Changes Associated with Chronic Cervical Pain

Original Editor - Mostafa Shahien

Top Contributors - Mostafa Shahien, Aminat Abolade, Alicia Fernandes, Oyemi Sillo and Kim Jackson

Introduction[edit | edit source]

Cervical Pain

Cervical pain is one of the most common complaints by patients presenting to physiotherapy clinics. It disturbs the overall function and quality of life for most patients. It may occur because of different reasons and with many different forms, hence, a good understanding of the possible presentation, changes that occur with chronic pain, and the best treatment modalities is essential.

Changes That Occur With Chronic Cervical Pain[edit | edit source]

Pain Centralisation[edit | edit source]

  • Reduced pain threshold is one of the findings that researchers have found in patients with chronic neck pain[1]. The decrease in pain threshold is recorded both locally and distally in the upper and lower limbs, suggesting that central changes occur with chronic cervical pain.
  • Implications: Centralisation of pain indicates a heightened sensitivity to pain signals, not only in the affected area but also in distant regions of the body, reflecting alterations in the central nervous system[2].
  • Clinical Consideration: Understanding pain centralization is crucial for tailoring interventions that address both local and widespread pain sensitivities in individuals with chronic cervical pain.

Proprioceptive Changes[edit | edit source]

  • Patients with chronic cervical disorders show deficit in the proprioceptive input, which affects postural stability[3]
  • Implications: Proprioception, the body's awareness of its position in space, plays a vital role in maintaining balance and coordination. Proprioceptive deficits may contribute to impaired postural control in individuals with chronic cervical pain.
  • Clinical Consideration: Rehabilitation programs for chronic cervical pain should include targeted exercises to improve proprioception, addressing the underlying deficit in postural stability[4]

Neuromuscular Dysfunction[edit | edit source]

  • Research has shown that patients with chronic cervical pain exhibit up to 90% deficit in cervical spine muscle strength[5].
  • Implications: Neuromuscular dysfunction, characterized by significant muscle strength deficits, can contribute to functional limitations and increased vulnerability to injuries in individuals with chronic cervical pain.
  • Clinical Consideration: Physiotherapy interventions should focus on strengthening exercises to address neuromuscular deficits, promoting improved muscle function, and reducing the risk of complications.[6]

Deep Neck Flexors Dysfunction[edit | edit source]

  •  Deep neck flexors have reduced EMG activity and delayed activation when performing arm movements, so the feedforward mechanism is disturbed[7]
  • Implications: Disturbed feedforward mechanisms in deep neck flexors suggest compromised anticipatory control during certain movements, potentially contributing to instability and pain exacerbation
  • Clinical Consideration: Targeted exercises aimed at retraining deep neck flexors and restoring proper activation patterns can be crucial in rehabilitation programs for chronic cervical pain[8]

Neck Flexor Muscles[edit | edit source]

  • Neck flexor muscles (SCM and anterior scalene) have shown side-specific weakness in unilateral cervical pain.[9]
  • Implications: Asymmetrical weakness in neck flexors may contribute to altered biomechanics and posture, potentially exacerbating pain and functional limitations.
  • Clinical Consideration: Rehabilitation strategies should address side-specific weakness through targeted exercises, aiming to restore balance and symmetry in neck muscle strength.[10]
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Changes in Mental Health with Chronic Cervical Pain[edit | edit source]

Chronic cervical pain not only affects the physical aspects of an individual's health but also has profound implications for mental well-being. Understanding the intricate relationship between chronic cervical pain and mental health is crucial for holistic patient care.

Emotional Distress and Anxiety[edit | edit source]

Studies, including that by McLean et al. [11], have consistently demonstrated a correlation between chronic cervical pain and heightened levels of emotional distress and anxiety.

The persistent nature of pain contributes to increased stress, exacerbating emotional challenges. The constant discomfort and limitations imposed by chronic cervical pain can lead to a cycle of heightened emotional responses, negatively impacting overall mental health.[11]

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Depression and Chronic Pain Syndrome[edit | edit source]

Chronic cervical pain is often linked to an increased risk of depression. The work of Bair et al.[12] emphasizes that individuals experiencing prolonged pain are more susceptible to developing depressive symptoms.

The reciprocal relationship between chronic pain and depression creates a challenging scenario, where one condition can exacerbate the severity of the other.[12]

Impact on Sleep Patterns[edit | edit source]

Sleep disturbances are prevalent in individuals with chronic cervical pain. The study by Smith et al.[13] highlights the bidirectional relationship between pain and sleep disruption.

Chronic pain interferes with sleep quality, leading to fatigue and exacerbating mental health issues. Conversely, poor mental health can contribute to sleep disturbances, creating a cyclical pattern.[13]

Coping Mechanisms and Psychological Resilience[edit | edit source]

Individuals with chronic cervical pain often employ various coping mechanisms to manage their condition. The research by Jackson et al.[14] suggests that the effectiveness of these coping strategies can impact mental health outcomes.

