Posts in neck and arm pain
What Is The Best Exercise For Painful Muscles?
painful-muscle-muscles-treatment-exercise

Muscles can be a significant source of pain in our bodies. Chronic muscular pain may be found locally over the muscle or can be felt in an area distant from the muscle known as referred pain. Multiple Physical Therapy interventions including dry needling, foam rolling, and soft tissue mobilizations can be utilized in the short term to reduce these symptoms. Conversely, long term relief of muscular pain requires examination of the muscle to determine why it remains painful.

Muscle imbalances are a common reason behind these chronic symptoms. Muscles worked above and beyond their normal function will become painful over time. A common example in the hip is the TFL muscle in the presence of glut weakness. Short term solutions can target the TFL but long term relief is found by strengthening the glut muscles allowing them to perform their appropriate function at the hip in turn relieving forces across the TFL. A second muscle imbalance is found when the painful muscle is not strong enough to withstand the forces applied during activity. The long term strategy with this type of imbalance is to strengthen the muscle of interest. A recent research study examined the impact of strengthening this type of chronic muscle pain.

Anderson and colleagues examined the neck muscle performance of patients with neck pain compared to their pain free peers (Bio Med Res Int. 2014). Patients with painful neck muscles were randomized to either 10 weeks of high intensity neck strength training, general fitness training, or a control group. As expected, significant weakness was found in the patient’s painful muscles at baseline compared to their asymptomatic peers. Authors reported improved strength capacity of these painful muscles following the focused strength training program. Improved functional tolerance of the painful muscles allows these muscles to be more resilient to the forces applied to them each day.

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Will traction help my neck and arm pain?
neck-arm-pain-traction-treatment

Arm pain referred from the cervical spine (cervical radiculopathy) often is the result of nerve root compression by either bone or soft tissue in the bony canals of the neck.  These canals protect the nerve roots as they exit from the spinal cord, but can also compress these neural structures leading to pain, numbness, pins and needles, or weakness in the arm and hand.  Physical Therapy interventions including manual therapy and exercise designed to optimize motion and reduce abnormal nerve contact have been shown to reduce pain and improve function in patients with neck and arm pain.  Another form of treatment, mechanical traction, has previously been shown to help in subsets of patients with neck and arm pain.  A recent systematic review examined the available evidence behind using traction for neck and arm pain.

In the journal Physical Therapy, researchers analyzed the available data on mechanical traction and patient's with cervical radiculopathy (Romeo et al. 2018).  Authors included 5 studies in the review and found both manual and mechanical traction improved pain in the short term.  Mechanical traction was shown to improve disability at intermediate follow up periods.  The authors concluded manual or mechanical traction may be helpful when combined with other Physical Therapy interventions in the short term.  Conversely, traction has a smaller effect at improving patient function. 

Consistent with our treatments, manual traction is best utilized as part of an effective short term program to reduce the symptoms of cervical radiculopathy.  Higher level exercises should be utilized once the symptoms are reduced to optimize patient function and prevent recurrence. 

Impact of Manipulation Direction on Outcomes in Patients with Neck Pain
boulder-neck-pain-treatment

Neck pain is a common problem affecting up to 70% of the population in their lifetime.  Cervical and thoracic manipulation remains an effective Physical Therapy treatment to restore mobility and decrease pain in patients with neck pain.  Recent research has shown no difference between one manipulation technique over another with both showing equal benefits for patients.  More importantly, the research supports choosing the right patient for the manipulation versus the right manipulation technique.  A recent study examined the impact of a Physical Therapy manipulation either matched or unmatched to a patient's restriction of motion.  

Karas and colleagues in the Journal of Manual and Manipulative Therapy examined the impact of directional specific thoracic spine manipulation in patients with neck pain (2018).  69 patients with neck pain were randomized to either a thoracic manipulation either matched or unmatched to their direction of mobility loss.  For example, patients with pain and difficulty looking toward the ceiling (cervical extension) were either manipulated to improve this direction or the opposite direction.  Consistent with our previous research, the authors reported both groups pain, range of motion, and disability improved but there was no significant difference with the matched or unmatched manipulation direction.  

This study highlights the importance of patient and clinician comfort during a manipulation technique versus a manipulation in the direction of movement loss.  

 

Muscle Activation During an Inverted Row
inverted-row-back-recruitment-muscles

The standing row is an excellent exercise to develop strength and stability in the upper back, shoulder, and arms.  In addition to the standard standing position, individuals may choose other positions including using TRX straps or a bar to increase the demands on the upper body and core musculature.  A recent article examined the recruitment of these muscles during various positions of the row exercise (Youdas et al. J Strength Cond Res. 2016).

Authors placed 26 patients through 4 different versions of the inverted row to determine their relative muscle recruitment patterns.  The authors noted all positions of the inverted row were excellent for targeting the biceps, deltoids, latissimus dorsi, and trapezius muscles.  Surprisingly no significant differences were noted performing the exercise in either a single or double leg supported position.   This article adds to the existing strengthening literature indicating the inverted row with straps or a bar is an excellent option to strengthen the upper back musculature. 

