Enter subtitle here (24pt, Arial Regular)

1
RCSI Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Cervical Radiculopathy a review of best
evidence to guide Primary Care practice
Enter subtitle here (24pt, Arial Regular) Enter
date 25.06.13
Louise Keating SMISCP, MPhtySt (Manip), Lecturer
in Physiotherapy Irish Pain Society Annual
Scientific Meeting, Sept 2015 lkeating_at_rcsi.ie
RCSI
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Outline

• Epidemiology
• Natural history
• Global Clinical Practice
• Best Evidence
• Assessment in Primary care
• Conservative management
• Outcome predictors
• Surgical management
• Indications for referral
• Outcome predictors
• Research gap

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Definition

• Pain in a radicular pattern in one or both upper
  extremities related to compression and/or
  irritation of one or more cervical nerve roots.
• Frequent signs and symptoms include varying
  degrees of sensory, motor and reflex changes as
  well as dysesthesias and paresthesias related to
  nerve root(s) without evidence of spinal cord
  dysfunction (myelopathy)
• NASS Work Group Consensus Statement (2011)

• Radiating pain in the arm with motor, reflex
  and/or sensory changes (such as paraesthesiae or
  numbness), provoked by neck posture(s) and
  /or movement(s)
• Thoomes et al (2012)

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Peripheral NeuP Pain

• IASP definition
• Pain caused by a lesion or disease of the
  peripheral somatosensory nervous system
• Jensen et al
  2011
• In developed countries, most frequent causes ?
• Diabetic Polyneuropathy and
• Radiculopathies with neuropathic pain components
• Haanpaa et al 2009

NeuP Pain
Cx Rad
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Most common
Reasons for non-dermatomal pain patterns
Schmid et al 2013
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Inclusion Criteria Variability
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Aetiology
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75
8
75
25

• Soft Disc

• Spondylosis

• Single level
• Inflammation
• Interleukins Prostaglandin
• Majority spontaneously resolve (weeks months)

• Uncovertebral joint degeneration
• Multiple levels common

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Natural History

• 88 CR patients show improvement within 4/52
• Alentado et al 2014
• 90 have no or mild symptoms after 4-5yrs
• 20 did not improve ? surgery Radhakrishan
  et al 1994
• Deg CR - Arm pain VAS 7 ? 5 in 6/52 Kuijper et
  al 2009
• Recurrence 12.5 in 1-2yrs
  Honet Puri 1976
• Limited studies supporting any optimal duration
  of conservative treatment prior to surgery ?
  evidence-based conclusions cannot be made
  
• Alentado et al 2014

Traditional failure of 6/52 conservative
management ? escalation
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Background

• WHO Bone Joint Decade
• Taskforce on Neck Pain
• Research Gap exists in CR
  
• Hurwitz et al 2008
• Higher levels of pain, disability healthcare
  costs
• Haldeman et al 2008
• Axial neck pain
• Chronic non-neuropathic pain

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Recommendations for Assessment Chronic NeuP in
Primary Care - NeuPSIG

• Consensus on Diagnostic processes
• Categorisation of Pain mechanism ? Neuropathic /
  Nociceptive pain
• Sensory tests Touch, pinprick, thermal
  vibration
• Identify Underlying cause
• Pivotal role for GPs
• Early identification Management
• Triage for appropriate Rx strand
• Mixed Pain
• Lack of response to Nociceptive analgesics ?
  Neuropathic pain may be primary
• 
  Haanpaa et al 2009

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Screening Tools

• LANSS
• S-LANSS
• painDETECT
• DN4

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QST for Cervical Radiculopathy - PPT
Symptom duration Maximal Pain Area (kPa) Derm area sensory loss (kPa) Nerve trunks (kPa) Articular pillar C5/6 (kPa) Remote site -Tib Ant (kPa)
Chien et al 2008 (n38) Mean 19.7 mos. /- 14.2 Median N 203 (95 CI 179-228) 199 (95 CI 173-226) 440 (95 CI 378-503)
Moloney et al 2013 (n17) Mean 4.9 yrs /- 6.2 Median N 161 (172) Ulnar N 223 (148) Radial N 217 (155) 381 (IQR 135)
Tampin et al 2013 (n23) 3-18 mos. 403 vs. 434 (asymp) 572 vs. 492 (asymp)
QST in the German Research Network on Neuropathic
Pain (DFNS) Somatosensory abnormalities in 1236
patients with different neuropathic pain
syndromes. (n15 radiculopathy) Maier et al,
Pain 150 (2010) 439-450
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QST for Cervical Radiculopathy - PPT

