Cervical radiculopathy is a common condition that is usually due to compression or injury to a nerve root by a herniated disc or other degenerative changes of the upper spine. The C5 to T1 levels are the most commonly affected. In such cases local and radiating pains, often with neurological deficits, are the most prominent symptoms. Treatment of this condition is often difficult.
The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR).
MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO were searched from inception to June 15, 2022, to identify studies that were randomized clinical trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.
Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. The results show very-low certainty evidence supporting the use of
- acupuncture,
- prednisolone,
- cervical manipulation,
- low-level laser therapy
for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term.
There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.
The authors concluded that there is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.
The fact that we cannot offer a truly effective therapy for CR has long been known – except, of course, to chiropractors, acupuncturists, osteopaths, and other SCAM providers who offer their services as though they are a sure solution. Sometimes, their treatments seem to work; but this could be just because the symptoms of CR can improve spontaneously, unrelated to any intervention.
The question thus arises what should these often badly suffering patients do if spontaneous remission does not occur? As an answer, let me quote from another recent systematic review of the subject: The 6 included studies that had low risk of bias, providing high-quality evidence for the surgical efficacy of Cervical Spondylotic Radiculopathy. The evidence indicates that surgical treatment is better than conservative treatment … and superior to conservative treatment in less than one year.
59 Responses to What Works Best For Cervical Radiculopathy?
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Pillows.
I used to suffer this regularly. Like many people, I only had one pillow and had restless sleep capped off by radiculopathy. At 189 cm, one pillow wasn’t the answer, so I added two more so my neck was horizontal.
Voila, gawn (sic), no pain since. I suspect many would find relief by finding the optimal pillow height.
Frank- perhaps Edzard would like a clinical trial of your anecdotal experience since he has little or no confidence in such tales since they do not represent ‘evidence’!
In the absence of evidence, we might use things like plausibility and common sense. In any case, you are quite wrong about the lack of evidence; there is more than you might think, e.g.: https://pubmed.ncbi.nlm.nih.gov/33895703/
So!
New pillows designs are Alternative Medicine 👌
Better than surgery ans opioids
I may suggest soft streching & breathing technics for daily relief
(Evidence based solutions)
“New pillows designs are Alternative Medicine”
I DID NOT SAY THAT
“Better than surgery anD opioids”
I DID NOT SAY THAT EITHER
“I may suggest soft stretching & breathing technics for daily relief”
SUGGESTIONS ARE FINE, EVIDENCE WOULD BE BETTER
Edzard- the references are excellent. I of course made no such claim as there being no evidence. What might be common sense to one person may not be so for another. The anecdote is evidence but of a low quality on a spectrum of evidences ( but in this case a good start). There are numerous examples where the anecdote has resulted, after research, into positive general advancements. They should not be so easily dismissed as is common on this blog on many occasions..
who dismisses the importance of anecdotes? Not I! They are however no evidence; they can sometimes lead to formulating a hypothesis that needs testing and subsequently might become evidence.
Edzard- I agree with what you say.. We differ slightly on what we mean by evidence. There were many anecdotes , in various parts of the world including Great Britain, relating that infection with cowpox could result in a level of immunity against smallpox. In hindsight perhaps , after Jenner experimented the anecdotes , in my view, were a low level of evidence of the efficacy of the cowpox’s infection being preventive of smallpox. As you say , it needed further, more substantial evidence from experimentation to establish a treatment for large numbers of people. Our difference seems a matter of semantics.
I don’t think that historic examples are helpful here.
we were discussing the value of anecdote in the age of EBM, I thought.
Edzard- the principle about anecdotal stories has not changed throughout history. Some may have benefit and result in say medical treatments others fail miserably There are many anecdotal stories among the ancients or ‘ modern’ tribes , say in the Amazon, or China about the benefits of plant materials for treatment of some human ailments . I think that ‘big pharma, is continually investigating many of these plant materials and sometimes finding ingredients that can be isolated, concentrated or manipulated and utilised for the treatment of human disease. The concept of science based medicine incorporates EBM and is a superior and more useful concept. To ignore or reject examples from the history of the development of medicine when considering some of the present day concepts and treatments, in my opinion, is a mistake. When Salk first injected his vaccine into family members , with positive results, his work was considered by many others working in the field as anecdotal until such time as the largest ever clinical trial was conducted . I don’t see how it is possible to claim that his first results were not evidence of some efficacy of his vaccine.
