Cervical pain is a common musculoskeletal problem. It can be caused by injuries or conditions affecting the cervical spine joints, ligaments, muscles or nerves. Clinical evaluation involves assessing the pain characteristics, neurological examination and diagnostic imaging when needed. The majority of acute cervical pain resolves within weeks with conservative treatment, but some may become chronic. Cervical myelopathy presents with signs of damage to the spinal cord like lower motor neuron signs in the upper limbs and upper motor neuron signs below the level of lesion.
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Cervical Spine Pain - Dr S L Yadav
1. Management of Cervical Pain
Dr S L Yadav, MD
Department of Physical Medicine & Rehabilitation
All India Institute of Medical Sciences, New Delhi
2. Neck pain is generally defined as pain and /or stiffness
felt dorsally in the cervical region
95% of patients with neck pain – Benign clinical diagnosis
(Neck sprain, mechanical neck pain, muscular neck pain, postural neck
pain, Myofascial pain syndrome)
Patients often search for a more definitive diagnosis
Cervical Pain
Gore D.R. Medscape General Medicine 1999;
Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
3. • Neck pain – Acute ( < 6 weeks) or Chronic (> 6 weeks)
• 80% of all acute neck pain resolves within days to weeks
• Common problem – Second only to Low back pain
• Population studies – prevalence of 13.8% (Norway)
• Slightly more common in Females (M:F :: 9.5% :13.5%)
• 10% of population – Neck pain on at least 7 days/month
• Neck pain occurs in 80% population at some time in their life
Cervical Pain – Epidemiology
Gore D.R. Medscape General Medicine 1999;
Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
4. Epidemiology
•Prevalence : 9-18% of general population.
•Workplace : 20-30% < 30 yrs age
50% over 45 yrs.
•Cervical pain- 2 types.
–Axial pain – pain occuring from inferior occiput to
superior interscapular region, localising to
midline or just paramidline.
–Radicular pain – pain involving shoulder girdle & distally,
manifests as pain in UE.
Equating cervical axial & cervical radicular pain can result in
misdiagnosis, inappropriate investigation & suboptimal treatment.
5. Biomechanics of Cervical Spine
• Support & stabilizes head: allowing movt. in all
planes.
• Protect spinal cord, nerve roots, vertebral artery.
• Atlanto-occipital (C0-1): 10
o
flexion & 25
o
extn.
• C1-2: 40-50% of all cervical rotation.
• Below C2-3 level, lat flexion coupled with rotation
in same direction. This motion is due to 45
o
sagital
inclination of zygapophyseal jt.
• Greatest flexion at C4-5 & C5-6
• Greatest lateral bending at C3-4 & C4-5.
6. Neck pain
Three categories
• Uncomplicated -joints,
ligaments and muscles
• Associated with
Radiculopathy [Single
nerve root ]
• Associated with
Myelopathy [Spinal
cord lesion, stenosis or
compression ]
7. Acute neck pain
• What Causes Acute Neck Pain?
– In most cases it is not
possible to pinpoint the cause
of the neck pain, or it may be
the result of an injury.
– In either case, it is necessary
to have a specific diagnosis of
the cause in order to manage
the pain effectively.
– There is a less than 1%
chance that the pain is due to
a serious medical condition.
http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp94c.pdf
10. How to differentiate the source of
Cervical pain
Pain from nerve roots or the spinal cord
c/o root pain
Sharp, intense often burning pain
Radiates to trapezi, interscapular
areas or down the arm Numbness &
motor weakness in a myotomal
distribution
Headache may occur with upper root
involvement
Symptoms aggravated by neck
hyperextension.
Pain from joints
ligaments/muscles
c/o pain & stiffness
Deep, dull aching & often episodic
pain
h/o excessive/unaccustomed activity
or of sustaining an awkward posture
No h/o injury
Localized asymmetric pain
Upper cervical pain is referred to the
head, lower cervical to the arm
Aggravated by movement, relieved
by rest
11. Clinical Evaluation
• History
• Pain
– Character/ location/
mechanism and timing
of onset/ duration/
clinical course
• Associated symptoms
– Radiation/ neurological
symptoms/ functional
limitations/
psychosocial stresses
etc.
