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Neck Pain 
 
 
 
Version 2 Final 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EBM – Neck Pain 
Version 2 Final 
MED S2 CMEP~0049(b) 
 
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Document control 
 
Version history 
Version Date 
Comments 
2 Final 
17 September 2010 
Signed off by CMMS 
2d draft 
12 February 2010 
External QA by Dr Thomas  
2c draft 
05 November 09 
Int. Q.A. 
2b draft 
June 2009 
Format and insert Appendix A 
2a draft 
March 2009 
Review draft 
2  draft 
16th August 2006 
Initial Draft 
 
 
 
Changes since last version 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1.  Introduction 
Pain in the neck can be due to injury, a mechanical or muscular problem, a 
trapped nerve caused by a bulge in one of the discs between the vertebrae, or 
from arthritis of the neck.  

 
Description 
The stability of the neck depends mainly on the 
musculature and ligamentous structures attached to the 
cervical spine which consists of seven vertebrae which 
articulate with each other through a system of joints of 
unusual complexity.  Each pair of cervical vertebrae is 
separated by an intervertebral disc and a pair of 
apophyseal joints but they also articulate through an 
additional pair of apophyseal joints at their posterolateral 
aspects. 
 
The cervical spine provides a protective passageway for 
the vertebral arteries and the spinal cord. 
 
Most cervical problems are mechanical and mainly affect the joints and 
associated ligaments and muscles1.  However, systemic disorders do give 
rise to similar symptoms and need to be excluded by careful history and 
examination techniques. There are also a number of important malignant 
conditions which need to be excluded, including cervical spine 
malignancy/metastasis and vertebral osteomyelitis, as well as head and 
neck soft tissue tumours.  
 
Neck pain is discussed in general followed by specific sections on 
degenerative change, whiplash injury and torticollis. 
Prevalence 
The prevalence of neck related discomfort has been estimated as 9% for 
adult males and 12% for adult females.  It has been estimated that two 
thirds of the population will suffer an episode of neck pain during their 
lifetime23 and that up to one third of patients attending general practitioners 
will complain of symptoms lasting more than six months or occurring in 
bouts.  Prevalence is highest in middle age, with women being affected 
more than men.  About 15% of hospital-based physiotherapy in the UK is for 
neck pain4
Cervical dystonia (torticollis or “wry neck”) is the most common adult form of 
focal dystonia, with prevalence in Europe of 5.7/100,000.
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2.  Aetiology 
Neck pain can arise from a variety of conditions including whiplash injury, 
cervical dystonia and cervical spondylosis; although in the latter case there 
is only poor correlation between symptoms and radiological evidence of 
degenerative disease in the cervical spine6
 
Although mechanical neck pain is common in the adult population, has 
significant morbidity and is a common cause of referral to hospital 
specialists, there is a scarcity of studies on the natural history and outcome. 
This may reflect the difficulty in assessing severity of neck pain, for while 
symptoms are most prominent, signs, which are difficult to quantify, are 
generally limited to tenderness and a reduced range of neck movement7
 
It is pain felt in the neck may be referred from many sources outwith the 
musculoskeletal structures of the cervical spine. These may include the 
mouth, jaw and teeth, the meninges, the middle and inner ear, the larynx, 
pharynx and sinuses, the cervical lymph nodes and the shoulder girdle. 
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3.  Diagnosis 
Symptoms arising in the neck are often poorly localised, making a precise 
anatomical diagnosis difficult.  However, particular features of the patient’s 
history and examination can distinguish between common mechanical 
disorders and more sinister disease. 
 
As spondylosis is most common in the lower cervical spine, any pain is 
usually felt low in the neck and often radiates to the occiput, trapezius and 
inter-scapular areas.  This distribution may be due to dural irritation.  Painful 
shoulder movement can lead to an erroneous diagnosis of a shoulder 
problem.  However, referred pain is rarely affected by shoulder movement 
and pain varying on neck movement is normally related to the cervical spine. 
 
Symptoms and signs of neck pain may be conveniently divided into those 
arising from either articular, dural or nerve root problems. 
 
 
Symptoms Signs 
Articular 
Intermittent neck pain movement 
Asymmetrical restriction of neck 
In occiput, vertex, trapezius, 
Rarely pain on shoulder 
Dural Pain 
deltoid and inter-scapular regions  adduction/external rotation 
Weakness of triceps, fingers and 
Severe pain in upper arm, 
Nerve root 
wrist 
dorsum of forearm, dorsum 
Usually C7 
Absent triceps reflex and sensory 
extensors 
impairment 
 
The presence of bilateral symptoms or signs or involvement of more than 
one nerve root usually signifies more severe or possibly sinister pathology, 
e.g. cold compression due to tumours. 
 
Plain x-rays of the cervical spine are rarely helpful in diagnosing the cause 
of neck pain except to look for major injury after trauma, an observation 
confirmed by a study in elderly patients which concluded that there was no 
place for routine radiological examination of the cervical spine in patients 
with vertebrobasilar insufficiency. 
 
