Cervical Nerve Root Neck Pain Treatment by Physiotherapy
A prolapsed disc or injury to the nerve exit foramen in the neck can give very severe neck and arm pain known as cervical radiculopathy. The sixth cervical nerve is affected in 25% of cases and the seventh in 60% of cases. Of all arm pains of neck origin, about a quarter are due to an acute disc prolapse. With age disc bulges, ligament and joint enlargement and bony osteophytes encroach on the space the nerve has to travel through and this is a more common cause of cervical radiculopathy in older persons. Neck pain from cervical disc prolapse is routinely assessed and treated by physiotherapists.
Risk factors for this type of neck pain and arm pain include smoking, lifting heavy weights regularly (e.g. 12kg, 25 pounds) and driving or operating vibrating equipment. Overall cervical radiculopathy is uncommon and much more so than lumbar disc syndromes such as sciatica. The discs between the vertebrae from C2 to C7 transmit loads down through the spine and dissipate some of the forces applied to it. At the side of the vertebrae are the nerve exits or foramina and the nerve takes up to a third of the exit space normally. Degenerative changes in any of the structures which surround and form the walls of the exit can compromise the exit channel itself and compress the nerve.
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.
To ensure the problem is radiculopathy the physio will take a history including the area and type of pain, muscle weakness or numbness, factors making the pain worse or better, how the injury happened, any current treatment and any lower limb or bowel or bladder problems. Commonly the pain has not come on quickly but insidiously and over time, initially presenting with a dull achy pain to a very severe burning pain in the neck and over the shoulder. This can worsen to the upper arm, then the forearm and the hand as the root irritation increases. Rarely there may be no real pain but loss of muscle power and sensibility.
Typically the pain comes on slowly and steadily with neck and arm discomfort, ranging from dull ache to a severe pain. Initially the complaint is shoulder pain, progressing to scapular, upper arm, lower arm and hand pain as the syndrome worsens. Changes in sensibility and motor power can also be present, in some cases without significant pain.
On physiotherapy examination patients look tired as they have not slept and they lose their sense of humour. They may hold their arm in a relieving posture cradled across the body or with the elbow out to the side and the hand behind the neck or over the head towards the opposite ear. This may reduce the tension through the irritated or compressed nerve root, reducing the pain.
Posture is usually abnormal with the head tilted away from the painful side and the neck held stiffly with reduced ranges of movement. The physio notes the muscle spasm and tests the muscle power to determine which nerve root is affected, looks for sensory and reflex loss and notes which combination of movements are provocative and if manual traction reduces symptoms.
Reducing the pain and inflammation is the first goal of treatment and the physiotherapist can employ analgesics such as NSAIDs, cryotherapy, mechanical or manual traction and avoidance of aggravating activities and postures. Limiting the forces transmitted through the nerve root is an overall goal of management, using a collar to reduce neck movement, a cervical pillow or collar at night and manual traction from the physio to distract the joints. After the acute phase has settled physiotherapy concentrates on regaining neck movement and muscle power, starting with isometric exercises and moving on to isotonic and exercises for multiple muscle groups. Long term adherence to a regime of aerobic exercise, muscle strengthening and stretching may be useful.
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