How Do You Rule Out the Cervical Spine as a Source of Arm Pain?

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Most musculoskeletal diagnoses are based upon the use of clinical prediction rules (CPR) to rule and diagnosis. Have you ever considered using a CPR to rule out a diagnosis? Traditionally, chiropractors use orthopedic testing to reproduce the patient's chief complaint.  After today’s blog, I hope you will consider negative tests just as important as positive tests in your initial or follow-up exam. 

Evidence-based chiropractors commonly encounter patients suffering from nerve irritation or compression from the cervical spine. Using the model of cervical radiculopathy (CR), I will explain why ruling out a diagnosis may be just as powerful as ruling in a specific diagnosis. Both are necessary before prescribing treatment, ADL modifications, and home rehabilitation exercises to create highly satisfied patients.

Rule Out Cervical Radiculopathy

Grondin et al. (2021) found that upper limb tension tests in isolation are not highly sensitive or specific for a single diagnosis. However, when 3 of 4 ULNT tests are positive, you can rule in CR.  Equally important, when all four ULNT are negative, you can rule out CR. This strategy should give you and the patient the confidence to move forward with the correct management strategy based upon tissue injury. 

Here are three of the neurodynamic tests found within the Clinical Skills > Clinical Evaluation section of your ChiroUp account. 

Median Nerve Test

Ulnar Nerve Test

Radial Nerve Test

Pro-Tip: These CPR’s are beneficial when a patient is not responding to care as expected. Nerve tension tests may confirm your initial diagnosis or lead you to perform a follow-up examination on another region to solve these complex cases.

Rule in Cervical Radiculopathy

• Spurling test

• Distraction test

• Upper-Limb Tension Test 1

• Ipsilateral cervical rotation <60 degrees. (2)

If these tests reproduce the patient’s chief complaint, then consider cervical radiculopathy as the etiology. The patient and provider should focus on treatment strategies directly related to reducing compression of the affected nerves at the spinal level.

Pro-Tip: Evidence-based chiropractors lead the way in generating highly satisfied patients. Click here for more information.

What Can You Do For Cervical Radiculopathy?

Use best-practice management skills to determine the best treatment methods for the principal dysfunction. The research suggests that no single treatment is effective in reducing cervical radicular problems. (3) Rather, cervical radiculopathy responds most favorably to a multimodal treatment approach that includes a combination of techniques including manipulation, mobilization, and traction – all designed to restore motion and open the IVF.

While manipulation is safe, appropriate, and valuable for the management of most radiculopathies, also consider non-thrust techniques for those cases that may not respond well to HVLA:

• A recent paper by Azful (2019) found that a Manual Intervertebral Foramen Opening Method, as described by Mulligan, is useful in treating cervical radiculopathy. (2)

• Cervical traction is helpful for both discogenic and degenerative causes of IVF encroachment. Cervical traction provided relief in 81% of patients with symptoms from mild to moderate cervical spondylosis. (4)

What Can Your Patients Do For Cervical Radiculopathy?

Carefully assessing the patient's habits, hobbies, and daily activities will often highlight fundamental postural faults that perpetuate tissue dysfunction. Identification and correction of these faults are crucial for timely healing and prevention of future reoccurrence. Consider these three tools to alleviate symptoms associated with cervical radiculopathies.

Cervical Retraction Exercise

Workstation Ergonomic Advice

Pillow Selection

Apply this paradigm to other regions of the body

The more we understand what tissue is affected, the better we will apply the best-practice methods to solve the problem. Ruling out a diagnosis will assist you and the patient in making better decisions throughout the treatment plan. This rationale is not unique to neck pain:

• Rotator Cuff Tendinopathy– Do we suppress the inflammation of tendonitis or generate a controlled inflammatory reaction for chronic tendinopathy?

• Low Back Pain– Do we prescribe knee to chest exercises for the flexion-biased patient or recommend sphynx movements for the extension-biased patient?

• Lateral Elbow Pain– Do we use a compression band for tendinopathy or avoid compression for radial tunnel syndrome?

In each of these cases, identifying your target of tissue dysfunction is crucial. The correct assessment leads to success while employing a shotgun approach, and guessing wrong lead to "pissed off" patients.

• References

  1. Grondin F, Cook C, Hall T, Maillard O, Perdrix Y, Freppel S. Diagnostic accuracy of upper limb neurodynamic tests in the diagnosis of cervical radiculopathy. Musculoskeletal Science and Practice. 2021 Oct 1;55:102427 Link

  2. Afzal R, Ghous M, Rehman SS, Masood T. Comparison between Manual Traction, Manual Opening technique, and Combination in Patients with cervical radiculopathy: Randomized Control Trial. J Pak Med Assoc. 2019 Sep;69(09). Link

  3. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series J Orthop Sports Phys Ther 2006; 36: 152-9. Link

  4. Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy1. American journal of physical medicine & rehabilitation. 1999 Jan 1;78(1):30-2. Link