|Year : 2020 | Volume
| Issue : 2 | Page : 134-140
Effect of myokinetic stretching technique and spinal mobilization with arm movement in subjects with cervical radiculopathy: A randomized clinical trial
Apeksha Hungund, Santosh C Metgud, Anand Heggannavar
Department of Orthopedic Manual Therapy, KAHER Insititute of Physiotherapy, Belagavi, Karnataka, India
|Date of Submission||29-Jun-2019|
|Date of Decision||29-Aug-2020|
|Date of Acceptance||15-Jun-2020|
|Date of Web Publication||04-Jan-2021|
Dr. Apeksha Hungund
S-4, Ishan Apartments – II, 29 Nanawadi, Belagavi - 590 009, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objective: Literature suggests spinal mobilization with arm movement (SMWAM) individually is effective in treating cervical radiculopathy. There is paucity of literature on myokinetic stretching technique (MST) and evidence which compare MST and SMWAM. The aim of the present study was to evaluate the effect of MST and SMWAM on range of motion (ROM), pain, functional disability, and grip strength in subjects with cervical radiculopathy.
Materials and Methods: A randomized clinical trial with thirty two subjects diagnosed with cervical radiculopathy were included in the study and randomly divided into two groups of 16 subjects each where, Group A received MST and Group B received Mulligan's SMWAM along with the conventional treatment. Outcome measures were assessed on the 1st day preintervention and 6th day postintervention where pain intensity was assessed using visual analog scale, ROM using universal goniometer, grip strength using hand dynamometer, and functional performance using neck disability.
Results: Within group analysis showed pain relief, improvement in ROM, and reduced disability which was statistically significant in both the groups (P < 0.0001) whereas the between group analysis revealed no statistical significance. There was no significant difference in grip strength scores between the groups (P = 1).
Conclusion: The study concluded that MST and SMWAM are equally effective in relieving pain, improving ROM, and functional disability in subjects with cervical radiculopathy.
Keywords: Cervical radiculopathy, Grip strength, Mulligan mobilization, Myokinetic stretching technique
|How to cite this article:|
Hungund A, Metgud SC, Heggannavar A. Effect of myokinetic stretching technique and spinal mobilization with arm movement in subjects with cervical radiculopathy: A randomized clinical trial. Indian J Phys Ther Res 2020;2:134-40
|How to cite this URL:|
Hungund A, Metgud SC, Heggannavar A. Effect of myokinetic stretching technique and spinal mobilization with arm movement in subjects with cervical radiculopathy: A randomized clinical trial. Indian J Phys Ther Res [serial online] 2020 [cited 2021 Jan 24];2:134-40. Available from: https://www.ijptr.org/text.asp?2020/2/2/134/189943
| Introduction|| |
Cervical radiculopathy is defined as a disease process marked by nerve compression from herniated disc material or arthritic bone spurs. Cervical radiculopathy leads to pain in the neck, radiating to arm or numbness in the distribution of a specific nerve root. The radicular pain is often accompanied by motor or sensory disturbances. In spite of the fact that the causes of radiculopathy are varied (e.g., acute disc herniations, cervical spondylosis, and foraminal narrowing) they all lead to compression and irritation of an exiting cervical nerve root.
Cervical radiculopathy constitutes 5%–36% of all radiculopathies. In general, rate of occurrence of cervical radiculopathy is 83/100,000 with an increased prevalence in the fifth decade of life (203/100,000). The treatment options for patients with cervical radiculopathy vary from conservative management to surgery. There are evidences that suggests that patients who are managed conservatively may have superior outcomes compared to those undergoing surgeries.
Physical therapy is a popular nonsurgical approach that is relatively safe and effective in the management of patient with cervical radiculopathy. Physical therapy includes treatment such as electrotherapy, exercise therapy, and manual therapy.
