Chiropractic + Naturopathic Doctor

Research Review Corner: April 2013

Shawn Thistle   

Features Research

This review was prepared by Michael Haneline, DC, MPH, of Research Review Service.

Study Title: Cervical radiculopathy: a systematic review on treatment by spinal manipulation and measurement with the Neck Disability Index

Author(s): Rodine, R. and Vernon, H.


Publication Information: Journal of the Canadian Chiropractic Association 2012; 56(1): 18–28.

This review was prepared by Michael Haneline, DC, MPH, of Research Review Service.


Cervical radiculopathy (CR) is reported to affect about 3.5 persons per 1000.  The condition mostly affects those who are in their 50s and 60s and it does not seem to be gender specific.  CR is not typically the result of trauma, rather it is most commonly caused by a cervical disc herniation or a combination of discogenic and spondylotic changes that have become aggravated.

Common symptoms of CR include neck and radicular pain as well as paresthesia.  Scapular pain is also common and was present in 51.6 per cent of cases in one study.1

Physical examination findings typically include painful cervical spine range of motion (ROM) and decreased deep tendon reflexes.  Other findings include muscle weakness in 15 per cent of cases, decreased sensation in one third of cases, and rarely muscle atrophy, which is present in less than 2 per cent of cases.

The C7 nerve root is the most commonly involved level, which was present in 39.3-46.3 per cent of patients in one study; followed by C6 in 17.6-42.6 per cent of cases.2

An extensive review of the literature found insufficient evidence to draw firm conclusions about which treatments are appropriate for CR, nor could they identify therapies that are contraindicated.3  Another review reported that the evidence for manipulative therapy in CR is minimal, low in quality and has a high risk of bias.4  Nonetheless, 93 per cent of chiropractors reported that they would use spinal manipulative therapy (SMT) in a patient with suspected or confirmed cervical disc herniation.4  Other manual medicine professionals employ this treatment as well.

This paper had two objectives,as follows:

1)   The primary objective was to review the use of SMT for CR, reflecting on chiropractic treatment practices.

2)   The secondary objective was to review the use of the neck disability index (NDI) in the management of patients with neck and arm pain.



Objective 1: Spinal Manipulation for Cervical Radiculopathy

The searches produced a number of papers, but only three remained after applying the study’s exclusion criteria.

Descriptions of the included studies are listed below:

1)   Howe et al.5 randomized 52 subjects to two groups (26 in each group).  The subjects had pain/stiffness in the neck with or without shoulder pain, as well as arm or hand pain/paresthesia that was attributed to a lesion of the cervical spine.  The treatment group received cervical SMT plus medication and a control group received the medication only.  In the subgroup of patients with arm and hand symptoms, the treatment group showed superior improvements in outcome measures as compared to controls, but the differences were not quite significant.  However, there were significant immediate improvements in symptoms and cervical rotation in the intact group.

2)   A study by BenEliyahu6 comprised a series of 27 cases in which patients had to have neck or back pain that referred into the associated extremity in order to be included.  Also, the extremity pain had to be reproduced by stretch testing, subjects had to have restricted ROM, neurological deficit and a clinically correlated MRI verified disc herniation.  Eleven cervical disc cases were included, but most of the data were pooled so that it was difficult to discern between clinical changes found in cervical versus lumbar cases.  Overall, 22 patients were reported to have a good clinical outcome, with 17 of them showing reduced herniation size in repeat MRIs. The one-year return to former occupation rate was 82 per cent among cervical cases.

3)   Murphy et al.7 prospectively followed a cohort of 32 confirmed cases of CR for an average of 8.2 months post-treatment . Patients were treated with a variety of techniques, including SMT, neural mobilization, muscle energy techniques, end-range loading and over-the-door traction.  At final re-examination, the mean self-rated improvement was 75.4 per cent, the mean Bournemouth Disability Questionnaire score was improved by 53 per cent, and the mean change in the Numerical Pain Scale was 62 per cent.

No major complications were reported in any of the studies, although temporary increased pain following treatment was reported in some patients.  Nonetheless, safety conclusions of high-velocity, low-amplitude (HVLA) procedures for CR cannot be drawn from these data and further research is needed in order to form more exact incidence estimates.

The authors thought that the study by Murphy et al. provided the best insight into the clinical-course of CR treated with HVLA-SMT. Even though the patients were not randomized and there was no control group, they indicated that this trial may help a general practitioner in designing a trial of therapy for patients with CR.

