Chapter 5 Discussion, Conclusion and Suggestions

DISCUSSION
Cervical radiculopathy is one of the common conditions resulting in neck pain

and associated upper extremity pain, numbness and weakness, which often

result in significant functional limitations and disability (Benini, 1987).

Several intervention strategies are commonly used in the

management of cervical radiculopathy and range from conservative

approaches, including physical therapy to surgical intervention (Heckmann et

al. 1999).

Honet et al. (1976) shown that people treated with conservative

management approaches may experience outcome superior to those

achieved with surgical intervention. Melloni et al. (1979) cervical disc

herniation and osteophytosis are the two most common space occupying

lesions that causes Cervical Radiculopathy. Jenis & An (2000) a cervical disc

herniation frequently impinges or encroaches upon cervical nerve root,

causing inflammation. The impingement of the cervical nerve root may cause

radicular symptoms. The radicular symptoms tends to follow a dermatomal

pattern, depending upon which cervical nerve root is impinged (Tanaka et al.

2000).

This study was done to compare efficacy of conventional

physiotherapy along with upper limb tension test 1 and intermittent cervical

traction along with upper limb tension test 1 in patients with C5-C6

radiculopathy. A total of thirty subjects participated in the study. Improvement

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in all patients was assessed using upper limb tension test 1, neck disability

index and visual analogue scale.

t-test value showed that there was significant improvements in

pain, disability & elbow extension range of motion in ULTT 1 for both the

intervention groups but group treated with intermittent cervical traction along

with upper limb tension test 1 showed better results.

In the study for upper limb tension test to act as outcome measure,

elbow extension range of motion was measured in position of ULTT 1. Elbow

extension showed a mean gain of 8.2 degrees in conventional physiotherapy

with ULTT 1 group (Group A) and a mean gain of 16.86 degrees in

intermittent cervical traction along with upper limb tension test 1 group (Group

B). Although improvement score or mean gain is significant for both the

Groups but Group B is more efficient in improving elbow extension in position

of ULTT 1 i.e. showing better result.

Neck Disability Index (NDI) shows mean reduction of 6.46 in

conventional physiotherapy with upper limb tension test 1 group (Group A)

and a mean reduction of 12.2 in intermittent cervical traction with upper limb

tension test 1 group (Group B). Although improvement score or mean

reduction is significant for both the groups but Group B is more efficient in

reducing neck disability or NDI score i.e. showing better result.

Visual Analogy Scale shows a mean reduction of 2.33 in

conventional physiotherapy along with upper limb tension test 1 group and a

mean reduction of 3.46 in intermittent cervical traction with upper limb tension

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test 1 group (Group B). Although improvement score or mean reduction is

significant for both the groups bur Group B is more efficient in reducing pain

or VAS score i.e. showing better result.

Therefore it is concluded that intermittent cervical traction along with

ULTT 1 (Group B) is more effective in improvement of pain, disability & elbow

extension range of motion in upper limb tension test 1 when compared with

conventional physiotherapy along with ULTT 1 (Group A) for treatment of C 5-

C6 radiculopathy because of:

 Traction enlarges the intervertebral foramen and eliminates direct

pressure on the nerve root. Increased intervertebral foramen helps

nerves to tense more when undergoes neurodynamic testing; thus

improving elbow extension range of motion in ULTT 1.

 Traction enlarges intervertebral segment with reduction of intradiskal

pressure, allowing displaced or protruded parts of the disk to return to

their original site, this also relieves pressure on nerve relieving pain &

allowing more space for nerve to be tensed during neurodynamic

testing; thus improving elbow extension range of motion in ULTT 1.

 Traction stretches intervertebral ligament and paravertebral muscles.

Muscle spasm caused by the intervertebral compression syndrome;

relaxes and pressure on neural elements and blood vessels is

reduced. All these helps to reduce pain, disability which in turn leads

to increase in elbow extension range of motion in ULTT 1.

 Traction increases the volume of the disk. This reduces the pressure

further. Pressure can even become negative with a strong enough

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traction. The pressure gradient between extradiskal and intradiskal

space accelerates fluid movement in the direction of the disk. With

increased space pressure is relieved from nerve root which in turn

reduces pain, disability & elbow extension range of motion in ULTT 1.

 Upper limb tension test 1 leads to improved neural blood supply,

helps in mobilization of scar tissue, effecting C-fiber mediated pain

perception, improved axoplasmic flow & increased flexibility of somatic

connective tissue. Due to these effects levels of pain, disability &

elbow extension range of motion in ULTT 1 improved.

 Local heating relieves pain by activation of pain gate mechanism. This

helps to improve VAS & NDI scores.

 Local heat reduces muscle spasm by reducing levels of ischaemia &

changes the output of muscle spindle and type 1 golgi tendon organ

fibres, this lead to inhibition of motor neuron pool & thus reduces level

of muscle excitement. Utilizing these effects level of pain & disability

are reduced.

 Local heat influences the speed of conduction of the motor nerves and

the activity of the spinal α and γ-motor neurons, so as to relax painfully

tense muscle zones. By relieving muscle spasm pressure on neural &

vascular structures decreases leading to pain relief & reduced

disability.

 Neck isometrics prevent or minimize muscle atrophy, facilitate muscle

firing, develop joint stability & improves dynamic and static muscle

strength. These effects accounts for reducing levels of disability.

