The Management of Neck pain: A Case Study
This case study follows the assessment and treatment of a client living in the Caribbean who experienced chronic neck and shoulder pain with numbness in her left arm and hand. According the study to the Global Burden of Disease 2010 neck pain ranked the 4th highest in terms of disability (as measured by years lived with disability (YLD) and increased from 23.9 million in 1990 to 33.6 million in 2010 for disability-adjusted life years, in St Lucia, in 2016, this ranked the 1st highest cause. The purpose of the study is to illustrate the importance of  thorough assessment and treatment based on evidence practice and treatment models,  the importance of multi-disciplinary team working and collaboration between professionals,  the importance of client education and empowerment limitations and difficulties of treating neck pain in the Caribbean.
Over recent years various studies have been undertaken and shown physiotherapy to be effective in the treatment of neck pain. Physiotherapy is not new to Caribbean Islands and although widely available and moderately utilised on the many of the bigger islands this is not always the case on the smaller islands. The following case highlights the need to raise the profile of our profession not only amongst individuals but also the medical fraternity. There are many factors that affect referral to physiotherapy. Until recently access to physiotherapists were limited, only being available in the three public hospitals, by on call services at the one private hospital and one private practice. Since 2009 the availability of hospital services has remained unchanged but there are now five private practice clinics available in the north part of the island with the number of registered physiotherapists on the island totalling 6.
As well as limited resources the other influencing factors are awareness of the role of physiotherapists amongst medical professionals and the general public, location, affordability and access to services. Although St Lucia has been rated as a middle high-income nation by the World Bank it still has a large amount of low income families and individuals who cannot afford services and/or prefer to seek interventions provided by self-taught, non-qualified persons. Although these claims are unsubstantiated, there is no research to support this, it is seen daily within my practice and through anecdotal accounts of the people I meet in daily life and in the clinic environment.The following case study illustrates the benefits of collaboration between medical professionals and the benefits of a treatment based approach to the management of neck pain. The client was seen in clinic twice, the first illustrates the use of a symptom based approach and the second a treatment based approach and how outcome measures and special tests can be used to differentiate between conditions and retest an hypothesis and the efficacy of treatment.
The client, 55 year old female college lecturer, was experiencing chronic neck and shoulder pain with numbness in her left arm and hand. Her symptoms first appeared in 1998, however, she was not referred to physiotherapy until 2016. At the time of onset of her symptoms she was living in a large Caribbean island with a population of 1,364,962 people. She initially consulted her primary care physician (PCP) in 1998 who prescribed pain medication and rest. This did not relieve her symptoms and it was suggested that the cause of her problems was poor posture, secondary to the size of her breasts and it was suggested that she have a breast reduction from 32GG to 32D. The surgery was undertaken in the same year and her symptoms were relieved and no referral to physiotherapy or further intervention was indicated or suggested.
However, in 2002/3 her symptoms returned and at this time she found it uncomfortable to wear a bra and removing the left bra strap from her shoulder eased some of the symptoms. Over the next 14 years her symptoms occasionally reocccured and she would consult with her (PCP) who prescribed rest, analgesia and on two occasions steroid injections into her shoulder. This method of management and occasional massages would temporarily relieve her symptoms; at no time during this period was physiotherapy intervention ever suggested. In 2010 she relocated to a smaller Caribbean Island with a population of 178,015 people. She continued to suffer from symptom flare-ups, which, at the beginning of 2015 her became more frequent and were no longer responding positively to analgesics. It was not until November 2015 that her (PCP) referred her to physiotherapy with a diagnosis of subacromion bursitis and tendonitis of the left shoulder.