• Examination
– Appearance/ posture/
stance/ gait
– Range of movement
– Neurological examination
– Specific tests
• Spurling test
• Axial cervical
distraction test
• Arm abduction test
12. Red Flags
• Bowel/ bladder of sexual
dysfunction:
– consider cervical
myelopathy
• Unexplained fever/ symptoms
of infection
– Consider infection related
to recent previous neck
surgery,
immunosuppressed
patient, intravenous drug
use, or prolonged steroid
use
• Unexplained weight loss
– Consider malignancy/
metastatic lesion
• Yellow flags:
– Non-physiological pain
distribution, non-organic
physical signs, repetitive
neck injuries, multiple
failed treatment, litigation
and or disability claims,
apparent secondary pain,
substance abuse,
depression or other
psychiatric diagnosis.
Carette S et. al. N Engl J Med 2005;353:392-9.
13. Physical Examination
• Cervical +shoulder ROM, Find
out whether movement
causes pain , and pain is felt
locally or radiating to UL.
• Neurologic examination -
sensory and motor + reflexes
is vital.
• Shoulder girdle, arm, forearm
& hand examination for
atrophy / fasciculation.
• Extrinsic causes of neck pain –
ear, throat conditions.
• Flexion :80°
• Extension :50°
• Lateral flexion :45°
• Rotation :80° to
either side
14. Neurological exam
• C1-C4 involvement will show no motor weakness or
reflex changes clinically
C5 C6 C7 C8
Sensory Lateral arm Thumb Middle finger Little finger
Motor Deltoid Wrst extensors Tricep Finger flexion
Disc C4-C5 C5-C6 C6-C7 C7-T1
Reflex Bicep Brachioradialis Tricep
15. Common Cervical Rediculopathy Patterns
Root Symptoms Motor Reflex
C2 Posterior occipital headaches, temporal pain - -
C3 Occipital headache, retro-orbital or retroauricular pain - -
C4 Base of neck, trapezial pain - -
C5 Lateral arm Deltoid Biceps
C6 Radial firearm, thumb and index fingers Biceps, wrist extension Brachioradialis
C7 Middle finger Triceps, wrist flexion Triceps
C8 Ring and little fingers Finger flexors -
T1 Ulnar forearm Hand intrinsics -
16. Referred Pain Pattern
• Occiput: C1-2, C2-3
(Headache: C3-4, C4-5, C5-6)
• Face: C1-2, C2-3, C3-4
• Posterior Neck: C3-4 & C4-5
• Supraspinatus fossa of scapula: C5-6
• Periscapular / trapezi: C4,5
• Lower end of scapula: C6-7,
C7,8.
• To Arm: C5
• To forearm & hand: C6,7,8.
17. Investigations
• Short lived neck pain and no
red flags – no tests needed
• Systemic disease
– Rheumatology screen
– Metabolic screen
• Ca/ Phosphate/ ALP
– Infection/ inflammatory
screen
• ESR/ CRP/ FBC/ cultures
• Neurological symptoms/ signs
– NCS/ EMG
• Radiological
– X-ray; dynamic views (as long
as stable)
– CT scan;
– MRI scan;
– Bone scan/ CT-SPECT scan
– Shoulder and upper limb
investigations
• X-ray/ Ultrasound/ MRI
– TOS investigations
• Doppler studies
18. X-RAY
• Plain radiographs evaluate chronic degenerative
changes, metastatic disease, infection, spinal
deformity, and stability.
• Use 7 views
– Flexion-extension views identify subluxations or
cervical spine instability.
– Open-mouth views evaluate the odontoid process and
C1-C2 stability.
– AP views identify tumors, osteophytes, and fractures.
– Lateral views assess stability and spondylosis (ie,
spurring, disc space narrowing).
– Oblique views reveal DDD, as well as foraminal
encroachment by uncovertebral or z-joint
osteophytes.
19. Computed Tomography
• Delineates cervical spine fracture and is used extensively
in trauma cases.
• CT-myelography
– A myelogram followed by CT scan may be obtained prior to
cervical decompressive spinal cord or nerve root surgery.
– This study evaluates the spinal canal, its relationship to the
spinal cord, and nerve root impingement from disc, spur, or
foraminal encroachment.
– CT-myelography, still the criterion standard, remains superior to
MRI in detecting lateral and foraminal encroachment, despite
greater expense and morbidity. Consequently, CT-myelography
is not the initial imaging study to evaluate cervical spine and is
reserved for complicated cases.
20. MRI
• MRI remains the imaging modality of choice to evaluate
cervical disk disease due to its low morbidity.
– Advantages include soft tissue definition (eg, cervical discs, spinal
cord), cerebrospinal fluid visualization, noninvasiveness, and lack of
patient radiation exposure.
