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Treatment for Cervical Radiculopathy: Skip the Traction
Physical therapists often treat patients with neck and arm pain from cervical radiculopathy. A variety of modalities are used. Modalities are treatment tools. For cervical radiculopathy these modalities include traction, postural education, exercise, or manual therapy. In this study, physical therapists attempts to find out if manual therapy and exercise work better when cervical traction is part of the treatment plan.
Cervical radiculopathy is another term for a pinched nerve in the neck. Pressure on the nerve roots as they exit the spinal column causes cervical radiculopathy. The most common problems leading to spinal nerve root compression are cervical disc protrusion, bone spurs, spinal joint degeneration, and other age-related changes in the cervical spine.
Any condition that puts pressure on the nerves where they leave the spinal column can result in cervical radiculopathy. Cervical radiculopathy occurs most often around age of 50 years old and older. As the spine ages, several changes occur in the bones and soft tissues.
The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.
Spinal instability is another cause of cervical radiculopathy. Instability means there is extra movement among the bones of the spine. Instability in the cervical spine (the neck) can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability.
Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical radiculopathy.
One of the goals of research is to find homogenous groups of patients with cervical radiculopathy who respond well to a specific treatment. Homogenous means they are alike in some way. The best way to match up homogenous groups with successful treatment techniques is to identify clinical prediction rules (CPRs). A clinical prediction rule for treatment identifies the best combination of signs, symptoms, and other findings that predict a high probability of a successful outcome.
There have been some efforts to find a CPR for the diagnosis of cervical radiculopathy but the research is still in its infancy. Making sure the patient really has a cervical radiculopathy is essential in testing for successful treatment approaches. So far, a diagnostic CPR for this condition has been defined, but it hasn't been tested enough to be validated yet. The authors used the current CPR while letting the reader know the present status of this portion of the research.
Patients with single-sided arm pain, numbness, and tingling with or without neck pain were tested for cervical radiculopathy. A physical therapist performed the diagnostic testing using the current CPR. There are four tests in the diagnostic CPR: Spurlings test, distraction test, upper-limb tension test, and neck rotation test. Patients who had a positive test on three out of the four tests, were considered to have cervical radiculopathy and were included in the study.
They divided the patients into two groups. One group was treated with manual therapy, exercise, and intermittent (on and off) cervical traction. The second group had the same treatment but the traction was a sham (pretend) treatment. Everyone received two treatments a week for four weeks. There was no control group -- in other words, patients who received no treatment.
Manual therapy involves moving the cervical (neck) spinal joints gently using a technique called mobilization or with force, a technique called manipulation. Postural exercises focused on strengthening neck and upper back muscles and pulling the head and neck back toward the spine, a movement called cervical retraction. This is a movement like turtles use to pull their heads back into their shells. The effect is to take pull and pressure off the spinal cord and spinal nerve roots.
Intermittent cervical traction pulls the head away from the spine and distracts (pulls apart) the vertebral bones. The machine cycles through on/off phases with a set amount of pull or traction. Traction force was started at 10 per cent of the patient's body weight and increased each visit in the treatment group. For the sham group, the machine was set to deliver a five-pound weight pull.
The results were measured using three areas: pain, function, and disability. Specific tests included the Numeric Pain Rating Scale (pain), Patient Specific Functional Scale (function), and Neck Disability Index (disability). Other tests administered included grip strength, patient satisfaction with treatment, and fear avoidance beliefs.
Patients in both groups got better equally. They experienced pain relief, improved function, and reduced disability. The results suggest that adding traction to manual therapy (spinal mobilization/manipulation) and exercise doesn't really add any value to the outcomes.
The authors were quick to point out some important considerations. First, it's possible that a different setting/dosage of traction might work better over a longer period of time. The results of this study don't really support doing away with traction altogether. More study is needed before that recommendation would be made. The patients received the traction lying down on their backs with their heads in a position of slight flexion. It's possible that a different head and neck angle would yield better results.
Second, it's possible that the tests used to measure results might not be the best ones for this condition treated with this treatment. Third, the sham traction still applied some force to the head and neck. This subtherapeutic traction force could have had a positive treatment effect. And finally, without a control group, there's no way to know if everyone would have gotten better after four weeks without treatment anyway.
Future studies are needed to follow-up the findings of this study. Because cervical radiculopathy can be so painful, limiting, and disabling, prediction rules are needed to make sure patients are identified early and receive the most effective treatment. Physical therapists will continue comparing treatment methods until its clear what works best for each homogenous group of patients.
Ian S. Young, PT, MS, OCS, SCS, Cert MDT, et al. Manual Therapy, Exercise, and Traction for Patients with Cervical Radiculopathy: A Randomized Clinical Trial. In Physical Therapy. July 2009. Vol. 89. No. 7. Pp. 632-642.
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