Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial

The Role of Orthoses in Chronic Axial Spinal Conditions

PURPOSE OF REVIEW

Bracing represents a prevalent conservative, non-surgical approach used in the management of chronic spinal conditions such as spondylosis, degenerative disc disease, and spondylolisthesis. A wide variety of orthoses are available to aid in addressing cervical, thoracic, lumbar, thoracic, and SI joint pain. In this review, we aim to comprehensively examine brace types with their current applications and implications of usage.

RECENT FINDINGS

There are multiple cervical bracing options, such as soft and rigid collars, to assist in managing acute trauma and chronic degenerative conditions. The review highlights the nuanced decision-making process between hard and soft collars based on the severity of bone or ligamentous injury and neurological findings. Orthoses for low back pain are commonly used. The review highlights the challenges of chronic neck and lower back pain, emphasizing the importance of clinicians exploring all treatment strategies including braces which can improve function and reduce pain.

Coexistence of Cervical Disc Herniation and Shoulder Soft Tissue Pathologies and the Effect of Sleeping Positions and Orthopedic Pillows

Background/aim This study investigates the degree of coexistence of cervical disc herniation and shoulder soft tissue pathology, as well as the effect of sleeping positions and orthopedic pillow use. Materials and methods This present study was conducted on 72 patients with shoulder/arm pain operated on for cervical disc herniation. Two groups were examined according to the presence of shoulder soft tissue pathology, four common sleeping positions, and the use of an orthopedic pillow. Preoperative and postoperative shoulder/arm visual analog scale (VAS) scores were compared. Results The preoperative VAS values were 7.35, while the postoperative VAS values were 3.32. Twenty-one patients (29.2%) had a disc at the C3-4 level, a rate equal to that for the C5-6 level. Twenty-four patients (33.3%) had a disc at the C4-5 level. Thirty-two cases (44.4%) slept in a side-lying position on the same side as their disc herniation. Among those with a herniated disc at the C3-4 level, 8 (53.3%) preferred sleeping side-lying on the opposite side of the disc. In contrast, those with a herniated disc at the C4-5 level more frequently (40.6%) slept side-lying on the same side as the disc. Mean VAS scores were significantly higher in cases with shoulder soft tissue pathology and were significantly lower in the group that used orthopedic pillows (p<0.001). Conclusion Shoulder soft tissue pathologies should be considered in postoperative shoulder pain. The use of orthopedic pillows is effective in preoperative and postoperative pain. Sleeping positions do not affect the shoulder/arm pain before and after the operation, but they affect the level of cervical disc herniations.

A No-Cost, Bedside, Self-Traction Maneuver for Relief From Chronic Cervical Radiculopathy: A Case Report

Cervical radiculopathy secondary to spondylosis is common in the elderly. Systematic reviews suggest that no single treatment modality represents the standard of care. A no-cost, bedside, self-traction intervention can be a useful adjunct to current options. A 60-year-old South Asian male presented with severe cervical radiculopathic pain in April 2019, proven by magnetic resonance imaging to be secondary to spondylosis. Since late 2019, he has been doing a daily self-traction procedure in which he lies prone with the anterior chest and abdomen flat on a bed, shoulders just off the mattress edge, and arms to the side. The position is maintained for 60 seconds, where the weight of the head provides traction. Overhead cervical traction has not been needed for the past three years, and the pain has been bearable. His Neck Disability Index has decreased from 25 to 2. This no-cost, minute-long daily maneuver has provided relief from chronic cervical neuropathic pain due to cervical spondylosis.

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.

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.

Appraising The Evidence for Conservative versus Surgical Management of Motor Deficits in Degenerative Cervical Radiculopathy

STUDY DESIGN

Systematic review.

OBJECTIVES

Understanding the prevalence and outcome of motor deficits in degenerative cervical radiculopathy is important to guide management. We compared motor radiculopathy outcomes after conservative and surgical management, a particular focus being painful vs painless radiculopathy.

METHODS

MEDLINE and EMBASE databases were searched. We stratified each study cohort into 1 of 6 groups, I-VI, based on whether radiculopathy was painful, painless or unspecified, and whether interventions were surgical or non-surgical.

RESULTS

Of 10 514 initial studies, 44 matched the selection criteria. Whilst 42 (95.5%) provided baseline motor radiculopathy data, only 22 (50.0%) provided follow-up motor outcomes. Mean baseline prevalence of motor deficits was 39.1% (9.2%-73.3%) in conservative cohorts and 60.5% (18.5%-94.1%) in surgical cohorts. Group VI, 'surgically-managed motor radiculopathy with unclear pain status' had the largest number of cohorts. Conversely, no cohorts were found in Group III, 'conservatively-managed painless motor radiculopathy'. Large disparities in data quality made direct comparison of conservative vs operative management difficult.

CONCLUSIONS

Overall pre-intervention prevalence of motor deficits in degenerative cervical radiculopathy is 56.4%. Many studies fail to report motor outcomes after intervention, meaning statistical evidence to guide optimal management of motor radiculopathy is currently lacking. Our study highlights the need for more evidence, preferably from a prospective long-term study, to allow direct comparisons of motor outcomes after conservative and surgical management.

The type of cervical disc herniation on MRI does not correlate to clinical outcomes

AIMS

The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment.

METHODS

The type and extent of disc herniation at the time of presentation in 108 patients who underwent anterior discectomy for cervical radiculopathy were analyzed on MRI, using a four-point scale. These were dichotomized into disc bulge and disc herniation groups. Clinical outcomes were evaluated using the Neck Disability Index (NDI), 36-Item Short Form Survey (SF-36), and a visual analogue scale (VAS) for pain in the neck and arm at baseline and two years postoperatively. The perceived recovery was also assessed at this time.

