Cervical Lecture 1: Epidemiology and Evaluation Framework

Epidemiology and Economic Impact of Neck Pain

• General Significance: Neck pain is the second most common musculoskeletal (MSK) cause of disability and injury claims globally.

• Economic Burden: In workers' compensation (WC) claims, the economic burden of neck pain is second only to low back pain (LBP).

• Recurrence and Persistence: According to Olson, approximately $50\%-85\%$ of individuals who experience neck pain will face recurrent or ongoing pain.

• Clinical Impact: Disorders of the cervical spine account for approximately $25\%$ of the patient population seen by outpatient (OP) physical therapists in the United States.

Prevalence and Recurrence Data

• Prevalence (Childs 2008, Blanpied 2017):

  • Point Prevalence: Approximately $15\%$

  • Annual Prevalence: Approximately $26\%$

  • Lifetime Prevalence: Up to $70\%$

• Recurrence Rates: Estimated between $33\% \text{ and } 65\%$

• Demographic Trends: Prevalence generally increases with age and is statistically higher in females.

Risk Factors for Development of Neck Pain

• Demographic and Physical Factors:

  • Female sex

  • Prior history of neck pain (one of the most significant variables)

  • Age greater than $40$

  • History of smoking

  • Concurrent or history of low back pain (LBP)

• Behavioral and Lifestyle Factors:

  • Cycling as a regular activity

  • Worrisome attitude or psychological outlook

• Social and Occupational Factors:

  • High job demands

  • Low social support

  • Poor Quality of Life (QOL)

Clinical Course and Prognostic Indicators

• Clinical Course (Childs 2008, Blanpied 2017):

  • Highly variable: Some patients recover rapidly and completely, while others do not.

  • Recovery Timeline: The most significant recovery typically occurs within the initial $6 \text{ to } 12$ weeks.

  • Chronic Phase: There is very slow or little recovery after the $12$-month mark.

  • Recurrence (Carroll 2008): $50\%-85\%$ of patients will experience a recurrence within $1 \text{ to } 5$ years.

• Prognostic Predictors:

  • Favorable: Younger age.

  • Unfavorable:

    • High initial pain intensity.

    • High self-reported disability.

    • High pain catastrophization.

    • Post-traumatic Stress symptoms (particularly in Whiplash Associated Disorders (WAD); should be measured using the Impact of Events Scale (IES)).

    • Cold hyperalgesia (pain or sensitivity to cold).

Framework for Examination and Differential Diagnosis

• Direct Pathoanatomical Cause: According to the 2017 JOSPT Clinical Practice Guidelines (CPG) by Blanpied et al., a direct pathoanatomical cause for neck pain is rarely identifiable.

• Primary Examination Goals:

  • Assess for red flags to rule out sinister or serious pathology.

  • Establish the necessity for medical imaging.

  • Imaging Guideline: MRI is generally indicated only if neurological symptoms exist.

• General Treatment Approach: In the absence of serious pathology, evaluate and treat based on impairments, tissue irritability, and symptom response.

Red Flag Screening and Categorization

Significant Red Flags

• Cancer

• Infection/Osteomyelitis

• Cardiac Involvement

• Progressive Cervical Myelopathy

• Fracture

• Upper Cervical Instability

• Cervical Arterial Dysfunction (CAD)

Categorization of Red Flag Findings (Sizer 2007)

• Category I (Requires Immediate Medical Attention):

  • Blood in sputum.

  • Loss of consciousness or altered mental status.

  • Neurological deficit not explained by monoradiculopathy.

  • Numbness or paresthesia in the perianal region.

  • Pathological changes in bowel and bladder function.

  • Symptom patterns not compatible with mechanical pain during physical examination.

  • Progressive neurological deficits.

  • Pulsatile abdominal masses.

• Category II (Requires Subjective Questioning and Precautionary Examination):

  • Age greater than $50$.

  • Clonus (may relate to past CNS disorders).

  • Fever.

  • Elevated sedimentation rate.

  • Gait deficits.

  • History of disorders with predilection for infection or hemorrhage.

  • History of metabolic bone disorder or cancer.

  • Impairment precipitated by recent trauma.

  • Long-term corticosteroid use or long-term workers' compensation.

  • Non-healing sores/wounds.

  • Recent unexplained weight loss.

  • Writhing pain.

• Category III (Requires Further Physical Testing and Differentiation Analysis):

  • Abnormal reflexes.

  • Bilateral or unilateral radiculopathy or paresthesia.

  • Unexplained referred pain.

  • Unexplained significant upper or lower limb weakness.

Specific Pathology Screens

Neoplastic Conditions (Cancer)

• Common Metastatic Sources: Breast, Lung, and Prostate.

• Red Flags:

  • Constant and severe pain, especially at night.

  • Difficulty finding any position of relief.

  • Pain that worsens after $1$ month.

  • Unexplained weight loss, loss of appetite, and fatigue.

  • Absence of a clear, benign MSK pattern.

Infection

• Nature: Spinal infection is usually blood-borne from elsewhere in the body.

• Signs/Symptoms: Fever, hyperhidrosis (excessive sweating), night sweats, loss of appetite, and chills.

• Local Infection Signs: Redness, warmth, swelling, and persistent symptoms.

• Relevant History: Recent skin rash, recent history of infection (UTI, mononucleosis), recent cuts, or intravenous drug use.

Meningitis

• Definition: Inflammation of the meninges lining the CNS (viral, bacterial, fungal, or parasitic).

• Risk Factors: History of recent infection or skull fracture.

• Signs/Symptoms: Fever, positive Lhermitte’s sign, headache, nausea/vomiting, confusion, seizures, sleepiness, and photophobia or phonophobia.

Cardiovascular and Myocardial Infarction (MI)

General Cardiovascular Screening

• Symptoms include angina, shortness of breath, syncope, or drop attacks.

• Symptoms increase with physical activity but lack a mechanical correlation to movement.

• Pain may present in the jaw, neck, shoulder, arm, or back.

• Other signs: Abnormal fatigue, pulse irregularities, palpitations, peripheral edema, nausea, and "heartburn" unresponsive to antacids.

Myocardial Infarction

• Signs: Angina lasting more than $30$ minutes not relieved by rest or nitroglycerin.

• Vitals/Other: Cold sweat, lightheadedness, rapid or irregular pulse, and high blood pressure.

• Clinical Pearl: $33\%$ of those with MI will not experience chest pain (more common in women and the elderly). Women are more likely to experience vague chest, shoulder, mid-back, or arm pain (American Heart Association).

Cervical Myelopathy

• Definition: An Upper Motor Neuron (UMN) lesion resulting from the narrowing of the spinal canal.

• Physical Therapy Management: Mild cases can be treated with PT, but consultation is required if PT is the initial provider. Rapidly progressive symptoms require immediate referral.

• Signs and Symptoms:

  • Lower extremity (LE) weakness, stiffness, or heaviness (often manifests in LE first).

  • Ataxic gait and early fatigue.

  • Headache and neck pain.

  • Numbness on one or both sides of the body.

  • Early UMN signs: Hyperreflexia, positive Babinski, positive Clonus.

  • Later findings: Progresses to mixed UMN/LMN or LMN dominant signs (atrophy, weakness, DTR changes).

• Cook 2010 Test Item Cluster (TIC):

  1. Age greater than $45$.

  2. Positive Hoffman’s Sign.

  3. Positive Babinski Reflex.

  4. Gait Deviation.

  5. Positive Inverted Supinator Sign.

• Clinical Utility of TIC:

  • <1/5 positive: Sensitivity (Sn) = $94\%$, negative Likelihood Ratio (-LR) = $0.18$.

  • >3/5 positive: Specificity (Sp) = $99\%$, positive Likelihood Ratio (+LR) = $31$.

Cervical Fracture: Canadian C-spine Rule (CCR)

• Function: The gold standard for ruling out cervical fracture following trauma. High sensitivity enables the clinician to rule out the need for radiography.

• Step 1: Any High-Risk Factor? (Mandates Radiography if YES):

  • Age greater than or equal to $65$ years.

  • Dangerous Mechanism: Fall from greater than $1 \text{ metre} \text{ or } 5 \text{ stairs}$, axial load to head (diving), high-speed MVC (>100\text{ km/h}), rollover, ejection, motorized recreational vehicle, or bicycle collision.

  • Paresthesias in extremities.

• Step 2: Any Low-Risk Factor? (Allows safe assessment of ROM. If NO, mandate Radiography):

  • Simple rear-end MVC (excludes being pushed into traffic or hit by a large truck/bus).

  • Sitting position in the Emergency Department.

  • Ambulatory at any time.

  • Delayed onset of neck pain (not immediate).

  • Absence of midline C-spine tenderness.

• Step 3: Able to Actively Rotate Neck?

  • Must be able to rotate $45^{\circ}$ left and right. If UNABLE, mandate Radiography.

• Diagnostic Accuracy (Stiell et al 2003): Sensitivity = $99.4\%$, Specificity = $45.1\%$.

Upper Cervical Instability and Arterial Dysfunction

Upper Cervical Instability (UCI)

• Risk Factors: History of trauma, Rheumatoid Arthritis, Down Syndrome, Os Odontoideum (separation of dens from C2).

