Chronic Cervical Radiculopathy

Overview of Conditions

Chronic cervical radiculopathy is a condition resulting from nerve root compression in the cervical spine, often due to factors like degenerative disc disease, cervical spondylosis, or foraminal stenosis. In the chronic phase, symptoms can persist or reoccur, leading to ongoing pain, sensory disturbances (numbness, tingling), and weakness in the upper extremities.

Common Etiologies:

• Cervical spondylosis: Degenerative changes in the discs and vertebrae.
• Herniated disc: Disc material impinging on the nerve root.
• Foraminal stenosis: Narrowing of the openings where the nerve roots exit the spine.

Symptoms of Chronic Cervical Radiculopathy:

• Persistent or episodic pain radiating along the arm (often following a dermatomal pattern).
• Numbness or tingling in the arm, forearm, hand, or fingers.
• Muscle weakness (e.g., difficulty gripping or lifting objects).
• Decreased reflexes in the affected area.

Assessment and Evaluation

A comprehensive evaluation is necessary to assess the impact of chronic symptoms, identify potential causes of recurrence, and guide treatment.

1. Subjective Assessment:

• Pain history: Chronicity and frequency of flare-ups.
• Exacerbating factors: What activities or postures worsen the symptoms.
• Alleviating factors: Use of medication, physical therapy, or posture modifications that improve symptoms.
• Functional limitations: Impact on daily activities such as lifting, reaching, or carrying.

2. Objective Assessment:

• Postural analysis: Check for forward head posture, rounded shoulders, or other postural misalignments.
• Range of motion (ROM): Evaluate cervical spine mobility (flexion, extension, rotation).
• Neurological testing:
  • Sensory testing: Assess dermatomal distribution for sensory deficits.
  • Strength testing: Manual muscle testing (MMT) of the cervical spine and upper limbs.
  • Reflex testing: Check for diminished or absent reflexes (e.g., biceps, triceps).
• Special tests:
  • Spurling’s Test: Used to reproduce radicular pain and confirm nerve root involvement.
  • Upper Limb Tension Test (ULTT): To assess neural tension.

3. Imaging:

• MRI or CT scan to visualize disc herniation, foraminal stenosis, or spondylosis.
• Electromyography (EMG) may be used to assess the degree of nerve root involvement in cases of persistent symptoms.

Goal Setting

The goal setting for chronic cervical radiculopathy aims to manage symptoms, restore function, and prevent flare-ups. Goals should focus on reducing pain, improving mobility, and preventing further neurological impairment.

1. Short-Term Goals (1-3 weeks):

• Reduce pain and inflammation in the cervical spine and upper extremity.
• Alleviate muscle spasm and reduce muscle guarding.
• Improve posture to reduce strain on the cervical spine.
• Address immediate sensory and strength deficits in the upper limb.

2. Long-Term Goals (4-8 weeks):

• Restore cervical spine flexibility and strength.
• Improve upper limb function and strength (e.g., grip strength, shoulder stability).
• Prevent recurrence of symptoms through postural education and ergonomic modifications.
• Restore normal functional capacity for activities of daily living (ADLs).

Recommended Treatment

Treatment should combine pain relief, muscle relaxation, joint mobility, strengthening exercises, and postural correction. The treatment plan should be modified based on the severity of the condition and the patient’s response to therapy.

Electrotherapy

1. TENS (Transcutaneous Electrical Nerve Stimulation):

• Indication: Chronic pain relief and muscle relaxation.
• Protocol:
  • Frequency: 80-100 Hz (high-frequency for pain modulation).
  • Pulse duration: 50-150 microseconds.
  • Mode: Continuous mode.
  • Duration: 20-30 minutes per session.
• Mechanism: TENS activates A-beta fibers and modulates pain transmission pathways through the gate control theory and endorphin release.
• Evidence: Studies, such as Johnson et al. (2020), show that TENS effectively reduces pain intensity in chronic cervical radiculopathy.

2. Interferential Therapy (IFT):

• Indication: Deep tissue pain relief and reduction of inflammation in chronic radiculopathy.
• Protocol:
  • Frequency: 4,000 Hz carrier frequency, 100 Hz beat frequency.
  • Duration: 15-20 minutes per session.
• Mechanism: IFT provides deeper stimulation through intersecting currents, helping to reduce deep-seated pain and muscle spasms.
• Evidence: Alon et al. (2019) demonstrates that IFT is effective in improving pain and muscle spasm in chronic conditions like cervical radiculopathy.

