Neck pain and cervical radiculopathy: predictors of positive outcomes with conservative interventions

Neck pain is a common issue, with a lifetime incidence as high as 54%.[i]  Over one-third of patients with neck pain will go on to develop chronic symptoms lasting more than 6 months[ii].  The spectrum of treatment options for people with neck pain range from watchful waiting to surgery with physical therapy falling somewhere in between. 

Neck pain originates from several different sources, including most commonly: discs, joints, muscle tissues and nerve.  A related post at: http://www.backexercisedoctor.com/journal/2009/12/7/neck-pain-generalities-and-my-favorite-neck-exercises.html.  

provides a more detailed discussion of pain generators in the neck and reviews treatment options.

For the purposes of this discussion, I would like to focus on those individuals with neck and arm pain.  Usually but not always this results from a disc issue (disc bulge or herniation) that is causing mechanical compression or chemical inflammation around a nerve root exiting the spinal canal towards the arm.  This condition is referred to as a cervical radiculopathy.

A study by Persson et al. demonstrated “outcomes with physical therapy that were as good as those associated with surgical intervention in the management of cervical radiculopathy.” [i]  One of the questions for clinicians managing these conditions is “how do we know which individuals will fare better with physical therapy and conservative interventions versus surgical care.”

Several recent studies have provided evidence-based clinical prediction rules for sorting through this question and deciding which individuals are likely to do better with physical therapy and traction specifically within this context of conservative treatments.

One study by Cleland et al. looked at short-term outcomes in people with neck and arm pain (more strictly defined as cervical radiculopathy).  The study looked at 96 people referred to a physical therapy clinic.  The patients received screening on intake and were treated according to the discretion of the individual therapists.  The authors looked at several different factors in an attempt to clarify variable predictive of positive outcome. 

They found that “a four variable model optimally identified subjects who were most likely to achieve success with physical therapy interventions ([1] age < 54 years; [2] dominant arm is not affected; [3] looking down does not worsen symptoms; and [4] multimodal treatment including manual therapy, cervical traction, and deep neck flexor strengthening for at least 50% of visits).” [ii] 

When 3 or these 4 variables were present the post-test probability of success was 85%.  When all 4 variables were present the post-test probability of success was 90%.[iii] 

These results suggest that a subset of predictor variables can accurately identify which people with cervical radiculopathy are likely to experience at least short-term success with physical therapy and conservative interventions.  Specifically, intermittent cervical traction, manual therapy, and deep neck flexor muscle strengthening seem to be beneficial tools in the management of this condition.[iv]

If we step back and consider some of the elements in this study, traction can be a very helpful tool for management of neck and as we can see arm symptoms.  Experts generally agree that “traction is most appropriate for patients with neck and upper extremity symptoms and signs of neurological compromise for whom centralization of symptoms is a treatment.”[v] 

Traction involves a pulling force to create distraction to unload joints and discs in the neck region.  Historically, traction units looked something like the picture below.

Basic cervical traction unitNowadays, the traction units are sleeker and easier to use (such as is pictured in the Pronex traction unit pictured below).

Pronex brand cervical traction unit

Also noteworthy is the impact of strengthening deep cervical neck flexors in the treatment of both neck and arm symptoms.   The deep cervical flexors often get stretched out in our chronically slouched postures.  These muscles are major stabilizers for the cervical spine and often need re-education in the context of neck pain.

Pictured below is a series of easy exercises that can help strengthen and re-educate these deep cervical flexors. 

Also noteworthy is the impact of strengthening deep cervical neck flexors in the treatment of both neck and arm symptoms.   The deep cervical flexors often get stretched out in our chronically slouched postures.  These muscles are major stabilizers for the cervical spine and often need re-education in the context of neck pain.

Pictured below is a series of easy exercises that can help strengthen and re-educate these deep cervical flexors.

Deep cervical flexor strengthening: Step 1: Lie supinewith head in a neutral position

Step 2: Flex (or pull towards the table) the chin

Step 3: Raise the head off the table slightly while maintaining a flexed position of the neck (with chin tucked so to speak)

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[i] Physical Therapy (2007) 12: 1619-1632

[ii] Eur Spine J (2009) 18: 382-391

[iii] Eur Spine J (2009) 18: 382-391

[iv] Eur Spine J (2009) 18: 382-391

[v] Eur Spine J (2009) 18: 382-391

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[i] Eur Spine J (2009) 18: 382-391

[ii] Eur Spine J (2009) 18: 382-391