Radiologically degenerative changes occur commonly in people over the 
age of forty, are often symptomless and do not correlate well with clinical 
findings. 
 
Magnetic Resonance Imaging (MRI) can be used to diagnose and assess 
anatomical problems such as atlantoaxial subluxation in rheumatoid 
disease, tumours, infections (abscesses) and injury. 
 
It can identify prolapsed cervical discs but is not yet able to demonstrate the 
anatomical abnormalities attributable to neck pain in most cases. 
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Differential Diagnosis 
Infective 
Infection in the cervical spine or retropharyngeal space causes persistent 
pain with symmetrically restricted movement.  Although the patient is usually 
unwell, this is not a constant feature.  The ESR, plasma viscosity and CRP 
is raised early but bone and joint changes on x-ray are a late feature.  
Expansion of the retropharyngeal space as a soft tissue shadow may be 
seen on a lateral x-ray of the neck. 
 
Non-infective inflammation 
This occurs in a wide range of connective tissue disorders particularly: 
 
Rheumatoid arthritis 
The upper cervical synovial tissue is affected causing ligamentous 
weakness and joint instability.  Atlantoaxial subluxation is common in about 
25% of inpatients with rheumatoid arthritis, while destruction of the lateral 
processes of the atlas can lead to vertical subluxation. 
 
Ankylosing spondylitis
 
This classically presents with sacroiliac problems but neck stiffness can be a 
presenting feature. 
 
Polymyalgia rheumatica 
Polymyalgia rheumatica and giant cell arthritis can also present with neck 
pain.  Classically they occur in the elderly, with pain and stiffness which is 
symmetrical.  The classical presentation involving shoulders etc is usually a 
straightforward diagnosis, but occipital artery involvement causing neck pain 
and stiffness is more difficult. 
 
Neoplastic disease
 
This is suggested by unremitting pain which radiates to both arms and is 
worse at rest. Sleep disturbance is common and neck movements are 
usually painfully limited in all directions. 
 
The following diseases should be considered in the differential diagnosis of 
cervical spondylosis with myelopathy: motor neurone disease, multiple 
sclerosis, spinal cord tumour and syringomyelia. 
 
While with cervical spondylosis with radiculopathy: nerve entrapment 
syndromes (carpal tunnel etc.) and brachial neuritis should be excluded. 
 
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4.  Degenerative Change 
Mild to moderate degenerative changes are often asymptomatic8, but when 
degenerative changes are severe they may be associated with neck pain 
which, because it is mechanical in nature, is usually intermittent and related 
to use.  With normal ageing the intervertebral discs fragment, lose water 
content and collapse.  This causes increased mechanical stress at the 
cartilaginous end plates and osteophyte formation which can extend 
ventrally and in some cases encroach on nervous tissue. 
 
Osteophyte formation, most common in patients over the age of 55 years, 
should be differentiated from the soft disc herniations which occur in the 
young and middle aged.  The most severe form of cervical spondylosis can 
involve the nerve roots (radiculopathy), the vertebrobasilar circulation and 
the spinal cord itself (myelopathy).  Cervical spondylosis is a condition in 
which degenerative changes in both the intervertebral disc and the annulus, 
as well as the formation of bony osteophytes, narrows the cervical canal or 
neural foramina which can, in severe cases, lead to cord compression. 
 
Spondylosis is most common in the low cervical spine, between C5-C6 and 
C6-C7, the joints associated with flexion and extension, and much less 
commonly in the upper spine, C1-C2 and C3-C4, which are associated with 
rotatory movements.  About 60-85% of middle-aged adults are affected by 
spondylotic changes between the third and seventh vertebrae. 
 
 
Intervertebral discs from C2-3 and below are subject to significant 
deformation during flexion and extension.  Disc herniation can lead to 
compression of the nerve root (radiculopathy) or of the spinal cord 
(myelopathy).  Eight pairs of spinal nerves exit bilaterally through the 
intervertebral foramina and each is named from the vertebra below.  
Therefore a herniated disc at the C5-6 level will most commonly involve the 
C6 nerve and its area of distribution.  
 
Cervical spondylotic myopathy has a variable natural course.  It usually 
develops insidiously although episodes of abrupt deterioration do occur.  It 
was assumed at one time that the spondylitic changes in the cervical spine, 
which occur with increasing age, may impinge on the spinal canal causing 
chronic cord compression.  However, at operation, the degree of cord 
compression was often not consistent with the neurological disturbance and 
decompression seldom led to significant neurological improvement.  It 
seems therefore that production of the myopathy in these cases is more 
than just simple compression and may involve compression of the radicular 
and/or anterior spinal arteries9
 
Fortunately, most adults with cervical spondylosis — nearly 90 percent — 
will not lose nerve function, even temporarily.10 
 
High compressive myelopathy (C3-C5) causes numb clumsy hands and is 
associated with loss of manual dexterity, diffuse non-specific weakness of 
the arms and abnormal sensations.  Lesions affecting levels C5-C8 cause a 
syndrome of spasticity and proprioceptive loss in the legs.  Improvement has 
been quoted to occur in 30-50% of patients with non-operative treatment. 
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The various myelopathic syndromes, e.g. Brown-Séquard, have different 
localising symptoms depending on the position of the compression. 
 
