Presentation on theme: "Cervical Radiculopathy Following MVA"— Presentation transcript:
1 Cervical Radiculopathy Following MVA Case StudyRamsee Pagel, SPTRegis universitySummer 2010
2 ObjectivesThe student will be able to understand the relationship between pathology and presentation of cervical radiculopathy following a MVAThe student will examine and understand the current best evidence supporting physical therapy intervention for cervical radiculopathy.The student will be able to understand the examination, evaluation, and intervention for those patients who present with cervical radiculopathy following MVA.
3 PurposeTo examine whether physical therapists are selecting interventions using an evidence based approach when treating patients who present with neck pain and radicular symptoms following trauma.
4 What we know… Pathology Pt Presentation Nerve root compression, inflammation, or improper functionRadicular symptomsHerniated discDegenerative changes in the spineOther injuries (trauma)Pt PresentationNeck painArm painNumbness and tingling in the UEPain will occur anywhere along the nerve root distribution
5 What we know…Using the knowledge we have learned in our education up to this point:Clinical Prediction Rule – Cervical Radiculopathy(+) ULTT A(+) Distraction(+) SpurlingsIpsilateral Cervical Rotation <65°Wainner et al., SPINE, 2003.
6 HistoryPt is a 33 year old female who works as a Respiratory Therapist.Pt was referred to physical therapy following an MVA.Rx: Evaluate and Treat (4/20/2010)Dx: Levator scapulae syndrome with cervical strain and right SI joint strain s/p MVA.Treatment Dx: Decreased cervical AROM with right UE radicular symptoms and pelvic asymmetry with piriformis dysfunction.
7 HistoryPIPs: pain limiting reaching overhead and her abilities to lift and care for her three children.At the time of initial examination, the patients stated that her low back pain was limiting most of her activities and the UE/Cervical spine symptoms were not as limiting.Images (plain films) were taken following the accident and no abnormalites were noted.A cervical MRI was also done after 10 PT visitsMild disc herniation at C4-C5 with no signs of cord compression.
8 Patient Presentation PROM UE: WNL AROM UE: Bilateral shoulder flexion limited by 20 degrees secondary to painAROM C-spine: flexion/extensionWNL, right rotation 65°, left rotation55°UE Strength: 4/5 throughout bilaterally with pain during testingReflexes: Bilateral UE reflexes2+ throughoutL UE Pain: 9/10Neck Pain: 9/10LBP:10/10NDI: 44%severely disabledODI: 40%moderately disabled
9 Cervical Special Tests At initial examination:(+) Sharp Purser(+) Right Spurlings(-) Left Spurlings(+) Distraction(-) ULTT BilateralMedianUlnarRadial
11 Other Factors Psychological Frequent flashbacksHigh anxietyLittle to no sleepFear about the inability to work and properly care for her 3 childrenPt was seeing a clinical psychologist 2x/month for counseling
12 Clinical Decision Making Using the patient identified problems, the initial intervention was directed towards the low back and pelvic asymmetry.Secondly, since the patient did not fall completely into any of the clinical prediction rules, cervical mechanical traction was not immediately initiated.Functional goals were set to decrease overall pain, improve mobility of the cervical and lumbar spine, and increase the patients overall function.
13 Response to Intervention Pt reported 1/10 LBP following 10 treatment sessionsInterventions:Pelvic METCore Stabilization ExercisesLumbar Flexion ManipulationsProne PA Thoracic MobilizationsIFC with HPPt reported slight decrease in neck and arm pain after 10 visitsSTMRotational METSub-Occipital ReleaseManual DistractionCervical Segmental Mobilizations
14 Cervical Special Tests After 10 visits:(+) L Spurlings(-) R Spulings(+) Distraction(+) Shoulder Abduction Test(+) ULTT A(-) Sharp PurserR Rotation: 65°L Rotation: 42°NDI score 48% (severely disabled)
15 What the Evidence Says… Treatment Based Classification SystemWhich category does the pt most match?Were the interventions provided matched to that category?At initial examination?After 10 visits?
