CERVICAL_SPONDYLOSIS PHYSIOTHERAPY MANAGEMENT

A case study done at Aminu kano teaching hospital

1. PHYSIOTHERAPY
MANAGEMENT OF CERVICAL
SPONDYLOSIS USING
MULLIGAN CONCEPT: A CASE
STUDY
BY
AMINU ALIYU ARKILLA
PHYSIOTHERAPY DEPARTMENT
AMINU KANO TEACHING HOSPITAL,
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2. SYNOPSIS
•Introduction
•Relevant Anatomy
•Epidemiology
•Etiology/Risk Factors
•Pathophysiology
•Clinical Features
•Diagnosis
•Differential Diagnosis
•Management
•Physiotherapy Management
•Case Study
•Conclusion
•Recommendation
•References
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3. INTRODUCTION •Cervical Spondylosis refers to the age related degeneration of cervical vertebrae, intervertebral
discs and intervertebral joints with osteophytic formations which may in extreme cases lead to
the compression of one or more of the nerve roots or even the spinal cord.
•This mainly leads to increasing pain in the neck and arm, weakness and changes in sensation.
•In extreme cases, it is accompanied by Cervical Spondylotic Radiculopathy (CSR) or Cervical
Spondylotic Myelopathy (CSM) to form the Cervical Spondylosic Syndrome.

(Rana, 2015)
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4. RELEVANT ANATOMY
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5. EPIDEMIOLOGY
•Cervical spondylosis is a common condition that is estimated to account for 2% of all hospital
admissions.
•It is the most frequent cause of spinal cord dysfunction in patients older than 55 years
•A study carried out in 2014 at a rheumatology clinic at Ogun state found 36 symptomatic CS pts
with male to female ratio of 1.8:1 and C4-C7 was the most affected cervical spine level

( Wang et al., 2005, Oguntona, 2014)
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6. CONT...
•A study of asymptomatic adults showed significant degenerative changes at 1 or more levels in 70% of
women and 95% of men at age 65 and 60.
•Investigators in a study involving Ghanaians reported, "out of 225 patients who carried loads on their head,
143 (63.6%) had cervical spondylosis, and of the 80 people who did not carry load on their head, 29 (36%)
had cervical spondylosis

( Hassan et al.., 2018)
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7. CONT...
RACE
•No apparent correlation between race and cervical spondylosis exists.
SEX
•Both sexes are affected
•Cervical spondylosis usually starts earlier in men than in women.
AGE
•Symptoms of cervical spondylosis may appear in persons as young as 30 years but are found most
commonly in individuals aged 40-60 years.

( Hassan et al., 2018)
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8. ETIOLOGY •Early spondylosis is associated with degenerative changes within the IVD where desiccation of
the disc occurs.
•This causes overall disc height loss and a reduction in the ability of the disc to maintain or bear
additional axial loads along the cervical spine.
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9. PATHOPHYSIOLOGY Age Related
Degeneration &
Dehydration of IVDs
Decreased between the
vertebral bodiesDevelopmental laxity
in the spinal
supportive ligaments
Compression of
cervical nerve roots
and spinal cord
Hyper-mobility of
spinal segment
Bone on bone
apposition, bone
spur formation
Narrowing of cervical
spinal canal and/or
intervertebral foramina
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10. CLINICAL FEATURES •Neck or shoulder pain that may radiate down the ipsilateral upper extremity which may worsen
with neck movement.
•Tingling sensation or numbness felt at the upper limb of affected side.
•Muscle weakness along the distribution of the nerve roots affected.
•Headache, stiffness, tenderness or spasm of neck and paraspinal muscles
•Limitation of ROM of neck on the affected UL.

( Kelly et al, 2011)
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11. RISK FACTORS •Age
•Previous injury
•Genetics
•Work activity e.g. Load carrying on the head


( Singh et al, 2014)
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12. DIAGNOSIS
•Thorough Medical History
•Physical Examination
•Imaging Studies e.g. X-rays, MRI etc

(Binder, 2007)
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13. DIFFERENTIAL DIAGNOSIS •Acute neck strain
•Rheumatoid Arthritis
•Ankylosing Spondylitis
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14. MANAGEMENT
Medical Management
•Pain relievers
•Muscle relaxants
•Steroid injections
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15. SURGICAL MANAGEMENT
Surgery is indicated when there is a progression of signs and symptoms that don’t
respond to conservative management
GOALS OF SURGICAL TREATMENT
•Improvement or preservation of neurological function
•Prevention or correction of spinal deformity
•Maintenance of spinal stability

