PHYSIOHEALER.

Cervical Radiculopathy Physical Therapy Management
Treatment Options:

Following includes:

Education and Advice:

Manual Therapy – PAIVMs (Passive Assessory.

Intervertebral Movements) / PPIVMs (Passive Physiological Intervertebral Movements) / NAGs (Natural Apophyseal Glides) / SNAGs (Sustained Natural Apophyseal Glides)

Exercise Therapy – AROM, stretching and strengthening.

Postural Re-education.

Education and Advice:

Education is key to getting the patient on side and to work co-operatively with physiotherapy.If a patient understands the condition and the reason for the neck and arm pain then they are more likely to be compliant with any rehabilitation plan.

In cases of a prolapsed disc, tobacco smoking causes constriction of the vascular network surrounding the intervertebral disc (IVD), reducing the indirect exchange of nutrients and anabolic agents from the blood vessels to the disc improvements in disc health suggesting that,besides quitting smoking, additional treatments should be implemented in the attempt to recover the health of an IVD degenerated by tobacco smoking.

Manual Therapy:

There are some contradictions for using manual therapy techniques and its efficacy is questioned.Reported mobilisation and/or manipulation when combined with exercise was beneficial for pain relief and improvement of function for persistent mechanical neck disorders with or without headache.

Furthermore,cervical spine manipulation carries a risk of complications like vertebral dissection and spinal cord compression because of massive disc herniation.

Therefore,this intervention should be discouraged in cervical radiculopathy, especially if imaging of the spine has not yet been performed.

Aware of any potential risk factors such as arterial insufficiency,Hypertension, Craniovertebral ligament insufficiency and upper motor neurone disorders is also essential.

Fritz JM et al examined the effectiveness of cervical traction in addition to exercise in patients with cervical radiculopathy.Adding mechanical traction to exercise for patients with cervical radiculopathy resulted in lower disability and pain, particularly at long-term follow-ups.

Boyles et al however found that manual therapy consisting of thrust mobilisations of the cervical or thoracic spine and cervical non-thrust mobilisations (PA glides/Lateral Glides in ULTT1 position/Rotations/Retractions) was shown to be effective at reducing pain levels, improving function and increasing joint ROM.

When combined with exercise therapy it was more effective than the control group of manual therapy or exercise therapy however both control groups were effective at reducing signs and symptoms.

A 25Y Old Football Player(patient) came To Physiotherapist at Physiotherapy OPD Sports Department With Severe Knee Fracture/Stiffness,pain is started since 40 days.Write The Treatment Plan according to SOAP!

Name:Haris Awan

Age:25Y

Occupation:Football player

Medical Diagnosis: Chondromalacia patella

Physical Diagnosis:Knee fracture/Stiffness

HPI: Patient reported pain started due to knee fracture,pain in started 40 days ago.Now,he is
recieving Physiotherapy at PSB,R&T wing.

PMH:

Accident/fracture about 40days ago.

Personal History:

HTN+

Treatment Protocol:

*RICE:

Rest,Ice, Compression, Elevation.

*Kine Tape.

Manual Therapy:

*Soft tissue Mobilization
*Stretching knee extensors/flexors.(3×10×1)
*Ant/Post glides(3 rep)
*Medial and lateral glide.(3 rep each)
*Patellar glide.(3 rep each)
*Quads and hamstrings strengthening.(3×10×1)

Electrotherapy:

Ultrasound.
Hot pack(10 mins)

Home Plan:

*Icing,Kine Tape.
“Do all exercises thrice a day ē 3 reps each.
*Cycling.

Treatment Outcome at End of Session:

“Relief in knee pain and improve strengthening and mobility.

*To improve muscle atrophy and muscle weakness.

The list below is derived from clinical implications from the research findings described earlier:

• Pick up, grasp and release objects of different shapes, sizes, weights,textures.

• Hold and transport objects from one place to another.

• Move objects within the hand.

• Manipulate objects for specific purposes.

• Reach for objects in all directions in sitting and standing.

• Use two hands to accomplish specific tasks, e.g.one hand holding and the other moving (unscrewing lid of jar)
– both hands doing the same movement (rolling out pastry)
– each hand doing two different movements (peeling an apple).

• Throwing and catching actions to regain the ability to time action and to respond quickly to the ball.

Sitting balance:

Head and trunk movements
Sitting on a firm surface, hands in lap,feet and knees approximately 15 cm
apart, feet on floor.

Turning head and trunk to look over the shoulder, returning to mid position and repeating to other side.

Check:

• Ensure patient rotates the trunk and head, with trunk erect, and remains
flexed at the hips.
• Provide visual targets, increasing the distance to be turned.
• Stabilized the affected foot and prevent external rotation and abduction
at the hip if necessary.
• Ensure hands are not used for support and that feet do not move and Looking up at the ceiling and returning to upright.

Check:

• Patient may overbalance backward and is warned to keep upper body
forward over the hips.


UPPER LIMB FUNCTION:

Training of muscle activity at the scapula and shoulder in supine until the patient can control his shoulder girdle in sitting without excessive compensatory movements.

