Cervical Osteoarthritis: Difference between revisions

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==== Stabilization exercises  ====
==== Stabilization exercises  ====


Exercises with for example © Chattanooga stabilizer pressure biofeedback can help to train the deep cervical flexor muscles. Stabilization exercises have been proven to be effective for the reduction of pain in patients with cervical pain due to cervical osteoarthritis.<ref name="dusunceli">Dusunceli Yesim et al.; Efficacy of neck stabilization exercises for neck pain: A randomized controlled study; Journal of Rehabilitation Medicine, Volume 41, Number 8 ( level of evidence: 1B)</ref><br> <br>fig: stabilization exercises.
Exercises with for example © Chattanooga stabilizer pressure biofeedback can help to train the deep cervical flexor muscles. Stabilization exercises have been proven to be effective for the reduction of pain in patients with cervical pain due to cervical osteoarthritis.<ref name="dusunceli">Dusunceli Yesim et al.; Efficacy of neck stabilization exercises for neck pain: A randomized controlled study; Journal of Rehabilitation Medicine, Volume 41, Number 8 ( level of evidence: 1B)</ref><br>


==== Stretching exercises  ====
==== Stretching exercises  ====

Revision as of 15:56, 10 February 2017

Definition/Description[edit | edit source]

The cervical spine consists of seven cervical vertebrae which are situated between the skull and the thoracic region. Osteoarthritis of the cervical spine may be defined as a degenerative disorder at those levels, complicated by inflammatory reactions. It is a very complex disease with multiple causes[1] which affects the intervertebral discs, vertebral bodies, intervertebral ligaments,[2] the hyaline cartilage, the underlying bone, joint capsule, zygophyseal joints and/or can lead to the formation of osteophytes [3] [4]
or subchondral cysts and/or can cause hypertrophy of the articular process.[5]
Although cervical osteoarthritis is often referred to as cervical spondylosis [4], it is not clear whether these two concepts may be considered synonyms.

                                            Definition COA.jpg


Clinically Relevant Anatomy[edit | edit source]

For a overview of the components which form the cervical spine, reference is made to the following Physiopedia page: http://www.physiopedia.com/Category:Cervical_Anatomy

Focusing on the cervical spine components that are affected by osteoarthritis, the following components should be taken into account:

  •  Articular cartilage [1] [6]: At first fibrillation and shallow pitting occur, which initially affect the surface of the cartilage focally. At a more progressed stage, this can evolve to deeper fibrillation and fissuring, peeling off and pitting until the subchondral bone is affected. [5]
  •  Synovium[1]
  •  Articulatio uncovertebralis ): Osteophytes are formed on the articular surfaces of the uncinate process. These osteophytes can impinge anatomical structures like the cervical spinal cord, spinal nerve root, radicular artery, vertebral artery and cervical sympathetic trunk.[7]
  •  Facet joints (Figure 2): they are inclinated 45° from horizontal. The joint surfaces are generally planar, but not flat.[5]
  •  Discus intervertebralis: between C0–C1 and C1-C2 there is no discus intervertebralis. Major factors in the development and progression of osteoarthritis of the facet joints are Joint alignment and load distribution.[5]
  •  Cervical plexus: Osteophyte formation or progressive cartilage thinning may narrow the foramina intervertebrale through which the cervical nerve roots emerge.[5] [8]
  •  Intervertebral ligaments.[2]

We speak off a “three-joint complex” at every spinal level except C1–C2. This motion segment, is formed by the three articulations between adjacent vertebrae. These three articulations consist of one disc and two facet joints. The superior articular processes of the lower vertebra is positioned upwards and will articulate with the smaller inferior articular processes of the vertebra above it. The cervical facet articular surface area is about two-thirds the size of the area of the vertebral end plate. The facet joint exhibits features typical of synovial joints: articular cartilage covers the opposed surfaces of each of the facets, resting on a thickened layer of subchondral bone, and a synovial membrane bridges the margins of the cartilaginous portions of the joint. A superior and inferior capsular pouch, filled with fat, is formed at the poles of the joint, and a baggy fibrous joint capsule covers the joint like a hood. A fibro adipose menisci projects into the superior and inferior aspect of the joint and consists of a fold of synovium that encloses fat, collagen, and blood vessels. These menisci’s serve to increase the contact surface area when the facets are brought into contact with one another during motion, and slide during flexion of the joint to cover articular surfaces exposed by this movement. [9]

