Typical Dermatomal Pattern of the Upper Limb
Typical symptoms of cervical radiculopathy are: irradiating arm pain corresponding a dermatomal pattern
, neck pain
, muscle weakness in a myotomal pattern
, reflex impairment/loss
, sensory and motor dysfunction
in upper extremities and neck.
At the most basic level these are the upper limb movements that are affected in the myotomal pattern.
- C1/C2- Neck flexion/extension
- C3- Neck lateral flexion
- C4- Shoulder elevation
- C5- Shoulder abduction
- C6- Elbow flexion/wrist extension
- C7- Elbow extension/wrist flexion
- C8- Thumb extension
- T1- Finger abduction
For more detailed information on the exact muscles or dermatomes that will clinically present themselves go here:
If a nerve root is compressed it can cause a combination of factors: inflammatory mediators, changes in vascular response and intraneural oedema which causes radicular pain.
Absence of radiating pain does not exclude nerve root compression.
The same appears with sensory and motor dysfunction that might be present without significant pain.
Symptoms are generally amplified with side flexion towards the side of pain and when an extension or rotation of the neck takes place because these movements reduce the space available for the nerve root to exit the foramen causing impingement.
This often causes the patient to present with a stiff neck and a decrease in cervical spine range of motion (ROM) as movement may activate their symptoms. This in turn results in secondary musculoskeletal problems which can manifest as a decrease in muscle length of the cervical spine musculature (upper fibres of trapezius, scaleni, levator scapulae), weakness, joint stiffness, capsule tightness and postural defects which can go on to affect movement mechanisms of the rest of the body.
It is possible that when you are assessing a patient it may not be easy to ‘bring on’ the radiating arm pain, if this is the case try not to rule out radiculopathy, just try and get more information about the movements, positions or functional tasks which bring on the pain and replicate them. Reproducing the S+S is a very useful tool in aiding diagnosis. Equally do not be alarmed if you cannot replicate the S+S in the assessment, give the patient exercises to do at home along with postural advice and continue to perform the activities which usually bring on the radiating arm symptoms and see if there is a change.
In a non-Physiotherapy sense, the most common diagnostic methods used to assess the presence of possible compression are imaging studies (radiograph and MRI) and electrophysiologic studies (EMG
+ Nerve Conduction Studies
) to examine the nerve root and nerve conduction velocity.
If either of these options have been performed on your patient then it is possible to assess and see if radiculopathy is present through commonly used Physiotherapy assessment and treatment starting with the Subjective Assessment .
The HPC and Mechanism of Injury (Patient History
) sections of a subjective assessment can be integral to diagnosis and the cause of the radiating arm pain.
More frequently acute radiating arm pain is caused by a disk herniation, while chronic bilateral axial neck and radiating arm pain is usually caused by cervical spondylosis.
Physiotherapy Special Tests
In 2003, Dr.
Robert Wainner and colleagues examined the accuracy of the clinical examination and developed a clinical prediction rule to aid in the diagnosis of cervical radiculopathy.
Their research demonstrated that these 4 clinical tests, when combined, hold high diagnostic accuracy compared to EMG studies: Positive tests for Spurlings Test
, Upper limb tension-1 Distraction test
and Cervical Flexion Rotation Test .
When all 4 of these clinical features are present, the post-test probablity of cervical radiculopathy is 90%
, if only three of the four test are positive the probability decrease to 65% .
Another combination of tests, with good reliability are the combination of the Spurlings Test
, Neck Distraction, Valsalva and Upper Limb Tension Tests 1
Due to the close proximity of the cervical spine vertebrae and nerve roots to the vertebral arteries it is crucial that during the initial assessment of a patient any conditions which can cause severe damage to the patients blood supply, especially during any manual therapy.
It is also important to be aware of other pathologies which mimic the S+S of radiculopathy.
- Spinal Tumor
- Systemic diseases known to cause peripheral neuropathies
- Cervical myelopathy
- Ligamentous Instability
- Vertebral Artery Insufficiency (VBI)
- Herniated nucleous pulposos (HNP)
- Shoulder Pathology
- Peripheral nerve disorders
- Thoracic outlet syndrome
- Brachial plexus pathology
- Systemic disease
- Parsonage-Turner syndrome
Outcome measures are an essential tool to assess whether or not you are having a positive.
negative or static effect on a patients’ condition.
