ences between groups at 0.05 level. In addition, results of ANCOVA
test, using catastrophizing as a covariate, showed that the pattern
of results and the interaction between group treatment and change
in baseline, there was not affected by catastrophizing values.
Additionally, Catastrophizing has been implicated as a prog-
nostic factor in patients with neck pain (Buitenhuis and de Jong,
2011; Karels et al., 2007). That Catastrophizing was also identified
in pain-free individuals suggests the importance of this factor in the
management of neck pain.
However, our results must be considered in light of study limi-
tations. One of our limitations is that the study was performed in
pain-free participants, therefore we can't extrapolate these results
to patients with neck pain. However, establishing these effects in
pain-free individuals establishes an important window into how
the nervous system reacts to mechanical inputs via MT. Another
potential limitation is that we evaluated immediate effects of MT
directed over cervical spine and epicondyle region but not long
term effects. We suggest that immediate hypoalgesia to pressure
remains relevant as this is often the primary goal within the
intervention session; i.e. the patient reports decreased pain to
palpation after receiving the MT. In addition, the implication of long
term hypoalgesia to pressure is not clear. A third possible limitation
is that we did not include a placebo group, therefore, placebo ef-
fects related expectations about the intervention are not clear. Nor
did we have a true resting control group to determine whether
changes were related to time or the intervention. However, we are
confident in our findings given prior studies by our group and
others that have compared individual MT techniques to resting
controls (Fernandez-Carnero et al., 2008; George et al., 2006).
One aspect to be considered is that although there were no
statistically significant differences between the groups in the
catastrophic variable, the magnitude of the measurement was
higher in the HVLA group, so we consider that the results of the
interaction should be interpreted with caution. It is important that
cultural factors such as the level of education are measured in
future studies as they may have an impact on treatment-related
expectations. Further randomized controlled studies implement-
ing this therapy in a large number of patients and extending the
duration of the study are needed to confirm these results and the
long-term benefits of the MT intervention We recommend further
large, high-quality, randomized controlled studies of such tech-
niques to demonstrate their validity.
5. Conclusion
All the MT applied to the cervical spine in this study produced
hypoalgesic effects in the neck and elbow region. Additionally,
catastrophizing interacted with change over time in PPT, and this
interaction was exclusive for changes at C7 in manipulation group.
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