Sensorimotor Impairment and Muscle Performance in Neck Pain Case Study
Freddy is a 22 year old male who has just graduated from university. He has not yet started working. At present, he exercises two times per week at the gym and plays lots of cricket, although this is not strenuous. Previously, he also played hockey and may like to return to this. His gym sessions are primarily focused on cardiovascular fitness (stationary bike, treadmill, rowing machine). Weights are mostly machine based, focusing on legs, back, arms, chest and core.
History of presenting condition
Freddy initially injured his neck when he was 13 years old in a rugby scrum. At the time, he had significant neck pain (VAS = 9/10). Pain following this injury soon resolved without treatment and he had no further issues for 3 years.
At 16 years old, Freddy began bowling in cricket and developed further neck pain (VAS 8-9/10). He noted a pinching sensation in his lower cervical spine. Because of this pain, he was unable to continue bowling and became a wicket keeper.
Since this time, he has had ongoing neck pain. While he is able to perform all activities of daily living and most sports, he reports a constant, low grade neck pain. This pain worsens with periods of prolonged poor posture (ie with long hours in front of a computer/device (VAS 4/10) or when playing sports like hockey where he has to adopt a flexed position. NB: Freddy does not mention a specific 24 hour pattern - sometimes patients with neck pain report worse pain in the morning when their neck is stiff or at the end of the day when their muscles are fatigued.
He notes he feels the urge to click his neck often. Movements feel “jolty and stiff” rather than “fluid”.
While his pain levels have decreased over the last couple of years, it remains an ongoing inconvenience.
Freddy has seen 3 different osteopaths over the last few years. He tends to seek treatment when his neck feels particularly sore.
Each osteopath offered different diagnoses and their treatments provided short term pain relief, but no long term effect. It has been shown that manual techniques are an essential part of diagnosing neck pain and are effective in reducing pain, but they have little effect on neuromuscular and sensorimotor function.
Possible diagnoses from osteopaths:
- Leg length discrepancy and a focus on the quadriceps nerve firing. Freddy notes this had the longest benefit with a significant reduction in pain for around 6 months.
- Alignment issue
- Pain related to first injury - provided manual techniques, which helped the most in the short term. Freddy notes he saw this osteopath multiple times, with his last appointment being around 10 months ago.
Freddy is now seeking a longer term solution. He has no particular self management plan beyond attempting to improve his posture.
Past medical history
Freddy reports good general health. He has had no surgery, major illness and is not taking any medications. His weight is stable. He does not report double vision, collapsing/fainting, pins and needles or numbness. He reports no history of stress, either at the time of his initial injury, or when his pain worsened again.
He notes occasionally feeling light-headed when standing up quickly. This symptom can be associated with sensorimotor dysfunction, but Freddy reports his mother also has the same issue.
There is a large body of research supporting the notion that dysfunction of the cervical afferents can cause dizziness, unsteadiness, visual disturbances, and changes in balance, as well as head and eye movement following neck trauma. This is especially true in patients with persistent symptoms. The objective assessment of this patient must, therefore, include an examination of the neck and shoulder, as well as head control and balance.
Neck pain also causes changes in sensorimotor function, which do not always resolve as pain decreases. Thus, a detailed assessment needs to include an examination of sensorimotor function. Please click here for an overview of sensorimotor impairment in neck pain.
It is also essential to assess muscle performance as patients with neck pain have been shown to have reduced strength, decreased endurance, and they fatigue more quickly. Please click here for an overview of muscle performance testing for the cervical spine.
The diagnosis in this case study is likely facet joint dysfunction with some sensitisation. The cervical facet joints are well recognised as a common cause of neck pain, headache and referred pain in the upper limbs. It is estimated that the prevalence of facet joint dysfunction in chronic axial neck pain ranges from 25 to 66 percent. While there is limited evidence to support the use of clinical tests when assessing the cervical spine of adults with neck pain, a recent systematic review by Lemeunier and colleagues suggests that the extension rotation test may be reliable and that it has adequate validity to rule out pain being generated by the facet joints. Moreover. a cluster of three tests has been found to be sensitive (94%) and specific (84%) when diagnosing cervical facet joint dysfunction. These tests are the extension rotation test, manual spine examination and palpation for segmental tenderness.Freddy's balance and postural control tests were unremarkable. When testing proprioception to the right side, he showed greater than 6.5cm deviation, which is a positive test (see video below for a reminder on how to perform this test), Testing to the left side didn't show any significant impairment - nor did the eye movement tests (he had no dizziness/blurry vision or saccadic eye movements). When neck pain originates in facet joints in the upper cervical spine, there is greater sensorimotor dysfunction as this region contains more muscle spindles, has greater connection to the visual and vestibular systems and it has more reflex activity than the lower region.