Acute cord compression by disc protrusion and spinal cord damage caused 
by a combination of cervical spondylosis and hyperextension injury 
(whiplash) may lead to severe cord compression, but is not related to 
spondylotic myelopathy. 
Treatment 
Episodes of acute neck pain are generally self limiting and require only 
symptomatic treatment.  
 
Active treatment involving mobilisation (moving the joints within their 
restrictive range) and manipulation (moving the joints briefly beyond their 
restrictive range) is now the treatment of choice.   
Collars, if prescribed, are generally only worn for activities likely to 
exacerbate the pain and then for only two to three weeks. 
 
Advice on the correction of postural abnormalities and neck stretching 
exercises is beneficial. 
 
Radicular pain is treated with rest and wearing a collar for up to two weeks. 
 
Approximately 75% of patients have complete or partial but significant relief of 
symptoms with non-operative management.11 Features suggesting a poor response 
to nonoperative treatment include advanced age, duration of symptoms, severity of 
myelopathy, and severity of stenosis12 
 
Limited studies have shown some improvement with muscle relaxants 
(cyclobenzaprine)13 but 60% of patients demonstrate side effects, mainly dry mouth 
and sedation.14 
 
A controlled trial comparing acupuncture with placebo failed to show a significant 
difference in pain relief but there were concerns about the quality of the placebo.15  
 
Intractable nerve root symptoms and the rare occurrence of spinal cord 
compression are investigated further and can require surgical intervention if 
conservative measures fail. 
 
Despite early recognition and improved surgical techniques, not all authors 
agree that surgery improves the variable clinical spectrum of cervical 
spondylotic myelopathy.  A variety of surgical techniques have been 
proposed including cervical laminectomy and anterior spinal fusion but the 
results are often disappointing and no single procedure has been found to 
be superior over another16.  In a recent series17 anterior cervical discectomy 
and fusion was associated with an acceleration of degenerative changes at 
the fused and adjacent levels. 
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Prognosis 
Neck pain from degenerative cervical disease usually responds to simple 
measures such are mobilisation and analgesia. 
 
Spondylotic radiculopathy also resolves with conservative therapy in most 
cases and surgical intervention is not considered unless there is persistent 
pain or progressive neurological problems. 
 
Myelopathy is the most severe form of the disease but a third to a half of 
these patients improve with simple measures such as wearing a collar18
 
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5.  Whiplash injury 
Between 2002 and 2009 the incidence of whiplash injury increased by 25% 
in the UK, and constitute 76% of motor insurance claims. It is estimated that 
they cost the UK economy £3.63billion a year. Whiplash injury, an acute soft 
tissue injury (extension sprain19) in the neck after a road traffic accident or 
sporting accident may occur after front, side or rear collision.  In road traffic 
accidents proper adjustment of head restraints should prevent whiplash 
injury in rear collisions but there is a general lack of knowledge on proper 
positioning of the head restraint.  
 
 
                                        (Image from www.bodymovesphysio.com.au ) 
 
Although the mechanism of injury appears well understood as a 
hyperextension strain beyond the normal anatomical limit, the immediate 
pathology and resultant long-term effects are not known and therefore 
treatment is empirical. 
 
It has been suggested that whether or not a victim pursues litigation is 
related to the severity of injury20.  However a study of 100 patients, mean 
age 47 years, who had sustained neck ‘sprains’ as a result of rear impact 
does not confirm this impression.  In nearly 60% of these cases, the patients 
were free of significant pain before settlement of their claims. 
 
Factors in the prognosis in whiplash injury were reported upon as follows: 
 
 
The patient’s sex was not statistically related to the duration or grade of 
pain. 
 
Age over 45 years was associated with longer duration of pain. 
 
Onset of pain occurring at least twelve hours after the accident was 
associated with a quicker recovery and a better end result. 
 
Previous symptoms in the cervical spine before injury resulted in a 
longer period of pain. 
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Cervical spondylosis diagnosed by X-ray at or prior to the injury was 
associated with longer duration of symptoms.  
 
The presence of root pain at any time after injury bore no relation to 
either the duration of symptoms or the final outcome. 
Grading whiplash injury 
The Quebec Task Force developed a classification for grading whiplash 
injury21
  
Parameters: 
(1) Neck complaint (pain, stiffness, tenderness) 
 
(2) Musculoskeletal signs (decreased range of motion and/or point 
tenderness) 
 
(3) Neurological signs (decreased or absent deep tendon reflexes [DTR], 
weakness, sensory deficit) 
 
(4) Vertebral fracture or dislocation 
  
Neck 
Musculo-
Neurological 
Fracture or 
Grade 
Complaint 
skeletal 
Signs 
Dislocation 
absent absent absent absent  0 
present absent  absent  absent  1 
present present  absent  absent  2 
present NA present 
absent 3 
NA NA NA 
present 

 
The following findings may be seen with any grade and are not used for 
classification: headache, dizziness, deafness, memory loss, dysphagia and 
temporomandibular joint pain. 
Treatment 
Caution is needed when attempting to draw conclusions regarding the 
efficacy of conservative treatments in whiplash-patients, because of the 
paucity of high-quality studies. 
 