Cervical Radiculopathy is no different.
There are a lot of outcome measures in existance and it is important to know if the tool you are using is measuring what you want to measure (Specificity
) and how good it is correctly identifying a pattern (Sensitivity
Management and Treatment Approaches
There are several intervention strategies for managing cervical radiculopathy with physical therapy and surgical interventions being the most common.
Long-term benefits of surgical interventions are questionable with reported numbers of 25% of people continuing to experience pain and disability at 12 month follow-ups.
There is a significant amount of evidence available to support the use of physical therapy interventions for patients with cervical radiculopathy, and the benefit of physical therapy and manual techniques in general for patients with neck pain with or without radicular symptoms (see key evidence for a list of references).
The nonoperative treatment includes a period (+/- one week, not more) of immobilisation with a cervical collar
to decrease the compression on the nerve root; cervical traction; medication to reduce the pain; physical therapy and manipulation including massage, stretching, exercices to improve range of motion and eventually ice, heat and electrical stimulation.
They must be used together and not separately to show improvement.
But all these elements of the treatment need further studies to prove more effectiveness. 
Although a definitive treatment progression for treating cervical radiculopathy has not been developed, a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as active range of movement (AROM), focussing on decreasing levels of pain and disability will most likely be the main focus of the patient.
If the patient has had long-term pain, an element of pain sensitisation may have developed and chronic pain behaves differently to acute pain. Therefore education about pain and reconceptualisation may be neccessary.
- Education and Advice
- Manual Therapy – PAIVMS/PIVMS/NAGS/SNAGS
- Exercise Therapy – AROM, Stretches and Strengthening
- Postural Re-Education
Education and advice
Education is key to getting the patient on your side and to work co-operatively with Physiotherapy. If a patient understands why they are having the neck pain which is causing them to have arm pain then they will more likely want to take part in rehabilitation. If they do not understand what the point in this ‘exercise’ or this ‘pressing’ then they will likely think it to be a waste of time. This is a generalisation of course but it is often accurate.
An important piece of advice to rehabilitation from a prolapsed disc, is that smoking can increase the pressure on the disc causing further damage and impingement, therefore this should not be overlooked.
Additionally it is always good to bring up the topic of smoking cessation with patients for their all round health, tying in with Holistic Management.
In a recent systematic review by Boyles et al in 2011
, manual therapy was shown to be effective at reducing pain levels, improving function and increasing joint ROM.
When combined with exercise therapy it was more effective than the control group of manual therapy or exercise therapy however both control groups were effective at reducing signs and symptoms.
The manual therapy techniques proven to be effective by the systematic review were:
- Thrust mobilisations of the cervical or thoracic spine
- Cervical mobilisations – A-P/P-A/Lateral Glides/Rotations/Retractions
The parameters were recorded in a study by Ragonese et al
; performing one set of 30 seconds or 15-20 repetitions at each desired level of the cervical spine at grade 3 or 4
Others stated that it was down to the practitioners discgression.
Cleland et al
utilised muscle energy techniques in 28 patients, 46% recieving positive outcomes, however details of the techniques used were insufficient and a variety of techniques were used as it was down to the practitioner to decide which technique would be used.
- Neurodynamics – Gliding and Sliding/Tensioning
performed the neurodynamics
sliding and tensioning techniques, outlined by Butler
, whilst having the patient in an upper limb tension positions described by Magee
, again having positive outcomes in regards to pain and function.
Overall a study by Persson et al
highlighted that there was no significant difference between outcome measures of patients who had had surgery, physiotherapy or cervical collar explaining that physiotherapy is at least as effective as surgery.
When performing manual therapy on the neck it is important to to be aware of any potential risk factors such as arterial insufficiency, Hypertension, Craniovertbral ligament insufficiency and upper motor neurone disorders.
Exercises targeted at opening the intervertebral foramen are the best choice for reducing the impact of radiculopathy.
