Mobility Deficits 2024 PDF

Neck Pain with Mobility Deficits Tommaso Cavicchi, PT, OMPT, MSc (Cognitive Science) Davide Seri PT, OMPT, MSc Jessica Cammareri, PT, OMPT Giulia Montefusco, PT, OMPT Giuliana Ros...

Neck Pain with Mobility Deficits Tommaso Cavicchi, PT, OMPT, MSc (Cognitive Science) Davide Seri PT, OMPT, MSc Jessica Cammareri, PT, OMPT Giulia Montefusco, PT, OMPT Giuliana Rosso, PT, OMPT 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 1  Where do we start from? Neck pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” in the neck region, which starts at the superior nuchal line and continues down to the level of the scapular spine 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 2  Where do we start from? 22% to 70% of the 54% of individuals population will have experienced neck neck pain some time pain within the last 6 in their lives months Increases with age, Ranks 19th overall in most common in global cause of women (lV to Vl Disability Adjusted decade) Life Year (DALY) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 3  Where do we start from? The highest frequency of new cases is from 40 to 69 yo Reduced physical activities Higher work and household/domestic demands Changes in cervical spine mobility and anatomy Onset of other acquired disorders (MSK or non-MSK) Kazeminasab 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 4  Where do we start from? Previous Spinal Low social or work Disorder support Female sex High job demands Older age (up to Being an ex 70) smoker APTA GL, 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 5  Where do we start from? Psychological Factors - Emotions Mood disorders → twice in people with NP Distress, anxiety, mood, emotions and pain-ralated behaviors → bidirectional association with onset and severity of pain Distress → adolescents reporting feelings of distress = increased Odds Ratio for NP General Anxiety Disorders and PTSD = highest comorbidities Depression → mediator between pain & disability Kazeminasab 2022, Martinez-Calderon 2020, Gureje 2008 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 6  Where do we start from? Psychological Factors – Cognitive variables Passive coping, attitudes and Fear Avoidance Beliefs = increased pain & disability (walking at slower speed) Higer level of catastrophizing/low level of self-efficacy → associated with NP and greater functional disability Impaired Cognitive Variables → altered central pain processing and HYPERALGESIA Pain catastrophizing & Fear Avoidance Beliefs are related to self-perceived poor health Kazeminasab 2022, Ahmed 2019, Alsultan 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 7  Where do we start from? Psychological Factors – Lifestyle - Sleep Quality/Quantity → more risk for female patients for developing NP, generally RF for increased odds of NP Sleep Quality is connected to Psychological Factors (e.g. depression) → higher activity of upper trap during night Social Support → patients who actively seek support show less neck complaints Avoidance oriented behavior (with annoyance and anger reaction) = longer duration of NP Kazeminasab 2022, Murugan 2021, Buitenhuis 2003, Aldabbas 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 8  Where do we start from? Behavioral Social Factors Support Emotional Cognitive Aspects Attitudes Kazeminasab 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 9  Work sucks Individual Factors for 1° episode Marital Status → people with bigger families (3 or more children) Low income & economic stress Perception of muscular tension/low perceived health status Genetics/autoimmune disease/NMSK comorbidities (e. g. Fibromyalgia) Kazeminasab 2022, Murugan 2021, Buitenhuis 2003 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 10  Work sucks Work Risk Factors for 1° episode (PS) Lack of coworkers support and conflicts about roles Perceived quantitative demands (high) Part time employments → + anxiety about economical status and income Effort Reward Imbalance → job stress is a result of situations in which efforts are not sufficiently reciprocated, in term of salary or benefits EMPOWER DIFFUSE LEADERSHIP Kim 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 11  Work sucks Work Risk Factors for 1° episode (Bio) Poor sitting adjustments, work in sustained positions → advice to change frequently positions Work in ankwarded position = RISK FACTORS Physical activity during Leisure time and Cervical Extensor Endurance = PROTECTIVE FACTORS Educational aspects are crucial for video terminal operators → MORE RISK for hyperalgesia, stress and related muscle tension Kim 2017, Nunes 2021, Jun 2017, Keyaerts 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 12  Is sitting position ALWAYS a RF? RISK FACTOR PROTECTIVE FACTOR ✓ Office workers ✓ High Physical ✓ Sedentary