Cervicobrachial pain - How Often is it Neurogenic?
Ranganath Gangavelli1, N. Sreekumaran Nair2, Anil K Bhat3, John M Solomon4
1 Assistant Professor -Selection Grade, Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, India.
2 Professor and Head, Department of Statistics, Manipal University, Manipal, India.
3 Professor and Head, Department of Orthopedics, Kasturba Medical College, Manipal University, Manipal, India.
4 Associate Professor, Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:Dr. Ranganath Gangavelli, Assistant Professor – Selection Grade, Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal- 576104, India. E-mail : ranga980@gmail.com; ranganath.g@manipal.edu
Introduction
Neck pain associated with pain in the arm (cervicobrachial pain) is a common complaint in patients seeking physiotherapy management. The source of symptoms for this complaint is commonly presumed to be neural. However, this pain pattern could also result from various other innervated tissue structures of the upper quarter. Knowledge about frequency of neural structures being a predominant source of symptoms would help in implementing appropriate therapeutic strategies such as neural tissue mobilization along with other complimentary therapies for optimal outcomes.
Aim
To determine the frequency of cervicobrachial pain being neurogenic.
Materials and Methods
Participants (n=361) aged between 20-65 years, reporting cervicobrachial pain were screened for neurogenic nature of symptoms. These physical signs included: active and passive movement dysfunction, adverse responses to neural tissue provocation tests, tenderness on palpating nerve trunks and related cutaneous tissues and evidence of a related local area of pathology (Clinical/radiological). The consistency of all these signs was checked to identify a significant neural involvement.
Results
Descriptive statistics were used to analyse data. Of 361 participants, 206 were males (44.6 ±10.8 years) and 155 were females (41.8 ± 11.2 years). The frequency of neurogenic cervicobrachial pain was determined to be 19.9% (n=72) and the non-neurogenic sources for symptoms were attributed to 80.1% (n=289) of screened participants.
Conclusion
Lower frequency of cervicobrachial pain being neurogenic indicates thorough screening for appropriate therapeutic interventions to be successful.
Introduction
Neck pain associated with tingling, numbness or discomfort in the arm, upper back and upper chest with or without an associated head ache is considered as cervicobrachial pain syndrome (CBPS) [1]. This complaint is common among the patients seeking physiotherapy interventions for neck and arm pain. Cervical radiculopathy can be a diagnosis of choice for this presentation in presence of frank sensorimotor deficits in the related nerve root territory (dermatome and myotome) [2]. However, thorough neuromusculoskeletal evaluation often indicates absence of deficits in the peripheral nervous system in patients with cervicobrachial pain. The possible reasons for such a presentation can be due to referred pain from dysfunctional somatic sources such as cervical discs, facet joints, upper quarter muscular imbalances with associated trigger or tender points and inflamed neural tissues [3,4]. Clinicians should also bear in mind about the possible non somatic referral patterns presenting as cervicobrachial pain [5]. The results of therapeutic interventions can be improved on identifying the probable predominant source of symptoms.
Previous studies had investigated specific therapeutic interventions for this cervicobrachial pain utilizing electro physical therapeutic modalities, cervical traction, manual therapy, strength and motor control training in cervical region. However, the diagnostic categories for therapeutic interventions are often non-specific or poorly defined [6–8]. Few studies with specific inclusion criteria have utilized neural tissue mobilization and demonstrated better reductions in pain with improved functional outcomes [9–11]. This treatment approach focuses on passive mobilization of mechanically sensitized neural tissue structures with a primary objective of restoring appropriate neurodynamics [9–14]. Hypothesized benefits of this technique include improved neurophysiological and neuromechanical functions of the peripheral nervous system [12,14–18]. However, the appropriate patient selection remains pivotal for success of this intervention.
The estimated frequency of neurogenic CBPS among the patients reporting to physiotherapy practice with neck and arm pain was not reported in the literature. This data on frequency of CBPS being neurogenic will direct the utility of neural tissue mobilization techniques. Appropriate implementation of specific therapy may enhance the chances for early recovery and may reduce recurrence rates. Hence the objective of this study was to determine the frequency of CBPS being neurogenic in nature among the patients seeking rehabilitation.
Materials and Methods
This study was conducted at Department of Physiotherapy in a multispecialty tertiary referral center located in coastal region of Karnataka state in India from January 2011 till February 2015. The data presented in this manuscript is an observational finding from the screening process for a pragmatic randomized controlled trial registered in Clinical Trial Registry of India {CTRI/2011/06/001851 -Registered on: 30/06/2011 - Trial Registered Retrospectively}. Approvals from Institutional Research Committee and University Ethics Committee were obtained prior to commencement of the study and were renewed in subsequent years.
Participants aged between 20 to 65 years from either gender with acute or sub-acute onset (symptom duration ranging from a week to six months) of cervicobrachial pain were considered for inclusion in the study. Prior to screening at physiotherapy department, all participants underwent a thorough evaluation by medical doctors of Department of Orthopedics, Neurology and General Medicine for non neuromusculoskeletal sources for symptoms (such as visceral referral source etc.). These participants were then evaluated for neurogenic nature of reported cervicobrachial pain at Department of Physiotherapy by a qualified physiotherapist with a decade of clinical experience in manual therapy practice.
Participants were considered to have neurogenic cervicobrachial pain syndrome, if their complaints were reproduced, and are consistent with all of the below mentioned physical signs and symptoms. The following signs and symptoms were suggested and described as indicators of neurogenic nature of cervicobrachial pain [1,2,4,5,9,10,14,19–27].
Active movements of cervical spine (extension, lateral flexion to either side and ipsilateral rotations) and arm movements reproducing pain.
Symptom reproduction on passive movements in the same pattern as with active movements.
Elicitation of adverse response (in terms of range of movement and reproduction of symptoms) to neural tissue provocation testing of median, ulnar and radial nerves and subsequent symptom alteration with neural tissue differentiating maneuvers.
Tenderness at transverse processes of cervical spine (nerve roots), nerve trunks of median, ulnar and radial nerves at different anatomical locations in the course of respective neural tissue.
Hyperalgesic related cutaneous tissues on palpation (tender points).
Evidence of a related pathology (example: positive spurling’s test or radiological evidence of cervical disc pathology in the vicinity of involved nerve roots or evidence of stenosis at cervical neural foramen as diagnosed by a qualified musculoskeletal Radiologist)
If this detailed physical evaluation failed to demonstrate the consistency of the signs and symptoms, the participant’s presentation was considered to be non-neurogenic. Further thorough physical examination with clinical reasoning was carried out to determine other possible sources of symptoms. In a difficult case scenario, consensus was obtained following discussion among authors. The frequency of cervicobrachial pain being neurogenic was documented and the data was computed in Statistical Package for the Social Sciences (SPSS) software version 14. Descriptive statistics were used to analyse the data.
Results
During the study period, 361 participants with complaints of cervicobrachial pain were randomly selected for screening. Of these participants, 206 were males (44.6 ± 10.8 years) and 155 were females (41.8 ± 11.2 years). Neurogenic CBPS was identified in 19.9% (n=72) of the participants as they fulfilled all the signs and symptoms required. These participants were from different work profiles {Business (n=13), Agriculture and related works (n=14), Home maker (n=13), Health care professionals (n=7), General duty workers (n=5), Computer operators and other technicians (n=20)}. The cervicobrachial symptoms in the rest 80.1% (n=289) of the participants were considered to be non-neurogenic in nature.
Among these participants with neurogenic CBPS (n=72), median nerve predominance on neural tissue provocative testing was observed in 68.06% (n=49) participants, radial nerve predominance in 15.28% (n=11) and ulnar nerve predominance was noticed in 11.11% (n=8). About 5.55% (n=4) participants were found to have bilateral neurological deficits and Lhermitte’s sign indicating possible compressive cervical myelopathy.
Upon thorough physical examination with clinical reasoning, the predominant non neurogenic sources for the symptoms were identified in the rest of the participants (n=289) reporting cervicobrachial pain. Among these participants, 83.39% (n=241) were identified to have cervical intervertebral disc or facet joint mediated symptoms and cervico-thoracic muscular imbalances (trigger points in levator scapulae, trapezius and scalene muscles). Often, more than one source was attributed for the symptoms in these participants.
Similarly, physician diagnosed cervical degenerative or inflammatory arthropathies contributed for 3.81% (n=11), rotator cuff and other shoulder girdle musculature dysfunctions contributed for 3.11% (n=9) of non-neurogenic sources. Authors also noted associated significant low back pain complaints among some of the screened participants contributing to 9.69% (n=28) indicating possible postural or structural abnormalities necessitating for further evaluation. However, these participants did not demonstrate neurogenic nature of symptoms as well.
Discussion
This study attempted to determine the frequency of cervicobrachial pain being neurogenic in nature and identified nearly one fifth of the screened participants to have neurogenic CBPS. The proportional involvement of the three major nerves of upper quarter was found to be different with predominant contribution from median nerve followed by radial and ulnar nerves subsequently.
Diagnostic blockade is a preferred method of differentiating and establishing the diagnosis for somatic source of symptom [3,20]. However in this study, the structural sources for symptoms were identified based on thorough physical examination complimented with suggestive radiological findings. The screening procedure had included evaluation for symptom reproduction with Spurling’s test, neural tissue provocative testing and deficits in ipsilateral cervical rotation range of motion. Existing literature suggests an increase in reliability and validity to identify a neurogenic cervicobrachial pain syndrome on utilizing the mentioned cluster of tests [21,28] This method of screening is justifiable, as the routine clinical decision making strategies depend predominantly on the currently adapted method.
The prevalence for neck pain was widely published in the existing literature [29,30]. However, many studies have failed to address the frequency of specific source of symptoms. The possible reason being multifactorial and multidimensional nature of chronic pain i.e. symptom presentation and nature of response on evaluation can have psychosocial and central sensitization dimensions. However, chronic presentations were not included for evaluation in this study. Hence authors presume the true nature of presenting symptoms as existing in any given clinical scenario.
Presently identified frequency of neurogenic CBPS (19.94%) is in accordance with available literature (6% -31%) indicating variation in frequency with nature of occupation. However, a systematic approach (using a cluster of sensitive and specific clinical evaluation methods) was adapted in the current study to hypothesize the significant and predominant sources of symptom rather than basing on a single test (Shoulder abduction external rotation test) [31]. Future studies may incorporate multiple qualified therapists from multiple centers in the process of screening to substantiate findings.
Conclusion
Cervicobrachial pain is a common complaint among the patients reporting to physiotherapy practice. Success of treatment strategies depend on their need for implementation. Lower frequency (19.94%) of neurogenic cervicobrachial pain indicates specific interventions such as neural mobilization techniques should be judiciously applied with appropriate patient selection.
Submission statement: We represent that this submission is original work, and is not under consideration for publication with any other journal.
[1]. Elvey RL, Hall T, Neural tissue evaluation and treatment Physical Therapy of the Shoulder 1997 New YorkChurchill Livingstone [Google Scholar]
[2]. Yoon SH, Cervical radiculopathy Phys Med Rehabil Clin N Am 2011 22(3):439-46. [Google Scholar]
[3]. Gellhorn AC, Cervical facet-mediated pain Phys Med Rehabil Clin N Am 2011 22(3):447-58. [Google Scholar]
[4]. Murphy DR, Hurwitz EL, A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain BMC Musculoskelet Disord 2007 Aug 3 8:75 [Google Scholar]
[5]. Alexander EP, History, physical examination, and differential diagnosis of neck pain Phys Med Rehabil Clin N Am 2011 22(3):383-93. [Google Scholar]
[6]. Koes B, Bouter L, Van Mameren H, Essers A, Verstegen G, Hofhuizen D, The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints: A randomized clinical trial Spine (Phila Pa 1976) 1992 17(1):28-35. [Google Scholar]
