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The Somatic Connection  |   July 2013
Manual Therapy Is Beneficial for Cervical Radiculopathy
Author Affiliations
  • Michael A. Seffinger, DO
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
Article Information
The Somatic Connection   |   July 2013
Manual Therapy Is Beneficial for Cervical Radiculopathy
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 571-573. doi:10.7556/jaoa.2013.012
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 571-573. doi:10.7556/jaoa.2013.012
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.  
Cervical radiculopathy is a common problem that limits activities and work productivity. The use of osteopathic manipulation or other forms of manual therapy for relief of cervical radiculopathy has been a controversial topic among osteopathic physicians, as well as among chiropractors and physical therapists. Some clinicians believe that manual therapy can aggravate the patient's pain, whereas others maintain that it can help alleviate it. Researchers in Australia sought to determine the safety and efficacy of manual physical therapy for providing short-term relief of cervical radicular pain. Using a prediction model, they identified patients with this condition who would be most likely to benefit from manual therapy1 and then developed a prospective, randomized clinical trial. Although they were unable to recruit the number of participants required to answer their research question as determined by a power analysis, manual therapy provided substantial benefits to patients compared with advice to remain active. 
Sixty participants (38 women, 22 men; mean [standard deviation (SD)] age, 47 [9] years; age range, 18-60 years) with nontraumatic nerve-related neck and unilateral arm pain spreading below the deltoid tuberosity were randomly assigned to an experimental group (n=40) or a control group (n=20). Pain had to have been present for at least 4 weeks and also had to have been preceded by a pain-free period of at least 4 weeks. The average intensity of any neck and arm pain occurring during the week prior to the study was assessed using separate 11-point numeric pain scales. The mean of these 2 pain scale scores had to be greater than or equal to 3 (with 0 indicating no pain and 10 indicating worst pain) for individuals to be included in the study. In addition, pain had to be reproduced during physical examination (namely, by use of the upper limb neurodynamic test for the median nerve, which assesses neural hypersensitivity) and changed by contralateral neck sidebending or releasing wrist extension. 
Potential participants were excluded from the study if they had 2 or more abnormal neurologic findings (eg, decreased strength, reflex, or sensation) at the same nerve root level (C5 through T1), because they were then considered unlikely to respond to the manual therapy maneuvers used in the protocol. Additional exclusion criteria were symptoms or signs consistent with a diagnosis of bilateral radiculopathy or cervical myelopathy; physiotherapy intervention for neck and arm pain within the previous 6 weeks; previous surgery on the neck or upper limb; medical red flags suggesting serious pathologic conditions; and lack of proficiency in speaking and reading English. 
Eight community physiotherapists who had postgraduate qualifications in musculoskeletal physiotherapy were assigned to provide neural tissue management to the experimental group. All physiotherapists attended a 2-hour training session before interventions occurred. 
Participants in both study groups were advised to continue their usual activities and medication after completing baseline assessments. Participants in the control group received no other intervention or education. In addition to receiving neural tissue management, the experimental group received an educational component, manual therapy techniques, and a home program of nerve-gliding exercises during 4 treatments over 2 weeks. Contralateral cervical lateral glide and a shoulder girdle oscillation combined with active craniocervical flexion were the manual therapy techniques used. A sliding and a tensioning technique for the median nerve and cervical nerve roots were part of the home program. To preload the neural tissues during manual therapy techniques and nerve-gliding exercises, shoulder abduction angles up to 90° were used. Neural tissue management techniques were prescribed to avoid provoking the participants' symptoms. A 2011 article by the same researchers1 details the protocols for applying neural tissue management techniques. 
Outcomes were evaluated at follow-up, which occurred 4 weeks after the baseline assessment. The primary outcome was participant-reported improvement or worsening after manual therapy according to responses on the Global Rating of Change scale. Secondary outcomes included neck pain, arm pain, patient-reported limitations of activities (as measured by the Neck Disability Index and the Patient-Specific Functional Scale), and adverse events related to treatment (ie, intensification of existing symptoms or an increase in other unpleasant sensations after manual therapy). 
Two participants from each group were lost to follow-up. Numbers-needed-to-treat analysis favored the manual therapy intervention for participant-reported improvement (2.7; 95% confidence interval [CI], 1.7-6.5), neck pain (3.6; 95% CI, 2.1-10.0), arm pain (3.6; 95% CI, 2.1-10.0), Neck Disability Index (4.3; 95% CI, 2.4-18.2), and Patient-Specific Functional Scale (3.0; 95% CI, 1.9-6.7). The prevalence of worsening in the experimental (13%) and control (20%) groups was not different (risk difference, −7%; 95% CI, −28 to 13). Adverse events such as aggravation of pain or headache had minimal impact on daily activities, were brief and nondisabling, and did not reduce the chance of improving with the experimental intervention at 4 weeks (relative risk, 1.03; 95% CI, 0.58-1.84). 
Because there were no sham control groups in this study, it is not possible to determine whether there were unintended benefits from the physiotherapy provided—that is, personal interaction with the clinician, the clinical environment, or simply being touched. It is important to note that the duration and extent of symptoms, as well as medication usage, were greater for participants in the experimental group than for participants in the control group. In addition, the long-term benefits and cost-effectiveness of physiotherapy were not assessed. Despite such limitations, these researchers made a solid effort toward addressing and supporting the controversial topic of whether manual therapy is beneficial for patients with cervical radiculopathy who fit the inclusion criteria of this study. 
Reference
Reference
Nee R, Vicenzino B, Jull G, Cleland J, Coppieters M. A novel protocol to develop a prediction model that identifies patients with nerve-related neck and arm pain who benefit from the early introduction of neural tissue management. Contemp Clin Trials. 2011;32(5):760-770. [CrossRef] [PubMed]