PHYSIOTHERAPY MANAGEMENT IN PATIENT WITH

CERVICORADICULOPATHY: A CASE STUDY

Minor Project
Submitted in partial fulfillment for the award of degree of
BACHELOR OF PHYSIOTHERAPY
SUBMITTED BY:
PREETI YADAV
Roll no. 0817141
BPT (Fourth year)


UNDER GUIDANCE OF:
Dr. NEERJA THUKRAL
MPT (NEUROLOGY)

DEPARTMENT OF PHYSIOTHERAPY
GURU JHAMBHESHWAR UNIVERSITY
OF SCIENCE AND TECHNOLOGY
HISAR (HARYANA)
2011-2012





Dedicated To
My
Grand Parents,
parents
&
To
My
Brothers $ sweet sister





CERTIFICATE

This is to certify that dissertation work entitled, PHYSIOTHERAPY MANAGEMENT IN
PATIENT WITH CERVICORADICULOPATHY: A CASE STUDY
submitted byPreetiYadav for partial fulfillment of requirement for the degree of
BACHELORS OF PHYSIOTHERAPY of Guru Jambheshwar University of Science and
Technology, Hisar is done under my guidance. The information given is authentic and has not
been copied from any other source.



Date: Guide
Place: Dr. NeerjaThukral, PT
MPT(Neurology),
Deptt. Of Physiotherapy
Guru Jambheshwar University
Science& Technology, Hisar.













ACKNOWLEDGEMENT

I would like to express my sincere gratitude to the following individuals without whom this
study would have been unattainable.
My sincere thanks to Dr.NeerjaThukral, MPT (Neurology), Assistant Professor,
Department of Physiotherapy, Guru Jambeshwar University of Science and Technology,
Hisar, whose guidance, constructive counseling, unmatchable suggestions, critical
appreciations and unstinted encouragement enlighten me throughout the project.
I am very grateful to Prof. D. C. Bhatt, Chairman, Department of Physiotherapy for
encouragement and for providing necessary facilities and normal support during the course of
this project.
I also thank Dr. Shabnam Joshi, MPT (Ortho), Dr.JaspreetKaur Malik, MPT (Neuro), Dr.
Manoj Malik MPT (Neuro), DrKulandaivelan MPT (sports),Dr.Pooja, AtreyMPT
(Ortho),Dr.MinaxiSaini(Cardio), ), Dr. Kalindi MPT (Cardiopulmonary), Dr. RekhaMPT
(Sports), Dr. Mamta Boora MPT (Neurology), Dr. Sonu MPT (Neurology) and Dr.Pradeep
Azad BPT for their constant inspiration and genius support in pursuing the study.
I finally thank to my friends, who rendered their invaluable help and support during my
research work.
Remarkable co-operation and dedication by subjects laid milestones for the success of project
completion.




(Preeti Yadav)







LIST OF FIGURES





















LIST OF TABLE





















CONTENTS
CHAPTER PAGE No.
CERTIFICATE
ACKNOLEDGEMENT
LIST OF FIGURES
LIST OF TABLES
CHAPTER I INTRODUCTION
CHAPTER II ANATOMY
CHAPTER III BIOMECHANICS
CHAPTER IV PATHOLOGY
CHAPTER V ETIOLOGY
CHAPTER VI CLINICAL PRESENTATION
CHAPTER VII DIFFERENTIAL DIAGNOSIS
CHAPTER VIII SPECIAL TEST
CHAPTER IX TREATMENT AND PHYSIOTHERAPY
MANAGEMENT
CHAPTER X DISCUSSION
CHAPTER XI CONCLUSION
REFERENCES
APPENDIX
APPENDIX I CONSENT FORM
APPENDIX II CASE STUDY
APPENDIX III CERVICAL SPINAL
ASSESSMENT
APPENDIX IV VISUAL ANALOGUES SCALE












CHAPTER - 1
INTRODUCTION














Cervical radiculopathy is a dysfunction of nerve root of the cervical spine. The seventh (C7-
60%) and sixth (C6- 25%) cervical nerve roots are the most commonly affected.
In the younger population, cervical radiculopathy is a result of disc herniation or an acute
injury causing foraminal impingement of an exiting nerve. Disc herniation accounts for 20-
25% of the cases of cervical radiculopathy. In the older patient, cervical radiculopathy is
often the result of foraminal narrowing from osteophyte formation, decreased disc height,
degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly.
Cervical radiculopathy usually starts earlier in men than in women. It develops in young
individuals, and is almost always secondary to predisposing abnormality in one of the joints
between the cervical vertebrae, probably as a result of previous mild trauma.
Symptoms of cervical radiculopathy may appear in person as young as 30 years but are found
most commonly in individuals aged between 40-60 years. Radiologic radiculopathy changes
increase as the patient ages, 70% of asymptomatic persons older than 70 years have some
form of degenrative change in the cervical spine.
Cervical radiculopathy in athletes can occur from several mechanisms. These injuries can
occur from an extension, lateral bending, or rotation mechanism, which closes the neural
foramen and results in ipsilateral nerve root injury. Conversely, a traction injury can occur
with a sudden flexion or extension, coupled with lateral bending away from the affected
nerve root.
Factors associated with increased risk include heavy manual labor requiring the lifting of
more than 25 pounds, smoking, and driving or operating vibrating equipment. Other, less
frequent causes include tumors of the spine, an expanding cervical synovial cyst, synovial
chondromatosis in the cervical facet joint, giant cell arteritis of the cervical radicular vessels,
and spinal infections.




