1

BENEFITS OF USING UPRIGHT AND FLEXION TECHNIQUE

OF CERVICAL TRACTION IN THE TREATMENT OF

CERVICAL SPONDYLOSIS

BY

IGWE, AUGUSTINE ASIDUBA

PG/M.Sc/05/45015

A DISERTATION SUBMITTED TO

THE DEPARTMENT OF MEDICAL REHABILITATION

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

COLLEGE OF MEDICINE, UNIVERSITY OF NIGERIA.

ENUGU CAMPUS.

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF

MASTER OF SCIENCE IN MEDICAL REHABILITATION.

…………………………………..

SUPERVISOR: PROF. G. C. OKOYE

APRIL, 2012.

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APPROVAL PAGE

NAME: IGWE, AUGUSTINE ASIDUBA

DEGREE: MASTER OF SCIENCE (M.Sc) IN

MEDICAL REHABILITATION

TITLE OF DISSERTATION: BENEFITS OF USING UPRIGHT

AND FLEXION TECHNIQUE OF

CERVICAL TRACTION IN THE

TREATMENT OF CERVICAL

SPONDYLOSIS

EXAMINING COMMITTEE

1. HEAD OF DEPARTMENT ………………………….. MR. S. E. IGWE 2. PROJECT SUPERVISOR ………………………….. PROF. G. C. OKOYE 3. EXTERNAL EXAMINER ………………………….. PROF. P. U. NWOHA 4. INTERNAL EXAMINER …………………………..

5. APPROVAL DATE …………………………..

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DEDICATION

I dedicate this work to all my patients as a clinical personnel

especially those that volunteered to participate in this study.

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ACKNOWLEDGEMENTS

I wish to acknowledge the following without whose

contributions; this work would not have been completed. My

greatest thanks go to my supervisor Prof. G. C. Okoye, Dean

Faculty of Health Sciences and Technology, College of Medicine,

University of Nigeria, Enugu Campus for all his encouragement,

patience and dedication towards nurturing this project to

completion. I also express my gratitude to Mr. S. E. Igwe, Head

Department of Medical Rehabilitation, Faculty of Health

Sciences and Technology, College of Medicine University of

Nigeria, Enugu Campus, for his kindness and assistance. I also

express my gratitude to Dr. G. O. Eyichukwu, Chairman,

Research, Education and Training, National Orthopaedic

Hospital Enugu for his advice and assistance.

My thanks also go to Dr. C. U. Eze, Head, Department of

Medical Radiography and Radiological Sciences, Faculty of

Health Sciences and Technology, College of Medicine University

of Nigeria, Enugu Campus, for his help. I also appreciate the

assistance of departmental secretary and all those who

contributed in one way or the other in bringing this work to

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conclusion. Most of all I thank the almighty God for giving me

the courage to persevere in bring the work to conclusion.

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Abstract

In this study an attempt was made to assess the use of cervical

traction for the treatment of pain in cervical spondylosis. Thirty

(30) patients (18 male and 12 female), mean age 50. 20 ± 8.51

years, mean weight 86.31 ± 14.83 were available for this study

whereby a cross over research design was used to evaluate infra

red radiation only as a control paradigm, and cervical traction

combined with infra-red radiation as experimental paradigm.

Infra red radiation was applied three times a week for six weeks

before a wash out period of 7 days and then cervical traction

and infra red radiation were applied on the same patients to

observe their therapeutic effect for the same six weeks at three

times per week.

The pain score using Numeric rating scale was evaluated before

the treatment, after two weeks, four weeks and then after the

sixth week. The patients were treated three times per week each

for 6 weeks. The result showed that both infra red radiation

alone and cervical traction combined with infra red radiation

showed relief of pain but infra red combined with cervical

traction was superior to infra red radiation alone in the

treatment of pain in cervical spondylosis (p < 0.05).

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TABLE OF CONTENTS Title Page Title Page………………………………………………………………………….i Approval Page……………………………………………………………..ii Dedication…………………………………………………………………iii Acknowledgements………………………………………………………iv Abstract………………………………………………..…………………..v Table of Contents………………………………………………..………vi List of Figures ……………………………………………………………ix List of Plates……………………………………………………………….x List of Tables……………………………………………………………..xi List of Graphs..………………………………………………………….xii CHAPTER ONE Introduction 1.1 Background of the study ……………………………………...1 1.2 Statement of problem …………………………………………..7 1.3 The main purpose of study……………………………………9 1.4 Objectives of study……………………………………………...9 1.5 Research Questions…………………………………………….9 1.6 Hypothesis………………………………………………….……10 1.7 Significance of the study……………………………………..10 1.8 Scope of study…………………………………………………..11 1.9 Definition of terms………………………………………….….11 CHAPTER TWO Literature Review 2.1 Relevant anatomy of the neck………………………………14 2.2 Aetiology of cervical spondylosis……………………………20 2.3 Prevention of cervical spondylosis…………………………21 2.3.1 Primary prevention……………………………………………21 2.3.2 Secondary prevention………………………………………..22 2.3.3 Tertiary prevention……………………………………………22 2.3.4 Sitting…………………………………………………….……22 2.3.5 Lying………………………………………………………….…24 2.4 Pathophysiology……………………………………………...24 2.5 Symptoms……………………………………………………..27

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2.6 Examination and test………………………………………30 2.6.1 Physical finding……………………………….…………... .31 2.6.2 Radiological Exam…………………………………………..32 2.6.3 Differential diagnosis………………………………………32 2.6.4 Comparison of cervical spondylosis with Acute

Cervical Joint Lock and cervical sprain………………34 2.6.5 Histologic findings………………………………..……….35 2.7 Rehabilitation programme……………………………....35 2.7.1 Physical Therapy………………………………………..…35 2.7.2Occupational Therapy……………………………………37 2.7.3 Recreational Therapy…………………………………….38 2.7.4 Medical Complications…………………………………..38 2.7.5 Surgical Intervention…………………………………….39 2.7.6 Consultations with the following Specialists

may be helpful…………………………………………….40 2.7.7Medication…………………………………….…………...40 2.7.8Deterence/Prevention………………………………….. 41 2.7.9Prognosis……………………………………..…………….42 2.8 Infra red radiation…………………………….…………42 2.9 Cervical traction………………………………………….43 CHAPTER THREE Subjects, Materials and Methods 3.1 Introduction……………………………………………….49 3.2 Research design……………………………………….…49 3.3 Area of the study…………………………………………49 3.4 Target population………………………………………..50 3.5 Sampling Technique…….……………………………...50 3.6 Sample size……………………………………………….51 3.7 Subject description……………………………………..52 3.8 Selection Criteria………………………………………..52 3.8.1 Inclusion Criteria………………………………………..52 3.8.2 Exclusion Criteria………………………………………52 3.9 Materials………………………………………………….53 3.10 Procedure for data collection…………………………54 3.10.1Ethical consideration…………………………………54 3.10.2 Subject Recruitment…………………………………55 3.10.3 Anthropometric and biodata collection………….55 3.10.4 Physiotherapy diagnosis……………………………56 3.10.5 Measurement………………………………………….56 3.10.6 Treatment…………………………………….………..55

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3.11 Method of Data Analysis……………………………59 CHAPTER FOUR Results and Discussions 4.1 Results………………………………………………….60 4.2 Test of Hypothesis……………………………………77 4.3 Discussion……………………………………………..79 CHAPTER FIVE Summary, Conclusion and Recommendation 5.1 Summary…………………………………………..…..81 5.2 Conclusion……………………….……………………82 5.3 Recommendation……………….……………………82 5.4 References………………………….………………….84 Appendices: Ethical Approval Master Sheet of Data Collected

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List of Figures

Figure I Spinal Skeleton………………………………………… 14 Figure II Fourth Cervical Vertebra…………………………… .16 Figure III Zygapophyseal Joint………………………………… 17

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List of Plates

Plate I Infra Red to the neck…………………………………… 56 Plate II Cervical Traction Inflexion ……………………………. 58 Plate III Cervical Traction in Extension ……………………. 58

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List of Tables

Table I Basic Data on Patients used………………………… 61 Table II Analysis of Control Group Infra Red

Radiation only………………………………………… 62 Table III Analysis of the Experimental Group – Cervical Traction and Infra Red Radiation………………………… 67 Table IV Comparing the Control (Infra Red Radiation) and Experimental Group (Cervical Traction and Infra Red Radiation) ……………………………………….… 72

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List of Graphs

Graph a. Comparing the Relief of pain in Infra Red Radiation and Cervical Traction plus Infra Red Radiation. …..75 Graph b. Sex in relationship to the relief of pain in the patients ………………………………………………………………….76 Graph c. Age in relationship to the relief of pain in the patients…………………………………………………………………. 77

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List of Figures

Figure I Spinal Skeleton………………………………………… 14

Figure II Fourth Cervical Vertebra……………………………. 16

Figure III Zygapophyseal Joint…………………………………. 17

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List of Plates

Plate I Infra Red to the neck…………………………………… 56

Plate II Cervical Traction Inflexion ……………………………. 58

Plate III Upright distraction……………… ……………………. 58

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List of Tables

Table I Basic Data on Patients used………………………… 61

Table II Analysis of Control Group Infra Red

Radiation only…………………………………………… 62

Table III Analysis of the Experimental Group – Cervical

Traction and Infra Red Radiation………………………… 67

Table IV Comparing the Control (Infra Red Radiation)

and Experimental Group (Cervical Traction and

Infra Red Radiation) ……………………………………….… 72

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List of Graphs

Graph a. Comparing the Relief of pain in Infra Red

Radiation and Cervical Traction plus Infra Red Radiation. …..75

Graph b. Sex in relationship to the relief of pain in the

patients ………………………………………………………………….76

Graph c. Age in relationship to the relief of pain in the

patients…………………………………………………………………. 77

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CHAPTER ONE

Introduction

1.1 Background to the study

Cervical spondylosis is a very common and painful condition

affecting many people. It is a disorder caused by abnormal wear

and tear of the cartilage and bones of the neck (cervical

vertebrae) leading to degeneration and mineral deposits in the

cushions between the vertebrae (cervical disk) (Freedman 2006).

