Safe physiotherapy interventions in large cervical disc herniations: Figure 1

Abstract

SummaryA 34-year-old woman was seen in a physiotherapy department with signs and symptoms of cervical radiculopathy. Loss of cervical lordosis and a large paracentral to intraforaminal disc prolapse (8 mm) at C5-C6 level was reported on MRI. She was taking diclofenac sodium, tramadol HCl, diazepam and pregabalin for the preceding 2 months and no significant improvement, except temporary relief, was reported. She was referred to physiotherapy while awaiting a surgical opinion from a neurosurgeon. In physiotherapy she was treated with mobilisation of the upper thoracic spine from C7 to T6 level. A cervical extension exercise was performed with prior voluntary extension of the thoracic spine and elevated shoulders. She was advised to continue the same at home. General posture advice was given. Signs and symptoms resolved within the following four sessions of treatment over 3 weeks. Surgical intervention was subsequently deemed unnecessary. BACKGROUND

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“…The altered mechanics or lordosis helps create the negative pressure in the nucleus pulposus in addition to the approximation of the posterior intervertebral endplates which may serve to push back the protruded material as reported previously. 8 The protruded nuclear material distracts the intervertebral endplates and may distract the adjacent spinous process by a fraction that cannot be appreciated through X-ray and MRI. The rupture of the annulus fibrosis and irritation of the sinovetebral nerve 29,30 in addition to the pressure on the thecal sac, inhibits the contraction of the lumbar multifidus and thereby the patient feels relatively comfortable in a flexed posture.…”

“…A-Novel and pragmatic intervention are based on the principle of negative pressure generation at the disc. 8 The following are considered for the generation of the negative pressure 1-Approximation of the spinous process 2-The Distraction of the anterior intervertebral endplates 3-Approximation of the posterior intervertebral endplates 4-A sustained force or oscillation for 10 seconds with or without deep breathing To achieve the above, a force is applied over the spinous process through the pisiform of the hand. Figure 1 shows the resolution of the applied force into 3 components.…”

“…In a flexed position, the direction of the generated force in the nucleus pulposus is in posterior or posterolateral, since the posterior margin of the vertebral endplates are distracted and anterior endplates approximated. 7,8 A tear in the annulus fibrosis developed either gradually or suddenly due to a sudden overload or repetitive loading. 7 The lordotic curvature of ORIGINAL ARTICLE the lumbar spine in erect posture ensures to direct the maximum force anteriorly since posterior margin of the lumbar vertebrae are in an approximated position about the anterior margins.…”

“…[9][10][11] Conversely, the straightening of the lumbar spine reverses the direction of the force and predisposes to disc prolapse. 8,12 The Cyriax techniques are generalized and its focus is a generalized mobilization of the spine through mobilization and manipulation techniques. 13 McKenzie's techniques are largely reliant on the gradual and graded extension from the flexed position of the spine and believe that the regression of the disc is secondary to these positions.…”

“…The creation of negative pressure within the disc 8 through pragmatic manual intervention and the subsequent effects on the restoration of the lumbar and cervical spine lordosis-and regression are not studied. Based on this principle, manual therapy protocols have been designed and tested.…”