RESULTS

At baseline, 46 patients had a disc bulge and 62 had a herniation. There was no significant difference in the mean NDI and SF-36 between the two groups at baseline. Those in the disc bulge group had a mean NDI of 44.6 (SD 15.2) compared with 43.8 (SD 16.0) in the herniation group (p = 0.799), and a mean SF-36 of 59.2 (SD 6.9) compared with 59.4 (SD 7.7) (p = 0.895). Likewise, there was no significant difference in the incidence of disabling arm pain in the disc bulge and herniation groups (84% vs 73%; p = 0.163), and no significant difference in the incidence of disabling neck pain in the two groups (70.5% (n = 31) vs 63% (n = 39); p = 0.491). At two years after surgery, no significant difference was found in any of the clinical parameters between the two groups.

CONCLUSION

In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively.Cite this article: Bone Joint J 2022;104-B(11):1242-1248.

Classification criteria for cervical radiculopathy: An international e-Delphi study

BACKGROUND

Establishing a set of uniform classification criteria (CC) for cervical radiculopathy (CR) is required to aid future recruitment of homogenous populations to clinical trials.

OBJECTIVES

To establish expert informed consensus on CC for CR.

DESIGN

A pre-defined four round e-Delphi study in accordance with the guidance on Conducting and Reporting Delphi Studies.

METHODS

Individuals with a background in physiotherapy who had authored two or more peer-reviewed publications on CR were invited to participate. The initial round asked opinions on CC for CR. Content analysis was performed on round one output and a list of discrete items were generated forming the round two survey. In rounds two to four, participants were asked to rate the level of importance of each item on a six-point Likert scale. Data were analysed descriptively using median, interquartile range and percentage agreement. Items reaching pre-defined consensus criteria were carried forward to the next round. Items remaining after the fourth round constituted expert consensus on CC for CR.

RESULTS

Twelve participants participated with one drop out. The final round identified one inclusion CC and 12 exclusion CC. The inclusion CC that remained achieved 82% agreement and was a cluster criterion consisting of radicular pain with arm pain worse than neck pain; paraesthesia or numbness and/or weakness and/or altered reflex; MRI confirmed nerve root compression compatible with clinical findings.

CONCLUSIONS

The CC identified can be used to inform eligibility criteria for future CR trials although caution should be practiced as consensus on measurement tools requires further investigation.

What is success of treatment? Expected outcome scores in cervical radiculopathy patients were much higher than the previously reported cut-off values for success

PURPOSE

Treatment success can be defined by asking a patient how they perceive their condition compared to prior to treatment, but it can also be defined by establishing success criteria in advance. We evaluated treatment outcome expectations in patients undergoing surgery or non-operative treatment for cervical radiculopathy.

METHODS

The first 100 consecutive patients from an ongoing randomized controlled trial (NCT03674619) comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy were included. Patient-reported outcome measures and expected outcome and improvement were obtained before treatment. We compared these with previously published cut-off values for success. Arm pain, neck pain and headache were measured by a numeric rating scale. Neck disability index (NDI) was used to record pain-related disability. We applied Wilcoxon signed-rank test to compare the expected outcome scores for the two treatments.

RESULTS

Patients reported mean NDI of 42.2 (95% CI 39.6-44.7) at baseline. The expected mean NDI one year after the treatment was 4 (95% CI 3.0-5.1). The expected mean reduction in NDI was 38.3 (95% CI 35.8-40.8). Calculated as a percentage change score, the patients expected a mean reduction of 91.2% (95% CI 89.2-93.2). Patient expectations were higher regarding surgical treatment for arm pain, neck pain and working ability, P < 0.001, but not for headache.

CONCLUSIONS

The expected improvement after treatment of cervical radiculopathy was much higher than the previously reported cut-off values for success. Patients with cervical radiculopathy had higher expectations to surgical treatment.

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.

Effect of manual therapy with exercise in patients with chronic cervical radiculopathy: a randomized clinical trial

BACKGROUND

Research that has examined the effects of cervical spine mobilization on hypoesthesia and hypersensitivity characteristics in patients with cervical radiculopathy is scarce. The aim of this study was to examine the short-term effects of vertebral mobilization on the sensory features in patients with cervical radiculopathy.

METHODS

Twenty-eight participants with chronic cervical radiculopathy were randomly allocated to (1) an experimental group [cervical vertebral mobilization technique and exercise] or (2) a comparison group [minimal superficial circular pressure on the skin and exercise]. Participants received a total of 6 sessions for 3-5 weeks. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI), pressure pain threshold (PPT), heat/cold pain threshold (HPT/CPT), and active cervical range of motion (ROM) were measured at baseline immediately after the first session and after the sixth session.

RESULTS

The experimental group showed improvements from baseline to session 6 in NPRS [mean difference 2.6; 95% confidence interval: -4.6, -0.7], NDI [14; -23.3, -4.3], and active cervical ROM in extension [14°; 2.3, 25.5], rotation [16°; 8.8, 22.5], and lateral flexion to the affected side [10°; 2.3, 16.8]. Improvements were also found in PPT at the neck [124 kPa; 57, 191.1] and C7 level at the hand [99 kPa; 3.6, 194.9]. There were no changes in the HPT and CPT at any tested area (P>0.050).

CONCLUSIONS

Cervical vertebral mobilization for patients with chronic cervical radiculopathy reduced localized mechanical, but not thermal, pain hypersensitivity.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03328351 ). Registered on November 1, 2017, retrospectively registered.

