Original Article
EFFECTIVENESS OF TENS VERSUS INTERM ITTENT CERVICAL
TRACTION IN PATIENTS W ITH CERVICAL RADICULOPATHY
Himanshi Sharma
* 1, Nirali Patel
2.
* 1 Lect urer, Pioneer Physiot herapy College, Vadodara Gujarat , India.
2 BPT (St udent-Intern), Pioneer Physiot herapy College, Vadodara, Gujarat , India.
Background: Cer vical radiculopat hy is a dysfunct ion of nerve root of t he cervical spine w here C6& C7 nerve root s are the most com monly affect ed. It encom passes im port ant sym pt om s ot her t han pain, such as parest hesia, num bness and m uscle w eakness in derm at om al or m yot om al dist ribut ion of an affect ed nerve root . A m ult it ude of physical t herapy interventions have been proposed t o be effect ive in the managem ent of cervical radiculopat hy, including m echanical cervical t ract ion, m anipulat ion, t herapeut ic exercises and TENS. St udies t o find out t he effect iveness of TENS versus Int erm itt ent Cervical Tract ion am ong pat ient s w it h Cervical Radiculopat hy are spar se.
Hence t he pr esent st udy w as undert aken t o f ind out and com pare t he effect iveness of TENS versus Int erm it t ent Cer vical Tract ion a new er t echnique t ow ards bet t erm ent in t reat m ent of cervical radiculopat hy pat ient s. M et hodology: 30 pat ient s from Baroda associat ion for t he blind (Lions club of Bar oda), Subhanpura & Sushrut Physiot herapy Clinic, Akot a w ere chosen based on t he inclusion and exclusion crit eria. Group A com prised of 15 people wit h cervical radiculopat hy w ere given TENS w ith Isom etric neck exercises and active neck m ovem ent s. Group B com prised of 15 people w it h cervical radiculopat hy w ere given Int erm itt ent Cervical Tract ion w it h Isom et ric neck exercise and act ive neck m ovem ent s. VAS Scale & Neck Disabilit y Index (NDI) w ere used as out com e m easures pre & post t reat m ent .
Results:The pre t est evaluat ion show ed t hat , t here is no significant difference (P> 0.05) bet w een t he t w o groups for all t he variables m easured. The post -t est evaluat ion of bot h groups show ed a very high significance (P< 0.05) w it hin t he group for all t he out com e m easurem ent s. A post -t est com par ison of m easur ed variables, bet w een t he groups show ed t hat t he Group A dem onst rat ed a st at ist ically significant (P< 0.05) reduct ion in pain and Neck Disabilit y Index.
Conclusion: Fr om t he above st udy concluded t hat TENS w as m or e eff ect ive in t he m anagem ent of cervical radiculopat hy along w it h isom et r icneck exercise, in r educing bot h neck & ar m pain, neck disabilit y & in im proving act ivit ies of daily living.
KEYW ORDS: Cervical Radiculopat hy, TENS, Int ermitt ent Cervical Tract ion Isom et ric Neck Exercise, Neck Disabilit y Index.
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Himanshi Sharma, M PT( M IAP), Lect urer, Pioneer Physiot herapy College, Vadodara, Gujarat , India. M obile No.: +918511157894 E-M ail: himanshi_anil@yahoo.co.in DOI: 10.16965/ ijpr.2014.693
Cervical radiculopat hy is a dysfunct ion of nerve root of t he cervical spinew here C6& C7 nerve r o ot s ar e t h e m ost com m onl y af f ect ed .1 ,2
In t he younger populat ion, it is a result of a disc
herniat ion or an acut e injury causing foraminal impingement of an exist ing nerve w hereas in older pat ient s, cervical radiculopat hy is oft en a result of foraminal narrow ing from ost eophyt e format ion, decreased disc height , degenerat ive changes of t he uncovert ebral joint s ant eriorly
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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Accept ed : 11-11-2014 Published (O): 11-12-2014 Published (P): 11-12-2014 Received: 01-11-2014
Peer Review : 01-11-2014 Revised: 05-11-2014
M ETHODOLOGY
& of t he facet joint s posteriorly.1,2It encompasses import ant sympt oms other t han pain, such as parest hesia, numbness and muscle w eakness in dermat omal or m yot omal dist ri-but ion of an affect ed nerve root .1,2
Alt hough pat ient s w it h cervical radiculopat hy may have com plaint s of neck pain, t he most frequent reason for seeking medical assist ance is arm pain.2
The first choice of m anagem ent of cervical radiculopat hy is non-operat ive, and various noninvasive int ervent ions have been used w it h mixed result s. A mult it ude of physical t herapy int ervention have been proposed t o be effect ive in t he management of cervical radiculopat hy, i n cl u d in g m ech an i cal cer v i cal t r act io n , manipulat ion, t herapeut ic exercises and TENS.2
TENS stands for Transcutaneous Elect rical Nerve St imulat ion used t o t reat pain.3
Pain cont r ol TENS unit s t ypically pr oduce a continuous train of pulsed current at frequencies in t he range 1 t o 120Hz, some as high as 200Hz. The pulses are normally rectangular, or close t o rect angular, in shape, biphasic & t he pulse durat ion is norm ally 50-200us.3 The aim is
select ively t o excit e A-B(bet a) [sensory] nerve fibers & produce an analgesic effect by ‘gat ing’ signals conveyed by pain {A-S(delt a) & C} fibers.
