This information-packed episode finishes the 2017 neck pain CPG by covering diagnosis and treatment of neck pain with movement coordination impairments and neck pain with radiating pain. Additionally, Austin covers a CPR for cervical radiculopathy (and points out where it needs to be updated) and a CPR for intermittent cervical traction.
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Hello and welcome back to the OCS field guide podcast. Today we will wrap up our coverage of the 2017 Neck pain CPG update with the final two treatment based classifications: Neck pain with movement coordination impairments and neck pain with radiating pain. We’ll cover these two classifications and along the way cover some important tests and a CPR you should probably know.
Let’s jump right in with neck pain with movement coordination impairments. The first thing you need to know about this classification is that, of all the classifications, it probably changed the MOST from the 2008 CPG to this version. This classification began as the “exercise and conditioning” classification before being renamed movement coordination impairments, which goes along with the naming system for low back pain. This classification described patients with chronic symptoms (>12 weeks), cervical motor control, endurance, and strength deficits, flexibility deficits in upper quarter muscles, and ergonimic inefficiencies. However, in the CPG update, all of the new literature reviewed associated with this category was actually specific to patient whiplash associated disorder, so you’ll notice a big shift in focus in the diagnosis as well as the treatment sections toward managing the patient recovering from trauma. You will notice, however, in the new mobility deficits category there is a much bigger focus on exercise addressing these same kind of strength, motor control, endurance deficits in the chronic stage in addition to manual therapy. So, I believe that in the new classification definitions, mobility deficits has taken over some of the patients that would have formerly fit into movement coordination impairments due to chronicity, that actually would benefit more from including manual therapy strategies in addition to the strong exercise focus. All that to say, the 2017 CPG update focuses primarily on whiplash or some sort of trauma as the mechanism of injury for the movement coordination impairments section. Without further ado, the common symptoms that should lead you to classifying a patient as having neck pain with movement coordination impairments are: mechanism of onset related to trauma or whiplash, associated (referred) shoulder girdle or upper extremity pain, Associated varied nonspecific concussive signs and symptoms, Dizziness/nausea; Headache, concentration, or memory difficulties; confusion; hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli; and heightened affective distress. The expected exam findings include: positive cranial cervical flexion test, positive neck flexor muscle endurance test, positive pressure algometry, Strength and endurance deficits of the neck muscles, Neck pain with mid-range motion that worsens with end-range positions, Point tenderness that may include myofascial trigger points, Sensorimotor impairment may include altered muscle activation patterns, proprioceptive deficit, and postural balance or control deficits, and Neck and referred pain reproduced by provocation of the involved cervical segments. Let’s pause here to go over the specifics about three of those tests, the cranial cervical flexion test, neck flexor muscle endurance test, and pressure algometry.
The cranial cervical flexion test is more of a motor control test of the deep neck flexor muscles. The patient is in supine with a pressure biofeedback cuff under their neck inflated to 20mmhg; the patient must initiate cranial cervical flexion sufficient to increase pressure to 22, 24, 26, 28, and 30mmhg, holding each level 10 seconds, with 10 seconds rest in between. Successfully completing at least through the 26mmhg level is considered a normal test, while abnormal would be either not being able to generate sufficient pressure to make it to the 26mmhg level, being unable to hold for 10 seconds, or having significant mm substitutions with superficial musculature during the test..
The neck flexor muscle endurance test is similar, but doesn’t require any equipment and is more focused on endurance. The patient is supine in hooklying and maximally tucks the chin and lifts the head an inch above the mat as long as possible without loosing that position. The clinician monitors the skin folds in the anterior neck and places a hand under the head. The test ends when the patient looses the chin tuck or touches the head down for more than a second. Average score for individuals without neck pain is 39 seconds, while average with neck pain is 24 seconds.
Pressure algometry is a way to objectively measure pain pressure thresholds. There aren’t specific cutoff scores mentioned though, so we won’t talk about it too much. But I did want to mention that this is a new test they include in the update and they recommend using it to classify pain presentations as having local mechanical hypersensitivity (aka, lower thresholds only at the site of the injury, in this case, the neck) versus having global lowered pain pressure thresholds, which could clue you in to central pain processing issues.
Let’s move on to treatment. If you’ve listened to the first neck pain cpg podcast on the clinical course of neck pain, you’ll remember that traumatic onset neck pain typically follows one of three possible clinical courses: (1) patients with mild disability and post traumatic stress who will likely have full and quick recovery, (2) patients with moderate disability and post traumatic stress who will have improvement, but likely incomplete recovery, and (3) patients with severe disability and post-traumatic stress who are likely to have chronic problems and incomplete recovery. Remember also that we use 5 constructs to determine if the patient will have a good or poor prognosis: high pain intensity on the NPRS, high self reported disability on the NDI, pain catastrophizing, high post-traumatic stress, and cold hyperalgesia. For the specifics on these constructs, refer back to the first neck pain CPG episode.
