Neck and Upper Extremity Pain in a Female Office Assistant


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Neck and Upper Extremity Pain in a Female Office Assistant


Where Does the Problem Lie?



Jodi L. Young, Joshua A. Cleland, Darren A. Rivett, Mark A. Jones



History


Kelly is a 27-year-old female who was referred to physical therapy with a 3-month history of neck and left upper extremity pain. Her primary symptoms were in the left anterior shoulder, with radiation to the left lateral elbow described as achy and dull, and her neck pain was located on the left side of her cervical spine in the C5–C6 region with radiation into her left midscapular region during active cervical left rotation and side flexion (Fig. 22.1). The shoulder pain had an insidious onset 3 months ago, and the elbow symptoms also appeared insidiously within the last month. Her neck symptoms were originally only noticeable in the morning when Kelly woke up with reported stiffness, which she noted began about 5 months prior, with a recent progression to neck pain over the last few weeks. The neck stiffness subsided after an hour or two of Kelly moving around and doing her activities of daily living (ADLs), so she had paid little attention to her neck symptoms. However, she did note that the stiffness and neck pain, along with the shoulder pain, seemed to be getting worse over the past 3 weeks, and Kelly said that she had not done anything differently in her normal daily routine at work or home to exacerbate her symptoms. The shoulder and elbow pain were most prevalent when Kelly was using her arm, specifically at work and if doing activities such as cooking, cleaning or folding laundry at home. Kelly worked as an office assistant, so most of her 8-hour work day was spent sitting at a desk, typing, answering the phone, or working on the computer. At times she had to file charts, which required her to use her left arm extensively for a short duration of time. Recreationally, Kelly ran 3–4 days a week anywhere from 1 to 5 miles. Running provoked her shoulder and elbow pain after about a mile, but it would quickly subside with 15 minutes of rest. Of note is that Kelly was left-hand dominant.


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Fig. 22.1 Kelly’s body chart.

Kelly’s symptoms started with morning stiffness of the neck, as indicated previously, that subsided within 1–2 hours after waking. She indicated that there was originally not much pain in her neck but instead general stiffness, specifically with left cervical rotation and side flexion. The numeric pain rating scale (NPRS) was used to capture Kelly’s level of pain. She was asked to indicate the intensity of current, best and worst levels of pain over the past 24 hours using an 11-point scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’). The NPRS has been shown to exhibit a minimal clinically important difference of 2 points (Cleland et al., 2008b). Because of the recent worsening of her neck symptoms, she said that she was actually now beginning to have pain rated 4/10 on the NPRS when turning her head to the left while driving. Kelly stated that the pain in her left shoulder and elbow varied depending on her activity level. On weekends, when Kelly was not at work, her shoulder and elbow symptoms were much less noticeable (1/10) and only occurred if she was cooking, cleaning or folding laundry for more than an hour. If she did these activities for short periods of time, such as 30 minutes, there were no symptoms. She indicated that the pain level would reach a 4/10 on the NPRS if she performed these activities for more than an hour. If she stopped doing those activities, her pain would subside within 15–20 minutes. Kelly reported her work is what triggered her symptoms the most, and after 2 hours of sitting at her desk performing her normal work duties, her symptoms in the left shoulder and elbow would reach a 6/10 pain level, and her neck had begun to exhibit pain in the last few weeks reaching a 4/10. If Kelly were to stand up, walk around or rest her arm, the symptoms in her shoulder and elbow would decrease to a 2/10 pain level after approximately 15 minutes. Her neck pain would decrease within only a few minutes of getting up and moving around. We discussed an ergonomic assessment, and Kelly had already undergone this assessment through her employer, and changes had been made to her desk setup a month prior, but her symptoms had not changed.


Because Kelly was exhibiting both left upper extremity (UE) and neck symptoms, she was asked to complete two functional outcome measures: the Upper Extremity Functional Index (UEFI) and the Neck Disability Index (NDI). For the UEFI, patients are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability. The reliability of the UEFI has been shown to be 0.95, and the minimal clinically important difference (MCID) has been identified at 9 points (Stratford et al., 2001).


