Cyriax Manipulation in Cervical Discogenic Pain
Condition: Cervical Discogenic Pain (Disorder)
Study type: Interventional

Summary: 
      The aim of this research is to find and compare the effect of traditional physical therapy
      and Cyriax manipulation on pain, range of motion and disability in patients with cervical
      discogenic pain. Randomized controlled trials done at Benazir Bhutto hospital, Rawalpindi .
      The sample size was 40. The subjects were divided in two groups, 20 subjects in traditional
      physical therapy group and 20 in Cyriax manipulation group. Study duration was of 6 months.
      Sampling technique applied was purposive non probability sampling technique. Only 25-45 years
      individual with cervical discogenic pain were included. Tools used in the study are Numeric
      pain rating scale (NPRS) and neck disablity index (NDI). Data was be analyzed through SPSS
      21.
    

Detailed description: 
      Cervical disc displacement is a significant cause of neck and arm pain and disability in
      majority of individuals. It causes a great burden on physical, social and emotional quality
      of life of patients. The cervical disc herniation is characterized by prolapsed nucleus
      pulposus material through the annulus into the spinal canal. The local mechanical or chemical
      irritation of neural structures typically leads to symptoms of radiculopathy, head and neck
      pain or myelopathy. The disc bulge may be postero-central to compress the dura matter,
      causing multi segmental pain and affect the scapular area. It can also be postero-lateral
      causing the root signs, that have dermatomal behavior and affect the upper limb in specific
      pattern. Postero-central bulge can also shift to postero-lateral with symptoms shifting from
      centralization to radiculopathy.

      The State of U.S. Health: Burden of Diseases, Injuries and Risk Factors describes cervical
      pain among 5 most contributing factor in causing years lived in disability. the ratio
      tremendously increases after 40 years. Studies describing impact of chronic neck pain on
      general health care reveals 14% of patients reports grade II to grade IV neck pain with high
      pain intensity and disability.

      Disc displacement disorders are included among the mechanical causes of neck pain.
      Symptomatic disc displacements can occur at any age but have different clinical features
      depending on the age group. In young adults nucleus pulposus can involve which is rare in old
      age. Diagnoses can be established on clinical findings along with patient's history and the
      functional examination. Disc displacement can occur in postero-central and Postero- lateral
      displacement. Movement of the disc posteriorly causes stress on the posterior longitudinal
      ligament and also on the anterior part of the Dura mater. As a result of this the pain
      travels in more than one segment with dural reference. Pain occurs in trapezius and scapular
      area. This typical poster central displacement causes the pain symptoms centrally and
      bilaterally. Poster lateral movement of disc tissue inserts force on the nerve root, which
      causes a Segmental pain or root pain and Segmental paraesthesia. Disc displacement may be
      primary or secondary. Secondary poster lateral displacement is more common type of
      displacement. Patient previously having pain in different segments like neck, trapezius and
      scapular region now feels pain in the upper limb area. It occurs due to the lateral shifting
      of disc tissues.

      The goal of treatment in discogenic problems is to stop the conflict between the displaced
      disc material and affecting sensitive structure. Disc fragment may affect the Dura matter,
      nerve roots and intervertebral joints. Manipulations and traction brings back the disc
      material to its place. The choice depends on the displacement. Nuclear displacements are
      treated by traction while annular ones are by manipulations. Injection usually is done to
      help pain less spontaneous recovery. If there is too much postero-central displacement that
      it compresses the spinal cord then surgery usually is done.

      Physiotherapy Treatment protocol for cervical discogenic pain include muscle strengthening
      and to relieve stress on muscles. Cyriax manipulation is a systematic technique of
      manipulation for the disc prolapse. this study hypothesize that there is a difference between
      the effects of traditional physical therapy and cyriax manipulation for the discogenic
      problems. The objecvtive of this study is to find the effects of cyriax manipulation and to
      compare it with traditional physical therapy treatment in patients with cervical discogenic
      pain.

