Literature Review One

Summary and Perspective of Recent Literature

Celia Monk, PT, Dip. MDT

Objective:

To summarise the recommended non-surgical treatment for patients with neck pain and/or radiculopathy of less than 12 weeks’ duration.

Design:

Two work groups performed systematic reviews and meta-analyses to answer clinical questions about the effectiveness of non-surgical treatment as represented in the literature. The subsequent report presented recommendations based on clinical evidence as well as patient preferences.

Setting:

The guidelines were funded for by the Danish Health Authority and the authors were from Universities and Health Institutions throughout Denmark.

Patients:

The target population for the systematic reviews search were patients older than 18 years of age with non-specific neck pain with/without arm pain of less than 12 weeks duration, or with clinical presentation of Cervical Radiculopathy of up to 12 weeks duration.

Main Outcome Measures:

The guidelines were developed around 19 clinical questions with primary outcomes of pain and pain-related activity limitations.

Secondary outcomes included worsening of neurological symptoms, pain at the end of treatment, dropout rates, surgery during the following year, adverse effects, return to work, sick leave, and quality of life.

Main Results:

Weak or good clinical practice recommendations were given for patients with neck pain and/or radiculopathy for:

  • Information and patient education
  • Advice to stay physically active
  • Different types of supervised exercise
  • Manual therapy alone or in combination with exercise

Weak recommendations were given against massage.

The recommendation for medication was to only use NSAID or tramadol for short-term use of severe, acute pain after careful consideration and not as the first choice.

In patients with neck pain (with or without somatic referred arm pain) the guideline recommends weakly for:

  • Acupuncture
  • Topical NSAID
  • Exercise over NSAID

In patients with cervical radiculopathy there is a weak recommendation for traction and against acupuncture.

The work group recommended that the choice of any treatment should be done in consideration of patient preferences and the amount and intensity of treatment should be proportionate with the duration and level of pain and disability.

Conclusions:

The recommendations presented by the guidelines are based on weak evidence or general consensus as there is a lack of good-quality research available for this topic.

Comments:

This paper again highlights the lack of evidence in the literature for many non-surgical treatment approaches for neck pain and radiculopathy. Interestingly, the author’s comment that there were no trials within their search parameters proving the effectiveness of directional exercise for cervical radiculopathy and that patients may find the exercises difficult to perform and to adjust to any worsening of symptoms. However, they do recommend the use of directional exercises due to the low risk of harm and the active patient approach. As MDT clinicians we have the responsibility to ensure our patients know exactly why they are doing any exercise and exactly how to perform it, and to adjust to any change in symptoms they may experience. We also have the responsibility to help increase the body of evidence of the effectiveness of directional exercises.

The four good clinical practice recommendations given for treatment of patients with neck pain and/or radiculopathy all reflect the mainstays of MDT: patient education, specific exercises, manual therapy when indicated, and staying active. That is very encouraging news for us as clinicians and for our patients. In their discussion, the authors state, “The informed clinician should choose an intervention in recognition of how different choices may be appropriate for different patients and that each management decision is consistent with the patients’ values or preferences.” It is important that as MDT clinicians we recognise one of the strengths of our system is that individual approach. Each decision we make as part of the clinical reasoning process should be based on the needs, values, and preferences of each of our patients.

An encouraging aspect of this paper is that all the recommendations are based on active treatment, demonstrating the international preference now for patient self-management and self-responsibility. Again, this is one of the founding principles of MDT and proves that not only is MDT still highly relevant, but its principles are recommended in the non-surgical treatment of recent onset neck pain and/or radiculopathy.

https://link.springer.com/article/10.1007/s00586-017-5121-8