clinical review

Osteoarthritis, Cervical

Indexing Metadata/Description

 Title/condition: Osteoarthritis, Cervical  Synonyms: Cervical spondylosis, degenerative disc disease  Anatomical location/body part affected: Anatomical location/body part affected: cervical vertebrae, cervical intervertebral discs, cervical nerve roots, spinal cord  ICD-9 codes 721.0 cervical spondylosis without myelopathy; cervical or cervicodorsal: arthritis, osteoarthritis, spondylarthritis 721.1 cervical spondylosis with myelopathy 722.4 degeneration of cervical intervertebral disc  ICD-10 codes M47.1 other spondylosis with myelopathy M47.8 other spondylosis; cervical spondylosis M50.3 other cervical disc degeneration  Reimbursement: No specific issues or information regarding reimbursement have been identified  Presentation/signs and symptoms Cervical osteoarthritis (OA) may exist asymptomatically or with minimal symptoms(1) A traumatic event may result in the herniation of a cervical disc, or an osteophytic impingement on the neural structures may induce symptoms(1) Symptoms may include cervical spine pain, paraspinal muscular spasm, radicular pain (varies depending on nerve root involved), loss of cervical range of motion (ROM), loss of cervical strength, and loss of upper extremity strength secondary to radiculopathy/myelopathy

Causes & Risk Factors

 Causes: Cervical OA occurs as a result of advancing age or trauma. It is a progressive degeneration of the spine, including the disc, the vertebral body, and the uncovertebral and facet joints.(2) Mechanical stress from chronic microtrauma can contribute.(3) Genetics may impact the development of cervical OA as loading patterns of the spine and spinal shape have a tremendous influence on the function of the spine(2, 3)  Pathogenesis: Degenerative changes of the intervertebral disc are often the first step in the progression of OA. Osteophytes of the vertebrae occur, along with arthrosis of the facet joints and thickening of the surrounding soft tissues, especially the ligamentum flavum.(3) The development of osteophytes and reduction of intervertebral space caused by loss of disc thickness may result in impingement on corresponding nerve roots, causing radicular symptoms  Risk factors: As with most degenerative conditions, aging is the major risk factor for the development of cervical OA. A history of injury or trauma to the cervical area may also increase risk for the development of cervical OA

Author
Lindsey Huber, MPT

Overall Contraindications/Precautions
 In individuals with cervical OA, strenuous activity should be avoided (i.e., heavy overhead lifting). In patients with any myelopathy present, spinal mobilization/manipulation is contraindicated. Traction is generally contraindicated in patients with cervical OA. Joint mobilization and traction are contraindicated if the patient has osteoporosis or a positive vertebral artery sign. Any evaluation or treatment technique that exacerbates the patients symptoms should be discontinued immediately. If the patient demonstrates vertebral artery symptoms or positive testing, the patient should be immediately referred back to the physician (see special testing, below). The patient should also be referred back to the physician if there is new onset or increased severity of myelopathy  See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan of Care

Reviewers
Joanne Minichillo, PT Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

Editor
Sharon Richman, MSPT Cinahl Information Systems

Examination
September 23, 2008

 Contraindications/precautions to examination Any evaluation or treatment technique that exacerbates the patients symptoms should be

