cervical spondylosis- need suggestions

[kpc_23]

hi,
i am treating a patient for neck pain with radiation to the left arm. MRI scan shows disk protrusion ( left paracentral disk bulge)at multiple levels with disk extrusion at C5-C6 level which is indention the thecal sac and compromising the exiting nerve root at this level. pl do suggest what would be the appropriate line of management. if he is not totally relieved his next option is surgery.

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[sdkashif]

For convenience of management of cervical spondylosis, the physiotherapy management programme has been divided in to the different phases according to the severity of the condition. Have a look over that.

Acute Phase:

During this stage physical therapy involves teaching the patient proper posture, body mechanics, how to implement an effective exercise programme, reducing forces compressing the nerve root by relative rest,avoiding positions that increase arm or neck symptoms, to relive pain and dysfunction, promote healing and recovery. This is achieved by the folllowing.

Passive Modalities:

Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (eg, moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).

Cervical Traction:

Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.

Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.

The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:

In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.

Have a look over a very useful article on Cervical Traction.

http://www.thesaundersgroup.com/cervical.pdf

Cervical Immoblization:

Cervical Immoblization with Cervical collar and cervical pillow are commom measure to relieve the neck pain and pain from sub occipital region. The collar commonly prescribed are philadelphia collar, soft cervical collar, hard cervical collar. They are usually prescribed for short period of time and as the symptoms improve, their use is often discarded. A home exercise programme of cervical isometric exercises may help to keep improve the tone loss resulting from cervical immoblization.

Exercises:

An exercise programme based on McKenzie Method may improve the early recovery and function.

The McKenzie Method is not merely extension exercises. In its truest sense, McKenzie is a comprehensive approach to the spine based on sound principles and fundamentals that when understood and followed accordingly are very successful. In fact, most remarkable, but least appreciated, is the McKenzie assessment process.

Assessment. Unique to the McKenzie Method is a well-defined algorithm that leads to the simple classification of spinal-related disorders. It is based on a consistent "cause and effect" relationship between historical pain behavior as well as the pain response to repeated test movements, positions and activities during the assessment process.

A systematic progression of applied mechanical forces (the cause) utilizes pain response (the effect) to monitor changes in motion/function. The underlying disorder can then be quickly identified through objective findings for each individual patient. The McKenzie classification of spinal pain provides reproducible means of separating patients with apparently similar presentations into definable sub-groups (syndromes) to determine appropriate treatment.

McKenzie has named these three mechanical syndromes: Postural, Dysfunction and Derangement.

Postural: End-range stress of normal structures

Dysfunction: End-range stress of shortened structures (scarring, fibrosis, n.root adherence)

Derangement: Anatomical disruption or displacement within the motion segment

(All three mechanical syndromes – postural, dysfunction, and derangement – occur in the cervical as well as thoracic and lumbar regions of the spine.)
Each distinct syndrome is addressed according to it unique nature with mechanical procedures utilizing movement and positions. The Derangement syndrome where the phenomenon of "centralization" occurs is most common.

Well-trained McKenzie practitioners will be able to identify those more difficult cases where advanced McKenzie techniques might benefit the patient versus those patients whose diagnosis is non-mechanical in nature, and those patients are then quickly referred for alternate care, thus avoiding unnecessary periods of inappropriate or expensive management.

Treatment. McKenzie treatment uniquely emphasizes education and active patient involvement in the management of their treatment in order to decrease pain quickly, and restore function and independence, minimizing the number of visits to the clinic. And if a problem is more complex, self-treatment may not be possible right away. However, a certified McKenzie clinician will know when to provide additional advanced hands-on techniques until the patient can successfully manage the prescribed skills on their own.

Ultimately, most patients can successfully treat themselves when provided the necessary knowledge and tools. An individualized self-treatment program tailored to the lifestyle of the patient puts the patient in control safely and effectively.

For detail See McKenzie Mechanical Diagnosis and therapy

Recovery Phase:

Once pain and inflammation are controlled, the patient's therapy should be progressed to restoration of full ROM and flexibility of the neck and should girdle muscles. This phase of rehabilitation focuses on soft tissue overload and biomechanical dysfunction. Goals of this phase are to eliminate pain, normalize spinal mechanics, and improve neuromuscular control of the injured cervical spine. Restoration of the resting muscle length and full, pain-free, cervical ROM are necessary. Strengthening exercises start in simple planes and progress to complex muscle patterns. The techniques are methods used are Cervicothoracic stablization, Neuromobilizations (Butler Approach), Cervical Mobilization and cervical manipulation, soft tissue mobilization or massage and functional restoration, aerobic conditioning.

Cervicothoracic stabilization:

It limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.

Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.

Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (ie, correct posturing) with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.

These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.

Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.

Spinal manipulation and mobilization:

It may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.

Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.

No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.

Spinal manipulation: Its safety is uncertain

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.

Influence of a cervical mobilization technique on respiratory and cardiovascular function.


Neuro Moblizations:

Butler's therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies "adverse neural tension," defined as pathological mechanical and physiological responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve's mechanical properties (eg, its mobilization around neighboring intervertebral discs) and physiological characteristics (eg, its response to ischemia, inflammation). Having tested the nerve in question, the therapist then may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.

Limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.

