Abstract
Background
Although flexion distraction performed to the lumbar spine is commonly utilized and documented as effective, flexion distraction manipulation performed to the cervical spine has not been adequately studied.
Objective
To objectively quantify data from the Visual Analogue Scale (VAS) to support the clinical judgment exercised for the use of flexion distraction manipulation to treat cervical radiculopathy.
Design and setting
A retrospective analysis of the files of 39 patients from a private chiropractic clinic that met diagnostic criteria for inclusion. All patients were diagnosed with cervical radiculopathy and treated by a single practitioner with flexion distraction manipulation and some form of adjunctive physical medicine modality.
Main outcome measures
The VAS was used to objectively quantify pain. Of the 39 files reviewed, 22 contained an initial and posttreatment VAS score and were therefore utilized in this study.
Results
This study revealed a statistically significant reduction in pain as quantified by visual analogue scores. The mean number of treatments required was 13.2 ± 8.2, with a range of 6 to 37. Only 3 persons required more treatments than the mean plus 1 standard deviation.
Conclusion
The results of this study show promise for chiropractic and manual therapy techniques such as flexion distraction, as well as demonstrating that other, larger research studies must be performed for cervical radiculopathy.
Keywords
Introduction
Radiculopathy is defined as a clinical syndrome resulting from damage to either the dorsal or ventral nerve root or both. These lesions may affect sensory and/or motor fibers.
1
Thus, patients may have radicular pain, paresthesia, or motor symptoms, such as painless weakness. Patients more commonly present with pain or a combination of symptoms. In this retrospective study, patients were clinically diagnosed with cervical radiculopathy based on this definition. When treating patients with radiculopathy, the primary goal is to centralize the pain toward the spine, ie, to have the pain move more proximal from distal in the extremity, and to eventually obtain complete relief of symptoms. This process is called the centralization phenomenon2
and was first described by McKenzie3
; it has been studied for the lumbar spine.4
Outcome assessment procedures, which document the effectiveness of care, are an important aspect of clinical practice. This is due, in part, to the necessity of determining and documenting whether a patient's condition has changed during the course of therapy. Proper documentation helps to justify the type, duration, and frequency of care and may help determine a point of maximum improvement.
Cervical pain is becoming a large medical problem. The incidence of cervical radiculopathy has been estimated to be approximately 85 per 100,000 people. Chronic neck syndrome was identified in 9.5% of the men and 13.5% of the women. However, Bovim et al
5
reported that 34.4% of a random sample of 10,000 people in Norway experienced neck symptoms that lasted for more than 1 month. Other research data reported from Minnesota found 561 patients with radiculopathy from 1976 to 1990.6
Patients presenting with pain radiating distally from the spine are a concern among practitioners of manual medicine, as well as other health care practitioners and spine specialists. The primary modalities that have been used for treatment are manual manipulation and surgery.
Many conditions are showing promising results with manipulation. Flexion distraction, primarily for the lumbar spine, is one of the most commonly utilized forms of treatment among chiropractic physicians.
7
However, studies on cervical flexion distraction are lacking. Therefore, we felt that it was important to document the results that were found by this practitioner.Methods
In this retrospective study, the files of 1 private chiropractic office were reviewed to identify patients who were diagnosed with cervical radiculopathy. The files of patients who presented from 1998 through 2001 with neck pain and radiating pain into 1 or both upper extremities and who were treated with flexion distraction manipulation were analyzed. Patient files meeting these criteria, independent of the type of condition that produced the radiating pain, (ie, disk, radiculopathy, or sclerotogenous referral pattern) formed the cohort analyzed in this study. Initially, 39 patients meeting these criteria were identified. Of these, 22 had completed initial and posttreatment pain drawings and Visual Analogue Scale (VAS) recording for pain within a given 6-month time frame. The first VAS was obtained on the initial office visit. The second VAS was completed at the end of their prescribed treatment schedule. In this manner, a subjective assessment of pain was obtained, yielding a quantitative measurement of individual patient discomfort.
Cervical flexion distraction treatment was administered on all of the patients in this clinical series. This is a type of manual manipulation that primarily uses traction as the mode of delivery for the adjustment.
8
The cervical headpiece of the flexion-distraction instrument was utilized. During the flexion distraction procedure, the contact hand was placed at the T1 level in an attempt to essentially treat the entire cervical spine. The treating physician then applied a gentle and steady force through the contact hand in the caudal and posterior-to-anterior direction. The physician uses the noncontact hand on the handle of the headpiece to cause the desired movement. Most of the patients in this study were treated in straight flexion. However, if lateral flexion of the cervical headpiece affected a significant decrease in radicular symptoms (centralization), the headpiece was place in lateral flexion, usually contralateral to the side of radiculopathy, prior to administering flexion.All the patients also received some form of adjunctive physical medicine modality, eg, low-volt galvanic stimulation, ultrasound, and hot/cold packs. All patients were treated by the same clinician (RK) in the same private practice clinical setting. Many patients had confirmatory electromyography studies, magnetic resonance imaging, or radiological reports that documented radicular conditions or anatomic reasons for the condition of radiating pain.
