Medical Rehabilitation of Cervical Spondylosis

Marina A Moeliono, dr, SpKFR Dept of Physical Medicine & Rehabilitation School of Medicine, Padjadjaran University PIT NC Bandung, 6 December 2012
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Function & demands of the cervical spine,, - Holding the head upright - Helps the upright posture - Moving the head in all directions - Protecting the spinal cord
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Cervical spondylosis, definition

Chronic degenerative condition of the cervical spine Most common cause of progressive spinal cord and nerve root compression Affects the vertebral bodies, intervertebral disks & intervertebral joints/facet joints, surrounding tissues (lig.longitudinal, lig.flavum), the contents of the spinal canal (nerve roots and/or spinal cord) Often develops at multiple interspaces Radiographic evidence of spondylotic changes frequently found in many asymptomatic adults, correlation between degenerative changes and patient symptoms or functional limitations not always in line

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Cervical spondylosis,
tissues involved, can contribute to pain.

The joints, uncovertebral & facet joint Discus intervertebralis, annulus fibrosus Cervical spinal nerves, exit the spinal cord as nerve roots The neural foramen, made up of the facet joint posteriorly and the intervertebral disc anteriorly; superior and inferior borders are comprised of the pedicles of the vertebral bodies above and below Ligaments & muscles of neck & upper
back

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Cervical spondylosis, pathophysiology

Discus intervertebralis, Dehydration loss of elasticity develops cracks and fissures collapses as a result of biomechanical incompetence Annulus, bulge outward Osteophytes /reactive hyperostosis/ bony overgrowth/ chondro-osseous spur formation, increases diameter of the vertebral body at level of disc. project posteriorly into the spinal canal, reduce space available for the spinal cord and its blood supply.
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Disc degeneration

Cervical spondylosis, pathophysiology

Disk space narrows Annulus bulges, posteriorly Joints, hypertrophy & osteoarthritic changes joints override uncovertebral joints/ Luschka (ventrolateral) facets (dorsolateral), Hypertrophy of lig.flavum Spinal canal & foramen i.v, compromised Med.spinalis / spinal root compressed
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Biomechanically, static & dynamic spine

The disc & facets, connecting structures between the vertebrae Spinal curves lordosis, kyphosis change in one segment of the spine will affect other segments transmission of external forces facilitate cervical spine mobility: flexion, extension, lateral-flexion, rotation
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Cervical spondylosis, epidemiology

United States, common condition, most frequent cause of spinal cord dysfunction in patients > 55 yrs; primary diagnosis in 36% cases admitted for surgical treatment of a degenerative cervical spine with myelopathy Radiologically, 90% men > 50 yrs & 90% women > 60 yrs have degenerative changes in the cervical spine. International, study in Ghana, cervical spondylosis in 63.6% carrying loads on the head, in 36% not carrying loads on the head
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Diagnostics & Differential Diagnostics of Neck Pain

Myelopathy, Radiculopathy Tumors, infections, Degenerative changes Osteoarthritis Stenosis of spinal canal/ canalis centralis, foramen inter-vertebrale Hernia Nucleus Pulposus Thoracic outlet syndrome Strain & sprains of musculotendineous tissue Fibromyalgia Postural strain

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Diagnostics & Differential Diagnostics of Neck Pain

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Clinical symptoms/syndromes
Morbidity, ranges from chronic neck pain or axial neck pain, radicular pain (cervical radiculopathy), diminished cervical range of motion (ROM), headache, cervical myelopathy leading to weakness and impaired motor coordination to quadriparesis and/or sphincter dysfunction The course of disease, development of disease & the ultimate prognosis for patients with cervical spondylosis is highly variable and extremely difficult to predict.
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Management
Conservative treatment Initial management, the early period, characterized by episodes of pain in the neck and upper extremities Effective, non-operative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case-by-case basis Surgical treatment Clinically significant neurologic deficits or myelopathy, Debilitating pain that is resistant to conservative modalities Instability in the setting of disabling radiculopathy Not responsive to conservative treatment

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Conservative management
Emphasize education of the patient, patients should play an active role in their own care and rehabilitation Modalities 1. Rest 2. Immobilization, orthoses 3. Medications 4. Physical modalities 5. Massage, Traction & Manipulation

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Conservative management
Intermittent bed rest, or rest of the neck relative to the cervical spine with immobilization and recumbency, for acute episode of pain in the neck or upper extremities. Prolonged bed rest, should not be prescribed too frequently due to the medical risks, particularly in elderly patients
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Conservative management
Immobilization, with a firm cervicothoracic orthosis (a collar or brace), to decrease the motion of the vertebral bodies, to reduce the inflammatory response & swelling of neural tissue caused by the impingement of the nerve roots by osteophytes Immobilization at night, when conscious control of movement of the neck is absent during sleep, is important Long-term use of an orthosis can cause atrophy of the paravertebral muscles, therefore for , it should be used for a limitted time, or intermittent, in combination with isometric exercises to maintain muscle tone.

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Conservative management
Medications,
Analgesics, may be needed for intense, acute episodes Non-steroidal anti-inflammatory agents can reduce chronic pain Muscle relaxants Prolonged administration of oral steroids are relatively contraindicated

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Conservative management
Physical modalities: Superficial heat TENS Ultrasound Laser

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Conservative management
Rehabilitative exercises/ Exercise program neck relaxation range of motion exercises isometric musclestrengthening exercises massage/soft-tissue techniques
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Conservative management
body mechanics/ ergonomic neck instruction cervical pillow

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Everyday Ergonomics
The computer, adjusting the monitor the key-board Positioning of the chair, feet on the ground Rest breaks and task rotation

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Conservative management
Cervical traction: manual, mechanical
Traction may be helpful but should be used with caution and careful monitoring, because, in some patients, the axial pull may increase pain and be counterproductive

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Conservative management
Spinal manipulation, Relatively contraindicated, given the risks involved with manipulation and the paucity of evidence showing any benefit, this therapy cannot be recommended as a predictable treatment option Indication: Contra-indication: any instability Undesirable side effects: vertebral artery injury

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Conservative management
Emphasis on education of the patient, patients should play an active role in their own care and rehabilitation Main focus should be on ergonomics and return-toactivity advice Modalities of rest, immobilization, medications, physical modalities, massage, traction & manipulation Literature suggests, a combination of therapies aids in the recovery of patients as compared to passive non-operative therapy
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In summary,
Presently, rehabilitation goals have shifted from exclusively reducing or eradicating pain to Improving patients' work and activity tolerance, avoiding illness behaviors, and preventing deconditioning and chronicity. Incorporating direct return-to-work advice into the treatment plan; patients will feel confident about abilities for work and general activities. Therapy should focus on restoring or maintaining flexibility, strength, and level of fitness while maintaining maximum productivity. After an acute treatment program, patients should participate in graded exercise regimens
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In summary,
Cervical spondylosis, caused by static and dynamic factors, involving osseous and soft-tissue structures , compromising the space available for the spinal cord or the vascular supply to the cord, or both. The clinical course, highly variable. Non-operative management can be applied to selected patients It is important to recognize myelopathy early, to facilitate appropriate intervention
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