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David and Richard (2004) used

intermittent cervical traction in a position of slight cervical flexion

because it is likely more effective in this population than intermittent

cervical traction in a more neutral position. Bradnam et al. (2000)

documented that traction cannot prevent degeneration of the disk, but

can temporarily change the height of the disk space and counteract

the changes occurring in night-day rhythm. Minimal increase in the

height of the disk space can often result in pain relief, especially when

a protruded disk or an uncovertebral osteophyte encroaches on the

nerve root.

Constantoyannis et al. (2002) concluded that intermittent

cervical traction has been widely purported to be an effective

intervention in treating cervical pathology with radicular symptoms.

Saal et al. (1996) described a study of 26 patients with cervical disc

herniation that were managed with traction and other conservative

measures. The authors found that a broad spectrum of conservative

care, including traction, appeared to help alleviate arm pain in patients

with cervical radiculopathy and reduce their chances of having surgery.

Mark Waldrop (2006) published a case series provided low-level

evidence that intermittent cervical traction used with a multimodal

approach may help centralize and reduce the symptoms in patients

with cervical radiculopathy. Akbino et al. (2006) published a study

examining what the most beneficial amount of total body weight (TBW)

would be for cervical traction. Trials were done with patients randomly

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assigned to 1 of 3 groups; with each group receiving traction of 7.5%,

10% or 15% of patient’s total body weight demonstrated the highest

therapeutic efficacy with the fewest side effects, compared with the

7.5% and 15% total body weight groups.

Butler (1994) described aim of the neurodynamic technique

was to mobilize scar tissue likely to be present, improve neural blood

supply and physiological function (e.g. axoplasmic flow). It should be

noted that neurodynamic techniques do not solely affect neural tissue.

Consequently changes in surrounding non-neural connective tissues

are expected. Recent anatomical studies demonstrated that

innervated non-neural tissue in the cervical spine undergoes

deformation during the ULTT (Kenneally et al. 1988). As a result of

neural mobilization, nerve conduction improves, nerve fibre in spinal

cord straighten and are tensioned during tension test (Shacklock et

al. 1994).

I. Zvulun (1998) concluded that influences of neural

mobilization include: improved neural mechanics, physiological

function, increased flexibility of somatic connective tissue, improved

motor performance and influences on pain mechanisms. Murphy et al.

(2006) incorporated neural mobilization in the management of patients

with cervical radiculopathy. Seventy seven percent of patients at the

short-term follow up and 93% of patients at the long term follow-up

exhibited a clinically important decrease in disability. Jason Beneciuk

(2009) demonstrated that neural mobilization tensioning had an

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immediate hypoalgesic effect on C-fiber mediated pain perception, but

not on A-delta fiber mediated pain perception. Coppieters et al. (2009)

described that neural mobilization technique also resulted in

improvements in elbow extension range of motion and sensory

descriptors at 3 weeks and the carryover assessment. Increased elbow

extension range of motion measures was result of longitudinal

elongation of the nerve bed.

On et al. (1997) suggested that the major pain relieving

effects of local heating are mainly reflex, possibly an activation of the

pain gate mechanism. Wright and Sluka (2001) concluded that heat

reduce muscle spasm by reducing the levels of ischaemia associated

with prolonged contraction in affected muscles. Gregory Grieve (1998)

suggested that the application of heat in its many forms is an important

component of the treatment of cervical disk syndromes, particularly

when the pain is acute. Heat exerts its beneficial effect through

hyperaemia and release of tension in the shoulder and neck muscles.

This is followed by a comparable reflex effect in the corresponding

motion segment.

Hoving et al. (2002) & Ylinen (2003) concluded that

the primary aim of cervical exercises in patients with cervical

radiculopathy is to restore normal flexibility, stability and postural

mechanics. Therefore, weak cervical stabilizers were targeted with

strengthening and conditioning exercises and limitations of normal

cervical spine movement were addressed with flexibility exercises.

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Postural correction is also frequently addressed in an attempt to

decrease abnormal mechanical stressors placed on the cervical spine.

Omer & ILhan (2003) noted that superficial thermotherapy in patients

with cervical spondylosis showed statistically significant improvement

on VAS scale for neck and arm pain on rest & during movement.

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CONCLUSIONS

The major findings of the study are summarised as follows-:

 Differences are statistically significant for Visual Analogue Score (VAS)

in both Groups A & B with more improvement score (mean difference)

in intermittent cervical traction along with ULTT 1 group i.e. B group at

the end of twenty two day protocol.

 Differences are statistically significant for Neck Disability Index (NDI)

score in both groups A & B with more improvement score (mean

difference) in intermittent cervical traction along with ULTT 1 group i.e.

B group at the end of twenty two day protocol.

 Differences are statistically significant for Elbow Extension range of

motion in ULTT 1 in both groups A & B with more improvement score

(mean difference) in intermittent cervical traction along with ULTT 1

group i.e. B group at the end of twenty two day protocol.

 It is concluded that intermittent cervical traction along with upper limb

tension test 1 is an effective treatment approach for C5-C6

radiculopathy as compared to conventional physiotherapy along with

upper limb tension test approach for improvement of pain, disability &

neural tensioning.

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SUGGESTIONS

 Cross validation on larger population.

 Study can be done with gender specification.

 Study can be done with follow up.

 Replication of study in terms of parameters like cervical goniometry,

Nottingham Health Profile (NHP).

 MRI analysis of changes in cervical cord and neural components

before & after treatment.

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