Unit 5 - Cervicothoracic Spine II

Pathoanatomy: Neck Pain with Headaches

What is the proposed underlying cause of neck pain with headaches?

• Cervicogenic Headaches (CGH)

  • Disorder of the cervical spine and its component bony, disk, and/or soft tissue elements

• Cervical Spine Impairments

  • Upper cervical spine (C0/C1, C1/C2, C2/C3) facet joint impairments

  • Muscle impairments including myofascial trigger points

Medical Screening: Neck Pain with Headaches

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

  • Inflammatory or systemic disease

  • Cardiopulmonary conditions

  • Cervical vascular pathology

Medical Screening: Neck Pain with Headaches

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

• Upper cervical ligamentous instability

Differential Diagnosis: Neck Pain with Headaches

What other conditions should be considered with this patient presentation?

Primary Headaches

• Migraine without aura

• Migraine with aura

• Frequent episodic tension-type

• Chronic tension-type

• Cluster headache (trigeminal autonomic cephalgia)

Differential Diagnosis: Neck Pain with Headaches

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with movement coordination impairments (WAD)

• Temporomandibular disorders

Subjective Examination: Neck Pain with Headaches

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Musculoskeletal

• Structure

  • Zygapophyseal joint, muscle (myofascial trigger points)

• Pain mechanism

  • Nociceptive

• Phase of healing

  • None

Subjective Examination: Neck Pain with Headaches

What are common subjective reports for neck pain with headache?

General symptoms

• Noncontinuous unilateral neck and associated (referred) headache

• Unilateral headache with onset preceded by neck pain

• Headache aggravated by neck movements or sustained positions

• Symptoms progress occipital to frontal in a ram's horn distribution

Subjective Examination: Neck Pain with Headaches

What are common subjective reports for neck pain with headache?

Nociceptive Pain

• Clear, proportionate mechanical/anatomic nature to aggravating and easing factors

• Localized pain with/without somatic referral

• Usually rapidly resolving in accordance with expected recovery times

• Often intermittent and sharp with movement/mechanical provocation

• May have more constant dull ache or throb at rest

• Responsive to simple analgesics/NSAIDs

• Clear diurnal or 24-hr pain pattern

Subjective Examination: Neck Pain with Headaches

What are common subjective reports for neck pain with headache?

Aggravating factors

• Dull ache with sustained positions

• Symptoms reproduced with active movements

Subjective Examination: Neck Pain with Headaches

What are common subjective reports for neck pain with headache?

Easing factors

• Frequent change of positions

• Progressive cervical spine movement

Subjective Examination: Neck Pain with Headaches

What are common subjective reports for neck pain with headache?

2-hour pain behavior

• Morning

  • Rarely morning pain unless neck maintained in an awkward position

• Noon to evening

  • Symptoms may vary throughout the day depending on the patient’s activities, may have increased pain with sustain positions or specific movements

• Night

  • Symptoms may disturb depending on sleeping positions, severity and irritability

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

Systems review (as indicated from the subjective exam): Cardiopulmonary

• Vitals

  • BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

  • AROM, PIVM, compression/distraction, neurodynamic tests

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

Systems review (as indicated from the subjective exam): Neuromusculoskeletal

• Cranial nerves

• Reflexes/pathological reflexes

• Dermatomes/myotomes

• Upper cervical ligamentous testing

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

• specific tests and measures

  • muscle performance exam

    • MLT

    • muscle palpation

    • muscle endurance, coordination, and strength

• ICHD-3 diagnostic criteria

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

MLT

• Limited length of the cervicothoracic musculature

• Upper trapezius, levator scapulae, scalenes, suboccipitals, SCM, pec minor/major

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

Muscle palpation

• Active and latent myofascial trigger points of the cervicothoracic musculature

• Upper trapezius, SCM, suboccipitals, temporalis, splenius capitis and cervicis, semispinalis capititis

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

Muscle endurance, coordination, and strength

• Longus capitus and longus colli

• Cervical multifidus

• Middle and lower trapezius

• Rhomboids and serratus anterior

Physical Examination: Neck Pain with Headaches

What are the key examination procedures for neck pain with headache?

