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4/11/2015

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  1. 4/11/2015 CERVICAL RADICULOPATHY CERVICAL RADICULOPATHY RADICULAR PAIN RADICULAR PAIN Pain perceived as arising in a limb or the trunk wall caused by ectopic Pain perceived as arising in a limb or the trunk wall caused by ectopic activation of activation of nociceptive nociceptive afferent fibers in a spinal nerve or its roots or afferent fibers in a spinal nerve or its roots or other neuropathic mechanisms. (IASP taxonomy) other neuropathic mechanisms. (IASP taxonomy) Radiculopathy Radiculopathy is differentiated from radicular pain: is differentiated from radicular pain:  Radiculopathy is a neurological state in which conduction is blocked along a spinal nerve or its roots => muscle weakness & sensory changes Radiculopathy and radicular pain commonly occur together, (Vervest, 1988; Bogduk, 2009).  Pain in patients with a CR might have a neuropathic pain component! no beneficial effect or biological (warning) advantage (Treede, 2008) 25% 75% Radhakrishnan, 1994 SYSTEMATIC REVIEW: EFFECTIVENESS OF EFFECTIVENESS OF CONSERVATIVE TREATMENT CONSERVATIVE TREATMENT FOR PATIENTS WITH CERVICAL FOR PATIENTS WITH CERVICAL RADICULOPATHY RADICULOPATHY Interesting Interesting group of group of patients patients with neck pain with neck pain Triage in Patients with Neck Pain (adapted fromWaddell, 1998) Specific Specific 5 5- -15% Non Non- -specific specific 85 15% 85- -95% 95% CLIN CLIN J PAIN, 2013 J PAIN, 2013 “ “serious serious” ” “ “non non- -serious serious” ” E J T H O O M E S , E J T H O O M E S , G G M S C H O L T E N - P E E T E R S , B M K O E S , D F A L L A , A P V E R H A G E N Assessment Assessment aims relevant relevant dysfunctions dysfunctions, , able to to explain explain complaints complaints aims to to find find able Cluster of tests Cluster of tests (Wainner 2003; Rubinstein 2007; Bono 2010) (Wainner 2003; Rubinstein 2007; Bono 2010) 1

  2. 4/11/2015 AIM: AIM: To assess the effectiveness of conservative treatments To assess the effectiveness of conservative treatments for patients with CR. for patients with CR. Why? •Surgery not more effective Surgery not more effective • Cochrane 2010; Peolsson, 2012; Enquist, 2013 • 29% 2 29% 2nd operation adjacent segment < 1 yr. • Bono, 2010; van Middelkoop, 2013 603 4 4 Why? duplicates removed n=573 Screening titles n=50 Eligible n=32 nd operation adjacent segment < 1 yr. 15 Studies included in qualitative synthesis (for 11 trials ) RESULTS RESULTS INTERVENTIONS & COMPARISONS INTERVENTIONS & COMPARISONS Grading of Recommendations Assessment, Development and Evaluation Grading of Recommendations Assessment, Development and Evaluation Low level evidence Low level evidence that a collar and physiotherapy that a collar and physiotherapy are (equally) effective on disability are (equally) effective on disability at short term follow up only. at short term follow up only. (and more effective than wait&see or surgery) • < 3 &6 wk: Kuijper 2009; < 12 wk Persson 1997, re Surgery that intermittent traction is no more effective than continuous that intermittent traction is no more effective than continuous traction. traction. Very low level evidence Very low level evidence • that traction is no more effective than placebo traction. that traction is no more effective than placebo traction. • that a collar is no more effective than traction. that a collar is no more effective than traction. (long term follow up) Intervention Intervention Comparison Comparison Comparison Comparison Comparison Comparison Author Author BAPM 1966 Collar Traction Sham Traction Placebo Intervention Persson 1997 Collar PT Surgery Kuijper 2009 Collar PT Wait & See Fukusaki 1995 Collar Injections Klaber Moffet 1990, Shakoor 2002 Traction Placebo Traction Elnaggar 2009, Jellad 2009, Wong 1997 Intermittent traction Continuous Traction Young 2009 (sham traction) MT + Exercise Traction + MT +Exercise (long term follow up) Ragonese 2009 MT Exercise MT + Exercise DUTCH MANUAL THERAPY GUIDELINE DUTCH MANUAL THERAPY GUIDELINE Intervention Effectiveness MULTI MODAL INTERVENTIONS Short term (<4 wks) more effective than separate intervention alone or wait&see on pain and disability Level of evidence Intervention Effectiveness UNI MODAL INTERVENTIONS Level of evidence Cervico-thoracic mobilisation & motor control exercises Low level; 1 RCT, low RoB (Langevin, 2015) and 1 RCT high RoB(Ragonese, 2009) Cervical manipulationShort term (< 1 wk) more Low level; 1 RCT with low RoB (Howe, 1983) effective than NSAIDs on pain Thoracic manipulationUnknown No RCTs found Short term (<4 wks) more effective than wait&see on pain, disability and GPE Short term (3 - 8 wks) more effective on pain Multimodal intervention with neurodynamic intent Low level; 1 RCT, low RoB (Nee, 2012) Cervical mobilisationsShort term (< 1 wk) more Very low level; 1 RCT with high RoB (Brodin, 1984) effective than placebo or wait&see on pain and ROM Multimodal intervention with combined intent (neurodynamic, joint, muscle) Low level; 2 RCTs, high RoB. (Ragonese, 2009; Allison, 2002) Thoracic mobilisations Unknown Cervical mobilisation with neurodynamic intent No RCTs found Low level; 1 RCT with low RoB (Coppieters, 2003) Direct positive effect on ULNT. Short term (<4 weken) no difference between traction - placebo traction Traction combined with cervical mobilisation, thoracic manipulation and exercise Low level; 1 RCT, low RoB (Young, 2009) 2

