cervical radiculopathy is caused by the compression of the cervical nerves or nerve 
 roots1 . a herniated intervertebral disc , 

the common 
 symptoms of cervical radiculopathy involve pain , muscle weakness spreading into the neck and 
 upper extremities , loss of sensation2 , and 
 proprioception deficits3 .
although the 
 symptoms experienced by patients with cervical radiculopathy vary , the symptoms generally 
 appear at certain regions and with specific characteristics depending on the level of nerve 
 compression .
the treatment options for cervical radiculopathy can be divided into surgical and 
 conventional treatments , both of which aim to reduce pain and symptoms , increase nerve 
 function , and prevent recurrence of cervical radiculopathy .
no study with a high level of 
 evidence has proved that surgical intervention alone for cervical radiculopathy is 
 effective4 .
surgical interventions are 
 often combined with conventional nonsurgical treatments , such as medications , use of a 
 cervical collar , cervical traction , and manual therapy .
these conventional treatments , 
 however , have not been proven effective by studies with a high level of evidence either5 , 6 . among the methods used for pain and symptom relief in cervical radiculopathy ,
however , no systematic 
 review has been made summarizing the effects of the exercise training on cervical 
 radiculopathy , either as an alternative to surgery or as a post - operative treatment option . 

the present study searched the literature to determine the treatment effects of exercise 
 interventions for patients with cervical radiculopathy after receiving nonsurgical or 
 surgical treatments .
studies from january 1997 to may 2014 found on four online databases ( i.e. , medline , 
 cinahl , scopus and pubmed ) were searched using the following key words : ( a ) cervical 
 radiculopathy or cervical spondylotic radiculopathy ; ( b ) exercise training or physiotherapy . 

the selection criterion was that the exercise programs used to treat the radiculopathy must 
 be detailed in the articles .
review articles or studies involving patients with the whiplash 
 syndrome or low back disorders were excluded .
individual assessors were assigned and 
 conducted the literature search of each of the databases using the search terms listed 
 above .
all of the identified relevant articles were then collectively presented to one of 
 the authors who then determined their eligibility and inclusion for further analysis .
the quality of the identified studies was assessed using the physiotherapy evidence 
 database ( pedro ) scale , a scale that is used to assess the strength of the evidence in 
 therapeutic research .
the pedro scale consists of 11 items and has been shown to be reliable 
 and valid9 .
the total score of the pedro 
 scale ranges from 0 to 10 points , and studies with high , medium , and low quality are 
 accredited 610 points , 45 points , and 03 points , respectively .
the levels of evidence of 
 the identified studies were evaluated using the oxford centre for evidence - based medicine 
 ( ocebm ) levels of evidence . based on the definition of ocebm
, studies are classified as 
 levels 1 to 5 according to the research design structure and the highest evidence level 
 ( level 1 ) is given to systematic literature reviews of randomized controlled trials 
 ( rcts ) .
the therapeutic effectiveness and outcomes of the identified studies were classified based 
 on the three major components of the international classification of functioning , disability 
 and health ( icf ) model : ( 1 ) body function and structure , including the numeric pain rating 
 scale ( nprs ) , visual analogue scale ( vas ) , craniovertebral angle , peak - to - peak amplitude of 
 dermatomal somatosensory evoked potentials ( dsep ) as an assessment of nerve root function , 
 pain location chart , global rating of change scale ( groc ) , grip strength , active range of 
 motion ( arom ) , neck endurance , manual dexterity , and arm elevation during neck extension ; 
 ( 2 ) activity and participation , including the neck disability index ( ndi ) , patient - specic 
 functional scale ( psfs ) , coping strategies questionnaire , and disability index rating ( dir ) ; 
 and ( 3 ) personal factors , including the mood adjective check list , hospital anxiety and 
 depression scale , patient satisfaction , and fear - avoidance beliefs questionnaire ( fabq ) .
eleven studies that met our search terms and inclusion criteria were examined in this study 
 ( fig . 1fig .
all the studies were categorized as 
 ocebm levels 1 and 2 , indicating a high level of evidence .
table 1table 1.pedro and oxford centre for evidence - based medicine levels of evidence of the 
 included articlesarticlepedrolevels of evidence * 1234567891011totalexercise interventiondiab , 201210111100011117ifritz , 201411111100111118iijoghataei , 200412110100110116ikuijper , 200913111100010116inar , 201414110100011116iyoung , 200915111100111118ipost - surgical exercise interventionengquist , 201316111100000115iipeolsson , 201317111100100116iisurgery vs. exercise interventionpersson , 199718111100011117ipersson , 200119111100011117ipersson ,
199820111100011117i provides quality assessments of the 11 studies according to the pedro scale . 
 because exercise was employed as the main intervention , the practice of blinding the 
 research participants and surveying personnel was impractical ; consequently , no scores were 
 obtained for questions 5 and 6 of the pedro assessment .
nevertheless , most of the studies 
 scored 6 to 8 points and thus were categorized as high - quality studies .
flowchart of the selection of articles in the six studies10 , 11 , 12 , 13 , 14 , 15 of non - surgical exercise interventions , not all the 
 participants were diagnosed as having cervical radiculopathy using the magnetic resonance 
 imaging ( mri ) or computed tomography ( table 
 2table 2.summary of the six studies involving exercise intervention without surgical 
 treatmentsstudy designbasic dataintervention(s)outcomes measure & follow - upoutcomediab et al .
201210rct2 groupsn : 96 age : 46.1mri : no mentioncontrol group ( 48)ultrasound and 
 infraredexercise group ( 48)4 times / week for 10 weeksexercise , 
 ultrasound , and infraredposture corrective exercise program strengthening 
 ( 12rep*3set ) : deep cervical flexors , shoulder retractors stretching ( 30s*3set ) : 
 cervical extensors , pectoral musclespeak - to - peak amplitude of dermatomal somatosensory 
 evoked potentials , craniovertebral angle , vasfollow up : 10-week , 6-month10-week , 6-month : signicant difference between the 
 exercise & control groups adjusted to baseline value of outcome for all 
 measured variablesfritzet al.201411rct3 groupsn:86age : 46.9neck/ arm pain : 4.22.1/4.32.4dosage : 3 times / week , 2 weeks 2 times / week , 2 
 weeksexercise group ( 28)1 .
scapular - strengthening exercisesmechanical traction+exercise group 
 ( 31)supine , 15 minutes , 5.44 kgover - door traction group 
 ( 27)sit , 15 minutes , 3.639.07 kgndi , nprs ( neck , arm ) , patients self - reported global 
 rating of change from beginning of treatment to presentfollow up : 4-week , 6-month , 
 12-monthmechanical traction+exercise group v.s .
exercise 
 group: lower disability and pain in mechanical traction+exercise group no 
 significance for ndi , nprsjoghataeiet al.200412rct2 groupsn : 30age : 47mridosage : 3 times / week , 10 physical therapy 
 sessionscontrol group ( 15)electrotherapy/ exercise 
 treatmentexercise : isometric strengthening neck exercise8 seconds for 25 
 repetitions each ( twice a day ) , dailyexperimental group ( 15)cervical 
 traction and electrotherapy / exercise treatmentgrip strengthfollow up:5th sessions , 10th 
 sessions5th sessions : greater change of grip strength in 
 experimental group10th sessions: significant increase in grip strength compared 
 with pretreatment no significant difference between groupskuijperet al.200913rct3 groupsn:205age : 47.1mri:1 . diagnosis by doctor2 . no 
 mentionneck/ arm pain : 6.22.8/7.21.9semi - hard collar group ( 69)36 
 weeksphysiotherapy & home exercises group ( 70)mobilizing and 
 stabilizing the cervical spinetwice a week for 6 weekscontrol group 
 ( 66)continuation of daily activities as much aspossible without specific 
 treatmentvas ( neck , arm ) , ndi , treatment , satisfaction , work 
 statusfollow up : 3-week , 6-week , and 6-month3-week and 6-week : reduced neck and arm pain in 
 semi - hard cervical collar group and physiotherapy & home exercises 
 group6-month: no or limited pain no significant differences for other 
 measurementsnar,201414rct ( the description of rct is not clear.)2 
 groupsn:30age : 44.5mri:1 . diagnosis by doctor2 .
no 
 mentionneck pain : 7.1 + 1.0once daily , 10 days , 6 days / weekcontrol group 
 ( 15)1 .
