Cervicobrachial Syndrome

Original Editors -

Top Contributors - Jeremy Luytens, Tim Secretin, Rachael Lowe, Nick Van Doorsselaer and Thijs Van Liefferinge  

Introduction

Cervicaobrachial Syndrome (Cervicobrachalgia) is term that describes pain and stiffness of the cervical spine with symptoms in the shoulder girdle and upper extremity[1]. It can be associated with tingling, numbness or discomfort in the arm, upper back and upper chest with or without an associated headache[2].

This term is outdated and not commonly used in clinical practice, although it may still be used in some parts of the world.

Definition/Description

When there is a combination of neck complaints and (radiating) complaints in the arm, we can call it a cervicobrachial syndrome or cervicobrachialgia. It refers to a cervical syndrome with pain radiating into the upper limb. Cervicobrachial syndrome was, therefore, previously known as “lower cervical syndrome”. It is characterized by pain, numbness, weakness, and swelling in the region of the neck and shoulder. Also by pain and sensory disturbances that radiate from the cervical spine into the upper limb, in a more or less clear radicular pattern i.e. in the distribution of the ventral branch of a spinal nerve. more or less clear radicular pattern i.e. in the distribution of the ventral branch of a spinal nerve. Cervical radiculopathy is mostly a non- radicular phenomenon can be diagnosed for this presentation in presence of frank sensorimotor deficits in the related nerve root territory[3]. The term ‘’cervicobrachial syndrome’’ should denote a collection of neck and arm symptoms for which there is no known and proven cause. If a patient can be proven to have cervical radiculopathy or thoracic outlet syndrome, then the specific and objectively documented diagnosis should be used[4][5].

Clinically Relevant Anatomy

The cervicobrachial syndrome may be the result of cervical radiculopathy. This discogenic brachialgia is produced by lesions affecting the C5/6 and C6/7 motion segments. The topography of the cervical dermatomes and myotomes is such that the myotome generally does not underlie the corresponding dermatome. Many of the muscles of the upper portion of the trunk are mainly supplied by the cervical nerve roots and are often affected in cervical syndromes. These muscles include the rhomboids, the supra- and infraspinatus muscles, deltoid, serratus anterior and latissimus dorsi muscles. The cervicobrachial syndrome can also be the result of neurogenic and/or vascular compression in the thoracic outlet. In this case the brachial plexus, subclavian artery or subclavian vein are compressed due to the narrowing of spaces in this region[4]

Epidemiology /Etiology

Cervicobrachialgia has been estimated to be more prevalent than neck pain in isolation[6]. This complaint is common among the patients seeking physiotherapy interventions for neck and arm pain. Radhakrishnan et al. found recurrences in 32% of patiënts with cervicobrachial pain and discomfort over a period of 4.9 years.[7]

The occupation of most patients is manual work with continuous, repetitive tasks like computer work, writing, manipulating or moving objects and lifting or overhead work. Tasks that require holding the same neck position for a long period are provocative[5].

Characteristics/Clinical Presentation

We can only speak of cervicobrachial syndrome when the patient complains about pain and a neurological disorder like tingling, sensory disturbance or even a loss of motor skills in arm, hand and fingers. In some cases there is loss power and even motion control.

There are no agreed clinical criteria for a diagnosis of cervicobrachialgia but the findings commonly include pain and fatigue of the wrist, forearm, shoulders and neck. There may be a swelling sensation in the hands and an heaviness or numbness of the upper extremity. Pain is mostly increased by activity and relieved by rest, but sometimes the pain increases at night which provides sleeping problems.
Individuals report the sensation of wearing gloves when they are not. The symptoms can also be accompanied by heavy headaches[4][5].

The term “cervicobrachial syndrome” is used by some physicians to describe symptoms they suspect come from cervical nerve root irritation that cannot be documented, whereas other physicians reserve the term for patients whose symptoms may come from undocumentable thoracic outlet syndrome. Still other physicians use the term as a synonym for “myofascial pain syndrome” with symptoms in the neck and/or shoulder that are believed to arise in muscle[8].