Demanding Jobs employments (Blue collars) ✓ High use of ✓ Histotechnicians communication ✓ Healthcare devices professionals Hallman 2016, Xie 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 13  Which workers are more at risk? WHITE COLLARS Office workers/PC High mental demanding job BLUE COLLARS HEALTH CARE PROFESSIONALS High working demands Repetitive movements Low job control and social Weight lifting and fixed position support (ankwarded neck position) Andersen 2015, Hallman 2016 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 14  The weight of the head Posture of the head is associated with the weight born by the cervical structure → SHOULD WE WORRY? It depends… Because many studies displayed a correlation between posture and neck pain and disability, but time spent at PC and age are important confounding factors Hansraj 2014, Unal 2024, Garcia-Remeseiro 2023, Mahmoud 2019, Kim 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 15  Stop scrolling on IG/Tik Tok We shall not be afraid about our posture, BUT adolescents… Spending > than 4h/day of phone usage lead to: Increase in NP Reduction of Cervical Extensor Muscle Endurance Spending more than 10h/w: Greater risk of NP (OR = 1.58) Elvan 2024, Minghelli 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 16  Just keep it strong F1 Drivers against G-Force Rugby players MVIC In specific circuits and 38kg for extension and curves they deal with 4-5g lateral movements Verstappen’s crash in 30kg for flexion, Forwards Silverstone was 51g are stronger than backs Chavarro-Nieto 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 17  Just keep it strong Chavarro-Nieto 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 18  And take it easy Posture & Neck Pain ✓ Confounding Factors (time, age, psychosocial factors) ✓ Static evaluations? Dynamic? ✓ Standing? Sitting? ✓ Cut offs? ✓ Chicken or Egg? ✓ CRANIOVERTEBRAL ANGLE → most used Nesreen 2019, Rani 2023 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 19  Where are we going to end up? Insidious-onset conditions, such as degenerative disc disease or postural syndromes, offer a less accurate onset date or magnitude of event, making prognostic research more difficult Older age (V-VII decades) - female Previous MSK disorders High pain intensity/High self-reported disability Poor physical health??? Poor psychological health (lower social support, passive coping strategy) APTA 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 20  Where are we going to end up? HCP or GP influence in Acute NP 1. Advise to “wait&see” → expected favorable prognosis Potential role of persuasion by the professionals Wait&see provided to patients with less severe complaints (spontaneous recovery) 2. Referral by GP to other HCPs, follow up by GP → do not improve outcomes related to prolonged sick leave Role of negative expectations (is my problem actually serious?) Delayed decision making Vos 2008 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 21  Where are we going to end up? Higher Pain and Disability Sociodemographic Age of the first episode Being Manual Workers Having > 2 sons High productivity Not working Lifting weight at work Gerard 2024, Verwoerd 2019 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 22  Where are we going to end up? Higher Pain and Disability Symptoms Concurrent LBP Baseline Pain Intensity No improvements in 2 weeks Presence of headache Numbness in hands Presence of radiating pain Gerard 2024, Verwoerd 2019 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 23  Where are we going to end up? Higher Pain and Disability Psychosocial Presence of Kinesiofobia Presence of Fear of Movement Self Reported Poor Health Presence of rumination High level of Worring Presence of anxiety/stress Gerard 2024, Verwoerd 2019 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 24  Where are we going to end up? POSITIVE Prognostic Factors More vitality Less need to socialise Alcohol Intake Gerard 2024, Verwoerd 2019 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 25  Where are we going to end up? Increased risk of sickness absence due to musculoskeletal disorders Sitting → less exposure to biomechanical risk factors occurring during heavy work = Neck pain is a risk factor for more recovery future long-term sickness absence More workload decision making → better outcome PC workers → higher level of NP 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 26  The shoemaker’ son go barefoot Study on SONOGRAPHERS 65% Low/resolving Disability 35% Moderate/Fluctuating Disability Workplace and Social Support = critical determinants for the clinical course of NP + 1h/w of vigorous physical activity = - 19% of risk for developing high levels of disability Depression & Anxiety → RR for Moderate/fluctuating Disability = 4 Widespread Pain & Nociceplastic features at baseline → higher levels of disability 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 27  Never understimate NP in young Study on HIGH COLLEGE STUDENTS 710 students after 1st episode of NP: 334 with persistent NP vs 370 recovered (>50%) Negative Prognostic Factors: Higher number of painful body sites Higher scores in CSI Being girls Depression & Anxiety → + pain Catastrophizing & - Self Efficacy → + disability 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 28  NP patients’ perspectives “I’m worried about my recovery” “My neck has gone wrong” “Pain limits my daily Maistrello 2022 life” 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 29  NP patients’ perspectives “My neck has gone Symptoms: wrong” Tightness, stiffness, blockage and difficulty during movements Headache, migraine-like, vertigo and dizziness Body Perception: Different shape of neck and shoulder structure and posture Neck movements innatural Difficult in focusing attention in non-painful area Maistrello 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 30  NP patients’ perspectives “I’m worried about my Psychological Consequences: recovery” Helplessness, frustration Impaired cognition (memory, concentration) & fear of movement Avoid talking openly about their pain Coping Strategies: Preferring to self-manage their pain Ignoring pain even when the symptoms worsen Seeking for excessive medication Maistrello 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 31  NP patients’ perspectives Mindset: “I’m worried about my Need to receive clear and concrete healthcare recovery” explanation Expecting to be understood & monitored Preference for challenging treatments Diagnostic procedres → COUNTERPRODUCTIVE Expectation from HCPs: Good therapeutic relationship Receiving specific diagnoses → NOT ESSENTIAL Maistrello 2022 = focus on strategy 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 32  NP patients’ perspectives Work: “Pain limits my daily Reduced capacity to perform at work, period of life” sick leave associated with stress ADL: Patients avoid I-ADl involving carrying weight and complain lack of concentration Hobby and Social Relationship: Sport, Physical Activity and Family = controversial aspect Strong need to feel socially connected, but fear Maistrello 2022 of stigma 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 33  Is NP prognosis usually favorable? Idiopathic neck pain does not resolve further after the first 6.5 weeks Chronic or insidious neck pain follows a clinical course described best as “recurrent” or “episodic” (50 to 85% rate of recurrence in the following 5 y) Complete resolution of such symptoms is the exception rather than the rule (≈ 45%) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 34  Is NP prognosis usually favorable? NP is not just a matter of PAIN 60% of patients with NP presented with some levels of disability and 30% failed to achieve satisfactory improvements at 6 weeks 47% of patients with NP presented with some levels of disability and 26% failed to achieve satisfactory improvements at 12 weeks 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 35  Is prognosis always favorable? Neck symptoms Biomechanical Performance Modifications → both true physiological and cognitive perceived modifications Activity of daily living → return to work, leisure time and sleep Self Efficacy → only 10% of the sample Evans 2014 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 36  Is prognosis always favorable? Different pain trajectories in people with Persistent Neck Pain 3% → slightly fluctuating 42% → small improvements 24% → moderate improvements 7% → large improvements 22% → persistent 2% → largely fluctuating Pico-Espinosa 2019 73% favorable trajectories 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 37  Is prognosis always favorable? Different pain trajectories in people with Persistent Neck Pain 3% → slightly fluctuating 42% → small improvements 24% → moderate improvements 7% → large improvements 22% → persistent 2% → largely fluctuating Pico-Espinosa 2019 31% favorable trajectories 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 38  What about people awareness? Q: Are patients conscious about their symptoms and clinical courses? A: Not completely SMS-based VS visual trajectories to understand if patients with NP recall properly their neck pain trends ✓ Generally Visual Self Reported Trajectories reflect patient’s symptom courses → useful for stratifications ✓ Recall bias & patients’ experience can influence their choices Irgens 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 39  What about people awareness? ✓ ONLY 18% of patients reporting Single Episode of NP had actually only one episode in an year (RECALL BIAS) ✓ Severe ongoing pain and fluctuating