Cervical Osteoarthritis: Difference between revisions

No edit summary
(updated categories - removed course pages)
 
(48 intermediate revisions by 12 users not shown)
Line 1: Line 1:
<div class="editorbox">
<div class="editorbox"> '''Original Editor '''- [[User:Bram Sorel|Bram Sorel]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>  
'''Original Editors ''' - [[User:Bram Sorel|Bram Sorel]]  
 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
<br></div>  
== Definition/Description  ==
== Definition/Description  ==


The cervical spine consists of seven cervical vertebrae which are situated between the skull and the thoracic region. Osteoarthritis of the cervical spine may be defined as a degenerative disorder at those levels, complicated by inflammatory reactions. It is a very complex disease with multiple causes<ref name="musumeci">Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst Century: Risk Factors and Behaviours that Influence Disease Onset and Progression. Int J Mol Sci 2015; 16(3): 6093-6112 (Level of Evidence: 2A)</ref> which affects the intervertebral discs, vertebral bodies, intervertebral ligaments,<ref name="sutbeyaz">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. Rhematol Int 2006; 26: 320-324 (Level of Evidence: 1A)</ref>&nbsp;the hyaline cartilage, the underlying bone, joint capsule, zygophyseal joints and/or can lead to the formation of osteophytes <ref name="michael">Michael J. Lee, K.Daniel Riew. The prevalence cervical facet arthrosis: an osseous study in cadaveric population. The spine Journal 9(2009) 711-714 (Level of evidence 5)</ref>&nbsp;<ref name="hartz">Hartz A J, Fisher M E, Bril G, et al. The association of obesity with joint pain and osteoarthritis in the HANES data. J Chronic Dis 1986;39:311-319 (Level of evidence 2B)</ref><br>or subchondral cysts and/or can cause hypertrophy of the articular process.<ref name="gellhorn">Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol 2013; 9(4): 216-224 (Level of Evidence: 2B)</ref><br>Although cervical osteoarthritis is often referred to as cervical spondylosis <ref name="hartz" />, it is not clear whether these two concepts may be considered synonyms.<br><br>  
Osteoarthritis of the cervical spine may be defined as a degenerative disorder of C1-C7, complicated by inflammatory reactions. It is a very complex disease with multiple causes<ref name="musumeci">Musumeci G, Aiello F, Szychlinska M, Di Rosa M, Castrogiovanni P, Mobasheri A. [https://www.mdpi.com/1422-0067/16/3/6093 Osteoarthritis in the XXIst century: risk factors and behaviours that influence disease onset and progression]. ''International journal of molecular sciences''. 2015 Mar;16(3):6093-112 Available from: https://www.mdpi.com/1422-0067/16/3/6093 [Accessed on 18 June 2019] </ref> which affects the intervertebral discs, vertebral bodies, intervertebral ligaments, the hyaline cartilage, the underlying bone, joint capsule and zygoapophyseal joints. It can lead to the formation of osteophytes or subchondral cysts and can cause hypertrophy of the articular process.<ref name="gellhorn">Gellhorn AC, Katz JN, Suri P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012322/ Osteoarthritis of the spine: the facet joints]. ''Nature Reviews Rheumatology''. 2013 Apr;9(4):216. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012322/ [Accessed 18 June 2019] </ref> Cervical osteoarthritis can also be referred to as [[Cervical Spondylosis|cervical spondylosis]].<br>
 
[[File:MRI of the Cervical Spine showing degenerative changes.jpg|center|Cervical spine MRI showing degenerative disc disease, osteophytes, and osteoarthritis of C5-C6|thumb]]
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Definition COA.jpg]]<br>
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;
 
<br>
 
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


For a overview of the components which form the cervical spine, reference is made to the following Physiopedia page: http://www.physiopedia.com/Category:Cervical_Anatomy
There is a 'three joint complex' at every spinal level except C1–C2. This motion segment is formed by the three articulations between adjacent vertebrae. These three articulations consist of one disc and two facet joints. The superior articular processes of the lower vertebra are positioned upwards and will articulate with the smaller inferior articular processes of the vertebra above it. The cervical facet articular surface area is about two-thirds the size of the area of the vertebral endplate. The facet joint has features typical of a synovial joint: articular cartilage covers the opposed surfaces of each of the facets, resting on a thickened layer of subchondral bone, and a synovial membrane covers this portion of the joint.  A superior and inferior capsular pouch, filled with fat, is formed at the poles of the joint, and a baggy fibrous joint capsule covers the joint like a hood. A fibro-adipose meniscus projects into the superior and inferior aspect of the joint and consists of a fold of synovium that encloses fat, collagen, and blood vessels. The menisci serve to increase the contact surface area when the facets are brought into contact with one another during motion, and slide during flexion of the joint to cover articular surfaces exposed by this movement.<ref name="gellhorn" />


Focusing on the cervical spine components that are affected by osteoarthritis, the following components should be taken into account:
The cervical spine components that are affected by osteoarthritis are;


*&nbsp;Articular cartilage <ref name="musumeci" />&nbsp;<ref name="boucher">Boucher P. Postural control in people with osteoarthritis of the cervical spine. Journal of Manipulative and Physiological Therapeutics 2008; 31(3): 184-190 (Level Of Evidence: 1B)</ref>: At first fibrillation and shallow pitting occur, which initially affect the surface of the cartilage focally. At a more progressed stage, this can evolve to deeper fibrillation and fissuring, peeling off and pitting until the subchondral bone is affected.&nbsp;<ref name="gellhorn" />  
*'''Articular cartilage.''' <ref name="musumeci" />&nbsp;Initially fibrillation and shallow pitting occur, which affects the surface of the cartilage focally at first. At a more progressed stage, this can evolve to deeper fibrillation and fissuring, peeling off and pitting until the subchondral bone is affected.&nbsp;<ref name="gellhorn" />  
*&nbsp;Synovium<ref name="musumeci" />  
*'''Synovium'''<ref name="musumeci" />  
*&nbsp;Articulatio uncovertebralis ): Osteophytes are formed on the articular surfaces of the uncinate process. These osteophytes can impinge anatomical structures like the cervical spinal cord, spinal nerve root, radicular artery, vertebral artery and cervical sympathetic trunk.<ref name="hartman">Hartman J, Anatomy and Clinical Significance of the Uncinate Process and Uncovertebral Joint: A Comprehensive Review. Clinical Anatomy 2014; 27: 431-440 (Level of Evidence: 2C)</ref>  
*'''Uncovertebral joints.''' Osteophytes are formed on the articular surfaces of the uncinate process. These osteophytes can impinge anatomical structures like the cervical spinal cord, spinal nerve root, radicular artery, vertebral artery and cervical sympathetic trunk.
*&nbsp;Facet joints (Figure 2): they are inclinated 45° from horizontal. The joint surfaces are generally planar, but not flat.<ref name="gellhorn" /><br>
*'''Facet joints.''' They are inclined 45° from the horizontal. The joint surfaces are generally planar, but not flat.<ref name="gellhorn" />  
*'''Intervertebral discs.''' Between C0–C1 and C1-C2 there is no intervertebral discs. Major factors in the development and progression of osteoarthritis of the facet joints are joint alignment and load distribution.<ref name="gellhorn" />  
*'''Cervical plexus.''' Osteophyte formation or progressive cartilage thinning may narrow the intervertebral foramen through which the cervical nerve roots emerge.<ref name="gellhorn" />&nbsp;<ref name="rand">Rand RW, Crandall PH. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1577768/ Surgical treatment of cervical osteoarthritis]. ''California medicine''. 1959 Oct;91(4):185. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1577768/ [Accessed 18 June 2019]  </ref>
*'''Intervertebral ligaments'''.<br><br>
[[File:Cervical vertebrae animation.gif|center|thumb|Anatomy of Cervical vertebrae animation]]
&nbsp;


*&nbsp;Discus intervertebralis: between C0–C1 and C1-C2 there is no discus intervertebralis. Major factors in the development and progression of osteoarthritis of the facet joints are Joint alignment and load distribution.<ref name="gellhorn" /><br>
== Epidemiology/Etiology  ==