ICHD-3 diagnostic criteria

• Evidence of causation demonstrated by at least two of the following:

  • Headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion

  • Headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion

  • Cervical range of motion is reduced, and headache is made significantly worse by provocative maneuvers

  • Headache is abolished following diagnostic blockade of a cervical structure or its nerve supply

Prognosis: Neck Pain with Headaches

What is the prognosis of the condition?

Clinical course and prognosis

• • Acute idiopathic neck pain has variable recovery with slowing of progress noted at 6-12 weeks from onset

• Chronic non-specific, atraumatic neck pain may be stable or fluctuating with periods of improvement and worsening

Prognosis: Neck Pain with Headaches

What is the prognosis of the condition?

Factors that may impact prognosis

• Older age

• Prior history of musculoskeletal disorders

• Prior health

• Regular exercise

• History of previous neck pain

• Sick leave

Prognosis: Neck Pain with Headaches

What is the prognosis of the condition?

Factors that may impact new onset or recurrence

• Female gender

• History of previous neck pain

• Older age

• High demand jobs

• History of smoking

• Low social support

• History of previous low back pain

Stage of Condition: Neck Pain with Headaches

How does this present differently based on stage of condition?

Acute

• Severity and irritability are often high

• Pain at rest or with initial to mid-range spinal movements: before tissue resistance

• Pain control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Headaches

How does this present differently based on stage of condition?

Subacute

• Severity and irritability are often moderate

• Pain experienced with mid-range motions that worsen with end-range spinal movements: at tissue resistance

• Movement control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Headaches

How does this present differently based on stage of condition?

Chronic

• Severity and irritability are often low

• Pain that worsens with sustained end-range spinal movements or positions: overpressure into tissue resistance

• Functional optimization is often the intervention goal at this stage

Interventions: Neck Pain with Headaches

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Acute

• Exercise

  • C1/C2 self-sustained natural apophyseal glide (SNAG)

Interventions: Neck Pain with Headaches

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Subacute

• Exercise

  • C1/C2 self-sustained natural apophyseal glide (SNAG)

• Manual therapy

  • Cervical mobilization and manipulation

Interventions: Neck Pain with Headaches

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Chronic

• Exercise

  • Combined cervicoscapulothoracic exercise including endurance, neuromuscular re-education with/or without biofeedback, stretching, and strengthening elements

• Manual therapy

  • Cervicothoracic manipulation and mobilization

Interventions: Neck Pain with Headaches

When should we consider interprofessional referral and what are other treatment options?

• Imaging

  • In the absence of red flag signs and for those classified as low risk, imaging is not indicated

• Medications/injections

  • NSAIDs

  • Facet joint injections

  • Radiofrequency ablation

Pathoanatomy: Neck Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

• “Direct pathoanatomical causes of mechanical neck pain are rarely identifiable.”

• “Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown.”4

• “There are numerous anatomical structures in the cervical region that can be sources of nociception, including zygapophyseal joints, vertebrae, muscles, ligaments, neural structures, and the intervertebral disc.”

• “Evidence is lacking to support the hypothesis that these pathoanatomical features are a primary source of mechanical neck pain across the age spectrum in the majority of patients.”

• spondylosis

• sprain / strain

Pathoanatomy: Neck Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Spondylosis

• Gradual progression of age-related joint changes

• Adaptive shortening of the joint connective tissue and periarticular soft tissue

Pathoanatomy: Neck Pain with Mobility Deficits

What is the proposed underlying cause of the condition?

Sprain / Strain

• Acute onset sudden awkward movement causing

• Muscle strain and/or ligament sprain

• Primary/secondary disk-related condition

• Intra-articular meniscus entrapment

Medical Screening: Neck Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Cardiopulmonary conditions

• Cervical vascular pathology

Medical Screening: Neck Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

• Upper cervical ligamentous instability

Differential Diagnosis: Neck Pain with Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with movement coordination impairments

• Neck pain with radiating pain

• Rotator cuff related shoulder pain

• Thoracic and/or rib pain with mobility deficits

Subjective Examination: Neck Pain with Mobility Deficits

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Musculoskeletal

• Structure

  • Zygapophyseal joint and periarticular soft tissue

• Pain mechanism

  • Nociceptive

• Phase of healing

  • Muscle strain 2-4 weeks, ligament sprain and cartilage injuries 10-12 weeks

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

General symptoms

• Central or unilateral symptoms

• Possible (somatic referred) upper extremity pain

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Spondylosis Symptoms

Gradual onset with progressive loss of motion

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Sprain/strain Symptoms

• Immediate onset of pain and loss of motion

• Recent unguarded/awkward movement or position

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Nociceptive pain

• Clear, proportionate mechanical/anatomic nature to aggravating and easing factors

