Physiotherapy for Cervical Radiculopathy: Techniques to Relieve Nerve Pain

Cervical Radiculopathy is a nerve root condition of the cervical spine (neck region), which becomes compressed or irritated, leading to pain, numbness or weakness that can radiate down the arm. This condition is often caused by herniated discs, bone spurs or other degenerative changes in the spine that exert pressure on the nerve roots. The most common level of nerve root compression is C7, followed by C6, compression of C5 and C8 roots is less frequent.

 

Causes of Cervical Radiculopathy

Cervical radiculopathy can be caused by several factors, primarily involving changes in the structures of the cervical spine. 

• Herniated Disc
• Degenerative Disc Disease
• Bone Spurs (Osteophytes)
• Spinal Stenosis
• Cervical Spondylosis
• Acute Injuries - such as whiplash or a fall leading to vertebral fractures or ligament injuries that compress nerve roots
• Infections - such as osteomyelitis 
• Cervical Misalignment
• Repetitive Strain

 

Signs and Symptoms of Cervical Radiculopathy

• localized sharp, burning or aching pain in the neck
• radiating arm pain which follows path of the affected nerve
• paresthesia in the arm, hand or fingers
• weakness in the muscles of the shoulder, arm or hand, which can make it difficult to perform tasks such as gripping or lifting objects
• difficulty with fine motor skills in the hand - such as buttoning a shirt or writing
• pain is also felt around or between the shoulder blades
• occipital headache, which is sometimes referred to as cervicogenic headaches
• symptoms that worsen with certain neck movements - such as looking towards ceiling, head rotation or maintaining certain postures for extended periods

 

Diagnosis

Patient History

• Ask about when the symptoms began, how they developed and whether they are constant or intermittent.
• Inquire about the location, nature (sharp, burning, dull) and radiation of the pain (e.g., from neck to arm).
• Identify movements or positions that exacerbate or alleviate symptoms.
• Check for any history of neck trauma, previous neck problems, or degenerative conditions.
• Consider repetitive strain from work or hobbies, as well as posture during daily activities.

Physical Examination

• Look for any visible signs such as poor posture, muscle atrophy, or asymmetry in the neck, shoulders, or arms.
• Assess for tenderness, muscle spasms, or trigger points along the cervical spine, shoulders, and upper back.
• Evaluate cervical spine movements (flexion, extension, rotation, lateral flexion) for any restrictions or pain.
• Test the strength of muscles innervated by cervical nerve roots, focusing on the deltoid, biceps, triceps, wrist extensors, and hand muscles.
• Check for changes in sensation along the dermatomes corresponding to cervical nerve roots (e.g., C5-C8, T1).
• Assess deep tendon reflexes (e.g., biceps, triceps, brachioradialis) to identify any abnormalities.

Differentiating Between Cervicalgia and Cervical Radiculopathy

Special Tests

• Spurling’s Test: This test compresses the cervical spine to reproduce symptoms. The patient extends and rotates the head toward the symptomatic side, and the therapist applies downward pressure. A positive test reproduces radicular pain.
• Distraction Test: Gently applying traction to the cervical spine can relieve symptoms, indicating nerve root compression.
• Upper Limb Tension Test (ULTT): This test assesses the irritability of the peripheral nerves. It involves positioning the arm in a specific manner to stretch the nerve. A positive test reproduces symptoms.
• Cervical Compression Test: Apply gentle downward pressure on the patient’s head while they are seated. Reproduction of radicular pain indicates nerve root compression.
• Shoulder Abduction Relief Test: Ask the patient to place their hand on top of their head. Relief of symptoms suggests cervical radiculopathy.

Imaging Studies

• In some cases, a referral for EMG may be appropriate to assess nerve function and confirm the diagnosis.
• Nerve Conduction Study helps differentiate between cervical radiculopathy and other conditions like peripheral neuropathy, brachial plexopathy, or carpal tunnel syndrome and evaluates the location, severity and extent of nerve damage.

Differential Diagnoses

• Shoulder Impingement Syndrome
• Rotator Cuff Tear
• Thoracic Outlet Syndrome
• Carpal Tunnel Syndrome
• Peripheral Neuropathy
• Brachial Plexopathy
• Myofascial Pain Syndrome
• Multiple Sclerosis
• Cervical Myelopathy
• Lung Apex Tumor (Pancoast Tumor)
• Complex Regional Pain Syndrome (CRPS)
• Herniated Thoracic Disc
• Cubital Tunnel Syndrome

 

Physiotherapy Management of Cervical Radiculopathy

Physiotherapy management for cervical radiculopathy focuses on alleviating pain, reducing inflammation, improving neck function and preventing recurrence. 

