Thoomes E1, van Geest S2, van der Windt D3, Falla D4, Verhagen A5,6, Koes B6, Thoomes M1,6, Kuijper B7, Scholten-Peeters W8, Vleggeert-Lankamp C2
1Fysio-Experts, Research Department, Hazerswoude, Netherlands, 2Leiden University Medical Centre, Department of Neurosurgery, Leiden, Netherlands, 3Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele, Staffordshire, United Kingdom, 4University of Birmingham, Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, Birmingham, United Kingdom, 5University of Technology Sydney, Department of Physiotherapy, Sydney, Australia, 6Erasmus MC University Medical Center Rotterdam, Department of General Practice, Rotterdam, Netherlands, 7Maasstad Hospital, Department of Neurology, Rotterdam, Netherlands, 8Vrije Universiteit Amsterdam, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Amsterdam, Netherlands
Background: In clinical practice, the diagnosis of cervical radiculopathy (CR) is based on information from the patient history, physical examination and diagnostic imaging. Various physical tests may be performed, but their validity is unknown. Additionally, the effectiveness of conservative treatments for patients with CR has recently been assessed.
Purpose: The purpose of this project was to assess the validity of diagnostic tests and the effectiveness of conservative treatments in patients with CR.
Methods: CENTRAL, PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Google Scholar databases were searched for randomized clinical trials of conservative therapies and also for diagnostic studies comparing results of tests performed during a physical examination in diagnosing cervical radiculopathy with a reference standard of imaging or surgical findings.
Independent sets of authors assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group as well as the methodological quality of studies using the QUADAS-2. The overall quality of the body of evidence of the intervention studies was evaluated using the GRADE method.
Results: Five diagnostic accuracy studies were identified evaluating Spurling's, Arm Squeeze, Traction-Distraction, Davidson's and Upper Limb Neural Tests. Only Spurling's test was evaluated in more than one study, showing high specificity ranging from 0.89-1.00 (95%CI: 0.59-1.00); sensitivity varied from 0.38-0.97 (95%CI: 0.21-0.99). No studies were found assessing validity of widely used neurological tests such as key muscle strength, tendon reflexes and sensory impairments.
There is low level evidence that a collar is no more effective than physiotherapy at short term follow up and that traction is no more effective than placebo traction. There is very low level evidence that a collar is no more effective than traction and that intermittent traction is no more effective than continuous traction.
There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions.
There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific (motor control) exercises are more effective on pain activity limitations and GPE than separate interventions or a wait-and-see policy.
Conclusion(s): There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. Based on low to very low level evidence, no one conservative intervention appears to be superior or consistently more effective than other interventions. But there is low level evidence that multimodal interventions are more effective on pain and activity limitations than separate interventions or a wait-and-see policy.
Implications: When consistent with the patient history, clinicians may use a combination of Spurling's, Traction-Distraction and an Arm Squeeze test to increase the likelihood of a cervical radiculopathy; whereas a negative combined neurodynamic testing and an Arm Squeeze test could be used to rule out the disorder.
Use of a collar and physiotherapy (consisting of multimodal interventions including spinal mobilization, specific exercises and mobilizations with a neurodynamic intent) show promising results at short term follow up.
Keywords: Cervical radiculopathy,, diagnostic accuracy, conservative therapy
Funding acknowledgements: This work was not funded
Purpose: The purpose of this project was to assess the validity of diagnostic tests and the effectiveness of conservative treatments in patients with CR.
Methods: CENTRAL, PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Google Scholar databases were searched for randomized clinical trials of conservative therapies and also for diagnostic studies comparing results of tests performed during a physical examination in diagnosing cervical radiculopathy with a reference standard of imaging or surgical findings.
Independent sets of authors assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group as well as the methodological quality of studies using the QUADAS-2. The overall quality of the body of evidence of the intervention studies was evaluated using the GRADE method.
Results: Five diagnostic accuracy studies were identified evaluating Spurling's, Arm Squeeze, Traction-Distraction, Davidson's and Upper Limb Neural Tests. Only Spurling's test was evaluated in more than one study, showing high specificity ranging from 0.89-1.00 (95%CI: 0.59-1.00); sensitivity varied from 0.38-0.97 (95%CI: 0.21-0.99). No studies were found assessing validity of widely used neurological tests such as key muscle strength, tendon reflexes and sensory impairments.
There is low level evidence that a collar is no more effective than physiotherapy at short term follow up and that traction is no more effective than placebo traction. There is very low level evidence that a collar is no more effective than traction and that intermittent traction is no more effective than continuous traction.
There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions.
There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific (motor control) exercises are more effective on pain activity limitations and GPE than separate interventions or a wait-and-see policy.
Conclusion(s): There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. Based on low to very low level evidence, no one conservative intervention appears to be superior or consistently more effective than other interventions. But there is low level evidence that multimodal interventions are more effective on pain and activity limitations than separate interventions or a wait-and-see policy.
Implications: When consistent with the patient history, clinicians may use a combination of Spurling's, Traction-Distraction and an Arm Squeeze test to increase the likelihood of a cervical radiculopathy; whereas a negative combined neurodynamic testing and an Arm Squeeze test could be used to rule out the disorder.
Use of a collar and physiotherapy (consisting of multimodal interventions including spinal mobilization, specific exercises and mobilizations with a neurodynamic intent) show promising results at short term follow up.
Keywords: Cervical radiculopathy,, diagnostic accuracy, conservative therapy
Funding acknowledgements: This work was not funded
Topic: Musculoskeletal: spine; Disability & rehabilitation; Neurology
Ethics approval required: No
Institution: CCMO
Ethics committee: National Dutch Central Committee on Research Involving Human Subjects
Reason not required: review from a Medical Ethical Committee for this project was not required
All authors, affiliations and abstracts have been published as submitted.