• Profile of altered mechanosensitivity previously
  found in WAD has also been identified in patients
  with chronic CR
• More gain vs. loss noted
• Chien et al 2008
• More loss vs. gain noted
• Tampin et al 2013
• CR research to date has not used PPT as outcome

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Clinical Prediction Rule Wainner et al
2003

• Diagnostic criteria
• Cluster of four items (3/4)
• Positive ULNT1
• Positive Spurlings A test
• Limited cervical rotation to affected side
  (lt60degs)
• Positive distraction test
• LR Point estimates
• 3 tests 6.1 (95 CI 2.0-18.6)
• 4 tests 30.3 (95 CI 1.7-538.2)

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Global Clinical Practice
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NeuPSIG Pharma Recommendations Finnerup et al
2015
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NICE Guidelines NeuP pain Pharma Mgmt adults in
non-specialist settings 2013

• First Line - choice of Amitriptyline, Duloxetine,
  Gabapentin or Pregabalin
• If the initial treatment is not effective or is
  not tolerated, offer one of the remaining 3
  drugs, and repeat.
• Consider tramadol only if acute rescue therapy is
  needed
• Consider capsaicin cream for people with
  localised neuropathic pain who wish to avoid, or
  who cannot tolerate, oral treatments.
• NICE Pathway for NeuP pain (2015)

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MSK Physiotherapy Practice
Nee et al 2013
Rank Treatment Options Type
1 Explanation Advice
2 Exercise Motor Control Muscle Strength Endurance ROM
3 Passive manual therapy Joint Mobilisation (not manipulation)
4 Nerve gliding exercises
5 Stretching Neck and Axioscapular muscles
6 Taping Neck Shoulder
7 Thermal agents Heat gt Cold
8 Traction Manual not mechanical / home
9 Prescription HEP
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Conservative Management (non-invasive and
non-pharma)

• Cohort studies
• Initially promising results
  Saal et al 1996, Murphy et al 2006
• Clinical Trials
• Persson et al 1997, Young et al 2009, Joghataei
  et al 2004, Kuijper et al 2009, Langevin et al
  2014, Fritz et al 2014
• Systematic Reviews
• Manual therapy
• Cochrane no conclusions
  Gross et al 2010
• No conclusions due to low quality trials
  Leininger et al 2011
• MT and Ex benefits chronic CR
  Boyles et al 2011
  
  
• Conservative Rx
• Collar or Physiotherapy show promising short-term
  results
  
• 
  
  Thoomes et al 2013

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0-12 weeks

• Systematic Review
• Cochrane RV Exercise low quality evidence for
  small benefit for pain reduction immediate post
  treatment with cervical stretch / strengthening /
  stabilization in acute CR
• 
  
  Gross et al 2015
• Clinical Trials emerging (Dose 4-6/52)
• Manual Therapy Exercise
• Postural Advice Pharma (analgesics, NSAIDs,
  steroids or anti-depressants) (n36)
• Langevin et al 2014
• Exercise
• Advice Pharma (Paracetamol, NSAIDs or
  Opioids) (n205)
  
• Kuijper et al 2009
• Rationale for early intervention
• Nerve unloading irritation vs. compression
• Manual therapy (non-provocative)
• Lateral Glide causes immediate change to ULNT 1
  NPRS
  Coppieters et al 2003

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Langevin et al (2014) Results both groups
received varied manual therapy exercise ? no
true control to measure natural hx.
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Arm Pain
Langevin et al 2015 n36
Baseline
Kuijper et al 2009 n205
4 wks
6 mo
12 mo
Fritz et al 2014 n86
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Neck Pain
Langevin et al 2015 n36
Baseline
Kuijper et al 2009 n205
4 wks
6 mo
12 mo
Fritz et al 2014 n86
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Neck Disability Index
Langevin et al 2015 n36
  Baseline 3 wks 6 wks 26 wks
Cervical Collar 41 (17.6) 33.8 (18.7) 25.9 (19.1) 8
Physio 45.1 (17.4) 34.6 (16.1) 27.8 (17.7) 10
Control 39.8 (18.4) 34.3 (18.8) 29.9 (20) 8
Baseline
Kuijper et al 2009 n205
12 mo
6 mo
4 wks
Fritz et al 2014 n86
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Predictors of good response to Physiotherapy