F.g :- 1.1Cervical Vertebrae

Th cervical disc herniations can occur with a sudden load with the neck in either flexion or
extension. In elderly persons with osteophyte formation, repetitive neck extension and
rotation in certain sports, such as swimming or tennis, may result in a more insidious injury.
16

In mild cases cervical radiculopathy often requires no treatment or may respond to
conservative treatment including wearing a neck brace and pain medication.
In more serve case of cervical radiculopathy, however particularly those involving pressure
on the spinal nerve or cord, may require treatment ranging from neck traction to stronger
medication to surgery.
Medical treatment includes rest as it allows soft part to heal by reducing inflammation
NSAIDS is given, Hot fomentation, antiemetics if giddiness is present.
The aims of physiotherapy treatment are to reduce pain, strengthening of neck muscles, neck
mobilization isometric neck exercises transcutaneous electrical nerve stimulation, infrared
radiation, thermotherapy, hot fomentation, ultrasound, short wave diathermy etc.
Cryotherapy can also be given,which includes ice pack and ice massage. Massage can also be
given in form of friction, circular kneading etc for the local pain. Cervical intermittent or
static traction is given to maintain the gap between vertebrae. Cervical collar are advised
towear by the patient at home and work places.
3














CHAPTER - II
ANATOMY













Cervical vertebra are the smallest of the true vertebrae, and can be readily distinguished from
those of the thoracic or lumbar regions by the presence of a foramen in each transverse
process. There are seven vertebra out of which the third to 6
th
are typical,while the 1
st
, 2
nd
&
7
th
are atypical.
Typical Cervical Vertebra
1. Body
Body is small and broader from side to side than from before backwards.
Superior Surface :- It is concave transversely with upward projecting lips on each side
and superior border of this surface may be beveled.
Inferior Surface :- It is saddle shaped, being convex fron side to side and concave
from before backwards. The lateral border are beveled and form synovial joints with
projecting lips of the next lower vertebra. The outerior border of the vertebrae project
downwards and may hide the intervertebral disc.
Anterior and Posterior Surface



Fig.2.1 Typical cervical vertebra.
2. Arches :-
Pedicles :- These are directed backwards and laterally. The superior and inferior
vertebral notches are of equal size.
Lamina :- They are relatively long and narrow being thinner above than below.
Superior and inferior articular processes form articular pillars which project laterally
at the junction of pedicle and the lamina.
The superior articular surface facets are flat. They are directed backwards and
upwards. The inferior articular facets are also flat but they are directed forwards and
backwards.
The transverse processes are pierced by foramina transversaria. Each process has
outerior and posterior roots which end in tubercle joined by the costotransverse bar.
The costal element is represented by anterior root. The anterior tuberlia of the 6
th

vertebra is large.
The spine is short notch. The notch is filled up by the ligamentumnuche.


Fig.2.2 Side view of a typical cervical vertebra.
Atypical
cervical vertebrae

fig. 2.3 Atypical cervical vertebrae


a.) First Cervical Vertebra
It is also called Atlas.
It is ring shaped. It has no body and no spine.
Arches :- The atlas was a short anteriorasly a long posterior arche.
Anterior Arch :- The anterior arch is marked by a median anterior tubercle on the
anterior aspect.
Posterior Arch :- The posterior arch forms about 2/5
th
of the ring & is much longer
than the anterior arch. Its posterior surface is marked by a median posterior tubercle.
The upper surface of the arch is marked by the behind lateral marks by a grow.



Fig. 2.4. First cervical vertebra, or atlas.
b.) Second Cervical Vertebra
This is called Axis.
(1) Body :- The superior surface of the body is fused and it is encroached upon on each side
by the superior articular facets, the anterior arch of the atlas and posteriorly with the
transverse ligament of the atlas.
(2) Arches :- The pedicles are concealed superiorly by the superior articular processes. The
inferior surface presents a deep and wide inferior vertebral notch placed in front of the
inferior articular processes.
The lamina are thick and strong.

Fig 2.5 second cervical vertebra or axis
c.) Seventh Cervical Vertebra
It is also known as vertebra promineus because of its long spinous process, the tip of which
can be felt through the skin at the lower end of nuchal furrow.
Its spine is thick, long and nearly horizontal. It is not ends is a tubercle.
The transverse processes are comparatively large in size, the posterior root is larger than the
anterior.

F.g:- 2.6. Seventh cervical vertebra.





Ligaments of cervical Region
1. Anterior Longitudinal Ligament
2. Posterior Longitudinal Ligament
3. Cruciate Ligament
4. Apical Ligament
5. Alar Ligament
6. Flavum Ligament Nuchal

















MUSCLES OF CERVICAL REGION AND THEIR FUNCTION
1. Rectus capitus posterior major - Extension , lateral Rotation
2. Rectus Capitus Posterior Minor - Extension, Rotation
3. Superior Oblique - Extension, Rotation
4. Inferior Oblique - Rotation
5.SemispinalisCapitis - Extension ,Lateral Rotation
6.SemispinalisCapitis - Extension , Lateral Rotation
7. Splenius Capitis and Cervicis - Extantion , Lateral Rotation
8.Levator Scapulae - Extention , Lateral Rotation
9.LongissimusCapitis - Extention , Lateral Rotation
10.Trapizius - Extention , Lateral Rotation
11.Strenoeleodomastoid - Flexion , Lateral Rotation
12.LongusColli - Flexion ,Lateral Rotation
13.LongusCapitis - Flexion ,Lateral Rotation
14. Rectus Capitis Anterior - Flexion ,Lateral Rotation
15. Rectus CapitisLateralis - Flexion ,Lateral Rotation
16. Scalene muscle - Flexion , Lateral Rotation



















