Cervical Osteoarthritis: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Bram Sorel|Bram Sorel]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>  
'''Original Editors ''' - [[User:Bram Sorel|Bram Sorel]]  
 
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== Definition/Description  ==
== Definition/Description  ==


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 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 </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 (LoE1B) </ref>&nbsp;the hyaline cartilage, the underlying bone, joint capsule and zygoapophyseal joints. It 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 </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 </ref> or subchondral cysts and 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 </ref> Cervical osteoarthritis can also be referred to as [[Cervical Spondylosis|cervical spondylosis]] <ref name="hartz" />.<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]]
[[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]]
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== Clinically Relevant Anatomy  ==
== Clinically Relevant 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 exhibits features typical of 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.&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 </ref>  
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" />  


The cervical spine components that are affected by osteoarthritis are;  
The cervical spine components that are affected by osteoarthritis are;  


*'''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 </ref> 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" />  
*'''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" />  
*'''Synovium'''<ref name="musumeci" />  
*'''Synovium'''<ref name="musumeci" />  
*'''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.<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 </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.  
*'''Facet joints.''' They are inclined 45° from the horizontal. The joint surfaces are generally planar, but not flat.<ref name="gellhorn" />  
*'''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" />  
*'''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. Surgical Treatment of Cervical Osteoarthritis. Calif Med 1959; 91(4): 185-188 </ref>  
*'''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'''.<ref name="sutbeyaz" /><br><br>
*'''Intervertebral ligaments'''.<br><br>
[[File:Cervical vertebrae animation.gif|center|thumb|Anatomy of Cervical vertebrae animation]]
[[File:Cervical vertebrae animation.gif|center|thumb|Anatomy of Cervical vertebrae animation]]
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== Epidemiology/Etiology  ==
== Epidemiology/Etiology  ==
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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.
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, <ref name="walker">Walker JA, Osteoarthritis: pathogenesis, clinical features and management. Nursing Standard 2009, Vol. 24, Nr. 1, 35-40 (LoE2A)</ref><ref name="boucher" /> women having a higher risk for cervical OA than men.<ref name="walker" /><ref name="michael" /> 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.  
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>


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. ''Hartz et al'' suggest that there is a relationship between the severity of cervical osteoarthritis and a higher body weight of the patient.<ref name="hartz" />
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|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="alfred" />
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 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 </ref><ref name="arno">Arno Bisschop, Which factors prognosticate spinal instability following lumbar laminectomy?,Eur Spine J. 2012 Dec; 21(12): 2640–2648. </ref><ref name="singh">Singh J.A. et al., Chondroitin for osteoarthritis, 2015, Cochrane review. </ref>&nbsp;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 <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 </ref>. Pain can radiate 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) </ref>. 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 <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. </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>  


Osteophytes can form around the intervertebral joints and cause neurological symptoms due to compression of the spinal nerves (C[[Cervical Radiculopathy|ervical Radiculopathy]]) <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.</ref>. 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]]).  
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]]).  


Awareness of potential [[Red Flags in Spinal Conditions|red flags]] is essential, which may indicate a more serious issue: <ref name="manheimer">Manheimer E. et al., Acupuncture for osteoarthritis, 2010, Cochrane review. (LoE1A) </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  
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*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 <ref name="hulme">Hulme J. et al., Electromagnetic fields for the treatment of osteoarthritis., Hulme J1, Robinson V, Cochrane Database Syst Rev. 2002;(1)</ref>.  
Prolonged peripheral inflammation in and around facet joints can lead to central sensitisation, neuronal plasticity, and the development of chronic spinal pain.  


== Differential Diagnosis ==
== Differential Diagnosis ==
There are other conditions to consider before making a diagnosis:<ref name="binder" />
*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]]  
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== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


A 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. </ref><ref name="musumeci" />
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
* Limitation of range of motion
* Limitation of range of motion
* Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
* Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
* Pseudoclaudication caused by [http://www.physio-pedia.com/Spinal_Stenosis spinal stenosis]
* 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="musumeci" /><ref>KNEW WW. Neck Pain Guidelines: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):511-2.</ref>. ''Kellgren and Lawrence'' developed a grading system for the radiological appearance of a joint with osteoarthritis<ref name="sutbeyaz" />. If more than one joint in a group is assessed, then the most severe grade is reported:&nbsp;  
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;  


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== 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|Neck disability index]] (NDI).<ref name="binder">Binder A, Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-531 (LoE5) </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 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 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" />&nbsp; &nbsp;
The NPAD and NDI are both seen as valid measures of self-reported neck pain related disabilities.&nbsp; &nbsp;


== Examination  ==
== Examination  ==


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., Osteoarthritis: diagnosis and treatment, Am Fam Physician, 2012 Jan 1;85(1):49-56. </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>  


Physical examination follows a normal [[Cervical Examination|cervical examination]] and includes:<ref name="gellhorn" />
Physical examination follows a normal [[Cervical Examination|cervical examination]] and includes:<ref name="gellhorn" />
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The following medical management strategies are only indicated when all other conservative treatment has failed.
The following medical management strategies are only indicated when all other conservative treatment has failed.