isometric neck exercises for flexion , extension , side flexion and 
 rotation with manual resistance .
sitting position , 10 repetitions , 6 seconds 
 hold.experimental group ( 15)ict , ift , isometric neck exercises & 
 neural mobilizationvasfollow - up : no significancepain decreased significantly for both groupsgreater 
 change of pain in the experimental groupyounget al.200915rct2 groupsn:81age : 47.1diagnosis by ptneck pain : 6.51.7dosage : 4.2 weeksmtex traction group 
 ( 45)manual therapy , exercise , & intermittent cervical 
 tractionmtex group ( 36)manual therapy , exercise , & sham 
 intermittent cervical tractionexercise1 .
scapular strengtheningnprs , psfs , ndi.fabq , groc , patient satisfaction , grip 
 strengthfollow up : 2-week , 4-weekno signicant differences between groups ) .
the duration of exercise interventions ranged from 10 days to 10 weeks , 
 while the exact time of each intervention session was not clearly defined .
the exercise 
 intervention items incorporated strength training ( eg , isometric exercises of the deep 
 cervical flexor muscles , shoulder retraction muscles , and scapular muscles ) and stretching 
 exercises ( stretches for the neck and chest muscles ) .
the outcome measures primarily focused 
 on pain ( vas or nprs ) and disability ( ndi ) .
the results of these six studies indicate that 
 patients in the exercise groups exhibited alleviated pain and reduced levels of disability . 

a significantly increased peak - to - peak amplitude of dsep , elevated grip strength , and 
 improved craniovertebral angle to lessen the forward head posture ( fhp ) were also 
 reported . among the five studies that involved a surgical control group , two studies16 ,
17 
 were published by the same research group and had identical participants ( table 3table 3.summary of the two studies with post - surgical exercise interventionreferencesstudy designbasic dataintervention(s)outcomes measure & follow - upoutcomeengquistet al .
medical exercise(1 ) 
 neck stabilization and endurance(2 ) strengthening of the scapular muscles(3 ) 
 stretching of neck and shoulder muscles(4 ) thoracic mobilization ( all performed 
 with postural correction)2 .
education(1 ) pain management was conducted by 1 
 time / week for the rst 14 weeks(2 ) physiology of pain , stress , exercise , breathing 
 technique , coping , pacing , and ergonomicsacdf+postoperative exercise group 
 ( 31)ndi , vas ( neck , arm)signicant reduction in ndi , neck pain , & arm pain 
 compared with baseline for both groupsgreater reduction of neck pain intensity in 
 acdf+postoperative exercise group at 6-month & 12-monthno signicant 
 between - group difference for arm pain intensity & ndipeolssonet al .
201317as aboveas aboveas abovearom , neck muscle endurance , hand strength , manual 
 dexterity , arm elevation during neck extensionfollow up : 6-month , 1-year , 
 2-yearno signicant differences between the two 
 treatmentsboth groups showed improvements over time in neck muscle endurance , 
 manual dexterity , and right - hand grip strength ) . after being diagnosed as having cervical radiculopathy by mri , the 
 participants in these two studies received exercise treatments that continued for 3 months 
 after surgery .
the protocols involved in the post - surgical exercise interventions were 
 similar to those in the nonsurgical exercise interventions , with nursing education 
 additionally incorporated .
the outcome measurements were pain , disability , range of motion 
 of the cervical joint , muscular endurance , and hand dexterity . compared with patients in an 
 exercise - only group ,
the patients who received post - surgical exercise interventions 
 experienced favorable improvements in terms of neck pain at the initial stage of the 
 post - surgical exercise intervention .
however , no significant difference was observed between 
 the two groups at the 2  year follow - up testing . regarding neck disability ,
no significant 
 difference was observed between the exercise and control groups before and after the 
 patients received treatments . while no significant differences in cervical joint angle and 
 neck muscular endurance were found between the two groups , both groups demonstrated a 
 post - treatment increase in neck muscle endurance .
the other three studies with surgical control groups18,19,20 compared the outcomes between the surgical and exercise treatments , 
 and they were also published by the same research group ( table 4table 4.summary of the three studies that involved a comparison between surgery and 
 exercise interventionreferencesstudy designbasic dataintervention(s)outcomes measure & follow - upoutcomeperssonet al .
