For an adult with cervical disc disease presenting with neck pain, limited cervical range of motion and mild‑to‑moderate radiculopathy without red‑flag signs, what is the recommended physiotherapy management?

Physiotherapy for Cervical Disc Disease

For adults with cervical disc disease presenting with neck pain, limited range of motion, and mild-to-moderate radiculopathy without red flags, structured physiotherapy targeting the cervical spine, scapulothoracic region, and upper extremities should be the first-line treatment, as 75-90% of cases resolve with conservative management alone. 1, 2, 3

Initial Conservative Management Protocol

Pain Control

• Start with NSAIDs or acetaminophen as first-line analgesia for pain management 2, 3
• Consider a short course of oral corticosteroids for acute severe radicular pain if initial analgesics are insufficient 1, 2, 3

Structured Physiotherapy Program

The physiotherapy program should include:

• Neck-specific exercises with a cognitive-behavioral approach targeting the cervical spine, scapulothoracic region, and upper extremities 1, 3, 4
• Strengthening and mobility exercises for the affected regions 3
• Active modalities should be prioritized over passive modalities (heat, ultrasound, electrical stimulation), which should only serve as temporary adjuncts and be discontinued as soon as the patient can tolerate active exercises 5
• Upper thoracic spine mobilization (C7-T6 level) combined with cervical extension exercises performed with voluntary thoracic extension and elevated shoulders 6

Patient Education and Activity Modification

• Provide reassurance that 75-90% of cervical radiculopathy cases resolve with nonoperative therapy 1, 2, 3
• Encourage return to work and productive activities from the outset 5
• Teach patients to take responsibility for their own recovery through home exercise programs 5, 6
• Modify workplace habits and lifestyle factors that may contribute to symptoms 5

Expected Clinical Course and Timeline

• Most patients improve within 6-12 weeks of initiating conservative therapy 2, 3
• Approximately 30-50% may experience residual or recurrent symptoms up to 1 year 2, 3
• Imaging is not required at initial presentation in the absence of red flags, as most cases resolve spontaneously or with conservative treatment 1

Red Flags Requiring Immediate MRI and Urgent Referral

Stop conservative management and obtain immediate MRI cervical spine (without contrast) if any of the following develop:

• Progressive motor weakness not explained by pain alone 1, 2, 3
• Bilateral symptoms affecting both upper extremities or combined upper and lower extremities (suggesting myelopathy) 1, 2, 3
• New bladder or bowel dysfunction 1, 2, 3
• Loss of perineal sensation 1, 2, 3
• Gait disturbance or difficulty with fine motor tasks such as dropping objects or buttoning 1, 2, 3

When to Escalate Care

Indications for MRI After Failed Conservative Management

• Order MRI cervical spine without contrast if symptoms persist despite 6-12 weeks of adequate conservative therapy 2, 3
• MRI is the most sensitive imaging modality for soft tissue abnormalities and correctly predicts 88% of cervical radiculopathy lesions 7, 2

Surgical Referral Criteria

Consider surgical consultation if:

• Progressive motor weakness despite conservative care 1, 2, 3
• Intractable pain despite 6-12 weeks of conservative therapy 1, 2, 3
• Significant functional impairment affecting quality of life 1
• Patient preference after informed discussion of surgical versus continued nonoperative options 3

Surgical outcomes show 80-90% relief of arm pain when appropriately indicated 1, 3

Evidence Supporting Physiotherapy as First-Line Treatment

A high-quality randomized controlled trial demonstrated that structured physiotherapy alone achieved equivalent functional outcomes compared to anterior cervical decompression and fusion (ACDF) followed by physiotherapy in patients with MRI-verified nerve root compression 4. Both groups showed significant improvements in neck muscle endurance, manual dexterity, and grip strength over 24 months, with no significant differences between surgical and nonsurgical approaches 4. This supports the recommendation that structured physiotherapy should precede any decision for surgical intervention to reduce unnecessary surgeries 4.

Critical Pitfalls to Avoid

• Do not order MRI immediately based solely on clinical symptoms without red flags, as MRI has high rates of false-positive findings in asymptomatic individuals, and abnormalities correlate poorly with symptoms in patients over 30 years of age 1, 3
• Do not treat shoulder pain as a separate orthopedic problem when it follows a dermatomal pattern or worsens with neck movement, as it is often referred pain from cervical pathology 3
• Do not rely on passive modalities (heat, ultrasound, TENS) as the primary treatment; these should only be temporary adjuncts to active exercise programs and discontinued as soon as tolerable 5
• Do not continue passive treatments beyond the acute phase, as this can promote dependency and delay functional recovery 5