final project cervical radiculopathy

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PHYSIOTHERAPY MANAGEMENT IN PATIENT WITH

CERVICORADICULOPATHY: A CASE STUDY

Minor Project

Submitted in partial fulfillment for the award of degree of

BACHELOR OF PHYSIOTHERAPY

SUBMITTED BY:

PREETI YADAV

Roll no. 0817141

BPT (Fourth year)

UNDER GUIDANCE OF:

Dr. NEERJA THUKRAL

MPT (NEUROLOGY)

DEPARTMENT OF PHYSIOTHERAPY

GURU JHAMBHESHWAR UNIVERSITYOF SCIENCE AND TECHNOLOGY

HISAR (HARYANA)

2011-2012



Dedicated To

My

Grand Parents, parents

&

To

My

Brother‟s $ sweet sister



CERTIFICATE

This is to certify that dissertation work entitled, PHYSIOTHERAPY MANAGEMENT IN

PATIENT WITH CERVICORADICULOPATHY: A CASE STUDY

submitted byPreetiYadav for partial fulfillment of requirement for the degree of

BACHELORS OF PHYSIOTHERAPY of Guru Jambheshwar University of Science and

Technology, Hisar is done under my guidance. The information given is authentic and has not

been copied from any other source.

Date: Guide

Place: Dr. NeerjaThukral, PT

MPT(Neurology),

Deptt. Of Physiotherapy

Guru Jambheshwar University

Science& Technology, Hisar.



ACKNOWLEDGEMENT

I would like to express my sincere gratitude to the following individuals without whom this

study would have been unattainable.

My sincere thanks to Dr.NeerjaThukral, MPT (Neurology), Assistant Professor,

Department of Physiotherapy, Guru Jambeshwar University of Science and Technology,

Hisar, whose guidance, constructive counseling, unmatchable suggestions, critical

appreciations and unstinted encouragement enlighten me throughout the project.

I am very grateful to Prof. D. C. Bhatt, Chairman, Department of Physiotherapy for

encouragement and for providing necessary facilities and normal support during the course of

this project.

I also thank Dr. Shabnam Joshi, MPT (Ortho), Dr.JaspreetKaur Malik , MPT (Neuro), Dr.

Manoj Malik MPT (Neuro), DrKulandaivelan MPT (sports),Dr.Pooja, AtreyMPT

(Ortho),Dr.MinaxiSaini(Cardio), ), Dr. Kalindi MPT (Cardiopulmonary), Dr. RekhaMPT

(Sports), Dr. Mamta Boora MPT (Neurology), Dr. Sonu MPT (Neurology) and Dr.Pradeep

Azad BPT for their constant inspiration and genius support in pursuing the study.

I finally thank to my friends, who rendered their invaluable help and support during my

research work.

Remarkable co-operation and dedication by subjects laid milestones for the success of project

completion.

(Preeti Yadav)



LIST OF FIGURES



LIST OF TABLE



CHAPTER - 1

INTRODUCTION



Cervical radiculopathy is a dysfunction of nerve root of the cervical spine. The seventh (C7-

60%) and sixth (C6- 25%) cervical nerve roots are the most commonly affected.

In the younger population, cervical radiculopathy is a result of disc herniation or an acute

injury causing foraminal impingement of an exiting nerve. Disc herniation accounts for 20-

25% of the cases of cervical radiculopathy. In the older patient, cervical radiculopathy is

often the result of foraminal narrowing from osteophyte formation, decreased disc height,

degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly.

Cervical radiculopathy usually starts earlier in men than in women. It develops in young

individuals, and is almost always secondary to predisposing abnormality in one of the joints

between the cervical vertebrae, probably as a result of previous mild trauma.

Symptoms of cervical radiculopathy may appear in person as young as 30 years but are found

most commonly in individuals aged between 40-60 years. Radiologic radiculopathy changes

increase as the patient ages, 70% of asymptomatic persons older than 70 years have some

form of degenrative change in the cervical spine.

Cervical radiculopathy in athletes can occur from several mechanisms. These injuries can

occur from an extension, lateral bending, or rotation mechanism, which closes the neural

foramen and results in ipsilateral nerve root injury. Conversely, a traction injury can occur

with a sudden flexion or extension, coupled with lateral bending away from the affected

nerve root.

Factors associated with increased risk include heavy manual labor requiring the lifting of

more than 25 pounds, smoking, and driving or operating vibrating equipment. Other, less

frequent causes include tumors of the spine, an expanding cervical synovial cyst, synovial

chondromatosis in the cervical facet joint, giant cell arteritis of the cervical radicular vessels,

and spinal infections.



