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Non-Operative Management of Cervical Radiculopathy Matthew R. Doyle, MS, ATC, LAT.

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Presentation on theme: "Non-Operative Management of Cervical Radiculopathy Matthew R. Doyle, MS, ATC, LAT."— Presentation transcript:

1 Non-Operative Management of Cervical Radiculopathy Matthew R. Doyle, MS, ATC, LAT

2 Why this topic?  Wrestling and Neck Injuries  In the past a lack of quality information on managing Cervical Radiculopathy (CR)

3 Goals  Update self, others on current evidence and best clinical practices  Paper with Clark, Rosenquist, McKinley  Discuss amongst colleagues, gain consensus for future cases at Iowa, multi-disciplinary approach

4 College Time Loss Injuries

5 Iowa Wrestling Cervical Disorders  August 2002 to current  56 total problems and cases  Minor= strains, sprains, facet syndrome, mechanical neck pain  10 caused time loss of greater than one week  9 cervical radiculopathy, one brachial plexus traction injury  3 cases to examine

6 Define the Problem  Neck Disorders  classification problems  Childs, 2004  SIMS by anatomy  List of diagnosis: facet syndromes, HNP, hard disc, soft disc, Mechanical neck pain, CR, neuropraxia, brachial plexopathy, spondylosis, jammed neck, stingers, myelopathy, Spinal Cord Neuropraxia  Focus today on cervical radiculopathy

7 Cervical Radiculopathy  Disease process marked by spinal or nerve root compression or irritation  Numbness, sensory and reflex deficits, or motor dysfunction in affected nerve root distribution  May be crossover between myotomes/dermatomes  Impingement may produce neck, upper trapezius, interscapular, shoulder girdle, and unilateral radiating arm pain Combination of above and changes in acute to chronic

8 Pathoanatomy  Inflammatory mediators, changes in vascular response, intraneural edema, hypoxia  Cervical spondylosis (70-75% of cases)  decreased disc height space, degenerative changes at uncovertebral and facet joints  Herniated nucleus pulposus (20-25%)  Tumors, infection

9 Clinical Diagnosis  No universally accepted criteria for the diagnosis of CR.  Wainner, 2000  Proposed guidelines to treat low back pain may be applied to neck pain and CR.  Carette, 2005  Match imaging to clinical signs

10 Cervical Radiculopathy  Clinical Diagnosis, unknown diagnostic accuracy  Can’t determine prognosis, risk factors, or effective interventions  Called for definitive diagnostic criteria and terms  Homogeneous groups  No evidence for any single intervention  Wainner, 2000  Literature review

11 Tx Cervical DDD  Pain generators, anatomical reference  Mechanical Neck Pain (facet and disc joint)  CR, myelopathy and stenosis  CR caused by disc herniations  Rest, immobilization, NSAIDS, traction, Physical Therapy  Narayan, 2001 and Zmurko, 2003

12 Rehabilitation  Phased progression for syndromes  Education, posture corrective exercises and stretching  Beazell, Magrum, 2003  Algorithm of progressive intervention  Nonspecific treatments  Included ESI, TENS, acupuncture  Saal, 1996

13 Clinical Prediction Rule  Test Item Cluster, 4 positive exam findings  Spurling, upper limb tension, cervical distraction tests  >60 deg rotation toward symptomatic side  Wainner, 2003

14 Multi-modal Treatment Approach  Case study of CR patients  Manual physical therapy  Cervical lateral glide mob in upper limb neurodynamic position  Mechanical intermittent cervical traction (ICT) (15 min)  18 lbs, 30 sec on and 12 lbs, 10 sec  Strengthening  Cervical Stabilization Exercises (deep neck flexor)  scapulothoracic strengthening  Screened in using CPR  Series suggests this tx approach may be appropriate for CR patients  Cleland, et al. 2005

15 Multi-modal Intervention Approach  Case series of CR patients  ICT, Thoracic thrust joint manipulation  Cervical stabilization exercises and ROM  Posture education  Used Clinical Prediction Rule  Possible that this approach can improve symptoms and functional outcomes  Waldrop, 2006

16 Multi-modal Intervention RCT, MNP patients w and w/o unilateral UE symptoms  Manual physical therapy targeted to impairments  Joint mobilization, thrust and non-thrust  Muscle energy  Stretching  Home exercise program, deep flexors and ROM  Outcomes support previous RCT w/ MNP  Walker, Boyles, et al. 2008

