Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy

Published:August 27, 2016DOI:https://doi.org/10.1016/j.apmr.2016.07.022

      Abstract

      Objective

      To investigate the immediate and 1-year effects of a multimodal program, with cervical lordosis and anterior head translation (AHT) rehabilitation, on the intensity of pain, disability, and peripheral and central nervous system function in patients with discogenic cervical radiculopathy (CR).

      Design

      A randomized controlled trial with 1-year and 10-week follow-up.

      Setting

      University research laboratory.

      Participants

      Patients (N=60; 27 men) with chronic discogenic CR, a defined hypolordotic cervical spine, and AHT posture were randomly assigned to a control group (n=30; mean age, 43.9±6.2y) or an intervention group (n=30; mean age, 41.5±3.7y).

      Interventions

      Both groups received the multimodal program; in addition, the intervention group received the Denneroll cervical traction device.

      Main Outcome Measures

      AHT distance, cervical lordosis, arm pain intensity, neck pain intensity, and disability (Neck Disability Index [NDI]), dermatomal somatosensory evoked potentials (DSSEPs), and central somatosensory conduction time (N13–N20). Measures were assessed at 3 time intervals: baseline, 10 weeks, and 1-year follow-up.

      Results

      After 10 weeks of treatment, between-group analysis showed equal improvement in arm pain intensity ( P=.40), neck pain intensity ( P=.60), and latency of DSSEPs ( P=.60) in both intervention and control groups. However, also at 10 weeks, there were significant differences between groups, favoring the intervention group for cervical lordosis ( P<.0005), AHT distance ( P<.0005), amplitude of DSSEPs ( P<.0005), N13 to N20 conduction time ( P<.0005), and NDI ( P<.0005). Although at 1-year follow-up, between-group analysis identified a regression back to baseline values for the control group. Thus, all variables were significantly different, favoring the intervention group at 1-year follow-up: cervical lordosis ( P<.0005), AHT distance ( P<.0005), latency and amplitude of DSSEPs ( P<.0005), N13 to N20 conduction time ( P<.0005), intensity of neck and arm pain, and NDI ( P<.0005).

      Conclusions

      The addition of the Denneroll cervical orthotic device to a multimodal program positively affected discogenic CR outcomes at long-term follow-up. We speculate that improved cervical lordosis and reduced AHT contributed to our findings.

      Keywords

      List of abbreviations:

      AHT ( anterior head translation), CR ( cervical radiculopathy), DSSEP ( dermatomal somatosensory evoked potential), NDI ( Neck Disability Index)
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      References