CHAPTER - III
BIOMECHANICS













The three bony components of the upper cervical spine are
a) Skull base
b) Atlas
c) Axis
These are the three components which form a functional unit. There are five joints in the
upper cervical spine which are stabilized by ligamentous check pain and muscular control.
Together these contribute to the movements in the neck substantially. This enables for a
rapid response and large-scale head excursion.
Upper cervical spine is thought to contribute approximately 60% of rotation, 40% of flexion-
extension, and 45% of overall neck motion.
The Atlanto-occipital joint and C12 flexion/extension excursion is similar for both joints at
20 to 30 degrees at each level.
Total left to right lateral bending at the C12 segment amounts to 20 degrees.
The alar ligaments play a key role in protecting normal cranio -cervical motion. At mid
position of the head these ligaments are slack.
By turning the head in one direction, the alar ligament contralateral to the direction of turning
tightens, while the ipsilateral ligament slackens. Together with the tectorial membrane the
alar ligament limits flexion but they play no role in limiting extension.
The contralateral alar ligament limits lateral bending.
Other ligamentous stabilizers of the craniocervical junction are the cranial portions of the
anterior longitudinal ligament and posterior longitudinal ligament of the spine and joint
capsules of the respective articulations.
Anteriorly, the well-developed atlanto occipital membrane limits extension, with the thinner
anterior atlantoaxial membrane contributing to a less significant degree.
A number of smaller ligaments, such as the apical and cruciate ligaments, obliquely aligned
accessory atlantoaxial ligaments, the anterior atlantodental ligament, and the facet joint
capsules also provide support.
The specific arrangement of ligaments at the cranio -cervical junction utilizes the atlas as a
washer or base for a coupled, multi -planar motion.
The combination of a high degree of mobility and relatively delicate ligamentous and bony
structures makes the upper cervical spine susceptible to injury from indirect high-energy
trauma.
Fracture-dislocations of the cranio cervical junction is the leading cause of death of motor
vehicle accidents.
The atlas is the most fragile vertebral segment in humans. It will fracture with as little as 1 to
2 mm of deformation and is very susceptible to bursting-type fractures with relatively low
axial loads.
The two most vulnerable bony structures of the axis are the pars interarticularis and the
odontoid waist. Forced hyperextension can lead to failure of either structure.
Flexion is believed to be causative in 80% of odontoid fractures by forcing the transverse
ligament against the odontoid.
Atlantoaxial rotation of more than 50 degrees in either direction as measured by CT scan is
suspicious for alar ligament insufficiency.
17






























CHAPTER - IV
ETIOLOGY










These are various causes which contribute in cervical radiculopathy.
1. Trauma:- In some patient it is associated with trauma either as a single severe episode
or related to repeated minor episode over many year, usually determined by nature i.e.
repeated muscular strain.
5

2. Wear and tear:- As a person grows old, there is always generalized wear and tear of
the joints.
1

3. Degeneration:- Degeneration of joints in old aged person.
4. Inheritance:- In some patient wide spread generalized osteoarthritic genetic factors are
dominant,the inheritance among female members of the family often being clearly
seen.
5. Obesity:- In some patient obesity may be a major factor.
5

6. Occupational stress:- it occurs early in person pursuringwhite collar jobs or thos
susceptible to neck strain because of keeping the neck constantly in one position
while working on computer,
2
occupational stress, e.g. typists at poorly positioned
desks, coal-miners and drivers, people whose work involves lifting, twisting and
carrying.
10

7. Poor posture:-May also be a cause for cervical radiculopathy.
2

8. Developmental abnormalities:- In many patients the cause is unclear although
developmental abnormalities and endocrine and metabolic factors may be invo
9. Body type:- Neck that are thickest with Dowagers Hump and long back are prone
to radiculopathy.




















CHAPTER - V
PATHOLOGY















Inter-vertebral discs lose hydration & elasticity with age, and these losses lead to cracks &
fissures. The surrounding ligaments also loose their elastic properties and develop traction
spurs. The disc subsequently collapses as a result of biomechanical incompetence, causing
the annulus to bulge outward, and the facets override. Acute disc herniation may complicate
chronic spondylotic changes.
As the annulus bulges, the cross-sectional area of the canal is narrowed. This effect may be
accentuated by hypertrophy of the facet joints (posteriorly) & the ligamentumflavum. Neck
extension causes the ligaments to fold inwards, reducing the A-P diameter. As disc
degeneration occurs, the uncinate process override (joints of Lushka) & hypertrophies,
compromising the ventro-lateral portion of the foramen.
Facet hypertrophy decreases the dorso-lateral aspect of the foramen. This change contributes
to the radiculopathy associated with cervical spondylosis. Marginal osteophytes begin to
develop and any additional stress in the form of trauma or long term heavy loading may
exacerbate this process.
18



Fig. 5.1 disc herniation





















CHAPTER - VI
CLINICAL FEATURES









Cervical radiculopathy is a constellation of symptoms consisting of neurogenic neck and
upper extremity pain emanating from the cervical nerve roots. In addition to the pain, the
patients with cervical radiculopathy may experience associated numbness, weakness, and loss
of reflexes. The causes of cervical radiculopathy include herniated disk, foraminal stenosis,
tumor, osteophyte formation, and rarely infection.
1. Pain :- This is commonest presenting symptom.
2,7
Patient complains of ill defined,
aching pain in the back of neck or in the trapezius area. Pain will be sharp and
stabling pain. Initially pain is intermittent but it becomes persistent later.
2. Sensory system:- Parasthesia may be persent in arm, forearm and hand in the form of
tingling or pins and needle sensation in a root distribution.
1,7

3. Stiffness:- Patient may complain of neck stiffness, grating and tightness on
movement.
4. Radiating pain:- The patient may present with pain radiating to the shoulder and
downward on the outer aspect of the forearm and hand.
2,11

5. Tenderness:- These may be tenderness over the lower cervical spine or in the muscle
of the paravertebral region(myalgia). The patient may have loss of cervical lordosis.
6. Range of motion:- There is limition in neck movement.
7. Occipital Headache:- Occipital headache may be a feature if the upper half of the
cervical spine is affected.
1,7