It can also be thought of as “grey hair” of the spine (Garfin and

Bono, 2011). Over the years, there had been divergent opinions

on the relevance of cervical traction in the management of neck

pain. The controversy was based on appropriate weight needed

for cervical traction on one side and the appropriate type of

conditions of neck pain that needs cervical traction on the other

side (Saunders, 1998). Consequently, there is no common

conclusive scientific opinion on this issue. The above

controversy makes it relevant for this study to be conducted in

order to assess the efficacy of this type of intervention in neck

pain management, especially with regards to pains associated

with cervical spondylosis.

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Most neck pains are caused by a strain and can be treated

without surgery. Affected patients may be required to undergo

cervical traction, wear a cervical collar to limit neck movement

and support one’s head, in addition to short term bed rest

which allows one to rest neck muscles (Freedman, 2006). Of all

these treatment options cervical traction appears to be a more

relevant non-invasive approach in managing pains related to

cervical spondylosis. This form of treatment gently pulls apart

the head and stretches neck muscles thereby allowing the

cervical vertebrae which lie in between the head and the

thoracic spine to distract, thus relieving nociceptive pressure

exerted on nerve roots which emerge from discal spaces to

supply the muscles of the neck and upper limbs (Last, 1986). A

portable cervical traction device can be used at home or office.

Most studies (Hinderer and Biglin, 2002) have concluded that

elongation of cervical spine, by 2 – 20mm, can be achieved with

12.5kg or more of tractive force, 5kg of which is needed to

counter balance the weight of the head (less in some persons,

more in others). It is proposed that prolonged pull on the

cervical spine with adequate force leads to fatigue of cervical

paraspinal muscles, which are potentially of therapeutic value

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in pain management when muscle spasm is present (Hinderer

and Biglin, 2002).

The amount of pull should be specified in the traction

prescription. Ordinarily cervical traction must comfortably pull

the head upward and forward at an angle of 30o from the

horizontal, and must be applied twice daily, and for periods of

30 minutes at a time. For cervical spine, distraction, forces

above 12.5kg needs to be achieved, but forces above 25kg

probably do not provide any additional advantage (Hinderer and

Biglin, 2002). In essence, available literature suggests that

properly applied cervical traction has great value in cervical

problems and needs to be further explored when pains arising

from cervical spondylosis are involved.

TYPES OF CERVICAL TRACTION

i. Halter Traction

This is a standard home cervical traction which is usually

accomplished in a sitting position. This apparatus affixes

to the back of an internal door and consists of a cervical

halter, a length of a cord over a pulley attached to the door

frame and weight most commonly a plastic bag filled with

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water or a metallic weight corresponding to certain

kilogrammes

ii. Cervical Traction in supine position without force exerted

on the chin.

iii. Manual Mobilization and/or manipulation of the cervical

spine. This is indicated for patients younger than 45years

old. This age limit however, is not absolute (Winkel, et, al,

1996).

In limitation of motion in the upper cervical spine,

mobilization is indicated only when instability in that area

has been specifically ruled out. Mobilization is indicated in

functional disturbance of the cervical column even without

the presence of a disc lesion; of course all contraindication

must first be ruled out (Winkel, et al, 1996)

iv. Self Treatment

This is a series of technique proposed by Mckenzie which

employs application of repeated movements and sustained

positions that centralizes and abolishes the patient’s

symptoms (Rath 1984)

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v. Cervical Airtrac

This is a scientific design; orthopaedic ambulatory traction

apparatus anatomically designed, thin weight, allows

nearly a full range, while wearing. “Airtrac 3000” helps

relieve weak shoulder muscle stress and radiating

discomfort. Soon after wearing cervical Airtrac 3000, the

disc compression and protruded cervical disc is reduced

due to the elongated intervertebral disc spaces and

foramina by cervical Airtrac Traction function. This

Cervical Airtrac elongates intervertebral disc resulting in

relief of the irritated nerve roots. By using Airtrac several

minutes each time, several times a day, Airtrac promotes

reduction of discomfort and relief of symptoms.

vi. Cervical Traction “Airplus or Airplus Deluxe”

Cervical Traction “Airplus” or “Airplus Deluxe” is a unique

designed neck elongation, and traction exercise device. It

relieves muscle spasm, stress and pressure in the neck,

shoulders, head and cervical vertebrae which gives result

in just a few short minutes after use. The main function is

based on relieving pressure from cervical disc.

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vii. Dr Riter’s “Real-Ease” Neck and Shoulder Relaxer

This cervical and shoulder support system is very

comfortable whenever one can lean back or lie down on it

for 10-15 minutes. The Real-Ease shoulder and neck

relaxer will do the rest by aiding in relaxation.

1.2 Statement of the problem

The Royal College of General Practitioners in London

reported that “traction does not appear to be effective for

neck pain and low back pain” (Saunders, 1998). This

conclusion was given a three star rating which means that

the weight of evidence was a general consistent finding.

However, Saunders (1998) disagreed with the conclusion

of the Royal College of General Practitioners and based her

assertion on the possibility that their study either involved

the patients who could not benefit from cervical traction or

that the patients were under-loaded. Nevertheless, the

findings of another study conducted by Al-shatoury and

Galhom (2009) seem to support earlier view demonstrating

that traction in treatment of cervical pain is not better

than placebo in 2 randomized group treated. However,

their views were contradicted by a more recent study by

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(Shakoor, et, al, 2010), and involved two groups of patients

suffering from cervical spondylosis who were treated with

cervical traction plus exercises and non-steroidal anti-

inflammatory drug (NSAID), respectively. It was found that

the improvement or relieve of pain among the patients

with cervical spondylosis was more in the group treated

with cervical traction plus exercise than those treated with

NSAID alone.

In essence, there is lack of convergence of expert opinions

on the clinical benefits of cervical traction prescription in

pain management among patients suffering from pain due

to cervical spondylosis. This suggests the need to reassess

the relevance of cervical traction as an adjunct therapy in

the physiotherapy treatment of patients with cervical

spondylosis. Moreover available literature suggests there is

no contemporary work of this kind in Nigeria, and thus

informs the need for this study.

1.3 The main purpose of the study

The main purpose of this study is to assess the use of

cervical traction with regard to physical management of

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cervical spondylosis in order to determine its relevance as

a clinical tool required to relieve pain among patients in

such conditions

1.4 Objectives of the study

1. To determine if cervical traction could significantly relieve

pain in patients with cervical spondylosis compared to

infra-red radiation alone.

2. To determine the influence of age on the rate of pain relief

after cervical traction in patients with cervical spondylosis.

3. To determine the influence of sex on the rate of pain relief

after cervical traction in patients with cervical spondylosis.

1.5 Research questions

1. Does cervical traction relieve pain in patients with cervical

spondylosis?

2. What is the influence of age on the rate of pain relief after

cervical traction, among patients with cervical

spondylosis?

3. What is the influence of sex on the rate of pain relief after

cervical traction, among patients with cervical

spondylosis?

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1.6 Hypothesis

This study sought to test that

1. Cervical traction when applied as a treatment modality in

patients with cervical spondylosis will reduce pain

significantly compared to infra–red radiation alone.

2. The rate of relief of pain using cervical traction therapy in

patients suffering from cervical spondylosis will be more in

younger than older patients.

3. Sex will have influence on the rate of relief of pain in

cervical spondylosis patients using cervical traction as a

therapy.

1.7 Significance of the study

1. If cervical traction relieved pain significantly in patients

with cervical spondylosis, this would help the clinicians to

prescribe straight forward adequate treatment instead of

under treating with only infra-red radiation in such

condition.

2. If the influence of age on the extent of pain relief after

cervical traction is determined it would be easier to plan

treatment regimen for the use of cervical traction for

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various age groups of patients suffering from such

conditions.

3. If the influence of sex on the extent of pain relief after

cervical traction is determined, dosage, frequency and

duration of cervical traction prescription to patients of

various gender groups would be easier to perform.

1.8 Scope of study

The study will be delimited to patients with pain arising

from uncomplicated cervical spondylosis referred to the

Physiotherapy Department, National Orthopaedic hospital,

Enugu. Study will be limited to demonstrating the efficacy

of cervical traction in the relief of pain arising from cervical

spondylosis using numerical rating scale.