In the acute stage, for patients who fit any of the prognosis catagories, the best evidence, receiving a “B” level recommendation is to educate the patient to return to normal, nonprovocative preaccident activities and activity level as soon as possible; minimize use of cervical collar; and to perform postural and mobility exercises in order to decrease pain and improve ROM; and to reassure the patient that significant recovery is expected to occur within the first 2-3 months. For the other recommended interventions we can classify the patient as either low or high risk for chronicity using the information we just discussed. For patients at low risk for chronicity there is a C level recommendation for providing one session of early advice, exercise instruction, and education and at least one follow up including comprehensive exercise program (including strength and/or endurance with/without coordination exercises), and use of TENS. For patients expected to experience moderate to slow recovery, there is a B level recommendation for a multimodal approach using: manual mobilization and/or manipulation PLUS exercise including strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises PLUS modalities such as ice, heat, and TENS. So to summarize, treatment in the acute phase should be focused more on education and gentle exercise, especially if the patient presents with mild symptoms, but you should be including exercise and manual therapy for patients that demonstrate higher pain, disability, and post traumatic stress. For patients in the chronic phase there is C level recommendation that therapists may provide: (1) Patient education and advice focusing on reassurance, encouragement, prognosis, and pain management; (2) Mobilization combined with an individualized, progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioral therapy; and (3) TENS. You’ve probably noticed that TENS is recommended a number of times, but remember this is never recommended as a stand-alone treatment, but rather within a multimodal active treatment approach.
Now on to neck pain with radiating pain. The classification of neck pain with radiating pain is made when a patient presents with the following clinical presentation. Common symptoms include neck pain with radiating pain into the upper extremity (which is defined as a narrow band of lancing pain) and upper extremity dermatomal paresthesia or numbness and or myotomal muscle weakness. Exam findings should include neck and upper extremity symptoms reproduced or relieved with radiculopathy cluster testing. Including: positive upper limb neural mobility testing, pain reproduced with Spurling's maneuver, symptoms relieved with the cervical distraction test, and pain reproduced or relieved with cervical range of motion. Patients also may present with objective upper extremity sensory, strength, or reflex deficits. You may have recognized that cluster if you’ve been studying some of the diagnostic clinical prediction rules. The cluster they describe is a slightly more general take on a clinical prediction rule presented by Wainner et al in 2003 which was: positive upper limb tension test A (or median nerve bias); Positive Spurling's; positive distraction test; and cervical rotation ROM of less than 60 deg to the involved side. This is a good clinical prediction rule to know, however I’ll remind you that one of the goals of the CPG update was to move away from some of the CPRs like this that have not been fully validated, so that’s why their criteria are a little more inclusive. And this just makes sense for a couple of reasons, the MOST sensitive of the upper limb tension tests is upper limb tension test 1/A which is median nerve bias, but that doesn’t mean you won’t have patients that do have radiculopathy, that due to which nerve root is involved may have other positive ULTT. Also, on cervical ROM, rotation ROM of less than 60 deg may be more specific to cervical radiculopathy, but you’re probably going to miss some people that do have cervical radiculopathy if you take more strict definition, thus the CPG keeps it a little more general and intuitive by saying neck and upper extremity radiating pain reproduced or relieved by cervical ROM.
As a bonus lets go through how to perform the most need to know upper limb tension tests. As we said, the most sensitive ULLT for cervical radiculopathy is ULTT A, or the median nerve bias, so we’ll cover that first. The patient is positioned in supine and placed in a series of positions that will progressively load the median nerve, while the therapist monitors at each point for onset of symptoms. First the shoulder girdle is fully depressed, then the shoulder is abducted to 90 degrees, then the wrist and fingers are extended fully, then the forearm is supinated and the shoulder is fully externally rotated, then the elbow is brought into full extension until the patient feels symptoms. At that point you stop and maintaining this position at each joint mentioned, you have the patient first sidebend the neck away from the test side, and then toward the test side. The test is considered positive if this test reproduces all or part of the patient’s familiar symptoms, if there is a 10 deg or more difference in the amount of elbow extension achieved, or if on the symptomatic side, sidebending the neck away increases symptoms while sidebending toward the symptomatic side decreases symptoms. To repeat, the median nerve biased upper limb tension test is combining full shoulder girdle depression, shoulder abduction, wrist and finger extension, forearm supination, and elbow extension. In contrast, the ulnar nerve biased upper limb tension test, or ULTT 3, also begins with shoulder girdle depression, shoulder abduction, and wrist and finger extension, but then it differs in that the forearm is maximally pronated, and then the elbow is slowly flexed until the patient reports symptoms or end range is met, and then the neck is sidebent away and then toward. The final ULTT test to know is the radial nerve bias. This one is a little different, though it also begins with full shoulder depression. The arm is then fully internally rotated and the forearm fully pronated. Then the thumb and fingers are flexed, then the wrist ulnarly deviated (think of the wrist/hand in a finklestein’s test position, and remember this could cause pain in someone with deQuarvain’s tenosynovits), then the shoulder is slowly abducted until symptoms are reported or 90 deg. Then sidebend the neck away and then toward taking note of symptoms at each step along the way. I recommend if you aren’t already, to get comfortable doing these tests over and over in the clinic or on your unsuspecting housemate to get most comfortable with the positions. Rather than just memorizing all the positions, you’ll get the most bang for you buck by knowing the path of each of these nerves in the arm. If you know that not only will these tests be intuitive, but you will also find the peripheral mononeuropathies to be much easier to learn and retain.