199718rct4 groupsn : 81 + 30age : 47.5mri , ctsurgical decompression with fusion group 
 ( 27)exercise group ( 27)1 . neck and shoulder stretching2 . flexibility 
 exercises3 .
tens , 
 heat3045 minutes / time , 15 times/3 monthsneck collar ( 27)daytime for 
 3 monthscontrol ( 30)vas , hand grip strength , pinch strengthfollow 
 up:3-month and 12-month post treatment3-month : greater improvement of pain intensity , muscle 
 weakness and sensory loss in surgery group12-month : no significant differences 
 between surgical and conservative therapy groupsperssonet al .
200119rct3 groupsn:81age : 47.5mri , ctneck pain : 5.02.1surgical decompression with fusion group 
 ( 27)exercise group ( 27)neck collar ( 27)mood adjective check list , hospital anxiety and 
 depression scale , coping strategies questionnaire , vas , disability index rating 
 ( dir)follow up:3-month and 12-month post treatmentgreater improvement of pain in surgery group but no 
 differences after one yeargreater improvement in the surgery and exercise groups 
 than in collar group after 3 monthsperssonet al .
199820rct4 groupsn : 81 + 30age : 47.5mri , ctsurgical decompression with fusion group 
 ( 27)exercise group ( 27)neck collar ( 27)control ( 30)vas , muscle tenderness , shoulder motion , neck 
 romfollow up:3-month and 12-month post treatmentlower pain intensity in surgery and exercise groups 
 than in collar grouplower muscle tenderness in surgery group than in exercise and 
 collar groupsgreater improvement of shoulder motion insurgery group than in collar 
 groupsignificantly greater neck rom in exercise group than in collar group at 
 pre - treatment and 3-month post treatment but no difference at 12-month ) . the participants were all recruited after being diagnosed as having cervical 
 radiculopathy by mri . unlike the exercise interventions employed in the studies mentioned 
 above , aerobic exercise was performed in these studies .
outcome measurements included pain 
 and disability as well as a questionnaire for assessing physical function and psychological 
 state .
at the initial stage , surgical treatment showed a favorable effect in terms of the 
 neck pain ; however , no significant difference was observed between the two groups at 1  year 
 follow - up .
no differences were observed between the two types of treatment regarding 
 improvements in the cervical joint angle , range of motion of the shoulder joint , or 
 anxiety .
our systematic review indicates that exercises for patients with cervical radiculopathy 
 primarily incorporated strength training and stretching of the neck muscles .
exercise 
 intensity ranged from twice per week to once per day , with intervention periods lasting from 
 10 days to 10 weeks .
strength 
 training of the neck and chest can increase the proprioception of patients and promote 
 muscle strength balance around the neck , thereby potentially reducing pain , strengthening 
 body function , and preventing recurring injury21 .
cervical radiculopathy is frequently associated with inactivity 
 and thus the aerobic capacity of patients may decrease rapidly and their deconditioned state 
 may prevent them from participating in strength training22 .
consequently , aerobic exercise training should be considered as 
 one of the exercise programs for patients with cervical radiculopathy .
neck stretching 
 exercises can maintain the active range of motion and normal function of the neck , avoiding 
 scarring , adhesion , and repetitive micro - trauma of the neck5 .
based on the results of the 11 studies , it is our conclusion that the overall effect of 
 exercise interventions is two - fold : ( 1 ) improving body structure and function : pain 
 reduction , fhp reduction , increase of peak - to - peak amplitude of dsep , and enhanced grip 
 strength , neck muscle endurance , and manual dexterity ; ( 2 ) facilitating activity and social 
 participation : decreased neck disability and improved patient self - care ability for daily 
 life .
the primary difference between the effects of the surgical and exercise treatments or 
 between those of the post - surgical exercise and exercise - only treatments pertained to pain , 
 especially within the first year of receiving the interventions as no significant 
 differences were reported between the two approaches after one year . in previous studies , 

although short - term pain was reduced 
 substantially in the control group , no evident improvement was shown in fhp . however ,
both 
 pain and fhp significantly improved in the exercise group , which was accredited to the 
 amelioration of muscle balance following exercise training .