8. Giddness:- The patient may present with an episode of giddness because of
vertebrobasilar syndrome.
9. muscle weakness:- Muscle weakness or sensory weak is rare or uncommon.
10. Muscle spasm:- The pain may produce muscle spasm.
11. Root sign:- It is radicular features it is dermatosensory loss and lower moterneurone
sign is according to side of lesion.
2

12. Vertebral artery compression syndrome:- Bony out growth may encroach on and
compress the vertebral arteries with in its canal which can leads to brain stem
ischaemia, particularly in the older people. It produces vertigo, tinnitus, difficulty in
speech and swalloing and nausea.
5

13. Oesophagus:- It may given rise to drop attack and dysphagia.
2

14. Myotomes and dermatomes:- Relationship between the spinal nerve and muscle at
called myotomes. It is relationship between the spinal nerve and skin it is called the
dermatomes.
14





Clinical Features of Cervical Radiculopathy
Cervical
Root
Pain Sensory Changes Weakness Reflex Changes
C-5 root Neck, shoulder, and
anterolateral arm
Numbness in
deltoid area
Deltoid and biceps Biceps reflex
C-6 root Neck, shoulder, and
lateral aspect of arm
Dorsolateral aspect
of thumb and index
finger
Biceps, wrist
extensors, and
pollicuslongus
Brachioradialis
reflex
C-7 root Neck, shoulder,
lateral aspect of arm,
and dorsal forearm
Index and middle
finger of dorsum of
hand
Triceps Triceps reflex

Patients may also note weakness and lack of coordination in the affected extremity. Muscle
spasms and neck pain as well as pain referred into the trapezius and intrascapular region
are common. Decreased sensation, weakness, and reflex changes are demonstrated on
physical examination. Patients with C-7 radiculopathy will commonly place the hand of the
affected extremity on top of their head to obtain relief. Occasionally, a patient suffering from
cervical radiculopathy will experience compression of the cervical spinal cord, resulting in
myelopathy. Cervical myelopathy is most commonly due to midline herniated cervical disk,
spinal stenosis, tumor, or, rarely, infection. Patients suffering from cervical myelopathy will
experience lower extremity weakness and bowel and bladder symptomatology. This
represents a neurosurgical emergency and should be treated as such.
2

Fig. 6.1 Patients with C-7 radiculopathy will often place the hand of the affected extremity on
the head to obtain relief.
19














CHAPTER - VII

DIFERENTIAL DIAGNOSIS
























1. Adhesive Capsulitis
2. Diabetic neuropathy
1. Brown Sequard Syndrome
2. Multiple Sclerosis
3. Carpal Tunnel Syndrome
4. Myofascial Pain
5. Central Cord Syndrome
6. Neoplastic Brachial Plexopathy
7. Cervical Disc Disease
10. Osteoporosis
11. Spinal Cord Injury
12. Cervical Myofacial Pain
13. Cervical Sprain and strain
14. Rheumatoid Arthritis
15. Chronic Pain Syndrome
16. Traumatic Brachial Plexopathy
17. Peripheral Nerve entrapment


OTHER CHANGES: Occipital neurologia as a result of radiculopathy changes at C
1
_
C
2
shoulder problems. Primary spinal cord tumors, syringomyelia, extramemedullary
elessions (tumors, thoracic disc herniation) Hereditary spastic paraplegia, Normal
pressure hydrocephalus, spinal cord infarction, spinal sepsis, whiplash syndrome(hyper
extension- hyper flexion injury),Pancoast tumors, double crush syndrome (coexistence of
a radiculopathy and peripheral Nerve compression in the carpal and cubital tunnel).
2,6,7
























CHAPTER VIII
SPECIAL TESTS













1. FORAMINAL COMPRESSION TEST (SPURLINGS TEST)
This test is done if the patient complaines of nerve root symptoms,which at the time
of examination are diminished or absent.
The patient side flexion the head to unaffected side followed by effected side.
The examiner carefully compression with head in extension and rotation to
unaffected side. The test result is classified as positive of pain radiaties to arm
towards which the head is side flexed during compression that indicates pressure on
nerve root.
fig. 8.1
2. DISTRACTION TEST:
The test is used for patient who has comp
Laion of radicular symptoms and show radicular signs during
Examination.
To perform the test the examiner places one hand under the
Patient chin and other around the occiput, than
slowly lifts the patient head and apply traction to the
cervical spine.
The test will be positive if the pain is decreased. This test may
also be used check radicular sign refessed to shoulder complex anteriorly or posteriorly.

fig. 8.2
3. UPPER LIMB TENSION TEST :
This test is done if the patient complained median nerve compression. The patient shoulder
depression and abduction 110
0
and Elbow extension. Forearm supination, wrist extension and-
and thumb extension than cervical spine contralateral side Flexion. The test result is
classified as positive if there is pain and tingling sensation in the area supplied by median
nerve.
8




































CHAPTER IX
TREATMENT













Medical treatment
Surgical treatment
Physiotherapy treatmet
MEDICAL TREATMENT
Injections
Cortisone- This injection is given the near the joint of the vertebral bodies of ease the
swelling of the nerves and
relieve pain.
4,6,7nt

Drugs
Non steroidalAnti inflammatory drugs:- These includes Ibprofen, Diclofenae, Aspirin,
Tolfenamic, Mefanamic
acid and Acetylsalicylic acid.
4
Muscle relaxant: Such as diazepam is prescribed for few days during a flare up of pain if
neck muscle become
tense and makes the pain worse.
4
A low dose tricyclic antidepressant, such as amitriptyline,is sometimes used for chronic
neck pain. The dose of
amitriptyline used for pain is 10-30 mg at night.A higher dose, tricyclic antidepressant are
used to trea
depression.However,at lower doses they have been found to help relive certain type of pain
including neck
pain.
4

