What Works
Tier 1 — Strong Evidence
Multimodal Exercise: Directional Preference + Segmental Stabilization HIGH
The McKenzie directional preference approach identifies which spinal movements centralize your symptoms — and programs those specific movements as your core exercise. Combined with deep cervical flexor or lumbar multifidus stabilization training, this is the highest-yield combination in the literature. Every other intervention works best as an adjunct to this foundation.
Cervical Retraction ("Head Nod Back")
Sit or stand. Glide your head straight backward — not tilting — as if making a double chin. Hold 1-2 seconds.
Deep Cervical Flexor Hold
Lying on your back. Make the smallest possible chin nod — you should feel deep effort at the front of your throat, not neck tension.
Prone Press-Up (Lumbar directional preference)
Face down, hands under shoulders like a push-up. Press upper body up, hips stay on the floor.
Tier 1 — Strong Evidence
Neural Mobilization — Sliders and Tensioners HIGH
Nerve slider exercises mobilize the neural tract by moving two joints in the same neural direction simultaneously. This reduces intraneural swelling, improves the nerve's ability to glide through surrounding tissue, and dramatically reduces mechanosensitivity. Transition from sliders to tensioners as irritability reduces — typically at 2-3 weeks.
Upper Limb Neural Slider (Cervical)
Seated. Place hand behind head. Gently tilt head away from the painful side while slowly straightening the elbow. Hold 1-2 seconds, return slowly.
Tier 2 — Moderate Evidence: Manual Therapy
Manual Therapy — Mobilization / Manipulation MODERATE
Non-thrust cervical/lumbar mobilization (Maitland grades III-IV) provides meaningful short-term pain relief and facilitates active movement. Best used as a facilitator for exercise, not a standalone treatment. Thrust manipulation should be used cautiously for cervical radiculopathy given the pre-screen requirements. Statistically equivalent to sham MT at long-term follow-up in some high-quality trials — its value is in the early phase where pain limits exercise engagement.
Dosing: 4-6 sessions combined with exercise. Not indicated as a sole treatment approach.
Tier 3 — Small Evidence: Mechanical Traction
Intermittent Mechanical Traction EMERGING
Cervical intermittent traction combined with exercise shows improved outcomes over exercise alone in chronic cervical radiculopathy. Benefit is small and disappears when traction is used as a standalone passive modality. Lumbar traction evidence is weaker. Use only as an adjunct in patients who are not responding to exercise alone after 3-4 weeks.
Dosing: 10-20 minutes at 10-15% body weight, 3×/week, always combined with exercise.
What Doesn't Work
- Strict bed rest and prolonged collar use: Causes muscle atrophy, fear-avoidance, and psychological deconditioning. Collars are useful only for acute pain modulation in the first 48-72 hours — not as a treatment strategy.
- Passive modalities in isolation (TENS, ultrasound, massage as standalone): No long-term structural benefit. May reduce pain briefly but don't address neural mechanosensitivity or motor control deficit.
- Traction as a standalone treatment: Short-term benefit disappears rapidly when exercise is not included. Don't use it without active exercise.
Exercise Prescription
The exercise cards above contain the full prescription. Core principle: pain-guided centralization. Any exercise that moves symptoms toward the spine = green light. Any exercise that sends symptoms further into the arm or leg = stop immediately.