F.g :- 1.1Cervical Vertebrae

Th cervical disc herniations can occur with a sudden load with the neck in either flexion or

extension. In elderly persons with osteophyte formation, repetitive neck extension and

rotation in certain sports, such as swimming or tennis, may result in a more insidious injury. 16

In mild cases cervical radiculopathy often requires no treatment or may respond to

conservative treatment including wearing a neck brace and pain medication.

In more serve case of cervical radiculopathy, however particularly those involving pressure

on the spinal nerve or cord, may require treatment ranging from neck traction to stronger

medication to surgery.

Medical treatment includes rest as it allows soft part to heal by reducing inflammation

NSAIDS is given, Hot fomentation, antiemetics if giddiness is present.

The aims of physiotherapy treatment are to reduce pain, strengthening of neck muscles, neck

mobilization isometric neck exercises transcutaneous electrical nerve stimulation, infrared

radiation, thermotherapy, hot fomentation, ultrasound, short wave diathermy etc.

Cryotherapy can also be given,which includes ice pack and ice massage. Massage can also be

given in form of friction, circular kneading etc for the local pain. Cervical intermittent or

static traction is given to maintain the gap between vertebrae. Cervical collar are advised

towear by the patient at home and work places.3



CHAPTER - II

ANATOMY



Cervical vertebra are the smallest of the true vertebrae, and can be readily distinguished from

those of the thoracic or lumbar regions by the presence of a foramen in each transverse

process. There are seven vertebra out of which the third to 6th

are typical,while the 1st

, 2nd

&

7th are atypical.

Typical Cervical Vertebra

1.

Body

Body is small and broader from side to side than from before backwards.

Superior Surface :- It is concave transversely with upward projecting lips on each side

and superior border of this surface may be beveled.

Inferior Surface :- It is saddle – shaped, being convex fron side to side and concave

from before backwards. The lateral border are beveled and form synovial joints with

projecting lips of the next lower vertebra. The outerior border of the vertebrae project

downwards and may hide the intervertebral disc.

Anterior and Posterior Surface

Fig.2.1 Typical cervical vertebra.

2. Arches :-

Pedicles :- These are directed backwards and laterally. The superior and inferior

vertebral notches are of equal size.

Lamina :- They are relatively long and narrow being thinner above than below.



Superior and inferior articular processes form articular pillars which project laterally

at the junction of pedicle and the lamina.

The superior articular surface facets are flat. They are directed backwards and

upwards. The inferior articular facets are also flat but they are directed forwards and

backwards.

The transverse processes are pierced by foramina transversaria. Each process has

outerior and posterior roots which end in tubercle joined by the costotransverse bar.

The costal element is represented by anterior root. The anterior tuberlia of the 6 th

vertebra is large.

The spine is short notch. The notch is filled up by the ligamentumnuche.

Fig.2.2 Side view of a typical cervical vertebra.

Atypical

cervical vertebrae

fig. 2.3 Atypical cervical vertebrae



a.) First Cervical Vertebra

It is also called Atlas.

It is ring shaped. It has no body and no spine.

Arches :- The atlas was a short anteriorasly a long posterior arche.

Anterior Arch :- The anterior arch is marked by a median anterior tubercle on the

anterior aspect.

Posterior Arch :- The posterior arch forms about 2/5 th of the ring & is much longer

than the anterior arch. Its posterior surface is marked by a median posterior tubercle.

The upper surface of the arch is marked by the behind lateral marks by a grow.

Fig. 2.4. First cervical vertebra, or atlas.

b.) Second Cervical Vertebra

This is called Axis.

(1) Body :- The superior surface of the body is fused and it is encroached upon on each side

by the superior articular facets, the anterior arch of the atlas and posteriorly with the

transverse ligament of the atlas.

(2) Arches :- The pedicles are concealed superiorly by the superior articular processes. The

inferior surface presents a deep and wide inferior vertebral notch placed in front of the

inferior articular processes.



The lamina are thick and strong.

Fig 2.5 second cervical vertebra or axis

c.) Seventh Cervical Vertebra

It is also known as vertebra promineus because of its long spinous process, the tip of which

can be felt through the skin at the lower end of nuchal furrow.

Its spine is thick, long and nearly horizontal. It is not ends is a tubercle.

The transverse processes are comparatively large in size, the posterior root is larger than the

anterior.

F.g:- 2.6. Seventh cervical vertebra.



Ligaments of cervical Region

1.

Anterior Longitudinal Ligament

2. Posterior Longitudinal Ligament

3. Cruciate Ligament

4. Apical Ligament

5.

