OCS Field Guide: A PT Podcast

Neck Pain with Mobility Deficits and Headaches

December 15, 2020 David Smelser and Austin Kercheville Season 1 Episode 11
OCS Field Guide: A PT Podcast
Neck Pain with Mobility Deficits and Headaches
Show Notes Transcript Chapter Markers

After providing an overview of the cervical spine treatment-based classification from 2004 and how it fits into the 2017 neck pain CPG, Dr. Austin Kercheville explains the diagnosis and treatment sections for neck pain with mobility deficits and neck pain with headaches.

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Hello and welcome again to another episode of OCS field guide. This episode will be part 3 in our series covering the 2017 Neck Pain clinical practice guideline update. Today we will be getting into more of the meat and potatoes, the stuff we PTs get more excited about: diagnosis and treatment. In this episode I’ll give the 10,000 ft view on the neck pain CPG’s treatment based classification system and then we’ll dig into two of the classfications specifically, neck pain with mobility deficits and neck pain with headaches. I’ll also be filling in some gaps and giving some clinical pearls along the way, and then we’ll cover the remaining two classifications in our next episode. 

As we’ve already stated, the best available evidence supports classification of patients based on symptoms and clinical examination findings into groups most likely to benefit from specific intervention, rather than treatment based on pathoanatomic diagnosis.  Before we get into the current TBC system, I’ll give a little history of the development of cervical treatment based classification. Although various models have been proposed, the best and most enduring model was first proposed by Childs et al in 2004, and was tested further by Fritz and Brennon in 2007. Depending on when you went to school and/or how your professors presented this material, you may be most familiar with their 5 subgroups rather than the 4 that you will see in the neck pain CPG. They classified patients as: Mobilization/manipulation, Exercise/conditioning, Centralization/traction, Pain control, and headache. The biggest difference from the original framework is that the current framework drops the pain control category, which described patients with acute sprain/strain that would benefit from more gentle ROM and mobilization, and separates them into the two groups that best fit their clinical presentation, mobilization/manipulation and exercise and conditioning, which are now neck pain with mobility deficits, and neck pain with movement coordination impairments. Another main difference between the 2008 and 2017 version is that the 2008 version included 3 different clinical prediction rules that the 2017 update does not, due to the fact that they have not been validated yet. I still think there are some CPRs you should know since they are still widely accepted, so I’ll talk you through those when they come up, but recognize that none of the CPRs surrounding the cervical spine that we commonly know have been validated to the proper extent for full adoption into clinical practice. 

Without further ado, let’s dig in. The CPG describes a 4 part process of evaluation and intervention. First, medical screening: this is where we assess and screen for more serious pathology (see part 2 in our neck pain CPG series), and make the classic decision if the patient is appropriate for PT evaluation and intervention, if they are appropriate for both PT AND referral, or if they are not appropriate for PT and thus need consultation with appropriate medical provider. You can almost guarantee that you will get a few questions on the exam that test your ability to make that determination. The second step, provided that the patient is appropriate for PT, is classifying the patient in the appropriate treatment based classification. 

The 4 classifications are: Neck pain with mobility deficits, neck pain with movement coordination impairments (which includes whiplash associated disorder), Neck pain with headaches, and neck pain with radiating pain. It’s important to note that these categories are not exclusive or exhaustive. The CPG states, “it is important for clinicians to understand that patients with neck pain often exhibit signs and symptoms that fit more than 1 classification, and that the most relevant impairments of body function and the associated intervention strategies often change during the patient’s episode of care. Thus, continual re-evaluation of the patient’s response to treatment and the patient’s emerging clinical findings is important for providing the optimal interventions throughout the patient’s episode of care.” So pay attention to how a patient presents in front of you right now when determining treatment strategy. The third component of evaluation and intervention is staging the patient based on level of acuity.  One of the benefits of the 2017 update is that the matched interventions are divided into what research has shown to be effective at different time-based stages where acute = <6 weeks, subacute 6-12 weeks, and chronic 12+ weeks. Still, when applying these stages its important to correlate the time based staging with the level of irritability the patient presents with. Theoretically we could assumed that an acute presentation has a higher level irritability and thus, pain experienced at rest and at initial ranges before tissue resistance; a subacute presentation should have moderate irritability and thus pain experienced with mid ranges that worsen at end range; and a chronic presentation has low irritability and pain that worsens with end range movements, sustained positions, or overpressure into tissue resistance. However, this doesn’t always line up. So, when you are reading cases on the OCS, its important to not only pay attention to time since onset, but also, how irritable does this condition look? 

The fourth and final component is selecting and performing intervention based on the classification and stage of the patient. 