• 4 variable model - at 4/52
• age greater than 54 years,
• non-dominant arm,
• cervical flexion not aggravating symptoms,
• Multimodal Physiotherapy MT, cervical traction
  and DNF strengthening at half of clinical visit
• LR ratio 8.3 (95 CI 1.9-63.9)
• 
  
  Cleland et al 2007

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Surgery vs. Conservative Rx

• Systematic Review - Cochrane
• Surgery leads to faster improvement in pain and
  disability at 3/12 vs. conservative management
  for chronic CR
• Similar outcomes at 1 yr
  
• Nikolaidis et al 2010
• RCT
• Physio vs. Surgery Physio no additional
  benefit from surgery
• Peolsson et al 2013
• Protocol
• CASINO Trial currently recruiting CR (disc)
  Surgery vs. GP care (n400)
  van Geest et al 2014

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Surgical Review Criteria for CR -Best evidence
synthesis

• Sensory symptoms (radicular pain and/or
  paraesthesia) in dermatome corresponding to
  involved cervical level
• AND
• Motor deficit OR reflex changes OR positive EMG
• AND
• MRI OR Myelogram with CT concordant
• AND
• At least 6/52 of conservative Rx
• Exception clear motor deficit after acute
  injury
• 
  
  Leveque et al 2015

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Surgical Review Criteria for CR Best evidence
synthesis

• Sensory symptoms (radicular pain and/or
  paraesthesia) in dermatome corresponding to
  involved cervical level
• AND
• Positive response (80 improvement or 5 VAS pts)
  to Selective Nerve Root Block (SNRB)
• Leveque et al 2015

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NHS National Pathway of Care for Low Back
Radicular Pain2014
Radicular Pathway
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Predictors of Surgical Outcome

• SHORT-TERM (1-2 yrs)
• Lower levels pre-op pain and disability
• Male
• Non-smoker
• Good hand strength neck AROM
• Peolsson Peolsson 2008
• LONG-TERM (10-13 yrs)
• Higher levels pre-op pain
• Male
• Non-smoker
• Low level depression
  Hermansen et al 2013
• Biopsychosocial assessment is suggested
  pre-surgery

Not MRI findings
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Research Gaps

• Primary Care practice patterns in Ireland
• Pharmacology
• Surgical referral
• Pain Specialist referral
• 0-12 weeks
• RCTs needed MMT Pharma vs. Pharma
• Sub-group responders
• Somatosensory biopsychosocial profile
• Surgery
• Recurrence
• Lack of guidance for secondary prevention

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Key Messages

• Best evidence Approach
• Assessment
• History taking for arm pain vs. neck pain,
• Categorise pain mechanisms (screening tools) and
  aetiology (MRI)
• Sensory testing
• Diagnosis CPR to rule in (MRI to confirm) and
  ULNT1 to rule out
• Self-report outcome measures VAS (neck arm),
  NDI

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Key Messages

• Best evidence Approach
• Conservative Rx
• Reassurance
• Pharmacology high level of evidence
• 0-12 weeks RCT evidence has not yet established
  efficacy of MMT vs. time. Exercise (/ collar) has
  efficacy in spondylotic CR.
• gt 12 weeks - Multimodal PT more evidence
• Surgical Referral Major motor radiculopathy,
  suspected myelopathy, failure of 6/52 Cons Rx,
  patient profile (non-tolerable pain)

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RCT of Multimodal Physiotherapy for Acute or
Sub-Acute Cervical Radiculopathy

• www.rcsi.ie/PACeRtrial
• Prof. Ciaran Bolger, Consultant Neurosurgeon,
  Beaumont Hosp
• Dr. Dara Meldrum, RCSI
• Dr. Catherine Doody, UCD,
• Caroline Treanor, Clinical Specialist
  Physiotherapist,
• Julie Sugrue, Senior Physiotherapist, Beaumont
  Hosp
• _at_UqLouise

