Cervical compressive CASE REPORT. David A. Browder, PT, MS, OCS 1 Richard E. Erhard, PT, DC, FAAOMPT 2 Sara R. Piva, PT, MS, OCS, FAAOMPT 3

Intermittent Cervical Traction and Thoracic Manipulation for Management of Mild Cervical Compressive Myelopathy Attributed to Cervical Herniated Disc: A Case Series CASE REPORT David A. Browder, PT, MS, OCS 1 Richard E. Erhard, PT, DC, FAAOMPT 2 Sara R. Piva, PT, MS, OCS, FAAOMPT 3 Journal of Orthopaedic & Sports Physical Therapy Study Design: Case series. Objective: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. Background: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. Methods and Measures: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. Results: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. Conclusions: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine. J Orthop Sports Phys Ther 2004;34:701-712. Key Words: conservative, Hoffmann s reflex, mechanical traction, spinal cord impingement, upper motor neuron 1 Staff Physical Therapist, Wilford Hall Medical Center, San Antonio, TX. 2 Head Chiropractor, University of Pittsburgh Medical Center Health System, Spine Specialty Center, Pittsburgh, PA; Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA. 3 Graduate Student, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA. This study was approved by the University of Pittsburgh Institutional Review Board. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Air Force or Department of Defense. Address correspondence to David A. Browder, 3604 Augusta Glade, Schertz, TX 78154. Email: atexanpt@earthlink.net Cervical compressive myelopathy (CCM) is a manifestation of long-tract signs resulting from a decrease in the space available for the cervical spinal cord. 40 CCM is the most common problem involving the spinal cord in patients over 55. 6 It is usually attributed to degenerative changes in the cervical spine, resulting in cervical spondylosis and consequent narrowing of the spinal canal. 1 Another common cause of CCM is a cervical herniated disc (HD) that compresses the spinal cord. 27 CCM often presents with lower motor neuron signs at the level of the lesion and upper motor neuron signs below the level of the lesion. 1,6 Common signs include a wide base or unsteady gait, hyperreflexia, presence of pathological reflexes such as the Hoffmann s reflex and Babinski reflex, sensory disturbances in the hand beginning in the fingertips and progressing proximally, intrinsic muscle wasting of the hands, loss of dexterity, and nonspecific weakness of the extremities. 1,6,11,12,17,28 Neck pain, headaches, dizziness, Journal of Orthopaedic & Sports Physical Therapy 701

and some component of radicular arm pain may be the primary symptoms in early or mild cases. 1,12 Symptoms are often unilateral or absent in the upper extremities and bilateral in the lower extremities. 6 The natural history of CCM has been described as being eventually progressive, with long periods of stable neurological function between exacerbations. 25 Nurick 35 classified CCM on the basis of gait dysfunction. Patients with grade 1 CCM have upper motor neuron signs with a normal gait. Grade 1 is considered mild CCM. Grades 2 through 5 CCM are characterized by worsening gait disturbance. 35 Grades 2 through 5 are considered moderate to severe CCM. Moderate to severe CCM has a poor prognosis and is generally treated surgically. 41 Conservative treatment has been recommended for patients with mild CCM. 1,25,27,40 Intermittent cervical traction (ICT) has been indicated for the conservative treatment of patients with HD, and it has been suggested as an appropriate intervention for patients with mild CCM when the spinal cord compression is believed to be caused by HD. 1,44 Few studies have investigated ICT in patients with cervical HD. Systematic reviews pertaining to the treatment of neck pain or radiculopathy with ICT have reported that the literature is inconclusive due to methodological errors in the few randomized studies available. 47,50 Despite this lack of evidence, ICT has long been a mainstay of treatment for radiculopathy attributed to HD 5,8,20,30,42-45,47,50 and may be a useful intervention for CCM attributed to HD. It has been theorized that due to the biomechanical relationship between the cervical and thoracic spine, disturbances in joint mobility in the thoracic spine may be an underlying contributor to musculoskeletal disorders of the cervical spine. 