Acute Cervical Radiculopathy Outcomes: Soft Disc Herniations vs Osteophytes

OBJECTIVE

Prospectively evaluate the clinical outcomes of acute cervical radiculopathy with respect to soft disc herniations vs osteophytes.

METHODS

Sixty consecutive patients who had had cervical radiculopathy for ≤1 month were enrolled in the study. Inclusion criteria were radicular pain greater than axial pain and a pain score ≥4 out of 10 on a numerical rating scale. Patients had at least one positive clinical finding: motor, sensory, or reflex changes. Plain films and magnetic resonance imaging were ordered. Follow-up was at 6 weeks and 3, 6, and 12 months. Outcomes included pain scores (neck and upper limb), neck disability index, medication use, opioid use, and need for surgery. Two attending musculoskeletal radiologists reviewed imaging findings for osteophytes vs soft disc herniations at the symptomatic level.

RESULTS

More than 75% reduction in pain was seen in 77% of patients with soft disc herniations and 66% of patients with osteophytes (P > 0.05) at 12 months. A pain score ≤2 out of 10 within 6 to 12 months was seen in 86% of patients with soft disc herniations and 81% of patients with osteophytes (P > 0.05). Moderate or marked improvement at 12 months was seen in 85% of patients with soft discs and 77% of patients with osteophytes (P > 0.05). Baseline-to-12-month numerical rating scale pain scores of patients with soft discs vs osteophytes had overlapping confidence intervals at each follow-up. At 12 months, very few had undergone surgery (7% of patients with soft discs, 11% of patients with osteophytes; P > 0.05) or were on opioids (7% of patients with soft discs, 9% of patients with osteophytes; P > 0.05).

CONCLUSIONS

The majority of patients, but not all patients, with acute radiculopathies improved with time. This was seen with both soft disc herniations and osteophytes.

Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis

Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine. It mainly presents with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution. The most common causes of cervical radiculopathy are cervical disc herniation and cervical spondylosis. It is important to find the exact symptomatic segment and distinguish between conditions that may mimic certain cervical radicular compression syndromes through meticulous physical examinations and precise reading of radiographs. Non-surgical treatments are recommended as an initial management. Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior and/or posterior approaches. The appropriate choice of surgical treatment should be individualized, considering the patient’s main pathophysiology, specific clinical symptoms and radiographic findings thoroughly.

The Effects of Exercise Dosage on Neck-Related Pain and Disability: A Systematic Review With Meta-analysis

OBJECTIVE

To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect.

DESIGN

Intervention systematic review with meta-analysis and meta-regression.

LITERATURE SEARCH

An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain.

STUDY SELECTION CRITERIA

We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SYNTHESIS

Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability.

RESULTS

Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes.

CONCLUSION

Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain. J Orthop Sports Phys Ther 2020;50(11):607-621. doi:10.2519/jospt.2020.9155.

Cervical spine thrust and non-thrust mobilization for the management of recalcitrant C6 paresthesias associated with a cervical radiculopathy: a case report

BACKGROUND

The conservative management of cervical radiculopathy is supported by moderate evidence to include interventions such as manual therapy, traction, and therapeutic exercise. There is sparse evidence, however, to support specific manual therapy techniques, particularly thrust manipulation.

CASE DESCRIPTION

A 35-year-old male presented to physical therapy with a clinical diagnosis of cervical radiculopathy. He complained of neck and upper arm pain with 1st and 2nd digit paresthesias. He was initially managed with repeated movements that restored the cervical range of motion and centralized neck and upper arm pain. Non-thrust upslope joint mobilizations resulted in improved sensation detection in the hand, but the paresthesias did not completely resolve. Immediately following cervical spine upslope thrust manipulation, symptoms fully resolved. Outcomes: The patient fully returned to prior level of function. His DASH score reduced from 40/100 to 2/100, PSFS improved from 1.66/10 to 9.66/10, and he reported to be 'a great deal better' on the GROC.

DISCUSSION

This case demonstrates the safe and effective utilization of cervical spine thrust manipulation and non-thrust mobilization in the management of a patient with cervical radiculopathy with lingering paresthesias in the distal upper extremity.

Multidimensional assessment of cervical spondylotic myelopathy patients. Usefulness of a comprehensive score system

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is caused by cervical spine degeneration and surgery may be beneficial, but selection for surgery might be challenging. We performed a multimodal analysis to assess predicting factors that may be useful to help surgeons in this choice.

PATIENTS AND METHODS

We retrospectively evaluated clinical, motor evoked potentials (MEP), and MRI data of patients who undergone surgery for CSM. Seventy-six consecutive patients (46 males) were enrolled. The median age was 65.5 [IQR: 57-71] years, and the duration of symptoms was 11 [8-13] months. A multivariate analysis in order to assess predictors of outcome and ROC curve analysis were performed.

RESULTS

Thirty patients (M:18, 39.5%) gained 6 or more points on mJOA and they were collected in good recovery group, whereas 46 patients (60.5%, M:28) showed a fair recovery. We developed a comprehensive score system (CSS) taking into account clinical, neurophysiological, and neuroradiological data. ROC curve analysis was performed to determine the discriminative power of four models derived from the multivariate logistic regression analysis for predictors of good outcome considering only clinical variables, MRI variables, and MEP variables or considering the comprehensive model, demonstrating a good accuracy of CSS model to predict outcome.

CONCLUSION

This study demonstrates that CSS model taking into consideration functional assessment by mJOA score, neurologic evaluation, cervical MRI, and MEP may be a feasible method to predict outcome in patients candidate to surgery, supporting surgeon's decisions both for those patients candidate to surgery and for patients in whom a "wait and see" approach could be proposed.

Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety

Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy

Background

Cervical radiculopathy is usually caused by disc herniation or spondylosis. The prognosis is expected to be good in most patients, but there is limited scientific evidence on the indications for nonsurgical and surgical treatments. The aim of the present study is to evaluate and compare the effectiveness of surgical and nonsurgical treatment in two trials – including disc herniation and spondylosis, respectively, and to evaluate factors that contribute to better decision making.

Methods/design

Patients with disabling radicular arm pain and MRI-proven cervical disc herniation or spondylosis will be randomised to receive nonsurgical or surgical treatment. The follow-up period is one year and the sample size is estimated to be 50 for each arm in the two trials, giving a total of 200 patients. The primary outcomes are the Neck Disability Index and arm pain. Secondary outcomes include neck pain; EQ-5D and costs to evaluate cost-effectiveness; prognostic factors; CT and MRI scans, to estimate intervertebral foraminal area and nerve root compression; and the expected minimal improvement for willingness to undergo treatment.

Discussion

The outcomes of this study will contribute to better decision making in the treatment of cervical radiculopathy.

Trial registration

This study has been registered at ClinicalTrials.gov as NCT03674619, on September 17, 2018.

Neck Pain and Lower Back Pain

Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.

Comparative study of curative effect of spinal endoscopic surgery and anterior cervical decompression for cervical spondylotic myelopathy

Background

The aim of this study was to compare the clinical efficacy of endoscopic cervical spinal surgery with anterior cervical decompression and fusion (ACDF) in the treatment of cervical spondylotic myelopathy (CSM).

Methods

A total of forty-six CSM patients who were admitted to the Medical School of Chinese PLA and treated with endoscopic spine surgery or ACDF from January 2015 to June 2017 were collected. The patients were divided into the spinal endoscopy group and the ACDF group, according to the operation methods. The operation time, intraoperative blood loss and hospitalization stay of the two groups were recorded and compared. Japanese Orthopaedic Association (JOA) score before operation, three months, and one year after operation were recorded for intra-group and inter-group comparison. The improvement rates of JOA were compared between the two groups to evaluate the clinical efficacy.

Results

There were twenty-two cases in the spinal endoscopy group and twenty-four cases in the ACDF group. The mean operation lasting time, intraoperative blood loss and hospitalization stay in the spinal endoscopy group were significantly lower than those in the ACDF group (P<0.05). The postoperative JOA score of the two groups were significantly higher than those before the operation (P<0.05). There were no significant differences in the JOA score before operation, three months and one year after operation between the two groups (P>0.05). The improvement rates in the spinal endoscopy group were not significantly different compared to those in the ACDF group (P>0.05). There was no significant difference in the excellent rate (81.8% vs. 83.3%) between the spinal endoscopy group and the ACDF group (P>0.05).

Conclusions

The short-term efficacy of spinal endoscopic surgery and ACDF was equal in the treatment of CSM. The spinal endoscopic surgery was significantly superior to ACDF in reducing the operation time, the intraoperative blood loss and the hospitalization stay.

The effect of exercise on cervical radiculopathy: A systematic review and meta-analysis

BACKGROUND

Cervical radiculopathy (CR), which is most often stems from degenerative disease in the cervical spine, has increasingly become a common and frequently occurring disease in clinic due to the popularity of electronic products, such as computes and cell phones. Some studies have shown that exercise or exercise combined with other treatments can effectively decrease pain and improve functional status. The objective was to analyze the effects of exercise for treating patients with CR.

METHODS

Seven databases were searched from inception to December 2018. Randomized controlled trials involving exercise alone or exercise combined with conventional treatment were enrolled. Data were pooled after trials quality assessment for meta-analysis. Outcomes were pain (visual analog scale [VAS]), quality of life (12-short form health survey, 36-short form health survey), and physical function accessed by neck disability index (NDI).

RESULTS

Ten studies involving 871 participants with CR were included. Meta-analysis revealed that compared with control group, there was a reduction in VAS (standardized mean difference = -0.89; 95% confidence interval [CI]: -1.34 to -0.44; Z = 3.89; P < .001). There was also an improvement of NDI (mean difference = -3.60; 95% CI: -6.27 to -0.94; Z = 2.65; P = .008)]. Additionally, although the results of subgroup analyses were changed due to the paucity of the quantity and quality of the included studies. The pooled results were verified to be stable by sensitivity analyses. Besides, the grading of recommendations assessment, development, and evaluation level of evidence is low for each outcome.

CONCLUSION

Exercise alone or exercise plus other treatment may be helpful to patients with CR. However, exercise option should be carefully considered for each patient with CR in accordance with their different situations. Large-scale studies using proper methodology are recommended.

Practical help for specifying the target difference in sample size calculations for RCTs: the DELTA2 five-stage study, including a workshop

BACKGROUND

The randomised controlled trial is widely considered to be the gold standard study for comparing the effectiveness of health interventions. Central to its design is a calculation of the number of participants needed (the sample size) for the trial. The sample size is typically calculated by specifying the magnitude of the difference in the primary outcome between the intervention effects for the population of interest. This difference is called the 'target difference' and should be appropriate for the principal estimand of interest and determined by the primary aim of the study. The target difference between treatments should be considered realistic and/or important by one or more key stakeholder groups.

OBJECTIVE

The objective of the report is to provide practical help on the choice of target difference used in the sample size calculation for a randomised controlled trial for researchers and funder representatives.

METHODS

The Difference ELicitation in TriAls2 (DELTA2) recommendations and advice were developed through a five-stage process, which included two literature reviews of existing funder guidance and recent methodological literature; a Delphi process to engage with a wider group of stakeholders; a 2-day workshop; and finalising the core document.

