I remember quite clearly back in the late 90’s when I was training to become a chiropractor that our instructors would tell us to be extremely cautious adjusting (manipulating) anyone with a suspected disc bulge. And the suggestion of adjusting a patients neck if they had a disc bulge with associated neurological findings (ie; skin, muscle or reflex changes) would send their sphincters into spasm.
But newly published research hot off the press, may allow for some less hypertonicity in my old lecturers perineum.
This new study was conducted on a relatively small population (n=50) all of who had to have an MRI confirmed disc herniation as well at least one neurological finding ie; sensory changes, motor changes or reflex changes corresponding to the nerve root involved on MRI, and at least 1 positive orthopaedic test for cervical radiculopathy. When I read this part of the paper, all I could think of was Dr. Allan Terrett going on about “myotomes, dermatomes, reflexes and nerve tensions signs”…….Ah, I miss Dr. Terrett and his funny myotome dances, stroke postures and cerebellar walks. But I digress.
The participants were divided into 2 groups. The first group (acute pain group) contained people whom had had pain for less than 4 weeks and the other group (subacute/chronic pain group) had pain for greater than 4 weeks (average 298 days). Each of the participants underwent between 3-5 neck manipulations over a period of 2-4 weeks. Baseline measurements for neck pain, arm pain and disability were taken, as were measurements at 2wks, 1mth and 3mths.
Both groups improved significantly in neck pain, arm pain and disability. Of the acute pain group, 93% rated their pain as ‘much better’ or ‘better’ and in the Subacute/Chronic pain group 76% rated their pain as ‘much better’ or ‘better’.
Interestingly, chronic neck pain is generally a particularly difficult issue to overcome. The authors note that another study that looked at treating subjects with cervical disc herniations with corticosteroid injections found that after 4 months, 25% of people had a reduction in pain levels. Although not directly comparable, the Subacute/Chronic pain group in this study who received manipulation did considerably better.
No adverse outcomes were reported in the study.
Of course there are some limitations to this study. No control group was used, meaning that some of the improvement in these patients may have been simply the ‘natural history’ of cervical disc herniation. That is, they were going to get better anyway, even without treatment. The authors do note, that very little is known about the natural history of cervical disc herniation. The authors also note that only one type of manipulative intervention was used, so the results may not be the same if different techniques are used. Luckily for us, they used a technique that is fairly widespread and taught at all universities in Australia. Because this is not a randomised, controlled trial and subjects were not blinded (that would be difficult given the type of procedure used) we can’t say for sure all the outcomes were directly related to the manipulation.
Still, I think this is an important study. A therapy, which would once have been avoided, may hold out some hope for patients suffering from neck pain and arm pain due to a cervical disc herniation.
Does this mean I will be cracking everyone’s neck who presents with a disc bulge, neurological deficits and positive nerve tension signs? I doubt it. But it does give me another option to discuss with patients who may not be improving as we’d like.