*&nbsp;Cervical plexus: Osteophyte formation or progressive cartilage thinning may narrow the foramina intervertebrale through which the cervical nerve roots emerge.<ref name="gellhorn" />&nbsp;<ref name="rand">Rand RW, Crandall PH. Surgical Treatment of Cervical Osteoarthritis. Calif Med 1959; 91(4): 185-188 (Level of Evidence: 2C)</ref>
Cervical osteoarthritis may be generalised, sometimes involving the entire cervical region, but it is usually more localised between the 5th and 6th and the 6th and 7th cervical vertebrae.
*&nbsp;Intervertebral ligaments.<ref name="sutbeyaz" />


We speak off a “three-joint complex” at every spinal level except C1–C2. This motion segment, is formed by the three articulations between adjacent vertebrae. These three articulations consist of one disc and two facet joints. The superior articular processes of the lower vertebra is positioned upwards and will articulate with the smaller inferior articular processes of the vertebra above it. The cervical facet articular surface area is about two-thirds the size of the area of the vertebral end plate. The facet joint exhibits features typical of synovial joints: articular cartilage covers the opposed surfaces of each of the facets, resting on a thickened layer of subchondral bone, and a synovial membrane bridges the margins of the cartilaginous portions of the joint. A superior and inferior capsular pouch, filled with fat, is formed at the poles of the joint, and a baggy fibrous joint capsule covers the joint like a hood. A fibro adipose menisci projects into the superior and inferior aspect of the joint and consists of a fold of synovium that encloses fat, collagen, and blood vessels. These menisci’s serve to increase the contact surface area when the facets are brought into contact with one another during motion, and slide during flexion of the joint to cover articular surfaces exposed by this movement.&nbsp;<ref name="alfred">Alfred C. Gellhorn et al., Osteoarthritis of the spine: the facet joints, Nat Rev Rheumatol. 2013 April ; 9(4): 216–224 (Level of evidence 2A)</ref><br><br>  
Anyone can develop cervical osteoarthritis, but it is rare in people younger than 40-50 years, the incidence increasing with age, women having a higher risk for cervical OA than men.<ref>Srikanth VK, Fryer JL, Zhai G, Winzenberg TM, Hosmer D, Jones G. [https://www.sciencedirect.com/science/article/pii/S1063458405001123 A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis]. ''Osteoarthritis and cartilage''. 2005 Sep 1;13(9):769-81. Available from: https://www.sciencedirect.com/science/article/pii/S1063458405001123 [Accessed 19 June 2019]</ref> It is common in people above the age of 50 and especially if those people who have had jobs that included remaining in a single static position for long periods, i.e. reading, writing and other desk-based careers.<ref>Plotnikoff R, Karunamuni N, Lytvyak E, Penfold C, Schopflocher D, Imayama I, Johnson ST, Raine K. [https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2529-0 Osteoarthritis prevalence and modifiable factors: a population study]. ''BMC Public Health''. 2015 Dec;15(1):1195. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2529-0 [Accessed 19 June 2019]</ref>  


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Clinically Relevant Anatomy COA.jpg|500px]]<br>
Cervical OA can have many causes such as mechanically over-stressing of a joint (e.g. working with tools which generate intense vibration), previous bone fractures or other injuries to the neck, overload at a young age, postural asymmetry or asymmetric loading of a joint.  
 
== Epidemiology/Etiology  ==


Cervical osteoarthritis may be generalized, sometimes involving the entire cervical region, but it is usually more localized between the fifth and sixth and sixth and seventh cervical vertebrae.<br>Everyone can have cervical osteoarthritis but it is rare in people younger than 40-50 years, the incidence increases with age .<ref name="walker">Walker JA, Osteoarthritis: pathogenesis, clinical features and management. Nursing Standard 2009, Vol. 24, Nr. 1, 35-40. (Level of evidence 1A)</ref>&nbsp;<ref name="boucher" />&nbsp;Also women have a higher risk for cervical OA than men.<ref name="walker" />&nbsp;<ref name="michael" /> It is rather common in people above the age of 50 and especially if those people had jobs that included staying in one position during a long period of time e.g. reading, writing and other table works. <br>The occurrence of cervical OA can have many causes. E.g. mechanically overstressing a joint (e.g. working with tools that generate intense vibration), past bone fractures or other injuries to the neck, overload at young age, posture asymmetry or asymmetric loading of a joint,… . A relation has been shown between the severity of the complaints of cervical osteoarthritis and a higher body weight of the patient.<ref name="hartz" /><br>Facet joint osteoarthritis (FJ OA) is intimately linked to the distinct but functionally related condition of degenerative disc disease, which affects structures in the anterior aspect of the vertebral column. FJ OA and degenerative disc disease are both thought to be common causes of back and neck pain, which in turn have an enormous impact on the health-care systems and economies of developed countries.&nbsp;<ref name="alfred" /><br><br>
Facet joint osteoarthritis (FJOA) is intimately linked to the distinct but functionally related condition of degenerative disc disease, which affects structures in the anterior aspect of the vertebral column. FJOA and [[Degenerative Disc Disease|degenerative disc disease]] are both thought to be common causes of back and neck pain, which in turn have an enormous impact on the health-care systems and economies.<ref name="gellhorn" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


OA is characterised by pain, stiffness, crepitus, limited range of movement and sometimes also joint instability and mild synovitis <ref name="grob">Grob D. et al., Transarticular screw fixation for osteoarthritis of the atlanto-axial segment, Eur spine journal 2006 Mar; 15(3):283:91 (Level of evidence: 3B)</ref>&nbsp;<ref name="arno">Arno Bisschop, Which factors prognosticate spinal instability following lumbar laminectomy?,Eur Spine J. 2012 Dec; 21(12): 2640–2648. (Level of evidence 2B)</ref>&nbsp;<ref name="singh">Singh J.A. et al., Chondroitin for osteoarthritis, 2015, Cochrane review. (Level of evidence: 1A)</ref>&nbsp;The pain is usually localized around the affected joint , but at the level of the spine referred pain may occur. For the cervical spine, pain associated with FJ OA can arise from nociceptors within and surrounding the joints, including nociceptors in the bone itself. The facet joints and their capsules are well innervated <ref name="cibulka">Cibulka M.T. et al., Hip pain and mobility deficits - hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability and health from orthopaedic section of the American Physical Therapy Association, J Orthop Sports Phys Ther, 39 (2009), pp A1-25 (Level of evidence 1A)</ref>. The pain radiates to the occiput, the medial border of the scapula and the upper limbs <ref name="mqic">MQIC, Medical management of adults with osteoarthritis, Michigan Quality Improvement Consortium (2011) (Level of evidence 5)</ref>. Pain often worsens with joint use and is more severe at the end of the day. If there is morning stiffness, it usually lasts less than 30 minutes <ref name="peter">Peter W.F. et al., Physiotherapy in hip and knee osteoarthritis: development of practice guideline concerning initial assessment, treatment and evaluation, Acta Reumatol Port, 36 (2011), pp 268-281. (Level of evidence 5)</ref>. Restricted movement can occur due to pain, capsular thickening and the presence of osteophytes <ref name="peter" />.
OA is characterised by pain, stiffness, crepitus, limited range of movement and sometimes joint instability and mild synovitis. The pain is usually localised around the affected joint, but referred pain may occur. Pain associated with FJOA can arise from nociceptors within and surrounding the joints, including nociceptors in the bone itself, as the facet joints and their capsules are well innervated. Pain can radiate to the occiput, the medial border of the scapula and the upper limbs. Pain often becomes worse with joint movement and can be more severe at the end of the day. Morning stiffness can be a common feature but usually dissipates with movement. Restricted movement can occur due to pain, capsular thickening and the presence of osteophytes.<ref>Hunter DJ, McDougall JJ, Keefe FJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597216/ The symptoms of osteoarthritis and the genesis of pain]. ''Rheumatic Disease Clinics of North America''. 2008 Aug 1;34(3):623-43. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597216/ [Accessed 19 June 2019] </ref>  


Pressure symptoms in the cervical spine are caused by Osteoarthritis of the uncovertebral joints. Osteophytes can form around the intevertbral joints and cause neurological symptoms due to compression of the spinal nerves <ref name="loew">Loew L. et al, Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis, Arch Phys Med Rehabil, 93 (2012), pp 1269-1285. (Level of evidence 2A)</ref>. Narrowing of the spinal canal can also cause circulation problems. Performing an MRI can be useful to confirm the presence of compression of the spinal cord.  
Osteophytes can form around the intervertebral joints and cause neurological symptoms due to compression of the spinal nerves ([[Cervical Radiculopathy|Cervical Radiculopathy]]). Narrowing of the spinal canal ([[Cervical Stenosis]]) can also cause compression on the spinal cord and circulation problems from compression of vascular structures. Performing an MRI can be useful to confirm the presence of any spinal cord compression ([[Cervical Myelopathy]]).  