Objective 2: Neck Disability Index for Patients with Neck and Arm Pain

The searches produced a total of 91 possible papers that had to do with the NDI and CR, but only six of them were included after applying the exclusion criteria.

The test-re-test reliability of the NDI was investigated in one study that involved neck and arm pain patients. The correlation value was 0.68, which is somewhat lower than the 0.89 that was previously reported for neck pain-only patients.

The responsiveness of the NDI in neck and arm pain patients was found to be similar to what was previously reported.  Minimum clinically important differences were found to be 7.5 and 7 NDI points (slightly higher than previously reported) and one of the included studies reported that a 20 per cent change would be required to indicate clinical success.

The studies also reported data on factors that predicted outcome as measured by the NDI, which found that low initial pain and distress levels and low impact on neck/arm function predicted greater short and long-term improvement in NDI scores.

Based on the data that was gathered from these papers, the use of the NDI in studies of SMT for CR is supported.


Objective 1: Spinal Manipulation for Cervical Radiculopathy

Several databases were searched using terms related to cervical radiculopathy and spinal manipulative therapy. In addition, hand-searches of pertinent manuscripts were conducted and content experts were contacted for feedback.

Studies were included if:

·       they were interventional studies that were published in a peer-reviewed journal;

·       they involved more than ten subjects;

·       patients received HVLA cervical manipulation; and

·       SMT was delivered by a licensed healthcare professional for the treatment of confirmed CR.

Studies were excluded if:

·       the data were reported via case-by-case format;

·       the cause of neck and arm pain was mechanical;

·       the principal method of manipulation was low-velocity, low-amplitude (e.g., mobilization and traction), although acceptable when secondary to HVLA-SMT;

·       primarily thoracic manipulation was used;

·       the mechanism of injury was traumatic; or

·       treatment fell outside the general scope of chiropractic practice.

Retrieved manuscripts underwent qualitative analysis, but no formal quality review or data pooling was conducted.

Objective 2: Neck Disability Index for Patients with Neck and Arm Pain

The PubMed database was searched using the terms “neck disability index” and “arm pain”. Also, the retrieved manuscripts were manually searched for additional citations.

Articles were included if they described the investigation of the psychometric properties of the NDI in the assessment of patients with neck and arm pain.  No exclusion criteria were listed.

The reliability or validity statistics of the studies were extracted and tabulated, but the quality of the studies was not assessed.

Study Critique

Few interventional studies have been conducted that dealt with CR and those that have been done are generally of low quality.  Thus, inferences that can be drawn from the collected data are limited.  The authors were fully aware of these limitations and their conclusions are consequently appropriate.

No attempt to assess the quality of the included studies was carried out. The authors thought this limitation was reasonable, however, since the target audience was clinicians rather than academics.

Given these limitations, the authors presented a realistic account of the evidence that was available. 

The evidence for or against SMT for patients with CR is limited. Moreover, a review by the Task Force on Neck Pain and Its Associated Disorders did not find enough evidence on any type of treatment to draw firm conclusions or to make appropriate recommendations for the management of patients with CR. Therefore, the authors’ conclusion that “…the cautious application of high velocity-low amplitude procedures in cases of confirmed or suspected CR” is sound.



  1. Radhakrishnan K, Litchy W, O’Fallon W et al. Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota, 1976 through 1990. Brain: A Journal of Neurology 1994; 117 (Pt 2): 325–335.
  2. Murphy D, Hurwitz E, Gregory A et al. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. J Manipulative Physiol Ther 2006; 29(4): 279–287.
  3. Hurwitz E, Carragee E, van der Velde G et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S123–52.
  4. Croft A. Appropriateness of cervical spine manipulation: a survey of practitioners. Chiropractic Technique 1996; 8(4): 178–81.
  5. Howe DH, Newcombe RG, Wade MT. Manipulation of the cervical spine—a pilot-study. J R Coll Gen Pract 1983; 33: 574–9.
  6. BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. J Manipulative Physiol Ther 1996; 19(9): 597–606.
  7. Murphy D, Hurwitz E, Gregory A et al. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. J Manipulative Physiol Ther 2006; 29(4): 279–287.

In addition to practising full time in Toronto, Dr. Shawn Thistle is founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners integrate current, relevant scientific evidence into their practice ( Shawn also recently launched The Epicurean Scholar, which offers continuing education seminars combined with gourmet food and wine events (  Dr. Thistle graduated from CMCC (where he lectures in the Orthopedics Department) and holds an Honours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medical Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Provider and Functional Range Release®/Functional Anatomical Palpation® instructor and provider.

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