Chapter 1 Introduction

INTRODUCTION

GENERAL INTRODUCTION

Cervical Radiculopathy is a common clinical diagnosis classified as a disorder

of a nerve root & most often is result of a compressive or inflammatory

pathology from a space occupying lesion such as disc herniation, spondylitic

spur or cervical osteophyte. (Joshua et al; 2005)

INCIDANCE/ PREVALENCE – The average annual incidence rate of

cervical Radiculopathy is 83 per 100000 for population in its entirely, with an

increased prevalence occurring in fifth decade of life ranging 203 per 100000

(Radhakrishnan et al; 1994). The prevalence of cervical radiculopathy has

been estimated at 3.3 cases per 1000 with an average age-adjusted

incidence rate of .8 cases per 1000 persons (Salemi et al; 1996). Peak

incidence of cervical radiculopathy is most frequently reported to occur in the

fourth to fifth decade of life (Kelsey et al; 1984). Radhakrishnan et al.,

(1994) & Kelsey et al., (1984) reported that cervical radiculopathy is

predominant in men. Whereas Salemi et al., (1996) reported predominance in

women. Ahlgren & Garfin, (1996) documented that involvement of the C6

and C7 nerve roots secondary to lesions of C5-C6 and C6-C7 motion

segments are most common.

Ellenberg et al., (1993) revealed that cervical

radiculopathy is said to be of non traumatic origin & occurs spontaneously in

the majority of cases. Radhakrishnan et al., (1994) in a large epidemiological

study reported that a history of physical exertion or trauma occurred in only

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Chapter 1 Introduction

14.8% of the 561 patients studied. Modic et al., (1986) done an epidemiologic

and surgical series reporting a higher incidence of cervical radiculopathy

secondary to spondylotic changes than cervical disc herniation. Cloward,

(1959) suggested that bony and ligamentous tissues affected by cervical disc

herniation and spondylosis conditions are themselves pain generators and are

capable of giving rise to the radicular or referred symptoms observed in

patients with nerve root pathology. Melloni et al., (1979) found that cervical

disc herniation and osteophytosis are the two most common space occupying

lesions that cause Cervical Radiculopathy.

Location & pattern of symptoms will vary; depending

on nerve root level affected & can include sensory and/or motor alterations if

dorsal and/or ventral nerve root is involved. Patient usually present with

complaints of pain, numbness, tingling & weakness in upper extremity, which

often result in functional limitations & disability (Joshua et al; 2005).

In a study of 82 patients, Wainner et al., (2003)

developed a clinical prediction rule of 4 items that was reliable and accurate in

diagnosing cervical radiculopathy. The items of clinical prediction rule include

the following:

 Spurling test.

 Distraction test.

 Ipsilateral cervical spine rotation less than 600.

 Upper limb tension test.

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Chapter 1 Introduction

The clinical prediction rule has 99% specificity when all 4

items were positive (positive likelihood ratio, 30.3) and 94% specificity when 3

of the items were positive (positive likelihood ratio, 6.1). Clinical prediction rule

help in clinically diagnose cervical radiculopathy, so proper treatment can be

started expeditiously.

Table 1.1 Classic Patterns of Cervical Radiculopathy

Abnormalities
Nerve
root Interspace Pain distribution Motor Sensory Reflex
C4 C3–C4 Lower neck, NA Cape distribution NA
trapezius (i.e., lower neck and
upper shoulder
girdle)
C5 C4–C5 Neck, shoulder, Deltoid, Lateral arm Biceps
lateral arm elbow
flexion
C6 C5–C6 Neck, dorsal Biceps, Lateral forearm, Brachioradialis
lateral (radial) arm, wrist thumb
thumb extension
C7 C6–C7 Neck, dorsal Triceps, Dorsal forearm, long Triceps
lateral forearm, wrist flexion finger
middle finger
C8 C7-C8 Neck, medial Finger Medial forearm, ulnar NA
forearm, ulnar flexors digits
digits
T1 C8-T1 Ulnar forearm Finger Ulnar forearm NA
intrinsics

NA = not applicable.

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Chapter 1 Introduction

Fig. 1.1 Dermatomal Distribution of upper limb.

Physiotherapy interventions to treat cervical radiculopathy

include postural ergonomics, motion exercises and cervical stabilization

exercises (Bronfort et al; 2001). Evidence suggests that patients treated

conservatively experience superior outcomes compared to those who

undergo surgery (Sampath et al; 1999). Cervical traction is often used to

treat cervical radiculopathy (Moeti & Marchetti, 2001). It is speculated that

traction unloads components of spine by stretching muscles, ligaments and

functional units (Ellenberg et al; 1994). Traction might prevent or reduce

adhesions within dural sleeve and relieve nerve root compression within

central foramina (Bland, 1994). Saunders speculated that traction decreases

pressure within intervertebral disc, while others have suggested that it relieves

tonic muscle contraction and improves vascular status within the epidural

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Chapter 1 Introduction

space and perineural structures (Colachis & Strohm, 1966). They also found

that negative intradiscal pressure that is thought to occur during traction might

result in reduction of herniated nuclear material. Hunterbuchner, (1985)

suggested that effects of traction were mainly mechanical and therefore use

of traction should be limited to those painful conditions where mechanical

effects would likely produce improvement. David and Richard, (2004) used

intermittent cervical traction in a position of slight cervical flexion because it is

likely more effective in this population than intermittent cervical traction in a

more neutral position. Intermittent cervical traction in flexion was selected

because in a cadaveric study Humphreys et al, (1998) found that a flexed

spine position increased central foraminal space, as compared to a neutral

position. In addition device utilized by Chung et al., (2002) also positions the

cervical spine in flexion.

