B6-7. Non-specific Neck Pain Flashcards
What are the 5 pathoanatomical causes of non-specific neck pain?
Sprain Strain Facet syndrome Disc derangement Fracture
What are the biomechanical causes of non-specific neck pain?
Joint dysfunction
Myofascial pain syndrome
What are the referral patterns for cervical facet syndrome
Scleratogenous around the affected joint but may go into shoulder even though there is no nerve damage
What is the clinical presentation of an acute facet syndrome In the cervical spine?
- Significant inflammation and splinting of the cervical spine
- pain that is dull and achy but can have episodes of sharp acute pain and immobility
- can be bilateral or unilateral
- may also complains of headaches
What are the palpatory findings associated with facet syndrome?
- tenderness over facet
- palpable tissue change/spasm
- joint restriction
What are the facet loading procedures that would be performed with suspected facet syndrome?
- active or passive extension or rotation
- quadrant positions (combined extension with rotation)
- cervical compression
- cervical Kemp’s
What would the diagnosis be if there are only palpatory findings of facet syndrome but orthopedic tests are negative?
Joint dysfunction
What would the diagnosis be if there are palpatory findings of facet syndrome and orthopedic tests are positive?
Facet syndrome AND joint dysfunction
What are some common negatives associated with facet syndrome?
- radiculitis and neurological deficits are rare and should not be present
- distal arm symptoms should not be reproduced by cervical orthopedic or tension tests
- pain should not centralize
The combination of what 3 findings in a phase 1 study showed a +LR of 4.95 that the patient had facet syndrome?
- ER/quadrant test
- Pain with static palpation over facet (familiar pain >/= 3/10)
- PA joint glide restriction
What are 3 ancillary studies that could be order when facet syndrome is suspected?
- medial branch blocks (need triple block when surgery is being considered and can have side effects of disequilibrium and presyncope)
- intra-facet block (not supported by current literature)
- radiofrequency neuroanatomy to denervate medial branch of dorsal ramus by coagulating and denaturing protein in the nerve (not destroying it)
What happens to the nerve when radio frequency Neurotomy is performed?
The nerve is denervated by coagulating and denaturing the proteins of the nerve which blocks the conduction of pain messages along the nerve to the DRG. Because the nerve is not destroyed, nerve function and therefore pain can return in 6-9 months
What are Cloward areas?
C-spine disc pain referral patterns
C2-3 to head C3-4 to upper trap C4-5 to upper scapula C5-6 to middle scapula C6-7 to lower scapula
NOTE: pain may refer farther such as into the hand
What is the clinical presentation of deranged cervical disc?
- pain centralization of deep referred arm pain
- neck extension and/or chin retraction helps
- neck flexion and/or chin protrusion aggravates
- tenderness may be more midline despite conventional wisdom that it is localized over facets
- Valsalva
- relieved by cervical distraction
- aggravated by cervical compression
What is the common age range for cervical deranged discs?
20-55
In children, deranged discs may be associated with what other condition?
Torticollis
What is the recommended sequence for determining directional preference which cervical disc derangement?
- chin protrusion
- chin retraction
- chin retraction + neck extension
- chin retraction + neck extension + manual traction
- ipsilateral flexion
Isometric muscle testing would be more painful with a sprain or strain?
Strain
AROM and PROM would be more painful with sprain or strain?
Sprain
During PROM, if there is pain at end range, what does it suggest? Strain or sprain?
Not useful at distinguishing between them
What are three variations of pain centralization?
- distal territory shrinks but local, proximal pain increases
- distal symptoms improve in intensity but local, proximal pain increases
- symptoms remain unchanged but AROM improves
What are examples of traumatic mechanism of injury causing sprains/strains in cervical spine?
- MVA
- slip and fall
- sports related accidents
What are examples of non-traumatic mechanism of injury causing sprains/strains in cervical spine?
- prolonged unusual posture
- chronic repetitive sprain/strains of neck
- functional instability
What are the referral patterns for cervical sprains?
- upper cervical refer to head
- mid and lower cervicals refer to shoulder, upper arm or upper thoracic
When examining the cervical spine for a sprain, what 4 components are you checking?