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discontinued immediately. If the patient demonstrates vertebral artery symptoms or positive testing, the patient should be immediately referred back to the physician (see special testing, below). The patient should also be referred back to the physician if there is new onset or increased severity of myelopathy  History History of present illness/injury Mechanism of injury or etiology of illness: Patients may present after a traumatic event, with sudden onset of cervical or radicular symptoms, even though cervical OA was present previously. What symptoms are being experienced? How long have symptoms been present? Can the patient identify any exacerbating or relieving factors? If present, are radicular symptoms unilateral or bilateral? Has the patient noted paresthesias or weakness of the upper extremities? Course of treatment Medical management: Usually treated conservatively Medications for current illness/injury: Nonsteroidal anti-inflammatory drugs (NSAIDS) and analgesics are commonly prescribed Diagnostic tests completed: X-ray is often used to evaluate spinal alignment, density, margins, and disc spaces.(1) CT scans and MRI are used to identify disc herniations and nerve root impingement. Recently myelography is used less frequently, as MRI is now used as a less invasive and equally reliable tool.(1) Electromyelogram (EMG) and nerve conduction velocity testing (NCV) may be used to assess muscle and nerve function Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative therapies (e.g., acupuncture) and whether or not they help Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and what specific treatments were helpful or not helpful Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased) Body chart: Use body chart to document location and nature of symptoms Nature of symptoms: Document nature of symptoms (constant vs. intermittent, sharp, dull, aching, burning, numbness, tingling) Rating of symptoms: Use a visual analog scale or 0-10 scale to assess symptoms at their best, at their worst, and at the moment (specifically address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day, PM, night); also document changes in symptoms due to weather or other external variables Sleep disturbance: Is the patient having trouble sleeping? How many pillows are being used? Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or symptoms that could be indicative of a need to refer to physician (e.g., dizziness, bowel/bladder/sexual dysfunction, saddle anesthesia). Symptoms of vertebral artery compression include dizziness and nystagmus. Symptoms of cervical myelopathy include gait disturbance, difficulty with fine motor activities, and bowel or bladder dysfunction(4) Barriers to learning Are there any barriers to learning? Yes No If Yes, describe _______________________ Medical history Past medical history Previous history of same/similar diagnosis: Does patient have osteoarthritis in other joints? Any other pertinent medical history, including cancer? Comorbid diagnoses: Ask patient about other problems, including diabetes, cancer, heart disease, pregnancy, psychiatric disorders, orthopedic disorders, etc. Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken (including over-thecounter drugs) Other symptoms: Ask patient about other symptoms he/she may be experiencing Social/occupational history Patients goals: Document what the patient hopes to accomplish with therapy and in general Vocation/avocation and associated repetitive behaviors, if any: Does the patient participate in overhead sports? What is the patients occupation? Does the patient participate in activities that require repetitive motion of the cervical spine? Functional limitations/assistance with ADLs/adaptive equipment: What functional deficits exist secondary to cervical range of motion (ROM) losses, upper extremity weakness, and other physical manifestations of cervical OA (e.g., difficulty looking over shoulder while driving, difficulty opening jars secondary to loss of grip strength)? Living environment: stairs, number of floors in home, with whom does patient live, caregivers, etc. Identify if there are barriers to independence in the home; any modifications necessary?  Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Assistive and adaptive devices: Does patient use a soft cervical collar? Is the use of adaptive equipment secondary to loss of strength? Cranial/peripheral nerve integrity Upper limb tension testing may be performed to rule out upper limb peripheral neurological involvement (ULTT1-4)(5) Assessment of cervical nerve roots should be made, including pain, loss of sensation, and loss of motor function. Myotomes to be tested via isometric contractions(5)

C1-C2: Neck flexion

C3: Neck lateral flexion C4: Shoulder elevation C5: Shoulder abduction

C6: Elbow flexion and wrist extension C7: Elbow extension and wrist flexion C8: Thumb extension and ulnar deviation

Gait: In patients with cervical myelopathy, there may be gait disturbance(4) Joint integrity and mobility: When radicular symptoms are present, the shoulder, elbow, wrist, and hand should be screened to rule out Muscle strength: Assess strength of cervical musculature. In patients with cervical OA demonstrating forward head posture, the deep
unrelated pathology neck flexors, rhomboids, serratus anterior, and lower trapezius may be weak.(5) Assess strength through functional tasks as well. For example, weakness in neck flexors is common. Observe patient in supine position, lift head from surface, look to feet, and move into sitting position. How does patient accomplish this task? Does he/she chin tuck? Does head lag? How great of an effort is this task? Observation/inspection/palpation Assess for provocation of pain with cervical ROM. Also assess for radicular pain into the upper extremities Palpate cervical vertebrae for tenderness and spondylolisthesis. Assess paraspinal musculature for tenderness, tightness, and spasm Assess for atrophy of musculature related to myelopathy and nerve root impingement Posture: Assess the cervical spine for forward head posture, torticollis, and loss of cervical lordosis. Assess clavicles, scapulae, and shoulders for abnormality. Does the patient posture him-/herself differently in various functional positions? Range of motion: Determine active range of motion (AROM) and passive range of motion (PROM) of cervical spine. Also, screen upper extremities Reflex testing: Assess and compare bilaterally(5) C5-C6: Biceps C5-C6: Brachioradialis C7-C8: Triceps Testing the following reflexes are recommended if cervical myelopathy is suspected(4) The Hoffman and extensor plantar reflexes will be positive if there is spinal cord compression The abdominal and cremasteric reflexes will be diminished or absent if there is spinal cord compression Sensory testing: Loss of sensation may occur in one or more dermatomes as a result of nerve root impingement or may be diffuse if there is cord compression. A thorough sensory evaluation should be performed, including light touch, two-point discrimination, and proprioception Special tests specific to diagnosis Spurlings (foraminal compression) test: To assess for cervical nerve compression. Should be used when the patient describes radicular symptoms that are not present at the time of the examination with patient in sitting position. The test involves compression of the head by the examiner with the head in several different positions. First compression of the head in neutral is attempted, then compression of the head in extension. Next, compression of the head with the head in extension and rotation to the unaffected side, followed by compression with the head in extension and rotation to the affected side. Positive finding if pain radiates into the arm toward which the head is rotated(6) Distraction test: To assess for cervical nerve compression. Should be used when the patient is currently experiencing symptoms with patient in sitting position. One hand is placed under the patients chin; the other is placed around the occiput. Then gentle manual traction is applied. Positive test if the pain is decreased or relieved while the head is lifted(6) Vertebral artery testing: Patient is positioned supine. Instruct the patient to keep eyes open. The examiner passively extends and side bends the patients neck. The neck is then rotated to the same side as the side bend. This position is held for 30 seconds. It is a positive test for compression of the contralateral vertebral artery if the position produces dizziness or nystagmus