Prolonged peripheral inflammation in and around facet joints can lead to central sensitization, neuronal plasticity, and the development of chronic spinal pain <ref name="hulme">Hulme J. et al., Electromagnetic fields for the treatment of osteoarthritis., Hulme J1, Robinson V, Cochrane Database Syst Rev. 2002;(1):CD003523. (Level of evidence: 1A)</ref>. The therapist must remain alert to several key characters, also called red flags, as this may indicate a more serious problem <ref name="manheimer">Manheimer E. et al., Acupuncture for osteoarthritis, 2010, Cochrane review. (Level of evidence: 1A)</ref>:
Awareness of potential [[Red Flags in Spinal Conditions|red flags]] is essential, which may indicate a more serious issue:<ref name="binder" />


*Malignancy, infection, or inflammation  
*Malignancy, infection, or inflammation  
Line 52: Line 47:
*Cervical lymphadenopathy  
*Cervical lymphadenopathy  
*Exquisite tenderness over a vertebral body  
*Exquisite tenderness over a vertebral body  
*Myelopathy
*Gait disturbance or clumsy hands, or both  
*Gait disturbance or clumsy hands, or both  
*Objective neurological deficit  
*Objective neurological deficit  
Line 59: Line 53:
*Drop attacks, especially when moving the neck, suggest vascular disease  
*Drop attacks, especially when moving the neck, suggest vascular disease  
*Intractable or increasing pain&nbsp; &nbsp;
*Intractable or increasing pain&nbsp; &nbsp;
Prolonged peripheral inflammation in and around facet joints can lead to central sensitisation, neuronal plasticity, and the development of chronic spinal pain.


[http://www.spine-health.com/video/cervical-facet-osteoarthritis-video http://www.spine-health.com/video/cervical-facet-osteoarthritis-video]<br>
== Differential Diagnosis ==
 
There are other conditions to consider before making a diagnosis:<ref name="binder" />
== Differential Diagnosis &nbsp;<ref name="rutjes">Rutjes A. W. S. et al., Therapeutic ultrasound for osteoarthritis, 2010, Cochrane review. (Level of evidence: 1A)</ref>&nbsp;<ref name="marley">Marley J; et al. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain, Syst Rev. 2014 Sep 19; 3:106) (Level of evidence: 1A)</ref><br>  ==
 
*Other non-specific neck pain lesions: acute neck strain, postural neck ache, or [[Whiplash Associated Disorders|whiplash]]  
*Other non-specific neck pain lesions: acute neck strain, postural neck ache, or [[Whiplash Associated Disorders|whiplash]]  
*[[Fibromyalgia|Fibromyalgia]] and psychogenic neck pain  
*[[Fibromyalgia|Fibromyalgia]] and psychogenic neck pain  
*Mechanical lesions: disc prolapse  
*Mechanical lesions: disc prolapse  
*[[Forestier Disease|Diffuse idiopathic skeletal hyperostosis]] &nbsp;  
*[[Forestier Disease|Diffuse idiopathic skeletal hyperostosis]] &nbsp;  
*Inflammatory disease: [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Ankylosing Spondylitis|ankylosing spondylitis]], [[Polymyalgia Rheumatica|polymyalgia rheumatica]], psoriatric arthritis, [[Septic Arthritis|septic arthritis]], [[Reactive Arthritis|reactive arthritis]]  
*Inflammatory disease: [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Ankylosing Spondylitis (Axial Spondyloarthritis)|ankylosing spondylitis]], [[Polymyalgia Rheumatica|polymyalgia rheumatica]], psoriatric arthritis, [[Septic (Infectious) Arthritis|septic arthritis]], [[Reactive Arthritis|reactive arthritis]]  
*Metabolic diseases: [[Paget's Disease|Paget’s disease]], [[Osteoporosis|osteoporosis]], [[Gout|gout]], or pseudo-gout  
*Metabolic diseases: [[Paget's Disease|Paget’s disease]], [[Osteoporosis|osteoporosis]], [[Gout|gout]], or pseudo-gout  
*[[Osteomyelitis|Osteomyelitis]] or [[Tuberculosis|tuberculosis]]  
*[[Osteomyelitis|Osteomyelitis]] or [[Tuberculosis|tuberculosis]]  
*Malignancy: primary tumors, secondary deposits, or myeloma&nbsp;&nbsp; &nbsp;<br>
*Malignancy: primary tumous, secondary deposits, or myeloma&nbsp;&nbsp; &nbsp;


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


The diagnosis is usually based on the clinical presentation <ref name="mike">Mike Murray et al. Specific exercise training for reducing neck and shoulder pain among military helicopter pilots and crew members: a randomized controlled trial protocol, BMC Musculoskelet Disord. 2015; 16: 198. (Level of evidence: 1B)</ref>&nbsp;<ref name="musumeci" /><br>
A diagnosis is usually based on the clinical presentation.<ref name=":0">Zhang Y, Jordan JM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920533/ Epidemiology of osteoarthritis]. ''Clinics in geriatric medicine''. 2010 Aug 1;26(3):355-69. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920533/ [Accessed 19 June 2019]</ref>
 
* Pain on range of motion
• Pain on range of motion<br>• Limitation of range of motion<br>• Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement<br>• Pseudoclaudication caused by [http://www.physio-pedia.com/Spinal_Stenosis spinal stenosis]<br>
* Limitation of range of motion
 
* Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
Radiology can also be used to determine OA, but one must take into account that people with radiological signs can remain asymptomatic <ref name="musumeci" />. Kellgren and Lawrence developed a grading system for the radiological appearance of a joint with osteoarthritis <ref name="sutbeyaz" />.&nbsp;  
* Pseudoclaudication caused by [http://www.physio-pedia.com/Spinal_Stenosis spinal stenosis]
Radiology can also be used to determine OA however, some individuals with radiological signs can remain asymptomatic.<ref name=":0" /> ''Kellgren and Lawrence'' developed a grading system for the radiological appearance of a joint with osteoarthritis.<ref>Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. ''Clinical Orthopaedics and Related Research.'' 2016. 474: 1886. ''A''vailable from: https://link.springer.com/article/10.1007/s11999-016-4732-4 [Accessed 19 June 2019] </ref> If more than one joint in a group is assessed, then the most severe grade is reported:&nbsp;  


{| width="800" border="1" cellspacing="1" cellpadding="1"
{| width="800" border="1" cellspacing="1" cellpadding="1"
Line 85: Line 79:
! scope="col" | Radiological appearance of osteoarthritis  
! scope="col" | Radiological appearance of osteoarthritis  
! scope="col" | Grade
! scope="col" | Grade
!Parameters
|-
|-
| normal (no signs of osteoarthritis)  
| normal (no signs of osteoarthritis)  
| 0
| 0
|
|-
|-
| doubtful change (uncertain)  
| doubtful change (uncertain)  
| 1
| 1
|osteophytes at the joint margins and periarticular ossicles
|-
|-
| definite, minimal to mild  
| definite, minimal to mild  
| 2
| 2
|narrowing of the joint space
|-
|-
| definite, moderate  
| definite, moderate  
| 3
| 3
|cystic areas with sclerotic walls in subchondral bone
|-
|-
| definite, severe  
| definite, severe  
| 4
| 4
|deformity of bone (altered shape)
|}
|}
If more than one joint in a group is assessed, then the most severe grade is reported.<br> Parameters:
#osteophytes at the joint margins and periarticular ossicles
#narrowing of the joint space
#cystic areas with sclerotic walls in subchondral bone
#deformity of bone (altered shape)
== Outcome Measures  ==
== Outcome Measures  ==


Functional status and disability measure (evaluation of the activities of daily living) can be assessed by the “Neck Pain and Disability Scale” (NPAD) and the “Neck disability index (NDI)”.<ref name="binder">Binder A, Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-531 (Level of evidence 1A)</ref>
Functional status and disability measure (evaluation of the activities of daily living) can be assessed by the [[Neck Pain and Disability Scale]] (NPAD) and the [[Neck Disability Index|Neck disability index]] (NDI).<ref>MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, Mcalpine C, Goldsmith CH. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.2930 Measurement properties of the neck disability index: a systematic review]. ''Journal of orthopaedic & sports physical therapy.'' 2009 May;39(5):400-17. Available from: https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.2930 [Accessed 19 June 2019] </ref>
 
#The Neck pain and disability scale (NPAD) is a composite index including 20 items, which measure the intensity of neck pain, its interference with vocational, recreational, social, and functional aspects of living and also the presence and extent of associated emotional factors.  
#The Neck disability index (NDI) is a patient-completed and condition-specific functional status questionnaire. This questionnaire consists of 10 items, including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. This questionnaire has been designed to give information as to how neck pain has affected the patient’s ability to manage in daily life.


