Dr Damian Muñoz

Dr Damian Muñoz
Curso mínima invasiva south beach

miércoles, 29 de enero de 2014

Kiva® VCF Treatment System Receives FDA Clearance For Vertebral Compression Fractures


Kiva® VCF Treatment System Receives FDA Clearance For Vertebral Compression Fractures 

SANTA CLARA, Calif., Jan. 28, 2014 /PRNewswire/ -- The Kiva® VCF Treatment System by Benvenue Medical, Inc. received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for the reduction and treatment of spinal fractures. The Kiva System is a novel implant-based solution for vertebral augmentation and a departure from balloon kyphoplasty (BKP), making it the first new approach to the treatment of vertebral compression fractures (VCFs) in over a decade. In the clinical studies provided in support of the 510(k) application for market clearance, the Kiva System was shown to meet or exceed the performance of BKP, the current standard of care in treating VCFs.

"Physicians and patients both benefit by having Kiva as a new, minimally invasive treatment option for painful VCFs. I'm excited to have been a part of KAST, an FDA-approved pivotal trial of the Kiva System, and I look forward to presenting the results at the Society for Interventional Radiology meeting in March," said Sean M. Tutton, MD, FSIR, Co-Principal Investigator in the KAST Study (Kiva System as a Vertebral Augmentation Treatment – A Safety and Effectiveness Trial) and Professor of Radiology and Surgery at the Medical College of Wisconsin inMilwaukee. KAST compared Kiva to the Medtronic KyphX® System for balloon kyphoplasty.

VCFs occur when a vertebra (bone in the spine) cracks, fractures or collapses.Over the last 10 years, the approaches to treating VCFs have included conservative therapies or vertebral augmentation, traditionally performed with balloon kyphoplasty or vertebroplasty. The Kiva System features a proprietary, cylindrical implant made from PEEK-OPTIMA®, representing a new approach to vertebral augmentation. The traditional approaches rely solely on a bolus of bone cement.

"We are excited to bring the Kiva System and its clinical benefits to the large and growing population of VCF patients in the US market," said Robert K. Weigle, CEO of Benvenue Medical, Inc. "The VCF segment has little Level I clinical data, and we are proud to have sponsored one of the largest randomized studies in this space to date."

VCFs are most often caused by osteoporosis, and there are 700,000 osteoporosis-related vertebral compression fractures annually in the U.S. alone, representing a large patient population which is only expected to continue growing as the population ages. Other causes of VCFs include trauma and malignant bone tumors that cause the spine to collapse.

About the Kiva VCF Treatment System

The Kiva VCF Treatment System provides a new, implant-based approach to vertebral augmentation in the treatment of painful VCFs. It is indicated for use in the reduction and treatment of spinal fractures in the thoracic and/or lumbar spine from T6-L5. It is intended to be used in combination with the Benvenue Vertebral Augmentation Cement Kit.

The Kiva System features a proprietary flexible implant made from PEEK-OPTIMA®, a biocompatible polymer that is widely used and well accepted as a spinal implant. The Kiva implant is designed to provide structural support to the vertebral body and a reservoir to direct and contain bone cement during vertebral augmentation. The implant is delivered percutaneously over a removable guidewire in a continuous loop into the vertebral body through a small diameter, single incision. The amount of the Kiva implant delivered is physician-customized during the procedure.

The Kiva System received CE Mark in 2008 and it is distributed by Zimmer Spine in Europe.

About Benvenue Medical, Inc.

Founded in 2004, Benvenue Medical, Inc. develops next-generation, minimally invasive expandable implants for the spine. The company is privately held and funded by Versant Ventures, DeNovo Ventures, Domain Associates and Technology Partners. Its first products are designed for the treatment of vertebral compression fractures and degenerative disc disease, which have combined revenues of $1.6 billion globally. For more information, visit www.benvenuemedical.com.

29 Best Travel Tips for Your Aching Back


29 Best Travel Tips for Your Aching Back 

Pain-Free Travel Tips
Has anyone booked travel for spring break? Getting to your destination can be hard on your joints, muscles, and nerves.
Traveling requires us to use our bodies in ways we're not used to, such as hoisting luggage over our heads into the bin and yanking it off the moving baggage claim. It requires us to sit still for long periods, often in a cramped space.
No wonder people with back pain and other types of pain avoid travel whenever possible. To help you have as pleasant a trip as possible, here are a number of things others have tried and found to work well:

