Manual Therapy as a Management of Cervical Radiculopathy: A Systematic Review.

BACKGROUND: Cervical radiculopathy is defined as a disorder involving dysfunction of the cervical nerve roots characterised by pain radiating and/or loss of motor and sensory function towards the root affected. There is no consensus on a good definition of the term. In addition, the evidence regarding the effectiveness of manual therapy in radiculopathy is contradictory. OBJECTIVE: To assess the effectiveness of manual therapy in improving pain, functional capacity, and range of motion in treating cervical radiculopathy with and without confirmation of altered nerve conduction. METHODS: Systematic review of randomised clinical trials on cervical radiculopathy and manual therapy, in PubMed, Web of Science, Scopus, PEDro, and Cochrane Library Plus databases. The PRISMA checklist was followed. Methodological quality was evaluated using the PEDro scale and RoB 2.0. tool. RESULTS: 17 clinical trials published in the past 10 years were selected. Manual therapy was effective in the treatment of symptoms related to cervical radiculopathy in all studies, regardless of the type of technique and dose applied. CONCLUSIONS: This systematic review did not establish which manual therapy techniques are the most effective for cervical radiculopathy with electrophysiological confirmation of altered nerve conduction. Without this confirmation, the application of manual therapy, regardless of the protocol applied and the manual therapy technique selected, appears to be effective in reducing chronic cervical pain and decreasing the index of cervical disability in cervical radiculopathy in the short term. However, it would be necessary to agree on a definition and diagnostic criteria of radiculopathy, as well as the definition and standardisation of manual techniques, to analyse the effectiveness of manual therapy in cervical radiculopathy in depth.

Clinical Efficacy and Safety of "Three-Dimensional Balanced Manipulation" in the Treatment of Cervical Spondylotic Radiculopathy by Finite Element Analysis.

Cervical spondylotic radiculopathy (CSR) is the most commonly encountered cervical spine disorder. Cervical manipulation has been demonstrated as an effective therapy for patients. However, the mechanisms of manipulations have not been elucidated. A total of 120 cervical spondylotic radiculopathy patients were divided into the "three-dimensional balanced manipulation" treatment group (TBM group) and control group randomly. The control group was treated with traditional massage; the TBM treatment group was treated with "three-dimensional balanced manipulation" based on traditional massage. The symptoms and clinical efficacy of the patients were compared before and after treatment for one month. A three-dimensional finite element model was established. The mechanical parameters were imported to simulate TBM, and finite element analysis was performed. The results showed that the total effective rate was significantly higher in the TBM group compared with the control group. The biomechanical analysis showed the vertebral body stress was mainly distributed in the C3/4 spinous processes; the deformation mainly concentrated in the anterior processes of the C3 vertebral body. The intervertebral disc stress in the C3~C7 segment was mainly distributed in the anterior part of the C3/4 intervertebral disc, and the deformation extends to the posterior part of the C3/4 nucleus pulposus. In summary, these data are suggesting that TBM was effective in CSR treatment. The results of the finite element model and biomechanical analysis provide an important foundation for effectively avoiding iatrogenic injuries and improving the effect of TBM in the treatment of CSR patients.

Acupotomy combined with massage for cervical spondylotic radiculopathy: A protocol for systematic review and meta-analysis.

BACKGROUND: Cervical spondylotic radiculopathy (CSR) is a clinical syndrome of radial neck and shoulder pain. Both Massage and Acupotomy have been widely used in the treatment of CSR, in China and achieved satisfied efficacy. Therefore, the aim of this study is to systematically evaluate the clinical efficacy of acupotomy combined with massage in the treatment of CSR. METHODS: The following electronic databases will be searched: PubMed, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library, Embase, SinoMed, Clinical Trials. gov, the China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database. Two review authors independently search databases from their respective inception dates to September 2019 to identify potentially eligible studies. Cochrane Handbook 5.1 risk of bias assessment tool will be used to evaluate the methodological quality of the included studies. The Review Manager 5.3 will be used for all statistical analysis of the final included study. RESULTS: The results of this systematic review and meta-analysis will provide a synthesis of existing evidences for the treatment of acupotomy combined with massage on CSR, especially in improving visual analog scale and symptom score. CONCLUSION: This study will summarize the current evidence of acupotomy combined with massage for the treatment of CSR. This study can further guide the promotion and clinical decisions. ETHICS AND DISSEMINATION: Ethical approval and patient consent are not required because this study is a literature-based study. This systematic review and meta-analysis will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020171825.

Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: A randomized controlled trial.

BACKGROUND: Exercise programs in the treatment of chronic lumbar pain are quite diverse, but it has been proven that stabilization exercises are the most effective. OBJECTIVE: We compared the lumbar stabilization exercise program in a closed and open kinetic chain (LSCO) and lumbar stabilization exercises and thoracic mobilization program in a closed kinetic chain (LSTMC), and evaluated the clinical effectiveness of each program. METHODS: Prospective, randomized, controlled trial in 80 chronic low back pain (CLBP) patients with lumbar radiculopathy of both sexes (35 male, 45 female), average age (48.45 ± 10.22 years), divided in two groups that performed different sets of exercises. Participants were given laser therapy, transcutaneous electro-nerve stimulation and an eight-week kinesiotherapy that included exercises to strengthen the deep lumbar spine stabilizers. Retesting was done after four and eight weeks. RESULTS: Statistically significant (p< 0.05) superior recovery of the LSTMC group subjects compared to the LSCO group was achieved at all measurement intervals in the pain intensity and functional disability parameters. CONCLUSION: Patients who performed the lumbar stabilization and thoracic mobilization exercise program in a closed kinetic chain had the most effective reduction of pain intensity and functional disability.

Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial.

BACKGROUND: Cervical radiculopathy is a relatively common musculoskeletal disorder resulting in a significant social and occupational impact. Manual therapy is thought to provide relief in cervical radiculopathy; however, evidence is lacking regarding the comparison of different manual therapy concepts. OBJECTIVE: To determine the effects of Maitland's oscillatory mobilization as compared to Kaltenborn's sustained stretch mobilization in the management of cervical radiculopathy. METHODS: A randomized controlled trial was conducted at Fauji Foundation Hospital comprising of 46 patients randomized into oscillatory and sustained stretch mobilization groups. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI) and cervical range of motion (ROM) were used as outcome variables. RESULTS: No significant differences were observed at base line between the two groups (P> 0.05) except for ROM in extension and left side bending (P< 0.05). In terms of pre and post treatment comparison, P value of less than 0.05 was observed for both groups, indicating both treatments to be effective in isolation. However, post treatment comparison between both groups showed oscillatory mobilization to be superior to sustained stretch mobilization (P< 0.05) in the management of cervical radiculopathy except for the outcomes of pain and side bending. CONCLUSION: Both oscillatory and sustained stretch mobilization techniques are found to be effective in the management of cervical radiculopathy in terms of pain, range and disability. However, oscillatory mobilization is found to be superior in terms of functional ability and range of motion.

Effect of Mulligan spinal mobilization with arm movement along with neurodynamics and manual traction in cervical radiculopathy patients: A randomized controlled trial.

OBJECTIVE: To determine the effect of Mulligan Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction on pain, disablity and cervical range of motion in cervical radiculopathy patients. METHODS: The randomised controlled trial (RCT) was conducted from August to December 2017 at the Railway General Hospital, Rawalpindi, Pakistan, and comprised cervical radiculopathy patients of either gender aged 20-60 years. They were randomised into two groups, with the experimental Group A getting treated with Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction, while the control group B only getting treated with neurodynamics and manual traction. The pain, disability and cervical range of motion were assessed before and after treatment of 3 weeks using Numeric Pain Rating Scale, Neck Disability Index and Goniometry. Data was analyzed using SPSS 21. RESULTS: Of the 31 patients, 19(61.3%) were females and 12(38.7%) were males. The overall mean age was 41.65±9.714 years. There were 15(48.4%) patients in Group A, and 16(51.6%) in Group B. Group A showed significantly better results in terms of pain, disability and cervical range of motion (p<0.05 each). CONCLUSIONS: Patients treated with Spinal Mobilisation with Arm Movement along with neurodynamics and manual traction had better outcome compared to those who only got neurodynamics and manual traction.

Cost-Effectiveness of Jingshu Granules Compared to Placebo for the Treatment of Patients with Cervical Radiculopathy in China: A Decision-Tree Model Based on Randomized Controlled Trial.