The NPAD and NDI are both seen as valid measures of self-reported neck pain related disabilities.<ref name="binder" />
*The Neck pain and disability scale (NPAD) is a composite index including 20 items, which measure the intensity of neck pain, its interference with vocational, recreational, social, and functional aspects of living and also the presence and extent of associated emotional factors.
*The Neck disability index (NDI) is a patient completed and condition-specific functional status questionnaire. This questionnaire consists of 10 items, including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. This questionnaire has been designed to give information as to how neck pain has affected the patient’s ability to manage in daily life.


&nbsp; &nbsp;
The NPAD and NDI are both seen as valid measures of self-reported neck pain related disabilities.&nbsp; &nbsp;


== Examination  ==
== Examination  ==


Because osteoarthritis is primarily a clinical diagnosis, physicians can confidently make the diagnosis based on the history and physical examination. Most patients with osteoarthritis of the neck will complain about joint pain in this area. The pain tends to worsen with activity, especially following a period of rest (gelling phenomenon). Besides pain on range of motion patients will have a limited range of motion.<ref name="sinusas">Sinusas K., Osteoarthritis: diagnosis and treatment, Am Fam Physician, 2012 Jan 1;85(1):49-56. (Level of evidence 2A)</ref>  
As osteoarthritis is primarily a clinical diagnosis, patient history and the physical examination is usually sufficient to make a confident diagnosis. Joint pain and limited range of motion are usual symptoms in patients with cervical osteoarthritis. The pain tends to worsen with activity, especially following a period of rest (gelling phenomenon). <ref name="sinusas">Sinusas K. [https://pdfs.semanticscholar.org/eea7/a33ce41435e52c0b1e4a25a3b375ffa97a6e.pdf Osteoarthritis: diagnosis and treatment.] ''American family physician''. 2012 Jan 1;85(1). Available from: https://pdfs.semanticscholar.org/eea7/a33ce41435e52c0b1e4a25a3b375ffa97a6e.pdf [Accessed 19 June 2019]  </ref>  


Electromyographic analysis shows a higher fatigue of the anterior and posterior neck muscles compared with healthy subjects.<ref name="gogia">Gogia et al.; Electromyograhic Analysis of Neck Muscle Fatigue in Patients With Osteoarthritis of the Cervical Spine. Cervical Spine/Basic Science march 1994 (Level of evidence: 2B)</ref><br>Physical examination includes:<ref name="gellhorn" />
Physical examination follows a normal [[Cervical Examination|cervical examination]] and includes:<ref name="gellhorn" />


*Inspection: posture, edema, erythema, evidence of trauma, muscle atrophy, skin abnormalities and joint deformity.
*Inspection: posture, oedema, erythema, evidence of trauma, muscle atrophy, skin abnormalities and joint deformity.
*Palpation of facet joints, examining of anatomic abnormality, temperature and tenderness.&nbsp;
*Palpation of facet joints, examining of anatomic abnormality, temperature and tenderness.&nbsp;
*Range of motion of the cervical region and shoulder region.
*Range of motion of the cervical region and shoulder region.
*Stress facet joints: pain increases with hyperextension, extension-rotation (3D) of the neck. Pain decreases while doing flexion of the neck.&nbsp;
*Stress of the facet joints: pain increases with hyperextension, extension-rotation of the neck. Pain decreases while doing flexion of the neck.&nbsp;
*Motor- and sensory evaluation: L’Hermitte sign: sense of feeling electrical shocks in both arms or legs while performing neck flexion.&nbsp;
*Neurological evaluation: motor and sensory evaluation of sensation, reflexes and muscle strength.  Other special tests may be indicated: L’hermitte sign, Hoffman's test, Babinski.&nbsp;
*Muscle testing: searching myofascial triggerpoints in the m. sternocleidomastoideus, cervical paraspinal muscles, m. levator scapulae, the upper trapezius and suboccipital musculature.&nbsp;<br><br>
*Muscle testing: searching for myofascial trigger points in the sternocleidomastoid, cervical paraspinal muscles, levator scapulae, the upper trapezius and suboccipital musculature.&nbsp;


== Medical Management  ==
== Medical Management  ==
The following medical management strategies are only indicated when all other conservative treatment has failed.


=== <u>Surgical treatment</u>  ===
=== Intra-articular Injections ===
 
Intra-articular corticosteroids are recommended for hip and knee osteoarthritis. The effects of corticosteroids on cervical osteoarthritis need to be researched.<ref name="sinusas" />
There are indications that excision and fusion of the anterior cervical intervertebral disc (Cloward operation) together with the removal of associated arthritic bone spurs pressing on the nerves and spinal cord can give relief of pain and muscle weakness in patients who have cervical osteoarthritis with neurologic pain <ref name="robert">Robert W. Rand and Paul H. Crandall, Surgical treatment of cervical osteoarthritis, Calif Med. 1959 Oct; 91(4): 185–188.</ref>.
 
=== <u>Transarticular screw fixation</u>  ===
 
Patients with atlantoaxial (C1-C2) facet joint osteoarthritis have a positive reaction on pain after the fusion of these two facet joints. This treatment has a relative low rate of serious complications <ref name="grob" />.
 
<u></u>
 
=== <u>Laminoplasty</u>  ===
 
Laminoplasty is used to decompress the cervical spinal cord. A risk of this surgical treatment is a reduced strength and shear stiffness (SS) of motion segments. As a result of this, the patient can suffer from instability. Also a great part of the patients had neck pain after the surgical the method of Kuang-Ting Yeh choses laminoplasty instead of laminectomy as a decompression method in posterior instrumented fusion for degenerative cervical kyphosis with stenosis <ref name="arno" />. In short-terms there are some benefits from chondroitin (alone or in combination with glucosamine). Benefits are small to moderate but clinically meaningful <ref name="singh" />.


Intra-articular corticosteroids are recommended for hip and knee osteoarthritis. The effects of corticosteroids on cervical osteoarthritis need to be researched <ref name="cibulka" /> <ref name="mqic" /> <ref name="peter" /> <ref name="loew" />.
=== Surgical Treatment  ===


<br>
There are indications that excision and fusion of the anterior cervical intervertebral disc (Cloward operation) together with the removal of associated arthritic bone spurs pressing on the nerves and spinal cord can give relief of pain and muscle weakness in patients who have cervical osteoarthritis with neurologic pain.<ref name="sinusas" /><u></u>
=== Pharmacology ===
In the short-term, some benefit may be gained from using chondroitin (alone or in combination with glucosamine). Other options can be acetaminophen, NSAIDS or opoids.<ref name="sinusas" />


== Physical Therapy Management<br> ==
== Physical Therapy Management  ==


The main goals of management for cervical OA are:&nbsp;<ref name="walker" />
The main goals of management for cervical OA are:&nbsp;


*reducing pain and stiffness  
*reducing pain and stiffness  
*improving joint mobility  
*improving joint mobility  
*inhibiting further progression of joint damage
*inhibiting any further progression of joint damage


