Neck Pain With Radiating Pain - Seri2024 PDF

NECK PAIN WITH RADIATING PAIN Davide Seri PT, MSc, OMPT Tommaso Cavicchi PT, MSc, OMPT Giulia Montefusco PT, OMPT Jessica Cammareri PT, OMPT...

NECK PAIN WITH RADIATING PAIN Davide Seri PT, MSc, OMPT Tommaso Cavicchi PT, MSc, OMPT Giulia Montefusco PT, OMPT Jessica Cammareri PT, OMPT Giuliana Rosso PT, OMPT «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Definition “Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs. This impingement typically produces neck and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities.” Eubanks, 2010 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Definition Cervical radiculopathy Cervicobrachial pain Cervical nerve root injury Radicular pain Radicular syndrome … Thoomes, 2012 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Other important definitions «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Radiculopathy vs Radicular Pain vs Referred Pain RADICULOPATHY RADICULAR PAIN REFERRED PAIN Nerve conduction Ectopic impulse Nociceptive pain block generation (convergence phenomenon) Neurological signs Symptom (Pain) Pain is stimulated by stimulation of primary pain site «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Neck Pain With Radiating Pain Cervical radiculopathy Radicular pain Thoracic Outlet Syndrome (TOS) Cervical herniation Cervical stenosis NOT REFERRED PAIN! «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Neck Pain With Radiating Pain Dermatomal distribution of symptoms is the exception rather than the rule Extradermatomal symptom distribution in up to 70% of patients with CTS and 64- 70% of patients with radicular pain Clinicians should not rule out entrapment neuropathies in the absence of a clearly defined dermatomal/peripheral symptom referral patterns Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Pathophysiology of entrapment neuropathies «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Risk factors Increased body mass index (BMI) Predisposing systemic diseases such as diabetes and hypothyroidism Genetics: Genetic susceptibility loci for EN (most of them related to connective tissue and extracellular matrix architecture) Unclear whether these genes increase vulnerability by altering the nerve itself (as a substantial proportion consists of connective tissue) or the environment through which the nerve travels (the “tunnels”) Heavy manual labor requiring lifting, driving, operate vibrating equipment Previous neck trauma Previous spinal nerve injury Smoking «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Most common EN in the upper quadrant (Prevalence) Cervical radiculopathy Thoracic Outlet Syndrome 1-3% (Radhakrishnan, (TOS) 1994; Salemi, 1996) 1-3/100.000 (Illig, 2021) Carpal Tunnel Syndrome Cubital Tunnel Syndrome 3% (Papanicolaou, 2001) 21/100.000 (Mondelli, 2005) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Most common EN in the upper quadrant (Prevalence) Cervical radiculopathy Thoracic Outlet Syndrome 1-3% (Radhakrishnan, (TOS) 1994; Salemi, 1996) 1-3/100.000 (Illig, 2021) Carpal Tunnel Syndrome Cubital Tunnel Syndrome 3% (Papanicolaou, 2001) 21/100.000 (Mondelli, 2005) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Thoracic Outlet Syndrome The term ‘thoracic outlet syndrome’ describes compression of the neurovascular bundle exiting the thoracic outlet Blanket term encapsulating many different clinical conditions It is one of the most controversial topics in MSK science Sanders, 2008; Laulan, 2011 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome TOS classification BASED ON STRUCTURES INVOLVED Neurovascular Neurological Vascular (Combined) Up to 90%! Jones, 2019 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Etiology BASED ON ETIOLOGY Traumatic Acquired Congenital Repetitive work Soft tissues Fractures Whiplash injury Cancer Cervical rib or sport activities abnormalities Jones, 2019 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Clinical presentation Neurological Vascular Upper extremity paresthesia (98%) Acute upper extremity swelling Neck pain (88%) Cyanosis Trapezius pain (92%) Heaviness Shoulder and/or arm pain (88%) Pain Supraclavicular pain (76%) Raynaud’s (unilateral) Chest pain (72%) Occipital headache (76%) Cooke, 2003 Paresthesias in all five fingers (58%), the fourth and fifth fingers only (26%), or the first, second, and third fingers Sanders, 2008 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Assessment Diagnostic modalities: Differential Cervical radiculopathy EMG diagnosis Upper limb nerve entrapment syndromes Anesthetic block Imaging: Assess upper extremity and cervical spine X-ray Muscle atrophy MR Physical Skin temperature, color, hair distribution, CT examination swelling Blood pressure