In the next installment of the Research Review Series, we discuss a recent randomized controlled study investigating the effectiveness of a manual therapy program specifically tailored to increase the intervertebral foramen (IVF) versus a general manual therapy program in patients presenting with cervical radiculopathy3.

Study Design

Participant and assessor blinded randomized clinical trial.

Subjects

Thirty-six subjects were included in the study following inclusion/exclusion criteria (18 in both the experimental and control group). There were no significant differences between groups with regards to age (47.8 v. 42.8), weight (76.3 kg v. 80.9 kg), symptom duration (5.7 weeks v. 5.4), NDI (32.0 v. 34.8), Quick DASH (42.3 v. 42.8), Cervical NPRS (4.1 v. 4.3), Upper Limb NPRS (4.6 v. 4.8), or Cervicothoracic mobility.

Inclusion Criteria: (1) between 18 and 65 years of age, (2) pain, paresthesia, or numbness in 1 upper limb, with cervical or periscapular pain of less than 3 months in duration, (3) at least 1 neurological sign of a lower motor neuron lesion in a cervical spine nerve root or spinal nerve, and (4) positive responses to at least 3 of the 4 clinical tests in the Clinical Prediction Rule proposed by Wainner et al4.

Exclusion Criteria: (1) prior surgery to the cervicothoracic spine, (2) bilateral symptoms, (3) signs of upper motor neuron impairments, (4) cervical spine injection in the previous 4 weeks, (5) current use of steroidal anti-inflammatory drugs, or (6) financial compensation for the cervical condition.

Methods

Outcome Measures: Neck Disability Index (NDI), Shortened Version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), Cervical Numeric Pain-Rating Scale (CNPRS), Upper Limb Numeric Pain-Rating Scale (ULNPRS), and Cervicothoracic Mobility utilizing the CROM device.

Randomization: An independent research assistant not involved in data collection generated a randomization list prior to the start of the study, using a random-number generator. Group allocations were concealed in sealed, opaque, sequentially numbered envelopes, and blocked randomization was used to make sure that two equal groups were obtained. The two programs were given in different clinics and the evaluation sessions took place outside the treating clinics in order to reduce potential contamination bias.

Interventions: Each patient received treatment sessions during a 4-week period and performed a home exercise program. The patients in the Control Group (CG) received 4 manual therapy techniques at each treatment session. The manual therapy techniques were chosen by the physical therapist according to the results of the biomechanical examination, but could not be used to specifically increase the affected IVF. These techniques could be cervical rotations, lateral glides in neutral, posteroanterior glides, posteroinferior medial glides, or anterosuperior anterior glides. Each manual therapy technique was performed for 10 repetitions of 30 seconds, with a force grade of 3 to 4. Following the mobilization techniques, a 5-minute global (nonspecific) static manual cervical traction was applied. In addition to the manual therapy program, a home exercise program was also included, but none of the exercises could be used to specifically increase the IVF.

Contrary to the CG, the Experimental Group (EG) utilized interventions that were supposed to directly influence the IVF in order to treat the symptoms of cervical radiculopathy. Of the 4 mobilization techniques used at each treatment session, 2 were mandatory techniques thought to increase the size of the IVF on the same side and at the same presumed level as the radiculopathy (global contralateral rotation mobilization and ipsilateral lateral glide in a flexed position). Additionally, the third exercise of the HEP was a repeated movement that is known to increase the size of the IVF (cervical spine rotation in the direction contralateral to the affected side, performed for 10 repetitions, 10 times per day).

Results

Both groups showed significant improvement in NDI, QuickDASH, CNPRS, ULNPRS scores from baseline to week 4 and to 8 weeks. With regards to cervicothoracic mobility, both groups had significant improvement in cervical extension and side-bending. With these improvements, there was no significant group-by-time interaction found between the two groups in any of the measures. In agreement with this finding, the proportion of success did not significantly differ between groups at week 4 or at week 8.

Limitations

The most significant limitation in this study is the lack of a true control group, which received “standard treatment” (i.e. a non-manual therapy group). Secondly, the only outcome measure that was adequately powered based on sample size was the primary outcome of NDI score.

Clinical Implications

According to a systematic review conducted by Boyles et al.1, the use of manual therapy (muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization) in addition to therapeutic exercise is effective in regards to increasing function, as well as AROM, while decreasing levels of pain and disability. However, often times, addressing a painful condition with a patho-anatomical approach is inadequate. As is demonstrated in this study, manual therapy in addition to a HEP provides decreased pain and improved function in the short-term and long-term, but the specific technique does not matter for cervical radiculopathy in general. This is where a patient response or bio-psychosocial approach should be utilized in order to drive treatment interventions/techniques instead of pathology-specific interventions. By utilizing an approach to identify and treat the patient’s comparable sign2, each patient’s complaints will be addressed without relying on the variable results of a patho-anatomical based treatment.

References

  1. Boyles R, et al. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review.Journal of Manual and Manipulative Therapy. 2011; 19(3): 135-142.
  2. Cook CE, et al. The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study. Manual Therapy. 2015 [Epub Ahead of Print]
  3. Langevin P, Desmeules F, Lamothe M, Robitaille S, Roy J-S. Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short-Term Effects. Journal of Orthopaedic & Sports Physical Therapy. 2015; 45(1): 4–17. doi:10.2519/jospt.2015.5211.
  4. Wainner CR, et al. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. 2003;28(1):52–62.

About the Author John Snyder, PT, DPT, OCS, CSCS

I am a Physical Therapist, a Board Certified Orthopaedic Specialist, a Strength & Conditioning Specialist, an Educator, and a Research Junkie. My goal is to provide resources for orthopedic and sports medicine clinicians to keep up to date with the current literature and allow them to translate it to their practice.

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