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Cervical Spondylosis

Cervical spondylosis is a degenerative condition of the neck caused by aging, resulting in changes to the bones, discs, and joints, often leading to symptoms like chronic pain and stiffness. It occurs in over 90% of people aged 60 and older, with risk factors including previous neck injuries, genetics, and poor posture. Diagnosis is typically through physical examination and imaging, with treatment options including physical therapy and exercise regimens to manage pain and improve function.

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Cervical spondylosis involves degeneration of neck bones and joints due to aging, affecting older adults.

Major risk factors include aging, previous neck injuries, poor posture, and genetic predisposition.

Degenerative changes found in 25% of adults under 40, increasing to 85% over 60, often asymptomatic.

Age-related degeneration of spinal elements causes syndromes including neck pain and myelopathy.

Symptoms include neck pain, cervical radiculopathy, and myelopathy, with potential for diagnostic imaging.

Common symptoms: pain, stiffness, neurological changes, dizziness, and poor balance.

Diagnostic steps include history, physical examination, neuro assessments, and imaging studies.

Assessment methods include evaluating mobility deficits and conducting specific clinical tests.

Tests for diagnosing nerve-related symptoms: ULTT1, ULTT2A, and ULTT2B focused on neural tension.

Positive tests indicate symptom reproduction, assessing nerve root compression in upper extremities.

Identifying various non-specific pain conditions and diseases that may mimic cervical spondylosis.

Non-surgical and surgical management options; exercise combined with therapies is more effective.

Key components include rehabilitation exercises, manual therapy, and the efficacy of physical modalities.

Used for treating myofascial pain, improving symptoms related to cervical spondylosis.

Citations from literature and guidelines regarding cervical spondylosis, surgery, and therapy.

