Latest Advancements in Physiotherapy for Degenerative Cervical Myelopathy (DCM) Treatment

Degenerative cervical myelopathy (DCM) is the most frequent cause of non-traumatic spinal cord impairment in elderly patients mostly after age 40, especially as spondylosis progresses. It is more prevalent in men than women.

 

Structural and Functional Changes in Degenerative Cervical Myelopathy

 

Causes of Degenerative Cervical Myelopathy

• Cervical Spine Spondylosis
• Ligament Hypertrophy, particularly the Ligamentum Flavum
• Calcification of the Posterior Longitudinal Ligament (OPLL)
• Intervertebral Disk Herniation
• Facet Joint Osteoarthritis

 

Signs and Symptoms of Degenerative Cervical Myelopathy

Symptoms depend on the severity and location of spinal cord and nerve root compression. Some patients may have significant spinal cord compression but without pain or neurologic symptoms.

• Insidious onset of pain with nondermatomal paresthesia in the upper extremities.
• Loss of hand dexterity is common.
• Some elderly patients report acute symptoms after neck hyperextension.
• As DCM progresses, symptoms include impaired gait, balance issues and bladder/bowel dysfunction.

Diagnosing Degenerative Cervical Myelopathy

MRI

MRI with and without contrast is the recommended imaging choice for suspected degenerative cervical myelopathy, per the American College of Radiology.

Alternative Imaging Options

• Plain Radiography:

Useful for assessing spinal canal narrowing, cervical curvature (lordosis or kyphosis), and stability, though it lacks soft tissue detail.

• Computed Tomography (CT):

Best for chronic cervical pain cases with signs of ossification in the posterior longitudinal ligament on radiography.

• CT Myelography:

Provides measurements of cervical intracanal dimensions and is an alternative when MRI is contraindicated. However, it is limited by its lack of soft tissue detail and requires contrast injection into the spinal column, making it less ideal for degenerative myelopathy.

• Electromyography and Nerve Conduction Studies:

Helpful for diagnosing neural injuries (e.g., carpal tunnel, cubital tunnel, thoracic outlet syndromes) and differentiating cervical myelopathy.

Findings:

Increased insertional activity, fasciculations, diminished motor unit recruitment, spontaneous activity, fibrillations, and positive sharp waves in cases of non-restored denervation.

 

Differential Diagnosis of DCM

Conditions with similar myelopathic symptoms include Intracranial, demyelinating, motor neuron, infectious, inflammatory and metabolic diseases.

Key Differential Diagnoses

Other Conditions Mimicking DCM:

• Cervical spondylotic myelopathy
• Amyotrophic lateral sclerosis (ALS)
• Multiple sclerosis (MS)
• Peripheral neuropathy
• Syringomyelia
• Spinal cord tumors
• Transverse myelitis
• Vitamin B12 deficiency
• Cervical radiculopathy
• Thoracic myelopathy
• Parkinson’s disease
• Myasthenia gravis

 

 

Physiotherapy Management of Degenerative Cervical Myelopathy

Physiotherapy management for Degenerative Cervical Myelopathy (DCM) focuses on maintaining or improving function, reducing symptoms and preventing further degeneration. It is considered for neurologically stable, mild to moderate cases. While surgical intervention is recommended for severe, progressive degenerative cervical myelopathy.

Pain Management

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord-related neuropathic pain. Treatments for neuropathic pain include:

• Electrical stimulation modalities like Transcutaneous Electrical Nerve Stimulation.
• Higher intensity exercise may provide greater improvements in mechanical hyperalgesia, likely due to:

1. Reduction of inflammatory cytokines in the spinal cord
2. Activation of endogenous opioid pathways
3. Improved expression of serotonin receptors and brain-derived neurotrophic factor

 

Upper Extremity Rehabilitation

High-Intensity, task-specific exercises are essential for effective recovery. Functional electrical stimulation (FES) and robotic assistance (e.g., robotic gloves) help enable more practice, benefiting those with central nervous system (CNS) injuries. These methods improve hand function and grip strength.