17 Treatment  Natural history, favorable prognosis long term  Non-operative Management is effective  Little high quality evidence on the best non- operative therapy for CR  Multimodal approach may alleviate symptoms

18 Interventions for CR  Some but few RCT, systematic reviews  Largely case studies and anecdotal experience  Clinical Practice Guidelines

19 Nonsurgical Management  Pharmacotherapy for tx low back  Analgesics, NSAIDS, muscle relaxants, antidepressants, anticonvulsants for CR  anecdotal, no RCT  Effexor, ultram, oral steroids  Epidural injections of corticosteroids (ESI)  Retro and prospective cohort studies reporting favorable results, complications?

20 Nonsurgical Management  Education –may help some, systematic review says no benefit.  Haynes  Short term immobilization, soft collar  Cervical Traction  Exercise therapy seems appropriate, not supported  Modalities may be beneficial  Manual Therapies, manipulation and mobilization



23 Cochrane Reviews  Exercises for mechanical neck disorders, 2009  Unclear, strength, stretch  Strong evidence for multi-modal care  Patient education for neck pain, 2009  Unclear  Mechanical traction for neck pain, 2010  Doesn’t support or refute  Electrotherapy for neck pain, 2010  Very low quality of evidence TENS effective  Acupuncture for neck disorders, 2010  Moderate evidence of effect MNP and chronic CR  Massage for mechanical neck disorders, 2007 (not Cochrane)(systematic review in Spine)  No recommendations

24 Case Study 1  College Wrestler (2 nd yr) reports neck pain while strength training in September  Tx with e-stim, ice, heat, massage, traction, joint mobilization, isometric strengthening, 4 way neck strengthening, soft collar, gradual functional progression  Lumbar Disc Bulge the next season (3 rd yr)  December of 4 th season treated for facet sprain  Heat, traction, joint mobilization, ice massage, protection with soft collar and partner selection  Seeks chiropractic care January

25 C-7 Nerve Radiculopathy  April of same year while wrestling noticed pain and weakness in his left arm  Tricep weakness and hand was tingly, neck/scapular pain  MRI  multilevel degenerative changes in discs  disc osteophyte complex at C6-C7 level on left side causing moderate narrowing of neural foramen

26 Cervical Herniated Disc  Acute treatment with ice, heat, e-stim, NSAIDs  Referred to Pain Clinic for epidural steroid injection mid-April  No wrestling, stiff collar for machine strength training  10 lbs restriction to lift with no valsalva  Aqua therapy, non-impact cardio  Address UE weakness with specific resistance exercises, t-bands, machines, dumbells

27 Summer Break  May  no pain in left arm, no neck pain, no numbness or tingling  Dramatically improved strength in triceps  Negative Spurling, full neck ROM  No additional ESI  Weight lifting restriction to 20 lbs.

28 Summer Training  June  Asymptomatic and allowed to resume strength training with no weight restrictions  Begins gradual, progressive functional return  Plan to resume live wrestling in 6 weeks  Aug 28 cleared to full return

29 Case Study 2  22 y.o. college wrestler has stinger while wrestling  Reports event several days later  Reports mild neck pain, normal cervical ROM, wants to continue wrestling but notices arm weakness  No previous neck problems  Treated with activity modifications

30 Case 2  4 weeks later has 4/5 tricep strength  MRI to evaluate for disc affecting C7 nerve root  Impression: No evidence of cervical spine injury or acute abnormality  Short pedicles present resulting in congenital narrow AP dimension of the central canal

31 Case 3  College Wrestler (2 nd yr) with two year history of repeated stingers  Current episode with neck extension, compression, lateral flexion  Causing acute radiating pain into right trap, shoulder and distally past elbow to hand  Previous tx activity modification, protection, strengthening, modalities, gradual return

32 Case 3  Normal myotome exam within minutes  Following acute phase normal neck motion  Neurodynamic testing revealed increased sensitivity and decreased right upper extremity ROM in median, radial, and ulnar nerve tracts  3 sets of 30 reps and instructions for self mobilization  Remainder of career 2 more episodes

33 Case 3  MRI during junior year  Posterolateral disk osteophyte complexes  bilaterally at C3-4  Right side at C4-5  Neural foraminal narrowing on right at both intervals  Managed with activity modification, modalities, neuromobilization, and ESI

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