The pretreatment and posttreatment Visual Analogue Scale scores were analyzed using paired t tests for females and the total sample. A U score was calculated for males using a Mann-Whitney test. This test was selected due to the small number of males in the sample group.
Results
In this study, the symptoms of the 22 patients who provided an initial and final estimate of their pain with the VAS diminished in correlation to treatment. The reductions in pain perception in this specific patient population were statistically significant. The mean change in VAS score was 41.4 ± 17.9. These results can be used to statistically estimate an optimal number of treatments. Dividing the average difference in VAS score (41.4) by the average change per treatment (3.9) yields an estimate of the number of treatments needed to reduce an average patient's pain by the average amount for the group: 10.6 or 11 treatments. This is reasonably congruent with the actual average number of treatments (13.2). These data are presented in Table 1.
Table 1Visual Analogue Scale scores
| Gender | Initial score | Final score | Change | Statistical significance |
|---|---|---|---|---|
| Male | 40.2±14.3 | 3.5±4.0 | 36.7±16.5 | U=9.34;P<.05 |
| Female | 53.8±19.8 | 10.6±16.5 | 43.2±18.6 | t=6.70;P<.05 |
| Total | 50.1±19.2 | 8.7±14.4 | 41.4±17.9 | t=8.09;P<.05 |
∗ Mean ± SD.
The number of treatments provided is based on a professional evaluation of a given patient's clinical condition. In this series, only 3 patients (13.6%) required more treatments than the average plus 1 standard deviation above the mean. This is consistent with a theoretical normal distribution in which approximately 16% of the area under the curve is more than 1 standard deviation above the mean. Further supporting the clinical judgments applied to the 3 patients receiving the most treatments, they had an average initial VAS score of 65.2 ± 22.2 and a mean final VAS score of 3.3 ± 2.3. Stated in other terms, these patients started with higher than average levels of pain and achieved greater than average reductions in their pain. Additional details concerning treatments are provided in Table 2.
Table 2Treatment data
| Gender | Number of treatments | Range | Change per treatment |
|---|---|---|---|
| Male | 16.0±10.0 | 7 to 31 | 2.6±0.6 |
| Female | 12.2±7.5 | 6 to 37 | 12.2±7.5 |
| Total | 13.2±8.2 | 6 to 37 | 3.9±2.4 |
∗ Mean ± SD.
Discussion
Defining radiculopathy is important to having a clear understanding of the clinical phenomenon. According to Cramer and Darby,
9
radicular pain is caused by activation of sensory fibers at the level of the dorsal root. It is described as a thin band of sharp shooting pain along the distribution of the nerve(s) supplied by the affected dorsal root. This is also termed the dermatomal pattern. Other descriptions can include long tract radiation into the upper or lower extremity. It may be accompanied by paresthesia, hypesthesia, or decreased reflexes, as well as being coupled with motor weakness secondary to compromise of the ventral roots.9
There are several possible causes of radicular pain, such as disk lesion, abscess, tumor, spondylolisthesis, malformation of the vertebral canal, malformation of the spinal nerve root and/or sheath, diseases of surrounding bone, and chemical inflammation due to degeneration of the intervertebral disk. Disk herniation is the most common cause of radiculopathy. However, other nonmechanical causes of radiculopathy include the following: leptomeningitis, meningeal carcinomatosis, and herpes zoster.
10
One common cause of cervical radiculopathy is due to encroachment of the cervical intervertebral foramen. The anatomy of a cervical foramen has been described as an hourglass with a narrowing at the center. Foraminal cross-sectional area of the cervical spine may be one of the causes of radiculopathy.
11
Humphreys et al12
studied symptomatic and asymptomatic patients with cervical radiculopathy. They found that the inferior foraminal width, but not the height, tends to decrease with age.The primary diagnosis of cervical radiculopathy is based on a patient's subjective symptoms. Patients commonly report neck pain and pain that radiates along specific dermatomes. Many patients also commonly present with a positive Bakody's sign (holding one's hand on one's own head to relieve the pain on the affected side).
