Physical Therapy for Chronic Neck Pain

Physical Therapy for Chronic Neck Pain Introduction

Every year, millions of people visit their doctors for a common problem; neck pain, which is often diagnosed as Cervicalgia. Cervicalgia causes localized pain, so it rarely radiates outward. You may experience something as light as a “stiff neck” or as severe as the inability to turn your head due to severe pain or tight muscles. Other symptoms include headaches and general neck stiffness, as well as a burning and aching sensation in your upper back and neck. Common physical therapy treatments for neck pain include, exercise, traction, postural correction, massage, and therapeutic modalities. Many studies indicate that exercise can be a main tool in the treatment of neck pain. Specific exercises may be prescribed in order to improve range of motion in the neck and to help decrease pain. Strengthening exercises may be prescribed if weakness is identified during the initial evaluation. Cervical traction may also be used to help reduce neck pain. Traction is used to separate the joint surfaces in the neck, which may be beneficial if arthritis is present. If poor sitting posture is thought to be the cause of neck pain, working to correct this posture can be beneficial. A lumbar support roll is often used to improve posture. If tight and sore muscles are considered to be a cause of neck pain, massage techniques may be used to help decrease tension and pain in these muscles. Heat and ice are also used to help relax muscles and to decrease inflammation. Passive treatments may feel good to the patient but should not take the place of active exercise and postural correction in the treatment of neck pain. (Sears, B. 2018) The implementation of exercise and manual therapy techniques were performed for chronic neck pain in order to decrease pain, decrease muscle tightness and to improve quality of life. Physical therapy interventions with combination of exercise and manual therapy has shown a gradual improvement in managing pain, decreasing muscle tightness, and improving range of motion.

Neck pain is pain felt in the back of the neck- the upper spine area, just below the head. When certain nerves are affected, the pain can extend beyond the back of the neck to areas such as the upper back, shoulder, and arm. It is estimated that neck pain affects approximately 30% of the US population each year. It can be caused by sudden trauma such as a fall, sports injury, car accident, or by long-term problems in the spine. Neck pain most frequently affects adults aged 30 to 50 years. Some studies indicate that women are more likely to suffer neck pain than men. Poor posture, obesity, smoking, repetitive lifting, office and computer work, and involvement in athletic activity are all risk factors for developing neck pain. People with neck pain can have difficulty performing activities such as working, driving, playing sports, or simply turning their heads. The majority of neck pain episodes do not require surgery and respond best to physical therapy. Physical therapist design individualized treatment programs to help people with neck pain reduce or eliminate pain, regain normal movement, and get back to their regular activities. Recent research has shown that physical therapy is a better treatment than surgery or pain medication (such as opioid medication) for relieving many cases of neck pain. Physical therapy treatments can often help people avoid the need for surgery or medication all together. The time it takes to heal varies with each condition, but an individualized physical therapy program can be effective and efficient and help heal neck pain in a matter of weeks (Neck pain. 2018).

Many studies have examined whether physical therapy can help reduce spine-related pain, such as in the lower back or neck. Current medical literature suggests moderate to strong evidence supporting the benefits of physical therapy’s role in reducing neck pain and improving range of motion. Some studies have found even more benefits from physical therapy when combined with other treatment methods, such as aerobic activity. When applied as part of a physical therapy program for neck pain, passive treatments are used to help reduce pain and/or stiffness. In theory, when pain and stiffness are reduced, exercises for the neck can be more effective (Rob D. Dickerman F. 2019).

Case Description

The patient is a 50-year-old female with a diagnosis of Cervicalgia and headaches due to chronic pain and postural deficits. Patient presents with faulty posture including increased cervicothoracic juncture and increased thoracic kyphosis. The patient complaints of increased dull achy pain along central cervical spine that radiates to upper trapezius and rhomboid area with headaches. Aggravating factors are prolonged positions with relieving factors being rest. Past medial history includes anxiety, osteoarthritis, depression, diabetes, headaches, and sleep apnea. The patient complains of frequent migraines that interfere with every day activities. There was no mechanism of injury noted aside from insidious onset with chronic pain over the past few years. An MRI was performed for the cervical region in 2016, with results showing degenerative disc disease on both right and left sides of the cervical region. Patient has received Botox injections once every 3 months for the past several years in order to control neck pain and migraines but has been less effective lately.