– disadvantages include expense, inability of claustrophobic patients to
tolerate the procedure, dependence on patient cooperation to
minimize artifact, high false-positive rate, and insensitivity compared
to CT scan in evaluating bony structures.
– MRI appears inferior in differentiating cervical disc prolapse (ie, soft
cervical disc) from spondylitic osteophytic compression (ie, hard
cervical disc).
• Contraindications to MRI include patients with
embedded metallic objects, such as pacemakers, surgical
clips, spinal cord stimulators, or prosthetic heart valves
that may be dislodged by MRI magnets
22. ELECTRODIAGNOSTIC STUDIES
• Electrodiagnostic studies continue to be standard
for evaluating neurologic function of the cervical
spine.
– Needle EMG: detect acute and chronic radicular features.
– A diagnosis of radiculopathy is apparent when needle EMG
reveals abnormal spontaneous potentials and/or certain changes
in motor unit action potentials, in 2 or more muscles innervated
by the same nerve root but different peripheral nerves. Ideally,
EMG abnormalities also should be demonstrated in the
paraspinal muscles to confirm the diagnosis of radiculopathy.
– CMAP amplitude drop of 50% or more indicates significant axonal
loss.
– NCS/EMG is especially helpful to differentiate cervical
radiculopathy from confounding neuropathic conditions (eg, ulnar
nerve entrapment, carpal tunnel syndrome, peripheral
neuropathy, plexopathy).
Can J Neurol Sci. Hassan A et al, 2013 Mar;40(2):219-24.
Clinical predictors of EMG-confirmed cervical and lumbosacral radiculopathy.
23. Clinical Maneuvers
• Spurling’s maneuver - Axial loading of the neck while
the head is extended and rotated will often provoke
radicular pain.
• Abduction Relief sign - Placing the affected hand on
top of the head takes stretch off of the affected nerve
root and may decrease or relieve radicular symptoms
• Lhermitte sign - An electric shock sensation down
the center of the back after neck flexion is indicative
of cervical spinal cord pathology such as cervical
myelopathy.
27. Clinical Tests
• Adson’s test – for thoracic outlet syndrome.
• Roos test – done in surrender position, to r/o thoracic outlet
syndrome..
• Hoffmann’s test – rapidly extend distal phalanx of middle finger
by flicking its ant surface. Test is +ve if it results in flx of IP jts of
thumb & index finger.
• Dynamic Hoffmann’s test – rpt while the pt flx / ext neck,
which often facilitates the response.
• Inverted radial reflex - +ve if fingers flex during brachioradial
reflex.
32. Hand: Clinical signs are useful in
detecting subtle myelopathy in the
upper extremities
33. Patient Outcome Assessment
• Disability
• Neck Disability Index (NDI)
• Neck and Arm Pain
• NRS
• Function - HRQol
• SF-12®V2
34. Each section is scored on a 0–5 scale,
5 representing the greatest disability.
(Vernon H, Mior S. "The Neck Disability Index: a study of
reliability and validity." J Manipulative Physiol Ther. 1991
Sep;14(7):409-15.)
35. RTA & Whiplash
• Whiplash is an acceleration-deceleration mechanism of energy
transfer to the neck. It may result from “...motor vehicle collisions...”.
The impact may result in bony or soft tissue injuries which in turn may
lead to a variety of clinical manifestations (Whiplash-associated
disorders).
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific
Monograph of the Quebec Task Force on Whiplash-Associated Disorders, Redefining
Whiplash and its Management. Spine 1995;20(8 Suppl):1S-73S.
• 62% of RTA victims have whiplash
• 33-66% develop symptoms within 24 hours
• 30-42% have intermittent pain at 1 year
• 6% have continuous pain at 1 year
• 28% have chronic pain
36. Specific…..
– Myelopathy
• LMN signs in the upper limbs at the level of
compression (flaccid paralysis, muscle atrophy,
absent reflexes)
• UMN signs below the level of the lesion,
mainly evident in the lower limbs.
