Cervical Nerve Root Neck Pain Treatment by Physiotherapy
by Jonathan Blood-Smyth
Cervical radiculopathy is a pain syndrome involving one of the cervical nerve roots, with the C7 root (60%) and the C6 root (25%) being the most commonly involved. In younger persons this is due a direct injury which compromises the nerve exit or due to an acute disc prolapse. In older age groups this syndrome can also occur, but in this case is due to narrowing of the nerve exit by arthritic joints and ligament enlargement, disc bulging and bony outgrowths. Cervical nerve root pain referred to physiotherapists for the management of neck pain and arm pain.
The regular lifting of weights over 12 kilograms (25 pounds), operating or driving machinery which vibrates and cigarette smoking are all risk factors for cervical radiculopathy. This kind of neck and arm pain is much less common than the lumbar syndrome of back and leg pain (sciatica). The discs between the cervical vertebrae allow loads to be transmitted down the spine and damp down unwanted shocks. The joint, disc, bone and ligamentous structures form exit spaces for the nerves on the sides of the vertebrae, with up to a third of their space taken up by the nerve. This space can be compromised if degenerative changes occur nearby, leading to nerve compression symptoms.
There can be many reasons for the onset of nerve root neck pain or it can come on slowly without clear reason. If the neck is moved backwards, tipped to one side and rotated to the same side this can sharply narrow the nerve exit space and injure the nerve, occurring in a traumatic accident or a sporting injury. The opposite can occur with a quick side bend, combined with flexion or extension, tractioning the nerve and causing injury. Sudden loading of the neck in any posture can cause disc prolapse. There may be degenerative changes in an older group and with repetitive or sustained neck postures an osteophyte can impinge the nerve and give a slower development of arm pain.
The physiotherapist will take a detailed history to establish the diagnosis is clearly that of cervical radiculopathy. The exact location and nature of the pain, numbness or weakness, aggravating or easing factors, mechanism of injury, previous occurrences, lower limb symptoms, bladder or bowel dysfunction and medical or other treatments are all noted.
People with root pain look tired due to poor sleep, don’t find anything funny and guard their arm in a protective posture against the abdomen or hold it out to the side with their hand on the back of their neck or the other side of the head. This may reduce the forces through the inflamed nerve root and so reduce pain.
Patients typically present to the physiotherapist in a distressed state, looking tired, having no sense of humour and holding their arm protectively. The arm may be held in front of the body or with the shoulder out to the side and the hand over the top of the head or behind the neck in an attempt to reduce the pain by relieving traction stress on the nerve root.
Initial management is to reduce the inflammation and pain and physiotherapists use cold therapy, anti-inflammatories, manual traction, mechanical traction and instruction to avoid activities or postures which are worsening. The physio reduces the forces applied to the nerve root area with a collar for day or night use to support the neck and limit the available neck movements and with careful manual tractioning to relax muscle spasm and allow the pain to settle.
Initially the physiotherapist concentrates on reduction of the pain and potential inflammation, using ice, non-steroidal anti-inflammatory drugs and other analgesia, avoiding aggravating postures and activities, manual or mechanical traction. The aim of treatment is to reduce the forces going through the nerve root and to allow it to settle. A collar for support and to reduce movement, especially at night, can be useful. Manual traction is a physiotherapy skill which needs to be carefully applied if it is not to worsen the condition. Once the acute phase is over the physio turns to restoring range of movement and neck and overall muscle power, beginning with isometric exercises and progressing. Patients should keep up strengthening, stretching and cardiovascular fitness over the long term.