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13-03-2013 | Pain medicine | Article

Manipulative therapy for neck pain lacks clinical criteria


Free abstract

medwireNews: A systematic review of randomized controlled trials (RCTs) has found an absence of reliable and valid diagnostic criteria for determining the need for spinal manipulation in patients with non-serious, idiopathic, or whiplash-associated neck pain.

The researchers who conducted the review stress the need for a "clear diagnostic rational[e] for considering a patient for cervical spine manipulation."

A comprehensive understanding of such diagnostic criteria is important "if prudent referral and case management is to be achieved by pain physicians and others who might consider manipulation as a treatment for neck pain," they add.

Of 30 RCTs reviewed, 63% used clinical criteria to determine the need for neck manipulation. In most cases, such criteria included tenderness on palpation or altered vertebral mobility in the neck or upper thoracic region, which Josephine Smith and Philip Bolton, from the University of Newcastle in Australia, note are known to lack validity.

Thirty percent of the remaining RCTs did not report a diagnostic strategy, while three did not specify the criteria, but reported that the need for manual therapy was determined by the treating clinician.

"This is concerning," they say, "as available literature casts doubt on both the reliability and validity of manual diagnosis."

The researchers write in Pain Medicine: "Most of the studies reviewed performed manipulation simply on the basis of a complaint of neck pain," the researchers write in Pain Medicine.

Acute and chronic "mechanical" neck pain was the most common diagnosis at study enrollment (43%), while 10% of studies reported a primary diagnosis of cervicogenic headache.

They also looked for evidence in the studies of a change in diagnostic signs following treatment as a possible indication of a manipulable lesion, but found that none of the studies provided such evidence."Implicitly, either the signs did not change or they were not tested," the authors report.

"Future studies of treatment should use inclusion criteria that have been shown to be reliable and valid; and they should show that relief of pain is associated with normalization of the clinical signs used to detect the manipulable lesion," the researchers highlight.

"However, until that is done, referring patients for manipulative therapy does not serve to address an elusive cause of pain but rather is simply transferring the care of a person with neck pain."

By Lucy Piper, Senior medwireNews Reporter