• Localized pain with/without somatic referral

• Usually rapidly resolving in accordance with expected recovery times

• Often intermittent and sharp with movement/mechanical provocation

• May have more constant dull ache or throb at rest

• Responsive to simple analgesics/NSAIDs

• Clear diurnal or 24-hr pain pattern

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Aggravating factors

• Dull ache and stiffness with inactivity

• Symptoms reproduced with certain active movements which may be sharp

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Easing factors

• Staying active

• Progressive cervical spine movement

Subjective Examination: Neck Pain with Mobility Deficits

What are common subjective reports for patients with mobility deficits?

24-hour pain behavior

• Morning

  • May have pain and stiffness that is worse upon waking that eases with activity and movement

• Noon to evening

  • Symptoms may vary throughout the day depending on the patient’s activities, may have increased pain and stiffness after being sedentary

• Night

  • Symptoms may disrupt sleep with changing positions depending on symptom irritability

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems review (as indicated from the subjective exam): Cardiopulmonary

• Vitals

  • BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

  • AROM, PIVM, compression/distraction

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems review (as indicated from the subjective exam): Neuromusculoskeletal

• Cranial nerves

• Reflexes/pathological reflexes

• Dermatomes/myotomes

• Upper cervical ligamentous testing

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

• Specific Tests and Measures

  • Movement and provocation exam

    • Active range of motion

    • Passive intervertebral motion (PIVM)

  • Diagnostic test-item cluster

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Active range of motion

• Cervical range of motion limitations and symptom provocation consistently reproduced at end range

• Symptom provocation with the addition of overpressure and/or combined motions

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Passive intervertebral motion (PIVM)

• Hypomobility of the cervicothoracic spine with characteristic pattern of restriction

• Hypomobility of the involved segment(s) with local and/or somatic referred symptom reproduction

Physical Examination: Neck Pain with Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Diagnostic test-item cluster

• Younger Individual (age < 50 years)

• Acute neck pain (duration < 12 weeks)

• Symptoms isolated to the neck

• Restricted cervical range of motion

Prognosis: Neck Pain with Mobility Deficits

What is the prognosis of the condition?

Clinical course and prognosis

• Acute idiopathic neck pain has variable recovery with slowing of progress noted at 6-12 weeks from onset

• Chronic non-specific, atraumatic neck pain may be stable or fluctuating with periods of improvement and worsening

Prognosis: Neck Pain with Mobility Deficits

What is the prognosis of the condition?

Factors that may impact prognosis

• Older age

• Prior history of musculoskeletal disorders

• Prior health

• Regular exercise

• History of previous neck pain

• Sick leave

Prognosis: Neck Pain with Mobility Deficits

What is the prognosis of the condition?

Factors that may impact new onset or recurrence

• Female gender

• History of previous neck pain

• Older age

• High demand jobs

• History of smoking

• Low social support

• History of previous low back pain

Stage of Condition: Neck Pain with Mobility Deficits

How does this present differently based on stage of condition?

Acute

• Severity and irritability are often high

• Pain at rest or with initial to mid-range spinal movements: before tissue resistance

• Pain control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Mobility Deficits

How does this present differently based on stage of condition?

Subacute

• Severity and irritability are often moderate

• Pain experienced with mid-range motions that worsen with end-range spinal movements: at tissue resistance

• Movement control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Mobility Deficits

How does this present differently based on stage of condition?

Chronic

• Severity and irritability are often low

• Pain that worsens with sustained end-range spinal movements or positions: overpressure into tissue resistance

• Functional optimization is often the intervention goal at this stage

Interventions: Neck Pain with Mobility Deficits

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Acute

• Education

  • General exercise and patient education to stay active

• Exercise

  • Cervical ROM, stretching, and isometric strengthening

  • Supervised exercise, including interventions for cervicoscapulothoracic strengthening, stretching, and endurance training

