Manual Therapy 18 (2013) 308e315

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Manual Therapy
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Original article

The effectiveness of Long’s manipulation on patients with chronic

mechanical neck pain: A randomized controlled trial
Jian Hua Lin a, b, Tong Shen c, Raymond Chi Keung Chung a, Thomas Tai Wing Chiu a, *
a
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
b
Department of Physical Therapy, Shanghai Sunshine Rehabilitation Center, Shanghai, PR China
c
Department of Rehabilitation Medicine, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, PR China

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

Article history: Long’s manipulation (LM) is a representative Chinese manipulation approach incorporating both spinal
Received 30 July 2012 manipulation and traditional Chinese massage (TCM) techniques. This randomized controlled trial (RCT)
Received in revised form aimed to compare the immediate and short-term relative effectiveness of LM to TCM on patients with
24 October 2012
chronic neck pain. Patients were randomly assigned to either LM group or TCM group. LM group was
Accepted 19 November 2012
treated with Long’s manipulation, while the TCM group received TCM therapy. Patients attended 8
sessions of treatment (one session every three days). Outcome measures included neck disability
Keywords:
(Northwick Park Neck Pain Questionnaire; NPQ), pain intensity (Numeric Pain Rating Scale; NPRS),
Spinal manipulation
Neck pain
patient perceived satisfaction of care (PPS) (11-point scale), craniovertebral angle (CV angle) and cervical
Cervical spine range of motion (ROM). A blinded assessor performed assessment at baseline, immediate after treatment
Randomized controlled trial and 3 months post treatment. LM group achieved significantly greater improvement than TCM group in
pain intensity (p < 0.001), neck disability (p ¼ 0.049) and satisfaction (p < 0.001) up to 3-month follow-
up. There was no significant difference in improvements in CV angle and most of cervical ROM between
groups (p ¼ 0.169 w 0.888) with an exception of flexion at 3-month follow-up (p ¼ 0.005). This study
shows that LM could produce better effects than TCM in relieving pain and improving disability in the
management of patients with chronic mechanical neck pain.
Ó 2013 Published by Elsevier Ltd.

1. Introduction relieve pain, increase cervical mobility and improve disability for
patient suffering neck pain (Martínez-Segura et al., 2006; Dunning
Neck pain is a common health problem recognized as a sig- et al., 2012; Grayson et al., 2012). There is also evidence showing
nificant source of disability in the general population (Picavet and that cervical manipulation could influence the muscle strength
Schouten, 2003; Hogg-Johnson et al., 2009; Linaker et al., 2011). It (Cleland et al., 2004), somatomotor reflex (Pickar, 2002) and the
was reported that the age and gender standardized annual incidence sympathetic nervous system (Schmid et al., 2008; Sillevis et al.,
of neck pain was 14.6% in general population (Côté et al., 2004). In 2010). In the latest Cochrane review, researchers concluded that
Hong Kong, an investigation carried out by Chiu et al. (2010) found cervical manipulation was superior to control in short-term pain
that the one-year prevalence of neck pain was 53.67%. Surveys of relief with low quality evidence (Gross et al., 2010).
neck pain in Chinese Mainland demonstrated that the prevalence at Massage is another traditional intervention for the pain-related
any given time ranged from 13.3% to 64.5% (Wang et al., 2004; Wu conditions, especially for the musculoskeletal disorders (Lewis and
et al., 2006; Ye et al., 2007; Zhong et al., 2010). Johnson, 2006). Despite the type of massage, the various techniques
Although little is known about the causes and mechanism of are believed to improve the compliance of soft tissue by mobilizing
chronic mechanical neck pain (Borghouts et al., 1998), occidental and elongating the connective and shorten soft tissue (Irnich et al.,
cervical manipulation is commonly used to treat these patients 2001; Cen et al., 2003; Sefton et al., 2011). There is evidence show-
(Gross et al., 2010). A great deal of research has investigated the ing that massage could increase the blood flow in the massaged region
effect of cervical manipulation in the management of neck pain as well as the adjacent region (Ouchi et al., 2006; Sefton et al., 2010). In
(Bronfort et al., 2001; Muller and Giles, 2005; Martínez-Segura the management of patient with neck pain, sufficient studies have
et al., 2006). The results indicate that cervical manipulation could demonstrated that massage can reduce muscle soreness and tension
(Danneskiold-Samsoe et al., 1983; Weerapong et al., 2005; Buttagat
* Corresponding author. Tel.: þ852 27666709; fax: þ852 23308656. et al., 2012), raise the pain threshold (Frey Law et al., 2008) and
E-mail address: Thomas.Chiu@inet.polyu.edu.hk (T.T.W. Chiu). reduce the pain (Cen et al., 2003; Mitchinson et al., 2007; Jane et al.,