Be smart about luggage 

  1. Lift luggage in stages. Move slowly when lifting your luggage and break the action into smaller parts. For example, when lifting a bag into an overhead bin, it can first be lifted to the arm of the seat, then to the top of the seatback, and then into the bin in separate motions.
  2. Never twist while lifting. This is a common cause of injury to the low back. Pivot with your feet so that your whole body moves instead of just twisting your back.
  3. Better yet, avoid lifting. Ask a flight attendant for help. If you explain you have a back condition, you will be surprised how helpful the airline staff will often be. If your bags are small and light, it will be less of a burden to ask someone to help you.
  4. Ship ahead. This is my favorite solution for luggage: just mail your essentials to your destination ahead of time. This way you avoid luggage entirely and can carry just one small bag onboard with you. No schlepping.No hassle. No pain.
  5. Pack light. Use 2 or 3 smaller bags rather than one large, heavy bag, especially if you will have to lift the bags in or out of car trunks, off airport baggage carousels, into and out of overhead bins, etc.
  6. Use a backpack. Do not sling a bag over one shoulder (unless it is a very light handbag). Use a good quality lightweight backpack. Use both straps.The generally recommended maximum weight of a backpack is 10-15% of your body weight and even less if you have a painful back. Using a backpack has the added advantage of leaving your hands free to hold onto handrails on escalators, stairs, the boarding ramp, etc.
  7. Plan ahead for medication 

  8. Get a prescription. If there's any chance you may run out of your medication while you're traveling, get a prescription from your doctor and bring it with you so that you can buy more when required. Remember that in foreign countries the medication that you usually take may have a completely different name.
  9. Keep your medication with you. This may be completely obvious, but it's worth saying anyway. Make sure you keep all your medication with you in flight and do not check it in with luggage. Don't just bring the medication you think you'll need for the flight, as you and your luggage may get separated indefinitely, or your flight could get seriously delayed or be worse than expected.
  10. Bring an OTC backup. As a backup, bring acetaminophen (such as Tylenol) and ibuprofen (such as Advil, Motrin or Nuprin). If your pain medicine runs out, these two can be taken together and have a powerful pain relieving effect. Neither requires a prescription. Of course, check with your doctor before doing this.
  11. Keep medications in their containers. Don't put different medications into the same containers. Keep each type of medication in its prescription bottle.In some situations, you could be detained in security for traveling with pills that aren't in separate labeled containers.
  12. Use easy pain relief tactics 

  13. Ice is key. There are many ways to make sure you have access to ice/cold to numb the lower back when traveling. The simplest is to bring extra Ziploc bags and whenever you need to, ask a flight attendant to fill it with ice for you. Place it between your lower back and the seat. Leave it on for 20 minutes to numb the lower back and repeat as needed. You can also use cold packs that are manually activated. If security will let you, bring a small gel ice pack on the airplane. Flight attendants will keep them in the fridge for you.
  14. Heat helps too. There are disposable, portable hot packs that heat up after you open them, so you can bring them on your travels and open and apply them as needed. Commercial heat wraps, such as ThermaCare, incorporate heating units across the low back area of the band. Such types of heat wraps last for several hours, making them ideal to provide back comfort during lengthy travel. If you want to bring gel heating packs, first check with your airline to see if they're allowed past security.
  15. OTC pain patch. Consider using a non-prescription pain patch, (such as the Bengay Pain Patch). It may reduce your need for pain medications. Of course, check with your doctor before using these patches.
  16. TENS units. For some people, a TENS unit can reduce pain. Get a letter from your physicians or physical therapist explaining your condition and the need for the TENS unit and what it is, as this may be needed to help you through security or to provide information to the flight crew.
  17. Consider muscle relaxants. Consider talking with your doctor about muscle relaxants that you can take before a plane trip. They may be helpful if you have a long plane ride ahead of you.
  18. Actively seek help from the airlines 

  19. Get an aisle seat. Ask for an aisle seat out of medical necessity (stress medical necessity). It is easier to get into and out of an aisle seat, and it allows you to get up and move around the cabin more easily. Since back pain can't be seen, traveling with a letter from your doctor that explains your condition will help you get accommodations such as an aisle seat.
  20. Get wheelchair assistance. Make sure the airline knows you are handicapped so they will wheel you around with a wheelchair. You won't have to carry your bags, walk to the gate, or stand while waiting in line at security. It is best to do this when you make the reservation. You just need to ask for wheelchair assistance to the plane door. Even if it is supposed to be just a short walk to the gate, remember that gates can change, there may be a lot of standing in line when going through security, and other issues may arise that would make a wheelchair worthwhile.
  21. Ask for a row of seats. If the airplane isn't full, when booking see if you can get the last row of seats (which usually no one else wants). Then you can pull up the seat arms and lie down.
  22. Recline. For many back conditions, sitting in a slightly reclined position is least stressful on the back. If this is the case, remember to check that your seat will recline when making your reservation and getting a seat assignment. Some seats in exit rows or at the back of the plane do not allow you to recline.
  23. Stretch key muscles. Sitting for extended periods can cause stiffness and tension in the hamstrings (the muscles in the back of the thighs) and hip flexor muscles, which in turn puts added stress on the low back. Ask your doctor for a few safe hamstring and hip stretches you can do while traveling.
  24. Pre-board. Make sure the gate agent knows you will need to pre-board.Conversely, if sitting for a moment longer than necessary will be unbearable, board last. If you do this, make sure your carry-on can fit beneath your seat, because if you board last the overhead bins might already be full. If you are worried about the overhead bins being full, ask if you can check your carry-on at the gate.
  25. Consider a handicapped parking sticker. If you will be parking at the airport but have trouble walking very far, you can ask your doctor to fill out an application for a handicapped parking permit.
  26. Avoid getting bumped. Due to overbooking, a practice that seems to be common lately, getting a seat assignment in advance can reduce the risk of getting bumped from your flight. If no seat assignment is given when you buy your airline tickets online, call the airline to get a seat assignment immediately. If you arrive at the ticket counter without a seat assignment on an overbooked flight, you probably will get bumped off the flight and be forced to take a later flight, which can be several hours or even one or two days later.
  27. Sit with support 