RESULTS

Advice is provided for definitive trials (Phase III/IV studies). Methods for choosing the target difference are reviewed. To aid those new to the topic, and to encourage better practice, 10 recommendations are made regarding choosing the target difference and undertaking a sample size calculation. Recommended reporting items for trial proposal, protocols and results papers under the conventional approach are also provided. Case studies reflecting different trial designs and covering different conditions are provided. Alternative trial designs and methods for choosing the sample size are also briefly considered.

CONCLUSIONS

Choosing an appropriate sample size is crucial if a study is to inform clinical practice. The number of patients recruited into the trial needs to be sufficient to answer the objectives; however, the number should not be higher than necessary to avoid unnecessary burden on patients and wasting precious resources. The choice of the target difference is a key part of this process under the conventional approach to sample size calculations. This document provides advice and recommendations to improve practice and reporting regarding this aspect of trial design. Future work could extend the work to address other less common approaches to the sample size calculations, particularly in terms of appropriate reporting items.

FUNDING

Funded by the Medical Research Council (MRC) UK and the National Institute for Health Research as part of the MRC-National Institute for Health Research Methodology Research programme.

Surgery for degenerative cervical spine disease in Finland, 1999-2015

Background

The incidence of surgery for degenerative cervical spine disease (DCSD) has risen by almost 150% in the USA in the last three decades and stabilized at slightly over 70 operations/100,000 people. There has been significant regional variation in the operation incidences. We aim to assess the diagnosis-based, age-adjusted trends in the operation incidences and the regional variation in Finland between 1999 and 2015.

Methods

Data from the Finnish Hospital Discharge Register (FHDR), the Cause of Death Register, and the registers of the Social Insurance Institution were combined to analyze all the primary operations for DCSD or rheumatoid atlanto-axial subluxation (rAAS). Combinations of the operative and the diagnosis codes were used to classify the patients into five diagnostic groups.

Results

A total of 19,701 primary operations were included. The age-adjusted operation incidence rose from 21.0 to 36.5/100,000 people between 1999 and 2013 and plateaued thereafter. The incidence of surgery for radiculopathy increased from 13.1 to 23.3 operations/100,000 people, and the incidence of surgery for DCM increased from 5.8 to 7.0 operations/100,000 people. The rise was especially pronounced in surgery for foraminal stenosis, which increased from 5.3 to 12.4 operations/100,000 people. Of the five diagnostic groups, only operations for rAAS declined. Operations increased especially in the 40- to 65-year-old age group. The overall operation incidences varied from 18.3 to 43.1 operations/100,000 people between the university hospitals.

Conclusions

The age-adjusted incidence of surgery for DCSD has risen in Finland by 76%, but the rise has plateaued. Surgery for radiculopathy, especially for foraminal stenosis, increased more steeply than surgery for degenerative medullopathy, with vast regional differences in the operation incidences.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-03958-6) contains supplementary material, which is available to authorized users.

A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy - the PACeR trial protocol

BACKGROUND

A research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6-8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome.

METHODS

Participants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants' report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200).

DISCUSSION

An internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites.

TRIAL REGISTRATION

NCT02449200 . Registered 20/05/15.

The Cervical Radiculopathy Impact Scale: development and evaluation of a new functional outcome measure for cervical radicular syndrome

Objective: To develop and validate an outcome scale for the cervical radicular syndrome and to build a mapping, predicting EQ-5D utility from the new scale.Study design and setting: An item pool was developed based on literature and patient and clinician interviews. Item selection was based on symptomatology, factor analysis, and internal consistency. We assessed: (a) test-retest reliability by standard error of measurement and intraclass correlation coefficients; (b) construct validity by testing 22 hypotheses on relationships with existing measures and known-group differences. For the mapping, performance was assessed by mean absolute error and root mean squared error.Results: A total of 254 patients with cervical radicular syndrome completed the first questionnaire, 61 stable patients a retest. Item selection led to a 21-item questionnaire consisting of three subscales: Symptoms, Energy and postures, and Actions and activities. Standard error of measurement values ranged from 6.7 to 11.2 on a 0 to 100 scale. All subscales showed good reliability (intraclass correlation coefficients: 0.84, 0.87, and 0.94). All hypotheses for construct validity were confirmed. A linear utility mapping was preferred, with reasonable statistical performance.Conclusion: We developed a reliable and valid cervical radicular syndrome specific outcome scale, called the Cervical Radiculopathy Impact Scale (CRIS). This new questionnaire may facilitate (cost-)effectiveness studies in this field.Implications for RehabilitationThe cervical radicular syndrome is a frequently occurring and invalidating health problem, which causes severe radiating pain in the arm and/or hand, which can be accompanied by motor and/or sensory deficits.The Cervical Radiculopathy Impact Scale (CRIS) is a newly developed self-report questionnaire which covers measurement of symptoms and limitations in patients with cervical radiculopathy due to irradiating pain, tingling sensations and sensory loss in the arm in combination with neck disability.The CRIS consists of 21 items divided over three subscales: (i) symptoms, (ii) energy and postures, and (iii) actions and activities.The CRIS shows good content validity, test-retest reliability, construct validity and is able to discriminate between groups.The CRIS predicts EQ-5D utility and is therefore useful for (cost)effectiveness studies in this field.

The effectiveness of therapeutic strategies for patients with radiculopathy: A network meta-analysis

Objectives

The aim of this network meta-analysis is to assess the effectiveness of therapeutic strategies for patients with radiculopathy, including physical, medical, surgical, and other therapies.

