Physical Therapy for Cervical Radicular Pain
Physical therapy, when treating neck and/or arm pain, is more efficacious if performed in a multi-modal fashion – combining stretch, strength, and manipulation/mobilization components (Gross, Kay et al. 2002; Kay, Gross et al. 2005; Salo, Hakkinen et al. 2010) or when combined with other treatment options (Saal, Saal et al. 1996). Systematic reviews of the use of mechanical traction (Graham, Gross et al. 2006; Graham, Gross et al. 2008) or massage (Haraldsson, Gross et al. 2006; Ezzo, Haraldsson et al. 2007) have not revealed strong evidence for their use, although inclusion of these modalities as part of a comprehensive physical therapy program is believed to be warranted. The inclusion of “directional preference” and “centralization” principles has been commonly employed in therapy programs to treat neck pain. (Kjellman and Oberg 2002; Moffett and McLean 2006; Moffett, Jackson et al. 2006) Cervical stabilization, with or without concomitant mobilization or manipulation, has been beneficial in treating axial neck pain, cervical radiculopathy, or headaches. (Jull, Trott et al. 2002; O’Leary, Falla et al. 2003; Bronfort, Haas et al. 2004; Costello 2008; Dusunceli, Ozturk et al. 2009; D’Sylva, Miller et al. 2010; Gross, Miller et al. 2010) Strategies to overcome barriers to non-adherence to a long-term self-care program would include patient education, promotion of “self-efficacy”, and assistance in overcoming anxiety and fear-avoidance behaviors. (Moffett, Jackson et al. 2006; Jack, McLean et al. 2010)
There are various approaches or “schools” of physical therapy for the treatment of cervical spine disorders. These include those of McKenzie (www.mckenziemdt.org) (McKenzie and May 2006), Sahrmann (Sahrmann 2011), Comerford (www.kineticcontrol.com) (Comerford and Mottram 2001; Comerford and Mottram 2001; Mottram and Comerford 2006), and others (Grant 2002; Cooper and Chait 2010). While it is not practical or possible to have PT providers certified, or even well versed, in all of the possible schools of cervical physical therapy, it is important that they be experienced and educated in cervical spine care. They may draw from various PT approaches, based on their level of expertise in each area. It is expected that each therapist may have a primary approach that they employ for spine care, but they are expected to be able to draw from all “schools” in order to provide individualized care to each subject while conforming to the “guidelines” of treatment. Spine physicians should have working relationships with multiple PT facilities and groups so that reasonable PT geographic location options are available to patients. This will greatly enhance patient participation.
A stepped, multi-modal physical therapy approach was taken with the physical therapy protocol (see Appendix III). (Moffett and McLean 2006) It should be emphasized that the protocol represents a guide, and the education and experience of each physical therapist should be matched with the individual needs of each patient/subject. Each of the elements of this protocol should be included, however, for each patient, when possible and appropriate.
Physical Therapy (2-3 times per week for total of 6-12 sessions):
1. Postural and ergonomic education
2. Postural, directional preference, and stability exercise training
3. Trial of 1-3 manual and/or mechanical cervical traction sessions
a. Home traction with pneumatic (or OTD) device if positive trial
4. Manual therapy limited to grade 3 joint mobilization (muscle energy technique; no HVLA manipulation of cervical spine)
5. Strength, stretch, and conditioning (including aerobic) exercise
6. Development of home exercise and symptom management program
7. Evaluation of subjects’ knowledge of appropriate exercise, ergonomic, and symptom management program details before discharge.
1. Home traction with pneumatic (or OTD) device if positive traction trial
2. Physical modalities– electrical stimulation, US, heat/ice, etc.
3. Soft tissue massage, myofascial release
4. HVLA manipulation of thoracic spine