1356-689X/$ e see front matter Ó 2013 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.math.2012.11.005
 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315 309

2011). Systematic reviews have demonstrated that the effectiveness the Guangzhou Medical College from February 2011 to March 2012.
of massage for neck pain remains inconclusive due to the limitations Explanation of the trial was given to each patient. After informed
of the existing research (Haraldsson et al., 2006; Lewis and Johnson, consent was obtained, the patient was assessed and then randomly
2006; Ezzo et al., 2007; Plastaras et al., 2011). allocated to either the LM group (experimental group) or the TCM
Chinese manipulation is a common intervention used to treat group (control group).
neck pain in China. There are several differences in theoretical and Individual was diagnosed as mechanical neck pain by a clinical
practical aspects between Chinese manipulation and occidental doctor according to the following criteria as recommended by van
manipulation. For example, Chinese manipulation is based on the Schalkwyk and Parkin-Smith (2000): (1) neck pain without neu-
channels and collaterals theory in which the symptoms of neck rologic or vascular deficit, (2) restriction of movement of a motion
pain patient are believed to result from channel blockage and joint segment(s) identified by static or motion palpation, (3) possible
displacement (Lin et al., 2012). Consequently, the Chinese manip- discomfort with joint challenge/pressure, (4) abnormal changes of
ulation approach uses traditional Chinese massage (TCM) to clear cervical curve and alignment in radiological test, (5) neck pain
the channels and utilize joint manipulation to restore joint align- referred from peripheral joints or viscera, rheumatic fibromyalgia
ment. The Chinese manipulation techniques for cervical spine can and neurasthenia were excluded.
be performed with patient in side-lying, supine lying or in sitting. Patients who satisfied the following inclusion criteria: a diag-
Some special Chinese manipulation techniques are specifically nosis of mechanical neck pain, more than three month history of
developed for patient with positive response in vertebrobasilar neck pain, age between eighteen and sixty-five and being able to
insufficiency test which is considered as a contraindication for read Chinese were recruited. The exclusion criteria included: (1)
cervical manipulation (Wei and Yang, 1995). Although a number of contraindications to manipulation (e.g., infection, malignancy,
studies reported that Chinese manipulation could provide pain osteoporosis, spinal fracture, inflammatory conditions, nerve root
relief for patient with neck pain, the effects of Chinese manipu- involvement, etc.), (2) history of whiplash or surgery to the neck,
lation on mobility and disability are still not well examined due to (3) congenital abnormality of the cervical spine, (4) diagnosis of
the methodological weakness of existing studies (Lin et al., 2012). cervical radiculopathy or myelopathy, (5) cardiac disease requiring
Long’s manipulation (LM) is one of the commonly used Chinese medical treatment, (6) having received LM or other bone-setting
manipulation approaches for neck pain in Chinese Mainland. treatment in the past 3 months.
Despite its popularity, little research has investigated the effec-
tiveness of LM in the management of chronic mechanical neck pain. 2.2. Outcome measures
In a randomized controlled trial on cervical spondylotic radicul-
opathy, Fan et al. (2010) demonstrated that the combination of LM The Chinese version Northwick Park Neck Pain Questionnaire
and abdominal acupuncture had achieved statistically higher (NPQ), which has been proven to be a valid (Spearman correlation
effective rate than LM and abdominal acupuncture, at the end of coefficient with generic 42-item Chinese health questionnaire,
intervention and at one month follow up. Another randomized r ¼ 0.59) and reliable tool (Intraclass correlation coefficient,