The treatment for cervical osteoarthritis is usually conservative and it can be treated using a variety of therapy possibility. <br>Another important part of the management of OA is exercise therapy. The exercise program should aim at mobilization exercises, strengthening local muscles around the affected joint and improving overall aerobic fitness. <ref name="walker" />&nbsp;<ref name="binder" />&nbsp;<ref name="sutbeyaz" /><br>There is considerable evidence that states that physical activity can help in in the management of chronic pain that is the direct cause of osteoarthritis. Physical activity should play a key role in the therapy. This will improve the disability over time and also reduce pain. Improving the patient physical level will also have multiple other health benefits.<br>Patients with chronic pain will have difficulties with the therapy but small changes in the beginning can also have great effect on the outcome.<br>The possibilities for therapy are:
=== Advice and Education  ===
Providing information related to the disorder, stress management and postural advice in daily activities, work and hobbies should also be part of any treatment plan.<ref name="binder">Binder AI. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819511/ Cervical spondylosis and neck pain]. ''Bmj''. 2007 Mar 8;334(7592):527-31. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819511/ [Accessed 19 June 2019]  </ref> Providing encouragement and motivation where necessary is also a key component.<ref name="cibulka">Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ. [https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.0301 Hip pain and mobility deficits—hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association]. ''Journal of Orthopaedic & Sports Physical Therapy''. 2009 Apr;39(4):A1-25. Available from: https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.0301 [Accessed: 18 June 2019] </ref>  


=== '''Heat and cold modalities&nbsp;''' ===
Advice and education regarding good neck posture is a key part of treatment as the condition progresses,  as neck posture can negatively affect any patient. Sleeping advice is that side lying is the preferred position and  a single pillow only under the head is recommended, although a butterfly pillow offers the best support, as it is flattened in the middle and the elevated sides support the head.  


Various physiotherapy modalities can be used to reduce pain. Even though there is a lack of evidence for the application of local heat or cold, it is often used by patients with OA to decrease pain.  
=== Exercise Therapy  ===
Treatment for cervical osteoarthritis is usually conservative and it can be treated using a variety of therapy possibilities with [[Manual Therapy and Exercise for Neck Pain: Clinical Treatment Tool-kit|exercise therapy]] being a key element. Exercise includes mobilisation exercises, strengthening of local muscles around the affected joint and improving overall aerobic fitness<ref name="binder" /><ref name="cibulka" /> There is considerable evidence that suggests physical activity can help in the management of chronic pain and should play a key role in the overall treatment plan. This will improve the disability over time and has other multiple health benefits.  
* Proprioceptive exercises


=== '''Manual therapy'''  ===
* Stabilisation exercises


Manual therapy, such as massage, mobilization, and manipulation, may provide further relief for patients with cervical osteoarthritis. Mobilization is characterized by the application of gentle pressure within or at the limits of normal motion. It is important not to cross the pain limit of the patient. The goal of this mobilization is to increase the range of motion of the neck. Patients reported preferring manual traction performed by a physiotherapist instead of mechanical traction. Sometimes manipulation can be considered. The intention of manipulation is to increase articular mobility or to realign the spine. Contraindications to manipulative therapy, such as myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability and vertebrobasilar insufficiency have to be taken into consideration.&nbsp;<ref name="almeida">Almeida GP, Carneiro KK, Marques AP. Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a comprehensive review. J Bodyw Mov Ther. 2013 Oct;17(4):504-9. (Level of Evidence: 2C)</ref>
* Stretching exercises


=== '''Pulsed electric stimulation'''  ===
=== Manual Therapy ===
[[Manual Therapy and Exercise for Neck Pain: Clinical Treatment Tool-kit|Manual therapy]] such as massage, mobilisation, and manipulation may provide further relief for patients with cervical osteoarthritis<ref name="cibulka" />. Mobilisation is characterised by the application of gentle pressure within or at the limits of normal motion to improve ROM.


Pulsed electric stimulation as a treatment for osteoarthritis, is a promising treatment because it has shown the stimulation of cartilage growth at the cellular level. On the other end there is an urgent need for further large-scale studies of pulsed electric stimulation to confirm these finding for purposes concerning the medical sector.<ref name="hulme" /> There is also research into new methods to use in the treatment of OA to reduce pain. It is thought that magnetic therapy represents an alternative therapy for patients suffering from cervical OA. Electromagnetic fields can be applied to treat cervical OA and are thought to have a pain-relief effect, but further studies are needed. <ref name="sutbeyaz" />&nbsp;<ref name="david">David H. Trock, Alfred Jay Bollet and Richard Markoll; The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, Double blind, placebo controlled trial ; J Rheumatol 1994 (level of evidence 1B)</ref><br>With current evidence at our disposal we can suggests that electrical stimulation therapy may provide significant improvements for osteoarthritis , but in addition they recommend that further studies are undertaken.<ref name="hulme" />
Manipulation may be considered, but there are numerous contraindications, such as myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability and vertebrobasilar insufficiency which have to be taken into consideration.


=== '''Hydrotherapy''' ===
=== Heat and cold modalities&nbsp; ===
It is recommended that when application of superficial heat or cold is considered in the management of OA that patients experiment to identify the intervention that offers them the greatest relief.<ref>Denegar CR, Dougherty DR, Friedman JE, Schimizzi ME, Clark JE, Comstock BA, Kraemer WJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920200/ Preferences for heat, cold, or contrast in patients with knee osteoarthritis affect treatment response]. ''Clinical interventions in aging''. 2010;5:199. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920200/ [Accessed 19 June 2019] </ref>


A study showed that underwater tractions of the cervical spine during weightbath therapy can be effective. The following parameters were improved by hydrotherapy: it mitigates the pain, increases the range of motion and improves the quality of life. The patient hangs in a construction that is made of steel and the patient’s head is supported by a collar which gives the traction. The water of the bath comes at the height of the chin. As a result the water carries most of the body weight so the traction force is acceptable.&nbsp;<ref name="mihaly">Mihaly Olah, Levente Molnar, Jozsef Dobai ;The effects of weightbath traction hydrotherapy as e component of complex physical therapy in disorders of the cervical and lumbar spine: a controlled pilot study with follow up;  12 January 2008 (level of evidence: 3B)</ref>&nbsp;<ref name="marta">Márta Kurutz and Tamás Bender ; Weightbath hydrotraction treatment: application, biomechanics, and clinical effects ; Journal of multidisciplinary Healthcare ; April 2010 (Level of evidence: 5)</ref>
=== Hydrotherapy  ===
It has been shown that hydrotherapy can give some relief to patients struggling with pain and OA. However, the research is poor and points to mostly short term effects.<ref name="cibulka" />


=== '''Acupuncture''' ===
=== Acupuncture  ===
The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. Evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis.<ref>Manyanga T, Froese M, Zarychanski R, Abou-Setta A, Friesen C, Tennenhouse M, Shay BL. [https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-14-312 Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis]. ''BMC'' complementary and alternative medicine. 2014 Dec;14(1):312. Available from: https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-14-312 [Accessed: 19 June 2019] </ref>


*The studies about acupuncture and osteoarthritis show small significant benefits which didn’t meet the pre-defined thresholds for clinical relevance. Most of the benefits are at least partially placebo effect. This has to be considered when choosing this option for the treatment.<ref name="manheimer" />&nbsp;
=== Electrotherapy  ===
*Another study has shown that the depth of the needle indicates a difference in long-term results. The results show that the deep insertion acupuncture is more effective than superficial acupuncture in patients with neck-shoulder pain. In the deep acupuncture group the needle was inserted to a depth of 15-20 millimeter while in the superficial group the needle was inserted to a depth of 5 millimeter.<ref name="nakajima">Nakajima et al., Difference in Clinical Effect between Deep and Superficial Acupuncture Needle Insertion for Neck-shoulder Pain: a Randomized Controlled Clinical Trial Pilot Study, January, 23, 2015 (Level of evidence : 1B)</ref>


=== '''Postural awareness''' ===
==== Ultrasound ====


As the condition progresses, the abnormality of posture also increases, thus from the initial stage itself, postural awareness through proper advice and education should be planned and initiated by the physiotherapist. The ideal posture is straight neck with chin tucked in and back straight with no compensatory actions or any trick movements. <br>While sleeping, side lying is the most preferred position, supine lying is also advised. A single pillow under the head for head support is allowed. A butterfly pillow is the best support for a patient suffering of cervical osteoarthritis, as it is flattened in the middle where the head rests and the elevated ends support the head on the sides.<ref name="kieran">Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton. Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis. Adv Orthop. 2012; 2012: 294857. (Level of evidence: 2B)</ref>
Ultrasound may be beneficial, but there is only low quality evidence for its effectiveness on osteoarthritis. Most studies, however, have investigated its effectiveness on hip and knee osteoarthritis. The magnitude of the effects on pain relief and function is still unclear and any positive results may wholly be due to placebo.<ref>Loyola-Sánchez A, Richardson J, MacIntyre NJ. [https://www.sciencedirect.com/science/article/pii/S1063458410002128 Efficacy of ultrasound therapy for the management of knee osteoarthritis: a systematic review with meta-analysis.] ''Osteoarthritis and Cartilage''. 2010 Sep 1;18(9):1117-26. Available from: https://www.sciencedirect.com/science/article/pii/S1063458410002128 [Accessed 19 June 2019] </ref>  


