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Clinical Kit 15-1-2015 All for One and One for All?

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Study identifies best way to treat neck pain Johns Hopkins Medicine, 24/1/2014
(based on the study – Cohen et al. Epidural Steroid Injections, Conservative Treatment, or Combination Treatment for Cervical Radicular Pain - A Multicenter, Randomized, Comparative-effectiveness Study. Anesthesiology (2014); 121:1045-55

Clinicians need to be able to see through the sensationalism of research!

Commentary by Dr. Shaun O’Leary FACP APAM

It’s always useful to read a bit more in depth when claims are made in the media regarding new “best ways” of managing health conditions . If one was to quickly scan the title and content of this article summary in MDLinx Orthopaedics, they could be mistaken that a new best approach has been developed for the management of neck pain. This is an interesting article, however it highlights the need to check out the original paper before making conclusions.

Firstly, when reviewing the article its actually not about neck pain in general, but rather a specific classification of neck pain, that being cervical radiculopathy. This is important because current emphasis is on correctly classifying different types of musculoskeletal conditions previously lumped together under the one term (i.e. low back pain, neck pain). This emphasis on classification is necessary to acknowledge that these conditions are not homogenous, but rather include a range of different conditions that may manifest as some similar clinical symptoms, but require different management approaches.

In this current example, the patients in this study have a “specific” neck disorder. The inclusion criteria necessitated the presence of cervical radicular arm pain of ≥4/10 severity as well as magnetic resonance imaging correlation of symptoms with pathology. That is, inclusion into this study required the individual be able to be diagnosed with a specific pathoanatomical diagnosis that justified their symptoms (i.e. cervical spine pathology with neural irritation/compromise) and justified the main studied intervention; epidural steroid injection. This is in stark contrast to the majority of neck pain patients that will enter your practice who can mostly be categorised as “non-specific” or “mechanical neck pain” of idiopathic origin. These diagnostic labels are given to disorders where current imaging techniques fail to identify a relevant lesion in the cervical structures, onset is not related to a motor vehicle crash (i.e. not a whiplash associated disorder), a cervical radiculopathy is not present and there is no evidence that neck pain comes from a non-musculoskeletal cause. [1] Over 80% of individuals with neck pain fall into this category. Treatments are therefore not able to be reliably targeted towards specific pathoanatomical causes but rather we are starting to explore other avenues of guiding management of non-specific musculoskeletal conditions such as classification systems based on movement disorders to name one. The case in point here, is that unless the original article is studied one could be easily mislead that this study can be extrapolated to neck pain sufferers in general, instead of the much smaller proportion of patients to which it actually applies.

Secondly, you can’t help get the feeling that the Physical Therapy (PT) intervention was a bit underrepresented in this study. The study stated that PT treatments could include education (good), electrical stimulation (questionable), ultrasound (questionable), massage (questionable), and exercise (good)”. No mention of the addition of manual therapy (e.g. mobilisation, neural mobilisation) despite some systematic review evidence suggesting the potential benefits for these conditions [2,3]. Anyhow that’s what happens when you don’t include a physical therapist on the investigator team!

Overall the authors conclude, “For the primary outcome measure (arm pain), no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures.” Not terribly convincing, given the media title would suggest, but I will let you read the article and decide for yourself how meaningful these differences are to your practice.

References

  1. Australian. AMPGG. Evidence Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press, 2004.
  2. Salt et al. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Therapy 2011; 16:53–65
  3. Allison et al., 2002 A randomised clinical trial of manual therapy for cervicobrachial pain syndrome. Manual Therapy, 7 (2) 2002; 95–102

Integrated Solutions for Head & Neck Pain - Dr. Shaun O'Leary FACP

In W.A. we are very fortunate to have Dr. O'Leary offer to come across and present his course in May that looks at assessment and treatment through clinical reasoning of head, neck and upper thoracic spine. Shaun in addition to completing his PhD in this area and lecturing at UQ, has completed his specialisation in musculoskeletal physiotherapy. Shaun brings a unique balance of inquiring clinician and experienced researcher. Shaun presents this course around the world and I thank him for being available to present in Perth in 2015.

All the best,



Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

email: doug@aapeducation.com.au

ph/fx: 08 90715055


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