‘It appears that "Rest makes rusty."  In other words, rest and immobilization 
using collars are not recommended for the treatment of whiplash, while 
active interventions, such as advice to 'maintain usual activities' might be 
effective in whiplash-patients’22. Physiotherapy may be of benefit, as well as 
Maitland’s manipulations. Non-steroidal anti-inflammatory analgesia can be 
used. In the chronic cases, facet blocks have been shown to show some 
short-term benefit, but have a 50% recurrence rate within a week. Botulinum 
toxin has been used and shown to produce only a 7% reduction in pain. In 
brachalgia, cervical fusion has produced a 32% success rate19. 
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Prognosis 
In the UK up to 40% of people continue to report symptoms 15 years after 
the accident.23 Just under 50% make a permanent recovery and 4.3% are 
permanently disabled.24  
 
There is compelling data from Germany and Greece indicating that the 
outcome of whiplash injury is culturally dependent.25 
 
In a prospective study of 210 consecutive persons experiencing rear-end 
collisions in Kaunas, Lithuania 47% reported initial symptoms but one year 
after the accident they had no more symptoms than a group of 210 matched 
controls who had not been in accidents26.  They concluded that, where there 
was no preconceived notion of chronic pain following rear-end collisions; no 
fear of long-term disability and usually no involvement by therapists, 
insurance companies or lawyers, symptoms from `whiplash injury' were brief 
and self- limiting. 
 
The wide variations in whiplash injury incidence and/or chronicity reported 
from country to country are more plausibly explained by cultural and 
psychosocial factors than by purely mechanical ones. The signs and 
symptoms of whiplash syndrome include psychological as well as physical 
components. This may involve impaired concentration, poor memory, 
somatoform disorder, post-traumatic stress disorder and depression. These 
symptoms may be as severe as after trauma involving multiple fractures. A 
pre-accident psychological history may predispose to these 
manifestations.19  
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6.  Torticollis (Cervical Dystonia) 2728 
Spasmodic torticollis, also known as cervical dystonia, and commonly called 
“wry neck”, is the condition of spasm affecting the muscles of the neck, 
causing the head to assume unnatural postures. 
 
The head may be pulled backwards (retrocollis), forwards (anterocollis) or to 
the side (torticollis), depending on which muscle groups are affected.  This 
muscle spasm may occur intermittently or continuously.  The cause of 
cervical dystonia is not known. 
In children, it is sometimes associated with congenital abnormalities of the 
shape of the head or of the spine, but it may occur at any age.  Cervical 
dystonia may persist for several years, or sometimes for life.  Some patients 
recover spontaneously. 
 
The movements may be sustained or jerky (myoclonic torticollis).  Muscle 
spasms or pinching nerves in the neck can be very painful.  The neck may 
eventually be held permanently in one position. 
 
Torticollis usually develops gradually.  At first, the patient may notice that the 
head turns during everyday activities.  In about a quarter of patients the 
hand may also develop some tremor, especially if trying to correct the 
involuntary movement.  The tremor is common but not usually disabling and 
is referred to as an enhanced physiologic tremor. 
 
The severity of torticollis can vary and may be worse if the patient is under 
stress.  Occasionally drinking alcohol can improve the torticollis. 
 
Some sufferers have a history of head or neck injury, but as yet there is no 
evidence to support the theory that torticollis is directly related to trauma. 
 
Patients with torticollis often find that their daily lives are affected.  Head 
turning can prevent a proper view of the road when driving.  
It may become difficult to eat, brush teeth or apply makeup.   
Many sufferers find embarrassment and anxiety the major handicap.If 
chronic, torticollis can lead to cervical spondylosis, radiculopathy and 
myelopathy29.   
Prevalence 
5.7 per 100,000 in Europe. 
There are thought to be 10,000 people in the UK suffering from this 
condition.  The average age of onset is in the early 40s and more women 
are affected than men. 
Aetiology 
Spasmodic (or adult-onset) torticollis is usually idiopathic.  About 5% of 
patients with spasmodic torticollis have a family history.  One third of these 
patients have other dystonias (e.g. eyelids, face, jaw, hand).  Torticollis can 
also be congenital or secondary to other conditions such as lesions of the 
brain stem and basal ganglia30
 
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Diagnosis 
The diagnosis is based on characteristic symptoms and signs and exclusion 
of alternative diagnoses, such as the following: 
 
Tardive dyskinesia can cause torticollis but can usually be distinguished by 
a history of chronic antipsychotic use and involuntary movements in muscles 
outside of the neck. 
 
Basal ganglia disease and occasionally CNS infections can cause 
movement disorders but usually also involve other muscles.   
Also, CNS infections are usually acute and cause other symptoms. 
 
