Physical Therapy Approach to Cervical Radiculopathy

Chris Ferrigno, MS, PT

Cervical radiculopathy can be a severely debilitating condition which can be difficult to manage for both the patient and the health care provider. While a far less common malady than lumbar radiculopathy, cervical radiculopathy is widespread and a very common diagnosis treated within a physical therapy practice. Physical therapists have many treatment options focusing on treating both the symptoms and the underlying origin of the condition.

Historically, physical therapists have been trained to use physical modalities to provide a short term decrease of patient’s symptoms. These modalities often include thermal agents such as hot packs, cold packs, or other physical agents like ultrasound, electrical stimulation, interferential current and iontophoresis, for pain control. I certainly see the benefit of using physical agents for pain control, especially with a patient who is experiencing acute, severe discomfort. However, there has recently been a shift in the approach many therapists take, including myself, to treat cervical radiculopathy. The focus for cervical radiculopathy is now centered more on the cause of symptoms rather than simply addressing symptoms themselves.

In 1932, Joel Goldthwait et al. wrote a marvelous description of posture and body mechanics relating to health and disease.¹ His writings were specific to the health of children, but his lessons were revolutionary, profound and very applicable to the approach that many physical therapists now take in treating cervical radiculopathy.¹ Goldthwait wrote, “Body mechanics may be defined as the mechanical correlation of various systems of the body with special reference to the skeletal, muscular and visceral systems and their neurological associations. Normal body mechanics may be said to obtain when this mechanical correlation is most favorable to the function of these systems.”¹ In other words, deviate from the norm and problems will occur. Many cases of cervical radiculopathy are discogenic,² and occur because of an accumulation of mictotrauma to the cervical spine. To understand the physical therapist’s approach to treating the cause of cervical radiculopathy, I would like to review discogenic pathology and discuss its relationship with posture and biomechanical deviations.

Discogenic pain results from either a bulge of a lower cervical disc in the posterior or posterolateral direction, migration of a disc or fragment, or from a herniation of the nucleus pulposis protruding through the annulus. The disc, while a highly stable structure, also has its breaking point, which is a crucial concept in understanding the progression of neck pain and cervical radiculopathy. In the case of the cervical spine, proper alignment is required for the optimal cervical disc environment. When improper forces are applied over a period of time, the disc degrades. In the case of poor posture, the most common postural deviation is the forward head posture.³ (See Figure 1.) This posture, which has been directly correlated to neck disability⁴ and pain,⁵ applies increased forces to the anterior aspects of each lower cervical disc and decreased forces to the posterior aspect of the disc, thereby creating a pressure differential. This differential in pressure, when repeatedly applied over decades of life, can cause the nucleus of the disc to migrate posteriorly,⁶ leading to the aforementioned bulge or herniation posteriorly.

Cervical radiculopathy and neck pain cases have been on the rise in my practice over the last few years. A quick anecdote might explain the reason for this increase:

As I was on an airplane a few months back, I was sitting slumped, staring at the mini screen of my MP3 player, and realized I was having a slight numbness in my thumb. I lifted my head, looked around the plane, and counted 34 passengers who were looking down at cell phones, MP3 players, and the countless other techie devices existing today, reading newspapers, and playing Soduku. (See Figure 2.) I envisioned the 34 poorly-postured passengers going to work the next day for 8-10 hours, logging on to the computer while placing a phone between an ear and shoulder, until they could return from work maybe via a train, like I do, where they would continue their barrage of texting, emailing, and song selection with their hand held devices, only to arrive home where they would spend the remainder of the evening on the sofa in front of the TV, laptop in hand, staring at the screen with forward head and shoulders, wondering who be the next person voted off the island or which couple lost the most weight, while updating their social network site and cleaning all the viruses off of their hard drive. Basically, many of these people would be spending 16+ hours of their day with a slumped, forward head posture, compressing both their lower cervical disc and opening up their neural foramen allowing spurs to form.

Yes, I know this was a bit of an exaggerated response, but I thought about my thumb numbness, and the pains and parasthesias of my patients, and realized that my approach to neck pain, which focuses on posture and mechanical treatment, was validated even more during the quick glance around the plane. I can give patients hot packs, home e-stim units, neck stretch exercises, mobilizations, and soft tissue massages, but unless the stimulus of their disorder was addressed, their condition was not going to be corrected in the long term.