Understanding and enhancing psychological resilience become crucial in mitigating the negative impact of chronic cervical pain on mental well-being.[14]

social isolation

Social Isolation and Impaired Quality of Life[edit | edit source]

Chronic cervical pain may contribute to social isolation due to limitations in daily activities. The study by Turner et al.[15] highlights the connection between social factors, quality of life, and mental health.

Addressing social aspects and promoting social support can be integral to managing the psychological impact of chronic cervical pain.[15]

Conclusion[edit | edit source]

Chronic cervical pain extends beyond its physical manifestations, significantly influencing mental health. Recognizing and addressing these changes are essential components of a comprehensive treatment approach. By integrating psychological support and tailored interventions, healthcare professionals can enhance the overall well-being of individuals navigating the complexities of chronic cervical pain.

Assessment[edit | edit source]

Assessment of chronic cervical pain should focus on different areas:

  • Postural assessment - observed from three different positions:
  1. Posterior: shoulder appears elevated (due to tightness of the upper trapezius and levator scapulae muscles).
  2. Lateral: appearance of a forward head posture.
  3. Anterior: cord-like appearance at SCM.
  • Balance assessment - patients with chronic neck pain typically present with impaired postural stability.
  • Gait assessment - in extreme cases of cervical dysfunction, the gait pattern may be changed.
  • Flexibility and muscle strength assessment

Physical Therapy Management[edit | edit source]

The main aims of physical therapy treatment are to restore the balance between the muscles by stretching the tight muscles and strengthening the weak ones, as well as, to improve proprioception. Some physical therapy treatments are:

  • Stretching for tight muscles

The most common tight muscles:

Upper trapezius

[16]

Sternocleidomastoid muscle (SCM)

[17]

Stretching alone is not sufficient to treat patients with chronic cervical pain, you should also work on deep neck flexor stabilization protocol as it is very important step in the rehabilitation program.

  • Proprioceptive exercises.

As stated above, patients with chronic neck pain show deficit in proprioception which affects postural stability. Exercises that involve head and eye movements are thought to improve proprioception, as the vestibular, visual, and proprioceptive systems are linked together[18] [19].

You may also look at Sensorimotor Impairment in Neck Pain to see the proprioceptive exercises.

References[edit | edit source]

  1. ↑ Sterling M, Treleaven J, Edwards S, Jull G. Pressure pain thresholds in chronic whiplash associated disorder: further evidence of altered central pain processing. Journal of Musculoskeletal Pain. 2002 Jan 1;10(3):69-81.
  2. ↑ Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical rheumatology. 2007 Apr;26(4):465-73.
  3. ↑ Malmström EM, Fransson PA, Jaxmar Bruinen T, Facic S, Tjernström F. Disturbed cervical proprioception affects perception of spatial orientation while in motion. Experimental brain research. 2017 Sep;235:2755-66.
  4. ↑ Moore A, Jull G. (2007). Modern Management of Chronic Neck Pain. Elsevier Health Sciences.
  5. ↑ Prushansky T, Gepstein R, Gordon C, Dvir Z. Cervical muscles weakness in chronic whiplash patients. Clinical biomechanics. 2005 Oct 1;20(8):794-8.
  6. ↑ Jull GA, O'leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of manipulative and physiological therapeutics. 2008 Sep 1;31(7):525-33.
  7. ↑ Falla D, Jull G, Hodges PW. Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental brain research. 2004 Jul;157:43-8.
  8. ↑ Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Physical therapy. 2007 Apr 1;87(4):408-17.
  9. ↑ Falla D, Jull G, Rainoldi A, Merletti R. Neck flexor muscle fatigue is side specific in patients with unilateral neck pain. European Journal of Pain. 2004 Feb 1;8(1):71-7.
  10. ↑ Jull GA, O'leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of manipulative and physiological therapeutics. 2008 Sep 1;31(7):525-33.
  11. ↑ 11.0 11.1 McLean SA, Clauw DJ, Abelson JL, Liberzon I. The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model. Psychosomatic medicine. 2005 Sep 1;67(5):783-90.
  12. ↑ 12.0 12.1 Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Archives of internal medicine. 2003 Nov 10;163(20):2433-45.
  13. ↑ 13.0 13.1 Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep medicine reviews. 2004 Apr 1;8(2):119-32.
  14. ↑ 14.0 14.1 Jackson T, Pope L, Nagasaka T, Fritch A, Iezzi T, Chen H. The impact of threatening information about pain on coping and pain tolerance. British journal of health psychology. 2005 Sep;10(3):441-51.
  15. ↑ 15.0 15.1 Turner JA, Holtzman S, Mancl L. Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain. Pain. 2007 Feb 1;127(3):276-86.
  16. ↑ Back Intelligence. Sternocleidomastoid Stretch. Available from: https://backintelligence.com/sternocleidomastoid-stretch/ (accessed 4 January 2023).
  17. ↑ Back Intelligence. Sternocleidomastoid Stretch. Available from: https://backintelligence.com/sternocleidomastoid-stretch/ (accessed 4 January 2023).
  18. ↑ Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Archives of physical medicine and rehabilitation. 1994 Aug 1;75(8):895-9.
  19. ↑ Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. Journal of orthopaedic research. 2007 Mar;25(3):404-12.
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