Physical Therapist's Guide to Cervical Radiculopathy
Cervical radiculopathy is often referred to as a pinched nerve in the neck. It is characterized by radiating pain from the neck to the shoulder, shoulder blade, arm, or hand. Weakness and lack of coordination in the arm and hand can also occur. The condition affects an average of 85 out of 100,000 people—most often individuals in their 50s. Athletes, heavy laborers, and workers who use vibrating machinery are commonly affected. People who sit for long periods of time, or individuals with arthritis in the cervical (neck) region can also be affected. Conservative care, including physical therapy, can help reduce symptoms. A physical therapist can help alleviate the acute neck and arm symptoms that result from the condition, as well as improve general strength and function. Most cases of cervical radiculopathy are resolved with physical therapy and do not require surgery.
Cervical radiculopathy occurs when a nerve root coming off the spinal cord becomes compressed. The compression can occur for various reasons. In younger people, it may occur when a cervical disc herniates due to trauma. In older individuals, it commonly occurs spontaneously as a result of arthritis or decreased disc height in the neck region.
The cervical spine consists of 7 cervical vertebrae (the bones that form the neck region). Each vertebra is separated by a gel-like disc. The discs provide shock absorption for the spine. The spinal cord travels through a canal in the cervical vertebrae. Spinal nerve roots extend from the spinal cord and branch off going to specific locations in the arm. The spinal nerves send signals to our muscles for movement as well as sensations that we feel in the entire arm. The spinal cord is like a tree trunk, and the spinal nerves are like the tree branches. If an impingement or abnormal pressure is placed on a branch near the trunk, everything along that branch will be affected.
Spinal nerves can be impinged by:
- Arthritis or disc wear-and-tear with age
- Herniated or bulging discs from trauma or degeneration
- Spinal stenosis, which is a narrowing of the spaces in which the nerves travel
- Tumor, which can be benign or malignant, impinging the nerve root
When the spinal nerves are impinged, they cannot properly send messages to the muscles from the brain, nor receive proper sensation from the specific arm location the nerve travels. Everywhere the spinal nerve travels will be affected. That is why a pinched nerve in the neck can cause pain, weakness, and loss of sensation in the arm, even though the pinch is in the cervical region.
Symptoms of cervical radiculopathy vary depending on the nerve root involved, and commonly occur on the same side of the body as the affected nerve. The symptoms may include:
- Pain in the neck, shoulder blade, shoulder, upper chest, or arm, with pain possibly radiating into the fingers following the path of the involved nerve root.
- Pain described as "sharp" or "pins-and-needles" or “popping sensation” in cervical region.
- General dull ache or numbness anywhere along the pathway of the nerve.
- Weakness in the shoulder, arm, or hand.
- Pain that worsens with certain neck movements.
- Pain that improves when the arm is lifted over and behind the head (relieving tension on the spinal nerve).
These symptoms may also be specific to the nerve root involved:
- C5 nerve root (between cervical vertebrae C4-C5): weakness in the deltoid muscle (front and side of the shoulder) and upper arm; shoulder pain and numbness
- C6 nerve root (between cervical vertebrae C5-C6): weakness in the bicep muscle (front of the upper arm) and wrist muscles; numbness on the thumb side of the hand
- C7 nerve root (between cervical vertebrae C6-C7): weakness in the triceps muscle (the back of the upper arm and wrist); numbness and tingling in the back of the arm and the middle finger of the affected hand
- C8 nerve root (between vertebrae C7-T1): weakness with hand grip; numbness in the little finger
The most common nerve root levels for this condition are C6 and C7.
When you seek the help of a physical therapist, the physical therapist performs a comprehensive evaluation and asks questions about your pain and your daily activities. These may include:
- How and when the pain started: Did the pain begin spontaneously or was there any trauma or popping experienced in the cervical region?
- Where are the symptoms located, and have they changed location or intensity since the onset?
- What makes the symptoms better or worse?
- What type of work do you perform?