(hypertonicity, hyperreflexia, clonus, Babinskis
sign)
• Sensory deficit is non dermatomal involving
large areas e.g. whole arm/forearm/wrist
• Bladder involvement may be present
• Funicular pain (burning pain)
37. Other signs of myelopathy
• Hoffman's test/dynamic Hoffmann's test
• Lhermittes sign
• Inverted supinator jerk/inverted radial reflex
• Clonus
• Myelopathy hand
• Gait abnormalities such as ataxic broad based
shuffling gait
39. UNCOVERTEBRAL JOINT
• Lower cervical vertebrae (C3-7) have unique
synovial joint-like articulations called
uncovertebral joint or joints of Luschka
• These joints commonly develop OA changes
• Proximity of UV joint to spinal nerve roots can
cause compression due to degenerative
change.
40. Neck Pain or injury
Immediate cervical radiographs indicate
diagnosis?
Red Flags present? Cervical injury risk factors ?
Diagnosis life-threatening or requiring referral
Referral to specialist
Begin diagnostic workup it surgery would be
considered Cervical films negative or show
spondylosis?
Symptomatic treatment 4 more weeks Continued pain
and disability?
Evaluate for complications or occult disease
(Basic lab tests)
Unsure of diagnostic course of action?
Referral to specialist Treatment
successful?
No further Treatment
Chronic neck pain
Confirming or unsure
Cervical films as needed:
MRI Cervical spine CT Cervical spine
Myelogram or
Electromyelography
Symptomatic treatment 2 more weeks Continued pain and Disability?
Symptomatic treatment for 2 weeks Continued pain and Disability?
Cervical radiculopathy or myelopathy Cervical neck strain, or cervical
spondylosis
Radicular pain and/or pattern?
Yes
No
Yes
Yes
Yes
Yes
No
No Diagnosis
Yes
Yes
OR
Yes No
No
No Yes
No
No
No
No
42. Acute Neck pain
• NSAIDs
• Exercise groups performed better compared to Rest groups (Rest
makes Rusty)
Chronic Neck pain
• Educational efforts & exercise rehabilitation programme helped
majority of patients in relieving psychological distress, pain and
helped patients to return to work
• Drug therapy may not be very useful in non specific chronic neck
pain
• Limited evidence of efficacy of Radiofrequency neurotomy for
facet joint pain
Neck Pain – Treatment
Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
43. Treatment Options
• Medications
– NSAID, COX-2 inhibiters
– Muscle relaxants – used to aid sleep if disrupted by muscular
guarding.
– Tricyclic antidepressants like amitryptiline / nortryptiline
prescribed at 10-25mg at bedtime can be beneficial in relieving
pain.
– Gabapentin & pregabalin 300-900mg/ day can be effective in
modulating pain.
– Other drugs are tiagabine, oxcarbamazepine , opiate analgesics
for resistant cases.
• Surgery:
– Diskectomy, Laminoforaminectomy, cervical arthroplasty
44. Radiculopathy: Medical vs. Surgical
management
Carette S et. al. N Engl J Med 2005;353:392-9.
• Few good-quality studies comparing surgical and non-surgical
treatments for cervical radiculopathy
• A significantly greater reduction in pain at 3 months in
surgical group than the patients who were assigned to
receive physiotherapy or who underwent immobilization in a
hard collar (reductions in VAS for pain: 42 %, 18 % & 2 %,
respectively).
• No difference among the 3 treatment groups in any of the
outcomes measured, including pain, function, and mood at 1
year follow up.