Objective: Traditional Chinese Medicines (TCMs), as well as physiotherapy and chemical drugs, are recommended for the treatment of cervical spondylosis by Chinese guidelines for cervical spondylosis diagnosis and treatment. The aim of this study was to evaluate whether TCM Jingshu Granules are cost-effective in patients with cervical radiculopathy in China. Methods: A multicenter, double-blinded, randomized placebo-controlled trial was performed. A total of 480 patients were recruited from 14 tertiary hospitals in China and were randomly divided into an experimental group (Jingshu Granules) or control group (placebo) at a 3:1 ratio. All patients received 4 weeks of treatment. Clinical outcomes and cost data were collected during the trial, including the neck disability index (NDI), visual analog scale (VAS) of pain, VAS of numbness, 36-Item Short Form Health Survey (SF-36) score, willingness to pay (WTP) for VAS of pain, direct medical costs, and transport costs. From a social perspective, a decision-tree model and cost-effectiveness analysis were conducted. Results: The treatment group has a significant advantage in reducing NDI (9.41 ± 10.51 vs. 4.83 ± 8.43, p < 0.05), VAS of pain (22.72 ± 15.08 vs. 12.86 ± 13.45, p < 0.05), and VAS of numbness (16.96 ± 17.53 vs. 11.64 ± 16.54, p < 0.05), respectively, while there was no significant difference in the improvement of quality of life (QoL; SF-36 score, p > 0.05). The expected mean cost of the experimental group was 1144.34 yuan, and the effective rates were 57.9% for NDI and 72.9% for VAS of pain. The expected mean cost of the control group was 767.41 yuan, and the effective rates were 33.3% for NDI and 51.6% for VAS of pain. For the primary indicators (VAS of pain and NDI), the incremental cost-effectiveness ratio was 17.69 and 15.32, respectively. The WTP per efficacy for pain resolution of patients was 19.10 yuan. Setting the WTP as threshold, Jingshu Granules were found to be a cost-effectiveness strategy, and sensitivity analysis showed that the effective rates and inspection fees of both groups had a greater impact on the results of both groups. Conclusions: Jingshu Granules were shown to be effective for treating patients with cervical radiculopathy. This treatment was found to be cost-effective when considering VAS of pain and NDI as clinical outcome indicators compared to no treatment (placebo). A clinical study with longer duration or real world study is needed to determine the impact on QoL of patients in the future.

Change in Low Back Movement Patterns After Neurosurgical Intervention for Lumbar Spondylosis.

OBJECTIVES: The purpose of this study was to assess the use of computer-aided combined movement examination (CME) to measure change in low back movement after neurosurgical intervention for lumbar spondylosis and to use a CME normal reference range (NRR) to compare and contrast movement patterns identified from lumbar disk disease, disk protrusion, and nerve root compression cases. METHODS: A test-retest, cohort observational study was conducted. Computer-aided CME was used to record lumbar range of motion in 18 patients, along with pain, stiffness, disability, and health self-report questionnaires. A minimal clinically important difference of 30% was used to interpret meaningful change in self-reports. z Scores were used to compare CME. Post hoc observation included subgrouping cases into 3 discrete pathologic conditions-disk disease, disk protrusion, and nerve root compression-to report intergroup differences in CME. RESULTS: Self-report data indicated that 11, 7, and 10 patients improved by ≥30% in pain, stiffness, and function, respectively. Three patients experienced clinically significant improvement in health survey. A CME pattern reduced in all directions suggested disk disease. Unilaterally restricted movement in side-flexed or extended directions suggested posterolateral disk protrusion with or without ipsilateral nerve root compression. Bilateral restrictions in extension suggested posterior disk protrusion with or without nerve root compression. In 11 of the 18 cases, CME converged toward the NRR after surgery. CONCLUSION: We described the use of CME to identify atypical lumbar movement relative to an NRR. Data from this short-term postoperative study provide preliminary evidence for CME movement patterns suggestive of disk disease, disk protrusion, and nerve root compression.

Low-Concentration Oxygen/Ozone Treatment Attenuated Radiculitis and Mechanical Allodynia via PDE2A-cAMP/cGMP-NF-κB/p65 Signaling in Chronic Radiculitis Rats.