High rat e TENS opt imally st imulat es A-B (bet a) fibers, not because of it s higher frequency but sm all pulse w idt h. The short pulse durat ion result s in preferent ial recruit ment of t he largest diamet er nerve fibers.
Pain relief has a rapid onset & t he st imulat ion can be used for ext ended periods of t ime in a day and for a longer period.3Low rat e TENS is
assumed by some t o opt imize t he product ion of encephalin & endorphins. Brief intense TENS has a rapid induct ion & is used for more int ense pain, such as prior t o or follow ing a painful local procedure.3 ICT has t he mechanical benefit of
t emporarily separat ing t he vert ebrae, causing m echanical sliding of t he facet joint s in t he spine, & increasing t he size of t he int ervert ebral foramina. If done intermittently, this motion may help reduce circulat ory congest ion & relieve pressure on t he dura, blood vessels, & nerve root s in t he int ervert ebral foramina.4 St udies t o
find out t he effect iveness of TENS versus ICT
among pat ient s w it h cervical radiculopat hy are sparse. Hence the present study was undertaken w it h an int ent ion t o f ind out and com par e ef f ect iveness o f TENS ver sus ICT a new er t echnique t ow ards bet t erment in t reat ment of cervical radiculopat hy pat ient s.
M ethod of data collection:
30 pat ient s from Baroda association for t he blind (Lions club of Baroda), Subhanpura & Sushrut physiot herapy clinic, Akota w ere chosen based on t he inclusion and exclusion crit eria. Pat ient s w ere explained about t he st udy.
Inclusion criteria
1) Bot h t he sexes bet w een age group 40 t o 60 years w ere taken.
2) Sympt oms posit ive t o cervical radiculopat hy
3) Pat i en t s sho w i ng p osi t iv e cer v ical compression t est , manual cervical dist ract ion t est ,
4) Sympt oms limit ed t o low er cervical spine(C 5, 6, 7)
Exclusion criteria
1) Cervical inst abilit y
2) Cord compression
3) Spinal t umors
4) Spinal infect ions
5) Previous spinal injury
6) Recent m ot or vehicle accident involving cervical spine
7) Syst emic disease
8) Severe ost eoporosis
9) Hist ory of psychological or physical illness
St u d y d e sign: pr o spect iv e lo n git u d in al int ervent ional st udy
Interventions
Group A comprised of 15 people w it h cervical radiculopat hy given TENS w it h Isomet ric neck exercises and act ive neck movement s.
TENS parameters:-Frequency: 5Hz Intensit y: high Pulse durat ion: 300 M icro sec.
Durat ion: 20 minut es, 4 session/ w eek.
Group B comprised of 15 people w it h cervical radiculopathy were given ICT w it h Isometric neck exercise and act ive neck movement s.
Tract ion parameters:-Tract ion force: 1/8 of body w eight
Rat io of hold: rest - 4:1 Durat ion: 15min once a day 4 session/ w eek.
Pat ient posit ion: supine lying
Samples size: 30 subject s (15 in each)
Study duration: The t ot al durat ion of t he st udy is 1 w eek.