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CERVICAL SPODYLOSIS By Dr. Shazia Abdul Hamid Khalfe, PT Vice Principal, Assistant Professor & Director PG IIRS-IUKC
• It is a condition involving changes to the bones, discs, and joints of the neck. These changes are caused by the normal wear-and-tear of aging. With age, the discs of the cervical spine gradually break down, lose fluid, and become stiffer. Cervical spondylosis usually occurs in middle-aged and elderly people. 3/22/2021 By Dr. Shazia Khalfe 2 Cervical Spondylosis
• As a result of the degeneration of discs and other cartilage, spurs or abnormal growths called osteophytes may form on the bones in the neck. These abnormal growths can cause narrowing of the interior of the spinal column or in the openings where spinal nerves exit, a related condition called cervical spinal stenosis. 3/22/2021 By Dr. Shazia Khalfe 3 Cervical Spondylosis
• The condition is present in more than 90 percent of people aged 60 and older. • Some people who have it never experience symptoms. For others, it can cause chronic, severe pain and stiffness. However, many people who have it are able to conduct normal daily activities. 3/22/2021 By Dr. Shazia Khalfe 4 Cervical Spondylosis
• In the cervical spine this chronic degenerative process affects the intervertebral discs and facet joints, and may progress to disk herniation, osteophyte formation, vertebral body degeneration, compression of the spinal cord, or cervical spondylotic myelopathy 3/22/2021 By Dr. Shazia Khalfe 5 Cervical Spondylosis
• Aging is the major factor for developing cervical osteoarthritis (cervical spondylosis). In most people older than age 50, the discs between the vertebrae become less spongy and provide less of a cushion. Bones and ligaments get thicker, encroaching on the space of the spinal canal. 3/22/2021 By Dr. Shazia Khalfe 6 Risk Factors for Cervical Spondylosis
• Another factor might be a previous injury to the neck. People in certain occupations or who perform specific activities -- such as gymnasts or other athletes -- may put more stress on their necks. 3/22/2021 By Dr. Shazia Khalfe 7 Risk Factors for Cervical Spondylosis
• Poor posture might also play a role in the development of spinal changes that result in cervical spondylosis. • Work-related Activities That Put Extra Strain On Your Neck From Heavy Lifting 3/22/2021 By Dr. Shazia Khalfe 8 Risk Factors for Cervical Spondylosis
• Genetic Factors (Family History Of Cervical Spondylosis) • Smoking • Increased incidence in patients who carried heavy loads on their heads or shoulders and in dancers and gymnasts. 3/22/2021 By Dr. Shazia Khalfe 9 Risk Factors for Cervical Spondylosis
• Evidence of spondylotic change is frequently found in many asymptomatic adults, with evidence of some disc degeneration in: • 25% of adults under the age of 40, • 50% of adults over the age of 40, and • 85% of adults over the age of 60 3/22/2021 By Dr. Shazia Khalfe 10 Epidemiology
• Asymptomatic adults showed significant degenerative changes at 1 or more levels • 70% of women and 95% of men at age 65 and 60 were affected • The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5". 3/22/2021 By Dr. Shazia Khalfe 11 Epidemiology
• The primary risk factor and contributor to the incidence of cervical spondylosis is age-related degeneration of the intervertebral disc and cervical spinal elements. 3/22/2021 By Dr. Shazia Khalfe 12 Etiology
• Degenerative changes in surrounding structures, including the facet joints, posterior longitudinal ligament (PLL), and ligamentum flavum all combine to cause narrowing of the spinal canal and intervertebral foramina. Consequently, the spinal cord, spinal vasculature, and nerve roots can be compressed, resulting in the three clinical syndromes in which cervical spondylosis presents: axial neck pain, cervical myelopathy, and cervical radiculopathy. 3/22/2021 By Dr. Shazia Khalfe 13 Etiology
• Factors that can contribute to an accelerated disease process and early-onset cervical spondylosis include exposure to significant spinal trauma, a congenitally narrow vertebral canal, dystonic cerebral palsy affecting cervical musculature, and specific athletic activities such as rugby, soccer, and horse riding. 3/22/2021 By Dr. Shazia Khalfe 14 Etiology
Cervical spondylosis presents in three symptomatic forms as: • Non-specific neck pain - pain localized to the spinal column. • Cervical radiculopathy - complaints in a dermatomal or myotomal distribution often occurring in the arms. May be numbness, pain or loss of function. 3/22/2021 By Dr. Shazia Khalfe 15 Clinical Presentation
• Cervical myelopathy - a cluster of complaints and findings due to intrinsic damage to the spinal cord itself. Numbness, coordination and gait issues, grip weakness and bowel and bladder complaints with associated physical findings may be reported. 3/22/2021 By Dr. Shazia Khalfe 16 Clinical Presentation
• Symptoms can depend on the stage of the pathological process and the site of neural compression. Diagnostic imaging may show spondylosis, but the patient may be asymptomatic and vice versa. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, so the boundary between normal ageing and disease is difficult to define. 3/22/2021 By Dr. Shazia Khalfe 17 Clinical Presentation
• Poorly localized tenderness • Limited range of motion • Minor neurological changes (unless complicated by myelopathy or radiculopathy) 3/22/2021 By Dr. Shazia Khalfe 18 Signs
• Cervical pain aggravated by movement • Referred pain (occiput, between the shoulder blades, upper limbs) • Retro-orbital or temporal pain • Cervical stiffness • Vague numbness, tingling or weakness in upper limbs • Dizziness or vertigo • Poor balance • Rarely, syncope, triggers migraine 3/22/2021 By Dr. Shazia Khalfe 19 Symptoms
• On basis of Sign & Symptoms • History • Physical examination with a focus on the neck, back, and shoulders • Reflexes, ROM, Muscle strength & power are evaluated • Sensory and motor evaluation • X-Ray, MRI etc.. 3/22/2021 By Dr. Shazia Khalfe 20 Diagnosis
• Neck Disability Index • The Patient-Specific Functional Scale (PSFS) for patients with neck pain • Performance‐based outcome measures 3/22/2021 By Dr. Shazia Khalfe 21 Outcome Measures