Alar Ligament

6. Flavum Ligament Nuchal



MUSCLES OF CERVICAL REGION AND THEIR FUNCTION

1. Rectus capitus posterior major - Extension , lateral Rotation

2. Rectus Capitus Posterior Minor - Extension, Rotation

3. Superior Oblique - Extension, Rotation

4. Inferior Oblique - Rotation

5.SemispinalisCapitis - Extension ,Lateral Rotation

6.SemispinalisCapitis - Extension , Lateral Rotation

7. Splenius Capitis and Cervicis - Extantion , Lateral Rotation

8.Levator Scapulae - Extention , Lateral Rotation

9.LongissimusCapitis - Extention , Lateral Rotation

10.Trapizius - Extention , Lateral Rotation

11.Strenoeleodomastoid - Flexion , Lateral Rotation

12.LongusColli - Flexion ,Lateral Rotation

13.LongusCapitis - Flexion ,Lateral Rotation

14. Rectus Capitis Anterior - Flexion ,Lateral Rotation

15. Rectus CapitisLateralis - Flexion ,Lateral Rotation

16. Scalene muscle - Flexion , Lateral Rotation



CHAPTER - III

BIOMECHANICS



The three bony components of the upper cervical spine are

a) Skull base

b) Atlas

c) Axis

These are the three components which form a functional unit. There are five joints in the

upper cervical spine which are stabilized by ligamentous check pain and muscular control.

Together these contribute to the movements in the neck substantially. This enables for a

rapid response and large-scale head excursion.

Upper cervical spine is thought to contribute approximately 60% of rotation, 40% of flexion-

extension, and 45% of overall neck motion.

The Atlanto-occipital joint and C1 – 2 flexion/extension excursion is similar for both joints at

20 to 30 degrees at each level.

Total left to right lateral bending at the C1 – 2 segment amounts to 20 degrees.

The alar ligaments play a key role in protecting normal cranio -cervical motion. At mid

position of the head these ligaments are slack.

By turning the head in one direction, the alar ligament contralateral to the direction of turning

tightens, while the ipsilateral ligament slackens. Together with the tectorial membrane the

alar ligament limits flexion but they play no role in limiting extension.

The contralateral alar ligament limits lateral bending.

Other ligamentous stabilizers of the craniocervical junction are the cranial portions of the

anterior longitudinal ligament and posterior longitudinal ligament of the spine and joint

capsules of the respective articulations.

Anteriorly, the well-developed atlanto occipital membrane limits extension, with the thinner

anterior atlantoaxial membrane contributing to a less significant degree.

A number of smaller ligaments, such as the apical and cruciate ligaments, obliquely aligned

accessory atlantoaxial ligaments, the anterior atlantodental ligament, and the facet joint

capsules also provide support.

The specific arrangement of ligaments at the cranio -cervical junction utilizes the atlas as a

washer or base for a coupled, multi -planar motion.

The combination of a high degree of mobility and relatively delicate ligamentous and bony



structures makes the upper cervical spine susceptible to injury from indirect high-energy

trauma.

Fracture-dislocations of the cranio cervical junction is the leading cause of death of motor

vehicle accidents.

The atlas is the most fragile vertebral segment in humans. It will fracture with as little as 1 to

2 mm of deformation and is very susceptible to bursting-type fractures with relatively low

axial loads.

The two most vulnerable bony structures of the axis are the pars interarticularis and the

odontoid waist. Forced hyperextension can lead to failure of either structure.

Flexion is believed to be causative in 80% of odontoid fractures by forcing the transverse

ligament against the odontoid.

Atlantoaxial rotation of more than 50 degrees in either direction as measured by CT scan is

suspicious for alar ligament insufficiency.17



CHAPTER - IV

ETIOLOGY



These are various causes which contribute in cervical radiculopathy.

1.

Trauma:- In some patient it is associated with trauma either as a single severe episode

or related to repeated minor episode over many year, usually determined by nature i.e.

repeated muscular strain.5

2. Wear and tear:- As a person grows old, there is always generalized wear and tear of

the joints.1

3. Degeneration:- Degeneration of joints in old aged person.

4. Inheritance:- In some patient wide spread generalized osteoarthritic genetic factors are

dominant,the inheritance among female members of the family often being clearly

seen.

5.

Obesity:- In some patient obesity may be a major factor.5

6. Occupational stress:- it occurs early in person pursuring”white collar jobs” or thos

susceptible to neck strain because of keeping the neck constantly in one position

while working on computer,2occupational stress, e.g. typists at poorly positioned

desks, coal-miners and drivers, people whose work involves lifting, twisting and

carrying.10

7. Poor posture:-May also be a cause for cervical radiculopathy.2

8.

Developmental abnormalities:- In many patients the cause is unclear althoughdevelopmental abnormalities and endocrine and metabolic factors may be invo

9. Body type:- Neck that are thickest with “Dowager‟s Hump” and long back are prone

to radiculopathy.



