Free
Letters to the Editor  |   October 2013
The Somatic Connection: Manual Therapy Is Beneficial for Cervical Radiculopathy
Author Affiliations
  • Benjamin M. Sucher, DO
    Electrodiagnostic Laboratories, Arizona Arthritis and Rheumatology Associates, Phoenix
Article Information
Neuromusculoskeletal Disorders
Letters to the Editor   |   October 2013
The Somatic Connection: Manual Therapy Is Beneficial for Cervical Radiculopathy
The Journal of the American Osteopathic Association, October 2013, Vol. 113, 725-726. doi:10.7556/jaoa.2013.040
The Journal of the American Osteopathic Association, October 2013, Vol. 113, 725-726. doi:10.7556/jaoa.2013.040
To the Editor: 
I read Dr Seffinger's review1 of the Nee et al article2 about nerve-related arm and neck pain with great interest. Cervical manipulation has been controversial for many years, particularly regarding potential complications.3-7 I believe it is incumbent on all osteopathic physicians and osteopaths to be aware of the risks of cervical spine manipulation, particularly high-velocity techniques, and specifically in patients who present with radicular complaints. 
I am concerned that Dr Seffinger's review of the 2012 article2 may lead to some confusion about the indications for use of manual treatment or therapy in various cervical conditions. Nee et al2 discuss manual therapy for nerve-related neck and arm pain,yet Dr Seffinger discusses such treatment for cervical radiculopathy,1 which may be entirely different from the neck and arm pain. In addition, one of the inclusion criteria required pain reproduction during a “neurodynamic test for the median nerve” by wrist extension,2 which introduces another variable that is not necessarily related to cervical radiculopathy. This criterion adds more confusion and less specificity to the proposed treatment regarding the indications. In other words, what is the condition that is actually being managed by the manipulation—what the authors2 term neural tissue management? It is important for practitioners to be mindful that equal reflexes and normal strength do not necessarily confirm the absence of a serious underlying condition.8 
The causes of neck pain are multifactoral, and regardless of the source of symptoms, the pain may remain localized or refer to the upper limb.8 Serious conditions can masquerade as less ominous disorders.8 Local muscular, ligamentous, or joint conditions certainly respond well to manual treatments.9 However, when disk protrusions compress nerve roots or the spinal cord, manipulation of the spine can become dangerous and counterproductive.3-7 Known complications from cervical spine manipulation include vertebrobasilar insufficiency or stroke, lateral medullary infarction, internal carotid artery dissection, cerebral infarct, cervical myelopathy, cervical radiculopathy, long thoracic nerve palsy, diaphragmatic palsy, central retinal artery occlusion, cervical fracture or dislocation, epidural hematoma, intervertebral disk herniation, and tracheal rupture.3-7 In fact, death can result from inappropriate manipulation.3-7 Therefore, it is essential to determine a specific diagnosis before initiating treatment. 
The use of advanced imaging and electrodiagnosis may be essential in patients who present with radicular features, because such testing can identify compromised neural structures and help guide appropriate management.8 The fact that patients treated in this study “safely receive short-term relief” is concerning, because offering manipulation as the initial treatment may delay a complete workup and more optimal long-term care. 
References
Seffinger MA. Manual therapy is beneficial for cervical radiculopathy [abstract of Nee RJ, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial. J Physiother. 2012;58(1):23-31]. J Am Osteopath Assoc. 2013;113(7):571-573. [CrossRef]
Nee RJ, Vicenzino B, Jull GA, Cleland JA, Coppieters MW. Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial. J Physiother. 2012;58(1):23-31. doi:10.1016/S1836-9553(12)70069-3. [CrossRef] [PubMed]
Gay RE, Bauer BA, Yang RK. Integrative medicine in rehabilitation. In: Braddom RL, ed. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:507-521.
Smith WS, Johnston SC, Skalabrin EJet al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424-1428. [CrossRef] [PubMed]
Sakaguchi M, Kitagawa K, Hougaku Het al. Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology. 2003;61(6):845-847. [CrossRef] [PubMed]
Vick DA, McKay C, Zengerle CR. The safety of manipulative treatment: review of the literature from 1925 to 1993. J Am Osteopath Assoc. 1996;96(2):113-115. [PubMed]
Laughlin TM. Complications of spinal manipulation: a literature review 1975-1984. Osteopathic Annals. 1986;14:21-23.
DePalma MJ, Slipman CW. Treatment of common neck problems. In: Braddom RL, ed. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:797-824.
Brault JS, Kappler RE, Grogg BE. Manipulation, traction and massage. In: Braddom RL, ed. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:437-457.