• Contains 10 items (7 related to ADLs, 2 related to pain, 1 related to concentration) • Each item is scored 0 – 5 and the total score is expressed as a percentage • Higher scores correspond to greater disability 3/22/2021 By Dr. Shazia Khalfe 22 Neck Disability Index
• Ask patient to list 3 activities that are difficult as a result of their symptoms/injury/disorder • The patient rates each activity on a scale of 0 – 10; 0 represents inability to perform the activity and 10 represents the ability to perform the activity as well as they could prior to the onset of symptoms • The 3 activity scores are averaged for a final score 3/22/2021 By Dr. Shazia Khalfe 23 The Patient-Specific Functional Scale (PSFS) for patients with neck pain
• Movement or activity limitations associated with the patient’s neck pain and be used to assess the changes in the patient’s level of function over the episode of care. These activities should be measurable and reproducible. 3/22/2021 By Dr. Shazia Khalfe 24 Performance‐based outcome measures
• When evaluating a patient with neck pain over an episode of care, assessment of impairment of body function should include measures that can rule in or rule out: • neck pain with mobility deficits, including cervical active range of motion, the flexion rotation test, cervical and thoracic segmental mobility tests, and • neck pain with radiating pain/cervical radiculopathy, including the upper limb tension test, Spurling's test, distraction test, and the Valsalva test. 3/22/2021 By Dr. Shazia Khalfe 25
• Posture • Functional movement • ROM • Muscle strength • Neurologic Assessment • Reflexes • MMT • Special tests 3/22/2021 By Dr. Shazia Khalfe 26 Observation
• The patient is positioned in supine. During the ULTT that places a bias towards testing the patient’s response to tension placed on the median nerve, the examiner sequentially introduces the following movements to the symptomatic upper extremity. Scapular depression • Shoulder abduction to approximately 90 degrees with the elbow flexed • Forearm supination, wrist and finger extension • Shoulder lateral rotation • Elbow extension • Contralateral then ipsilateral cervical side- bending 3/22/2021 By Dr. Shazia Khalfe 27 Neck Flexor Muscle Endurance Test
• A positive test is indicated by the presence of any of the following findings: Reproduction of all or part of the patient’s symptoms • Side-to-side differences of greater than 10 degrees of elbow or wrist extension • On the symptomatic side, contralateral cervical side-bending increases the patient’s symptoms, or ipsilateral side-bending decreases the patient’s symptoms 3/22/2021 By Dr. Shazia Khalfe 28
1.Shoulder girdle depression 2.Shoulder abduction 3.Shoulder external rotation 4.Forearm Supination 5.Wrist and Finger extension 6.Elbow extension 7.Cervical side flexion 3/22/2021 By Dr. Shazia Khalfe 29 Upper Limb Tension Test 1 (ULTT1, Median nerve bias)
1.Shoulder girdle depression 2.Elbow extension 3.Lateral rotation of the whole arm 4.Wrist, finger and thumb extension 3/22/2021 By Dr. Shazia Khalfe 30 Upper Limb Tension Test 2A (ULTT2A, Median nerve bias)
• Shoulder girdle depression • Elbow extension • Medial rotation of the whole arm • Wrist, finger and thumb flexion 3/22/2021 By Dr. Shazia Khalfe 31 Upper Limb Tension Test 2B (ULTT2B, Radial nerve bias)
• The patient is seated and asked to side bend and slightly rotate head to the painful side. • The clinician places a compressive force of approximately 7 kg through the top of the head in an effort to further narrow the intervertebral foramen. • The test is considered positive when it reproduces the patient’s symptoms. The test is not indicated if the patient does not have upper extremity or scapular region symptoms. 3/22/2021 By Dr. Shazia Khalfe 32 Spurling’s Test
• The patient is positioned in supine. • The examiner grasps under the chin and occiput, flexes the patient’s neck to a position of comfort, and gradually applies a distraction force of up to approximately 14 kg. • A positive test occurs with the reduction or elimination of the patient’s upper extremity or scapular symptoms. The test is not indicated if the patient has no upper extremity or scapular region symptoms. 3/22/2021 By Dr. Shazia Khalfe 33 Distraction Test
• Other non-specific neck pain lesions - acute neck strain, postural neck ache or Whiplash • Fibromyalgia and psychogenic neck pain • Mechanical lesions - disc prolapse or diffuse idiopathic skeletal hyperostosis • Inflammatory disease - Rheumatoid arthritis, Ankylosing spondylitis or Polymyalgia rheumatica • Metabolic diseases - Paget's disease, osteoporosis, gout or pseudo- gout, Infections - osteomyelitis or tuberculosis • Malignancy - primary tumours, secondary deposits or myeloma 3/22/2021 By Dr. Shazia Khalfe 34 Differential Diagnosis
• Medical management i. Non surgical ii. Surgical • Physical therapy management 3/22/2021 By Dr. Shazia Khalfe 35 Treatment
• There is little evidence for using exercise alone or mobilisation and/or manipulations alone. • Mobilisation and/or manipulations in combination with exercises are effective for pain reduction and improvement in daily functioning in sub- acute or chronic mechanical neck pain with or without headache. • There is moderate evidence that various exercise regimens, like proprioceptive, strengthening, endurance, or coordination exercises are more effective than usual pharmaceutical care 3/22/2021 By Dr. Shazia Khalfe 36 Physical Therapy Management
• Treatment should individualised, but generally includes rehabilitation exercises, proprioceptive re- education, manual therapy and postural education • Manual therapy • Postural education • Electrotherapeutic modalities • Patient education • Home exercises 3/22/2021 By Dr. Shazia Khalfe 37 Physical Therapy Management
• A Costello M et al 2018 study comparing isometric exercises to dynamic exercises, both with traditional physiotherapeutic methods concluded that short-term physiotherapy plays a significant role in the treatment of cervical spondylosis. Comparison between the two treatment techniques gives priority to dynamic exercises, contrary to isometric exercises 3/22/2021 By Dr. Shazia Khalfe 38 Physical Therapy Management
• Physical modalities such as cervical traction, heat, cold, therapeutic ultrasound, massage, and transcutaneous electrical nerve stimulator (TENS) lacked sufficient evidence regarding their efficacy in the treatment of acute or chronic neck pain. • In patients experiencing radicular pain, cervical traction may be incorporated to alleviate the nerve root compression that occurs with foraminal stenosis 3/22/2021 By Dr. Shazia Khalfe 39 Philadelphia Panel finding
