Cx 1 - Mrs Green

chronic neck pain and stiffness

most likely clinical pres

mechanical age related Cx spondylosis + postural loading

differential diagnoses

• upper Tx dysfunction

• myofascial pain

• cervicogenic headache

assessment technique + why

Cx AROM + Tx ext

• primary limitation
• Sx mechanical, chronic, non-Rx, postural contributor
• no neuro signs
• gives SINS info

assessment technique results

expect

• rot moderately less, pain/stiff at end
• ext reduced, upper Cx hinge
• side flex reduced
• flexion intact
• movement - guarding, trunk compensation in rot, fearful behaviour
• Tx ext - reduced, kyphosis apparent
• retest w/Tx ext - increase rot, decreased Sx/pain, supports mechanical/postural diagnosis

assessment technique performance

• Ax global Cx AROM - flex, ext, rot L/R, side flex L/R
• observe range (less, symmetry), pain location, end range, movement quality, fear avoidance behaviour
• Tx ext - repeat rot, sit tall, function (check blind spot), observe trunk movement

assessment supports/refutes

supports WD - mech neck pain, age, posture, no Rx refutes DDs

• upper Tx dysfunction - if Cx rot limited even w/Tx ext, pain diffuse ache>sharp
• myofascial pain - global stiffness>direction specific, rot symmetry, end block>stretch
• cervicogenic headache - no reproduction head pain, Sx local Cx/Tx

management - education

postural re-edu - sit tall, head back so ears inline w/shoulders, chin tuck>look down, roll shoulders back/down, avoid long slump sit, change position regularly, move every 30-60mins key messages - not 'worn out', age changes normal, imaging does not equal pain, wrinkles on inside

• move/PA safest + most effective treatment, less stiff, work together to increase confidence

management - education cont.

fear avoidance - safe to move, no nerve compression/SC pressure/red flags, start gentle + build

• AROM work so pt in control Mulligan SNAG - towel tucked in Cx/Tx level, hold one side down tight, pull other side down + rot away

management - pharmacological

NICE on NS neck pain

• oral analgesics eg ibuprofen, paracetamol, codeine
• topical NSAID
• consider severity of pain, personal preference, tolerability, adverse effects
• consider psychological therapy
• consider referral to pain clinic >12 weeks

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 + multiple SRs

• reassurance + activity more effective than rest for chronic mechanical neck pain
• fear avoidance linked to disability, decrease it to increase outcomes
• favour education + reassurance, exercise + self management, manual therapy adjuncts
• advise firm pillow, normal activities

management - exercise 1 justification

Cx ROM - Mulligan SNAGs

• sustained natural apophyseal glides
• main limitation turning head
• SNAGs combine therapist applied glide w/pt active movement, often producing immediate improvement in rom

Mulligan SNAGs demo + dose

demo

• pt sit up, stand behind them
• use thumb/hypothenar eminence over SP restricted level
• apply sustained glide in plane of FJ
• pt actively rot to restricted side
• return to neutral + release
• PILL - pain free, immediately increase, long lasting benefit dose - 6-10x2-3, hold end 2-3secs, reassess rot immediately after

Mulligan SNAGs pro/regression

regression

• less rom
• gentle oscillatory SNAG
• perform in supported sit
• use Tx if Cx too irritable progression
• more rom
• add overpressure
• teach self-SNAG
• progress to functional eg checking blind spot quickly

Mulligan SNAG evidence

Elkomy et al 2025 - single trial Barbosa de Silva et al 2025 - SR+MA, 33 studies

• superior outcomes when combined w/other interventions esp chronic

management - exercise 2 justification

postural - Tx extension

• decrease mechanical load on Cx spine + increase mobility

Tx extension demo + dose

demo

• sit tall in chair
• back of chair below shoulder blades
• support head w/hands, lean back dose
• 2x10 daily, slow, control

Tx extension pro/regression

regression

• less rom
• hands fully support head progression
• foam roller increase extension
• add rotation at end range