pain reported higher pain severity and almost no pain free weeks → role of high perceived disability and low expectancies about recovery ✓ Episodic and Mild pain reported comparable results in most parameters ✓ 38% patients Visual ≠ SMD-based Irgens 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 40  HCPs have an important role → creating correct expectations, avoiding waste of time & resources NP is a musculoskeletal Work RFs need to be carefully disorder, characterized by detected (Forward Head recurrent symptoms Posture and weight lifting) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 41  The specificity of ascpecific NP Symptoms have mechanical features Presence of aggravating or relieving factors Pain can be radiated, without neuropathic characteristics APTA 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 42  Neck Pain & Arm/Shoulder Pain Aspecific NP can trigger arm/shoulder pain (related to nociceptive signals from zygapophyseal joints, intervertebral discs, and paravertebral muscle) Pain widely distributed (scapular region, arm/forearm) Shoulder Pain occurring during neck movements Examination: Neck ROM, neck provocative tests (e.g. Spurling Test), symptoms modification Mechanism: referred pain & cervical roots involvement Slipmann 2005, Requejo-Salinas 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 43  The specificity of ascpecific NP Stop searching the specific pain structure Use of tests/manouvres to provoke pain (not to search segmental restriction) Strength is a key factor in persistent or chronic conditions APTA 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 44  The specificity of ascpecific NP This classification: Does not include all patients Is not based on strong evidence of reliability Provides information about clincal complaints Helps to define how to structure the evaluation process APTA 2017 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 45  Specifying of ascpecific NP ASPECIFIC NP NP Mobility NP Motor Control Deficits Impairment Acute Chronic SubAcute NOCICEPTIVE NEUROPATHIC NOCIPLASTIC LOW DISABILITY INTERFERRED ADL HIGH DISABILITY 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 46  The 4 Pillars of Assessment Use of validated self reported questionnaires (NDI, PSFS, GPE) ROM measurement to assess mobility deficits (goniometer, inclinometer, CROM tools) Poor interexaminer reliability of passive intervertebral motion (PAIVM) Physical tests for NP with mobility deficits (Active CROM, CFRT, cervical and thoracic mobility) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 47  Assessing Posture (reliability) Visual inspection of: Forward head posture → poor reliability (better with goniometer, inclinometer, head posture spinal curvature instrument) Thoracic Kyphosis → NO!!! Excessive scapular protraction → better reproducibility Lemeunier 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 48  Assessing Posture (validity) CROM device, Digital Caliper, or goniometer = inconsistent evidence in distinguishing differences in Forward Head Posture between patients with NP compared to healthy participants Greater Craniovertebral angle → associated with increased perceived disability in patients with NP compared to asymptomatic age-matched controls, not with pain Lemeunier 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 49  How about manual evaluation? Manual palpation (reliability) Measurement of segmental examination (C2-7) using joint static palpation to identify pain in patients with NP → inconsistent Assessment of tenderness on: Articular structures → higher value amongst examiners Muscular structures → conflicting evidence Combine perceived segmental stiffness with pain Lemeunier 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 50  How about manual evaluation? Manual palpation (validity) NP with PSFs → presence of muscular and referred tenderness (temporalis, upper trapezius, sternocleidomastoid, levator scapula, scalene, and suboccipital muscles) Joint and muscular palpation together increase the validity of assessment Joint motion palpation on mobility has very low value * PSF = psychosocial factors Lemeunier 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 51  Mobility Deficits? Cervical ROM (reliability) Measurment of CROM through visual estimation: ❖ flexion, lateral flexion, rotation ❖ extension Measurment of CROM through tools (goniometer, inclinometer, smartphone) → good intra and interreliability Lemeunier 2018, Araujo 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 52  Mobility Deficits? Cervical ROM (reliability) Patient with acute neck pain vs healty controls → reduced CROM (8.7° in lateral flexion to 29.2° in extension) Active CROM is negatively correlated with neck pain related impairments: Acute → catastrophizing, disability, number of active painful sites Chronic → neck pain & disability, physical HRQoL, pain behaviour Lemeunier 2018, Araujo 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 53  Bigger, Better, Stronger, Power? Reduced Cervical Extensor Higher disability → more Endurance = RF for the electrical activity of anterior onset of NP in office workers muscles during the CCFT Association between FI% 70% of patients with chronic and aCSA of the specific neck pain exhibit decline in muscles with cervical disk muscular strength of SCF degeneration and DCF during CCFT Huang 2022, Shadidi 2015, Jull 2008, Bonilla-Barba 2020 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 54  Bigger, Better, Stronger, Power? FLEXOR ASSESSMENT 2 main assessment used to test the performance of Deep/Superficial Flexor Muscles (strength & endurance) Cranio Cervical Flexion Test → active head nodding, patients have to target five progressive stages (from 20 to 30 mmHg) Neck Flexor Endurance Test → patients are asked to lift head holding chin tuck (normal Jull 2008, Juul 2013, Grimmer 1994 values = M: 38.9 s; F: 29.3”) va 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 55  Bigger, Better, Stronger, Power? FLEXOR ASSESSMENT Cranio Cervical Flexion Test CCFT reflects the activity of the deep neck flexor muscles → positive convergent validity High intra and interrater reliability scores Easy implementation in clinical settings BUT Poor responsiveness De Araujo 2020, Abichandani 2023 Minimal detectable change?? 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 56  CCFT: one, nobody, hundred of k FLEXOR ASSESSMENT Cranio Cervical Flexion Test (5 versions) CCFT AS → pressure achieved and hold for 10” CCFT PI → number of time an individual can hold for 10 seconds at the highest-pressure increment achieved CCFT CPI → the preceding score to the CCFT PI to reflect the entire test CCFT1 e 2 → holding position without SCM activation Romeo 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 57  CCFT: one, nobody, hundred of k FLEXOR ASSESSMENT Cranio Cervical Flexion Test (5 versions) CCFT versions are mostly reliable only at a group level CCFT PI and CCFT CPI showed sufficient intrarater reliability for making clinical decisions on individuals Patients with NP → compensatory strategy = clinical expertise needed CCFT AS → high discriminant validity, but low Romeo 2021 correlation with NP severity 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 58  CCFT: one, nobody, hundred of k Craniocervical Flexion ROM Patients with NSNP = larger increases in the different increase of SCF activity, stages of the test lower increase of DCF* Patients with NSNP = -20% of CCFTs are able to detect CCF ROM → qualitative longitudinal changes at group monitoring levels not at individuals’ Romeo 2021 *D/SCF = deep/superficial cervical flexor muscles 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 59  Look up EXTENSOR ASSESSMENT Neck Extensor Endurance Test → dynamic test where patients (prone) is asked to keep their neck in neutral position while rotating the head side-to-side. Outcome: how many seconds patients are able to maintain (M: 47”, F: 40”) Dynamometer (MVIC) → neck extension against dynamometer kept still by a bend. Caution: avoiding compensatory movements of the neck Juul 2013, Grondin 2022, Joona 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 60  Look up EXTENSOR ASSESSMENT Extensor muscles – Dynamometer (MVIC) Higher reliability than CCFT → less need for specific training to perform the test (intra- rater: ICC = 0.96, inter-rater: ICC = 0.88- 0.97). Normative values → F: 20kg No significant difference between NP vs nonHCs (hp: general mucle deconditioning) Useful for baseline evaluation Grondin 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 61  Neck Pain & Sensitization ACUTE NECK PAIN A subset of patients with Acute Non-Specific NP → signals of impaired CPM, mechanical Temporal Summation (involving Abeta & C fibers) = very similar to Chronic WAD Mechanical hyperalgesia was found only inside the cervical regions at group level, but there are individuals who complain widespread mechanical analgesia Jente 2023 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 62  Neck Pain & Sensitization - PPT CHRONIC NECK PAIN PPT → the most assessed QST in patients with NP CS signs are not always present in people with NP = people with moderate/severe pain = lower PPT widespread Office workers with Chronic Neck Pain → lower PPT in upper trap (localized) Temporal Summation of Pain explains the pain intensity in people with Chronic NP Nunes 2020, Arribas-Romano 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 63  C’mon let’s go treating GENERAL RECOMMENDATION from GL: Multimodal approach, patients’ involvement, shared decision making Subacute and Chronic stages → reduced evidence in favour of passive treatments = exercises addressed to cervical and scapulothoracic region Home exercise → maximize improvements in LT Outcome → reduce pain, increase QoL 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 64  C’mon let’s go treating 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 65  C’mon let’s go treating CONSIDERATIONS: Limited sample sizes in primary sources examined → downgrade of the strength of evidence High variability of: - inclusion/exclusion criteria - therapeutic approaches Small and transient side effects for all therapeutic modalties evaluated (no serious adverse effect) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 66  Do we have to treat Acute NP? General Education/general exercise Acute neck pain with Mobilization/manipulation of neck/thorax Mobility Deficits Specific Exercise Low PSF, low physical impairments Specific Education/CFT 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 67  Do we have to treat Acute NP? General Education/general exercise Acute neck pain with Mobilization/manipulation of neck/thorax Mobility Deficits Specific Exercise High PSF, low physical impairments Specific Education/CFT 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 68  Do we have to treat Acute NP? General Education/general exercise Acute neck pain with Mobilization/manipulation of neck/thorax Mobility Deficits Specific Exercise Low PSF, high physical impairments Specific Education/CFT 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 69  Thoracic Manipulation for NP Thoracic Manipulation → not indicated just in people with Acute NP Short-term effects have been noticed on Cervical ROM, QoL and Disability in pateints with Chronic NP Techniques used: A-P manipulation Supine distraction manipulation (dog) Thoracic Screw Manipulation Tsegay 2023, Yang 2024, Yoshida 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 70  Cervical Manipulation for NP Cervical Manipulation → promising approach in people with Mechanical Neck Pain (Persistent & Chronic) Most of the studies assess Cervical HVLAT associated with exercise Outcomes: Less pain/disability Increased ROM (MCID) Increased PPT (C0-3, suboccipital muscles) Rodriguez-Sans 2020, Akguller 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 71  Cervical Manipulation for NP Change in CCFT Change in GROC Rodriguez-Sans 2020 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 72  Mobilization for NP Articular treatment → the most used approach for the treatment of NP NAGs & SNAGs directed to cervical region = similar results between Mulligan treatments and exercise and thermal therapies on: pain, neck rotation, mental subcategory of SF-36 MT improves ROM, TSK and QoL NO difference between Thrust & Non-Thrust Manipulation (pragmatically applyed) Buyukturan 2018, Griswold 2018 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 73  Mobilization for NP Articular treatments → are more effective than oral medications for the management of NP Lower risk associated to the delivery of the treatment Lots of different techniques assessed MT is reported to be more effective as a stand-alone treatment in NP, compared to inert treatments Makin 2024, Castellini 2022, Gross 2015 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 74  Which massage technique for NP Soft Tissue Techniques → a plethora of different techniques ranging from acupuncture to massage and from Connective tissue massage to manual pressure techniques Very effective in pain reduction in the short term in Chronic NP Upper Trap & Suboccipital Muscles → higher improvements after myofascial release = MOST EFFECTIVE Guo 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 75  Should we prick our neck? Dry needling → one of the most discussed therapy (in Italy = DANGER) At most = just IMMEDIATE effect on pain&PPT DN are: Less effective than Manual Techniques in the short term for pain, disability, GROC, and Fear Avoidance Beliefs Effective in short term, but the improvements Martin-Sacristan 2022, Pandya 2024 were reversed at intermediate term 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 76  Let’s Practice for NP Stretching/self Flexor/Extensor mobilization Strengthening Scapular Resistence Aerobic Exercise Training Virtual Reality Programs 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 77  Just shut up & run AEROBIC TRAINING High heterogeneity amongs studies on proposals Bike, treadmill, walking, swimming, jogging, endurance training 8, 12, 36, 40 sessions in 6, 8, 12, 48 weeks 2/3 times x week, 30/45’ per session 60% mHR, Borg’s score = 11-16 Patients with NP, headaches (migraine) Daher 2021, Paraskevopoulos 2023 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 78  Just shut up & run AEROBIC EXERCISE TRAINING AET are beneficial for PAIN, function and level of disability BUT No clear indications about which kind of patients could benefit from AET Sample of the studies analyzed were heterogeneous (migraine/mechanical NP) Intervention treatments were different among studies Daher 2021, Paraskevopoulos 2023 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 79  Pull your chest out! SCAPULAR RESISTANCE TRAINING Open Kinetic Chain → TheraBand or body weight exercises targeting Upper and Mid- Lower Traps, Romboids, Serratus Anterior Closed Kinetic Chain body weight exercises like push up, press up, pull down Inconsistent definition between Stabilizzation/Resistance Training Prakash 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 80  Pull your chest out! SCAPULAR RESISTANCE TRAINING Scapular training exercises are generally considered as safe and effective interventions for people with NP Evidence of effectiveness are LOW (and specifically on PAIN, not for disability) Use of clinical reasoning is crucial (assess posture, thorax mobility and movement pattern) Use them as a part of rehabilitation program Prakash 2024, Dalager 2023, Chen 2023 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 81  Keep your head up NECK EXTENSOR STRENGTHENING They look superior to other active approach like stretching programs in the management of Chronic NP (+ cross sectional area) Restoring balance between flexor and extensor muscles is crucial for the support of the lordotic curvature of the cervical spine C2 is the key vertebra for the activation of the deep extensor muscles (PUT THE BAND Zhang 2024 THERE!!) 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 82  Nodding is the way DEEP FLEXOR CERVICAL STRENGTHENING Different studies show the superiority of DEEP FLEXOR MUSCLES over Conventional Exercise Treatment for all the core oucomes for NP (pain, disability, neck functioning) NO difference in FHP, but increase neuromuscular coordination, re-establishing the correct balance between DCF and SCF and increase ROM in upper cervical levels Iqbal 2021, Sikka 2020, Blomgren 2018, Garzonio 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 83  We all are Mulligan fans MWM SELF-MOBILIZATION Easy to perform, with immediate improvements Sustaining the movements, people have the chance to work on the painful mobility, reducing the symptoms Hp: reduce levels of TNFα and IL-1β, downregulation of chemokines and inhibit endogenous pain Sun 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 84  Educating patients with NP PAIN NEUROPHYSIOLOGY EDUCATION PNE are effective both in combination with other treatments and as a stand-alone modalty as well Two main outcomes: PAIN & KINESIOPHOBIA It works better on adult than adolescents The longer the total duration of PNE, the better the pain relief Emotions in the delievering of PNE is crucial Lin 2024, Andias 2022 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 85  Educating patients with NP COGNITIVE FUNCTIONAL THERAPY CFT is a behavioral approach for individualizing the management of spinal pain, targeting the bio-psycho-social factors of rehabilitation, and enabling the patients to self-manage their condition The literature is much less expanded in CNP as compared to CLBP, but the results from preliminary studies are encouraging for pain, disability, kinesiophobia and catastrophizing Ploutarchou 2024 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 86  Educating office workers with NP Moderate certainty that exercise Nevertheless the high heterogeity interventions reduced the risk of of studies on exercise treatments developing NP in 12 months in in NP → 3 times/week are office workers (OR = 0.5) sufficient in reducing NP Exercises available: Active break and postural shift Strength/resistance training, interventions reduced new onset stretching, ROM, proprioception, of neck and low back pain by balance, endurance 55%-81% Johnston 2021, Teichert 2023, Jones 2024, Akkarakittichoke 2021 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 87  SUMMARY TREATMENT HAS TO BE MT, EXERCISE AND MULTIFACTORIAL PSYCOTHERAPY ARE USEFUL KEEP ATTENTION ON PHYSICAL NOTHING DEFINITELY SUPERIOR IMPAIRMENTS ONE ANOTHERS INDIVIDUAL STRATEGIES HAVE TO BE IMPLEMENTED, RELATED TO PATIENTS’ PROFILING 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 88  Let’s play…a little bit Virtual Reality is a safe treatment The integration of VR and suitable for domestic demonstrates significant implementation, implementing improvements in pain, disability, the adherence and kinematic in CNP patients 3 modules (ROM, proprioception, and velocity) were designed to enhance the specific kinematic functions of individuals with CNP Luc 2024, Gao 2024, Hao 2/11/2024 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar 89 Master’s Degree NPET 2024/2025 – Cervical Spine Seminar