Patients with cervicobrachialgia are more susceptible of sensomotoric stimuli. Even more so on the side where they have complaints. Their detection thresholds are elevated in comparison with patients without cervicobrachialgia.
There is a high prevalence that patients with cervicobrachialgia have poor postural control when compared with healthy patients[9].

Differential Diagnosis

A painful neck can occur due to different causes. Due to pain originating in the shoulders and arms (painful shoulder),cervical radiculopathy ,levator scapulae syndrome ,polymyalgia rheumatica (painful shoulder), early stage of rheumatic diseases (rheumatoid arthritis (any age) or ankylosing spondylitis (30 years)) or due to infections or bone lesions of the cervical spine (e.g. Spondylodiscitis, metastases). Sudden movements or repeated muscular strains can provoke cervical pains. Very often such pains are caused by irritation of the joints and ligaments. The fact that the vertebral artery and autonomic nerve fibres are very close proximity to the joints adds a neurovascular component. Other possible diagnoses are: trapped nerve, sprained shoulder muscles, supraspinatus tendinitis for shoulder pain with positive static muscle tests, sprained rib muscle for medial scapula pain, carpal tunnel syndrome if hand pins and needles only, epicondylitis if pain in the forearm.( 31, level of evidence 2A)

Just like thoracic outlet syndrome we can determine verifiable vascular compression or neurologic compression but in contrast to thoracic outlet syndrome, cervicobrachial syndrome has some unexplainable symptoms. These symptoms are similar to the symptoms of repetitive strain injury[10].

Diagnostic Procedures

A painful neck can occur due to different causes. Due to pain originating in the shoulders and arms (painful shoulder),cervical radiculopathy ,levator scapulae syndrome ,polymyalgia rheumatica (painful shoulder), early stage of rheumatic diseases (rheumatoid arthritis (any age) or ankylosing spondylitis (30 years)) or due to infections or bone lesions of the cervical spine (e.g. Spondylodiscitis, metastases). Sudden movements or repeated muscular strains can provoke cervical pains. Very often such pains are caused by irritation of the joints and ligaments. The fact that the vertebral artery and autonomic nerve fibres are very close proximity to the joints adds a neurovascular component.


Before the symptomatic treatment can take place, the following diagnostic procedures have to be finished:
- Further examination of the neck and the shoulder to disqualify a cause of this region: see physical examination
- An X-ray examination of the neck (CWK) in various directions
- Consult by a neurologist (possible EMG and MRI or CT of the neck)
- Angiography or venography for possible vascular injuries

The radiographic images are taken primarily to rule out objectively verifiable causes for the symptoms. These X-rays may identify first rib abnormalities or the presence of accessory ribs. Spinal injury or pathology (current or prior) may be evaluated by MRI or CT imaging. Nerve damage can be identified or ruled out using EMG. Any vascular injury or thrombosis may be evaluated by conventional angiography, by magnetic resonance angiography or by venography[4].

Outcome Measures

In patients with cervicobrachialgia the function can be measured by the Northwick Park Neck Pain Questionnaire. This questionnaire has been demonstrated to have short-term repeatability and long-term sensitivity to change.
Pain can be measured using the Short-Form McGill Pain Questionnaire (SF-MPQ). This also includes the Present Pain Intensity (PPI) index of the standard MPQ and a visual analogue scale (VAS).
As physical outcome measure the cervical range of motion (CROM) can be measured[11]

You can use the Patient Rated Wrist Evaluation. It’s a 15-item questionnaire designed to measure wrist pain and disability in activities of daily living.
The PRWE allows patients to rate their levels of wrist pain and disability from 0 to 10, and consists of 2 subscales:
1. Pain subscale: it contains 5 items each. This is then rated form 1-10. The maximum score is 50 and the lowest score is 0.
2. Function subscale: It contains in total 10 items which are divided into 2 sections i.e specific activities (having 6 items) and usual activities (having 4 items). The maximum score in this section is 50 and the lowest score is 0[12].

Examination

Radiographic images must superiorly be taken to rule out objectively verifiable causes for the symptoms.

