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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Cervical Spine:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Independent Study
Course 31.2.2
Eric K. Robertson, PT, DPT, OCS, FAAOMPT
Associate Professor
Department of Physical Therapy and Athletic Training
University of Utah
Salt Lake City, UT
Associate Professor of Clinical Physical Therapy
Division of Biokinesiology and Physical Therapy
University of Southern California
Los Angeles, CA
Mary K. Derrick, PT, DPT, OCS, FAAOMPT
PhD candidate, Department of Physical Therapy and Athletic Training
University of Utah
Salt Lake City, UT
Cervical Spine:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Guy G. Simoneau, PT, PhD, FAPTA—Editor
Dhinu Jayaseelan, PT, DPT, OCS, FAAOMPT—Associate Editor
Cover Illustration by Joseph Kinstler
Dear Colleagues,
I am pleased to welcome you to the Cervical Spine: Evidence-Informed Physical erapy Patient Management monograph written by Eric
K. Robertson, PT, DPT, OCS, FAAOMPT and Mary K. Derrick, PT, DPT, OCS, FAAOMPT. is work is part of the Academy of
Orthopaedic Physical erapy Independent Study Course series 31.2, Current Concepts of Orthopaedic Physical erapy, 5
Dr. Eric Robertson is an Associate Professor of clinical physical therapy at both the University of Utah and University of Southern
California. Previously, he served as director of graduate physical therapy education for Kaiser Permanente in Northern California. Dr.
Robertson has taught musculoskeletal physical therapy, pharmacology differential diagnosis, and radiology courses in several physical
therapy education programs, and he authored several web-based continuing education courses for entry-level and post-professional
physical therapy residency and fellowship programs. Dr. Robertson has expertise in the development and implementation of hybrid and
distance-based physical therapy education from entry-level through residency and fellowship education. Dr. Robertson currently serves
as an associate editor for the Journal of Physical erapy Education and is a member of the Standards Committee for the International
Federation of Orthopaedic Manual Physical erapists. Dr. Robertson was also an author for the most recent Academy of Orthopaedic
Physical erapy clinical practice guidelines for patients with neck pain. Dr. Robertson is a board-certified clinical specialist in orthopaedic physical therapy. He received a bachelor’s degree in physical therapy from Quinnipiac University and a Doctor of Physical erapy
degree from Boston University. He is a Fellow of the American Academy of Orthopaedic Manual Physical erapists.
th
Edition.
Dr. Mary Derrick is a PhD candidate in the Department of Physical erapy and Athletic Training at the University of Utah, in Salt Lake
City, Utah. Dr. Derrick studies the acquisition of pain beliefs in health providers and is a Research Assistant for the College of Health
while teaching musculoskeletal physical therapy. Dr. Derrick is also adjunct faculty in the Division of Biokinesiology and Physical erapy at the University of Southern California in Los Angeles, California. In addition to entry-level Doctor of Physical erapy instruction,
Mary has taught in a variety of residency and fellowship programs. Clinically, Dr. Derrick focuses her practice treating patients with persistent pain as part of multidisciplinary pain programs. She also has expertise in the adaptation of manual therapy techniques for various
providers' sizes including those who are outsized by their patients. She obtained her Doctor of Physical erapy degree at Texas State
University in 2013 and graduated from the Evidence in Motion Orthopaedic Manual Physical erapy Fellowship program in 2016. She
is a Fellow of the American Academy of Orthopaedic Manual Physical erapists and is a board-certified orthopaedic clinical specialist.