Exercises such as contralateral rotation and sideflexion are amongst the simplest forms of exercises which are effective against signs and symptons, given in the form of active ROM.
Due to the intricate and close relationship of muscles on the intervertebral foramen and the likely presentation of reduced ROM, stretching is also an effective form of treatment to regain ROM.
Once ROM increases strengthening can also be utilised to create new stability and reduce the risk of developing nerve root irritation in the future, as long as it is not caused by a structure which cannot be influenece by physiotherapy.
During the initial stages of treatment, strengthening should be limited to isometric exercises in the involved upper limb.
Once the radicular symptoms have been resolved, progressive isotonic strengthening can begin.
This should initially stress low weight and high repetitions (15-20 repetitions).
Closed kinetic chain activities can be very helpful in rehabilitating weak shoulder girdle muscles.
However, a multicenter randomized controlled trial found no significant difference with the addition of specific neck stabilization exercises to a program of general neck advice and exercise
Regarding physical therapy interventions, in 2007 Joshua Cleland and colleagues examined the predictors of positive short-term outcomes in people with a clinical diagnosis of cervical radiculopathy. The following clinical features were found to be most predictive of a positive short-term outcome:
- Dominant arm not affected
- Looking down does not worsen symptoms
- Treatment involves manual therapy, cervical traction, and deep neck flexor strengthening for at least 50% of visits
If 3 of these features are present, the probability of success is 85%, and increases to 90% if all 4 are present
The following are key evidence pieces for physical therapy interventions as they relate to both cervical radiculopathy and neck pain in general:
- Manual therapy compared to ‘usual’ physical therapy and general practitioner care
- Clinical Practice Guidelines
- Classification System for Neck Pain
- Proposal of Treatment-Based Classification System
- Prognostic factors for neck pain in the general population
- Immediate effects of thoracic manipulation for patients with neck pain
- Clinical prediction rule for thoracic manipulation in patients with neck pain
Recent Related Research (from Pubmed )
- ↑ Eubanks J. Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. Am Fam Physician. 2010 Jan 1;81(1):33-40.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Eubanks, JD.Cervical Radiculopathy:Nonoperative Management of Neck Pain and Radicular Symptoms.American Family Physician 2010;81,33-40
- ↑ 3.0 3.1 3.2 Kenneth A. Olson. Manual physical therapy of the spine.Saunders Elsevier 2009.p 253, 257, 258
- ↑ Marc J. Levine, Todd J. Albert, Michael D. Smith.Cervical Radiculopathy: Diagnosis and Nonoperative Management.Journal of the American Academy of Orthopaedic Surgeons 1996;4:305-316
- ↑ Ellenberg M, Honet J, Treanor W. Cervical Radiculopathy. Arch Phys Med Rehabil. 1994; 75:342-352.
- ↑ Radhaknshnank et al. Epidemiology of Cervical Radiculopathy. A Population Based Study. Brain. 1994: 117; 325-335
- ↑ 7.0 7.1 7.2 7.3 Lipetz JS. Pathophysiology of Inflammatory, Degenerative, and Compressive Radiculopathies. Phys Med Rehabil Clin N Am. 2002;13:439-449
- ↑ 8.0 8.1 8.2 8.3 Young IA,Michener LA,Cleland JA,Aguilera AJ,Snyder AR.Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomize clinical trial.Physical Therapy 2009;89:632-642 (B)
- ↑ Radhakrishnan K, Litchy WJ, O’Fallon M, et al. Epidemiology of cervical radiculopathy: A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994; 117:325-335.
- ↑ 10.0 10.1 Bogduk N. Twomey CT. Clinically Relevant Anatomy for the Lumbar Spine. 2ed. Edinburgh UK: Churchill Livingston. 1991
- ↑ Anatomy Zone. Brachial Plexus – Branches – 3D Anatomy Tutorial. Available from:http://www.youtube.com/watch?v=VdiFNYdIo1ofeature=c4-overview-list=PLmGQgRI4QyEDCSPyYurmzj_zatY5BWz_r
- ↑ Ellenberg MR. Horet JC. Treanor WS. Cervical Radiculopathy. Arch Phys Med Rehabil. 1994;75(3):342-352
- ↑ Kenneth W. Lindsay, Ian Bone.Neurology and neurosurgery illustrated.4th ed. Churchill Livingstone.p408
- ↑ Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M.Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy : randomised trial.BMJ 2009;p1-7
- ↑ Partanen J, Partanen K, Oikarinen H, et al. Preoperative electroneuromyography and myelography in cervical root compression.Electromyogr Clin Neurophysiol. 1991; 31:21-26.