  28. Fix the seat. Place a small rolled-up airline pillow, blanket, towel, or lumbar pillow between your back and the seat to support the natural inward curve of your lower back. You may also use commercial low back supports if you prefer. Supporting the curve in your low back is especially important with many airplane seats, as they are often worn out and force your lower back to an unnatural, stressful position. If the bottom of the seat is concave from too much use, place a folded blanket on the seat.
  29. Use your feet. Bottom-up leverage from your feet is also required to support your low back. While seated, your knees should be bent at a right angle. If your seat is too high, place your feet on something that can act as a firm footrest, like a book or box, to keep your knees at a right angle and avoid stressing the low back.
  30. General advice 

  31. Bring a letter. Obtain a letter from your physician explaining your condition, medications, and treatment requirements. This can come in handy in many ways: when requesting an aisle seat, wheelchair assistance, getting your medications through security, requiring medical care while traveling, etc.
  32. Drink water. Water circulates healing nutrients and oxygen throughout the body. Drink water frequently to help keep your pain at bay and to keep your body hydrated.
  33. Get up and move. Sitting in one position for extended periods of time stiffens the back muscles, which can put stress on the spine. Get up to stretch and move around every 20 to 30 minutes if possible. Movement stimulates blood flow, and blood brings important nutrients and oxygen to your back, which reduces stiff muscles and helps curb inflammation.Movement also helps prevent blood clots from forming in the leg (called deep vein thrombosis), which is one of the most dangerous risks of sitting still for long periods.
  34. Wear slip-on shoes. Wear high quality, comfortable supportive shoes if you will be walking distances through airports, train stations, etc. Slip-on shoes are easy to slip on and off without having to bend over when going through security.
I also advocate diversions to help keep the pain at bay, especially if traveling will be stressful for you. One option is to treat yourself to something special like a great new book or a movie during the flight. Another option is to do something for someone else (write a letter to an elderly relative or neighbor, write down memories of your children, etc.) to focus your mind elsewhere.
Happy travels!

martes, 28 de enero de 2014

Advierten problemas de postura al usar nuevas tecnologías


Advierten problemas de postura al usar nuevas tecnologías 

11 de Enero, 2014
El jefe del Servicio de Rehabilitación y Medicina Física del Instituto Mexicano del Seguro Social (IMSS) en Jalisco, Jorge Romano Romero, afirmó que hay muchas secuelas a causa de la mala postura al utilizar las modernas herramientas tecnológicas.
Guadalajara, 11 Ene.- El jefe del Servicio de Rehabilitación y Medicina Física del Instituto Mexicano del Seguro Social (IMSS) en Jalisco, Jorge Romano Romero, afirmó que hay muchas secuelas a causa de la mala postura al utilizar las modernas herramientas tecnológicas.

Sugirió a la población usuaria de herramientas tecnológicas no descuidar su higiene de columna y postura al momento de utilizar de forma prolongada artículos, como: computadoras de escritorio o portátiles, celulares y tabletas debido al desgaste que genera mantener una posición "agachada" o encorvada.

Indicó que es importante alinear la silla frente al monitor porque si rotas continuamente el cuello, y en un lapso de una jornada de trabajo, se pueda dar un dolor o si se está agachado se termina con tensión en el cuello o región lumbar.

Aseguró que los problemas por defectos de postura se incrementan cada vez más, por lo que no se recomienda estar en una misma postura por más de dos horas de forma continua.

"Lo ideal es hacer pausas para cambiarse de posición o realizar algún estiramiento de extremidades o movimientos de cuello antes de retomar la actividad que se estaba llevando a cabo", explicó el especialista del Seguro Social.

