Tingling, Weakness & Pain? Let’s Talk Cervical Radiculopathy with Dr. Erik Thoomes | EP. 074

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# Physiotherapists Podcast Episode 74 Hi and welcome to the Physiotherapists Podcast, episode 74. Today, we're joined by Dr. Eric TS, a leading musculoskeletal clinician, educator, and researcher with a keen focus on neck pain, cervical radiculopathy, and related spinal conditions. Eric's extensive research and publications have helped shape evidence-based practice in both diagnosis and conservative management strategies. We're thrilled to have him here to share his insights and practical guidance. Let's dive in! ## Introduction **Host:** Hi Eric, welcome to the podcast! **Eric:** Hi guys, thank you very much for inviting me. It's an honor to be here, and the way you introduced me makes me feel slightly more important than I actually am, but thank you for inviting me. **Host:** That's the idea! Great to have you, Eric. ## Understanding Cervical Radiculopathy **Host:** Let's jump right in. To set the stage, could you quickly explain what cervical radiculopathy is and how it differs from more common non-specific neck pain? **Eric:** That's a good question. I think it's very common. The muscular skeletal classification system initially separates specific from non-specific disorders, especially in the lumbar and cervical spine. In specific neck pain, we think we know what the cause of neck pain is, whereas in non-specific neck pain, we cannot determine the cause but only the consequences and contributing factors. Cervical radiculopathy is a specific cause of neck pain, but a non-serious one, as opposed to serious causes such as tumors, fractures, and systemic diseases. In one of our publications, we've defined cervical radiculopathy as radiating pain into the arm of a neuropathic nature or with an anatomic quality provoked by neck postures and neck movements, with concomitant or concurrent mechanical neck pain. So, it's mainly arm pain, periscapular shoulder pain more than neck pain, but it is still labeled as a neck pain condition. Cervical radiculopathy is a clinical condition mainly associated with symptoms of shoulder pain, periscapular pain, and arm pain, as well as neck pain, but that's not dominant. It's also associated with upper limb paresthesia and muscle weakness, all of which are caused by cervical nerve root irritation or compression. That cervical nerve root can be compressed by cervical disc herniations, but it is equally common for the intervertebral foramen to become more narrow, usually as a result of spondylotic changes. Of course, both causes can also present simultaneously. In non-specific neck pain, we can also have referred pain to the shoulder and arm region, but this is from another origin and not due to nerve root compression. ## Differences Between Cervical and Lumbar Herniations **Host:** You briefly touched on differences to the lumbar area. Can you give some more details on how, for example, neck herniations differ from lumbar herniations? **Eric:** Yes, well, the first obvious difference is that the cervical spine is completely different from the lumbar spine; it has a completely different function and functional anatomy. For instance, the cervical spine can rotate up to 180° from left to right, whereas the lumbar spine can rotate no more than approximately 70°. All this functional anatomy again has implications on how much the intervertebral diameter is, how large it is, and how much we can influence that diameter by, for instance, rotation or side flexion. There are certain similarities for sure, but I tend to look at the cervical spine as a separate entity. When we do not have enough evidence, we can always look at the lumbar spine and see if we can draw lines between the two of them, but I enjoy looking at the spine as a different section from the lumbar spine. During our masters, we always used to call it cervical radiculopathy, while in the lumbar spine we talked about a combination of lumbar radiculopathy and/or lumbar radicular pain, which then fell under the umbrella term lumbar radicular syndrome. Is this the same in the cervical area, or is it different? **Eric:** We would very much like that to be universal. Yes, radiculopathy in itself is not painful. We use the term cervical radiculopathy, but especially we as physiotherapists see patients with what we would like to call a cervical radicular syndrome. The syndrome includes the pain factor because patients mainly come to us because they have radicular pain, and radicular pain commonly occurs together, but they are separate entities. The International Association for the Study of Pain has separated the two of them, so we need to be as clear as possible in our terminology. In the Netherlands, we are now trying to use the universal term radicular syndrome for the lumbar and cervical spine, which then includes pain, and pure radiculopathy is something that usually only neurologists would see, and then the patient would only have paresthesia or muscle weakness but no pain. ## Epidemiology of Cervical Radiculopathy **Host:** Moving on from an epidemiological standpoint, what do we know about the prevalence and risk factors for cervical radiculopathy, or I better say cervical radicular syndrome? **Eric:** We really do not know a lot. The data are very limited and are mainly based on one large population-based study from Rochester, Minnesota, in the '70s. A recent systematic review tried to gather all the information and mentioned that we're still mainly relying on that one huge study by Karpinski. They indicated an annual incidence of approximately 107 per 100,000 for men and 46 per 100,000 for women. The age group of 50 to 60 has