16 Treatment-Based Classification Fritz, J. Brennan, G. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther, 2007.Purposes of the studyExamine proposed treatment-based classification system by describing prevalence of subgroups in a sample of patients receiving PT for neck painCompare other characteristics of patients placed in these subgroups
18 Neck pain classification categories and matched interventions MobilityMobilization/ Manipulation of cervical or thoracic spineStrengthening exercises for the deep neck flexors (DNF)CentralizationMechanical or manual cervical tractionCervical retraction exerciseExercise and conditioningStrengthening exercises for upper-quarter musculatureStrengthening exercises for neck/ DNFPain controlCervical spine mobilizationCervical range-of-motion exercisesHead AcheCervical spine manipulation/mobilizationStrengthening exercises for DNF
19 Results 297 patients with neck pain were evaluated 274 were included in analysis113 (41.2%) patients received interventions that matched prespecified treatment components161 (58.8%) received nonmatched interventionsPatients receiving matched interventions showed greater changes in both NDI and pain rating scores.Among patients receiving matched interventions, 72.5% achieved the minimal detectable change (MDC), whereas only 53.8% of patients receiving nonmatched interventions did so (p=.002).
20 Exercise and Conditioning Where do we go from here?Using the treatment based classification system:Initially, the pt fell mostly into the pain control categoryAfter 10treatment sessions, the pt fell more into the centralization categoryMobilityCentralizationPain ControlHeadacheExercise and Conditioning
21 Matched Intervention- Mechanical Traction Raney, N. et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine JParameters- TractionAngle of pull: 24° flexionOn/off cycle: 60:20Initial pull: poundsProgressed per patient toleranceMaximum pull: 40 poundsRest force: 50% of pull forceTotal time: 15 minutesExercise protocolDNF and Postural exercises (scapular squeezes)
22 Matched Intervention- Mechanical Traction Clinical Prediction Rule- Success from mechanical traction and exercisePatient reported peripheralization with lower cervical spine mobility testing(+) ULTT A(+) Distraction(+) Shoulder Abduction TestAge ≥ 55Likelihood of patient reported success5/5=100%4/5=94.8%3/5=79.2%Raney, N. Eur Spine J
23 Matched Intervention Mechanical Traction and Exercise Initiated after 12 visitsParameters:Max pull 14 poundsTotal pull time 6 minutesIntermittent 60:10
24 Intervention Progression Traction pull was progressed after 4 sessionsMax pull 16 poundsTotal pull time 6 minutesIntermittent 60:10Pull was then progressed by 2 pounds each session per pt toleranceTotal pull time was also progressed by 2 min each session per pt toleranceAt the conclusion of CE IIMax pull24 poundsTotal pull time14 minutes
25 Exercise and Manual Therapy Interventions DNF10 x 10 secTheraband Rows blue band x 15Theraband Extenstions blue band x 15Scapular Squeezes x 20Cervical rotation METSTMManual Scalene StretchSubocciptal ReleaseProne PA Thoracic Spine MobilizationsCervical Segmental Mobilizations
26 So what can we expect??Cleland, J. et al. Predictors of short-term outcome in people with the clinical diagnosis of cervical radiculopathy. Phys TherPurpose: to determine which factors noted at baseline evaluation can be predictive of short term outcome in patients with the clinical diagnosis of cervical radiculopathy.Outcomes used:NDINPRSPSFS
27 So what can we expect?? Results: The study design did not allow for a cause and effect relationship to be establishedThe results suggest that mechanical traction, deep neck flexor strengthening, postural education, and manual therapy may be beneficial in the management of cervical radiculopathyWith 3 of the 4 treatment variables present the +LR=5.2 with the posttest probability of success =85%
28 Pt Presentation On 7/2/2010 VAS 3/10 neck VAS 3/10 L UE Pain is inconsistent and is much worse at nightPain is still limiting her ability to perform ADL’sNDI: 30% moderate disabilityPt states she is feeling much better but it is a slow process and she just wants to be able to be a mom with no pain again.Pt continues to have 0-1/10 LBP
29 What could have been done differently?? Utilized other outcome tools?FABQPSFSReassessed more frequently?Progressed traction more frequently using the published literature?Pt tolerance/anxiety levels
30 Check For Understanding 1. Which of the following is not a test included in the CPR for cervical radiculopathy?A. Cervical DistractionB. Craniocervical FlexionC. SpurlingsD. ULTT A2. T/F: all patients will fall into a single category according to the treatment based classifications.3. T/F: there is evidence to support the use of mechanical traction, manual therapy, and exercise in the management of patients with cervical radiculopathy.
32 ReferencesCleland, J. et al. Predictors of short-term outcome in people with the clinical diagnosis of cervical radiculopathy. Phys TherFritz, J. Brennan, G. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther, 2007.Raney, N. et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine JWainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine