Cervical Radiculopathy: Effectiveness of Adding Traction to Physical Therapy-A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Use of cervical traction for managing neck pain: A cross-sectional survey of physiotherapists in India

BACKGROUND

Neck pain remains the fourth leading cause of disability and work loss, and a multimodal treatment approach is effective in reducing neck pain and disability.

PURPOSE

The purpose of this study is to examine the use of cervical traction for managing neck pain by Physiotherapists in India, including how and when the traction is used, the modes and parameters of traction, any additional interventions given with traction, and the influence of professional demographic characteristics in decision making in traction usage.

STUDY DESIGN

A cross-sectional survey.

METHODOLOGY

A random sample of approximately 2500 musculoskeletal physiotherapists was surveyed, and the data was presented in a descriptive form. Chi-square analyses were used to identify the association between responders' qualifications and traction usage.

RESULTS

From the total physiotherapist approached 18.52% (n = 463) responses were obtained, and 62% (n = 287) respondents reported that they would use traction in their clinical practice. Out of 92.3% of responders indicated using traction for radiculopathy, 78.7% of respondents used traction for patients with neck pain without radiculopathy. It is used as a combination therapy by 58.8% for radiculopathy and 52.2% for stiffness. There was no association between the responder's qualification and traction usage (χ2 = 0.707, p = 0.40). Traction is used in combination with other physiotherapeutic techniques.

CONCLUSION

Traction use was consistent with the proposed criteria identifying patients likely to benefit. However, disregarding current guidelines, physiotherapists also use traction for non-radicular neck pain. Various traction delivery modes and parameters were used within a comprehensive plan of care incorporating multiple interventions.

Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain

Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.

Comparative effectiveness of manual intermittent cervical longitudinal mobilization versus pain modalities in cervical radiculopathy: A double blinded randomized controlled study

BACKGROUND

Cervical radiculopathy is a common condition encountered in clinical practice and is characterized by compression or irritation of the nerve roots in the cervical spine.

OBJECTIVE

To compare the effectiveness of manual intermittent cervical longitudinal mobilization (mICLM) and therapeutic modalities in managing acute, sub-acute and chronic radiculopathy pain.

METHODS

This was a multicenter, double-blinded, randomized controlled trial. Individuals with radiculopathies were randomized into interventional; (IG, n= 18) receiving mICLM and control group; (CG, n= 17), receiving Microwave Diathermy (MWD) and transcutaneous electrical nerve stimulation (TENS) at the cervico-dorsal area daily for two weeks. The neck pain disability index (NPDI), numeric pain rating scale (NPRS), and global rating of change score (GRoC) were used as outcome measures. Statistical analysis was conducted using SPSS version 23.0.

RESULTS

Both mICLM and MWD with TENS were equally effective in reducing the pain and disability in either group. However, it was noted that mICLM had a better impact on acute, sub-acute and chronic cases of radiculopathy pain comparatively. Mean age was 42.3 (SD =± 10.9) years. 54.3% were between the age group of 40-60 years out of which 51.4% were male and 48.6% were female. 51.4% were in IG and 48.6% were in CG. The mean comparison of NPAD and NPRS within groups was significant with p< 0.01*. Post treatment mean comparison of NPAD outcomes in IG and CG remain significant with p= 0.004* and p< 0.01* respectively. The post NPAD and NPRS between IG and CG were found statistically insignificant with p= 0.75 and p= 0.57 respectively.

CONCLUSION

mICLM and therapeutic modalities showed similar outcomes in managing radiculopathy pain. The study highlights the need for further research to understand the effectiveness of these interventions in larger patient populations.

Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews

BACKGROUND

Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy.

METHODS

An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2.

RESULTS

Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies).

CONCLUSION

This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

It might take a village: developing a rehabilitation program of care for degenerative cervical radiculopathy from the patient perspective

PURPOSE

The aim of our study is to inform the development of a rehabilitation program of care from the perspectives of those suffering from degenerative cervical radiculopathy (DCR).