Background: Oxygen/ozone therapy is a minimally invasive technique for the treatment of radiculitis from lumbar disc herniation. This study aimed at investigating whether intrathecal administration of low-concentration oxygen/ozone could attenuate chronic radiculitis and mechanical allodynia after noncompressive lumbar disc herniation and at elucidating the underlying mechanisms. Methods: First, we transplanted autologous nucleus pulposus into dorsal root ganglions to establish chronic radiculitis in rats. Then, filtered oxygen or oxygen/ozone (10, 20, or 30 µg/mL) was intrathecally injected on day 1 after surgery. The ipsilateral paw withdrawal thresholds (PWTs) to mechanical stimuli were tested daily with von Frey filaments. The expression of the tumor necrosis factor- (TNF-) α, interleukin- (IL-) 1ß, IL-6, cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), phosphodiesterase 2A (PDE2A), and nuclear factor- (NF-) κB/p65 in spinal dorsal horns was measured by enzyme-linked immunosorbent assay, polymerase chain reaction, and western blot on day 7 after surgery. Results: Chronic radiculitis was established in rats. Intrathecal administration of 10 µg/mL, 20 µg/mL, or 30 µg/mL oxygen/ozone significantly attenuated the decreased mechanical PWTs, downregulated the overexpression of spinal TNF-α, IL-1ß, and IL-6, and increased the expression of cGMP and cAMP in chronic radiculitis rats. In addition, the effects of treatment with 20 µg/mL oxygen/ozone were greater than the effects of the 10 µg/mL or 30 µg/mL doses. Moreover, intrathecal administration of 20 µg/mL oxygen/ozone reversed the increased levels of spinal PDE2A and NF-κB/p65 mRNA and protein expressions in rats with chronic radiculitis. Conclusion: Intrathecal administration of low-concentration oxygen/ozone alleviated mechanical allodynia and attenuated radiculitis, likely by a PDE2A-cGMP/cAMP-NF-κB/p65 signaling pathway in chronic radiculitis rats.

Boosted Regeneration and Reduced Denervated Muscle Atrophy by NeuroHeal in a Pre-clinical Model of Lumbar Root Avulsion with Delayed Reimplantation.

The "gold standard" treatment of patients with spinal root injuries consists of delayed surgical reconnection of nerves. The sooner, the better, but problems such as injury-induced motor neuronal death and muscle atrophy due to long-term denervation mean that normal movement is not restored. Herein we describe a preclinical model of root avulsion with delayed reimplantation of lumbar roots that was used to establish a new adjuvant pharmacological treatment. Chronic treatment (up to 6 months) with NeuroHeal, a new combination drug therapy identified using a systems biology approach, exerted long-lasting neuroprotection, reduced gliosis and matrix proteoglycan content, accelerated nerve regeneration by activating the AKT pathway, promoted the formation of functional neuromuscular junctions, and reduced denervation-induced muscular atrophy. Thus, NeuroHeal is a promising treatment for spinal nerve root injuries and axonal regeneration after trauma.

Advances in the diagnosis and management of neck pain.

Neck pain imposes a considerable personal and socioeconomic burden-it is one of the top five chronic pain conditions in terms of prevalence and years lost to disability-yet it receives a fraction of the research funding given to low back pain. Although most acute episodes resolve spontaneously, more than a third of affected people still have low grade symptoms or recurrences more than one year later, with genetics and psychosocial factors being risk factors for persistence. Nearly half of people with chronic neck pain have mixed neuropathic-nociceptive symptoms or predominantly neuropathic symptoms. Few clinical trials are dedicated solely to neck pain. Muscle relaxants and non-steroidal anti-inflammatory drugs are effective for acute neck pain, and clinical practice is mostly guided by the results of studies performed for other chronic pain conditions. Among complementary and alternative treatments, the strongest evidence is for exercise, with weaker evidence supporting massage, acupuncture, yoga, and spinal manipulation in different contexts. For cervical radiculopathy and facet arthropathy, weak evidence supports epidural steroid injections and radiofrequency denervation, respectively. Surgery is more effective than conservative treatment in the short term but not in the long term for most of these patients, and clinical observation is a reasonable strategy before surgery.