• Manual therapy

  • Thoracic manipulation

  • Cervical mobilization and/or manipulation

Interventions: Neck Pain with Mobility Deficits

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Subacute

• Exercise

  • Cervicoscapulothoracic endurance exercise

• Manual therapy

  • Thoracic manipulation

  • Cervical mobilization and/or manipulation

Interventions: Neck Pain with Mobility Deficits

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Chronic

• Education

  • “Stay active” lifestyle approaches

• Exercise

  • Combined cervicoscapulothoracic exercise

  • Mixed exercise for cervicoscapulothoracic regions including coordination, proprioception, postural training, aerobic conditioning, and cognitive effective elements

• Manual therapy

  • Thoracic manipulation and cervical mobilization

  • Biophysical agents

  • Dry needling, TENS, low-level laser, pulsed or high-powered ultrasound, intermittent mechanical traction, repetitive brain stimulation, and electrical muscle stimulation

Interventions: Neck Pain with Mobility Deficits

What additonal interventions are recommended for this condition?

Clinical Prediction Rule

• 3/4 (+LR 13.5; 90% probability)

  • Symptom duration less than 38 days

  • A positive expectation that manipulation will help

  • Side-to-side difference in cervical rotation ROM of 10 degrees or greater

  • Pain with posteroanterior spring testing of the middle cervical spine

Interventions: Neck Pain with Mobility Deficits

When should we consider interprofessional referral and what are other treatment options?

• Imaging

  • In the absence of red flag signs and for those classified as low risk, imaging is not indicated

• Medical Intervention

  • Medications/injections

    • NSAIDs

    • Facet joint injections

ICF example: Neck Pain with Mobility Deficits

Pathoanatomy: Neck Pain with Radiating Pain

What is the proposed underlying cause of the condition?

• Lateral foraminal stenosis (70-75%)

• Herniated nucleus pulposus (25%)

Pathoanatomy: Neck Pain with Radiating Pain

What is the proposed underlying cause of the condition?

Lateral foraminal stenosis (70-75%)

• Space-occupying lesion of the intervertebral foramen

• Combination of factors including

  • Decreased disk height

  • Degenerative changes (spondylosis)

    • Uncovertebral joints anteriorly

    • Zygapophysial joints posteriorly

Pathoanatomy: Neck Pain with Radiating Pain

What is the proposed underlying cause of the condition?

Herniated nucleus pulposus (25%)

• Less prevalent

  • Structural differences in the cervical disk

    • Vertically oriented posterior annular fibers

    • Posterior annulus reinforcement

      • Posterior longitudinal ligament

      • Uncovertebral joints

Medical Screening: Neck Pain with Radiating Pain

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Cardiopulmonary conditions

• Cervical vascular pathology

Medical Screening: Neck Pain with Radiating Pain

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

• Upper cervical ligamentous instability

Differential Diagnosis: Neck Pain with Radiating Pain

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Mobility deficits or movement coordination impairments

  • Somatic referred pain (disc, ligaments, facets, muscles)

• Thoracic outlet syndrome

• Rotator cuff related shoulder pain

• Lateral epicondylalgia

• Radial nerve entrapment

• Carpal tunnel syndrome

Subjective Examination: Neck Pain with Radiating Pain

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Neuromusculoskeletal

• Structure

  • Nerve root and disk (if HNP)

• Pain mechanism

  • Neuropathic5 (nerve root), nociceptive4 (disk)

• Phase of healing

  • Disk/annulus tear 10-12 weeks

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Neuropathic pain

• May be described as burning, shooting, sharp, aching or electric-shock-like

• May have other neurological symptoms e.g., pins and needles, numbness, weakness

• Can refer in a dermatomal pattern

• Not as responsive to NSAIDs, more responsive to anti-epileptics/anti-depressants

• Often presents with pain that is of high severity/irritability

• May spontaneous and/or sudden intensification of pain

• Can have latent pain response to movement/mechanical stress

• Often worse at night with sleep disturbances

• Often associated with psychological affect

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Lateral foraminal stenosis

Gradual onset of worsening lancinating arm pain

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Herniated nucleus pulposus

May be gradual or immediate onset of local and/or somatic referred neck pain and lancinating arm pain

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Lateral foraminal stenosis: Aggravating factors

• Intensification and/or peripheralization of radicular symptoms into the upper extremity with activities and movements that place a mechanical load on the neural structure

• Cervical extension, ipsilateral rotation and lateral flexion, axial compression