In spinal mobilization with arm movement (SMWAM), a sustained transverse glide to the spinous process of a vertebra is applied while the restricted peripheral joint movement is performed actively or passively. The mobilization must result in a symptom-free movement. This technique is based on the knowledge that when the shoulder girdle moves, the muscles attached to the scapula, cervical vertebrae, and upper thorax cause simultaneous spine movement.
Myokinetic stretching technique (MST) is a form of myofascial release, which involves active or passive stretching and movement as well as muscle energy techniques until a desirable release from the taut band is achieved. MST was used in infants with congenital muscular torticollis, which showed improvement in range of motion (ROM) and muscle thickness as well as shortened the treatment duration.
Literature reported that SMWAM individually is effective in subjects with cervical radiculopathy. However, there is paucity of literature on MST and evidence which compare MST and SMWAM. Hence, the present study intends to evaluate the effect of MST and SMWAM on ROM, pain, functional disability, and grip strength in subjects with cervical radiculopathy.
| Materials and Methods|| |
Design and sampling
This randomized clinical trial included 32 subjects with cervical radiculopathy. The sample size was calculated as 32 with 16 in each group with power = 90% and α error = 5%. An approval of the study was obtained from the Institutional Ethical Committee. All patients provided informed consent following an explanation of the study. The trial is registered with clinical trial registry – India with trial number CTRI/2018/07/014925.
Both male and female subjects between the age group of 30–50 years, with radiating pain from neck to upper limb for more than 3 weeks, Spurling's test positive, cervical distraction test positive, positive upper limb neurodynamic test, and neck disability score <50% were included in the study. Subjects with any trauma or injury to the head and neck region <6 months, any comorbid factors such as congenital, malignant, autoimmune, and neurological conditions involving cervical spine and head, vestibular impairment demonstrated by vertigo, dizziness or motor imbalance, subjects with any skin allergy or skin conditions, osteoporosis, pregnancy, and any systemic illness were excluded in the study. A total of 32 individuals were included in the study and randomized into two Groups A and B, 16 in each group by envelope method [Figure 1].
The outcome measures included were ROM, pain intensity, functional disability, and grip strength.
- Pain intensity: The intensity of pain was assessed on visual analog scale which is a continuous scale with a horizontal line of 10 cm (100 mm) in length anchored by two visual descriptors, one for each extreme symptom (0 as no pain and 10 as maximum pain). The scale was shown to the study subject and was asked to mark his/her pain on the basis of the severity
- Cervical ROM: ROM was assessed using universal goniometer in supported sitting position. The ROM was taken for cervical movements such as cervical flexion, extension, lateral flexion, and rotation
- Grip strength was assessed using Jamar hand dynamometer. The subject was in sitting position with shoulder adducted and neutrally rotated, elbow flexed to 90°, forearm in neutral position and wrist in neutral position. Each test was repeated three times and the average was calculated
- Functional disability was assessed using Neck Disability Index (NDI). The NDI was developed by Vernon and Mior in 1991. It consists of ten questions with six answers each (scoring 0–5 points). The sum of the score obtained is doubled to give a percentage score out of 100.
All the outcomes were measured pre- and post-intervention after 6 sessions.
Group A (myokinetic stretching technique)
Subject was asked to lie supine on the plinth and the head was held at the edge of the plinth by the therapist. Then with one hand the therapist held the neck in cervical lateral flexion to the opposite side so as to achieve the stretching of the trapezius muscle. Myofascial release by applying sustained finger pressure for 5–10 s on the involved trapezius was given. A gentle myofascial stretching force was applied to take up slack and sustained until a release occurred [Figure 2]. The MST protocol comprised four sets of 15 stretches with 3 min rest for 6 sessions.
Group B (spinal mobilization with arm movement)
Subject was in upright sitting position on chair and the therapist stood behind the subject. The therapist placed the medial aspect of the thumb of one hand, reinforced by the index finger of the other hand on the spinous process of the desired level of vertebra. From the affected to the unaffected side, a pure transverse glide was performed. The glide was sustained by the therapist and patient was asked to perform the offending movements, i.e., shoulder/arm flexion, abduction, horizontal adduction, and horizontal [Figure 3]. The dosage was 10 repetitions in one set, 3 sets per session for 6 sessions.