Let’s get into the classifications. In this episode, we’ll cover in depth the diagnosis and recommended interventions for: Neck pain with mobility Deficits, and neck pain with headaches.

Neck pain with mobility deficits will typically come with symptoms such as central and/or unilateral neck pain, limitation in neck motion that consistently reproduced symptoms, and associated or referred shoulder girdle or upper extremity pain.  The common exam findings o look for are as follows: limited cervical ROM, neck pain reproduced at end ranges of active and passive ROM, restricted cervical and thoracic segmental mobility, neck and referred pain reproduced with provocation of the involved cervical or upper thoracic segments or cervical musculature, and then in subacute and chronic cases, you can expect to find deficits in cervical, scapular, and thoracic strength and motor control. 

Now as we cover treatment strategies, you’ll note that the best evidence almost always supports a multimodal treatment approach including both manual therapy and exercise interventions. You’ll also note that for each stage, thoracic manipulation and cervical manipulation and mobilization are always recommended. For the acute stage of neck pain with mobility deficits, the best evidence, receiving a B level recommendation is to perform thoracic manipulation, supervised neck ROM, stretching, and isometric exercises, and scapulothoracic and upper extremity stretching and strengthening. Cervical manipulation and/or mobilization may also be performed and receives a C level recommendation. And this just makes sense for the acute stage.  You are almost always going to be able to manipulate the thoracic spine, while irritability of the cervical spine be prohibitive to manipulation especially in this stage, so that should be easy to remember. Other interventions in this stage can include general fitness, advice to stay active, home cervical ROM and isometric exercise. 

For he next two stages, subacute and chronic, there should be decreasing focus on manual therapy, and increasing focus on exercise.  So for subacute neck pain with mobility deficits, the strongest evidence receiving B level recommendation is for neck and shoulder girdle endurance exercise. Then consider thoracic manipulation and cervical manipulation and/or mobilization, which receive a “C” level recommendation.

IN the chronic stage, the strongest evidence, again “b” level recommendation is for a multimodal approach made up of the following: thoracic manipulation and cervical manipulation or mobilization; Mixed exercise for cervical and scapulothoracic region including neuromuscular training, stretching, strengthening, endurance, aerobic conditioning, and cognitive affective strategies; and finally modalities are recommended including dry needling, laser, or intermittent traction. Separately there is a C level recommendation for neck, shoulder girdle, and trunk endurance exercise approaches along with education and counseling to promote active lifestyle. So, the general theme with the mobility deficits category is including thoracic manipulation and at least cervical mobilization if not manipulation AND exercise. The more acute phase has greater focus on manual therapy, especially thoracic manipulation, and exercise is more focused on ROM and stretching; Subacute focuses more on more aggressive exercise such as cervical, thoracic, and scapular endurance , but still includes thoracic manipulation and cervical mobilization or manipulation; and then in the chronic phase,  you basically want to include all of these with general fitness, and some of the cognitive affective training strategies, which make sense with a chronic presentation. Another important thing to note about the chronic phase is that some modalities ARE recommended: the best evidence being for dry needling, low level-laser and intermittent traction. However this is one of the few treatment categories across all of physical therapy literature where there is still some support although very weak, for using pulsed or high powered ultrasound and TENS or EMS for short term pain relief

That was a lot, so let’s apply this to a case. 

A 32 year old female presents to PT with an 3 week history of left sided neck pain. She reports when it started she woke up in the middle of the night laying on her stomach and when she went to move she could not turn her head to the left and had a lot of trouble getting comfortable to go back to sleep due to the pain in her neck. She reports the pain has improved some but that she still has pain at rest. She has been taking tylenol, but that only provide some short-term relief and she prefers not to take medicine if she can avoid it. She reports pain at rest of 3/10, and pain of 6/10 if she tries to turn her head to the left or look up and that she is still having trouble sleeping because of her neck pain. Clinical exam reveals: 

  • Limited and painful cervical AROM with L rotation of 45 degrees which reproduces L neck and shoulder pain; and R rotation of 75 degrees during which she reports a pull in the L side of her neck. 
  • Normal dermatomes, myotomes, and deep tendon reflexes
  • Grossly 4/5 in upper extremity MMT
  • Pain reproduced into L periscapular region and L posterior shoulder with UPA to L C5

What is the most appropriate action at this time?

