Cervical
Spondylosis
Wong Kah Wei I20018770
Introduction
● Also known as the arthritis of the neck
● Age-related, progressive, abnormal wear-and-tear degenerative changes that
occur over time affecting all the components of the cervical spine, commonly at
C5-C7
●
Disc herniation can be an early precursor to the development of spondylosis.
●
Cervical spondylosis may cause one of three syndromes: radiculopathy,
myelopathy, or mechanical neck pain
(“Cervical Spondylosis (Arthritis of the Neck) - OrthoInfo - AAOS,” 2021)
(Scott & Kerr, 2006)
Pathophysiology
●
Cervical spondylosis occurs in response to dehydration or degeneration of intervertebral disks
that causes lost in disc space height and bulging of the disc
●
As a result of this degeneration, the disks become less capable of load bearing and transfer this
load to facet joints and vertebral bodies, which causes adjacent bony structures contact each
other and form bone spurs, osteophytes, bony ridges.
●
Additionally, the ligamentum flavum hypertrophy occurs posterior to the spinal cord which
narrows the spinal canal with impingement of nerve roots or the spinal cord
●
If the spinal cord is compressed, myelopathic symptoms develop.
●
If nerve roots are compressed, radicular symptoms develop.
●
Pain may be a prominent symptom of cervical spondylosis even in the absence of neural
compromise due to mechanical dysfunction
Clinical features
●
Neck pain and stiffness
●
Headaches
●
Grinding or popping noise or sensation when moving the neck
●
Numbness and weakness in the arms, hands, and fingers when nerve is
compressed by the osteophytes
●
Impaired gait
●
Muscle spasm in neck and shoulder muscles
●
Lack of coordination
Risk factors
●
Age of 60 and above
●
Gender: Males has higher likelihood and severity of cervical spondylosis
●
Genetics factors: a family history of neck pain and spondylosis
●
Smoking: increases neck pain
●
Occupation: Involves carrying heavy loads on their head & shoulders, repetitive
neck motion and overhead work
●
Previous significant spinal trauma
●
Dystonic cerebral palsy that affects neck musculature
●
Specific athletic activities: horse riding, rugby, soccer
Differential diagnosis
Epidemiology
●
Most affected patients are asymptomatic, with 25% of individuals under the age of 40,
50% of individuals over the age of 40, and 85% of individuals over the age of 60
showing some evidence of degenerative changes and neck pain
●
The most frequently affected levels are C6-C7, followed by C5-C6.
●
According to the Global Burden of Disease 2015, low back and neck pain remain the
leading cause of years lived with disability (YLD) and the fourth leading cause of
disability-adjusted life years (DALYs)
(Kuo & Prasanna Tadi, 2022)
01
Subjective Assessment
●
●
●
●
●
●
●
●
●
●
●
Name: Ms B
Age: 47
Occupation: Admin staff
Hand dominance: Right
Dr diagnosis: Cervical spondylosis
Dr management: Conservative (referred to PT)
Chief complaint: Frequent neck spasm which radiates to the base of head & right
shoulder blade, causing her to miss work and ADL is affected
Current history: Started feeling neck discomfort since an accident 5 years ago and
taking ointment currently
Past history:Surgical history:Family history:-
●
●
●
●
●
●
Investigation: Done X- Ray and MRI 2 weeks ago
Present medical conditions: HPT, DM (both under controlled)
Medications: for HPT, DM
Socioeconomical history: Doesn’t smoke or drink, sedentary, financially stable,
married, likes to cook & bake
Expected outcome: Get back to work with minimal or no pain
Environmental history: Living with family members in a double storey house, using
sitting toilet
Pain Assessment
●
Side & site: Right shoulder blade & base of head (temporal pain at C1-C2)
●
Type of pain: Constant dull aching pain with numbness & tingling sensation
●
Duration: Since 5 years ago
●
24 Hours: At night, sometimes during sleep
●
Aggravating factors: Computer work & cooking
●
Relieving factors: Rest, lie down, stop doing activities
●
Irritability: Moderate
●
VAS: 1/10 at rest, 6/10 during activity
02
Objective Assessment
●
Posture: Forward head posture (hyperflexed lower cervical spine, hyperextended upper cervical spine)
●
Deformity: Cervical kyphosis
●
Gait: Trouble walking due to weakness of hands and legs and loss of balance
●
Palpation:
○
Muscle spasm in neck and shoulder muscles
○
Localised tenderness at the midline of cervical spine
