Chief Fellow, Regis University Fellowship In Orthopedic Manual Physical Therapy

Thrust and Non-Thrust Manipulation in the Management of Cervical Radiculopathy – A Case Report 1 MacDonald C , Hammond L & MacDonald S 1-

Manual Therapy Fellowship

Chief Fellow, Regis University Fellowship in Orthopedic Manual Physical Therapy Functional Outcomes

Case Description:

Background: Clinical management of patients presenting with symptoms consistent with cervical radiculopathy1 has recently been focused on direct non-thrust cervical mobilization, thoracic thrust manipulation and cervical lateral glides 2,3 combined with neural mobilization .

P1 – Severe burning pain from neck to half way down forearm. Directly related pain down dorsal scapula and into axilla.

Pain did not extend past 6 inches proximal to wrist

• 44 year-old female with two weeks severe neck and right arm pain radiating to approximately six inches above the wrist. Self attempted mobilization C/S, self traction of R UE with internal rotation and L CS flexion. • Presentation was consistent with right C5 radiculopathy, referral diagnosis was dorsal scapular nerve impingement with cervical myopathy. (refer body chart) • Baseline measures DASH index of 28%, NPRS 10/10. High irritability, NDI at 4th visit 18% • First four visits comprised evidence based treatment for cervical radiculopathy including lateral cervical glides with neural mobilization, cervical traction and thoracic thrust manipulation. • Secondary to lack of progress, and assessed clinical impairments, traction gapping manipulation of the cervical spine in combination with neural mobilization was completed for two visits (5 & 6). • With clinical progression post visit 5 & 6, initial treatments were re-introduced for the last two sessions with additional neuromuscular re-education of deep neck flexors and peri-scapular muscles. • MRI completed after 2nd visit, with results obtained prior to 4th visit showed severe right foraminal stenosis of C4/5 which was completely unchanged despite full resolution of symptoms at repeat imaging 3 months later.

Results: • Nocturnal symptoms significantly decreased post visits five and six. Discharged after eight sessions. • NDI 0%, DASH 0%, and NPRS 0% after 8th visit • Follow up MRI at three months showed no change in patho-anatomy at any cervical level. • Patient was symptom free at six months, minimal cervical motion restriction without significant functional restrictions reported at twelve months.

Body Chart (symptom paths)

Purpose: This case report describes the clinical management of a patient with initially non-responsive cervical radiculopathy to usual manual PT care with first nonthrust traction manipulation combined with neural mobilization, then thrust traction manipulation combined with neural mobilization.

Pictures: R neutral gapping with traction of UE, R C/Spine up-glide manipulation with early neural tension, progressive rotation with traction and lateral break traction manipulation with mid-point neural gliding. Manipulation in combination with moving nerve glide/slide not shown. Ref: 1 – Wainner RS et al. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient self-Report Measures for Cervical Radiculopathy. Spine. 2003;28:1,52-62. 2 - Cleland J et al. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. JOSPT. 2005;35:802-11. 3 – Coppieters MW et al. The Immediate Effects of a Cervical Lateral Glide Treatment Technique in Patients with Neurogenic Cervicobrachial Pain. JOSPT. 2003;33:369-378.

100

90

NDI

DASH

80

NPRS 70

60

50

40

30

20

10

0

Baseline

4th visit

5th visit

8th 6 months visit/DC

Conclusions: The utilization of thrust high-velocity low amplitude cervical traction manipulation, in combination with neural mobilization, following clinical non-response to best evidence interventions for cervical radiculopathy, led to complete symptom resolution in this patient case. Clinical Relevance: No cause and effect can be established by this case report, but the unique combination of manual physical therapy techniques described, offers the potential for further options in impairment based management of patients with non-responsive cervical radiculopathy. The lack of change in repeat MRI study provides support for impairment based interventions over imagery based interventions.