• Trigger point injections can be employed to treat myofascial trigger points, which can clinically manifest as neck, shoulder, and upper arm pain. 3/22/2021 By Dr. Shazia Khalfe 40
3/22/2021 By Dr. Shazia Khalfe 41
• Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83. • Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008. • Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365. • Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154- 159. • Childs JD et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. The Journal of Orthopaedic Sports Physical Therapy. 2008;38(9):A1-A34. • O’Sullivan SB, Schmitz TJ. Physical Rehabilitation: Fifth Edition. Philadelphia: F.A. Davis Company; 2007. • Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis- based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007, Aug 3;8:75. 3/22/2021 By Dr. Shazia Khalfe 42 References
• Kuo DT, Tadi P. Cervical Spondylosis. InStatPearls [Internet] 2019 Nov 26. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551557/ (last accessed 31.1.2020) • Xiong W, Li F, Guan H. Tetraplegia after thyroidectomy in a patient with cervical spondylosis: a case report and literature review. Medicine (Baltimore) 2015;94(6):e524. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25674751 (last accessed 1.2.2020) • Ferrara LA. The biomechanics of cervical spondylosis. Advances in orthopedics. 2012 Feb 1;2012. Available from: https://www.hindawi.com/journals/aorth/2012/493605/ (last accessed 1.2.2020) • Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. Journal of clinical orthopaedics and trauma. 2014 Dec 31;5(4):221-6. • D.H. Irvine, J.B. Foster, Prevalence of cervical spondylosis in a general practice, The Lancet, May 22 1965 • Sandeep S Rana, MD, Diagnosis and Management of Cervical Spondylosis. Medscape, 2015 • Kelly JC, Groarke PJ, Butler JS, Poynton AR, O'Byrne JM. The natural history and clinical syndromes of degenerative cervical spondylosis. Advances in orthopedics. 2011 Nov 28;2012. • Moon MS, Yoon MG, Park BK, Park MS. Age-Related Incidence of Cervical Spondylosis in Residents of Jeju Island. Asian spine journal. 2016 Oct 1;10(5):857-68. • McCormack BM, Weinstein PR. Cervical spondylosis. An update. West J Med. Jul-Aug 1996;165(1-2):43-51. • Takagi I, Cervical Spondylosis: An Update on Pathophysiology, Clinical Manifestation, and Management Strategies. DM, October 2011 • Binder AI. Cervical spondylosis and neck pain. BMJ: British Medical Journal. 2007 Mar 10;334(7592):527. 3/22/2021 By Dr. Shazia Khalfe 43 References
• Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. Mar 1994;75(3):342-52 • Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. Jul 1992;23(3):381-94. (Level: A1) • Kaye JJ, Dunn AW. Cervical spondylotic dysphagia. South Med J. May 1977;70(5):613- 4. (Level: A1) • Kanbay M, Selcuk H, Yilmaz U. Dysphagia caused by cervical osteophytes: a rare case. J Am Geriatr Soc. Jul 2006;54(7):1147-8. (Level: C) • Binder AI. Cervical spondylosis and neck pain: clinical review. BMJ 2007:334:527-31 • Zhijun Hu et al., A 12-Words-for-Life-Nurturing Exercise Program as an Alternative Therapy for Cervical Spondylosis: A Randomized Controlled Trial, 20 March 2014 • J. Lafuente, A.T.H. Casey, A. Petzold, S. Brew, The Bryan cervical disc prosthesis as an alternative to arthrodesis in the treatment of cervical spondylosis, The Bone and Joint Journal, 2005. • M. Pumberger, D. Froemel, Clinical predictors of surgical outcome in cervical spondylotic myelopathy, The Bone and Joint Journal, 2013 • Fukui M, Chiba K, Kawakami M, Kikuchi SI, Konno SI, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K. Japanese orthopaedic association cervical myelopathy evaluation questionnaire (JOACMEQ): Part 2. Endorsement of the alternative item. Journal of Orthopaedic Science. 2007 May 1;12(3):241. • Revanappa KK, Rajshekhar V. Comparison of Nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy. European Spine Journal. 2011 Sep 1;20(9):1545-51. • D.R. Lebl, A. Hughes, P.F. O’Leary, Cervical Spondylotic Myelopathy: Pathophysiology, Clinical Presentation, and Treatment, the Musculoskeletal Journal of Hospital for Special Surgery, Jul 2011. • Hyun-Jin Jo et al., Unrecognized Shoulder Disorders in Treatment of Cervical Spondylosis Presenting Neck and Shoulder Pain, The Korean Spinal Neurosurgery Society, 9(3):223-226, 2012 3/22/2021 By Dr. Shazia Khalfe 44 References
• Todd AG. Cervical spine: degenerative conditions. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):168. • Melvin D. Law, Jr., M.D.a, Mark Bemhardt, M.D.b, and Augustus A. White, III, M.D., Cervical Spondylotic Myelopathy: A Review of Surgical Indications and Decision Making, Yale journal of biology and medicine,1993 • Kyoung-Tae Kim and Young-Baeg Kim, Cervical Radiculopathy due to Cervical Degenerative Diseases : Anatomy, Diagnosis and Treatment, The Korean Neurosurgical Society, 2010 (Level: 2a) • Rahim KA, Stambough JL. Radiographic evaluation of the degenerative cervical spine. Orthop Clin North Am. Jul 1992;23(3):395-403. (Level: 3a) • Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. Jul 1992;23(3):381-94. (Level: 4) • Binder AI. Cervical spondylosis and neck pain: clinical review. BMJ 2007:334:527-31 (Level: 5) • Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton , Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis, Advances in Orthopedics, 2011 (Level: 1b) • Ian A. Young, Lori A. Michener, Joshua A. Cleland, Arnold J. Aguilera, Alison R. Snyde, Manual Therapy, Exercise, andTraction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial, 2009 (Level: 1b) • Azemi, Arjeta & Ibrahimaj Gashi, Arbnore & Zivkovic, Vujica & Gontarev, Seryozha. (2018). THE EFFECT OF DYNAMIC EXERCISES IN THE TREATMENT OF CERVICAL SPONDYLOSIS. 7. 19-24. • ichale Costello, Treatment of a Patient with Cervical Radiculopathy Using Thoracic Spine Thrust Manipulation, Soft Tissue Mobilization, and Exercise, the Journal of Manual and manipulative therapy (Level: 3b) • Ibrahim M. Moustafa and Aliaa A. Diab, Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial, Journal of Chiropractic Medicine (2014) 13, 157–167 (Level: 1b) 3/22/2021 By Dr. Shazia Khalfe 45 References
3/22/2021 By Dr. Shazia Khalfe 46