controlled trial compared the effectiveness of LM to that of multi- ICC ¼ 0.95) in measuring disability in individuals with neck pain (Chiu
physiotherapy protocol for patients with cervical spondylotic rad- et al., 2001), was employed as the primary outcome measures. In the
iculopathy (Huang and Pan, 2008). The results indicated that the study by Chiu et al. (2001), the standard deviation and ICC of teste
LM could significantly relief the symptoms for patient with cervical retest reliability of NPQ are 21.62% and 0.95, respectively. The mini-
spondylotic radiculopathy. However, previous trials were not spe- mal detectable change (MDC) with 95% confidence interval (CI) of
cific for chronic neck pain patients and the outcome measures were NPQ is estimated to be 13.40% according to Steffen and Seney (2008).
not validated which made their results questionable. The minimal clinically important difference (MCID) of NPQ was
Sufficient research with reasonable quality has evaluated the demonstrated to be 25% change, which means changes larger or equal
clinical effectiveness and neurophysiological effects of occidental to 25% in NPQ could be considered as clinically significant (Sim et al.,
manipulation on patients with neck pain (Gross et al., 2010). 2006). Patients were asked to complete the questionnaire at baseline,
However, no study has examined the effectiveness of the LM in immediately and 3 months after treatment. The total score of the
treating chronic mechanical neck pain. It remains unclear that questions was converted to percentage scored (Leak et al., 1994).
whether such a combination of soft tissue massage and joint Secondary outcomes measures included pain intensity, cranio-
manipulation approach could produce changes to health status for vertebral (CV) angle and cervical range of motion (CROM).
this population, as determined with comprehensive outcome Pain intensity was rated by patients on the 11-point Numerical
measures. Given the high prevalence and economical cost of neck Pain Rating Scale (NPRS), for which 0 score means no pain while 10
pain, it is necessary to evaluate the effectiveness of LM in man- score means the worst pain (Jensen et al., 1986). The NPRS is a
agement of patients with chronic mechanical neck pain. reliable (ICC ¼ 0.76, 95% CI, 0.51e0.87) and valid (Pearson r ¼ 0.57,
This perspective randomized controlled trial intended to com- p ¼ 0.01) measurement tool for measuring pain intensity on patient
pare the immediate and short-term relative effectiveness of LM to with mechanical neck pain (Cleland et al., 2008). Cleland et al.
TCM on pain, disability and mobility for patients with chronic (2008) demonstrated that the MCID and MDC of NPRS were 1.3
mechanical neck pain. It was hypothesized that the Long’s manip- and 2.1, respectively.
ulation could decrease pain intensity, improve the disability and The CV angle was assessed by using an electronic head Posture
increase the craniovertebral angle and cervical range of motion Instrument (EHPI), which has been demonstrated to be valid and
when compared to traditional Chinese massage. reliable (Validity, Pearson’s r ¼ 1.000; Intra-rater reliability: ICC
ranged from 0.86 to 0.94) in measuring CV angle for patient with
2. Methods chronic neck pain with a MDC of 3.31 (Lau et al., 2009).
The cervical range of motion (CROM) device was employed to
2.1. Participants measure the active cervical range of motion (Youdas et al., 1992).
This device has good validity (Pearson’s r value of six movement
This randomized controlled trial was approved by the ethic ranged from 0.93 to 0.98) and testeretest reliability (ICC of six
review board of the Hong Kong Polytechnic University. Patients movement ranged from 0.89 to 0.98), and the MDC of this device
were recruited in outpatient clinic of the first affiliated Hospital of for the movements ranged from 3.6 to 6.5 (Audette et al., 2010).
310 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315

