Cx 2 - Mr Evans

acute neck pain + R arm neuro Sx

most likely clinical pres

R C6 radiculopathy

differential diagnoses

• median nerve entrapment

• Cx facet referral

• brachial plexus irritation

assessment technique + why

Spurling's test - foraminal compression

• Sx dermatomal C6 pattern

• laptop aggravates - Cx ext + compress

• Bakody's - NR unloading

• test directly loads C5-6 foraminal space

• reproduces radicular Sx not ULNT1 - median nerve test - not C6 specific, Sx derm

assessment technique results

positive - reproduces Rx Sx

• pain lateral forearm, pain/p+n thumb, shooting sensation expect - positive

assessment technique performance

• pt sit upright, stand behind

• gently guide neck side flex R (Sx side)

• add small ext/rot (narrows foramina)

• gentle downward pressure top of head

• keep pressure light, stop if sharp/unusual, uncomfortable

• inform if arm Sx reproduced

assessment technique Bakody's

• relief test > provocation

• strong diagnostic w/Spurling's positive - hand on head decreases Sx

• supports C6 Rx

• opens foramen, decompresses, slackens brachial plexus

management - education

• reduce fear and misconceptions, increase confidence in PA

• Sx fit irritation C6 NR - common + treatable

• Sx ease w/Bakody's - reassuring + shows NR response to unload

• nerves strong, don't get 'trapped' but can become more sensitive - movement helps recovery

• 'stop all upper body exercise' can increase sensitivity

• use gentle movements to calm nerve, improve confidence

• gradually get back towards gym/swim

management - pharmacological

NICE on Cx Rx

• offer oral analgesics eg ibuprofen, paracetamol, codeine

• consider neuropathic pain management - gabapentin, duloxetine, pregabalin, amitriptyline

• dosage based on response/tolerability

beliefs and disability evidence

Schwab+Silva 2023 - research on how beliefs about damage strongly influence disability

• align with pain principle that fear avoidance and catastrophising increases disability

• education decreases fear and enhances recovery

• addressing and correcting misconceptions essential for improving patient outcomes

education evidence

NICE on Cx Rx

• reassurance + activity 1st line management

• explain nerve irritation does not equal damage to decrease anxiety and increase adherence

• advise firm pillow

• advise not to drive if rom restricted

management - exercise 1 justification

neurodynamic - median slider

• decrease neural mechanosensitiivity

• increase neural mobility

• decrease arm pain/p+n

median slider demo + dose

demo

• sit/stand tall - bent elbow, abduct 90, turn palm up

• ext wrist to point of resistance

• flex wrist/palm down as neck side flex away

• neck neutral, ext elbow, ext wrist

• slow, rhythmic, avoid Sx provocation beyond mild stretch/tingle dose

• 10-15 x 2-3 daily, slow and controlled

median slider pro/regression

regression

• less range

• keep shoulder lower/less abduction

• seated progression

• increase range

• more shoulder abduction

• add Cx side flex away at end

median slider evidence

NICE - activity one of 1st line management Cx Rx Papacharalamboua et al 2022 - SR of RCTs, 25 studies

• slider better for acute, tensioner better for chronic (analgesic effect)

• slider technique beneficial to reduce pain and improve function

• increase intraneural blood flow, reduce inflam, better mobility

management - exercise 2 justification

postural strength - scapula retractions

• reduce compression Cx NR by increasing scapula support
• decrease forward head posture w/laptop work

scapula retraction demo + dose

demo

• sit/stand tall
• squeeze shoulder blades back/down
• hold 3 secs, relax dose
• 3x10 every other day, slow and controlled

scapula retraction pro/regression

regression

• less range
• hands on thighs to reduce arm weight
• supine progression
• prone
• scapula press up
• increase hold or reps
• add resistance

scapula retraction evidence

NICE - postural retraining recommended for Cx Rx

• reduce Cx loading and improve posture - less NR compression

exercise evidence

NICE on Cx Rx

• pacing tasks and avoid prolonged static structures
• regular gentle exercise to maintain mobility and strength
• pain management analgesics or short term anti-inflam meds
• gradual return to work and daily activities to support recovery

goal relevance of education/exercise

return to gym

• reduce misconceptions/fear of 'trapped nerve'
• build confidence and work towards return to exercise worry nerve 'trapped'
• slider calms nerve, decrease worry, support return to ADLs settle Sx
• gradually reintroduce upper body exercise
• light resistance, swimming
• build tolerance step by step - safety increases confidence

C6 radiculopathy

disc + foramina

• C5/6 NR exits intervertebral foramen
• age/posture can cause disc herniation, FJ hypertrophy, less foraminal space, local inflam, mech/chem irritation mechanical compression - less intraneural blood flow, impaired axonal transport, high sensitive nociceptive fibres - causes arm pain, p+n, weakness C6 dermatomal pattern chemical irritation - inflam mediators from disc/tissue, more sensitive NR, low pain threshold, more mechanosensitivity

C6 derm/myo + Bakody's

dermatome

• lateral forear, + thumb myotome
• wrist ext, biceps Bakody's
• shoulder abduction opens C5-6 foramen
• less tension on NR, slackens brachial plexus
• less neural irritation - Sx relief

DD median nerve entrapment + why not

mechanism

• compress MN along course, commonly at carpal tunnel
• focal demyelination, slow conduction, sensory changes/weakness, relief w/shake why not
• Sx would be thumb/index/middle
• no neck pain/Bakody's/derm patterm
• increase Sx w/gripping, wrist flex, repetitive hand use

DD facet referal + why not

mechanism

• synovial irritation, rich innervation, local nociception, refer pain shoulder/upper arm
• often due to ext based load or postural strain why not
• would be local neck pain
• no derm, p+n, thumb, Bakody's
• arm pain below elbow

DD brachial plexus irritation + why not

mechanism

• stretch/compress upper BP C5-6 trunks
• often from postural strain, load, overhead activity
• diffuse N irritation>single NR compression why not
• diffuse pain > derm, whole arm>forearm/thumb
• Bakody's would increase Sx as tensions BP

outcome measures

• VAS pain scale
• NDI - most widely used for Cx Rx
• NPRS - monitor arm and neck separately
• PSFS - laptop work, gym training, upper body exercise
• Tampa Scale Kinesiophobia TSK - address fear 'trapped nerve'
• QuickDASH - UL function, useful when Sx affect activities best 3 - NDI, PSFS, TSK

safety

• ask 5Ds and Ns, no red flags
• presentation mechanical, stable, safe to manage conservatively
• C6 derm Sx, decrease w/unload - reassuring
• no sign myelopathy/VBI
• upper body exercise safe, beneficial, keep PA comfy + monitor

fear avoidance

• validate, reframe, educate, empower
• makes sense to worry, nerve pain can be alarming
• nerves strong, not permanent damage but high sensitivity
• avoiding PA increases sensitivity, movement helps recover
• gentle controlled exercise calms nerve

adherence

• simple plan - 1 NxDx/1 posture
• short and doable 10-15mins daily
• link goal - upper body training
• demo clear, check technique to increase confidence at home
• review progress and adapt plan, maintain consistency

onward referral

not at present - Sx stable, unilateral, dermatomal, no neuro degen

• 5Ds + 3Ns
• red flag pathologies
• progressive motor weakness
• gait disturbance/hand clumsiness - myelopathy
• failure to improve w/treatment - liaise w/GP for med optimising
• consider imaging if would change management