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Cervical Spondylosis

  • 1.
    CERVICAL SPODYLOSIS By Dr. Shazia AbdulHamid Khalfe, PT Vice Principal, Assistant Professor & Director PG IIRS-IUKC
  • 2.
    • It isa condition involving changes to the bones, discs, and joints of the neck. These changes are caused by the normal wear-and-tear of aging. With age, the discs of the cervical spine gradually break down, lose fluid, and become stiffer. Cervical spondylosis usually occurs in middle-aged and elderly people. 3/22/2021 By Dr. Shazia Khalfe 2 Cervical Spondylosis
  • 3.
    • As aresult of the degeneration of discs and other cartilage, spurs or abnormal growths called osteophytes may form on the bones in the neck. These abnormal growths can cause narrowing of the interior of the spinal column or in the openings where spinal nerves exit, a related condition called cervical spinal stenosis. 3/22/2021 By Dr. Shazia Khalfe 3 Cervical Spondylosis
  • 4.
    • The conditionis present in more than 90 percent of people aged 60 and older. • Some people who have it never experience symptoms. For others, it can cause chronic, severe pain and stiffness. However, many people who have it are able to conduct normal daily activities. 3/22/2021 By Dr. Shazia Khalfe 4 Cervical Spondylosis
  • 5.
    • In thecervical spine this chronic degenerative process affects the intervertebral discs and facet joints, and may progress to disk herniation, osteophyte formation, vertebral body degeneration, compression of the spinal cord, or cervical spondylotic myelopathy 3/22/2021 By Dr. Shazia Khalfe 5 Cervical Spondylosis
  • 6.
    • Aging isthe major factor for developing cervical osteoarthritis (cervical spondylosis). In most people older than age 50, the discs between the vertebrae become less spongy and provide less of a cushion. Bones and ligaments get thicker, encroaching on the space of the spinal canal. 3/22/2021 By Dr. Shazia Khalfe 6 Risk Factors for Cervical Spondylosis
  • 7.
    • Another factormight be a previous injury to the neck. People in certain occupations or who perform specific activities -- such as gymnasts or other athletes -- may put more stress on their necks. 3/22/2021 By Dr. Shazia Khalfe 7 Risk Factors for Cervical Spondylosis
  • 8.
    • Poor posturemight also play a role in the development of spinal changes that result in cervical spondylosis. • Work-related Activities That Put Extra Strain On Your Neck From Heavy Lifting 3/22/2021 By Dr. Shazia Khalfe 8 Risk Factors for Cervical Spondylosis
  • 9.
    • Genetic Factors(Family History Of Cervical Spondylosis) • Smoking • Increased incidence in patients who carried heavy loads on their heads or shoulders and in dancers and gymnasts. 3/22/2021 By Dr. Shazia Khalfe 9 Risk Factors for Cervical Spondylosis
  • 10.
    • Evidence ofspondylotic change is frequently found in many asymptomatic adults, with evidence of some disc degeneration in: • 25% of adults under the age of 40, • 50% of adults over the age of 40, and • 85% of adults over the age of 60 3/22/2021 By Dr. Shazia Khalfe 10 Epidemiology
  • 11.
    • Asymptomatic adultsshowed significant degenerative changes at 1 or more levels • 70% of women and 95% of men at age 65 and 60 were affected • The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5". 3/22/2021 By Dr. Shazia Khalfe 11 Epidemiology
  • 12.
    • The primaryrisk factor and contributor to the incidence of cervical spondylosis is age-related degeneration of the intervertebral disc and cervical spinal elements. 3/22/2021 By Dr. Shazia Khalfe 12 Etiology
  • 13.
    • Degenerative changesin surrounding structures, including the facet joints, posterior longitudinal ligament (PLL), and ligamentum flavum all combine to cause narrowing of the spinal canal and intervertebral foramina. Consequently, the spinal cord, spinal vasculature, and nerve roots can be compressed, resulting in the three clinical syndromes in which cervical spondylosis presents: axial neck pain, cervical myelopathy, and cervical radiculopathy. 3/22/2021 By Dr. Shazia Khalfe 13 Etiology
  • 14.
    • Factors thatcan contribute to an accelerated disease process and early-onset cervical spondylosis include exposure to significant spinal trauma, a congenitally narrow vertebral canal, dystonic cerebral palsy affecting cervical musculature, and specific athletic activities such as rugby, soccer, and horse riding. 3/22/2021 By Dr. Shazia Khalfe 14 Etiology
  • 15.
    Cervical spondylosis presentsin three symptomatic forms as: • Non-specific neck pain - pain localized to the spinal column. • Cervical radiculopathy - complaints in a dermatomal or myotomal distribution often occurring in the arms. May be numbness, pain or loss of function. 3/22/2021 By Dr. Shazia Khalfe 15 Clinical Presentation
  • 16.
    • Cervical myelopathy- a cluster of complaints and findings due to intrinsic damage to the spinal cord itself. Numbness, coordination and gait issues, grip weakness and bowel and bladder complaints with associated physical findings may be reported. 3/22/2021 By Dr. Shazia Khalfe 16 Clinical Presentation