The neck, shoulders and arms usually appear normal but are in fact painful to touch. The neck may be stiff with a clear limited range of motion, particularly neck extension. Some patients may have poor posture with rounded shoulders and stooped head and neck. Raising the arm (abduction) may increase the symptoms. Observation of possible asymmetries of the upper chest, including the clavicle, has to be done.
To reproduce the symptoms some physical tests can be employed:
- the Adson maneuver: the head is placed in extension and bent to the side while the patient holds his breath and the physician observes for symptoms
- the elevated arm stress test: hyperabduction of the arm may produce symptoms
A loss of pulse during these tests indicates the thoracic outlet syndrome[5].

You can use the Shoulder Abduction test, spurling test an upper limb tension test to test if it’s a chronic problem or an acute problem for a cervical radiculopathy.
The shoulder abduction test and the spurling test were specific for proving it was a cervical radiculopathy. While the upper limb tension test is more sensitive. If these test are positive you can diagnose for a cervical radiculopathy instead of a cervicobrachialgia[13].
The neural tissue provocation test (NTPT) via median nerve could be used to assess the compliance and mechanosensitivity of neural tissues in the upper limb. However, for this test requires 90° of shoulder abduction. This position can be unsuitable for patients with cervicobrachial pain, therefore we can use the modified NTPT test[14].

Medical Management

The treatment of cervicobrachialgia is conservative and symptomatic. Surgical interventions can’t be used to treat cervicobrachialgia[15].

Pain and sleep disorders are relieved with medication. This medication includes painkillers, anti-inflammatory medication (NSAID’s) and muscle relaxants, in case of chronic pain.
If there is vascular compression, doctors may prescribe vasodilators or calcium-channel blockers.
A cervical epidural injection of corticosteroids can also be considered to reduce the inflammation. This injection is an effective method for achieving immediate and long-standing pain relief and improvement in motion and performance in chronic cervicobrachialgia[15].


A Cervical epidural steroid injection in the posterior neck muscles is a conservative treatment that has an effect immediately after the injection and over an extending period of time.
It relieves the pain, it increases the range of motion, the patients can lower their dose of analgesics, and they can start working more rapidly than people who didn’t get a steroid injection[16].

In this study we had two groups: Single injection and a continuous injection.
The group with a single injection got an epidural block with bupivacaine and methylprednisolone at intervals of 4 to 5 days . The group with a continuous epidural bupivacaine every 6, 12, or 24 hours plus methylprednisolone every 4 to 5 days.
The group with a continuous injection relieved the pain better than the group with a single injection. Evidence level[17]

Physical Therapy Management

Manual physical therapy is a part of a conservative treatment, which is effective in managing pain joint restrictions and disability, certainly if this is combined with therapeutic exercises.
In this study there are 2 kinds of traction, manual and mechanically.


• They applied Mechanical traction in supine position by manually adjusted mechanical traction equipment, with a 10 second pull and 5 second rest for 10 minutes in a single session in group A. They used a traction force equal to 10-15% of the body weight from each patient and calculated prior to intervention.


• Manual traction was applied in supine position at 25 degree neck flexion with a 10 second pull and 5 second rest for 10 times in a single session in group B. C-3 till C-7 segments were mobilized by central posterior anterior glide in prone position and each glide was sustained by 5 seconds for 10 repetitions per session in both groups. Active Range of motion, stretching and isometric strengthening home exercise program were advised to all patients in both groups.

From these 2 therapies mechanical traction was more effective in managing the pain and disability than in the group who were treated with manual traction.
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In another study they concluded that the combination of mechanical traction and exercises for patients with a radiculopathy improve the functioning of a patient and reduce the pain[18](LoE:1B).
Moretti et al also concluded that manipulative therapy in the treatment of benign cervicobrachialgia of mechanical origin showed greater effectiveness in short and in long term[19](LoE:1B).

You can also combine mobilization with a manipulation, this has a small beneficial effect towards patients who don’t get therapy[20] (LoE:1A)

The multimodal care ( mobilization, manipulation and exercises ) provide pain relief, and is the best therapy in comparison with only manipulation and manipulation + mobilization[20] (LoE:1A).