The minimal clinically important difference (MCID) of CROM device 2.4. Randomization
is still undetermined in current literature.
Patients were assessed at baseline, the end of intervention and at 3- The random allocation was achieved by using computer-
month follow-up by the independent assessor who was blinded to the generated minimization method taking into account of age, gen-
patient’s allocation. In addition, patient perceived satisfaction (PPS) der, and degree of disability resulting from the neck pain (Jensen,
with care was asked immediately after treatment and at 3-month 1991). After the baseline assessment, a senior manual therapist
post-treatment follow up on an 11-point scale (Chiu et al., 2005). input the data and allocated the patient to either LM group or TCM
Any clinical adverse effects, such as increased neck pain and group according to the generated result. The computer generated
transient neurological symptoms (Carlesso et al., 2010), were randomization helps to ensure allocation concealment.
assessed and recorded, as well as the reasons for attrition.
2.5. Interventions
2.3. Sample size calculation
Patients allocated to the experimental group were treated with
Chinese version NPQ was chosen as the primary outcome LM. LM was performed through the following procedure (Fig. 1):
measure in this study. The effect size (ES) of NPQ was estimated to
be medium (ES ¼ 0.25). The correlation among repeated meas- (1) Relaxation step: subject lay supine or on the side with the neck
urements was assumed to be 0.5 (Lau et al., 2011). Since three and head fully supported by pillow. The manual therapist
measurements were performed, the nonsphericity correction e was massaged the soft tissue that covers 3 vertebras up and down
determined as 0.5. With the power of 0.8, alpha level of 0.05, it was from the targeted level to release the tension or spasm. Mas-
estimated that 22 subjects would be required for each group by sage techniques, such as kneading, pinching and plucking, were
using the software G*power 3.0.18 (Faul et al., 2007). selected accordingly.

Fig. 1. Procedure of Long’s manipulation.

 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315 311

(2) Manipulation step: subject lay on the side. One hand of the Table 1
therapist placed under the patient’s face to gently hold the head. Baseline characteristics of patients.

