Cervical Radiculopathy Treatment And Assessment

Cervical radiculopathy is defined as cervical nerve root compression. Many times, what causes this so-called compression is things like herniated disc material or arthritic bone spurs. It’s essentially the “sciatica” of the upper extremity. Common symptoms include neck and radiating arm pain which can travel all the way down into the fingers. Often, this pain is accompanied by sensory disturbances (i.e. pins-and-needles or burning sensations) and even loss of muscle function in more severe cases (muscle weakness and abnormal reflexes). Headaches, neck pain, and scapular pain can also accompany cervical radiculopathy. While not as common as sciatic nerve irritation (only a 0.4% prevalence rate), it can be just as debilitating and a significant cause of neck pain and disability. In this article, we will show you assessment and cervical radiculopathy treatment approaches that you and your physical therapist can employ to get you out of pain!

While the definition of cervical radiculopathy is technically nerve root compression, there is increasing evidence that inflammation surrounding the nerve root is most responsible for the signs and symptoms that accompany cervical radiculopathy. Furthermore, there does not need to be signs of nerve root compression on imaging to make the diagnosis of cervical radiculopathy. This is important to understand because it implies that just because you have “nerve root compression” on an MRI, it does NOT necessarily mean it is the cause of your pain! (READ: You are NOT your MRI!). To further support this claim, Kuijper and colleagues found a 45% false positive rate of root compressions in MRIs. This finding means that an MRI determined that there was nerve root compression at some level despite the fact that patients presented with no signs and symptoms of nerve root compression. Furthermore, Teresi and colleagues found that 25% of patients aged 45-54 years and 57% of patients older than 64 years had cervical disc protrusions visible on MRI, but showed no clinical symptoms.  After successful physical therapy treatment, chances are you will still have the same arthritic osteophytes or herniated disc material in your cervical spine – yet your symptoms are gone because the inflammation is gone! Suffice to say that your MRI findings do not dictate how you will present!

Cervical Radiculopathy Self Assessment

Before determining how to treat your pain, you must first determine beyond a reasonable doubt that you do in fact have cervical radiculopathy! Luckily, there is a battery of tests you can do at home to help you recognize the signs and symptoms of cervical radiculopathy. A physical therapist will use what’s known as the “Wainner Cluster” to objectively determine the probability that you have cervical radiculopathy. Of course, we advise that you seek out a qualified physical therapist in your local area to screen and treat your symptoms, but if you can’t get in to see a PT, follow along in the video below and I’ll walk you through a modified version of the Wainner cluster you can perform at home!

***IMPORTANT*** – PLEASE BE GENTLE WHEN ADMINISTERING THESE TESTS. Is your pain severe (>6/10)? Does it take a long time to go away if it’s bad? If so, please be extremely gentle with this screen! Once you begin to feel your symptoms, STOP!

Wainner Cluster Self Assessment

  • Spurling’s Test. This test aims to close down the intervertebral foramen in your cervical spine, adding further compression to the nerve root. Tilt your head back and sideways towards the side of your pain (i.e. if your pain is on the right, tilt back and to the right side). Does this neck position recreate your neck/arm symptoms? If yes, the test is positive and move on to the next one. If no, SLOWLY apply pressure with your opposite (left) hand. If this test brings on your symptoms, it’s also considered a positive test.
  • Distraction Test. This test aims to open up the intervertebral foramen in your cervical spine, decompressing the nerve root. This test can only be performed if you experience your symptoms at rest. What you will do is LIFT your head up and apply a traction force. If this maneuver alleviates or lessens your symptoms, it’s considered a positive test.
  • Upper Limb Nerve Tension Test. This test aims to add a traction force to the nerve root, which nerves do not typically like. Keeping your shoulder down, stick your arm out forward at 90 degrees with your palm facing in. Next, extend your wrist back. Finally, slowly bring your arm out to the side. BE GENTLE AND MOVE SLOWLY!! If at any point in this movement your symptoms are worsened or recreated, it’s a positive test.
  • Cervical Rotation Test. Rotate your head in the direction to the side of your symptoms. If you cannot rotate your head 60 degrees, which is approximately your earlobe to your shoulder, it is considered a positive test.

These self-administered tests are not the exact same ones used in the Wainner cluster, but they are decently good enough to help you determine if you may have cervical radiculopathy. According to Wainner and colleagues, if 3 of the 4 tests are positive, there is a 65% of cervical radiculopathy. If 4 of the 4 tests are positive, it’s essentially a golden ticket and the probability jumps to 90%!

Decrease Your Pain Immediately!

Now that you’ve determined there’s a high probably you may have cervical radiculopathy, what do you do about it? Lucky for you, there’s a host of cervical radiculopathy treatment options available. And by far THE BEST CERVICAL RADICULOPATHY TREATMENT is to AVOID THOSE THINGS THAT AGGRAVATE YOUR PAIN!!