14
Bakody's sign has also been described as the shoulder abduction relief test.15
Other orthopedic testing that decreases the size of the cervical intervertebral foramina will increase the radicular symptoms. Conversely, tests that increase the cervical intervertebral foramina usually decrease the radicular findings.The prognosis varies for cervical radiculopathy. In cases of radiculopathy, the first changes of denervation are found in the paraspinal muscles within 7 to 10 days.
16
Within 2 to 3 weeks, deficits in the limb muscles of the affected myotome become evident. Healing and reinnervation can be seen at 3 to 6 months after the original injury.Magnetic resonance imaging (MRI) is the primary imaging modality when radiculopathy is suspected.
16
Needle electromyography (EMG) is the gold standard for an electrodiagnostic evaluation.17
However, both tests have their disadvantages. EMG will not display radiculopathies if they are mild or primarily sensory. MRI may show structural changes that are not clinically significant. The timing of the study may also influence MRI results. According to Nardin et al,16
some studies have shown that large disk herniations regress with time. Therefore, radiculopathy that is due to a disk herniation may show differing disk appearances depending on the time that the diagnostic study was performed relative to the time of injury.Dynamic motion is also an important factor in the cervical spine. Researchers have studied the intervertebral foramen sizes with different motions. Extension combined with axial rotation has been shown to decrease the foraminal size.
18
Muhle et al18
also reported that, among symptomatic patients, the foraminal size increased with flexion and axial rotation to the side opposite to the pain. Biomechanical studies have shown that extension reduces the size of the spinal canal compared with neutral, with extension decreasing the canal size and area of the intervertebral foramen.19
, 20
These motions may also increase the symptoms that many patients experience.Chronic neck pain has been effectively treated by several different approaches.
21
, 22
, 23
, 24
Some studies show support of manual manipulation for neck pain,25
but others show that the data are inconclusive.21
, 26
, 27
Traction has also been shown to be effective.28
In one study of 503 patients, 246 were found to have cervical radiculopathy without myelopathy. After evaluation, only 86 were recommended for surgery.28
According to these researchers, surgical patients improved significantly in regards to pain and functional status. Heller15
reported that surgical intervention for neck pain without neurological deficit had no benefits.Studies of conservatively treated patients who were treated without surgery reported larger improvements in many areas, including reflexes, motor weakness, and pain, than those treated with surgery.
24
Skargren and Oberg22
showed that 5 different variables were involved when reviewing individuals' responses to treatment. The factors were duration of current episode, Oswestry score29
at entry into the study, number of areas involved or number of localizations, expectations of treatment, and patient well-being. In a 12-month study,22
patients that had a poorer prognosis had a longer duration of pain (>1 month), more than 1 localization, and fewer positive expectations. However, Skargren and Oberg22
reported that age, gender, smoking, previous history of a similar problem, neck or low back pain, pain intensity and frequency, and general health did not contribute significantly to the prediction of outcome. However, the incidence of neck pain in general has been found to be greater in women than men.30
The VAS is a form of patient perception outcome assessment that has been described as “generally relevant, valid, reliable, responsive, and safe.”
31
, 32
With the VAS, patients are asked to place a mark on a horizontal line, 10 cm in length, to indicate the severity of their pain. The left end of the line represents no pain, and the right end represents severe, or unbearable, pain. A clinician can then measure the distance from the left end of the line to the patient's mark and give it a numeric value. In this way, future assessments can be measured and compared, thereby documenting progress.One concern of the present study was not having final VAS recordings for all patients. This occurred because they did not return for scheduled additional treatments or were not officially dismissed from care. A total of 17 individuals never completed a second VAS form and were therefore not included in the study. Neither the mean initial score for these patients nor the range of scores was significantly different from those for whom 2 VAS scores were available. Complete details can be found in Table 3.
Table 3Comparison of initial VAS scores for two groups of patients
| Attribute | Initial and final VAS scores available | Only initial VAS score available | Statistical significance |
|---|---|---|---|
| Minimum | 26 | 5 | |
| Maximum | 91 | 100 | |
| Male | 40.2±14.3 | 51.0±24.7 | U=1.07;P>.05 |
| Female | 53.8±19.8 | 40.4±27.4 | t=1.23;P>.05 |
| Total | 50.1±19.2 | 49.1±21.8 | t=0.15;P>.05 |
∗ Mean ± SD.
Conclusion
All patients utilized in this study were diagnosed clinically with cervical radiculopathy, independent of results from supportive diagnostic testing such as MRI or EMG. Studies of individuals with cervical radiculopathy demonstrate that not all patients are candidates for surgery. This leaves a significant portion that can benefit from other means of treatment. Many conditions are showing promising results with manipulation. Flexion distraction, primarily for the lumbar spine, is one of the most commonly utilized forms of treatment among chiropractic physicians.