Estos malos hábitos pueden agudizar dolor y tensión en articulaciones y músculos en personas mayores de 40 años quienes ya tienen un desgaste previo asociado al proceso natural de envejecimiento, indicó el experto.

En tanto, dijo, que en adolescentes y jóvenes en proceso de crecimiento y desarrollo, las malas posturas pueden ocasionar deformidades como las llamadas sifosis o jorobas, caracterizadas por curvaturas dorsales.

"Cada vez lo vemos más frecuente en los jóvenes, los ves menos erguidos, más encorvados porque pasan mucho tiempo en esa posición como agachada, aunado a que ahora los chicos son personas más sedentarias que los jóvenes de antes por los videojuegos y las computadoras", advirtió Romano Romero.

Al utilizar una computadora, o fijar la vista en las llamadas tablets o teléfonos inteligentes, se debe estar sentado cómodamente en una silla colocando la pelvis y la espalda alta y baja pegadas al respaldo de la misma.

Además de que el monitor debe estar más o menos a la altura de los hombros de la persona, dependiendo su estatura para evitar tenga que flexionarse, el elemento debe quedar frente a la persona dado que no debe rotar su cuello constantemente.

Reiteró que los defectos posturales son frecuentes en la población en general y "casi todos vamos a presentar sus efectos ya sea en columna, cadera, rodillas o pies".

Indicó que desde los cuatro años de edad, se debe vigilar la postura del niño y su forma de caminar y constantemente evaluarlo en este sentido, además de descartar que no tenga una alineación incorrecta de sus piernas o acortamiento, entre otros aspectos.

Expuso que en los adultos los defectos posturales prácticamente son irreversibles, pero se puede evitar su progresión adoptando medidas de higiene de columna, realizando ejercicios de rehabilitación física así como complementarios como algunos tipos de natación.

Exhortó a la población derechohabiente asistir al taller de Higiene de Columna que se imparte en el servicio de Rehabilitación Física del Hospital de Especialidades todos los viernes a las 9:00 horas.


What sign does this spinal tumour demonstrate? Likely diagnosis?

domingo, 26 de enero de 2014

Enfermedad de Dupuytren: cirugía de la mano en un pianista profesional

Enfermedad de Dupuytren: cirugía de la mano en un pianista profesional

jueves, 23 de enero de 2014


Cervical Radiculopathy


Cervical Radiculopathy 


Basic Picture of a Cervical Vertebral Body
Basic Picture of a Cervical Vertebral Body
"Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs. This impingement typically produces neck and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities."[1]
Cervical radiculopathy occurs with pathologies that causes symptoms on the nerve roots. [2] Those can be compression , irritation, traction, and a lesion on the nerve root caused by either a herniated disc , foraminal narrowing or degenerative spondylitic change  (Osteoarthritic changed or degeneration) leading to stenosis of the intervertebral foramen[2] [3].
Most of the time cervical radiculopathy appears unilaterally, however it is possible for bilateral symptoms to be present if severe bony spurs are present at one level, impinging/irritating the nerve root on both sides. If peripheral radiation of pain, weakness or pins and needle are present, the location of the pain will follow back to the concerned afected nerve root [2].

Clinically Relevant Anatomy 

Cervical radiculopathy is defined as a disorder affecting a spinal nerve root in the Cervical Spine, therefore a knowledge of the brachial plexus is crucial to understanding the impact of nerve root impingement or damge has on the body.
Anatomical illustration of the brachial plexus with areas of roots, trunks, divisions and cords marked.
Anatomical illustration of the brachial plexus with areas of roots, trunks, divisions and cords marked.
Having an understanding of anatomy is key to effective physiotherapy practice, putting this anatomy into a functional sense is even more crucial for treatment considerations and movement analysis. In the cervical spine 50% of cervical rotation occurs at the C1-2 joints (AtlantoAxial Joint) and 50% of flexion and extension occurs at the Occipitoatlanto joint. Another important consideration is that the cervical facet joints are at a 45° meaning that below C2 sideflexion is coupled with rotation to the same side[6]. This is an example of when anatomical knowledge is crucial to understand movement. With this in mind you will now be able to tell is a cervical radiculopathy patient has a stiff neck or movement dysfunction if more than 50% of flexion occurs lower than C0-1 and can help to open up the fact joints.
We have 8 cervical nerve roots, for 7 cervical vertebrae and this may seem confusing at first. However a nerve root comes out of the spinal column between C7 and T1, hence the name C8 as T1 already exists [2].
Nerve roots and the local vessels lack a perineurium and have a poorly developed epineurium, making them vulnerable to mechanical injury when compared to the periphery. The blood supply is also less secured and vulnerable to ischemic damage[7]. These anatomical difference to peripheral nerves may explain why low pressures on the nerve root elicit large changes and S+S. The nerve roots are vulnerable to pressure damage which is why small impingements can cause S+S. At 5-10mmHg (0.1psi) capilliary stasis and ischemia has been observed with partial blockage of axonal transport. At 50mmhg tissue permeability increases with an influx of oedema, higher to 75mmhg, there is nerve conduction failure if sustained for 2 hours. At 70+mmhg neural ischemia is complete and conduction is not possible[7]. It is rare to get pressures that high but 5-10mmhg is a large small amount of pressure and S+S occur[7]. These pressures can occur with a less severe clinical picture in unique circumstances, if the pressure is acute then the symptoms are severe however if chronic the nervous tissue is given time to adapt and evolve to the surrounding structure and have less severe symptoms.  