MATERIAL AND METHODS

We conducted a qualitative study, purposefully recruiting individuals with DCR. Transcripts from virtual semi-structured interviews were iteratively analyzed using interpretative phenomenological methods.

RESULTS

Eleven participants were recruited and depicted their ideal rehabilitation program of care. Participants described the importance of a patient centered-approach, health care providers who were validating, reassuring and attentive, easier access to health services, a supportive and collaborative team environment, and receiving peer support. Furthermore, participants expressed that they would expect the program of care to result in their symptoms being less intense and intermittent. In consideration of the participant perspectives, the ideal rehabilitation program of care can be conceptualized by the enactive-biopsychosocial model, which provides a theoretical framework for developing and implementing the program of care.

CONCLUSION

We obtained valuable information from individuals living with DCR regarding their preferences and expectations of a rehabilitation program of care. The participant descriptions will provide the groundwork for its development to meet patient needs and expectations. Future research to guide implementation will also be explored.

2. Cervical radicular pain

INTRODUCTION

Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.

METHODS

The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.

RESULTS

The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.

CONCLUSIONS

There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].

Comparison of biomechanical parameters of two Chinese cervical spine rotation manipulations based on motion capture and finite element analysis

Objective: The purpose of this study was to obtain the stress-strain of the cervical spine structure during the simulated manipulation of the oblique pulling manipulation and the cervical rotation-traction manipulation in order to compare the mechanical mechanism of the two manipulations. Methods: A motion capture system was used to record the key kinematic parameters of operating the two manipulations. At the same time, a three-dimensional finite element model of the C0-T1 full healthy cervical spine was established, and the key kinematic parameters were loaded onto the finite element model in steps to analyze and simulate the detailed process of the operation of the two manipulations. Results: A detailed finite element model of the whole cervical spine including spinal nerve roots was established, and the validity of this 3D finite element model was verified. During the stepwise simulation of the two cervical spine rotation manipulations to the right, the disc (including the annulus fibrosus and nucleus pulposus) and facet joints stresses and displacements were greater in the oblique pulling manipulation group than in the cervical rotation-traction manipulation group, while the spinal cord and nerve root stresses were greater in the cervical rotation-traction manipulation group than in the oblique pulling manipulation group. The spinal cord and nerve root stresses in the cervical rotation-traction manipulation group were mainly concentrated in the C4/5 and C5/6 segments. Conclusion: The oblique pulling manipulation may be more appropriate for the treatment of cervical spondylotic radiculopathy, while cervical rotation-traction manipulation is more appropriate for the treatment of cervical spondylosis of cervical type. Clinicians should select cervical rotation manipulations for different types of cervical spondylosis according to the patient's symptoms and needs.

Is the quality of systematic reviews influenced by prospective registration: a methods review of systematic musculoskeletal physical therapy reviews

INTRODUCTION

It is unknown if verified prospective registration of systematic reviews (SRs) and the randomized clinical trials (RCTs) that they use affect an SR's methodological quality on A MeaSurement Tool to Assess Systematic Reviews 2 (AMSTAR 2).

METHODS

Data originated from interventional SRs published in International Society of Physiotherapy Journals Editors (ISPJE) member journals, indexed in MEDLINE, between 1 January 2018 and 18 August 2021. Blinded reviewers identified the SRs and extracted the data for the variables of interest for the SRs and the RCTs.

RESULTS

Two of 14 ISPJE member journals required prospective SR registration. Twenty SRs were identified, and 169 unique, retrievable RCTs were included within those SRs. One (5.0%) of the 20 SRs and 15 of the 169 (8.9%) RCTs were prospectively registered and published consistent with this intent. Nineteen (95.0%) of the 20 identified SRs was categorized as 'critically low' on the AMSTAR 2.

DISCUSSION

SRs and the RCTs identified within them were infrequently prospectively registered, prospectively verifiable, or prospectively verified based on the established research record.