[7]. Berg HE, Berggren G, Tesch PA, Dynamic neck strength training effect on pain and function Arch Phys Med Rehabil 1994 75(6):661-65. [Google Scholar]
[8]. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Manipulation and mobilization of the cervical spine: A systematic review of the literature Spine (Phila Pa 1976) 1996 1;21(15):1746-59. [Google Scholar]
[9]. Allison G, Nagy B, Hall T, A randomized clinical trial of manual therapy for cervico- brachial pain syndrome–a pilot study Man Ther 2002 7(2):95-102. [Google Scholar]
[10]. Cowell I, Phillips D, Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study–experimental design Man Ther 2002 7(1):31-38. [Google Scholar]
[11]. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K, The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain J Orthop Sports Phys Ther 2003 Jul 33(7):369-78. [Google Scholar]
[12]. Butler DS, Jones MA, Gore R, Mobilisation of the nervous system 1991 Churchill Livingstone Melbourne [Google Scholar]
[13]. Butler D, Shacklock M, Slater H, Treatment of altered nervous system mechanics Grieve’s Modern Manual Therapy: The Vertebral Column 1994 2nd edEdinburgh, UKLivingston Churchill:693-703. [Google Scholar]
[14]. Shacklock M, Clinical neurodynamics: A new system of musculoskeletal treatment 2005 Elsevier Health Sciences [Google Scholar]
[15]. Shacklock M, Neurodynamics Physiotherapy 1995 81(1):9-16. [Google Scholar]
[16]. Ellis RF, Hing WA, Neural mobilization: A systematic review of randomized controlled trials with an analysis of therapeutic efficacy J Man Manip Ther 2008 16(1):8-22. [Google Scholar]
[17]. Kitteringham C, The effect of straight leg raise exercises after lumbar decompression surgery-a pilot study Physiotherapy 1996 82(2):115-23. [Google Scholar]
[18]. Sweeney J, Harms A, Persistent mechanical allodynia following injury of the hand: treatment through mobilization of the nervous system J Hand Ther 1996 Oct-Dec 9(4):328-38. [Google Scholar]
[19]. Anekstein Y, Blecher R, Smorgick Y, Mirovsky Y, What is the best way to apply the Spurling test for cervical radiculopathy? Clin Orthop Relat Res 2012 470(9):2566-72. [Google Scholar]
[20]. Bogduk N, The anatomy and pathophysiology of neck pain Phys Med and Rehabil Clin N Am 2011 22(3):367-82. [Google Scholar]
[21]. Murphy DR, A clinical model for the diagnosis and management of patients with cervical spine syndromes Australas Chiropr Osteopathy 2004 12(2):57-71. [Google Scholar]
[22]. Murphy DR, Hurwitz EL, Application of a diagnosis-based clinical decision guide in patients with neck pain Chiropr Man Therap 2011 27(19):1:19 [Google Scholar]
[23]. Murphy DR, Hurwitz EL, Gerrard JK, Clary R, Pain patterns and descriptions in patients with radicular pain: Does the pain necessarily follow a specific dermatome? Chiropr Osteopat 2009 21(17):9 [Google Scholar]
[24]. Murphy DR, Hurwitz EL, Nelson CF, A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature Chiropr Osteopat 2008 Aug 11 16:7 [Google Scholar]
[25]. Donelson R, Mechanical diagnosis and therapy for radiculopathy Phys Med Rehabil Clin N Am 2011 22(1):75-89. [Google Scholar]
[26]. Fish DE, Gerstman BA, Lin V, Evaluation of the patient with neck versus shoulder pain Phys Med Rehabil Clin N Am 2011 22(3):395-410. [Google Scholar]
[27]. Gifford L, Acute low cervical nerve root conditions: symptom presentations and pathobiological reasoning Man Ther 2001 6(2):106-15. [Google Scholar]
[28]. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S, Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy Spine (Phila Pa 1976) 2003 1;28(1):52-62. [Google Scholar]
[29]. Fejer R, Kyvik KO, Hartvigsen J, The prevalence of neck pain in the world population: a systematic critical review of the literature Eur Spine J 2006 15(6):834-48. [Google Scholar]
[30]. Hoy DG, Protani M, De R, Buchbinder R, The epidemiology of neck pain Best Pract Res Clin Rheumatol 2010 24(6):783-92. [Google Scholar]
[31]. Sällström J, Schmidt H, Cervicobrachial disorders in certain occupations, with special reference to compression in the thoracic outlet Am J Ind Med 1984 6(1):45-52. [Google Scholar]