CHAPTER - V

PATHOLOGY



Inter-vertebral discs lose hydration & elasticity with age, and these losses lead to cracks &

fissures. The surrounding ligaments also loose their elastic properties and develop traction

spurs. The disc subsequently collapses as a result of biomechanical incompetence, causing

the annulus to bulge outward, and the facets override. Acute disc herniation may complicate

chronic spondylotic changes.

As the annulus bulges, the cross-sectional area of the canal is narrowed. This effect may be

accentuated by hypertrophy of the facet joints (posteriorly) & the ligamentumflavum. Neck

extension causes the ligaments to fold inwards, reducing the A-P diameter. As disc

degeneration occurs, the uncinate process override (joints of Lushka) & hypertrophies,

compromising the ventro-lateral portion of the foramen.

Facet hypertrophy decreases the dorso-lateral aspect of the foramen. This change contributes

to the radiculopathy associated with cervical spondylosis. Marginal osteophytes begin to

develop and any additional stress in the form of trauma or long term heavy loading may

exacerbate this process.18

Fig. 5.1 disc herniation



CHAPTER - VI

CLINICAL FEATURES



Clinical Features of Cervical Radiculopathy

Cervical

Root

Pain Sensory Changes Weakness Reflex Changes

C-5 root Neck, shoulder, and

anterolateral arm

Numbness in

deltoid area

Deltoid and biceps Biceps reflex

C-6 root Neck, shoulder, and

lateral aspect of arm

Dorsolateral aspect

of thumb and index

finger

Biceps, wrist

extensors, and

pollicuslongus

Brachioradialis

reflex

C-7 root Neck, shoulder,

lateral aspect of arm,

and dorsal forearm

Index and middle

finger of dorsum of

hand

Triceps Triceps reflex

Patients may also note weakness and lack of coordination in the affected extremity. Muscle

spasms and neck pain as well as pain referred into the trapezius and intrascapular region

are common. Decreased sensation, weakness, and reflex changes are demonstrated on

physical examination. Patients with C-7 radiculopathy will commonly place the hand of the

affected extremity on top of their head to obtain relief. Occasionally, a patient suffering from

cervical radiculopathy will experience compression of the cervical spinal cord, resulting in

myelopathy. Cervical myelopathy is most commonly due to midline herniated cervical disk,

spinal stenosis, tumor, or, rarely, infection. Patients suffering from cervical myelopathy will

experience lower extremity weakness and bowel and bladder symptomatology. This

represents a neurosurgical emergency and should be treated as such.2

Fig. 6.1 Patients with C-7 radiculopathy will often place the hand of the affected extremity on

the head to obtain relief.19



CHAPTER - VII

DIFERENTIAL DIAGNOSIS



1.

Adhesive Capsulitis

2. Diabetic neuropathy

1. Brown – Sequard Syndrome

2. Multiple Sclerosis

3.

Carpal Tunnel Syndrome4. Myofascial Pain

5. Central Cord Syndrome

6. Neoplastic Brachial Plexopathy

7. Cervical Disc Disease

10. Osteoporosis

11. Spinal Cord Injury

12. Cervical Myofacial Pain

13. Cervical Sprain and strain

14. Rheumatoid Arthritis

15. Chronic Pain Syndrome

16. Traumatic Brachial Plexopathy17. Peripheral Nerve entrapment

OTHER CHANGES: Occipital neurologia as a result of radiculopathy changes at C1

_ C2 shoulder problems. Primary spinal cord tumors, syringomyelia, extramemedullary

elessions (tumors, thoracic disc herniation) Hereditary spastic paraplegia, Normal

pressure hydrocephalus, spinal cord infarction, spinal sepsis, whiplash syndrome(hyper

extension- hyper flexion injury),Pancoast tumors, double crush syndrome (coexistence ofa radiculopathy and peripheral Nerve compression in the carpal and cubital tunnel).2,6,7



CHAPTER – VIII

SPECIAL TESTS



1. FORAMINAL COMPRESSION TEST (SPURLING’S TEST) –

This test is done if the patient complaines of nerve root symptoms,which at the time

of examination are diminished or absent.

The patient side flexion the head to unaffected side followed by effected side.The examiner carefully compression with head in extension and rotation to

unaffected side. The test result is classified as positive of pain radiaties to arm

towards which the head is side flexed during compression that indicates pressure on

nerve root.

fig. 8.1

2. DISTRACTION TEST:

The test is used for patient who has comp

Laion of radicular symptoms and show radicular signs during

Examination.

To perform the test the examiner places one hand under the

Patient chin and other around the occiput, than

slowly lifts the patient head and apply traction to the

cervical spine.