Curcumin alleviates lumbar radiculopathy by reducing neuroinflammation, oxidative stress and nociceptive factors.

Current non-surgical treatments for lumbar radiculopathy [e.g. epidural steroids and Tumour necrosis factor-α (TNF-α) antagonists] are neither effective nor safe. As a non-toxic natural product, curcumin possesses an exceptional anti-inflammatory profile. We hypothesised that curcumin alleviates lumbar radiculopathy by attenuating neuroinflammation, oxidative stress and nociceptive factors. In a dorsal root ganglion (DRG) culture, curcumin effectively inhibited TNF-α-induced neuroinflammation, in a dose-dependent manner, as shown by mRNA and protein expression of IL-6 and COX-2. Such effects might be mediated via protein kinase B (AKT) and extracellular signal regulated kinase (ERK) pathways. Also, a similar effect in combating TNF-α-induced neuroinflammation was observed in isolated primary neurons. In addition, curcumin protected neurons from TNF-α-triggered excessive reactive oxygen species (ROS) production and cellular apoptosis and, accordingly, promoted mRNA expression of the anti-oxidative enzymes haem oxygenase-1, catalase and superoxide dismutase-2. Intriguingly, electronic von Frey test suggested that intraperitoneal injection of curcumin significantly abolished ipsilateral hyperalgesia secondary to disc herniation in mice, for up to 2 weeks post-surgery. Such in vivo pain alleviation could be attributed to the suppression, observed in DRG explant culture, of TNF-α-elicited neuropeptides, such as substance P and calcitonin gene-related peptide. Surprisingly, micro-computed tomography (µCT) data suggested that curcumin treatment could promote disc height recovery following disc herniation. Alcian blue/picrosirius red staining confirmed that systemic curcumin administration promoted regeneration of extracellular matrix proteins, visualised by presence of abundant newly-formed collagen and proteoglycan content in herniated disc. Our study provided pre-clinical evidence for expediting this natural, non-toxic pleiotropic agent to become a new and safe clinical treatment of radiculopathy.

Structure-Specific Movement Patterns in Patients With Chronic Low Back Dysfunction Using Lumbar Combined Movement Examination.

OBJECTIVE: A test-retest cohort study was conducted to assess the use of a novel computer-aided, combined movement examination (CME) to measure change in low back movement after pain management intervention in 17 cases of lumbar spondylosis. Additionally we desired to use a CME normal reference range (NRR) to compare and contrast movement patterns identified from 3 specific structural pathologic conditions: intervertebral disc, facet joint, and nerve root compression. METHODS: Computer-aided CME was used before and after intervention, in a cohort study design, to record lumbar range of movement along with pain, disability, and health self-report questionnaires in 17 participants who received image-guided facet, epidural, and/or rhizotomy intervention. In the majority of cases, CME was reassessed after injection together with 2 serial self-reports after an average of 2 and 14 weeks. A minimal clinically important difference of 30% was used to interpret meaningful change in self-reports. A CME NRR (n = 159) was used for comparison with the 17 cases. Post hoc observation included subgrouping cases into 3 discrete pathologic conditions, intervertebral disc, facet dysfunction, and nerve root compression, in order to report intergroup differences in CME movement. RESULTS: Seven of the 17 participants stated that a "combined" movement was their most painful CME direction. Self-report outcome data indicated that 4 participants experienced significant improvement in health survey, 5 improved by ≥30% on low back function, and 8 reported that low back pain was more bothersome than stiffness, 6 of whom achieved the minimal clinically important difference for self-reported pain. Subgrouping of cases into structure-specific groups provided insight to different CME movement patterns. CONCLUSION: The use of CME assists in identifying atypical lumbar movement relative to an age and sex NRR. Data from this study, exemplified by representative case studies, provide preliminary evidence for distinct intervertebral disc, facet joint, and nerve root compression CME movement patterns in cases of chronic lumbar spondylosis.

The effects of neural mobilization on cervical radiculopathy patients' pain, disability, ROM, and deep flexor endurance.