○
Paraspinal tenderness radiating into the trapezius
○
Facet joint crepitus at neck flexion & extension
○
Swelling over neck muscles
●
ROM: Limited flexion, extension, lateral flexion & rotation to both sides and limited scapular mobility
●
Muscle power: severe motor weakness in uni- or bilateral upper extremities due to muscle wasting (cervical spondylotic
amyotrophy)
●
Special tests:
○
+ve Distraction test: Less pain due to opening of cervical spine
○
+ve Spurling’s test: Increased pain & paresthesia along the arm (suggesting cervical radiculopathy)
●
Sensory examination: Absent appreciation of pain, touch, vibration, or position sense
●
Deep tendon reflex: Decreased brachioradialis (C6) & triceps (C7) reflexes
03
Analysis
●
Impairments:
○
Pain at the base of head & right shoulder blade
○
Muscle spasm in neck and shoulder muscles
○
Weakness of hands and legs
○
Limited range of motion of neck and scapulae
●
Activity limitations: need assistance in work and ADLs
●
Participation restrictions:
○
Unable to cook and bake
○
Miss work due to pain
●
Short term goals:
○
03
Reduce pain at the base of head & right shoulder blade from 6/10 to
2/10 w/in 4/7
○
Reduce muscle spasm in neck and shoulder muscles w/in 5/7
○
Improve muscle strength of hands and legs from MMT= 1/5 to 3/5
w/in 2/52
○
Analysis
Improve range of motion of neck and scapulae by 5 degrees w/in
2/52
●
Long term goals:
○
Completely reduce the pain from 6/10 to 0/10 w/in 1/12
○
Improve gait pattern without requiring assistance w/in 2/12
○
Return to work with full physical function w/in 3/12
○
Improve forward head posture w/in 4/12
04
Plan of Tx
●
Pain management
●
Cervical traction
●
Isometric & resistance strengthening exercise
●
Stretching exercise
●
Posture therapy
●
Patient & caregiver education
●
Precautions & contraindications
05
Intervention
Precautions
●
Monitor the patient’s vital signs before, during & immediately after the intervention, especially in patients with
HPT or cardiac problems
●
Always get patient’s consent and comprehension before starting the intervention
●
Conduct the intervention in an environment without distractions and obstructions
●
If a heated towel is used in thermotherapy, be careful not to overheat to avoid skin injury
Contraindications
●
Do not perform cervical traction if patient has untreated hypertension, osteoporosis, vertebral-basilar artery
insufficiency, severe anxiety, old age, spinal cord tumor etc.
●
Do not apply cervical hot pack if patient has muscle strains with internal bleeding or inflammation, applied pain
relieving gels which numbs discomfort, or impaired sensation (Physical Therapy 101, 2020)
●
Do not perform spinal manipulation if patient has acute pain
●
Do not perform intervention if patient complains of dizziness or worsening pain
●
Do not perform intervention if patient has sudden weight loss
5.1 Pain Management (Cervical Hot Pack)
●
Aim: To relieve neck pain by relaxing the neck muscles and reducing muscle tension over the neck
●
Put a towel atop the hot pack to provide another barrier
●
Place the hot pack on patient’s neck and tighten it but remain it comfortable
●
Patient position: supine lying with pillow under the neck or sitting
●
Duration: 20 minutes
●
Frequency: 2-3 times a day
5.2 Manual Cervical Traction
●
Aim: To treat neck pain & improve ROM with lightly pull on the head in different positions or different amounts
of bend to create additional space between the cervical vertebrae that reduces pressure and tension
●
Patient position: crook lying with a pillow under the head & knees, head in a neutral position
●
PT position: sitting over the patient’s head
●
Hand placement: hand webspace is over patient’s suboccipital space
●
Apply pressure with fingers over the suboccipital space first to relax the neck muscles by inhibiting the Golgi
tendons
●
After the patient is relaxed, flex the head to 30 degrees & apply stationary traction
○
Intensity: 15-20 lbs
○
Duration: Intermittent periods of traction for about 10 seconds, last for 8-10 minutes
○
Frequency: 3 reps per day, twice weekly
(Marquis, 2019)
(“Cervical Traction: What It Is, Types & Benefits,” 2022)
(Abi-Aad & Derian, 2022)
5.3 Strengthening Exercises
●
Isometric exercise
○
Aim: To improve neck pain and disability caused by cervical spondylosis which affects deep
cervical flexors
○
Patient position: sit on a chair with feet flat on the floor and body weight balanced on the buttcks,