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


Patients with atlantoaxial (C1-C2) facet joint osteoarthritis have a positive reaction on pain after the fusion of these two facet joints with transarticular screw fixation. This treatment has a relatively low rate of serious complications<ref name="grob" />.<u></u>
=== Surgical Treatment  ===
 
Laminoplasty is used to decompress the cervical spinal cord. A risk of this surgical treatment, however, is reduced strength and shear stiffness (SS) of motion segments and the patient can suffer from instability as a result. Numerous patients also had neck pain following surgery. <ref name="arno" />.


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 ===
=== Pharmacology ===
In the short-term, some benefit may be gained from using chondroitin (alone or in combination with glucosamine). Benefits have been shown to be small to moderate, but clinically meaningful<ref name="singh" />.
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  ==
== 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  
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*inhibiting any further progression of joint damage
*inhibiting any further progression of joint damage


=== Advice and education ===
=== 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" /> Providing encouragement and motivation where necessary is also a key component.<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) (LoE1A)</ref>  
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>  


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. <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. (LoE5) </ref>
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.


=== [[Manual Therapy and Exercise for Neck Pain: Clinical Treatment Tool-kit|Exercise Therapy]] ===
=== Exercise Therapy  ===
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 local muscles around the affected joint and improving overall aerobic fitness<ref name="walker" /><ref name="binder" /><ref name="sutbeyaz" /> 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.  
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


==== Proprioceptive exercises ====
* Stabilisation exercises


Studies have shown positive results with 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 Disorders BMC series – open, inclusive and trusted 201415:382 (LoE1A) </ref><ref name="ar">A.R. Gross et al.; Exercises for mechanical neck disorders: A Cochrane review update; Manual Therapy 24 (2016) 25-45 (LoE1A) </ref>
* Stretching exercises
==== Stabilisation exercises  ====


Exercises with, for example, a Chattanooga stabiliser pressure biofeedback can help to train the deep cervical flexor muscles. Such exercises have been proven to be effective for the reduction of cervical pain in patients suffering from 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>
=== 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.


==== Stretching exercises ====
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.
A regular stretching exercise program  can help to decrease neck and shoulder pain and improve neck function and quality of life of individuals.<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. (LoE1B) </ref>
 
=== [[Manual Therapy and Exercise for Neck Pain: Clinical Treatment Tool-kit|Manual therapy]]  ===
 
Manual therapy, such as massage, mobilisation, and manipulation may provide further relief for patients with cervical osteoarthritis. 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.&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. (LoE3A) </ref>


=== Heat and cold modalities&nbsp; ===
=== Heat and cold modalities&nbsp; ===
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.  
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>


=== Hydrotherapy  ===
=== 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" />
Underwater traction of the cervical spine during weight bath therapy demonstrated positive outcomes. It mitigated the pain, increased the range of motion and improved quality of life. The patient hangs in a steel construction with their head supported by a collar which creates the traction with their body weight supported by the water.<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 (LoE2B) </ref><ref name="marta">Márta Kurutz and Tamás Bender ; Weightbath hydrotraction treatment: application, biomechanics, and clinical effects ; Journal of multidisciplinary Healthcare ; April 2010 </ref>


=== 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>  
*Studies have shown minimal significant benefits of acupuncture for osteoarthritis which do not meet the defined thresholds for clinical relevance. Most of the benefits are suggested to be placebo.<ref name="manheimer" />
*''Nakijima et al'' suggested that the depth of the needle has significant relevance for long-term benefit. The results showed that a deeper needle insertion (15-20mm) was more effective than a superficial one (5mm) in patients with neck and shoulder pain.<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 (LoE1B) </ref>  


=== Electrotherapy  ===
=== Electrotherapy  ===
Line 191: Line 174:
==== Ultrasound  ====
==== Ultrasound  ====


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 name="rutjes">Rutjes A. W. S. et al., Therapeutic ultrasound for osteoarthritis, 2010, Cochrane review.(LoE1A) </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>  


==== TENS  ====
==== TENS  ====


TENS can also provide symptomatic relief.<ref name="walker" /><ref name="binder" /><ref name="sutbeyaz" />
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>
 
==== Pulsed electric stimulation ====
It has been suggested that this treatment causes the stimulation of cartilage growth at the cellular level, yet there is a need for further large scale studies of pulsed electric stimulation to confirm these finding.<ref name="hulme" /> 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" /><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 </ref><ref name="hulme" />
 
==== Low power Laser Therapy  ====


Several studies have shown the effectiveness of low power laser therapy. They demonstrated a reduction in pain and an improvement in neck function. ''Chow et a''l 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 </ref><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 </ref><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 randomised placebo or active-treatment controlled trials; the lancet; nov 13,2009 </ref>
== References ==
 
=== '''References''' ===
<references />  
<references />  


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[[Category:Osteoarthritis]]  
[[Category:Osteoarthritis]]  
[[Category:Interventions]]
[[Category:Interventions]]
[[Category:Cervical Conditions]]
[[Category:Cervical Spine - Conditions]]  
[[Category:Cervical Spine Joints]]
 
[[Category:Conditions]]
[[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, Admin, Jason Coldwell, Bram Sorel, Evan Thomas, Simisola Ajeyalemi, Rucha Gadgil, Jess Bell, Olajumoke Ogunleye, Nicolas Casier and WikiSysop

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]


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