BACKGROUND: Cervical radiculopathy (CR) is a disease of the cervical spine and a space-occupying lesion that occurs because of pathological problems with cervical nerve roots. Nerve root injury to produce functional disability. OBJECTIVE: The purpose of this study was to examine the effects of neural mobilization with manual cervical traction (NMCT) compared with manual cervical traction (MCT) on pain, functional disability, muscle endurance, and range of motion (ROM) in individuals with CR patients. METHODS: A blinded randomized clinical trial was conducted. Thirty CR patients were divided into two groups - those who received NMCT and those who received MCT. The intervention was applied three times per week for eight weeks. It was measured in order to determine the pain and functional disability in patients with CR. The numeric pain rating scale (NPRS), neck disability index (NDI), ROM, and deep flexor endurance of patients were measured prior to the experiment, four weeks, and eight weeks after the experiment to compare the time points. A repeated-measures analysis of variance was used to compare differences within each group prior to the experiment. And Bonferroni test was performed to examine the significance of each time point. RESULTS: There were significant differences within each group prior to the intervention, four weeks after the intervention, and eight weeks after the intervention in NPRS, NDI, ROM, and deep flexor endurance (P< 0.05). NPRS and NDI more decreased, and, ROM and deep flexor endurance increased in the NMCT group than the MCT group (P< 0.05). CONCLUSIONS: These results suggest that the NMCT can pain relief, recovery from neck disability, ROM, and deep flexor endurance for patients with CR.

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.

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.

Effectiveness of neural mobilization in patients with spinal radiculopathy: a critical review.

Spinal radiculopathy (SR) is a multifactorial nerve root injury that can result in significant pain, psychological stress and disability. It can occur at any level of the spinal column with the highest percentage in the lumbar spine. Amongst the various interventions that have been suggested, neural mobilization (NM) has been advocated as an effective treatment option. The purpose of this review is to (1) examine pathophysiological aspects of spinal roots and peripheral nerves, (2) analyze the proposed mechanisms of NM as treatment of injured nerve tissues and (3) critically review the existing research evidence for the efficacy of NM in patients with lumbar or cervical radiculopathy.

Chiropractic and rehabilitation management of a patient with extraforaminal entrapment of L4 nerve with balance problem.

BACKGROUND: Disc herniation is one of the most common causes of low back pain with radicular pain. Among various types of disc herniation, the extraforaminal disc herniation is a rare cause of lumbar radiculopathy. The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in the treatment of a rare case of extraforaminal L4 nerve entrapment causing severe L4 radiculopathy and chronic mild low back pain (LBP). OBJECTIVE: The aim of presenting this case study is to demonstrate the benefits of Chiropractic care including spine and extremity manipulation and rehabilitation in treatment of rare case of extraforaminal L4 nerve entrapment which caused severe L4 radiculopathy and chronic mild low back pain (LBP). METHOD: A 45-year old female patient arrived at the clinic with chronic mild low back pain and right buttock pain, all of which had presented for two years' duration. During the preceding month, the radicular pain initiated in medium to high intensity, radiating to her right leg following the L4 dermatomal pattern with a periodic tingling sensation in her right foot. A neuro exam demonstrated a proprioception deficit in her right leg. A Romberg test was positive. The patient was treated by low amplitude high velocity spinal and extremity manipulation for 10 consecutive sessions (2 weeks), followed by rehabilitation and exercise therapy including advanced myofascial release therapy for an additional 12 sessions (4 weeks). RESULTS: After treatment, the patient reported a significant improvement in her low back pain and radiculopathy. In addition, she achieved some improvement in balance. CONCLUSION: It seems that Chiropractic care and rehabilitation therapy may be a safe and effective modality in treatment of an L4 radiculopathy in a patient with an extraforaminal L4 nerve entrapment. Although it is rare, an L4 extraforaminal disc herniation should be considered as a possible cause of symptoms in patients with chronic mild low back pain and severe L4 radiculopathy.

Comparison of 2 manual therapy and exercise protocols for cervical radiculopathy: a randomized clinical trial evaluating short-term effects.

