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

The majority of clinical trials assessing mobilization and manipulation for neck pain lack a pragmatic approach: a systematic review of 174 trials

BACKGROUND

Disorders of the cervical spine are some of the costliest musculoskeletal conditions to manage globally. Joint mobilization and manipulation have been shown to be an effective treatment for neck pain. However, the generalizability and clinical translation depends on the nature of the trial designs that inform its use. The extent to which randomized control trials (RCTs) assessing manual therapy treatments for cervical spine disorders fall on the efficacy (explanatory) -effectiveness (pragmatic) spectrum often informs how the findings are translated into clinical practice.

OBJECTIVE

The aim of this systematic review was to determine where RCTs of manual therapy for neck disorders fall on the efficacy-effectiveness spectrum.

METHODS

A search of three electronic databases including PubMed, CINAHL, and CENTRAL were completed for trials published from inception to May 2023. RCTs in which joint mobilization or manipulation were used to treat cervical spine disorders were assessed on the effectiveness-efficacy spectrum using the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool and risk of bias using the Revised Cochrane Risk of Bias tool.

RESULTS

A total of 174 trials met eligibility. RITES domain two trial setting (71.3% vs 16.1%), domain three flexibility of intervention(s) (62.1% vs 23%), and domain four clinical relevance of experimental and comparison intervention(s) (51.7% vs 29.3%) all favored efficacy over effectiveness. Domain one participant characteristic(s) had a slightly greater emphasis on effectiveness compared to efficacy (36.8% vs 44.8%). Most studies (96%) had at least some risk of bias.

CONCLUSION

Over half of the RCTs assessing the treatment effect of joint mobilization and manipulation for neck pain favor efficacy (explanatory) over effectiveness (pragmatic) designs. Future RCTs on this topic should consider a greater emphasis on pragmatic trial design components in order to better reflect real-world translation to clinical practice.

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research

ABSTRACT

Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Bibliometric Analysis of Research Trends on Tuina Manipulation for Neck Pain Treatment Over the Past 10 Years

Tuina is an effective treatment for neck pain (NP). However, there has been no bibliometric analysis of the global application and emerging trends of tuina performed for NP. Therefore, this study aimed to provide an overview of the current state and future trends in the field. Articles about tuina for NP, published from January 1, 2013, to January 1, 2023, were searched in the Web of Science Core Collection database. CiteSpace (6.1.R6) and VOSviewer (1.6.18) software were used to analyze annual trends in literature posts, countries, institutions, authors, cited references, and knowledge graphs of keyword co-occurrence, clustering, and burst using standard bibliometric indicators. The final analysis comprised 505 valid documents. The results demonstrate that the number of articles in the field of tuina therapy for NP has gradually increased over the years, showing the most active countries, institutions, journals, and authors. There were 323 keywords in the field, 322 research authors, and 292 research institutions, with the USA having the most publications (n = 140). The most published institution is Vrije University Amsterdam, and the most published journal is the Cochrane Database of Systematic Reviews. Peter R Blanpied is the most influential and most-cited author. Interventions (dry needling, massage therapy, and muscle energy techniques), common treatment sites for NP (upper trapezius), and complications (cervicogenic headache) are the top three frontiers mentioned in the field of tuina research for NP. The bibliometric study showed the current status and trends in clinical research on treating patients with NP using tuina, which may help researchers identify topics of interest and scope for future research in this field.

Incomplete reporting of manual therapy interventions and a lack of clinician and setting diversity in clinical trials for neck pain limits replication and real-world translation. A scoping review

INTRODUCTION

Neck pain is a leading cause of disability, and manual therapy (MT) is a common intervention used across disciplines and settings to treat it. While there is consistent support for MT in managing neck pain, questions remain about the feasibility of incorporating MT from research into clinical practice. The purpose of this scoping review was to assess the adequacy of MT intervention descriptions and the variability in clinician and setting for MT delivery in trials for neck pain.

METHODS

Medline (via PubMed), CINAHL, PEDRo, and the Cochrane Central Registry for Controlled Trials were searched for clinical trials published from January 2010 to November 2021. A 11-item tool modified from the Consensus on Exercise Reporting Template was used to assess appropriateness of intervention reporting. Clinicians, subclassifications of neck pain, and clinical settings were also extracted.

RESULTS

113 trials were included. A low percentage of studies provided the recommended level of detail in the description of how MT was delivered (4.4%), while 39.0% included no description at all. Just over half of trials included clinician's qualifications (58.4%), dose of MT (59.3%), and occurrence of adverse events (55.8%). The proportion of trials with clinicians delivering MT were physical therapists (77.9%), chiropractors (10.6%), and osteopaths (2.7%).