The other hand stabilized the head and neck with one finger LM CTM P value for
palpating the tension of the tissues. Therapist gently flexed the independent t-test
patient’s neck until the tension was palpated at the targeted Number 33 30
level, and then rotated the neck around the axis of the cervical Age (year)
Mean (SD) 38.94 (11.71) 40.90 (11.80) 0.511
spine to endpoint. A high velocity low amplitude technique was
Gender (n)
applied to the joint if no discomfort was reported by patient. Female 24 22 e
(3) Reinforcing step: provocative massage techniques, including Male 9 8
pinching, plucking, clapping and acupressure, were performed Duration (month)
to improve sensation in the neck area or upper limb accordingly. Mean (SD) 37.06 (35.20) 39.23 (28.73) 0.791
NPQ
(4) Painful region massage step: gentle massage techniques, such Mean (SD) 35.44 (14.05) 36.14 (14.23) 0.846
as stroking, rubbing and shaking, were applied to the affected NPRS
region. Mean (SD) 5.79 (1.96) 5.63 (1.90) 0.753
CV
Mean (SD) 51.21 (5.22) 51.20 (6.61) 0.994
Patients in control group received TCM therapy. All the massage
F
techniques applied for LM group were used for patients in the Mean (SD) 59.70 (11.37) 60.33 (10.39) 0.818
control group. The TCM was performed through the step 1, 3 and 4 E
as aforementioned for LM group. Mean (SD) 53.82 (15.66) 56.20 (10.69) 0.488
Each patient received eight 20-min sessions of assigned therapy. RSF
Mean (SD) 32.91 (8.80) 34.73 (5.45) 0.332
They were asked to attend the treatment every three days. Two
LSF
trained manual therapists, of whom one performed LM and another Mean (SD) 32.97 (8.92) 36.33 (6.08) 0.088
one performed TCM, were appointed to carry out the therapy. Both RR
therapists had at least five years’ experience of practice LM or TCM Mean (SD) 67.52 (10.04) 67.73 (7.50) 0.923
LR
for neck pain, respectively. The manual therapist varied the force of
Mean (SD) 69.70 (9.36) 70.03 (8.36) 0.881
the therapy according to patient’s response.
Note: LM ¼ Long’s manipulation group; CTM ¼ Chinese traditional massage group;
NPQ ¼ Chinese version of the Northwick Park Neck Disability Questionnaire;
2.6. Data analysis NPRS ¼ numerical pain rating scale; CV ¼ craniovertebral angle; F ¼ flexion;
E ¼ extension; LSF ¼ left side flexion; RSF ¼ right side flexion; RR ¼ right rotation;
LR ¼ left rotation.
The analysis procedure was performed with the IBM SPSS sta-
tistics 20. The baseline data of the two groups were compared by
greater improvement than TCM immediate after treatment
independent-samples t-test. The linear mixed model (LMM) was
(p < 0.001) and at 3-month follow-up (p ¼ 0.001).
employed to assess the time effect, group effect and their inter-
action effect for the measurements of NPQ, NPRS, PPS, CV angle,
3.1.2. Numerical pain rating scale (NPRS)
CROM. This model has already taken the missing data into account.
The group*time interaction effect for NPRS was demonstrated to
One-way repeated-measures analysis of variance (ANOVA) was
be statistically significant [F (2, 154) ¼ 8.090, p < 0.001] (Table 2).
adopted to investigate the changes within each group after inter-
Patients in LM group demonstrated significant reduction in NPRS
vention. Paired t-tests with Bonferroni adjustment were performed
throughout the whole study period (p < 0.001) (Table 3). The TCM
for the post-hoc analysis. The missing data was handled by using
group showed a significant decrease in NPRS immediate after
intention to treat (ITT) approach with last observation carried forward
treatment (p ¼ 0.002) and the improvement did not remain up to
(LOCF) method. Statistically significant level was set as less than 0.05.
3-month follow-up (p ¼ 0.040) (Table 3). The reductions in LM
group were statistically superior to that in TCM at subsequent
3. Results follow-ups (immediate follow-up, p < 0.001; 3-month follow-up,
p < 0.001) (Table 2).
A total of 63 patients were recruited and randomly allocated to
either LM group or TCM group. There was no difference between 3.1.3. Patient perceived satisfaction (PPS)
the LM and the TCM group in terms of demographic characteristics In addition, patients in the LM group showed greater sat-
and the results of baseline comparison is shown in Table 1. There isfaction with the care than that in the TCM group from immediate
were six and seventeen drop outs during the treatment period and post treatment (p < 0.001) up to the 3-month post-treatment fol-
the follow-up, respectively. No serious adverse event was noticed low-up (p < 0.001) (Table 2).
except increased neck pain was reported by one patient in the TCM
group. The details of the patient recruitment, participation and 3.2. Changes of objective outcome measurements
drop outs are demonstrated in Fig. 2. The group means, standard
deviations and 95% CI of all measurements at subsequent follow- 3.2.1. Craniovertebral (CV) angle
ups are illustrated in Tables 2 and 3. There is no significant between-group difference in CV angle at
subsequent follow-ups (immediate follow-up, p ¼ 0.495; 3-month
3.1. Changes of subjective outcome measurements follow-up, p ¼ 0.718) (Table 2). The LM group demonstrated sig-
nificant increase in CV angle throughout the study period (imme-
3.1.1. Northwick Park Neck Pain Questionnaire (NPQ) diate follow-up, p ¼ 0.014; 3-month follow-up, p < 0.001) (Table 3).
As is shown in Table 2, a significant group*time interaction effect Although the one-way repeated measures ANOVA revealed a sig-
was detected for NPQ [F (2, 154) ¼ 3.079, p ¼ 0.049]. Both LM and nificant within-group change (p ¼ 0.026) in TCM group, the
TCM group achieved significant decrease in NPQ immediate post changes at immediate follow-up (p ¼ 0.028) and 3-month follow-
treatment (LM, p < 0.001; TCM, p < 0.001) and up to the 3-month up (p ¼ 0.030) were not significant as the significant level of
follow-up (LM, p < 0.001; TCM, p < 0.001). The LM produced post-hoc test with Bonferroni adjustment was p ¼ 0.017. There is no
312 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315

Assessed for eligibility

(n=75)

Enrollment
Excluded (n=12)
Not meeting inclusion
criteria (n=4)

Eligible but refused to

participate (n=8)

Randomized (n=63)

Long’s Manipulation Group Chinese traditional massage Group

Allocation

Allocated to intervention (n=33) Allocated to intervention (n=30)