1.9 Definition of terms

i. Cervical Spondylosis: This is a type of disorder caused by

abnormal wear and tear on the cartilage and bone of the

neck with degeneration and mineral deposits in the

cushions between the vertebrae.

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ii. Operational Definition of Terms

a. Level of pain: The degree or magnitude of noxious

discomfort which in the opinion of the patient represents

the scale of limitation to comfortable activities of living due

to cervical spondylosis

b. Uncomplicated cervical spondylosis: This refers to any

case of cervical spondylosis with no other disability than

pain and parasthesia.

c. Therapeutic Value: This refers to immediate benefits

arising from treatment that leads to pain reduction among

patients with cervical spondylosis.

d. Patients with cervical spondylosis: Patients who have

problem of cervical spondylosis and have been diagnosed

with this condition for at least 1 month prior to the study.

e. Parasthesia: This is a term used to signify diminished

sensory information. This refers to tingling and numbness

of the affected body area and may be the result of lesion of

any part of the afferent system.

f. Pain: Noxious discomfort which in the opinion of the

patient represents the scale of limitation to comfortable

activities of living due to cervical spondylosis.

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CHAPTER TWO

Literature Review

2.1 Relevant anatomy of the neck

The cervical spine is the most mobile region of the spinal

column. The connection of the cervical spine with the head

leads to significant functional consequences in this area.

The first thoracic vertebra lies at the highest part of the sloping

thoracic operculum. From its upper border rises the cervical

spinal column, gently convex forward and supporting the skull.

A mass of extensor musculature lies behind the vertebrae. It is

supplied segmentally by posterior primary rami and supports

the cervical spine and head. The center of gravity of head lies

relatively forward. A much smaller amount of prevertebral flexor

musculature lies in front of the vertebrae and more laterally is

attached to the thoracic operculum and the scapula. It is

supplied segmentally by anterior primary rami. This

musculature comprises longus coli, rectus capitis anterior and

rectus capitis lateralis, longus capitis, scalenus anterior,

scalenus posterior and levator scapulae. Further back the neck

extends as high as the base of the skull. On each side of the

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pharynx is a carotid sheath with the cervical sympathetic trunk

behind it. Emerging into the neck are the ninth, tenth, eleventh

and twelfth cranial nerves. Finally surrounding the whole neck

is a collar of fascia the investing layer of deep cervical fascia

which contains trapezius and sternomastoid muscle.

Functionally, the cervical spine is composed of two segments.

The upper consists of occiput, atlas (C1) and the axis (C2) while

the lower comprises functional units C3 - C7 vertebrae, flexion

and extension movements occur at the atlanto occipital joint.

The movement at C3 – C7 results in all above motions to a

variable extent at various segments.

(See diagram below)

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Figure 1: The spinal skeleton (Adapted from Spine Universe, 2007)

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The head is a lot to carry around. It can weigh about 7kg or

more. Not only does the neck fully support all that weight, it

enables one to nod, shake and turns ones head. There is no

other part of ones spine that has the ability to move so much;

90o of forward motion, 90o of backward motion, 180o of side-to-

side motion and almost 120o of tilt to either shoulder.

Technically, the neck is called the cervical spine and it begins

at the base of the skull. It contains 7 small bones (vertebrae)

which is labeled C1 – C7 the (‘C’ means cervical). The number 1

to 7 indicates the level of the vertebrae. C1 is closest to the

skull while C7 is closest to the chest.

In between each vertebrae are tough fibrous-absorbing pads

called the intervertebral discs. Each disc is made up of a tyre-

like outer band (annulus fibrosus) and a gel-like inner

substance (nucleus pulposus).

Besides the bones and the discs, the neck has joints, muscles

and ligaments. They are what make the neck so moveable.

They also stabilize the neck.

The neck houses the upper part of the spinal cord, nerve roots

and an elaborate system of arteries and veins. The nerves in

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the neck help the brain communicate with the shoulders,

arms and chest. The arteries and veins circulate blood

between the brain and the heart.

All in all, the neck is amazing and intricate. However, because

it has such freedom of movement, it’s at a high risk of pain

and injury (see figure below).

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Figure 2: The Fourth Cervical Vertebra (Adapted from Spine Universe, 2007).

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Zygapophyseal Joints

On the posterior aspect of the cervical vertebrae lie two superior

articular processes and two inferior articular processes. They

form joints with the adjacent cranial and caudal vertebrae,

respectively (See figure below).

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Figure 3: Zygapophyseal Joint between two cervical vertebrae. The joint lies within the box 1. Superior articular process: 2. Inferior articular process. (Adapted from diagnosis and treatment of the spine by Winkel et al, 1996).

37

The capsule of these joints is rather loose except at the aspect

where the laxity of the capsule decreases. The position of the

joint surfaces in the frontal plane is nearly horizontal. In the

parasagital plane, the joint facets are oriented in such a way

that when an imaginary line is drawn parallel to the joint

surface, these lines converge cranially in the direction of the

eyes. The facets of the upper disc containing segments are

oriented approximately 40o in relation to the transverse plane.

The facets of the lower disc containing segments are inclined

approximately 65o in relation to the transverse plane. To a great

extent, the position of these articular surfaces determines the

movement possibilities of the cervical spine from C2 to C7.

The zygapohyseal joints contain so called meniscoid folds which

have grown into joints from the capsule. It is still not clear

whether or not these structures are innervated and thus can

cause pain. Bogduk and Engel (1984) stated that pain does not

occur through damage to the meniscus itself but rather, for

instance because of tearing of the meniscus from the capsule.

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Pain

Pain of cervical origin has long been a challenge to physicians

and a plague to mankind. The timeless phrase “pain in the

neck” has characterized the human condition for centuries.

Mountcastle (2004) states that “pain is that sensory experience

evoked by stimuli that injure or threaten to destroy tissue,

defines introspectively by every man as that which hurts”. The

tissue sites where nociception occur are the posterior

longitudinal ligaments, nerve roots and their dural sheaths, the

facet capsule and the neck muscles. Nociception occurs from

injury, irritation, or infection of the sites. The intervertebral disc

consists of annular fibers within a mucopolysaccharide matric

with blood supply and no nerve ending other than minimal

unmyelineated nerve endings in the outer peripheral annulus

fibrosus.

Consequently only damage to the outer annular fibers can

conceivably cause pain. The nerve root emerge from cervical

spine through the foramina which contain the dorsal root

ganglion and their dural sheath both sides of nociception.

Flexion opens the foramina and extension closes them. Rotation

and lateral flexion of the neck close the foramina on the

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concave side and open those on the convex side. Passive and

active movement of the neck triggers pain by nerve compression

(Cailliet, 2002).

A functional unit is two adjacent vertebrae separated by an

intervertebral disc and posteriorly two lamina, two pedicles and

zygapophyseal joints termed facets.

2.2 Aetiology of cervical spondylosis

Cervical spondylosis results from degeneration of the cervical

spine including the cushions between the cervical vertebrae and

joints between the bones of the cervical spine. There may be

abnormal growth or “spurs” on the vertebrae. These

accumulated changes caused by degeneration can gradually

compress one or more of the nerve roots. This can lead to

increasing pain in the neck and arm, weakness and changes in

sensation.

In advanced cases, the spinal cord becomes involved. This can

affect not only the arms but the legs as well. A previous neck

injury (which may have occurred several years prior can

predispose to spondylosis, but the major risk factor is aging. By

age 60, 76% of women and 85% of men show changes, that is

40

osteophytes, marginal lipping and narrowing of disc spaces;

consistent with cervical spondylosis on x-ray (Freedman, 2006).

2.3 Prevention of cervical spondylosis

The concept of prevention can be classified into primary,

secondary and tertiary prevention.

2.3.1 Primary prevention

Primary prevention in technology entails the prevention of

harmful influences on humans during the developing stages of

products, technical systems and processes. For example, this

primary prevention occurs when government requirements are

placed on certain products or processes. These are protective

regulations in relation to noise, radiation, fire, vehicles, harmful

materials and electrical safety or house hold products. In these

instances, there is an obvious relationship; between the cause

and the possible detrimental result.

2.3.2 Secondary prevention

This concerns the early detection of physical problems and early

diagnoses. In this sense, periodic preventive examinations are

important.

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2.3.3 Tertiary prevention

Tertiary prevention can be described as prevention of worsening

of a situation. Specific technical resources are used in this

instance.

2.3.4 Sitting

Sitting on chair, should not be taken for granted. Still today, in

many countries, people squat, kneel or sit on the ground. The

origin of chairs probably lies in the boulder or other platform on

which the tribal chief sat, as time went on, ornate chairs were

made not to sit on, rather as status symbols. Even today the

status elements in thrones and directors’ chairs can be

recognized. The chair was also a symbol indicating the

scholarly, in the University setting, one still speaks of a

professorial chair. Western society without chairs is

unimaginable. Chairs can be classified roughly into upright

(hard) chairs and easy chairs.

Sitting for prolonged periods is required in schools and office

settings. Office workers spend up to three fourths of their

working time sitting. Half the working force consists of office

workers. There is much to criticize about office chairs.

