Cyriax Manipulation in Cervical Discogenic Pain

Study Overview
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Brief Summary
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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
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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.

Official Title
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Effects of Cyriax Manipulation in Cervical Discogenic Pain

Conditions
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Cervical Discogenic Pain (Disorder)

Intervention / Treatment
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* Other: Traditional physical therapy
* Other: Cyriax manipulation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosed and confirmed cases of cervical disco genic pain by Weiner's criteria and Cyriax clinical assessment, Discogenic cases with pain either in cervico-scapular area, radiating to arm without any neurological symptoms were the main objects of study. Exclusion Criteria: Patients have vertebrobasilar insufficiency (tested by VBI tests), Altanto axial instability (tested by sharp purser test), Osteoporosis, Rheumatoid arthritis, Neuropathies, Recent surgeries and neuropathies were excluded from study.

Ages Eligible for Study
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Minimum Age: 25 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Traditional physical therapy<br>Cervical isometrics and Muscle Stretching | Other: Traditional physical therapy<br>* 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.<br>|
| Experimental: Cyriax manipulation<br>Experimental group was given cyriax manipulation protocol along with the cervical isometrics and muscle stretching. | Other: Cyriax manipulation<br>* 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.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Neck disability index | Changes from base line Northwick disability index was developed first in Northwick Park hospital, England. It was designed to measure the neck pain and disability over time. It consists of 10, five parts sections. At the end, score is calculated by dividing the obtained score by total (50) multiplied by 100. As the driving section was missing in all the female patients, total score was considered as 45 instead of 50. | 4th Day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| NPRS | Changes from base Line Numeric Pain rating scale is a scale for pain starting from 0-10. where 0 indicate no pain and 10 indicate severe pain. | 4th Day | 
| ROM Cervical Spine ( Flexion) | Changes from the Baseline ROM range of Motion of Cervical spine flexion was taken with the Help of Goniometer | 4th Day | 
| ROM Cervical Spine ( extension) | Changes from the Baseline ROM range of Motion of Cervical spine extension was taken with the Help of Goniometer | 4th Day | 
| ROM Cervical Spine ( Right side flexion) | Changes from the Baseline ROM range of Motion of Cervical spine right side flexion was taken with the Help of Goniometer | 4th Day | 
| ROM Cervical Spine ( left side Flexion) | Changes from the Baseline ROM range of Motion of Cervical spine left side flexion was taken with the Help of Goniometer | 4th Day | 
| ROM Cervical Spine ( right rotation) | Changes from the Baseline ROM range of Motion of Cervical spine right rotation was taken with the Help of Goniometer | 4th Day | 
| ROM Cervical Spine ( left rotation) | Changes from the Baseline ROM range of Motion of Cervical spine left rotation was taken with the Help of Goniometer | 4th Day | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Cervical Discogenic pain, Cyriax manipulation, Neck Pain Disability index