the largest incidence, with the peak of instances usually between the 50th and 60th year. That's about all we know basically, and we really should replicate that study if we have the time and the money. ## Diagnostic Tests for Cervical Radiculopathy **Host:** What are the most clinically useful tests or clusters of tests that can help us improve diagnostic accuracy in the clinic? **Eric:** It's a no-brainer. The first and most important step in diagnosing a patient you suspect of having cervical radiculopathy is complete history taking, building a complete patient profile covering all aspects and domains of the International Classification of Function, Health, and Disability (ICF) that we use. Great history taking should take a long time to do that in the clinic. We published a systematic review in 2017 for my thesis and recently updated it. There's not a lot of robust evidence on which diagnostic tests or provocation tests are reliable; there's still low-level evidence. But from that study, we propose to at least use the Spurling test and all four upper limb tension tests, perhaps at the outcome of the shoulder abduction relief test or Davidson's test and the arm squeeze test for good measure. Those four are probably the most reliable cluster. We couldn't reuse the cluster; we haven't done any calculations on it, but it's a good set of tests to use. Once they all add up to your clinical history taking and making your hypothesis more and more reliable, if you suspect a nerve root compression, you would then establish either a motor dysfunction or a sensory dysfunction. If the nerve root is compressed, you must have either a motor dysfunction and/or a sensory dysfunction. So, key muscle strength testing and reflexes are then important, and for diminished sensibility testing, you could use two-point discrimination, Fray filaments, and cotton wool swabs for light touch. Extensive sensibility testing would be the best way to go forward in the clinic. ## Distinguishing Between Normal Neck Pain and Cervical Radicular Syndrome **Host:** You also mentioned that patient history is probably more important than clinical testing. What items can help you distinguish between normal neck pain and cervical radicular syndrome? **Eric:** A typical patient with cervical radiculopathy will usually have more arm pain than periscapular pain from the scapular region than neck pain. They might complain of feelings of tingling and numbness in the arm and hand. Sometimes they might be able to differentiate which specific fingers are more involved than others, but that's not always the case. They usually describe that pain as sharp, shooting, or stabbing, with a constant nagging pain underneath. They might have feelings of diminished grip strength or less dexterity with their fingers in buttoning small shirts and stuff. Their pain is nearly always provoked by specific neck movements or specific neck postures, which should be related to either closing the intervertebral foramen or putting more pressure on a disc. ## Reliability of Dermatomes and Myotomes **Host:** How reliable and useful are dermatomes and myotomes that we are taught? **Eric:** Yes, that's well. I've been taught the same way, but recent research has nearly shoved that completely out of the window. There is so much inter-individual change that they are perhaps a broad view of approximately in that area. You're more likely to have C7 nerve root compression, but they are by no means reliable. They only give us a broad indication. ## Treatment Options for Cervical Radicular Syndrome **Host:** Moving on to our interventions, what are treatment options for cervical radicular syndrome based on our current evidence? **Eric:** In my PhD studies, we looked extensively at the effectiveness of conservative management for patients with cervical radiculopathy. One of the more interesting outcomes I always feel was that cervical traction is no more effective than a placebo. So perhaps we should stop putting people in strange masks and putting weight on traction machines. A recent systematic review by Colombo et al. in 2020 has corroborated that, so I thought that was interesting. Effective treatment modalities should probably include neurodynamic mobilization, especially with safe spinal manipulative therapy techniques, and exercises aimed at both general aerobic fitness and targeted strength training of the deep neck flexors and extensors, as well as specific key muscles that might have wasted in the process. ## Adapting Management Strategies **Host:** How should physiotherapists adapt their management strategies as a patient progresses from, say, the acute stage to subacute to chronic stages of the disease? **Eric:** That's a very important question. Current evidence suggests that targeted, individualized physiotherapy is the preferred first treatment option for patients with cervical radiculopathy. The words "targeted" and "individualized" are the key words here; there is no one-size-fits-all approach. We've recently published a Delphi study in which we outlined that one of the first things to consider with your patients is the stage the disorder is in. Is it in the acute or recent onset stage? Then we need to be much more careful and not aggravate symptoms, as we are most likely dealing with a very irritable compressed nerve root. As the natural course progresses, and it is a positive course, most patients will recover. We can slowly change our interventions and load the patient more and more. In that acute stage, I think one of the most important interventions is explaining to the patient exactly what is causing their problems, explaining that the natural course is a positive one. Most patients gradually recover in something like