Epidemiology / Etiology 

Simply defined cervical radiculopathy is a dysfunction of a nerve root in the cervical spine, as this is such a broad disorder with several mechanisms of pathology people of any age can be affected[8], with peak prominence between the ages of 40-50[2][9][10] with a reported prevelance of 83 people per 100,000 people[10]
The two main mechanisms of the nerve root irritation or impingement are:
  1. Spondylosis leading to stenosis or bony spurs - More common in older patients
  2. Disc Herniation - More common in younger patients
This rule is not correct 100% of the time but it is a good basis to go on for a logical reason: As you age, disc height decreases and there is less material within the intervertebral disc itself making a prolapse less likely and making it harder for a prolapse to impinge a nerve root.
Just think: There is more material to prolapse from a disc of a younger person!
Of all of the potential nerve roots to be impinged upon the C7 (46.3%) and C6 (16.7%) roots are most commonly affected, the potential explanation for this is that the foramina are largest in the upper cervical region and progressively decrease in size as you descend making nerves more susceptable[11]. The order of most commonly affected nerve roots goes:
                                                 C7 (46%) --> C6 (18%) --> C5 (6%) --> C8 (6%)[12]

Clinical Presentation 

Typical Dermatomal Pattern of the Upper Limb
Typical Dermatomal Pattern of the Upper Limb
To understand the clinical presentation of cervical radiculopathy you must have a functional understanding of the clinically relevant anatomy section.
Typical symptoms of cervical radiculopathy are: irradiating arm pain corresponding a dermatomal patternneck painparasthesiamuscle weakness in a myotomal patternreflex impairment/lossheadaches,scapular painsensory and motor dysfunction in upper extremities and neck[2][8][3][13][14].
 At the most basic level these are the upper limb movements that are affected in the myotomal pattern.
  • C1/C2- Neck flexion/extension
  • C3- Neck lateral flexion
  • C4- Shoulder elevation
  • C5- Shoulder abduction
  • C6- Elbow flexion/wrist extension
  • C7- Elbow extension/wrist flexion
  • C8- Thumb extension
  • T1- Finger abduction
For more detailed information on the exact muscles or dermatomes that will clinically present themselves go here:
If a nerve root is compressed it can cause a combination of factors: inflammatory mediators, changes in vascular response and intraneural oedema which causes radicular pain. Absence of radiating pain does not exclude nerve root compression. The same appears with sensory and motor dysfunction that might be present without significant pain[2].
Symptoms are generally amplified with side flexion towards the side of pain and when an extension or rotation of the neck takes place because these movements reduce the space available for the nerve root to exit the foramen causing impingement[2]. This often causes the patient to present with a stiff neck and a decrease in cervical spine range of motion (ROM) as movement may activate their symptoms. This in turn results in secondary musculoskeletal problems which can manifest as a decrease in muscle length of the cervical spine musculature (upper fibres of trapezius, scaleni, levator scapulae), weakness, joint stiffness, capsule tightness and postural defects which can go on to affect movement mechanisms of the rest of the body.
It is possible that when you are assessing a patient it may not be easy to 'bring on' the radiating arm pain, if this is the case try not to rule out radiculopathy, just try and get more information about the movements, positions or functional tasks which bring on the pain and replicate them. Reproducing the S+S is a very useful tool in aiding diagnosis. Equally do not be alarmed if you cannot replicate the S+S in the assessment, give the patient exercises to do at home along with postural advice and continue to perform the activities which usually bring on the radiating arm symptoms and see if there is a change.

Diagnostic Procedures 

In a non-Physiotherapy sense, the most common diagnostic methods used to assess the presence of possible compression are imaging studies (radiograph and MRI) and electrophysiologic studies (EMG  + Nerve Conduction Studies ) to examine the nerve root and nerve conduction velocity[15][2][8]. If either of these options have been performed on your patient then it is possible to assess and see if radiculopathy is present through commonly used Physiotherapy assessment and treatment starting with the Subjective Assessment .