Bradnam et al., (2000) documented that traction cannot

prevent degeneration of the disk, but can temporarily change the height of the

disk space and counteract the changes occurring in night-day rhythm. Minimal

increase in the height of the disk space can often result in pain relief,

especially when a protruded disk or an uncovertebral osteophyte encroaches

on the nerve root. Constantoyannis et al., (2002) concluded that intermittent

cervical traction has been widely purported to be an effective intervention in

treating cervical pathology with radicular symptoms. Saal et al., (1996)

described a study of 26 patients with cervical disc herniation that were

managed with traction and other conservative measures. The authors found

that a broad spectrum of conservative care, including traction, appeared to

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Chapter 1 Introduction

help alleviate arm pain in patients with cervical radiculopathy and reduce their

chances of having surgery.

Mark Waldrop, (2006) Published a case series provided

low-level evidence that intermittent cervical traction used with a multimodal

approach may help centralize and reduce the symptoms in patients with

cervical radiculopathy. Akbino et al., (2006) published a study examining

what the most beneficial amount of total body weight (TBW) would be for

cervical traction. Trials were done with patients randomly assigned to 1 of 3

groups, with each group receiving traction of 7.5%, 10% or 15% of patient’s

total body weight demonstrated the highest therapeutic efficacy with the

fewest side effects, compared with the 7.5% and 15% total body weight

groups.

Upper limb tension test was developed by Elvey,

(1979). Kenneally et al., (1988) have called upper limb tension test the

‘Straight leg raise of arm’. This is useful & helpful for examining upper limb,

neck & spinal disorders. Smith, (1956) did cadaver studies involving arm

movements, similar to those described for ULTT 1. Resultant movements on

cervical cord were duly noted in these studies. Cyriax, (1978) suggested

addition of elbow extension to symptomatic wrist positions. Kenneally et al.,

(1988) suggested it should be possible to develop techniques that selectively

stress individual nerves. He suggests that, for upper limb, four base tests be

used. These tests are bases on powerful nervous system tensioning

manoeuvres, each individual test allowing a bias o a particular nerve trunk.

Butler (1994), described aim of the neurodynamic technique was to mobilize

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Chapter 1 Introduction

scar tissue likely to be present, improve neural blood supply and physiological

function (e.g. axoplasmic flow). It should be noted that neurodynamic

techniques do not solely affect neural tissue. Consequently changes in

surrounding non-neural connective tissues are expected. Recent anatomical

studies demonstrated that innervated non-neural tissue in the cervical spine

undergoes deformation during the ULTT (Kenneally et al; 1988). As a result

of neural mobilization, nerve conduction improves, nerve fibre in spinal cord

straighten and are tensioned during tension test (Shacklock et al; 1994).

I. Zvulun, (1998) concluded that influences of neural

mobilization include: improved neural mechanics, physiological function,

increased flexibility of somatic connective tissue, improved motor performance

and influences on pain mechanisms. Murphy et al., (2006) incorporated

neural mobilization in the management of patients with cervical radiculopathy.

Seventy seven percent of patients at the short-term follow up and 93% of

patients at the long term follow-up exhibited a clinically important decrease in

disability. Jason Beneciuk, (2009) demonstrated that neural mobilization

tensioning had an immediate hypoalgesic effect on C-fiber mediated pain

perception, but not on A-delta fiber mediated pain perception. Coppieters et

al., (2009) described that neural mobilization technique also resulted in

improvements in elbow extension range of motion and sensory descriptors at

3 weeks and the carryover assessment. Increased elbow extension range of

motion measures was result of longitudinal elongation of the nerve bed.