        • Yoon S.H.
        Cervical radiculopathy.
        Phys Med Rehabil Clin N Am. 2011; 22 (viii): 439-446
        • Radhakrishnan K.
        • Litchy W.J.
        • O'Fallon W.M.
        • Kurland L.T.
        Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990.
        Brain. 1994; 117: 325-335
        • Salemi G.
        • Savettiere G.
        • Meneghini F.
        • et al.
        Prevalence of cervical spondylotic radiculopathy: a door-to-door survey in a Sicilian municipality.
        Acta Neurol Scand. 1996; 93: 184-188
        • Schoenfeld A.J.
        • George A.A.
        • Bader J.O.
        • Caram Jr., P.M.
        Incidence and epidemiology of cervical radiculopathy in the United States military: 2000 to 2009.
        J Spinal Disord Tech. 2012; 25: 17-22
        • Kelley L.A.
        In neck to neck competition are women more fragile?.
        Clin Orthop. 2000; 372: 123-130
        • Hurwitz E.
        • Carragee E.
        • Van Der Velde G.
        • et al.
        Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
        Spine (Phila Pa 1976). 2008; 33: S123-S152
        • Kuijper B.
        • Tans J.T.
        • Schimsheimer R.J.
        • et al.
        Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review.
        Eur J Neurol. 2009; 16: 15-20
        • Cleland J.A.
        • Fritz J.M.
        • Whitman J.M.
        • Heath R.
        Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy.
        Phys Ther. 2007; 87: 1619-1632
        • Murphy D.R.
        • Hurwitz E.L.
        • Gregory A.
        • Clary R.
        A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study.
        J. Manipulative Physiol Ther. 2006; 29: 279-287
        • Rodine R.J.
        • Vernon H.
        Cervical radiculopathy: a systematic review on treatment by spinal manipulation and measurement with the Neck Disability Index.
        J Can Chiropr Assoc. 2012; 56: 18-28
        • Thoomes E.J.
        • Scholten-Peeters W.
        • Koes B.
        • Falla D.
        • Verhagen A.P.
        The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review.
        Clin J Pain. 2013; 29: 1073-1086
        • Harrison D.E.
        • Cailliet R.
        • Harrison D.D.
        • Troyanovich S.J.
        • Harrison S.O.
        A review of biomechanics of the central nervous system, Part II: spinal cord strains from postural loads.
        J Manipulative Physiol Ther. 1999; 22: 322-332
        • Harrison D.E.
        • Harrison D.D.
        • Janik T.J.
        • William Jones E.
        • Cailliet R.
        • Normand M.
        Comparison of axial and flexural stresses in lordosis and three buckled configurations of the cervical spine.
        Clin Biomech (Bristol, Avon). 2001; 16: 276-284
        • Wei W.
        • Liao S.
        • Shi S.
        • Fei J.
        • Wang Y.
        • Chen C.
        Straightened cervical lordosis causes stress concentration: a finite element model study.
        Australas Phys Eng Sci Med. 2013; 36: 27-33
        • Harrison D.E.
        • Harrison D.D.
        • Betz J.J.
        • et al.
        Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial.
        J Manipulative Physiol Ther. 2003; 26: 139-151
        • Harrison D.E.
        • Cailliet R.
        • Harrison D.D.
        • Janik T.J.
        • Holland B.
        A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial.
        Arch Phys Med Rehabil. 2002; 83: 447-453
        • Tang J.A.
        • Scheer J.K.
        • Smith J.S.
        • et al.
        The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery.
        Neurosurgery. 2012; 71: 662-669
        • Villavicencio A.T.
        • Babuska J.M.
        • Ashton A.
        • et al.
        Prospective, randomized, double-blind clinical study evaluating the correlation of clinical outcomes and cervical sagittal alignment.
        Neurosurgery. 2011; 68: 1309-1316
        • Hu X.
        • Ohnmeiss D.D.
        • Zigler J.E.
        • Guyer R.D.
        • Lieberman I.H.
        Restoration of cervical alignment is associated with improved clinical outcome after one and two level anterior cervical discectomy and fusion.
        Int J Spine Surg. 2015; 9: 61
        • Smith J.S.
        • Lafage V.
        • Ryan D.J.
        • et al.
        Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy study.
        Spine (Phila Pa 1976). 2013; 38: S161-S170
        • Grosso M.J.
        • Hwang R.
        • Mroz T.
        • Benzel E.
        • Steinmetz M.P.
        Relationship between degree of focal kyphosis correction and neurological outcomes of patients undergoing cervical deformity correction surgery.
        J Neurosurg Spine. 2013; 18: 537-544
        • Harrison D.E.
        • Harrison D.D.
        • Cailliet R.
        • Troyanovich S.J.
        • Janik T.J.
        • Holland B.
        Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis.
        Spine (Phila Pa 1976). 2000; 25: 2072-2078
        • Harrison D.D.
        • Janik T.J.
        • Troyanovich S.J.
        • Holland B.
        Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine.
        Spine (Phila Pa 1976). 1996; 21: 667-675
        • Harrison D.D.
        • Harrison D.E.
        • Janik T.J.
        • et al.
        Modeling of the sagittal cervical spine as a method to discriminate hypolordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects.
        Spine (Phila Pa 1976). 2000; 29: 2485-2492
        • McAviney J.
        • Schulz D.
        • Bock R.
        • Harrison D.E.
        • Holland B.
        Determining the relationship between cervical lordosis and neck complaints.
        J Manipulative Physiol Ther. 2005; 28: 187-192
        • Purves A.M.
        • Penny K.
        • Munro C.
        • et al.
        Defining chronic pain for epidemiological research—assessing a subjective definition.
        Pain Clin. 1998; 10: 139-147
        • Wainner R.S.
        • Fritz J.M.
        • Irrgang J.J.
        • Boninger M.L.
        • Delitto A.
        • Allison S.
        Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
        Spine (Phila Pa 1976). 2003; 28: 52-62
        • Costello M.
        Treatment of a patient with cervical radiculopathy using thoracic spine thrust manipulation, soft tissue mobilization, and exercise.
        J Man Manip Ther. 2008; 16: 129-135
        • Shanahan C.
        • Ward A.R.
        • Robertson V.J.
        Comparison of the analgesic efficacy of interferential therapy and transcutaneous electrical nerve stimulation.
        Physiotherapy. 2006; 92: 247-253
        • French S.D.
        • Cameron M.
        • Walker B.F.
        • Reggars J.W.
        • Esterman A.J.
        Superficial heat or cold for low back pain.
        Cochrane Database Syst Rev. 2006; : CD004750
        • Mintken P.E.
        • Derosa C.
        • Little T.
        • Smith B.
        • American Academy of Orthopaedic Manual Physical Therapists
        A model for standardizing manipulation terminology in physical therapy practice.
        J Man Manip Ther. 2008; 16: 50-56
        • Bryans R.
        • Decina P.
        • Descarreaux M.
        • et al.
        Evidence-based guidelines for the chiropractic treatment of adults with neck pain.
        J Manipulative Physiol Ther. 2014; 37: 42-63
        • Vasudevan J.M.
        • Plastaras C.
        • Becker S.
        Cervical radiculopathy.
        in: Wyss J.F. Patel A.D. Therapeutic programs for musculoskeletal disorder. DemosMedical, New York2013: 279-288
        • Harman K.
        • Hubley-Kozey C.L.
        • Butler H.
        Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial.
        J Man Manip Ther. 2005; 13: 163-176
        • MacDermid J.C.
        • Walton D.M.
        • Avery S.
        • et al.
        Measurement properties of the Neck Disability Index: a systematic review.
        J Orthop Sports Phys Ther. 2009; 39: 400-417
        • Lundeberg T.
        • Lund I.
        • Dahlin L.
        • et al.
        Reliability and responsiveness of three different pain assessments.
        J Rehabil Med. 2001; 33: 279-283
        • Bijur P.E.
        • Latimer C.T.
        • Gallagher E.J.
        Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department.
        Acad Emerg Med. 2003; 10: 390-392
        • Diab A.A.
        • Moustafa I.M.
        The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial.
        Clin Rehabil. 2012; 26: 351-361
        • Mochizuki H.
        • Yagi K.
        • Tsuruta K.
        • et al.
        Prolonged central sensory conduction time in patients with chronic arsenic exposure.
        J Neurol Sci. 2016; 361: 39-42
        • Bouwes A.
        • Doesborg P.G.
        • Laman D.M.
        • et al.
        Hypothermia after CPR prolongs conduction times of somatosensory evoked potentials.
        Neurocrit Care. 2013; 19: 25-30
      1. Harrison DE. BioPhysics insights: determining the appropriate home traction for abnormalities of the cervical lordosis. Available at: http://www.chiropractic-biophysics.com/clinical_chiropractic/2010/9/14/biophysics-insights-determining-the-appropriate-home-tractio.html. Accessed January 3, 2014.

