The effect of cervical traction combined with neural mobilization on pain and disability in cervical radiculopathy. A case report
From: Man Ther. 2012 Jul 17. [Epub ahead of print]
Cervical radiculopathy is a pathological condition of the cervical nerve root that may lead to chronic pain and disability. The onset of this disorder is typically insidious and most commonly is caused by cervical disc derangement or other space occupying lesion, resulting in nerve root inflammation, compression or both.
Although the causes of cervical radiculopathy have been established, the exact mechanism underlying the production of cervical radiculopathy pain has not been fully understood. To date, several researchers have reported that the cervical radiculopathy pain is probably caused by mechanical (compressive forces) and/or chemical (inflammation) stimuli found around the cervical nerve roots. The presence of these stimuli around the cervical nerve roots alters their normal structure and function leading to possible neural inflammation, edema, hypoxia, ischaemia, fibrosis, limited gliding movement and increased mechanosensitivity. Based on this notion, many manual therapy interventions have been proposed to restore these alterations and therefore to eliminate pain and disability caused by cervical radiculopathy.
Cervical traction and neural mobilization techniques have been advocated in the management of cervical radiculopathy due to their immediate analgesic effect. Cervical traction is applied to provide pain inhibition, through the widening of the cervical neural foramina and the reduction of the intradiscal pressure. In addition, neural mobilization techniques are widely used to normalize the cervical nerve root’s structure and function via the possible reduction of nerve adherence, facilitation of nerve gliding and decreased neural mechanosensitivity. The analgesic effect of these two modalities has been explored and recognized in many RCT studies with these in turn being analyzed in systematic reviews. However, the methodological quality of these studies has been questioned due to inappropriate use of outcome measures, lack of control group, homogeneous participants and short-term follow-ups.
Although the analgesic action of cervical traction and neural mobilization techniques has been recognized in many studies, the effect of both modalities applied simultaneously has not been previously investigated. Therefore, the objective of this case study is to present the effect of cervical traction combined with neural mobilization on pain and disability in a patient experiencing cervical radiculopathy.
The present study has looked at the effect of cervical traction combined with neural mobilization in a patient experiencing cervical radiculopathy and its findings have demonstrated significant improvements in terms of pain and disability.
Although the analgesic mechanism of cervical traction is still controversial, several imaging studies with the use of MRI and CT scans have revealed that cervical traction can increase the intervertebral space leading to neural foramen elongation and reduction of intradiscal pressure. It is also reported that the analgesic effect of cervical traction is a result of reduction in inflammation of the cervical nerve roots. Based on these findings, the present study used cervical traction to elongate the cervical foramen at C4–C5 level and therefore to eliminate mechanical stimuli which were hypothesized to compress the C5 nerve root. Neural mobilization was performed to normalize the structure and function of the C5 nerve root through the possible facilitation of nerve gliding, reduction of intraneural swelling, pressure and inflammation, improvement of axoplasmic flow and decreased neural mechanosensitivity.
In this study, cervical traction and neural mobilization were applied simultaneously instead of separately for two reasons:
1) To provide a more effective pain management in cervical radiculopathy. Cervical traction and neural mobilization techniques are used in relation to pathologies of the cervical nerve roots due to their analgesic action. Therefore, it was hypothesized that the simultaneous use of these two modalities will further enhance the analgesic effect of manual therapy in the treatment of cervical radiculopathy.
2) To prevent possible aggravation of cervical radiculopathy pain. The rationale of using neural mobilization techniques in cervical radiculopathy is to mobilize the affected cervical nerve roots. However, in nerve root compression, the presence of mechanical stimuli around the cervical nerve roots may not allow their mobilization and this may increase cervical radiculopathy pain. Thus, cervical traction was applied to elongate the cervical neural foramen at C4–C5 level and decompress the C5 nerve root. Maintaining the application of cervical traction for 1 min, slider neural mobilizations were given in this period to mobilize and restore the normal structure and function of the C5 nerve root.
In terms of evidence based practice, these two modalities need further investigation because the existing research is limited in methodological quality due to the lack of control groups and homogeneous participants, short-term follow-ups, weaknesses in random allocation of subjects and blinding of raters. In addition, while a small amount of clinical evidence supports the effectiveness of neural mobilization techniques, much more clinical research is necessary to explore the validity of the proposed analgesic mechanism.
Even though the analgesic effect of cervical traction combined with neural mobilization in cervical radiculopathy has been reported in the present paper, its study design limits the generalization of these findings. The use of a mechanical cervical traction could offer a high accuracy in measurement, although this would not have always represented the application of cervical traction in clinical practice. A further limitation of this study was the lack of objective outcome measures to accurately assess cervical spine movement and muscle strength.
This study describes the effect of cervical traction combined with neural mobilization on pain and disability in cervical radiculopathy. It was found that the simultaneous use of cervical traction and neural mobilization techniques can treat the particular pathology. Future studies using larger sample sizes and objective outcome measures are required to further enhance knowledge on the analgesic effect of cervical traction combined with neural mobilization in cervical radiculopathy.