- What hobbies or household activities do you regularly perform?
Your physical therapist will gently test the movement of your neck and arms. The therapist will check your tendon reflexes and strength, and conduct special tests on your neck and upper extremity to determine which spinal nerve root(s) may be involved, and to rule out other conditions. To provide a definitive diagnosis, your therapist may collaborate with an orthopedist or other health care provider. The orthopedist may order further tests, such as magnetic resonance imaging (MRI) or electromyography (EMG). An MRI can show soft tissues, including the spinal cord and nerve roots. This test can determine what is causing the compression on the nerves, including disc bulges or disc herniation. An EMG measures the nerve and muscle function. This test can tell how well your spinal nerves are communicating to your muscles.
Physical therapy is an effective treatment for cervical radiculopathy, and in many cases, it completely resolves symptoms. Your physical therapist will develop an individual treatment plan based on the findings of your initial evaluation. The treatment plan may include:
Pain Management. The first goal is to reduce the pain and inflammation in the area. Ice packs applied to the neck and scapular (shoulder blade) region during the first 24 to 48 hours following the onset of pain, help reduce inflammation. Moist heat can be used after this time period to help the surrounding muscles relax. Your physical therapist may advise you to wear a soft cervical collar at times throughout the day, to allow the neck to relax. A cervical contoured pillow may be recommended to properly support the neck, and allow you to sleep more comfortably.
Manual Therapy. Your physical therapist may use manual therapy techniques, such as manual cervical traction, to relieve pressure in the cervical (neck) region. This procedure can provide immediate relief of pain and numbness radiating into the arm. Gentle massage may also be performed on the muscles of the cervical spine and scapular (shoulder blade) region. This technique helps the muscles relax and improves circulation to the area, promoting healing and pain relief.
Posture Education. Posture education is an important part of rehabilitation. Your physical therapist may suggest adjustments to your workstation and work habits, to promote good posture to protect your neck. In the early stages of recovery this may mean sitting only 15 to 20 minutes at a time. You will also receive instructions on how to bend, reach, and lift throughout the day in safe positions that place minimal pressure on your spinal discs.
Range-of-Motion Exercises. Your physical therapist will teach you gentle cervical mobility exercises to relieve your symptoms, and allow you to return to normal movement. In the beginning stages of recovery, it is important that none of these exercises increase the pain radiating down into your arm. It is important to communicate your symptoms accurately to your physical therapist. If you spend many hours sitting at a desk during your workday, your neck may become stiff. Your therapist will teach you neck stretches to take pressure off of your neck from extended periods of sitting, to help improve your mobility.
Strengthening Exercises. Your physical therapist will help you determine which muscle groups need to be strengthened based on which spinal nerves are involved in your particular case. When pain no longer radiates down your arm, you may begin more aggressive strengthening exercises. Neck stability (strengthening) exercises will also be performed. You will receive a home-exercise program to continue strengthening your neck, shoulder, arm, and upper back long after your formal physical therapy has ended.
Functional Training. As your symptoms improve, your physical therapist will work on functional exercises to help you return to your job, sport, or other daily activities. For example, if your job duties require overhead reaching, pushing, pulling, and long periods of sitting, you will be taught ways to perform these tasks to reduce undue stress to the neck.
Your physical therapist will educate you on the best ways to prevent cervical radiculopathy from recurring, including:
- Maintaining proper posture. Use a supportive pillow and proper posture when sitting at a desk or in the car.
- Setting up your workstation to minimize undue forces on the spine.You may be advised to use a hands-free phone, or adjust your computer monitor to avoid excessive twisting or extending of your neck in repetitive directions during the workday.
- Continuing with regular exercise to maintain spinal muscles flexibility and strength, including the upper body, middle back, and core muscles.
- Keeping a healthy weight to minimize unnecessary forces on the spine.