        • Kourtis D.
        • Magnusson M.L.
        • Smith F.
        • Hadjipavlou A.
        • Pope M.H.
        Spine height and disc height changes as the effect of hyperextension using stadiometry and MRI.
        Iowa Orthop J. 2004; 24: 65-71
        • Masaracchio M.
        • Cleland J.A.
        • Hellman M.
        • Hagins M.
        Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial.
        J Orthop Sports Phys Ther. 2013; 43: 118-127
        • Gross A.R.
        • Goldsmith C.
        • Hoving J.L.
        • et al.
        Conservative management of mechanical neck disorders: a systematic review.
        J Rheumatol. 2007; 34: 1083-1102
        • Langevin P.
        • Desmeules F.
        • Lamothe M.
        • Robitaille S.
        • Roy J.S.
        Comparison of 2 manual therapy and exercise protocols for cervical radiculopathy: a randomized clinical trial evaluating short-term effects.
        J Orthop Sports Phys Ther. 2015; 45: 4-17
        • Grob D.
        • Frauenfelder H.
        • Mannion A.F.
        The association between cervical spine curvature and neck pain.
        Eur Spine J. 2007; 16: 669-678
        • Howell E.R.
        The association between neck pain, the Neck Disability Index and cervical ranges of motion: a narrative review.
        J Can Chiropr Assoc. 2011; 55: 211-221
        • Baker P.F.
        • Ladds M.
        • Rubinson K.A.
        Measurement of the flow properties of isolated axoplasm in a defined chemical environment [proceedings].
        J Physiol. 1977; 269 (10P-11P)
        • McCormick P.C.
        • Stein B.M.
        Functional anatomy of the spinal cord and related structures.
        Neurosurg Clin N Am. 1990; 1: 469-489
        • Lundborg G.
        Intraneural microcirculation.
        Orthop Clin North Am. 1988; 19: 1-12
        • Naito M.
        • Owen J.H.
        • Bridwell K.H.
        • Sugioka Y.
        Effects of distraction on physiologic integrity of the spinal cord, spinal cord blood flow, and clinical status.
        Spine (Phila Pa 1976). 1992; 17: 1154-1158
        • Breig A.
        Adverse mechanical tension in the central nervous system: an analysis of cause and effect: relief by functional neurosurgery.
        Almqvist & Wiksell International, Stockholm, Sweden1978
        • Abdulwahab S.S.
        Treatment based on H-reflexes testing improves disability status in patients with cervical radiculopathy.
        Int J Rehabil Res. 1999; 22: 207-214
        • Sabbahi M.
        • Abdulwahab S.
        Cervical root compression monitoring by flexor carpi radialis H-reflex in healthy subjects.
        Spine (Phila Pa 1976). 1999; 24: 137-141
        • Stallard N.
        Optimal sample sizes for phase II clinical trials and pilot studies.
        Stat Med. 2012; 31: 1031-1042
        • Julious S.A.
        Sample size of 12 per group rule of thumb for a pilot study.
        Pharm Stat. 2005; 4: 287-291
        • Hertzog M.A.
        Considerations in determining sample size for pilot studies.
        Res Nurs Health. 2008; 31: 180-191