relax the shoulders and keep the head level
○
Press the palm against forehead and resist with the neck muscles, repeat with the palm pressing
against both sides and the back of the head respectively
○
Duration: 10 seconds
○
Frequency: 2 sets, 5 reps per day
○
For patients suffering from chronic neck pain that performed neck isometric strength exercises for
4 consecutive weeks, neck pain and disability is significantly alleviated (Sadeghi et al., 2022)
5.3 Strengthening Exercises
●
Resistance band exercise
○
Aim: To strengthen the muscles of shoulder girdle, neck and upper back
○
Patient position: sitting with a light resistance band around the side of head to be strengthened,
hold it at the opposite side
○
Bend the head to the shoulder on the same side, but do not lift the shoulder up, then slowly come
back up
○
Duration: hold for 1o seconds
○
Frequency: 3 sets, 10 reps per day
○
Chronic neck pain patients with muscle imbalance has significant reduce in pain, cervical ROM,
upper trapezius tone, disability level, and QOL after 4 weeks of cervical resistance exercise
program (Kang & Kim, 2022)
5.4 Stretching exercise
●
Aim: To restore length, flexibility and strength to the neck muscles in order to relieve pain and
gain back range of motion
●
Stretching exercises are effective in decreasing pain intensity, functional disability and improving
neck range of motion in patients with chronic cervical spondylosis. (Magdolin Mishel, 2021)
●
Head tilt stretches
○
Patient position: sitting on a chair with neck and back straight
○
Move the neck forward and backward by lifting the chin upward & bringing the chin to
chest
○
Then bring the neck to the shoulder on both sides
○
Hold for 5–10 seconds on each directions, repeat 2–4 times
5.4 Stretching exercise
●
●
Head turn
○
Patient position: sitting on a chair with the back straight and shoulders neutral
○
Turn the head over the shoulder with the chin being straight.
○
Hold for 5–10 seconds, return to the center, and repeat on the other side.
○
Repeat the exercise 5 times on each side.
Shoulder rolls:
○
To relieve tension in the shoulders and upper back in order to alleviate neck tension
○
Patient position: sitting on a chair with neck and back straight
○
During inhalation, bring the shoulders up to the ears
○
During exhalation, bring the shoulders down
○
Repeat 5-10 times for 3 sets per day
5.5 Posture correction
●
Sit and walk tall, with ears aligned vertically with shoulders and chin slightly tucked.
●
Avoid sitting in the same position or overhead work for a prolonged duration, take short breaks throughout
the day.
●
Adjust the computer monitor to the eyes level, avoid looking up or down at a computer monitor
●
Avoid putting pressure on the upper back with things like backpacks, over-the-shoulder purses, or carrying
children.
●
Maintain a good posture by holding the head up and keeping the shoulders back and down, avoid hunching
forward.
●
Sleep with the neck neutral by using a small pillow under the nape of the neck and a pillow under the knees to
flatten the spine and relax the neck muscles in supine lying. If in side lying, sleep with enough pillows to keep
the neck straight in line with the body. Avoid prone lying with the head turned to one side.
●
Carry heavy objects close to the body rather than with outstretched arms.
(“UpToDate,” 2023)
5.6 Patient & caregiver education
●
Stress reduction: To prevent recurring neck pain as emotional stress worsens neck tension and
interfere with or delay the recovery process. Relaxation exercise includes breathing exercises,
progressive muscle relaxation, meditation etc.
●
Smoking cessation: Smoking leads to disc degeneration and further neck and shoulder pain as tobacco
inhibits bone growth and bone health of the vertebrae especially at the lower cervical disc. Nicotine
reduces blood circulation and makes oxygen and nutrients transport throughout the body harder,
which induces poor healing process.
●
Regular exercise: Incorporate strengthening, flexibility and cardiovascular exercises for long term neck
pain relief and prevention as neck muscles are conditioned to better support and stabilize nearby joints
and bones
●
Healthy weight maintenance: Excess weight implies unnecessary pressure on the spinal structures,
which accelerate breakdown and leads to arthritis and bone spurs formation.