16,22 Norlander et al 32-34 investigated the relationship between mobility of the upper thoracic motion segments and neck/shoulder pain, and demonstrated that decreased mobility in the upper thoracic region significantly predicted neck/shoulder pain and related subjective symptoms. Flynn et al 15 recently performed thoracic manipulation on 26 patients with primary complaints of cervical pain, resulting in significant and clinically meaningful improvement in cervical active range of motion (AROM) directly after the manipulation. Furthermore, in patients with CCM, the use of manual therapy in the thoracic spine instead of the cervical spine may potentially decrease the risk of distortion of the cervical spinal cord. We have used ICT and manipulation of the middle and upper thoracic spine to treat patients with signs and symptoms of mild CCM attributed to HD for more than a decade. No evidence is available in the peer-reviewed literature demonstrating the effectiveness or safety of these techniques in this population. However, in our experience, the overall results have been favorable. The purpose of this case series is to describe the management of 7 patients with mild CCM attributed to HD. We emphasize that this report concerns a specific subset of patients and that the treatment approach described should not be generalized for use in all patients with CCM. In this series, all patients were treated with ICT and manipulation of the thoracic spine. The importance of a thorough neurological screening examination is also highlighted. METHODS Patients This study was approved by the University of Pittsburgh Institutional Review Board. Patients were included in this case series if they had complaints of neck pain and/or referred pain to the upper extremities in conjunction with 1 or more of the following upper motor neuron signs: positive Hoffmann s reflex, clonus, and hyperreflexia. Patients also had to have a magnetic resonance image (MRI) of the cervical spine that demonstrated at least 1 HD that occupied space in the central spinal canal, such that the above signs and symptoms could potentially be attributed to the HD. Wainner and Gill 50 reviewed the available literature concerning MRI use in diagnosing radiculopathy and concluded that MRI is among the most definitive means of diagnosis currently available. MRI, when used to diagnose cervical radiculopathy attributed to HD, has been reported to demonstrate from 74% to 91% agreement with surgical observation. 50 Exclusion criteria included gait disturbances such as wide base of support, unsteady or ataxic walking, history of pathologies that might preclude spinal manipulation (ie, rheumatoid arthritis, vascular compromise, malignancy, hypermobility, infectious disease of the spine, pregnancy, or osteoporosis), 44 and evidence of vertebral artery disease or occlusion. Patients were also excluded if they could not complete the prescribed treatment regimen. Eleven patients were identified over a 6-month period as having neck or upper extremity pain and positive upper motor neuron signs. Of these, 1 had a negative cervical MRI and was referred for further imaging, and 3 were referred for conservative treatment elsewhere due to transportation issues. Seven patients, all women, with a median age of 40 years (range, 35-45 years), met the above criteria. They completed a course of conservative treatment for mild CCM at 1 clinic. Table 1 describes each patient s baseline characteristics and MRI results. Clinical Examination The clinical examination consisted of self-report data, the collection of historical data, and a physical 702 J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

TABLE 1. Baseline demographic, history, self-report and imaging data. Patient Age (y) Symptom Duration (d) Mechanism of Injury Number of Visits NPRS FRI Condensed MRI Findings 1 38 1 Fall 2 8 60 C5-6 paracentral herniated disc (HD) abuts the spinal cord 2 37 30 Insidious 5 5 44 C5-6 paracentral HD abuts the spinal cord 3 40 365 Insidious 6 4 43 C3-4, C4-5, C5-6 central HD, C5-6 HD indents spinal cord 4 44 120 Insidious 9 7 71 C4-5, C5-6, C6-7 HD with mild to moderate cord compression, mild to severe neural foraminal narrowing 5 44 4 Yoga 9 8 65 C6-7 broad central HD abuts the spinal cord. Mild central canal narrowing 6 45 14 Insidious 9 4 38 C5-6 paracentral HD and osteophyte, C4-5 small paracentral HD, mild bilateral neural foraminal narrowing 7 35 60 Insidious 12 6 35 C6-7 disc herniation slightly impresses the cervical cord Abbreviations: FRI, Functional Rating Index (expressed in percent, higher scores represent greater disability); HD, herniated disc; MRI, magnetic resonance imaging; NPRS, Numeric Pain Rating Scale (0 to 10 scale with 0 meaning no pain and 10 meaning the worst imaginable pain ). CASE REPORT Journal of Orthopaedic & Sports Physical Therapy examination. All patients referred for treatment to this clinic are examined in a similar fashion prior to the initiation of treatment. Medical Screening and Self-Report Measures of Pain and Function The medical screening questionnaire was only completed at baseline, whereas pain and function questionnaires were completed at each visit to assess changes during treatment. Medical Screening Questionnaire The medical questionnaire is designed to alert the clinician about red flags that may indicate possible serious underlying conditions such as cancer, immunosuppression, infections, or central nervous system pathology. 