Upon initial evaluation, the patient’s functional deficits included pain with end-range cervical rotation while driving, ability to lift light items only, pain with overhead reaching, and has several nightly disturbances while sleeping. Patient stated current pain a 4/10 at the evaluation with reports of pain increasing to 8/10 at times. A functional test was performed to determine weight limit for overhead reaching. For this test, the patient was asked to start with no weight and hold arms at side, then do a bicep curl, followed by an overhead press. The patient was advised to verbalize any pain or discomfort with either of the 3 motions. The patient had no complaints of pain therefore the weight was increased to 1 pound, and then 2 pounds which caused an increase in pain. Palpation to the Erector Spinae, Levator Scapula, Rhomboids and Upper Trapezius produced high levels of pain. Manual muscle test for bilateral upper extremities were 5/5. Range of motion was limited for flexion, extension, rotation and side bend bilaterally in the cervical spine. Sensation and deep tendon reflexes were tested to C5-6 (Biceps Brachii), C6 (Brachioradialis), and C7-8 (Triceps Brachii) with results being within normal limits. When reflex responses are absent, this could be an indication that the spinal cord, nerve root, peripheral nerve, or muscle has been damaged. When reflex response is abnormal, it may be due to the disruption of the sensory (feeling) or motor (movement) nerves or both. To determine if there is a neural problem and where it may be, the reflexes are tested in different parts of the body (Sonntag, V. K.). However, the patient had normal reflex and sensory responses determining that there were no neural deficits. A Spurling’s test was done for the right and left side. This test was performed using a technique that involved the patient in a sitting position, bending their head to the right side and pressure was applied. This was performed again to the left side. No signs of radiculopathy were noted therefore the results of the Spurling’s test were negative. The Spurling’s test is used during a musculoskeletal assessment of the cervical spine when looking for cervical nerve root compression causing cervical radiculopathy. Cervical radiculopathy occurs when a nerve in your neck is pinched near the area where it branches away from the spinal cord. Common symptoms of a compromised nerve include pain, weakness, or numbness in your arms or hand muscles. Pain may also be felt across the upper back, shoulders, or neck (Seladi-Schulman, 2018). Considering the Spurling’s test was negative, cervical radiculopathy was not an issue with this patient. The overall problem list includes decreased cervical range of motion, pain with activities of daily living, pain with palpation to the cervical region musculature, and functional activities including pain with overhead reaching. Each problem area had a goal set to be reached within 1 month with two visits per week. The patient’s goal is to be able to perform all activities of daily living without an increase in pain. Education was provided to the patient for sleeping positions, use of hot and cold pack, postural awareness. A home exercise program was provided as well to include stretching of the cervical musculature.

Patient was informed of what to expect with the first treatment session, which came 5 days after the initial evaluation. This information provided to the patient about the first session included stretching the cervical muscles, some light strengthening exercises to start out with, followed by some manual therapy techniques including suboccipital release, manual traction, and soft tissue to the Erector Spinae. The patient’s overall prognosis was good. Interventions. Treatment sessions began 5 days after initial evaluation. Caution was taken due to the patient having limited range of motion, a lot of pain, and sudden onsets of migraines.

Day one: Treatment session began with the upper body ergometer x10 minutes forward x5 minutes and backwards x5 minutes. Next, the patient performed self-stretches for the Levator Scapulae, Pectoralis Major and Upper Trapezius. Levator Scapulae and Upper trapezius stretch were both performed in a seated position. The Pectoralis Major stretch was performed bilaterally in a doorway in order to decrease muscle tightness and correct posture due to lumbar extension. Each stretch was performed 3 times with 30 second holds. Patient reported no pain with stretching but complained of tightness in the cervical musculature. Range of motion exercises were chest lift chin tucks in the seated position for 10 repetitions with 5 second holds for each repetition. This exercise increased pain per patient report. Due to the patient having increased pain, soft tissue was performed to Erector Spinae musculature. This technique included, soft/deep tissue technique (S/DTT) with myofascial release, cervical distraction and suboccipital release x15 minutes. This was performed with the patient in the supine position and fully relaxed. The patient ended the treatment session with a cold back on the cervical spine. After manual therapy techniques (MTT) the patient had increased cervical range of motion per visual inspection.

Day two: Noted complaints of migraine after last treatment session. Upper body ergometer, and stretches were not performed on this day due to the patient having a migraine after the last treatment and trying to avoid over working the cervical muscles. The patient tolerated stretching in the supine position on a ½ foam roll with a moist hot pack to the cervical spine for 10 minutes. Chest lift-chin tucks x10 repetitions with 5 second holds. Chin tuck/head lift x15 repetitions with 5 second holds in the prone position with the patient’s head off the edge of the table. In the supine position, the patient performed alternating upper extremity lifts with a red (2 pound) weighted ball. Bilateral upper extremities were used for ball transfer from one upper extremity to the other. The patient maintained a chin tuck while performing the ball transfers. Patient was able to tolerate this x10 minutes. Stabilization training was performed in the prone position x15 repetitions, performing a chin tuck with scapular depression and upper extremity extension. Not all MTT were performed due to increased pain after the last session and trying to determine what may have caused the increase in pain.

Day 3: Began treatment session with self-stretching for Levator Scapulae musculature, Pectoralis Major and Upper Trapezius muscle. All stretches were performed 3 times with 30 second holds. Patient did not perform ½ foam roll stretch in supine position, chest lift-chin tucks, upper body ergometer, alternating upper extremity lift, chin tuck/head lifts, or chin tucks with scapular depression and upper extremity extension due to trying to determine what may have caused increased pain after the last treatment session. S/DTT x10 minutes with myofascial release to the erector spinae, cervical distraction, and suboccipital release was performed with ice pack around cervical spine. Noted reduction of headache with gentle cervical manual traction, and decreased tightness in suboccipital region after MTT.