45. Neck Pain : Algorithm for management
History / physical examination
Whiplash
associated
disorder
Radiculopathy Axial Neck
pain
Suspected
infection /
neoplasm
Suspected
myelopathy
X-ray MRI/Labs
Confirmed
NSAID ± Muscle
Relaxant + early
return to usual activities
GIII/IV
GI/II
If -ve
If -ve
Consultation
Grade IV
confirmed
Immobilize /
Consultation
Opioid, Anticonvulsant or antidepressant
If not resolved
Investigate further
If not resolved
* Douglass AB et. al. J. Am. Board
Fam Pract 2004;17: S13-22
46. Recommendations for Diagnosis and Imaging
• RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be
considered in patients with arm pain, neck pain, scapular or periscapular pain, and
paresthesias, numbness and sensory changes, weakness, or abnormal deep
tendon reflexes in the arm. These are the most common clinical findings seen in
patients with cervical radiculopathy. Grade of Recommendation: B
• RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be
considered in patients with atypical findings such as deltoid weakness, scapular
winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain,
and headaches. Atypical symptoms and signs are often present in patients with
cervical radiculopathy, and can improve with treatment. Grade of
Recommendation: B
• RECOMMENDATION: Provocative tests including the shoulder abduction and
Spurling’s tests may be considered in evaluating patients with clinical signs and
symptoms consistent with the diagnosis of cervical radiculopathy. Grade of
Recommendation: C
• RECOMMENDATION: Because dermatomal arm pain alone is not specific in
identifying the pathologic level in patients with cervical radiculopathy, further
evaluation including CT, CT myelography, or MRI is suggested prior to surgical
decompression. Grade of Recommendation: B
North American Spine Society Evidence-Based Clinical Guidelines for
Multidisciplinary Spine Care 2010
47. Recommendations for Diagnosis and
Imaging
• RECOMMENDATION: MRI is suggested for the confirmation of correlative
compressive lesions (disc herniation and spondylosis) in cervical spine
patients who have failed a course of conservative therapy and who may be
candidates for interventional or surgical treatment. Grade of
Recommendation: B
• RECOMMENDATION: CT myelography is suggested for the evaluation of
patients with clinical symptoms or signs that are discordant with MRI
findings (eg, foraminal compression that may not be identified on MRI). CT
myelography is also suggested in patients who have a contraindication to
MRI. Grade of Recommendation: B
• RECOMMENDATION: In the absence of reliable evidence, it is the work
group’s opinion that CT may be considered as the initial study to confirm a
correlative compressive lesion (disc herniation or spondylosis) in cervical
spine patients who have failed a course of conservative therapy, who may
be candidates for interventional or surgical treatment and who have a
contraindication to MRI. Work Group Consensus Statement
North American Spine Society Evidence-Based Clinical Guidelines for
Multidisciplinary Spine Care 2010
48. Outcome Measures for Medical/Interventional
and Surgical Treatment
• RECOMMENDATION: The Neck Disability Index (NDI), SF-
36, SF-12 and VAS are recommended outcome measures
for assessing treatment of cervical radiculopathy from
degenerative disorders. Grade of Recommendation: A
• RECOMMENDATION: The Modified Prolo, Patient Specific
Functional Scale (PSFS), Health Status Questionnaire,
Sickness Impact Profile, Modified Million Index, McGill
Pain Scores and Modified Oswestry Disability Index are
suggested outcome measures for assessing treatment of
cervical radiculopathy from degenerative disorders.
GRADE OF RECOMMENDATION: B
North American Spine Society Evidence-Based Clinical Guidelines for
Multidisciplinary Spine Care 2010
49. Medical and Interventional Treatment
• RECOMMENDATION: Emotional and cognitive factors (e.g., job dissatisfaction) should be
considered when addressing surgical or medical/interventional treatment for patients with cervical
radiculopathy from degenerative disorders. GRADE OF RECOMMENDATION: I (Insufficient
Evidence)
• RECOMMENDATION: As the efficacy of manipulation in the treatment of cervical radiculopathy
from degenerative disorders is unknown, careful consideration should be given to evidence
suggesting that manipulation may lead to worsened symptoms or significant complications when
considering this therapy. Pre-manipulation imaging may reduce the risk of complications. Work
Group Consensus Statement
• RECOMMENDATION: Transforaminal epidural steroid injections using fluoroscopic or CT guidance
may be considered when developing a medical/interventional treatment plan for patients with
cervical radiculopathy from degenerative disorders. Due consideration should be given to the
potential complications. GRADE OF RECOMMENDATION: C
• RECOMMENDATION: Ozone injections, cervical halter traction and combinations of medications,
physical therapy, injections and traction have been associated with improvements in patient
reported pain in uncontrolled case series. Such modalities may be considered recognizing that no
improvement relative to the natural history of cervical radiculopathy has been demonstrated.
Work Group Consensus Statement
North American Spine Society Evidence-Based Clinical Guidelines for
Multidisciplinary Spine Care 2010
50. EBM of Acute Cervical Pain
• There is both a lack of evidence (i.e. few
or no scientific studies conducted) and a
lack of high quality studies on pain-
relieving treatments in this area
• Not effective
– There is scientific evidence that
collars are not effective for acute
neck pain
• Effective Measures
• Measures that are effective for relieving
acute neck pain are:
– Staying active and keeping the neck
moving;
– gentle neck exercises (these can be
started soon after the pain starts);
– combined (or ‘multi-modal’)
treatments involving cervical passive
mobilisation with exercises, or
– exercises with other types of
treatments;
– and pulsed electromagnetic therapy
(reduces pain in the short term).
www.nhmrc.gov.au
51. EBM of Acute cervical Pain
• Inconclusive Studies on
– TENS,
– electrotherapy and
– micro-breaks (small breaks from
computer work) for acute neck
pain
• have not tested these
treatments against placebo.