                                        Clinically Relevant Anatomy COA.jpg

Epidemiology/Etiology[edit | edit source]

Cervical osteoarthritis may be generalized, sometimes involving the entire cervical region, but it is usually more localized between the fifth and sixth and sixth and seventh cervical vertebrae.
Everyone can have cervical osteoarthritis but it is rare in people younger than 40-50 years, the incidence increases with age .[10] [6] Also women have a higher risk for cervical OA than men.[10] [3] It is rather common in people above the age of 50 and especially if those people had jobs that included staying in one position during a long period of time e.g. reading, writing and other table works.
The occurrence of cervical OA can have many causes. E.g. mechanically overstressing a joint (e.g. working with tools that generate intense vibration), past bone fractures or other injuries to the neck, overload at young age, posture asymmetry or asymmetric loading of a joint,… . A relation has been shown between the severity of the complaints of cervical osteoarthritis and a higher body weight of the patient.[4]
Facet joint osteoarthritis (FJ OA) is intimately linked to the distinct but functionally related condition of degenerative disc disease, which affects structures in the anterior aspect of the vertebral column. FJ OA and degenerative disc disease are both thought to be common causes of back and neck pain, which in turn have an enormous impact on the health-care systems and economies of developed countries. [9]

Characteristics/Clinical Presentation[edit | edit source]

OA is characterised by pain, stiffness, crepitus, limited range of movement and sometimes also joint instability and mild synovitis [11] [12] [13] The pain is usually localized around the affected joint , but at the level of the spine referred pain may occur. For the cervical spine, pain associated with FJ OA can arise from nociceptors within and surrounding the joints, including nociceptors in the bone itself. The facet joints and their capsules are well innervated [14]. The pain radiates to the occiput, the medial border of the scapula and the upper limbs [15]. Pain often worsens with joint use and is more severe at the end of the day. If there is morning stiffness, it usually lasts less than 30 minutes [16]. Restricted movement can occur due to pain, capsular thickening and the presence of osteophytes [16].

Pressure symptoms in the cervical spine are caused by Osteoarthritis of the uncovertebral joints. Osteophytes can form around the intevertbral joints and cause neurological symptoms due to compression of the spinal nerves [17]. Narrowing of the spinal canal can also cause circulation problems. Performing an MRI can be useful to confirm the presence of compression of the spinal cord.

Prolonged peripheral inflammation in and around facet joints can lead to central sensitization, neuronal plasticity, and the development of chronic spinal pain [18]. The therapist must remain alert to several key characters, also called red flags, as this may indicate a more serious problem [19]:

  • Malignancy, infection, or inflammation
  • Fever, night sweats
  • Unexpected weight loss
  • History of inflammatory arthritis, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression
  • Excruciating pain
  • Intractable night pain
  • Cervical lymphadenopathy
  • Exquisite tenderness over a vertebral body
  • Myelopathy
  • Gait disturbance or clumsy hands, or both
  • Objective neurological deficit
  • Sudden onset in a young patient suggests disc prolapse
  • History of severe osteoporosis
  • Drop attacks, especially when moving the neck, suggest vascular disease
  • Intractable or increasing pain   

http://www.spine-health.com/video/cervical-facet-osteoarthritis-video

Differential Diagnosis  [20] [21]
[edit | edit source]

Diagnostic Procedures[edit | edit source]

The diagnosis is usually based on the clinical presentation [22] [1]

• Pain on range of motion
• Limitation of range of motion
• Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
• Pseudoclaudication caused by spinal stenosis

Radiology can also be used to determine OA, but one must take into account that people with radiological signs can remain asymptomatic [1]. Kellgren and Lawrence developed a grading system for the radiological appearance of a joint with osteoarthritis [2]