Anti emetics: If there is giddness is present.
2

SURGICAL TREATMENT
Surgical treatment for cervical radiculopathy is rare conservative treatment fails or
neurological signs and symptoms ,such as weakness in arms and legs are getting worse,
surgery may be needed. The surgical procedure will depend on underlying condition such as
bone spur or spinal stenosis.
a. Frontal approach:- Surgeon makes an incision in frontal part of neck and
moves aside the trachea and oesophagus to expose the cervical spine. Surgeon
can then remove a herniated disc or bone spur, depending on underlying
problems.Relieve pressure an spinal cord from bone or from multiple disc
protrusion by removing to disc and the bone between them.
4,13nt

b. Back approach(Laminectomy):- Surgeon removes back part of the bone over
the spinal cord through an incision in the back of the neck.
13nt

III PHYSIOTHERAPY TREATMENT:-
Aims of physiotherapy treatment:
1. To decrease pain
2. To reduce muscle spasm
3. To maintain normal range of motion
4. To increase functional activity
5. To increase circulation of the affected part
6. To induced relaxation
7. To maintain general body health
8. To reduce inflammatory condition
9. To given psychological support
10. Ergonomics Advise
TO decrease pain:
In acute phase- Electrotherapy treatment.
Ultrasonic Therapy:- In initial stage
Pulsed Ultrasonic Therapy- 1:4 or 1:6
Intensity = 0.25 or 0.5 watt/cm square.
Time duration = 2-3 minute.
If condition improve than progression of dosage is unnecessary. Failure to
improved might required a slight increase intensity of ultrasonic to 0.8 watt/cm square and
time duration up to 4-5 minute.
If a dose produce beneficial effect it is repeated next time. If no improvement results, the
dose can be gradually increased by increasing intensity and the period of treatment.
4,6,7

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT
INTERMITTENT CERVICAL TRACTION: Effects of traction: Mechanical benefits of
temporarily separating the vertebrae & causing mechanical sliding of facet joints in the spine.
May relieve symptoms from a disc protrusion. Angle of pull of traction: Flexion, Neutral or
Hyper-extension. Duration of traction: 10-15 minutes. Traction force: 1/10 to 1/7 of patients
body weight. Position of patient: Supine or sitting.
CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT
INTERFERENTIAL CURRENT THERAPY: Mechanism of action of IFT: Higher
frequencies (100-130 Hz) close the pain gate mechanism. May act directly on the peripheral
nerves by slowing the conduction.May act as placebo effect. Duration of treatment: 10-12
minutes.
CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT ISOMETRIC
NECK EXERCISE: INE is helpful for maintaining or improving strength, endurance and
tone of the cervical muscles. Alternating isometric contractions also enhance stability.
TO MAINTAIN NORMAL RANGE OF MOTION:-
Static Neck Exercise:- 2times a day(10 sets) during isometric neck exercise 10
repetitions were given for Fiexions, Extention and side rotation or flexors.Resistance
applied while neck remains stratight. During this 10 sec. hold and 3 second rest were
given.
7

Chin tuck exercise and head lifts should be taughtnto the patient.
Stretching of trapizius muscle: To maintain functional lenth of muscle.
Active Scalene muscle stretch can be advised to the patient.
7nt

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT MAITLAND
MOBILIZATION: Grades of mobilization: Grade I: Small-amplitude rhythmic oscillations
are performed at the beginning of the range. Grade II: Large-amplitude rhythmic oscillations
are performed with in the range, not reaching the limit. Grade III: Large-amplitude rhythmic
oscillations are performed up to the limit of the available motion and are stressed into the
tissue resistance. Grade IV: Small-amplitude rhythmic oscillations are performed at the limit
of the available motion and stressed into the tissue resistance. Grade V: A small-amplitude,
high velocity thrust technique is performed to snap adhesions at the limit of the available
motion.

CERVICAL RADICULOPATHY OF PHYSIOTHERAPY TREATMENT MAITLAND
MOBILIZATION: Neuro-physiological Effects: Small amplitude oscillatory & distraction
movements are used to stimulate the mechanoreceptors that may inhibit the transmission of
nociceptive stimuli at the spinal cord or brain stem levels. Mechanical Effects: Small
amplitude distraction or gliding movements of the joints are used to cause synovial fluid
motion, help to maintain nutrient exchange & thus prevent the painful & degenerating effects
of stasis when a joint is swollen or painful.

EXERCISE PROGRAMME:
There are basically five type of exercise which are commonly used either single or in
combination. The type of extent of exercise is to be planned accoding to the patient needs.
4,6,7

1. Relaxed Passive Movement: This include manipulation and
mobilization.When the chif aim is mobilization.
2. Strong isometrics are indicated when mobility is contraindicated but
strength. Endurance and tone of the cervical muscle are to be
maintained and improved.
3. Active Assisted Movement: When the basic objective is to improved
the weak muscle without exerting.
4. Active Resisted Exersice: To strenghten the cervical muscle.
6,7



Fig. 9.1 isometric exercises










CHAPTER X

DISCUSSION













The study was done on 5 patient. All of them having cervical radiculopathy due to any
trauma or injury. Three patient was female and two patient was male. Two patient was 45
years old. Two patient was 60 years old and one patient was 39 years old. Two patient was
housewife and other two patient was workers and other one patient was teacher. All patient
was given physiotherapy Treatment.
Physiotherapy techniques were applied on the skin or muscle to educate them. First of all the
intermittent cervical traction will be done for promotes circulation, reduce swelling,
inflammation, spasm and pain or may help in breaking the adhesions. After than ultrasound
therapy, massage for reduce the muscle spasm. After than static neck exercise, chin tuck
exercise,active movement, passive movement and stretching for maintain normal range of
motion. After these techniques all the patient gained relief the pain, reduced muscle spasm
and strength the muscle.































