Abstract. Introduction

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1 THE EFFECTIVENESS OF MANUAL PHYSICAL THERAPY IN THE TREATMENT OF SUB ACUTE AND CHRONIC CERVICAL SPINE PAIN Authors; Muhammad Shoaib, Muhammad Naveed Babur, Akhtar Rasul Abstract Objectives: To determine the effectiveness of manual therapy in neck pain and to contribute to physical therapy literature for new research. Neck pain is a common complaint with high prevalence and is sometimes associated with shoulder and / or headaches. To treat the neck pain various interventions are being used by physical therapists which may include electrotherapy, exercise therapy, neuromobilization, traction & manual therapy. Study Design: RCT (Randomized control trial) included forty patients in total who were divided into two groups of twenty patients in each, receiving manual therapy and electrical therapy evaluated by using patient orient primary outcome measures (Neck Disability Index). The Patients were selected at EERA (MRDEA) Centre, physical therapy and neurology department in Abbas Institute of medical science Muzafrabad, AJ&K, Pakistan. Methods: Forty patients suffering for at least 2 weeks from neck pain were randomized to receive a 6-week treatment strategy of manual therapy and electrotherapy three a week. The primary outcome measures were perceived recovery and functional disability. Results: In 6 weeks a considerable decrease in disability scores was observed for manual therapy treatment for all outcomes. The success rate, decrease in disability scores, based on perceived recovery was 29.5% for manual therapy including manipulation and mobilization, which is higher than successful rate for electrotherapy (23.9%). Manual therapy scored consistently better than electrotherapy as outcomes. Conclusion: The results suggested that the recommendations made with confidence regarding the use of manual therapy are good option for the management of neck pain. In Future similar trails should be examined for the value of manual therapy for neck pain Key words: Neck pain, manual therapy, effectiveness, electrotherapy, neck disability index, randomized control trail. Introduction Neck pain is a very widespread problem; next to low back pain in its frequency in the general population and in musculoskeletal practice [1]. Neck or cervical pain has a prevalence of 67% in young adults. Approximately 15% of females and 10% of males suffer from chronic neck pain at any one time in their life span [2]. 25% of Patients seen in outpatient physical therapy are referred for treatment for cervical pain [2]. Chronic neck pain produces a high level of morbidity by affecting occupational and vocational activities of daily living and by affecting quality of life. Non-specific neck pain, which could not be linked to prior injury or illness, was found to be the most frequent symptom in a broad survey of employees of the Finnish Broadcasting Company. The point prevalence for frequent or continuous neck pain was 38% [3]. Though this survey was not conducted in Pakistan but it shows the prevalence of non-specific neck pain. Neck pain may be highly disabling and costly, while little is known about its clinical course [4, 5]. Decreased range of motion and a subjective feeling of stiffness may accompany neck 10

2 pain, which is often provoked by neck movements or sustained neck postures. Headache, dizziness, and other signs and symptoms may also be present in combination with neck pain [6, 7]. Although history taking and diagnostic examination can suggest a potential cause, in most cases the pathologic basis for neck pain unclear and the pain labeled is nonspecific. At present, no classification criteria exist that are suitable for use in population-based studies in classifying neck pain, shoulder pain or cervical headache or in combination form. [8]. Neck and shoulder pain have been defined in different ways in different studies: ache, discomfort, stiffness, numbness, tenderness, and myalgia are examples of words used. The incidence of pain and its fluctuation, intensity and duration in one episode or repetition in different episodes, are other items in outcome measurements. The Pain affects a person s activities (personal or work). Different symptoms like pain ache and stiffness cannot be separated in terms of where they originate, so a separate anatomical description is necessary to the problem. One trouble in risk dimensions is that in the real world it is hard to talk about individual risk factors separately. Most risk factors are not isolated: they overlap and work together. The use of diverse definitions for similar risk factors and similar definitions for risk factors that are completely different are common in the literature [9]. The findings of studies on musculoskeletal disorders show that age is associated with the occurrence of musculoskeletal problems in different professional categories such as nursing staff, railway workers and miscellaneous occupations. [10, 11] Age is often understood to be correlated with musculoskeletal problems, such as physiological changes, for example decline in physical work capability, diminishing aerobic and musculoskeletal capacity. The variable age is also related to the number of years the workers spent in their work, and this increases exposure time to other probable possible risk factors. Although a little evidence has shown that musculoskeletal disorders and injuries, accidents, sickness and absences are more common among younger workers [11,12 ], In some of these studies prevalence has also been reported with a peak in mid- life. [12]. One reason for this may be that females have less muscle mass and strength than males. Gender has been considered in a number of studies as a possible risk factor for the development of general health problems and musculoskeletal disorders. Occupation has a great influence on the factors that can cause neck pain. Several studies show that the manual workers often have a higher incidence of neck and shoulder pain than office going. [10, 12]. Education may have a direct influence on healthrelated behavior: children who do well in education tend to report better behavior in adult life in terms of diet, smoking and exercise. A number of studies have indicated that the prevalence of back pain is associated with a low educational level [12]. The level of education may act as an indicator for other factors such as socio-economic status, occupational level or lifestyle. Stressful events elevate hyperventilation, reducing PCO2 in the arterial blood system. This phenomenon eventually leads to an increase in muscle ischemia and hypoxia. It also changes the potassium ions in the blood and upsets muscle function. According to this theory, the communication between sensory nerves and blood vessels dilate the blood vessels affecting the muscles and causing pain similar to hit of migraine. Various mechanisms have been described in this regard [13]. 11

