Cervical Radiculopathy Exercises

cervical radiculopathy exercises 1
image cervical radiculopathy exercises 1

Cervical Radiculopathy Exercises

Cervical radiculopathy is a disorder of a cervical nerve root1 and is common in the general population, with an annual incidence of approximately 83 per 100,0002. Patients with cervical radiculopathy often report neck pain; however, they most frequently seek treatment to address their arm pain1,3,4. People with neck pain combined with upper extremity symptoms experience greater levels of disability than do people with neck pain alone4. Authors have suggested that patients with neck and arm pain should be treated more expeditiously in order to avoid the further negative impact on mental health status associated with chronic symptoms4.Treatment strategies for patients with cervical radiculopathy range from conservative management to surgery. Evidence suggests that patients who are treated conservatively may experience superior outcomes compared to those who undergo surgery5; however, there is little evidence to suggest which non-operative interventions are the most effective6,7. Recently, two case series3,8 used a combination of thrust and non-thrust mobilization/manipulation techniques directed at the cervical and thoracic spine, mechanical cervical traction, and exercise to treat patients with a clinical diagnosis of cervical radiculopathy. Cleland et al3 reported that 10 of 11 patients demonstrated clinically meaningful improvement in pain and function at discharge and 6-month follow-up. Waldrop8 reported improvement of 13% to 88% in the Northwick Park Neck questionnaire scores in 6 patients, with scores ranging from 13% to 88%. A recent prospective cohort study7 also described the use of an individualized approach including thrust and non-thrust cervical mobilization/manipulation techniques, repeated endrange exercises to promote centralization of symptoms, neural mobilization, traction, and cervical stabilization exercises. Of the participants, 77% surpassed the minimally clinically important difference on the Bournemouth Disability Questionnaire at discharge (mean=11 visits). This value increased to 93% at long-term follow-up (mean=8.2 months).While these preliminary reports suggest that a multimodal treatment approach may be beneficial for patients with cervical radiculopathy, exactly which interventions should be included in this approach, and in what combination, requires further research. The purpose of this case report is to describe the evaluation, clinical decision-making process, and treatment of a patient with cervical radiculopathy. The rationale for thrust manipulation of the thoracic spine and soft tissue mobilization are discussed. Approval for this case report was provided by the Institutional Review Board at Cayuga Medical Center, Ithaca, New York.
cervical radiculopathy exercises 1

Cervical Radiculopathy Exercises

DiscussionThis case report describes the physical therapy management of a patient with cervical radiculopathy. Physical impairments of limited ROM, tenderness to palpation, and provocative testing all improved dramatically after the first session and were maintained over the next three weeks. Large improvements were observed in the NPRS and GROC, and the patient reported complete resolution of functional disability as indicated by the PSFS.There has been emerging evidence to suggest that patients who meet the diagnostic classification for cervical radiculopathy might benefit from a multimodal treatment package that includes manual therapy, mechanical traction, and strengthening exercises3,7,8. Cleland et al recently reported that for patients with cervical radiculopathy, receiving this multimodal package was a predictor of a positive outcome6. The therapist in this case study chose a treatment approach that included manual therapy techniques and therapeutic exercises that included strengthening of the deep neck flexors and scapular stabilizers. Since the patient did not demonstrate a positive cervical distraction test, mechanical traction was not included in the treatment plan because it was not expected to be beneficial.Impairments of the thoracic spine may be related to complaints of neck and shoulder pain33. Immediate improvements in AROM and pain have been demonstrated in patients with neck pain following thoracic thrust manipulation32,34. Thoracic thrust manipulation has also been used as a part of the multimodal package to treat patients with cervical radiculopathy3,8. Cleland et al has identified a clinical prediction rule (CPR) for patients with neck pain who are likely to benefit from thrust manipulation of the thoracic spine (see Table ​Table55)32. The patient demonstrated only two of the six factors from the CPR, raising the post-test probability to 71%. The Fear-Avoidance Beliefs Questionnaire (FABQ) was not administered; however, the therapist believed that the patient could be classified as having low fear-avoidance beliefs because he continued to work full time performing heavy manual labor despite his condition. If he had indeed tested to a FABQ-PA score of >12, he would have scored 3/6 on the thoracic spine CPR, raising the post-test probability of success to 86%. Considering the evidence supporting the use of thoracic thrust manipulation for this patient and the lack of contraindications, the therapist determined that thoracic thrust techniques would be used at the initial session. Following the thoracic thrust techniques, the patient reported decreased pain with cervical AROM, and an increase in available ROM was observed. These improvements were maintained over the follow-up sessions.TABLE 5Clinical prediction rule for patients with neck pain likely to benefit from thoracic spine manipulation. Adapted from Cleland et al32.Neural mobilization techniques have been used as a component of treatment for patients with cervical radiculopathy3,7. While there is evidence that the lateral cervical glide mobilization may be beneficial for patients with a positive ULNT3,19, this author is not aware of any research describing the use of soft tissue mobilization to address this impairment. It has been the experience of this therapist that patients who present with a positive ULNT and tightness and tenderness of the upper quarter musculature respond positively to soft tissue mobilization techniques applied with the intention of decreasing tenderness and improving mobility of the soft tissue structures that surround the neural pathways. The therapist often uses the two techniques in combination. Considering the therapist’s experience and the patient’s positive experience of reduced symptoms after massage, the therapist chose to perform soft tissue mobilization prior to the lateral glide technique. Immediately after the application of soft tissue mobilization, this patient demonstrated a large increase in elbow ROM during the ULNT and reported that he no longer experienced his familiar pain during the test. Due to the significant improvement in the ULNT during the first session, which was maintained at all follow-up sessions, the lateral glide mobilization was not used.Strengthening exercises for the deep cervical flexors and scapular muscles were chosen to address the postural impairments, which were considered a contributing factor to the patient’s condition since he reported that his symptoms were affected by changing his posture. Falla et al35 reported that subjects with chronic neck pain demonstrated an improved ability to maintain upright posture following an exercise program targeted at training the deep cervical flexors. Strengthening of the neck and shoulder muscles has also been successfully used as a component of a multimodal program for patients with neck pain36 and cervical radiculopathy8.Although no cause-and-effect relationship can be established from a case report, this patient demonstrated a significant improvement in ROM and pain during the ULNT immediately after receiving soft tissue mobilization and that improvement was maintained over the next three weeks. Further research into the effects of soft tissue mobilization for patients with a clinical diagnosis of cervical radiculopathy or with an impairment of the mobility of the neural structures of the upper quarter is warranted. It is possible that the dramatic improvement observed in this patient is due to any one of the interventions, their combination, or the natural history of the patient’s condition.
cervical radiculopathy exercises 2

Cervical Radiculopathy Exercises

Clinical PresentationJump to section + Abstract EpidemiologyPathoanatomyClinical PresentationDiagnostic EvaluationNatural HistoryNonoperative Management StrategiesReferralReferencesChronic neck pain associated with spondylosis is typically bilateral, whereas neck pain associated with radiculopathy is more often unilateral.3 Pain radiation varies depending on the involved nerve root, although some distributional overlap may exist. Absence of radiating extremity pain does not preclude nerve root compression. At times, pain may be isolated to the shoulder girdle.3 Similarly, sensory or motor dysfunction may be present without significant pain. Symptoms are often exacerbated by extension and rotation of the neck (Spurling sign; Figure 1), which decreases the size of the neural foramen. Holding the arm above the head (shoulder abduction sign) decompresses the exiting nerve root. Table 1 presents the classic patterns of cervical radiculopathy based on the affected nerve root.3,4View/Print FigureFigure 1.Spurling sign. Axial compression of the spine and rotation to the ipsilateral side of symptoms reproduces or worsens cervical radiculopathy. Pain on the side of rotation is usually indicative of foraminal stenosis and nerve root irritation.Figure 1.Spurling sign. Axial compression of the spine and rotation to the ipsilateral side of symptoms reproduces or worsens cervical radiculopathy. Pain on the side of rotation is usually indicative of foraminal stenosis and nerve root irritation.View/Print TableTable 1Classic Patterns of Cervical RadiculopathyAbnormalitiesNerve rootInterspacePain distributionMotorSensoryReflexC4C3–C4Lower neck, trapeziusNACape distribution (i.e., lower neck and upper shoulder girdle)NAC5C4–C5Neck, shoulder, lateral armDeltoid, elbow flexionLateral armBicepsC6C5–C6Neck, dorsal lateral (radial) arm, thumbBiceps, wrist extensionLateral forearm, thumbBrachioradialisC7C6–C7Neck, dorsal lateral forearm, middle fingerTriceps, wrist flexionDorsal forearm, long fingerTricepsC8C7-T1Neck, medial forearm, ulnar digitsFinger flexorsMedial forearm, ulnar digitsNAT1T1-T2Ulnar forearmFinger intrinsicsUlnar forearmNANA = not applicable.Information from references 3 and 4.Table 1Classic Patterns of Cervical RadiculopathyAbnormalitiesNerve rootInterspacePain distributionMotorSensoryReflexC4C3–C4Lower neck, trapeziusNACape distribution (i.e., lower neck and upper shoulder girdle)NAC5C4–C5Neck, shoulder, lateral armDeltoid, elbow flexionLateral armBicepsC6C5–C6Neck, dorsal lateral (radial) arm, thumbBiceps, wrist extensionLateral forearm, thumbBrachioradialisC7C6–C7Neck, dorsal lateral forearm, middle fingerTriceps, wrist flexionDorsal forearm, long fingerTricepsC8C7-T1Neck, medial forearm, ulnar digitsFinger flexorsMedial forearm, ulnar digitsNAT1T1-T2Ulnar forearmFinger intrinsicsUlnar forearmNANA = not applicable.Information from references 3 and 4.Before diagnosing cervical radiculopathy, physicians should consider other potential causes of pain and dysfunction (Table 2).2,4 Myelopathic symptoms or signs (e.g., difficulty with manual dexterity; gait disturbance; objective, upper motor neuron signs such as Hoffman sign, Babinski sign, hyperreflexia, and clonus) may suggest compression of the spinal cord rather than nerve root. Spinal cord compression typically requires surgical decompression because myelopathy is progressive and does not improve with nonoperative measures. The following factors may also indicate an alternate diagnosis: age younger than 20 years or older than 50 years, especially if the patient has signs or symptoms of systemic disease; unrelenting pain at rest; constant or progressive signs or symptoms; neck rigidity without trauma; dysphasia; impaired consciousness; central nervous system signs and symptoms; increased risk of ligament laxity or atlantoaxial instability, such as in patients with Down syndrome or heritable connective tissue disorders; sudden onset of acute and unusual neck pain or headache with