Subjective Assessment 

The HPC and Mechanism of Injury (Patient History ) sections of a subjective assessment can be integral to diagnosis and the cause of the radiating arm pain.More frequently acute radiating arm pain is caused by a disk herniation, while chronic bilateral axial neck and radiating arm pain is usually caused by cervical spondylosis[2].

Physiotherapy Special Tests 

In 2003, Dr. Robert Wainner and colleagues examined the accuracy of the clinical examination and developed a clinical prediction rule to aid in the diagnosis of cervical radiculopathy.  Their research demonstrated that these 4 clinical tests, when combined, hold high diagnostic accuracy compared to EMG studies:  Positive tests for Spurlings Test Upper limb tension-1 Distraction test and  Cervical Flexion Rotation Test . When all 4 of these clinical features are present, the post-test probablity of cervical radiculopathy is 90%, if only three of the four test are positive the probability decrease to 65%[16] [3][8][17].Another combination of tests, with good reliability are the combination of the Spurlings Test , Neck Distraction, Valsalva and Upper Limb Tension Tests 1,2a and 2b[18].

Differential Diagnosis 

Due to the close proximity of the cervical spine vertebrae and nerve roots to the vertebral arteries it is crucial that during the initial assessment of a patient any conditions which can cause severe damage to the patients blood supply, especially during any manual therapy. It is also important to be aware of other pathologies which mimic the S+S of radiculopathy[19].
  • Spinal Tumor
  • Systemic diseases known to cause peripheral neuropathies
  • Cervical myelopathy
  • Ligamentous Instability
  • Vertebral Artery Insufficiency (VBI)
  • Herniated nucleous pulposos (HNP)
  • Shoulder Pathology
  • Peripheral nerve disorders
  • Thoracic outlet syndrome
  • Brachial plexus pathology
  • Systemic disease
  • Parsonage-Turner syndrome

Outcome Measures 

Outcome measures are an essential tool to assess whether or not you are having a positive. negative or static effect on a patients' condition. Cervical Radiculopathy is no different. There are a lot of outcome measures in existance and it is important to know if the tool you are using is measuring what you want to measure (Specificity ) and how good it is correctly identifying a pattern (Sensitivity )[20].

Management and Treatment Approaches 

Medical Management  

There are several intervention strategies for managing cervical radiculopathy with physical therapy and surgical interventions being the most common.  Long-term benefits of surgical interventions are questionable with reported numbers of 25% of people continuing to experience pain and disability at 12 month follow-ups[21].  There is a significant amount of evidence available to support the use of physical therapy interventions for patients with cervical radiculopathy, and the benefit of physical therapy and manual techniques in general for patients with neck pain with or without radicular symptoms (see key evidence for a list of references).
The nonoperative treatment includes a period (+/- one week, not more) of immobilisation with a cervical collar to decrease the compression on the nerve root; cervical traction; medication to reduce the pain; physical therapy and manipulation including massage, stretching, exercices to improve range of motion and eventually ice, heat and electrical stimulation. They must be used together and not separately to show improvement. But all these elements of the treatment need further studies to prove more effectiveness. [2]

Physiotherapy Management  

Although a definitive treatment progression for treating cervical radiculopathy has not been developed, a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as active range of movement (AROM), focussing on decreasing levels of pain and disability will most likely be the main focus of the patient[22].
If the patient has had long-term pain, an element of pain sensitisation may have developed and chronic pain behaves differently to acute pain. Therefore education about pain and reconceptualisation may be neccessary. 
Treatment Options:
  • Education and Advice
  • Manual Therapy - PAIVMS/PIVMS/NAGS/SNAGS
  • Exercise Therapy - AROM, Stretches and Strengthening
  • Postural Re-Education

Education and advice 

Education is key to getting the patient on your side and to work co-operatively with Physiotherapy. If a patient understands why they are having the neck pain which is causing them to have arm pain then they will more likely want to take part in rehabilitation. If they do not understand what the point in this 'exercise' or this 'pressing' then they will likely think it to be a waste of time. This is a generalisation of course but it is often accurate. 
An important piece of advice to rehabilitation from a prolapsed disc, is that smoking can increase the pressure on the disc causing further damage and impingement, therefore this should not be overlooked[7]. Additionally it is always good to bring up the topic of smoking cessation with patients for their all round health, tying in with Holistic Management.

