by a physician before being seen in physical therapy and will be cleared for cervical spine fractures. However, as patients directly access physical therapy, clinicians should employ these algorithms to clear the cervical spine when the patient has not been seen by a physician or had radiographs and Mechanical neck pain (also called nonspecific neck pain ) typically arises insidiously and is consider multifactorial in nature (Mechanical Neck Pain, n.d.) According to Masaracchio et al. (2019), mechanical 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 structural pathology (Hidalgo et al., 2017). Factors associated with the onset of mechanical neck pain include poor posture, depression, 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. when their history includes a velocity injury. Mechanical (soft tissue-related) neck pain The most common postural abnormality associated with mechanical 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 devices 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 patients 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 upper 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 odontoid view (Murphy, 2021). Algorithm for Canadian C-Spine Rule Any high-risk factors
mandating radiography? • Fall from >1m/5 stairs. • Axial loading (e.g., diving). • Motor vehicle accident (MVA) >100 km/h, rollover, ejection. • MVA in recreational vehicle. • Bicycle collision.
If yes , imaging required
NO Any low-risk factors?
If no , imaging required
• Simple rear-end MVA. • Sitting in the emergency department. • Ambulatory after injury. • Delayed onset neck pain. • Absence of midline tenderness.
If yes , able to rotate neck 45 degrees left and right If yes , no imaging required
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 NEXUS. Although the methodologic quality of the studies included was modest, they found that the Canadian C-Spine Rule had better diagnostic accuracy than the NEXUS criteria. The Canadian C-Spine Rule and NEXUS are used to evaluate patients in the emergency department. For that reason, most patients with high-velocity injuries will be seen 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 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 trapezius 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 and control the patient’s 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)
of C7. The craniovertebral angle is the most widely used measurement to assess forward head posture.
neck while the other hand is used to stabilize 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.
(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
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