9 None of the patients indicated responses requiring further follow-up. Functional Rating Index (FRI) The FRI is a disability scale for patients with spinal disorders. It consists of 10 items addressing frequency and intensity of symptoms during the activities of sleeping, traveling, working, lifting, walking, standing, recreation, and personal care. Each question is scored from 0 to 4, with a maximum score of 40 points. The patient s total score is then interpreted as a percentage of a maximum of 40 points. Higher scores represent increased levels of disability. The FRI was designed to combine elements of the Oswestry Low Back Disability Questionnaire and the Neck Disability Index with decreased time to administer. 14 The FRI has been demonstrated to be a reliable, valid, and responsive outcome measure for patients with spinal conditions. 14 Numeric Pain Rating Scale (NPRS) The NPRS is a 11-point scale (0-10) used to measure pain intensity. The scale is anchored on the left with the phrase no pain and on the right with the phrase worst imaginable pain. Patients rate their current level of pain and their worst and least amount of pain in the last 24 hours. Numeric pain scales have been shown to be reliable and valid. 10,21,23 We used the current level of pain to represent the patient s level of pain for the purposes of this case series. Demographic and Historical Information Patients were queried at baseline with respect to age, occupation, symptom duration, mechanism of onset, location and description of symptoms, positions and factors that worsen or relieve symptoms, number and characteristics of previous episodes of neck pain, and response to previous interventions. Physical Examination The physical examination was performed at baseline and prior to each treatment session. Neurologic Testing The neurologic screening examination is designed to identify signs consistent with lower motor neuron (diminished or absent muscle stretch [deep tendon] reflexes, decreased sensation to light touch in a dermatomal pattern, and muscle weakness in specific myotomes) or upper motor neuron lesions (hyperreflexia, sensory changes in a nondermatomal pattern, clonus, a positive Hoffmann s reflex, general weakness below the level of compression, and gait disturbance). Sensation was tested with a pinprick (point of a paper clip) over key areas of dermatomes C5 through T1 on each limb as described by Magee. 26 The strength of key muscles of each myotome was tested bilaterally for levels C5 through T1, as described by Kendall, 24 with the exception of the triceps brachii, which was tested J Orthop Sports Phys Ther Volume 34 Number 11 November 2004 703

seated with the arms overhead. 13 Interrater reliability of sensation and strength testing performed as in this case series have kappa values ranging from 0.40 to 0.64. 48 Muscle stretch reflexes were assessed for the biceps brachii, brachioradialis, triceps brachii, pectoralis major, quadriceps, and triceps surae muscles. 26 The interrater reliability of reflex testing has been reported to be low. 48 The presence or absence of clonus was assessed in sitting by providing a quick stretch to the triceps surae muscles. Gait was assessed by visual observation. Hoffmann s reflex was utilized as a screening tool to detect the presence of a potential upper motor neuron lesion. The test for the presence of Hoffmann s reflex was conducted with the patient s wrist in a resting position with the third, fourth, and fifth digits passively held in a neutral position. The examiner then aggressively snapped the pad of the subject s middle finger in the dorsal direction. A reflex was considered positive if there was flexion of the interphalangeal joint of the thumb. 12,26,46 A positive reflex may denote spinal cord compression in the cervical spine or intracranial pathology. It has been reported that the Hoffmann s reflex and hyperreflexia are the most sensitive tests with the highest accuracy for the diagnosis of CCM. 46 Baseline data from neurological testing is shown in Table 2. Movement Testing Measurements of cervical AROM were taken using a fluid-filled inclinometer. Cervical AROM measurements using this method have demonstrated good reliability. 37,38,49 Cervical flexion, extension, and bilateral side bending were measured in the seated position. If judged to be grossly asymmetrical with visual estimation, bilateral cervical rotation was measured in supine. Quantity and symmetry of bilateral thoracic rotation AROM was visually estimated in a seated position with arms crossed across the chest. During AROM, we noted the quantity, quality, and TABLE 2. Signs and symptoms at baseline. Patient Upper Extremity Distal Symptoms Upper Extremity Hypoesthesia Headache Dizziness provocation of symptoms with each movement (increase, decrease, centralization, or peripheralization of symptoms). 