Received allocated intervention Received allocated intervention
(n=33) (n=30)
Refused allocated intervention Refused allocated intervention
(n=0) (n=0)

Attrition (n=2) Attrition (n=4)

Immediate

Not enough time to attend =2 Not enough time to attend =2

Follow up

Concurrent treatment =0 Concurrent treatment =1

Worsening of symptoms =0 Worsening of symptoms =1
Other reason =0 Other reason =0

Attrition (n=4) Attrition (n=13)

Post 3-month

Not enough time to attend =2 Not enough time to attend =5

Follow up

Concurrent treatment =2 Concurrent treatment =8

Worsening of symptoms =0 Worsening of symptoms =0
Other reason =0 Other reason =0
Analysis

Analyzed (n=33) Analyzed (n=30)

Fig. 2. Participant flow and follow-up evaluation.

Table 2
Results of linear mixed model analysis.

Outcome Immediate post-treatment 3-month post-treatment follow-up Group*time effect

measures
LM TCM P value for LM TCM P value for P value F (2, 154) value
between-group between-group
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
comparison comparison
NPQ 12.08 (7.30) 21.43 (11.18) <0.001 15.07 (7.47) 25.88 (11.91) 0.001 0.049 3.079
NPRS 2.06 (1.65) 4.04 (1.59) <0.001 2.07 (1.44) 4.54 (2.26) <0.001 <0.001 8.090
PPS 8.81 (1.01) 7.65 (1.09) <0.001 8.45 (0.99) 7.31 (1.09) <0.001 0.828
CV 53.74 (4.95) 52.69 (6.57) 0.495 54.44 (3.73) 54.00 (3.37) 0.718 0.870 0.139
F 63.81 (8.27) 61.92 (8.30) 0.396 63.56 (6.66) 57.38 (5.06) 0.005 0.204 1.607
E 63.94 (11.44) 58.77 (11.57) 0.097 64.22 (12.65) 63.23 (8.43) 0.800 0.251 1.394
RSF 35.94 (5.40) 34.62 (5.27) 0.357 35.56 (5.03) 35.54 (4.77) 0.992 0.377 0.981
LSF 36.39 (5.90) 35.31 (5.88) 0.494 36.67 (5.71) 38.92 (4.13) 0.212 0.169 1.799
RR 73.61 (7.49) 71.23 (6.79) 0.218 76.44 (6.38) 72.92 (7.10) 0.123 0.467 0.765
LR 76.00 (8.28) 74.92 (7.53) 0.612 78.15 (6.81) 77.54 (6.00) 0.785 0.888 0.119

Note: LM ¼ Long’s manipulation group; CTM ¼ Chinese traditional massage group; NPQ ¼ Chinese version of the Northwick Park Neck Disability Questionnaire;
NPRS ¼ numerical pain rating scale; PPS ¼ patient perceived satisfaction; CV ¼ craniovertebral angle; F ¼ flexion; E ¼ extension; LSF ¼ left side flexion; RSF ¼ right side
flexion; RR ¼ right rotation; LR ¼ left rotation.
 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315 313

Table 3
Results of within-group comparison.

Outcome measures Group Immediate post-treatment 3-month post-treatment follow-up P value for one-way
repeated measures ANOVA
95% CI P value for paired t-test 95% CI P value for paired t-test
NPQ LM 10.07e16.03 <0.001 13.19e19.09 <0.001 <0.001
CTM 19.19e28.62 <0.001 22.58e31.81 <0.001 <0.001
NPRS LM 1.65e3.08 <0.001 1.91e3.25 <0.001 <0.001
CTM 3.74e5.12 0.002 4.09e5.58 0.040 0.005
PPS LM 8.43e9.18 e 8.09e8.82 0.078 e
CTM 7.21e8.10 e 6.87e7.75 0.260 e
CV LM 51.30e55.12 0.014 52.71e55.90 <0.001 <0.001
CTM 50.12e54.94 0.028 50.20e54.73 0.030 0.026
F LM 60.05e66.50 0.006 59.02e64.74 0.053 0.008
CTM 57.45e64.01 0.240 57.03e62.97 0.668 0.474
E LM 59.55e67.60 <0.001 59.65e67.99 <0.001 <0.001
CTM 53.90e62.23 0.274 56.34e63.66 0.099 0.146
RSF LM 33.97e37.79 0.022 33.86e37.29 0.048 0.029
CTM 32.97e37.03 0.724 32.77e36.56 0.944 0.842
LSF LM 34.34e38.63 <0.001 34.61e38.72 <0.001 <0.001
CTM 33.53e37.93 0.862 34.69e38.64 0.274 0.295
RR LM 70.65e75.90 <0.001 71.72e77.37 <0.001 <0.001
CTM 68.64e73.76 0.015 69.53e74.87 0.001 0.002
LR LM 72.75e78.52 0.001 74.48e79.70 <0.001 <0.001
CTM 70.24e76.56 0.002 71.74e77.46 <0.001 <0.001

