Article Information

Mohammad Ainur Nishad Rhajib^1*, MD. Waliul Islam², MD. Zakir Hossain^2, Ehsanur Rahman³

¹Clinical Physiotherapist, Musculoskeletal Unit, Department of physiotherapy, Centre for the Rehabilitation of the Paralysed, Dhaka, Bangladesh

²Clinical physiotherapist, Department of Physiotherapy, Dhaka, Bangladesh

³Associate Professor, BHPI, Dhaka, Bangladesh

^*Corresponding Author: Mohammad Ainur Nishad Rhajib, Clinical Physiotherapist, Musculoskeletal Unit, Department of physiotherapy, Centre for the Rehabilitation of the Paralysed, Savar, Dhaka, Bangladesh

Received: 10 March 2022; Accepted: 24 March 2022; Published: 01 April 2022

Citation:

Mohammad Ainur Nishad Rhajib, MD. Waliul Islam, MD. Zakir Hossain, Ehsanur Rahman. Evidence based Physiotherapy Management of a Cervical Radiculopathy Patient by using Clinical Reasoning Process. Journal of Spine Research and Surgery 4 (2022): 054-062.

Abstract

Keywords

Hypothetico Deductive Reasoning, Cervical Radiculopathy, Neural Mobilization, Neck Disability Index

Article Details

Abbreviations:

CR: Clinical reasoning; HDR: Hypothetico-deductive reasoning; ICF: International classification of functioning, disability and health; MCT: Manual cervical traction; MMT: Manual muscle testing; NMCT: Neural mobilization with manual cervical traction; NDI: Neck disability index; RCT: Randomized clinical trial, ROM: Range of motion; ULNT: Upper limb neural tension test; VAS: Visual analogue scale; BHPI: Bangladesh Health Professions Institute

1. Introduction

Neck pain is one of the most common musculosk-eletal disorder in the general population, second only to low back pain [1]. It is estimated that 30-50% of the population affected in every year & up to almost two of every three persons will experience neck pain at a certain time during their life time. Approximately 50-80% of individual with neck pain do not experi-ence complete recovery of symptom and many of them go on to experience chronic neck pain [2, 3]. Cervical pain or neck pain with radiculopathy is a common presentation in our daily practice. Cervical radiculopathy is a dysfunction of a nerve root in the cervical spine resulting in producing radicular symptom such as pain, paresthesia, weakness, numb-ness in the upper extremity. Annual incidence has been reported to be 107.3 per 100,000 for men and 63.5 per 100,000 for women affected with cervical radiculopathy [4]. The most common causes of cervical radiculopthy are cervical disc lesions and osteophyte encroachment, which results in nerve root or spinal nerve impingement or inflammation. As a result, produces radicular symptom in the ipsilateral extremity according to the affected nerve root [5]. The most common level of root compression is C7 (reported percentages 46.3–69%), followed by C6 (19-17.6%); compression of roots C5 (2–6.6%) and C8 (10-6.2%) are less frequent. One possible explanation is that intervertebral foramina are largest in the upper cervical region and progressively decre-ase in size in the middle and lower cervical areas, with an exception of the C7-T1 foramen (C8) [6].

Radiculopathy is differentiated from radicular pain, where radiculopathy is a neurological state in which conduction is limited or blocked along a spinal nerve or its [7]. When sensory fibers are blocked, numbness is the presentaion to dermatomal distribution and when motor fibers are blocked, weakness follow myotomal pattern [8]. However, radiculopathy is not defined by pain rather than is defined by objective neurological signs. Although radiculopathy and radicular commonly occur together, radiculopathy can occur in the absence of pain, and radicular pain can occur in the absence of radiculopathy. Radicular pain is usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression, for instance, because of inflammation of the nerve [9].

Clinical reasoning is fundamental to physical thera-pist’s practice. Clinical reasoning strategy play vital role in diagnosis and management process of clients [10]. One well-known clinical reasoning approach is hypothetico-deductive reasoning process where generating the multiple hypothesis based on cue or information acquisition and testing these hypothesis steps by steps. Hypothesis generation and testing involves both inductive reasoning where moving from a set of specific observation to a generalization to generate hypothesis and slower, detailed deductive reasoning (moving from a generalization to a conclusion in relation to a specific case) to test hypothesis [11, 12].