The NDI is the most widely used condition-specific disability scale for patients with neck pain and consists of 10 items addressing different aspects of function, each scored from 0 to 5, with a maximum score of 50 points. The score is then doubled and interpreted as a percentage of the patient-perceived disability. Higher scores represent increased levels of disability. The NDI has been demonstrated to be a reliable and valid outcome measure for patients with neck pain (Hains et al., 1989; Riddle and Stratford 1998). The NDI has been shown to exhibit an MCID of 19 points (Cleland et al., 2008b). Kelly scored a 46/50 on the UEFI and a 56% on the NDI at the time of the initial visit.


Kelly also completed a modified Fear-Avoidance Beliefs Questionnaire to assess for any possible psychosocial involvement related to her symptoms. Kelly’s overall score on the work and physical activity subscales did not indicate that her symptoms were related to a psychosocial component.


Kelly noted that she would continue to perform her work duties regardless of the pain level, trying to make modifications like standing up and walking around as often as possible. She also stated that there was no pattern of worsening pain or symptoms throughout the day; it solely depended on her overall activity level at work or home.


She woke up approximately three to four times per night with shoulder symptoms if she slept on her left side. However, Kelly stated that this was not much of a problem for her because she would fall asleep within a few minutes if she repositioned herself on her back or right side.


Kelly’s past medical history was unremarkable for any significant illness, injury or hospitalizations, and her family history was also unremarkable. She denied any paresthesia in her upper extremities, reported no significant weakness in her upper or lower extremities and had no history of unexplained weight loss. She did not exhibit dizziness, diplopia, dysarthria, dysphagia, drop attacks, nystagmus, nausea or numbness that may be indicative of cervical arterial dysfunction (Sizer et al., 2007). Lastly, she did not report any dexterity loss or clumsiness during gait, ruling out cervical myelopathy (Cook et al., 2009).


Kelly had not been taking any medications until most recently when she was prescribed an anti-inflammatory by her physician for her current issue. However, she stated that she stopped taking it after a week because it did not seem to change any of her symptoms and resulted in gastrointestinal irritation.


At this point in time, it appeared that Kelly’s symptoms in both her left shoulder and elbow were primarily originating from her shoulder, but because there seemed to be a recent, unexplained increase in neck and shoulder pain, the cervical spine was still considered the primary source of Kelly’s symptoms.



Reasoning Question:



  1. 1. Please discuss your reasoning underpinning your analysis that Kelly’s symptoms are originating from two sources, with the cervical spine being dominant.

Answer to Reasoning Question:


After working through the history with Kelly, it was apparent that there were a few possible pathologies to explore during the physical examination. The primary hypothesis was mechanical neck pain based on the behavior of Kelly’s symptoms. Because Kelly’s shoulder and elbow pain, as well as cervical spine pain and stiffness, had increased recently, it appeared these two symptom locations were related. Because there is evidence for dysfunction in the cervicothoracic region being related to lateral elbow pain (Berglund et al., 2008) and further evidence for positive outcomes for intervention directed toward the thoracic spine (Strunce et al., 2009) and cervicothoracic region in individuals with shoulder symptoms (Mintken et al., 2010), it was thought that the cervical spine was the primary source of Kelly’s symptoms.


However, Kelly’s shoulder and elbow presentation could not be neglected, as there could have also been local sources of nociception, for example, subacromial structures through a mechanism of subacromial impingement or symptomatic rotator cuff pathology. The presence of dull and achy anterior shoulder pain is common with rotator cuff pathology or subacromial impingement, and radiation to the lateral elbow may be seen in patients with these.


With the radiation of symptoms into Kelly’s shoulder and elbow, cervical radiculopathy and a possible neurodynamic issue were also considered. Individuals with neck symptoms may have cervical radiculopathy or neurodynamic symptoms, but it is less common to have symptoms similar to Kelly’s, and it would have been more likely to see symptoms originating in the neck, radiating to the anterior shoulder and lateral elbow, instead of neck symptoms that radiated to the midscapular region as Kelly described. Hence, although these were still on the hypotheses list to be examined, they were considered less likely.


Reasoning Question:



  1. 2. What are your hypotheses in relation to the most likely ‘pain type’ (nociceptive, neuropathic, nociplastic) for the cervical and shoulder symptoms, and is it the same for both?

Answer to Reasoning Question:


Based on Kelly’s description of pain in the cervical spine and left shoulder both at rest and during activity, a nociceptive pain type was hypothesized. She described her symptoms as a dull ache in the shoulder and elbow, and some somatic referral was present with her cervical symptoms; this description of symptoms is common in nociceptive pain. Kelly was able to describe specific activities that would increase her symptoms, specifically, active cervical left rotation and side flexion of the cervical spine and home and work duties for shoulder and elbow symptoms. She also described particular activities she could do to decrease or relieve the symptoms in both the cervical spine and upper extremity, which is also indicative of nociceptive pain (Smart et al., 2012a).