Tx extension evidence

Blanpied et al 2017

• Cx mobility exercises decrease pain, increase rom + function in mechanical neck pain literature
• education/exercise > passive treatments
• Tx ext increases Cx rot and decreases forward head posture + pain
• forward head posture increases load on Cx FJ and reduces rot
• postural re-education decreases pain and increases function

exercise evidence

NICE on NSNP

• advice + education, reassurance
• stretch/strengthen/rom exercises, manual therapy
• yoga, tai chi, qigong
• neck exercises available for sites eg CSP, Versus Arthritis

goal relevance of education/exercise

independent driving

• increased rotation helps check blind spot
• better posture + movement - less Sx, more function at any age changes work at every age
• increase education and motivation to exercise
• increase confidence to return to independent tasks

Cx spondylosis + degenerative changes

disc degen - initiating process

• age, dehydrate, less height/shock absorption, more load FJ, instability in segments - earliest change in spondylosis FJA - pain generation
• cartilage thins, capsule thickens, synovial irritation, osteophytes
• highly innervated, produce mech pain esp rot/ext/combo osteophytes - stabilise
• increases stiffness, can initiate pain, sensitive structures

Cx spondylosis C5/6

• most common degen level for age related spondylosis + FJA
• highest mechanical load due to posture, hinge point
• movement pattern matches Sx (rot, ext, combo)
• posture matches level, forward head increases load lower Cx/upper Tx
• Sx mechanical - often stiff, ache, less rot, pain ext, upper Tx ache

postural loading and presentation

forward head - compress load lower Cx facets esp C5-6

• more upper Cx ext - suboccipital tightness
• less mid Cx flex - chronic stiffness and less rot
• Tx kyphosis - less Tx ext, Cx compensate, less Cx rot Sx - chronic stiff - facet capsule thick and less disc height
• upper Tx ache - compensatory loading at cervicothoracic junction

DD upper Tx dysfunction + why not

mechanism

• local J restriction/irritation FJ due to posture/stiffness
• produces segmental mechanical pain why not
• pain sharper and more local/unilateral
• reproduce pain w/movement
• may increase/decrease w/Tx posture changes

DD myofascial pain + why not

mechanism

• trigger points Cx/scapula muscles from overload/stress/posture
• pain in referred pattern why not
• pain direction specific
• trigger points Sx on palpation
• rom painful>stiff
• may refer pain to temporal region or shoulder

DD radiculopathy + why not

mechanism

• nerve root compression from disc herniation/foraminal narrowing/osteophytes
• age degen, disc degen, neuroforaminal narrow, compression why not
• derm/myo Sx
• arm pain/p+n/numb
• increase Sx w/Spurling's test or cough

DD myelopathy + why not

mechanism

• compress SC from stenosis
• lig flavum thickens
• osteophytes
• UMN signs why not
• reduced balance
• gait disturbance
• hand clumsiness
• bilateral Sx
• b/b changes
• sensory deficits

outcome measures

• VAS pain scale
• Neck Disability Index NDI - neck equiv ODI, gold standard neck
• NPRS
• PSFS - check blind spot, reversing car, independent travel
• Cx AROM - goniometer, useful due to reduced rot
• Fear Avoidance Beliefs Questionnaire FABQ - address drive av best 3 - NDI, PSFS, Cx ROM

safety

• ask 5Ds+3Ns
• no neuro Sx or red flags
• presentation mechanical, stable, safe to manage conservatively
• pain chronic, predictable, posture related - typical mech spond
• no signs NR compression/danger
• age related stiffness responds well to movement

fear avoidance

• makes sense to worry as stiffness can feel restricting/confined
• 'worn out' changes normal, wrinkles inside
• 'exercise wont help' evidence strong that exercise will help neck pain at any age
• avoiding PA increases stiffness, gentle PA increases strength + rom
• less catastrophising, more confidence, support return to meaningful activity
• more rot - confidence to drive independently

adherence

• plan must show practical strategies to help stick to program
• exercises meaningful - driving
• simple 2-3 exercises, low time burden 10-15min daily
• clear instructions, demo, check technique
• pacing, encourage gentle movement
• follow up - arrange review to alter plan and encourage

onward referal

not at present - Sx chronic, mechanical, stable, no neuro - safe to conservatively manage

• 5Ds+3Ns
• neuro signs/red flags
• if conservative management fails/pain unresponsive to treatment liaise w/GP for med optimising
• consider imaging if would change management