RAND Corporation, Santa Monica, CA.
Division of Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada.
Clin J Pain. 2020 Apr;36(4):273-280. doi: 10.1097/AJP.0000000000000800.
Cervical mobilization and manipulation are 2 therapies commonly used for chronic neck pain (CNP). However, safety, especially of cervical manipulation, is controversial. This study identifies the clinical scenarios for which an expert panel rated cervical mobilization and manipulation as appropriate and inappropriate.
An expert panel, following a well-validated modified-Delphi approach, used an evidence synthesis and clinical acumen to develop and then rate the appropriateness of cervical mobilization and manipulation for each of an exhaustive list of clinical scenarios for CNP. Key patient characteristics were identified using decision tree analysis (DTA).
Three hundred seventy-two clinical scenarios were defined and rated by an 11-member expert panel as to the appropriateness of cervical mobilization and manipulation. Across clinical scenarios more were rated inappropriate than appropriate for both therapies, and more scenarios were rated inappropriate for manipulation than mobilization. However, the number of patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included red flags (eg, fever, cancer, inflammatory arthritides, or vasculitides), and some others involving major neurological findings, especially if previous manual therapy was unfavorable, were rated as inappropriate for both cervical mobilization and manipulation. DTA also identified the absence of cervical disk herniation, stenosis, or foraminal osteophytosis on additional testing as the most important patient characteristic in predicting ratings of appropriate.
Clinical guidelines for CNP should include information on the clinical scenarios for which cervical mobilization and manipulation were found inappropriate, including those with red flags, and others involving major neurological findings if previous manual therapy was unfavorable.
颈椎推拿和手法治疗是两种常用于慢性颈痛（CNP）的疗法。然而，颈椎推拿的安全性，特别是其安全性，存在争议。本研究确定了专家组认为颈椎推拿和手法治疗适当和不适当的临床情况。
专家组采用经过充分验证的改良 Delphi 方法，利用证据综合和临床敏锐性，为 CNP 的详尽临床情况列表中的每一种情况制定并评估颈椎推拿和手法治疗的适当性。使用决策树分析（DTA）确定关键患者特征。
由 11 名成员组成的专家组定义了 372 种临床情况，并对颈椎推拿和手法治疗的适当性进行了评估。在所有临床情况下，对于两种治疗方法，被评估为不适当的情况多于适当的情况，对于手法治疗，不适当的情况多于推拿治疗。但是，目前还不知道每个场景中出现的患者数量。然而，DTA 表明，所有包含危险信号（例如发热、癌症、炎性关节炎或血管炎）的临床情况，以及涉及主要神经学发现的其他情况，特别是如果先前的手法治疗效果不佳，均被评估为颈椎推拿和手法治疗均不适当。DTA 还确定了在其他测试中不存在颈椎间盘突出、狭窄或椎间孔骨赘增生是预测适当评分的最重要患者特征。
CNP 的临床指南应包括颈椎推拿和手法治疗不适当的临床情况的信息，包括有危险信号的情况，以及如果先前的手法治疗效果不佳，涉及主要神经学发现的其他情况。