3 Post trial scores and January-June 2012 International Journal of Rehabilitation Sciences (IJRS) Volume I, Issue I Long- term static load causes dysfunctions in the muscle spindle system, by enhancing activity in nerve cells [14]. According to this theory, prolonged head-down neck flexion and psychological stress decrease intracellular oxygen and nitric oxide elimination because of reducing capillary blood flow [15]. Materials and Methods This was a single blind clinical randomized controlled trail. The participants of the study were from the out patients of physical therapy department and referred indoor patients from neurology ward. The participants of the study were from both male and female sides with the age ranges from 20 to 60yrs. The duration of the study was three months. Total 40 patients were selected for this experimental study from AIMS Hospital AJ&K.20 patients were in controlled group and 20 in experimental group. Sample was drawn through simple randomized sampling. Patients with neck pain at least two weeks before the therapy, aged between 20 and 60 years were included. The patients had cervical surgery in the past, Pregnancy, Whiplash trauma were excluded Results The sample size was 40, 20 in control group and 20 in experimental group (control group had electrotherapy and experimental group manual therapy with their regular sessions).their progress was measured after six-week continuous manual therapy regime and electrical therapy. In the graph 1 and graph 2 it is clear that there is a considerable change in the NDI scores. There is a decrease in disability scores as a whole that is 593 to 298. The score difference is 295 five that is a considerable change. With this change the disability as a whole has been changed in the patients with manual therapy group. The decrease in the disability score in work is substantial for the person to go early to work. In the electrotherapy group the disability scores have also been decreased from 578 to 339 so the difference in disability is 239. The change is also good in 6 weeks with electro therapy. pretrial scores and Graph no. 1; Pretrial values for Group 1 Manual Therapy Graph no.2; Pretrial values for Group 2 Electrical therapy, Where series 1 are the NDI scores and series 2 are the NDI Group 1: Pretrial Graphical presentation of individual disability scores and No. of Participants Post-trial graphical presentation of scores and No. of Participants Pretest score Series1 Series2 Graph no.3; Post-trial values for Group 1 Manual Therapy, Where series 1 are the NDI scores and series 2 are the NDI 12