• No studies done to prove is work or not
• There are no studies that have looked at:
– acupuncture,
– pain-relieving medication
(analgesics), anti-inflammatory drugs
(NSAIDs),
– Cervical manipulation, cervical
passive mobilisation,
– multi-disciplinary treatment in the
workplace,
– Muscle relaxants,
– neck school,
– patient education,
– spray and stretch therapy and
– traction for the treatment of acute
neck pain.
www.nhmrc.gov.au
52. Neck pain with radiculopathy
• There is little credible evidence to
support one best course of
treatment for neck pain with
radiculopathy
• One non-blinded randomized trial of
patients with more than 3 months of
radicular pain compared surgery
with physical therapy or
immobilization in a collar.
The long-term result was no
difference in pain, although the
surgery group had a greater short-
term reduction in pain, and a large
proportion of patients in all groups
eventually had surgery
• One very real problem in the study of
the treatment of radicular symptoms is
that the natural history of symptomatic
radiculopathy is not known.
The belief that untreated patients will
develop progressive disability is not
supported by reliable evidence. The
reported death rates from surgical
procedures are 0% to 1.8%, and the rate
of non-fatal complications is reported as
1% to 8% .
Therefore, there are no clear
indications for which patients with neck
pain and radiculopathy should be
referred for surgery and the choice of
surgical procedure has not been
established by appropriately designed
studies.
www.nhmrc.gov.au
53. Pain Physician. Kaye AD et al; 2015
Nov;18(6):E939-1004.
Efficacy of Epidural Injections in Managing
Chronic Spinal Pain: A Best Evidence Synthesis.
CONCLUSION:
This systematic review, with an assessment of the quality of
manuscripts and outcome parameters, shows the efficacy of
epidural injections in managing a multitude of chronic spinal
conditions.
Data sources included relevant literature identified through searches of PubMed for a
period starting in 1966 through August 2015; Cochrane reviews; and manual searches
of the bibliographies of known primary and review articles.
A systematic review of randomized controlled trials of epidural injections in
managing chronic spinal pain.
54. Strong Evidence of Treatment Effect
Moderate Evidence of Treatment Effect (2)
1. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, Cervical overview group, The Cochrane Collaboration. Manipulation
and mobilization for mechanical neck disorders (Review).
2. Gross AR, Goldsmith, C, Hoving, JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C, and the Cervical Overview Group. Con-servative
Management of Mechanical Neck Disorders: A Systematic Review. The Journal of Rheumatology 2007; 34:3, 1083-102.
3. Gross AR, McLaughlin L, Cervical Overview Group. Lecture notes from HaNSA meeting, McMaster University, 2008.
4.Sterling M, Jull G, Wright A. Cervical Mobilisation: concurrent effects on pain, sympathetic nervous system activity, and motor activ-ity. Manual
Therapy 2001 6(2), p.72-81.
55. Gross A, Kay TM, Paquin J, Blanchette S, Lalonde P, Christie T, Dupont G,
Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL,
Brønfort G, Santaguida PL; 28 January 2015
Cochrane
No high quality evidence was found, indicating that there is still uncertainty about
the effectiveness of exercise for neck pain. Using specific strengthening exercises as
a part of routine practice for chronic neck pain, cervicogenic headache and
radiculopathy may be beneficial. Research showed the use of strengthening and
endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial
in reducing pain and improving function. However, when only stretching exercises
were used no beneficial effects may be expected. Future research should explore
optimal dosage.
56. ISRN Pain. Pia Damgaard et al,Volume 2013 (2013), 23
pages; Evidence of Physiotherapy Interventions for
Patients with Chronic Neck Pain: A Systematic Review
of Randomised Controlled Trials
Review Article
Only exercise therapy, focusing on strength and endurance training, and multimodal
physiotherapy, cognitive-behavioural interventions, massage, manipulations, laser
therapy, and to some extent also TNS appear to have an effect on CNP.
However, sufficient evidence for application of a specific physiotherapy modality or
aiming at a specific patient subgroup is not available.
57. Take home message…
• Thorough evaluation and assessment is
essential for proper diagnosis & management
• Significant patients are looking around for
specific diagnosis which may reduce their
anxiety
• The clinical picture is often non-specific
• Beware of alerts in evaluation & treatment