four to six months, so we need to be very careful to avoid nocebo messages and just paint a positive picture. Once patients have a clearer understanding of the mechanisms involved, they are much better suited to manage their own symptoms on a day-to-day basis, empowering them to have their hands on their own treatment process. In order for our therapy, especially in that acute stage, to be effective, it needs to be supported with effective pharmacological pain management, considering there is likely an inflammation of sorts and possibly an aspect of neuropathic pain. Neuropathic pain has a completely different pain management system than somatic pain, so we need to be careful in establishing which pain mechanisms are dominant. As far as physiotherapy treatment is concerned in that acute stage, starting patients finding their offloading positions and how to diminish symptoms themselves during the day, perhaps assisting them in wearing a cervical collar in the first three to maximum six weeks could help. It's something worth considering. Gentle neurodynamic mobilization techniques combined with gentle thoracic mobilization and cervical mobilization in the cervical area, mainly aimed at opening that foramen, can be effective too. As symptoms slowly subside in the subacute stage, thoracic manipulation can be added in a safe way, and individualized exercises will now be more and more important, including motor control exercises aimed at the deep neck flexors and extensors. There is still room for active and passive neurodynamic mobilization, and then as the symptoms subside more and more in the chronic stage, we increase our active approach. It should include targeted strength training of wasted key muscles, general aerobic fitness exercises, and still perhaps some neurodynamic exercises combined with spinal manipulative therapy as a way of getting rid of the last barriers to good movement. ## Manual Therapy Considerations **Host:** You also mentioned manual therapy. You talked about thoracic manipulations. What about cervical manipulation? **Eric:** It's an interesting question because there's very little real evidence supporting this. We need to look at sound clinical reasoning and clinical expertise. I feel that we can all agree that cervical high-velocity low-amplitude thrust techniques are out of the question. There is some evidence supporting the use of thrust manipulations on the thoracic spine in cervical radiculopathy, but for the cervical spine, I think we should stay away from manipulating that. When we use high-velocity techniques on the thoracic spine, we should have safe techniques safeguarding the position of the cervical spine while we execute the thoracic techniques. Cervical-thoracic mobilization techniques, especially when aimed at opening that intervertebral foramen, can be used very effectively. There is some evidence to support the contralateral cervical lateral glide technique. It's a sort of a combination of cervical joint mobilizations and neurodynamic mobilization; that's a great technique to use. ## Role of Motor Control and Strengthening Exercises **Host:** When it comes to cervical motor control and cervical strengthening, what is the role of those exercises when it comes to cervical radiculopathy? **Eric:** There's a huge body of evidence supporting the importance of deep cervical flexion and extensor muscles in the presence of prolonged neck pain. I think that's one of the most researched areas in physiotherapy. In patients with cervical radiculopathy, they fall into that category; they will have longer periods of neck pain. Somewhere in the period between the subacute and the more chronic stages, retraining of coordination and endurance of deep cervical flexors and extensors is warranted. I believe it's an essential part of the longer-term management strategy. Of course, the stabilizer is a valid instrument to measure both coordination and endurance of those deep flexors. Nowadays, there are a lot of software and do-it-yourself gadgets available to support exercising patients. It's a bit expensive to hand out stabilizers to every patient with neck pain, although some clinics do that, and it's a great way to move forward. But just a lot of do-it-yourself gadgets as home exercises. I myself use a headband with a laser pointer light attached to it with a sort of Velcro track; it costs nothing. I hand them out to patients together with plastic sheets of figures they need to trace, and all these figures become increasingly more difficult. That way, they can also assist their joint position error and work on improving that. So basically, independent of the fact that patients fall into a different category of neck pain, just because they have pain for a longer period of time, their motor control is probably impaired. That's what we want to retrain. **Host:** Is that fair to say? Likely that will happen? **Eric:** Yes, but again, it's like a no. You assess for it; you do not treat what you have not assessed. So you assess for whether this patient has diminished endurance or diminished coordination, preferably with a valid instrument like the stabilizer. If you do assess for diminished strength, endurance, or coordination, then you manage that. But I have had the occasional patient with a longer history of neck pain in which I could not find any diminished strength or endurance or coordination, so then I wouldn't treat it. **Host:** Yeah, there is no one-size-fits-all. As I said in the beginning, you assess for what you treat. **Eric:** Exactly. Every patient is different, which is the fun of our work. There are similarities, but no patient is identical to another, and that makes it fun. **Host:** As a quick side question, in the lumbar