Neck P! with Radiating Pain Flashcards
What are the 2 pathoanatomical conditions that may cause Neck P! with radiating pain?
- Lateral Foraminal Stenosis (Most common; 70-75%)
- Herniated Nucleus Pulposus (25%)
With Neck Pain with Radiating pain, what is Lateral Foraminal Stenosis?
A condition that is the result of a space-occupying lesion in the intervertebral foramen, this may be caused by:
- Decreased disk height
- Degenerative disk height (Spondylosis)
–Uncovertebral joint anteriorly
–Zygopophyseal joints posteriorly
This reduces the space the nerve root has to exit
With Neck Pain with Radiating pain, what is Herniated Nucleus Pulposus?
This condition is less prevalent than lateral foraminal stenosis.
- This is due to the structural differences in the cervical disk compared to the lumbar spine
–There are vertically oriented posterior annular fibers
–Posterior annulus reinforcement (PLL, uncovertebral, joints)
What other conditions should be considered with patients with Neck P! with Radiating pain?
- Mobility deficit or movement coordination impairments
- Thoracic Outlet Syndrome (TOS)
- Rotator cuff related shoulder pain
- Lateral Epicondylalgia
- Radial nerve entrapment
- Carpal tunnel entrapment
What system, structure, pain mechanism, and phases of healing are unique to patients with Neck P! Radiating Pain?
System
- Neuromusculoskeletal
Structure
- Nerve Root and Disk (if HNP)
Pain Mechanism
- Neuropathic (Nerve Root), Nociceptive (Disk)
Phase of Healing
- Disk/annulus tear 10-12 weeks
What are common subjective reports with patients with radiating pain (Lateral Foraminal Stenosis)?
Gradual onset of worsening lancinating arm pain
What are common subjective reports with patients with radiating pain (Herniating Nucleus Pulposus)?
May be gradual or immediate onset of local and/or somatic referred neck pain and lancinating arm pain
With Neck Pain with Radiating Pain, what are the Aggravating and Easing Factors for Lateral Foraminal Stenosis?
Aggravating
- Intensification and/or peripheralization of radicular symptoms into the UE with activities and movements that place a mechanical load on the neural structure
- Cervical extension, ipsilateral rotation and lateral flexion, axial compression
–Looking up or over the ipsilateral shoulder
- Positions of the upper quarter that tension the nerve root
Easing
- Reduction and/or centralization of radicular symptoms into the UE with activities and movements that reduce the mechanical load on the neural surface
- Cervical flexion, contralateral rotation and lateral flexion, axial distraction
–Looking down or over the contralateral shoulder
- Positions of the upper quarter that reduce tension to the nerve root
–Shoulder abduction sign/babinski sign
With Neck P! with Radiating Pain, what is the 24 hour pain behavior, with Lateral Foraminal Stenosis?
Morning
- Sleeping in cervical extension, ipsilateral rotation or lateral flexion or in an upper extremity position the tensions the nerve root, they may wake up with arm pain
Noon to evening
- Symptoms will vary through the day depending on the patients activities
Night
- Sleeping in cervical extension, ipsilateral rotation or lateral flexion or in an upper extremity position the tensions the nerve root, they may wake up with arm pain
- Neuropathic pain is often worse at night
- May have disrupted sleep
With Neck Pain with Radiating Pain, what are the Aggravating and Easing Factors for Herniated Nucleus Pulposus?
Aggravating Factors
- Intensification and/or peripheralization of radicular symptoms into the UE with activities and movements that place mechanical load on the disk and nerve root
- Cervical protraction and flexion
–Forward head position (often sitting) of looking down to read
- Positions of the upper quarter that tension the nerve root
–Median nerve upper limb tension position of the UE
Easing
- Reduction and/or centralization of radicular symptoms into the UE with activates and movements that reduce mechanical load on the disk and nerve root
- Cervical retraction and extension
–Neutral to extended head position (often during standing/walking) or looking up
- Positions of the upper quarter that reduce tension to the nerve root
–Shoulder Abduction sign/Bakody’s sign
With Neck P! with Radiating Pain, what is the 24 hour pain behavior, with Herniated Nucleus Pulposus?
