Neck Pain Epidemiology and Cervical Anatomy

Epidemiology of Neck Pain

• 22-70% incidence and 30-50% prevalence over a 12-month period.
• The incidence increases with age.
• Neck pain is most common in females in their 50s.
• It costs billions of dollars.
• Risk factors include being over 40, low back pain, hand weakness, poor quality of life, worrisome attitude, and low vitality.
• It's important to assess ROM, strength, posture, and joint accessory motion.
• The clinical course often involves chronic symptoms.
• Cervical radiculopathy often has good outcomes.
• Cases involving "whiplash" tend to have poor outcomes.
• Diagnosis and classification should compare ICF classifications to TBC.
• Canadian Cervical Spine Rule is used for imaging.
• 25% of an orthopedic physical therapy caseload involves cervical spine issues.

Cervical Bony Anatomy

• There are 7 cervical vertebrae and 8 cervical nerves.
• The upper cervical spine consists of C0-C1 and C1-C2.
• The lower cervical spine consists of C3-C7.
• C1 is the Atlas which has no body or spinous process.
• C2 is the Axis which has dens.
• The transverse foramen is a special feature as it hosts the vertebral artery.

Thoracic Bony Anatomy

• There are 12 thoracic vertebrae and 12 thoracic nerves.
• The upper thoracic spine consists of T1-T3.
• The middle thoracic spine consists of T4-T7.
• The lower thoracic spine consists of T8-T12.
• Special features include facets for articulation with the ribs, including the costotransverse and costovertebral joints.
• There is a narrow vertebral foramen.
• There are regions of the thoracic ring.

Cervical Ligamentous Anatomy

• The anterior longitudinal ligament is a key structure.
• The posterior longitudinal ligament is a key structure.
• Alar ligaments contribute to stability.
• The transverse ligament is essential.
• The cruciform ligament is important.
• These ligaments maintain passive stability, keep the upper cervical spine intact, and protect the dens.
• The ligamentum nuchae is important.

Cervical Spine Muscles: Posterior Upper

• Superior oblique.
• Inferior oblique.
• Rectus capitis posterior major.
• Rectus capitis posterior minor.

Cervical Spine Muscles: Anterior Upper

• Rectus capitis anterior.
• Rectus capitis lateralis.
• Longus colli.

Cervical Spine Muscles: Anterior Lower

• Sternocleidomastoid.
• Longus capitis.
• Longus colli.
• Scalenes include anterior, middle, and posterior.
• Splenius capitis and cervicis.

Arthrology: Flexion

• Flexion at AO (atlanto-occipital joint).
• Flexion at AA (atlanto-axial joint).
• Flexion at C2-C7.
• Facet orientation influences movement.

Arthrology: Extension

• Extension at AO.
• Extension at AA.
• Extension at C2-C7.

Arthrology: Rotation

• Rotation at AA.
• Rotation at C2-C7.

Arthrology: Lateral Flexion

• Lateral flexion at AO.
• Lateral flexion at C2-C7.
• Lateral flexion at T1-T12.
• Facet orientation influences movement.

Lab Exercise: Visualizing Cervical Motion

• Assess rotation, side bending, flexion, and extension visually.
• Rotate and side bend ipsilaterally and contralaterally with a partner.
• Palpate C7/T1 and C2 spinous processes during rotation to identify asymmetry.

Neck Pain Causes

• It is important to determine if the patient's symptoms point to a visceral disorder or serious pathology.
• Pinpoint the source of the pain.
• Spinal pathoanatomical diagnoses can be challenging.
• Explore individual factors that may perpetuate the pain experience.

Red Flags for Neck Pain

• Neoplastic conditions: Age ≥ 50.
• Systemic disease: Temperature >100ºF or BP >160/95.
• Upper cervical ligamentous instability: Occipital headache, numbness, or severe ROM limits during AROM.
• Vertebrobasilar insufficiency (VBI): Drop attacks or dizziness linked to neck movement.
• Cervical myelopathy: Sensory disturbances in hands or unsteady gait.

Pathoanatomical Diagnoses: Cervical Myelopathy

• Compression of spinal cord due to osteophytes or disc degeneration.
• Common symptoms include hyperreflexia, non-dermatomal sensory changes, clonus, Babinski/Hoffman reflexes, weakness, and gait clumsiness.

Cervical Myelopathy Clinical Prediction Rule

• A clinical prediction rule exists for cervical myelopathy, incorporating five tests with pre-test probability at 35%.
• The tests include the Hoffman test (thumb adduction/opposition), age >45 years, gait disturbance, Babinski test (great toe extension) and inverted supinator sign.

Inverted Supinator Sign

• The patient is seated, the examiner rests the patient's forearm on his/her forearm in slight pronation and applies a quick tap with a reflex hammer to the radius just proximal to the styloid process.
• A positive test is finger flexion or elbow extension

Cervical Spondylosis

• It involves degeneration of the cervical spine, affecting 90% of individuals over 50.
• This condition is different from an acute disc herniation.
• Disc degeneration and osteophyte formation impinge on nerve roots or the spinal cord causing radiculopathy or myelopathy.
• Presenting symptoms include headache, restriction of motion, crepitus, and pain.
• Surgical options are available.

Cervical Radiculopathy

• Presenting symptom is a dermatomal/myotomal pattern.
• Nerve root compression is caused by osteophytes, disc issues, or tumors.
• The pattern is proximal pain, distal paresthesias, and muscle weakness.
• Clinical prediction rule components include a positive Spurling Test, distraction, ULTTA median nerve test, and less than 60 degrees rotation on the involved side.
• Surgical options are available.

Thoracic Outlet Syndrome

• Compression of the neurovascular bundle in the thoracic outlet.
• Compression sources: superior thoracic outlet, scalene triangle, clavicle and rib 1, pectoralis minor/thoracic wall.
• The prevalence is 1/500 individuals have a cervical rib.
• Source can be vascular or neurogenic.
• Vascular sources are the brachial plexus, subclavian artery/vein, vagus/phrenic nerves.
• Arterial symptoms include pain and numbness, discoloration, coolness, worsened by cold temperatures.
• Venous symptoms includes: pain, heaviness, cyanotic discoloration, distended veins, and edema.
• Neurogenic symptoms include pain, paresthesia, numbness, weakness that is often radicular.
• Special tests with questionable accuracy include the Roos test (reproduction of symptoms) and Adson's test (decreased radial pulse).
• Treatment includes manual therapy, clavicle upward rotation, soft tissue mobilization, shoulder flexion, scapular rotation/tilt, thoracic mobility, rotator cuff strengthening, and core control.
• Surgical interventions include botox injections, first rib removal, scalenectomy, and anterior capsular plication.
• Movement impairments are not corrected with surgery.

Visceral Conditions Causing Referred Thoracic Pain

• Myocardial Ischemia: female > 65, male > 55, vascular disease history, exercise-induced pain, pain not reproducible, cardiac origin.
• Thoracic Aortic Aneurysm: chest/back pain, aorta involvement, sudden onset, labored breathing.
• Peptic Ulcers: mid-thoracic pain, changes after eating, dyspepsia history.
• Cholecystitis: right upper quadrant pain, right scapular referral, nausea, vomiting, fever.
• Neoplasms: cancer history, weight loss, treatment failure, age > 50.
• Inflammatory pathologies: stiffness > 30 min, limited chest expansion, exercise improvement, night pain, alternating buttock pain.
• Fractures: thoracic fractures in women > 65, age > 50, major trauma, pain/tenderness.

Canadian C-Spine Rule

• Used to determine the necessity of X-rays.
• High-risk factors include age 65 or dangerous mechanism, or paresthesias in extremities.
• Low-risk factors allowing ROM assessment include simple rear-end MVA, sitting position, ambulatory status, delayed onset pain, no midline tenderness.
• Active neck rotation of 45 degrees left and right is necessary.

International Framework for Cervical Artery Dysfunction

• It is important to review contraindications and precautions.
• Contraindications include multilevel nerve root pathology, neurological decline, unremitting pain, recent trauma, upper motor neuron lesions, or spinal cord damage.
• Precautions include local infection, inflammatory disease, cancer, steroid use, osteoporosis, hypermobility, connective tissue disease, age extremes, cervical anomalies, throat infections, recent manipulation.
• Serious conditions mimicking musculoskeletal dysfunction include CAD and upper cervical instability.
• History, risk factor recognition, neurovascular pathology are useful.

Cervical Artery Dysfunction Risk Factors

• History of trauma, migraine, hypertension, hyperlipidemia, cardiac/vascular disease, previous cerebrovascular accident or transient ischemic attack, diabetes, clotting disorders, anticoagulant therapy, steroid use, smoking, infection, post-partum, head/neck trauma, or unexplained symptoms.

Upper Cervical Instability Risk Factors

• Trauma history, throat infection, collagenous compromise, inflammatory arthritis, neck/head/dental surgery.

Differential Diagnosis

• Symptoms vary depending on the affected artery (internal carotid vs. vertebrobasilar) or the presence of upper cervical instability, necessitating a thorough assessment.

Differential Diagnosis of Internal Carotid Artery

• Early: mid-upper cervical pain, carotidynia, head pain, ptosis, lower cranial nerve dysfunction, acute/unusual pain.
• Late: transient retinal dysfunction, ischemic attack, cerebrovascular accident.

Vertebrobasilar Artery Diagnosis

• Early presentation: Mid-upper cervical pain, occipital headache; pain unlike any other.
• Late presentation: Hindbrain ischemic attack (diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, facial numbness, ataxia, vomiting, hoarseness, memory loss, vagueness, hypotonia/limb weakness, anhidrosis, hearing disturbances, malaise, perioral dysesthesia, photophobia, papillary changes, clumsiness/agitation); Cranial nerve dysfunction; Hindbrain stroke (e.g. Wallenberg's syndrome, locked-in syndrome).

Upper Cervical Instability Diagnosis

• Neck/head pain, instability feeling, muscle hyperactivity, head support needed, worsening symptoms.
• Bilateral foot/hand dysesthesia; lump in throat, metallic taste, arm/leg weakness, incoordination.

Treatment Based Classification System

• A system developed by Childs et al.
• Mobility: recent symptoms, non-radicular, restricted ROM; spinal mobilization/manipulation, AROM.
• Centralization: radicular in upper quarter, peripheralization, nerve root signs; traction, repeated movements.
• Exercise/Conditioning: low pain/disability, longer duration, no nerve root signs; strengthening, aerobic exercise.
• Pain Control: high pain/disability, trauma, referred pain, poor tolerance; gentle AROM, modalities.
• Headache: unilateral, neck pain, triggered by position, posterior neck pain; mobilization/manipulation, postural education, strengthening.

Clinical Practice Guidelines for Neck Pain

• This system is similar to the TBC system for neck pain but correlated to the ICF model.
• Neck Pain with Mobility Deficits: Unilateral pain, movement limitations, referred arm pain, mobility restrictions; Thoracic/Cervical manipulation or mobilization, cervical ROM, active exercises.
• Neck Pain with Radiating Pain: UE symptoms, dermatomal pattern, diminished reflexes, radiculopathy tests; Low-level laser, short-term collar, combined exercise and manual therapy.
• Neck Pain with Movement Coordination Impairments: Acute or trauma/whiplash, motion worsens, UE symptoms; Advise to stay active, Home ROM and postural ex Neck pain with movement:
• Coordination impairments is acute from truama or whiplash with a motion that worsens and effects the lower UE.
• Advice to stay active, home of ROM and postural exercises.

Clinical Practice Guidelines for Neck Pain Continued

• Neck pain with headaches: Dizziness/nausea, concentration difficulties, chronic; Reduce collar use, combined exercise and STM, AROM, strengthening, endurance, coordination, posture, aerobics, and function, TENS, Cervical mobilization.
• Non-continuous unilateral neck pain with headache+ C1-C2 SNAG, Cervical mobilization, Thoracic manipulation, cervical and scapulothoracic strength and endurance.

Clinical Practice Guidelines for Neck Pain Treatment

• With mobility deficits: Cervical/thoracic manipulation/mobilization, ROM exercises, supervised exercise.
• With movement coordination impairments: Educate to remain active, cervical ROM, minimize collar, and cervical mobilization.
• With headache: Exercise focusing on C1-2, cervical/thoracic manipulation/mobilization.
• With radiating pain: Mobilizing or stabilizing exercises, low-level laser, short term collar use, manual therapy for the spine, education and encouragement to participate, intermittent traction.

Examination Components

• Review patient-reported materials.
• Start with initial observation and progress to system reviews, structural inspection, screening exam, movement analysis, ROM, and tests.

Structural Inspection: Posture Correction

• Create neutral lumbar spine with normal lumbar lordosis, decreasing thoracic, and cervical flexion.
• Static assessment involves observing the lumbar spine position, while dynamic assessment checks motion and stability.

Thoracic & Cervical Spine (Posture)

• Re-aligning from the lumbar to thoracic and cervical regions.
• The thoracic spine involves decreasing flexion, with the aim being improved mobility and activity in the extensors.
• The cervical spine aims to decrease flexion to optimize alignment.

Spinal Preferences

• Flexed spine with slumped posture.
• Extended with sitting up straight
• Neutral which is midline of both

Testing

• Dermatomes: C1-T1 assess sensory function along specific skin patterns related to nerve roots.
• Myotomes: C1/2 - T1 assess muscle strength.
• Reflexes: Biceps (C5), Brachioradialis (C6), Triceps (C7).

Active Range of Motion (AROM)

• Assess cervical spine movement in all directions, noting quality, quantity, and pain compared to normative values.
• Differentiate between upper and lower function to determine if spine is functioning together: side-bending, and cervical movement (de-rotation)
• Thoracic range of motion assess in extension and rotation.

Passive Range of Motion (PROM)

• Involves osteokinematic and arthrokinematic assessments to identify joint motion restrictions.
• PAIVM assesses joint glides and the quality of movement.
• PIVM and pain provocation provides additional information on segmental motion and pain response.

Lab Exercises: Assessment and Treatment

• Upper cervical flexion/extension (OA), side bending (OA), and rotation (AA).
• Assess lower cervical PA mobility.
• First rib mobility to assess CRLR functions.
• Perform various manipulations and thrusts.

Resistive Tests

• Endurance tests for the spine are useful predictors.
• Deep Neck Flexor Endurance Test: A patient can tuck their chin and lift their head 1 inch off table.
• Cranio Cervical Flexion Test to assess for motor control of DNF for posture.

Muscle Length Tests

• Assess short muscles by testing SCM, levator scapulae, scalenes, and pectoralis muscles.
• Assess long muscles for Longus Colli/Capitis and Middle/Lower Trapezius.

Vertebral Basilar Insufficiency Test (VBI)

• This a special test.
• Involves end-range cervical rotation and extension for 10 seconds (held).
• A positive test is diplopia, dizziness, drop attacks, dysarthria, dysphagia, numbness, nausea, or nystagmus.

Spurling's Test

• Used tests for Cervical radiculopathy, and involves axial compression and side bending of the neck.
• A positive test reproduces these radicular symptoms.

Distraction Test

• A test for Cervical radiculopathy, and the examiner applies an axial traction force.
• A reduced symptoms during the test is positive.

Upper Limb Tension Tests (ULTT)

• These are neurological tension tests for median, radial, and ulnar nerves with specific diagnostic criteria for the reproduction and or release of symptoms.

Tests for Cervical Instability

• Sharp Purser Test to assess for myelopathic presentation.
• Alar Ligament Test to observe how the c2 is moving.
• Transverse Ligament Test to confirm any excess movement.