Neck infections or tumours are usually differentiated by features of the 
primary process. 
 
Antipsychotics and other drugs can cause acute torticollis, but the 
symptoms usually develop in hours and resolve within days. 
 
Torticollis may be graded by the Toronto Western Spasmodic Torticollis 
Rating Scale 31 
Treatment30 
Spasms can sometimes be temporarily inhibited by physical therapy and 
massage, including sensory biofeedback techniques (slight tactile pressure 
to the jaw on the same side as head rotation - sensory trick) and any light 
touch. 
Touching an affected or adjacent body part can sometimes significantly 
reduce contractions. For example, placing a hand on the chin, side of the 
face or back of the head may reduce neck muscle contractions.  
People with dystonia typically discover and use this trick to reduce their own 
dystonic contractions. Some physical therapists have developed head or 
neck braces, hand splints or other devices that mimic the sensory trick.  
 
Injections of botulinum toxin type A & B into the dystonic muscles can 
reduce painful spasms for 1 to 3 months in about 70% of patients, restoring 
a more neutral position of the head.  However, this treatment can lose 
effectiveness with repeated injections because antibodies develop against 
the toxin. 
 
Drugs can usually relieve pain. However they suppress dystonic movements 
in only about 25 to 33% of patients.  Anticholinergics such as trihexyphenidyl 
may help.  All drugs should be started in low doses.  Doses should be 
increased until symptoms are controlled or intolerable adverse effects 
(particularly likely in the elderly) develop. 
 
Surgery is controversial in adult torticollis.  The most successful surgical 
approach, selective peripheral denervation, selectively severs nerves to 
affected neck muscles, permanently weakening or paralysing them.  Results 
are favourable when the procedure is done at centres with extensive 
experience.  Patient selection for this procedure is important.  Patients 
should be offered the procedure only when their disease has become 
refractory to best non-surgical treatment.27 In congenital torticollis 
sternomastoid release is a more successful and accepted procedure. 
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Rarely, an emotional problem contributes to spasmodic torticollis when 
psychiatric treatment is indicated.   
Prognosis is best if symptom onset coincided with exogenous stress. 
Prognosis 
Most patients find the condition deteriorates over the first five years, but 
their symptoms then stabilise.  One third of patients progress to a 
segmental dystonia, usually involving the arm.  The symptoms of about 
10 per cent may resolve spontaneously, but then later recur. 
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7.  Main Disabling Effects of Neck Pain 
These can be considered under musculoskeletal, neurological and 
ischaemic factors.  Ultimately, significant disability arising from pathology in 
the neck may lead to chronic periodic pain, bent jerky gait and clumsy 
hands. 
 
Musculoskeletal disorders give rise to stiffness and acute or developing 
chronic pain.  In many cases of acute pain they settle without medical 
advice.  Treatment for acute pain includes, rest, support, education about 
movement and analgesia.  About 10% of those presenting for medical 
opinion progress to chronic pain.  This is both local and referred to head, 
shoulder or arm. 
 
A ‘functional disability scale’ has been developed [Appendix A – The 
Copenhagen Neck Functional Disability Scale] and used to demonstrate that 
patients with ‘chronic pain’ have reduced neck muscle strength and 
endurance, particularly of the extensor muscles. 32 
 
Lesions at C1-2 refer pain to the occiput and at C5-6 refer pain to the 
forearm and hand. 
 
Neurological disabilities due to disc herniation or isolated osteophytes may 
be localised, of a lower motor neurone type1 and related to one or more 
nerve roots. 
 
In spondylosis, multiple level disease develops in 60-85% of cases. 
 
The C6 and C7 nerve roots are most commonly affected causing weakness 
of the triceps muscle which may affect reaching but not lifting, and sensory 
impairment of the index and middle fingers which may affect pinch grip 
function. 
 
75% of patients with radiculopathy as a result of cervical spondylosis will 
resolve spontaneously18. 
 
Involvement of a nerve root will involve loss of power with flaccid paralysis 
and referred pain and paraesthesia. 
 
Myelopathy produces more general effects and is the result of cord 
compression.  This may be more likely in people with narrow vertebral 
foramina which is usually a familial complaint and is also associated with 
achondroplasia.  Mechanical relief of cord compression does not always 
lead to improvement because ischaemia of the cord is also though to be a 
factor. 
 
Myelopathy with cord compression at C3-5 causes clumsiness of the hands 
with weakness and loss of dexterity. 
 
Compression lower down at C5-8 causes spasticity with loss of 
proprioception in the legs. 
 
 
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Myelopathy is a serious condition and although the progress of the disease 
varies greatly, 30-50% can improve with non-surgical treatment1
 
Extreme cases will exhibit urinary frequency and urgency. 
 
Major anatomical deformity in the cervical spine produces cerebellar 
ischaemia resulting in giddiness especially on rotation or extension of the 
neck. 
 
The Division of Industrial Accidents at the University of California has 
attempted to develop guidelines for the evaluation of medical factors of 
disability in neck (and back) injuries over the past ten years33
 
The guidelines are very comprehensive and consist of a list of 37 factors of 
disability. 
 