In this monograph, the authors provide a contemporary, evidence-based perspective on the management of neck pain, one of the most
common conditions treated in orthopedic physical therapy practice. e monograph begins with a review of the intricate anatomy of the
cervical spine along with updated information on screening for serious vascular and ligamentous instability conditions. e remainder
of the monograph, on evaluation and treatment of cervical spine conditions, is based on the classification system proposed by the 2017
neck clinical practice guidelines from the Academy of Orthopaedic Physical erapy. is information is augmented with description of
assessment and evaluation techniques, and clinical reasoning strategies. e authors also incorporate the use of radar plots as an approach
to efficiently manage patients within a biopsychosocial framework. For additional clinical context, the monograph concludes with pertinent clinical scenarios. is monograph represents a relatively succinct, yet comprehensive, resource for the management of individuals
with neck pain.
My sincere thanks to the authors for their contribution to the Current Concepts series.
Sincerely,
Guy Simoneau, PT, PhD, FAPTA
Editor
2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Office 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965
TABLE OF CONTENTS
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ACRONYM LIST ................................................................................................................................................................................................................5
ABSTRACT ..........................................................................................................................................................................................................................7
LEARNING OBJECTIVES ..............................................................................................................................................................................................7
PRE-LEARNING ASSESSMENT..................................................................................................................................................................................7
INTRODUCTION .............................................................................................................................................................................................................8
CLINICAL ANATOMY, KINESIOLOGY, AND BIOMECHANICS ...................................................................................................................9
Cervical Vertebrae and Discs ......................................................................................................................................................... 9
Age-related morphologic changes to the cervical disc ............................................................................................................. 9
Atypical Cervical Vertebrae ........................................................................................................................................................... 9
Ligaments of the Cervical Spine .................................................................................................................................................... 9
Muscles of the Cervical Spine ...................................................................................................................................................... 10
Anterior cervical muscles ...................................................................................................................................................... 10
Posterior/lateral cervical muscles ......................................................................................................................................... 10
Neurovascular Structures in the Cervical Spine ...........................................................................................................................12
Kinesiology and Biomechanics for the Cervical Spine .................................................................................................................14
CLINICAL EXAMINATION AND DECISION-MAKING PROCEDURES ................................................................................................ 15
Screening for Serious Conditions ................................................................................................................................................ 15
Fractures .............................................................................................................................................................................. 16
Vascular problems ................................................................................................................................................................ 16
Ligamentous instability ........................................................................................................................................................ 18
Malignancy and referred pain ............................................................................................................................................... 18
Screening for Psychosocial Factors ............................................................................................................................................... 19
Patient-reported Outcome Measures ........................................................................................................................................... 19
History and Interview ................................................................................................................................................................. 19
History of present illness ...................................................................................................................................................... 19
Symptom location................................................................................................................................................................20
Behavior of symptoms.......................................................................................................................................................... 20
Determining the Nature of the Problem ......................................................................................................................................20
Tests and Measures ...................................................................................................................................................................... 22
Observation ......................................................................................................................................................................... 22
Active movement assessment ................................................................................................................................................23
Segmental motion assessment .............................................................................................................................................. 24
Muscle length assessment for cervical related muscles ........................................................................................................... 25
Decision-making Algorithm for Patients with Neck Pain ............................................................................................................27
Assessing Neck Pain with Mobility Deficits .......................................................................................................................... 27
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
3
Assessing Neck Pain with Movement Coordination Impairments, WAD ............................................................................. 29
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Assessing Neck Pain with Headache ..................................................................................................................................... 31