Morning
- Sleeping in cervical flexion or in an UE position that tensions the nerve root, they may wake up in arm pain
Noon to evening
- Symptoms may vary throughout the day depending on the patients activities
Night
- Sleeping in cervical flexion or in an UE position that tensions the nerve root, they may wake up with arm pain
- Neuropathic pain is often worse at night
- May have disrupted sleep
With Neck P! and Radiating pain, what should take place in the Neurological Examination?
DTRs
- Bicep, Tricep, Brachioradialis
Dermatomes
- C4-T1
- Sharp/Dull
Myotomes
- C4-T1
During the Movement and Provocation examination with Neck P! with Radiating Pain, what would you see with Active ROM?
ROM limitations and symptom provocation will depend on individual patient presentation
During the Movement and Provocation examination with Neck P! with Radiating Pain, what would you see with Passive Intervertebral Motion (PIVM)?
- Hypomobility and symptom reproduction at the involved segment(s)
- Possible hyper or Hypomobility at adjacent segments
During the Movement and Provocation examination with Neck P! with Radiating Pain, what Orthopaedic examination test would you do?
- Spurling A
- Distraction Test
- Arm Squeeze Test
During Neurodynamic Testing, what test are you going to conduct and what are they for?
- ULTTA/ULND1 & 2a (For Median Nerve)
- ULTTB/ULND2b (For Radial Nerve)
- ULND 3 (For Ulnar Nerve)
- Shoulder Abduction Test (Symptom relief)
With Neck P! with Radiating Pain, what is the Diagnostic Test-Item Cluster?
Wainner Cluster:
- (+) ULTTA
–Reproduction of symptoms or sensitization with distal maneuver or side to side difference of 10° elbow extension - Ipsilateral Rotation Less than 60°
- (+) Distraction
–Alleviation of distal symptoms - (+) Spurling A
–Reproduction of distal symptoms
3/4 (65% probability)
4/4 (90% probability)
What is the Clinical course and Prognosis with Neck P! with Radiating Pain?
- The condition is self-limiting with a favorable prognosis with resolution of symptoms occurring weeks to months
- 70-90% of patients experience improvement without surgery
- Most patients will see symptom improvement over time in both lateral foraminal stenosis and herniated nucleus pulposus
- Spontaneous resolution of disk herniations are common
- Patients should be monitored for progressive neurological dysfunction
What are factors that may impact prognosis?
- High pain intensity (NPRS >/=6/10)
- High self-reported disability (NDI >/= 30%)
- High pain catastrophizing (PCS >/= 20)
- Older age
- Prior health
- Previous exercise
- History of previous neck pain
- History of other musculoskeletal disorder
A patient with Neck P! with headache, how would they present when they are in the Acute stage?
- Severity and Irritability are often high
- Pain at rest or with initial to mid-range spinal movements: before tissue stretch
- Pain control is often the intervention goal at this stage
A patient with Neck P! with headache, how would they present when they are in the Subacute stage?
- Severity and Irritability are often moderate
- Pain experiences with mid-range motions that worsens with end-range spinal movements: at tissue resistance
- Movement control is often the intervention goal at this step
A patient with Neck P! with headache, how would they present when they are in the Chronic stage?
- Severity and Irritability are often low
- Pain that worsens with sustained end-range spinal movements or positions overpressure: Overpressure into tissue resistance
- Functional optimization is often the intervention goal at this stage
With Neck P! with Radiating Pain, what are the recommended interventions in the Acute Stage?
Education
- Possible short-term semi-rigid collar use
Exercise
- Exercise with mobilizing and stabilizing elements
Biophysical Agents
- Low-level laser
With Neck P! with Radiating Pain, what are the recommended interventions in the Chronic Stage?
Education
- Education counseling to encourage participation in occupational and exercise activity
Exercise
- Combined exercise: stretching and strengthening elements
Manual Therapy
- Mobilization or manipulation to cervical and thoracic region
Biophysical Agents
- Intermittent Traction