At the time of assessment, no red or yellow flags were identified. She was experiencing both neck and shoulder pain with numbness in her left arm and hand. Although she expressed that she had restricted movement and pain in her arm, her neck pain was her primary concern. On assessment she stated that she was unable to identify a relationship between the pain in her neck and shoulder, however, the numbness in the arm and hand would only be present when her neck pain levels exceeded 5 on the visual analogue scale (VAS). The pain in her neck and shoulder were described as deep with an ache and occasional burning, with an intensity that ranged from 0-8 on VAS. She was quite definite on the factors that aggravated/caused her symptoms: sleeping on left side, wearing bra strap, punching forward with left arm and reaching behind her back.
On physical assessment it was noted that she had poor posture, particularly noticeable was her forward head posture and the asymmetry between left and right upper body; she had signs of atrophy in the left upper trapezius and in the area of the left scapula.
Range of Motion and Power – Cervical Spine
Rotation was limited to 40⁰ and painful to the left (ipsilateral side of the shoulder and arm pain and numbness); side flexion was also limited and painful on the ipsilateral side. Rotation also caused increased pain and heavy sensation in the arm. Power was tested using the Oxford manual muscle testing protocol. The client was advised ‘do not let me move you’, she was unable to maintain an isometric contraction in extension and flexion and experienced immediate pain on left rotation and side flexion.
Range of Motion Upper Limb
The client was unable to actively lift her left arm above 30⁰, when assisting this movement with her right arm she was able to achieve 140⁰ flexion. Once in position she was able to maintain this position independently. She was able to move the arm into abduction to 110⁰ however, anterior deviation was present, with early activation of the scapula from 40⁰ and side flexion of the trunk. With the scapula stabilised the client was only able to achieve 40⁰, anterior deviation was still evident. On initial movement pain was experienced in the upper arm but no change to the heavy feeling in her arm or hand. Horizontal flexion and hand behind the back were also limited.
Using the findings from the assessment and to differentiate between cervical radiculopathy and cervical spondylosis the ULTT and spurlings tests were carried out, both of these were positive and used as an indicator of Cervical Radiculopathy.
Based on these findings and the client’s needs goals were set; her primary concern was to relieve her neck and shoulder pain and improve the function of her left arm. The focus of the physiotherapy programme was to improve posture, reduce pain and increase range of motion and improve function and activities of daily living The client attended 16 follow up appointments over 24 weeks. As her pain was high and her symptoms highly irritable for the first session she received electrotherapy (TENs) prior to her treatment programme. As her pain subsided this modality was only used if her pain levels increased above 6 (VAS). The programme consisted of upper limb neural stretches, maitland mobilisations of the cervical spine and a home programme of stretching and strengthening exercises. Throughout each session the client was encouraged to discuss her improvements and limitations. These conversations were used to guide treatment and to empower and educate the client on self management of her condition and symptoms.
The client initially attended 2 sessions per week and showed a good response to treatment and always left the clinic with improved function less pain, however initially symptoms returned within a few days. By the end of the December the relief after treatment was lasting for on average 3 days. Despite this even when her symptoms returned they were not intense and her neck pain was now intermittent and there was no pain radiating into the arm. She also had full range of flexion and abduction, however, abduction was still not following a true movement pattern and pain was still present on the anterosuperior aspect of the shoulder.As her symptoms improved she was attending one session per week and these were further reduced to once every two weeks.
In March on the advice of her (PCP) she travelled to Trinidad for an MRI, unfortunately the travel caused an exacerbation of her symptoms and pain increased in her neck and the numbness in her arm and hand returned. During this period her appointments were increased to one a week. At the beginning of May the results of MRI revealed degeneration and spondylosis of the Cervical spine; her (PCP) suggested that this is the cause of the neural pain in the left arm and diagnosed bursitis as the cause of pain in left upper trapezius and at the front of left. Her treatment continued and her symptoms improved enough for her to continue self-management through her home exercise programme. She was discharged in May and received three follow up calls in June, August and October and was successfully managing her symptoms with no indication of any further intervention.