DISCUSSION/CONCLUSION

These results reveal incomplete reporting of essential treatment parameters, and a lack of clinician diversity. To foster reproducibility, researchers should report detailed descriptions of MT interventions. Future research should incorporate a variety of MT practitioners to improve generalizability.

Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature.

SUMMARY OF BACKGROUND DATA

A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic.

MATERIALS AND METHODS

We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies.

RESULTS

Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively.

CONCLUSIONS

Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Remission of cervicogenic dysphagia associated with biomechanical dysfunction following chiropractic therapy

Cervicogenic dysphagia is a complex condition that can arise from biomechanical dysfunction in the cervical spine. Conventional treatment outcomes are not always guaranteed. Chiropractic treatment is considered an alternative treatment for dysphagia, yet there is a lack of evidence supporting its effectiveness. We present the case of a 48-year-old male who had difficulty swallowing for eight months. He had a feeling of food stuck in his throat when eating hard food but without any pain when swallowing, and eventually, he could not swallow any dry food. He was diagnosed with dysphagia associated with an anxiety disorder and was treated with medication, but there was no improvement in his condition. A full-spine radiograph revealed biomechanical dysfunction, including reduced cervical lordosis and levoscoliosis of the upper thoracic spine. After nine months of conventional physiotherapy, the patient completely recovered from his symptoms, with significantly improved biomechanical parameters. This study highlights the potential mechanism of cervicogenic dysphagia and the effect of chiropractic treatment in managing it. Applying chiropractic treatment, including spinal manipulative therapy, instrument-assisted soft tissue manipulation, and mechanical traction, might bring a positive outcome for dysphagia patients with careful consideration.

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.

Improvement of Chronic Neck Pain After Posterior Atlantoaxial Surgical Fusion via Multimodal Chiropractic Care: A Case Report

There is a lack of research regarding the effectiveness and safety of manual therapies, including spinal manipulative therapy (SMT), for patients with previous cervical spine surgery. A 66-year-old, otherwise healthy, woman who underwent C1/2 posterior surgical fusion for rotatory instability during adolescence presented to a chiropractor with a six-month history of progressive worsening of chronic neck pain and headaches despite acetaminophen, tramadol, and physical therapy. Upon examination, the chiropractor noted postural changes, limited cervical range of motion, and muscle hypertonicity. Computed tomography revealed a successful C1/2 fusion, and degenerative findings at C0/1, C2/3, C3/4, and C5/6, without cord compression. As the patient had no neurologic deficits or myelopathy and tolerated spinal mobilization well, the chiropractor applied cervical SMT, along with soft tissue manipulation, ultrasound therapy, mechanical traction, and thoracic SMT. The patient's pain was reduced to a mild level and the range of motion improved over three weeks of treatment. Benefits were maintained over a three-month follow-up as treatments were spaced apart. Despite the apparent success in the current case, evidence for manual therapies and SMT in patients with cervical spine surgery remains limited, and these therapies should be used with caution on an individual patient basis. Further research is needed to examine the safety of manual therapies and SMT in patients following cervical spine surgery and determine predictors of treatment response.

Manual Therapy Effect in Placebo-Controlled Trials: A Systematic Review and Meta-Analysis

PURPOSE

Background: Evaluate whether the design of placebo control groups could produce different interpretations of the efficacy of manual therapy techniques.

METHODS

Nine databases were searched (EMBASE, CINAHL, PsycINFO, MEDLINE, PubMed, SCOPUS, WEB of SCIENCE, COCHRANE, and PEDro). Randomized placebo-controlled clinical trials that used manual therapy as a sham treatment on subjects suffering from pain were included. Data were summarized qualitatively, and meta-analyses were conducted with R.

RESULTS

53 articles were included in the qualitative analysis and 48 were included in the quantitative analyses. Manipulation techniques did not show higher effectiveness when compared with all types of sham groups that were analyzed (SMD 0.28; 95%CI [-0.24; 0.80]) (SMD 0.28; 95%CI [-0.08; 0.64]) (SMD 0.42; 95%CI [0.16; 0.67]) (SMD 0.82; 95%CI [-0.57; 2.21]), raising doubts on their therapeutic effect. Factors such as expectations of treatment were not consistently evaluated, and analysis could help clarify the effect of different sham groups. As for soft tissue techniques, the results are stronger in favor of these techniques when compared to sham control groups (SMD 0.40; 95%CI [0.19, 0.61]). Regarding mobilization techniques and neural gliding techniques, not enough studies were found for conclusions to be made.

CONCLUSIONS

The literature presents a lack of a unified placebo control group design for each technique and an absence of assessment of expectations. These two issues might account for the unclear results obtained in the analysis.