=== '''Ultrasound''' ===
==== TENS ====


Ultrasound may be beneficial but there is only low quality evidence about the effect of ultrasound on osteoarthritis. Most studies investigate whether it is effective for hip and knee osteoarthritis. Ultrasound may be effective, but the magnitude of the effects on pain relief and function is still unclear. It has to be considered that part of the effect may still be due to placebo.<ref name="rutjes" />
TENS can also provide symptomatic relief.<ref>Osiri M, Welch V, Brosseau L, Shea B, McGowan JL, Tugwell P, Wells GA. [http://www.oegpmr.at/wp-content/uploads/Beilage-7-Transcutaneous_electrical_nerve_stimulation.pdf Transcutaneous electrical nerve stimulation for knee osteoarthritis]. ''Cochrane Database of Systematic Reviews.'' 2000(4). Available from: http://www.oegpmr.at/wp-content/uploads/Beilage-7-Transcutaneous_electrical_nerve_stimulation.pdf [Accessed 19 June 2019] </ref>


=== '''Relaxation'''  ===
== References ==
 
<references />  
=== '''TENS'''  ===
 
TENS can also provide symptomatic relief.&nbsp;<ref name="walker" />&nbsp;<ref name="binder" />&nbsp;<ref name="sutbeyaz" />
 
=== '''Neck support'''  ===
 
Immobilisation of the neck can be done both with soft collars or with more rigid collars. The soft collars can give good results explained by the placebo effect because the collar does not restrict the movements of the neck at all. The rigid braces limit more the range of motion of the neck and as such, can reduce the tone of the muscle. <br>A negative effect of the use of collars can be that they cause stiffness of the neck. So it is important to combine the use of collars with exercises of the neck to counteract stiffness.<ref name="sandeep">Sandeep S Rana ; Diagnosis and Management of Cervical Spondylosis Treatment &amp; Management ;Augustus 2015 (level of evidence: 5)</ref>
 
=== '''Low-power Laser Therapy'''  ===
 
Several studies have shown the effectiveness of low laser therapy. The studies showed a pain reduction and an improvement of the functions of the neck. An RCT compared low laser therapy with a placebo treatment. The treatment group showed significant improvement on several parameters: pain, paravertebral muscle spasm, lordosis angle and range of motion of the neck.<ref name="f.">F. Özdemir, M. Britane and Kokino ; Department of Physical therpy and rehabilitation, Medical faculty of Trakya university ;The clinical efficacy of low-power laser therapy on pain and function in Cervical Osteoarthritis. ; Clinical Rheumatology , 2001 , Turkey (Level of evidence: 1B)</ref>&nbsp;<ref name="bjordal">Bjordal et al: A systematic review of low level laser therapy with location-specific doses for pain from joint disorders; Australian Journal of Physiotherapy 2003 Vol. 49, 107-116 (Level of evidence: 1A)</ref>&nbsp;<ref name="chow">Chow RT. et al; efficacy of low level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials; the lancet; nov 13,2009 (Level of evidence: 1A)</ref>
 
=== '''Encouragement and motivation&nbsp;<ref name="marley" />'''<br>  ===
 
=== '''Neck exercises'''<br>  ===
 
The treatment for cervical OA should also aim at providing information related to the disorder, stress management and postural advice in daily activities, work and hobbies.&nbsp;<ref name="binder" />
 
==== Resistance Band Exercises ====
 
Thera-band: 6 color-coded levels of resistance (red, green, blue, black, silver and gold)<br>A training program consisted of four training exercises for the prime movers of the neck during cervical flexion, extension and lateral flexion. Exercises were performed with a head harness (Neck Flex) using different color-coded elastic resistance bands (Thera-Band®). <br>During the exercises it is advised to maintain a proper posture:<br>• Keep a straight back<br>• Position their head in an anatomically neutral position<br>• Lean the trunk forward (~20-30°)<br>• Arms were held straight with the hands placed underneath the knees.
 
<u>'''Cervical flexion against resistance (Fig. 3)'''</u>
 
A Thera-Band is stretched between a door anchor and the back of the head harness. During the exercise, the participants have to perform a low cervical spine flexion (against resistance) followed by a low cervical spine extension.
 
<u>'''Cervical extension against resistance (Fig. 4)'''</u>
 
During neck extension, participants are positioned in the same way as during neck flexion, but the Thera-Band is stretched between the hands and front of the head harness. The exercise is performed with a low cervical spine flexion followed by a low cervical spine extension (against resistance)
 
<u>'''Lateral flexion against resistance (Fig. 5, 6)'''</u>
 
Lateral flexion is performed standing erect with the head in an anatomically neutral position. One hand has to be placed horizontally against a wall and a Thera-Band is stretched between the hand and side of the head harness. The exercise is performed with a low lateral spine flexion followed by a low lateral spine extension (against resistance). The exercise has to be performed for the right (Fig. 3, Exercise 5) and left side.<br><br>
 
<br>
 
[[Image:Physical Therapy Management COA.png]]<br>  


<br>  
<br>  


<u>'''Flexion and rotation against rotation (Fig. 7, 8)'''</u><br>This exercise can be introduced afterwards as a complementary part of the therapy. The exercise is performed seated with a straight back and trunk leaned forward (~20°). The head is held in an anatomically neutral position and rotated approximately 45° degrees to either the right or left side. A Thera-Band has to be stretched between the head harness and a door anchor.<br>Keeping a static upper body, the hips has to be flexed and the body also (against resistance) this is followed by an extension. The exercise has to be performed to the right and left side.&nbsp;<ref name="mike" />
[[Category:Osteoarthritis]]
 
[[Category:Interventions]]
==== Proprioceptive exercises  ====
[[Category:Cervical Spine - Conditions]]
 
Proprioceptive exercises can also be used in the therapy of cervical osteoarthritis. Some studies have shown a positive result in using proprioceptive exercises. <ref name="michael a">Michael A McCaskey et al.; Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review; BMC Musculoskeletal DisordersBMC series – open, inclusive and trusted201415:382 (level of evidence: 1A)</ref>&nbsp;<ref name="ar">A.R. Gross et al.; Exercises for mechanical neck disorders: A Cochrane review update; Manual Therapy 24 (2016) 25-45 (level of evidence: 1A)</ref>
 
<br>
 
==== Stabilization exercises  ====
 
Exercises with for example © Chattanooga stabilizer pressure biofeedback can help to train the deep cervical flexor muscles. Stabilization exercises have been proven to be effective for the reduction of pain in patients with cervical pain due to cervical osteoarthritis.<ref name="dusunceli">Dusunceli Yesim et al.; Efficacy of neck stabilization exercises for neck pain: A randomized controlled study; Journal of Rehabilitation Medicine, Volume 41, Number 8 ( level of evidence: 1B)</ref><br>
 
==== Stretching exercises  ====
 
A regular stretching exercise program performed for four weeks can decrease neck and shoulder pain and improve neck function and quality of life of people who suffer of cervical osteoarthritis.&nbsp;<ref name="tunwattanapong">Tunwattanapong P et al.; The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial. Clin Rehabil. 2016 Jan;30(1):64-72. (Level of evidence: 1B)</ref><br> <br><br><br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>feed://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1n1suG1n0N6Z_6TulHUQ34QMAPaRAVE5qVizAxqxuyAJ_LuMEJ|charset=UTF-8|short|max=10</rss></div>
 
== References  ==
 
<references />
 
<br>


[[Category:Osteoarthritis]] [[Category:Cervical_Spine]] [[Category:Musculoskeletal/Orthopaedics]]
[[Category:Conditions]]
[[Category:Cervical Spine]]
[[Category:Rheumatology]]

Latest revision as of 11:36, 15 November 2023

Original Editor - Bram Sorel Top Contributors - Lisa Pernet, Sheik Abdul Khadir, Nina Myburg, Kim Jackson, Rachael Lowe, Kenneth de Becker, Scott Cornish, Jason Coldwell, Admin, Bram Sorel, Evan Thomas, Simisola Ajeyalemi, Nicolas Casier, WikiSysop, Rucha Gadgil, Jess Bell and Olajumoke Ogunleye

Definition/Description[edit | edit source]

Osteoarthritis of the cervical spine may be defined as a degenerative disorder of C1-C7, complicated by inflammatory reactions. It is a very complex disease with multiple causes[1] which affects the intervertebral discs, vertebral bodies, intervertebral ligaments, the hyaline cartilage, the underlying bone, joint capsule and zygoapophyseal joints. It can lead to the formation of osteophytes or subchondral cysts and can cause hypertrophy of the articular process.[2] Cervical osteoarthritis can also be referred to as cervical spondylosis.