42

Furthermore, the chairs found in homes are more often bad

than good. Most of the time, the biomechanical requirement

that should be incorporated into a chair’s body supporting

surfaces to guarantee relaxed mood (passive sitting) is not

observed (Winkel et al, 1996).

Arm rest for supporting the arm while sitting is of advantage by

unloading of the shoulder girdle and subsequently also of the

cervical spine. The height of the arm rest should correspond to

the level of the elbows with the arms in a slightly abducted

position. This also applies to the levels of the tabletops. Without

arm rests; the individual crosses the arms in front of the body

leaning on the table; or flexes the spine to rest the arms in the

laps. In automobiles an individual often props one arm on the

edge of the window pane or car door, or with the other arm

reaches across the back rest of the passenger seat. Seldom does

an individual drive for a long period with the hand in a “ten and

two position”. If the work requires that the centre of gravity of

the arms lies in front of the shoulders rather than underneath,

easing the work load can be attained by hanging up the arms.

43

2.3.5 Lying

When lying down on a bed, pillows could be easily deformable

and at the same time provide a good support for the head as

well as the neck.

2.4 Pathophysiology

Intervertebral disc loses hydration and elasticity with age and

these losses lead to other surrounding ligaments also losing

their elastic properties and developing traction spurs because of

loss of hydration. The disc subsequently collapses as a result of

biomechanical incompetence, causing the annulus to bulge

outward. As the disc space narrows, the annulus bulges and

the facets override. This change in turn increases motion at

that spinal segment and further hastens the damage of the

disk. Annulus fissures and herniation may complicate chronic

spondylotic changes.

As the annulus bulges, the cross-sectional area of the canal is

narrowed. This effect may be accentuated by hypertrophy of the

facet joints (posteriorly) and the ligamentum flavium, which

becomes thick with age. Neck extension causes the ligaments to

44

fold inwards, reducing the anterior-posterior (AP) diameter of

the spinal canal (Galholm, 2007).

As disc degeneration occurs, the uncinate process overrides and

hypertrophies, compromising the ventrolateral portion of the

foramen. Likewise, facet hypertrophy decreases the dorsolateral

aspect of the foramen. This change contributes to the

radiculopathy associated with cervical spondylosis. Marginal

osteophytes begin to develop. Additional stresses such as

trauma or long term heavy use may exacerbate this process.

These osteophytes stabilize the vertebral bodies adjacent to the

level of the degenerating disk and increases the weight bearing

surface of the vertebral end plates. The result is decreased

effective force on each of these structures.

Degeneration of the joints surface and ligaments decreases

motion and can act as a limiting mechanism against further

deterioration. Thickening and ossification of the posterior

longitudinal ligament (OPLL) also decreases the diameter of the

canal.

The blood supply of the spinal cord is an important anatomic

factor in pathophysiology. Radicular arteries in the dural

45

sleeves tolerate compression and repetitive minor trauma

poorly. The spinal cord and canal size are also factors. A

congenitally narrow canal does not necessarily predispose a

person to myelopathy, but symptomatic disease rarely develops

in individuals with canal larger than 13mm (Galhom, 2007).

Age

� Cervical spondylosis is a disease observed most commonly

in elderly individuals.

� Among those younger than 40 years, 25% have

degenerative disk disease (DDD) and 4% have foraminal

stenosis, as confirmed with magnetic resonance imaging

(MRI).

� In those older than 40 years, almost 60% have DDD, and

20% have foraminal stenosis, as confirmed with MRI (Galhom,

2007).

Trauma

� The role of trauma in spondylosis is controversial

� Repetitive subclinical trauma probably influences the

onset and rate of progression of spondylosis.

46

Work activity

Cervical spondylosis is significantly higher in patients who

carry loads on their heads than those who do not.

2.5.1 Symptoms

� Neck pain (may radiate to the arm or shoulder)

� Loss of sensation or abnormal sensation of the

shoulders, arms, or (rarely) legs.

� Weakness of the arm or (rarely) legs

� Neck stiffness that progressively worsens

� Loss of balance

� Headaches, particularly in the back of the head

� Loss of control of the bladder or bowels if spinal

cord is compressed (Freedman, 2006).

History

Common cervical syndromes associated with cervical

Spondylosis includes:

Cervical Pain

� Chronic suboccipital headache may be present. Mechanism

includes direct nerve compression, degenerative disk, joint or

ligamentous lesions and segmental instability.

47

� Pain can be perceived locally, or it may radiate to the occiput,

shoulder, scapula, or arm.

� The pain, which is worse when the patient is in certain

positions, can interfere with sleep.

Cervical Radiculopathy

� Compression of the cervical nerve roots leads to ischaemic

changes that cause sensory dysfunction (e.g. radicular pain)

and/or motor dysfunction (e.g. weakness). Radiculopathy most

commonly occurs in those aged 40 - 50 years.

� An acute herniated disk or chronic spondylosis changes

can cause cervical radiculopathy and or myelopathy.

� The C6 root is most commonly affected because of the

predominant degeneration at the C5 – C6 interspace, the next

most common sites are C7 and C5.

� Most cases of cervical radiculopathy resolve with conservative

management, few require surgical intervention (Freedman

2006).

Cervical Myelopathy

� Cervical myelopathy is the most serious consequence of

cervical intervertebral disk degeneration, especially when it is

associated with a narrow cervical canal.

48

� Cervical myelopathy has an insidious onset, which typically

become apparent in those aged 50 – 60 years. Complete

reversal is rare once myelopathy occurs.

� Involvement of the sphincters is unusual at presentation,

as based on the patient’s perception of symptoms.

� Five categories of cervical spondylotic myelopathy are

described; these are based on the predominant neurological

findings; as follows:

- Motor syndrome: This primarily involves the

corticospinal or anterior horn cells.

- Central cord syndrome: Motor and sensory

involvement is greater in the upper extremities than

the lower extremities.

- Brown sequard syndrome: Unilateral cord lesion with

ipsilateral corticospinal tract involvement and

contralateral analgesia are present below the level of

the lesion.

- Brachialgia and cord syndrome: Predominant upper

limb pain is present with some associated long tract

involvement.

49

Less Common Manifestations

� Primary sensory loss may be present in a glove like

distribution.

� Tandem spinal stenosis is a simultaneous cervical and

lumber stenosis due to spondylosis. It is a triad of findings:

neurogenic claudication complex gait abnormality and a

mixed pattern of upper and lower motor neuron signs.

� Dysphagia may be present if the spurs are large enough to

compress the oesophagus.

� Vertebrobasilar insufficiency and vertigo may be observed.

� Elevated hemidiaphragm, due to spondylotic compression of

C3 – C4 may be another finding.

2.6 Examination and test

A pain in the neck that continues to get worse is a sign

ofcervical spondylosis. It may be the only symptom in many

cases. Examination often shows limited ability to flex the hand

to the side (bend the head towards the shoulder) and limited

ability to rotate the head.

Weakness or sensation losses indicate damage to specific

nerve roots or the spinal cord. Reflexes are often reduced.

50

2.6.1 Physical finding

Finding at physical diagnosis may include the following:

� Spurling Sign: Radicular pain is exacerbated by extension

and lateral bending of the neck towards the side of the lesion,

which results in further foraminal compromise.

� Lhermite Sign: This generalized electrical shock sensation is

associated with neck extension.

� Hoffman Sign: Reflex contraction of the thumb and index

finger occur in response to nipping of the middle finger. This

sign is evidence of an upper motor neuron lesion. A Hoffman

sign may be significant if present bilaterally.

� Distal Weakness

� Decreased range of motion (ROM) in the cervical spine

especially with neck extension.

� Hand Clumsiness

� Loss of sensation

� Increased reflexes in the lower extremities and in the upper

extremities below the level of the lesion.

� Gait characteristically broad-based, stoop, and spastic

� Extensor planter reflex in severe myelopathy

51

2.6.2 Radiological exam

� A spine or neck x-ray shows abnormalities that

indicate cervical spondylosis.

� A computerized tomography scan (CT scan) or Spine

MRI confirms the diagnosis.

� A myelogram (X – ray or CT scan after injection of

dye into the spinal column) may be recommended to

clearly identify the extent of injury.

� An EMG may also be recommended

� An x-ray of the lower (lumbar) spine may reveal

degenerative changes in this region (Freedman 2006).

2.6.3 Differential diagnosis

� Adhesive Capsulitis

� Brown Sequard Syndrome

� Cervical Disc Disease

� Cervical Myofascial pain

� Cervical Sprain and Strain

� Chronic Pain Syndrome

� Diabetic Neuropathy

� Multiple Sclerosis

� Myofacial Pain

52

� Neoplastic Brachial Plexopathy

� Osteoporosis and Spinal Cord Injury

� Radiation-Induced Brachial Plexopathy

� Rheumatoid Arthritis

� Traumatic Brachial Plexopathy

Other problems to be considered:

- Ossification of the posterior longitudinal ligament (OPLL)

- Occipital neuralgia as a result of spondylotic changes

at C1 – C2

- Shoulder Problems

- Primary Spinal Cord Tumours

- Syringomyelia

- Extramedularly lesions – Tumours And Thoracic Disk

herniation

- Hereditary spastic paraplegia

- Normal pressure hydrocephalus

- Spinal cord infarction

- Spinal sepsis

- Whiplash syndrome-hyper extension

- Hyperflexion injury

53

- Double Crush Syndrome – coexistence of a radiculopathy

and peripheral nerve compression in the carpal or cubital

tunnel.

54

2.6.4 TABLE 1 Comparison Of Cervical Spondylosis With Acute Cervical Joint Lock And Cervical Sprain ASSESSMENT VARIABLES

ACUTE CERVICAL JOINT LOCK

CERVICAL SPONDYLOSIS

CERVICAL SPRAIN

Age of occurrence Late adolescence Usually over 30 Variable

History Sudden onset associated with quick movement but no

trauma

Gradual onset that may be related to minor trauma

Related to trauma

Common protective deformity

Rotation and lateral flexion away from the side of pain with slight flexion

Rotational and lateral flexion away from the side of pain with significant flexion

Often held rigid and unable to move in any direction

Area of pain Local cervical (C4 to C6

area) on the affected side away from which the head is tilted

More lateral (C4-C7 area)

may spread to ipsilateral scapulae often referred to ipsilateral limb and to occipital area

Varies but often

bilateral and generalized, including anterior upper chest and neck area

Neurological Findings

None The signs of altered nerve conductions may

be found

Extremely variable

Tissues likely responsible

Apophyseal joint Intervertebral junction (disk) and or osteophytes

Muscles, ligaments, tendons, joints

and discs.

55

2.6.5 Histologic Findings

Thinning and fragmentation of the articular cartilage may be

observed. The normal, smooth white articular surface becomes

irregular and yellow. Continued loss of articular cartilage leads

to exposure of areas of subchondral bone, which appears as

shiny foci on the surface (eburnation). Fibrosis, increased bone

formation, cystic changes frequently occur in the underlying

bone. Loss of articular cartilage stimulates new bone formation

usually in the form of nodules (osteophytes) at the bone edges.

2.7 Rehabilitation Programme

2.7.1 Physical Therapy

Immobilization of the cervical spine is a good treatment for

patients with cervical spondylosis. Immobilization limits the

motion of the neck, thereby reducing nerve irritation. Soft

cervical collars are recommended for daytime use only (Galhom

et al, 2007) but they are unable to appreciably limit the motion

of the cervical spines.

More rigid orthosis (e.g. Philadelphia Collar, Minerva Body

Jacket) can significantly immobilize the cervical spine. With the

use of any of the braces, the patient’s tolerance and compliance

56

are considerations. A program of isometric cervical exercise may

help limit the loss of muscle tone that results from the use of

more restrictive orthosis.

Model cervical pillow can better align the spine during sleep and

provide symptomatic relief for some patients:

� Cervical traction is also of benefit to patients

� The use of cervical exercises has been advocated in

patients with cervical spondylosis. Isometric exercises often

are beneficial to maintain strength of the neck muscles.

Neck and upper back stretching exercises as well as light

aerobic activities also are recommended. The exercise

programs are best initiated and monitored by a physical

therapist (Galhom et al, 2007).

� Passive modalities generally involve the application of heat

to the tissues in the cervical region, either by

means of superficial devices (e.g. moist heat packs) or

mechanism for deep heat transfers (e.g. ultra sound,

diathermy).

� Manual therapy (e.g. massage, mobilization, manipulation)

may provide further relief for patients with cervical

spondylosis. Mobilization is performed by a physical

57

therapist and is characterized by application of gentle

pressure within or at the limits of the normal motion with

the goal of increasing the ROM. Manual traction may be

better tolerated than mechanical traction in some patients.

Manipulation is characterized by a high velocity thrust,

which is often delivered at or near the limit of the ROM.

The intention is to increase articular mobility or realign

the spine. Contraindications to manipulative therapy

include mylopathy, severe degenerative changes, fracture

or dislocation, infection, malignancy, ligamentous

instability and vertebrobasilar insufficiency.

2.7.2 Occupational therapy

Patients with upper extremity weakness often lose their ability

to perform activities of daily living (ADL), vocational activities or

recreational activities. Lifestyle modifications may involve an

evaluation of workplace ergonomics, postural training, neck

school (supervised small-group therapy), stress management

and vocational assistance. Disability can be improved with

specific strengthening exercises of the upper extremities, special

splinting to compensate for weakness, and the use of assistive

58

devices that allow the patient to perform previously impossible

activities.

2.7.3 Recreational therapy

The recreational therapist can use recreational and community

activity to:

a. Help the patient maintain their physical strength, social

skills and motivation.

b. Assist the patient and family in adjusting to the disability.

c. Decrease the patient’s dependence.

d. Reinforce other therapies.

e. Provide community integration and

f. further evaluate the level of functioning in cases of severe

disability due to cervical spondylosis.

2.7.4 Medical complications

Cervical spondylosis may result in complications including:

� Cervical myelopathy

� Paraplegia

� Tetraplegia

� Recurrent chest infection

� Pressure sores

59

� Recurrent urinary tract infection

2.7.5 Surgical intervention

� Indications for surgery include the following:

a. Progressive neurological deficits

b. Documented compression of the cervical nerve root, spinal

cord, or both;

c. Intractable pain

� The aim of surgery is to relieve pain and neuronal

structured compression and to achieve stabilization in

select cases.

� Approaches for surgery are anterior or posterior

� Anterior approaches include the following diskectomy

without bone graft, diskectomy with bone graft, and

cervical instrumentation.

� Posterior approaches include the following decompressive

laminectomy, and foraminetomy, hemilaminectomy, and

laminoplasty.

2.7.6 Consultations with the following specialists may be

helpful:

� Psychologist or psychiatrist

60

� Neurologist

� Neurosurgeon and/or orthopaedic spinal surgeon

� Urologist

� Internist

� Occupational therapist

� Physical therapist

� Recreational therapist

� Social worker

2.7.7 Medication

The goal of pharmacology is to reduce morbidity and prevent

complications.

Drug Category Used

Non steroid anti inflammatory drugs – these agents are used in

the treatment of cervical spondylosis. If one class seems to be

ineffective after a 2 – week trial, a formulation from another

class may be tried – the most commonly used drugs are:

Ibuprofen, acetylsalicyclic acid, naproxen, indomethacin,

mefenamic acid, and piroxicam.

2.7.8 Deterrence/prevention

61

� Patients may apply the following measures to help prevent

cervical spondylosis or its complications:

- Avoid high impact exercise (e.g. running, jumping)

- Maintain cervical Rom with daily Rom exercise

- Maintain neck muscle strength, especially neck extensor

strength

- Avoid holding period (e.g. while driving or watching TV).

- Avoid prolong neck extension

- Be careful when performing physical activities that are done

infrequently; such activities can trigger a flare in symptoms.

� If the patient has early morning stiffness, a long, hot shower

every day may help.

� Cervical spondylosis is difficult to prevent because it is a part

of the normal ageing process. Individuals may reduce their

risk by maintaining good neck strength and flexibility, along

with leading an active and healthy life style. Preventing neck

injuries (e.g. using proper equipment in contact sports, head

rest and seat belt use in automobiles) may also reduce the

risk of developing this condition.

2.7.9 Prognosis

62

� Cervical spondylosis is a slowly progressive, chronic joint

disability especially when it is associated with neuronal

compression.

� Cervical spondylotic myelopathy is the most serious

consequence.

� High – signal intensity lesions can be seen on MRIs of spinal

cord compression; this finding indicates a poor prognosis.

2.8 Infra – red radiation

Infra-red radiation is emitted by luminous sources (bulbs of

various wattages) and non luminous sources (heating elements

or resistant materials). Since skin is a poor heat conductor, the

radiation penetrates the skin surface less than 10mm before

being absorbed by the tissue and converted to heat energy. A

rise in the skin temperature over 42.8oC rapidly produces

arteriolar flare and wheal. The patient feels the heat instantly.

Infra-red is commonly used for relaxation inducing relief of pain

from muscle spasm or tension, myofibrositis and rheumatic

joints. It has also been used to dry the skin over the inguinal

and perineal areas and gluteal fold to prevent bedsores. It

should not be used if the patient is sensitive to light. Reactions

63

such as heat induced urticaria have been observed (Weics,

Wodell and Brown 1976).

2.9 Cervical traction

Traction for disorders in the cervical spine ranges from

skeletal traction for fractures and for deformities, to the

use of manual traction with Turkish towel under the

occiput to separate the articular surfaces of the

zygapophyseal joints (Rath, 1984).

According to Rath (1984) cervical traction has the

following effects

a. Prevention and free up of adhesion within the dural

sleeves, nerve roots and adjacent capsular structures.

b. Relief of nerve root compression and irritation within the

intervertebral foramen

c. Separation (distraction) of the articular surfaces of the

apophyseal joint.

d. Improvement of the circulatory status within the epidural

spaces of the spinal and lateral root canals

e. Decompression of the intervertebral joint with reduction of

derangement of disk; and

64

f. Reduction of the inflammatory response pain and

subsequent muscle spasm (Rath 1984).

The intervertebral discs lying between successive vertebral

bodies from the second cervical vertebra downwards are

composed of fibro cartilage, the outer portion of which consists

chiefly of concentric rings of fibrous tissue; the annulus

fibrosous while the center of the disc nucleus pulposus is softer

and gelatinous.