  • 17.
    • Symptoms candepend on the stage of the pathological process and the site of neural compression. Diagnostic imaging may show spondylosis, but the patient may be asymptomatic and vice versa. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, so the boundary between normal ageing and disease is difficult to define. 3/22/2021 By Dr. Shazia Khalfe 17 Clinical Presentation
  • 18.
    • Poorly localizedtenderness • Limited range of motion • Minor neurological changes (unless complicated by myelopathy or radiculopathy) 3/22/2021 By Dr. Shazia Khalfe 18 Signs
  • 19.
    • Cervical painaggravated by movement • Referred pain (occiput, between the shoulder blades, upper limbs) • Retro-orbital or temporal pain • Cervical stiffness • Vague numbness, tingling or weakness in upper limbs • Dizziness or vertigo • Poor balance • Rarely, syncope, triggers migraine 3/22/2021 By Dr. Shazia Khalfe 19 Symptoms
  • 20.
    • On basisof Sign & Symptoms • History • Physical examination with a focus on the neck, back, and shoulders • Reflexes, ROM, Muscle strength & power are evaluated • Sensory and motor evaluation • X-Ray, MRI etc.. 3/22/2021 By Dr. Shazia Khalfe 20 Diagnosis
  • 21.
    • Neck DisabilityIndex • The Patient-Specific Functional Scale (PSFS) for patients with neck pain • Performance‐based outcome measures 3/22/2021 By Dr. Shazia Khalfe 21 Outcome Measures
  • 22.
    • Contains 10items (7 related to ADLs, 2 related to pain, 1 related to concentration) • Each item is scored 0 – 5 and the total score is expressed as a percentage • Higher scores correspond to greater disability 3/22/2021 By Dr. Shazia Khalfe 22 Neck Disability Index
  • 23.
    • Ask patientto list 3 activities that are difficult as a result of their symptoms/injury/disorder • The patient rates each activity on a scale of 0 – 10; 0 represents inability to perform the activity and 10 represents the ability to perform the activity as well as they could prior to the onset of symptoms • The 3 activity scores are averaged for a final score 3/22/2021 By Dr. Shazia Khalfe 23 The Patient-Specific Functional Scale (PSFS) for patients with neck pain
  • 24.
    • Movement oractivity limitations associated with the patient’s neck pain and be used to assess the changes in the patient’s level of function over the episode of care. These activities should be measurable and reproducible. 3/22/2021 By Dr. Shazia Khalfe 24 Performance‐based outcome measures
  • 25.
    • When evaluatinga patient with neck pain over an episode of care, assessment of impairment of body function should include measures that can rule in or rule out: • neck pain with mobility deficits, including cervical active range of motion, the flexion rotation test, cervical and thoracic segmental mobility tests, and • neck pain with radiating pain/cervical radiculopathy, including the upper limb tension test, Spurling's test, distraction test, and the Valsalva test. 3/22/2021 By Dr. Shazia Khalfe 25
  • 26.
    • Posture • Functionalmovement • ROM • Muscle strength • Neurologic Assessment • Reflexes • MMT • Special tests 3/22/2021 By Dr. Shazia Khalfe 26 Observation
  • 27.
    • The patientis positioned in supine. During the ULTT that places a bias towards testing the patient’s response to tension placed on the median nerve, the examiner sequentially introduces the following movements to the symptomatic upper extremity. Scapular depression • Shoulder abduction to approximately 90 degrees with the elbow flexed • Forearm supination, wrist and finger extension • Shoulder lateral rotation • Elbow extension • Contralateral then ipsilateral cervical side- bending 3/22/2021 By Dr. Shazia Khalfe 27 Neck Flexor Muscle Endurance Test
  • 28.
    • A positivetest is indicated by the presence of any of the following findings: Reproduction of all or part of the patient’s symptoms • Side-to-side differences of greater than 10 degrees of elbow or wrist extension • On the symptomatic side, contralateral cervical side-bending increases the patient’s symptoms, or ipsilateral side-bending decreases the patient’s symptoms 3/22/2021 By Dr. Shazia Khalfe 28
  • 29.
    1.Shoulder girdle depression 2.Shoulderabduction 3.Shoulder external rotation 4.Forearm Supination 5.Wrist and Finger extension 6.Elbow extension 7.Cervical side flexion 3/22/2021 By Dr. Shazia Khalfe 29 Upper Limb Tension Test 1 (ULTT1, Median nerve bias)
  • 30.
    1.Shoulder girdle depression 2.Elbowextension 3.Lateral rotation of the whole arm 4.Wrist, finger and thumb extension 3/22/2021 By Dr. Shazia Khalfe 30 Upper Limb Tension Test 2A (ULTT2A, Median nerve bias)
  • 31.
    • Shoulder girdledepression • Elbow extension • Medial rotation of the whole arm • Wrist, finger and thumb flexion 3/22/2021 By Dr. Shazia Khalfe 31 Upper Limb Tension Test 2B (ULTT2B, Radial nerve bias)