The physical therapy treatment is built up out of several different aspects:

In the conservative treatment the primary goal in the rehabilitation of cervicobrachialgia is the reduction of pain.
• Transcutaneous electric nerve stimulation (TENS)
• Cryotherapy
• Deep heat treatment
• Ultrasound
• Cognitive and behavioral pain management[15] (LoE:1A)
• Deep tissue massage[21] (level of evidence 2B)
The second goal is to improve the function and range of motion of the patient through:
• Passive manual therapy techniques
• Indirect manual therapy techniques[21](LoE:2B)
• Manipulative physiotherapy treatment involved a cervical lateral glide mobilization technique[21][22] (LoE:2B)
• Active exercise therapy for neck, shoulder and arm to improve range of motion and functionality
• Therapy to induce strength and endurance


Exercises for postural control and the endurance of the posture during activities of daily living. It is important to teach the patient a correct posture. The goal is to have the patient do ADL while maintaining a correct posture in the cervical region. First the physical therapist will teach the patient how to maintain a correct posture. This starts with a psychological recognition of the wrong posture by the patient. Afterwards a correction is made in the posture, with feedback of the therapist. When the patient is able to do this, then it is possible to go over to active exercises in a lying position whilst the patient keeps a good cervical posture. The next step would be in a standing position, again, doing active exercises while keeping good cervical posture. And eventually the goal is to transfer these learned methods to functional everyday life situations, for example: lifting something while keeping a good posture. These exercises will also reduce the neck pain and dizziness if this is present. Afterwards the postural performance will gradually improve[20](LoE:1A)



In this study cervical mobilization is an effective treatment for cervicobrachialgia. More specifically a contralateral glide technique. It increases the range of motion that is possible in the upper limbs and it decreases the pain.
They compared it with ultrasound which doesn’t have any effect.
The lateral glide was practiced in this way : the therapist cradled the head and neck above, and including, the level to be treated and performed a lateral translatory movement away from the involved side while minimizing gross cervical side flexion or rotation (Figure 1).40 This technique was aimed to move the structures around the nerve and has been described and analyzed in detail.
During the lateral glide, several components of the neural tissue provocation test were applied on the involved side, which is considered to preload the median nerve and brachial plexus . If this position was uncomfortable, the patient’s arm was positioned in an unloaded position, ie, with the hand on the abdomen and the elbow supported by a pillow[23](level of evidence 2B)

Snags ( self sustained natural apophyseal glide ) provide pain relief for patients. Endurance exercises for the cervicalscapular region improves pain relief in patients in comparison with patient who don’t get treatment.
Combining a cervical stretch + strengthening + stabilization in the cervical region has beneficial effects in comparison with no treatment. There was pain reduction immediately after the treatment. But not after an interemediate follow up.

Home exercises and ergonomic evaluation play an important role in the rehabilitation of patients[21](LoE:2B).Evaluation can provide information regarding the activities and positions at work that may support the disease.
Improvements were found in pain and pain intensity, pain quality scores and functional disability levels[21](LoE:2B)

Sleeping with neck support showed a significantly smaller increase in the intensity of cervical spine pain[24] (LoE:1B)and can be given as an (home) advice towards the patients. Another study concluded that complaints in the post-treatment period can be reduced by prescription of special pillows[25](LoE:1B)

Clinical Bottom Line

Several studies have investigated specific therapeutic interventions for cervicobrachial pain such as manual therapy, cervical traction, strength and postural control training. However, there are few studies with specific inclusion criteria. Future studies should identify which categories of cervicobrachial pain respond to specific therapeutic interventions.