I said value, not principle.
“There are many anecdotal stories among the ancients or ‘ modern’ tribes , say in the Amazon, or China about the benefits of plant materials for treatment of some human ailments . I think that ‘big pharma, is continually investigating many of these plant materials and sometimes finding ingredients that can be isolated, concentrated or manipulated and utilised for the treatment of human disease.”
PRECISELY!
Anecdotes are no longer the starting point for clinical use; they are the starting point for further investigation.
Edzard- agreed- but the anecdote may be the very start of a scientific investigation as may be a formulated hypothesis, of which clinical use will probably be a near end result of such investigations. I don’t think we are disagreeing on much. It’s to do with the philosophy of science of which much has been written I know you will agree that the science doesn’t start with the clinical trial although it is potentially the most powerful tool in establishing efficacy of treatments.
“I know you will agree that the science doesn’t start with the clinical trial although it is potentially the most powerful tool in establishing efficacy of treatments.”
No, it isn’t. An RCT can be used to indicate an effect size, but an RCT should never be used to determine whether or not an intervention is efficacious. E.g. multiple trials of an ineffective treatment will give some/many positive results, but they will all be false positives, irrespective of the p‑value.
See:
https://en.m.wikipedia.org/wiki/Misuse_of_p-values
especially the reference:
Colquhoun D (November 2014). “An investigation of the false discovery rate and the misinterpretation of p-values”. Royal Society Open Science. 1 (3): 140216
Pete Atkins- thanks for that correction and clarification . Please inform me of the most reliable testing methods ( if not the RCT) that can conclude that a treatment is efficacious or better than another. Whatever it is ( or they are) I’ll wager it doesn’t change my view( although I will not be dogmatic about that) of the anecdote being at the very beginning ( or near to ) the start of the science involved in establishing treatments.
Peter Atkins- having delved a little deeper, this is from the NIH(gov):
RCTs are prospective studies that measure the effectiveness of a new intervention or treatment…..provides a rigorous tool to examine cause-effect relationships between an intervention and outcome. I see nothing in your very comprehensive reference that contradicts this – just the misuse of data.
Leonard Sugarman,
I’m not the slightest bit interested in changing your view, I simply pointed out that your statement[*] was incorrect.
1. An RCT tells us very little.
2. Multiple replications of said RCT, if properly executed, tell us useful things.
3. Systematic reviews (especially Cochrane reviews) tell us a great deal more.
[*]. “I know you will agree that the science doesn’t start with the clinical trial although it is potentially the most powerful tool in establishing efficacy of treatments.”
See also
https://en.m.wikipedia.org/wiki/Replication_(statistics)
https://en.m.wikipedia.org/wiki/Systematic_review
https://en.m.wikipedia.org/wiki/Cochrane_(organisation)
https://edzardernst.com/2018/07/non-reproducible-single-occurrences-are-of-no-significance-to-science-the-example-of-the-homeopathic-diarrhoea-trials/
Peter Attkins-Your view that RCTs tell us very little may or may not be correct depending on the nature and quality of the trial . The one off large scale RCT for Salk’s polio vaccine was deemed to convey a great deal of information and the efficacy of the vaccine , enough to convince
the associated experts, pharmaceutical companies and their paymasters to go into it’s production on a large scale and vaccinate many thousands of people with a great measure of success. Of course you are correct that further studies and reviews will improve the data, improve the science and can modify the use of an already efficacious treatment. The NIH consider the blinded RCT as a gold standard method for ascertaining cause and effect ( as do other authorities) and with which I have to agree, especially since they are experts in the field.. So we’ll agree to differ on it’s potential value. None of your exposition on repetition, reproducibility etc changes this fact of the immense value of the well conducted trial although it is not at the apex of the scientific endeavour but does reside close by.
Leonard Sugarman,
Your original statement, as written, was erroneous. That is all.