 

Balance and Proprioception

In people with compromised proprioception and balance due to cervical myelopathy, sensory and proprioceptive enhancement therapies can help restore stability and functional movement.

1. Vibratory Therapies for Sensory Augmentation

Vibratory therapies provide sensory stimulation to muscle spindles and mechanoreceptors, enhancing sensory input to the brain and spinal cord. It can be classified into:

• Whole-Body Vibration (WBV):

WBV applies vibrations to the entire body, stimulating proprioceptive pathways and improving balance control. This can support re-learning of balance and postural control.

• Localized Vibration:

For the upper limbs, localized tendon vibration (e.g., wrist tendons) helps reduce compensatory muscle activity. For instance, wrist tendon vibration can stabilize end-point positioning by enhancing awareness of wrist position, helping better control of upper limb movements with reduced shoulder and proximal muscle compensations.

2. Robotic-Augmented Therapy for Joint Proprioception

Robotic devices can be programmed to enhance proprioceptive feedback during joint movement, helping patients re-learn accurate joint positioning and controlled movements. It involves targeting:

• Leg Joint Repositioning and Targeted Stepping
• Wrist Position Training

3. Virtual Reality (VR) in Balance Rehabilitation

VR allows patients to practice balance and motor tasks in controlled, realistic environments, which is especially helpful for those hesitant to engage in real-life balance challenges due to fear of falling.

 

Gait Training

In gait training for individuals with Degenerative Cervical Myelopathy (DCM), various strategies can improve walking ability, stability, and coordination by directly addressing gait disturbances and promoting neuroplasticity.

High-Intensity Exercise and Neurochemical Benefits

Exercising at higher intensities (70–85% of maximum heart rate) has been shown to be more effective than lower-intensity training for improving walking speed and function in individuals with motor impairments.

It boosts the release of neurochemicals like serotonin and norepinephrine, enhancing motor neuron activity. It also increases brain-derived neurotrophic factor (BDNF) and insulin-like growth factor, both of which support neuroplasticity, synaptic growth, and overall motor function.

• Body Weight Support Treadmill Training (BWSTT) and Robotic Assistance

Body weight support treadmill training reduces the load on the patient’s lower limbs, allowing them to practice walking without the full impact of their body weight. This is especially beneficial for individuals with significant weakness or coordination issues due to DCM, as it enables safe, repetitive practice.

• Sensory Stimulation:

The repetitive stepping motion in BWSTT stimulates sensory pathways that are vital for maintaining balance and gait. This sensory input helps retrain spinal and supraspinal (brain) circuits, encouraging recovery by activating pathways that may have been dormant or less active due to DCM.

Robotic Assistance: Robotic devices, such as Lokomat or exoskeletons, can provide precise, consistent movement patterns during gait training. This facilitates high-repetition, high-intensity gait practice, enhancing neuromuscular stimulation without exhausting the patient.

 

Bladder/Bowel Function 

Bladder and bowel function are crucial aspects often overlooked in DCM rehabilitation. Pelvic Floor Muscle Strengthening can be beneficial in treating urinary incontinence. More studies are needed on how exercise patterns and rehabilitation strategies impact peristalsis, bowel regularity, and sphincter control in DCM patients.

 

Postoperative Physiotherapy in Degenerative Cervical Myelopathy

Postoperative physiotherapy could potentially reduce pain, as imaging studies show neck muscle fat distribution correlates with pain in DCM patients. Plus data from other spinal cord injuries suggest postoperative physiotherapy may be worth exploring in DCM.

According to the clinical research very few studies have evaluated the effectiveness of physiotherapy for degenerative cervical myelopathy (DCM) after surgical decompression, but there was no standardized postoperative care for DCM following surgery. Conclusively, limited and low quality evidence is present against postoperative physiotherapy in DCM, underscoring a need for further research.