CONCLUSIONS

Ensuring that SRs and RCTs have fidelity with the research record from conception to publication may help rule out low-value interventions, decrease variability in physical therapy practice, and solidify evidence-based physical therapy practice.

Conservative Management of Cervical Radiculopathy: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR).

METHODS

We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

DISCUSSION

There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up

Sagittal cervical alignment is a clinically related feature in patients suffering from chronic cervical spondylotic radiculopathy (CSR). We designed this randomized trial to explore the effects of cervical lordosis (CL) correction in thirty chronic lower CSR patients with CL < 20°. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received neck stretching and exercises and infrared radiation; additionally, the SG received cervical extension traction. Treatments were applied 3× per week for 10 weeks after which groups were followed for 3 months and 2 years. The amplitude of dermatomal somatosensory evoked potentials (DSSEPS), CL C2−C7, and pain scales (NRS) were measured. The SG had an increase in CL post-treatment (p < 0.0001), this was maintained at 3 months and 2 years. No statistical improvement in CL was found for the CG. A significant reduction in NRS for SG after 10 weeks of treatment with non-significant loss of change at 3 months and continued improvement at 2 years was found. CG had less significant improvement in post-treatment NRS; the 3-month and 2-year measures revealed significant worsening in NRS. An inverse linear correlation between increased CL and NRS was found (r = −0.49; p = 0.005) for both groups initially and maintained in SG at the final 2-year follow-up (r = −0.6; p = 0.01). At 10 weeks, we found significant improvements in DSSEPS for both groups (p < 0.0001). We identified a linear correlation between initial DSSEPs and CL for both groups (p < 0.0001), maintained only in the SG at the final follow-up for all levels (p < 0.0001). Improved CL in the SG correlated with significant improvements in nerve root function and pain rating in patients with CSR at short and long-term follow-up. These observed effects indicate that clinicians involved in the treatment of patients with symptoms of cervical degenerative disorders should add sagittal curve correction to their armamentarium of rehabilitation procedures for relevant patient populations.

Changes of Endothelin-1 and Calcitonin Gene-Related Peptide Concentrations in Patients with Cervical Radiculopathy after Wrist-Ankle Acupuncture-Moxibustion and Hot Compression with Chinese Herbal Medicine

Objective

This study aimed at investigating the effects of wrist-ankle acupuncture-moxibustion and hot compression with Chinese herbal medicine on pain symptoms, endothelin-1 (ET-1), and calcitonin gene-related peptide (CGRP) concentrations of patients with cervical radiculopathy (CR).

Methods

A total of 82 patients with CR were randomly divided into the study group and control group, with 41 cases in each group. The control group was treated with standard treatment. In addition to standard treatment, the study group was additionally treated with wrist-ankle acupuncture-moxibustion and hot compression with Chinese herbal medicine. The ET-1 and CGRP concentrations in the plasma were measured by the radioimmunoassay method.

Results

The total response rate in the study group and the control group was 97.55% and 82.93%, respectively. The study group showed lower scores of the visual analogue scale (VAS), Northwick Park Neck Pain Questionnaire (NPQ), McGill Pain Questionnaire (MPQ), numbness intensity assessment, and neck disability index (NDI) but higher scores of the Short Form-36 (SF-36) health survey questionnaire than the control group after treatment. Besides, the study group exhibited reduced ET-1 and substance P (SP) concentrations concomitant with increased CGRP and β-endorphin (β-EP) concentrations compared with the control group.

Conclusion

Wrist-ankle acupuncture-moxibustion and hot compression with Chinese herbal medicine could effectively alleviate the pain of CR patients, affect ET-1 and CGRP concentrations, promote the recovery of cervical function, and improve the quality of life.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Effect of manual therapy with exercise in patients with chronic cervical radiculopathy: a randomized clinical trial

BACKGROUND

Research that has examined the effects of cervical spine mobilization on hypoesthesia and hypersensitivity characteristics in patients with cervical radiculopathy is scarce. The aim of this study was to examine the short-term effects of vertebral mobilization on the sensory features in patients with cervical radiculopathy.