  • Looking up or over the ipsilateral shoulder

• Positions of the upper quarter that tension the nerve root

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Lateral foraminal stenosis: Easing factors

• Reduction and/or centralization of radicular symptoms into the upper extremity with activates and movements that reduce the mechanical load on the neural structure

• Cervical flexion, contralateral rotation and lateral flexion, axial distraction

  • Looking down or over the contralateral shoulder

• Positions of the upper quarter that reduce tension to the nerve root

  • Shoulder abduction sign/Bakody’s sign

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Lateral foraminal stenosis: 24-hour pain behavior

• Morning

  • Sleeping in cervical extension, ipsilateral rotation or lateral flexion, or in an upper extremity position that tensions the nerve root, they may wake up with arm pain

• Noon to evening

  • Symptoms will vary through the day depending on the patient's activities

• Night

  • Sleeping in cervical extension, ipsilateral rotation or lateral flexion, or in an upper extremity position that tensions the nerve root, they may wake up with arm pain

  • Neuropathic pain is often worse at night

  • May have disrupted sleep

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Herniated nucleus pulposus: Aggravating factors

• Intensification and/or peripheralization of radicular symptoms into the upper extremity with activities and movements that place mechanical load on the disk and nerve root

• Cervical protraction and flexion

  • Forward head position (often in sitting) or looking down to read

• Positions of the upper quarter that tension the nerve root

  • Median nerve upper limb tissue tension position of the upper extremity

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Herniated nucleus pulposus: Easing factors

• Reduction and/or centralization of radicular symptoms into the upper extremity with activates and movements that reduce mechanical load on the disk and nerve root

• Cervical retraction and extension

  • Neutral to extended head position (often during standing/walking) or looking up

• Positions of the upper quarter that reduce tension to the nerve root

  • Shoulder abduction sign/Bakody’s sign

Subjective Examination: Neck Pain with Radiating Pain

What are common subjective reports for patients with radiating pain?

Herniated nucleus pulposus: 24-hour pain behavior

• Morning

  • Sleeping in cervical flexion or in an upper extremity position that tensions the nerve root, they may wake up with arm pain

• Noon to evening

  • Symptoms may vary throughout the day depending on the patient's activities

• Night

  • Sleeping in cervical flexion or in an upper extremity position that tensions the nerve root, they may wake up with arm pain

  • Neuropathic pain is often worse at night

  • May have disrupted sleep

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Systems review (as indicated from the subjective exam): Cardiopulmonary

• Vitals

  • BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

  • AROM, PIVM, compression/distraction, neurodynamic tests

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Systems review (as indicated from the subjective exam): Neuromusculoskeletal

• Cranial nerves

• Reflexes/pathological reflexes

• Dermatomes/myotomes

• Upper cervical ligamentous testing

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Specific Tests and Measures

• Neurological examination

• Movement and provocation examination

• Neurodynamic testing

• Shoulder abduction test (+LR 2.1. –LR 0.91)

• Diagnostic test-item cluster

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Neurological examination

• Deep tendon reflexes

  • Bicep (+LR 4.8, -LR 0.8), tricep (+LR 0.42, -LR 1.04), brachioradialis (+LR 1.2, -LR 0.98)

• Dermatomes (light touch and/or sharp/dull)

  • C4-T1

  • Sharp/dull (+LR 0.7 to 2.07, -LR 0.82 to 1.15)

• Myotomes

  • C4-T1

  • (+LR 0.37 to 17.5, -LR 0.66 to 1.12)

• Cluster of dermatomes, myotomes, and reflexes

  • (+LR 9.0, -LR 0.83)

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Movement and provocation examination: AROM

Range of motion limitations and symptom provocation will depend on individual patient presentation

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Movement and provocation examination: Passive intervertebral motion

• Hypomobility and symptom reproduction at the involved segment(s)

• Possible hyper- or hypomobility at adjacent segments

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Movement and provocation examination: Orthopaedic examination tests

• Spurling A (+LR 3.5, -LR 0.58)

• Distraction test (+LR 4.4, -LR 0.62)

• Arm squeeze test (+LR 10.6 to 48.0, -LR 0.04 to 0.44)

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Neurodynamic testing

• ULTTA/ULND1 (median) (+LR 1.3, -LR 0.12)

• ULTTB/ULND2b (radial) (+LR 1.1, -LR 0.85)

• ULND 3 (ulnar)

• ULND 1-3 cluster

  • 1/3 (Sp 0.69)

  • 0/3 (Sn 0.97)

Physical Examination: Neck Pain with Radiating Pain

What are the key examination procedures for patients with radiating pain?