or without neurologic symptoms; suspected cervical artery dissection; transient ischemic attack, which may indicate vertebrobasilar insufficiency or carotid artery ischemia or stroke; suspected neoplasia; suspected infection, such as diskitis, osteomyelitis, or tuberculosis; failed surgical fusion; progressive or painful structural deformity; abnormal laboratory examination results.5View/Print TableTable 2Differential Diagnosis of Cervical RadiculopathyConditionCharacteristicsCardiac painRadiating upper extremity pain, particularly in the left shoulder and arm, that has possible cardiac originCervical spondylotic myelopathyChanges in gait, frequent falls, bowel or bladder dysfunction, difficulty using the hands, stiffness of the extremities, sexual dysfunction accompanied by upper motor neuron findingsComplex regional pain syndrome (reflex sympathetic dystrophy)Pain and tenderness of the extremity, often out of proportion with examination findings, accompanied by skin changes, vasomotor fluctuations, or dysthermia; symptoms often occur after a precipitating eventEntrapment syndromesFor example, carpal tunnel syndrome (median nerve) and cubital tunnel syndrome (ulnar nerve)Herpes zoster (shingles)Acute inflammation of dorsal root ganglion creates a painful, dermatomal radiculopathyIntra- and extraspinal tumorsSchwannomas, osteochondromas, Pancoast tumors, thyroid or esophageal tumors, lymphomas, carcinomatous meningitisParsonage-Turner syndrome (neuralgic amyotrophy)Acute onset of proximal upper extremity pain, usually followed by weakness and sensory disturbances; typically involves upper brachial plexusPostmedian sternotomy lesionOccurs after cardiac surgery; C8 radiculopathy may develop secondary to an occult fracture of the first thoracic ribRotator cuff pathologyShoulder and lateral arm painThoracic outlet syndromeMedian and ulnar nerve (lower brachial plexus nerve roots, C8 and T1) dysfunction from compression by vascular or neurogenic causes, often a tight band of tissue extending from first thoracic rib to C7 transverse processInformation from references 2 and 4.Table 2Differential Diagnosis of Cervical RadiculopathyConditionCharacteristicsCardiac painRadiating upper extremity pain, particularly in the left shoulder and arm, that has possible cardiac originCervical spondylotic myelopathyChanges in gait, frequent falls, bowel or bladder dysfunction, difficulty using the hands, stiffness of the extremities, sexual dysfunction accompanied by upper motor neuron findingsComplex regional pain syndrome (reflex sympathetic dystrophy)Pain and tenderness of the extremity, often out of proportion with examination findings, accompanied by skin changes, vasomotor fluctuations, or dysthermia; symptoms often occur after a precipitating eventEntrapment syndromesFor example, carpal tunnel syndrome (median nerve) and cubital tunnel syndrome (ulnar nerve)Herpes zoster (shingles)Acute inflammation of dorsal root ganglion creates a painful, dermatomal radiculopathyIntra- and extraspinal tumorsSchwannomas, osteochondromas, Pancoast tumors, thyroid or esophageal tumors, lymphomas, carcinomatous meningitisParsonage-Turner syndrome (neuralgic amyotrophy)Acute onset of proximal upper extremity pain, usually followed by weakness and sensory disturbances; typically involves upper brachial plexusPostmedian sternotomy lesionOccurs after cardiac surgery; C8 radiculopathy may develop secondary to an occult fracture of the first thoracic ribRotator cuff pathologyShoulder and lateral arm painThoracic outlet syndromeMedian and ulnar nerve (lower brachial plexus nerve roots, C8 and T1) dysfunction from compression by vascular or neurogenic causes, often a tight band of tissue extending from first thoracic rib to C7 transverse processInformation from references 2 and 4.

Cervical Radiculopathy Exercises

Cervical Radiculopathy Exercises
Cervical Radiculopathy Exercises
Cervical Radiculopathy Exercises
Cervical Radiculopathy Exercises

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