Kelly denied any numbness and tingling, which is often associated with peripheral neuropathic pain, and she also had never felt her pain was burning, shooting, sharp or similar to an electric shock. Kelly’s symptom severity and irritability were relatively low or moderate, whereas individuals with neuropathic pain often have high severity and irritability (Smart et al., 2012b), so neuropathic pain was judged less likely.


As far as nociplastic pain, Kelly’s history of symptoms was worsening over time, but she only had a 3-month history of neck and upper extremity symptoms, and it was not expected that her symptoms would be recovering more quickly at this time due to expected healing time frames. She did not describe constant, unremitting pain, and although she had some difficulty sleeping if she fell asleep on her left shoulder, this was not of concern for the presence of central sensitization. She had distinct locations of cervical, shoulder and elbow symptoms, not widespread pain locations or hypersensitivity as would be seen in patients with nociplastic pain. Most importantly, Kelly was very clear about which activities and positions provoked and decreased her symptoms. In those who have nociplastic pain, it is difficult to find clear aggravating and easing factors (Nijs et al., 2010). The only factor for nociplastic pain being present in Kelly’s case is the possibility that her elbow symptoms were the result of a secondary hyperalgesia, although this will need to be tested in the physical examination.


Clinical Reasoning Commentary:


Clinical reasoning regarding potential ‘sources of symptoms’ can incorporate hypotheses regarding body areas (e.g. cervical spine versus shoulder complex) and specific structures (e.g. specific levels of whole cervical motion segments such as C4–C6, specific segmental cervical structures such as the posterior intervertebral joint, intervertebral disc, or shoulder subacromial tissues versus rotator cuff, subacromial bursa, biceps, etc.). Although symptoms can exist without overt pathology (e.g. postural strain precipitating nociception), hypotheses for symptomatic pathology can also be made through recognition of typical clinical patterns. However, because hypotheses regarding tissue ‘sources’ and symptomatic ‘pathology’ cannot usually be confirmed through the clinical examination, it is important to balance this diagnostic reasoning regarding source and pathology with impairment-focused reasoning (e.g. symptomatic restriction of shoulder flexion or symptomatic restriction of a specific cervical physiological or accessory movement).


At this stage, Kelly’s presentation is hypothesized as being nociceptive dominant. As discussed in Chapter 1, clinical patterns exist in ‘pain type’ as they do in clinical syndromes and pathologies. Although the pain type cannot be confirmed clinically at present, typical clinical patterns have been described through expert consensus, enabling therapists to hypothesize regarding the dominant pain type or combination of pain types. This evolving focus of our reasoning is important because it has significant implications for other categories of clinical judgement, such as ‘precautions’, ‘management’ and ‘prognosis’.


Reasoning Question:



  1. 3. Kelly mentioned that she thought her work was what triggered her symptoms most. Can you comment on whether you thought this was entirely from a physical perspective (e.g. posture) or whether you considered that there might be other psychosocial factors?

Answer to Reasoning Question:


When Kelly presented to physical therapy, she was given a modified Fear-Avoidance Beliefs Questionnaire for her neck symptoms, which is standard practice in this clinic. Although this questionnaire was developed by Waddell et al. (1993) for patients with low back pain, its psychometric properties for patients in neck pain has been studied in more recent years (Cleland et al., 2008a) and found to have substantial test-retest reliability and high internal consistency. The Fear-Avoidance Beliefs Questionnaire has two subscales, physical activity and work. Several questions are asked about patient beliefs in regard to how particular activities may increase their pain, and if overall scores are low in both of the subscales, it is less likely that psychosocial factors may impact the patient’s overall symptoms and progress with physical therapy.


In the case of Kelly, she had a score of 4 out of 24 on the physical activity subscale and a score of 16 out of 42 on the work subscale (Waddell et al., 1993). Also, Kelly never discussed any stressful events in her life or in relation to her work that may have impacted her overall mental and physical health. Because of these reasons, it was felt that Kelly’s cervical and upper extremity symptoms were solely from physical impairments, including poor posture and limited mobility of the cervicothoracic and shoulder joints.


