Cervicobrachialgia

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Original Editors

Top Contributors -

Jeremy Luytens and Thijs Van Liefferinge  

Contents

Search Strategy


The medical library of the Vrije Universiteit Brussel was consulted. A literature search was conducted using Pubmed, Pedro and Web of Knowledge. Keywords used in the search were: cervicobrachialgia, cervicobrachial pain, treatment, physiotherapy, cervicobrachial syndrome, …

Definition/Description

When there is a combination of neck complaints and (radiating) complaints in the arm, we can call it a cervicobrachial syndrome or cervicobrachialgia. It refers to a cervical syndrome with pain radiating into the upper limb. Cervicobrachial syndrome was, therefore, previously known as “lower cervical syndrome”. It is characterized by pain, numbness, weakness, and swelling in the region of the neck and shoulder. Also by pain and sensory disturbances that radiate from the cervical spine into the upper limb, in a more or less clear radicular pattern i.e. in the distribution of the ventral branch of a spinal nerve. The term ‘’cervicobrachial syndrome’’ should denote a collection of neck and arm symptoms for which there is no known and proven cause. If a patient can be proven to have cervical radiculopathy or thoracic outlet syndrome, then the specific and objectively documented diagnosis should be used. ( 1, level of evidence:1 . 2, level of evidence: 3 )

Clinically Relevant Anatomy

The cervicobrachial syndrome may be the result of cervical radiculopathy. This discogenic brachialgia is produced by lesions affecting the C5/6 and C6/7 motion segments. The topography of the cervical dermatomes and myotomes is such that the myotome generally does not underlie the corresponding dermatome. Many of the muscles of the upper portion of the trunk are mainly supplied by the cervical nerve roots and are often affected in cervical syndromes. These muscles include the rhomboids, the supra- and infraspinatus muscles, deltoid, serratus anterior and latissimus dorsi muscles. The cervicobrachial syndrome can also be the result of neurogenic and/or vascular compression in the thoracic outlet. In this case the brachial plexus, subclavian artery or subclavian vein are compressed due to the narrowing of spaces in this region. ( 1, level of evidence: 1 )

Epidemiology /Etiology

The occupation of most patients is manual work with continuous, repetitive tasks like computer work, writing, manipulating or moving objects and lifting or overhead work. Tasks that require holding the same neck position for a long period are provocative. ( 2, level of evidence: 3 )

Characteristics/Clinical Presentation

We can only speak of cervicobrachial syndrome when the patient complains about pain and a neurological disorder like tingling, sensory disturbance or even a loss of motor skills in arm, hand and fingers. In some cases there is loss power and even motion control.

There are no agreed clinical criteria for a diagnosis of cervicobrachialgia but the findings commonly include pain and fatigue of the wrist, forearm, shoulders and neck. There may be a swelling sensation in the hands and an heaviness or numbness of the upper extremity. Pain is mostly increased by activity and relieved by rest, but sometimes the pain increases at night which provides sleeping problems.
Individuals report the sensation of wearing gloves when they are not. The symptoms can also be accompanied by heavy headaches. ( 1, level of evidence: 1 . 2, level of evidence: 3 )

The term “cervicobrachial syndrome” is used by some physicians to describe symptoms they suspect come from cervical nerve root irritation that cannot be documented, whereas other physicians reserve the term for patients whose symptoms may come from undocumentable thoracic outlet syndrome. Still other physicians use the term as a synonym for “myofascial pain syndrome” with symptoms in the neck and/or shoulder that are believed to arise in muscle. ( 9, level of evidence: 1 )

Differential Diagnosis

Just like thoracic outlet syndrome we can determine verifiable vascular compression or neurologic compression but in contrast to thoracic outlet syndrome, cervicobrachial syndrome has some unexplainable symptoms. These symptoms are similar to the symptoms of repetitive strain injury. ( 8, level of evidence: 1 )

Diagnostic Procedures

Before the symptomatic treatment can take place, the following diagnostic procedures have to be finished:
- Further examination of the neck and the shoulder to disqualify a cause of this region: see physical examination
- An X-ray examination of the neck (CWK) in various directions
- Consult by a neurologist (possible EMG and MRI or CT of the neck)
- Angiography or venography for possible vascular injuries

The radiographic images are taken primarily to rule out objectively verifiable causes for the symptoms. These X-rays may identify first rib abnormalities or the presence of accessory ribs. Spinal injury or pathology (current or prior) may be evaluated by MRI or CT imaging. Nerve damage can be identified or ruled out using EMG. Any vascular injury or thrombosis may be evaluated by conventional angiography, by magnetic resonance angiography or by venography. ( 1, level of evidence: 1 )