First, a little background anatomy on the cervical spine. The nerve roots responsible for cervical radiculopathy run through little spaces called intervertebral foramen (IVF) in the cervical spine. As we discussed earlier, when lesions like herniated disc material or arthritic osteophytes get into this space, they can lead to nerve root compression. This compression can cause inflammation to arise in the IVF and around the nerve root, causing your symptoms. Therefore, if we can alleviate the trigger (i.e. the compression) causing the inflammation, we can alleviate your pain!

We can EASILY do this by PREVENTING THOSE MOTIONS THAT CLOSE THE INTERVERTEBRAL FORAMEN, namely EXTENSION, ROTATION (turning your head) to the side, and SIDEBEND (tilting your head) to the side. All of these motions cause the IVF to get smaller, and subsequently compress the nerve root! So, if you have right sided cervical radiculopathy, STOP LOOKING TO THE RIGHT!!!

  • When standing, turn your body instead of your neck!
  • If you’re at work, try to position your computer screen and other objects of interest on the OPPOSITE side so you don’t have to look to the right!

Avoid Neck Positions that Hurt!

Furthermore, LOOKING UP is usually an aggravating position. Try your best to look up with your EYES and your thoracic spine. One of the worst things you can do at the computer is to let your head come forward. When you do so, you are essentially extending at the cervical spine to keep your eyes forward on the screen!

Manual Therapy as Cervical Radiculopathy Treatment

Manual therapy has been shown to be more effective than a wait-and-see approach (i.e. doing nothing) in countless studies. There are many different manual therapy treatments for cervical radiculopathy, including but not limited to cervical spine up glides, lateral glides, posterior-to-anterior mobilizations, manipulations, thoracic spine mobilizations and manipulation, and various soft tissue mobilizations. No one single intervention has been shown to be more effective than another; however, a multimodal approach incorporating many of the above manual therapy treatments in addition to therapeutic exercises and education has been shown to be the most effective cervical radiculopathy treatment approach of all.

Manual Therapy Cervical Radiculopathy Treatment

In the video above, I demonstrate some various manual therapy techniques that your physical therapist may employ to treat your symptoms. In order, they are a cervical upglide, cervical manipulation, cervical lateral glide, cervical unilateral posterior-to-anterior mobilization, thoracic mobilization, and thoracic manipulation.

Exercises for Cervical Radiculopathy Treatment

Last but not least, therapeutic exercises with the intent of downregulating the nervous system, decreasing inflammation, opening the intervertebral foramen, and postural re-education are effective in the management of cervical radiculopathy. From a mobility standpoint, start first with neural mobilization. The rationale behind neural mobilizations is to increase the circulation to the nerve and disperse intraneural edema or inflammation. When nerves are stretched, there is an accompanying increase in tension and intraneural pressure on the nerve, which nerves do not like! We know from animal experiments that when a nerve is inflamed and irritated, a minimal stretch (<3%) is enough to lead to the provocation of pain!

We can combat this inflammation with specific exercises called nerve glides or nerve tensioners. By increasing the mobility of the nerve/dura itself, or the structures that surround the nerve such as neighboring muscles and joints (called the nerve bed), we can facilitate an optimal environment to disperse inflammation and desensitize the nervous system. Nerve glides are best used when your pain is extremely acute or severe. Nerve glides produce a high level of nerve movement with minimal tension and can help facilitate dispersing inflammation around the nerve. A nerve gliding technique entails elongating the nerve bed at one joint, while simultaneously reducing the length of the nerve bed at an adjacent joint.

Nerve Slider Technique

On the other hand, nerve tensioners entail elongating the nerve bed at two joints at the same time. While this may seem harmful at first glance, your nerves are meant to be move and elongated! The goal of nerve tensioners are to downregulate the nervous system and get it accustomed to nerve tension. However, in the acute stage when your pain levels are high, it is best to avoid nerve tensioners and stick to nerve glides. As the pain dissipates, you can then progress to nerve tensioners. While you can move any joint along the nerve bed to perform nerve glides and tensioners, we recommend moving your wrist and neck – as the nerves run from your neck all the way down to your hand!

You should also focus your exercises on improving cervical and thoracic spine mobility. You can perform SNAGs or lateral cervical slides for your neck with a towel. Or hop on a foam roller for your thoracic spine. From a strength standpoint, you’ll want to work on your deep neck flexors and extensors as well as your scapular stabilizers. From a motor control and postural re-education standpoint, you’ll want to work on maintaining a neutral cervical spine – again, avoiding those positions that aggravate your symptoms!

Cervical Radiculopathy Treatment Exercises

In conclusion, the cervical radiculopathy treatment involves more than just decompression of the nerve root. Often, it is the inflammation itself that is responsible for the pain and symptoms you feel, and thus exercises and movement are crucial in the treatment paradigm. Furthermore, research has strongly indicated that psychosocial factors such as low self-efficacy and depression play a large role in determining how disabled one feels and plays a role in determining prognosis.