  • 32.
    • The patientis seated and asked to side bend and slightly rotate head to the painful side. • The clinician places a compressive force of approximately 7 kg through the top of the head in an effort to further narrow the intervertebral foramen. • The test is considered positive when it reproduces the patient’s symptoms. The test is not indicated if the patient does not have upper extremity or scapular region symptoms. 3/22/2021 By Dr. Shazia Khalfe 32 Spurling’s Test
  • 33.
    • The patientis positioned in supine. • The examiner grasps under the chin and occiput, flexes the patient’s neck to a position of comfort, and gradually applies a distraction force of up to approximately 14 kg. • A positive test occurs with the reduction or elimination of the patient’s upper extremity or scapular symptoms. The test is not indicated if the patient has no upper extremity or scapular region symptoms. 3/22/2021 By Dr. Shazia Khalfe 33 Distraction Test
  • 34.
    • Other non-specificneck pain lesions - acute neck strain, postural neck ache or Whiplash • Fibromyalgia and psychogenic neck pain • Mechanical lesions - disc prolapse or diffuse idiopathic skeletal hyperostosis • Inflammatory disease - Rheumatoid arthritis, Ankylosing spondylitis or Polymyalgia rheumatica • Metabolic diseases - Paget's disease, osteoporosis, gout or pseudo- gout, Infections - osteomyelitis or tuberculosis • Malignancy - primary tumours, secondary deposits or myeloma 3/22/2021 By Dr. Shazia Khalfe 34 Differential Diagnosis
  • 35.
    • Medical management i.Non surgical ii. Surgical • Physical therapy management 3/22/2021 By Dr. Shazia Khalfe 35 Treatment
  • 36.
    • There islittle evidence for using exercise alone or mobilisation and/or manipulations alone. • Mobilisation and/or manipulations in combination with exercises are effective for pain reduction and improvement in daily functioning in sub- acute or chronic mechanical neck pain with or without headache. • There is moderate evidence that various exercise regimens, like proprioceptive, strengthening, endurance, or coordination exercises are more effective than usual pharmaceutical care 3/22/2021 By Dr. Shazia Khalfe 36 Physical Therapy Management
  • 37.
    • Treatment shouldindividualised, but generally includes rehabilitation exercises, proprioceptive re- education, manual therapy and postural education • Manual therapy • Postural education • Electrotherapeutic modalities • Patient education • Home exercises 3/22/2021 By Dr. Shazia Khalfe 37 Physical Therapy Management
  • 38.
    • A CostelloM et al 2018 study comparing isometric exercises to dynamic exercises, both with traditional physiotherapeutic methods concluded that short-term physiotherapy plays a significant role in the treatment of cervical spondylosis. Comparison between the two treatment techniques gives priority to dynamic exercises, contrary to isometric exercises 3/22/2021 By Dr. Shazia Khalfe 38 Physical Therapy Management
  • 39.
    • Physical modalitiessuch as cervical traction, heat, cold, therapeutic ultrasound, massage, and transcutaneous electrical nerve stimulator (TENS) lacked sufficient evidence regarding their efficacy in the treatment of acute or chronic neck pain. • In patients experiencing radicular pain, cervical traction may be incorporated to alleviate the nerve root compression that occurs with foraminal stenosis 3/22/2021 By Dr. Shazia Khalfe 39 Philadelphia Panel finding
  • 40.
    • Trigger pointinjections can be employed to treat myofascial trigger points, which can clinically manifest as neck, shoulder, and upper arm pain. 3/22/2021 By Dr. Shazia Khalfe 40
  • 41.
    3/22/2021 By Dr.Shazia Khalfe 41
  • 42.
    • Blanpied PR,Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83. • Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008. • Osman A et al. The Pain Catastophizing Scale:Further Psychometric Evaluation with Adult Samples. Journal of Behavioral Medicine. 2000; Vol.23(4): 351-365. • Rivest K et al. Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury. Journal of Manual Therapy. 2010; Vol 15:154- 159. • Childs JD et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. The Journal of Orthopaedic Sports Physical Therapy. 2008;38(9):A1-A34. • O’Sullivan SB, Schmitz TJ. Physical Rehabilitation: Fifth Edition. Philadelphia: F.A. Davis Company; 2007. • Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis- based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007, Aug 3;8:75. 3/22/2021 By Dr. Shazia Khalfe 42 References
  • 43.