37 Cervical AROM values at baseline are included in Table 3. Segmental Mobility Testing Segmental mobility testing of the middle and upper thoracic spine was performed with the patient seated and in prone. While seated, the patient s neck was passively moved into flexion and then side bending was performed while the clinician palpated the interspinous space between vertebral levels T3 through C7. A segment was judged to be hypomobile if the segment moved less than the segment above or below. In prone, spring testing of the thoracic spine was performed with the patient prone and the neck in neutral rotation. A gentle anteriorly directed pressure was applied over the spinous processes from T8 to T1. This maneuver tests both symptom provocation and segmental mobility. The mobility at each segment was judged as normal, hypomobile, or hypermobile. Although some patients had limited and painful cervical movements, segmental mobility testing of the cervical spine was not performed at baseline, because no cervical manual therapy would be utilized to treat these patients in the initial intervention protocol. Intervention Our first consideration when determining the initial management of patients with cervical disorders is to assess limitation of motion and symptom reproduction with cervical AROM. It has been suggested that limitation in cervical AROM may implicate middle or upper thoracic spine dysfunction. 13 In the presence of limited cervical AROM, we directed treatment first to the middle and upper thoracic spine. In our experience, this treatment approach often improves cervical AROM and decreases symptom provocation Hoffmann s Reflex Hyperreflexia Hyporeflexia Weakness 1 No No No No Yes T*, BB*, BR*, Q*, P* 2 Unilateral Unilateral No No Yes Right T, BB*, BR*, G*, Q* Left T Left C7 3 No No Yes Yes Yes Left BB, BR 4 Unilateral Unilateral Yes No Yes Left BB, BR Left T Left C7 5 Bilateral Bilateral No Yes Yes T*, BB*, BR*, Q*, G*, P 6 No No No Yes Yes T*, BB*, BR*, P* 7 Bilateral Bilateral Yes Yes Yes T*, BB*, BR*, Q*, G* Left C5 Abbreviations: P, pectoralis major reflex; T, triceps brachii reflex; BB, biceps brachii reflex; BR, brachioradialis reflex; Q, quadriceps reflex; G, gastrocnemius reflex. * Bilateral. 704 J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

TABLE 3. Cervical active range of motion (degrees) at baseline/discharge. Patient Flexion* Extension Bending Right Side Left Side Bending 1 55/full 50/full 40/50 50/50 2 70/full 45/52 50/47 50/45 3 50/full 45/full 47/50 50/50 4 54/full 45/full 36/42 42/42 5 48/full 55/full 45/52 50/52 6 70/full 58/50 55/60 65/55 7 59/full 45/50 47/44 38/48 * Full flexion: chin to sternum. Full extension: eyes to ceiling directly overhead without moving torso. with cervical movement. Cervical AROM, thoracic rotation AROM, and segmental mobility testing of the thoracic spine were re-evaluated after each manual treatment technique. All 7 patients were treated with thoracic manipulation followed by ICT. Thoracic manipulation was utilized until the patient demonstrated full or symmetrical cervical AROM without provocation of symptoms. Thoracic manipulation was performed during all visits for the patients who completed less than 6 visits and during at least the first 6 visits for the patients that completed more than 6 visits. ICT was performed during each visit. Thoracic Manipulation We used high-velocity, lowamplitude thrust techniques in the middle and upper thoracic spine, as indicated below, prior to each ICT treatment. A general upper thoracic traction manipulation was performed for patients with local symptoms in the upper thoracic region accompanied by a decrease in cervical flexion AROM and decreased segmental mobility in the upper thoracic region. 13 As shown in Figure 1, this technique is performed by looping the hands through the patient s arms. The therapist s fingers are placed at the motion segment of interest. The patient s shoulders are retracted and spinal extension is introduced using the therapist s hands and chest. The therapist s legs are used to push upwards to perform a traction manipulation. We believe this technique, while general in its effects, is appropriate for patients with CCM. The cervical spine is kept in a neutral position, without rotation or side bending, and the technique is performed with predominantly a traction force. 