The nice thing about the Sperling's test and the Upland Neural Tension Test is that Sperling's test is a highly specific test and the Upland Neural Tension Test combined are way more sensitive than specific, although they are rather specific. And combined those two, you've got sort of one very high specific test, one very high sensitive test. Combined those two, you've got a nice cluster of tests.
SPEAKER_02:In today's episode we're joined by Eric Toombs to talk through the differential diagnoses of cervical radiculopathy. Eric joins us after completing a fantastic masterclass for the Physio Network on expert approaches to cervical radiculopathy. A brilliant masterclass and one that I recommend everyone checks out and in fact you can do exactly that by clicking the link in the show notes to watch Eric's masterclass for free with our seven day trial. Now Eric is a BSc Physiotherapy graduate and has a MSc in Manual Therapy and Sports Therapy. He's currently finishing his PhD on the diagnosis and conservative management of patients with cervical radiculopathy. and has published and co-authored several manuscripts concerning cervical radiculopathy, neck pain, headache and dizziness. He's taught both at an undergraduate and postgraduate level and has a special interest in clinical reasoning and motor control dysfunction and still teaches CPD courses nationally and internationally. He was also a member of the executive committee of the International Federation of Orthopaedic Manipulative Physical Therapists, IFOMT, from 2008 to 2016. This is a fantastic episode and is just going to make you want to check out the Masterclass even more. So, I'm James Armstrong and this is Physio Explained. Eric, thank you so much for coming on to the podcast today. It's great to have you on the Physio Explained podcast. How are you?
SPEAKER_01:I'm fine, thank you. And thank you very much for having me on this podcast.
SPEAKER_02:I think we've got a really juicy topic to talk about, which listeners are going to find really interesting. We're going to be talking about cervical radiculopathy and particularly around our differential diagnosis, which I think is a really important area that most clinicians always need a bit of brushing up on. I think it's something that we can always learn more about and feel maybe more comfortable with. So we're going to kickstart this off, Eric, with the question of why do we need to differentiate cervical radiculopathy from somatic radiating neck pain. What are we talking about there and why is it important?
SPEAKER_01:The short answer is because the prognosis and the management plan differ hugely. Allow me to provide some background information for this. Something like 80 to 90% of patients with neck pain we see as clinicians will be labelled as having non-specific neck pain. And as I'm sure you know, in non-specific neck pain we're unable to find an exact anatomical structure as a nociceptive source of neck pain. Recognitions, we assess these patients and we find whatever dysfunctions in a neuromusculoskeletal system, and we might assess them for contextual factors that might be counterproductive to the body's natural capacity to heal, which is the biopsychosocial model in a nutshell. Opposite to that, there are a number of specific causes of neck pain as well, and serious specific causes of neck pain often labeled are the fractures and the tumors and systemic inflammation, systemic diseases. They all need to be diagnosed with medical tests, and we are able to diagnose them with medical tests like imaging and blood work and stuff like that. And some of these patients might need our expertise, but most just go on to the medical system in managing their neck pain. And we might see them not for the cause of the neck pain, but perhaps for consequences of that specific cause. And right there in the middle is the non-serious specific cause of neck pain, which I find interesting. It is a specific cause because we can identify it or label it or diagnose it with medical imaging tests. But it's not as serious as a tumor or as a fracture. The net result of having a cervical radiculopathy is the prognosis is good. It'll take a long time to heal, but the prognosis is good. But most patients with a cervical radiculopathy will recover within 48 months. Targeted conservative management can assist that process and perhaps speed that process up. But it's a completely different management plan from the non-specific net plan. And when I say speed the process up, I actually mean creating an atmosphere in which the speediest biological processes can operate, because obviously we cannot defy biological processes and speed recovery up beyond that process with natural limitations. So I think that's why it's important to do that.
SPEAKER_02:Absolutely, definitely. And it kind of leads us on to that, you know, what are we doing to exam? What are we doing to test these things? And the role that provocation tests have opposed to your normal generic neurological examination. So talk us through that a little bit, Eric.
SPEAKER_01:Well, In a clinical reasoning process, as I see it, of every patient we see, we should start with a detailed and a comprehensive history taking. And that is still the most important diagnostic tool that we have as clinicians. We try to find a complete patient profile operating within the international classification of functional disability and health, looking at contextual factors, personal factors, and working through that diagnostic history taking, we create hypotheses about what the cause of the problem might be. And then ideally, we corroborate or negate those hypotheses with physical tests to turn the second or third step we take. And there are a relatively well-known number of physical provocation tests for cervical liquidopathy, the Sperling's test, traction-distraction test, the shoulder abduction or the Davidson's relief test, upper neural tension tests are very important, and a number of recent tests, which I might cover later on. Now, for me, in my PhD process, it was of interest to note that only Sperling's test and the upper limb neural tension tests have been studied, assessed in more than one diagnostic study. All the others have only been assessed once and then usually by the people who have proposed the test as well. Generic neurological examination has not been assessed yet for its diagnostic accuracy. Very recently, one Dutch study has looked at it, but for now... the generic neurological examination that medical doctors or neurologists will do has not been assessed for his diagnostic accuracy, which makes sense in a way because a strength deficit in the key muscle, you might find a strength deficit in the key muscle in a patient with a cervical arachnopathy, but it does not tell you that it is a cervical arachnopathy because there could be many other different causes for that strength difference. And the same goes for sensory dysfunction and for reflex dysfunctions. They do appear in patients with a cervical recovery. They must appear because if the nerve root is compressed relevantly, there must be either a motor dysfunction or a sensory dysfunction, but it's not targeted to diagnose it. And these clinical provocation tests, especially Sperling's test and the upper limb neural tension tests have been tested more than once. And we found that these two are the best provocation tests to use. So generic neurological examination has sort of a third step, but you need to corroborate your hypothesis from your clinical reason, from your history taking with your provocation test, and then you do a generic neurological examination.
SPEAKER_02:What do you think, Eric, about sort of your, obviously we've got our sort of sensitivity and specificity, and in terms of generic neurological examination, maybe having a relatively good sensitivity, but actually being incredibly unspecific. Would you say that would be about right?
SPEAKER_01:Yeah, that'd be very correct. And the nice thing about the Sperling's test and the upland neural tension test is that Sperling's test is a highly specific test. And the upland neural tension tests combined are way more sensitive than specific, although they are rather specific. And combined those two, you've got sort of one very high specific test, one very high sensitive test. Combined those two, you've got a nice cluster of
SPEAKER_02:tests. It's always a dream, isn't it, when we can cluster tests together and these sort of special tests that we're on their own don't necessarily tell us an awful lot can tell us an awful lot when combined together which makes this much more useful for us as well. You mentioned the upper limb tension test there and you said they're really useful. I see clinically with clinicians a bit of a mixed opinion in terms of their usefulness. What are your thoughts around the usefulness of the upper limb tension tests?
SPEAKER_01:I think they're highly useful but they are difficult to perform correctly. And there has been some discussion about what determines a positive or negative outcome. And I think there are three main issues around neural tension testing. It needs to reproduce patient-specific symptoms. There needs to be a relevant left-to-right difference. And you need to be able to use structural differentiation, as it's called, to identify if it's a neurological and peripheral neurological problem, a neurodynamic problem, or something like a muscle or fascial problem. especially the structural differentiation is slightly difficult to do for clinicians perhaps.
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SPEAKER_02:That was my belief and it's quite interesting to kind of have that confirm. I often think of the upper limb tension test similar to the straight leg raise in lower back pain. If you're performing it and the patient goes, ouch, it doesn't really mean anything. Is it producing their symptoms? Is it producing their pain? And that's really important. And you've said that the same with the upper limb tension test. So yeah, really, really interesting, Eric. So we've got our differentiation test. from radiculopathy, somatic radiating pain. We've got some useful clusters of tests, which we know the limitations, but put together can be really useful. So then we sort of start looking at what matters from the patient's point of view we're going to next talk about. And this is the use of patient reported outcome measures, which I'm quite passionate about elsewhere in some of my practice. And I'd be really interested to hear your thoughts around this in terms of vial radiculopathy. So what are we using and What are the good, the bad, and tell us more?
SPEAKER_01:Well, patient-reported outcome measures, or PROMs as we'll call them from now on, they assess the patient's experience of their symptoms. They assess their functional status and their health-related quality of life. So they can help you determine the outcome of care from the patient's perspective because they are the expert in the experience of their own health. They're often self-report measures, of course, and they should be free of observer bias. and they are the most often used tool to determine progress in the individual patient. Now, the NDI neck disability index, developed in the 1990s, as we use this, is the most often used for patients with neck pain, especially in scientific studies. In the clinic, however, patients with cervical arachnopathy usually generally experience greater arm pain than neck pain or periscapular pain. And it has been proposed that the NDI might not be the most suitable problem for patients with cervical rictopathy. We did a recent study in 2021 reporting that patients with cervical rictopathy rated their level of self-assessed disability on the eye, NDI, differently than compared to the patient-specific functional scale. Now, I am a huge fan of this patient-specific functional scale. There are versions of it, which one might cover. We recently published an updated version of the patient-specific cancer scale 2.0. It basically asks your patients, what are your top three activities in your daily life that you feel disabled in due to your problem? And that is what the patient's main problem is. And if you can assess those main problems with your patients after your treatment and follow those activities up in the progress of your management plan, I think it's the ideal problem for just about every condition we come across. We recently published the updated version, which not only has that top three disabilities, you ask your patients and then you have a list down below, because as you are probably aware, some patients do struggle to find their own top three or aren't really aware of which activities in their daily life they find disabled in. And we've created lists of the most often used or named disabilities with patients, so we have different specific functional scales for different conditions, and we list down at the bottom, we have a list of, they can choose from, ah, yes, of course, driving a car, I've really forgotten about that, that's what really troubles me, or yes, reaching up, so we've made that list, and then we've compared that patient specific functional scale with other problems designed for cervical radiopathy, And we did sort of think aloud interviews. We asked patients to think out loud while they were completing their PROMs. And we asked them which of the PROMs they actually preferred using. And we found that most patients prefer that patient's specific functional scale. They feel they... they can explain their own problem much more relevantly from their own point of view, and it gives them sort of a self-empowerment of these are the things that I'd like you to target for you as a physical therapist, because these are the things in my life I feel disabled in. We published a study recently, and the chair of the patient generally only preferred, but actually were able to assess the level of disability better using that patient-specific functional scale.
SPEAKER_02:That's really interesting, yeah. It's one of those things, it's just making those problems, those goals that as a physiotherapist we're going to help with relevant to what they want, to what was useful to them, isn't it? And I think it's really interesting you picked up on that. Sometimes patients find it difficult to think of those activities. And I found in my practice, quite often when patients come to physiotherapists, it's very much they think it's going to be quite physical activity and they forget to come down to those really basic movements, like you said there, just reaching up to the cupboard. Those small things, being able to lift or to work to something in their job and not be on light duties and feeling like they're letting the team down.
SPEAKER_01:I'm a huge fan of that basic functional skill because basically you get the chance to just tell their own story. And we can assist them in selling that store because they find it difficult at times. We can assist them in finding often used disabilities and activities. Things out of daylight, fastening your bra or reaching up or finding your shoelaces or just general stuff like that. Many patients mention.
SPEAKER_02:Absolutely. And it's being able to draw out of the patient what's important to them. And that's, I suppose, we'd like to think we're going to get that from our subjective history taking. but sometimes it does take a little bit more drawing out. And I think something I find really useful about the outcome measures is to open up a dialogue of conversation.
SPEAKER_01:Definitely. And one of the reasons I'm not a huge fan of problems like the Quebec backscale or the NDI, they're really useful for scientific research, but they are comparing cohorts of patients and they're not really used to assess an individual patient. And a patient-specific functional scale can do both. You can use it in scientific research, as we've shown, but for a clinician, they're way more useful, in my opinion.
SPEAKER_02:Absolutely. Eric, that's really good. I think we've covered the cervical radiculopathy really, really well. It's been only a short period of time, but the great news is that you've done a masterclass for the Physio Network on expert approaches to cervical radiculopathy. Do you want to give the listeners a little teaser about what they can expect from that masterclass?
SPEAKER_01:Yeah, of course. There are two masterclasses, basically. There are two different sections. One is on diagnosis of, and the second one is on the management of, conservative management of patients. There are quite a few practical videos in both, showing them diagnostics of the performance testing, the physical test to assist you in the diagnostic process. There's even a short video on some of the treatment possibilities. Both modules combined take you through the patient journey. They come into your clinic. They just tell you, I have a pain in my neck and my arm, and what do you do then? And I just lead you through that journey of diagnosing the condition, level of severity, and what to do in which stage of disorder, through the acute, the subacute, the more chronic stage, the different treatment plans, management plans, and I'll just... talk you through the entire process until together you just manage to get that patient free of most of their problems. Wonderful.
SPEAKER_02:We were just saying off air, actually, it's something that I knew was coming up and I've got to put on my to-do list to watch. I think it'd be a really interesting masterclass, Eric. And having listened to you today, I think a lot of listeners are going to really want to get on that masterclass. So thank you. And thank you for your time today.
SPEAKER_01:More than welcome. It's fun talking about my research. I'm still passionate about the research I do right now. I'll continue doing that. So I hope the listeners and the viewers will have lots of fun as well.
SPEAKER_02:Marvellous. We'll have to get you on again to talk more about the research. So for those of you listening, as we say, Eric has completed a masterclass. So if you're interested, which I'm sure you will be, do head on down to the show notes where you'll find a link to find out more about the masterclass. Eric, once again, thank you very much for your time. Have a good evening.
SPEAKER_01:Thank you. Yeah, you're welcome.
UNKNOWN:Bye-bye.