Cervical Discogenic Pain (Disorder) Clinical Trial
Official title:
Effects of Cyriax Manipulation in Cervical Discogenic Pain
The aim of this research is to find and compare the effect of traditional physical therapy and Cyriax manipulation on pain, range of motion and disability in patients with cervical discogenic pain. Randomized controlled trials done at Benazir Bhutto hospital, Rawalpindi . The sample size was 40. The subjects were divided in two groups, 20 subjects in traditional physical therapy group and 20 in Cyriax manipulation group. Study duration was of 6 months. Sampling technique applied was purposive non probability sampling technique. Only 25-45 years individual with cervical discogenic pain were included. Tools used in the study are Numeric pain rating scale (NPRS) and neck disablity index (NDI). Data was be analyzed through SPSS 21.
Cervical disc displacement is a significant cause of neck and arm pain and disability in
majority of individuals. It causes a great burden on physical, social and emotional quality
of life of patients. The cervical disc herniation is characterized by prolapsed nucleus
pulposus material through the annulus into the spinal canal. The local mechanical or chemical
irritation of neural structures typically leads to symptoms of radiculopathy, head and neck
pain or myelopathy. The disc bulge may be postero-central to compress the dura matter,
causing multi segmental pain and affect the scapular area. It can also be postero-lateral
causing the root signs, that have dermatomal behavior and affect the upper limb in specific
pattern. Postero-central bulge can also shift to postero-lateral with symptoms shifting from
centralization to radiculopathy.
The State of U.S. Health: Burden of Diseases, Injuries and Risk Factors describes cervical
pain among 5 most contributing factor in causing years lived in disability. the ratio
tremendously increases after 40 years. Studies describing impact of chronic neck pain on
general health care reveals 14% of patients reports grade II to grade IV neck pain with high
pain intensity and disability.
Disc displacement disorders are included among the mechanical causes of neck pain.
Symptomatic disc displacements can occur at any age but have different clinical features
depending on the age group. In young adults nucleus pulposus can involve which is rare in old
age. Diagnoses can be established on clinical findings along with patient's history and the
functional examination. Disc displacement can occur in postero-central and Postero- lateral
displacement. Movement of the disc posteriorly causes stress on the posterior longitudinal
ligament and also on the anterior part of the Dura mater. As a result of this the pain
travels in more than one segment with dural reference. Pain occurs in trapezius and scapular
area. This typical poster central displacement causes the pain symptoms centrally and
bilaterally. Poster lateral movement of disc tissue inserts force on the nerve root, which
causes a Segmental pain or root pain and Segmental paraesthesia. Disc displacement may be
primary or secondary. Secondary poster lateral displacement is more common type of
displacement. Patient previously having pain in different segments like neck, trapezius and
scapular region now feels pain in the upper limb area. It occurs due to the lateral shifting
of disc tissues.
The goal of treatment in discogenic problems is to stop the conflict between the displaced
disc material and affecting sensitive structure. Disc fragment may affect the Dura matter,
nerve roots and intervertebral joints. Manipulations and traction brings back the disc
material to its place. The choice depends on the displacement. Nuclear displacements are
treated by traction while annular ones are by manipulations. Injection usually is done to
help pain less spontaneous recovery. If there is too much postero-central displacement that
it compresses the spinal cord then surgery usually is done.
Physiotherapy Treatment protocol for cervical discogenic pain include muscle strengthening
and to relieve stress on muscles. Cyriax manipulation is a systematic technique of
manipulation for the disc prolapse. this study hypothesize that there is a difference between
the effects of traditional physical therapy and cyriax manipulation for the discogenic
problems. The objecvtive of this study is to find the effects of cyriax manipulation and to
compare it with traditional physical therapy treatment in patients with cervical discogenic
pain.
Literature review A systematic and evidence based search of relevant literature was performed
by utilizing PubMed and Google Scholar as search engines. Search term for the initial
literature review was discogenic pain, prevalence of neck pain, financial burden of
discogenic pain, causes of neck pain, pathophysiology of discogenic pain, treatment options
for discogenic pain, manipulation, cyriax manipulation, short term effects of manipulation.
The search was limited to papers in English preferably published since 2000 with full text
available. Different studies were available regarding cervical manipulation and its effects
but limited data was available regarding cyriax manipulation in recent years.
In 2004, previously concluded 33 high quality RCTs in a Cochrane review on mobilization and
manipulation of mechanical neck pain. There was strong evidence that mobilization or
manipulations when combined with exercises are beneficial for acute or chronic neck pain with
or without headache. 3 -11 sessions were compared against placebo.
In literature June 2004, worked to find best evidence in a systematic review on efficacy of
spinal manipulation and mobilization for low back pain and neck pain. They showed that there
is moderate evidence that spinal manipulative therapy for chronic neck pain is superior when
compared to physical therapy and family physician care.
Another randomized controlled trial to correlate the results of manual therapy,
physiotherapy, general practitioner care, placebo in treatment of persistent neck and back
pain. They took the patients well defined in sub-groups. Physiotherapy included exercises,
massage and modalities (heat, ultra-sound, short-wave diathermy). Manual therapy included
spine mobilization and manipulation. General practitioner provided analgesics, posture
correction, home exercises and bed rest. Placebo consisted of detuned shortwave diathermy and
ultra-sound for 10 mines.).Changes in severity of chief complain and functional limitation
was main outcome measured by blinded research assistant. Results shows that manual therapy is
significantly better than other sub-groups in chronic conditions younger than 40 years of
age.
In 2015, in a Cochrane systematic review on mobilization and manipulation on neck pain showed
immediate effects of a single manipulation on sub-acute to chronic neck pain. Multiple
sessions of cervical manipulations on acute and chronic neck pain produce immediate and long
term effects on the pain, function and quality of life.
Howe et al suggested that Manipulation produced a significant immediate improvement in
symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder,
and a nearly significant improvement in those with pain/paraesthesia in the arm/hand.
Study on the non-surgical treatment of cervical radiculopathy suggest manipulation to be very
effective and safe in reducing pain, hypo-mobility and disability.
Randomized clinical trial suggest in their current randomized clinical trial that cervical
and thoracic thrust manipulation induce similar changes in Pressure Pain Threshold,(PPT) neck
pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain.
The combination of manual therapy and manipulation provide better results than manual therapy
alone.
Compared intensive training, physiotherapy and manipulation for patients with chronic neck
pain after 6 months and 1 year follow up. They found that there was no significant difference
between the three treatments. They suggested that as it is not clear whether it is the result
of treatment or effect of time. Future studies are necessary to find out the exact treatment.
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