Assessing Neck Pain with Radiating Pain ............................................................................................................................. 31
Summary of Key Examination Findings ...................................................................................................................................... 34
Stage of Healing Considerations .................................................................................................................................................. 34
Summary .................................................................................................................................................................................... 34
CONDITIONS-SPECIFIC EVIDENCE-BASED REHABILITATION CONCEPTS .................................................................................. 35
Interventions Strategies: Neck Pain with Mobility Deficits .......................................................................................................... 36
Central and unilateral PA mobilizations ............................................................................................................................... 36
Cervical lateral glide ............................................................................................................................................................. 36
Cervical upglide ................................................................................................................................................................... 37
Cervical downglide ..............................................................................................................................................................38
Cervicothoracic junction manipulation (seated) ................................................................................................................... 38
oracic manipulation (seated) ............................................................................................................................................ 39
oracic manipulation (supine) ........................................................................................................................................... 39
oracic manipulation (prone) ............................................................................................................................................ 40
Intervention Strategies: Neck Pain with Movement Coordination Impairments .......................................................................... 40
Deep neck flexors training ................................................................................................................................................... 41
Intervention Strategy: Neck Pain with Headaches ....................................................................................................................... 41
Atlanto-occipital (OA) joint flexion mobilization .................................................................................................................41
Atlanto-occipital (OA) joint flexion contract-relax ............................................................................................................... 42
Atlanto-occipital (OA) joint distraction manipulation..........................................................................................................42
Atlanto-axial (AA) joint rotation contract-relax .................................................................................................................... 42
Intervention Strategy: Neck Pain with Radiating Pain ................................................................................................................. 43
Other Cervical Conditions .......................................................................................................................................................... 43
Cervical disc pathology ........................................................................................................................................................ 43
Cervical myelopathy ............................................................................................................................................................44
Summary .................................................................................................................................................................................... 44
CASE SCENARIOS
Case Scenario 1 ........................................................................................................................................................................... 44
Case Scenario 2 ........................................................................................................................................................................... 45
Case Scenario 3 ........................................................................................................................................................................... 46
Case Scenario 4 ........................................................................................................................................................................... 46
REFERENCES..................................................................................................................................................................................................................47
........................................................................................................................................................................................................ 44
Academy of Orthopaedic Physical erapy, APTA.
4
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
ACRONYM LIST
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AA: atlanto-axial
CAD: cervical artery dysfunction
CCF: craniocervical flexion
CID: clinically important difference
CPG: clinical practice guideline
CRLF: cervical rotation lateral flexion
DSM-V: American Psychiatric Associations Diagnostics and Statistical Manual – V
FABQ: Fear-Avoidance Beliefs Questionnaire
HVLA: high-velocity low-amplitude
ICA: internal carotid artery
ICC: intraclass correlation coefficient
IES-R: Impact of Event Scale-Revised
IFOMPT: International Federation of Orthopaedic Manual Physical erapists
MCP: metacarpophalangeal
MDC: minimal detectable change
MPQ: McGill Pain Questionnaire
NDI: Neck Disability Index
OA: atlanto-occipital
OMT: orthopaedic manual therapy
PA: posterior-to-anterior
PCS: Pain Catastrophizing Scale
PHQ-2: 2-item Patient Health Questionnaire
PPT: pressure pain threshold
PSFS: Patient-Specific Functional Scale
ROM: range of motion
SCM: sternocleidomastoid
SEM: standard error of measurement
SNAG: sustained natural apophyseal glide
VBI: vertebrobasilar artery insufficiency
WAD: whiplash and associated disorders
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Opinions expressed by the authors are their own and do not necessarily reflect the view of the
Academy of Orthopaedic Physical erapy. e authors declare no conflict of interest.
e publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
© 2021, Academy of Orthopaedic Physical erapy. For personal use only. No other uses without permission.
Course content is not intended for use by participants outside the scope of their license or regulations.
5
https://t.me/med1917
6
Cervical Spine:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Eric K. Robertson, PT, DPT, OCS, FAAOMPT
Associate Professor
Department of Physical erapy and Athletic Training
University of Utah
Salt Lake City, UT
Associate Professor of Clinical Physical erapy
Division of Biokinesiology and Physical erapy
University of Southern California
Los Angeles, CA
3.
Understand critical aspects of patient history as part of a
physical therapy evaluation.
Apply best evidence supporting objective examination
4.
to guide intervention for the patient with cervical spine
pathology.
5. Categorize neck pain, including subgrouping based on the
International Classification of Functioning, Disability, and
Health impairment-based classification.
6. Select interventions based on best current evidence related to
the neck pain classification category and clinical guidelines.