You can’t even be bothered to write my name consistently, let alone correctly. Good day to you.
Peter Attkins- I apologise for only just recognising the correct spelling of your name. Although you have elaborated and expanded on various aspects of scientific procedures and requirements which I felt no need to do , although quite familiar with most all to which you refer, you have not shown in any valid way that I wrote something in error: in fact the very opposite since you are in error stating that little of value can be obtained from an RCT and is considered , by those who ‘know’ that it can be a very powerful and informative tool. Even Edzard refers to them very frequently often to show that the trial has displayed no efficacy whatever in the proposed treatment. Since you do not want to engage further I’ll reciprocate with ‘have a good day’.
“Even Edzard refers to them very frequently often to show that the trial has displayed no efficacy whatever in the proposed treatment.”
1) I refer to RCTs usually in terms of effectiveness, not efficacy.
2) I regularly stress that one RCT might mislead us and we thus need systematic reviews of the totality of the reliable evidence.
Edzard-you may use the word effectiveness rather than efficacious but I’ll let you try and parse the difference since I see none of any substance. I have said all along I agree with further reviews and studies to improve on any single RCT result . How could it be otherwise? The well conducted blinded RCT hopefully will produce results that don’t mislead even though further studies and reviews are essential. Without wishing to disturb you with some old study ( 1950s) I think the polio vaccine is a good illustration. After the trial did the result publicised extensively, world wide, show that the vaccine was effective or efficacious or both? Take your pick. The answer is obvious!
” I see none of any substance.”
There is a big difference!
Look it up
Edzard- thanks for that instruction. I need pushing sometimes. Using the Concise Oxford Dictionary;
Effective -having a definite or desired effect
Efficacious-producing or sure to produce the desired effect.
It’s a matter of preference, which word to use but there is no obvious difference. Perhaps ‘effective’ is less ‘posh’; you know- more down to earth. Your desire or determination to add a corrective to my contribution is falling flat. When I am shown to be wrong or ignorant i have no hesitation in conceding and relearning since we are all hugely ignorant in the vast expanse of human knowledge.
The Oxford Dictionary does not define it as used specifically in medicine.
In medicine, effectiveness relates to how well a treatment works in practice under real-life conditions, as opposed to efficacy, which measures how well it works under optimal conditions.
There are many treatments that are efficacious but not effective!
Edzard- you have clarified something I was not aware of. So effectiveness cannot be measured in controlled clinical trials but efficacy can since it only assesses ‘can a treatment work?’ So nobody reading a scientific report of an RCT only can determine from this report if it is effective only if it has efficacy. Is this correct?
both can be tested in RCT; but the boundary conditions of efficacy trials differ from those of effectiveness studies.
Edzard- if effectiveness involves qualitative assessments, which can be loaded with bias, how can this be incorporated into a blinded RCT? Thanks for your efforts with me.
effectiveness does not normally involve qualitative assessments
Edzard- If effectiveness is a description and assessment of what occurs in the normal everyday clinical setting I cannot envisage being able to exclude qualitative judgements. We’ll leave it here but you have given me a stimulus for further study.
depends on what you understand by it.
qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences; and these are not necessary [and rarely used] for RCTs testing effectiveness.
Edzard- doesn’t the quantitative data off the measure of effectiveness emerge from questioning the patients ,with all the variables involved in a normal clinical setting. Is this not loaded with bias from clinician and patient?
the primary outcome of an effectiveness RCT could be subjective, e.g. pain; or objective, e.g. survival
Edzard- let this be my last question(s)/ problem for the time being. By definition ‘effectiveness’ is an outcome that is established in a normal clinical setting- ordinary circumstances. It seems contradictory that ‘effectiveness’ can be established in a RCT ( very much not ‘normal’/ordinary ) setting which produces the result of ‘efficacy’. There seems some very muddy water here. Is there universal medical acceptance of these definitions of efficacy and effectiveness and how they are established?
in fact, there is a continuum between the two: rarely is one study totally this or than; most studies are between the extremes and just a bit more on one side of the continuum.
Edzard- thanks for your input. I have now collected some papers on the subject and will go away and learn some more
“Peter Attkins- I apologise for only just recognising the correct spelling of your name.”
