|
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
References
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.
|