the increased peak - to - peak 
 amplitude of the dsep suggests that exercise interventions may improve the function of 
 patients nervous systems10 .
many of the 11 reviewed studies of exercise interventions also included other auxiliary 
 physical treatments .
the primary purpose 
 of the auxiliary physical treatments was to relieve pain , which may have influenced the 
 treatment effect of the exercise interventions .
the baseline conditions of the patients in 
 each study differed , such as the intensity of pain ( tables 24 ) .
in addition , not all 
 diagnoses of cervical radiculopathy were confirmed by mri , and the therapeutic doses varied 
 substantially .
these factors might have influenced the treatment efficacy and by extension , 
 the validity of the results of meta - analysis .
first , three studies exclusively 
 comparing outcomes between surgical and physical treatments18,19,20 were from the same research group ( hereinafter referred to as the 
 first research group ) , and the participants in these studies possibly overlapped . in 
 addition , two studies that compared exercise - only treatment and post - surgical exercise 
 treatment16 , 17 were also conducted by the same research group with identical 
 participants ( hereinafter referred to as the second research group ) . because the first 
 research group provided vas data at different stages and the second research group showed 
 vas data as changes between the pre- and post - treatment periods , making direct comparison 
 and meta - analysis impossible . regarding the range of motion of the cervical spine , the first 
 research group considered the sum of the angles in three orthogonal planes , whereas the 
 second research group provided separate angle data for each plane
; consequently , direct 
 comparison and meta - analysis were not possible in this instance .
second , the first research 
 group indicated that no exercise treatments was performed by the patients within 3 months of 
 receiving surgical treatment , but it was not clearly stated whether exercise through 
 self - participation or other methods was prohibited within this 3-month period .
therefore , 
 the results obtained at 1  year after surgery may not be treated as the exclusive effects of 
 the surgical intervention .
third , thus far , patients receiving post - surgical exercise 
 treatment have only been followed for up to 2 years16 , 17.thus , the long - term effect 
 of exercise treatment beyond 2  years remains unknown .
fourth , these studies did not detail 
 or classify the severity of the nerve root compression experienced by the patients ; 
 therefore , the variation in the baseline conditions among the participants may also have 
 influenced treatment effects .
our systematic review of eleven randomized controlled trial studies indicates that 
 nonsurgical treatments were mostly combined with multiple treatment patterns and that few 
 studies investigated the effects of post - surgical exercise treatment .
the exercise 
 treatments for cervical radiculopathy involved deep cervical flexor muscle training , posture 
 correction , and muscle stretching .
it appears that exercise treatment can improve body 
 structure and function , as well as the activity participation of the patients . however , 
 these studies were not focused on assessing personal factors and the environment .
future 
 studies are warranted in order to incorporate the icf model in the assessment , and to yield 
 more evidence capable of verifying that post - surgical exercise interventions are beneficial 
 for patients with radiculopathy .
 [ purpose ] cervical radiculopathy is a clinical condition associated with pain , numbness 
 and/or muscle weaknesses of the upper extremities due to a compression or irritation of 
 the cervical nerve roots . 
 it is usually managed conservatively but surgical intervention 
 is sometimes required for those who fail to respond adequately . 
 this study performed a 
 literature review to determine the effects of exercise on non - operative and post - operative 
 cervical radiculopathy patients . 
 [ methods ] the pubmed , medline , cinahl and scopus 
 databases were searched to identify relevant articles published from january 1997 to may 
 2014 , which explicitly stated that an exercise program was employed as an intervention for 
 cervical radiculopathy . the therapeutic effectiveness and outcomes 
 were then classified 
 based on the international classification of functioning , disability and health ( icf ) 
 model . 
 [ results ] eleven studies were identified and included in the final analysis . in 
 these studies , 
 the main forms of exercise training were specific strengthening and general 
 stretching exercises . 
 levels of evidence were graded as either i or ii for all studies 
 according to the oxford centre for evidence - based medicine . the pedro scale score of these 
 studies ranged from 5 to 8 . [ conclusion ] a review of eleven high - level evidence and 
 high - quality studies revealed that , based on the icf model , exercise training is 
 beneficial for improving the body function as well as activity participation of cervical 
 radiculopathy patients . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION