1. Cervical Radiculopathy Following MVA
Case Study
Ramsee Pagel, SPT
Regis university
Summer 2010

2. Objectives
The student will be able to understand the relationship between pathology and presentation of cervical radiculopathy following a MVA
The student will examine and understand the current best evidence supporting physical therapy intervention for cervical radiculopathy.
The student will be able to understand the examination, evaluation, and intervention for those patients who present with cervical radiculopathy following MVA.

3. Purpose
To examine whether physical therapists are selecting interventions using an evidence based approach when treating patients who present with neck pain and radicular symptoms following trauma.

4. What we know… Pathology Pt Presentation
Nerve root compression, inflammation, or improper function
Radicular symptoms
Herniated disc
Degenerative changes in the spine
Other injuries (trauma)
Pt Presentation
Neck pain
Arm pain
Numbness and tingling in the UE
Pain will occur anywhere along the nerve root distribution

5. What we know…
Using the knowledge we have learned in our education up to this point:
Clinical Prediction Rule – Cervical Radiculopathy
(+) ULTT A
(+) Distraction
(+) Spurlings
Ipsilateral Cervical Rotation <65°
Wainner et al., SPINE, 2003.

6. History
Pt is a 33 year old female who works as a Respiratory Therapist.
Pt was referred to physical therapy following an MVA.
Rx: Evaluate and Treat (4/20/2010)
Dx: Levator scapulae syndrome with cervical strain and right SI joint strain s/p MVA.
Treatment Dx: Decreased cervical AROM with right UE radicular symptoms and pelvic asymmetry with piriformis dysfunction.

7. History
PIPs: pain limiting reaching overhead and her abilities to lift and care for her three children.
At the time of initial examination, the patients stated that her low back pain was limiting most of her activities and the UE/Cervical spine symptoms were not as limiting.
Images (plain films) were taken following the accident and no abnormalites were noted.
A cervical MRI was also done after 10 PT visits
Mild disc herniation at C4-C5 with no signs of cord compression.

8. Patient Presentation PROM UE: WNL
AROM UE: Bilateral shoulder flexion limited by 20 degrees secondary to pain
AROM C-spine: flexion/extensionWNL, right rotation 65°, left rotation55°
UE Strength: 4/5 throughout bilaterally with pain during testing
Reflexes: Bilateral UE reflexes2+ throughout
L UE Pain: 9/10
Neck Pain: 9/10
LBP:10/10
NDI: 44%severely disabled
ODI: 40%moderately disabled

9. Cervical Special Tests
At initial examination:
(+) Sharp Purser
(+) Right Spurlings
(-) Left Spurlings
(+) Distraction
(-) ULTT Bilateral
Median
Ulnar
Radial

10. Differential Diagnosis
Cervical Radiculopathy
Fracture
Vertebral
Scapular
Humeral
Shoulder Impingement
Biceps Tendonitis/Bicep Tendon Rupture
Rotator cuff inflammation/rupture

11. Other Factors Psychological
Frequent flashbacks
High anxiety
Little to no sleep
Fear about the inability to work and properly care for her 3 children
Pt was seeing a clinical psychologist 2x/month for counseling

12. Clinical Decision Making
Using the patient identified problems, the initial intervention was directed towards the low back and pelvic asymmetry.
Secondly, since the patient did not fall completely into any of the clinical prediction rules, cervical mechanical traction was not immediately initiated.
Functional goals were set to decrease overall pain, improve mobility of the cervical and lumbar spine, and increase the patients overall function.

13. Response to Intervention
Pt reported 1/10 LBP following 10 treatment sessions
Interventions:
Pelvic MET
Core Stabilization Exercises
Lumbar Flexion Manipulations
Prone PA Thoracic Mobilizations
IFC with HP
Pt reported slight decrease in neck and arm pain after 10 visits
STM
Rotational MET
Sub-Occipital Release
Manual Distraction
Cervical Segmental Mobilizations

14. Cervical Special Tests
After 10 visits:
(+) L Spurlings
(-) R Spulings
(+) Distraction
(+) Shoulder Abduction Test
(+) ULTT A
(-) Sharp Purser
R Rotation: 65°
L Rotation: 42°
NDI score 48% (severely disabled)

15. What the Evidence Says…
Treatment Based Classification System
Which category does the pt most match?
Were the interventions provided matched to that category?
At initial examination?
After 10 visits?