4,13 We intentionally avoid other techniques that put the cervical spine into nonneutral positions and utilize a rotary force. Indications for midthoracic manipulation were a decrease in cervical AROM, with symptoms produced in the midthoracic region, symptom provocation in the thoracic region during thoracic rotation, and hypomobility in 1 or more midthoracic spine motion segments. Midthoracic dysfunction was addressed with either a general traction manipulation in sitting or a more specific manipulation in supine. The general midthoracic traction manipulation is performed with the patient sitting with hands clasped behind his/her neck and with elbows joined in front of the chest. The clinician stands behind the patient, grasps the patient s elbows and applies a thrust, lifting the patient s upper trunk against the clinician s sternum (Figure 2). 4,13 Thoracic manipulation performed in supine potentially allows for more specific application FIGURE 1. Traction manipulation of the upper thoracic spine performed in sitting. FIGURE 2. General traction manipulation of the thoracic spine performed in sitting. CASE REPORT J Orthop Sports Phys Ther Volume 34 Number 11 November 2004 705

of force. To perform this manipulation, the clinician establishes hand contact over the inferior vertebra of the hypomobile motion segment. The patient is positioned in supine with hands clasped behind the neck and with elbows joined in front of the chest. Downward pressure is applied with the weight of the clinician s body through the patient s elbows until motion is felt at the selected segment. A manipulative thrust is then applied in an anterior-posterior direction (Figure 3). 4,13 Intermittent Cervical Traction The patient s cervical flexion AROM after thoracic manipulation was utilized to determine the amount of cervical flexion desired during ICT treatment. All but 1 patient (patient 4) had full cervical flexion AROM after manipulation, therefore, we applied ICT in a position of 24 of cervical flexion on all but that patient. 7 For patient 4, who had flexion still limited to 60 after thoracic manipulation, ICT was applied in a position of 15 of cervical flexion. In our experience, a patient with persistent cervical flexion AROM limitation will better tolerate ICT in a less flexed position. A fluid-filled inclinometer was used to set the flexion angle. The treatment time for traction ranged from 15 to 20 minutes. The maximum force used for each patient was sufficiently high to decrease peripheral symptoms, if present. The minimum force was set such that peripheral symptoms, if present, did not recur during the release phase. Maximum force used varied from 7 to 11 kg (16-24 lb). An initial maximum-minimum force ratio of 3:1 was used. For example, if 9 kg (20 lb) of force provided relief of peripheral symptoms, the minimum force during the traction cycle would initially be set at 3 kg (7 lb). Patients were monitored during the traction treatment to ensure that the treatment did not aggravate their symptoms. No patients reported increased symptoms during or immediately after traction treatment. All traction was performed with a Triton Traction Machine (Chattanooga Group, Hixon, TN) using a Saunders traction device that pulls from the occipital area (The Saunders Group, Inc, Chaska, MN). Special Treatment Considerations Patients with CCM often present with lower motor neuron signs at the level of the lesion. 1,6 Three patients demonstrated hyporeflexia and/or weakness in a myotomal pattern (Table 2). After 3 to 4 trials of thoracic manipulation and ICT, these 3 patients still presented with hyporeflexia and/or weakness. Generally, the presence of neurological signs, especially upper motor neuron signs, would lead us to rule out any rotatory cervical manipulation that could potentially cause distortion of the spinal cord. However, due to the lower motor neuron signs, we wanted to attempt to achieve further distraction between the intervertebral foramen. Therefore, in these 3 patients we per FIGURE 3. Manipulation of the thoracic spine performed in supine. FIGURE 4. Traction manipulation of the cervical spine. formed a cervical manipulation with a predominantly cephalic-directed (traction) force at the cervical segment above the level of the lower motor neuron signs (Figure 4). Prior to the manipulation, cervical segmental mobility testing was performed. Overall, interrater reliability of cervical segmental mobility testing has been reported to be poor. 37,38 These patients were also further assessed for signs and symptoms of vertebral artery insufficiency in the manipulation position. 4 A traction manipulation between C6-7 was performed on patients 2 and 4, and a traction manipulation between C4-5 was performed on patient 7. Patients 2 and 7 received 2 traction manipulations each and patient 4 received 3 traction manipulations throughout the course of treatment. We attempted to localize the manipulation by slightly flexing the cervical spine to the desired level, slightly side bending towards the affected side to acquire the contact for the second metacarpophalangeal (MCP) area of the manipulating hand, and very slightly rotating to the opposite 706 J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