- posture: protective splinting
- palpation: pain with pressure on sprain
- muscle test: negative for pain
- ROM: pain as ligament is tractioned
What ligaments of the cervical spine would be tractioned with extension and therefore painful if sprained?
ALL
Joint capsule
What ligaments of the cervical spine would be tractioned with flexion and therefore painful if sprained?
Supraspinous
Interspinous
PLL
What ligaments of the cervical spine would be tractioned with lateral flexion and therefore painful if sprained?
Joint capsules
What is the BEST clue for a cervical strain?
Isometric contraction of neck muscles is painful and weak
Muscle tests should be negative for pain with a sprain except when?
Sometimes during the “set”phase, which is the initiation of a contraction
How does PROM of the cervical spine different between a sprain and strain?
With a strain, PROM is normal in midrange and will have pain only if muscle is stretch at end range
With a sprain, PROM is often painful and limited in mid range
What are residual/late effects of cervical sprain?
- adhesions
- joint dysfunction
- chronic facet syndrome or disc derangement
- chronic instability
What are residual/late effects of cervical strain?
- adhesions
- myofascial pain syndromes
- joint dysfunction
What are the Evidenced-based Canadian Guidelines Recommendations for treatment of acute non-specific neck pain?
- home exercises
- spinal manipulative therapy or mobilization
What are the Evidenced-based Canadian Guidelines Recommendations for treatment of chronic non-specific neck pain?
- exercise including stretching, isometric, stabilization and strengthening
- manual therapy
In one study that analyzed the short and long term efficacy of spinal manipulation, medication and home exercise, what were the findings?
- spinal manipulation was more effective than meds in short and long term
- no difference in pain between spinal manipulation and home exercise
Acute severe neck pain could be secondary to what?
- facet syndrome
- meniscoid entrapment
- disc derangement
- joint dysfunction
During the acute phase of acute, severe non-specific neck pain, what are the treatment options?
- directional preference manipulation and home exercises
- manual cervical traction
- PIR to relax muscles to level that they can be palpated and adjusted
- manipulate joint dysfunction
- use pain reduction electromodalities
- NSAIDs
What patient’s should NSAIDs be used with extra caution?
- over 65
- heart disease
How does CMT differ for facet syndrome vs. disc derangement in the cervical spine?
Facet syndrome you adjust in the painful direction
Disc derangement you adjust in directional preference, use cervical traction or flexion-distraction
How does forward head carriage affect the cervical spine and therefore affect both facet syndrome and disc derangement
It causes flexion in the lower cervical spine (therefore aggravates disc derangement) and extension in the upper cervical spine (therefore aggravates facet syndrome)
What are three immediate interventions that can be incorporated for rehab of nonspecific neck pain?
- active range of motion in pain free directions
- isometric contractions
- directional preference exercises
What is the length of a rehab program for nonspecific neck pain?
6-12 weeks
Although some may last 3-6 months
What are the 4 strategies for a rehab program for non-specific neck pain?
- evaluate and train deep neck stabilizers
- asses and treat posture and respiration
- address muscle imbalances of large torque muscles
- retrain sensory motor loop
When can a patient with non-specific neck pain return to play?
- minimal or no tenderness
- full AROM
- neck strength is WNL
- no neuro signs or symptoms
What are the referral patterns for a myofascial pain syndrome of the scalenes?
- medial border of the scapula (mimicking discogenic)
- lateral shoulder, arm and 2 digits (mimicking c6 neuropathy)
Shoulder abduction can offer relief with what cause of neck pain? It can aggravate what other cause of neck pain?
Shoulder abduction relieves arm symptoms associated with cervical root irritation but may aggravate TOS
What are the referral patterns for a myofascial pain syndrome of levator scapula?
- medial border of the scapula
- upper trapezius
- posterior glenohumeral area
What are the referral patterns for a myofascial pain syndrome of upper trapezius?
- postural lateral neck
- temporal head
- jaw at angle of mandible
What position/posture can relieve the load on upper trapezius, brachial plexus and nerve roots?
Hand in pockets