Cervical spine MRI showing degenerative disc disease, osteophytes, and osteoarthritis of C5-C6

                                            

Clinically Relevant Anatomy[edit | edit source]

There is a 'three joint complex' at every spinal level except C1–C2. This motion segment is formed by the three articulations between adjacent vertebrae. These three articulations consist of one disc and two facet joints. The superior articular processes of the lower vertebra are positioned upwards and will articulate with the smaller inferior articular processes of the vertebra above it. The cervical facet articular surface area is about two-thirds the size of the area of the vertebral endplate. The facet joint has features typical of a synovial joint: articular cartilage covers the opposed surfaces of each of the facets, resting on a thickened layer of subchondral bone, and a synovial membrane covers this portion of the joint. A superior and inferior capsular pouch, filled with fat, is formed at the poles of the joint, and a baggy fibrous joint capsule covers the joint like a hood. A fibro-adipose meniscus projects into the superior and inferior aspect of the joint and consists of a fold of synovium that encloses fat, collagen, and blood vessels. The menisci serve to increase the contact surface area when the facets are brought into contact with one another during motion, and slide during flexion of the joint to cover articular surfaces exposed by this movement.[2]

The cervical spine components that are affected by osteoarthritis are;

  • Articular cartilage. [1] Initially fibrillation and shallow pitting occur, which affects the surface of the cartilage focally at first. At a more progressed stage, this can evolve to deeper fibrillation and fissuring, peeling off and pitting until the subchondral bone is affected. [2]
  • Synovium[1]
  • Uncovertebral joints. Osteophytes are formed on the articular surfaces of the uncinate process. These osteophytes can impinge anatomical structures like the cervical spinal cord, spinal nerve root, radicular artery, vertebral artery and cervical sympathetic trunk.
  • Facet joints. They are inclined 45° from the horizontal. The joint surfaces are generally planar, but not flat.[2]
  • Intervertebral discs. Between C0–C1 and C1-C2 there is no intervertebral discs. Major factors in the development and progression of osteoarthritis of the facet joints are joint alignment and load distribution.[2]
  • Cervical plexus. Osteophyte formation or progressive cartilage thinning may narrow the intervertebral foramen through which the cervical nerve roots emerge.[2] [3]
  • Intervertebral ligaments.

Anatomy of Cervical vertebrae animation

 

Epidemiology/Etiology[edit | edit source]

Cervical osteoarthritis may be generalised, sometimes involving the entire cervical region, but it is usually more localised between the 5th and 6th and the 6th and 7th cervical vertebrae.

Anyone can develop cervical osteoarthritis, but it is rare in people younger than 40-50 years, the incidence increasing with age, women having a higher risk for cervical OA than men.[4] It is common in people above the age of 50 and especially if those people who have had jobs that included remaining in a single static position for long periods, i.e. reading, writing and other desk-based careers.[5]

Cervical OA can have many causes such as mechanically over-stressing of a joint (e.g. working with tools which generate intense vibration), previous bone fractures or other injuries to the neck, overload at a young age, postural asymmetry or asymmetric loading of a joint.

Facet joint osteoarthritis (FJOA) is intimately linked to the distinct but functionally related condition of degenerative disc disease, which affects structures in the anterior aspect of the vertebral column. FJOA and degenerative disc disease are both thought to be common causes of back and neck pain, which in turn have an enormous impact on the health-care systems and economies.[2]

Characteristics/Clinical Presentation[edit | edit source]

OA is characterised by pain, stiffness, crepitus, limited range of movement and sometimes joint instability and mild synovitis. The pain is usually localised around the affected joint, but referred pain may occur. Pain associated with FJOA can arise from nociceptors within and surrounding the joints, including nociceptors in the bone itself, as the facet joints and their capsules are well innervated. Pain can radiate to the occiput, the medial border of the scapula and the upper limbs. Pain often becomes worse with joint movement and can be more severe at the end of the day. Morning stiffness can be a common feature but usually dissipates with movement. Restricted movement can occur due to pain, capsular thickening and the presence of osteophytes.[6]

Osteophytes can form around the intervertebral joints and cause neurological symptoms due to compression of the spinal nerves (Cervical Radiculopathy). Narrowing of the spinal canal (Cervical Stenosis) can also cause compression on the spinal cord and circulation problems from compression of vascular structures. Performing an MRI can be useful to confirm the presence of any spinal cord compression (Cervical Myelopathy).

Awareness of potential red flags is essential, which may indicate a more serious issue:[7]

  • Malignancy, infection, or inflammation
  • Fever, night sweats
  • Unexpected weight loss
  • History of inflammatory arthritis, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression
  • Excruciating pain
  • Intractable night pain
  • Cervical lymphadenopathy
  • Exquisite tenderness over a vertebral body
  • Gait disturbance or clumsy hands, or both
  • Objective neurological deficit
  • Sudden onset in a young patient suggests disc prolapse
  • History of severe osteoporosis
  • Drop attacks, especially when moving the neck, suggest vascular disease
  • Intractable or increasing pain   

Prolonged peripheral inflammation in and around facet joints can lead to central sensitisation, neuronal plasticity, and the development of chronic spinal pain.

Differential Diagnosis[edit | edit source]

There are other conditions to consider before making a diagnosis:[7]

Diagnostic Procedures[edit | edit source]

A diagnosis is usually based on the clinical presentation.[8]

  • Pain on range of motion
  • Limitation of range of motion
  • Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
  • Pseudoclaudication caused by spinal stenosis

Radiology can also be used to determine OA however, some individuals with radiological signs can remain asymptomatic.[8] Kellgren and Lawrence developed a grading system for the radiological appearance of a joint with osteoarthritis.[9] If more than one joint in a group is assessed, then the most severe grade is reported: 

Radiological appearance of osteoarthritis Grade Parameters
normal (no signs of osteoarthritis) 0
doubtful change (uncertain) 1 osteophytes at the joint margins and periarticular ossicles
definite, minimal to mild 2 narrowing of the joint space
definite, moderate 3 cystic areas with sclerotic walls in subchondral bone
definite, severe 4 deformity of bone (altered shape)

Outcome Measures[edit | edit source]

Functional status and disability measure (evaluation of the activities of daily living) can be assessed by the Neck Pain and Disability Scale (NPAD) and the Neck disability index (NDI).[10]

  • The Neck pain and disability scale (NPAD) is a composite index including 20 items, which measure the intensity of neck pain, its interference with vocational, recreational, social, and functional aspects of living and also the presence and extent of associated emotional factors.
  • The Neck disability index (NDI) is a patient completed and condition-specific functional status questionnaire. This questionnaire consists of 10 items, including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation. This questionnaire has been designed to give information as to how neck pain has affected the patient’s ability to manage in daily life.

The NPAD and NDI are both seen as valid measures of self-reported neck pain related disabilities.   

Examination[edit | edit source]

As osteoarthritis is primarily a clinical diagnosis, patient history and the physical examination is usually sufficient to make a confident diagnosis. Joint pain and limited range of motion are usual symptoms in patients with cervical osteoarthritis. The pain tends to worsen with activity, especially following a period of rest (gelling phenomenon). [11]

Physical examination follows a normal cervical examination and includes:[2]

  • Inspection: posture, oedema, erythema, evidence of trauma, muscle atrophy, skin abnormalities and joint deformity.
  • Palpation of facet joints, examining of anatomic abnormality, temperature and tenderness. 
  • Range of motion of the cervical region and shoulder region.
  • Stress of the facet joints: pain increases with hyperextension, extension-rotation of the neck. Pain decreases while doing flexion of the neck. 
  • Neurological evaluation: motor and sensory evaluation of sensation, reflexes and muscle strength. Other special tests may be indicated: L’hermitte sign, Hoffman's test, Babinski. 
  • Muscle testing: searching for myofascial trigger points in the sternocleidomastoid, cervical paraspinal muscles, levator scapulae, the upper trapezius and suboccipital musculature. 