side to neutralize the side bending. From this static position, a thrust was given with high velocity parallel to the longitudinal axis of the cervical spine. As has been described previously by Erhard, 13 an immediate improvement in strength and reflex response is anticipated after the utilization of this technique. This response was noted after each cervical traction manipulation was performed in these 3 patients. Data Analysis Results are presented descriptively in tables and figures. The correlation between extent of improvement and duration of symptoms was examined by calculating the Pearson correlation coefficient. RESULTS Seven patients were treated a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Figures 5 and 6 illustrate changes in NPRS and FRI, respectively, at baseline, midtreatment, and discharge. The median decrease in NPRS scores was 5 points (range, 2-8 points) and median improvement in FRI scores was 26% (range, 10%-50%). Patients 1 and 2 appeared to experience the greatest change with the intervention. They reported complete cessation of pain as well as 50% and 43% improvement in FRI scores, respectively, at discharge. Patients 4, 5, 6, and 7 also improved, with NPRS scores decreasing to 1/10 at discharge, and the FRI showing improvement ranging from 20% to 45%. The patient who reported the least improvement was patient 3, with a decrease in NPRS score of 2 points (from 5 to 3) and 10% improvement in FRI score at discharge. Neurological deficits were improved in some cases. All 3 patients (patients 2, 4, and 7) who initially demonstrated myotomal weakness and received cervical traction manipulations demonstrated full strength at discharge. The 2 patients with triceps muscle stretch reflex hyporeflexia (patients 2 and 4) were judged to have normal triceps reflexes at discharge. Normal sensation was restored in only 1 of the 4 patients that initially reported hypoesthesia (patient 7). In addition, Hoffmann s reflex was no longer present in 2 patients at discharge (patients 6 and 7). Hyperreflexia was persistent in all cases at discharge. Other symptoms were also affected. Three out of 4 patients who complained of dizziness reported cessation of this symptom at discharge (patients 3, 6, and 7). Two out of 3 patients who initially complained of headaches reported cessation of symptoms (patients 3 and 7), while the remaining patient (patient 4) reported a decrease in frequency and intensity of headache. Table 4 summarizes the signs and symptoms present at discharge. There were no adverse events or outcomes during the course of this study. CASE REPORT FIGURE 5. Numerical pain rating scores over the course of treatment. Pain rated on a0to10scalewith0definedas nopain and10 defined as worst imaginable pain. J Orthop Sports Phys Ther Volume 34 Number 11 November 2004 707

Functional Rating Index 80 70 60 50 40 30 20 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 10 0 Baseline Midtreatment Discharge Journal of Orthopaedic & Sports Physical Therapy FIGURE 6. Functional rating index scores over the course of treatment. Expressed in percentage values, higher scores represent greater disability. DISCUSSION TABLE 4. Signs and symptoms at discharge. Patient Upper Extremity Distal Symptoms Upper Extremity Hypoesthesia Headache Dizziness The results described in this case series provide preliminary low-level evidence that intervention with ICT combined with thoracic spine manipulation (and occasionally cervical spine manipulation) is a potentially useful treatment approach for patients with mild CCM attributed to HD. This finding agrees with previous studies that concluded that conservative intervention, as opposed to surgical intervention, is indicated in patients with mild CCM. 17,27,31,41 Matsumoto et al 27 retrospectively reported on 27 patients with mild CCM attributed to HD. Sixty-three percent of patients were effectively treated conservatively with cervical bracing and activity modification, whereas 37% failed conservative treatment and went to surgery. Nakamura et al 31 retrospectively reviewed 64 patients with mild to moderate CCM treated with a variety of immobilization methods. They reported that 26% of patients had no disability at follow-up of 3 to 10 years and that patients with lower levels of initial disability responded more favorably to treatment. Both of these studies concluded that nonoperative treatment is indicated for patients with mild CCM. 27,31,41 However, specific conservative management techniques have not been identified and have varied within the available studies. Hoffmann s Reflex Hyperreflexia (See Key) Hyporeflexia Weakness 1 No No No No Yes T*,BB*,BR*,Q*,P* 2 Unilateral Unilateral No No Yes T*, BB*,BR*,G*,Q* Resolved Resolved 3 No No Resolved Resolved Yes Left BB,BR 4 Unilateral Unilateral Decreased No Yes Left BB,BR Resolved Resolved 5 Bilateral Bilateral No Yes Yes T*,BB*,BR*,Q*,G*,P 6 No No No Resolved Resolved T*,BB*,BR*, P* 7 Resolved Resolved Resolved Resolved Resolved T*,BB*,BR*,Q*,G* Resolved Abbreviations: P, pectoralis major reflex; T, triceps brachii reflex; BB, biceps brachii reflex; BR, brachioradialis reflex; Q, quadriceps reflex; G, gastrocnemius reflex. * Bilateral. 708 J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