Day 4: Treatment started with self-stretching for Levator Scapulae musculature, Pectoralis major and Upper Trapezius muscle. All stretches were performed 3 times with 30 second holds. Supine stretch on ½ foam roll for 5 minutes with moist hot pack around cervical spine. Chest lift-chin tucks x10 reps with 5 second holds, alternating upper extremity lift with red (2 pound) weighted ball transferring back and forth between bilateral upper extremities while maintaining chin tuck. Stabilization training in the prone position included chin tucks with scapular depression and upper extremity extension x15 reps. Intermittent cervical traction was added x15 minutes with an on/off ratio of 20/10 with max weight being 17 pounds. S/DTT x10 minutes with myofascial release to erector spinae, cervical distraction, and suboccipital release was performed with ice pack around cervical spine. Noted improved mobility and decreased pain after cervical traction. Continued weakness in cervical stabilizers apparent during strengthening exercises.

Day 5: Self-stretching for Levator Scapulae musculature, Pectoralis Major and Upper Trapezius muscle. All stretches were performed 3 times with 30 second holds. Supine stretch on ½ foam roll for 5 minutes with moist hot pack around cervical spine. Chest lift-chin tucks x10 reps with 5 second holds, alternating upper extremity lift with red (2 pound) weighted ball transferring back and forth between bilateral upper extremities while maintaining chin tuck. Stabilization training in the prone position included chin tucks with scapular depression and upper extremity extension x15 reps. Intermittent cervical traction x15 minutes with an on/off ratio of 20/10 and max weight being 17 pounds. S/DTT x10 minutes with myofascial release to erector spinae, cervical distraction, and suboccipital release was performed with ice pack around cervical spine.

Day 6: Treatment session started with upper body ergometer x10 minutes, 5 minutes forward, 5 minutes backwards. Self-stretching for Levator Scapulae musculature, Pectoralis Major and Upper Trapezius muscle. All stretches were performed 3 times with 30 second holds. Supine stretch on ½ foam roll for 5 minutes with moist hot pack around cervical spine. Chest lift-chin tucks x10 reps with 5 second holds, alternating upper extremity lift with red (2 pound) weighted ball transferring back and forth between bilateral upper extremities while maintaining chin tuck. Stabilization training in the prone position included chin tucks with scapular depression and upper extremity extension x15 reps. More strengthening exercises added this treatment. Cervical walk outs were performed with yellow tubing hooked to TheraBand wall mount and attached to adjustable strap that was placed around patient’s forehead and went all the way around the head above the ears. Patient walked out with tubing behind head for isometric cervical extension, the strap was turned for the patient to walk laterally to the right for isometric cervical side bend to the left, strap was turned for the patient to walk backwards for isometric cervical flexion, and then strap was turned for the patient to walk laterally to the left for isometric cervical side bend. Patient walked out far enough to feel resistance but not too far to cause discomfort. Once at a comfortable distance the patient paused for 10 seconds resisting against the tubing and maintain an upright posture 5 times in each direction. After 10 seconds, the patient took steps towards the band to release the tension and paused for 5 seconds and then walked back out to gain tension. Intermittent cervical traction x15 minutes with an on/off ratio of 20/10 and max weight being 17 pounds. S/DTT x10 minutes with myofascial release was performed to erector spinae, cervical distraction, and suboccipital release was performed with ice pack around cervical spine.

Outcomes

The patient is currently still attending therapy with continued progress. A re-evaluation has not yet been performed to note a difference in objective measurements. However, muscle tightness has been assessed at every visit and decreased tightness has been noted upon palpation. From the first day of therapy until now, the patient has reported a significant decrease in pain. Per visual assessment, the patient has gained range of motion, and is able to report how much better they are feeling, along with the ability to perform exercises more efficiently. With continuing the combination of stretching, strengthening, cervical traction, and manual therapy techniques, it is believed that the patient will continue to progress and exceed all goals. However, considering the factors that may affect the patient’s progress, such as frequent and insidious onsets of migraines, it is important to progress the patient cautiously but efficiently in order to avoid causing an increase in pain or migraines.

Discussion

For chronic neck pain, the combination of an exercise program including stretching and strengthening along with MTT and traction is believed to be beneficial for decreasing pain and allowing for an improved quality of life thus far for this patient. Neck pain can have numerous causes and finding the exact cause can better assist with determining an intervention. A previous research study has shown that manual therapy combined with exercise therapy has not been more effective in reducing neck pain intensity at rest, neck disability or improving quality of life in adult patients with grade I-II neck pain, than exercise therapy alone (Fredin, K., 2017). However, the severity of neck pain may also be a contribution as to whether this intervention would be effective. Suggestions for further research should determine the effects of combining manual therapy with exercise therapy based on the severity of neck pain. Furthermore, follow ups should be achieved in order to obtain information on the duration of relief or if there has been a relapse.