Second Course Of Physiotherapy Treatment
In June 2017 the client returned to physiotherapy complaining of neck and thoracic pain. Since her last course of physiotherapy treatment, her (PCP), based on the findings of her MRI report, advised her to seek an assessment from the Laser Spine Institute as to whether surgical intervention was indicated. After another MRI scan in 2017 it was confirmed that surgery was indicated and she underwent a laminectomy and discectomy. The day after surgery she awoke with no pain in her cervical and thoracic spine or her arm and she had full range of movement in her neck. However, over the next few weeks she lost the range of movement in her neck and felt discomfort and tightness in her neck and shoulder.
At the time of assessment, no red or yellow flags were identified. Her primary complaints neck and shoulder pain with tingling in her left arm and hand and a constant discomfort by her left shoulder blade, especially if her hair was touching it. She expressed that the tingling in the arm and hand was worse in the morning and at the end of the day, although she could not identify which postures or activities were exacerbating her symptoms. Neck pain was 0-4 on VAS.
On assessment posture was symmetrical and aligned with adequate curves observed in the cervical thoracic and lumbar spines. It was however noted that there was muscle atrophy in the area of the left scapula.
Range of Motion and Power – Cervical Spine
Rotation was limited to 30⁰, pain was not immediate but noted after repeated movements. Rotation also caused tingling in the arm and hand. All other movements were full and pain free. Power was tested using the Oxford manual muscle testing protocol and the client was able to resist strong pressure without pain.
Range of Motion Upper Limb
The client’s movements of flexion, abduction, internal rotation and external rotation all limited but did not produce and tingling in the arm. Although she did mention a heaviness in the anterior, upper deltoid region.
Based on the findings of the assessment and to differentiate between conditions that can present the same symptoms for example spinal tumour, cervical myelopathy, ligamentous stability, vertebral insufficiency, shoulder pathology and thoracic outlet syndrome  and to confirm the hypothesis that the tingling in the arm was caused by cervical radiculopathy four tests were carried out; spurling’s test, upper limb tension test 1, distraction test and cervical rotation test. She was positive on all four tests confirming the diagnosis of cervical radiculopathy. Only 3 out of 4 tests need to show positive to confirm this diagnosis.
Unlike the previous course of physiotherapy this episode of treatment was managed differently. One of the first priorities was to find a suitable outcome measure to provide a baseline to record and monitor the changes in her symptoms and the efficacy of treatment. After reviewing the evidence and literature the Neck Pain Disability Index (NDI) was chosen, this has been proven to be an effective outcome measure in assessing and monitoring the treatment of neck pain. My client scored 23 point (46%) which indicated moderate disability. Her treatment programme followed the treatment based protocol which focuses on the treatment outcome rather than designing treatments based on pathology and symptoms. There are four distinct categories Neck Pain with mobility deficits, Neck Pain with movement co-ordination impairments, Neck Pain with headache (Cervicogenic) and Neck Pain with radiating pain (radicular).
The protocol for neck pain with Radiating pain is as follows:
The client attended 8 follow up appointments over 4 weeks. She was also given a home exercise programme and encouraged to participate in her normal routine with adaptations rather than avoidance where necessary. Assessment of the client at week 3 showed that the client had no radiating neural signs into her arm but still experienced altered sensation in the thoracic area and neck discomfort first thing in the morning which eased throughout the day but returned in the evening and intermittent shoulder pain. Neck pain was exacerbated by brushing her teeth, doing the washing up and reading. In order to retest the earlier hypothesis of radicular pain the tests were performed again; all were negative.
Presentation at this stage indicated that there may be weakness of the deep muscles of the neck and the cranial cervical flexion test was performed. Using a blood pressure cuff the client was unable to maintain neck flexion for 10 seconds at 24mmg. She experienced pain, after which she had increased sensitivity in the left scapula region. Her home programme was changed to include this as an exercise and she was encouraged to monitor her posture and the position of her head when doing activities that triggered symptoms.
