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Letters to the Editor  |   October 2013
Response
Author Affiliations
  • Michael A. Seffinger, DO
    Associate Editor, The Journal of the American Osteopathic Association; Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
Article Information
Imaging / Neuromusculoskeletal Disorders / Pain Management/Palliative Care
Letters to the Editor   |   October 2013
Response
The Journal of the American Osteopathic Association, October 2013, Vol. 113, 726-727. doi:10.7556/jaoa.2013.041
The Journal of the American Osteopathic Association, October 2013, Vol. 113, 726-727. doi:10.7556/jaoa.2013.041
Dr Sucher brings up several good points in his letter to the editor.1 The indications for use of manual management of the cervical spine have been debated among manual practitioners and physicians for decades. Physical therapists have developed clinical practice guidelines based on patients' functional response to physical maneuvers and recommend manual treatment for patients with nerve-related arm and neck pain—without making a definitive diagnosis of the cause. Patient improvement in the short term has been demonstrated,2 but as Dr Sucher points out, does this improvement create a scenario of delay of care if there is an occult pathologic condition that is missed? With appropriate follow-up, manual therapists should determine if their patients' symptoms or functioning do not improve, regress, or worsen, and they should refer patients for further diagnostic examinations and treatment as needed. 
However, some questions remain: Should patients be thoroughly evaluated first by means of specific tests? And if so, will insurance companies or patients pay for these tests? I recently had lancinating, shooting pain down my left arm from my neck to my elbow that was persistent for 6 weeks and had not improved with cervical traction, massage, acupuncture, or osteopathic manipulative treatment. The pain was reproduced with neck extension and concomitant left sidebending. Spurling maneuver focused at the left C6 nerve root also reproduced the pain. A cervical spine radiograph showed only mild degenerative changes in the C5-C7 vertebrae. I was given gabapentin, which helped control the pain. In addition, my physiatrist ordered a magnetic resonance image, but it was denied by my insurance company because I had not had 6 weeks of physical therapy first and because I did not have left arm or hand muscle weakness. 
I saw a physical therapist, and he performed nerve tissue gliding, muscle stretching, cervical mobilization, and cervical soft tissue manipulation. He instructed me in exercises to strengthen my postural and shoulder support muscles. The pain resolved within a week and I no longer needed medication. It would seem prudent to diagnose the condition first, but that is not the way the economic world works. I do not know what the long-term benefit will be yet, but I certainly would feel more comfortable if I had a magnetic resonance image to rule out or identify any nerve pathologic condition. I suppose I can pay for one myself. However, I, along with my physicians, physical therapist, and wife, am happy I am out of pain and off medication, and because I am progressively functioning better, there is no longer any immediate concern about underlying pathologic conditions. 
Indeed, as Dr Sucher points out,1 there is a difference between radiculopathy and other types of nerve-related arm pain, such as carpal tunnel syndrome and referred pain to the arm from somatic or visceral pathologic conditions. I admit I used the term radiculopathy too loosely in my abstract3 and stand corrected. I agree that a precise diagnosis leads to the safest, most appropriate, and timeliest treatment; it would be great if the health care reimbursement system worked that way, too. 
References
Sucher BM. The Somatic Connection: manual therapy is beneficial for cervical radiculopathy [letter]. J Am Osteopath Assoc. 2013;113(10):725-726. doi:10.7556/jaoa.2013.040. [CrossRef] [PubMed]
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]
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. doi:10.7556/jaoa.2013.012. [CrossRef]