Ortho I Cervical Article Review

Describes the physical impairment measures that should be used in the examination of neck pain and the association classification.

a. Range of Motion (ROM): Measure cervical spine flexion, extension, rotation, and lateral flexion.

b. Strength Testing: Assess muscle strength of cervical and upper thoracic musculature.

c. Pain Assessment: Utilize scales like the Visual Analog Scale (VAS) to quantify pain intensity.

d. Functional Tests:*Conduct tests like the Neck Disability Index (NDI) to evaluate the impact of neck pain on daily activities.

Review the intervention recommendations specific to the 4 classifications of neck pain and appreciate the differences between acute/subacute/chronic pain interventions:

Acute Pain: Focus on reducing pain and preventing chronicity through manual therapy, therapeutic exercises, and education.

Subacute Pain: Emphasize restoration of function through continued manual therapy, exercises, and possibly modalities like heat.

Chronic Pain: Address psychosocial factors, use more intensive and prolonged exercise programs, and consider cognitive-behavioral therapy.

Radicular Pain: Utilize traction, nerve mobilization techniques, and specific exercises to alleviate nerve root compression.

Level I Evidence for Intervention/Prevention

High-quality Systematic Review with consistent findings from multiple high-quality primary sources

Level I Evidence for Pathoanatomic/Risk/Prognosis/Diagnosis

Systematic Review of prospective cohort studies, high-quality prospective cohort study

Level I Evidence for Diagnosis/Diagnostic Accuracy

Systematic Review of high-quality diagnostic studies, high-quality diagnostic study with validation

Level I Evidence for Prevalence of Condition/Disorder

Systematic Review or high-quality cross-sectional studies

Level I Evidence for Exam/Outcomes

Systematic Review of prospective cohort studies, high-quality prospective cohort study

Level II Evidence for Intervention/Prevention

High or acceptable-quality SR, consistent findings from at least one high-quality large RCT or multiple small RCTs

Level II Evidence for Pathoanatomic/Risk/Prognosis/Diagnosis

SR of retrospective cohort studies, lower-quality prospective cohort study, high-quality retrospective cohort study

Level II Evidence for Diagnosis/Diagnostic Accuracy

SR of exploratory diagnostic studies or consecutive cohort studies, high-quality exploratory diagnostic studies

Level II Evidence for Prevalence of Condition/Disorder

SR allowing relevant estimates, lower-quality cross-sectional study

Level II Evidence for Exam/Outcomes

SR of lower-quality prospective cohort studies, lower-quality prospective cohort study

Level III Evidence for Intervention/Prevention

High or acceptable-quality SR with moderate primary sources, consistent findings from one high-quality RCT or multiple moderate-quality RCTs

Level III Evidence for Pathoanatomic/Risk/Prognosis/Diagnosis

Lower-quality retrospective cohort study, high-quality cross-sectional study, case-control study

Level III Evidence for Diagnosis/Diagnostic Accuracy

Lower-quality exploratory diagnostic studies, nonconsecutive retrospective cohort

Level III Evidence for Prevalence of Condition/Disorder

Local nonrandom study, high-quality cross-sectional study

What type of study corresponds to Level IV evidence for Intervention/Prevention?

High or acceptable-quality SR with a trend, inconsistent findings from case-control/retrospective studies, consensus statements

What type of study corresponds to Level IV evidence for Pathoanatomic/Risk/Prognosis/Diagnosis?

Case series

What type of study corresponds to Level IV evidence for Diagnosis/Diagnostic Accuracy?

Case-control study

What type of study corresponds to Level IV evidence for Prevalence of Condition/Disorder?

Lower-quality cross-sectional study

What does Level V evidence indicate for Intervention/Prevention?

Low-rated SR with very low confidence, case series, expert opinion, physiology, bench research, or theoretical constructs

What type of evidence is associated with Pathoanatomic/Risk/Prognosis/Diagnosis in Level V?

Individual expert opinion

What type of evidence is linked to Diagnosis/Diagnostic Accuracy in Level V?

Individual expert opinion

What type of evidence is considered for Prevalence of Condition/Disorder in Level V?

Individual expert opinion

Grades of Recommendation

Grade A: Strong

One or more level I systematic reviews support the recommendation, providing evidence for a strong magnitude of effect

Grades of Recommendation

Grade B: Moderate

One or more level II systematic reviews or a preponderance of level III systematic reviews or studies support the recommendation, providing evidence for a mild to moderate magnitude of effect

Grades of Recommendation

Grade C: Weak

One or more level III systematic reviews or a preponderance of level IV evidence supports the recommendation, providing minimal evidence of effect

Grades of Recommendation

Grade D: Conflicting

Higher-quality studies conducted on this topic disagree with respect to their conclusions and effect. The recommendation is based on these conflicting studies

Grades of Recommendation

Grade E: Theoretical/Foundational Evidence

A preponderance of evidence from animal or cadaver studies, from conceptual models or principles, or from basic science or bench research supports the recommendation, providing theoretical/foundational evidence of effect

Grades of Recommendation

Grade F: Expert Opinion

Best practice to achieve a beneficial effect and/or minimize a harmful effect, based on the clinical experience of the guidelines development team

What are the common symptoms of Neck Pain With Mobility Deficits?