Clinical Reasoning Commentary:


As with all assessment (interview, physical, outcome re-assessments), it is an error of reasoning to assume the absence of something without explicitly assessing it. Screening (for other symptoms and health comorbidities, for other aggravating and easing factors, for psychosocial factors) is discussed in Chapter 1 as a strategy that promotes thoroughness and minimizes errors of bias. Explicit screening for potential involvement of psychosocial factors in patients’ pain and disability experiences, as occurs in this case, is essential to reason and practice in a biopsychosocial framework. Refer to Chapters 3 and 4 for theory underpinning the importance of psychosocial factor screening and discussion of questionnaires and suggested areas to question in the patient interview.



Physical Examination


Observation


Kelly presented with a slight forward head posture, and when cued to improve her posture, she was able to exhibit neutral posture. She noted that she attempted to remind herself at work to maintain good posture but that she often found herself with an increased forward head posture in order to ‘get closer to the computer to see the screen better’. Her thoracic spine was slightly flexed from the cervicothoracic junction to T2. She had a relatively flat thoracic spine from T3 to T6.



Cervical Range of Motion


Active cervical flexion, right side flexion and rotation were all full and pain-free. Overpressure was performed on all full and pain-free movements, with no provocation of symptoms. Active extension, left side flexion and rotation were all stiff and provoked Kelly’s most recent neck pain. Kelly had full cervical extension but noted feeling considerable stiffness and a pain level of 2/10 at end range. With left side flexion and rotation, Kelly experienced similar symptoms, but she was also restricted by approximately 20 degrees for each motion as measured by a bubble inclinometer (side flexion) and a universal goniometer (rotation). A passive quadrant test on the left side provoked Kelly’s neck symptoms, with radiation into her left midscapular region. With left side flexion and rotation, Kelly noted increased anterior shoulder pain that radiated to the lateral elbow, similar to the symptoms that brought her to physical therapy.



Shoulder/Elbow Range of Motion


Kelly’s right shoulder active range of motion and left shoulder extension and external rotation were full and painless, but she did have restricted left shoulder flexion to 140 degrees, left shoulder abduction to 120 degrees and internal rotation of 45 degrees when assessed at 60 degrees of abduction and functional internal rotation as measured with the hand behind the back, where Kelly was able to reach the L4 level. Each of these motions provoked Kelly’s primary shoulder and elbow pain. When Kelly was cued to improve her posture prior to performing range of motion, her active range of motion improved by approximately 5 degrees with shoulder flexion and abduction, but she continued to have shoulder and elbow pain. Passively, Kelly had 155 degrees of left shoulder flexion, 130 degrees of shoulder abduction and 50 degrees of internal rotation when assessed at 60 degrees of abduction. Her right shoulder passive range of motion in all planes was full and painless, as expected, per the results of active range-of-motion assessment. Overpressure was performed on all full and painless active motions bilaterally, with no reproduction of symptoms. When overpressure was performed on left shoulder flexion and abduction after passive range of motion, Kelly reported provocation of her shoulder and elbow pain at end range.



Reasoning Question:



  1. 4. Could you comment on the scapula humeral kinematics and, in particular, any abnormal muscle activity/recruitment with the active shoulder movements?

Answer to Reasoning Question:


During active shoulder flexion and abduction, it did appear that Kelly had decreased upward rotation of the scapula (serratus/upper and lower trapezius) and instead appeared to be elevating her scapula through dominant use of her upper trapezius and levator scapulae. She also had delayed downward rotation and depression when returning to a neutral position from a flexed or abducted position actively.


Before even testing the strength of her musculature through scapular biomechanical observation, it appeared Kelly had a weak serratus anterior, rhomboid major/minor and middle and lower trapezius, all muscles that assist with upward rotation, downward rotation and depression of the scapula during shoulder motion (Ludewig and Braman, 2011).


These findings pointed further to the possibility of shoulder impingement (Ludewig and Braman, 2011), and as such, this disorder continued to be on the list of potential diagnoses. However, the idea of regional interdependence defined as ‘the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint’ (Wainner et al., 2007) was the primary reasoning at this point in time. Kelly had left shoulder and elbow symptoms that were increasing in nature, but so was her cervical pain and stiffness. It was still believed that the impairments from the shoulder and elbow were related to the cervical spine, consistent with the concept of regional interdependence.


