February QoM:

OCS/SCS Super Bowl Edition

Peyton Manning and Cervical Radiculopathy

Imagine you’re working in clinic and your next evaluation is Peyton Manning.

He Says:

“I can’t feel anything in my fingertip. It’s crazy. Well I can probably manage, but when you’re a quarterback and it’s your right hand, you’re certainly concerned as far as being able to do your job.”

Your examination reveals

Hypo reflexive deep tendon reflex
Positive upper limb tension test
Decreased force production when throwing a football.

What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

B. Mechanical constant traction

C. Repeated cervical extension (at least 10 repetitions)

D. Mechanical intermittent traction

Which is not part of the cluster of tests used to rule in cervical radiculopathy?

A. Spurling’s

B. Distraction

C. Upper limb tension test A

D. Active cervical rotation less than 45 degrees

What visceral structure can cause radiculopathy in a C8-T1 nerve root distribution pattern?

A. Liver

B. Spleen

C. T4 Syndrome

D. Heart

FIND ANSWERS BELOW…..

What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

B. Mechanical constant traction

~~C. Repeated cervical extension (at least 10 repetitions)~~

You should always assess if your patient centralizes with various cervical movements, however, if you could only pick one answer this is not the best. According the Clinical Practice Guidelines for Neck Pain published in JOSPT in 2008, centralization procedures were given a grade C recommendation. Centralization procedures for the spine have been more heavily studied in the lumbar spine rather than the cervical spine.

D. Mechanical intermittent traction

What is the best physical therapy intervention for this patient?

~~A. Manipulation or mobilization of the cervical spine + chin tucks~~

Although manipulation and mobilization was given a grade A recommendation from the Clinical Practice Guidelines, this was in regards to patients with mechanical neck pain or headaches and not patients with radicular symptoms. Again, this doesn’t suggest that you shouldn’t assess for the effects of your manual therapy techniques on the patient’s radicular symptoms.

B. Mechanical constant traction

~~C. Repeated cervical extension (at least 10 repetitions)~~

D. Mechanical intermittent traction

What is the best physical therapy intervention for this patient?

~~A. Manipulation or mobilization of the cervical spine + chin tucks~~

~~B. Mechanical constant traction~~

For this patient, mechanical traction is indicated, however intermittent traction rather than constant traction.

~~C. Repeated cervical extension (at least 10 repetitions)~~

D. Mechanical intermittent traction

Answer choice D is correct.

Which is not part of the cluster of tests used to rule in cervical radiculopathy?

A. Spurling’s

Spurling’s test is classically defined as passively side bending the cervical spine and providing a caudal force through the head. Reproduction of radicular symptoms is a positive test. This test is part of the cluster.

B. Distraction

Distraction of the cervical spine results in reduction of radicular symptoms, and is part of the cluster.

C. Upper limb tension test A

Upper limb tension test A puts tension on the nerve roots with a bias for the median nerve, and is part of the cluster.

D. Active cervical rotation less than 45 degrees

Answer choice D is the best answer. Although a patient with less than 45 degrees of cervical rotation would test positive for this aspect of the cluster, it’s actually active rotation less than 60 degrees to the affected side that’s part of the cluster. Active cervical rotation less than 45 degrees is important when deciding if a patient requires a radiograph with the Canadian C-Spine rules.

PubMed Citation: Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ, Godges JJ, Flynn TW; American Physical Therapy Association. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008 Sep;38(9):A1-A34. Epub 2008 Sep 1. Erratum in: J Orthop Sports Phys Ther. 2009 Apr;39(4):297. PubMed PMID: 18758050.

Link to Article: http://www.ncbi.nlm.nih.gov/pubmed/18758050

What visceral structure can cause radiculopathy in a C8-T1 nerve root distribution pattern?

A. Liver

Answer choice A is incorrect because the liver may cause increased pain in the right upper quadrant of a patient and refer into neck.

B. Spleen

Answer choice B is unlikely to cause symptoms mimicking cervical radiculopathy. Patients with pancreatitis commonly present with back pain and upper abdominal pain.

C. T4 Syndrome

Answer choice C is characterized by pain in the thoracic spine and paresthesias in a stocking glove pattern.

D. Heart

Myocardial infarction can often mimic radicular symptoms into the arm, and should always be on the differential diagnosis of a clinician when evaluating a client with cardiac risk factors.

PubMed Citation: Sizer PS Jr, Brismée JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Pract. 2007 Mar;7(1):53-71. Review. PubMed PMID: 17305681.

Link to Article: http://www.ncbi.nlm.nih.gov/pubmed/17305681

Other notes: As I was creating this post, it was interesting to find out more details about the oldest Manning brother. Apparently he was just as stellar of an athlete as his younger brothers, but had to have surgery after experiencing numbness and atrophy in his right biceps.

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