The test will be positive if the pain is decreased. This test may

also be used check radicular sign refessed to shoulder complex anteriorly or posteriorly.

fig. 8.2

3. UPPER LIMB TENSION TEST :



CHAPTER – IX

TREATMENT



problems.Relieve pressure an spinal cord from bone or from multiple disc

protrusion by removing to disc and the bone between them.4,13nt

b. Back approach(Laminectomy):- Surgeon removes back part of the bone over

the spinal cord through an incision in the back of the neck.13nt

III PHYSIOTHERAPY TREATMENT:-

Aims of physiotherapy treatment:

1. To decrease pain

2. To reduce muscle spasm

3. To maintain normal range of motion

4.

To increase functional activity

5. To increase circulation of the affected part

6.

To induced relaxation

7. To maintain general body health

8.

To reduce inflammatory condition

9. To given psychological support

10.

Ergonomics Advise

TO decrease pain:

In acute phase- Electrotherapy treatment.

Ultrasonic Therapy:- In initial stage

Pulsed Ultrasonic Therapy- 1:4 or 1:6

Intensity = 0.25 or 0.5 watt/cm square.

Time duration = 2-3 minute.

If condition improve than progression of dosage is unnecessary. Failure to

improved might required a slight increase intensity of ultrasonic to 0.8 watt/cm square and

time duration up to 4-5 minute.

If a dose produce beneficial effect it is repeated next time. If no improvement results, the

dose can be gradually increased by increasing intensity and the period of treatment.4,6,7



CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT

INTERMITTENT CERVICAL TRACTION: Effects of traction: Mechanical benefits of

temporarily separating the vertebrae & causing mechanical sliding of facet joints in the spine.

May relieve symptoms from a disc protrusion. Angle of pull of traction: Flexion, Neutral or

Hyper-extension. Duration of traction: 10-15 minutes. Traction force: 1/10 to 1/7 of patient‟s body weight. Position of patient: Supine or sitting.

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT

INTERFERENTIAL CURRENT THERAPY: Mechanism of action of IFT: Higher

frequencies (100-130 Hz) close the pain gate mechanism. May act directly on the peripheral

nerves by slowing the conduction.May act as placebo effect. Duration of treatment: 10-12

minutes.

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT ISOMETRIC

NECK EXERCISE: INE is helpful for maintaining or improving strength, endurance and

tone of the cervical muscles. Alternating isometric contractions also enhance stability.

TO MAINTAIN NORMAL RANGE OF MOTION:-

Static Neck Exercise:- 2times a day(10 sets) during isometric neck exercise 10

repetitions were given for Fiexions, Extention and side rotation or flexors.Resistance

applied while neck remains stratight. During this 10 sec. hold and 3 second rest were

given.7

Chin tuck exercise and head lifts should be taughtnto the patient.

Stretching of trapizius muscle: To maintain functional lenth of muscle.

Active Scalene muscle stretch can be advised to the patient. 7nt

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT MAITLAND

MOBILIZATION: Grades of mobilization: Grade I: Small-amplitude rhythmic oscillations

are performed at the beginning of the range. Grade II: Large-amplitude rhythmic oscillations

are performed with in the range, not reaching the limit. Grade III: Large-amplitude rhythmic

oscillations are performed up to the limit of the available motion and are stressed into the

tissue resistance. Grade IV: Small-amplitude rhythmic oscillations are performed at the limitof the available motion and stressed into the tissue resistance. Grade V: A small-amplitude,

high velocity thrust technique is performed to snap adhesions at the limit of the available

motion.

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT MAITLAND

MOBILIZATION: Neuro-physiological Effects: Small amplitude oscillatory & distraction

movements are used to stimulate the mechanoreceptors that may inhibit the transmission of

nociceptive stimuli at the spinal cord or brain stem levels. Mechanical Effects: Smallamplitude distraction or gliding movements of the joints are used to cause synovial fluid



motion, help to maintain nutrient exchange & thus prevent the painful & degenerating effects

of stasis when a joint is swollen or painful.

EXERCISE PROGRAMME:

There are basically five type of exercise which are commonly used either single or in

combination. The type of extent of exercise is to be planned accoding to the patient needs.4,6,7

1. Relaxed Passive Movement: This include manipulation and

mobilization.When the chif aim is mobilization.

2.

Strong isometrics are indicated when mobility is contraindicated but

strength. Endurance and tone of the cervical muscle are to bemaintained and improved.

3. Active Assisted Movement: When the basic objective is to improved

the weak muscle without exerting.

4. Active Resisted Exersice: To strenghten the cervical muscle.6,7



Fig. 9.1 isometric exercises

CHAPTER X

DISCUSSION



The study was done on 5 patient. All of them having cervical radiculopathy due to any

trauma or injury. Three patient was female and two patient was male. Two patient was 45

years old. Two patient was 60 years old and one patient was 39 years old. Two patient was

housewife and other two patient was workers and other one patient was teacher. All patient

was given physiotherapy Treatment.