16. Treatment-Based Classification
Fritz, J. Brennan, G. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther, 2007.
Purposes of the study
Examine proposed treatment-based classification system by describing prevalence of subgroups in a sample of patients receiving PT for neck pain
Compare other characteristics of patients placed in these subgroups

17. Decision Making Algorithm

18. Neck pain classification categories and matched interventions
Mobility
Mobilization/ Manipulation of cervical or thoracic spine
Strengthening exercises for the deep neck flexors (DNF)
Centralization
Mechanical or manual cervical traction
Cervical retraction exercise
Exercise and conditioning
Strengthening exercises for upper-quarter musculature
Strengthening exercises for neck/ DNF
Pain control
Cervical spine mobilization
Cervical range-of-motion exercises
Head Ache
Cervical spine manipulation/mobilization
Strengthening exercises for DNF

19. Results 297 patients with neck pain were evaluated
274 were included in analysis
113 (41.2%) patients received interventions that matched prespecified treatment components
161 (58.8%) received nonmatched interventions
Patients receiving matched interventions showed greater changes in both NDI and pain rating scores.
Among patients receiving matched interventions, 72.5% achieved the minimal detectable change (MDC), whereas only 53.8% of patients receiving nonmatched interventions did so (p=.002).

20. Exercise and Conditioning
Where do we go from here?
Using the treatment based classification system:
Initially, the pt fell mostly into the pain control category
After 10treatment sessions, the pt fell more into the centralization category
Mobility
Centralization
Pain Control
Headache
Exercise and Conditioning

21. Matched Intervention- Mechanical Traction
Raney, N. et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J
Parameters- Traction
Angle of pull: 24° flexion
On/off cycle: 60:20
Initial pull: pounds
Progressed per patient tolerance
Maximum pull: 40 pounds
Rest force: 50% of pull force
Total time: 15 minutes
Exercise protocol
DNF and Postural exercises (scapular squeezes)

22. Matched Intervention- Mechanical Traction
Clinical Prediction Rule- Success from mechanical traction and exercise
Patient reported peripheralization with lower cervical spine mobility testing
(+) ULTT A
(+) Distraction
(+) Shoulder Abduction Test
Age ≥ 55
Likelihood of patient reported success
5/5=100%
4/5=94.8%
3/5=79.2%
Raney, N. Eur Spine J

23. Matched Intervention Mechanical Traction and Exercise
Initiated after 12 visits
Parameters:
Max pull 14 pounds
Total pull time 6 minutes
Intermittent 60:10

24. Intervention Progression
Traction pull was progressed after 4 sessions
Max pull 16 pounds
Total pull time 6 minutes
Intermittent 60:10
Pull was then progressed by 2 pounds each session per pt tolerance
Total pull time was also progressed by 2 min each session per pt tolerance
At the conclusion of CE II
Max pull24 pounds
Total pull time14 minutes

25. Exercise and Manual Therapy Interventions
DNF10 x 10 sec
Theraband Rows blue band x 15
Theraband Extenstions blue band x 15
Scapular Squeezes x 20
Cervical rotation MET
STM
Manual Scalene Stretch
Subocciptal Release
Prone PA Thoracic Spine Mobilizations
Cervical Segmental Mobilizations

26. So what can we expect??
Cleland, J. et al. Predictors of short-term outcome in people with the clinical diagnosis of cervical radiculopathy. Phys Ther
Purpose: to determine which factors noted at baseline evaluation can be predictive of short term outcome in patients with the clinical diagnosis of cervical radiculopathy.
Outcomes used:
NDI
NPRS
PSFS

27. So what can we expect?? Results:
The study design did not allow for a cause and effect relationship to be established
The results suggest that mechanical traction, deep neck flexor strengthening, postural education, and manual therapy may be beneficial in the management of cervical radiculopathy
With 3 of the 4 treatment variables present the +LR=5.2 with the posttest probability of success =85%

28. Pt Presentation On 7/2/2010 VAS 3/10 neck VAS 3/10 L UE
Pain is inconsistent and is much worse at night
Pain is still limiting her ability to perform ADL’s
NDI: 30% moderate disability
Pt states she is feeling much better but it is a slow process and she just wants to be able to be a mom with no pain again.
Pt continues to have 0-1/10 LBP

29. What could have been done differently??
Utilized other outcome tools?
FABQ
PSFS
Reassessed more frequently?
Progressed traction more frequently using the published literature?
Pt tolerance/anxiety levels

30. Check For Understanding
1. Which of the following is not a test included in the CPR for cervical radiculopathy?
A. Cervical Distraction
B. Craniocervical Flexion
C. Spurlings
D. ULTT A
2. T/F: all patients will fall into a single category according to the treatment based classifications.
3. T/F: there is evidence to support the use of mechanical traction, manual therapy, and exercise in the management of patients with cervical radiculopathy.

31. Questions??

32. References
Cleland, J. et al. Predictors of short-term outcome in people with the clinical diagnosis of cervical radiculopathy. Phys Ther
Fritz, J. Brennan, G. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther, 2007.
Raney, N. et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine