An Overview on the Efficacy of Manual Therapy on Nonspecific Cervical Pain

An Overview on the Efficacy of Manual Therapy on Nonspecific Cervical Pain Blog  Manual therapy

Cervical pain is very commonly associated with patients who are overweight. Doctors today do not understand how manual therapy can reduce neck pain, and it has not yet been established whether it can provide any relief. Manual therapy for cervical pain comes in two different forms:

Spinal Manipulation – Certain manual techniques that are done at high speed, with low pressure, and are applied to precise areas of an individual vertebra. These manual techniques are to increase range of motion to normal levels without going over; and

Spinal Mobilization – Low-speed chiropractic movements applied to multiple vertebrae while maintaining normal limits of range of motion.

This kind of manual treatment is generally used for pain in the back, usually physically pain of an unknown origin. Sometimes this is the only therapy applied, while other patients suffering from cervical pain will also undergo other types of physical therapy and/or take pharmaceutical medicines.

For our focus, we examined and reviewed a multitude of studies that used random control trials (RCTs) because we feel this is the most scientific approach to evaluating evidence-based medicine.

Results

After careful analysis, we searched through the available literature and sorted all of the results by the year of their publication. We discovered five low-quality RCTs from 1991 or before. Because of this, we were unable to get enough quality evidence to draw a firm conclusion, and we urge researchers to conduct better quality studies.

Between 1992 and 1996, we found 24 RCTs of sufficiently high quality. These were categorized by the type of chiropractic therapy applied, including 12 that applied physical medicine, nine that relied on manual therapy, four that used multiple kinds of therapy, four that involved the use of pharmaceutical compounds, and three that relied on education alone. For this period of analysis, we were able to conclude that the subject was not studied in enough detail for us to be able to accurately draw any conclusions. Furthermore, the published results were often quite contradictory.

Starting in 1997 and continuing to the present, we found 14 RCTs that were performed on a total of 892 people. It was this group of research papers that we found the best evidence on the differences between mobilization and manipulation, further subdivided into patients suffering from chronic, acute, and subacute cervical discomfort. Unfortunately, there were no RCTs on spinal manipulation, and we were only able to find three low-quality RCTs on spinal mobilization, all of which dealt with the subject of whiplash.

During the period 1998-2002, we found 20 medium-quality RCT reports. These seem to indicate that chiropractic therapy and exercise (both mobilization and manipulation) was somewhat effective. Nonetheless, there was no statistical evidence that patients who underwent manual manipulation received better results than the control group.

After examining 33 RCTs from 2003, we assessed that 42% of them were of sufficiently high quality. These studies, however, indicated that manipulation succeeded no better than the treatment given to the control group.

In the period of 2004 to 2012, we found 12 studies of sufficiently high quality. We also found an additional eight low-quality RCTs, and six of these reported good results for manipulation, while two found the opposite. Therefore, we determined that there was simply not enough evidence to conclude whether or not cervical spine therapy is effective.

Acute Neck Pain

We found no RCTs that covered whether or not chiropractic manipulation was effective for the treatment of acute neck pain. We did, however, find three low-quality RCTs that covered mobilization, and two that discussed treating whiplash. In the group of random patients that underwent therapy for neck pain, all of whom had also received the use of collars and pain relievers, we could find no difference in the results of using mobilization, TENS, or the control groups. We found no evidence that concluded that spinal manipulation was effective, and we were only able to find very scant evidence that mobilization was effective for treating acute cervical neck discomfort.

Cervical Whiplash

On the subject of whiplash, we were able to find evidence that patients who received mobilization therapy reported statistically significant reductions in pain reduction and increased range of motion than the control group that received pain relievers, education, and underwent exercise at home. These patients reported reduced discomfort after two years when they underwent mobilization right after their injury, while those patients who underwent other forms of physical therapy or collars reported less favorable results. Therefore, we concluded that there is some evidence that early mobilization potentially was effective, while we found no such corroboration of the use of manipulation for treating whiplash injuries.

Chronic Subacute Neck Pain

We did find two RCTs that demonstrated some efficacy in both mobilization and manipulation of the spine. But we were unable to see any evidence that concluded that pain was reduced in the short term, or that patients experienced a better range of motion with either mobilization or manipulation. Therefore, we concluded that there is not enough evidence to state whether mobilization or manipulation is a more effective therapy for treating subacute neck pain.

We did locate four RCTs that efficiently demonstrated the difference between manipulation and/or mobilization with other forms of treatments. Patients who took aspirin and received mobilization therapy reported less pain after three months, but this did not continue into long-term relief.

These studies also showed that the short-term efficacy of using manipulation and mobilization in comparison with physiotherapy, conventional therapy, or the use of a placebo, but these positive results did not remain after three months or a full year. We did discover that manipulation did result in better muscle relaxation, but this had no significant impact on patient discomfort. Therefore, there is not enough evidence to conclusively state that either manipulation or mobilization is useful in treating chronic subacute neck discomfort.

However, patients in the manual therapy group reported better results that patients in either the physical therapy or medical treatment groups at both seven and 26 years, but this difference evaporated after one year. Patients reported greater pain relief at the intervals of four months and one year after treatment, but there was no difference between the different groups. We found that the studies showed that mobilization and strength-building treatment programs did result in better pain relief and functional recovery than for patients in the control group after one year.

When we randomized the three different treatment groups, we could find no significant difference between these patients after three months. Nonetheless, patients who underwent both manipulation and who performed conventional strength-building exercises reported better results after three months, one year, and two years later.

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

image

Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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