1.1 Aim

The aim of this study is evidence-based physio-therapy management of a single case of cervical radiculopathy patient by using clinical reasoning process.

2. Case Report

Mrs “X” is 42 years old housewife suffering from neck pain with radicular symptom for about 3-3.5 months. Initially ignored her pain & gradually increase pain and radiated below elbow at the right upper limb. Also, face difficulties in her daily activities such as cooking, clothes washing, watching television etc. She consulted with general practisioner and take medication for some weeks. His neighbor advised him to consult physiotherapist in Centre for the Rehabilitation of the Paralysed (CRP).

2.1 Baseline assessment

Neck pain is one of the leading causes of disability in the glove. A person with any form of disability to manage is a multi-dimensional and comprehensive approach and ICF (International classification of Functioning, Disability and Health) encounters the requirement of understanding disability state for make certain person with disability with a better quality of life [13]. As impairments in body structure and functions, patient came to me complained of intermittent severe radiating pain and mild numbness at her right upper limb for about 3.5 months that day by day increases. She also noticed that her pain as like as electric shock which make his life untearable. On assessment, her pain at the right side of the neck and severe radiating at the lateral aspect of the forearm and intermittent mild numbness at the thumb and index finger. According to VAS scale resting was 8 out of 10 and mild decrease range of motion of cervical right side rotation, side bending and flexion. There is no muscle wasting as well as reflex also normal. The activity limitation include pain aggra-vated by household activities such as washing clothes, cooking and watching TV programme. She also faced participation restriction as like social gathering, family programme. Her environmental factor was poor ergonomics set up of kitchen, place of TV and her daily activities. Her only son who studying in Chittagong Cadet College and can’t meet with her regularly. In addition, her husband was not interested to come with him in physiotherapy center also felt disturb due to long time of pain. All of these difficulties and situation make him depressed, worried and less confidence. I found her neck disability index (NDI) was 41%, which indicates severe disability.

2.2 Flags

During assessment found some factors which may obstacle the recovery and also helps in intervention.

2.3 Hypothetico deductive reasoning

As this was a complex case to detect initialy I carried

out diagnosis and management plan step by step. Even though I have propositional knowledge but there is limited non-propositional knowledge about this case

2.3.1 Cue acquisition: Initially I have asked lots of

questions and gathered answer to find out the best possible clue that is related to my case. Those questions are given below:

1. Is the pain constant, intermittent, and early morning stiffness & sleep disturbance? The reason for asking this question to identify causes of pain such as mechanical, non-mechanical, pathological involvement or any kind of arthritis.
2. Is the pain gradual or sudden onset and unilateral or bilateral referred?
3. The intendant to ask this question was to detect the source of symptoms.
4. Which activities aggravate or relieve your symptom?
5. Which site are you fell pain at first?
6. These two questions asked for to identify the exact which structure is involved and to see the severity of symptom.
7. Can you explain me your nature of pain such as burning, tingling, dull-aching, electric-shock & lancinating like?
8. This question was asked to understand the characteristics and nature of pain so that I can easily distinguish between somatic, visceral or radicular pain.
9. Does your pain influence by cough, sneezing or deep breathing?
10. This question was asked to see the relationship with dural involvement.
11. Any sequence of trauma or fell disturbance during walking?
12. This question asked to find out any cord compression.

2.3.2 Hypothesis generation: Hypothesis generation

was vital part of the systematic problem-solving process. It was an inductive reasoning, which provides a set of specific observation to a generali-zation. After cue acquisition and getting the answers, few hypotheses are generated in the clinician mind which are given below:

1. There may have an association of pathological cause due to early morning stiffness and sleep disturbance influence this hypothesis
2. Thoracic outlet syndrome may be another reason, intermittent numbness at her thumb and radiating pain at right forearm indicates this hypothesis.
3. Cervical spondylosis may have strong relationship of symptom. Patient’s age, gradual onset and radiating pain may have probabilities this hypothesis.
4. Cervical disc prolapse with C6 radicular symptom may be main pain generator source. Pain on coughing and intermittent unilateral symptom such as numbness, radiating pain. In addition, pain charact-eristics was electric shock like and lancinating type pain according to the dermatome distribution. All of these provocative this hypothesis