Clinicians can address patient’s posture and biomechanical deviations in a variety of ways. In order to promote improved alignment in all spinal segments, I start with instructing patients on proper pelvic positioning moving up through the lumbar and thoracic spine. I teach patients which surfaces are good for sitting, including firmer surfaces and chairs which fit their body geometry. I discuss how to properly position themselves in the appropriate chair as well as how to position themselves within their workstations, whether at home or at the job. (See Figure 3.) I then look at various ways to enhance scapular stabilization, which will provide a solid base for the cervical spine. This is achieved by having patients work the stabilizing muscles such as serratus anterior, middle and lower trapezius, rhomboids, and latissimus dorsi. After the patient has a comprehensive understanding of how to effectively contract these muscles, then additional exercises are issued to combine scapular stabilization with cervical retraction with everyday arm movements, such as reaching overhead, carrying their briefcase, or simulating typing at their desk.

After the lumbar, thoracic, and scapular positions have been addressed, the cervical spine is managed through the use of a mechanical approach involving cervical retraction. This movement, if performed properly, will decrease lower cervical spine flexion and upper cervical extension, both of which occur in forward head positioning. As lower cervical flexion decreases, the pressure on the anterior aspect of the lower cervical disc decreases. This results in even disc pressure—the best environment for the disc.

While cervical retraction is an exercise to progress and promote proper posture, it also can be used as both a palliative and therapeutic exercise to directly and immediately address the patient’s pain. An important concept of cervical retraction is taking the movement to the end range of that movement. (See Figure 4.) The exercise may be done in sitting, supine or even prone, depending on the patient’s response during a thorough evaluation. End range movement is crucial to initiate pain centralization. By retracting the cervical spine, pressure is place on the posterior aspect of the cervical disc. With repeated movements at end range, the disc has the potential to creep anteriorly and take pressure off the irritated nerve.^7,8 Cervical retraction exercises can also be coupled with cervical extension at some point during the treatment so as to provide increased force from posterior to anterior on the cervical spine. (See Figure 5.) The upper thoracic and upper cervical spine would also be addressed, to reduce the stresses in the affected lower cervical spine. With significant repetition and progression of force on the disc (using all of the mentioned methods), centralization of symptoms can occur,⁹ resting cervical posture can improve,⁹ and the chance of reoccurrence of symptoms can be reduced.^8,10,11

CASE STUDY #1

A 52 year-old, female attorney came in with complaints of right arm pain, which was medically diagnosed from the referring physician as cervical radiculopathy. This patient reported a 50% reduction of symptoms from cervical ESI (epidural steroid injection). She presented with C6 dermatomal pain, with intermittently severe symptoms. Following a mechanical evaluation, which initially exacerbated her symptoms, the patient was instructed on cervical retraction exercises to perform every two hours during waking hours. The patient returned one week later for follow up with slight pain in the upper arm and neck only. The patient was reinstructed on the retraction exercise, and in the clinic the patient was able to abolish her radicular symptoms and had moderate axial pain. During that visit, the retraction movement was changed slightly in order to emphasize a higher degree of endrange movement. On second follow-up, another week later, the patient reported no significant pain with an occasional axial aching pain.

CASE STUDY #2

A 48 year-old, male restaurateur presented to physical therapy with significant, nearly constant right upper trap and right lower humeral pain, and intermittent pain into his right thumb. The patient could easily turn on and off his thumb pain when sitting at work by simply changing the chair at his desk, and found significant relief sleeping in a foldable beach lounger. During mechanical evaluation, the patient’s symptoms were exacerbated with end-range cervical retraction. By the end of evaluation, the patient could tolerate a movement approximately 25% of his end-range movement. The patient required a total of six visits, required various posture changes, including changing the position in which the patient performed his exercises, from supine, to prone, to sitting.

In summary, the treatment of cervical radiculopathy requires considerable attention to the patient’s posture and body mechanics. Clinicians need to make the patient aware that they can manage their condition with a few basic movement principles which include a well-performed cervical retraction coupled with cervical extension motion. (See Figure 6.) While not all patients respond to mechanical treatment, which usually includes cervical retraction, cervical and thoracic extension, and posture education, most patients are successful in significantly reducing their peripheral and central symptoms.