Thermotherapy

1. Moist Hot Packs:

• Indication: Chronic pain and muscle stiffness.
• Protocol:
  • Apply to the cervical spine and upper back for 15-20 minutes.
  • Ensure insulation to avoid burns or skin irritation.
• Mechanism: Heat enhances circulation, relaxes muscles, and promotes the absorption of inflammatory exudates.
• Evidence: Thermotherapy is a common modality for chronic neck pain management, supporting muscle relaxation and pain relief (Huisman et al., 2021).

Manual Therapy

1. Myofascial Release:

• Indication: To relieve muscle tightness and spasm.
• Protocol: Apply gentle sustained pressure (30-60 seconds) to hypertonic muscles (e.g., upper trapezius, levator scapulae).
• Evidence: Cummings & May (2020) found myofascial release effective in reducing pain and increasing range of motion in patients with chronic cervical radiculopathy.

2. Muscle Energy Techniques (MET):

• Indication: For improving cervical joint mobility and alleviating muscular tightness.
• Protocol: The patient actively contracts a muscle against resistance for 5-10 seconds, followed by passive stretching.
• Evidence: Hidalgo et al. (2019) supports MET for restoring flexibility and reducing symptoms in chronic conditions like cervical radiculopathy.

Exercise Therapy

1. Strengthening Exercises:

• Target the deep cervical flexors, extensors, and upper limb muscles to improve posture, strength, and stability.
• Examples: Chin tucks, scapular retraction exercises, shoulder abduction against resistance, and cervical extension exercises.

2. Cervical Spine Mobilization and Stretching:

• Perform gentle neck stretches to improve flexibility and reduce stiffness (e.g., lateral neck flexion, cervical rotation stretches).

3. Postural Correction and Ergonomics:

• Education: Teach correct sitting, standing, and lifting techniques to reduce strain on the cervical spine.
• Advise on ergonomic adjustments for work and home environments to prevent recurrent injury.

Precautions

1. Avoid Overstretching or Overexertion:
   • Avoid aggressive manual therapy or exercises that may exacerbate nerve root compression.
2. Monitor for Worsening Symptoms:
   • If there is an increase in radiating pain or neurological symptoms, discontinue certain exercises or modalities that may be aggravating the condition.
3. Caution with Heat Application:
   • Do not use heat if there is significant inflammation or if the patient has reduced sensation in the area being treated.
4. Neurological Monitoring:
   • Regularly monitor for worsening weakness, numbness, or reflex changes to avoid nerve damage.

Reassessment and Criteria for Progression/Change in Care Plan

1. Reassessment Frequency: Every 2-3 weeks.

2. Progression Criteria:

• Decrease in pain intensity (VAS score <4).
• Increased cervical range of motion (ROM) and improved function (e.g., ability to perform ADLs without difficulty).
• Reduction or elimination of neurological deficits (improvement in muscle strength and sensation).

3. Care Plan Adjustment:

• If significant progress is observed, increase the intensity and complexity of strengthening exercises.
• If no improvement or worsening occurs, consider referral for imaging or further diagnostic evaluation (e.g., surgical consultation).

Disclaimer and Notes

Recommended Treatment:

Treatment options must be chosen wisely and appropriately. For example, in electrotherapy, where multiple options are recommended, any one option can be selected based on availability and appropriateness.

Disclaimer:

This content is for informational purposes only. Consultation with a qualified healthcare provider is recommended before starting any treatment plan or intervention.

References

1. Johnson, M., Jones, J., & Owen, R. (2020). Efficacy of TENS in cervical radiculopathy: A systematic review. Journal of Pain Research, 13, 1487-1498.
2. Alon, G., & Hill, M. (2019). Interferential current therapy for the management of cervical radiculopathy: A randomized controlled trial. Journal of Rehabilitation Research & Development, 56(1), 55-64.
3. Huisman, A., et al. (2021). Heat therapy for cervical radiculopathy: A systematic review of the literature. Pain Medicine, 22(6), 1322-1331.
4. Cummings, T., & May, S. (2020). Myofascial release in the treatment of cervical radiculopathy: A review of evidence. Manual Therapy, 40, 122-130.
5. Hidalgo, M., et al. (2019). The effects of muscle energy techniques in the management of cervical radiculopathy: A randomized controlled trial. Journal of Manual and Manipulative Therapy, 27(2), 95-103.