2.3.3 Cue interpretation: It involves in appropriately evaluating which cues are most relevant to my specific hypothesis under consideration. Elastin [14] reported a three point scale for cue interpretation where ‘+1’ cue confirms hypothesis, ‘-1’ disconfirms hypothesis and ‘0’ cue does not contribute to hypothesis. The cue interpretation are given below

1. Patient had no significant weight loss, pyrexia, systemic illness and pathological report. In this way the hypothesis of pathological involvement disconfirms (-1).
2. Even though, there is radiating pain at the lateral aspect of the forearm and thumb, the adson’s test (specificity 87% and sensitivity 94%) was negative and also X-ray do not show any cervical rib [15]. Thus, this hypothesis has no contribution on the symptom (0).
3. The radiological findings does not show any degenerative change such as osteophytic formation, intervertebral discs space [16]. These finding exclude the possibilities of cervical spondylosis. Clinician confirmed that the hypothesis of cervical spondylosis has no contribution to the symptom (0).
4. The dural symptom (pain on coughing) was positive. Clinician perform spurling test (40%-60% Sensitivity, 85%-95% specifi-city) by lateral flexion and rotation to the affected side with axial compression of the head reproduces radicular pain and found positive. Clinician also performed neck distraction test (40%-50% Sensitivity, 90% specificity) and found relief of radicular symptoms when grasps patient’s head under occiput and chin and then lifts, applying axial traction . Examiner also noticed that her pain location according to the C6 nerve root that means pain at the neck, lateral aspect of the forearm and first and second digit. Examiner also performed upper limb tension test (ULNT1) for C6 symptom and this test done by shoulder depression, shoulder abduction 110°, wrist and finger extension, shoulder lateral rotation, elbow extension, contralateral lateral flexion of the cervical spine where the sensitivity of 0.97 and a specificity of 0.69 [17]. Moreover, active range of motion of cervical ipsilateral rotation, latreral flexion decreased. Conver-sely, Babinski sign was negative. All of these cue strongly confirm the hypothesis no IV (+1).

2.3.4 Hypothesis evaluation: The final stage of hypothetico deductive approach was hypothesis evaluation. I made weighing up the advantage and disadvantage of each possible explanation for patient’s sign and symptom and choosing the favored one by the evidence. After completion of all ideas, I would like to say the hypothesis number IV support the evidence [7] stated that although radiculopathy and radicular commonly occur together, radicul-opathy can occur in the absence of pain, and radicular pain can occur in the absence of radiculopathy. Radicular pain is usually caused by compression of the nerve root due to cervical disc herniation. The pain quality was lancinating and electric shock like which is radicular pain [9]. A double blinded randomized clinical trial (RCT) was conducted to find out the efficacy of neural mobilization with manual cervical traction (NMCT) for reducing cervical radiculopathy patient’s pain [18]. They found significant difference between control group and experimental group and suggested that NMCT can pain relief and increase range of motion. Experimental group received manual cervical traction simultaneously with neural mobilization and conventional physiotherapy and control group received manual cervical traction along with conventional physiotherapy.

2.4 Intervention

I have started intervention with the Mckenzie Mech-anical Diagnosis and Therapy (MDT) of cervical spine. Then neural mobilization with manual traction, cervical stability training and postural reeducation. The description of these interventions is given below.

2.5 Outcome measurement

Outcome measurement tool included visual analogue

scale (VAS) for pain intensity Goniometer for range of motion (ROM) and Manual muscle testing technique by using OXFORD muscle grade scale to assess the muscle strength of cervical spine. The reliability of VAS is 0.94 [19]. On the other hand, disability was measured by Neck Disability Index (NDI). NDI is a commonly used outcome measure to demonstrate the actual level of disability among patients with neck pain and also it has higher level of validity and reliability [20].

Table 1: Flags.

Table 2: Interventions.

Table 3: Outcome measurement.

4. Discussion

Neck pain is one of the most common musculoskeletal disorder in the general population, second only to low back pain. Cervical pain or neck pain with radiculopathy is a common presentation in our daily practice. Cervical radiculopathy is a dysfunction of a nerve root in the cervical spine resulting in producing radicular symptom such as pain, paresthesia, weakness, numbness in the upper extremity. Clinical reasoning refers to professional judgments made before, during and after clinical sessions in physical therapy and it support profess-sional autonomy [21]. Though, I have a propositional knowledge but due to enough lack of non- propositional knowledge and novice practitioner, I went through the HDR process instead of pattern recognition. Recently a randomized control trail was conducted on cervical radiculopathy patient [18]. The primary goal was effectiveness of cervical neural mobilization with manual traction which treatment approach was applied in our current study. In that randomized trial, patient receive 4 weeks of physiotherapy treatment, outcome measurement was pain and functional disability. Finally, they conclu-ded that neural mobilization with cervical traction is significantly effective for pain reduction, reducing the functional neck disability and increased range of motion. So, in our study found similar effect to the patient.