CHAPTER XI
CONCLUSION













All the patient were recovered after the treatment. Some patients required iong term
treatment. This study have beenevalvated the good prognosis after the condition. All the
patient treat will be same. One patient advise the cervical collar.After the treatment patient
relief the pain, reduced the muscle spasm, increase the blood circulation of the area and
maintain the strength of muscle and cervical radiculopathy are done completely.



































REFFERENCES














1. John Crawford Adams, David L. Hambler, Outline of orthopaedics- Thirteenth edition.
2. J. Maheshwari, Essential Orthopaedics-Revised 3
rd
edition.
3. Donnatelli Wooden, Orthopaedics Physical Therapy 3
rd
edition.
4. Hassan Ahmad Al-Shatoury, Ayman Ali Galhom, Cervical Radiculopathy, April 24,
2009.
5. Patrila A, Downie, Cashs Text Book Of Orthopaedics And Rheumatology For
Physiotherapists,1
st
edition.
6. John Ebnezar, Essential OfOrthopaedics For Physiotherapist.
7. Jayant Joshi, PrakashKotwal, Essential OfOrthopaedics And Applied Physiotherapy.
8. B.D Chaurasias Human Anatomy Part 3
rd
-4
th
edition.
9. Pamela K. Levangie, Lyuthia C. Norkin, Joint Structure And Function, A
Comprehensive Analysis,4
th
edition.
10. Ann Themson, Alison Skinver, Joan Piercy, Tidys Physiotherapy 12
th
edition.
11. M. Natarajan, MayilvahananNatarajan, Natrajan Text Book Of Orthopaedics And
Traumatology Revised 5
th
edition.
12. David J Magee, Orhopaedics Physical Assessment 4
th
edition.
13. Russel Williams Bulstrode, Hodden Arnold, BaibyAnd Loves Short Practice Of
Surgery-24
th
edition.
14. Carolyn Kisher, Lynn Allen Colby, Therapeutic Exercise-5
th
edition.
15. Wewers M.E And Lowe N.K (1990), A Critial Review Of Visual Analogue Scales In
The Measurement Of Clinical Phenomena, Research In Nursing And Health 13
th
,
Vol.227-236.
16. Gerard A Malanga, Sherwin Ho, Cervical Radiculopathy,Dec.14
th
, 2011.
17. Arun Pal Singh, Biomechanics Of Upper Cervical Spine, Sports Rehab. Las, Vegas
Chirofractor 14 feb, 2012.
18. vishal B. Boricha, Cervical Radiculopathy, Sports medicine.
19. John F. Petriglia, Interventional pain medical group, 24 April 2012.













APPENDICES



























APPENDIX I
CONSENT FORM














CONSENT FORM
I ____________ voluntarily consent to participate in the study. All my questions have been
satisfactorily answered and the risk involved have been explained to me. I reserve my right to
withdraw at any instant and I have the contact address of PreetiYadav if I require any further
information.

Signature:-

Contact address:-


























APPENDIX II
CASE STUDY





















CASE STUDY 1
Name : XYZ
Age : 60 Years
Occupation : Worker
Chief complaints:-
Patient complains of neck pain since 10 days back. Pain increases during holding
heavy objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back
region to arm. Pins and needles sensation is there in hand and finger of both sides.
History of present illness:-
Patient was asymptomatic 10 days back then suddenly feel pain in neck.Pain increases on
movement and slight giddiness is also present.Radiating pain is there from upper scapular
region to arm along with pins and needle sensation in both hand and finger.
Past History:-
Patient has Road Traffic Accident and got fractured both bone lower limb(Left).
Medical History:-
Plaster of paris cast was applied. Patient recovered.
Personal History:-
Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,
tuberculosis.
Marital Status:-
Patient is married.
Family History:-
Patient is present with family history of hypertension.
Physical Examination:-
OBSERVATION
Anterior view: Head is in midline with no evidence of Torticollis or other neck
deformities.
Right shoulder is sligt lower than the left, Shoulder contour is normal.
No redness is present in the neck or in the shoulder muscle.
Lateral view: Cervical lordosis is normal.
PALPATION
Tenderness: Present at C
5
-C
6
Spinous process
Muscle spasm: Present at bilateral upper fiber of trapezius and Levator Scapulae.
ON EXAMINATION
1. Pain:
Type of pain : Pinching type pain
Intensity of pain : 8/10
Duration of pain : 10 days
Relieving factor : Rest,Medication
Aggravating factor : During farmer work

2. Active movement:
Flexion : Painful
Extension : Painful
Side flexion : Painful(RIGHT)
Rotation : Painful(Left)
3. Passive movement:
All passive movement are painful due to tissue stretch.
4. Sensory Examination:
Normal on both sides.
5. Special test:
Spurlings compression test : positive
Distraction test : Positive
ULTT Test : Positive
6. X-Ray Findings:-
Osteophytes formation in almost all cervical vertebrae.Joint space reduced at C
5-
C
6

Ver
tebrae.
7. Visual Analogus Scale: Was found to be 9/10

Treatment:-
Traction- Intermittent cervical Traction
Hold time - 10 Second
Rest Time - 5 Second
Duration - 10 minute
Weight - 7Kg
Session - 1 time for 5 day
Static Neck Exercise - 2 time a day (10sets) during isometrics neck
exercise 10 repetitions were given for flexors, extensors and side flexors.
Stretching -of trapezius muscle.
KNEADING - To relive muscle spasm and to increase blood circulation
of the area.
Hot packs -to relieve muscle spasm.
Postural correction.
Ergonomics advise.
PROGRESS REPORT:-
Patient record 90% relif of pain. Visual Analogus Scale up 3/10