Central and/or unilateral neck pain, Limitation in neck motion reproduces symptoms, Possible associated shoulder girdle or upper extremity pain

What are the expected exam findings for Neck Pain With Mobility Deficits?

Limited cervical ROM, Neck pain at end ranges of motion, Restricted cervical and thoracic segmental mobility, Neck and referred pain with provocation of cervical/upper thoracic segments or musculature, Deficits in cervical scapulothoracic strength and motor control in subacute/chronic cases

What are the common symptoms of Neck Pain With Movement Coordination Impairments (WAD)?

Onset linked to trauma or whiplash, Associated shoulder girdle or upper extremity pain, Nonspecific concussive signs and symptoms, Dizziness, nausea, headache, concentration/memory difficulties, confusion, hypersensitivity to stimuli, affective distress

What are the expected exam findings for Neck Pain With Movement Coordination Impairments (WAD)?

Positive cranial cervical flexion test, Positive neck flexor muscle endurance test, Positive pressure algometry, Strength and endurance deficits of neck muscles, Neck pain with mid-range motion worsening at end-range, Point tenderness, myofascial trigger points, Sensorimotor impairments: altered muscle activation, proprioceptive deficits, postural balance/control issues, Neck and referred pain with provocation of cervical segments

What are the common symptoms of Cervicogenic Neck Pain With Headache?

Noncontinuous, unilateral neck pain with associated headache; Headache precipitated or aggravated by neck movements or sustained postures

What are the expected exam findings for Cervicogenic Neck Pain With Headache?

Positive cervical flexion-rotation test; Headache with provocation of upper cervical segments; Limited cervical ROM; Restricted upper cervical segmental mobility; Strength, endurance, and coordination deficits of neck muscles

What are the common symptoms of neck pain with radiating pain (radicular)?

Neck pain with radiating pain in the involved extremity, upper extremity dermatomal paresthesia/numbness, myotomal muscle weakness

What are the expected exam findings for neck pain with radiating pain (radicular)?

Neck and neck-related radiating pain with positive radiculopathy testing (upper-limb nerve mobility, Spurling's test, cervical distraction, cervical ROM), possible upper extremity sensory, strength, or reflex deficits

Intervention Strategies for Mobility Deficits in the Acute Stage

Thoracic manipulation, cervical mobilization/manipulation, cervical ROM/stretching/isometric strengthening exercises, advice to stay active, supervised exercises

Intervention Strategies for Movement Coordination Impairments in the Acute Stage

Education to remain active, home exercise for pain-free cervical ROM, minimize collar use

Intervention Strategies for Headache in the Acute Stage

Exercise (C1-2 self-SNAG)

Intervention Strategies for Radiating Pain in the Acute Stage

Exercise with mobilizing/stabilizing elements, low-level laser, possible short-term collar use

Intervention Strategies for Mobility Deficits in Subacute Stage

Cervical mobilization/manipulation, thoracic manipulation, cervicoscapulothoracic endurance exercises

Intervention Strategies for Movement Coordination Impairments in Subacute Stage

Education, combined exercise with active cervical ROM, isometric low-load strengthening, cervical mobilization/manipulation, physical agents (ice, heat, TENS), supervised exercise

Intervention Strategies for Headache in Subacute Stage

Cervical manipulation/mobilization, exercise (C1-2 self-SNAG)

Intervention Strategies for Mobility Deficits in Chronic Stage:

Thoracic manipulation, cervical mobilization, combined cervicoscapulothoracic exercise plus mobilization/manipulation, mixed exercise (neuromuscular coordination, stretching, strengthening, endurance, aerobic conditioning, cognitive elements), supervised individualized exercises, 'stay active' lifestyle, adjunctive therapies (dry needling, low-level laser, pulsed/high-power ultrasound, intermittent mechanical traction, repetitive brain stimulation, TENS, electrical muscle stimulation)

Intervention Strategies for Movement Coordination Impairments in Chronic Stage:

Education on prognosis, reassurance, pain management, cervical mobilization, individualized progressive exercise, vestibular rehabilitation, eye-head-neck coordination, TENS

Intervention Strategies for Headache in Chronic Stage:

Cervical and thoracic manipulation, strengthening and endurance exercise with neuromuscular training, combined manual therapy and exercise

Intervention Strategies for Radiating Pain in Chronic Stage:

Combined exercise (stretching/strengthening) with cervical and thoracic manual therapy, education counseling, intermittent traction

Cleland JA, et al., Describe the inclusion criteria for the patients in the study:

Patients with mechanical neck pain.

