Causes, Incidence and Risk Factors and Physiotherapy Approach

1.Introduction:
Cervical spondylosis is a common degenerative condition of the cervical spine. It encompasses a sequence of degenerative changes in the intervertebral discs, osteophytosis of the vertebral bodies, hypertrophy of the facets and laminal arches, and ligamentous and segmental instability. As spondylosis refers degenerative osteoarthritis of joint, it may cause pressure on nerve roots with subsequent sensory or motor disturbance. Clinically, several syndromes, both overlapping and distinct, are seen. These include neck and shoulder pain, sub occipital pain and headache, radicular symptoms, and cervical spondylotic myelopathy (CSM). Radiculopathy is characterized by sensory and motor disturbances, such as severe pain in the neck, shoulder, arm, back, and/or leg, accompanied by muscle weakness, whereas, less commonly, direct pressure on the spinal cord (typically in the cervical spine) may result in myelopathy, characterized by global weakness, gait dysfunction, loss of balance, and loss of bowel and/or bladder control.

The patient may experience a phenomenon of shocks (paresthesia) in hands and legs due to nerve root compression. Frequently, associated degenerative changes in the facet joints, hypertrophy of the ligamentum flavum, and ossification of the posterior longitudinal ligament occur. All can contribute to impingement on pain-sensitive structures (eg, nerves, spinal cord), thus creating previously described clinical syndromes.

The natural history of cervical spondylosis is associated with the aging process. Spondylotic changes are often observed in the aging population. However, only a small percentage of patients with radiographic evidence of cervical spondylosis are symptomatic. Everyday wear and tear may start these changes. People who are very active at work or in sports may be more likely to have them. The major risk factor is aging. By age 60, most women and men show signs of cervical spondylosis on x-ray. Other factors that can make a person more likely to develop spondylosis are being overweight and not exercising, having a job that requires heavy lifting or a lot of bending and twisting, past neck injury (often several years before), past spine surgery, ruptured or slipped disk, severe arthritis, small fractures to the spine from osteoporosis.

Although pain is predominantly in the cervical region, it can be referred to a wide area, and is characteristically exacerbated by neck movement. Neurological change should always be sought in the upper and lower limbs, but objective changes occur only when spondylosis is complicated by myelopathy or radiculopathy, or when unrelated causes like disc prolapsed, thoracic outlet obstruction, brachial plexus disease, malignancy, or primary neurological disease are present.

Presenting features of cervical spondylosis are closely related to pain. Symptoms include cervical pain aggravated by movement, referred pain (occiput, between the shoulder blades, upper limbs), retro-orbital or temporal pain (from C1 to C2), cervical stiffness—reversible or irreversible, vague numbness, tingling, or weakness in upper limbs, dizziness or vertigo, poor balance and rarely, syncope, triggers migraine, “pseudo-angina” etc. Several signs can be observed such as, poorly localised tenderness, limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides), minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy) etc.

An exam may show that you have trouble moving your head toward your shoulder and rotating your head. Health care provider may ask you to bend your head forward and to the sides while putting slight downward pressure on the top of your head. Increased pain or numbness during this test is usually a sign that there is pressure on a nerve in your spine. Weakness or loss of feeling can be signs of damage to certain nerve roots or to the spinal cord. Reflexes are often reduced. Diagnostic tests include a spine or neck x-ray to look for arthritis or other changes in your spine. MRI of the neck is done when severe neck or arm pain that does not get better with treatment or weakness or numbness in arms or hands is present. EMG and nerve conduction velocity test may be done to examine nerve root function.

Cervical spondylosis can be complicated by myelopathy or radiculopathy, although cervical disc prolapse, plexopathy, motor neuron disease, or other diseases can cause similar symptoms; magnetic resonance imaging, electro diagnostic tests, and other investigations may be needed to exclude other diagnoses. Neurological complications can occur in established cervical spondylosis or can be the presenting feature of the disease. A major problem related to this disease is vertebrobasilar insufficiency. This is a result of the vertebral artery becoming occluded as it passes up in the transverse foramen. The spinal joints become stiff in cervical spondylosis. Thus the chondrocytes which maintain the disc become deprived of nutrition and die. The weakened disc bulges and grows out as a result of incoming osteophytes. A ‘drop attack’ in older people is a sign of vertebrobasilar insufficiency.

Background:
Studies of the early treatment of whiplash provide moderate evidence that early mobilization physiotherapy and advice to “act as usual” are more effective than immobilization and less active treatments in speeding up recovery and reducing chronic disability. Randomized controlled trials identified by systematic reviews provide moderate evidence that various exercise regimens—using proprioceptive, strengthening, endurance, or coordination exercises—are more effective than usual care (analgesics, non-steroidal anti-inflammatory drugs, or muscle relaxants) or stress management, although not all studies have found exercise beneficial. One randomized controlled trial found exercise plus infrared heat no more effective than transcutaneous electrical nerve stimulation plus heat at relieving pain at six weeks and six months, although both were better than heat alone.

Mobilization, manipulation, and exercise seem to be equally effective. A study comparing combined exercise and manipulation with either modality alone found the combination to be more effective at three months, but no difference was seen compared with exercise alone at one and two years. Strength training therapy, or resistance training therapy, helps preserve or increase strength in the muscles that surround and support your cervical vertebrae. There are two main types of vertebral strength training: isometric and isotonic. Isometric strength training exercises for your cervical vertebrae tighten and strengthen your upper back muscles without changing joint position and are most useful when joints are in pain. Isotonic cervical vertebrae strength training exercises tighten and strengthen the muscles.

When the joints in between your cervical vertebrae become stiff and loose function and mobility, scar tissue can form. Scar tissue is made up of many tiny collagen fibers that create a web of material that surrounds cervical vertebrae. The presence of scar tissue can cause deformity, pain, and loss of function and mobility. Deep tissue massage is designed to break up the collagen fibers on cervical vertebrae so one can regain normal function in joints. Warm water helps relieve pain and relax the muscles that support cervical vertebrae. Patients do not need to swim to perform water exercises. Instead, water exercises for cervical vertebrae may be done while sitting in a shallow pool or standing in shoulder-high water. The support of the water decreases the stress placed on your vertebrae by body weight and can help move joints through range of motion exercises more easily.

Mechanical traction is a widely used technique. This form of treatment may be useful because it promotes immobilization of the cervical region and widens the foraminal openings. However, traction in the treatment of cervical pain was not better than placebo in 2 randomized groups. Electrical stimulation can be performed within the clinic and if extremely successful, a TENS unit can be issued to a patient for home use. It stimulates the muscles through variable (but safe) intensities of electrical current. It helps reduce muscle spasms and also relax and re-educate the muscles involved.

Justification of the study:
Justification of the selective study is performed for the following reasons which are described deliberately one after another as per their inevitability. * To find out a best possible treatment procedure for cervical spondylosis. * To find out the reason of recurrence in the conventional measures. * To find out the modified method to treat the patient at home with mobilization. * Treatment with steroid injection and surgical treatment are costly and have a wide variety of side effects.

2. Objective:

2.1: General objective: To determine or identify the role of physical therapy in the treatment of cervical spondylosis along with its cause, incidence and risk factors.
2.2: Specific objective:
* To state the sign and symptom of cervical spondylosis.
* To determine the prevalence of cervical spondylosis among the outdoor patients.
* To find out the ergonomics related factors associated with cervical spondylosis.
* To determine the socio demographic factors associated with cervical spondylosis.
* To compare the patients clinical conditions before and after receiving physical therapy.

3. Methodology:
3.1: Study design:
Descriptive cross-sectional study will be conducted.

3.2: Sample size:
50% of the total attended patients in physiotherapy out patients.

3.3: Sampling technique:
Convenient/ purposive.
3.4: Research instrument:
Interviewer administered questionnaire. The interviewer will ask from the structured questionnaire which will design to collect information on related cervical spondylosis. Example:

1) Where is the pain?
2) Behavior of pain?
3) What aggravates pain?
4) What eases pain?
5) What functional activities are restricted?
6) Do you have any radiation of pain?
7) Do you have any history of trauma?

3.5: Study Population:
The entire patient with cervical spondylosis (collected from physiotherapy outpatient department). Pre-test will be done. 3.6: Place of work:
NITOR, Room no- 108
3.7: Duration:
From February 2013 to October 2013.
3.8: Variable:
* Name
* Age
* Sex
* Occupation
* Height
* Weight
* Range of motion
* BMI

3.9: Operational Definition:

a) Degenerative disease: Disease in which the function or structure of the affected tissue or organs will progressively deteriorate over time.

b) Range of motion: The range of motion or muscle work is the extent of the muscular contraction or joint movement.

c) Pain: Pain is the protective mechanism of the body when any tissue is being damaged.

d) Stiffness: The resistance of a structure to the deforming force.

e) Exercise therapy: Use of specific stylized movements to improve the way the body functions. It focuses on moving the body and its different parts to relieve symptoms and improve mobility and of course levels of fitness.

3.10: Ethical consideration:
* Permission will be taken from the course coordinator or head of the department of physiotherapy to initiate my work. * All ethical issue which is related to research involving human subjects will address according to the guidelines of Bangladesh Medical Research Council (BMRC) and the ethical review committee of the World Health Organization (WHO). * Prior to collect the data, the objectives of the study will be explained to the participants in an understandable language. * The written in formed consent will be taken from the participants. * The prospective participants will be given free opportunity to receive summery information on the study. * Participant’s right to refuse and withdraw from the study will be accepted.

3.11: Data Analysis:
After collecting data, it will be checked for editing and analysis will be done according to the findings of the study results by the following way – * After collection of data from the viewer, all interviewed questions will be checked for its correction, completeness and internal consistency. * To exclude missing and inconsistent data those will be discarded as well as corrected data will be entered into the computer. * Collected data will be analyzed by using the statistical software what is known as statistical package for social science (SPSS).

4. References:

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