The first ten factors are ‘subjective’ and in this system only count towards a 
final assessment if supported by ‘objective’ factors such as muscle strength. 
Trigger points and ranges of flexion, extension etc. 
 
Currently many of the objective factors require measurement using 
instruments which have significant inter-observer error. 
 
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Reference 
 
1 Matthews JA. Acute neck pain – differential diagnosis and management. ARC 
2 Måkelå M, Heliövaara M, Sievers K, et al. Prevalence, determinants, and consequences of 
chronic neck pain in Finland. Am J Epidemiol 1991;134:1356–1367 
3 Côté P, Cassidy D, Carroll L. The Saskatchewan health and back pain survey: the 
prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998;23:1689–
1698. 
4 Hackett GI, Hudson MF, Wylie JB, et al. Evaluation of the efficacy and acceptability to 
patients of a physiotherapist working in a health centre. BMJ 1987;294:24–26.  
5 Epidemiological Study of Dystonia in Europe (ESDE) Collaborative Group. A prevalence 
study of primary dystonia in eight European countries. J Neurol 2000; 247:787–792. 
6 Jayson M I V. Work related upper limb disorders. ARC reports on rheumatic diseases Series 
3, May 1977 No 11 
7 Leak A M et al. The Northwick Park Neck Pain Questionnaire. Brit. J Rheumatol. 1994; 33: 
469-474 
8 Barry M, Jenner J R. Pain in the neck, shoulder and arm. ABC of Rheumatology Ed M 
Snaith. 1996 BMJ Publishing Group. 
9  Oxford Textbook of Medicine (CD). Oxford University Press. Published in print form by 
PasTest Third Edition 1996 Editors: D J Weatherall, JGG Ledingham and DA Warrell Cervical 
Spondylosis 1996; 165(1/2): 43-51 
10 http://www.mayoclinic.com/health/cervical-spondylosis/DS00697 
11 Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery: 60(1) 
(Supp);S1-43–S1-50. 2007 
12 Edwards CC 2nd, Riew D, Anderson PA, Hilibrand AS, Vaccaro AF: Cervical myelopathy: 
Current diagnosis and treatment strategies. Spine J 3:68–81, 2003. 
13 Aker PD, Gross AR, Goldsmith CH, Peloso P: Conservative management of mechanical 
neck pain: A systematic overview and meta-analysis. BMJ 313: 1291–1296, 1996 
14 Browning R, Jackson JL, O'Malley PG: Cyclobenzaprine and back pain: A meta-analysis. 
Arch Intern Med 161:1613–1620, 2001 
15 White P, Lewith G, Prescott P, Conway J: Acupuncture versus placebo for the treatment of 
chronic mechanical neck pain: A randomized controlled trial. Ann Intern Med 141:911–919, 
2004 
16 L D Lunsford et al. Anterior surgery for cervical disc disease. J Neurosurg 1980; 53: 12-197 
17 Wu W et al. Degenerative changes following anterior discectomy. Acta Radiologica 1996; 
37: 614-617. 
18 McCormack B M, Weinstein P R Cervical Spondylosis. An update. 1996; 165(1/2): 43-51 
19 Parmar H V, Raymakers R. Neck injuries from rear impact road traffic accidents: prognosis 
in persons seeking compensation. Injury. 1993; 24(2): 75-78 
20 Pennie B, Agambar I. Patterns of injury and recovery in whiplash. Injury. 1991; 22: 57 
21 Spitzer WO, Skovron ML, et al. Scientific monograph of The Quebec Task Force on 
Whiplash-Associated Disorders: Redefining "whiplash" and its management. Spine. 1995; 20 
(Supplement): 8S to 58S. 
22 Conservative treatment for whiplash.  Cochrane Database Syst Rev. 2001; (4):CD003338  
Verhagen AP, Peeters GG, de Bie RA, Oostendorp RA. Department of General Practice, 
Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands. 
23 www.clinicalevidence.bmj.com 
24 Bannister G, Amirfeyz R, Kelley S, Gargan M. Whiplash injury. Journal of Bone and Joint 
Surgery. (British volume): Jul 2009. Vol. 91B(7);845-51 
25 Kwan O, Friel J. Clinical relevance of the sick role and secondary gain in the treatment of 
disability syndromes. Med Hypo 2002; 59: 129-34. 
26 Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a 
prospective controlled inception cohort study. • Neurol Neurosurg Psychiatry 1999;66:279±83  
27 National Institute Clinical Excellence Interventional Procedure Guidance 80. Selective 
peripheral denervation for cervical Dystonia.  August 2004. 
 