Gregory Grieve, (1998) suggested that the application of heat

in its many forms is an important component of the treatment of cervical disk

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Chapter 1 Introduction

syndromes, particularly when the pain is acute. Heat exerts its beneficial

effect through hyperaemia and release of tension in the shoulder and neck

muscles. This is followed by a comparable reflex effect in the corresponding

motion segment. Deep heat alleviates local irritation of the ligaments and

periosteum, such as commonly occurs during the process of disk

degeneration. It also influences the speed of conduction of the motor nerves

and the activity of the spinal α and γ-motor neurons, so as to relax painfully

tense muscle zones. Borman et al., (2008) selected forty two patients with at

least 6 weeks of non specific neck pain for the study. Each patient was

randomly assigned to Group 1- receiving only standard physical therapy

including hot pack, ultrasound therapy and exercise program and Group 2-

treated with traction therapy in addition to standard physical therapy. The

patients were re-evaluated at the end of the therapy. The main outcome

measures of the treatment were pain intensity by visual analogue scale

(VAS), disability by neck disability index (NDI) and quality of life assessed by

Nottingham Health Profile (NHP). There was no difference between the

groups in terms of age, sex, pain intensity and scores of NHP and NDI at

entry. There were 21 patients in both groups. Both groups improved

significantly in pain intensity and scores of NDI and physical subscles of NHP

at end of therapies (p<0.05).

Hoving et al., (2002) & Ylinen, (2003) showed that

the primary aim of cervical exercises in patients with cervical radiculopathy is

to restore normal flexibility, stability and postural mechanics. Therefore, weak

cervical stabilizers were targeted with strengthening and conditioning

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Chapter 1 Introduction

exercises and limitations of normal cervical spine movement were addressed

with flexibility exercises. Postural correction is also frequently addressed in an

attempt to decrease abnormal mechanical stressors placed on the cervical

spine. Hettinger et al., (1953) reported that Isometric resistance training was

an effective alternative to dynamic resistance exercise and was considered a

more effective and efficient method of muscle strengthening. It was also

reported that isometric strength gains of 5% per week occurred when healthy

subjects performed a single, near maximal isometric contraction everyday

over a 6-week period of time. Krout & Anderson, (1966) hypothesized that

improving the endurance & strength of deep neck flexors helps improve the

mechanics of the cervical spine, as it relates to normalizing cervical lordosis.

1.1 STATEMENT OF STUDY

Effectiveness of intermittent Cervical Traction & ULTT-1 in patients with C5-

C6 radiculopathy.

1.2 NEED OF STUDY

As effectiveness of traction & upper limb tension test for treatment of cervical

spinal syndromes remains controversial. On basis of studies with small

samples, design flaws and lack of clinically relevant outcome measures, it

was not possible to formulate a strong and valid evidence of specific effects of

traction from available literature. Therefore an appropriate protocol is lacking

for the patients of cervical radiculopathy. I hope that my study will add to pre-

existing data on effectiveness of cervical traction with upper limb tension test

& helps to find out more efficient treatment for cervical radiculopathy.

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Chapter 1 Introduction

1.3 CLINICAL SIGNIFICANCE

Through the comparison of Cervical Traction with ULTT 1 and Conventional

physiotherapy with ULTT 1; we can frame more efficient, specific and safe

treatment approach in patient with C5-C6 radiculopathy.

1.4 AIM OF STUDY

 To determine effect of cervical radiculopathy on elbow extension range

of motion on neural testing.

 To help reduce pain and disability associated with cervical

radiculopathy.

 To design a suitable management program for restoration of function.

1.5 OBJECTIVES OF STUDY

 To know efficacy of conventional physiotherapy with ULTT 1 in C 5-C6

cervical radiculopathy.

 To know efficacy of intermittent cervical traction with ULTT 1 in C 5-C6

radiculopathy.

 To compare efficacy of conventional physiotherapy with ULTT 1 and

intermittent cervical traction with ULTT 1 in C5-C6 cervical

radiculopathy.

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Chapter 1 Introduction

HYPOTHESIS

1.6 NULL HYPOTHESIS

 Conventional physiotherapy with ULTT 1 leads to a reduction in pain

arising out of C5-C6 radiculopathy.

 Conventional physiotherapy with ULTT 1 leads to reduction in disability

arising out of C5-C6 radiculopathy.

 Conventional physiotherapy with ULTT 1 is an effective treatment

approach for C5-C6 radiculopathy.

1.7 ALTERNATE HYPOTHESIS

 Intermittent cervical traction with ULTT 1 leads to a greater reduction in

pain as compared to conventional physiotherapy with ULTT 1 in C5-C6

radiculopathy.

 Intermittent cervical traction with ULTT 1 leads to a greater reduction in

disability arising out of C5-C6 radiculopathy.

 Intermittent cervical traction with ULTT 1 leads to greater increase in

elbow extension while median nerve tensioning in C5-C6 radiculopathy.

 Intermittent cervical traction with ULTT 1 is better treatment approach

for C5-C6 radiculopathy as compared to conventional physiotherapy

with ULTT 1.

1.8 LIMITATIONS OF STUDY

 No follow up was given to subjects.

 Study conducted in a small sample (30 patients).

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Chapter 1 Introduction

 Study can be done using more outcome measures such as cervical

goniometry, patient-specific functional scale (PSFS).

1.9 DELIMITATIONS OF STUDY

 Study was not gender specific.

 Age group was confined to 45-55 years.

 Male subjects were less as compared to female subjects.

 Patients were not taking any medication during the study.

 Patients had stopped their exaggerating physical activities during

study.

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