      Literature review A systematic and evidence based search of relevant literature was performed
      by utilizing PubMed and Google Scholar as search engines. Search term for the initial
      literature review was discogenic pain, prevalence of neck pain, financial burden of
      discogenic pain, causes of neck pain, pathophysiology of discogenic pain, treatment options
      for discogenic pain, manipulation, cyriax manipulation, short term effects of manipulation.
      The search was limited to papers in English preferably published since 2000 with full text
      available. Different studies were available regarding cervical manipulation and its effects
      but limited data was available regarding cyriax manipulation in recent years.

      In 2004, previously concluded 33 high quality RCTs in a Cochrane review on mobilization and
      manipulation of mechanical neck pain. There was strong evidence that mobilization or
      manipulations when combined with exercises are beneficial for acute or chronic neck pain with
      or without headache. 3 -11 sessions were compared against placebo.

      In literature June 2004, worked to find best evidence in a systematic review on efficacy of
      spinal manipulation and mobilization for low back pain and neck pain. They showed that there
      is moderate evidence that spinal manipulative therapy for chronic neck pain is superior when
      compared to physical therapy and family physician care.

      Another randomized controlled trial to correlate the results of manual therapy,
      physiotherapy, general practitioner care, placebo in treatment of persistent neck and back
      pain. They took the patients well defined in sub-groups. Physiotherapy included exercises,
      massage and modalities (heat, ultra-sound, short-wave diathermy). Manual therapy included
      spine mobilization and manipulation. General practitioner provided analgesics, posture
      correction, home exercises and bed rest. Placebo consisted of detuned shortwave diathermy and
      ultra-sound for 10 mines.).Changes in severity of chief complain and functional limitation
      was main outcome measured by blinded research assistant. Results shows that manual therapy is
      significantly better than other sub-groups in chronic conditions younger than 40 years of
      age.

      In 2015, in a Cochrane systematic review on mobilization and manipulation on neck pain showed
      immediate effects of a single manipulation on sub-acute to chronic neck pain. Multiple
      sessions of cervical manipulations on acute and chronic neck pain produce immediate and long
      term effects on the pain, function and quality of life.

      Howe et al suggested that Manipulation produced a significant immediate improvement in
      symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder,
      and a nearly significant improvement in those with pain/paraesthesia in the arm/hand.

      Study on the non-surgical treatment of cervical radiculopathy suggest manipulation to be very
      effective and safe in reducing pain, hypo-mobility and disability.

      Randomized clinical trial suggest in their current randomized clinical trial that cervical
      and thoracic thrust manipulation induce similar changes in Pressure Pain Threshold,(PPT) neck
      pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain.

      The combination of manual therapy and manipulation provide better results than manual therapy
      alone.

      Compared intensive training, physiotherapy and manipulation for patients with chronic neck
      pain after 6 months and 1 year follow up. They found that there was no significant difference
      between the three treatments. They suggested that as it is not clear whether it is the result
      of treatment or effect of time. Future studies are necessary to find out the exact treatment.
    

Intervention name(s): Traditional physical therapy; Cyriax manipulation
Intervention type(s): Other; Other
Intervention description(s): Cervical isometrics 10 repetitions×1 set, 4 days/week and targeted muscle strechings (trapezius, scalenes and sternocleidomastoid) 10 repetitions×1 set, 4 days/week.
Total of 4 sessions were given each consisting of 40 mins.; Experimental group was given cyriax manipulation protocol along with the cervical isometrics and muscle strechings.
Traction with rotation was not given in cases of bilateral arm pain. cervical isometrics 10 repetitions×1 set, 4 days/week and targeted muscle strechings (trapezius, scalenes and sternocleidomastoid) 10 repetitions×1 set, 4 days/week.
Total of 4 sessions were given each consisting of 40 mins.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Cervical Discogenic pain; Cyriax manipulation; Neck Pain Disability index