Outcome Measures

In patients with cervicobrachialgia the function can be measured by the Northwick Park Neck Pain Questionnaire. This questionnaire has been demonstrated to have short-term repeatability and long-term sensitivity to change.
Pain can be measured using the Short-Form McGill Pain Questionnaire (SF-MPQ). This also includes the Present Pain Intensity (PPI) index of the standard MPQ and a visual analogue scale (VAS).
As physical outcome measure the cervical range of motion (CROM) can be measured ( 5, level of evidence: 1 )

Examination

The neck, shoulders and arms usually appear normal but are in fact painful to touch. The neck may be stiff with a clear limited range of motion, particularly neck extension. Some patients may have poor posture with rounded shoulders and stooped head and neck. Raising the arm (abduction) may increase the symptoms. Observation of possible asymmetries of the upper chest, including the clavicle, has to be done.
To reproduce the symptoms some physical tests can be employed:
- the Adson maneuver: the head is placed in extension and bent to the side while the patient holds his breath and the physician observes for symptoms
- the elevated arm stress test: hyperabduction of the arm may produce symptoms
A loss of pulse during these tests indicates the thoracic outlet syndrome. ( 2, level of evidence: 3 )

Medical Management

The treatment of cervicobrachialgia is conservative and symptomatic. Surgical interventions can’t be used to treat cervicobrachialgia. ( 3, level of evidence: 1 )

Pain and sleep disorders are relieved with medication. This medication includes painkillers, anti-inflammatory medication (NSAID’s) and muscle relaxants, in case of chronic pain.
If there is vascular compression, doctors may prescribe vasodilators or calcium-channel blockers.
A cervical epidural injection of corticosteroids can also be considered to reduce the inflammation. This injection is an effective method for achieving immediate and long-standing pain relief and improvement in motion and performance in chronic cervicobrachialgia. ( 3, level of evidence: 1 .7, level of evidence: 3 )

Physical Therapy Management

In the conservative treatment the primary goal in the rehabilitation of cervicobrachialgia is the reduction of pain.
• Transcutaneous electric nerve stimulation (TENS)
• Cryotherapy
• Deep heat treatment
• Ultrasound
• Cognitive and behavioral pain management ( 3, level of evidence: 1 )
• Deep tissue massage ( 4, level of evidence: 3 )
The second goal is to improve the function and range of motion of the patient through:
• Passive manual therapy techniques
• Indirect manual therapy techniques ( 4, level of evidence: 3 )
• Manipulative physiotherapy treatment involved a cervical lateral glide mobilization technique ( 5, level of evidence: 2 ) ( 6, level of evidence: 2)
• Active exercise therapy for neck, shoulder and arm to improve range of motion and functionality
• Therapy to induce strength and endurance
• Stretching exercises of the neck and shoulder ( 3, level of evidence: 1 )
• Exercises for postural control and the endurance of the posture during activities of daily living
Home exercises and ergonomic evaluation play an important role in the rehabilitation of patients. (4, level of evidence: 3 ). Evaluation can provide information regarding the activities and positions at work that may support the disease.
Improvements were found in pain and pain intensity, pain quality scores and functional disability levels. ( 5, level of evidence: 1 )

Key Research

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Resources

Pubmed
Web of knowledge
Medical library of the VUB
Pedro
Google scholar

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

1. Jürgen Krämer et al; Intervertebral Disk Diseases, causes, diagnosis, treatment, and prophylaxis; Thieme 3th Edition 2009
Level of evidence: 1

2. Aynesworth, Kenneth H. "The Cervicobrachial Syndrome." Annuals of Surgery 111 5 (1940): 727-742.
Level of evidence:  3

3. Salt E. et al., A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain, Manual Therapy, 2011 Feb;16(1),53-65
Level of evidence: 1

4. Allison GT, Nagy BM, Hall T., A randomized clinical trial of manual therapy for cervico-brachial pain syndrome -- a pilot study, Manual Therapy. 2002 May;7(2):95-102.
Level of evidence: 3

5. Cowell IM., Phillips DR., Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study - experimental design, Manual Therapy. 2002 Feb;7(1):31-8.
Level of evidence: 2

6. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K., The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain, Journal of orthopedics and sports Phys. Ther., 2003 Jul;33(7):369-78.
Level of evidence: 2

7. Stav A. et al., Cervical epidural steroid injection for cervicobrachialgia., Acta Anaesthesiol Scand., 37(6): 562-566. (2008)
Level of evidence: 3

8. Gross, A. R., et al. "Physical Medicine Modalities for Mechanical Neck Disorders." Cochrane Database System Review 2 (2000): CD000961. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008
Level of evidence: 1

9. Gross, A. R., et al. "Manipulation and Mobilisation for Mechanical Neck Disorders." Cochrane Database System Review 1 (2004): CD004249. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008
Level of evidence: 1