CASE STUDY 2

Name : XYZ
Age : 39 Years
Occupation : House wife
Chief Complaints:-
Patient complains of Stiffness and pain in neck radiating up to her left elbow along with
clumness in left hand.
History of present illness:-
Patient onset was gradual and had similar episodic of pain of pain two year of back which
lasted for one month and resolved with 15 day of medical therapy.
Past history:-
No
Medical History:-
Medical Therapy is given
Personal History:-
Patient is vegitarian.
Marital Status:-
Married
Family History:-
No
Physical Examination:-
Observation
Anterior View:- Head is in midline with no evidence of neck deformity. Left shoulder is
slight lower than the right. Shoulder contour is normal. Redness is present in the neck and
shoulder.
Lateral view:- cervical lordosis is normal.
Palpation
Tenderness: Present at C
4
-C
5
spinous process.
Muscle spasm: Present at bilateral upper fiber of levator.
On examination
1. Pain:-
Type of pain : Pinching and dull pain.
Intensity of pain : 6/10
Duration of pain : 15 days.
Relieving factor : massage and stretching.
Aggravating factor : activity performed with bent
neck.
2. Active movements:-
Flexion :painfull.
Extension :painfull.
Side flexion :painfull(left).
Rotation :painfull(right).
3. Passive movement:-
All movements are painfull due to tissue stretch.
4. Sensory Examination:-
Normal on both sides.
5. Special test:-
Spurlings compression test: Positive
Distraction test: Positive.
ULTT Test: Positive.
6. X-Ray Findings:-
Flattening of cervical lordosis.
Osteophytes formation body and significant at C
5
vertebrae.
Narrowing of space between C
5
-C
6
vertebrae body and facet joint.
7. Visual Analogus Scale:-was found 6/10.
Treatment:-
1. Hot packs:-15 min.
2. Traction:-Intermittent cervical traction.
Hold time : 20 seconds.
Rest time : 10 seconds.
Duration : 15 minutes.
Weights : 5 kg.
Session : 1 time for 5 day.
3. Static neck exercise:-2 times a day (10 sets) during isometric neck exercise 10 repetitions
were given for flexors, extensors and side flexors. Resistance applied while neck remains
straight. During this 10 second hold and 3 second rest were given.
4. Stretching:-stretchingof trapezius muscle, Pactoralis major, and steno(5cm)with 3
repetitions. During 30 second hold and 2 set a day.
5. Kneading and Picking up:-To relive muscle spasm and to increase blood circulation of the
area.
6. IFT:-to relieve pain.
7. Postural correction.
8. Ergonomics advise.
Progress Report:-
Patient record 95% relief of pain. Visual Analogus
Scale up 2/10.






CASE STUDY 3
Name : XYZ
Age : 45 Years
Occupation : Teacher
Chief complaints:-
Patient complains of neck pain since 12 days back. Pain increases during holding
heavy objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back
region to arm. Pins and needles sensation is there in hand and Lateral 3 finger of both sides.
History of present illness:-
Patient has neck pain for the past two years due to any trauma.
Past History:-
Patient put lifting heavy weight during working.
Medical History:-Medical Therapy is given.
Personal History:-
Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,
tuberculosis.
Marital Status:-
Patient is married.
Family History:-
Patient is present with family history of hypertension.
Physical Examination:-
OBSERVATION
Anterior view: Head is in midline with no evidence of Torticollis or other neck
deformities.
Right shoulder is sligt lower than the left, Shoulder contour is normal.
No redness is present in the neck or in the shoulder muscle.
Lateral view: Cervical lordosis is normal.
PALPATION
Tenderness: Present at C
4
-C
5
Spinous process
Muscle spasm: Present at bilateral upper fiber of trapezius and deltoid.
ON EXAMINATION
1. Pain:
Type of pain : Pinching type pain
Intensity of pain : 7/10
Duration of pain : 12 days
Relieving factor : Rest,Medication
Aggravating factor : During farmer work

Active movement:
Flexion : Painful
Extension : Painful
Side flexion : Painful(RIGHT)
Rotation : Painful(Left)
Passive movement:
All passive movement are painful due to tissue stretch.
Sensory Examination:
Normal on both sides.
Special test:
Spurlings compression test : positive
Distraction test : Positive
ULTT Test : Positive
X-Ray Findings:-
Osteophytes formation in almost all cervical vertebrae.Joint space reduced at C
4-
C
5

Vertebrae.
Visual Analogus Scale: Was found to be 7/10

Treatment:-
1. Traction- Intermittent cervical Traction
Hold time - 20 Second
Rest Time - 5 Second
Duration - 15 minute
Weight - 5Kg
Session - 1 time for 7 day
2. Static Neck Exercise - 2 time a day (10sets) during isometrics neck exercise
10 repetitions were given for flexors, extensors and side flexors.
3. Stretching -of trapezius muscle.
4. KNEADING - To relive muscle spasm and to increase blood circulation of
the area.
5. Hot packs -to relieve muscle spasm.
6. Postural correction.
7. Ergonomics advise.
PROGRESS REPORT:-
Patient record 95% relif of pain. Visual Analogus Scale up 1/10.











CASE STUDY 4
Name : XYZ
Age : 60 Years
Occupation : House wife
Chief complaints:-
Patient complains of neck pain since 15 days. Pain increases during holding heavy
objects, putting hand in back pocket, lifting etc. Patient complain pain from upper back
region to arm. Pins and tingling sensation is there in hand and finger of both sides.
History of present illness:-
Patient was any asymptomatic 15 days back then suddenly feel pain in neck . Patient increase
on movement is present . Radiating pain is there from upper scapular region to arm along
with pins and needle sensation in both hand and finger.
Past History:-
Patient put lifting heavy weight during working.
Medical History:-Medical Therapy is given.
Personal History:-
Patient is non-vegetarian. Patient is hypertensive with no history of Diabetes mellitus and T.B
Marital Status:-
Patient is married.
Family History:-
Family history of hypertension
Physical Examination:-
OBSERVATION
Anterior view: Head is in midline with no evidence of Torticollis or other neck
deformities.
Right shoulder is sligt lower than the left, Shoulder contour is normal.
Redness is present in the neck or in the shoulder muscle.
Lateral view: is normal.
PALPATION
Tenderness: Present at C
5
-C
6
and Spinous process
Muscle spasm: Present at bilateral upper fiber of trapezius and deltoid.
ON EXAMINATION
1. Pain:
Type of pain : Pinching type pain
Intensity of pain : 7/10
Duration of pain : 15 days
Relieving factor : Rest,Medication
Aggravating factor : During work