- ↑ Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52-62.
- ↑ C: Wainner et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.Spine 2003 Jan 1. 28(1):52-62.
- ↑ A1: Sidney M. Rubinstein et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. European Spine Journal. Volume 16, Number 3, 307-319
- ↑ C: R. Erhard et al. Cervical Radiculopathy or Parsonage-Turner Syndrome: Differential Diagnosis of a Patient With Neck and Upper Extremity Symptoms. JOSPT. OCTOBER 2005fckLRVolume 35, No. 10
- ↑ Lalkhen A. McCluskey A. Clinical tests: sensitivity and specificity. Contin Educ Anaesth Crit Care Pain (2008) 8 (6): 221-223.
- ↑ Heckmann J, Lang J, Zobelein I, et al. Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.
- ↑ Boyles, Robert; Toy, Patrick; Mellon, James; Hayes, Margaret; Hammer, Bradley.Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review Journal of Manual & Manipulative Therapy 19 (2011) 135-142.
- ↑ Boyles R. Toy P. Mellon J. Hayes M.Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy a systematic review. Journal of Manipulative therapy. 19 (3) 2011
- ↑ 24.0 24.1 24.2 Ragonese J. A randomized trial comparing manual physical therapy to therapeutic exercises, to a combination of therapies,for the treatment of cervical radiculopathy. Orthop Prac 2009;21(3):71–7.
- ↑ Maitland G. Vertebral manipulation. Oxford: Butterworths;fckLR1986
- ↑ Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Ortho Sports Phys Ther 2005;35:802–11.
- ↑ Butler, 0 (1991). Mobilisation of the Nervous System, Churchill Livingstone, Edinburgh
- ↑ Magee DJ. Orthopedic physical assessment. 5th ed. St. Louis,MO: Saunders Elsevier; 2008.
- ↑ Persson LC, Carlsson CA, Carlsson JY. Long lasting cervicalradicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine 1997;22(7):751–8
- ↑ Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International Framework for Examination of the Cervical Region http://www.physio-pedia.com/Section_5:_Physical_examination
- ↑ Langevin P. Rou JS. Desmeules F. Cervical radiculopathy: Study protocol of a randomised clinical trial evaluating the effect of mobilisations and exercises targeting the opening of intervertebral foramen. BMC Msk Disorders.13:10 2012.
- ↑ 32.0 32.1 Malanga G. Sherwin SW.Cervical Radiculopathy Treatment &amp;amp;amp;amp;amp;amp;amp; Management 2013 [ONLINE]fckLRAvailable fromhttp://emedicine.medscape.com/article/94118-treatment#aw2aab6b6b2
- ↑ Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. Feb 2009;36(2):390-7
- ↑ Cleland JA, Fritz JM, Whitman JM, et al. Predictors of short-term outcomes in people with a clinical diagnosis of cervical radiculopathy. Phys Ther. 2007;87(12):1619-1632.
- ↑ Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Ann Intern Med. 2002;136(10):713-722.
- ↑ Childs JD, Cleland JA, Elliott JM, et al. Neck Pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Assoction. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.
- ↑ Childs JD, Fritz JM, Piva SR, et al. Proposal of a Classification System for Patients with Neck Pain. J Orthop Sports Phys Ther. 2004;34(11):686-700.
- ↑ Fritz JM & Brennan GP. Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Phys Ther. 2007;87(5):513-524.
- ↑ Carroll LJ, Hogg-Johnson S, van der Velde G, et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4S):S75-S82.
- ↑ Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10:127-135.
- ↑ Cleland JA, Childs JD, Fritz JM, et al. Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients with Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education. Phys Ther. 2007;87(1):9-23.