A.    treat with thoracic manipulation and cervical AROM exercises

B.    treat with cervical endurance exercise 

C.     refer to PCP due to having red flag of “night pain”

D.    treat with a home program of upper trapezius stretches and aerobic exercise

First, lets see if we can rule out any options. Option C , “refer to PCP due to red flag of “night Pain” is not a good answer, since this doesn’t truly classify as a true red flag because the reason for her night pain is clearly related to position. Although options B and D are likely acceptable treatments for this patient, both are incorrect because (1) they do not include any manual therapy to the thoracic or cervical spine, and (2) because they fit better in later, less irritable stages of neck pain with mobility deficits. Option A is correct because the strongest recommendation for patients presenting with neck pain with mobility deficits is to provide thoracic manipulation, cervical ROM exercises, and scapulothoracic and UE stretching and strengthening. Notice a couple things about this question that are very common for OCS questions. First, most of the answers are very plausible, but one answer is “best”. Second, It didn’t ask you what classification this patient fits in or what stage they fit in, rather, it asked you to reason and apply that information. 

This seems like a good time to bring up a clinical prediction rule for cervical manipulation that this patient actually meets by Puentedura et al in 2012. So far this is in the derivation phase, but still has made enough impact that it is probably something you should know even though the CPG is not ready to adopt it yet. The CPR is as follows:

  • symptom duration less than 38 days
  • positive expectation that manipulation will help
  • side to side difference in cervical rotation ROM of 10 deg or more
  • pain with PA spring testing of the middle cervical spine

Having ¾ factors was highly sensitive and specific to identify positive responders to cervical manipulation in their derivation study. So if the correct answer said cervical manipulation instead of thoracic manipulation in the question above, based both on this clinical prediction rule and the practice guideline, that still would have been the best answer. 

Due to the similarity of the two categories, we’ll cover neck pain with headaches next. (As side note, David will be coming in with a little more in depth discussion on headaches later on, for today, we’ll just cover whats in the CPG.) The neck pain with headaches category is bascally the neck pain with mobility deficits category, but applied to the upper cervical spine. The classification of neck pain with headache can be made when a patient presents symptoms such as: non-continuous, unilateral neck pain with associated (referred) headache, and/or a headache that is precipitated or aggravated by neck movements or sustained positions and postures. The expected exam findings are: positive cervical flexion rotation test (which we’ll cover in a minute), headache reproduced with provocation of the involved upper cervical segments, limited cervical ROM, restricted upper cervical mobility, and strength, endurance, and coordination deficits of the cervical muscles (an example of which would be having a positive cranial cervical flexion test, which we’ll cover along with our discussion of neck pain with movement coordination impairments in our next episode). The cervical flexion rotation test was a new test added in the 2017 CPG update. It is a test to differentiate mobility deficit in the c1-2 segment from the rest of the cervical spine and is a useful test to perform both for patients in this classification and with the mobility deficit category if you are looking to rule out upper cervical mobility deficit. The patient lies supine and the clinician maximally flexes the neck to end range, and maintains this while passively rotating the head to the left and right until either onset of pain or resistance is felt. Obviously, not a test to do with someone in whom you suspect upper cervical instability! Normal is considered 39-45 deg either direction, and the cutoff for a positive test is considered less than 32 deg, or a 10 deg difference side to side in visually estimated range of motion. 

On to treatment. Overall you’ll notice some gaps in the literature here, and in some cases, a treatment may be left out not because there is evidence against, but because there has not yet been a study done with a population in that level of acuity. In the acute phase the only recommendations are, B level recommendation for supervised active mobility exercise, and C level recommendation for C1-2 self-sustained natural apophyseal glide or “self-SNAG” exercise. You see manual therapy is conspicuously left out, not because there is evidence against, but because there have not been studies on  manual therapy for cervicogenic headache specifically in the acute phase. For subacute neck pain with headache the strongest recommendation (level B) is for cervical manipulation and mobilization, and a C level recommendation for the C1-2 self-SNAG exercise. For chronic presenations, B level recommendation supports a combination of cervical or cervicothoracic manipulation and/or mobilization and shoulder girdle and neck stretching, strengthening, and endurance exercise, which in the studies referenced typically included craniocervical flexion training with pressure biofeedback and other common isometric cervical strengthening. To recap, Acute neck pain with headaches should receive the C1-2 self-SNAG exercise, Subacute should receive cervical manipulation along with the C1-2 self-SNAG exercise. And chronic cases should receive multimodal treatment including manipulation, shoulder girdle and neck stretching, strengthening and endurance exercise. 

That wraps up part 3 of our neck pain clinical practice guideline series. Be on the lookout for our next episode which will cover neck pain with movement coordination impairments, and neck pain with radiating pain. 

Treatment-Based Classification Overview
Neck Pain with Mobility Deficits Diagnosis
Neck Pain with Mobility Deficits Treatment
Patient Case
Cervical Manipulation CPR
Neck Pain with Headaches Diagnosis
Neck Pain with Headaches Treatment