Medical Management[edit | edit source]

The following medical management strategies are only indicated when all other conservative treatment has failed.

Intra-articular Injections[edit | edit source]

Intra-articular corticosteroids are recommended for hip and knee osteoarthritis. The effects of corticosteroids on cervical osteoarthritis need to be researched.[11]

Surgical Treatment[edit | edit source]

There are indications that excision and fusion of the anterior cervical intervertebral disc (Cloward operation) together with the removal of associated arthritic bone spurs pressing on the nerves and spinal cord can give relief of pain and muscle weakness in patients who have cervical osteoarthritis with neurologic pain.[11]

Pharmacology[edit | edit source]

In the short-term, some benefit may be gained from using chondroitin (alone or in combination with glucosamine). Other options can be acetaminophen, NSAIDS or opoids.[11]

Physical Therapy Management[edit | edit source]

The main goals of management for cervical OA are: 

  • reducing pain and stiffness
  • improving joint mobility
  • inhibiting any further progression of joint damage

Advice and Education[edit | edit source]

Providing information related to the disorder, stress management and postural advice in daily activities, work and hobbies should also be part of any treatment plan.[7] Providing encouragement and motivation where necessary is also a key component.[12]

Advice and education regarding good neck posture is a key part of treatment as the condition progresses, as neck posture can negatively affect any patient. Sleeping advice is that side lying is the preferred position and a single pillow only under the head is recommended, although a butterfly pillow offers the best support, as it is flattened in the middle and the elevated sides support the head.

Exercise Therapy[edit | edit source]

Treatment for cervical osteoarthritis is usually conservative and it can be treated using a variety of therapy possibilities with exercise therapy being a key element. Exercise includes mobilisation exercises, strengthening of local muscles around the affected joint and improving overall aerobic fitness[7][12] There is considerable evidence that suggests physical activity can help in the management of chronic pain and should play a key role in the overall treatment plan. This will improve the disability over time and has other multiple health benefits.

  • Proprioceptive exercises
  • Stabilisation exercises
  • Stretching exercises

Manual Therapy[edit | edit source]

Manual therapy such as massage, mobilisation, and manipulation may provide further relief for patients with cervical osteoarthritis[12]. Mobilisation is characterised by the application of gentle pressure within or at the limits of normal motion to improve ROM.

Manipulation may be considered, but there are numerous contraindications, such as myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability and vertebrobasilar insufficiency which have to be taken into consideration.

Heat and cold modalities [edit | edit source]

It is recommended that when application of superficial heat or cold is considered in the management of OA that patients experiment to identify the intervention that offers them the greatest relief.[13]

Hydrotherapy[edit | edit source]

It has been shown that hydrotherapy can give some relief to patients struggling with pain and OA. However, the research is poor and points to mostly short term effects.[12]

Acupuncture[edit | edit source]

The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. Evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis.[14]

Electrotherapy[edit | edit source]

Ultrasound[edit | edit source]

Ultrasound may be beneficial, but there is only low quality evidence for its effectiveness on osteoarthritis. Most studies, however, have investigated its effectiveness on hip and knee osteoarthritis. The magnitude of the effects on pain relief and function is still unclear and any positive results may wholly be due to placebo.[15]

TENS[edit | edit source]

TENS can also provide symptomatic relief.[16]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Musumeci G, Aiello F, Szychlinska M, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst century: risk factors and behaviours that influence disease onset and progression. International journal of molecular sciences. 2015 Mar;16(3):6093-112 Available from: https://www.mdpi.com/1422-0067/16/3/6093 [Accessed on 18 June 2019]
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nature Reviews Rheumatology. 2013 Apr;9(4):216. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012322/ [Accessed 18 June 2019]
  3. ↑ Rand RW, Crandall PH. Surgical treatment of cervical osteoarthritis. California medicine. 1959 Oct;91(4):185. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1577768/ [Accessed 18 June 2019]
  4. ↑ Srikanth VK, Fryer JL, Zhai G, Winzenberg TM, Hosmer D, Jones G. A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis. Osteoarthritis and cartilage. 2005 Sep 1;13(9):769-81. Available from: https://www.sciencedirect.com/science/article/pii/S1063458405001123 [Accessed 19 June 2019]
  5. ↑ Plotnikoff R, Karunamuni N, Lytvyak E, Penfold C, Schopflocher D, Imayama I, Johnson ST, Raine K. Osteoarthritis prevalence and modifiable factors: a population study. BMC Public Health. 2015 Dec;15(1):1195. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2529-0 [Accessed 19 June 2019]
  6. ↑ Hunter DJ, McDougall JJ, Keefe FJ. The symptoms of osteoarthritis and the genesis of pain. Rheumatic Disease Clinics of North America. 2008 Aug 1;34(3):623-43. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597216/ [Accessed 19 June 2019]
  7. ↑ 7.0 7.1 7.2 7.3 Binder AI. Cervical spondylosis and neck pain. Bmj. 2007 Mar 8;334(7592):527-31. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819511/ [Accessed 19 June 2019]
  8. ↑ 8.0 8.1 Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clinics in geriatric medicine. 2010 Aug 1;26(3):355-69. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920533/ [Accessed 19 June 2019]
  9. ↑ Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clinical Orthopaedics and Related Research. 2016. 474: 1886. Available from: https://link.springer.com/article/10.1007/s11999-016-4732-4 [Accessed 19 June 2019]
  10. ↑ MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, Mcalpine C, Goldsmith CH. Measurement properties of the neck disability index: a systematic review. Journal of orthopaedic & sports physical therapy. 2009 May;39(5):400-17. Available from: https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.2930 [Accessed 19 June 2019]
  11. ↑ 11.0 11.1 11.2 11.3 Sinusas K. Osteoarthritis: diagnosis and treatment. American family physician. 2012 Jan 1;85(1). Available from: https://pdfs.semanticscholar.org/eea7/a33ce41435e52c0b1e4a25a3b375ffa97a6e.pdf [Accessed 19 June 2019]
  12. ↑ 12.0 12.1 12.2 12.3 Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki K, Fagerson TL, Slover J, Godges JJ. Hip pain and mobility deficits—hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2009 Apr;39(4):A1-25. Available from: https://www.jospt.org/doi/pdfplus/10.2519/jospt.2009.0301 [Accessed: 18 June 2019]
  13. ↑ Denegar CR, Dougherty DR, Friedman JE, Schimizzi ME, Clark JE, Comstock BA, Kraemer WJ. Preferences for heat, cold, or contrast in patients with knee osteoarthritis affect treatment response. Clinical interventions in aging. 2010;5:199. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920200/ [Accessed 19 June 2019]
  14. ↑ Manyanga T, Froese M, Zarychanski R, Abou-Setta A, Friesen C, Tennenhouse M, Shay BL. Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC complementary and alternative medicine. 2014 Dec;14(1):312. Available from: https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-14-312 [Accessed: 19 June 2019]
  15. ↑ Loyola-Sánchez A, Richardson J, MacIntyre NJ. Efficacy of ultrasound therapy for the management of knee osteoarthritis: a systematic review with meta-analysis. Osteoarthritis and Cartilage. 2010 Sep 1;18(9):1117-26. Available from: https://www.sciencedirect.com/science/article/pii/S1063458410002128 [Accessed 19 June 2019]
  16. ↑ Osiri M, Welch V, Brosseau L, Shea B, McGowan JL, Tugwell P, Wells GA. Transcutaneous electrical nerve stimulation for knee osteoarthritis. Cochrane Database of Systematic Reviews. 2000(4). Available from: http://www.oegpmr.at/wp-content/uploads/Beilage-7-Transcutaneous_electrical_nerve_stimulation.pdf [Accessed 19 June 2019]


Retrieved from "https://www.physio-pedia.com/index.php?title=Cervical_Osteoarthritis&oldid=344659"