Radiological appearance of osteoarthritis Grade
normal (no signs of osteoarthritis) 0
doubtful change (uncertain) 1
definite, minimal to mild 2
definite, moderate 3
definite, severe 4

If more than one joint in a group is assessed, then the most severe grade is reported.
Parameters:

  1. osteophytes at the joint margins and periarticular ossicles
  2. narrowing of the joint space
  3. cystic areas with sclerotic walls in subchondral bone
  4. deformity of bone (altered shape)

Outcome Measures[edit | edit source]

Functional status and disability measure (evaluation of the activities of daily living) can be assessed by the “Neck Pain and Disability Scale” (NPAD) and the “Neck disability index (NDI)”.[23]

  1. The Neck pain and disability scale (NPAD) is a composite index including 20 items, which measure the intensity of neck pain, its interference with vocational, recreational, social, and functional aspects of living and also the presence and extent of associated emotional factors.
  2. The Neck disability index (NDI) is a patient-completed and condition-specific functional status questionnaire. This questionnaire consists of 10 items, including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. This questionnaire has been designed to give information as to how neck pain has affected the patient’s ability to manage in daily life.

The NPAD and NDI are both seen as valid measures of self-reported neck pain related disabilities.[23]

   

Examination[edit | edit source]

Because osteoarthritis is primarily a clinical diagnosis, physicians can confidently make the diagnosis based on the history and physical examination. Most patients with osteoarthritis of the neck will complain about joint pain in this area. The pain tends to worsen with activity, especially following a period of rest (gelling phenomenon). Besides pain on range of motion patients will have a limited range of motion.[24]

Electromyographic analysis shows a higher fatigue of the anterior and posterior neck muscles compared with healthy subjects.[25]
Physical examination includes:[5]

  • Inspection: posture, edema, erythema, evidence of trauma, muscle atrophy, skin abnormalities and joint deformity.
  • Palpation of facet joints, examining of anatomic abnormality, temperature and tenderness. 
  • Range of motion of the cervical region and shoulder region.
  • Stress facet joints: pain increases with hyperextension, extension-rotation (3D) of the neck. Pain decreases while doing flexion of the neck. 
  • Motor- and sensory evaluation: L’Hermitte sign: sense of feeling electrical shocks in both arms or legs while performing neck flexion. 
  • Muscle testing: searching myofascial triggerpoints in the m. sternocleidomastoideus, cervical paraspinal muscles, m. levator scapulae, the upper trapezius and suboccipital musculature. 

Medical Management[edit | edit source]

Surgical treatment[edit | edit source]

There are indications that excision and fusion of the anterior cervical intervertebral disc (Cloward operation) together with the removal of associated arthritic bone spurs pressing on the nerves and spinal cord can give relief of pain and muscle weakness in patients who have cervical osteoarthritis with neurologic pain [26].

Transarticular screw fixation[edit | edit source]

Patients with atlantoaxial (C1-C2) facet joint osteoarthritis have a positive reaction on pain after the fusion of these two facet joints. This treatment has a relative low rate of serious complications [11].

Laminoplasty[edit | edit source]

Laminoplasty is used to decompress the cervical spinal cord. A risk of this surgical treatment is a reduced strength and shear stiffness (SS) of motion segments. As a result of this, the patient can suffer from instability. Also a great part of the patients had neck pain after the surgical the method of Kuang-Ting Yeh choses laminoplasty instead of laminectomy as a decompression method in posterior instrumented fusion for degenerative cervical kyphosis with stenosis [12]. In short-terms there are some benefits from chondroitin (alone or in combination with glucosamine). Benefits are small to moderate but clinically meaningful [13].

Intra-articular corticosteroids are recommended for hip and knee osteoarthritis. The effects of corticosteroids on cervical osteoarthritis need to be researched [14] [15] [16] [17].


Physical Therapy Management
[edit | edit source]

The main goals of management for cervical OA are: [10]

  • reducing pain and stiffness
  • improving joint mobility
  • inhibiting further progression of joint damage

The treatment for cervical osteoarthritis is usually conservative and it can be treated using a variety of therapy possibility.
Another important part of the management of OA is exercise therapy. The exercise program should aim at mobilization exercises, strengthening local muscles around the affected joint and improving overall aerobic fitness. [10] [23] [2]
There is considerable evidence that states that physical activity can help in in the management of chronic pain that is the direct cause of osteoarthritis. Physical activity should play a key role in the therapy. This will improve the disability over time and also reduce pain. Improving the patient physical level will also have multiple other health benefits.
Patients with chronic pain will have difficulties with the therapy but small changes in the beginning can also have great effect on the outcome.
The possibilities for therapy are:

Heat and cold modalities [edit | edit source]

Various physiotherapy modalities can be used to reduce pain. Even though there is a lack of evidence for the application of local heat or cold, it is often used by patients with OA to decrease pain.

Manual therapy[edit | edit source]

Manual therapy, such as massage, mobilization, and manipulation, may provide further relief for patients with cervical osteoarthritis. Mobilization is characterized by the application of gentle pressure within or at the limits of normal motion. It is important not to cross the pain limit of the patient. The goal of this mobilization is to increase the range of motion of the neck. Patients reported preferring manual traction performed by a physiotherapist instead of mechanical traction. Sometimes manipulation can be considered. The intention of manipulation is to increase articular mobility or to realign the spine. Contraindications to manipulative therapy, such as myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability and vertebrobasilar insufficiency have to be taken into consideration. [27]

Pulsed electric stimulation[edit | edit source]

Pulsed electric stimulation as a treatment for osteoarthritis, is a promising treatment because it has shown the stimulation of cartilage growth at the cellular level. On the other end there is an urgent need for further large-scale studies of pulsed electric stimulation to confirm these finding for purposes concerning the medical sector.[18] There is also research into new methods to use in the treatment of OA to reduce pain. It is thought that magnetic therapy represents an alternative therapy for patients suffering from cervical OA. Electromagnetic fields can be applied to treat cervical OA and are thought to have a pain-relief effect, but further studies are needed. [2] [28]
With current evidence at our disposal we can suggests that electrical stimulation therapy may provide significant improvements for osteoarthritis , but in addition they recommend that further studies are undertaken.[18]

Hydrotherapy[edit | edit source]

A study showed that underwater tractions of the cervical spine during weightbath therapy can be effective. The following parameters were improved by hydrotherapy: it mitigates the pain, increases the range of motion and improves the quality of life. The patient hangs in a construction that is made of steel and the patient’s head is supported by a collar which gives the traction. The water of the bath comes at the height of the chin. As a result the water carries most of the body weight so the traction force is acceptable. [29] [30]

Acupuncture[edit | edit source]

  • The studies about acupuncture and osteoarthritis show small significant benefits which didn’t meet the pre-defined thresholds for clinical relevance. Most of the benefits are at least partially placebo effect. This has to be considered when choosing this option for the treatment.[19] 
  • Another study has shown that the depth of the needle indicates a difference in long-term results. The results show that the deep insertion acupuncture is more effective than superficial acupuncture in patients with neck-shoulder pain. In the deep acupuncture group the needle was inserted to a depth of 15-20 millimeter while in the superficial group the needle was inserted to a depth of 5 millimeter.[31]

Postural awareness[edit | edit source]

As the condition progresses, the abnormality of posture also increases, thus from the initial stage itself, postural awareness through proper advice and education should be planned and initiated by the physiotherapist. The ideal posture is straight neck with chin tucked in and back straight with no compensatory actions or any trick movements.
While sleeping, side lying is the most preferred position, supine lying is also advised. A single pillow under the head for head support is allowed. A butterfly pillow is the best support for a patient suffering of cervical osteoarthritis, as it is flattened in the middle where the head rests and the elevated ends support the head on the sides.[32]

Ultrasound[edit | edit source]

Ultrasound may be beneficial but there is only low quality evidence about the effect of ultrasound on osteoarthritis. Most studies investigate whether it is effective for hip and knee osteoarthritis. Ultrasound may be effective, but the magnitude of the effects on pain relief and function is still unclear. It has to be considered that part of the effect may still be due to placebo.[20]