Functional Restoration:

Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology.

Aerobic Connditioning:

It also plays a role in reduction of Pain.


Maintenance Phase:

This phase requires proper function pain free ROM, proper spinal and shoulder girdle mechanics. Emphasis is placed on continually achieving and improving strength, flexibility and mobility. Neck and shoulder girdle muscles should be stretched and strengthened by routine exercises. Proper head and neck positioning is maintained in every day activities.

[david_wb]

Get a grip!

[alophysio]

Hi,

I don't think "get a grip" will help but thanks for the info sdkashif.

Perhaps david_wb thought the information too comprehensive to digest quickly???

Kpc23, when considering the cervical discs, also consider the patient's age. The cervical discs start to change their morphology in the second decade and become more fibrocartilage. They are NOT like L/S discs at all. From what i understand, Mackenzie's theory and treatment is based on a fluid disc model. Here is some further information from an answer i had to write on this topic...

Cervical discs are not smaller versions of those found in the lumbar regions. The anterior, posterolateral and posterior annulus fibrosis (AF) as well as the nucleus pulposus (NP) will be considered below.

The annulus fibrosis of the L/S discs envelop the nucleus pulposus completely with 15-25 concentric rings, which alternate in angulation around 70 (Pooni, Hukins et al. 1986; Urban and Roberts 2003). Movement at the L/S disc are flexion/extension and lateral flexion – these movements are tilting movements and are accommodated by bulging of the disc (Penning 1988). Rotation is limited because rotation is resisted by the annulus in the L/S even when posterior elements are removed (Penning 1988; Dolan and Adams 2001). The lumbar disc suffers herniations and tears, which can be painful (Urban and Roberts 2003).

The NP of the L/S is a fluid, gelatinous core of the disc with hydrostatic properties and takes up 50% of the entire disc (Mercer SR and Jull 1996; Sato, Kikuchi et al. 1999; Edmondston, Song et al. 2000; Dolan and Adams 2001; Mercer S 2003; Urban and Roberts 2003).

Compared to the lumbar discs, the cervical discs differ in the annulus in a number of ways. Firstly, there are not concentric lamellae around a fluid NP. The anterior annulus is more like a crescent-shaped mass of fibres that taper towards the posterolateral corners of the disc (Mercer S and Bogduk 1999; Bogduk and Mercer 2000; Mercer S 2003). The orientation of these fibres are more of an interweaving rather than separate layers of lamellae that alternate in direction like that found in the L/S (Mercer S and Bogduk 1999) and they converge superiorly to the lower anterior edge of the vertebral body above(Mercer S 2003). The lateral corners of the cervical disc, in the uncovertebral regions, there is no substantive annulus at all, just a thin layer of fascial tissue (Mercer SR and Jull 1996; Mercer S and Bogduk 1999; Bogduk and Mercer 2000; Mercer S 2003; Urban and Roberts 2003). Posteriorly there are thin, vertically orientated fibres, not the multi-layered, alternating orientation seen in the L/S (Mercer SR and Jull 1996; Mercer S and Bogduk 1999; Dolan and Adams 2001; Mercer S 2003; Urban and Roberts 2003).

Lastly, the NP in the adult cervical disc has been described more as a fibrocartilaginous core as opposed to a fluid, gelatinous core as seen in the L/S (Mercer S and Bogduk 1999; Mercer S 2003). Also, clefts form in the uncovertebral region across the posterior disc, which seems to aid and protect the disc from degeneration and assist rotation (Penning 1988; Mercer S and Bogduk 1999; Bogduk and Mercer 2000; Mercer S 2003). The disc also becomes split into cranial and caudal sections (Penning 1988; Mercer S 2003). This is a normal development in the cervical disc of adults and coincides with the development and maturation of the uncinate processes (Mercer SR and Jull 1996; Mercer S 2003). The NP also has higher levels of collagen, which are thought to be reflective of the stresses incurred in the C/S (Mercer SR and Jull 1996). Developmentally, the NP in the cervical disc at birth is only about 25% of the total disc (Mercer S and Bogduk 1999).

In summary, there are large morphological, biochemical and functional differences between cervical and lumbar discs as listed above.

Secondly, remember that the disc is not whole - there are clefts that develop in the cervical disc that allow rotational movement and that these clefts seem to be related to the uncinate process size.

Also, Grubb and Kelly (2000) [Grubb SA and Kelly CK (2000). Cervical discography: clinical implications from 12 years of experience. Spine 25(11): 1382-1389.] speak about many levels contributing to pain. Where you mention that the patient had many levels of disc herniation, the likelihood of just C5/6 (which is indenting the thecal sac and nerve root) being the only cause of arm pain is quite unlikely.

So to help you help this patient, I would not worry too much about the disc herniation but treat what i find. You don't mention how long the patient had the pain for nor how he got the pain to begin with. Was massive trauma involved like a bad car accident or did the pain begin slowly?

If you find restricted motion, why is it restricted - bony or myofascial?
If you find neuro signs, which nerves? Do neuromobes help?
If you find poor stability during load transfer tests, does stabilising the segment during loading (like lifting an arm) help?

Please give more information about your patient so we can help...

Thanks

[kpc_23]

thanx a lot for the info. its new to me n will look into it in the future.