It is essential to understand that the treatment techniques used in this report should only be used to treat patients with mild (grade 1) CCM attributed to cervical HD. Use of these treatment techniques in patients with more severe CCM or with other conditions such as severe spondylosis or rheumatoid arthritis may be harmful. Furthermore, the use of this treatment approach in patients with mild CCM that is not attributable to cervical HD may not produce the same results and may, at best, delay definitive diagnosis. While severe CCM is most commonly referred to in the literature as a disease of the elderly, mild CCM appears to occur more often in middle-age patients, as would perhaps be expected of a degenerative process. Our reported median age of 40 years (range, 35-45 years) is similar to that described by Matsumoto et al 27 (mean age, 44 years) and Sampath et al 41 (mean age, 49 years) when describing patients with mild CCM. Several theories regarding the mechanism by which ICT might potentially aid the resolution of symptoms caused by HD have been proposed. Those theories include unloading of spinal components, reduction of dural adhesions, decreased pressure within the intervertebral discs, and relief of compression within the central foramina. 2,3,5,19,20,30,36,39,42-45,51 However, much of the research reported in this area has involved the lumbar disc. 36,39,44,42 Recently, the reduction of cervical HD during mechanical traction sessions was reported. 5 Chung et al 5 applied traction to 29 patients with cervical HD while performing MRI using a nonmagnetic, static traction device. In addition to lengthening the cervical spine, the authors found that 18 patients demonstrated instantaneous partial reduction of HD and 3 demonstrated complete reduction. Considering these findings, it is possible that ICT reduces HD and may speed the regression of cervical HD. We used ICT in a position of slight cervical flexion because it is likely more effective in this population than ICT in a more neutral position. ICT in flexion was selected because in a cadaveric study Humphreys et al 20 found that a flexed spine position increased central foraminal space, as compared to a neutral position. In addition, the device utilized by Chung et al 5 described previously also positions the cervical spine in flexion. The use of cervical manipulation in the presence of CCM is controversial. Even in cases of radiculopathy, manipulation has been considered contraindicated by some authors, while other authors considered it a primary treatment. 50 Most cervical manipulation techniques are considered to be contraindicated in the presence of upper motor neuron signs. However, the cervical traction manipulation we utilized is a high-velocity, low-amplitude thrust in the same direction as the distraction force imparted through ICT. Because the technique attempts to minimize any side bending or rotary forces, we feel it may be used with care by properly trained individuals in this specific patient population. As a further precaution, the response of each patient to mechanical traction was assessed prior to cervical manipulation. Rare catastrophic vascular events (115 reported cases in the English language literature from 1966-1993) have been associated with cervical spine manipulation. 18 In a 1999 review of the literature, Haldeman et al 18 concluded that the literature does not assist in identification of the type of manipulation or risk factors that precipitate these rare events. However, to minimize the risk of such an event, each patient with dizziness was further questioned and prior to manipulation each patient was assessed for signs or symptoms of vertebral artery insufficiency in the manipulation position. 4 All patients in this case series were referred from primary care providers with a diagnosis of neck pain or cervical radiculopathy. In all cases, the first indication of CCM was during the neurological screening examination. Testing for the presence of Hoffmann s reflex was an important part of this examination. Sung and Wang 46 prospectively studied 16 asymptomatic subjects with a positive Hoffmann s reflex using cervical radiographs and MRI. All but 1 patient had cervical involvement with spinal cord compression from a HD. The authors suggested that the presence of this pathological reflex denotes the need for a detailed neurological workup in patients with accompanying neurologic signs or symptoms. CCM can present in middle-age patients (median age, 40 years) without peripheral symptoms (patients 1, 3, and 6) and can be found in conjunction with signs and symptoms commonly seen with nerve root compression (patients 2, 4, and 7). Upper motor neuron signs are often unilateral or even absent in the upper extremities. 