METHODS

Twenty-eight participants with chronic cervical radiculopathy were randomly allocated to (1) an experimental group [cervical vertebral mobilization technique and exercise] or (2) a comparison group [minimal superficial circular pressure on the skin and exercise]. Participants received a total of 6 sessions for 3-5 weeks. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), pressure pain threshold (PPT), heat/cold pain threshold (HPT/CPT), and active cervical range of motion (ROM) were measured at baseline immediately after the first session and after the sixth session.

RESULTS

The experimental group showed improvements from baseline to session 6 in NPRS [mean difference 2.6; 95% confidence interval: -4.6, -0.7], NDI [14; -23.3, -4.3], and active cervical ROM in extension [14°; 2.3, 25.5], rotation [16°; 8.8, 22.5], and lateral flexion to the affected side [10°; 2.3, 16.8]. Improvements were also found in PPT at the neck [124 kPa; 57, 191.1] and C7 level at the hand [99 kPa; 3.6, 194.9]. There were no changes in the HPT and CPT at any tested area (P>0.050).

CONCLUSIONS

Cervical vertebral mobilization for patients with chronic cervical radiculopathy reduced localized mechanical, but not thermal, pain hypersensitivity.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03328351 ). Registered on November 1, 2017, retrospectively registered.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: An exploratory, prospective, observational pilot study

BACKGROUND

Cervical radiculopathy is a relatively common and disabling condition involving local pain in the neck region and pain that radiates into the upper limb. Recent data suggest that cervical traction may effectively reduce disability and pain, with a dose-response relationship. The main aim of this study was therefore to evaluate the mid-term effect of an intensive cervical traction protocol for patients with cervical radiculopathy on disability, and to compare the effects with those reported by non-intensive protocols in the literature.

METHODS

We conducted a prospective open observational study of 36 patients referred by their general practitioner for symptoms suggestive of cervical radiculopathy. All patients underwent the same treatment: a 30-minute cervical traction protocol, twice a day, for five consecutive days. The main objective was the evaluation of disability at 3 months. We evaluated at baseline (D1), the end of the protocol (D5) and at mid-term (M3) disability, cervical pain, radiating pain, pain on motor imagery, presence of neuropathic pain and medication consumption. The primary outcome was the proportion of patients for whom the Neck Disability Index improved by more than the minimum clinically important difference of 7 points by M3.

RESULTS

Thirty-six patients were included in this study. The Neck Disability Index improved by more than the minimum clinically important difference in 48.3% at M3. Mean Neck Disability Index (p < .001), mean cervical VAS (p < .001), mean radiating VAS (p < .001), and mean VAS for imagined lateral flexion and rotation (p < .002) improved significantly from D1 to D5 and from D1 to M3. Consumption of medication reduced at each time point. The proportion of patients with neuropathic pain reduced from 61.1% at D1 to 33.3% at D5 and 48.3% at M3.

CONCLUSION

Disability reduced by more than the minimum clinically important difference in almost half of the participants following the intensive traction protocol. These results are encouraging and suggest that this complex condition can be treated with relatively simple methods.

Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature

The aim of this study was to describe and update current knowledge of manual therapy accuracy in treating cervical and lumbar radiculopathy, to identify the limitations in current studies, and to suggest areas for future research. The study was conducted according to PRISMA guidelines for systematic reviews. A comprehensive literature review was conducted using PubMed and Web of Science databases up to April 2020. The following inclusion criteria were used: (1) presence of radiculopathy; (2) treatment defined as manual therapy (i.e., traction, manipulation, mobilization); and (3) publication defined as a Randomized Controlled Trial. The electronic literature search resulted in 473 potentially relevant articles. Finally, 27 articles were accepted: 21 on cervical (CR) and 6 in lumbar radiculopathy (LR). The mean PEDro score for CR was 6.6 (SD 1.3), and for LR 6.7 (SD 1.6). Traction-oriented techniques are the most frequently chosen treatment form for CR and are efficient in reducing pain and improving functional outcomes. In LR, each of the included publications used a different form of manual therapy, which makes it challenging to summarize knowledge in this group. Of included publications, 93% were either of moderate or low quality, which indicates that quality improvement is necessary for this type of research.