The client responded well to treatment and now has no restriction or pain in the Cervical Spine and no neurological symptoms in her arm or hand. After including deep neck flexor exercises she experiences less pain on daily activities and normalised sensation in her scapula region. She also has less pain in her shoulder and has noticed an improvement in range and movement.At the time of writing this study the client did the NDI again and her score improved from 23 (46%) to 5 (10%) indicating that she had a mild disability. This shows a vast improvement and is an indicator of the efficacy of physiotherapy and self-management
There are different approaches to treating neck pain and on the clients first physiotherapy course of treatment a pathoanatomical model was used. This identified signs and symptoms and treatment was chosen based on her reaction to the chosen modalities. After a review of the literature and evidence this approached was changed to the treatment based model which the evidence shows is more effective and cost efficient. In order for this method to be effective it is essential to identify the type of presenting neck pain. Based on the treatment based model there are four classifications of neck pain with mobility deficits, neck pain with radiating pain (radicular), neck pain with movement coordination impairments (WAD), and neck pain with headache (cervicogenic).
The use of special tests and outcome measure are advocated to monitor client’s response to treatment and also to confirm or disprove an hypothesis, this is particularly pertinent to this case study. During the first course of treatment only two tests were used which did not follow guidelines that 3 out of 4 positive results need to be present for a diagnosis of cervical radiculopathy. This was corrected during the second course of treatment; at the beginning of treatment 4 out of 4 were positive indicating cervical radiculopathy. When retested as symptoms changed only 1 was positive and a different diagnosis was identified. This allowed for changes to the treatment programme based on treatment based protocols. Education has proven to be very effective in encouraging the client to participate in her recovery.
She understands that pain should not be a limiting factor to movement and she now seeks ways, independently and by asking question, to improve her function and reduce her pain. This has had a positive effect on her daily routine and the level of pain and discomfort she experiences. It has also had a positive effect on her compliance to her home exercise programme. She does her exercises daily and also has found ways to incorporate some of the exercises into her daily routine, for example when brushing her teeth and washing up she performs deep neck flexor exercises, reducing her pain during and after the activity.
- D. Hoy, L. March, A. Woolf, F. Blythe, P. Brooks, E. Smith, T. Vos, J. Barrendregt, J. Blore, C. Murray, R. Burstein and R. Buchbinder, "The Global burden of neck pain: estimates from the Global Burden of Disease 2010 study," Annals of the Rheumatic Diseases, pp. 73:1309-1315, 2014
- "What health problems cause the most disability?," Institute for Health Metrics and Evaluation, 2016. [Online]. Available: http://www.healthdata.org/saint-lucia.
- "Data - St Lucia," The World Bank, 2016. [Online]. Available: https://data.worldbank.org/country/st-lucia?view=chart.
- "Data - Trinidad," The World Bank, 2016. [Online]. Available: https://data.worldbank.org/country/trinidad-and-tobago?view=chart.
- R. Gu, M.-Y. Kang, Z.-L. Gao, J.-W. Zhao and Z.-C. Wang, "Differential diagnosis of cervical radiculopathy and superior pulmonary sulcus tumor," Chinese Medical Journal, pp. 125(15):2755-2757, 2012
- C. J. Mamula, R. Erhard and S. Piva, "Cervical Radiculopathy or Parsonage-Turner," Journal of Orthopaedic & Sports Physical Therapy, vol. 35, no. 10, pp. 659-664, 2017.
- J. C. Macdermid, D. M. Walton, S. Avery, A. Blanchard, E. Etruw, C. Mcalpine and C. H. Goldsmith, "Measurement Properties of the Neck Disability Index: A Systematic Review," Journal of Sports and Physical Therapy, vol. 39, no. 5, pp. 400-C12, 2009.
- H. Vernon and S. Mior, "The neck disability index: A study of reliability and validity," Journal of Manipulative and Physiological Therapeutics, vol. 14, no. 7, pp. 409-415, 1991
- J. Fritz and G. Brennan, "Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain," Physical Therapy, vol. 87, no. 5, pp. 513-524, 2007.