Subjects in both the groups were treated with 6 sessions of hot moist pack, manual traction along with deep neck flexor, and isometric neck strengthening. The hot moist pack (HMP) was given for 20 min over the cervical region. Manual traction was given in supine position at 25° of neck flexion with 10 s pull and 5 s rest for 10 times during each session. For deep neck flexor strengthening, subject was in supine position, with the cervical spine in neutral. They were instructed to flatten the curve of the neck by nodding the head. The position was held for 10 s and repeated for 10 times. Isometric strengthening neck exercises were given twice a day with 25 repetitions in each direction with 7 s hold and 5 s of rest.
R software (version i3184.108.40.206, Vienna, Austria) was used for statistical analysis. Data were summarized as mean ± standard deviation for continuous variable and categorical variables are represented using percentages. The data were not normally distributed between the two groups and hence nonparametric tests of significance were applied for data analysis. Comparison between the groups was by using independent t-test/Mann–Whitney U-test. Pre- and post-data were compared using paired t-test/Wilcoxon sign rank test. P < 0.05 is considered as statistically significant.
| Results|| |
[Table 1] describes the demographic details of all the subjects. The study included a total of 32 subjects, of which 17 were male and 15 were female. The mean age of participants in group A was 44.31 ± 5.41 and in Group B was 41 ± 7.52 with no significant difference (P = 0.163) between groups. Similarly, the height (P = 0.3647), weight (P = 0.7682), and body mass index (P= 0.6503) of the study participants matched in both the study groups.
As shown in [Table 2], the mean of visual analog scale (VAS) (P = 0.0005), NDI (P < 0.0001), and ROM with respect to cervical extension (P = 0.0038), right lateral flexion (P = 0.0088), left lateral flexion (P = 0.0494), right rotation (P = 0.0031), and left rotation (P = 0.0036) score after the treatment was statistically significant from the mean score before the treatment within the two groups. There was no statistical significant difference in the mean score of grip strength within the two groups (P = 0.3711).
|Table 2: Comparison of variables pre- and post-intervention within the two groups|
Click here to view
There was no statistical significant difference in the VAS (P = 0.9099), NDI (P = 0.7713), grip strength (P = 1), and ROM with respect to cervical flexion (P = 0.8491), cervical extension (P = 0.1322), right lateral flexion (P = 0.4015), left lateral flexion (P = 0.8082), right rotation (P = 0.4233), and left rotation (P = 0.585) between the two groups which suggests that both the groups are equally effective in treating cervical radiculopathy [Table 3].
|Table 3: Comparison of difference in pre- and post-intervention scores between the groups|
Click here to view
| Discussion|| |
The results from the statistical analysis of the present study reported, that there was no difference in the effect of MST and SMWAM on reducing pain, increasing ROM, and improving functional disability in subjects with cervical radiculopathy. The demographic details of the two groups were collected and showed homogeneity at the baseline.
The age group between 30 and 50 years was taken as inclusion criteria, as literature suggest that prevalence of cervical radiculopathy is most commonly seen in this age group. A study was done on prevalence of cervical spondylotic radiculopathy, which suggested that chances of occurrence of the disease increases at the age of 50–59 years due to degenerative changes in the spine. In the current study, the total percentage of males was 53.1% and females were 46.9%. The present study supports the findings of epidemiological study done in Rochester Minnesota where incidence rate per 100,000 population for cervical radiculopathy was 107.3 for males and 63.5 for females.
On the basis of literature review, MST and SMWAM were found to be effective in various other conditions. In the present study, MST and SMWAM proved to be effective in reducing pain, increasing ROM, and improving functional disability. There was significant pain relief with MST the reason being due to the sustained pressure or stretch on the taut band of the trapezius muscle fibers must have released, thereby inhibiting excessive hyper contraction or shortening. A similar study was done where myofascial release technique was administered for upper trapezius which showed improvement on pain and disability in subjects with cervical radiculopathy.