Neck Pain and Physical Therapy Treatments
neck pain, physical therapy, treatment

Neck Pain Background Information

Neck pain affects 10-15% of the population at any one time, with a lifetime incidence of 22-70% (1). Only 6% of patients with neck pain report resolution of symptoms at one year (2).

A recent systematic review demonstrated the prognosis from idiopathic neck pain is poor (3) and 50-75% of patients with neck pain will report symptoms at 1 and 5 year follow up (4).

Evidence suggests the utilization of manual therapy and exercise is a more cost effective intervention compared to primary care management alone or standard physical therapy (see graph). (5)

Our effectiveness in treating patients increases as we match interventions to a patient’s signs and symptoms. Evidence suggests outcomes are improved by correctly matching each Physical Therapy intervention to a specific patient category see below.(6)

Patients with mechanical neck pain, cervical radiculopathy, and cervicogenic headaches can benefit from Physical Therapy interventions including manual therapy and exercise to reduce pain and improve disability. 

neck pain costs, manual therapy, boulder physical therapy

Physical Therapy Interventions for Neck Pain

Exercise and Conditioning

Physical Therapy strengthening, neck pain

Patients within this category may display lower pain and disability levels and report a longer duration of symptoms.

Exercises will aim to improve muscle function within the deep cervical flexors and scapular muscles.

A recent systematic review provided Level 1 evidence on the benefits of exercise for patients with mechanical neck pain.(7)

Strong evidence supports the utilization of proprioception and strengthening exercises for patients with recurrent or chronic neck pain.(8)

Headaches

A recent Cochrane review documented the improved effectiveness of manual therapy and exercise over manual therapy alone in patients with neck pain with or without headaches.(10)

Authors report the benefit of cervical manipulation on reducing head- ache intensity and frequency in patients with headache.(9)

The utilization of manual therapy and cervical strengthening has been show to reduce pain, disability, and headaches over both the short and long term (see graph) (11). 

headache, neck pain, boulder physical therapy treatments

Neck and Arm Pain/Cervical Radiculopathy

Centralization

Patients within this category include those who have signs and symptoms of nerve root impingement or radicular symptoms.

Studies demonstrate 26% of patients with cervical radiculopathy who undergo surgery continue to experience high levels of pain at a 1-year follow-up.(12) Studies also suggest that patient outcomes may be superior with conservative management versus surgical interventions.(13, 14)

Physical therapy interventions consisting of manual therapy (17), cervical traction (15, 16), and cervical centralization exercises have been shown to decrease pain and improve function in this population.

Recently authors reported 91% of patients with cervical radiculopathy who underwent treatment of manual physical therapy, cervical traction and strengthening exercises showed significant functional improvement. (17). 

neck and arm pain, boulder physical therapy treatments, centralization

Pain Control

This subgroup comprises patients with acute or traumatic onset of neck pain, including whiplash injury, and those presenting with high levels of pain and disability.

Physical therapy interventions for this category aim to decrease pain and allow transition into other subgroups for treatment to reduce disability.

Evidence suggests utilization of thoracic spine manipulation18, cervical spine mobilizations19, neck active ROM exercises20, gentle soft tissue massage(21), and physical modalities such as TENS (22).

Interventions matched to patient’s signs and symptoms within the category demonstrate greater changes in pain and disability than unmatched interventions (6). 

Mobility

neck pain, mobility, boulder physical therapy treatments

Patients within this group include those with symptoms proximal to the elbow, an acute onset (<30 days), and are younger than 60 years old.(6)

Evidence supports the utilization of both cervical and thoracic mobilization/manipulation, with exercise, to restore mobility, decrease pain, and improve function. (1, 22, 23)

Utilization of manual therapy can reduce long term management costs by as much as 2/3 in comparison with exercises or medical management alone. (24) 

References

Childs, J. Cleland, J. 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. J Orthop Sports Phys Ther 2008;38(9):A1-A34.

Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102:167-178.

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Arch Phys Med Rehabil 2011;92:824-9

Carroll L. Hogg-Johnson, S. et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4):S75–S82.

Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ. 2003.

Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524.

Kay, T. Gross, A. et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2005. CD004250.

Sarig-Bahat, H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy. 2003;8:10-20.

Nilsson, N. Christensen, J. et al. The effect of cervical manipulation on cervicogenic headache. J Manip Phys Ther. 1997;20:326-330.

10. Gross, A. Hoving, J. et al. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Pain. Spine 2004;29:1541–1548

11. Jull, G. Trott, P. et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835–1843

12. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky A, Neundorfer B. Herniated cervical intervertebral discs with radiculopa- thy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.

13. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12-16.

14. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. 1999;24:591-597.

15. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006;38:145-152.

16. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2001;31:207-213.

17. Cleland, J; Whitman, J; Fritz, J; Palmer, J. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005:35(12):802-809.

18. Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J., & Gutierrez-Vega, M. (2009). Thoracic spine manipulation for the

management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20-27.

19. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash- associated disorders, part I: non-invasive interventions. Pain Res Manag. 2005;10:21-32.

20. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782-1787.

21. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68.