Let’s head back to neck pain with radiating pain and discuss treatment. Of all the areas, there has been the least update here from the 2008 CPG, so I’ll repeat the 2008 recommendations which include; B level recommendation for upper extremity neural mobilization techniques; C level recommendation that centralization exercise are NOT beneficial in reproducing disability compared to other interventions; and a B level recommendation for a combined intermittent traction with manual therapy, stretching and strengthening exercise. The 2017 update separates interventions into acute and chronic categories. In the acute phase, the only recommendation is a C level recommendation treatment involving mobilizing and stabilizing exercise, low level laser, and possible short-term semi-hard collar use. For the chronic category, there is B level recommendation for combined approach involving intermittent traction, cervical mobilization and stabilization exercises, PLUS cervical and thoracic mobilization and/or manipulation. There is a second B level recommendation for education and counseling that encourages engaging occupational and exercise activities.
This is a good time include a clinical prediction rule derived by Raney et al in 2009 for patients likely to benefit from intermittent traction and exercise. The CPR includes 5 criteria: Age >/= 55; positive shoulder abduction test (which is defined as an alleviation of symptoms when the patient rests their hand on their head, which relieves tension on cervical nerve roots); positive upper limb tension test A, positive neck distraction test, and symptom peripheralization with PA testing of the lower cervical spine. This shares two constructs with the cervical radiculopathy cluster, positive neck distraction and upper limb tension test A, so that should be easy to remember, and tell you how important those tests are. If a patient has 3 or more, this has a positive likelihood ratio of about 5 and if a patient has 4 or more, this has a positive likelihood ratio of 23, which translates to a post-test probability of 95% that the patient will have success with a combination of intermittent traction and exercise. In case you were wondering the two exercises they used were a seated posture exercise where the patient is cued to sit up straight and hold that position repeatedly, and the supine deep neck flexor endurance exercise.
We’ve covered a lot of information, so let’s dive into a practice question that will make you apply the information covered both treatment based classification episodes:
A 42 year-old male presents outpatient physical therapy clinic with a script for treatment of cervical radiculopathy. He reports having right sided neck pain and pain around the back of his shoulder blade that sometimes extends into the R upper arm that began about 3 months ago. He reports not knowing exactly what started this pain, but that he had helped a friend move the day before. He denies any numbness, tingling, or weakness in his arms and reports that his PCP did a radiograph which showed that he has degenerative disc disease, but that no other imaging or testing has been ordered at this time. Your clinical exam reveals the following:
What is the most appropriate treatment approach?
A. Intermittent cervical traction and instructing in postural exercise
B. Deep neck flexor endurance exercise and education on resuming normal preinjury activities
C. Perform thoracic manipulation and instruct in cervical mobility exercise
D. Intermittent cervical traction and home TENS unit.
Let’s work through the case. This one is tricky because the patient comes in with a diagnosis of cervical radiculopathy, degenerative disc disease, and upper extremity pain, but you still have to look at the patient presentation in front of you to determine your treatment strategy. The only history and clinical finding that would lead you toward classification of neck pain with radiating pain is neck and UE pain reproduced with cervical ROM and however, the patient has no neuro signs, and has negative upper limb tension testing. Its also tricky because it requires you to know what a true positive Spurling's test and neck distraction test are. A true positive Spurling's is one that reproduces radiating pain or neuro symptoms, and in this case it only reproduced local neck pain, which is known as a positive quadrant test, and a positive neck distraction test is one that relieves or centralizes radiating pain rather than reproducing neck pain, which did in this case. So, you can pretty confidently knock out answers A and D because you can’t classify the patient as neck pain with radiating pain which lead you to perform intermittent traction. Answer B may be a good exercise and recommendation, but it does nothing to address the patient’s objective ROM deficit and is not the BEST approach for the presentation in front of you. Answer C is correct, thoracic manipulation and cervical mobility exercise, because this patient actually fits best in the chronic neck pain with mobility deficits category. It’s important to note that neck pain with associated or referred upper extremity pain is on of the common symptoms associated with 3 of the classifications, mobility deficits, movement coordination impairments, and radiating pain. So if a patient presents with neck and related arm pain, you can’t automatically assume they need cervical traction. Be sure you look at ULTT, and true positive findings on Spurling's and the cervical distraction test to tease this out.
That wraps up our coverage of the 2017 neck pain clinical practice guideline update. Thanks for listening, and remember: the best way to ingrain this material is to apply it in the clinic. This week, try to take one neck pain patient every day and apply the information from this classification system, and see what happens.