In the present study, SMWAM showed improvement in the pain and functional disability posttreatment. The reason for the same is explained by the Mulligan's concept of mobilization that in case of radiating pain, there may be neural tissues adhered to the surrounding structures which results into lack of sliding and gliding and hence gives additional stretch to the nerve. In SMWAM, transverse glide was delivered along with arm movement, resulting in opening of the foramina on the affected side by rotation of vertebral body toward same side. As shoulder girdle muscles have their attachments from cervical, addition of arm movement along with spinal movement will further unload the muscles resulting in decrease in reduction of pain. A related research on the effectiveness of SMWAM in mechanical neck pain was performed by Chaudhery and Dabholkar who concluded that combined with controlled exercise program, SMWAM has greater effect on pain and impairment than group exercise alone. The results of the present study were in accordance with the above study in subjects with cervical radiculopathy, whereas the results of the current study were not in accordance with the study conducted to check the effect of neural mobilization SMWAM and McKenzie exercises in individuals with cervical spondylitis and concluded that in the treatment of cervical spondylitis, McKenzie exercises with neural stimulation are ideal for reducing pain and functional impairment. In the present study, there was significant improvement in cervical ROM in both the groups. The results showed statistically significant improvement in the cervical ROM in both groups pre- to post-intervention, but when between groups comparison was done the obtained results were not statistically significant. Both the groups were equally effective. Improvement in cervical ROM in MST could be due to the increase in flexibility of the muscle which could have led to increased ROM. It also may have led to pain reduction that improved movement.
In terms of NDI, there was significant improvement when compared before and after intervention in both the study groups. However, there was no statistical significance between the two groups. In this study, subjects in both groups showed significant reduction in percentage of disability on NDI pre- to post-intervention. This could be due to reduction of pain level in both the groups and improved cervical ROM, subsequently leading to improved functional capabilities.
The use of manual cervical traction can be suggested as an adjunct to other interventions such as manual therapy and strengthening exercises for reducing pain, disability, and improving ROM in patients with neck and neck-related arm pain. The distraction in the slight flexion position is reported to open the posterior articulations, widens intervertebral foramen, disengage the facet surfaces, and elongate the posterior musculature and ligaments. Cervical traction also has analgesic effect as a result of reduction in inflammation of the cervical nerve root. The rationale for traction is based on mechanical and reflex mechanisms., Relaxation of spinal muscles is assumed to be the mechanism by which traction can be proved effective in reducing pain, improving spinal mobility, and associated disability.
In addition to manual cervical traction, exercises were also included in the treatment protocol as an adjunct in both the groups. Isometric exercises increase the intramuscular coordination by enhancing motor unit activation, synchronization and/or firing rate within a given muscle. The isometric contraction generates high tension in the muscle than concentric contraction. This will help in improving muscle strength and mobility. The dosage of isometric neck exercises in this study was in accordance to previous literature that suggested the duration for isometric contraction held for 7 s with 3–5 repetitions are optimal or most effective.
In the current study, hand grip strength was assessed, as the literature suggests that there is significant reduction in the grip strength and hand functions in patients with cervical radiculopathy. In the present study, there was no significant improvement in grip strength after the 6 sessions of treatment. A study was done to determine if cervical traction along with conventional physical therapy is more effective than using conventional therapy alone in improving grip strength in patients with cervical radiculopathy which concluded that, cervical traction combined with electrotherapy and exercises are effective in improvement in the hand grip function. The result of the present study contradicts with the study stated above as there was no improvement in the hand grip strength. The reason for this could be due to the shorter duration of the study without the application of therapeutic modalities.
As both the groups showed significant improvement on pain relief, cervical ROM, and functional disability, this study provides evidence for the use of either MST or SMWAM in combination with cervical manual traction, HMP, and exercises in subjects with cervical radiculopathy.