6 For this reason, we recommend that a neurological screening examination including upper and lower extremity muscle stretch reflexes and testing for the presence of Hoffmann s reflex be performed prior to any mechanical treatment of the cervical spine. Neurological screening should be included in the examination process, regardless of the presence or absence of peripheral symptoms. In the presence of upper motor neuron signs of unknown etiology, further investigation should be performed prior to initiating mechanical treatment of the cervical spine. There is a possibility that the signs and symptoms observed in these patients were not the result of the HD demonstrated on MRI. MRI has been used in other studies to identify HD, to which upper motor neuron signs may be attributed. 27,29,31,46 However, due to high false positive rates in asymptomatic populations, interpretation of MRI results must be CASE REPORT J Orthop Sports Phys Ther Volume 34 Number 11 November 2004 709

performed in the context of the patient s clinical presentation. 46,49 Other potential causes of upper motor neuron signs include lesions of the brain. Intracranial imaging studies were not performed to investigate this possibility. Sung and Wang 46 recommended not performing a brain-imaging study in the presence of a Hoffman s reflex and hyperreflexia in an asymptomatic population. The patients in this case series did not report any neurological symptoms indicating the need for further evaluation or imaging. The degree of improvement experienced by each patient in this series appears to correlate with the duration of symptoms experienced prior to treatment. Patients 1 and 2 were most improved and had relatively short duration of symptoms (1 and 30 days, respectively). Patient 3 was least improved and had the longest symptom duration (365 days). To confirm this empirical observation, we calculated Pearson correlation coefficients between duration of symptoms and change in NPRS and FRI scores, and found moderate to good correlations (r = 0.65 and 0.75, respectively). Moeti and Marchetti 30 reported similar findings in patients with radiculopathy treated with traction and suggested that the decreased response may be due to an increase in illness behaviors associated with chronicity. Decreased response seen with longer symptom duration may also be due to the severity of the initial lesion or a reflection of the natural history of this progressive degenerative disorder. 1,6,17,40 Limitations of this study are inherent to its case series design. Without a comparison group, we cannot determine if similar improvements would have occurred had these patients received a different treatment approach or no treatment at all. Spontaneous regression of cervical HD without surgery has been reported by several authors at long-term follow-up after conservative treatment. 3,27,29 However, because symptom duration was prolonged in several of the patients and the improvements were obtained over a relatively low number of visits, we believe that this treatment approach contributed to the observed results. In addition, because patients in this case series received combined treatments within each treatment session, the contribution that each type of treatment made to the total change in status cannot be determined. Because this is a description of clinical practice, the tester was not masked from each patient s treatment. Although we acknowledge that this may have produced unintentional bias during physical examination, we believe that the use of self-reports of pain and function, which are less susceptible to the tester s influence, help to minimize the potential for bias in determining improvement with treatment. Another limitation was the absence of long-term follow-up data, which prevents us from being able to determine if the observed improvements were maintained. This case series is the first step in planning future research that may yield stronger evidence. This study aimed to report the characteristics of a group of patients with mild CCM attributed to cervical HD, to describe the intervention and the rationale behind the interventions used, and to report each patient s progression when these interventions were applied. Randomized, controlled trials assessing the safety and effectiveness of these and other interventions for the conservative treatment of CCM are needed. CONCLUSION Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild CCM attributed to HD. Other signs and symptoms, such as weakness, headache, dizziness, and hypoesthesia, were positively affected. 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