Upper limb movement problems are usually secondary to shortening of soft tissues due to habitual posturing, use of the intact arm to compensate for the affected arm and learned non-use of the affected arm.

MANAGEMENT:

Early active mobilization of the affected arm in functional patterns.

CAUTION:

Soft tissue damage, chronic inflammation and joint stiffness may be caused by inappropriate passive exercises that do not accommodate the normal biomechanical relationship between the humerus and scapula.

Common Problems and Compensatory Responses:

Impaired scapular movement, especially rotation and protraction.
Persistent depression of the shoulder girdle.
Impaired control over the deltoids causing the inability to sustain shoulder abduction and flexion.

Compensation:

Excessive shoulder girdle elevation.
Lateral trunk flexion.
Excessive shoulder internal rotation,elbow flexion and forearm pronation.
Weakness of glenohumeral joint (GHJ) abductors, flexors and external rotators and of supinators has a significant effect on reaching actions.

Weakness of wrist extensors, finger and thumb flexors and extensors,abductors and adductors affect the manipulation of objects.

Sustaining and controlling grip force during grasping and lifting objects is a common problem.




Reaching Actions:

Sitting,reaching to touch objects with the paretic hand: forward (flexing at the hips),sideways (both sides),backward, returning to mid position.

Very weak patients can practise reaching forward with arms
resting on a high table.

Reaching forward: shoulder girdle elevation, lateral flexion of spine,abduction of shoulder with elbow flexion, internal rotation of shoulder and pronation of forearm.

• Pre-grasp:Excessive opening of hand for grasp to compensate.

• Releasing objects: finger extension with wrist flexed due to contracted long
finger flexors,weak wrist extensors; extending thumb at carpometacarpal
joint (CMC) and metacarpophalangeal joint instead of abducting at
CMC.

Movement:

• Grasping: excessive flexor force in compensation for poor control.
In addition, there are three common adaptive sequelae of stroke:
• Use of the non-paretic limb preferentially when active movement is
possible, and subsequent ‘learned non-use’
• habitual posturing of the paretic limb, leading to adaptive length-associated
changes to soft tissues including loss of extensibility and increased stiffness
of muscle.



Standing Balance:

Head and body movements
Standing with feet a few cm apart, look up at ceiling and return to upright position.

Check:

• Ensure standing alignment is preserved, with hips extended while body rotates.
• Disallow foot movement.If necessary put your foot against patient’s foot to stop movement.

Reaching actions:

• Correct tendency to fall back by a reminder to bring hips forward (hip extension beyond neutral) before looking up.
• Disallow foot movement. Standing with feet a few cm apart, turn head and body mass and look behind,return to mid position, repeat to other side.

Check:

Standing, reaching to take object forward, sideways (both sides),backward.One hand, both hands.Variety of objects and tasks.Reaches should be
beyond arm’s length, challenging the patient to extend the limit of stability and return.

Check:

• Ensure movement of body mass takes place at the ankles and hips, not just within the trunk.
• Discourage a stiff posture and breath holding – encourage relaxed movement.

Single leg support (with or without harness or splint)
Stepping forward with non-paretic limb to place foot on a step.
Standing with either foot on step, practise reaching tasks.

Check:

• Ensure that the stance hip extends. Exercise can be practised initially in a harness.
Note
• Laufer et al. (2000) have shown that stepping forward on to a step of different heights with the non-paretic leg significantly increases weight borne through the paretic limb.

• The exercise directs attention to the concrete goal of raising the leg rather than the more abstract goal of shifting body mass.

Sideways walking:

This exercise enables practice of shifting weight from side to side with hips extended.

Picking up objects:

Standing, lowering body mass to pick up or touch object, forward, sideways,
backward and return.

Check:

• Ensure that hips, knees and ankles flex and extend.
• Start with object on stool to minimize distance to be moved (see Fig. 2.17c).
• Increase flexibility by changing base of support.

Action Reaching :

Forward: flexion at GH joint*

Sideways: abduction at GH joint*

Backward: extension at GH joint* with
– elevation of shoulder girdle
– external rotation at GH joint
– extension of elbow
– supination and pronation of forearm
– extension at wrist

Grasping:

Extension of wrist and fingers, with abduction and conjunct
rotation (‘opposition’) of the CMC joint of thumb and 5th finger.
Flexion of fingers and thumb around object.

Releasing:

Extension at wrist.
Extension at MCP joint of fingers.
Abduction and extension at CMC joint of thumb.

Manipulation:

Flexion and extension of MCP joints of fingers with wrist in
extension.

Palmar abduction and conjunct rotation of CMC joint of thumb.
Combined flexion and conjunct rotation at CI”IC joints of 5th
finger and thumb (e.g. cupping)
Independent finger flexion and extension (e.g. tapping)

Key grasp configurations, for example thumb-index; thumb-5th finger; 4th, 5th finger into palm; thumb + flexed MCP, extended interphalangeal (IP) joints of fingers (paper-holding grasp)