Manual Therapy as a Management of Cervical Radiculopathy: A Systematic Review

BACKGROUND

Cervical radiculopathy is defined as a disorder involving dysfunction of the cervical nerve roots characterised by pain radiating and/or loss of motor and sensory function towards the root affected. There is no consensus on a good definition of the term. In addition, the evidence regarding the effectiveness of manual therapy in radiculopathy is contradictory.

OBJECTIVE

To assess the effectiveness of manual therapy in improving pain, functional capacity, and range of motion in treating cervical radiculopathy with and without confirmation of altered nerve conduction.

METHODS

Systematic review of randomised clinical trials on cervical radiculopathy and manual therapy, in PubMed, Web of Science, Scopus, PEDro, and Cochrane Library Plus databases. The PRISMA checklist was followed. Methodological quality was evaluated using the PEDro scale and RoB 2.0. tool.

RESULTS

17 clinical trials published in the past 10 years were selected. Manual therapy was effective in the treatment of symptoms related to cervical radiculopathy in all studies, regardless of the type of technique and dose applied.

CONCLUSIONS

This systematic review did not establish which manual therapy techniques are the most effective for cervical radiculopathy with electrophysiological confirmation of altered nerve conduction. Without this confirmation, the application of manual therapy, regardless of the protocol applied and the manual therapy technique selected, appears to be effective in reducing chronic cervical pain and decreasing the index of cervical disability in cervical radiculopathy in the short term. However, it would be necessary to agree on a definition and diagnostic criteria of radiculopathy, as well as the definition and standardisation of manual techniques, to analyse the effectiveness of manual therapy in cervical radiculopathy in depth.

Shoulder Pain of Spinal Source in the Military: A Case Series

Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD) service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the potential to reduce the substantial burden of MSI in the military.

Is Dry Needling Effective When Combined with Other Therapies for Myofascial Trigger Points Associated with Neck Pain Symptoms? A Systematic Review and Meta-Analysis

Objective

To evaluate the effects of combining dry needling with other physical therapy interventions versus the application of the other interventions or dry needling alone applied over trigger points (TrPs) associated to neck pain. Databases and Data Treatment. Electronic databases were searched for randomized controlled trials where at least one group received dry needling combined with other interventions for TrPs associated with neck pain. Outcomes included pain intensity, pain-related disability, pressure pain thresholds, and cervical range of motion. The risk of bias (RoB) was assessed using the Cochrane risk of bias tool, methodological quality was assessed with PEDro score, and the quality of evidence was assessed by using the GRADE approach. Between-groups mean differences (MD) and standardized mean difference (SMD) were calculated.

Results

Eight trials were included. Dry needling combined with other interventions reduced pain intensity at short-term (SMD -1.46, 95% CI -2.25 to -0.67) and midterm (SMD -0.38, 95% CI -0.74 to -0.03) but not immediately after or at long-term compared with the other interventions alone. A small effect on pain-related disability was observed at short-term (SMD -0.45, 95% CI -0.87 to -0.03) but not at midterm or long-term. The inclusion of dry needling was also effective for improving pressure pain thresholds only at short-term (MD 112.02 kPa, 95% CI 27.99 to 196.06). No significant effects on cervical range of motion or pain catastrophism were observed.

Conclusion

Low-to-moderate evidence suggests a positive effect to the combination of dry needling with other interventions for improving pain intensity, pain-related disability, pressure pain thresholds, and cervical range of motion in people with neck pain associated with TrPs at short-term. No midterm or long-term effects were observed.

