Rehabilitation Methods in Cervical Radicular Pain

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CHAPTER 58 Rehabilitation Methods in Cervical Radicular Pain

Treatment of cervical radiculopathy spans the spectrum from medication and activity modulation through surgical decompression. Treatment recommendations are based on the specific patient’s history and physical findings. The wide variation in the approach to similar patterns of patient symptoms, history, and findings is indicative of the lack of clear evidence-based practice algorithms. The armamentarium of treatments available includes medications, activity modification, rest, physical therapy, bracing, complementary medicine techniques, spinal injections and percutaneous procedures and surgery.¹^–⁸ Nonsurgical treatment has been shown to be effective and safe for cervical radiculopathy, with outcomes similar to those for surgical intervention.^1,^2,^5,⁷ The decision of which treatment to recommend and its timing is primarily based on the physician’s experience and training, with little conclusive empirical evidence in most cases. Approaching treatment based on history and exam and response to treatment with reevaluation and modification of the treatment plan as indicated is a sensible approach.

EVALUATION

History and physical examination should focus on musculoskeletal and neurologic evaluation and, as always, should be expanded depending on the patient’s history and exam. The prior treatment and responses should be noted. Depending on the duration and extent of symptoms, neurologic deficits and presence or absence of provocative maneuvers, an initial treatment plan will be formulated. Patients may already have had diagnostic studies and others will need imaging, electrodiagnostic studies, or other tests performed. If there is a clear diagnosis of radiculopathy with concordant history, exam, and diagnostic studies, treatment is instituted.

MEDICATIONS

There are many classes of medications available to treat cervical radicular pain.^2,⁶ For pain and presumed inflammation nonsteroidal antiinflammatory drugs (NSAIDs) are often used as the first line of medication therapy. Traditional NSAIDs are generally recommended unless there is a contraindication such as a history of ulcer disease or upper GI bleed. The controversy surrounding the use of COX-2 selective antiinflammatory agents continues to evolve. At issue are cardiovascular adverse events, which led to the voluntary withdrawal of Vioxx by Merck on September 30, 2004. The recent FDA hearings (February 2005) seem to suggest that these drugs should be restricted to use in patients who are in the category of those patients at elevated risk for GI adverse events with low CV risk factors. At the time of the final edit of this chapter the formal outcome of the hearings and the recommendations/package insert changes were not known.

Narcotic medications are the mainstay of treatment for pain unresponsive to NSAIDs. The American Pain Society recommends opioids for acute pain when non-opioids fail.⁹ For episodic pain or short-term usage, short-acting narcotics are effective. Patients with constant moderate to severe pain are better treated with long-acting narcotic medications (sustained release) for a stable level of pain control. They avoid the peaks and troughs often associated with short-acting prn medications.

Adjuvant medications are often useful for pain management to help decrease narcotic usage and, in certain cases, control pain without narcotics. Tricyclic antidepressants (TCAs) are the most studied medicine for neuropathic pain. They are utilized in lower doses than would be given for depression.¹⁰ Selective serotonin reuptake inhibitor (SSRI) antidepressants may be beneficial for pain management in some patients. One of the benefits of TCAs is their sedating effect on most patients. Patients often have difficulty sleeping so if the TCA is taken at night it serves a dual purpose. Gabapentin has been helpful in treating neuropathic pain as have other anticonvulsants.¹¹

Steroids orally and via spinal injections are another medication option. Oral steroids may be beneficial when NSAIDs fail ^2,⁶ but treat a focal problem with a systemic treatment. Muscle relaxers, major tranquilizers, and hypnotics may also be tried for pain relief. There are also other pain medications which are often helpful such as tramadol, a non-scheduled pain medication which acts at the opioid receptors.