Physiotherapy techniques were applied on the skin or muscle to educate them. First of all the

intermittent cervical traction will be done for promotes circulation, reduce swelling,

inflammation, spasm and pain or may help in breaking the adhesions. After than ultrasound

therapy, massage for reduce the muscle spasm. After than static neck exercise, chin tuck

exercise,active movement, passive movement and stretching for maintain normal range of

motion. After these techniques all the patient gained relief the pain, reduced muscle spasm

and strength the muscle.



All the patient were recovered after the treatment. Some patient‟s required iong term

treatment. This study have beenevalvated the good prognosis after the condition. All the

patient treat will be same. One patient advise the cervical collar.After the treatment patient

relief the pain, reduced the muscle spasm, increase the blood circulation of the area and

maintain the strength of muscle and cervical radiculopathy are done completely.



1. John Crawford Adams, David L. Hambler, Outline of orthopaedics- Thirteenth edition.

2. J. Maheshwari, Essential Orthopaedics-Revised 3rd edition.

3.

Donnatelli Wooden, Orthopaedics Physical Therapy 3rd edition.

4.

Hassan Ahmad Al-Shatoury, Ayman Ali Galhom, Cervical Radiculopathy, April 24,

2009.

5. Patrila A, Downie, Cash‟s Text Book Of Orthopaedics And Rheumatology For

Physiotherapists,1st edition.

6. John Ebnezar, Essential OfOrthopaedics For Physiotherapist.

7. Jayant Joshi, PrakashKotwal, Essential OfOrthopaedics And Applied Physiotherapy.

8.

B.D Chaurasia‟s Human Anatomy Part 3

rd

-4

th

edition.

9. Pamela K. Levangie, Lyuthia C. Norkin, Joint Structure And Function, A

Comprehensive Analysis,4th edition.

10.

Ann Themson, Alison Skinver, Joan Piercy, Tidy‟s Physiotherapy 12th edition.

11. M. Natarajan, MayilvahananNatarajan, Natrajan Text Book Of Orthopaedics And

Traumatology – Revised 5th edition.

12.

David J Magee, Orhopaedics Physical Assessment 4th edition.

13.

Russel Williams Bulstrode, Hodden Arnold, BaibyAnd Love‟s Short Practice Of

Surgery-24th edition.

14. Carolyn Kisher, Lynn Allen Colby, Therapeutic Exercise-5th edition.

15. Wewers M.E And Lowe N.K (1990), A Critial Review Of Visual Analogue Scales In

The Measurement Of Clinical Phenomena, Research In Nursing And Health 13th,

Vol.227-236.

16. Gerard A Malanga, Sherwin Ho, Cervical Radiculopathy,Dec.14th, 2011.

17.

Arun Pal Singh, Biomechanics Of Upper Cervical Spine, Sports Rehab. Las, Vegas

Chirofractor 14 feb, 2012.

18. vishal B. Boricha, Cervical Radiculopathy, Sports medicine.

19.

John F. Petriglia, Interventional pain medical group, 24 April 2012.



APPENDICES



APPENDIX I

CONSENT FORM



CONSENT FORM

I ____________ voluntarily consent to participate in the study. All my questions have been

satisfactorily answered and the risk involved have been explained to me. I reserve my right to

withdraw at any instant and I have the contact address of PreetiYadav if I require any further

information.

Signature:-

Contact address:-



APPENDIX II

CASE STUDY



CASE STUDY – 1

Name : XYZ

Age : 60 Years

Occupation : Worker

Chief complaints:-

Patient complains of neck pain since 10 days back. Pain increases during holding

heavy objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back

region to arm. Pins and needles sensation is there in hand and finger of both sides.

History of present illness:-

Patient was asymptomatic 10 days back then suddenly feel pain in neck.Pain increases on

movement and slight giddiness is also present.Radiating pain is there from upper scapular

region to arm along with pins and needle sensation in both hand and finger.

Past History:-

Patient has Road Traffic Accident and got fractured both bone lower limb(Left).

Medical History:-

Plaster of paris cast was applied. Patient recovered.

Personal History:-

Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,

tuberculosis.

Marital Status:-

Patient is married.

Family History:-

Patient is present with family history of hypertension.

Physical Examination:-

OBSERVATION

Anterior view: Head is in midline with no evidence of Torticollis or other neck

deformities.

Right shoulder is sligt lower than the left, Shoulder contour is normal.



No redness is present in the neck or in the shoulder muscle.

Lateral view: Cervical lordosis is normal.

PALPATION

Tenderness: Present at C5-C6Spinous process

Muscle spasm: Present at bilateral upper fiber of trapezius and Levator Scapulae.