difference (>20mmHg), pulse Sonography angiography Roos test (Elevated arm stress test) Adson’s test Wright’s test Provocation Costoclavicular maneuver DIAGNOSIS OF tests Cervical rotation lateral flexion test Supraclavicular pressure EXCLUSION! ULNTTs «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Double crush syndrome ✓ “Double crush syndrome is a distinct compression at two or more locations along the course of a peripheral nerve that can coexist and synergistically increase symptom intensity.” ✓ Also defined “Multifocal neuropathy” ✓ Compressions at multiple sites can be the cause for failure of treatment at one site ✓ Controversial diagnosis Kane, 2015 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome TOS Management Conservative: first choice for NTOS ✓ Education: Explanation of disease and possible Surgical: prognosis Promote self-efficacy and compliance ✓ Particularly recommended for ✓ Manual therapy: VTOS Mobilization/manip ✓ To consider when NTOS does not respond to conservative Myofascial treatment, or when neurological ✓ Exercise: symptoms are worsening Neurodynamics ✓ Decompression surgery Increase load capacity Breathing Stretching ✓ Pharmacological: Injection of botulinum toxin NSAIDs Hooper, 2010 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome TOS Management Hooper, 2010 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Clinical course Key points: ✓ Not clearly established ✓ About 50% recovered at 6-12 months ✓ About 78% recovered at 24-36 months ✓ Improvement occur mainly in the first 4-6 months «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Prognostic factors +VE -VE Presence of paresthesia at Longer duration of symptoms baseline Greater active rotation toward Higher baseline neck pain the affected side intensity Higher baseline disability score «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Etiology INFLAMMATION (Chemical) Main COMPRESSION causes: (Mechanical) Most common sites of compression: C7 (46.3 – 69%) Spondylosis (> older patients) C6 (17 – 19%) Disc herniation (> younger patients) C8 (6.2 – 10%) C5 (2 – 6.6%) Kuijper, 2009; Ellenberg, 1994; Woods, 2015 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Neck-related arm disorders Neurological deficit No neurological deficit Somatic referred Nerve Neuropathic/radicular Radiculopathy symptoms mechanosensitivity symptoms Nociceptive Neuropathic Kapitza, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Gain vs Loss of function LOSS OF FUNCTION GAIN OF FUNCTION Muscle weakness Pain Muscle hypo/atrophy Paresthesia/dysesthesia Reduced DTR Nerve mechanosensitivity Hypo/anestesia Hyperalgesia Allodynia CO-EXISTENCE OF CLINICAL PRESENTATIONS Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Diagnosis The core sign of nerve damage in entrapment neuropathies is loss of function Neurological Electrodiagnostic examination studies Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Imaging MRI Root compression DIAGNOSIS CONFIRMATION RULE OUT OTHER Spiral CONDITIONS CT Stenosis ❑ X-ray and MRI often yields false positives (compression not related to clinical presentation) ❑ Always to be interpreted in relation to the clinical context Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Electrodiagnostic studies May be normal in some patients (eg, approximately 25% of patients with CTS), even though the reported symptoms are strongly indicative of a neural involvement Acute and severe injury: large fibers Together with «standard» neurological examination, they only examine large myelinated fibers (Aβ and motor), which only make up approximately 20% of a peripheral nerve Progressive, mild injury: More appropriate for peripheral nerve small fibers entrapment syndromes Schmid, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Electrodiagnostic studies May be normal in some patients (eg, approximately 25% of patients with CTS), even though the reported symptoms are strongly indicative of a neural involvement Acute and severe injury: large fibers Together with «standard» neurological examination, they onlyRELYING examine large SOLELY ON LARGE FIBERS myelinated fibers (AβTESTING and motor), MAY which NOTonly BE SUFFICIENT make up approximately 20% of a peripheral nerve Progressive, mild injury: More appropriate for peripheral nerve small fibers entrapment syndromes Schmid, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Clinical assessment Subjective examination Objective examination Diagnostic findings Thoomes, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Subjective examination OBJECTIVES WHAT TO ASK FOR WHAT TO LOOK FOR ++++ ✓ Rule out serious ✓ Localization and ✓ «Arm pain is worse than pathology (eg. distribution of symptoms neck pain» Myelopathy) (body chart) ✓ «Symptoms provoked ✓ Differential diagnosis ✓ Quality when ironing» ✓ Identify psychosocial ✓ Intensity ✓ «Symptoms decreased factors ✓ Behaviour over 24 hours while walking with hand ✓ Identify physical and in the pocket» neurological impairments ---- ✓ Absence of paresthesia/numbness Schmid, 2020; Sleijser-Koehorst, 2021 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Non-compressive radiculopathies Polston, 2007 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Objective examination NEUROLOGICAL EXAMINATION PROVOCATIVE TESTS Thoomes, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Neurological deficit Neurological deficit No neurological deficit Somatic referred Nerve Neuropathic/radicular Radiculopathy symptoms mechanosensitivity symptoms Nociceptive Neuropathic Kapitza, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Neurological examination Assessment of nerve integrity and function (conduction) Key muscles Deep tendon reflexes Sensation Thoomes, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome What are we testing? Large diameter myelinated fibers: Aα, Aβ 20% Motor, Reflexes, Light touch, EMG Small diameter myelinated fibers: Aδ Cold, Nociception 80% Unmyelinated fibers: C Warm, Nociception Schmid, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome OE: Observation «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Observation: Posture WHAT WOULD YOU EXPECT? «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Observation: Posture «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Key muscle testing NERVE ROOT TEST MUSCLE(S) PERIPHERAL NERVE C4 1) Shoulder elevation 1) Upper trapezious 1) Spinal accessory 2) Breathing 2) Diaphragm nerve, C4 ventral rami 2) Frenic C5 1) Shoulder ABD 1) Deltoid 1) Axillary 2) Shoulder ER 2) Infraspinatus 2) Suprascapular C5-C6 1) Elbow FLEX 1) Biceps 1) Muscolocutaneous 2) Wrist EXT 2) Wrist extensors 2) Radial C7 1) Elbow EXT 1) Triceps 1) Radial 2) Wrist FLEX 2) Wrist flexors 2) Median, Ulnar C8 1) Fingers FLEX 1) Flexor digitorum 1) Median, Ulnar 2) Thumb EXT 2) Extensor pollicis longus 2) Radial T1 1) Thumb ABD 1) Abductor pollicis brevis 1) Median 2) Fingers ADD 2) Palmar interossei 2) Ulnar «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Key muscle testing Weak Extensor pollicis longus: C8 or Radial Nerve? 1) Test a C8 but not 2) Test a radial nerve radial nerve but not C8 innervated innervated muscle muscle Motor symptoms can be related Repeated testing or test after more to fatigue than maximal physical exertion strength Bender, 2023 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Key muscle testing MRC, 1942 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Reflexes Biceps (C5-C6) Brachioradialis (C5-C6) Triceps (C7) «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Sensory testing Kang, 2020 Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  How to test for sensory deficit Light touch Pin prick Thermal: hypo Cold hyperalgesia Ridehalgh, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome How to test for sensory deficit Key sensory points? 1. Dermatomal maps vary 2. Nerve trunk neuropathies? Circumferential testing: 1. Two circles around both the upper and lower arms/legs 2. Single digit testing (palmar/plantar and dorsal) 3. If changes are detected, test that area in more detail Bender, 2023 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome How to test for sensory deficit Key sensory points? 1. Dermatomal maps vary 2. Nerve trunk neuropathies? Circumferential testing: 1. Two circles around both the upper and lower arms/legs 2. Single digit testing (palmar/plantar and dorsal) 3. If changes are detected, test that area in more detail Bender, 2023 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Small-fibers testing Ridehalgh, 2018 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Neuropathic/radicular symptoms Neurological deficit No neurological deficit Somatic referred Nerve Neuropathic/radicular Radiculopathy symptoms mechanosensitivity symptoms Nociceptive Neuropathic Kapitza, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Neuropathic pain Grading system: Determining the presence of neuropathic pain Probable is considered enough to initiate treatment Critical issues: ❑ Non-dermatomal distribution ❑ Subtle sensory loss ❑ Diagnostic tests Finnerup, 2016; Schmid, 2020 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome Screening tools for NeP They can be useful to guide management Miss 10-20% of patients with a diagnosis of neuropathic pain To use only as an adjunct to the clinical examination Bennett, 2007 «Neuromusculoskeletal & Exercise Therapy Master» Tor Vergata University of Rome  Wainner’s cluster Cluster of 4 tests: Cervical rotation towards Used EMG as a reference affected side