Posts in cervical radiculopathy
Neck Pain and Physical Therapy Treatments
neck pain, physical therapy, treatment

Neck Pain Background Information

Neck pain affects 10-15% of the population at any one time, with a lifetime incidence of 22-70% (1). Only 6% of patients with neck pain report resolution of symptoms at one year (2).

A recent systematic review demonstrated the prognosis from idiopathic neck pain is poor (3) and 50-75% of patients with neck pain will report symptoms at 1 and 5 year follow up (4).

Evidence suggests the utilization of manual therapy and exercise is a more cost effective intervention compared to primary care management alone or standard physical therapy (see graph). (5)

Our effectiveness in treating patients increases as we match interventions to a patient’s signs and symptoms. Evidence suggests outcomes are improved by correctly matching each Physical Therapy intervention to a specific patient category see below.(6)

Patients with mechanical neck pain, cervical radiculopathy, and cervicogenic headaches can benefit from Physical Therapy interventions including manual therapy and exercise to reduce pain and improve disability. 

neck pain costs, manual therapy, boulder physical therapy

Physical Therapy Interventions for Neck Pain

Exercise and Conditioning

Physical Therapy strengthening, neck pain

Patients within this category may display lower pain and disability levels and report a longer duration of symptoms.

Exercises will aim to improve muscle function within the deep cervical flexors and scapular muscles.

A recent systematic review provided Level 1 evidence on the benefits of exercise for patients with mechanical neck pain.(7)

Strong evidence supports the utilization of proprioception and strengthening exercises for patients with recurrent or chronic neck pain.(8)

Headaches

A recent Cochrane review documented the improved effectiveness of manual therapy and exercise over manual therapy alone in patients with neck pain with or without headaches.(10)

Authors report the benefit of cervical manipulation on reducing head- ache intensity and frequency in patients with headache.(9)

The utilization of manual therapy and cervical strengthening has been show to reduce pain, disability, and headaches over both the short and long term (see graph) (11). 

headache, neck pain, boulder physical therapy treatments

Neck and Arm Pain/Cervical Radiculopathy

Centralization

Patients within this category include those who have signs and symptoms of nerve root impingement or radicular symptoms.

Studies demonstrate 26% of patients with cervical radiculopathy who undergo surgery continue to experience high levels of pain at a 1-year follow-up.(12) Studies also suggest that patient outcomes may be superior with conservative management versus surgical interventions.(13, 14)

Physical therapy interventions consisting of manual therapy (17), cervical traction (15, 16), and cervical centralization exercises have been shown to decrease pain and improve function in this population.

Recently authors reported 91% of patients with cervical radiculopathy who underwent treatment of manual physical therapy, cervical traction and strengthening exercises showed significant functional improvement. (17). 

neck and arm pain, boulder physical therapy treatments, centralization

Pain Control

This subgroup comprises patients with acute or traumatic onset of neck pain, including whiplash injury, and those presenting with high levels of pain and disability.

Physical therapy interventions for this category aim to decrease pain and allow transition into other subgroups for treatment to reduce disability.

Evidence suggests utilization of thoracic spine manipulation18, cervical spine mobilizations19, neck active ROM exercises20, gentle soft tissue massage(21), and physical modalities such as TENS (22).

Interventions matched to patient’s signs and symptoms within the category demonstrate greater changes in pain and disability than unmatched interventions (6). 

Mobility

neck pain, mobility, boulder physical therapy treatments

Patients within this group include those with symptoms proximal to the elbow, an acute onset (<30 days), and are younger than 60 years old.(6)

Evidence supports the utilization of both cervical and thoracic mobilization/manipulation, with exercise, to restore mobility, decrease pain, and improve function. (1, 22, 23)

Utilization of manual therapy can reduce long term management costs by as much as 2/3 in comparison with exercises or medical management alone. (24) 

References

Childs, J. Cleland, J. et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(9):A1-A34.

Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102:167-178.

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Arch Phys Med Rehabil 2011;92:824-9

Carroll L. Hogg-Johnson, S. et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4):S75–S82.

Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ. 2003.

Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524.

Kay, T. Gross, A. et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2005. CD004250.

Sarig-Bahat, H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy. 2003;8:10-20.

Nilsson, N. Christensen, J. et al. The effect of cervical manipulation on cervicogenic headache. J Manip Phys Ther. 1997;20:326-330.

10. Gross, A. Hoving, J. et al. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Pain. Spine 2004;29:1541–1548

11. Jull, G. Trott, P. et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835–1843

12. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky A, Neundorfer B. Herniated cervical intervertebral discs with radiculopa- thy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.

13. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12-16.

14. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. 1999;24:591-597.

15. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006;38:145-152.

16. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2001;31:207-213.

17. Cleland, J; Whitman, J; Fritz, J; Palmer, J. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005:35(12):802-809.

18. Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J., & Gutierrez-Vega, M. (2009). Thoracic spine manipulation for the

management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20-27.

19. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash- associated disorders, part I: non-invasive interventions. Pain Res Manag. 2005;10:21-32.

20. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782-1787.

21. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68.

