cervical radiculopathy

[sharadphysio]

hi guys!!
i got a query regardin a case of cx radiculopathy.pt 40 yr old female suffering from neck pain with tingling numbness in lt arm and hand,to be specific pt has tingling numbness in resting position this happens quite a lot thruout day,frequency of tinglin is 15 times/day approx.,no muscle weakness present,cx movts r free,x ray shows severe osteophytic changes at various level
treatment tried-
1)started with swd to neck with cx traction(mechanical)gradual progression
no significant improvemnt with above traditional protocol
2)manual traction gives temporary relief-pt does not have symtoms during traction -symtoms improves with manual traction -tried for 10 days but in vain
3)cx lateral glides with neural tissue mobilization-median and radial nerve biased are positive
pt had tremendous improvemnt on the following day , hardly had tingling in hand but did not last long-again the frequency is 12 to 14 times /day
4)now pt is only doing neural tissue mobilization-auto streching with thera band
5) tried with improving posture since pt has forwar head posture...strengthning deep neck flex with chin tuck also creates tingling in hand????????
i m bit confused how to go about the case????/
plez guide
reg.
bye

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[gcoe]

Hi Sharadphysio

Sounds like you are generally proceeding through things logically. The fact that you get temporary relief seems significant to me. Only thing is point number 3. It looks to me like you may have dropped the ball here. As the improvements were dramatic even if just temporary maybe you need to unpackage this. Did you combine both lateral glides + neural mobs from the start? If so that wasn’t very logical. Did you only do the combination of lateral glides + neural mobs once? From what you have written it isn't clear if it was the lateral glides or the neural mob that improved matters (or if it was both). Maybe you should go back to just applying the lateral glides, see if you get an improvement just with this and apply a few times. If you don't get an immediate response then you know that probably wasn't easing technique. Then you could work on just applying the neural mob, but do it several times and do it yourself rather than self stretches. In short: refine your detective work so you can identify the technique that may likely provide the most benefit on reapplication and progression.

A couple of things to consider:

Do you think the radiculopathy has an inflammatory component (Go back to your 24hr behaviour and irriatbility). If yes this may be why it isn't settling. The mechanical therapy is providing a temporary space for the nn root but on release of the technique several hours/day or two later their is mechanical irritation of the inflamed nn root.

Are you sure the paraesthesia and numbness is due to nerve conduction problems? the positive ULTT with radial bias would suggest that. However think about the dermatome. Does this match? There is no frank weakness, Is the numbness both subjective and objective? If only subjective could it be epiphenomena eg. trigger point or autonomic as in T4 syndrome? If so the temporary response to treatment might be more due to the pain gate mechanism rather than mechanical effects. So why don’t you go back and really confirm your neuro signs

Do we have an opinion from a MSK physiotherapist who may be more on to it than me?

[sharadphysio]

thanx gcoe for ur prompt response
u mentioned some points
like trigger point....since the pt is getting symptoms in palm and also there is radiation component present ,i doubt it could be becoz of trigger point??
2)u mentioned to check with dermatome!!!clinically and subjectively pt has c5,c6,c7 and c8 dermatome involvement mainly parasthetias.
3)inflammatory component!!
had it been inflammtory it could have been more irritable????? but for me it seems moderately irritable (between irritable and non irritable)...as pt has been doing neuro tissue mobi successfully.....without provoking with progression of stretches
my queries over ur comment---
as i have mentioned in previous note pt has severe degenerative changes in cx spine x ray so how much we can go with cx mobi?
secondly,i mentioned in the previous note,pt gets tigling with neck isometric contractions??i tried with towel exr....when i tried with pressure feed back with mild contractions so symptoms but with vigorous contractions she gets the same???? so i m a litle confused about the region of involvement i mean primary....whether upper cx is primary or lower cx ?????

ur take on this

thanx

[gcoe]

like trigger point....since the pt is getting symptoms in palm and also there is radiation component present ,i doubt it could be becoz of trigger point??

Trigger points follow non dermatomal patterns. And then there is the satellite phenomenon where a more proximal muscle will invoke myofascial symptoms more distally Have a look at my commnet about the scalenes below re: distribution of symptoms into the hand. So you have to actually check for trigger points. It seems you haven't done this.

u mentioned to check with dermatome!!!clinically and subjectively pt has c5,c6,c7 and c8 dermatome involvement mainly parasthetias.

That is a very extensive dermatome distribution. If it was a radiculopathy it should really match one segment. Possibley it could be more dital BP involvement, or pseudo-neural symptoms from ANS or trigger points. And you haven't really answered my question about objective signs - you need to do sensory testing to try to sort this through.

as I have mentioned in previous note pt has severe degenerative changes in cx spine x ray so how much we can go with cx mobi?

I think this is a pertinent point. However basing a decision on plain xray is not a solid foundation for cause-effect thinking. All the xray is telling you is that here are signs of severe degeneration - doesn't indicate that the symptoms are necessarily due to one of the patho-physiological processes underlying the degeneration (osteophytes, spondylosis episode etc). The relationship between visible degeneration and severity of symptoms is notoriously unreliable. As you achieved a temporary but effective-at-the time improvement in symptoms isn't that what you should be proceeding with first? You haven't answered my question about whether it was lateral glides or BP mobs that relieved her symptoms. You really have to go back and look at this.

pt gets tingling with neck isometric contractions??i tried with towel exr....when i tried with pressure feed back with mild contractions so symptoms but with vigorous contractions she gets the same????

