Cervical Radiculopathy Case Series

Given the lack of evidence to support the management of patients with cervical radiculopathy, attached is a nice case series from Dr. Cleland and colleagues just published in JOSPT. JOSPT offers a nice supplementary video of one of the treatment techniques. Thanks for this valuable contribution.

Download Cleland-JOSPT-2005-CxRadicCaseSeries.pdf

John

Comments

[Chris Adams, MPT]

I found his case series very informative despite my young PT career. I currently have a patient that would definitely benefit from the intervention used by Dr. Cleland, but I cannot place her UE in the ULTT1 position. She basically had an AC decompression in June and was receiving 'physical therapy' in her doctor's office (I think they have a tech oversee the patients) for 3 months. She came to me essentially with adhesive capsulitis and radiculopathy in the same right UE. Given the effectiveness of the intervention utilized in the case series, I'm struggling to get my patient into an appropriate position to perform the technique. Any thoughts?

Sorry for being long-winded and I'm unsure if this is a place for treatment feedback...I'm new. :)

[Josh Cleland]

Chris,

How about starting the patient with the arm in neutral and still performing the lateral cervical glides? Can she tolerate the ULNDT position II? If so then maybe you could start there? Is she also receiving the other treatments (traction- t-spine work)?

Josh

[Chris Adams, MPT]

Josh,

I appreciate your reply! I have attempted lateral glides with the shoulder in neutral and she responded well. I suppose I was thinking with the addition of the ULNDT I position it would help her that much more. I will see about position II the next time I see her. I have been performing traction and some t-spine work and this has helped her significantly, however, she is still VERY guarded.

[John Ware]

Chris,
Maybe some "soft tissue" work prior to attempting the lateral glides may help her get accustomed to your hands being on her chronically sore neck. With soft tissue work, in my experience, slower is better. Make sure your grades III and IV are not too aggressive and "pokey." Re-check your technique on a peer who will give you feedback regarding your force application. By the way, sometimes sustained mobs are more comfortable than oscillatory ones, particularly on the neck-same force, just don't bounce. If you have not had a manual therapy residency and your new at this, chances are your technique is a little coarse. Good luck.
John

[Carina Lowry]

Chris,

I agree that changing the UE position would likely help. There is no preferred ULNDT position over the others when doing these glides with the c-spine (an area for future research). Using brief soft tissue mobilization may also help for relaxation, but the biggest thing is to use soft hands to get the pt to relax. You may also want to take the arm out of abduction and into scaption when you are doing the c-spine glides, progressing back into the abduction position. I just prop the shoulder with pillows. This position is also more comfortable with the GH/AC/SC glides you should be doing for the adhesive capsulitis. Don't forget the t-spine...very crucial. Best of luck to you.

Carina

[Chris Adams, MPT]

Thanks for all your replies! What I failed to mention earlier was that I have been performing quite a bit of STM/DTM around the neck, shoulder, and periscapular muscles since day one. She has improved greatly in reference to AROM and decreased sensitivity. I was just curious about how to perform the aforementioned technique given her lack of ROM and/or tolerance of some positions.

John,

My skills may be a little coarse as I am barely a few years out of school. I imagine a manual therapy residency/fellowship would benefit me greatly.

Carina,

How did I not think of that?!? I'll place her in scaption tomorrow and try again.

Lastly, for purposes of clarification, what are you referring to when you say don't forget the t-spine? Are you talking about segmental mobility, manipulation, etc.? If so, then we're on the same page.

Thanks again! :)

[Carina Lowry]

Chris,

Yes, I do believe we are on the same page, either manipulation or mobilization of the thoracic spine. I am sure we could go to great lengths in discussing the differences, but the point is to get it moving. In this particular study, the manip used by Cleland et al for supine manipulation is quite effective. Since your pt is already limited in shoulder ROM, a rolled towel will decrease the amount of horiz add needed and may be more comfortable for her.

Carina

[John Goodrich]

Question: When tracking back through the literature, including the bibliography for one of Dr. Erhard's earlier articles, the studies ultimately cited regarding the efficacy of cervical traction use static traction? Is there a study that compares intermittent vs static. I used to use Maitland's recommendations for intermittent, but I moved away from it because I did not find it any more effective, especially with radiculopathy. Thanks.

[John Childs]

Actually, more of the studies have utilized some variation of intermittent traction. I am unaware of any studies that have compared intermittent versus static traction. Regardless, there is still wide variability in the protocols that are used. I think most of us agree that distraction-oriented treatments such as traction seem to work for some patients. The question of course is - exactly who? There is ongoing research to address this very issue, which should help clinicians determine which patients are most likely to benefit. This is one of those scenarios where clinical expertise and small dose of evidence is all we have. More data is forthcoming for sure.

John

[Robin Saunders Ryan]

I am also unaware of studies that compare intermittent vs. static cervical traction. I think of it very much like manual therapy - you know what you're theoretically trying to achieve (increased motion and other benefits of joint and muscle movement), then modify the technique for patient tolerance and response. It's very much like the mob technique/UE position discussion on this thread - try one (theoretically ideal) method, then modify prn to suit the situation. The question for cervical traction is, "which is the ideal method?" I don't think that question has been answered yet. Even though more studies have used intermittent traction, I believe it's by "default" rather than any good evidence (i.e., each researcher uses intermittent because the previous researchers did!) My suspicion is that a study directly comparing static to intermittent CERVICAL traction, with all else equal, would show no significant difference. It's the movement, the mobility, that makes the difference - not the particulars of how that movement was achieved...

[John Goodrich]

Thanks. A study by Chung, et al in Radiology (2002,225:895-900)reported a complete or partial resolution of HNP in 72% of cases using a static traction device(I believe it was for 10 minutes). While this issue is hardly at the top of the heap (since the good news is that both have been demonstrated to be effective), it seems that in the context of classification and algorithm based treatment, it may be worth reviewing. For me, if I alleviate a patient's radiating sxs with manual traction, and again with mechanical traction, I am hard pressed to justify intermittent traction. I would be interested in Drs. Cleland and Erhard weighing in -- their articles have been excellent.

[Josh]

John,

I selected to use the intermittent traction based on the Moeti and Marchetti case series. Beyond this I have no evidence to suggest that intermittent traction would be superior to static traction with this population. My guess is (zero evidence) the differences in outcomes on the functional or disability level between static/intermittent traction would probably be negligible. However, we would of course need an RCT to either prove or refute this hypothesis.

Josh

[John Goodrich]

Josh, (If you get this)Thanks for the response and sharing your process. Again, I appreciate your contributions.