Speaking of prognosis, most patients with cervical radiculopathy have a favorable prognosis with non-surgical management. While re-occurrence is common, a large-scale epidemiology study found that at final follow-up, 90% of patients were asymptomatic or only mildly incapacitated by their symptoms.

So if you have cervical radiculopathy or “pathologic” findings on your cervical MRI – do not fear! Avoid those positions that cause your symptoms. Schedule an appointment with your local physical therapist to provide you with some manual therapy and sound educational advice. And give these exercises a shot!!

 

 

Works Cited

  1. Basson, Cato A., Aimee Stewart, and Witness Mudzi. “The Effect of Neural Mobilisation on Cervico-brachial Pain: Design of a Randomised Controlled Trial.” BMC Musculoskeletal Disorders 15.1 (2014)
  2. Bove, G. M. “Inflammation Induces Ectopic Mechanical Sensitivity in Axons of Nociceptors Innervating Deep Tissues.” Journal of Neurophysiology 90.3 (2003): 1949-955.
  3. Cheng, Chih-Hsiu, Liang-Ching Tsai, Hui-Chu Chung, Wei-Li Hsu, Shwu-Fen Wang, Jaw-Lin Wang, Dar-Ming Lai, and Andy Chien. “Exercise Training for Non-operative and Post-operative Patient with Cervical Radiculopathy: A Literature Review.” Journal of Physical Therapy Science 27.9 (2015): 3011-018.
  4. Coppieters, Michel W., Alan D. Hough, and Andrew Dilley. “Different Nerve-Gliding Exercises Induce Different Magnitudes of Median Nerve Longitudinal Excursion: An In Vivo Study Using Dynamic Ultrasound Imaging.” Journal of Orthopaedic & Sports Physical Therapy 39.3 (2009): 164-71.
  5. Coppieters, Michel W., Alan D. Hough, and Andrew Dilley. “Different Nerve-Gliding Exercises Induce Different Magnitudes of Median Nerve Longitudinal Excursion: An In Vivo Study Using Dynamic Ultrasound Imaging.” Journal of Orthopaedic & Sports Physical Therapy 39.3 (2009): 164-71.
  6. Falla, D., R. Lindstrøm, L. Rechter, S. Boudreau, and F. Petzke. “Effectiveness of an 8-week Exercise Programme on Pain and Specificity of Neck Muscle Activity in Patients with Chronic Neck Pain: A Randomized Controlled Study.” European Journal of Pain (2013).
  7. Kuijper, B., J. T. J. Tans, B. F. Van Der Kallen, F. Nollet, G. J. Lycklama A Nijeholt, and M. De Visser. “Root Compression on MRI Compared with Clinical Findings in Patients with Recent Onset Cervical Radiculopathy.” Journal of Neurology, Neurosurgery & Psychiatry 82.5 (2010): 561-63.
  8. Langevin, P., J.-S. Roy, F. Desmeules, M. Lamothe, and S. Robitaille. “Cervical Radiculopathy: A Randomized Clinical Trial Evaluating the Short-term Effect of Two Manual Therapy and Exercise Protocols.” Physiotherapy 101 (2015).
  9. Radhakrishnan, Kurupath, William J. Litchy, W. Michael O’fallon, and Leonard T. Kurland. “Epidemiology of Cervical Radiculopathy.” Brain 117.2 (1994): 325-35..
  10. Teresi, L. M., R. B. Lufkin, M. A. Reicher, B. J. Moffit, F. V. Vinuela, G. M. Wilson, J. R. Bentson, and W. N. Hanafee. “Asymptomatic Degenerative Disk Disease and Spondylosis of the Cervical Spine: MR Imaging.” Radiology 164.1 (1987): 83-88.
  11. Thoomes, E. J. “Effectiveness of Manual Therapy for Cervical Radiculopathy, a Review.” Chiropractic & Manual Therapies 24.1 (2016).
  12. Wibault, Johanna, Birgitta O–berg, Asa Dedering, Hakan Lofgren, Peter Zsigmond, Liselott Persson, and Anneli Peolsson. “Individual Factors Associated with Neck Disability in Patients with Cervical Radiculopathy Scheduled for Surgery: A Study on Physical Impairments, Psychosocial Factors, and Life Style Habits.” European Spine Journal 23.3 (2013): 599-605.
  13. Zhu, Liguo, Xu Wei, and Shangquan Wang. “Does Cervical Spine Manipulation Reduce Pain in People with Degenerative Cervical Radiculopathy? A Systematic Review of the Evidence, and a Meta-analysis.” Clinical Rehabilitation 30.2 (2016): 145-55.

1 thought on “Cervical Radiculopathy Treatment And Assessment

  • Cervical radiculopathy typically causes patients to have arm pain that is consistent with the particular nerve root that is being compressed. The most common cause is from a cervical disc herniation, which is called a “slipped disc” in layman’s terms. This pain may go into the shoulder area, down into the arm, or may extend all the way into the hand and fingers. This article describes 10 treatment options for pain relief.

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