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28 Dr Helen Hanson, Movement Disorders Unit, King's College Hospital, London and Dr K 
Ray Chaudhuri, Movement Disorders Unit, King's College Hospital, London. 
www.netdoctor.co.uk 
29 Hagenah JM, Vieregge A, Vieregge P (2001) Radiculopathy and myelopathy 
in patients with primary cervical dystonia. Eur Neurol 45: 236–240 
30 Sally Pullman-Mooar, MD. The Merck Manuals Online Library. June 2008 
31 Consky ES. Clinical assessments of patients with cervical dystonia. In: Jankovic J, Hallett 
M, eds. Therapy With Botulinum Toxin. New York, NY: Marcel Dekker; 1994:211-237 
32 Jordan Alan (Chiropractor) Functional assessment of the cervical spine and treatment of 
chronic neck pain patients. Danish Medical Bulletin 1997; 44(3): 325-6 
33 Clark W, Haldeman S The development of guidelines for the evaluation of disability in neck 
and back injuries. Spine; 18(13): 1736-1745 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX A 
 
The Copenhagen Neck Functional Disability Scale  
Overview: The Copenhagen Neck Functional Disability Scale can be used to evaluate the 
disability experienced by patients with neck pain. The scores can be monitored over time to 
evaluate the disease course and response to any interventions.  
Questions:  
(1) Can you sleep at night without neck pain interfering?  
(2) Can you manage daily activities without neck pain reducing activity levels?  
(3) Can you manage daily activities without help from others?  
(4) Can you manage putting on your clothes in the morning without taking more time  
      than usual?  
(5) Can you bend over the washing basin in order to brush your teeth without getting 
      neck pain?  
(6) Do you spend more time than usual at home because of neck pain?  
(7) Are you prevented from lifting objects weighing from 2-4 kilograms due to neck     
     pain?  
(8) Have you reduced your reading activity due to neck pain?  
(9) Have you been bothered by headaches during the time that you have had neck    
     pain?  
(10) Do you feel your ability to concentrate is reduced due to neck pain?  
(11) Are you prevented from participating in your usual leisure time activities due to   
       neck pain?  
(12) Do you remain in bed longer than usual due to neck pain?  
(13) Do you feel that neck pain has influenced your emotional relationship with your   
        nearest family?  
(14) Have you had to give up social contact with other people during the past two       
        weeks due to neck pain?  
(15) Do you feel that neck pain will influence your future?  
 
 
 
 
 
 
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Direction of questions:  
• "positive" (a yes indicates good function): 1-5  
• "negative" (a yes indicates poor function): 6 - 15  
 
Response  
Points for "Positive" 
Points for "Negative" 
Directed  
Directed  
yes  
0  
2  
occasionally 
1  
1  
no  
2  
0  
 
disability index = SUM(points for all 15 questions)  
Interpretation:  
• minimum score: 0  
• maximum score: 30  
• The higher the score the greater the disability.  
References:  
Jordan A Manniche C et al. The Copenhagen Functional Disability Scale: A study of reliability 
and validity. J Manipulative Physiological Therapeutics. 1998; 21: 520-527.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX B 
 
Toronto Western Spasmodic Torticollis Rating Scale 
 

I.  Torticollis Severity Scale (maximum=35; sum of A through F) 
 
A. Maximal Excursion: Rate the maximum amplitude of excursion by asking the patient not to oppose 
the abnormal movement; the examiner may use distracting or aggravating maneuvers. When the degree 
of deviation is between scores, choose the higher of the two. 
1. Rotation (turn: right or left) 
    0=None (0°) 
    1=Slight (<1/4 range, 1°-22°) 
    2=Mild (1/4-1/2 range, 23°-45°) 
    3=Moderate (1/2-3/4 range, 46°-67°) 
    4=Severe (>3/4 range, 68°-90°) 
 
2. Laterocollis (tilt: right or left, exclude shoulder elevation) 
    0=None (0°) 
    1=Mild (1°-15°) 
    2=Moderate (16°-35°) 
    3=Severe (>35°) 
 
3. Anterocollis/Retrocollis (a or b) 
  a. Anterocollis 
    0=None 
    1=Mild downward deviation of chin 
    2=Moderate downward deviation (approximates 1/2 possible range) 
    3=Severe (chin approximates chest) 
  b. Retrocollis 
    0=None 
    1=Mild backward deviation of vertex with upward deviation of chin 
    2=Moderate backward deviation (approximates 1/2 possible range) 
    3=Severe (approximates full range) 
 
4. Lateral Shift (right or left) 
    0=Absent 
    1=Present 
 
5. Sagittal Shift (forward or backward) 
    0=Absent 
    1=Present 
 
B. Duration Factor: Provide an overall score estimated through the course of the standardized 
examination after estimating the maximal excursion (exclusive of asking the patient to allow the head to 
deviate maximally) (weighted × 2). 
    0=None 
    1=Occasional deviation (<25% of the time, most often submaximal) 
    2=Occasional deviation (<25% of the time, often maximal) or intermittent deviation (25%-50% of the   
      time, most often submaximal) 
    3=Intermittent deviation (25%-50% of the time, often maximal) or frequent deviation (50%-75% of the 
      time, most often submaximal) 
    4=Frequent deviation (50%-75% of the time, often maximal) or constant deviation (~75% of the time,  
     most often submaximal) 
    5=Constant deviation (>75% of the time, often maximal) 
 