Pain Relief and Symptom Management

• Advise the patient to avoid activities that exacerbate symptoms, such as heavy lifting, prolonged neck flexion or overhead activities. Encourage relative rest but not complete immobilization.
• Use modalities like TENS (Transcutaneous Electrical Nerve Stimulation) to manage pain, or IFC (Interferential Current) to reduce pain and inflammation. Plus apply cold packs (Cryotherapy) in the acute phase to reduce inflammation and heat therapy in the sub-acute phase to relieve muscle tension.

• Myofascial release technique ia preformed to relieve muscle tension, improve circulation, and reduce pain. Focus on the upper trapezius, levator scapulae, and suboccipital muscles.
• Cervical Traction is performed manually or mechanically. Start with low force and gradually increase based on patient tolerance.

Intermittent Cervical Traction

The traction force is applied to the cervical spine in a cyclic manner, with periods of pulling (traction) followed by periods of rest (release). Commonly used patient postion is neck flexion (about 15°).

Physiological Effects of Cervical Traction:

1. separation of vertebral bodies
2. movement of facet joints
3. expansion of intervertebral foramen
4. stretching of soft tissues

Improving Neck Mobility

• Gentle, pain-free cervical spine range of motion exercises (flexion, extension, lateral flexion, rotation) to maintain or restore mobility. Perform exercises slowly and in a controlled manner.
• Manual therapy techniques such as joint mobilizations (grade I-II), of the cervical or thoracic spine, is performed to improve joint mobility and reduce pain. Mobilizations should be gentle and within the pain-free range. SimillaryNon-Thrust Mobilization techniques are also used.

Non-Thrust Joint Mobilization Includes

1. PA glides
2. rotational glides
3. lateral glides to the cervical spine

• Muscle Energy Techniques (METs) can be a valuable component of a physiotherapy treatment plan, it improves neck mobility and reduce nerve root compression. Here's how METs can be applied:

Post-Isometric Relaxation (PIR)

Focus on upper trapezius, levator scapulae, scalene muscles and other muscles that may be contributing to cervical tension.

Reciprocal Inhibition (RI)

Focus on SCM (sternocleidomastoid), scalenes and suboccipital muscles.

Joint Mobilization METs

Cervical facet joints and the upper thoracic spine is targeted.

Neural Mobilization (Nerve Glides): 

Nerve gliding exercises helps improve the mobility of the affected nerve. Start with mild tension and progress gradually as tolerated.

Median Nerve Mobilization

• Position: The patient is in supine, with the arm abducted, externally rotated and the elbow extended. The wrist and fingers are extended.
• Technique:

1. Sliding: The therapist alternates between wrist extension and elbow flexion/extension to glide the median nerve.
2. Tensioning: The therapist fully extends the elbow and wrist to apply tension along the median nerve. The patient’s shoulder may be gently depressed to increase the stretch.

Strengthening and Stabilization

• Focus on strengthening the deep neck flexors (longus colli and longus capitis) using exercises like the chin tuck. 
• Strengthen the muscles around the scapula (e.g., lower trapezius, rhomboids, serratus anterior) to support the neck and upper back. Exercises like scapular retraction and wall slides are effective.
• Incorporate exercises to strengthen the shoulder girdle and upper back muscles, such as rows and shoulder external rotations. These exercises help to offload the cervical spine.

 

Postural Education and Ergonomics

• Teach exercises to correct forward head posture, rounded shoulders and winging of the scapula. Emphasize the importance of maintaining good posture throughout the day. Further, provide guidance on proper workstation setup, including monitor height, chair support and keyboard positioning. Recommend regular breaks to avoid prolonged static postures.
• Advise on optimal sleeping positions, such as using a supportive pillow that maintains the neck's natural curvature, avoiding stomach sleeping, and possibly sleeping on the back or side.

 

Education and Self-Management

• Educate the patient on techniques for managing pain at home, including the use of ice, heat and over-the-counter medications (if appropriate).
• Teach gentle self-mobilization techniques or stretching exercises that the patient can perform at home.
• Educate the patient on avoiding activities that aggravate their symptoms and suggest alternatives that are less likely to provoke pain.

Functional Rehabilitation

• Gradually progress the intensity of strengthening exercises as the patient improves. Incorporate thera-bands or light weights as tolerated.
• Include exercises that simulate daily activities or work-related tasks to help the patient return to normal function. For example, if the patient is an office worker, focus on posture and endurance during typing or computer use.

Monitoring and Re-assessment

• Schedule regular follow-up sessions to monitor progress, adjust the treatment plan as needed, and ensure that the patient is adhering to the home exercise program.
• Use outcome measures like the Neck Disability Index (NDI) or visual analog scale (VAS) to track improvements in pain, function, and quality of life.