Relaxation[edit | edit source]

TENS[edit | edit source]

TENS can also provide symptomatic relief. [10] [23] [2]

Neck support[edit | edit source]

Immobilisation of the neck can be done both with soft collars or with more rigid collars. The soft collars can give good results explained by the placebo effect because the collar does not restrict the movements of the neck at all. The rigid braces limit more the range of motion of the neck and as such, can reduce the tone of the muscle.
A negative effect of the use of collars can be that they cause stiffness of the neck. So it is important to combine the use of collars with exercises of the neck to counteract stiffness.[33]

Low-power Laser Therapy[edit | edit source]

Several studies have shown the effectiveness of low laser therapy. The studies showed a pain reduction and an improvement of the functions of the neck. An RCT compared low laser therapy with a placebo treatment. The treatment group showed significant improvement on several parameters: pain, paravertebral muscle spasm, lordosis angle and range of motion of the neck.[34] [35] [36]

Encouragement and motivation [21]
[edit | edit source]

Neck exercises
[edit | edit source]

The treatment for cervical OA should also aim at providing information related to the disorder, stress management and postural advice in daily activities, work and hobbies. [23]

Resistance Band Exercises[edit | edit source]

Thera-band: 6 color-coded levels of resistance (red, green, blue, black, silver and gold)
A training program consisted of four training exercises for the prime movers of the neck during cervical flexion, extension and lateral flexion. Exercises were performed with a head harness (Neck Flex) using different color-coded elastic resistance bands (Thera-Band®).
During the exercises it is advised to maintain a proper posture:
• Keep a straight back
• Position their head in an anatomically neutral position
• Lean the trunk forward (~20-30°)
• Arms were held straight with the hands placed underneath the knees.

Cervical flexion against resistance (Fig. 3)

A Thera-Band is stretched between a door anchor and the back of the head harness. During the exercise, the participants have to perform a low cervical spine flexion (against resistance) followed by a low cervical spine extension.

Cervical extension against resistance (Fig. 4)

During neck extension, participants are positioned in the same way as during neck flexion, but the Thera-Band is stretched between the hands and front of the head harness. The exercise is performed with a low cervical spine flexion followed by a low cervical spine extension (against resistance)

Lateral flexion against resistance (Fig. 5, 6)

Lateral flexion is performed standing erect with the head in an anatomically neutral position. One hand has to be placed horizontally against a wall and a Thera-Band is stretched between the hand and side of the head harness. The exercise is performed with a low lateral spine flexion followed by a low lateral spine extension (against resistance). The exercise has to be performed for the right (Fig. 3, Exercise 5) and left side.


Physical Therapy Management COA.png


Flexion and rotation against rotation (Fig. 7, 8)
This exercise can be introduced afterwards as a complementary part of the therapy. The exercise is performed seated with a straight back and trunk leaned forward (~20°). The head is held in an anatomically neutral position and rotated approximately 45° degrees to either the right or left side. A Thera-Band has to be stretched between the head harness and a door anchor.
Keeping a static upper body, the hips has to be flexed and the body also (against resistance) this is followed by an extension. The exercise has to be performed to the right and left side. [22]

Proprioceptive exercises[edit | edit source]

Proprioceptive exercises can also be used in the therapy of cervical osteoarthritis. Some studies have shown a positive result in using proprioceptive exercises. [37] [38]


Stabilization exercises[edit | edit source]

Exercises with for example © Chattanooga stabilizer pressure biofeedback can help to train the deep cervical flexor muscles. Stabilization exercises have been proven to be effective for the reduction of pain in patients with cervical pain due to cervical osteoarthritis.[39]

Stretching exercises[edit | edit source]

A regular stretching exercise program performed for four weeks can decrease neck and shoulder pain and improve neck function and quality of life of people who suffer of cervical osteoarthritis. [40]



Key Research[edit | edit source]

Alfred C. Gellhorn et al., Osteoarthritis of the spine: the facet joints, Nat Rev Rheumatol. 2013 April; 9(4): 216–224 (LoE: 1A)