ON EXAMINATION

1. Pain:

Type of pain : Pinching type pain

Intensity of pain : 8/10

Duration of pain : 10 days

Relieving factor : Rest,Medication

Aggravating factor : During farmer work

2. Active movement:

Flexion : Painful

Extension : Painful

Side flexion : Painful(RIGHT)

Rotation : Painful(Left)

3. Passive movement:

All passive movement are painful due to tissue stretch.

4.

Sensory Examination:

Normal on both sides.

5. Special test:

Spurling‟s compression test : positive

Distraction test : Positive

ULTT Test : Positive

6. X-Ray Findings:-



Osteophytes formation in almost all cervical vertebrae.Joint space reduced at C5-C6

Ver tebrae.

7. Visual Analogus Scale: Was found to be 9/10

Treatment:-

Traction- Intermittent cervical Traction

Hold time - 10 Second

Rest Time - 5 Second

Duration - 10 minute

Weight - 7Kg

Session - 1 time for 5 day

Static Neck Exercise - 2 time a day (10sets) during isometrics neck

exercise 10 repetitions were given for flexors, extensors and side flexors.

Stretching -of trapezius muscle.

KNEADING - To relive muscle spasm and to increase blood circulation

of the area.

Hot packs -to relieve muscle spasm.

Postural correction.

Ergonomics advise.

PROGRESS REPORT:-

Patient record 90% relif of pain. Visual Analogus Scale up 3/10



CASE STUDY – 2

Name : XYZ

Age : 39 Years

Occupation : House wife

Chief Complaints:-

Patient complains of Stiffness and pain in neck radiating up to her left elbow along with

clumness in left hand.


Patient onset was gradual and had similar episodic of pain of pain two year of back which

lasted for one month and resolved with 15 day of medical therapy.

Past history:-

No

Medical History:-

Medical Therapy is given

Personal History:-

Patient is vegitarian.

Marital Status:-

Married

Family History:-

No


Observation

Anterior View:- Head is in midline with no evidence of neck deformity. Left shoulder is

slight lower than the right. Shoulder contour is normal. Redness is present in the neck and

shoulder.

Lateral view:- cervical lordosis is normal.



Palpation

Tenderness: Present at C4 -C5 spinous process.

Muscle spasm: Present at bilateral upper fiber of levator.

On examination

1. Pain:-

Type of pain : Pinching and dull pain.


Duration of pain : 15 days.

Relieving factor : massage and stretching.

Aggravating factor : activity performed with bent

neck.

2. Active movements:-

Flexion :painfull.

Extension :painfull.

Side flexion :painfull(left).

Rotation :painfull(right).

3. Passive movement:-

All movements are painfull due to tissue stretch.

4. Sensory Examination:-


5.

Special test:-

Spurling‟s compression test: Positive

Distraction test: Positive.

ULTT Test: Positive.

6. X-Ray Findings:-

Flattening of cervical lordosis.

Osteophytes formation body and significant at C5 vertebrae.



Narrowing of space between C5-C6 vertebrae body and facet joint.

7. Visual Analogus Scale:-was found 6/10.

Treatment:-

1.

Hot packs:-15 min.

2. Traction:-Intermittent cervical traction.

Hold time : 20 seconds.

Rest time : 10 seconds.

Duration : 15 minutes.

Weights : 5 kg.

Session : 1 time for 5 day.

3. Static neck exercise:-2 times a day (10 sets) during isometric neck exercise 10 repetitions

were given for flexors, extensors and side flexors. Resistance applied while neck remains

straight. During this 10 second hold and 3 second rest were given.

4. Stretching:-stretchingof trapezius muscle, Pactoralis major, and steno(5cm)with 3

repetitions. During 30 second hold and 2 set a day.

5. Kneading and Picking up:-To relive muscle spasm and to increase blood circulation of the

area.

6. IFT:-to relieve pain.

7. Postural correction.

8. Ergonomics advise.

Progress Report:-

Patient record 95% relief of pain. Visual Analogus

Scale up 2/10.



CASE STUDY – 3

Name : XYZ

Age : 45 Years

Occupation : Teacher

Chief complaints:-

Patient complains of neck pain since 12 days back. Pain increases during holding

heavy objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back

region to arm. Pins and needles sensation is there in hand and Lateral 3 finger of both sides.


Patient has neck pain for the past two years due to any trauma.

Past History:-

Patient put lifting heavy weight during working.

Medical History:-Medical Therapy is given.

Personal History:-

Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,tuberculosis.

Marital Status:-

Patient is married.

Family History:-

Patient is present with family history of hypertension.


OBSERVATION


deformities.


No redness is present in the neck or in the shoulder muscle.




PALPATION

Tenderness: Present at C4-C5Spinous process

Muscle spasm: Present at bilateral upper fiber of trapezius and deltoid.