(“UpToDate,” 2023)
(Chen, Li, Pan, Wu, & Li, 2018)
●
06
ROM:
○
Improved in neck and scapulae muscles by 5
degrees
○
●
Full ROM is regained by the end of 2 months
VAS:
○
Evaluation
Pain is reduced to VAS 2/1o at the base of head &
right shoulder blade
○
●
Pain is completely eliminated to VAS 0/10
Neck disability scale: Pain and disability is reduced to 514 with moderate disability
07
Review
●
Spurling’s test
●
Clearing test for shoulder muscle power and
ROM
●
Upper limb tension test 1 (median nerve)
●
Hoffman’s sign
●
Ask more on the X-Ray and MRI results
References
Abi-Aad, K. R., & Derian, A. (2022, August 8). Cervical Traction. Retrieved January 26, 2023, from Nih.gov
website: https://www.ncbi.nlm.nih.gov/books/NBK470412/#_article-19260_s4_
Cervical Spondylosis (Arthritis of the Neck) - OrthoInfo - AAOS. (2021). Retrieved January 25, 2023, from Aaos.org
website: https://orthoinfo.aaos.org/en/diseases--conditions/cervical-spondylosis-arthritis-of-the-neck
Cervical Traction: What It Is, Types & Benefits. (2022). Retrieved January 26, 2023, from Cleveland Clinic website:
https://my.clevelandclinic.org/health/treatments/23093-cervical-traction
Chen, Z., Li, X., Pan, F., Wu, D., & Li, H. (2018). A retrospective study: Does cigarette smoking induce cervical disc
degeneration? International Journal of Surgery, 53, 269–273. https://doi.org/10.1016/j.ijsu.2018.04.004
References
Do mobilization or manipulation techniques help relieve neck pain? (2019, February 14). Retrieved January 26, 2023,
from Nih.gov website:
https://www.ncbi.nlm.nih.gov/books/NBK338114/#:~:text=In%20mobilization%2C%20the%20therapist%20slowly,als
o%20known%20as%20chiropractic%20adjustment.
Dr Laurence Knott. (2019, August 11). Examination of the Spine. Retrieved January 25, 2023, from Patient.info website:
https://patient.info/doctor/examination-of-the-spine#nav-1
Kuo, D. T., & Prasanna Tadi. (2022, May 8). Cervical Spondylosis. Retrieved January 25, 2023, from Nih.gov website:
https://www.ncbi.nlm.nih.gov/books/NBK551557/
References
Magdolin Mishel. (2021). Efficacy of Stretching Exercises Versus Postisometric Relaxation Technique on Pain, Functional
Disability and Range of Motion in Patients with Cervical Spondylosis. A Randomized controlled trial. Retrieved January
26, 2023, from https://www.semanticscholar.org/paper/Efficacy-of-Stretching-Exercises-Versus-RelaxationMishel/dae2b33411fbca6c3f2288ea1838826f0290b748
Marquis, P. (2019). Cervical traction/How and When to do it Manually [YouTube Video]. Retrieved from
https://www.youtube.com/watch?v=xBtMnPCKN5A
Physical Therapy 101. (2020). Neck Pain Relief - Cervical Hot Pack for Neck Pain [YouTube Video]. Retrieved from
https://www.youtube.com/watch?v=DCQ5HOiZiOg
References
Sadeghi, A., Rostami, M., Ameri, S., Karimi Moghaddam, A., Karimi Moghaddam, Z., & Zeraatchi, A. (2022).
Effectiveness of isometric exercises on disability and pain of cervical spondylosis: a randomized controlled trial. BMC
Sports Science, Medicine and Rehabilitation, 14(1). https://doi.org/10.1186/s13102-022-00500-7
Scott, E., & Kerr, D. (2006). CERVICAL SPONDYLOSIS. Current Therapy in Neurologic Disease, 61–64.
https://doi.org/10.1016/b978-0-323-03432-6.50019-2
UpToDate. (2023). Retrieved January 26, 2023, from Uptodate.com website:
https://www.uptodate.com/contents/neck-pain-beyond-the-basics#H21
Voorhies, R. M. (2001). Cervical spondylosis: recognition, differential diagnosis, and management. The Ochsner Journal,
3(2), 78–84. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116771/