7. Modify interventions as the patient with neck pain progresses
through an episode of care.
8. Apply information from clinical guidelines and best available
evidence to a pragmatic approach to patient cases.
Mary K. Derrick, PT, DPT, OCS, FAAOMPT
PhD Candidate, Department of Physical erapy and Athletic
Training
University of Utah, Salt Lake City, UT
ABSTRACT
Neck pain is one of the most common complaints for
which patients seek physical therapy care. is monograph
provides an in-depth exploration of evidence-driven physical
therapy management for patients with neck pain, including
information from the 2017 Clinical Practice Guidelines (CPG)
Linked to the International Classification of Functioning,
Disability and Health from the Academy of Orthopaedic
Physical erapy of the American Physical erapy Association.
e CPG includes efficient decision-making tools that enable
classification and subsequent management of patients with neck
pain into 4 primary categories: neck pain with mobility deficits,
neck pain with movement coordination impairment, neck pain
with cervicogenic headaches, and neck pain with radiating
pain. Decision-making tools to screen for serious pathologies
including conditions related to cervical vasculature risks are also
reviewed. Finally, clinical case scenarios aimed at challenging
the reader to apply presented concepts of examination and
intervention to patient care are presented.
Key Words: clinical reasoning, dysfunction, interventions, neck
pain
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant
will be able to:
1. Apply relevant anatomy of the cervical spine and its functional
relationship to clinical assessment and intervention of this
region.
2. Identify appropriate self-report questionnaires and
examination techniques and procedures to determine the
optimal physical therapy intervention.
PRE-LEARNING ASSESSMENT
Dominic is a 65-year-old male self-referred to physical
therapy with complaints of neck pain and stiffness that are
worse in the morning and eases when taking ibuprofen
(400mg) and using moist heat. Dominic also reports pain in
both shoulders and occasional left elbow pain. His symptoms
have been present for about 3 months. Dominic’s past medical
history is significant for hypertension, hyperlipidemia, and a
cardiovascular accident (CVA) 3 years prior, which was mild
with no obvious residual functional impact. Dominic presents
in the clinic wearing a walking boot as well, and reports he fell
and twisted his right ankle in the driveway 1 week prior. He
reports taking lisinopril, lovastatin, and coumadin and that his
last blood pressure reading 1 week prior was 145/92.
1.
Which of the following procedures would likely yield a
positive finding based on your initial hypothesis list?
a. Sharp-Purser test.
b. Segmental mobility assessment.
c. Craniocervical flexion test.
d. Valsalva test.
e correct answer is b. Segmental mobility assessment.
Based on complaints of neck pain and stiffness that is worse
in the morning, the most likely diagnosis includes neck pain
with mobility deficit, for which segmental mobility could
provide confirmatory findings. A craniocervical flexion test
would be performed primarily for a patient in the movement
coordination impairments classification, this would be the
second best answer given the duration of symptoms which
could potentially influence muscle activity and endurance.
ere is no indication of neurological disorders or trauma that
would suggest a need for the Sharp-Purser test. e Valsalva test
would be inappropriate to perform due to the cardiopulmonary
risk factors that are present.
2. Given Dominic’s complaints of stiffness and neck pain,
the physical therapist is considering using cervical spinal
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7
manipulation as part of the treatment plan. Which of the
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following best describes Dominic’s risk for this procedure?
a. No risk.
b. Minimal risk.
c. Some risk.
d. High risk.
e correct answer is d. High risk. e patient presents with
several cardiovascular risk factors as evident by his medication
list, medical history, and ongoing hypertension. According to
the International Federation of Orthopaedic Manual Physical
erapists cervical framework, he falls in the high-risk category.