William is a 50-year-old man who enjoys coaching his son’s Little League baseball team. At a recent practice session, he joined the team, playing in right field. The third batter hit a ball high to right field. As William stretched his left arm and neck to reach for the ball, he felt a popping in his neck on the left side. Within 3 hours, he began experiencing severe pain radiating from the left shoulder blade, down the back of the upper arm, and into the thumb, index, and middle finger of his left hand. The pain continued to worsen over the next 24 hours. He was unable to sleep at night or lay flat. His pain was somewhat relieved when he stretched his left arm overhead with the elbow bent. The next day, William called his physical therapist.
William's physical therapist performed a full evaluation of his cervical spine and left upper extremity. She measured his cervical range of motion and upper extremity strength, and checked his reflexes in his left arm. She asked William when the pain first started; he told her about the incident on the ball field. She also asked about his job duties; he told her he spends a lot of time at work on a computer.
His physical therapist finds that William has limited mobility in the cervical spine, especially for side-bending to the left. He also has weakness in the left triceps muscle. She uses gentle touch techniques to determine that William has muscle tightness and tenderness in the left side of the neck and shoulder blade region. She performs some special tests, including a gentle cervical compression test called the Spurling’s test. During the test, William's symptoms increase down his left arm, indicating the spinal nerve on that side is involved. Based on her findings, she determines that William has a cervical radiculopathy at the C7 level on the left. She contacts an orthopedic physician, who orders an MRI, which confirms her findings.
William and his physical therapist work together to establish short- and long-term goals for his treatment. She designs a 6-week treatment program of 2 to 3 rehabilitation sessions per week. She prescribes ice for pain management and the use of a cervical collar intermittently throughout the day to alleviate pressure on the cervical spine, allowing it to heal. She instructs William in the use of a cervical pillow to properly support his spine at night, so he can begin sleeping more comfortably. She also educates William in correct posture to limit prolonged positioning (eg, limited sitting with frequent breaks).
William's physical therapist performs light, manual cervical traction and soft-tissue mobilizations to relieve the pain radiating down his arm, and to relieve muscle tightness in the neck and shoulder blade regions. She instructs William in self-care techniques at home, including ice and gentle exercises. As his symptoms improve, they begin working on improving his left-shoulder strength, especially in the triceps region. She teaches him strengthening exercises for the shoulder blade region to promote better posture, and stretching exercises to help him safely return to the ball field. She encourages him to start a walking program to promote general physical fitness and spinal health.
Together they evaluate his workstation, and determine that a square back spinal cushion in his office chair will support his lower back and improve his seated posture. She creates a comprehensive home-exercise program to help him meet his goals, and to continue progressing long after he has completed physical therapy.
After a few weeks of diligent therapy sessions and working with his home-exercise program, William notices he is able to sleep again without pain. He can also resume his regular work, household, and recreational activities, including returning to coaching his son’s baseball team free of pain.
All physical therapists are prepared through education and experience to treat cervical radiculopathy. However, you may want to consider:
- A physical therapist who is experienced in treating people with cervical radiculopathy. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics, spinal, or manual physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using “Find a PT,” the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have an underlying spinal diagnosis, including cervical radiculopathy.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment ofcervical radiculopathy. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Langevin P, Roy 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 [NCT01500044]. BMC Musculoskelet Disord. 2012;13:10. Free Article.
Boyles R, Toy P, Mellon J Jr, et al. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systems review. J Man Manip Ther. 2011;19(3):135–142. Free Article.
Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011;7(3):265–272. Free Article.
Dmytriv M, Rowland K, Gavagan T, Holub D. PT or cervical collar for cervical radiculopathy? J Fam Pract. 2010;59(5):269–272. Free Article.
Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007;16(3):307–319. Free Article.
Cervical radiculopathy. Medscape website. http://emedicine.medscape.com/article/94118-overview. Accessed March 15, 2014.
Cervical radiculopathy clinical presentation. Medscape website. http://emedicine.medscape.com/article/94118-clinical. Accessed March 15, 2014.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Julie A. Mulcahy, PT, MPT. Reviewed by the MoveForwardPT.com editorial board.
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