Enter subtitle here (24pt, Arial Regular)Enter date: 25.06.13

Cervical Radiculopathy – a review of best evidence to guide Primary Care

practice

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Louise Keating SMISCP, MPhtySt (Manip),Lecturer in Physiotherapy

Irish Pain Society Annual Scientific Meeting, Sept 2015

lkeating@rcsi.ie RCSI

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

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)

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 componentsHaanpaa et al 2009

Cx Rad

NeuP Pain

Reasons for non-dermatomal pain patterns Schmid et al 2013

Most common

Inclusion Criteria Variability

Aetiology 25%

75%

Soft Disc

• Single level• Inflammation:

– Interleukins & Prostaglandin

• Majority spontaneously resolve (weeks – months)

Spondylosis

• Uncovertebral joint degeneration

• Multiple levels common

75%25%

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 2014Traditional failure of 6/52 conservative management

escalation

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

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

Screening Tools

• LANSS• S-LANSS• painDETECT*• DN4

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 (n=38)

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 (n=17)

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 (n=23)

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. (n=15 radiculopathy)

Maier et al, Pain; 150 (2010) 439-450

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

Clinical Prediction Rule Wainner et al 2003

• Diagnostic criteria:Cluster of four items (3/4)1.Positive ULNT12.Positive Spurling’s A test3.Limited cervical rotation to affected side (<60degs)4.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)

Global Clinical Practice

NeuPSIG Pharma Recommendations Finnerup et al 2015

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)

MSK Physiotherapy Practice Nee et al 2013

Rank Treatment Options Type

1 Explanation & Advice

2 Exercise Motor ControlMuscle Strength & EnduranceROM

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 > Cold

8 Traction Manual not mechanical / home

9 Prescription HEP

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

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)

(n=36) Langevin et al 2014

– Exercise + Advice + Pharma (Paracetamol, NSAIDs or Opioids) (n=205)

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

Langevin et al (2014) Results – both groups received varied manual therapy & exercise no true control to measure natural hx.

Arm Pain

Baseline

4 wks 6 mo 12 mo

Kuijper et al 2009n=205

Langevin et al 2015n=36

Fritz et al 2014n=86

Neck Pain

Baseline

4 wks 6 mo 12 mo

Kuijper et al 2009n=205

Fritz et al 2014n=86

Langevin et al 2015n=36

Neck Disability Index

Baseline

12 mo 6 mo4 wks

Kuijper et al 2009n=205

Fritz et al 2014n=86

Langevin et al 2015n=36

Baseline 3 wks 6 wks 26 wksCervical 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

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

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 (n=400) van Geest et al 2014

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

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

NHS National Pathway of Care for Low Back & Radicular Pain2014

Radicular Pathway

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

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

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

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.

• > 12 weeks - Multimodal PT more evidence

• Surgical Referral: Major motor radiculopathy, suspected myelopathy, failure of 6/52 Cons Rx, patient profile (non-tolerable pain)

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

@UqLouise

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 2000–2010 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. doi:10.2519/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@rcsi.ie