Freddy had segmental pain on palpation. In addition, his muscle performance tests showed weakness and loss of endurance/control. He was able to reach 30mmHg on the cranio-cervical flexion test. This test is considered a reliable and valid clinical test, but it is recommended that it only be used with caution as a discriminative test or as an outcome measure. Freddy found this provocative and was unable to hold for 10 seconds, which is typical for someone with neck pain. Muscle performance issues were most pronounced during the neck flexor endurance test (see video below for a reminder on how to perform this test). Freddy was only able to hold the position for 15 seconds and reported a VAS of 3-4/10. Domenech et al (2011) found that on average, male subjects without neck pain had a mean endurance hold of 38.9 ± 20.1 seconds (the average for female subjects was 29.4 ± 13.7 seconds). Post assessment, Freddy noted that his neck felt weak and vulnerable, rather than powerful. He felt his concordant pain with all muscle performance tests.
Treatment should focus on strengthening and improving muscle performance. Particularly relevant for Freddy is the finding that deep neck flexor training can reduce pain. In addition to his usual gym work, possible exercises include shoulder shrugs and lateral raises. For a detailed discussion of muscle strengthening for the neck, click here.
- Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. journal of orthopaedic & sports physical therapy. 2009 May;39(5):364-77. [Accessed 26 June 2018] Available from: http://www.neckcare.com/wp-content/uploads/Sensorimotor-function-and-dizziness-in-neck-pain_Implication-for-assessment-and-management.pdf
- Jull, G. Non-specific neck pain: The case for specific treatment (Webinar). IFOMPT. 2019.
- Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502.
- Sterling, M, Jull, G, Vicenzino B, Kenardy, J, Darnell, R. Development of motor system dysfunction following whiplash injury. Pain. 2003; 103(1-2): 65-73.
- Reid, SA, Rivett, DA, Katekar, MG, Callister, R. Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Physical Therapy. 2014; 94(4): 466-476.
- Jull, G, Trott, P, Potter, H, Zito, G, Niere, K, Shirley, D et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002; 27(17): 1835-43.
- Blomgren J, Strandell E, Jull G, Vikman I, Röijezon U. Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review. BMC Musculoskelet Disord. 2018;19(1):415.
- Jull, G. Non-specific neck pain: The case for specific treatment (Webinar). IFOMPT. 2019.
- Manchikanti L, Kosanovic R, Cash KA, Pampati V, Soin A, Kaye AD et al. Assessment of Prevalence of Cervical Facet Joint Pain with Diagnostic Cervical Medial Branch Blocks: Analysis Based on Chronic Pain Model. Pain Physician. 2020;23(6):531-40.
- Kirpalani, D. Mitra, R. Cervical Facet Joint Dysfunction: A Review. Archives of Physical Medicine and Rehabilitation. 2008; 89(4): 770-4.
- Lemeunier N, da Silva-Oolup S, Chow N, Southerst D, Carroll L, Wong JJ et al. Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1-A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. Eur Spine J. 2017;26(9):2225-41.
- Schneider, GM, Jull, G, Thomas K, Smith, A, Emery, C, Faris, P et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil. 2014; 95(9): 1695-701.
- Chris Worsfold Assessing proprioception of the neck - YouTube. Available from: https://www.youtube.com/watch?v=SFjAMaAdqXY[last accessed 28/06/18]
- Araujo FX, Ferreira GE, Scholl Schell M, Castro MP, Ribeiro DC, Silva MF. Measurement Properties of the Craniocervical Flexion Test: A Systematic Review. Phys Ther. 2020;100(7):1094-117.
- Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
- Domenech, MA, Sizer, PS, Dedrick, G, McGalliard, MK. The Deep Neck Flexor Endurance Test: Normative Data Scores in Healthy Adults, PM&R. 2011; 3(2): 105-110.
- Jull GA, O'leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of Manipulative & Physiological Therapeutics. 2008 Sep [Accessed 7 Jun 2018] 1;31(7):525-33. Available from: https://scholar.google.com/scholar_url?url=http://portalsaude.dominiotemporario.com/doc/teste_cranio_cervical.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=i1IZW_DMNYGnywSN4o3ABQ&scisig=AAGBfm3AjnSQA5jlgWBbIawh20NsI2sFmA