Diagnostic test-item cluster

• Wainner Cluster

• 3/4 (LR+ 6.1; 65% probability), 4/4 (+LR 30.3; 90% probability)

  • + ULTTA

    • Reproduction of symptoms or sensitized with a distal maneuver or side to side difference of 10deg elbow extension

  • Ipsilateral rotation less than 60deg

  • + Distraction test

    • Alleviation of distal symptoms

  • + Spurling A

    • Reproduction of distal symptoms

Prognosis: Neck Pain with Radiating Pain

What is the prognosis of the condition?

Clinical course and prognosis

• The condition is self-limiting with a favorable prognosis with resolution of symptoms occurring weeks to months

• 70-90% of patients experience improvement without surgery

• Most patients will see symptom improvement over time in both lateral foraminal stenosis and herniated nucleus pulposus

• Spontaneous resolution of disk herniations are common

• Patients should be monitored for progressive neurological dysfunction

Prognosis: Neck Pain with Radiating Pain

What is the prognosis of the condition?

Factors that may impact prognosis

• High pain intensity (NPRS >/= 6/10)

• High self-reported disability (NDI >/= 30%)

• High pain catastrophizing (PCS >/= 20)

• Older age

• Prior health

• Previous exercise

• History of previous neck pain

• History of other musculoskeletal disorders

Stage of Condition: Neck Pain with Radiating Pain

How does this present differently based on stage of condition?

Acute

• Severity and irritability are often high

• Pain at rest or with initial to mid-range spinal movements: before tissue resistance

• Pain control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Radiating Pain

How does this present differently based on stage of condition?

Subacute

• Severity and irritability are often moderate

• Pain experienced with mid-range motions that worsen with end-range spinal movements: at tissue resistance

• Movement control is often the intervention goal at this stage

Stage of Condition: Neck Pain with Radiating Pain

How does this present differently based on stage of condition?

Chronic

• Severity and irritability are often low

• Pain that worsens with sustained end-range spinal movements or positions: overpressure into tissue resistance

• Functional optimization is often the intervention goal at this stage

Interventions: Neck Pain with Radiating Pain

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Acute

• Education

  • Possible short-term semi-rigid collar use

• Exercise

  • Exercise with mobilizing and stabilizing elements

• Biophysical agents

  • Low-level laser

Interventions: Neck Pain with Radiating Pain

What are interventions recommended by the clinical practice guidelines based on stage of condition?

Chronic

• Education

  • Education counseling to encourage participation in occupational and exercise activity

• Exercise

  • Combined exercise: stretching and strengthening elements

• Manual therapy

  • Mobilization or manipulation to cervical and thoracic region

• Biophysical agents

  • Intermittent traction

Interventions: Neck Pain with Radiating Pain

What additional interventions are recommended for this condition?

• Exercise

  • Craniocervical flexion exercises

  • Exercises that promote the accessibility of an upright posture

  • Repeated or sustained motions in the direction of symptoms centralization

• Manual therapy

  • Upper quarter nerve mobilization procedures

  • Manual traction

  • Cervicothoracic manipulation

• Biophysical agents

  • Mechanical traction

Interventions: Neck Pain with Radiating Pain

What additional interventions are recommended for this condition?

Clinical Prediction Rule (cervical traction)

• Raney CPR

• 3/5 (+LR 4.81; 79.2% probability), 4/5 (+LR 23.1; 94.8% probability)

  • Peripheralization of symptoms with a PA at C4-C7

  • Positive shoulder abduction test

  • Age >55 years

  • + ULTTA/ULND 1

  • + Neck distraction test

Interventions: Neck Pain with Radiating Pain

When should we consider interprofessional referral and what are other treatment options?

• MRI

  • Patients with progressive neurological deficits or those without improvement over 4-6 weeks should be referred for imaging

  • Preferred modality for patient who do not respond to conservative care

• Medical Intervention

  • Medications/injections

    • SSRIs/SNRIs, antiepileptics5

    • Spinal injections

  • Surgical

    • Laminectomy/discectomy with cervical fusion