Clinical Reasoning Commentary:


The recognition of impaired scapular humeral kinematics allows for inference of weakness in the muscle force couples responsible for scapular control and the possibility that poor scapular control may be a ‘contributing factor’ to a subacromial problem. Such hypotheses can then be tested through manual muscle and functional tests of strength and interventions that modify scapular kinematics to assess the effect on shoulder symptoms and movement impairments. The value of holding clinical judgements as hypotheses, particularly this early in the patient assessment, is that a range of possible explanations for a patient’s disability can be abductively postulated and then ‘tested’ through the physical examination and the ongoing management–re-assessment process.



Joint Mobility


Joint mobility was assessed in the cervical spine, thoracic spine, shoulder and elbow. The elbow joint mobility was normal bilaterally, with no provocation of symptoms during left elbow joint mobility assessment. The sternoclavicular and acromioclavicular joints were assessed and determined to have normal mobility bilaterally. With a caudal and posterior glide of the glenohumeral joint on the left from a position of elevation short of pain, Kelly’s primary shoulder and elbow symptoms were provoked. Along with the provocation of symptoms, there was also stiffness with these glides. Central posterior-anterior glides to the cervical spine exhibited stiffness at the C4–C6 region, along with provocation of Kelly’s neck and shoulder symptoms. Unilateral posterior-anterior glides of the cervical spine in the C4–C6 region on the left side again provoked Kelly’s neck and shoulder symptoms. Mobility of the cervicothoracic junction was hypomobile with central posterior-anterior glides, but there was no provocation of Kelly’s primary symptoms. Thoracic spine mobility assessment revealed asymptomatic stiffness, both central and unilateral from T1–T7.



Reasoning Question:



  1. 5. Examination of both cervical and shoulder joint mobility reproduced shoulder pain. Can you comment on the significance of this finding and how it may relate to your initial hypothesis regarding the source of the pain?

Answer to Reasoning Question:


Initially, the hypotheses for Kelly’s symptoms included mechanical neck pain but also local shoulder structures, for example, as involved in subacromial impingement or rotator cuff pathology. After seeing that Kelly had provocation of symptoms in her left shoulder and elbow with caudal and posterior glides of the glenohumeral joint, involvement of the shoulder was further supported, suggesting Kelly had both a cervical spine and shoulder component to her presentation. Yet the reproduction of the same symptoms with both cervical spine and shoulder joint mobility assessment was pointing toward a primary issue in the cervical spine.


After further thought, however, with the shoulder region being innervated by peripheral nerves emanating from C4–C6, it could still make sense that an individual with cervical spine pain and stiffness could have symptoms in the shoulder region that are actually from the cervical spine but mimic a shoulder pathology. Based on the discussion earlier regarding individuals with shoulder pain who respond well to interventions to the cervicothoracic region (Strunce et al., 2009; Mintken et al., 2010) and those who have cervical spine pathologies that present with elbow pain (Berglund et al., 2008), mechanical neck pain with subsequent shoulder and elbow symptoms was still the primary hypothesis. However, this hypothesis could only be confirmed with further objective information, as well as manual intervention.


Clinical Reasoning Commentary:


As previously commented, the physical examination provides the opportunity to screen the patient’s physical status and to explicitly ‘test’ hypotheses formulated in the subjective examination (history). Here, physical impairments in shoulder movement associated with provocation of relevant symptoms are acknowledged as supporting a local shoulder component to the problem. The relationship between shoulder innervation and Kelly’s demonstrated cervical impairment occurring at these same levels provides a mechanism for cervical somatic referral to the shoulder and/or sensitization of shoulder tissues. This highlights the importance of avoiding premature conclusions and the value of more open, hypothesis-oriented reasoning that considers physical findings as ‘supporting’ different components to a presentation. In this case, both cervical and shoulder components are acknowledged, even if one is judged more likely, keeping the reasoning open until further ‘testing’ is carried out through trial treatment interventions.

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Applying Contemporary Pain Neuroscience for a Patient With Maladaptive Central Sensitization Pain A Professional Football Career Lost A 30-Year History of Left-Sided ‘Chronic Sciatica’ A Multifaceted Presentation of Knee Pain in a 40-Year-Old Woman Incorporating Biomechanical Data in the Analysis of a University Student With Shoulder Pain and Scapula Dyskinesis Physical Therapy Chosen Over Lumbar Microdiscectomy

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Apr 2, 2020 | Posted by in SPORT MEDICINE | Comments Off on Neck and Upper Extremity Pain in a Female Office Assistant

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