3. Given the age of the patient, the physical therapist
includes cervical myelopathy in the list of potential cervical
conditions. Which of the historical factors might also
increase your suspicion of the patient having this condition?
a. Recent fall.
b. Neck stiffness.
c. History of a CVA.
d. Pain into the arms.
e correct answer is a. Recent fall. A recent fall on a level
surface could indicate ataxic gait, which is a sign for cervical
myelopathy and present in the test item cluster from Cook
1
et al.
While pain into the arms and neck stiffness can also be
related to cervical myelopathy, these items are not included in
the cluster of tests helpful for diagnosis proposed by Cook et al.
1
Assuming cervical myelopathy was ruled out and the
4.
working hypothesis is neck pain with mobility deficits,
given the information available, which intervention should
be prioritized for this patient?
a. Deep neck flexor strengthening.
b. Unilateral posterior-to-anterior (PA) joint mobilizations.
c. Home cervical traction.
d. Neurodynamic glides with ulnar nerve bias.
e correct answer is b. Unilateral posterior-to-anterior
(PA) joint mobilizations. Because this patient best fits the
neck pain with mobility deficits classification, the intervention
best suited to this patient should be primarily focused on
regaining motion. In this case, unilateral PA joint mobilizations
to the cervical spine is the best answer. Deep neck flexor
strengthening would be most appropriate for the movement
coordination deficits classification, but the pain and stiffness
that eases with movement and ibuprofen indicates more a
mobility deficit classification. ere is not enough information
provided to indicate the shoulder or elbow pain is radicular
in nature, therefore, neurodynamic glides with ulnar nerve
bias is incorrect. Similarly, home cervical traction would not
be appropriate without more evidence of the radicular nature
of symptoms, but also not until a trial treatment of traction is
performed in the clinic to assess response.
INTRODUCTION
e cervical spine is an extraordinary area of the body that
somehow combines a critical protective role while affording
a large amount of motion to enable function. It is the most
mobile portion of the spine and yet has to dutifully protect the
spinal cord and critical head and neck vasculature. Our cervical
spine allows us to move, often quickly, through substantial
ranges of motion to maintain our visual orientation and
respond both functionally and socially to the world around us.
is dichotomy of mobility and protection are often at odds,
and so it is not surprising that neck pain is among the most
common disorders experienced by patients seeking physical
therapy care.
lifespan, although the nature of the injuries change according to
age. Neck pain is the 4th leading cause of disability, impacting
up to 30% of the population and it has been estimated that
around a quarter of patients seeking outpatient orthopedic
care do so due to neck pain.
pain has been reported to be 16% in a review of large trials.
Accordingly, this monograph will review risk factors for neck
pain, many of which belong to the psychosocial realm rather
than the physical one.
One particular consideration for the cervical spine is that
clinicians must be able to rule out the presence of serious vascular
pathology, which can present with neck pain as a primary
symptom. Furthermore, based on the specific functional
anatomy of the cervical spine, the inherent complexity in the
region, the inherent limitations in our assessments, and the
many imaginative ways that humans have found to injure
this body region, the clinical presentation for neck pain can
be overwhelming to clinicians. erefore, we will discuss a
classification-based strategy for decision making for patients
with neck pain.
Importantly, many factors related to examination and
intervention of the cervical spine have been extensively
researched. While we still have much to learn, one byproduct of
this research influx is that the clinical practice guideline (CPG)
published by Blanpied et al
systematic reviews, and reviews of reviews. ey wrote, “Since
the original neck pain CPG was published in 2008, publication
of the results of a large number of trials has coincided with an
increased number of systematic reviews and reviews of reviews.
e current update appraises high level systematic reviews using
updated criteria for levels of evidence and recommendations
consistent with contemporary research methodology. e
authors encourage the reader to note these changes in
interpreting the guideline recommendations.”
clinical guidelines combine various levels of evidence, including
expert opinion, but it is notable that primary evidence sources
were of such high quality for this body of work.
2–7
Cervical injuries can occur throughout the
2,3,8
e global prevalence for neck
8,10
8
in 2017 was based primarily on
8
Of course, all
9
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8
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