The normal disc is capable of withstanding heavy load with

relatively little deformation and serves as an efficient shock

absorber. It can adapt to spinal movements and should

distribute rapidly changing stresses evenly up and down the

spine. Research suggests that many spines fail to achieve even

distribution of stresses (Mowat and Wood 1985). The tissue

sites where nociception occurs are the posterior longitudinal

ligaments, nerve root and their dural sheaths, the facet capsule

and the neck muscles.

Properly applied, cervical traction has great value in cervical

problems. It must comfortably pull the head upward and

forward at a 30 degree angle and be applied twice daily and for

65

a period of 30 minutes (Caillet 2002). Elnaggar et al (2009) was

of the opinion that both intermittent and continuous cervical

traction have a significant effect on neck and arm pain

reduction, a significant improvement in nerve function and a

significant increase in neck mobility.

In general sense, traction is another form of immobilization.

Additionally and probably most importantly, traction provides

mechanical distraction of the cervical spine. In a study carried

out by American Physical Therapy Association (2008), they

stated that clinicians should consider the use of mechanical

intermittent cervical traction, combined with other interventions

such as manual therapy and strengthening exercises for

reducing pain and disability in patients with neck and related

arm pain.

Theoretically, this opens the neuro foramen and tends to flatten

a bulging disc by placing the posterior longitudinal ligament

under stretch. Furthermore, if accompanied with some flexion,

it may relieve the pressure of osteophytes on the vertical floor of

the neural canal (Murphy and Lieponis 1989). Some however,

believe that it may increase ischaemia in the synovial tissue of

66

these joints. Quantitative changes in the cervical neural

foramen resulting from axial traction, noted a significant

increase in intervertebral foraminal area and height after each 5

kg increment in traction weight compared with the position in

which no weight was applied (Spine, 2008).

Whatever the mechanism, traction generally produced some

relief of pain particularly in the patients who exhibit a radicular

component (Murphy and Lieponis 1989). The presence of long

tract signs or myelopathy is a relative contraindication to

cervical traction in patients with severe spondylosis or disc

disease. Patients with frank disk herniation may also complain

of increased pain or radiculopathy and once traction has been

initiated, this complaint should prompt further evaluation by

means such as CT, MRI or Myelography.

Patients with massive para-cervical muscle spasm may also

complain of increased neck pain and spasm with initiation of

traction. Generally, it is advisable to control the spasm

adequately before initiation of traction.

The method of applying traction is very important. Although

some physical therapy centres have special apparatus for

67

applying cervical traction in the supine position, it has been

impractical to reproduce at bed rest. The standard home

cervical traction is usually accomplished in the sitting position.

This apparatus affixes to the back of an interior door and

consists of a cervical halter, a length of a cord over a pulley

attached to a door frame and a weight most commonly a plastic

bag that can be filled with a specific level corresponding to a

certain number of kilogram (kg). It has been found that the

optimum position imparting mild cervical flexion is achieved

with the patient facing door. As general, 4 to 6 kg of traction is

applied for 14 to 20 minutes per session. These parameters can

be adjusted according to patient’s tolerance and several

sessions per day, may be optimum tractions. Traction is

continued so long as it appears to contribute to clinical

improvement (Murphy and Lieponis, 1989).

An experiment was carried out by Cyriax (1971) to find out how

much pull is exerted when reducing cervical disc displacement.

The maximum was found to be 140kgf. Radiology was carried

out before and during fairly strong traction on the neck. It

showed that traction increased each joint space by 2.5mm. In

other words, it almost doubled the distance between the bones.

68

This is why disc lesions are not difficult to reduce as long as the

traction is adequate. In chronic or severe cases of cervical

spondylosis, the patient is admitted for halter traction (1-3

week), when the pain is severe (Murkle 1986).

In the management of cervical pain, if the traction (distraction)

manoeuvre relieves pain, cervical spine traction should be

considered (Bonica and Sola 1990). The amount of pull should

be specified in traction prescription. For cervical spine

distraction forces > 12.5kg need to be achieved but forces

>25kg probably do not provide any additional advantage

(Hinderer and Biglin, 2002). Studies (Renkens 2011) have

shown that neck traction must be constant so that the muscles

may tire and the strain fall on the joints. It generally takes 2

minutes of sustained traction before the intervertebral spaces

begin to widen. Forces between 10 and 25 kg are commonly

used to achieve intervertebral separation (Renkens, 2011). A

retrospective study found that cervical traction provided

symptomatic relief in 81% of the patients with mild-to-

moderately severe cervical spondylosis syndromes (Rana and

Crystal, 2011).

69

CHAPTER THREE

Subjects, materials and methods

3.1 Introduction

This chapter presented a detailed account of all aspects of the

method employed in this study including the study design, the

sampling process, materials for the study, procedure for data

collection and projected methods for data analysis. It also dealt

with ethical issues, reliability and validity of the instruments

that were employed in the study.

3.2 Research design

This study employed a case cross-over design. This was

adequate because the patients that were recruited for this study

already had cervical spondylosis. The response to the

experimental treatment was compared against a control

paradigm in the same patients to determine their therapeutic

effects. Thus a cross-over research design proved more relevant

to achieve the research objectives of this study.

3.3 Area of the study

The study was carried out at the Department of Physiotherapy,

National Orthopaedic Hospital, Enugu. National Orthopaedic

70

Hospital Enugu was established in the year 1974 with the

mission of taking care of those that sustained injury during the

1967-1970 Nigerian Civil War and also to take care of accident

and degenerative diseases in the former Eastern region of

Nigeria and environ. The National Orthopaedic Hospital Enugu

is a metropolitan hospital made up of approximately 8 wards

and 3 theatres. It has an estimated land mass of 120 acres of

land with a staff strength of 838 which includes 51 doctors, 217

nurses, 11 physiotherapists, 38 pharmacists, 44 laboratory

scientists, 8 radiographers amongst others.

3.4 Target population

The population of this study comprised all adult patients

between the age range of 30 – 60 years, suffering from cervical

spondylosis who were referred to the physiotherapy department

of the National Orthopaedic Hospital, Enugu between June and

October 2010. The population was made up of both male and

female patients.

3.5 Sampling technique

The study was a total study; all the patients that met the

selection criteria were included in the study.

71

3.6 Sample size

The minimum sample size for a finite population according to

Colditz (1994) is given by relation n = Z2P (1-P)/d2.

Where n = Sample Size

Z = 1.96 at 95% confidence interval

P = estimated population based on prevalence

d = precision allow 5% = 0.05.

Since the value of P is not known, the prevalence rate of cervical

spondylosis at the National Orthopaedic Hospital Enugu was

used to determine the number of patients to be involved in this

research. The prevalence rate of cervical spondylosis at National

Orthopaedic Hospital Enugu as at 2005, 2006, 2007, 2008,

2009 were 2.0%, 2.09%, 2.07%, 2.06% and 2.25% respectively

but that of the most current, that is 2009 was used thus

n = {1.962 x 0.0225 (1 – 0.0225)}/0.052 = 32

But all the available patients referred for physiotherapy

treatment within the duration of study were involved. The

number available was 30 which is less than the minimum size

of 32 and therefore allows for possible error.

72

3.7 Subject description

Subjects recruited for the study were only those with

uncomplicated cervical spondylosis between 30 and 60 years of

age.

3.8 Selection criteria

The following inclusion and exclusion criteria were applied to

this study.

3.8.1 Inclusion criteria

1. Only the patients who had uncomplicated cervical

spondylosis were included in the study

2. Only patients between 30 and 60 years of age were

included in the study

3. Only patients without visual, communication and hearing

disabilities were recruited for the study.

4. Only patients with a history of pain arising from diagnosed

cervical spondylosis, for at least 1 month prior to the

study, were involved

3.8.2 Exclusion criteria

a. Patients who had neck pain due to

i. Infection

73

ii. Trauma

iii. Tumour and

iv. Instability of the cervical spine were not included

b. Those patients with complications such as

i. Paralysis of the upper limbs

ii. Bedridden

iii. Severe hypertension or diabetes were not included

c. Patients with poor/absent thermal sensation were excluded

from the study.

3.9 Materials

- Traction kit (Model PA 51933 Cincinnati Ohio USA): A set

of traction kit (halter traction kit) was used to apply the

cervical traction on the patients.

- Graded Weights (kg, UK): Graded weights were used to

load the traction kit for traction of the cervical spine.

- Infra-red radiation lamp (Model Hanua Sollux 70 150W,

250V, UK): Infra-red lamp (luminous) was applied to the

patients to improve circulation of blood and relax muscle

spasm.

- A numeric rating scale instrument (NRS): This pain rating

scale was used for measuring the level of pain before

74

initiating treatment and at regular two weeks interval after

instituting the treatment intervention. The NRS

instrument is calibrated from 0 to 10 where 0 means no

pain and 10 is the worst pain ever experienced by the

patients.

- Soap, towel and sponge: For skin toileting to remove oil

and enhance vasodilation.