7
However, studies on cervical flexion distraction are lacking.Within this private practice setting, the ability to perform preexaminations and postexaminations was sometimes hampered. We found that patients may not be willing to spend extra time to complete research instruments. Continued pain or other personal agendas may bias research results. Patients may also not return for follow-up care or a release examination when they believe (erroneously) that maximum improvement has occurred or they may not be satisfied with the progress of their treatments. Because patients in a private practice setting have to bear the financial costs for their treatment, they may not be fully compliant with suggestions concerning care and follow-up treatment.
This study objectively demonstrates that in this patient population, there was a significant decrease in pain levels and provides the basis for further research. This study also did not include all clinic patients, as they may have been treated with other forms of chiropractic care that did not use flexion distraction or were referred to other providers for other forms of treatment. While the results of this study show promise for chiropractic and manual therapy techniques, specifically cervical flexion distraction, it demonstrates that other, larger research studies must be performed.
Acknowledgements
The authors would like to thank Gregory Cramer, DC, PhD and Jerrilyn Cambron, DC, MPH of the National University of Health Sciences for assistance with this study.
References
- Neurology for non-neurologists. 4th ed. W.B. Saunders Co, Philadelphia2000: 205-211
- A descriptive study of the centralization phenomenon.Spine. 1999; 24: 676-683
- The lumbar spine.in: Spinal Publications, Wikanae, New Zealand1981: 22-80
- The centralization phenomenon.Spine. 1995; 20: 2513-2521
- Neck pain in the general population.Spine. 1994; 19: 1307-1309
- Epidemiology of cervical radiculopathy.Brain. 1990; 117: 325-335
- Distraction chiropractic adjusting.Topics Clin Chiropr. 1996; 3: 45-59
Cox J. Low back pain: mechanism, diagnosis and treatment. 6th ed. Baltimore: Williams and Wilkins; 1999. p. 1-4
- Basic and clinical anatomy of the spine, spinal cord, and autonomic nervous system.in: Mosby, St. Louis1995: 366-370
- Pain and temperature.in: Goetz C.C. Pappert E.J. Textbook of clinical neurology. W. B. Saunders, Philadelphia1999: 333-349
- Cervical radiculopathy and pseudoradicular syndromes.in: Murphy D.R. Conservative management of cervical spine syndromes. McGraw-Hill, New York2000: 189-194
- The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging—a descriptive approach.Spine. 1998; 23: 2180-2184
- Cervical radiculopathy.Neuroimaging Clin N Am. 1995; 5: 349-366
- Illustrated essentials in orthopedic physical assessment.in: Mosby, St. Louis1994: 22-23
- The syndromes of degenerative cervical disease.Orthop Clin North Am. 1992; 23: 381-393
- Electromyography and magnetic resonance imaging in the evaluation of radiculopathy.Muscle Nerve. 1999; 22: 151-155
- Essentials of skeletal radiology.in: Williams and Wilkins, Baltimore1987: 314
- Exacerbated pain in cervical radiculopathy at axial rotation, flexion, extension, and coupled motions of the cervical spine.Invest Radiol. 1998; 33: 279-288
- Dynamic changes of the spinal canal in patients with cervical spondylosis at flexion and extension using magnetic resonance imaging.Invest Radiol. 1998; 33: 444-449
- Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement.Spine. 1996; 21: 2412-2420
- Intensive training, physiotherapy, or manipulation for patients with chronic neck pain.Spine. 1998; 23: 311-319
- Predictive factors for 1-year outcome of low-back and neck pain in patients treated in primary care.Pain. 1998; 77: 201-207
- Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain.Spine. 1997; 22: 2167-2177
- Herniated cervical intervertebral discs with radiculopathy.J Spinal Disord. 1999; 12: 396-401
- Anatomic and clinical studies of radicular symptoms.Spine. 1984; 9: 23-30
- A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain.Spine. 2001; 2: 196-205
- Spinal manipulation and mobilization for back and neck pain.Br Med J. 1991; 303: 1298-1303
- Outcome in patients with cervical radiculopathy.Spine. 1999; 24: 591-597
- The Oswestry disability index.Spine. 2000; 25: 2940-2953
- Epidemiology, physical examination, and neurodiagnostics.Spine. 1998; 23: 2663-2673
Haldeman S, Chapman-Smith D, Peterson DM. Guidelines for chiropractic quality assurance and practice parameters: proceedings of the Mercy Center Consensus Conference. Gaithersburg (MD): Aspen Publishers; 1993. p. 141-4, 151
- The neck disability index.J Manipulative Physiol Ther. 1991; 14: 409-415
Article info
Publication history
Received in revised form:
June 25,
2002
Received:
February 12,
2002
Identification
Copyright
© 2003 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