22. Cassidy, J.D., Lopes, A.A., Young-Hing, K. The immediate effect of manipulation vs mobilization on pain and range of motion in the cervical spine: a randomized control trial. Journal of Manipulative and Physiological Therapeutics. 1992. 15:9.

23. Cleland, J.A., Mintken, P.E., Carpenter, K., Fritz, J.M., Glynn, P., Whitman, J., Childs, J. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a generally cervical range of motion exercise: multi-center randomized control trial. Physical Therapy. 2010. 90: 9.

24. Ingeborg, B.C., Korthals-de Bos, Hoving, J.L., Tulder, M.W., Rutten-van Molken, M., Ader, H.J., CW de Vet, H., Koes, B.W., Vondelling, K., Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practicioner care for neck pain: economic evaluation alongside a randomized control trial. British Medical Journal. 2003. 326:911 

 

Cervical Radiculopathy and Physical Therapy Solutions
Neck and Arm Pain Physical Therapy Interventions

Cervical Radiculopathy Injuries and Symptoms 

Cervical radiculopathy occurs when a nerve from the neck becomes irritated or compressed by space occu- pying lesion including fluid, soft or bony tissues as it exits the spine. Patients often complain of sharp, burning pain down the arm, numbness, tingling, or weakness.

This condition is most common in the 5th decade of life with an annual incidence of 83 per 100,000 individuals(2).

The C6 and C7 cervical nerve roots are most com- money involved(3). EMG/NCV testing is considered the gold standard for the diagnosis of this disorder.

A clinical prediction rule developed by Wainner et al. showed four clinical tests/measures are helpful for diagnosis of this condition:

1. (+) Spurling’s Test
2. (+) Distraction Test
3. Ipsilateral cervical rotation <60 degrees                                                                                                             4. (+) median nerve upper limb tension test

Authors reported a specificity of 94% and 100% for 3/4 and 4/4 variables, respectively(4). 

Physical Therapy Interventions 

Recent reviews of cervical radiculopathy suggest conservative treatments may be superior to surgical interventions(5,6).

Authors suggest evidence supports the utilization of short term epidural corticosteroid injections for patients with radicular pain(6).

A multimodal Physical Therapy treatment plan involving manual therapy (joint mobilization/ manipulation and soft tissue mobilization), exercise, mechanical traction, and education provides short and long term reductions in pain and disability. 

Neck and Arm Pain Physical Therapy Manual Treaments
Mechanical Traction in Physical Therapy

Physical Therapy Evidence for Cervical Radiculopathy

Literature reviews report the combination of manual therapy and exercise is effective at reducing pain and disability, as well as, increasing AROM in patients with cervical radiculopathy(5).

Cleland et al. demonstrated 91% of patients treated with manual therapy, exercise, and mechanical trac- tion had successful short and long term outcomes(7).

Fritz et al. reported mechanical traction and exercise was superior to exercise or exercise and over the door traction for reducing pain and disability. The group receiving mechanical traction and exercise was the only group to sustain the benefits of the 4 week treat- ment at 6 and 12 month follow ups(1).

Raney et al. suggested four variables may assist in determining which patients will best respond to cervical mechanical traction:

1. Peripheralization with manual therapy testing                                                                                                      2. (+) shoulder abduction test
3. Age >55 years old
4. (+) median nerve upper limb tension test                                                                                                               5. (+) neck distraction test                                                                                                                                            If 4/5 variables are met there was a 95% success rate(9). 

When to Seek Physical Therapy Treatment

Patient’s with neck and arm pain with or without symptoms of nerve root irritation including numbness, paresthesias, or weakness should be referred to PT for short and long term reduction of pain and disability.

Health Care practitioners may use Wainner’s CPR noted above for the clinical diagnosis of Cervical Radiculopathy.

Cleland et al. noted four variables help predict patients who will respond favorably to physical therapy interventions for cervical radiculopathy:

1. Age <54
2. Dominant arm not affected
3. Cervical flexion does not worsen symptoms                                                                                                          4. Patient received multimodal PT treatment

A 85% and 90% success rate was found if patients met 3/4 or 4/4 variables, respectively(8). 

References

1. Fritz et al. Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consider- ation of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial. JOSPT. 2014;44(2):45- 57.

2. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy: a population- based study from Rochester, Minnesota, 1976–1990. Brain 1994; 117:325–35.

3. Dillin W, Booth R, Cuckler J, Balderston R, Simeone F, Rothman R. Cervical radiculopathy: a review. Spine 1986;11:988–91.

4. Wainner RS, Gill H. Diagnosis and nonoperative manage- ment of cervical radiculopathy. J Orthop Sports Phys Ther 2000;30:728–44.

5. Boyles et al. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011. 19(3):135-142.

6. Carragee, E. et al. Treatment of Neck Pain. Injections and Surgical Interventions. Spine. 2008. 33(45):S153-S169.

7. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Orthop Sports Phys Ther 2005;35:802–11.

8. Cleland, J. et al. Predictors of Short-Term Outcome in People With a Clinical Diagnosis of Cervical Radiculopathy. JOSPT. 2007

9. Raney, N. Development of clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009.