3.10. Procedure for data collection

3.10.1 Ethical Consideration

When carrying out a research, it is envisaged that this should

cause no harm or distress to the subjects for this reason ethical

permission and approval should be given. For this research

involving human subject, ethical approval from the Ethical

Committee of National Orthopaedic Hospital, Enugu was

obtained before conducting the study. All participants’

confidentiality was maintained using code numbers instead of

names and ensuring that records were destroyed after the

study. Informed consent was obtained from participants, which

means that they had adequate information regarding the

research and were capable of comprehending the information

and had the power of free choice enabling them to voluntarily

75

consent to participation in the research or decline participation.

In line with the views canvassed by Polit and Hungler (1993), it

was made clear to the participants of the study that they had

the right to refuse to participate or to withdraw at any stage of

the project.

3.10.2 Subject Recruitment

The patients were recruited from the physiotherapy clinic of the

National Orthopaedic Hospital, Enugu. Patients were enrolled in

the physiotherapy clinic at the hospital. The diagnosis of

cervical spondylosis were made at the out-patient department of

National Orthopaedic Hospital and confirmed by a referral letter

from their respective medical consultants. All the patients with

uncomplicated cervical spondylosis registered in the

physiotherapy clinic during the time of research (June –

October 2010) were recruited for the study.

3.10.3 Anthropometric and bio-data collection

The bio-data and anthropometric data (age, height, weight) of

the patients were obtained and recorded. The subjects were

required to fill a consent form after the purposes of the

experiment had been explained to them. The anthropometric

data was obtained using weighing scale (kg) and height scale

76

(cm) whereas the bio-data of the subjects were obtained based

on information given by the subjects.

3.10.4 Physiotherapy diagnosis

Physical diagnosis of cervical spondylosis was performed by

employing the Spurling Test. This was performed by

reproducing the radicular pain by extending the neck, rotating

it to one side, and pressing down on the head towards the side

of complaint. A positive test reproduces the radicular pain

(Cailliet, 2002). The cervical X-ray or radiograph was also

examined for classic features of cervical spondylosis including

the pressure of osteophytes, marginal lippings and narrowing of

discal spaces as well as degenerative changes of the cervical

vertebrae.

3.10.5 Measurement

Height

The patient’s height was obtained using the standiometer. Each

subject was asked to stand, backing the standiometer,

barefooted and eyes looking straight ahead, while the

researcher read off the height to the nearest 0.01 meter. The

measurement was taken thrice and average taken and recorded.

77

Weight

This was obtained using the weighing scale. The subjects

dressed in light clothes and were asked to stand barefooted on

the weighing scale looking ahead while the weight was read off

to the nearest kilogram. The measurement was taken thrice and

the average taken and recorded.

Pain Score

The pain intensity perceived by the subjects was obtained

through the Numeric Rating Scale of 0 – 10 (verified by Moran

et al, 2002). The procedure was explained and the subject

requested to point at the number that corresponded to the pain

he/she experiences, whereby 0 is no pain and 10 is worst

imaginable pain. The value chosen by the subject was then

recorded as the pain score. The procedure was carried out

before the treatment then at two weeks interval till the sixth

week.

78

3.10.6 Treatment

Control paradigm

Application of Infra-Red Radiation

The subjects came into the cubicle dressed in light clothing and

were administered with numeric rating scale measurement

before initiating treatment. Their necks were exposed. After a

thermal sensation test, the standing infra-red lamp was set

perpendicular to the neck for 15 minutes at a distance of 75cm

from the body to avoid scalding, after skin toileting. The

treatment was performed thrice a week for six weeks and

numeric rating scale (NRS) measurement was administered

after every two week and finally after 6 weeks. After the control

paradigm there was a 7 days wash-out before experimental

treatment was administered on the same patients.

79

Plate 1: Infra Red to the neck

Experimental Paradigm

Infra-red is applied as in the control paradigm followed by

application of load using cervical traction.

The subjects came into the treatment cubicle with light

clothing. Then he or she was instructed to sit on an

armless chair in the traction unit with both hips and

knees flexed at right angle to the vertical and horizontal

respectively. Then the canvas was hooked to the head and

the halter, and suspended on the over hanging pulley with

a cord on which opposite end was attached to the

appropriate weight. There was alternation of extension

(backing the door) and flexion (facing the door) at

subsequent visits. The weights were graded in kg and were

80

added until the tolerable weight was reached. Then 1kg

weight was removed to make the subject bear the weight

with ease for 15 minutes. The treatment was performed

thrice a week for six weeks and numerical rating scale

(NRS) measuring instrument was administered before

initiating treatment and after every two weeks and finally

at the end of 6th week.

81

Plate 2: Cervical Traction in flexion

Plate 3: Cervical Traction in upright distraction

82

Method of Data Analysis

Descriptive statistics for mean and standard deviation was

obtained and compared before and after treatment and

also obtained for age and sex. For test of significance in

the difference in mean, that is, before and after treatment

paired t-test was used (t-value < 0.05). For test of

significance in the difference in the various groups that is,

male and female and age category, independent t-test was

used. In this case the procedure was first tested F(1) equal

variance is assumed and (2) equal variance not assumed.

83

CHAPTER FOUR

Results and Discussions

Table 2 Baseline characteristics of patients evaluated at

initial assessment.

N Range Mean (x + SD)

Age (years)

Duration (months) Before treatment

Height (m)

Weight (kg)

Valid N

30

30

30

30

30

30 – 60

1-48

1.45 – 1.90

61 – 128

50.20 ± 8.51

12.53 ± 1.28

1.62 ± 0.13 86.30 ± 14.83

Note: X ± SD = mean ± standard deviation

The above table shows the baseline characteristics of the

participants of the study. It shows that the age range of the

participants is between 30 and 60 years old and that the

participants who came for the study earliest came 1 month after

the beginning of the problem and one that came latest came 48

months after and that their average age was 50.20 ± 8.51 and

that the heaviest patient was 128 kg and lightest 61kg.

84

Table 3 Pain relief with time in control group

Group N Mean (x + SD) Correlation (r) T p- Value

Pair NRS Before 1. Treatment x/10 and NRS after 2

weeks of treatment. Pair NRS Before 2. Treatment x/10 and NRS after 4 weeks of

treatment x/10 Pair NRS Before 3. Treatment x/10

and NRS after 6 weeks of treatment x/10

30

30

30

0.53 ± 0.57

0.90 ± 0.61

1.53 ± 0.87

0.91

0.90

0.91

5.11

8.12

14.70

0.00

0.00

0.00

NRS = Numerical Rating Scale

X ± SD = mean ± standard deviation

There is progressive increase in mean NRS difference as weeks

go by. The above table shows progressive increase in mean

numeric rating scale from the period before treatment to the 6th

week of treatment and the 2nd, 4th and 6th weeks shows p-value

at 0.00 which means p <0.05, that is significant.

85

Table 4. Difference in rate of pain relief by sex in control

group

Sex

N Mean (x + SD) t F P- Value

Difference in NRS After Treatment

Equal variance

assumed

Male

Female

18

12

1.56 ± 0.51

1.50 ± 0.67

0.257

1.67

0.799

X ± SD = mean ± standard deviation NRS = Numeric Rating Scale When p < 0.05 = Significant p > 0.05 = Non significant

The table above shows that the mean numeric rating scale

difference in the male at 1.56 ± 0.51 is not much different from

that of the female group at 1.50 ± 0.67. The p-value is 0.79.

That is p > 0.05, showing non-significance.

86

Table 5 Difference in rate of pain relief by age in control group.

Age N Mean (x ± SD)

t f-value

p-value

Difference in NRS after Treatment X/10

Equal variance assumed

Equal variance

30 – 44yrs

45 – 60 yrs

8

22

1.88 ± 0.64

1.4 ± 0.50

2.09

0.23

0.04

NRS = Numeric rating scale X ± SD = Mean ± Standard Deviation When P< 0.05 = Significant P> 0.05 = Non-Significant The table above shows that there is reasonable difference

between the mean numeric rating scale difference in younger

age group at 1.88+ 0.64 and older age group at 1.4. ± 0.50.

That is the younger is greater by 0.47 and P< 0.05, that is

significant.

87

Table 6 Pain relief with time in experimental group

N Mean (X ± SD)

Correlation t-value p-value

1. Pair NRS before Treatment x/10 - NRS after 2 weeks of Treatment pair

2. Pair NRS before Treatment

x/10 - NRS After 4 weeks of Treatment x/10 3. Pair NRS before Treatment

x/10 - NRS After 6 weeks of Treatment x/10

30

30

30

2.77 ±1.04

4.93 ± 1.57

6.10 ± 1.35

0.65

0.01

0.12

14.57

17.17

24.79

0.00

0.00

0.00

NRS = Numeric rating scale X ± SD = Mean ± Standard Deviation When p < 0.05 = Significant P>0.05 = non significant

The table above shows that there is progressive increase in the

mean numeric rating scale difference from before treatment to

the sixth week of treatment and the p- value for the 2nd 4th and

6th weeks showed 0.00 that is p<0.05 that is significant.

88

Table 7

Difference in rate of pain relief by sex in experimental group.