Manual Therapy 

In a recent systematic review by Boyles et al in 2011[23], manual therapy was shown to be effective at reducing pain levels, improving function and increasing joint ROM. When combined with exercise therapy it was more effective than the control group of manual therapy or exercise therapy however both control groups were effective at reducing signs and symptoms[24].
The manual therapy techniques proven to be effective by the systematic review were:
  • Thrust mobilisations of the cervical or thoracic spine
  • Cervical mobilisations - A-P/P-A/Lateral Glides/Rotations/Retractions
The parameters were recorded in a study by Ragonese et al[24]; performing one set of 30 seconds or 15-20 repetitions at each desired level of the cervical spine at grade 3 or 4[25](Mobilisations ). Others stated that it was down to the practitioners discgression.
  • Muscle Energy Techniques 
Cleland et al[26] utilised muscle energy techniques in 28 patients, 46% recieving positive outcomes, however details of the techniques used were insufficient and a variety of techniques were used as it was down to the practitioner to decide which technique would be used.
  • Neurodynamics - Gliding and Sliding/Tensioning
Another study[24] performed the neurodynamics  sliding and tensioning techniques, outlined by Butler[27], whilst having the patient in an upper limb tension positions described by Magee[28], again having positive outcomes in regards to pain and function.
Overall a study by Persson et al[29] highlighted that there was no significant difference between outcome measures of patients who had had surgery, physiotherapy or cervical collar explaining that physiotherapy is at least as effective as surgery.
When performing manual therapy on the neck it is important to to be aware of any potential risk factors such as arterial insufficiency, Hypertension, Craniovertbral ligament insufficiency and upper motor neurone disorders[30].

Exercise Therapy 

Exercises targeted at opening the intervertebral foramen are the best choice for reducing the impact of radiculopathy. Exercises such as contralateral rotation and sideflexion are amongst the simplest forms of exercises which are effective against signs and symptons, given in the form of active ROM[31]. Due to the intricate and close relationship of muscles on the intervertebral foramen and the likely presentation of reduced ROM, stretching is also an effective form of treatment to regain ROM[32].
Once ROM increases strengthening can also be utilised to create new stability and reduce the risk of developing nerve root irritation in the future, as long as it is not caused by a structure which cannot be influenece by physiotherapy. During the initial stages of treatment, strengthening should be limited to isometric exercises in the involved upper limb. Once the radicular symptoms have been resolved, progressive isotonic strengthening can begin.This should initially stress low weight and high repetitions (15-20 repetitions).Closed kinetic chain activities can be very helpful in rehabilitating weak shoulder girdle muscles. However, a multicenter randomized controlled trial found no significant difference with the addition of specific neck stabilization exercises to a program of general neck advice and exercise[32][33]


Regarding physical therapy interventions, in 2007 Joshua Cleland and colleagues examined the predictors of positive short-term outcomes in people with a clinical diagnosis of cervical radiculopathy.  The following clinical features were found to be most predictive of a positive short-term outcome:
  • Age <54
  • Dominant arm not affected
  • Looking down does not worsen symptoms
  • Treatment involves manual therapy, cervical traction, and deep neck flexor strengthening for at least 50% of visits
If 3 of these features are present, the probability of success is 85%, and increases to 90% if all 4 are present[34]

Key Evidence 

The following are key evidence pieces for physical therapy interventions as they relate to both cervical radiculopathy and neck pain in general:
  • Manual therapy compared to 'usual' physical therapy and general practitioner care[35]
  • Clinical Practice Guidelines[36]
  • Classification System for Neck Pain[37]
  • Proposal of Treatment-Based Classification System[38]
  • Prognostic factors for neck pain in the general population[39]
  • Immediate effects of thoracic manipulation for patients with neck pain[40]
  • Clinical prediction rule for thoracic manipulation in patients with neck pain[41]

Recent Related Research (from Pubmed  )


