Author Names

Kachmar,O; Kushnir,A; Matiushenko,O; Hasiuk,M

Reviewer Name

Katharina Nevsimal SPT Class of 2024

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Objectives: The aim of this study was to investigate the short-term effects of spinal manipulation (SM) on wrist muscle spasticity and manual dexterity in participants with cerebral palsy (CP).  Methods: After baseline examination, 78 participants with spastic CP (7-18 years) without contractures or hyperkinetic syndrome were randomly allocated into 2 groups. The experimental group underwent SM to the cervical, thoracic, and lumbar spine, and the control group received sham SM. A second evaluation was performed 5 minutes postintervention. Wrist muscle spasticity was measured quantitatively with NeuroFlexor (Aggero MedTech AB, Solna, Sweden), a device assessing resistance to passive movements of different velocities. Between-group difference was calculated using the Mann-Whitney U test. Manual dexterity was evaluated by the Box and Block test.  Results: In the experimental group, muscle spasticity was reduced by 2.18 newton from median 5.53 with interquartile range 8.66 to median 3.35 newton with interquartile range 7.19; the difference was statistically significant (P = .002). In the control group, reduction in spasticity was negligible. The between-group difference in change of muscle spasticity was statistically significant (P = .034). Improvement of manual dexterity was not statistically significant (P = .28).  Conclusions: These findings suggest that SM may, in the short term, help to reduce spasticity in participants with CP. Long-term effects of SM on muscle spasticity have yet to be studied.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • Yes
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • No
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • No
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • No
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

A treatment plan that includes spinal manipulation at the lumbar, thoracic, and cervical levels has the ability to decrease spasticity in those with Cerebral Palsy.

Key Finding #2

While spinal manipulation helped decrease spasticity it did not have an effect on dexterity.

Key Finding #3

This study had a short-term design due to difficulties in recruiting people for longer-term observation. The spinal manipulation was given during the first half of the day when participants arrived for treatment. There needs to be a longer follow-up period in future studies to understand the effects.

Key Finding #4

This study while showing positive support of decreased spasticity through spinal manipulations, the findings are preliminary and further studies need to be done.

 

Please provide your summary of the paper

This randomized controlled trial studied the effects of spinal manipulation to the cervical, thoracic, and lumbar spine on wrist muscle spasticity and manual dexterity in participants with spastic cerebral palsy. The participants were split up randomly into two groups: experimental group who received spinal manipulation and the control group who received sham spinal manipulation. The participants, 79 total, ranged from the ages of 8-18 years old. Muscle spasticity in the wrist was the primary outcome measure and was measured at baseline and postintervention. Spasticity was measured quantitatively with a NeuroFlexor device which looked at the resistance to passive movements of the wrist performed at different velocities. The secondary outcome measure looked at manual dexterity at baseline and after the intervention through the Box and Block test. The manual therapy protocol included high-velocity, low-amplitude for all levels of the spine. For the cervical spine the participant was in a seated position with the head flexed sideways and slightly rotated and the weight of the head supported by the practitioner’s hand with traction/side-bending force applied. Thoracic manipulation was done with the patient in prone while applying a postero-anterior pressure in a counterclockwise rotation. For the lumbar spine the patient was in a lateral recumbent position with the upper leg flexed at the hip and knee, lower leg straight, and the lumbar spine put into extension with rotational forces applied at the shoulder and thigh. While the controlled group did not receive the spinal manipulations, they received sham of the spinal manipulation that physically and visually resembles the spinal manipulations of the experimental group but without applying substantial force. The study showed a statistically significant decrease of spasticity after spinal manipulation in the experimental group but was not statistically significant in the control group. Regarding hand dexterity the experimental group had a more pronounced improvement with a difference of 1.05 blocks per minute in between-group analysis. This difference was not statistically significant. No conclusion could be drawn in on the influence of spinal manipulation on manual dexterity in participants with spastic cerebral palsy. Thus, using the manual therapy techniques on the spine can help decrease spasticity, especially at the wrist, in cerebral palsy but does not influence the dexterity of the participant. This was a short-term study, and the long-term effects were not measured.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This paper showed the value of manual therapy to help decrease spasticity for the neurologic patient population of Cerebral Palsy. It discussed the importance of spinal manipulations for the cervical, thoracic, and lumbar levels in order to help with a decrease in muscle spasticity and improve manual dexterity. While no statistical significance was found between the experimental and control group regarding dexterity, manual therapy of the spine did show to decrease spasticity in the short-term. This is important for this patient population because it will allow them to move more freely while also helping improve motor development throughout their treatment sessions with physical therapists.