What therapeutic exercise program should be prescribed for a patient with cervical radiculopathy without red‑flag signs?

Therapeutic Exercise for Cervical Radiculopathy

For patients with cervical radiculopathy without red-flag signs, prescribe a multimodal exercise program consisting of deep neck flexor strengthening, scapulothoracic muscle strengthening, and McKenzie cervical retraction exercises, combined with manual therapy and cervical traction. 1, 2

Core Exercise Components

The evidence supports a specific combination of exercises rather than any single approach:

Deep Neck Flexor Strengthening

• Target the deep cervical flexor muscles specifically, as these stabilize the cervical spine and reduce nerve root compression 1
• This addresses the underlying mechanical dysfunction contributing to radiculopathy 1

Scapulothoracic Muscle Strengthening

• Include scapular retraction exercises with postural correction, as scapular positioning directly affects cervical nerve root tension 1, 2
• These exercises improve upper quarter mechanics and reduce radicular symptoms 2

McKenzie Cervical Retraction Exercises

• Prescribe cervical retraction exercises to promote symptom centralization, which predicts favorable outcomes 2
• While not supported in isolation, these exercises show promise when integrated into the multimodal approach 2
• The goal is to move peripheral arm symptoms proximally toward the neck, indicating decompression 2

Additional Therapeutic Interventions

Manual Physical Therapy

• Combine exercises with thoracic manipulation and cervical mobilizations, as manual therapy addresses joint restrictions that perpetuate nerve root irritation 1, 2
• Rib mobilizations may be necessary when thoracic restrictions contribute to cervical dysfunction 2

Cervical Traction

• Incorporate intermittent cervical traction to temporarily decompress the neural foramen 1, 3
• This provides symptomatic relief while strengthening exercises address the underlying dysfunction 1

Peripheral Nerve Mobilization

• Add nerve gliding techniques to reduce neural adhesions and improve nerve mobility 2
• This is particularly important when radicular symptoms persist despite mechanical improvements 2

Treatment Frequency and Duration

• Plan for approximately 7 visits over 4-6 weeks with emphasis on patient education and home exercise independence 1, 2
• Most patients (75-90%) achieve symptomatic relief with conservative therapy 4, 5
• Reassess at 4-6 weeks to determine if symptoms are resolving or if escalation of care is needed 6

Expected Outcomes

Based on high-quality evidence, 91% of patients demonstrate clinically meaningful improvement in pain and function with this multimodal exercise approach 1. The prognosis is favorable, with most cases being self-limiting 4, 3.

Critical Pitfalls to Avoid

• Do not prescribe exercises in isolation—the evidence consistently shows that multimodal approaches combining strengthening, manual therapy, and traction are superior to single interventions 1, 5, 3, 7
• Do not delay treatment waiting for imaging in the absence of red flags, as imaging findings correlate poorly with symptoms and most patients improve with conservative care 6, 4
• Monitor for red flags requiring urgent evaluation: progressive motor weakness, bilateral symptoms suggesting myelopathy, new bladder/bowel dysfunction, or symptoms affecting both upper and lower extremities 4
• Avoid prolonged cervical collar use—collars should only be used for short periods of immobilization, as extended use promotes deconditioning 3

Evidence Quality Note

The recommendation is based on Level I-II evidence with PEDro scores ranging from 5-8, indicating high-quality research supporting this multimodal exercise approach 7. While individual treatment components show variable effectiveness when studied in isolation, the combined approach demonstrates consistent benefit across multiple studies 1, 5, 3, 7.