Note: LM ¼ Long’s manipulation group; CTM ¼ Chinese traditional massage group; NPQ ¼ Chinese version of the Northwick Park Neck Disability Questionnaire;
NPRS ¼ numerical pain rating scale; PPS ¼ patient perceived satisfaction; CV ¼ craniovertebral angle; F ¼ flexion; E ¼ extension; LSF ¼ left side flexion; RSF ¼ right side
flexion; RR ¼ right rotation; LR ¼ Left rotation.

significant between-group difference in CV angle at subsequent 4.3. Changes in subjective outcome measures
follow-ups (immediate follow-up, p ¼ 0.495; 3-month follow-up,
p ¼ 0.718). The LM group demonstrated significantly better improvement in
NPQ than the TCM group up to 3-month. Both groups achieved
3.2.2. Cervical range of motion (ROM) substantial gains in NPQ immediately after intervention, but only the
The LM produced significant gains in most ROM (p < 0.006) improvement of the LM group remained at 3-month post-treatment
except the right side flexion (p ¼ 0.022) immediate after treatment follow-up. According to Chiu et al. (2001), the minimal detectable
and the improvement persisted up to 3-month follow-up change (MDC) of Chinese version NPQ in Chinese population is 13.4%,
(p < 0.001) except the flexion (p ¼ 0.053) (Table 3). Significant which means that change more than 13.4% in NPQ represents a real
increases were observed in both right and left rotation in the TCM change. In current study, LM group achieved changes of mean of
group throughout the study period (p < 0.015). There is no stat- 23.36% and 20.37% for NPQ immediate after treatment and 3-month
istically significant between-group difference in the measurement post treatment, respectively, while that in TCM group are 14.71% and
of ROM (p > 0.097) except the flexion (p ¼ 0.005) at 3-month 10.26%, respectively. This suggests that the significant improvement
follow-up (Table 2). in the LM group is not due to measurement error. However, it is
noticed that improvement in LM group could not be considered as
4. Discussion clinically meaningful because the MCID of NPQ is 25% change as
reported by Sim et al. (2006). Although the changes in NPQ are
4.1. Summary of findings in current study significant in TCM group, the improvement observed at 3-month
post-treatment follow-up may result from measurement error
Results of this study demonstrate that the Long’s manipulation instead of real treatment effect. Hence, the results indicate that the
produces greater immediate and short-term pain reduction, manipulation component of LM conferred statistically significant
improvement of disability and patient perceived satisfaction with additional effect for patients with chronic mechanical neck pain
care compared to traditional Chinese massage therapy. There is no which remained for a 3-month period. Giles and Muller (2003)
significant between-group difference observed in craniovertebral compared the effectiveness of 9 weeks spinal manipulation with
angle and most of the cervical range of motion during the whole medication and acupuncture in treating chronic neck pain. The
study period with flexion at 3-month post-treatment follow-up as results showed that spinal manipulation achieved the best overall
an exception. results, including mobility, general health and disability. Their
further study revealed that the significant improvement of spinal
4.2. The strengths of current study manipulation remained for one year post intervention (Muller and
Giles, 2005). In current study, patients in LM group demonstrated
To the authors’ knowledge, this is the first study to evaluate the significant improvement in disability which was remained at
effectiveness of LM by using both subjective and objective outcome 3-month post treatment follow-up. It is important to note that
measures. The employment of validated outcome measures patients in current study only received 8 sessions treatment within
enhanced the confidence of the results revealed in this study. Given around 3 weeks, while the treatment in the study by Giles and
the lack of evidence to demonstrate its long-term effect for neck Muller (2003) lasted for 9 weeks. Further study is needed to inves-
pain, the traditional Chinese massage was adopted as the control tigate the long-term effectiveness of LM in treating chronic neck
condition, which made it possible to evaluate the additional effect pain, as well as the potential doseeeffect relationship.
of the spinal joint manipulation component of LM. In addition, this Both groups showed significant improvement in pain relief at
study performed a 3-month follow-up to examine the short-term subsequent follow-ups. According to the MCID and MDC of NPRS
effectiveness of LM for patients with chronic mechanical pain. reported by Cleland et al. (2008), the reduction of pain intensity in
314 J.H. Lin et al. / Manual Therapy 18 (2013) 308e315