Traction Therapy for Cervical Radicular Syndrome is Statistically Significant but not Clinically Relevant for Pain Relief. A Systematic Literature Review with Meta-Analysis and Trial Sequential Analysis

Aim: We aimed to investigate the effectiveness of traction therapy in reducing pain by performing a systematic review with meta-analysis. We also explore the best modality for administering traction to patients with cervical radicular syndrome (CRS). Methods: We searched the Medline, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases. Two reviewers independently selected randomized controlled trials (RCTs) that compared traction in addition to other treatments versus the effectiveness of other treatments alone for pain outcome. We calculated the mean differences (MDs) and 95% confidence intervals (CIs). We used Cochrane’s tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence and summarize the study conclusions. Results: A total of seven studies (589 patients), one with low risk of bias, were evaluated. An overall estimate of treatment modalities showed low evidence that adding traction to other treatments is statistically significant (MD −5.93 [95% CI, −11.81 to −0.04] P = 0.05 and I² = 57%) compared to other treatments alone. The subgroup analyses were still statistically significant only for mechanical and continuous modalities. Conclusions: Overall analysis showed that, compared to controls, reduction in pain intensity after traction therapy was achieved in patients with cervical radiculopathy. However, the quality of evidence was generally low and none of these effects were clinically meaningful.

Cervical traction combined with neural mobilization for patients with cervical radiculopathy: A randomized controlled trial

BACKGROUND

Although both neural mobilization (NM) and cervical traction (CT) are widely used interventions in cervical radiculopathy (CR), there is limited clinical data to support their use.

OBJECTIVE

To evaluate the effects of CT, with or without the addition of NM, on pain, function, and disability in patients with CR.

DESIGN

A randomized, double-blinded, placebo-controlled clinical trial.

METHODS

66 patients with CR were randomly allocated to: a group (n = 22) received CT combined with NM (CT + NM), a group (n = 22) received CT combined with sham NM (CT + shamNM) and a wait-list control (WLC) group (n = 22). The Neck Disability Index (NDI), the Patient-Specific Functional Scale, the Numeric Pain Rating Scale (NPRS), grip strength and cervical spine mobility were used as outcome measures. A two-way analysis of variance was used to evaluate differences between the three groups at baseline and at 4-week follow-up.

RESULTS

Statistically and clinically significant between-group differences at 4-week follow-up were found between CT + NM and WLC groups in favor of CT + NM group in NDI scores (d = 1.30), NRPS (d = 1.94), and active cervical rotation towards the opposite arm (d = 1.18) and between CT + NM and CT + shamNM groups in favor of CT + NM group in NRPS (d = 1.21). No significant differences were observed between CT + shamNM and WLC groups in all outcome measures. Clinically significant within-group improvements were found only for the CT + NM group.

CONCLUSION

At 4-week follow-up, CT in combination with NM resulted in improved outcomes in pain, function and disability in patients with CR.

The Functional and Morphological Changes of the Cervical Intervertebral Disc after Applying Lordotic Curve Controlled Traction: A Double-Blind Randomized Controlled Study

The newly developed cervical lordotic curve-controlled traction (C-LCCT) appears to be an ideal method to improve the treatment outcome in patients with cervical intervertebral disc disease. The purpose of this study was to investigate the treatment outcomes of C-LCCT including the functional and morphological changes of the cervical intervertebral disc compared to traditional traction (TT) with a randomized controlled trial design. A total of 40 patients with cervical intervertebral disc disease at the C5/6 level confirmed by magnetic resonance imaging were recruited and assigned to either the C-LCCT group or the TT group. The comprehensive health status changes of the patients were recorded using pain and functional scores (Visual Analogue Scale, Oswestry Disability Index) and morphological changes (cervical lordosis, cervical central canal area) before and after the traction treatment. Both groups showed a significant improvement in pain scores after traction (p < 0.05). The functional score and morphological changes improved significantly after treatment in the C-LCCT group. However, there was no significant improvement in the TT group (p < 0.05). The C-LCCT showed significant pain, functional, and morphological improvement compared to TT. C-LCCT could be effective in improving the treatment outcomes of the traction technique in patients with cervical intervertebral disc disease.

Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With Cervical Radiculopathy: A Randomized Controlled Trial

BACKGROUND

Thoracic spine thrust manipulation has been shown to improve patient-rated outcomes for individuals with neck pain. However, there is limited evidence of its effectiveness in patients with cervical radiculopathy.

OBJECTIVES

To compare the immediate and short-term effects of thoracic manipulation to those of a sham thoracic manipulation in patients with cervical radiculopathy.

METHODS

In this multicenter randomized controlled trial, participants with cervical radiculopathy were randomized to receive either manipulation (n = 22) or sham manipulation (n = 21) of the thoracic spine. Outcomes were measured at baseline, immediately after treatment, and at a follow-up 48 to 72 hours after manipulation. A repeated-measures analysis of variance was used to analyze neck and upper extremity pain (numeric pain-rating scale), disability (Neck Disability Index), cervical range of motion (ROM), and endurance (deep neck flexor endurance test). The chi-square test was used to analyze changes in neck and upper extremity pain, centralization of symptoms, and beliefs about receiving the active manipulation treatment using a global rating of change scale.

RESULTS

Neck and upper extremity pain, cervical ROM, disability, and deep neck flexor endurance all showed significant interactions between group and time (P<.01). Immediately after treatment and at the 48-to-72-hour follow-up, the manipulation group had lower neck pain (P<.01), better cervical ROM (P<.01), lower disability (P<.01), and better deep neck flexor endurance (P = .02) compared to the sham manipulation group. The manipulation group had moderate to large effect-size changes over time. No between-group differences for upper extremity pain were found immediately following the intervention (P = .34) and at 48 to 72 hours after the intervention (P = .18). At 48 to 72 hours after treatment, a greater proportion of participants in the manipulation group reported improvement (global rating of change scale score of 4 or greater) in neck and upper extremity symptoms (P<.01), centralization of symptoms (P<.01), and beliefs about receiving an active manipulation (P = .01) compared to the sham manipulation group.

CONCLUSION

One session of thoracic manipulation resulted in improvements in pain, disability, cervical ROM, and deep neck flexor endurance in patients with cervical radiculopathy. Patients treated with manipulation were more likely to report at least moderate change in their neck and upper extremity symptoms up to 48 to 72 hours following treatment.

LEVEL OF EVIDENCE

Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):299-309. doi:10.2519/jospt.2019.8150.

Effect of virtual reality on balance and gait ability in patients with Parkinson's disease: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effectiveness of virtual reality interventions for improving balance and gait in people with Parkinson's disease.

DESIGN

This is a systematic review and meta-analysis of randomized controlled trials.

METHODS

Databases of MEDLINE, Cochran Central Register of Controlled Trials, EMBASE, PEDro, Web of Science and China Biology Medicine disc were searched from their inception up to 1 March 2019. Two reviewers individually appraised literatures for inclusion, extracted data and evaluated trial quality.

RESULTS

A total of 12 studies with a median PEDro score of 6.4 and involving 419 participants were included. This review first demonstrated significant improvements in Berg Balance Scale (mean difference = 2.69; 95% confidence interval = 1.37 to 4.02; p < 0.0001), Timed Up and Go Test (mean difference = -2.86; 95% confidence interval = -5.60 to -0.12; p = 0.04) and stride length (mean difference = 9.65; 95% confidence interval = 4.31 to 14.98; p = 0.0004) in Parkinson patients who received virtual reality compared with controls. However, there was no significant difference in gait velocity and walk distance.

CONCLUSION

This systematic review and meta-analysis supports the use of virtual reality to enhance the balance of patients with Parkinson's disease. However, the review does not find any definite effect upon gait by the use of virtual reality.