Sex N Mean (x ± SD)

t f-value p-value

Difference in NRS after Treatment X/10 Difference in NRS after

treatment X/10 Equal variance assumed

Male Female

18 12

5.94 ± 1.16 5.83 ± 1.53

0.23

0.24

0.82

NRS = Numeric Rating Scale X ± SD = Mean ± Standard Deviation The table above shows that the difference in mean numeric

rating scale difference between male and female groups is very

minimal, that is male 5.94 ± 1.16 and female 5.83 ± 1.53

and p-value is 0.82. That is the P>0.05, showing non

significant.

89

Table 8 Difference in rate of pain relief by age in

experimental group

Age Mean

(X ± SD)

t f-Value P-Value

Difference in NRS after Treatment x/10

Equal variance

assumed Difference in

30 – 44yrs 45 – 60yrs

X ± SD 6.75 ± 1.58 5.59 ± 1.05

26.81

47.46

0.00

Note x ± SD = mean ± standard deviation P< 0.05 = significant P>0.05 = non significant The above table shows that the mean numeric rating scale

difference is more in younger age group that is 30 -44 year

group at 6.75+ 1.58 than the older age group that is 45-60

years group at 5.59+ 1.05. And the p-value 0.00 shows high

level of significance.

90

Table 9 The difference between the control and experimental group in pain relief.

MEAN

Difference

F t-value P-Value

IRR, NRS X/10 IRR, Cervical

Traction NRS x/10

1.53

6.100

0.93

38.71

4.80

24.38

0.34

0.00

When P< 0.05 = Significant P> 0.05 = Non Significant The table above shows high mean numerical rating scale

difference that is 6.10 the experimental that is IRR + Cervical

Traction group compared to 1.53 in the control that is IRR

group and the level of P-value 0.00 in infra red + cervical

traction is very high comparable to infra red alone at 0.34.

91

a.

After 6 WeeksAfter 4 WeeksAfter 2 WeeksBefore

Treatment Period

7

6

5

4

3

2

1

0

Me

an

NR

S x

/10

IRR,Cervical Traction

IRR

Treatment Received

Fig a Comparing the relief of pain in Infra Red Radiation and Cervical Traction plus Infra Red

Radiation

The above graph shows that there is drastic progressive

decrease in numerical rating scale tending to zero in cervical

traction plus infra red group comparable to infra red alone.

92

b.

IRR

,Cervic

al T

ractio

nIR

R

Treatm

en

t Receiv

ed

After 6 WeeksAfter 4 WeeksAfter 2 WeeksBefore

Treatment Period

7

6

5

4

3

2

1

0

Mean

NR

S x

/10

7

6

5

4

3

2

1

0

Mean

NR

S x

/10

Female

Male

Sex

Fig. b. Sex in relationship to relief of pain in the patients

The above graph shows that in both cervical traction plus infra

red and infra red alone, there is no sex difference in the rate of

relief of pain.

93

IRR

,Ce

rvic

al T

ra

ctio

nIR

R

Tre

atm

en

t Re

ce

ive

d

After 6 WeeksAfter 4 WeeksAfter 2 WeeksBefore

Treatment Period

7

6

5

4

3

2

1

0

Mea

n N

RS

x/1

0

7

6

5

4

3

2

1

0

Me

an

NR

S x

/10

45-60 yrs

30-44 yrs

Age

Fig. c. Age in relationship to relief of pain in the patients

The above graph shows that there in both cervical traction plus

infra red and infra red alone there is slight difference in age

pain relief.

94

4.2 Test of Hypothesis

Hypothesis I

Statement: cervical traction when applied treatment modality in

patients with cervical spondylosis will reduce pain significantly

compared to Infra-red radiation therapy only.

For cervical traction and infra red

Before treatment:

NRS mean value: 6.13

After 6 weeks:

NRS mean value: 0.03

For IRR only:

Before treatment:

NRS mean value: 6.13

After 6 weeks 4.60

P – Value for CT + IRR: 0.00: significant

P – Value for IRR only: 0.338: not significant (p > 0.05)

So the hypothesis is upheld.

95

Hypothesis II

Statement: The rate of relief of pain using cervical traction

therapy in patients suffering from cervical spondylosis will be

more in younger than older patients.

For Age 30 – 44yrs

Mean difference in NRS after treatment: 6.75

For Age 45 – 60yrs

Mean difference in NRS after treatment: 5.59 which gave a

difference of: 1.16 more in younger adult (that is 30 – 44yrs) so

the hypothesis is upheld.

96

Hypothesis III

Statement: sex will have influence on the rate of relief of pain in

cervical spondylosis patients using cervical traction.

For male:

Mean difference in NRS after treatment: 5.94

For female:

Mean difference in NRS after treatment: 5.83

The difference: 0.11

P – Value: 0.878

Not significant (P > 0.05)

So the hypothesis is rejected.

97

4.3 Discussion

4.3.1 To determine if cervical traction could significantly

relieve pain in patients with cervical spondylosis compared

to infra red radiation alone.

Cervical traction relieved pain very significantly in experimental

group compared to the result got in the control group that is

infra red alone. This is in agreement with Shakoor et, al 2012

who stated in the research where they had two groups, cervical

traction plus exercise and non-steroidal anti inflammatory drug

respectively that relieve of pain in group with cervical traction

and exercise was more than that of the group with non steroidal

anti inflammatory drug. Also the use of high weight starting

from 12.5kg for the cervical traction was beneficial and this is

in line with Hinderer and Biglin (2002) and Renkens (2011) who

stated that at least 12.5kg weight is necessary to distract the

cervical spine. The benefit of cervical traction was also

documented by Rana and Crystal (2011) who found in their

retrospective study that cervical traction provided symptomatic

relief in 81% of the patients with mild to moderately severe

cervical spondylosis syndromes. The effect of traction was also

98

demonstrated by Murphy and the Lie- ponis, (1989) who

observed that flexion traction with 4 to 6kg weight takes care of

pressure of osteophytes on the vertical floor of the neural canal.

It was observed in the study that the rate of relief of pain in

experimental group that is cervical traction and infra red

combined was visible even by the second week. This might be

probably because of alternation of upright distraction and

flexion traction which is unique for this study.

4.3.2 To determine the influence of age on the rate of

pain relief after cervical traction in patents with cervical

spondylosis

The study shows that relief of pain after cervical traction is

slightly more pronounced a younger age group than the older in

both control and experimental group but this distinction was

not very sharply defined probably because of the small number

of patents who participated in the study. It is likely that

involving higher number of participants will give a better

outcome. No available current literature has come out with an

authentic view on this (Ellenberg et, al, 1994).

99

4.3.3 To determine the influence of sex on the rate of pain

relief after cervical traction in patients with cervical

spondylosis

From the result of the study it was noticed that sex has no

influence on the rate of relief of pain. This fact is shown in both

control and experimental group. This implies that sex has no

effect on the rate of pain relief. The past literatures have not

had any authentic documentation on this fact (Ellenberg et, al,

1994).

100

CHAPTER FIVE

Summary, Conclusion and Recommendation

5.1 Summary

Cervical Spondylosis is a disorder caused by abnormal wear on

the cartilage and bones of the neck with degeneration and

mineral deposits in the cushions between the vertebrae. It is a

degenerative disease which comes up with the aging process.

This makes it a bit difficult to treat. This study aims at

assessing the use of cervical traction as an adjunct treatment

for this condition. Literature was reviewed in the relevant

anatomy of the neck spine, the pathophysiology of cervical

spondylosis, the different types of cervical traction application

and infra red radiation. A Standiometer and weighing scale were

used at initial visit. Age was got from the patients while

Numeric Rating Scale was used to ascertain pain intensity at

initial visit, after two weeks, four weeks and after the sixth

week. A total of 30 patients who met the criteria for selection

participated in the study. All the patients were referred by the

medical consultant at National Orthopaedic Hospital Enugu

Out Patients Department. All the data obtained were analyzed

using the statistical package for social sciences (SPSS) version

101

13.0. The results of the measurements and out outcome of

analysis were also presented.

The Infra Red only paradigm showed significant improvement

after the 6th week but quite insignificant comparable to infra red

and cervical traction paradigm, that is experimental paradigm.

That is to say that cervical traction and infra red combined is

superior to only infra red treatment (P < 0.05).

5.2 Conclusion

1. Each of the treatment, cervical traction combined with

infra red, infra red alone significantly reduced patients

pain

2. Cervical traction combined with infra red radiation showed

a better outcome than the infra red radiation only

treatment.

3. When infra red radiation only treatment outcome was

compared with infra red radiation and cervical traction

therapy, the outcome of infra red only was not significant.

5.3 Recommendation

1. Cervical traction should be included in all the treatment of

cervical spondylosis.

102

2. Where selection criteria allows, heat modality should

always be combined with cervical traction for the

management of cervical spondylosis.

3. The influence of sex, Age, height and weight on the rate of

pain relief should be investigated.

4. The study should be replicated using larger sample size.

5. Other forms of heat therapy such as shortwave diathermy

and ultra sound therapy should be used in alternative to

infra red radiation to investigate their effect on cervical

spondylosis.

5.4 Limitations Of The Study

1. Small number of patients involved in the study may have

affected the optimum accuracy of the study.

2. Other prevailing health of the problems among the

participants could have interfered with the result.

3. Some medication the patients were using might have

affected the result of the study.

103

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