ON EXAMINATION

1. Pain:





Aggravating factor : During farmer work

Active movement:

Flexion : Painful

Extension : Painful



Passive movement:




Special test:




X-Ray Findings:-


Vertebrae.



Visual Analogus Scale: Was found to be 7/10

Treatment:-

1. Traction- Intermittent cervical Traction




Weight - 5Kg


2. Static Neck Exercise - 2 time a day (10sets) during isometrics neck exercise

10 repetitions were given for flexors, extensors and side flexors.

3. Stretching -of trapezius muscle.

4. KNEADING - To relive muscle spasm and to increase blood circulation of

the area.

5. Hot packs -to relieve muscle spasm.

6.

Postural correction.


PROGRESS REPORT:-

Patient record 95% relif of pain. Visual Analogus Scale up 1/10.



CASE STUDY – 4

Name : XYZ

Age : 60 Years

Occupation : House wife

Chief complaints:-

Patient complains of neck pain since 15 days. Pain increases during holding heavy

objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back

region to arm. Pins and tingling sensation is there in hand and finger of both sides.


Patient was any asymptomatic 15 days back then suddenly feel pain in neck . Patient increase

on movement is present . Radiating pain is there from upper scapular region to arm along

with pins and needle sensation in both hand and finger.

Past History:-



Personal History:-

Patient is non-vegetarian. Patient is hypertensive with no history of Diabetes mellitus and T.B

Marital Status:-

Patient is married.

Family History:-

Family history of hypertension


OBSERVATION


deformities.


Redness is present in the neck or in the shoulder muscle.



Lateral view: is normal.

PALPATION

Tenderness: Present at C5-C6 and Spinous process


ON EXAMINATION

1. Pain:





Aggravating factor : During work

Active movement:

Flexion : Painful

Extension : Painful



Passive movement:




Special test:




X-Ray Findings:-




and Vertebrae.

Visual Analogus Scale: Was found to be 8/10

Treatment:-

1. Traction- Intermittent cervical Traction




Weight - 7Kg


2. Static Neck Exercise -2 time a day (10sets) during isometrics neck exercise

10 repetitions were given for flexors, extensors and side flexors.

3. Stretching -of trapezius muscle and Levator Scapulae muscle.

4. Kneading - To relive muscle spasm and to increase blood circulation of the

area.

5. Hot packs -to relieve muscle spasm.

6. Postural correction.


PROGRESS REPORT:-

Patient record 85% relif of pain. Visual Analogus Scale up 3/10.



CASE STUDY – 5

Name : XYZ

Age : 45 Years

Occupation : Worker

Chief complaints:-

Patient complains of neck pain since 1 month. Pain increases during holding heavy

objects, putting hand in back pocket, lifting etc. Patient complain pain from upper scapular

region to left arm. Pins and tingling sensation was there in hand and 3 fingers of both sides.


Patient was asymptomatic one month before and then suddenly felt pain in neck . Patient

increase on movement is present . Radiating pain is there from upper scapular region to left

arm.

Past History:-



Personal History:-

Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,

tuberculosis.

Marital Status:-

Patient is married.

Family History:-

No family history.


OBSERVATION


deformities.


Redness is present in the neck or in the shoulder muscle.




PALPATION

Tenderness: Present at C5-C6 and C6-C7Spinous process


ON EXAMINATION

1. Pain:



Duration of pain : One month


Aggravating factor : During work

Active movement:

Flexion : Painful

Extension : Painful



Passive movement:




Special test:




X-Ray Findings:-



APPENDIX II

CERVICAL SPINE ASSESSMENT FORM



CERVICAL SPINE ASSESSMENT

History

Observation

Examination

Active movement

Flexion

Extension

Side flexion(Right and Left)

Rotation

Combined Movement(if necessary)

Repetitive Movement

Sustained Movement

Myotome

Neck flexion(C1-C2)

Neck side flexion(C3)

Shoulder flexion(C4)

Shoulder abduction(C5)

Elbow flexion(C6)and Extention(C7)

Wrist flexion(C7)and Extention(C6)

Thumb extention(C8)and ulnar deviation(C8)

Hand intrinsic(T1)

Special Test

Foraminalcompression(Spurling‟s) Test



Distraction Test

ULTT Test

Reflexes and cutanious distributions

Biceps(C5-C6)

Triceps(C7-C8)

Hoffman Sign

Examination

Passive Movement

Active Movement



APPENDIX-III

VISUAL ANALOGUES SCALE



The VAS-used in the study consisted of a continous horizontal line of 10cm in the length

with anchor point of no pain(0) and worst pain(10) on the left and right ends of linerespectively.

How severe is your pain?

________________________________________

0 10

NO pain Worst pain

imaginable

The patient is asked to mark on the line where patient feels severity of pain correspond.

final project cervical radiculopathy

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