The Neck's Tale: Exploring Cervicalgia and Recommended Treatment Strategies

Cervicalgia, simply put, is neck pain. However, this seemingly straightforward term encompasses a wide range of causes and complexities. From muscle strains to herniated discs and degenerative changes, our necks can experience various issues that lead to discomfort and pain. As physiotherapists, our goal is to get to the root of the problem and provide targeted solutions.

Causes of Cervicalgia

As a physiotherapist, the approach involves thorough assessment of individual situation to identify the underlying causes of cervicalgia. It includes the following:

• Muscle Strain and Imbalance - poor posture or sudden movements can strain the muscles supporting the neck.
• Poor Posture - prolonged sitting and device use plus slouching or craning the neck forward for extended.
• Herniated Discs - it can result in pain, numbness, or tingling sensations down the arms.
• Degenerative Changes - changes such as osteoarthritis and spinal stenosis can narrow the spinal canal and put pressure on nerves, causing cervicalgia.
• Trauma and Injuries - Accidents, falls, or sudden impacts can result in neck injuries.
• Stress - manifest physically as muscle tension in the neck and shoulders. Persistent stress-related muscle tension can contribute to chronic cervicalgia.
• Poor Ergonomics -  Incorrect ergonomics during tasks like typing or reading.
• Repetitive Movements - such as continuous lifting or twisting of the neck, can strain the neck muscles and lead to discomfort over time.
• Health Conditions - fibromyalgia, rheumatoid arthritis, or cervical spondylosis.
• Lack of Physical Activity -  Inactivity weakens the muscles.

 

How to Diagnose Cervicalgia

A thorough diagnosis is the foundation of effective treatment. It includes following details:

• Comprehensive Assessment - a detailed assessment about the symptoms, medical history, and any recent injuries or activities that might have triggered the pain.
• Physical Examination -  a hands-on physical examination is crucial. Evaluation of posture, neck's range of motion, and identifying  any muscle tension or tender points in the neck and surrounding areas.
• Neurological Assessment – performing neurological tests to assess muscle strength, reflexes, and sensory responses in your arms and hands.
• Functional Testing – asking  about tasks that exacerbate the pain and any positions that provide relief.
• Movement Analysis - analyze the movement patterns, looking for abnormalities or compensations that might contribute to your cervicalgia
• Specialized Tests - use specific tests to narrow down potential causes. For example, if a herniated disc is suspected, use tests to reproduce the symptoms and confirm the diagnosis.
• Diagnostic Imaging - identifying any underlying issues like disc herniations or degenerative changes.

 

Differential Diagnosis

• Cervical Radiculopathy
• Cervical Herniated Disc
• Cervical Osteoarthritis
• Cervical Spondylosis
• Tension Headaches
• Fibromyalgia
• Myofascial Pain Syndrome
• Thoracic Outlet Syndrome
• Referred Pain from Upper Back or Shoulder

Types of cervicalgia Pain

As a physiotherapist, It is important to understand the different types of cervicalgia pain. Here's a breakdown of the various types of cervicalgia pain:

Muscular Pain:

It's often characterized by aching, tightness, or discomfort in the muscles of the neck and upper back. This type of pain can result from muscle strains, overuse, poor posture, or muscle imbalances.

Sharp or Stabbing Pain:

IT is triggered by specific movements or activities. It might indicate nerve involvement or irritation, such as in cases of cervical radiculopathy.

Dull Ache:

It's often associated with muscle tension, postural issues, or chronic conditions like osteoarthritis.

Radiating Pain:

Radiating pain is when discomfort extends beyond the neck area and travels down the arms. This can be indicative of nerve compression, such as a herniated disc pressing on nerve roots. The pain might be accompanied by numbness, tingling, or weakness in the affected arm.

Stiffness and Limited Range of Motion:

Patients might find it challenging to turn their head or tilt it sideways. This can be due to muscle spasms, joint inflammation, or even psychological factors like stress.

Tension Headaches:

These headaches often start at the base of the skull and radiate to the forehead. They are frequently associated with muscle tension and poor posture.

Trigger Points:

Trigger points are localized areas of muscle that are sensitive to touch and can refer pain to other areas. Patients might feel knots or tender spots in their neck muscles, contributing to their cervicalgia.

Numbness and Tingling:

These sensations might occur in the neck, shoulder, or arm, pointing to nerve involvement or compression.

Intermittent Pain:

Some individuals experience intermittent cervicalgia, where pain comes and goes. It might be linked to specific activities, postures, or even weather changes. Identifying the triggers is essential for managing this type of pain.

Chronic Pain:

Chronic cervicalgia refers to persistent pain that lasts for greater then six months. It can significantly impact an individual's quality of life, leading to sleep disturbances, decreased activity levels, and emotional distress.

Clinical Tests to Diagnose Cervicalgia

These tests help us gather information about patients symptoms, movements, and physical responses, aiding in accurate diagnosis and treatment planning:

Cervical Range of Motion (ROM) Assessment:

This involves measuring your neck's range of motion in different directions, such as flexion, extension, lateral bending, and rotation. Limited range of motion can provide clues about muscle stiffness, joint dysfunction, or other issues.