Methods

We electronically searched electronic databases including PubMed and Embase for randomized controlled trials. The response rate and visual analog scale of pain change were considered as primary outcomes. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or standardized mean difference (MD) with 95% CrIs. Besides, surface under cumulative ranking curve (SUCRA) were performed to rank efficacy and safety of treatments on each end points.

Results

A total of 16 eligible studies with 1071 subjects were included in this analysis. Our results showed that corticosteroid was significantly more effective than control regarding the response rate (OR = 3.86, 95% CrI: 1.16, 12.55). Surgery had a better performance in pain change compared with control (MD = −1.92, 95% CrI: −3.58, −0.15). According to the SUCRA results, corticosteroid, collar, and physiotherapy ranked the highest concerning response rate (SUCRA = 0.656, 0.652, and 0.610, respectively). Surgery, traction, and corticosteroid were superior to others in pain change (SUCRA = 0.866, 0.748, and 0.589, respectively).

Conclusion

According to the network meta-analysis result, we recommended surgery as the optimal treatment for radiculopathy patients; traction and corticosteroids were also recommended for their beneficial interventions.

Value of physical tests in diagnosing cervical radiculopathy: a systematic review

BACKGROUND CONTEXT

In clinical practice, the diagnosis of cervical radiculopathy is based on information from the patient's history, physical examination, and diagnostic imaging. Various physical tests may be performed, but their diagnostic accuracy is unknown.

PURPOSE

This study aimed to summarize and update the evidence on diagnostic performance of tests carried out during a physical examination for the diagnosis of cervical radiculopathy.

STUDY DESIGN

A review of the accuracy of diagnostic tests was carried out.

STUDY SAMPLE

The study sample comprised diagnostic studies comparing results of tests performed during a physical examination in diagnosing cervical radiculopathy with a reference standard of imaging or surgical findings.

OUTCOME MEASURES

Sensitivity, specificity, likelihood ratios are presented, together with pooled results for sensitivity and specificity.

METHODS

A literature search up to March 2016 was performed in CENTRAL, PubMed (MEDLINE), Embase, CINAHL, Web of Science, and Google Scholar. The methodological quality of studies was assessed using the QUADAS-2.

RESULTS

Five diagnostic accuracy studies were identified. Only Spurling's test was evaluated in more than one study, showing high specificity ranging from 0.89 to 1.00 (95% confidence interval [CI]: 0.59-1.00); sensitivity varied from 0.38 to 0.97 (95% CI: 0.21-0.99). No studies were found that assessed the diagnostic accuracy of widely used neurological tests such as key muscle strength, tendon reflexes, and sensory impairments.

CONCLUSIONS

There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. When consistent with patient history, clinicians may use a combination of Spurling's, axial traction, and an Arm Squeeze test to increase the likelihood of a cervical radiculopathy, whereas a combined results of four negative neurodynamics tests and an Arm Squeeze test could be used to rule out the disorder.

What's the best surgical treatment for patients with cervical radiculopathy due to single-level degenerative disease? A randomized controlled trial

Background

To investigate the efficacy of adding supplemental fusion or arthroplasty after cervical anterior discectomy for symptomatic mono-level cervical degenerative disease (radiculopathy), which has not been substantiated in controlled trials until now.

Methods

A randomized controlled trial is reported with 9 years follow up comparing anterior cervical anterior discectomy without fusion, with fusion by cage standalone, or with disc prosthesis. Patients suffering from symptomatic cervical disk degeneration at one level referred to spinal sections of department of neurosurgery or orthopedic surgery of a large general hospital with educational facilities were eligible. Neck Disability Index (NDI), McGill Pain Questionnaire Dutch language version (MPQ-DLV), physical-component summary (PCS), and mental-component summary (MCS) of the 36-item Short-Form Health Survey (SF-36), and re operation rate were evaluated.

Findings

142 patients between 18 and 55 years were allocated. The median follow-up was 8.9±1.9 years (5.6 to 12.2 years). The response rate at last follow-up was 98.5%. NDI at the last follow-up did not differ between the three treatment groups, nor did the secondary outcomes as MPQ-DLV and PCS or MCS from SF-36. The major improvement occurred within the first 6 weeks after surgery. Afterward, it remained stable. Eleven patients underwent surgery for recurrent symptoms and signs due to nerve root compression at the index or adjacent level.

Conclusions

This randomized trial could not detect a difference between three surgical modalities for treating a single-level degenerative disk disease. Anterior cervical discectomy without implant seems to be similar to anterior cervical discectomy with fusion by cage stand-alone or with disk prosthesis. Due to the small study sample size, this statement should be considered as inconclusive so far.

Trial registration

ISRCTN41681847

Non-surgical relief of cervical radiculopathy through reduction of forward head posture and restoration of cervical lordosis: a case report

[Purpose] To present a case demonstrating the relief of cervical radiculopathy following the dramatic reduction of forward head posture and restoration of the cervical lordosis by use of a multi-modal rehabilitation program incorporating cervical extension traction. [Subject and Methods] A 31-year-old male patient presented with severe cervical radiculopathy and muscle weakness as well as neck pain. The patient had limited neck range of motion, and multiple positive orthopedic tests. Radiography revealed excessive forward head posture with a cervical kyphosis. [Results] The patient received a multi-modal rehabilitation protocol including mirror image extension exercises, cervical extension traction, and spinal manipulative therapy. After forty treatments over 17 weeks, the patient reported a complete resolution of radiculopathy and significant improvement in neck pain level. Post radiography demonstrated correction of the spine and posture alignment. The patient remained well and maintained corrected posture with limited treatment one year later. [Conclusion] Our case demonstrates the relief of cervical radiculopathy resulting from the non-surgical correction of forward head posture and cervical kyphosis.