P E T E
What a doofus.
Pete- thanks for that kind comment.
“When I am shown to be wrong or ignorant i have no hesitation in conceding and relearning since we are all hugely ignorant in the vast expanse of human knowledge.”
Abject BS.
Pete Attkins-I have to thank you again for your precise and insightful comment.
From the surgery comparison paper:
“…we think that surgery is not necessary for patients who do not need rapid pain relief.”
From my post:
” the symptoms of CR can improve spontaneously, unrelated to any intervention.”
Sure. But what is the goal of the intervention?
Is it to provide some increased function and comfort while the condition spontaneously resolves?
Isn’t that the purpose of medications?
“Of the non-narcotic medications, non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of management. NSAIDs have both analgesic and anti-inflammatory effects [21] and provide relief by targeting the inflammatory cascade at the nerve roots.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958381/
you lost me
If CR spontaneously resolves in most cases, why do anything, like give medications?
who said MOST cases?
symptomatic treatment!
“Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks. [9][10][11].”
https://www.ncbi.nlm.nih.gov/books/NBK441828/
@DC
Exactly !
“Is it to provide some increased function and comfort while the condition spontaneously resolves?
Isn’t that the purpose of medications ?”
The MD writes a prescription that will affect the patient in one of four ways.
1- A placebo effect
2- A benefit that is that addresses the cause of the dis-ease.(In most cases only with repeated medication)
3- An effect that treats the symptoms of the dis-ease.
4- No beneficial effect.
Severe chronic illnesses aside, time is the best friend of the MD (or quack), because there is a good chance that the condition spontaneously resolves itself at any time. How great is THAT !
“Doc” RG,
Would you go see a MD/!quack in the event you are afflicted with severe chronic dumb-assery or is the condition self-limiting and a visit is not necessary?
It took a year and days of ending in the fetal position with pain to get relief. My right arm started feeling strange and the pain was in my jaw, shoulder, arm, and wrapped up behind my head. Finally after I requested a second opinion I had surgery. In recovery I reached for my water bottle, picked it up. For the first time in a year I had no arm/shoulder pain. My hand was even working. It was a miracle. I still have issues above and below the fusion. But the McKenzie method of Physical Therapy has been helpful. It has kept me from injections and gently worked me out of pain for the past 15 years now. I’m 63. I’ve had all lumbar fused. Two bad car accidents. A knee replacement that left me with nerve damage in my sacrum/low back/hip. (That nothing has worked to relieve the burning, jolts, weakness 24/7 pain except my limited well managed opioid pain meds that the government has deemed evil) and warm water workouts.) The years of SCAM awareness, the things I was “required” to try… but then chose to not because it just did not make sense. I always need to know how and why. Give me your research. Before I got smart, I got harmed. So I read and learn. And what works for one patient may not work for another. The U.S. is great at doing a one size fits all healthcare when it comes to pain treatment.
The U.S. is great at doing a one size fits all healthcare when it comes to pain treatment.
Probabilities with trial and error.
N Elliot
Thanks for the testimony of your experience, I’m happy to hear you found some pain relief. Nobody here noticed because they are too busy arguing about the semantics of theory with regard to efficacy.
If you would, will you please be more specific about your particular diagnosis that led you to the fusion surgery.
“Nobody here noticed because they are too busy arguing about the semantics of theory with regard to efficacy.”
ONLY RG, THE ONLY CLEVER ONE HERE!
Chiropractic practices and procedures are a valid intervention when incorporating rehabilitation that improves the re-alignment of cervical lordosis. Reducing the damaging effects of chiropractic spinal subluxations such as abnormal cervical sagittal curvature is suggested to provide long-term relief to this clinical group of patients. These procedures are designed by chiropractors and tested by physiotherapists. https://www.mdpi.com/2077-0383/11/21/6515
yes, that’s what most chiros try to make us believe.
How about Ernst provides us with a critical analysis of the paper?
why should he?
did you have a look at the study design or that verum intervention or the control intervention?
I’ve read most of the papers put out by that group.
and do you find THAT study worth commenting?
Well, you can take on the whole concept.