DIAGNOSTIC STUDIES

A patient with radicular pain that brings them to the doctor, for the most part, requires diagnostic work-up to identify the cause of the radiculopathy. In general, X-rays with dynamic views and MRI imaging are helpful to evaluate for instability and to identify any neural impingement. If MRI is not an option, CAT scan may be helpful to elucidate the anatomy and cause of the radiculopathy. If there is a question of a systemic process, bone scan and lab studies are indicated. In patients without a clear localization of radiculopathy to a specific root level, or if there is a question of plexopathy, peripheral entrapment or polyneuropathy, EMG and NCS are often helpful.¹²

BRACING

For comfort, a soft cervical collar may be worn, particularly when traveling. The negative effect is that it may lead to further deconditioning of the neck muscles. A soft collar may also help with sleep. For sleep, keeping the neck in a neutral position with pillows or a cervical pillow is beneficial. Rigid collars have also been used to treat cervical radiculopathy.^2,^4,^5,¹³ There are no controlled studies showing a beneficial effect compared to no treatment but use of a collar has been part of a conservative treatment program that was effective. In one study, cervical collars were shown to have the same outcome at 16 months as surgery or physical therapy.⁵

PHYSICAL THERAPY

Introduction

Because the superiority of any one rehabilitation method for cervical radiculopathy has not been firmly established, many physical therapists use a combination of conservative interventions. Some of the methods and techniques are evidence-based, while others are anecdotal or traditional. These interventions may include repeated movement exercise, manual techniques, modalities, traction, neural mobilization, dynamic stabilization exercise, postural training, patient education and ergonomics. Although research is inconclusive, there have been a number of studies published advocating the effectiveness and success of conservative rehabilitation treatment.1–3,^14,¹⁵ The success of any rehabilitation treatment plan begins with the evaluation. An effective evaluation utilizes signs and symptoms, which the clinician identifies during the history and physical examination to govern clinical decision-making.^16,¹⁷ Treatment decisions are made based upon a patient’s symptom response to movement and the mechanical stresses that reproduce these symptoms.^16,¹⁷ This type of interactive evaluation enables the clinician to develop a treatment algorithm. The algorithm presented in this chapter can be used to direct treatment, categorize patients into different treatment paradigms, and determine the most appropriate intervention to create an objectively based treatment program.

Patient evaluation

The evaluation should consist of an accurate patient history, a physical exam, an assessment, and an appropriate treatment selection. Physician referrals should include the medical diagnosis and appropriate precautions. The physical exam should include posture analysis, range of motion measurements, neurological examination, and repeated movement testing.

Posture analysis is typically performed by observing the patient in various positions. Neutral spine posture can be defined as ‘a vertical line passing through the lobe of the ear, the seventh cervical vertebra, the acromion process, the greater trochanter, just anterior to the midline of the knee, and slightly anterior to the lateral malleolus.’¹⁸ Postural abnormalities may be the result of habitual adoption of poor posture or the result of an acquired deformity. The common habitual postural abnormality that the clinician should be aware of is termed the forward head position. In this position, kyphosis or flexion of the lower cervical and upper thoracic spine causes a compensatory extension or excessive lordosis in the upper cervical spine to achieve a level head position.¹⁹ Over time, excessive upper cervical lordosis may be a source of headaches, and excessive lower cervical kyphosis may lead to cervical radicular pain.¹⁹^–²¹ There are two acquired cervical postural deformities associated with cervical radiculopathy: kyphosis and torticollis.^16,^22,²³ In both cervical kyphosis and acute cervical torticollis, patients become locked in a protective position and are unable to move out of this acquired deformity. The physical examination continues with a range of motion assessment, which is divided into physiologic and accessory motion. The physiologic motion, or the normal gross movements of the cervical spine, includes retraction and protrusion, sagittal plane extension and flexion, transverse plane rotation and coronal plane lateral flexion (side-bending) (Table 58.1). Accessory motion is the gliding of one cervical segment on another. Assessment of accessory motion is segment specific and assists the clinician in determining the possible level of the pathology.

Table 58.1 Chart of normal cervical spine motion

Movement	Range of normal motion
Upper cervical flexion and extension	1–15°
Cervical flexion	80–90°
Cervical extension	70°
Cervical rotation	70–90°
Cervical lateral flexion	20–45°