RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / Name of the candidate & address / VIRALI RASHMIKANT RAVAL
4/A/20, Vivekanand Nagar, S.V Road, Near Mc’Donalds, Borivali (West), Mumbai- 92.
2. / Name of the Institution / K.T.G COLLEGE OF PHYSIOTHERAPY
Hegganahalli Cross, Vishwaneedam Post,
Sunkadakatte Via Magadi Road,
Bangalore – 560091
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and Sports Physiotherapy )
4. / Date Of Admission To Course / 13/07/2012
5. / Title of The Topic:
“EFFECT OF SIMULTANEOUS APPLICATION OF CERVICAL TRACTION AND NEURAL MOBILIZATION FOR SUBJECTS WITH UNILATERAL CERVICAL RADICULOPATHY”
6.
7.
8. / Brief resume of the intended work:
6.1 Need for the study:
Cervical radiculopathy (CR) is a pathological condition of the cervical nerve root (CNR) and results from a pathology such as disc herniation, spondylotic spur or cervical osteophyte which may may lead to chronic pain and disability.1,2,3,4 The average annual incidence rate of cervical radiculopathy is 83 per 100 000 for the population in its entirety, with an increased prevalence occurring in the fifth decade of life (203 per 100 000).5
The onset of cervical radiculopathy is typically insidious and the exact mechanism underlying the its natural history and production of pain has not been fully understood.6,7,8 but it has been found that the pain from cervical radiculopathy is probably caused by (mechanical) Nerve root compression initiating an inflammatory process9,10,11 The presence of inflammatory mediators around the CNRs alters their normal structure and function leading to possible neural inflammation, edema, hypoxia, ischaemia, fibrosis, limited gliding movement and increased mechanosensitivity.11,12
The location and pattern of symptoms will vary depending on nerve root level affected and can include sensory and motor alterations if the dorsal and/or ventral root is involved. Cervical radiculopathy primarily presents with unilateral motor and sensory symptoms into the upper limb with muscle weakness (myotome), sensory alteration (dermatome), reflex hypoactivity and sometimes focal activity being the primary sign. Patients usually present with complaints of pain, numbness, tingling and weakness in the upper extremity which often result in significant
functional limitations and disability. 13
Based on this notion, many manual therapy interventions have been proposed to restore these alterations and therefore to eliminate pain and disability caused by CR. 14
Neural tissue mobilization techniques are passive or active movements that focus on restoring the ability of the nervous system to tolerate the normal compressive, friction, and tensile forces associated with daily and sport activities.9 Tensioning technique, Sliding technique and Single Joint Movement technique are the commonly used Neural Mobilization techniques.15
NMTs are widely used to normalize the CNR’s structure and function via the possible reduction of nerve adherence, facilitation of nerve gliding and decreased neural mechanosensitivity. 9
Mechanical Cervical traction has been shown to decrease pain and perceived disability in patients with cervical radiculopathy; however, no standard parameters have been reported. It is speculated that traction unloads the components of the spine by stretching muscles, ligaments and functional units which is thought to result in distraction of articular surfaces. Traction might prevent or reduce adhesions within the dural sleeve and relieve nerve root compression within the central foramina. It is speculated that traction decreases pressure within intervertebral discs.16,17,18
Cervical traction is applied to provide pain inhibition, through the widening of the cervical neural foramina and the reduction of the intra discal pressure.19
Cervical traction and neural mobilization techniques (NMTs) have been advocated in the management of CR due to their immediate analgesic effect.15,20
The analgesic effect of these two modalities has been explored and recognized in many RCT studies with these in turn being analyzed in systematic reviews.14,21
But the combined effect of both these techniques applied simultaneously has not been explored much. However, Christos Savva and Giannis Giakas in their case study, studied the effect of cervical traction combined with neural mobilization on pain and disability and found it effective in a patient with cervical radiculopathy. The study has been limited with a single case, there is a need recommended for studies to find the combined effect on larger sample size with standardized outcome measure. Knowing the combined effect of cervical traction with neural mobilization is clinically beneficial to enhance the knowledge on the analgesic effect in the rehabilitation of cervical radiculopathy.
There are no studies found on finding effectiveness by simultaneous application of Cervical Traction and Neural Mobilization on pain, disability.
Hence the purpose of the present study is to find the effect of simultaneous application of cervical traction and neural mobilization on neck pain, radicular symptoms and neck disability in subjects with Cervical Radiculopathy.
Research Question
Whether the simultaneous application of Cervical Traction and Neural Mobilization does have effect on improving neck pain, radicular symptoms and neck disability in subjects with unilateral cervical radiculopathy?
Hypothesis:
Null hypothesis
Simultaneous application of cervical traction and neural mobilization will not have a significant difference in effect on improving neck pain, radicular symptoms and neck disability in subjects with unilateral cervical radiculopathy.
Experimental hypothesis
Simultaneous application of cervical traction and neural mobilization will have a significant difference in effect on improving neck pain, radicular symptoms and neck disability in subjects with unilateral cervical radiculopathy.
6.2 Review of Literature:
Review on Cervical Radiculopathy :
Christos Savva, et al. (2012) Studied the effect of cervical traction combined with neural mobilization on pain and disability in cervical radiculopathy in a case report. The findings of their study supported that the application of cervical traction combined with neural mobilization can produce significant improvements in terms of pain and disability in cervical radiculopathy. However they recommended for future study on large sample size and standardized outcome measures.23
Christopher M. Bono, et al (2010) studied an Evidence-Based Guideline for the diagnosis and treatment of Cervical Radiculopathy from degenerative disorders using the best available evidence to aid both practitioners and patients involved with the care of this condition. They have
provided with recommendations on key clinical questions concerning the diagnosis and treatment of cervical radiculopathy from degenerative disorders. The guideline addresses these questions based on the highest quality clinical literature available on this subject as of May 2009. The guideline’s recommendations assist the practitioner in delivering optimum efficacious treatment
of and functional recovery from this common disorder. 24
Radhakrishnan K, et al. (1994) conducted an Survey on Epidemiology of cervical radiculopathy on a population from Rochester, Minnesota, 1976 through 1990. The average annual incidence rate of cervical radiculopathy was found to be 83 per 100 000 for the population with an increased prevalence occurring in the fifth decade of life (203 per 100 000).5
Review on Cervical Radiculopathy and Traction:
Prisca Moeti, et al (2001) studied the clinical outcome from Mechanical Intermittent Cervical Traction for the treatment of Cervical Radiculopathy (A case Series) and in their study they concluded that Intermittent Cervical Traction can be used to treat patients with Cervical Radiculopathy. A reduction in pain level and in level of disability was observed in their case series. In particular, patients with a short duration of symptoms (12 weeks or less) had the best outcome. The NDI (Neck Disability Index), when used in conjunction with the NPRS (Numerical Pain Rating Scale), provides a comprehensive assessment of the patient, allowing the clinician to make good judgements about the clinical effects of cervical traction.17
Review on Cervical Radiculopathy and Neural Mobilization:
Michel W. Coppieters, et al (2008) carried out an analysis of neurodynamic techniques and
considerations regarding their application. They studied the different techniques for nerve mobilization on median and ulnar nerve and their findings clearly demonstrated that different types of nerve gliding exercises have largely different mechanical effects on the peripheral nervous system. Longitudinal excursion and strain associated with a particular joint movement is strongly influenced by the position or simultaneous movement of an adjacent joint.15
Shacklock M.(1995) in his study described the interactions between nervous system- mechanical and physiological responses and presented a concept of neurodynamics in MOTNS (Mobilization of the Nervous System). 25
Review on Inclusion Criteria:
Rubinstein, et al. (2007) in their systematic review for diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy suggested that, when consistent with the history and other physical findings, a positive Spurling’s, traction/neck distraction, and Valsalva’s might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care.1
Wainner S, et al. (2003) assessed the reliability and accuracy of individual clinical examination items and patient self-report measures for diagnosis of cervical radiculopathy using the Provocative Tests (Spurling’s Test, Shoulder Abduction Test, Neck Distraction Test, Valsalva
Maneuver and ULTT (A and B). They stated that this test item cluster was identified as more useful for indicating cervical radiculopathy than any single test item.26
G.J Kleinrensik, et al (2000) studied the Upper Limb Tension Tests as tools in the diagnosis of nerve and plexus lesions and found that these tests are sensitive and specific. Their findings justified investigation of exclusively the Median Nerve ULTT and ULTT on their clinical validity.27
Review on Outcome measurement
Young AI, et al (2010) studied the Reliability, construct validity and responsiveness of the neck disability index, patient-specific functional scale and numeric pain rating scale in patients with cervical radiculopathy. In their study they found that both the Neck Disability Index and Numeric Pain Rating Scale exhibited fair test-retest reliability, whereas the Patient-Specific Functional Scale exhibited poor reliability in patients with cervical radiculopathy. All three outcome
measures showed adequate responsiveness in this patient population.22
Steve J Kamper, et al (2009) studied review of strengths and weaknesses and considerations for design for GRC (Global Rating of Change) Scale. In their study they stated that that GRC Scale offers a flexible, quick and simple method of charting self assessed clinical progress in research and clinical settings and has clinical relevance, adequate reproducibility and sensitivity to changes. Test retest reliability was found to be high (ICC 0.9) and face validity (0.90).28
Howard Vernon, et al (1991) studied the reliability and validity of neck disability index and in their study they concluded that the NDI is the most widely used and most strongly validated
instrument for assessing self-rated disability in patients with neck pain. It has been used effectively in both clinical and research settings in the treatment of this very common problem.29
Review on Methodology
Janine Gray, et al (2009) in their study described the Assessment of ULTT in The upper limb tension (brachial plexus) test (ULTT1) is used to examine the mobility of the brachial plexus and has a bias to the median nerve. The Procedure for testing the same was described. Also the indirect confirmation of the specificity of the ULTT1 to a median nerve bias has been demonstrated.30
Saunders Cervical Traction (2004) did a study on effective treatment for neck pain and dysfunction.18 In his study he described the Indications for Cervical Traction, Optimum Angle for Cervical Traction, Optimum Force for Cervical Traction.31 and Optimal Position for applying cervical traction.18
6.3 Objectives of the study:
1.  To find the effect of simultaneous application of Cervical Traction and Neural Mobilization by analyzing neck pain, radicular symptoms and neck disability in subjects with cervical radiculopathy.
2.  To compare the combined effects with the groups who received only Neural mobilization or only Mechanical Cervical Traction by analyzing neck pain, radicular symptoms and neck disability in subjects with cervical radiculopathy.
Materials and Method
7.1 Study Design
Pre to post test experimental Study design with three groups- Group A, Group B and Group C.
7.2 Methodology
Study Subjects
Patients with Cervical Radiculopathy with Unilateral Radicular Involvement and ULTT1 positive. for median nerve bias.
Sample size
The study will be carried on total of 60 subjects. 20 in each Group A, Group B and Group C respectively.
Study Setting and Source of data
Subjects will be recruited from KTG Hospital, K.C General Hospital and Rai Kiroskal Memorial Hospital, Bangalore.
Study will be carried out at KTG Hospital, Bangalore.
Sampling Method
Simple Random Sampling.
Study Duration
Four weeks study with 12 treatment sessions which includes 3 treatment sessions in a week.18
Sample Selection
Inclusion Criteria
· Subjects with age of 45 to 55 years.36
· Both male and female subjects.
·  Patients having a 2 month history of neck pain and radicular pain. The symptoms, which presented suddenly without any apparent causes, with a constant burning pain below the occiput and unilateral side of the neck and a constant electric pain, radiating from the lateral side of the shoulder to the elbow joint, along with a tingling sensation occurring on the lateral aspect of the elbow joint.23
·  Patients positive for the Test Item cluster for Provocative Tests which include the Spurling’s test, Shoulder Abduction test, Valsalva Maneuver, Neck Distraction test and Upper limb tension test26
·  Patients showing positive history from the Six Historical Questions Diagnostic for Cervical Radiculopathy26 which include the following questions:
1.  Which are your most bothersome symptoms: Pain, Numbness / Tingling, Loss of feeling
2.  Where are the symptoms most bothersome :Neck, Shoulder, Scapula, Arm above elbow, Arm below elbow, Hand, Fingers
3.  Symptom behaviour – Constant, Intermittent, Variable
4.  Entire limb numbness.
5.  Are the symptoms keeping you away from sleep?
6.  Does the neck movement improve or worsen the arm pain.
·  Complaints of pain radiating to Upper Extremity that was provoked or exacerbated by Cervical Range of Motion.17
·  Paraesthesias in a dermatomal pattern (For Median Nerve)33
·  Mild to moderate severity of radicular symptoms measured by Visual Analogue Scale between 5 to 7 cm.
·  Patients having clear or unequivocal relief of the Radicular Pain with the Manual Cervical Distraction Test.17
·  Patients positive for ULTT1 , Median Nerve Bias.30
Exclusion Criteria
·  Patients with sensory loss or motor weakness due to cervical radiculopathy.