Cervical Radiculopathy

Problem:

Cervical radiculopathy is a condition that affects mostly adults who have reached their 50’s. It occurs when a nerve in the neck gets compressed or irritated by space occupying lesion including fluid, soft or bony tissues as it leaves the spine. This causes sharp, burning pain through the arm, numbness, tingling, and/or weakness. It affects approximately 83 individuals out of every 100,000 individuals annually. The C6 and C7 cervical nerve roots are most commonly the nerve roots involved. In order to diagnose this disorder, EMG/NCV tests are administered.

Wainner et al. established a clinical prediction rule which is helpful in determining which the following clinical approaches were determined to be best for diagnosing cervical radiculopathy:

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.

Neck Pain Combining Exercise and Manual Therapy for Your Neck and Upper Back Leads to Quicker Reductions in Pain
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Interventions:

Recently, reviews have suggested that conservative treatments may be better options than surgical interventions for cervical radiculopathy. Authors have suggested that utilization of short-term epidural corticosteroid injections is one of the most effective interventions for those with radicular pain. A multimodal physical therapy treatment plan that would provide reduction both in short-term and long-term pain and disability includes the following: manual therapy (joint mobilization/manipulation and soft tissue mobilization), exercise, mechanical traction, and education.

Evidence:

The literature reviews report that combining manual therapy with exercise is effective at reducing pain and disability. Combining these two approaches would also increase AROM in those with cervical radiculopathy.

Cleland et al. showed that about 91% of patients who underwent manual therapy, exercise, and mechanical traction experienced successful short-term and long-term results. Fritz et al. reported that as opposed to exercise alone or exercise with over the door traction, combining mechanical traction with exercise was most effective in reducing pain and disability.

At the 6- and 12-month follow-ups, the group that practiced mechanical traction and exercise was the only group that showed sustained benefits from the 4-week treatment.

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

Refer:

Patients who have neck and arm pain but no symptoms of nerve root irritation (such as numbness, paresthesias, or weakness) should be referred to a physical therapist. The physical therapist can assist with the reduction of pain and disability.

In order to clinically diagnose patients with cervical radiculopathy, healthcare practitioners may use Wainner’s CPR which is noted above.

The following are four variables noted by Cleland et. al. that help predicts what types of patients will respond favorably to physical therapy interventions for this condition:

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
   
   

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 Consideration 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 management 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.