Resources[edit | edit source]

R1. Physioworks. http://physioworks.com.au/images/Injuries-Conditions/ucx.wry.neck2.jpg Visited on 26 March 2016
R2. Your neurologist. http://www.your-neurologist.com/images/cervicalspine1.jpg Visited on 26 March 2016

Clinical Bottom Line[edit | edit source]

With osteoarthritis being a common disease among the general population more attention should be drawn to this disease. A lot of research is done concerning knee and hip OA but more research is needed for cervical OA. Though It may be clear that physiotherapists can have an influence on a patient with cervical OA especially in terms of daily life.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  2. 2.0 2.1 2.2 2.3 2.4 2.5 Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rhematol Int 2006; 26: 320-324 (Level of Evidence: 1A)
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  4. 4.0 4.1 4.2 Hartz A J, Fisher M E, Bril G, et al. The association of obesity with joint pain and osteoarthritis in the HANES data. J Chronic Dis 1986;39:311-319 (Level of evidence 2B)
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2013; 9(4): 216-224 (Level of Evidence: 2B)
  6. 6.0 6.1 Boucher P. Postural control in people with osteoarthritis of the cervical spine. Journal of Manipulative and Physiological Therapeutics 2008; 31(3): 184-190 (Level Of Evidence: 1B)
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  21. 21.0 21.1 Marley J; et al. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain, Syst Rev. 2014 Sep 19; 3:106) (Level of evidence: 1A)
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  27. Almeida GP, Carneiro KK, Marques AP. Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a comprehensive review. J Bodyw Mov Ther. 2013 Oct;17(4):504-9. (Level of Evidence: 2C)
  28. David H. Trock, Alfred Jay Bollet and Richard Markoll; The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, Double blind, placebo controlled trial ; J Rheumatol 1994 (level of evidence 1B)
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  30. Márta Kurutz and Tamás Bender ; Weightbath hydrotraction treatment: application, biomechanics, and clinical effects ; Journal of multidisciplinary Healthcare ; April 2010 (Level of evidence: 5)
  31. Nakajima et al., Difference in Clinical Effect between Deep and Superficial Acupuncture Needle Insertion for Neck-shoulder Pain: a Randomized Controlled Clinical Trial Pilot Study, January, 23, 2015 (Level of evidence : 1B)
  32. Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton. Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis. Adv Orthop. 2012; 2012: 294857. (Level of evidence: 2B)
  33. Sandeep S Rana ; Diagnosis and Management of Cervical Spondylosis Treatment & Management ;Augustus 2015 (level of evidence: 5)
  34. F. Özdemir, M. Britane and Kokino ; Department of Physical therpy and rehabilitation, Medical faculty of Trakya university ;The clinical efficacy of low-power laser therapy on pain and function in Cervical Osteoarthritis. ; Clinical Rheumatology , 2001 , Turkey (Level of evidence: 1B)
  35. Bjordal et al: A systematic review of low level laser therapy with location-specific doses for pain from joint disorders; Australian Journal of Physiotherapy 2003 Vol. 49, 107-116 (Level of evidence: 1A)
  36. Chow RT. et al; efficacy of low level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials; the lancet; nov 13,2009 (Level of evidence: 1A)
  37. Michael A McCaskey et al.; Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review; BMC Musculoskeletal DisordersBMC series – open, inclusive and trusted201415:382 (level of evidence: 1A)
  38. A.R. Gross et al.; Exercises for mechanical neck disorders: A Cochrane review update; Manual Therapy 24 (2016) 25-45 (level of evidence: 1A)
  39. Dusunceli Yesim et al.; Efficacy of neck stabilization exercises for neck pain: A randomized controlled study; Journal of Rehabilitation Medicine, Volume 41, Number 8 ( level of evidence: 1B)
  40. Tunwattanapong P et al.; The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial. Clin Rehabil. 2016 Jan;30(1):64-72. (Level of evidence: 1B)