Gross assessment of lower extremity strength is recommended if cervical myelopathy is suspected(4)

T1: Abduction and adduction of intrinsic hand muscles

Assessment/Plan of Care

 Contraindications/precautions Joint mobilization and traction are contraindicated if the patient has acute pain, osteoporosis, or vertebral artery occlusion Any evaluation or treatment technique that exacerbates the patients symptoms should be discontinued immediately  Diagnosis/need for treatment: Cervical spine pain or loss of ROM; radicular symptoms or upper extremity weakness  Rule out Cervical disc herniation (with or without radiculopathy) Cervical vertebral fracture Spinal tumor Spinal stenosis Upper extremity nerve entrapment Brachial plexus disorders; thoracic outlet syndrome

Shoulder, elbow, wrist, or hand pathology Infection Rheumatoid arthritis Cervical sprain/strain  Prognosis: Cervical OA is a progressive condition. Prognosis will vary widely depending on numerous factors, including interventions (conservative and surgical) and patient compliance  Referral to other disciplines Massage therapy: to further address muscular tightness/spasm Physician if myelopathy or new nerve root compression is suspected. May also perform epidural steroid injections for pain relief  Treatment summary: Pain management, strengthening, and stretching are the main physical therapy interventions recommended. In individuals with cervical OA, strenuous activity should be avoided (i.e., heavy overhead lifting). Additionally, weight loss may help to decrease weight-bearing load on the cervical spine, although it is less helpful than in hip/knee osteoarthritis(1) Expected Progression
N/A

Problem
Pain

Goal
Eliminate/decrease pain

Intervention
Adaptive/assistive equipment Soft or rigid collar, cervical pillow as needed. The use of a soft collar provides cervical immobilization, which may help to prevent irritation of the nerve and allow inflammation to subside.(7) Use of a collar should be temporary, or at least intermittent, to limit loss of cervical ROM and strength Manual therapy Massage/myofascial release to address muscular tightness and spasm, passive stretching to increase ROM, mobilization of cervical spine as appropriate Electrical modalities Significant pain relief was obtained in two studies involving pulsed electromagnetic fields in cervical OA, although the exact mechanism of its effect is not well understood(8, 9)

Home Program
Instruct patient in pain management techniques

Reduced cervical ROM

Improve cervical ROM

Therapeutic exercises Stretching of restricted tissues in pain-free range Kinesthetic training Teach awareness and control of cervical movements; cervical retraction Therapeutic exercises Isometric strengthening exercises for flexion, extension, rotation, and side bending Teach body mechanics for specific skills in work and home environment

Therapeutic exercises Progress stretching as tolerated Therapeutic exercises Spinal and scapular stabilization exercises with focus on controlling position while moving extremities Therapeutic exercises Progress to dynamic exercises to increase endurance and strength Higher intensity functional activities to facilitate return to previous functional level

Instruct patient in selfstretching program Instruct patient to maintain neutral postures with ADL

Poor posture

Correction of faulty posture

Weakness

Increase strength of affected musculature and improve overall endurance Restore prior functional level

Encourage aerobic activities; walking, cycling, swimming, etc. Instruct patient in prevention of further injury; safe exercises to perform, body mechanics with functional activities, and modifications of work and home environment

Functional limitations

Desired Outcomes/Outcome Measures

Relief of pain, radicular symptoms, improved cervical ROM/strength, posture, resumption of functional activities with or without adaptations.

Maintenance or Prevention
Patients with cervical OA will need to maintain a consistent home exercise program, including ROM and strengthening activities. Heavy lifting and strenuous activity should be avoided. Good posture and ergonomic setups should be maintained.

Coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RCT Published research (randomized controlled trial) RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other CP Conference proceedings, abstracts, presentations

PGR Published government report PFR Published funded report

such materials

References
1. 2. 3. 4. 5. 6. 7. 8. 9. Hobday EC. Evaluation and management of cervical disk disease. J Am Acad Phys Assist. 1992;5:412-421 (RV) Fast A, Thomas MA. Cervical degenerative disease. In: Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. Philadelphia, PA: Hanley & Belfus, Inc.; 2002:12-18. (GI) McClure P. The degenerative cervical spine: pathogenesis and rehabilitation concepts. J Hand Ther. 2000;13(2):163-174. (RV) Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am. 2002:84(10):1872-1881. (RV) Magee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia, PA. Saunders; 1992. (GI) Magee DJ. Orthopedic Physical Assessment. 4th ed. Philadelphia, PA: Saunders Elsevier; 2002. (GI) Glaser V. Osteoarthritis, shoulder impingement, cervical radiculopathy, plantar fasciitis. Patient Care. 1999;33(12):176-178, 181-182, 184 passim. (RV) Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006;26(4):320-324. (RCT) Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine: report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994;21(10):1903-1911. (RCT)