The current study has a few limitations. The cause of the radiculopathy was not considered and the grip strength was not compared with unaffected side. The future scope of the study may be a prospective study can be taken up, to evaluate the long-term effects of the interventions of present study. Ultrasound imaging may be done in further studies to see the change in the muscle thickness.
| Conclusion|| |
The present study provided evidence to prove that both MST and SMWAM along with the neck strengthening exercises, manual cervical traction and HMP are equally effective in reducing pain, increasing ROM and improving functional ability in subjects with cervical radiculopathy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Eubanks JD. Cervical radiculopathy: Nonoperative management of neck pain and radicular symptoms. Am Fam Physician 2010;81:33-40.
Solanki M, Shah Effectiveness of Mulligan mobilization versus neural mobilization in patients with cervical radiculopathy: A comparative study. Int J Sci Res 2015;4:2387-9.
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 Orthop Sports Phys Ther 2005;35:802-11.
Costello M. Treatment of a patient with cervical radiculopathy using thoracic spine thrust manipulation, soft tissue mobilization, and exercise. J Man Manip Ther 2008;16:129-35.
Chaudhery JK, Dabholkar A. Efficacy of spinal mobilization with arm movements (SMWAMs) in mechanical neck pain patients: Case-controlled trial. Int J Ther Rehabil Res 2017;6:18-23.
Chon SC, Yoon SI, You JH. Use of the novel myokinetic stretching technique to ameliorate fibrotic mass in congenital muscular torticollis: An experimenter-blinded study with 1-year follow-up. J Back Musculoskelet Rehabil 2010;23:63-8.
Mathur H, Singh A, Sharma A. Comparison of spinal mobilisation with arm movement (SMWAM) with conventional treatment on grip strength in patients with radiating neck pain. Int J Jaipur Natl Univer 2017;6:75-81.
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis Care Res 2011;63:S240-52.
Farooq MN, Mohseni Bandpei MA, Ali M, Khan GA. Reliability of the universal goniometer for assessing active cervical range of motion in asymptomatic healthy persons. Pak J Med Sci 2016;32:457-61.
Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 1984;9:222-6.
McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G. The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire. Eur Spine J 2007;16:2111-7.
Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994;117(Pt 2):325-35.
Salemi G, Savettieri G, Meneghini F, Benedetto ME, Ragonese P, Morgante L, et al
. Prevalence of cervical spondylotic radiculopathy: A door-to-door survey in a Sicilian municipality. Acta Neurol Scand 1996;93:184-6.
Sambyal R, Moitra M, Samuel AJ, Kumar SP. Does myofascial release technique contribute to cervical radiculopathy treatment? Cues from a noncontrolled experimental design study. Rev Pesquisa Fisioterapia 2016;6.
Kotagiri S, Songa AK, Gad MV, Sulthan N. Effectiveness of mulligans mobilizations with upper limb movement and McKenzie exercises with neural mobilizations in patients with cervical spondylitis. IAIM 2018;5:146-55.
Onel D, Tuzlaci M, Sari H, Demir K. Computed tomographic investigation of the effect of traction on lumbar disc herniations. Spine (Phila Pa 1976) 1989;14:82-90.
Murphy MJ. Effects of cervical traction on muscle activity. J Orthop Sports Phys Ther 1991;13:220-5.
Kitai TA, Sale DG. Specificity of joint angle in isometric training. Eur J Appl Physiol Occup Physiol 1989;58:744-8.
Leon C. Advanced Soft Tissue Technique – Muscle Energy Technique. 2nd
ed.. University of Michigan: Churchill Livingstone; 2001.
Faisal CK, Mathew N, Mathias L, Ajith S. Grip strength and hand function changes in unilateral cervical radiculopathy. Int J Curr Res Rev 2012;4:82.
Joghataei MT, Arab AM, Khaksar H. The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy. Clin Rehabil 2004;18:879-87.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]