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References

• BONO, C. M., GHISELLI, G., GILBERT, T. J.,
  KREINER, D. S., REITMAN, C., SUMMERS, J. T.,
  BAISDEN, J. L., EASA, J., FERNAND, R., LAMER, T.,
  MATZ, P. G., MAZANEC, D. J., RESNICK, D. K.,
  SHAFFER, W. O., SHARMA, A. K., TIMMONS, R. B.
  TOTON, J. F. 2011. An evidence-based clinical
  guideline for the diagnosis and treatment of
  cervical radiculopathy from degenerative
  disorders. Spine J, 11, 64-72.
• BOYLES, R., TOY, P., MELLON, J., JR., HAYES, M.
  HAMMER, B. 2011. Effectiveness of manual physical
  therapy in the treatment of cervical
  radiculopathy a systematic review. J Man Manip
  Ther, 19, 135-42.
• CHIEN, A., ELIAV, E. STERLING, M. 2008.
  Whiplash (Grade II) and Cervical Radiculopathy
  Share a Similar Sensory Presentation An
  Investigation Using Quantitative Sensory Testing.
  The Clinical Journal of Pain, 24, 595-603
  10.1097/AJP.0b013e31816ed4fc.
• FOUYAS, I., SANDERCOCK, P, STATHAM P, NIKOLAIDIS,
  I 2010. How beneficial is surgery for cervical
  radiculopathy and myelopathy? BMJ, 341.
• HALDEMAN, S., CARROLL, L., CASSIDY, J., SCHUBERT,
  J. NYGREN, A. 2008. The Bone and Joint Decade
  20002010 Task Force on Neck Pain and Its
  Associated Disorders - Executive Summary. Spine
  (Phila Pa 197), 633, S5-7.
• HURWITZ, E. L., CARRAGEE, E. J., VELDE, G.,
  CARROLL, L. J., NORDIN, M., GUZMAN, J., PELOSO,
  P. M., HOLM, L. W., CÔTÉ, P., HOGG-JOHNSON, S.,
  CASSIDY, J. D. HALDEMAN, S. 2008. Treatment of
  Neck Pain Noninvasive Interventions. European
  Spine Journal, 17, 123-152.
• NIKOLAIDIS, I., FOUYAS, I., SANDERCOCK PAG PF,
  S. 2010. Surgery for cervical radiculopathy or
  myelopathy. Cochrane Database Syst Rev.
• KAY, T. M., GROSS, A., GOLDSMITH, C. H.,
  RUTHERFORD, S., VOTH, S., HOVING, J. L.,
  BRONFORT, G. SANTAGUIDA, P. L. 2012. Exercises
  for mechanical neck disorders. Cochrane Database
  Syst Rev, 8, CD004250.
• LANGEVIN, P., DESMEULES, F., LAMOTHE, M.,
  ROBITAILLE, S, ROY, J. S. 2015. Comparison of 2
  Manual Therapy and Exercise Protocols for
  Cervical Radiculopathy A Randomized Clinical
  Trial Evaluating Short-Term Effects. J Orthop
  Sports Phys Ther 45(1)4-17. Epub 24 Nov 2014.
  doi10.2519/jospt.2015.5211
• LANGEVIN, P., ROY, J. S. DESMEULES, F. 2012.
  Cervical radiculopathy study protocol of a
  randomised clinical trial evaluating the effect
  of mobilisations and exercises targeting the
  opening of intervertebral foramen NCT01500044.
  BMC Musculoskelet Disord, 13, 10.
• PEOLSSON, A., SODERLAND, A. ENGQUIST, M. 2013.
  Physical function outcome in cervical
  radiculopathy patients after physiotherapy alone
  compared with anterior surgery followed by
  physiotherapy. A prospective randomized study
  with a 2-year follow-up. Spine (Phila Pa 1976),
  38, 300-307.
• RADHAKRISHNAN, K., LITCHY WJ, O FALLON WM LT.,
  K. 1994. Epidemiology of cervical radiculopathy.
  A population-based study from Rochester,
  Minnesota, 1976 through 1990. Brain, 117, 325-35.
• WAINNER, R. S., FRITZ, J. M., IRRGANG, J. J.,
  BONINGER, M. L., DELITTO, A. ALLISON, S. 2003.
  Reliability and diagnostic accuracy of the
  clinical examination and patient self-report
  measures for cervical radiculopathy. Spine (Phila
  Pa 1976), 28, 52-62.
• Full list available on request
• Lkeating_at_rcsi.ie