spine, especially in the acute phase, some people see benefits when they apply exercises like the McKenzie exercise or McKenzie-like exercises with a directional preference. Do you also see this in the cervical spine? **Eric:** From my point of view, less so. I find it a very useful technique in the lumbar spine indeed. In the cervical spine, I tend to see more patients that aggravate their symptoms with directional preference exercises, and I find it very difficult in a significant number of patients to find that directional preference that actually works. So I do use it in my assessment, but I rarely use it as a treatment option. **Host:** It's also what I experience in a patient that I saw; it's usually not—there's no preference so much, and there's usually an aggravation more often than not. **Eric:** Yes. **Host:** You also mentioned after or you might want to start with motor control exercises and then later move on to higher load exercises. What sort of exercises might we prescribe for those patients? **Eric:** Targeting the cervical-thoracic region is very individualized. I tend to really look at what my patient is doing in their day-to-day activities. Do they have a sedentary job, or are they heavy lifters in their work? That's very individualized. Targeted strength training of wasted key muscles, which might often involve grip strength or finger strength, is something that I would use, but general strength training is very individualized. # Physiotherapists Podcast Episode 74 (Continued) ## Patient Education and Self-Management **Host:** If we move on from treatment to patient education and self-management, from your perspective, what key educational messages or self-management strategies should physiotherapists emphasize to empower patients in their recovery? **Eric:** That's a great question. Patient education on the nature, course, and prognosis is perhaps our most important and powerful treatment modality. I always advocate using that more often. It’s a hands-off technique, but I think it plays an essential role in the management of all our patients. As I mentioned before, in the early onset stage, it's essential to teach patients to stop irritating and compressing their nerve root to avoid continuous flare-ups. I sometimes use a log fire analogy, where the irritated, inflamed nerve root is like a burning log of wood. The pain medication and their aggravation are reasonably effective firefighters. Once those firefighters have reduced the log fire to smoldering embers, we need to avoid aggravating and putting fresh logs on that bed of embers, or else we'll flare up to a log fire once again, and then we need to call the fire department again. So, stop aggravating your symptoms. This is also why treating cervical radiculopathy is completely different from non-specific neck pain. A key message for all patients is that, as I mentioned before, it has a favorable prognosis. Most patients will recover within four to six months, and surgery is more often than not unnecessary. They will get better, but they need to take their time and manage their symptoms. They need to really understand what is happening in their neck. ## Common Mistakes and Misconceptions **Host:** What are some common mistakes or misconceptions physiotherapists make in diagnosing and managing cervical radicular syndrome, and how can we avoid them? **Eric:** That's a difficult question to answer. One of the first diagnostic hurdles we have to cross is differentiating radicular pain due to cervical radiculopathy from somatic referred pain in non-specific neck pain. Non-specific neck pain referred pain might have a touch of peripheral increased neuromechanical sensitivity, but that's not due to nerve root compression. Differentiating cervical radiculopathy from conditions like thoracic outlet syndrome, particularly the neurogenic form, is also difficult. We need to be aware of other differential diagnoses, such as B-turn syndrome or neurologic atrophy. It's rare, but it's out there. Not all patients you suspect of having cervical radiculopathy actually have that. If you hear hooves, do not only think horses; think zebras, think deer, think all the possibilities. Sound clinical reasoning is crucial. Constantly look at whether your patient's features fit your diagnostic hypothesis, and if you find features you cannot explain, then think again and don't just jump to conclusions. ## Red Flags and Imaging **Host:** Under what circumstances should we consider imaging essential, and what red flags should prompt immediate referral to other healthcare professionals? **Eric:** The North American Spine Society and the Dutch Medical Specialist Federation have both adopted the same strategy: imaging is not necessary unless you are unsure of your diagnosis and feel you need collaboration on a diagnosis. If you have features that don't fit, perhaps then imaging is warranted. Their advice is to only use imaging once you have decided that conservative therapy is not effective and you're considering either injections or surgery, and you want to predetermine the level your injection or surgery might target. Imaging really has no place in the initial stages. As for red flags, rapidly increasing symptoms, rapidly increasing muscle wasting, and odd behavior of pain—unexplainable odd behavior of pain—are the three main red flags, apart from the usual ones we always cover. ## Lessons from Lumbar Radiculopathy **Host:** Are there any lessons that we can learn from lumbar radiculopathy research or clinical practice that physiotherapists can apply when dealing with cervical conditions? **Eric:** Yes, we've covered that a bit. Mechanical therapy, like McKenzie-style therapy, tends to be more effective in the lumbar