structural pathology (Hidalgo et al., 2017). Factors associated with the onset of mechanical neck pain include poor posture, depres- sion, neck strain, and sporting or occupational activities that are taxing to the cervical structures (physiopedia.com). Joshi et al. (2019) report that the most common contributor to mechanical neck pain is poor posture, but any event that leads to altered joint mechanics or muscle function can be contributory. The most common postural abnormality associated with mechani- cal neck pain is forward head posture (physiopedia.com). Forward head posture is defined as excessive anterior positioning of the head (external auditory meatus) in relation to a vertical reference line (Balthillaya et al., 2022). This leads to shortening of the upper trapezius, levator scapulae, pectoral muscles, and suboccipital muscles as well as weakness in the deep neck flexors, rhomboids, and serratus anterior muscles. Forward head posture can cause a decrease in cervical motion (Balthillaya et al., 2022). This posture has been associated with prolonged use of communication devic- es such as smartphones and computers (Balthillaya et al., 2022). A study by Mahmoud et al. (2019) found a correlation between increased forward head posture and increased neck pain. A second postural abnormality associated with mechanical neck pain is thoracic spine dysfunction (physiopedia.com). Changes in thoracic spine alignment have been shown to alter the mechanical loading of the cervical spine (Balthillaya et al., 2019). Older pa- tients with increased thoracic kyphosis exhibit a higher incidence of neck problems. Reduced thoracic mobility is a known predictor of neck pain (Balthillaya et al., 2019). Furthermore, it has been shown that improving thoracic articular movement via thrust and nonthrust mobilizations produces positive effects on the severity of neck pain, neck motion, and self-reported disability (Balthillaya et al., 2019).
Healthcare consideration: Visualization of the upper cervical spine via radiograph can be difficult because of the skull. For that reason, open-mouth x-rays are used to visualize the up- per cervical spine. This view focuses primarily on the odontoid process of C2 and is useful in visualizing odontoid and Jefferson fractures. This view is called the AP open mouth view or odon- toid view (Murphy, 2021). NEXUS versus Canadian C-Spine rules Michaleff et al. (2012) conducted a systematic review to compare the diagnostic accuracy of the Canadian C-Spine Rule and NEX- US. Although the methodologic quality of the studies included was modest, they found that the Canadian C-Spine Rule had bet- ter diagnostic accuracy than the NEXUS criteria. The Canadian C-Spine Rule and NEXUS are used to evaluate pa- tients in the emergency department. For that reason, most pa- tients with high-velocity injuries will be seen by a physician before being seen in physical therapy and will be cleared for cervical spine fractures. However, as patients directly access physical ther - apy, clinicians should employ these algorithms to clear the cervi- cal spine when the patient has not been seen by a physician or had radiographs and when their history includes a velocity injury. Mechanical (soft tissue-related) neck pain Mechanical neck pain (also called nonspecific neck pain ) typically arises insidiously and is consider multifactorial in nature (Mechani - cal Neck Pain, n.d.) According to Masaracchio et al. (2019), me- chanical neck pain can be defined as cervical spine pain located in the posterior and lateral aspects of the neck between the superior nuchal line and the first thoracic vertebrae. Mechanical neck pain is typically exacerbated by cervical motion, sustained posture, and/or palpation of the cervical musculature with no identifiable Measuring the craniovertebral angle The craniovertebral angle is an acute angle formed between a horizontal line passing through the spinous process of C7 and the line connecting the tragus to the spinous process of C7. The cra- Assessing scalene muscle length The scalene muscles are often involved in mechanical neck pain and are often more difficult to assess/palpate than the upper tra- pezius and levator scapulae muscles. To evaluate the tone of the scalene muscles, the examiner should position themselves behind the patient, who is supine or seated. With one hand, they hold Whiplash-associated disorder (WAD) Differential diagnosis of neck pain associated with whiplash- associated disorder has the distinguishing factor of a history of traumatic injury, typically a motor vehicle crash (MVC) (Walton & Elliott, 2017). Historically, the widely accepted origin of WAD symptoms is the facet joints (Walton et al., 2017), although both soft tissue and psychological factors have also been implicated (Hayashi et al., 2019). Walton et al. (2019) also list the cervical proprioceptive afferents, the vestibular apparatus, and mild trau- matic brain injury as possible contributors. Symptoms associated with WAD include neck pain and stiffness, headache, and radicu- lar symptoms (Hayashi, 2019). WAD injuries can become chronic. According to Hayashi et al. (2109), up to 50% of patients report pain and/or disability 12 months after their injuries. Evidence supports the presence of central sensitization with chronic WAD. Although therapists may easily arrive at the diagno- sis of whiplash-associated neck pain based on a history of motor vehicle crash, a deeper understanding of all the factors that are or may be contributing to your client’s ongoing pain and dysfunction is essential to effective treatment. Addressing maladaptive pain beliefs can help with decreasing pain and disability. A dysfunc- tional stress response may be present and can be addressed via stress management interventions.
niovertebral angle is the most widely used measurement to assess forward head posture.
and control the patient’s neck while the other hand is used to sta- bilize the first rib. For the right anterior scalene, the patient’s head is side bent to the left and simultaneously rotated right. For the right middle scalene, the head is side bent to the left; for the right posterior scalene, slightly flex the head and rotate it to the left.
Case Study: Emma Ellis Ms. Ellis presents to physical therapy complaining of neck and left shoulder pain. She was in an accident one month ago when she was stopped in traffic and rear-ended by an SUV going about 30 miles per hour. She was taken to the emergency department, where an x-ray ruled out cervical fracture. She continued to have significant pain and recently had an MRI that showed a bulging disc at C5–C6 with no neural compromise or spinal cord compres - sion. She presents with ongoing neck and left shoulder pain that does not involve the left upper extremity. She does not have any tingling, numbness, or weakness in her left arm. She has “muscle spasms” in the left posterolateral cervical muscles. Questions What conditions would you consider as you work through the pro - cess of differential diagnosis give the mechanism of injury, the location of the client’s symptoms, and the MRI findings? Discussion With the MRI finding of a bulging disc, one of the first consider - ations is whether this is a case of cervical radiculopathy. However, the client does not have any myotome or dermatome findings. The mechanism of injury with a rear-end collision is extension, while flexion injuries (as in head-on collisions) are more often as - sociated with cervical disc damage. Although there is evidence for
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