22. Cassidy, J.D., Lopes, A.A., Young-Hing, K. The immediate effect of manipulation vs mobilization on pain and range of motion in the cervical spine: a randomized control trial. Journal of Manipulative and Physiological Therapeutics. 1992. 15:9.

23. Cleland, J.A., Mintken, P.E., Carpenter, K., Fritz, J.M., Glynn, P., Whitman, J., Childs, J. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a generally cervical range of motion exercise: multi-center randomized control trial. Physical Therapy. 2010. 90: 9.

24. Ingeborg, B.C., Korthals-de Bos, Hoving, J.L., Tulder, M.W., Rutten-van Molken, M., Ader, H.J., CW de Vet, H., Koes, B.W., Vondelling, K., Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practicioner care for neck pain: economic evaluation alongside a randomized control trial. British Medical Journal. 2003. 326:911 

 

Cervical Radiculopathy and Physical Therapy Solutions
Neck and Arm Pain Physical Therapy Interventions

Cervical Radiculopathy Injuries and Symptoms 

Cervical radiculopathy occurs when a nerve from the neck becomes irritated or compressed by space occu- pying lesion including fluid, soft or bony tissues as it exits the spine. Patients often complain of sharp, burning pain down the arm, numbness, tingling, or weakness.

This condition is most common in the 5th decade of life with an annual incidence of 83 per 100,000 individuals(2).

The C6 and C7 cervical nerve roots are most com- money involved(3). EMG/NCV testing is considered the gold standard for the diagnosis of this disorder.

A clinical prediction rule developed by Wainner et al. showed four clinical tests/measures are helpful for diagnosis of this condition:

1. (+) Spurling’s Test
2. (+) Distraction Test
3. Ipsilateral cervical rotation <60 degrees                                                                                                             4. (+) median nerve upper limb tension test

Authors reported a specificity of 94% and 100% for 3/4 and 4/4 variables, respectively(4). 

Physical Therapy Interventions 

Recent reviews of cervical radiculopathy suggest conservative treatments may be superior to surgical interventions(5,6).

Authors suggest evidence supports the utilization of short term epidural corticosteroid injections for patients with radicular pain(6).

A multimodal Physical Therapy treatment plan involving manual therapy (joint mobilization/ manipulation and soft tissue mobilization), exercise, mechanical traction, and education provides short and long term reductions in pain and disability. 

Neck and Arm Pain Physical Therapy Manual Treaments
Mechanical Traction in Physical Therapy

Physical Therapy Evidence for Cervical Radiculopathy

Literature reviews report the combination of manual therapy and exercise is effective at reducing pain and disability, as well as, increasing AROM in patients with cervical radiculopathy(5).

Cleland et al. demonstrated 91% of patients treated with manual therapy, exercise, and mechanical trac- tion had successful short and long term outcomes(7).

Fritz et al. reported mechanical traction and exercise was superior to exercise or exercise and over the door traction for reducing pain and disability. The group receiving mechanical traction and exercise was the only group to sustain the benefits of the 4 week treat- ment at 6 and 12 month follow ups(1).

Raney et al. suggested four variables may assist in determining which patients will best respond to cervical mechanical traction:

1. Peripheralization with manual therapy testing                                                                                                      2. (+) shoulder abduction test
3. Age >55 years old
4. (+) median nerve upper limb tension test                                                                                                               5. (+) neck distraction test                                                                                                                                            If 4/5 variables are met there was a 95% success rate(9). 

When to Seek Physical Therapy Treatment

Patient’s with neck and arm pain with or without symptoms of nerve root irritation including numbness, paresthesias, or weakness should be referred to PT for short and long term reduction of pain and disability.

Health Care practitioners may use Wainner’s CPR noted above for the clinical diagnosis of Cervical Radiculopathy.

Cleland et al. noted four variables help predict patients who will respond favorably to physical therapy interventions for cervical radiculopathy:

1. Age <54
2. Dominant arm not affected
3. Cervical flexion does not worsen symptoms                                                                                                          4. Patient received multimodal PT treatment

A 85% and 90% success rate was found if patients met 3/4 or 4/4 variables, respectively(8). 

References

1. Fritz et al. Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consider- ation of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial. JOSPT. 2014;44(2):45- 57.

2. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy: a population- based study from Rochester, Minnesota, 1976–1990. Brain 1994; 117:325–35.

3. Dillin W, Booth R, Cuckler J, Balderston R, Simeone F, Rothman R. Cervical radiculopathy: a review. Spine 1986;11:988–91.

4. Wainner RS, Gill H. Diagnosis and nonoperative manage- ment of cervical radiculopathy. J Orthop Sports Phys Ther 2000;30:728–44.

5. Boyles et al. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011. 19(3):135-142.

6. Carragee, E. et al. Treatment of Neck Pain. Injections and Surgical Interventions. Spine. 2008. 33(45):S153-S169.

7. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Orthop Sports Phys Ther 2005;35:802–11.

8. Cleland, J. et al. Predictors of Short-Term Outcome in People With a Clinical Diagnosis of Cervical Radiculopathy. JOSPT. 2007

9. Raney, N. Development of clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009.