Do you mean she gets NO symptoms on mild contractions? I am not sure if this is really going to be very instructive. The onset of symptoms could be due to:
* contracting the muscles around the course of the brachial plexus thereby increasing adverse neural tension - but that doesn't tell you where
* compressive force generated on the offending cervical mobility segment thereby increasing encroachment of the spinal nerve
* flexion movement of the cervical spine or a combination of movement + compression. Again not very instructive.
* active contraction of of para cervical muscles that have trigger points. For example the scalenes produce symptoms into the lateral forearm thumb and forefinger and back of hand. If your patient has trigger points.

I think your thinking has become clouded and you have to go back to a getting a clear diagnosis.Giving her exs of whatever sort at this stage means you are just working in the dark. In the long term ex's may be warranted but you have to have a clear reason for doing them. On the positive side you have effected a significant but temporary improvement so this gives you a lead in your diagnosis.

[sharadphysio]

hi! thanks for ur second reply to my counter queries
ur suggestions
1)trigger pts
yes ..u r absolutely right..that trigger point refer pain in non dermatomal pattern.as far as i know neck muscles like trep.,suboccipital ,levator scapulae etc.-have referral pattern in arm max till elbow.From ur response i came to know about scalane referral area which is in hand and forearm.my pt had trigger point in trep.so with local pressure on trigger point,the pain used to get referred in distal arm,after treating the triger point,the severity of paresthetias has been reduced but not completely abolished.still pt get paresthetias in dorsal hand and fore arm(as per ur advice i wil certainly check for trigger point in scalenae which i have not checked yet)
i also would like to know the muscles(trigger point) which refer pain in distal hand and fore arm.

2)secondly,objective signs
pt does not have significant positive objective finding which is a bit confusing me.pt's neuromeningeal extensibility was reduced initially,now with neu. tissue mobi. the frequency of paresthetias in hand and fore arm has been reduced but again not completely abolished.(i have seen gradual improvement with addition of components of neu.tissue mobi.)so it gives the answer for one of ur query which says whether neu.tissue mobi has affected the symtoms or not.yeah...but i am not sure about cx lateral glide which i applied during the course of treatment...so i m not sure about lat glide effectivity.

3)one more thing ....according to u which cx mobilization is effective for radiculopathy cases
i mean whether cx lat glide or unilateral post ant mobili. or plain post ant mobi
since in this particular case what i found with passive physiological movt test of cx spine-post ant mobility ,unilateral post ant mobility and cx lateral glides........were significantly reduced....any experience with this issue???

thanx

[gcoe]

Hi Sharadphysio

i wil certainly check for trigger point in scalenae which i have not checked yet)
i also would like to know the muscles(trigger point) which refer pain in distal hand and fore arm.

have you looked at Travell and Symmond's book:
Travell & Simons' Trigger Point Manuals (Volumes 1 & 2)

these books are old but they give great information and illustrations are impeccable. The first volume covers the upper quadrant. the treatments are more oriented towards physicians - coolant spray, needling etc. However stretching the muscle is useful and often when combined with STM and ischaemic pressure on the TPs.

pt does not have significant positive objective finding which is a bit confusing me

Neural examination is not that reliable and I understand there is some doubt cast on its validity. At present it is still consider an essential part of the examination. A negative result could be due to:

a false negative - either the test was not accurate enough to pick up an impairment
a true negative - the symptoms your patient has are not due to neural deficit as such. In which case this supports an alternative hypothesis such as the trigger points or possibly an autonomic component such as in T4 syndrome.

but i am not sure about cx lateral glide which i applied during the course of treatment...so I am not sure about lat glide effectivity.

This is why it is important to be empirical. Only introduce one technique at a time and observe the response. You can use more than one treatment at a time but never introduce techniques simultaneously. However rather than going back to this now you have established that neural mobs may have at least a partial beneficial effect. Or is the improvement just due to a change in the patient's presentation?

one more thing ....according to u which cx mobilization is effective for radiculopathy cases
i mean whether cx lat glide or unilateral post ant mobili. or plain post ant mobi
since in this particular case what i found with passive physiological movt test of cx spine-post ant mobility ,unilateral post ant mobility and cx lateral glides........were significantly reduced....any experience with this issue???

Do you mean the movements were stiff? Have a read of Maitland (vertebral manipulation). In selecting the technique usually cervical rotation (appropriate angle of flexion to emphasise the lower cervical segments) away from the side of the symptoms is a good starting point. Traction is often a second choice but you have already tried it. In choosing a technique you need to be aware that just as it can do good it can also cause harm in the case of a radiculopathy. However I think you need to read about this. And certainly you still haven't diagnosed the problem. You have complete a thorough reassessment before going on to these techniques. And you really must know how to apply the techniques - something that can't be done over the internet.

sharadphysio I hope you won't take offence at this comment but I think it needs to be said. You obviously are interested in this area of physio but you seem quite lacking in knowledge and approach. Have you considered completing a post graduate qualification? At the very least you need to read more widely. What books do you have?

Will be interested to know how you get on with your patient.