(Melvin et al., 1993)
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16. SURGICAL PROCEDURES
•Anterior Cervical Diskectomy and Fusion
•Laminectomy
•Laminoplasty
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17. PHYSIOTHERAPY MANAGEMENT
•TENS
•ROM exercises
•Traction
•Immobilization by use of neck collar
•Isometric neck exercises
•Cryotherapy
•Ultrasound
•Lifestyle modification
(Kieran et al, 2011)
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18. MULLIGAN CONCEPT The Mulligan concept encompasses a number of mobilising treatment techniques that can be
applied to the spine, these include ‘NAGs’ (natural apophyseal glides), ‘SNAGs’ (sustained
natural apophyseal glides), and ‘SMWLMs’ (spinal mobilisations with limb movements).
These techniques are described and the general principles of examination and treatment are
outlined. Clinical examples are used to illustrate the concept's application to the spine, how it
has evolved and been integrated into constantly changing physiotherapy practice. New
applications are considered which can assist in the correction of dysfunctional movement. The
paper reflects on the possible role that this concept has to play within evidence-based practice. A
future research direction is proposed in the light of presently available preliminary research
results.
(JH Abbott et al, 2011)
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19. CONT…•The Mulligan concept involves several different mobilising techniques to treat the spine.
•The technique also treats limbs affected by damage to spine.
•The mobilising techniques includes;
i.Natural Hypophyseal Glides (NAGs)
ii.Sustained Natural Hypophyseal Glides (SNAGs) and
iii.Mobilisations with Movement (MWMs).
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20. NAGs
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21. SNAGs
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22. CASE STUDY•Age : 36yrs
•Gender: Female
•Occupation: Teacher
•C/O: Severe neck pain radiating to the Lt UL x 6/52 ago
•Hx: Pt was healthy until 6/52 ago when she started experiencing pain at her back of the neck
after she woke up from sleep where she found out that her neck was stiffed, she could not move it
to the full range. When she realized that the pain was aggravating, she went to a private hospital
(Sonobean) where an X-ray was done and she was diagnosed with cervical spondylosis. Then she
was referred to AKTH for physiotherapy management.
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23. •PMHx: HTN-, DM-,RTA+(16yr)
•FSHx: A class room teacher married and blessed with 2 children. She does not takes kolanut or
smoke neither drink alcohol.
•O/e: A healthy looking lady entered into the cubicle with normal gait pattern, afebrile,
acyanosed, anicteric and not in obvious respiratory distress.
ASSESSMENT
•Systematic
•CNS: Concious, alert and oriented in TPP
•CVS: BP: 120/80mmHg
PR: 99bpm
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24. Segmental
•H & N
•No restriction in ROM except in right side flexion due to pain
•On palpation there’s tenderness
•Neck pain (VAS 9/10)
SPECIAL TEST
•Spurlings test: +ve
•Compression test +ve
•Distraction test –ve
•DCT pain present from c4 to c7
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25. CASE STUDY CONT...
UPPERLIMBSRIGHT LEFTGMP5/52/5ROMFull and pain free Full painful at end range SENSATIONIntact Intact SPASTICITY Absent Absent ATROPHY Absent Absent
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26. •T& A: NAD
•Lower limbs: NAD
Investigation:
•X-ray reveals osteophytic outgrowth on C5-C7 vertebral
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27. 27

28. Impression: Neck pain radiating to the left UL 2° to Cervical Spondylosis
Functional abilities/disabilities
•Patient can perform her basic ADLs
•Patient can not lift her lt hand properly
RX PLAN
•NAGs
•SNAGs
•IRR to the neck and shoulder × 15 mins
•STM with volini
•ROM exercise to the neck × 10 reps each
•Assisted active exercise to the lt UL × 10 reps
•H/P
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29. AFTER 3 SESSIONS : Plan were modified to;
•TENS × 30 minutes
•Cryotherapy × 15 minutes
•Ultrasound to the neck × 6 minutes
•Isometric exercise to the neck × 10 secs hold × 5 reps each
•Free active exercise × 10 reps
•Insist on lifestyle modification
•H/P
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30. OUTCOMES AFTER 5 SESSIONS
•There was significant reduction in neck pain (VAS 4\10)
•Muscle power increased from 2/5 to 5/5
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31. CONCLUSION
•Physiotherapy has proven to be very effective in the management of
patient with cervical spondylosis.
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32. RECOMMENDATION
•Patients with cervical spondylosis should be referred early to
physiotherapy
•Lifestyles of the patients should be modified
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33. REFERENCES
•Wang MC, Kreuter W, Wolfla CE, et al. Trends and variations in cervical spine surgery in the United States:
Medicare beneficiaries, 1992 to 2005. Spine. 2009 Apr 2. [Medline]
•Cervical Spondylosi Author: Hassan Ahmad Hassan Al-Shatoury, MD, PhD, MHPE; Chief Editor: Dean H
Hommer, MD 2018
•Iheukwumere N, Okoye EC. Prevalence of symptomatic cervical spondylosis in Nigerian tertiary health
institution. Trop J Med Res 2014;17:25-7
•Oguntona SA. Cervical spondylosis in South West farmers and female traders. Ann Afr Med 2014;13:61-4
•Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. Journal of clinical orthopaedics and trauma.
2014 Dec 31;5(4):221-6.
•Kelly JC, Groarke PJ, Butler JS, Poynton AR, O’Byrne JM. The natural history and clinical syndromes of
degenerative cervical spondylosis. Advances in orthopedics. 2011 Nov 28;201-2.
•Sandeep S Rana, MD. Diagnosis and Management of Cervical Spondylosis. Medscape, 2015.
•Binder AI. Cervical Spondylosis and neck pain: clinical review. BMJ 2007;334:527-31
•Kieran MH, Joseph SB, Roisin TD, John MO and Ashely RP. Nonoperative Modalities to Treat Symptomatic
Cervical Spondylosis, Advances in Orthopedics, 2011.
•Ferrara L: The biomechanics of cervical spondylosis. Advances in orthopedics. 2012 Feb 1:2012
•Melvin D. Law, Jr M D Mark Bemhart M.D and Augustus A. White III, M.D., Cervical Spondylotic
Myelopathy: A review of surgical indications and decision making, Yale journal of biology and Medcine, 1993.
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34. THANK YOU FOR
LISTENING
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