• Signs: Occipital headache and numbness, severe limitation in Active Range of Motion (AROM), signs of Cervical Myelopathy, relief with external support, sharp pain with sudden movements, heavy head sensation, and muscle guarding.

Cervical Arterial Dysfunction (CAD)

• Anatomy: Involves the Posterior System (vertebrobasilar) or Anterior System (internal carotids). The vertebral artery is compromised with contralateral AA rotation.

• Positioning Evidence: End-range rotation or combined extension/rotation may decrease flow in the Internal Carotid Artery (ICA) or Vertebrobasilar Artery (VBA). However, studies show little correlation between decreased flow and clinical symptoms in healthy populations.

• VBI Test: Known to have zero value as a screening tool due to low sensitivity ($0\%-57\%$), though specificity is high ($67\%-100\%$).

CAD Clinical Presentation

• Vertebral Artery (Ischemic Signs):

  • The 5 D’s: Dizziness, Diplopia, Dysarthria, Dysphagia, Drop attacks.

  • The 3 N’s: Nausea, Numbness (facial), Nystagmus.

  • Other: Ataxia, hoarseness, memory loss, hearing disturbance, photophobia.

• Internal Carotid Artery (Ischemic Signs):

  • Hemiparesis and sensory loss (contralateral face/UE/LE).

  • Speech impairments and visual loss.

• Internal Carotid Artery (Non-Ischemic Signs):

  • Horner’s syndrome and pulsatile tinnitus.

  • Cranial Nerve Palsies (specifically CN IX-XII): Uvular displacement, weak shoulder shrug, tongue deviation.

IFOMPT CAD Screening Framework (2020)

• Principle: Clinicians cannot rely on a single test. Assessment must be individualized and multi-faceted.

• Risk Factors: Past cervical trauma, migraine-type headaches, hyperlipidemia, cardiac/vascular disease, previous CVA/TIA, diabetes, clotting disorders, anticoagulant therapy, long-term steroids, smoking, recent infection, and immediate post-partum state.

• UCI Risk Factors within Framework: Throat infection, congenital collagenous compromise (Down’s, Ehlers-Danlos), Rheumatoid Arthritis, Ankylosing Spondylitis, and recent surgeries.

• Physical Exam Components:

  • Blood Pressure: Hypertension is a risk factor; drastic increases may indicate acute arterial trauma.

  • Upper Cervical Ligamentous Testing.

  • Neurological Exam: Typical neuro exam plus cranial nerves.

  • Carotid Artery Palpation: Check for pulsatile masses (aneurysm risk); palpate one side at a time.

Yellow Flag Screening: Psychosocial Factors

• Inappropriate Attitudes/Beliefs: Belief that pain is harmful or disabling, belief that pain must be completely gone before returning to activity, catastrophizing, and passive attitude toward rehab.

• Inappropriate Behaviors: Reduced activity level, reliance on aids (braces/crutches), reports of extremely high pain intensity, and substance/alcohol use increases.

• Central Sensitization: These factors contribute to the chronicity and perception of pain.

ICF-Based Classification and the Pathoanatomic Mindset

• Anatomical Diagnosis Limitations: Identifying a specific pathoanatomic cause for mechanical spine pain is difficult.

• "Wrinkles on the Inside": Nakashima (2015) found that in asymptomatic individuals:

  • $88\%$ have significant disc bulges.

  • $5\%$ have spinal cord compression.

  • Gore found that $95\%$ of men and $70\%$ of women have degenerative changes by age $60-65$, with only $15\%$ developing symptoms over $10$ years.

• Classification Efficacy: Fritz & Brennan (2007) found that patients "matched" to the treatment-based classification system had greater reductions in pain and disability than those who were unmatched.

Components of Evaluation and Outcome Measures

Outcome Measures

• Numeric Pain Rating Scale (NPRS): $0-10$ pain level.

• Neck Disability Index (NDI): $10$ questions rated $0-5$; total score doubled to reflect a percentage ($0\% =$ no limitation, $100\% =$ total inability).

• Patient Specific Functional Scale (PSFS): Patient identifies $3$ limited activities and scores them $0-10$.

Physical Impairment Measures

• Cervical Flexion-Rotation (CFR) Test

• Craniocervical Flexion Test (CCFT)

• Neck Flexor Muscle Endurance Test

• Upper Limb Tension Test (ULNT1)

• Spurling’s Test, Distraction Test, and Valsalva Test

• Pain Pressure Threshold (PPT) Algometry

The Four Evaluation Components

1. Medical Screening (Triage): Determine if the patient is appropriate for PT, PT with consultation, or requires referral out.

2. Classification: Identify the ICF category based on MSK impairments.

3. Staging: Based on severity and irritability (not just time).

4. Intervention Strategy: Driven by staging and classification per the 2017 CPG.