References

  1. DeStefano LA. Greenman’s Principles of manual medicine – 4th ed. Baltimore, MD : Lippincott Williams & Wilkins/Wollters Kluwer. 2011
  2. Elvey RL, Hall T. Neural tissue evaluation and treatment. Physical Therapy of the Shoulder. New York: Churchill Livingstone. 1997 
  3. Yoon SH. Cervical radiculopathy. Phys Med Rehabil Clin N Am. 2011;22(3):439- 46
  4. 4.0 4.1 4.2 4.3 Jürgen Krämer et al; Intervertebral Disk Diseases, causes, diagnosis, treatment, and prophylaxis; Thieme 3th Edition 2009
  5. 5.0 5.1 5.2 5.3 Aynesworth, Kenneth H. "The Cervicobrachial Syndrome." Annuals of Surgery 111 5 (1940): 727-742.
  6. Daffner . et al.. Impact of neck and arm pain on overall health status. Spine 2003;28(17):2030e5.
  7. Radhakrishnan K et al. Epidemiology of cervicalradiculopathy. A population based study from Rochester, Minnesota, 1976 through to 1990. Brain 1994;117:325e35
  8. Gross, A. R., et al. "Manipulation and Mobilisation for Mechanical Neck Disorders." Cochrane Database System Review 1 (2004): CD004249. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008
  9. Elevated Detection Thresholds for Mechanical Stimuli in Chronic Pain Patients: Support for a Central Mechanism; Voerman et al. ; 2000 ;
  10. Gross, A. R., et al. "Physical Medicine Modalities for Mechanical Neck Disorders." Cochrane Database System Review 2 (2000): CD000961. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008
  11. Cowell IM., Phillips DR., Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study - experimental design, Manual Therapy. 2002 Feb;7(1):31-8.
  12. MacDermid JC et al. Patient rating of wrist pain and disability: a reliable and valid measurement tool.; LOE =1B 31. Gifford et al. Acute low cervical nerve root conditions: symptom presentations and pathobiological reasoning. Manual Therapy (2001) 6(2), 106–115
  13. Majid Ghasemi et al. ; The value of provocative tests in diagnosis of cervical radiculopathy; march 2013
  14. Van Der Heide B et al. Test-Retest Reliability and Face Validity of a Modified Neural Tissue Provocation Test in Patients with Cervicobrachial Pain Syndrome. The journal of manual & manipulative therapy, 2006
  15. 15.0 15.1 15.2 Salt E. et al., A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain, Manual Therapy, 2011 Feb;16(1),53-65(level of evidence1A)
  16. tav.A. et al.;CERVICAL EPIDURAL STEROID INJECTION FOR CERVICOBRACHIALGIA; 1993;
  17. Alberto MD et al.Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical Brachial Radicular Pain: Single Injection Versus Continuous Infusion, Pasqualucci,
  18. Fritz JM, Thackeray A, Brennan GP, Childs JD. Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial.(level of evidence 1B)
  19. Moretti B et al. Manipulative therapy in the treatment of benign cervicobrachialgia of mechanical origin. Chir Organi Mov. 2004 Jan-Mar;89(1):81-6 (level of evidence 1B)
  20. 20.0 20.1 20.2 Anita R. Gross et al.A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders;; 2004 (level of evidence 1A)
  21. 21.0 21.1 21.2 21.3 21.4 Allison GT, Nagy BM, Hall T., A randomized clinical trial of manual therapy for cervico-brachial pain syndrome -- a pilot study, Manual Therapy. 2002 May;7(2):95-102.(level of evidence 2B)
  22. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K., The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain, Journal of orthopedics and sports Phys. Ther., 2003 Jul;33(7):369-78.(level of evidence 2B)
  23. Michel W. Coppieters et al. The Immediate Effects of a Cervical Lateral Glide Treatment Technique in Patients With Neurogenic Cervicobrachial Pain;(level of evidence 2B) 
  24. Bernateck M et al. Sustained effects of comprehensive inpatient rehabilitative treatment and sleeping neck support in patients with chronic cervicobrachialgia: a prospective and randomized clinical trial. Int J Rehabil Res. 2008 Dec;31(4):342-6 (level of evidence 1B)
  25. Gutenbrunner C et al. Prospective study of the long-term effectiveness of inpatient rehabilitation of patients with chronic cervicobrachial syndromes and the effect of prescribing special functional pillows. Rehabilitation (Stuttg). 1999 Aug;38(3):170-6(level of evidence1B)