Neck PainRecent evidence supports the use of high-velocity, low-amplitude thrust manipulation (cracking the back) to the thoracic spine in people with neck pain. You read that right, cracking your back (midback, the thoracic spine to be specific) helps with neck pain, but what about cervical radiculopathy? We have all heard the song, the head bone is connected to the neck bone, but how does this transference actually help?
Arm pain related to neck pain is most commonly cervical radiculopathy which is most commonly associated with a cervical disc or other space-occupying item, resulting in nerve root inflammation, impingement, or both. Simply put, there is limited space in the cervical spine and something is impeding on this space and pressing on nerves. Past research supports the use of physical therapy for cervical radiculopathy, suggesting manual therapy, exercise, and cervical traction as beneficial treatment for cervical radiculopathy. However, few studies have isolated thoracic spine manipulation and function in patients with cervical radiculopathy.A recent study isolated thoracic spine manipulation and compared thoracic spine manipulation to a sham manipulation (a fake back crack) in patients with cervical radiculopathy and found: “Patients randomized to receive thoracic manipulation as compared to sham manipulation had greater improvements in neck pain, neck-related patient-rated disability, and cervical impairments (ROM and deep neck flexor endurance) immediately and up to 48 to 72 hours after treatment. At both follow-up time points, a greater proportion of patients in the manipulation group reported at least a moderate change in their neck and upper extremity symptoms and centralization of their symptoms compared to patients in the sham manipulation group.” This is an exciting finding, but is simply cracking your back enough to fix your cervical radiculopathy…probably not. Before we explore how to fix neck and arm pain, we need to understand how cervical radiculopathy is diagnosed. How to Diagnose Cervical Radiculopathy Typically, an MRI is used to diagnose cervical radiculopathy; however, there are manual tests which can be used for diagnosis. Wainner (2012) concluded positive scores on 3 of 4 clinical tests accurately diagnosed cervical radiculopathy:
- Spurling’s test: The Spurling test is a medical maneuver used to assess nerve root pain, where the nerve exits the spinal cord.
- Upper-limb neurodynamic test/median nerve bias: This test assess the mobility of the median nerve while moving the arm, elbow, wrist, and neck. If the median nerve does not slide properly through the body and upper extremity, it can induce pain or symptoms.
- Cervical distraction test: This test determines if providing more joint space for the nerve root provides relief.
- Cervical rotation toward the symptomatic side of less than 60°: Simply rotating the head to the side can determine if an impaired range of motion exists.
Why does Cracking Your Back Help Neck PainIn the introduction, we noted the support of cracking your back for improving neck pain and cervical radiculopathy. Unfortunately, we don’t know the exact science of how this helps, but the proposed theories include:
- Improved Joint Movement From the Release of Gas: Although this theory is proposed by many chiropractors, there is no evidence supporting the notion that cracking your back releases gas within the synovial fluid (read the article from Scientific America).
- Neural Response: A neural response is the most supported notion of how cracking an unaffected joint improves pain and movement. Hearing or feeling a joint crack, can provide a calming or relaxing sensation (when not over forced or done on someone who is resisting) and cause the whole body to relax. This is a positive neural response.
- Placebo: Placebos are plentiful in our world, including medicine. Many people associate cracking any joint with feeling better. Therefore, simply believing cracking your back will make you feel better can cause improvement.
What We Still Need to Research for Thoracic Manipulation for Cervical RadiculopathyAlthough the aforementioned study is supportive, it doesn’t answer the following questions:
- Is thoracic spine manipulation the best treatment for cervical radiculopathy? The Young (2019) study only compared manipulation to a fake or sham manipulation. Therefore, we are not sure if this treatment is best compared to other forms of manual therapy, traction, exercise, or something else. Also, there are various phases of an injury, making it difficult to say if manipulation is the best form of treatment during all phases of an injury.
- What are the long term effects of thoracic spine manipulation? We currently do not know the long-term effects of spinal manipulation. Anecdotally, it seems regular spinal manipulation is non-harmful, as many have received this form of treatment for years without any long-term negative effects (however, there are stories of negative short-term effects noted).
- Is one type of treatment all that is needed? Simply put, no. Like most injuries, multiple types of treatment are necessary for not only symptom resolution, but long-term prevention and injury resolution.
6 Best Treatments for Cervical RadiculopathyAs stated, one type of treatment is rarely the best course of treatment for symptom resolution and prevention of injury recurrence. The current evidence-based physical therapy treatment for cervical radiculopathy may include any and possibly all of the following:
- Thoracic spine manipulation: As stated earlier, thoracic spine manipulation has recently been shown to improve short-term function and reduce pain.
- Manual therapy (traction, soft tissue mobilization): Similar to thoracic spine manipulation, the actual physiological changes with certain types of manual therapy are not well established. However, many patient report symptom improvement after manual therapy. Our clinic often finds manual therapy can help reduce pain and open the window for more neuromuscular re-education and strengthening.
- Taping: Although the literature is limited and mixed on the effects of taping, we find it can be used during the initial phases of treatment as a supplement to strengthening. It is impossible to magically give someone more strength, but tape can be utilized to improve postural education (reducing stress on certain nerves), provide neuromuscular re-education (help learn proper positions and relax overactive muscles), and strengthening (supplement strength until this is achieved).
- Postural education: We all have poor posture. A forward head and rounded midback can place excess stress and stretch on the nerves, increasing pain signals. Postural education can reduce the overall stress on these nerves.
- Neuromuscular re-education (targeted strengthening): Simply performing strength exercises isn’t going to fix poor movement patterns. A common exercise for cervical radiculopathy is a midrow. Most untrained individuals will overuse their suboccipital and upper trapezius muscles during this exercise. This faulty pattern will increase the stress on the neck and cervical nerves. Trained individuals will use their middle and lower trapezius muscles to perform this movement. This movement will put more stress on the midback. This type of patterning requires training and self-awareness.
- Strengthening: Once pain is reduced and proper neuromuscular patterning is accomplished, then muscle strength and endurance are necessary to handle the demands of our lives. Our robust body can handle some stress, but we all overstress certain areas in our bodies. Muscular strength and endurance provide more wiggle room for daily stress, helping prevent the recurrence of an injury.
Conclusion on Cervical Radiculopathy Physical TherapyPain in the neck and arms can be alarming, but like most injuries, proper diagnosis, systematic treatment, and patience are the keys for a successful recovery. Physical therapy is highly successful for this condition; but unfortunately, when neck and arm pain have gone untreated for years, or in cases of extremely traumatic events, further intervention may be necessary.
- Young IA, Pozzi F, Dunning J, Linkonis R, Michener LA. Immediate and Short-term Effects of Thoracic Spine Manipulation in Patients With CervicalRadiculopathy: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2019 May;49(5):299-309. doi: 10.2519/jospt.2019.8150. Epub 2019 Apr 25.
- Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. 2000; 30: 728– 744. https://doi-org.libproxy2.usc.edu/10.2519/jospt.2000.30.12.728