LM group at the end of treatment (3.73 points) and 3-month post- and the increased pain experienced by the patient in the TCM group
treatment (3.72 points) are not only statistically significant but relieved within one day.
also clinically relevant. Although the pain relief in the TCM group
were statistically significant, the change of the mean of NPRS were 4.6. Limitations of current study
under the MDC (immediate after treatment, 1.59; 3-month post-
treatment follow-up, 1.09). In addition, the reduction of pain Due to the nature of the interventions, this study failed to keep
intensity in the LM group was superior to that in the TCM group at patients blinded to the treatment group. Another limitation is the
each follow-up. This finding suggests that LM is effective in pain lack of a long-term follow-up. Given the course of chronic neck pain
relieving for patient with chronic mechanical neck pain and the proceeding with periods of remission and exacerbation, a mini-
influence can last for 3 months. mum of one-year follow-up, as recommended by Hudson and Ryan
In a previous study, a single cervical manipulation was dem- (2010), is necessary to determine the long-term effectiveness of LM.
onstrated to obtain greater improvement in pain and neck mobility This study did not include a true controlled group which may risk
(Martínez-Segura et al., 2006). The patients treated with cervical the confidence of the results. In addition, a considerable high
manipulation achieved a mean reduction of 3.5 points on visual attrition rate occurred in the TCM group making the findings vul-
analog scale (VAS), while that of patients received mobilization was nerable to bias. Results of this study can only be applied to patients
only 0.4 points. In current study, the LM group showed a mean with chronic mechanical neck pain. Further study is warranted to
decrease of 3.73 points on NPRS, which is consistent to their find- investigate the effectiveness of Long’s manipulation in patients
ings. In addition, the improvement in this study remained for 3 with acute neck pain or whiplash associated disorder (WAD), etc.
months post treatment, suggesting that LM can provide short-term
pain relief benefit for patient with chronic mechanical neck pain.
In the present study, patient perceived satisfactions of care of 5. Conclusion
LM group are significant greater than that of TCM group at sub-
sequent follow-ups. This concurs with a longitudinal study by Chiu The Long’s manipulation was showed to produce greater effects
et al. (2005), which demonstrated that the correlations between than traditional Chinese massage in relieving pain and improving
disability and patient satisfaction, and that between pain and disability in the management of patients with chronic mechanical
patient satisfaction were moderate (r range: 0.50e0.65) and fair (r neck pain. However, the Long’s manipulation demonstrated no
range: 0.43e0.48), respectively. significant benefit for head posture and cervical range of motion
compared with traditional Chinese massage.
4.4. Changes in objective outcome measures
Acknowledgements
Significant improvement in CV angle was demonstrated in the
LM group. However, the differences between the LM and TCM The authors thank all the patients for their participation. Special
groups are not statistically significant at the subsequent follow-ups. thanks are also extended to the colleagues in the first affiliated
Lau et al. (2011) reported that 8 sessions anterioreposterior Hospital of the Guangzhou Medical College for their support in
thoracic manipulation produced significant gains in CV angle patient recruitment and intervention.
compared to the control protocol. They suggested that the resto-
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