Age 18-60 years.

Neck pain of less than 30 days duration.

No contraindications to thoracic spine manipulation.

Cleland JA, et al., Describe the outcome measures used in the study:

Neck Disability Index (NDI).

Visual Analog Scale (VAS) for pain.

Patient satisfaction scores.

Range of Motion (ROM) measurements.

Cleland JA, et al., Describe the treatment provided to the intervention group:

Thoracic spine thrust manipulation.

General cervical range of motion exercises.

Cleland JA, et al., Describe the clinical bottom line:

The study suggests that patients with acute mechanical neck pain may benefit from thoracic spine thrust manipulation and cervical ROM exercises, showing improvements in pain and disability measures.

Review the four recommendations regarding management of cervical myelopathy:

Regular clinical monitoring for mild cases.

Physical therapy focused on strength and flexibility.

Use of cervical collars or braces in certain cases.

Patient education on symptom management and activity modifications.

Define mechanical neck pain:

Pain originating from the cervical spine structures, excluding inflammatory, infectious, or systemic causes.

Describe the difference between TM and NTM:

TM (Thrust Manipulation): High-velocity, low-amplitude techniques aimed at joint cavitation.

NTM (Non-Thrust Manipulation): Gentle mobilization techniques without joint cavitation.

Describe the effectiveness of TM vs. NTM based on a review of the evidence:

TM has been shown to provide more immediate relief in some patients compared to NTM, but both methods can be effective depending on patient-specific factors.

Describe the difference between a pragmatic trial vs. a RCT:

Pragmatic Trial: Designed to evaluate the effectiveness of interventions in real-world clinical settings.

Randomized Controlled Trial (RCT): Conducted under controlled conditions to determine the efficacy of interventions.

How was treatment of a specific spinal segment determined?

Based on clinical assessment and patient-reported symptoms, along with palpation findings.

Describe the NDI and GROC scoring and test statistics:

NDI (Neck Disability Index): Measures the impact of neck pain on daily activities, with scores ranging from 0 (no disability) to 50 (complete disability).

GROC (Global Rating of Change): Patient’s self-reported perception of improvement or worsening, typically on a 7 to 15-point scale.

Describe the interventions for the MIN and MTE groups:

MIN (Minimal Intervention Group): Received minimal therapeutic intervention, focusing on advice and education.

MTE (Manual Therapy and Exercise Group): Received manual therapy techniques and structured exercise programs.

Describe the VAS scoring and MCID:

VAS (Visual Analog Scale): A 10 cm line used to measure pain intensity, with scores ranging from 0 (no pain) to 10 (worst pain imaginable).

MCID (Minimal Clinically Important Difference): The smallest change in a treatment outcome that a patient would identify as important, typically around 1.5-2.0 points on the VAS for pain.

Describe the results of the study:

The MTE group showed significantly greater improvements in pain and functional outcomes compared to the MIN group, indicating the effectiveness of manual therapy combined with exercise.

Define cervical radiculopathy:

A condition caused by compression or irritation of cervical nerve roots, leading to pain, numbness, or weakness radiating from the neck into the shoulder and arm.

(Young IA, et al) Describe the treatment provided:

Thoracic spine manipulation and adjunctive cervical range of motion exercises.

Describe the primary and secondary outcomes and the clinical implication as it relates to patients presenting with cervical radiculopathy:

Primary Outcomes: Pain intensity (VAS) and disability (NDI).

Secondary Outcomes: Range of motion, patient satisfaction.

Clinical Implications: Thoracic spine manipulation can provide significant pain relief and functional improvement in patients with cervical radiculopathy.

(Young IA, et al) What is one limitation of the study:

A potential limitation could be the short duration of follow-up, which may not capture long-term outcomes.

Describe the most prevalent age and sex for patients presenting with migraine HA:

Migraines are most prevalent in women aged 18-44 years.

Describe the 3 criteria for ending the neck extensor endurance test:

Inability to maintain head position.

Significant increase in pain.

Voluntary termination due to fatigue.

Describe the 2 criteria for ending the neck flexor endurance test:

Loss of proper form.

Significant discomfort or pain.

(Florencio LL, et al.) Describe the findings and clinical implications for this study:

Women with migraines demonstrated lower cervical muscle endurance compared to those without migraines. This suggests that enhancing cervical muscular endurance may be beneficial in managing migraine symptoms.