  3. 4/11/2015 CONCLUSION CONCLUSION PROMISING? PROMISING? One low risk of bias study indicated that at 3 week One low risk of bias study indicated that at 3 week follow up, a collar is more effective on neck pain and disability than collar is more effective on neck pain and disability than physiotherapy and a wait & see policy. physiotherapy and a wait & see policy. At the 6 week follow up, both a collar and physiotherapy are At the 6 week follow up, both a collar and physiotherapy are more effective on neck and arm pain than a wait and see more effective on neck and arm pain than a wait and see policy. policy. (Kuijper, 2009) Seems Seems logical logical, , considering considering patho follow up, a There is a lack of high quality RCTs. There is a lack of high quality RCTs. • Based on low to very low level evidence, no one Based on low to very low level evidence, no one single intervention intervention appears to be superior or consistently more appears to be superior or consistently more effective than other interventions. effective than other interventions. Multi Multi- -modal modal therapy therapy not not well well researched prove prove preferential preferential (Moore & Jull, 2006; Hurwitz, 2008; Hodges, 2013) single researched as as yet yet, , but but might might patho- -physiology physiology? ? IMPLICATION FOR PRACTICE IMPLICATION FOR PRACTICE Effectiveness of use of a collar or physiotherapy at short term Effectiveness of use of a collar or physiotherapy at short term follow up (<3 wks) seems promising compared to a wait & follow up (<3 wks) seems promising compared to a wait & see policy. see policy. PT should consist of multimodal interventions: PT should consist of multimodal interventions: Spinal Mobilisation Spinal Mobilisation Neurodynamic Mobilisation Neurodynamic Mobilisation Motor Control Exercises Motor Control Exercises Regardless of the intervention assignment, patients seem to Regardless of the intervention assignment, patients seem to improve over time ( improve over time (≈6 months), indicating a favourable 6 months), indicating a favourable natural course. natural course. OKAY, SO NOW WHAT? COMBINING CLINICAL EXPERIENCE & COMBINING CLINICAL EXPERIENCE & CONTEMPORARY RESEARCH, IT WOULD CONTEMPORARY RESEARCH, IT WOULD MAKE SENSE THAT: MAKE SENSE THAT: CLINICAL MANAGEMENT: LINICAL MANAGEMENT: PLAN AHEAD PLAN AHEAD AFTER HISTORY TAKING: AFTER HISTORY TAKING: ? WHAT WOULD YOU EXPEC ? WHAT WOULD YOU EXPECT T TO FIND ? ASSESS FOR THESE SIGNS & SYMPTOMS ASSESS FOR THESE SIGNS & SYMPTOMS DON’T TREAT THE PATHOLOGY; DON’T TREAT THE PATHOLOGY; TREAT THE PATIENT TREAT THE PATIENT Multimodal Multimodal therapy therapy might might be be more more effective effective. . TO FIND ? Moore & Jull, 2006; Cleland, 2007; Hurwitz, 2008; Forbush, 2011; Boyles, 2011; Salt, 2011; Hodges, 2013 The kind of treatment of a The kind of treatment of a radiculopathy radiculopathy should depend on the stage it is in: stage it is in:  a more hands a more hands- -off pharmaceutical approach in the acute off pharmaceutical approach in the acute inflammation stage, inflammation stage,  turning into a more active multi turning into a more active multi- -modal approach aimed at the functional restoration of the ensuing physiological changes. functional restoration of the ensuing physiological changes. should depend on the modal approach aimed at the 3