Spurling's Test:

This test is used to assess nerve root compression. Patient is asked to tilt his head to one side while physiotherapist gently applies downward or axial pressure on head. If this reproduces symptoms or causes radiating pain, it might indicate nerve irritation or compression.

Cervical Compression Test:

This test involves gently pressing down on the top of your head while patient is seated. If this causes pain or radiating symptoms, it suggests nerve root compression or other structural issues.

Distraction Test:

In this test, the physiotherapist  gently lift head of patient upwards, relieving pressure on the cervical spine. If this provides relief from your symptoms, it could indicate issues like disc compression or joint dysfunction.

Upper Limb Tension Test (ULTT):

This series of tests assesses the tension and mobility of nerves in the upper limb. It helps identify if nerve tension or irritation is contributing to your cervicalgia.

Palpation and Muscle Testing:

The physiotherapist palpates (touch and feel) various muscles and structures in your neck to identify areas of tenderness, muscle tightness, or trigger points. Manual Muscle testing helps assess muscle strength and imbalances.

Joint Mobilization Assessment:

Physiotherapists assess the mobility of individual cervical joints through passive movements. Restricted joint mobility can contribute to cervicalgia.

Postural Assessment:

Observing the patients standing and sitting posture can reveal any misalignments or imbalances that might be contributing to your cervicalgia.

Neurological Examination:

This assessment evaluates sensory, motor, and reflex responses in upper limbs. It helps identify nerve-related issues like cervical radiculopathy.

Exercises for Cervicalgia

The physiotherapist targets the following muscles like the upper trapezius, levator scapulae, and pectoralis major etc. Below is a list of exercises that can be performed.

Neck Stretches:

Neck Flexion Stretch: Gently tuck your chin toward your chest, feeling a stretch at the back of your neck.

Neck Extension Stretch: Look up towards the ceiling while keeping your chin level, feeling a stretch along the front of your neck.

Neck Range of Motion Exercises:

Neck Rotation: Turn your head to one side, then the other, while keeping your shoulders relaxed.

Neck Lateral Bending: Gently tilt your ear towards your shoulder, holding the stretch on each side.

Scapular Squeezes:

Squeeze your shoulder blades together without shrugging your shoulders. This helps improve posture and reduces strain on the neck.

Shoulder Shrugs:

Elevate your shoulders towards your ears, hold briefly, then relax. This can relieve tension in the neck and shoulder muscles.

Isometric Neck Exercises:

Isometric Neck Flexion: Place your palm against your forehead and gently press, while simultaneously resisting with your neck muscles.

Isometric Neck Extension: Place your palms against the back of your head and gently press, resisting with your neck muscles.

Isometric Lateral Flexion: Place one hand against the side of your head and gently press, resisting with your neck muscles.

 

Pectoral Stretch:

Stand by a doorway with your elbow bent at 90 degrees and your forearm resting on the door frame. Gently turn your body away, feeling a stretch in your chest and front shoulder.

 

Upper Trapezius Stretch:

Gently tilt your head to one side, then use your opposite hand to gently pull your head towards your shoulder, feeling a stretch along the side of your neck.

 

Chin Tuck with Thera Band:

Loop the thera band around the back of your head and hold the ends with your hands. Gently perform chin tucks against the resistance of the band.

Levator Scapulae Stretch:

1. Gently tilt your head to the side and rotate it slightly, then bring your chin towards your armpit.
2. Use your hand to gently guide your head for a deeper stretch.
3. Hold for 20-30 seconds on each side.

Manual Therapy Techniques:

Manual therapy is a hands-on approach that involves the skilled manipulation of joints, muscles, and soft tissues to reduce pain, improve mobility, and enhance overall function. It's a commonly used technique in physiotherapy to treat various musculoskeletal conditions, including cervicalgia.

Thoracic spine self-mobilization technique:

Kaltenborn’s wedge:

Patients performs a dorsal push with his body on the wedge at each dorsal segment.

 

Foam Roller Extension:

1. Lie on your back with a foam roller placed horizontally under your upper back.
2. Support your head with your hands, interlocking your fingers behind your head.
3. Use your legs to gently roll back and forth along the foam roller, targeting the thoracic region.
4. If you find a tender or tight spot, pause and allow the foam roller to provide gentle pressure to that area for about 20-30 seconds.

Rotation Mobilization:

1. Sit or stand with your arms crossed over your chest.
2. Slowly rotate your upper body to one side, allowing your head and shoulders to follow the movement.
3. Hold the end position for a few seconds, feeling a gentle stretch.
4. Return to the center and then repeat the rotation to the opposite side.

 

Upper cervical translational mobilization

Upper cervical translational mobilization increases upper cervical spine range of motion both in the short- and mid-term scenario in patients with chronic mechanical neck pain and restricted upper cervical rotation.