Outcome measures: VAS Scale, Neck Disabilit y Index
RESULTS
The collect ed dat a w as analyzed using t he Graph Pad Pr ism 6. The d at a col l ect ed b y Neck Disabilit y Index w as analyzed using paramet ric t est s as t he dat a w as int erval in nat ure. The intra gr oup pr e and post -t est dat a for NDI w ere analyzed using paired t -t est , w hile t he post -t est int er group dat a w ere analyzed w it h unrelat ed t -t est . The dat a collect ed by visual analog scale w ere analyzed using non-parametric tests as the dat a is ordinal in nat ure. The int ra group pre and p o st -t est VAS sco r es w as an al y zed u si n g Wilcoxon signed rank t est , and post -t est int er group VAS scores w ere analyzed w it h M ann Whit ney U-t est . The st at ist ical significance or t he P value for all t he analyzed dat a w as fixed at 0.05.
The m ean age for Group I w as 46.6±6.15and Group B was 49.40±6.60 as show n in Table-1.
Group I consist ed of 15 subject s (n = 15), w it h a gender dist r ibut ion of 12 m ales (80%) and 3females (20%). Group II also consist ed of 15 subject s (n=15) and a gender dist ribut ion of 9 males (60%) and 6 females (40%). This dat a is presented in Table-2.
The m ean and t he st andard deviat ion (SD) of pre and post -t est NDI scores for bot h, Group I and Group II are presented in Table -3. Compared w it h t he base line, t he post-t est mean NDI score f or Gr oup I w as 16.4±0.7and Gr oup II w as 20.6±2.25.The int ra group pre and post-t est analysis of t he NDI scor e in Gr oup I show s p<0.01,t cal=19.32), w hich is highly significant st at ist ically (p < 0.05). These result s are
p r esen t ed in Tab l e-6& f ig-2.Th e r esul t s presented in Table -9 and Fig-4 show s t he post-t espost-t com parison of post-t he NDI scores bepost-t w een Group I and Group II. Group I show s p<0.0028) w hich is st at ist ically significant (P>0.05).The mean and t he standard deviation (SD) of pre and post-test VAS scores for bot h, Group I and Group II are presented in Table-4& fig-3& 4. Compared w it h t he base line, t he post-test mean VAS score f o r Gr ou p I w as 6±1.14an d Gr o u p II w as 4.6±1.04The pre-post t est comparison of VAS score for Group I (t cal=20.02, p<0.002), show s a st at ist i cally high ly si gnif icant r edu ct ion in r epo r t ed r at e of p ai n af t er o n e w eek o f intervent ion. The post test comparison of VAS score between the tw o groups reveals that Group I fared bet t er t han Group II as show n in t able10.
Table 1: Show ing Age, m ean, SD for Group I & II.
GROUP-1 GROUP-2
AGE
M EAN 46.6 49.4
SD 6.15 6.6
Table 2: Percent age of gender dist ri but ion in bot h t he gr oups
Table 3: M EAN & SD for NDI for Group I & II.
PRE
TREATM EN T 25 1.4 25.4 4.14
POST
TREATM EN T 16.4 0.7 20.6 2.25
M ean SD Group -2 Group -1
M ean SD
Table 4: M EAN & SD for VAS Scale for Group I & II.
Pre
t reat m ent 6.5 1.12 4.2 1.15
Post
t reat m ent 6 1.14 4.6 1.04
SD M ean SdD
Group-1 Group-2
M ean
Table 5: NDI for ICT pre & post t reat m ent .
NDI(ICT) Pre Treat m ent VS Post Treat m ent P Value P<0.001
Table 6: NDI for TENS pre & post t reat m ent .
NDI TENS Pre Treatm ent V/ S Post Treat ment
P Value <0.001 19.32 Tcal
Table 7: VAS for TENS pre & post treat m ent .
VAS for TEN S Pre & Post Treat m ent P Value P<0.002
Tcal 20.02
Table 8: VAS for ICT pre & post t reat m ent .
VAS score ICT Pr e and post t reat ment P Value P<0.0001
Tcal 9.283
Table 9: Post t reat m ent NDI difference bet w een TENS v/ s ICT.
NDI Post t reat m ent TENS V/ S ICT P Value P<0.0028
Table 10: Post t reat m ent VAS scoredifference bet w een TENS v/ s ICT.
VAS score Post Tre atm ent TEN S V/ sS ICT P Value P<0.003
Fig. 1: NDI for ICT pre & post t reat m ent .
Fig. 2: NDI for TENS pre & post t reat m ent .
Fig. 3: VAS for TENS pre & post t reat m ent .
0 2 4 6 8 10
Fig. 4: VAS for ICT pre & post t reat m ent .
Fig. 5: post t reat m ent NDI difference bet w een TENS v/ s ICT.
Fig. 6: Post t reat m ent VAS difference bet w een TENS v/ s ICT.