Comparison of Prescribed Physical Therapy to a Home Exercise Program for Pediatric Sports-Related Concussion Patients

The purpose of this retrospective chart review was to compare sports-related concussion (SRC) recovery time in protracted recovery (≥28 days) patients who were prescribed physical therapy (PPT) with those who were only provided a home exercise program (HEP). We hypothesized PPT would be associated with shorter recovery times relative to HEP. Associations were evaluated with multivariable zero-truncated negative binomial regressions. Among the 48 (30.2%) PPT and 111 (69.8%) HEP patients, the majority were female (57.9%), the mean age was 15.3 ± 1.4 (PPT) and 14.2 ± 2.8 (HEP), and time to clinic was a median 6.0 (IQR = 3.0–27.0; PPT) and 7.0 (IQR = 3.0–23.0; HEP) days. After adjusting for demographic (age, sex) and clinical measures (concussion history, convergence, VOMS, PCSS score, and days to clinic), PPT unexpectedly was associated with 1.21 (95% CI: 1.05, 1.41) additional recovery days compared with HEP. One reason for this could be related to patients adhering to the number of a priori prescribed PT sessions which may or may not have aligned with the patient’s symptom resolution. Future research should explore this hypothesis while aiming to evaluate the effect of PPT versus HEP using a randomized design. If confirmed, these findings are encouraging for patients who could not otherwise access or afford specialty rehabilitation.

Timing of Evidence-Based Nonsurgical Interventions as Part of Multimodal Treatment Guidelines for the Management of Cervical Radiculopathy: A Delphi Study

OBJECTIVE

Conservative management of cervical radiculopathy (CR) is a first treatment option because the risk-benefit ratio for surgery is less favorable. Systematic reviews and clinical practice guidelines reporting on the effectiveness of nonsurgical management have not considered the timing of management. The aim of this study was to establish consensus on effective nonsurgical treatment modalities at different stages (ie, acute, subacute, or chronic) of CR using the Delphi method approach.

METHODS

Through an iterative multistage process, experts within the field rated their agreement with a list of proposed treatment modalities according to the stage of CR and could suggest missing treatment modalities. Agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Consensus for Round 3 was based on ≥2 of the following: a median Likert scale value of ≥4, interquartile range value of ≤1, and/or a percentage of agreement ≥70%.

RESULTS

Data analysis produced a consensus list of effective treatment modalities in different stages of recovery.

CONCLUSION

According to experts, the focus of multimodal management in the acute stage should consist of patient education and spinal manipulative therapy, specific (foraminal opening) exercises, and sustained pain-relieving positions. In the subacute stage, increasing individualized physical activity including supervised motor control, specific exercises, and/or neurodynamic mobilization could be added. In the chronic stage, focus should shift to include general aerobic exercise as well as focused strength training. Postural education and vocational ergonomic assessment should also be considered.

IMPACT

Multimodal conservative management of individuals with CR should take the stage of the condition into consideration. The focus of therapeutic interventions should shift from passive pain-relieving intervention in the acute stage to increasingly more individualized physical activity and self-management in the chronic stage.

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.

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.

Physical therapy treatment of a pediatric patient with symptoms consistent with a spinal cord injury without radiographic abnormality: A retrospective case report

BACKGROUND

A spinal cord injury without radiographic abnormality (SCIWORA) is a relatively uncommon event that occurs in children following cervical trauma primarily due to sports-related injuries or physical abuse.

CASE DESCRIPTION

This case report describes an 11-year-old wrestler that developed signs and symptoms consistent with a SCIWORA following neck trauma during competition. Despite all diagnostic tests being inconclusive, the patient demonstrated increased cervical, thoracic, and lumbar paraspinal tone along with pain, loss of sensation, loss of mobility, and weakness of the lower extremities. As a result, the patient was confined to a wheelchair and required maximum assistance to transfer and ambulate with a walker. The patient was referred to physical therapy nine days after the traumatic event, where he received interferential current with moist heat, myofascial release of paraspinal muscles, functional exercise, gait training, and spinal manipulative therapy targeting the cervical, thoracic, and lumbar vertebrae.

OUTCOME

After 13 physical therapy treatments over 5-weeks, the patient was able to ambulate independently and perform all activities of daily living without pain or functional limitation. The following case report outlines this patient's successful journey toward recovery.

CONCLUSION

This case report suggests that spinal manipulative therapy may be a safe and effective intervention when used within a multi-modal treatment strategy for patients with signs and symptoms consistent with SCIWORA. Moreover, spinal manipulative therapy may be considered a beneficial treatment in some pediatric patients. However, this report describes a single patient, and further research is required on the use of spinal manipulation in this patient population.