National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy

PURPOSE

To summarise recommendations about 21 selected non-surgical interventions for recent onset (<12 weeks) non-specific neck pain (NP) and cervical radiculopathy (CR) based on two guidelines from the Danish Health Authority.

METHODS

Two multidisciplinary working groups formulated recommendations based on the GRADE approach.

RESULTS

Twelve recommendations were based on evidence and nine on consensus. Management should include information about prognosis, warning signs, and advise to remain active. For treatment, guidelines suggest different types of supervised exercise and manual therapy; combinations of exercise and manual therapy before medicine for NP; acupuncture for NP but not CR; traction for CR; and oral NSAID (oral or topical) and Tramadol after careful consideration for NP and CR.

CONCLUSION

Recommendations are based on low-quality evidence or on consensus, but are well aligned with recommendations from guidelines from North America. The working groups recommend intensifying research relating to all aspects of management of NP and CR.

A Prospective Study of Clinical and Radiological Outcomes of Zero-Profile Cage Screw Implants for Single-Level Anterior Cervical Discectomy and Fusion: Is Segmental Lordosis Maintained at 2 Years?

Study Design

Prospective cohort study.

Purpose

To study clinicoradiological parameters of zero-profile cage screw used for anterior cervical discectomy and fusion (ACDF).

Overview of Literature

Radiological parameters of various implants used for ACDF are available, but those for zero-profile cage are sparse.

Methods

Patients with unilateral intractable brachialgia due to single-level cervical disc prolapse between April 1, 2011 and March 31, 2014 were included. Clinical assessment included arm and neck pain using visual analogue score (VAS) and neck disability index (NDI) scores. Radiological assessment included motion segment height, adjacent disc height (upper and lower), segmental and cervical lordosis, implant subsidence, and pseudoarthrosis. Follow-ups were scheduled at 1, 3, 6, 12, and 24 months.

Results

Thirty-four patients (26 males, 8 females) aged 30–50 years (mean, 42.2) showed excellent clinical improvement based on VAS scores (7.4–0 for arm and 2.0–0.6 for neck pains). Postoperative disc height improved by 11.33% (p<0.001), but at 2 years, the score deteriorated by 7.03% (p<0.001). Difference in the adjacent segment disc height at 2 years was 0.08% (p=0.8) in upper and 0.16% (p<0.001) in lower disc spaces. Average segmental lordosis achieved was 5.59° (p<0.001) from a preoperative kyphosis of 0.88°; at 2 years, an average loss of 7.05° (p<0.001) occurred, resulting in an average segmental kyphosis of 1.38°. Cervical lordosis improved from 11.59° to 14.88° (p=0.164), and at 2 years, it progressively improved to 22.59° (p<0.001). Three patients showed bone formation and two mild protrusion of the implant at 2 years without pseudoarthrosis/implant failure.

Conclusions

The zero-profile cage screw device provides good fusion and cervical lordosis but is incapable of maintaining the segmental lordosis achieved up to a 2-year follow-up. We also recommend caution when using it in patients with small vertebrae.

Current practice of cervical disc arthroplasty: a survey among 383 AOSpine International members

OBJECTIVE

The use of cervical disc arthroplasty (CDA) in spinal practice is controversial. This may be explained by the lack of studies with a large sample size and long-term outcomes. With this survey the authors aimed to evaluate the opinions of spine surgeons on the use of CDA in the current treatment of cervical disc herniation (CDH).

METHODS

A web-based survey was sent to all members of AOSpine International by email using SurveyMonkey on July 18, 2016. A single reminder was sent on August 18, 2016. Questions included geographic location; specialty; associated practice model; number of discectomies performed annually; the use of CDA, anterior cervical discectomy (ACD), and anterior cervical discectomy and fusion (ACDF); and the expectations for clinical outcomes of these procedures.

RESULTS

A total of 383 questionnaires were analyzed. Almost all practitioners (97.9%) were male, with a mean of 15.0 ± 9.7 years of clinical experience. The majority of responders were orthopedic surgeons (54.6%). 84.3% performed ACDF as the standard technique for CDH. 47.8% of the surgeons occasionally used CDA, whereas 7.3% used CDA as standard approach for CDH. The most common arthroplasty device used was the ProDisc-C. Low evidence for benefits and higher costs were the most important reasons for not offering CDA. The risk of adjacent-level disease was considered smaller for CDA as compared with ACDF. However, ACDF was expected to have the highest effectiveness on arm pain (87.5%), followed by CDA (77.9%), while ACD had the least (12.6%).

CONCLUSIONS

In this survey, CDA was not considered to be the routine procedure to treat CDH. Reported benefits included the reduced risk of adjacent-level disease and preservation of motion of the neck. Lack of enough evidence on its effectiveness as well as higher costs were considered to be disadvantages of CDA. More research should be conducted on the implementation impact of CDA and the cost-effectiveness from society's perspective.

Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises.

PURPOSE

To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III.

STUDY DESIGN/SETTING

Systematic review and best evidence synthesis.

SAMPLE

Studies comparing the effectiveness of exercise to other conservative interventions or no intervention.

OUTCOME MEASURES

Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events.

METHODS

We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice.

CONCLUSIONS

We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.

Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration

BACKGROUND CONTEXT

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

PURPOSE

This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD.

STUDY DESIGN/SETTING

This is a systematic review and best evidence synthesis.

SAMPLE

The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention.

OUTCOME MEASURES

The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events.

METHODS

We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance.

RESULTS

We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I-II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I-II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I-II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I-II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I-II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits.