4 Post-trial scores and Post-trial graphical presentation of scores and Graph no.4; Post-trial values for Group 2 Electrotherapy, Where series 1 are the NDI scores and series 2 are the NDI. In the comparison the differences are not very much substantial but in the manual therapy group the rate of disability is decreased as a whole. In the manual therapy group, subjects went early in the work placement and also they went on the recreational activity. The subjects concerning with the desk job or the computer work have also more decrease in disability as compared with electrotherapy group. For the personal care again subjects in the manual therapy group have reduced disability as compared with electrotherapy. Pain is considered to be the most important factor, in both groups, it has been reduced but pain reduction in manual therapy group is more. Because the pain is the basic factor, the hinderance in all aspects of an activity and contribute more to the disability, so the subjects in the manual therapy show more reduction in the disability scale as compared to the subjects in the electrotherapy. No. of participants Series1 Series2 Total score of the group 1 before the manual therapy was 59.3% of the total disability scale and it was reduced to 29.8% after 6 weeks of manual therapy treatment with the follow up of three times per week. The difference achieved in reduction in disability score was 29.5%. Likewise the total score of group 2 before the treatment of electrotherapy was 57.8% and it reduced to 33.9% after electrotherapy treatment with the follow up three days per week. The difference achieved was 23.9% after 6 weeks. To check the difference between means of the total disability score of the two groups, the group 1 and group 2, student t test was applied as it is the most appropriate test. The confidence interval was set to be at 95% with 38 degree of freedom. The resultant value came out to be statistically 100% significant showing that the difference between means does exist. Group 1 corresponds to experimental group and group 2 corresponds to control group, receiving manual therapy and electrical therapy respectively. Discussion This was a comparative study of manual therapy and electrotherapy effectiveness in clinical practice cervical pain. It was found that manual therapy is more effective than electrotherapy, and the results consistently favored manual therapy on almost all out come measures. In addition, although manual therapy seemed to be more effective than electrotherapy, the differences were small for all outcome measures except perceived recovery. This is because perceived recovery combines other outcomes, such as pain, disability, and patient satisfaction; it may be a responsive outcome. The differences among groups in scores on NDI were small and are considered clinically important that is 56. In this issue, coworkers report the findings of RCT study examining the effectiveness of manual therapy, continuing care by a general practitioner with the patients of nonspecific neck pain that had been present for longer than 2 weeks. Manual therapy consisted of what authors name an eclectic mixture of coordination, stabilization, muscular and joint mobilization techniques. Physical therapy by other means primarily focused on active strength, ROM, stretching and electrotherapy. To prevent cross 13

5 contamination of interventions, physical therapy was administered by therapists. NDI assessments were taken and the success rate was 68.3% for those who received manual therapy, 50.8% for the participants who received physical therapy by other means and 35.9% by continued care. Referral for manual therapy appears to have the best outcomes. It seems that study has some deficiency for example success was on a multi factorial subjective scale. Because the study was not blinded so the patients can exaggerate the outcomes with the favor. Previous studies failed to show the significant differences between manual therapy and physical therapy by other means. But it is clear from the previous studies and the present study that manual therapy outcomes are better than the other forms of physical therapy. In the present study the outcome measures by manual therapy are: 30.85% decrease in disability scores and 18.1% decrease in disability scores by other means of physical therapy. The results are not extraordinary but it supports the results of Koes and colleagues (1991) who compared the effectiveness of manual therapy including manipulation and mobilization and physical therapy by other means [15]. This study confirms their study s findings that manual therapy is superior to physical therapy by other means. During the study it was also clear that the mobilization and manipulation, which are the passive components of the manual therapy are the main contrasts with the physical therapy by other means especially electrotherapy were considered the most important and effective components. When figured out from other studies the results of mobilization and manipulation are not very satisfactory for long term effects. There is a long list of studies that had been researched for neck pain manipulations and mobilizations for example Livingstone (1967), Lewit (1977), Schultz (1977), Vernone (1982), Droz and Krot (1985), Turk and Ratkolb (1987), Mennell (1990), Rundcrants (1991) and many more. The literature suggests that cervical spine manipulation and mobilization may affect for short-term relief with muscle tension headaches. [14] Although the differences are not large for all outcome measures, manual therapy seems to be an effective treatment option for cervical pain. It should be recognized that the data were collected at only one clinical site and by one physical therapist. Future studies are necessary to validate this study s results and determine whether similar findings occur in other patient population with different treating clinicians. Additionally, a validation study should include a long-term follow-up and a comparison group to further investigate the effectiveness of manual therapy in neck pain. If the manual therapy is validated, an impact analysis of application of the manual therapy on clinical practice patterns, outcomes, and costs of care should be investigated. Conclusion This study showed that the manual therapy methods especially manipulation and mobilization are effective treatment choices when compared with electrotherapy for the management of cervical pain either associated with headaches or radiation to arm. This study also observed the fact that both the treatment groups showed decrease in disability due to neck pain during the course of treatment but the manual therapy appeared to be a more effective treatment. References: 1. Jan Lucas Hoving, PT, PhD, Bart W. Koes, PhD, Henrica C.W. de Vet, PhD, Danielle A.W.M. van der Windt, PhD, Willem J.J. Assendelft, MD, PhD, 14

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