spine than in the cervical spine, from my personal point of view. Perhaps not just for physiotherapists, but also in pain management, pharmacological pain management—there's not a lot of evidence in the cervical spine, so we tend to borrow from the evidence available in the lumbar spine. We need to be aware that the cervical spine has a completely different functional anatomy and function in daily life compared to the lumbar spine. There are analogies and similarities, but it is a different region. Sound clinical reasoning and being patient-specific with your individual patient is a lesson we can learn from all of these things. ## Future Research Directions **Host:** Based on the gaps you've identified in the literature, where do you believe future research should focus, and how can physiotherapists contribute to filling those gaps? **Eric:** One of the things future research regarding cervical radiculopathy should address is the lack of epidemiological data. We should repeat that large population-based study that Karpinski did in the '70s or in 1994. We should really redo that in a different area of the world, perhaps in Europe, and incorporate what we know now about diagnosing patients with cervical radiculopathy. More studies on neurodynamic mobilization are warranted. Our current understanding is that neurodynamic mobilization is thought to improve neurovascular nerve movement and restore optimal neural homeostasis, but there is a need for fundamental research to better understand all the mechanisms involved and associated with why improved nerve excursions lead to better clinical outcomes. From a diagnostics point of view, one of the first things we should try to do is standardize the Spurling test. All studies that have studied the test use a different version, so we should look at which is the most effective version and then universally use that one. There is a study from Anex in 2011 that looked at different versions. Finally, we should conduct research on the generally accepted and most often used neurological examinations, such as muscle strength, reflex testing, and sensibility testing. Most medical doctors and neurologists only use neurological testing in their diagnostic procedures; they rarely use the Spurling test or upper limb tension tests. However, there have only been two studies that have prospectively studied neurological examination, and we have no idea about the diagnostic accuracy of those procedures. We really should study that better. ## Clinical Gems for Management **Host:** Do you have any clinical gems to improve the management of cervical radiculopathy that you would like to share? **Eric:** Be proficient in the gentle use of neurodynamic mobilizations. Come up with as large a variety of exercises as you can, essentially doing all the same thing but in different functional activities. Neurodynamic mobilizations are an important part of the management strategy. In the early onset stage, when there is a lot of pain and inflammation, we should use very passive and gentle techniques and slowly increase that as time continues. Monitor for flare-ups and don't be afraid to downshift occasionally. Lastly, avoid much of the passive modalities, such as cervical traction, kinesiology tape, and dry needling, as there is no evidence to support their use in patients with cervical radiculopathy. Active approaches have evidence supporting them. I know it is more difficult and takes up much more of your time and mental energy to be active with your patients instead of just sticking some plaster on or pricking a needle in, but spend time and energy on individualized and targeted specific exercises with your patients. ## Conclusion **Host:** We're coming towards the end of our podcast, and I always ask our guests if there is anything that we haven't touched on that you would like to add to the discussion. **Eric:** No, I think my last comments have covered a lot for discussion afterwards. I think we've covered diagnosing and managing patients with cervical radiculopathy. I like the word "managing." We're not treating them; we're managing them through their natural process that will get better. We can help them get better faster and with less chance of recurrences. **Host:** Perfect! And lastly, where can people find you if they want to reach out or learn more about you? **Eric:** That's a difficult one. They can email me, and they are sure to get an answer. Perhaps we can post that email address somewhere. I love my work; I love treating patients, and I still do that on a day-to-day basis. I also enjoy doing research, and combining the two makes my life interesting every day. I appreciate questions from colleagues, so if people email me, they will surely get an answer. It might take a few days or a week, but I answer all of my emails. **Host:** Perfect! Eric, thank you so much for your time and insights. It was a pleasure to have you on the podcast. **Eric:** Thank you for having me! I've enjoyed listening to your videos and your podcast, so it's been an honor to be part of one of them. Thank you all for listening to this episode! To listen to this and other episodes, maybe even in your own language, including German, French, Spanish, Italian, Portuguese, and Dutch, download our new and free PhysiTutors app. Additionally, if you're a premium member, you can also access the transcript and infographics and find more useful physio content. If you enjoyed this episode, hit the subscribe button or follow our podcast on Spotify or Apple Podcasts, and consider leaving a review if you really enjoyed it. With this being said, this was Kai from PhysiTutors, and I'll talk to you in the next episode. Bye!

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