Active movement:
Flexion : Painful
Extension : Painful
Side flexion : Painful(RIGHT)
Rotation : Painful(Left)
Passive movement:
All passive movement are painful due to tissue stretch.
Sensory Examination:
Normal on both sides.
Special test:
Spurlings compression test : positive
Distraction test : Positive
ULTT Test : Positive
X-Ray Findings:-
Osteophytes formation in almost all cervical vertebrae.Joint space reduced at C
5-
C
6
and Vertebrae.
Visual Analogus Scale: Was found to be 8/10

Treatment:-
1. Traction- Intermittent cervical Traction
Hold time - 10 Second
Rest Time - 5 Second
Duration - 10 minute
Weight - 7Kg
Session - 1 time for 5 day
2. Static Neck Exercise -2 time a day (10sets) during isometrics neck exercise
10 repetitions were given for flexors, extensors and side flexors.
3. Stretching -of trapezius muscle and Levator Scapulae muscle.
4. Kneading - To relive muscle spasm and to increase blood circulation of the
area.
5. Hot packs -to relieve muscle spasm.
6. Postural correction.
7. Ergonomics advise.
PROGRESS REPORT:-
Patient record 85% relif of pain. Visual Analogus Scale up 3/10.








CASE STUDY 5
Name : XYZ
Age : 45 Years
Occupation : Worker
Chief complaints:-
Patient complains of neck pain since 1 month. Pain increases during holding heavy
objects, putting hand in back pocket, lifting etc. Patient complain pain from upper scapular
region to left arm. Pins and tingling sensation was there in hand and 3 fingers of both sides.
History of present illness:-
Patient was asymptomatic one month before and then suddenly felt pain in neck . Patient
increase on movement is present . Radiating pain is there from upper scapular region to left
arm.
Past History:-
Patient put lifting heavy weight during working.
Medical History:-Medical Therapy is given.
Personal History:-
Patient is alcoholic and smoker. Patient is hypertensive with no history of Diabetes mellitus,
tuberculosis.
Marital Status:-
Patient is married.
Family History:-
No family history.
Physical Examination:-
OBSERVATION
Anterior view: Head is in midline with no evidence of Torticollis or other neck
deformities.
Right shoulder is sligt lower than the left, Shoulder contour is normal.
Redness is present in the neck or in the shoulder muscle.
Lateral view: Cervical lordosis is normal.
PALPATION
Tenderness: Present at C
5
-C
6
and C
6
-C
7
Spinous process
Muscle spasm: Present at bilateral upper fiber of trapezius and deltoid.
ON EXAMINATION
1. Pain:
Type of pain : Pinching type pain
Intensity of pain : 9/10
Duration of pain : One month
Relieving factor : Rest,Medication
Aggravating factor : During work

Active movement:
Flexion : Painful
Extension : Painful
Side flexion : Painful(RIGHT)
Rotation : Painful(Left)
Passive movement:
All passive movement are painful due to tissue stretch.
Sensory Examination:
Normal on both sides.
Special test:
Spurlings compression test : positive
Distraction test : Positive
ULTT Test : Positive
X-Ray Findings:-
Osteophytes formation in almost all cervical vertebrae.Joint space reduced at C
5-
C
6
and C
6
-C
7
Vertebrae.
Visual Analogus Scale: Was found to be 9/10

Treatment:-
1. Traction- Intermittent cervical Traction
Hold time - 20 Second
Rest Time - 5 Second
Duration - 15 minute
Weight - 5Kg
Session - 2 time for 7 day
2. Static Neck Exercise -2 time a day (10sets) during isometrics neck exercise
10 repetitions were given for flexors, extensors and side flexors.
3. Stretching -of trapezius muscle and Levator Scapulae muscle.
4. Kneading - To relive muscle spasm and to increase blood circulation of the
area.
5. Hot packs -to relieve muscle spasm.
6. Postural correction.
7. Ergonomics advise.
PROGRESS REPORT:-
Patient record 70% relif of pain. Visual Analogus Scale up 5/10.


















APPENDIX II
CERVICAL SPINE ASSESSMENT FORM

















CERVICAL SPINE ASSESSMENT

History
Observation
Examination
Active movement
Flexion
Extension
Side flexion(Right and Left)
Rotation
Combined Movement(if necessary)
Repetitive Movement
Sustained Movement
Myotome
Neck flexion(C
1
-C
2
)
Neck side flexion(C
3
)
Shoulder flexion(C
4
)
Shoulder abduction(C
5
)
Elbow flexion(C
6
)and Extention(C
7
)
Wrist flexion(C
7
)and Extention(C
6
)
Thumb extention(C
8
)and ulnar deviation(C
8
)
Hand intrinsic(T
1
)
Special Test
Foraminalcompression(Spurlings) Test
Distraction Test
ULTT Test
Reflexes and cutanious distributions
Biceps(C
5
-C
6
)
Triceps(C
7
-C
8
)
Hoffman Sign
Examination
Passive Movement
Active Movement




























APPENDIX-III

VISUAL ANALOGUES SCALE

















The VAS-used in the study consisted of a continous horizontal line of 10cm in the length
with anchor point of no pain(0) and worst pain(10) on the left and right ends of line
respectively.

How severe is your pain?

________________________________________
0 10
NO pain Worst pain
imaginable

The patient is asked to mark on the line where patient feels severity of pain correspond.