DISCUSSION
This st udy show s t hat “ cervical radiculopat hy is most ly seen in housew ives & computer w orkers than t he drivers and policemen due t o prolonged st at ic post ure and poor ergonom ics.13,14 The
result s of t his st udy revealed t hat bot h groups demonstrated a highly significant improvement in reducing pain as measured by VAS (P<0.05) & decreasing neck disabilit y & improving functional act ivit ies as measured by NDI (P<0.05).Furt her
it show ed t hat , t he reduct ion in pain & neck d i sab i li t y i s si gn if i can t m o r e i n t h e TENS combined w it h Isomet ric Neck Exercise & act ive m o vem ent s w h en co m p ar ed again st t h e Intermittent Cervical Tract ion group.
The highly reduct ion in t he pain could be due t o t he analgesic effect s of TENS. In TENS pain gat e t heory w ork. The possible mechanism of non-acut e pain relief by low rat e TENS at mot or level st imulat ion is peripheral block or act ivat ion of cent ral inhibit ion. The induct ion of rhyt hm ic cont ract ion may also act ivat e t he endogenous opiat e mechanisms of analgesia7. It gives best
result s in shorter durat ion.7 Young et al. (2009)
exam ined t he eff ect s of m anual t her apy & exercise, w it h or w it hout t he addit ion of cervical t ract ion, on pain, funct ion & disabilit y in pat ient s w it h cervical radiculopat hy. The result s suggest t hat t he addit ion of mechanical cervical t ract ion t o a mult imodal t reat ment program of manual t her apy and exer cise yi elds no sign if icant addit ion benefit t o pain, funct ion, or disabilit y in pat ient s w it h cervical radiculopat hy.5 Subhas
Chandra Rai et al st at ed t hat even t hough TENS and neck exercise are effect ive, t he addit ion of int erm it t ent cervical t ract ion w it h TENS and exer ci se i s ev en m or e ef f ect i v e i n t h e management of cervical radiculopat hy and t hat ICT should have a place in t he management of cervical radiculopat hy.7
Graham N et al stated that ‘ The current literat ure does not support the effectiveness of ICT for pain r educt ion, im pr ove funct ion. Conser vat ive t r eat m en t w h i ch i n cl u d e TENS, neck st rengt hening exercise are more effect ive t han t hat .11
The mechanism by w hich ICT reduces neck & ar m p ai n is p ossi bl y by u nl o adi n g t h e component s of t he spine by st ret ching muscles, ligament s & functional unit s, reducing adhesions within the dura sleeve, nerve root decompression
w it hin t he cent ral foramina. But in int ermit t ent cervical t ract ion pat ient is not aw are of hold and rest period. So pat ient cont ract his muscle. A lit tle post t reat ment muscle soreness in the neck is common, but too much soreness or an increase in peripheral sympt oms is a sign t hat t he force may have been increased t oo quickly.12,13
A common problem from administ ering cervical t ract ion w hen using a head halt er is aggravat ion of the t emporomandibular joint s because of t he force applied at t he chin. 14,15,16 Wit h advancing
age, t he t issues become m ore suscept ible t o disrupt ion & joint t rauma, w hich, in some cases, may be irreversible. Cervical t ract ion should be car ried out w it h caut ion 15,16,17. In t he older
pat ient s part icularly, excessive pressure on t he j aw can lead t o i n t r acapsu lar bl eed i n g & hemat oma in t he t emporomandibular joint .15
CONCLUSION
From t he above st udy it can be concluded t hat TENS w as more effect ive in t he management of cervical radiculopathy along with INE, in reducing bot h neck & ar m pain, neck disabilit y & in improving act ivit ies of daily living.
Limitations of Study
St udy w as done on sm all sam ple size and object ive measures w ere limit ed
Abbreviations
TENS- Tr anscu t an eou s El ect r i cal Ner v e Stimulat ion
ICT-Intermittent Cervical Tract ion
INE-Isomet ric Neck Exercise
VAS-Visual analog scale
NDI-Neck Disabilit y Index
ACKNOW LEDGEM ENT
I w ould like t o t hank all t he pat ient s w ho w ere a part of my st udy.
REFERENCES
Conflicts of interest: None
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How to cite this article
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Him anshi Sh ar m a, Ni r al i Pat el. EFFECTIVENESS OF TENS VERSUS INTERM ITTENT CERVICAL TRACTION IN PATIENTS W ITH CERVICAL RADICULOPATHY. Int J Physiot her Res 2014;2(6):787-792.