  1.  Eubanks J. Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. Am Fam Physician. 2010 Jan 1;81(1):33-40.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Eubanks, JD.Cervical Radiculopathy:Nonoperative Management of Neck Pain and Radicular Symptoms.American Family Physician 2010;81,33-40
  3. ↑ 3.0 3.1 3.2 Kenneth A. Olson. Manual physical therapy of the spine.Saunders Elsevier 2009.p 253, 257, 258
  4.  Marc J. Levine, Todd J. Albert, Michael D. Smith.Cervical Radiculopathy: Diagnosis and Nonoperative Management.Journal of the American Academy of Orthopaedic Surgeons 1996;4:305-316
  5.  Ellenberg M, Honet J, Treanor W. Cervical Radiculopathy. Arch Phys Med Rehabil. 1994; 75:342-352.
  6.  Radhaknshnank et al. Epidemiology of Cervical Radiculopathy. A Population Based Study. Brain. 1994: 117; 325-335
  7. ↑ 7.0 7.1 7.2 7.3 Lipetz JS. Pathophysiology of Inflammatory, Degenerative, and Compressive Radiculopathies. Phys Med Rehabil Clin N Am. 2002;13:439-449
  8. ↑ 8.0 8.1 8.2 8.3 Young IA,Michener LA,Cleland JA,Aguilera AJ,Snyder AR.Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomize clinical trial.Physical Therapy 2009;89:632-642 (B)
  9.  Radhakrishnan K, Litchy WJ, O'Fallon M, et al. Epidemiology of cervical radiculopathy: A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994; 117:325-335.
  10. ↑ 10.0 10.1 Bogduk N. Twomey CT. Clinically Relevant Anatomy for the Lumbar Spine. 2ed. Edinburgh UK: Churchill Livingston. 1991
  11.  Anatomy Zone. Brachial Plexus - Branches - 3D Anatomy Tutorial. Available from:http://www.youtube.com/watch?v=VdiFNYdIo1ofeature=c4-overview-list=PLmGQgRI4QyEDCSPyYurmzj_zatY5BWz_r
  12.  Ellenberg MR. Horet JC. Treanor WS. Cervical Radiculopathy. Arch Phys Med Rehabil. 1994;75(3):342-352
  13.  Kenneth W. Lindsay, Ian Bone.Neurology and neurosurgery illustrated.4th ed. Churchill Livingstone.p408
  14.  Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M.Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy : randomised trial.BMJ 2009;p1-7
  15.  Partanen J, Partanen K, Oikarinen H, et al. Preoperative electroneuromyography and myelography in cervical root compression.Electromyogr Clin Neurophysiol. 1991; 31:21-26.
  16.  Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52-62.
  17.  C: Wainner et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.Spine 2003 Jan 1. 28(1):52-62.
  18.  A1: Sidney M. Rubinstein et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. European Spine Journal. Volume 16, Number 3, 307-319
  19.  C: R. Erhard et al. Cervical Radiculopathy or Parsonage-Turner Syndrome: Differential Diagnosis of a Patient With Neck and Upper Extremity Symptoms. JOSPT. OCTOBER 2005fckLRVolume 35, No. 10
  20.  Lalkhen A. McCluskey A. Clinical tests: sensitivity and specificity. Contin Educ Anaesth Crit Care Pain (2008) 8 (6): 221-223.
  21.  Heckmann J, Lang J, Zobelein I, et al. Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.
  22.  Boyles, Robert; Toy, Patrick; Mellon, James; Hayes, Margaret; Hammer, Bradley.Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review Journal of Manual &amp; Manipulative Therapy 19 (2011) 135-142.
  23.  Boyles R. Toy P. Mellon J. Hayes M.Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy a systematic review. Journal of Manipulative therapy. 19 (3) 2011
  24. ↑ 24.0 24.1 24.2 Ragonese J. A randomized trial comparing manual physical therapy to therapeutic exercises, to a combination of therapies,for the treatment of cervical radiculopathy. Orthop Prac 2009;21(3):71–7.
  25.  Maitland G. Vertebral manipulation. Oxford: Butterworths;fckLR1986
  26.  Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Ortho Sports Phys Ther 2005;35:802–11.
  27.  Butler, 0 (1991). Mobilisation of the Nervous System, Churchill Livingstone, Edinburgh
  28.  Magee DJ. Orthopedic physical assessment. 5th ed. St. Louis,MO: Saunders Elsevier; 2008.
  29.  Persson LC, Carlsson CA, Carlsson JY. Long lasting cervicalradicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine 1997;22(7):751–8
  30.  Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International Framework for Examination of the Cervical Region http://www.physio-pedia.com/Section_5:_Physical_examination
  31.  Langevin P. Rou JS. Desmeules F. Cervical radiculopathy: Study protocol of a randomised clinical trial evaluating the effect of mobilisations and exercises targeting the opening of intervertebral foramen. BMC Msk Disorders.13:10 2012.
  32. ↑ 32.0 32.1 Malanga G. Sherwin SW.Cervical Radiculopathy Treatment &amp;amp;amp;amp;amp;amp;amp;amp; Management 2013 [ONLINE]fckLRAvailable fromhttp://emedicine.medscape.com/article/94118-treatment#aw2aab6b6b2
  33.  Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. Feb 2009;36(2):390-7
  34.  Cleland JA, Fritz JM, Whitman JM, et al. Predictors of short-term outcomes in people with a clinical diagnosis of cervical radiculopathy. Phys Ther. 2007;87(12):1619-1632.
  35.  Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Ann Intern Med. 2002;136(10):713-722.
  36.  Childs JD, Cleland JA, Elliott JM, et al. Neck Pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Assoction. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.
  37.  Childs JD, Fritz JM, Piva SR, et al. Proposal of a Classification System for Patients with Neck Pain. J Orthop Sports Phys Ther. 2004;34(11):686-700.
  38.  Fritz JM &amp; Brennan GP. Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Phys Ther. 2007;87(5):513-524.
  39.  Carroll LJ, Hogg-Johnson S, van der Velde G, et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4S):S75-S82.
  40.  Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10:127-135.
  41.  Cleland JA, Childs JD, Fritz JM, et al. Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients with Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education. Phys Ther. 2007;87(1):9-23.