SCIATICA OF THE ARM
The great chameleon; the spine. It can mimick any symptom that you are feeling, or believe to be feeling. I can remember my first year in practice treating a patient with an amputation from WWII. He would tell me about his pain in the foot (which was no longer there). This is well before the mirror box studies became popular and the whole Graded Motor Imagery style of treatment. At the time I only knew directional preference and mechanical assessment procedures. Luckily for me, he fit the paradigm. This patient complaining of leg pain, without a leg, responded rapidly to repeated extension in lying.
Many patients will experience neck pain, which also radiates into the shoulder blade, chest, arm or hand region. I know, because I am also one of the 70% that will experience these symptoms in his/her lifetime. It was so bad that I had to go to the ER because I thought I was having a heart attack at the time. It doesn’t matter how much information may be known, chest pain is still no joke. After ruling out a heart attack, I was able to rapidly fix the chest pain through a few sets of cervical exercises.
When a person is experiencing symptoms that radiate into the arm, with associated neurological signs, such as weakness, numbness, or reflex loss, this is called cervical radiculopathy. There is a clinical prediction rule that is very strong for classifying patients with cervical radiculopathy, prior to the patient receiving any type of test, such as an EMG or NCV, while in the clinic.
We as therapists will do well to know the evidence. Whether we fall on the side of Chad Cook regarding CPR’s having little utility until they have been verified or we fall on the side of believing everything that is written, we at least have to respect the information and know it…more knowledge can’t be harmful when we have more options with which to treat patients.
Facts from the following:
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;28:52-62.
- No universally accepted criteria for dx of CS radic have been est (2ndary)
- Useful to establish accurate clinical examination findings for a diagnosis of cervical radiculopathy
- Purpose of theis study was twofold: to assess the reliability and accuracy of
selected clinical examination findings for the dx of c/s radic using an electophysiologic reference criterion, and to identify and assess the accuracy of an optimum cluster of clinical examination findings for the dx of C/s radic.
- 82 patients
- consecutive patients from 18-70
- suspected of CS radic or CTS
- systemic disease that causes peripheral neuropathy
- primary report of bilateral radiating arm pain
- h/o condition affecting the UE interfering with function
- no work >=6 m 2nd to symptoms
- h/o surgical procedures for pathologies giving rise to neck pain or CTS
- Previous EMG and NCS testing for CR and/or CTS
- workman’s comp or litigation
patient self report items
Standardized Electrophyologic examination procedure
- Needle EMG and NCS served as reference criterion for radic
Standardized clinical examination procedure
- 34 items performed by examiner one after EMG and NCS
- same by examiner two after 10 minute rest to determine reliability
- blinded to EMG/NCS/PT 1 results
- 6 questions thought to be diagnostic for CR
Conventional Neurologic Examination and Provocative Tests
- MMT of C5-T1
- Reflex of biceps, brachioradialis, Triceps
- absent/reduced, normal, increased
- Pin-prick sensation C5-C8
- Spurling test A+B
- Shoulder abduction test
- Valsalva maneuver
- Neck Distraction
- ULTT A+B
- All inclinometer for saggital and frontal and goni for rotation
- Prevalence of CR and CTS was 23% and 35%
- ULTTA + (+LR 1.3)
- involved cervical rotation < 60 degrees (+ LR 1.8)
- distraction test (+LR 4.4)
- Spurling A (+LR 3.5)
- Two positive: +LR 0.88 PTP: 21%
- Three positive: +LR: 6.1 PTP: 65%
- All positive: +LR: 30.3 PTP: 90%
Clinical Utility: Three + tests increase the liklihood from 23% to 65%, which makes this cutoff worth looking at clinically. The fact that the PTP with all 4 is 90% is very clinically useful. With experience, I see that there are neurologists and orthopedic spine surgeons utilizing a version of this CPR . I am not aware if the study was read by these clinicians.