STUDY DESIGN: Participant- and assessor-blinded randomized clinical trial. OBJECTIVES: To compare a rehabilitation program thought to increase the size of the intervertebral foramen (IVF) of the affected nerve root to a rehabilitation program that doesn't include any specific techniques thought to increase the size of the IVF in patients presenting with cervical radiculopathy (CR). BACKGROUND: Clinical approaches for the treatment of CR commonly include exercises and manual therapy techniques thought to increase the size of the IVF, but evidence regarding the effectiveness of these specific manual therapy techniques is scarce. METHODS: Thirty-six participants with CR were randomly assigned either to a group that received a manual therapy and exercise program aimed at increasing the size of the IVF of the affected nerve root (experimental group, n=18) or to a group that received a manual therapy and exercise program without the specific goal of increasing the size of the IVF of the affected level and side (comparison group, n=18). Primary (Neck Disability Index) and secondary (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire [QuickDASH] and numeric pain-rating scale) outcomes were evaluated at baseline, at the end of the 4-week program (week 4), and 4 weeks later (week 8). A mixed-model, 2-way analysis of variance was used to analyze treatment effects. RESULTS: No significant group-by-time interaction or group effect was observed for Neck Disability Index, QuickDASH, and numeric pain-rating scale scores (P≥.14) following the intervention. However, both groups showed statistically and clinically significant improvement from baseline to week 4 and to week 8 in Neck Disability Index, QuickDASH, and numeric pain-rating scale scores (P<.05). CONCLUSION: Results suggest that manual therapy and exercises are effective in reducing pain and functional limitations related to CR. The addition of techniques thought to increase the size of the IVF of the affected nerve root yielded no significant additional benefits. Given the absence of a "no treatment" group, a spontaneous resolution of symptoms cannot be excluded. However, the magnitude of improvement makes spontaneous resolution unlikely. The trial was registered at ClinicalTrials.gov (NCT01500044). LEVEL OF EVIDENCE: Therapy, level 1b-.

[Electrophysiological mechanisms of spinal systems plasticity in people with dysfunctions of the locomotor system].

The reflex motor responses of some bilateral muscles of hip, shin and foot were evoked by percutaneous surface electrical spinal cord stimulation at the lumbosacral levels (T11-L3) in the patients with marked lumbosacral radiculopathy caused by spinal osteochondrosis and in neurologically healthy physically inactive individuals, as well as in healthy qualified athletes and athletes with knee joint injuries. There was used the technique of registration of posterior root-muscle reflexes. In the subjects with neurologic pathology and in the group of athletes with knee joint injuries the data demonstrated similar signs of plasticity of spinal neural circuits, innervating the muscles of the low extremities.

Sustained neuronal hyperexcitability is evident in the thalamus after a transient cervical radicular injury.

STUDY DESIGN: This study used extracellular electrophysiology to examine neuronal hyperexcitability in the ventroposterolateral nucleus (VPL) of the thalamus in a rat model of painful radiculopathy. OBJECTIVE: The goal of this study was to quantify evoked neuronal excitability in the VPL at day 14 after a cervical nerve root compression to determine thalamic processing of persistent radicular pain. SUMMARY OF BACKGROUND DATA: Nerve root compression often leads to radicular pain. Chronic pain is thought to induce structural and biochemical changes in the brain affecting supraspinal signaling. In particular, the VPL of the thalamus has been implicated in chronic pain states. METHODS: Rats underwent a painful transient C7 nerve root compression or sham procedure. Ipsilateral forepaw mechanical allodynia was assessed on days 1, 3, 5, 7, 10, and 14 and evoked thalamic neuronal recordings were collected at day 14 from the contralateral VPL, whereas the injured forepaw was stimulated using a range of non-noxious and noxious mechanical stimuli. Neurons were classified on the basis of their response to stimulation. RESULTS: Behavioral sensitivity was elevated after nerve root compression starting at day 3 and persisted until day 14 (P < 0.049). Thalamic recordings at day 14 demonstrated increased neuronal hyperexcitability after injury for all mechanical stimuli (P < 0.024). In particular, wide dynamic range neurons demonstrated significantly more firing after injury compared with sham in response to von Frey stimulation (P < 0.0001). Firing in low threshold mechanoreceptive neurons was not different between groups. CONCLUSION: These data demonstrate that persistent radicular pain is associated with sustained neuronal hyperexcitability in the contralateral VPL of the thalamus. These findings suggest that thalamic processing is altered during radiculopathy and these changes in neuronal firing are associated with behavioral sensitivity. LEVEL OF EVIDENCE: N/A.