  4. 4/11/2015 ACUTE STAGE (<6 WEEKS) ACUTE STAGE (<6 WEEKS) EXPLAIN: EXPLAIN: • EXPLAIN & EXPLAIN & focussed • Relative Relative rest; NO rest; NO symptom Contrary Contrary to to guidelines • EFFECTIVE EFFECTIVE early early pain management NSAIDs - inflammation (Ibuprofen, Naproxen) Opioïds – nerve / neuropathic pain?(Oxycodone) • Soft Soft collar collar ( (turned turned backways backways?..)  (Kuijper, 2009) • Hands Hands- -off off; ; initially initially... ... Neuro-mechanosensitivity?  (Coppieters, 2003;Nee, 2012) focussed advice symptom provocation guidelines Non Non- -specific pain management advice provocation specific Neck Neck Pian Pian DN4, LANSS iPad iPad apps, video apps, video ?..) 3 3- -D model D model SUB SUB- -ACUTE STAGE (6 ACUTE STAGE (6 - -12 WEEKS) 12 WEEKS) MOTOR CONTROL IMPAIRMENT MOTOR CONTROL IMPAIRMENT Deep Deep Neck Pain inhibition (Falla, Jull, O’Leary, Cagnie,...) (RCTs: Cleland 2007; Frobush 2011,…) Neuro Neuro- -mechanosensitivity mechanosensitivity Neurodynamic Openers & Sliders (Shacklock, Coppieters, Nee) “Unfolding” of nerve & root (Dilley; Ellis 2008, 2012) Neck Flexors Flexors Deep Neck Flexors & Extensors Deep Neck Flexors & Extensors Control of inner range of flexion Control of inner range of extension Control of outer range of extension Integrate into function (ADL) NERVE SLIDERS VS. NERVE SLIDERS VS. TENSIONERS TENSIONERS SUB SUB- -ACUTE STAGE (6 ACUTE STAGE (6 - -12 WEEKS) CONT. 12 WEEKS) CONT. Offloading positions Offloading positions Sliders Sliders Unfolding Inner range of movement Tensioners Tensioners Elongation Outer range of movement > EOR Slump Slump Pre-tensioning How much? Coppieters; Dilley; Greening; Ellis Gentle mobilisation cervical spine Gentle mobilisation cervical spine Miller 2010, Gross 2010 Manipulation Thoracic Spine Manipulation Thoracic Spine Cleland 2004; González-Iglesias 2009 Axio Axio- -scapular scapular muscles muscles Johnston 2008, Wegner 2010, Zakharova-Luneva 2012 PAIN PAIN↓ accent MOBILITY MOBILITY↑ Unfolding phase 4

  5. 4/11/2015 LONG TERM MANAGEMENT LONG TERM MANAGEMENT EVIDENCE EVIDENCE BASED BASED CLINICAL CLINICAL REASONING REASONING Driven Driven by Patient Patient Specific Specific Functional Limitations Limitations in in Activities Evidence Evidence Based Based Clinical by: : Functional Complaints Complaints (PSFS) Activities and and Participation Participation (NDI) (PSFS) (NDI) General development in Physical Therapy: from tissue tissue- -based based diagnostics to functional functional diagnosis Sackett, 2000 Clinical Reasoning Reasoning! ! 5