Title: Change in Function, Pain and Quality of Life following Structured Nonoperative Treatment in Patients with Degenerative Cervical Myelopathy: A Systematic Review
Authors: Lindsay Tetreault1, Mohammed Shamji1, John Rhee2, Heidi Prather3, Jeff Wilson1, Ian B. Andersson4, Anna H. Dembek4, Krystle Pagarigan5, Joseph R. Dettori5, Michael G. Fehlings1
Affiliations: 1. Toronto Western Hospital, Toronto 2. Emory clinic, Atlanta 3. School of Medicine, Washington University at St. Louis 4. School of Physical Therapy, University of Puget Sound 5. Spectrum Research, Tacoma
Purpose: To perform a systematic review of the current literature to analyze (1) the change in pain, function, and quality of life resulting from structured nonoperative treatment for degenerative cervical myelopathy (DCM); (2) the variability of change in function, pain and quality of life after different nonoperative treatments; (3) the differences in outcomes observed among subgroups (i.e baseline severity score, duration of symptoms); and (4) negative outcomes and harms resulting from physical therapy intervention.
Materials and Methods: A systematic search was conducted in Embase, the Cochrane Collaboration, and PubMed for research published between January 1, 1950 and February 9, 2015. Articles were included if they evaluated outcomes related to structured nonoperative treatment, including manual therapy, therapeutic exercise, cervical bracing and/or traction. Outcomes of interest include functional status (Japanese Orthopedic Association (JOA), Nurick), upper extremity and neck pain, quality of life (Neck Disability Index), and/or surgical intervention. The quality of each study was assessed using the Newcaste-Ottawa Scale and the strength of evidence was rated using guidelines from the Grading of Recommendation Assessment, Development and Evaluation Working Group.
Results: Of the 570 citations, eight met the criteria for inclusion in this review. There is very low evidence implying that structured nonoperative treatment for DCM garners a positive or negative change in pain, function, and quality of life as interpreted by the JOA score. There is also limited evidence from three studies showing that early nonoperative treatment (symptoms <1 year) is associated with positive clinical outcomes. No studies directly compared structured nonoperative treatment types nor explored outcomes based on patient subgroups. The incidence of conversion to surgery ranged from 23-54%; primarily involving cases of mild or moderate myelopathy (JOA≥12).
Conclusion: There is a general lack of evidence to discern the role of nonoperative treatment for patients with DCM. In the majority of studies, however, patients did not achieve clinically significant gains in functional status with structured nonoperative treatment. Rates of failed conservative treatment among all included studies were between 23-54%.
Clinical Relevance: The role of structured nonoperative treatment for the management of DCM is not well defined, and the typical recommendation for patients with moderate to severe DCM is surgical intervention.
- Fehlings MG, Ibrahim A, Tetreault L, et al. A Global Perspective on the Outcomes of Surgical Decompression in Patients with Cervical Spondylotic Myelopathy: Results from the Prospective Multicenter AOSpine International Study on 479 patients. Spine. 2015.
- Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain : a journal of neurology. 1972;95(1):101-108.
- Nouri A, Tetreault L, Singh A, Karadimas SK, Fehlings MG. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine. 2015;40(12):E675-693.
Key Words: cervical myelopathy, degenerative myelopathy, nonsurgical management, nonoperative, conservative, physical therapy, manual therapy, therapeutic exercise, cervical traction, OPLL, spondylotic myelopathy, cervical stenosis
University of Puget Sound
Andersson, Ian and Dembek, Anna, "Change in Function, Pain and Quality of Life following Structured Nonoperative Treatment in Patients with Degenerative Cervical Myelopathy: A Systematic Review" (2016). Physical Therapy Research Symposium. 16.