1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Walker JA, Osteoarthritis: pathogenesis, clinical features and management. Nursing Standard 2009, Vol. 24, Nr. 1, 35-40. (Level of evidence 1A)
2. ↑ 2.0 2.1 Boucher P, Postural control in people with osteoarthritis of the cervical spine. Journal of Manipulative and Physiological Therapeutics, Volume 31, Number 3, p.184-190 (Level of evidence 1B)
3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Alfred C. Gellhorn et al., Osteoarthritis of the spine: the facet joints, Nat Rev Rheumatol. 2013 April ; 9(4): 216–224 (Level of evidence 2A)
4. ↑ 4.0 4.1 4.2 Wilder FV, Radiographic cervical spine osteoarthritis progression rates: a longitudinal assessment. Rheumatol Int (2011) 31:45–48 (Level of evidence 2B)
5. ↑ Michael J. Lee, K.Daniel Riew. The prevalence cervical facet arthrosis: an osseous study in cadaveric population. The spine Journal 9(2009) 711-714 (Level of evidence 5)
6. ↑ Hartz A J, Fisher M E, Bril G, et al. The association of obesity with joint pain and osteoarthritis in the HANES data. J Chronic Dis 1986;39:311-319 (Level of evidence 2B)
7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Binder A, Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-531 (Level of evidence 1A)
8. ↑ 8.0 8.1 8.2 8.3 8.4 Sutbeyaz ST, The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int (2006) 26: 320–324 (Level of evidence 2A)
9. ↑ 9.0 9.1 Sinusas K., Osteoarthritis: diagnosis and treatment, Am Fam Physician, 2012 Jan 1;85(1):49-56. (Level of evidence 2A)
10. ↑ Robert W. Rand and Paul H. Crandall, Surgical treatment of cervical osteoarthritis, Calif Med. 1959 Oct; 91(4): 185–188. (Level of evidence 2B)
11. ↑ Grob D. et al., Transarticular screw fixation for osteoarthritis of the atlanto-axial segment, Eur spine journal 2006 Mar; 15(3):283:91 (Level of evidence: 3B)
12. ↑ Arno Bisschop, Which factors prognosticate spinal instability following lumbar laminectomy?,Eur Spine J. 2012 Dec; 21(12): 2640–2648. (Level of evidence 2B)
13. ↑ Singh J.A. et al., Chondroitin for osteoarthritis, 2015, Cochrane review. (Level of evidence: 1A)
14. ↑ Cibulka M.T. et al., Hip pain and mobility deficits - hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability and health from orthopaedic section of the American Physical Therapy Association, J Orthop Sports Phys Ther, 39 (2009), pp A1-25 (Level of evidence 1A)
15. ↑ MQIC, Medical management of adults with osteoarthritis, Michigan Quality Improvement Consortium (2011) (Level of evidence 5)
16. ↑ Peter W.F. et al., Physiotherapy in hip and knee osteoarthritis: development of practice guideline concerning initial assessment, treatment and evaluation, Acta Reumatol Port, 36 (2011), pp 268-281. (Level of evidence 5)
17. ↑ Loew L. et al, Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis, Arch Phys Med Rehabil, 93 (2012), pp 1269-1285. (Level of evidence 2A)
18. ↑ 18.0 18.1 Hulme J. et al., Electromagnetic fields for the treatment of osteoarthritis., Hulme J1, Robinson V, Cochrane Database Syst Rev. 2002;(1):CD003523. (Level of evidence: 1A)
19. ↑ Manheimer E. et al., Acupuncture for osteoarthritis, 2010, Cochrane review. (Level of evidence: 1A)
20. ↑ Rutjes A. W. S. et al., Therapeutic ultrasound for osteoarthritis, 2010, Cochrane review. (Level of evidence: 1A)
21. ↑ Marley J; et al. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain, Syst Rev. 2014 Sep 19; 3:106) (Level of evidence: 1A)
22. ↑ Mike Murray et al. Specific exercise training for reducing neck and shoulder pain among military helicopter pilots and crew members: a randomized controlled trial protocol, BMC Musculoskelet Disord. 2015; 16: 198. (Level of evidence: 1B)
23. Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst Century: Risk Factors and Behaviours that Influence Disease Onset and Progression. Int J Mol Sci 2015; 16(3): 6093-6112 (Level of Evidence: 2A)
24. Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rhematol Int 2006; 26: 320-324 (Level of Evidence: 1A)
25. Boucher P. Postural control in people with osteoarthritis of the cervical spine. Journal of Manipulative and Physiological Therapeutics 2008; 31(3): 184-190 (Level Of Evidence: 1B)
26. Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2013; 9(4): 216-224 (Level of Evidence: 2B)
27. Hartman J, Anatomy and Clinical Significance of the Uncinate Process and Uncovertebral Joint: A Comprehensive Review. Clinical Anatomy 2014; 27: 431-440 (Level of Evidence: 2C)
28. Rand RW, Crandall PH. Surgical Treatment of Cervical Osteoarthritis. Calif Med 1959; 91(4): 185-188 (Level of Evidence: 2C)
29. Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rhematol Int 2006; 26: 320-324 (Level of Evidence: 1A)
30. The clinical efficacy of low-power laser therapy on pain and function in Cervical Osteoarthritis. ; F. Özdemir, M. Britane and Kokino ; Department of Physical therpy and rehabilitation, Medical faculty of Trakya university ; Clinical Rheumatology , 2001 , Turkey (Level of evidence: 1B)
31. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, Double blind, placebo controlled trial ; David H. Trock, Alfred Jay Bollet and Richard Markoll; J Rheumatol 1994 (level of evidence 1B)
32. Bjordal et al: A systematic review of low level laser therapy with location-specific doses for pain from joint disorders; Australian Journal of Physiotherapy 2003 Vol. 49, 107-116 (Level of evidence: 1A)
33. Gogia et al.; Electromyograhic Analysis of Neck Muscle Fatigue in Patients With Osteoarthritis of the Cervical Spine. Cervical Spine/Basic Science march 1994 (Level of evidence: 2B)
34. Nakajima et al., Difference in Clinical Effect between Deep and Superficial Acupuncture Needle Insertion for Neck-shoulder Pain: a Randomized Controlled Clinical Trial Pilot Study, January, 23, 2015 (Level of evidence : 1B)
35. Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2013; 9(4): 216-224 (Level of Evidence: 2B)
36. Almeida GP, Carneiro KK, Marques AP. Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a comprehensive review. J Bodyw Mov Ther. 2013 Oct;17(4):504-9. (Level of Evidence: 2C)
37. Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton. Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis. Adv Orthop. 2012; 2012: 294857. (Level of evidence: 2B)
38. The effects of weightbath traction hydrotherapy as e component of complex physical therapy in disorders of the cervical and lumbar spine: a controlled pilot study with follow up; Mihaly Olah, Levente Molnar, Jozsef Dobai ; 12 January 2008 (level of evidence: 3B)
39. Weightbath hydrotraction treatment: application, biomechanics, and clinical effects ; Márta Kurutz and Tamás Bender ; Journal of multidisciplinary Healthcare ; April 2010 (Level of evidence: 5)
40. Diagnosis and Management of Cervical Spondylosis Treatment & Management ; Sandeep S Rana ; Augustus 2015 (level of evidence: 5)
41. Michael A McCaskey et al.; Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review; BMC Musculoskeletal DisordersBMC series – open, inclusive and trusted201415:382 (level of evidence: 1A)
42. A.R. Gross et al.; Exercises for mechanical neck disorders: A Cochrane review update; Manual Therapy 24 (2016) 25-45 (level of evidence: 1A)
43. Dusunceli Yesim et al.; Efficacy of neck stabilization exercises for neck pain: A randomized controlled study; Journal of Rehabilitation Medicine, Volume 41, Number 8 ( level of evidence: 1B)
44. Tunwattanapong P et al.; The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial. Clin Rehabil. 2016 Jan;30(1):64-72. (Level of evidence: 1B)
45. Chow RT. et al; efficacy of low level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials; the lancet; nov 13,2009 (Level of evidence: 1A)