Cervical Translational Mobilization:

Cervical translational mobilization is typically performed as following:

1. Patient Positioning: The patient is usually seated comfortably on a treatment table or chair. The physiotherapist will ensure the patient's posture is aligned properly before starting the technique.
2. Stabilization: The physiotherapist will use one hand to stabilize the patient's head while the other hand is used to perform the mobilization. Stabilization is crucial to ensure that the movement is targeted to the specific vertebra being treated.
3. Gliding Movement: The physiotherapist will gently apply a controlled gliding movement to the targeted vertebra in a specific direction. The direction of the glide will depend on the patient's individual condition and the assessment of their mobility restrictions.
4. Patient Participation: Depending on the patient's tolerance and comfort, they may be asked to actively participate by performing slight movements in coordination with the therapist's mobilization. This active involvement can enhance the effectiveness of the technique.
5. Dosage and Progression: The physiotherapist will adjust the force, speed, and amplitude of the gliding movement based on the patient's response. Treatment dosage and progression will be tailored to the patient's specific needs and tolerance.
6. Assessment and Reassessment: Before and after performing the mobilization, the physiotherapist will assess the patient's range of motion, pain level, and any changes in symptoms. Reassessment helps determine the effectiveness of the technique and guides further treatment.

Inhibitory Suboccipital Technique:

Inhibitory Suboccipital technique improves the flexion–rotation movement in the short-term scenario.

Inhibitory Suboccipital Technique:

Here's how the Inhibitory Suboccipital technique is typically performed:

1. Patient Positioning: The patient is usually positioned lying on their back on a treatment table. The head and neck are supported comfortably with a pillow or towel roll.
2. Therapist Positioning: The physiotherapist stands at the head of the table and positions their fingers or thumbs on the Suboccipital muscles, which are located just below the occipital bone (the bony prominence at the back of the skull).
3. Gentle Pressure: The physiotherapist applies gentle and sustained pressure to the Suboccipital muscles using their fingers or thumbs. The pressure is directed downward and slightly posteriorly, towards the table. The goal is to release muscle tension and promote relaxation.
4. Breathing: The patient is usually guided to take slow and deep breaths during the technique. Deep breathing helps enhance relaxation and allows the muscles to respond more effectively to the pressure.
5. Feedback and Communication: The patient's comfort and tolerance are monitored throughout the technique. Communication between the patient and physiotherapist is important to ensure that the pressure is within the patient's comfort level.
6. Duration: The pressure is usually applied for around 20 to 30 seconds at a time. The physiotherapist may release and reapply pressure as needed to gradually release tension.
7. Reassessment: After the inhibitory suboccipital technique is performed, the physiotherapist will assess the patient's response. This may include checking for changes in muscle tension, pain levels, and any improvements in range of motion or discomfort.

Clinical Scenario of Cervicalgia

Meet Jane, a 35-year-old office worker who recently started experiencing neck pain. She describes the pain as a constant dull ache at the base of her neck that occasionally radiates down her right arm. Jane's pain started after a long day at work, where she spent several hours hunched over her computer.

Assessment:

Patient History: During the initial assessment, physiotherapist sat down with Jane to discuss her symptoms, medical history, and any relevant activities that might have triggered her pain. She mentioned her sedentary job and how she often craned her neck forward while working.

Physical Examination:

The physiotherapist performs a physical examination, assessing her posture, neck range of motion, muscle tension, and neurological responses. He noticed that Jane's posture showed signs of forward head posture, and she had limited neck rotation.

Special Tests:

To further assess her condition, physiotherapist conducted Spurling's test, which reproduced her radiating pain down the arm when her head was tilted to the right.

Diagnosis:

Based on the assessment, it appeared that Jane was experiencing cervicalgia with potential signs of nerve involvement. Her forward head posture and prolonged computer use were likely contributing factors. The Spurling's test indicated possible nerve compression.

Treatment Plan:

1. Postural Education: The physiotherapist explaines to Jane how her posture was affecting her neck and recommended ergonomic adjustments to her workstation. 
2. Manual Therapy: He incorporated joint mobilizations to improve the mobility of her cervical spine, focusing on the affected segments. Soft tissue mobilizations were used to release tension in her neck and upper back muscles.
3. Therapeutic Exercises:
4. Neck Stretches: Jane was taught neck flexion and extension stretches to relieve muscle tension.
5. Chin Tucks: Physiotherapist showed her how to perform chin tucks to strengthen her neck muscles and improve alignment.
6. Scapular Squeezes: To address her rounded shoulders, scapular squeezes were incorporated to strengthen her upper back muscles.
7. Neural Gliding Exercises: Given her radiating symptoms, He introduced neural gliding exercises to help improve the mobility of her nerves and reduce irritation.

It is important to teach self-management techniques to patients, including taking breaks during work, maintaining proper posture, and practicing relaxation exercises to manage stress. The patient-therapist collaboration plays a crucial role in recovery and improving cervicalgia.