Spine ICF - Cervical Mobility Deficits: Neck Pain with Mobility Deficits

Red flag screen

• Canadian C spine test

• Screen for:

  • Cervical myelopathy

  • Upper cervical ligamentous instability

  • Vertebral artery insufficiency

  • Neoplastic conditions

  • Inflammatory or systemic disease

Pt presentation (symptoms)

• Neck pain

  • Clear for fracture/red flags

• Neck motion limitations

  • Active or passive or both

• Onset of symptoms often linked to recent unguarded/awkward motion or position of cervical spine

• Associated referred upper extremity pain may be present

Pt impairments

• Limited cervical ROM

• Neck pain reproduced at end range of active and passive motions

• Restricted cervical and upper thoracic segmental mobility

• Neck and neck-related upper extremity pain reproduced with provocation of the involved cervical or upper thoracic segments

Common causes

• Postural deficits

  • Especially forward head posture

• Muscle tightness/soft tissue restriction

  • Upper traps

  • Levator scap

  • SCM

• Joint hypomobility (stiff facet joints)

• Degenerative changes

• Pain & guarding

  • Protective muscle contraction

• Prolonged immobilization or inactivity

Examination (special tests)

• Upper quarter screen

  • Palpation and structural screening

    • Therapist observes pt looking for FHP or protracted scapulae

    • Palpation used to assess temp of tissue and presence of muscle guarding

  • Assessment of AROM and PROM

  • Neurological exam focusing on myotomes, dermatomes, and DTR

  • Special tests such as Wainner cluster to rule out nerve involvement

    • Spurling test A

    • Neck distraction

    • Upper limb neurodynamic test 1

    • Limited cervical AROM <60 deg

  • PAs used to identify painful or limited segment just like other areas of the spine

Interventions

• When mobility deficits are the primary impairment w the absence of radicular arm symptoms spinal manipulation is indicated as the primary intervention

• Neck pain guidelines recommend a combination of mobilization/manipulation technologies paired w neck and shoulder girdle exercises

• Thoracic spine manip techniques can also be used in adjunct to cervical manips and have been shown to improve pt mobility and pain

• If 3 or more of attributes are present then the likelihood of a successful outcome increased from 39% to 90%

  • Clinical prediction rule:

    • Symptom duration less than 38 days

    • A positive expectation that manipulation will help

    • Side to side difference in cerv rotation ROM of 10 deg or greater

    • Pain w posteroanterior spring testing of middle cervical spine

• Pts w a positive expectation of manipulation had better outcomes

• If a pt has fear of manipulation or lacks confidence in the treatment or clinician the manip should be avoided

• These pts should receive an active based exercise approach and education

• Treatment goals are to restore mobility, inhibit pain, and return the pt to full functional activity

• Exercises are given to improve neuromuscular control and address strength and endurance deficits in the cervical and scapular muscles

• As the PT program continues exercise therapy is needed and focus is on progressing intensity and duration of the given exercises