McKenzie MDT for cervical spine, neural mobile-zation, manual cervical traction along with cervical stabilization exercise was used for this cervical radiculopathy patient. After following this process, at the end of 6^th week patient was smiling face and tickled mood. She can participate in routine and activities as well as her family member became supportive and helpful. Now she is continuing treat-ment as follow-up patient with a pleased.

5. Conclusion

Clinical reasoning is the foundation in our clinical practice. It enables the therapist to take the best- judged action for individual patients and make sure quality service. Mckenzie MDT for cervical spine, neural mobilization, manual cervical traction along with cervical stabilization exercise was effective for this cervical radiculopathy patient.

Conflict of Interest

No conflict of interest is relevant to the content of this case study.

Acknowledgements

Mohammad Anwar Hossain, Associate Professor of Physiotherapy (BHPI),

Sr. consultant & head, CRP.

References

1. Bertozzi L, Gardenghi I, Turoni F, et al. Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Physical therapy 93 (2013): 1026-1036.
2. Carroll LJ, Hogg-Johnson S, van der Velde G, et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physi-ological therapeutics 32 (2009): S87-S96.
3. Woods BI, Hilibrand AS. Cervical radicu-lopathy. Journal of Spinal Disorders and Techniques 28 (2015): E251-E259.
4. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series. Journal of Orthopa-edic & Sports Physical Therapy 36 (2006): 152-159.
5. Kuijper B, Tans JT, Schimsheimer RJ, et al. Degenerative cervical radiculopathy: diagno-sis and conservative treatment. A review. European journal of neurology 16 (2009): 15-20.
6. Thoomes EJ, van Geest S, van der Windt DA, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. The Spine Journal 18 (2018): 179-189.
7. Wong JJ, Côté P, Quesnele JJ, et al. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. The Spine Journal 14 (2014): 1781-1789.
8. Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain 147 (2009): 17-19.
9. Gummesson C, Sundén A, Fex A. Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews 23 (2018): 29-34.
10. Higgs J, Jones MA. Clinical decision making and multiple problem spaces. Clinical reason-ning in the health professions 3 (2008): 3-17.
11. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. InMayo Clinic Proceedings 90 (2015): 284-299.
12. Elstein AS, Shulman LS, Sprafka SA. Medical problem solving an analysis of clinical reasoning (1978).
13. Sanders RJ, Hammond SL, Rao NM. Diag-nosis of thoracic outlet syndrome. Journal of vascular surgery 46 (2007): 601-604.
14. Binder AI. Cervical spondylosis and neck pain. Bmj 334 (2007): 527-531.
15. Apelby-Albrecht M, Andersson L, Kleiva IW, et al. Concordance of upper limb neuro-dynamic tests with medical examination and magnetic resonance imaging in patients with cervical radiculopathy: a diagnostic cohort study. Journal of manipulative and physio-logical therapeutics 36 (2013): 626-632.
16. Kim DG, Chung SH, Jung HB. The effects of neural mobilization on cervical radiculopathy patients’ pain, disability, ROM, and deep flexor endurance. Journal of back and musculoskeletal rehabilitation 30 (2017): 951-959.
17. Hawker GA, Mian S, Kendzerska T, et al. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis care & research 63 (2011): S240-S252.
18. MacDermid JC, Walton DM, Avery S, et al. Measurement properties of the neck disability index: a systematic review. Journal of orthopaedic & sports physical therapy 39 (2009): 400-417.
19. Øberg GK, Normann B, Gallagher S. Embodied-enactive clinical reasoning in physical therapy. Physiotherapy theory and practice 31 (2015): 244-252.
20. Akkan H, Gelecek N. The effect of stabilization exercise training on pain and functional status in patients with cervical radiculopathy. Journal of back and muscul-oskeletal rehabilitation 31 (2018): 247-252.