CONCLUSIONS

Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.

The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

STUDY DESIGN

Systematic review of randomized controlled trials (RCT).

OBJECTIVES

To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

BACKGROUND

Neck pain is a leading cause of disability that affects 22-70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

METHODS

A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht-Amsterdam assessment tool to assess quality among RCTs.

RESULTS

A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

CONCLUSIONS

Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.

Cervical radiculopathy

Cervical radiculopathy is a common clinical scenario. Patients with radiculopathy typically present with neck pain, arm pain, or both. We review the epidemiology of cervical radiculopathy and discuss the diagnosis of this condition. This includes an overview of the pertinent findings on the patient history and physical examination. We also discuss relevant clinical syndromes that must be considered in the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. The natural history of cervical radiculopathy is reviewed and options for management are discussed. These options include conservative management, non-operative modalities such as physical therapy, steroid injections, and operative intervention. While the exact indications for surgical intervention have not yet been elucidated, we provide an overview of the available literature regarding indications and discuss the timing of intervention. The surgical outcomes of anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF) are discussed.

Exercises for mechanical neck disorders: A Cochrane review update

BACKGROUND

Neck pain (NP) is disabling and costly.

OBJECTIVES

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP.

METHODS

We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence.

MAIN RESULTS

The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

AUTHORS' CONCLUSIONS

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Comparison between effectiveness of Mechanical and Manual Traction combined with mobilization and exercise therapy in Patients with Cervical Radiculopathy

Background and Objective:

Cervical radiculopathy is a common neuro-musculo-skeletal disorder causing pain and disability. Traction is part of the evidence based manual physical therapy management due to its mechanical nature, type of traction and parameters related to its applicability and are still to be explored more through research. Our objective was to determine the Effects of Mechanical versus Manual Traction in Manual Physical Therapy combined with segmental mobilization and exercise therapy in the physical therapy management of Patients with Cervical Radiculopathy.

Methods:

This randomized control trial was conducted at department of physical therapy and rehabilitation, Rathore Hospital Faisalabad, from February to July 2015. Inclusion criteria were both male and female patients with evident symptoms of cervical spine radiculopathy and age ranged between 20-70 years. The exclusion criteria were Patients with history of trauma, neck pain without radiculopathy, aged less than 20 and more than 70. A total of 72 patients with cervical radiculopathy were screened out as per the inclusion criteria, 42 patients were randomly selected and placed into two groups by toss and trial method, and only 36 patients completed the study, while 6 dropped out. The mechanical traction was applied in group A and manual traction in group B along with common intervention of segmental mobilization and exercise therapy in both groups for 6 weeks. The patient’s outcomes were assessed by self reported NPRS and NDI at the baseline and after completion of 06 weeks exercise program at 3 days per week. The data was analyzed through SPSS version-21, and paired T test was applied at 95% level significance to determine the statistical deference between two groups.

Results:

Clinically the group of patients treated with mechanical traction managed pain (mean pre 6.26, mean post 1.43), and disability (mean pre 24.43 and mean post 7.26) more effectively as compared with the group of patients treated with manual traction (Pain mean pre 6.80, mean post 3.85 and disability mean pre 21.92 and post 12.19). Statistically the results of both mechanical and manual traction techniques are equally significant in group A and B for pain and disability (p-value less than 0.05).

Conclusion:

If patients of cervical radiculopathy treated with mechanical traction, segmental mobilization, and exercise therapy will manage pain and disability more effectively than treated with manual traction, segmental mobilization, and exercise therapy.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS

This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1

Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2

Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3

Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4

For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5

For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6

For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Long term follow-up of cervical intervertebral disc herniation inpatients treated with integrated complementary and alternative medicine: a prospective case series observational study

Background

Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.

Methods

A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.

Results

Of 165 patients who received inpatient treatment 20.8 ± 11.2 days, 117 completed the long term follow-up up at 625.36 ± 196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (n = 117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI 14.6 (95 % CI, 11.89, 17.32), and corresponding scores in the non-long term follow-up group (n = 48) were 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 (95 % CI, 1.84, 3.12) for arm pain, and that of NDI was 14.86 (95 % CI, 10.41, 19.3). Difference in long term NRS of neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64), and 2.64 (95 % CI, 1.99, 3.29), respectively. PGIC was reported to be “satisfactory” or higher in 79.5 % of patients at long term follow-up.

Conclusions

Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.

Trial registration

ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.

Exercise training for non-operative and post-operative patient with cervical radiculopathy: a literature review

[Purpose] Cervical radiculopathy is a clinical condition associated with pain, numbness and/or muscle weaknesses of the upper extremities due to a compression or irritation of the cervical nerve roots. It is usually managed conservatively but surgical intervention is sometimes required for those who fail to respond adequately. This study performed a literature review to determine the effects of exercise on non-operative and post-operative cervical radiculopathy patients. [Methods] The PubMed, MEDLINE, CINAHL and Scopus databases were searched to identify relevant articles published from January 1997 to May 2014, which explicitly stated that an exercise program was employed as an intervention for cervical radiculopathy. The therapeutic effectiveness and outcomes were then classified based on the International Classification of Functioning, Disability and Health (ICF) model. [Results] Eleven studies were identified and included in the final analysis. In these studies, the main forms of exercise training were specific strengthening and general stretching exercises. Levels of evidence were graded as either I or II for all studies according to the Oxford Centre for Evidence-based Medicine. The PEDro Scale score of these studies ranged from 5 to 8. [Conclusion] A review of eleven high-level evidence and high-quality studies revealed that, based on the ICF model, exercise training is beneficial for improving the body function as well as activity participation of cervical radiculopathy patients.