PT Classroom - A Review of Cervical Radiculopathy ׀ by Benjamin Sweeney, SPT


A painful and debilitating diagnosis for many individuals, cervical radiculopathy is a diagnosis associated with pain that begins in the neck that radiates into the arm (1). This can occur as a result of cervical disk herniations or spondylitic changes such as bone spurs in the cervical spine, causing inflammation and compression of the spinal nerve roots that extend into the arm (1). While there is no commonly accepted definition, radiculopathy is defined as a neurological state in which a conduction along a spinal nerve root is blocked, resulting in pain as well as sensory or motor dysfunction (1). Many common causes of cervical radiculopathy include a weakening of the core muscles of the spine due to a lack of exercise and altered body mechanics that can lead to muscular instability (3). Its incidence and impact on quality of life is typically undervalued, as a report from the Global Burden of Disease indicated that cervical discomfort is the “4th primary source of years leading to a disability” and that half of those surveyed will experience a clinically significant cervical discomfort during their lifetime (3).

While there are many forms of neck pain, it is important to effectively establish a diagnosis of Cervical Radiculopathy to establish an appropriate line of care. While EMG/nerve conduction studies are considered the gold standard for establishing an appropriate diagnosis, Clinical Prediction Rules (CPR) have evolved to help establish a diagnosis through alternative tests if EMG/nerve conduction studies are not available (2). These four variables include a positive Spurling test, cervical rotation less than 60 degrees, positive upper limb tension test, and a positive distraction test. Understanding the effectiveness of both surgical and non-surgical interventions is important for initiating an appropriate plan of care that best meets a patient’s needs.

While there are limitations to research on both conservative and surgical treatment of cervical radiculopathy, several options of conservative treatment are effective, in particular manual therapy. In a study comparing active range of motion (AROM) exercises, transcutaneous electric nerve stimulation (TENS), and superficial thermotherapy, with or without manual traction, the group experiencing manual traction had a statistically reduced level of pain (6.06 +-1.63 in the control group, compared with 1.68 +-.58 in the experimental group, utilizing VAS (1-10)(3)). Protocols for traction included utilizing the towel method for 20 minutes and a ten second on, five second off protocol, as previous research has supported this protocol for achieving maximal vertebral separation without exacerbating patient symptoms (3). Previous research has also found statistically significant findings for a physiotherapy protocol consisting of TENS, neck exercises as well as intermittent cervical traction, stressing the importance of intermittent traction and neck exercises for management of cervical radiculopathy. In addition, core strengthening in combination with cervical traction was more effective that a single intervention(4). An additional protocol that have found statistically positive results when utilizing high velocity thrust of thoracic and cervical spine muscles, intermittent cervical traction, and strengthening of deep cervical muscles. Consistent throughout all research protocols is the notion of ensuring that multiple interventions of manual therapy are utilized for maximum return to function, ability to complete ADLs, as well as reduce pain. A systematic review further supported that manual therapy can significantly reduce pain for individuals with cervical radiculopathy (2). Furthermore, thrust mobilizations of the thoracic spine showed statistically significant improvements in the Neck Disability Index (NDI), Patient-Specific Functional Scale (PSFS), and Numeric Pain Rating Scale (NPRS), and 18 out of 27 patients demonstrated a successful outcome(5). Non-thrust mobilizations were also used, and often at the discretion of the therapist, and also showed positive outcomes for 27 out of 47 patients (5). While research has concluded that there are benefits to utilizing cervical and thoracic spine mobilization techniques, research has not isolated specific techniques in randomized controlled trials, making it difficult to determine the extent of its positive benefit.

Although manual therapy has shown positive benefits for improving the outcomes for patients with cervical radiculopathy, one research study compared the outcomes of surgical and non-surgical/manual therapy interventions to decide if surgery is necessary. While there are many surgical options available, anterior cervical decompression and fusion is considered the “gold standard” for cervical treatment, usually cited as necessary when symptoms persist for longer than three months with conservative treatment without improvement (7). A randomized controlled trial recently compared the outcomes of ACDF surgery followed by physical therapy versus physical therapy alone (7). Results indicated that significant pain reduction and global assessment was noted at twelve months after surgery compared to conservative measurements, but these differences not significant at 24 months (7). Furthermore, the group receiving physical therapy completed neck exercises, general exercises, and pain coping strategies, but did not receive manual traction or joint mobilization techniques (7). Due to the lack of comparing specific manual therapy techniques and specific surgeries, it is difficult to make a definitive comparison between surgical and conservative options for improving outcomes. Authors concluded that physical therapy should be attempted before considering surgery, as the outcomes have been shown to be very positive.

Due to the promising research demonstrating positive effects on cervical radiculopathy, manual therapy is a promising intervention at improving outcomes. While surgery is at times necessary, manual therapy techniques are often sufficient for improving outcomes. Since limited research exists with specific intervention protocols to compare manual therapy techniques, further research is necessary in order to improve knowledge and outcomes for patients with cervical radiculopathy.


Last revised: August 28, 2018
by Benjamin Sweeney, SPT

1) Falla, D, Thoomes, E.J., Koes, B., Scholten-Peeters, W., Verhagen, A.P. (2013). The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clinical Journal of Pain, 29 (12), 1073-1086.
2) Boyles, R., Hammer, B., Hayes, M., Mellon Jr., J., Toy, P. (2011). Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Journal of Manual and Manipulative Therapy, 19(3), 135-142.
3) Yasmeen, S., Imdad, F., Ishaque, F., Khan, K., Khanzada, S., Lal, W., Kumar, N., Sheikh, S.A. (2016). Effectiveness of manual cervical traction and other physiotherapy treatment in the management of painful cervical radiculopathy. International Journal of Physiotherapy, 3(3), 286-190.
4) Umar, M., Naeem, A., Badshah, M., & Amjad, I. (2012). Effectiveness of cervical traction combined with core muscle strengthening exercises in cervical radiculopathy. Journal Of Public Health and Biological Sciences, 1(4), 115-120.
5) Cleland, J.A.; Fritz, J.M., Whitman, J.M., Palmer, J.A. (2005). Manual physical therapy, cervical traction, , and strengthening exercises in patients with cervical radiculopathy: a case series. Journal of Orthopedic Sports Physical Therapy, 35, 802-811.
6) Persson LC, Carlsson CA, Carlsson JY. (1997). Long lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine, 22,(7), 751-758.
7) Enquist, M., Holtz, A., Lind, B., Lofgren, H., Oberg, B., Peolsson, A., Soderlund, A., Vavruch, L. (2013). Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine, 38(20), 1715-1722.

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