The effect of neural mobilisation on cervico-brachial pain

A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg 2017.Neck pain is one of the most common debilitating musculoskeletal complaints seen in physiotherapy practice. It is often associated with headache, upper back and shoulder/arm pain (cervico-brachial pain) and such patients are more disabled than patients with neck pain only. Cervico-brachial pain syndrome is an upper quarter pain syndrome in which neural tissue sensitivity to mechanical stimulus is thought to play a role. Neuropathic pain is a problem associated with and prevalent in neck and arm pain. Psychosocial factors, such as fear-avoidance beliefs and catastrophising, have been shown to play an important role in treatment outcomes. Neural mobilisation (NM) is often used to influence the neural structures in conditions with signs of neural involvement or neural mechano-sensitivity. It seems reasonable to use neural mobilisation in cervico-brachial pain as neural structures play an important role in this condition The optimal treatment intervention for cervico-brachial pain is yet to be established. The prevalence of cervico-brachial pain in a South African population is also unknown. Aims of the study The aims of the study were to: i. To establish the prevalence of cervico-brachial pain in patients being seen in physiotherapy practices in Pretoria, South Africa. ii. To establish the effect of neural mobilisation on the pain, function and quality of life of patients with acute and sub-acute cervico-brachial pain. iii. To establish the influence of high catastrophising scores and neuropathic pain on treatment outcomes. iv. To establish the effect of demographic factors on the pain, function and quality of life of patients with cervico-brachial pain. Methods Research Question 1. A retrospective survey of physiotherapy patient records dated 1 January 2011 to 31 December 2011 was conducted. The prevalence of patients with neck pain in relation to other musculoskeletal complaints was calculated and expressed as a percentage. Symptoms recorded included the following; headache, dizziness, pins and needles, feeling of weakness, other sensations, more than one symptom and pain in other area/s. Based on body charts, areas of pain were coded as neck pain only, pain in the shoulder, shoulder and upper arm, shoulder to elbow, lower arm, hand, neck and arm up to wrist, neck and arm including hand. Research Questions 2, 3 and 4 A single blind randomised clinical trial was conducted to establish the effect of neural mobilisation on cervico-brachial pain. The intervention group (IG) received cervical and thoracic mobilisation exercises, advice and NM. The usual care (UC) had the same treatment without NM. Outcomes were assessed at 3 weeks, 6 weeks, 6 months and 12 months. The Numerical Pain Rating Scale was used to determine the effect of NM on pain. The Patient Specific Functional Scale was used to determine the effect of NM on function and the EuroQual5 instrument was used to establish the effect of NM on the quality of life. At 6 weeks the Global Rating of Change was administered to measure patient’s perception of recovery. The Neuropathic Diagnostic Questionnaire (DN4) was used to classify patients with neuropathic pain and the Pain Catastrophising Scale to identify catastrophisers. Results and Discussion Prevalence of neck and radiating arm pain in physiotherapy private practice, Pretoria South Africa The prevalence of neck pain in private physiotherapy practices in Pretoria, SA is high (46.4% of the total musculoskeletal complaints) with radiating arm pain (52.2% of neck pain population) and pain in other areas (22.6% of neck pain population) being commonly associated with neck pain. Furthermore, other symptoms such as headache (25.4% of the neck pain population) and paraesthesia (11.2%) are also frequently present. Neck pain is multi-faceted and this has implications for its management. Future studies with a bigger, representative population sample are needed to establish the prevalence of neck pain in SA. The effect of neural mobilisation on cervico-brachial pain All patients improved significantly in terms of pain, function and quality of life over the 12-month period. However, the IG had significantly less pain than the UC group at 6 months (p=0.03 95% CI 0.96 - 2.03) and this difference was more pronounced in patients with neuropathic pain (IG 2.91 95%CI 1.74 - 4.08 and CG 5.5 95% CI 3.45 - 7.55 p=0.01). There were no significant differences between groups in terms of function or quality of life. Patients with neuropathic pain had significantly more pain at 6 months (positive neuropathic pain 3.71 95%CI 2.57 – 4.84; negative neuropathic pain 1.44 95% CI 0.93 – 1.96 p=0.0001) and 12 months (positive neuropathic pain 3.23 95% CI 1.74 – 4.71; negative neuropathic pain 1.38 95% CI 0.88 – 1.91 p=0.01) compared to those without neuropathic pain. At 12 months function was also negatively affected by the presence of neuropathic pain (positive neuropathic pain 23.91 95%CI 20.96 – 26.86; negative neuropathic pain 27.15 95% CI 25.95 – 28.36 p=0.04). It did not have an effect on quality of life. Catastrophisers had more pain at 6 months (catastrophisers 4.25 95% CI -1.90 – 10.40; non-catastrophisers 1.70 95% CI 1.22 – 2.17 p=0.02) and 12 months (catastrophisers 3.56 95% CI 1.10 – 6.02) compared to non-catastrophisers (1.47 95% CI 0.96 – 1.99 p=0.02). There was no difference in their function at any time, however at baseline they reported a lower quality of life (Catastrophisers 61.96 95% CI 52.04 – 71.87; non-catastrophisers 75.79 95% CI 71.91 – 79.66 p=0.002). Conclusion The addition of NM to cervical and thoracic mobilisation, exercises and advice to stay active, in the management of cervico-brachial pain, resulted in less pain at 6-month follow-up. For patients with neuropathic pain the positive effect was more pronounced. Adding NM as an adjunct to usual care is effective to improve pain for patients with cervico-brachial pain especially for those with a neuropathic pain component. The presence of neuropathic pain and catastrophising resulted in poor pain-related outcomes.MT201

Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review

PURPOSE: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use. DESIGN: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4(th) February 2021. PARTICIPANTS: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition. INTERVENTION: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored. METHOD: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach. RESULTS: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition. CONCLUSION: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12887-022-03781-6

Spinal manipulation and mobilisation in paediatrics–an international evidence-based position statement for physiotherapists

Introduction: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy–International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) &amp; International Organisation of Physiotherapists in Paediatrics (IOPTP)–to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (&lt;18 years) with varied musculoskeletal or non-musculoskeletal conditions. Method: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes). Results: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate. 1. It is not recommended to perform: • Spinal manipulation and mobilisation on infants. • Cervical and lumbar spine manipulation on children. •Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media. 2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising: • Spinal mobilisation and manipulation on adolescents; • Spinal mobilisation on children; or • Thoracic manipulation on children for neck-back pain only. 3. No high certainty evidence to recommend these interventions was available. Reports of mild to severe harms exist; however, risk rates could not be determined. Conclusion: Specific directives to guide physiotherapists’ clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.</p

Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists

Objective: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. Results: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included: Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels. Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic). Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels.Conclusion: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.</p

Perceived factors and barriers affecting physiotherapists’ decision to use spinal manipulation and mobilisation among infants, children, and adolescents: an international survey

Objective: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. Results: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist’s knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. Conclusion: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.</p

The effectiveness of neural mobilization for neuromusculoskeletal conditions: a systematic review and meta-analysis

STUDY DESIGN: Systematic review with meta-Analysis. OBJECTIVES: To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. BACKGROUND: Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. METHODS: A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-Analysis, with pain, disability, and function as the primary outcomes. RESULTS: Forty studies were included in this review, of which 17 had a low risk of bias. Meta-Analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01;

Psychometric Properties of Outcome Measures Used to Determine Effects of Spinal Mobilizations and Manipulation in a Pediatric Population: A Systematic Review

This review will aim to summarise and critically appraise the psychometric properties of the objective measurements used to evaluate the effectiveness of spinal manipulation and mobilisations in children as determined in the scoping review “Spinal manipulation and mobilisations in the treatment of infants, children and adolescents: a scoping review protocol” (Milne et al, 2020). This project has been planned as a joint project between IFOMPT (International Federation of Orthopedic Manipulative Physical Therapists) and IOPTP (International Organisation of Physical Therapists in Paediatrics). It will explore the findings from empirical research and reviews as part of the review

Psychometric measurement properties of patient-reported and observer-reported outcome measures for spinal mobilisations and manipulation on paediatric subjects with diverse medical conditions: A systematic review

Introduction: Reliable, valid, and responsive outcomes is foundational to address concerns about the risks and benefits of performing spinal manipulation and mobilization in pediatric populations. The aim of this systematic review was to synthesize evidence on measurement properties from cohort/case-control/cross-sectional/randomized studies on patient-reported (SQLI–Scoliosis Quality of Life Index; VAS-Visual Analog Scale; PAQLQ–Pediatric Asthma Quality of Life Questionnaire), observer-reported (Crying Diaries; ATEC–Autism Treatment Evaluation Checklist) and mixed (PedsQL–Pediatric Quality of Life Inventory) outcome measurements identified through a scoping review on manipulation and mobilization for pediatric populations with diverse medical conditions. Method and Analysis:Electronic databases, clinicaltrial.gov and Ebsco Open Dissertations were searched up to 21 October 202221 October 2022. Two independent reviewers selected studies, extracted data, and assessed risk of bias. Qualitative synthesis was performed using COSMIN and Cochrane GRADE methodology to establish the certainty of evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), indeterminate (?). Results: Eighteen studies (2 SQLI for scoliosis; 1 VAS–perceived influence of exertion or movement/position on low back problems; 1 PAQLQ for asthma; 1 Crying Diaries for infantile colic; 8 ATEC for autism; 5 PedsQL for cerebral palsy/scoliosis/healthy) with 9653 participants were selected. ATEC and PedsQL had overall sufficient (+) measurement properties with moderate certainty evidence. PAQLQ had indeterminate measurement properties with moderate certainty evidence. Very low certainty of evidence identified measurement properties to be indeterminate (?) for SQLI, Crying Diaries, and VAS- perceived influence of exertion or movement/position on low back problems. Conclusion: ATEC for autism and PedsQL for asthma may be a suitable clinical outcome assessment (COA); additional validation studies on responsiveness and the minimal important difference are needed. Other COA require further validation.</p