    • Kuo DT,Tadi P. Cervical Spondylosis. InStatPearls [Internet] 2019 Nov 26. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551557/ (last accessed 31.1.2020) • Xiong W, Li F, Guan H. Tetraplegia after thyroidectomy in a patient with cervical spondylosis: a case report and literature review. Medicine (Baltimore) 2015;94(6):e524. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25674751 (last accessed 1.2.2020) • Ferrara LA. The biomechanics of cervical spondylosis. Advances in orthopedics. 2012 Feb 1;2012. Available from: https://www.hindawi.com/journals/aorth/2012/493605/ (last accessed 1.2.2020) • Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. Journal of clinical orthopaedics and trauma. 2014 Dec 31;5(4):221-6. • D.H. Irvine, J.B. Foster, Prevalence of cervical spondylosis in a general practice, The Lancet, May 22 1965 • Sandeep S Rana, MD, Diagnosis and Management of Cervical Spondylosis. Medscape, 2015 • Kelly JC, Groarke PJ, Butler JS, Poynton AR, O'Byrne JM. The natural history and clinical syndromes of degenerative cervical spondylosis. Advances in orthopedics. 2011 Nov 28;2012. • Moon MS, Yoon MG, Park BK, Park MS. Age-Related Incidence of Cervical Spondylosis in Residents of Jeju Island. Asian spine journal. 2016 Oct 1;10(5):857-68. • McCormack BM, Weinstein PR. Cervical spondylosis. An update. West J Med. Jul-Aug 1996;165(1-2):43-51. • Takagi I, Cervical Spondylosis: An Update on Pathophysiology, Clinical Manifestation, and Management Strategies. DM, October 2011 • Binder AI. Cervical spondylosis and neck pain. BMJ: British Medical Journal. 2007 Mar 10;334(7592):527. 3/22/2021 By Dr. Shazia Khalfe 43 References
  • 44.
    • Ellenberg MR,Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. Mar 1994;75(3):342-52 • Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. Jul 1992;23(3):381-94. (Level: A1) • Kaye JJ, Dunn AW. Cervical spondylotic dysphagia. South Med J. May 1977;70(5):613- 4. (Level: A1) • Kanbay M, Selcuk H, Yilmaz U. Dysphagia caused by cervical osteophytes: a rare case. J Am Geriatr Soc. Jul 2006;54(7):1147-8. (Level: C) • Binder AI. Cervical spondylosis and neck pain: clinical review. BMJ 2007:334:527-31 • Zhijun Hu et al., A 12-Words-for-Life-Nurturing Exercise Program as an Alternative Therapy for Cervical Spondylosis: A Randomized Controlled Trial, 20 March 2014 • J. Lafuente, A.T.H. Casey, A. Petzold, S. Brew, The Bryan cervical disc prosthesis as an alternative to arthrodesis in the treatment of cervical spondylosis, The Bone and Joint Journal, 2005. • M. Pumberger, D. Froemel, Clinical predictors of surgical outcome in cervical spondylotic myelopathy, The Bone and Joint Journal, 2013 • Fukui M, Chiba K, Kawakami M, Kikuchi SI, Konno SI, Miyamoto M, Seichi A, Shimamura T, Shirado O, Taguchi T, Takahashi K. Japanese orthopaedic association cervical myelopathy evaluation questionnaire (JOACMEQ): Part 2. Endorsement of the alternative item. Journal of Orthopaedic Science. 2007 May 1;12(3):241. • Revanappa KK, Rajshekhar V. Comparison of Nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy. European Spine Journal. 2011 Sep 1;20(9):1545-51. • D.R. Lebl, A. Hughes, P.F. O’Leary, Cervical Spondylotic Myelopathy: Pathophysiology, Clinical Presentation, and Treatment, the Musculoskeletal Journal of Hospital for Special Surgery, Jul 2011. • Hyun-Jin Jo et al., Unrecognized Shoulder Disorders in Treatment of Cervical Spondylosis Presenting Neck and Shoulder Pain, The Korean Spinal Neurosurgery Society, 9(3):223-226, 2012 3/22/2021 By Dr. Shazia Khalfe 44 References
  • 45.
    • Todd AG.Cervical spine: degenerative conditions. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):168. • Melvin D. Law, Jr., M.D.a, Mark Bemhardt, M.D.b, and Augustus A. White, III, M.D., Cervical Spondylotic Myelopathy: A Review of Surgical Indications and Decision Making, Yale journal of biology and medicine,1993 • Kyoung-Tae Kim and Young-Baeg Kim, Cervical Radiculopathy due to Cervical Degenerative Diseases : Anatomy, Diagnosis and Treatment, The Korean Neurosurgical Society, 2010 (Level: 2a) • Rahim KA, Stambough JL. Radiographic evaluation of the degenerative cervical spine. Orthop Clin North Am. Jul 1992;23(3):395-403. (Level: 3a) • Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. Jul 1992;23(3):381-94. (Level: 4) • Binder AI. Cervical spondylosis and neck pain: clinical review. BMJ 2007:334:527-31 (Level: 5) • Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton , Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis, Advances in Orthopedics, 2011 (Level: 1b) • Ian A. Young, Lori A. Michener, Joshua A. Cleland, Arnold J. Aguilera, Alison R. Snyde, Manual Therapy, Exercise, andTraction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial, 2009 (Level: 1b) • Azemi, Arjeta & Ibrahimaj Gashi, Arbnore & Zivkovic, Vujica & Gontarev, Seryozha. (2018). THE EFFECT OF DYNAMIC EXERCISES IN THE TREATMENT OF CERVICAL SPONDYLOSIS. 7. 19-24. • ichale Costello, Treatment of a Patient with Cervical Radiculopathy Using Thoracic Spine Thrust Manipulation, Soft Tissue Mobilization, and Exercise, the Journal of Manual and manipulative therapy (Level: 3b) • Ibrahim M. Moustafa and Aliaa A. Diab, Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial, Journal of Chiropractic Medicine (2014) 13, 157–167 (Level: 1b) 3/22/2021 By Dr. Shazia Khalfe 45 References
  • 46.
    3/22/2021 By Dr.Shazia Khalfe 46