C. Effect of Sensory Tricks 
    0=Complete or partial relief by one or more tricks 
    1=Partial or only limited relief by tricks 
    2=Little or no benefit from tricks 
 
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D. Shoulder Elevation/Anterior Displacement 
    0=Absent 
    1=Mild (<1/3 possible range) and intermittent or constant 
    2=Moderate (1/3-2/3 possible range) and constant (>75% of the time) or severe (>2/3 possible range) 
      and intermittent 
    3=Severe and constant 
 
E. Range of Motion (without the aid of sensory tricks). If limitation occurs in more than one plane of 
motion, use the individual score that is highest. 
    0=Able to move to extreme opposite position 
    1=Able to move head well past midline but not to extreme opposite position 
    2=Able to move head barely past midline 
    3=Able to move head toward but not past midline 
    4=Barely able to move head beyond abnormal posture 
 
F. Time (up to 60 seconds) for which patient is able to maintain head within 10° of neutral position 
without using sensory tricks (the mean of two attempts). 
    0=>60 seconds 
    1=46-60 seconds 
    2=31-45 seconds 
    3=16-30 seconds 
    4=<15 seconds 
 
 
II. Disability Scale (maximum=30; sum of A through F) 
 
A. Work (occupation or housework/home management) 
    0=No difficulty 
    1=Normal work expectations with satisfactory performance at usual level of occupation but some        
       interference by torticollis 
    2=Most activities unlimited, selected activities very difficult and hampered but still possible with           
      satisfactory performance 
    3=Working at lower than usual occupation level; most activities hampered, all possible but with less    
      than satisfactory performance in some activities 
    4=Unable to engage in voluntary or gainful employment; still able to perform some domestic                
      responsibilities satisfactorily 
    5=Marginal or no ability to perform domestic responsibilities 
 
B. Activities of Daily Living (eg, feeding, dressing, or hygiene, including washing, shaving, makeup, etc) 
    0=No difficulty with any activity 
    1=Activities unlimited but some interference by torticollis 
    2=Most activities unlimited, selected activities very difficult and hampered but still possible using         
      simple tricks 
    3=Most activities hampered or laborious but still possible; may use extreme "tricks" 
    4=All activities impaired, some impossible or require assistance 
    5=Dependent on others in most self-care tasks 
 
C. Driving 
    0=No difficulty (or has never driven a car) 
    1=Unlimited ability to drive but bothered by torticollis 
    2=Unlimited ability to drive but requires "tricks" (including touching or holding face, holding head         
      against headrest) to control torticollis 
    3=Can drive only short distances 
    4=Usually cannot drive because of torticollis 
    5=Unable to drive and cannot ride in a car for long stretches as a passenger because of torticollis 
 
D. Reading 
    0=No difficulty 
    1=Unlimited ability to read in normal seated position but bothered by torticollis 
    2=Unlimited ability to read in normal seated position but requires use of "tricks" to control torticollis 
    3=Unlimited ability to read but requires extensive measures to control torticollis or is able to read only 
      in nonseated position (eg, lying down) 
    4=Limited ability to read because of torticollis despite tricks 
 
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    5=Unable to read more than a few sentences because of torticollis 
 
E. Television 
    0=No difficulty 
    1=Unlimited ability to watch television in normal seated position but bothered by torticol is 
    2=Unlimited ability to watch television in normal seated position but requires use of tricks to control     
      torticollis 
    3=Unlimited ability to watch television but requires extensive measures to control torticollis or is able  
      to view only in nonseated position (eg, lying down) 
    4=Limited ability to watch television because of torticollis 
    5=Unable to watch television more than a few minutes because of torticollis 
 
F. Activities Outside the Home (eg, shopping, walking about, movies, dining, and other recreational 
activities) 
    0=No difficulty 
    1=Unlimited activities but bothered by torticollis 
    2=Unlimited activities but requires simple "tricks" to accomplish 
    3=Accomplishes activities only when accompanied by others because of torticollis 
    4=Limited activities outside the home, certain activities impossible or given up because of torticollis 
    5=Rarely if ever engages in activities outside the home 
 
III. Pain Scale (maximum=20; sum of A through C) 
 
A. Severity of Pain: Rate the severity of neck pain due to torticollis during the last week on a scale of 0-
10, where a score of 0 represents no pain and 10 represents the most excruciating pain imaginable. 
Score calculated as [worst+best+(2×usual)]/4. 
Best_____ 
Worst_____ 
Usual_____ 
 
B. Duration of Pain 
    0=None 
    1=Present <10% of the time 
    2=Present 10%-25% of the time 
    3=Present 26%-50% of the time 
    4=Present 51%-75% of the time 
    5=Present >75% of the time 
 
C. Disability Due to Pain 
    0=No limitation or interference from pain 
    1=Pain is quite bothersome but not a source of disability 
    2=Pain definitely interferes with some tasks but is not a major contributor to disability 
    3=Pain accounts for some (less than half) but not all of the disability 
    4=Pain is a major source of difficulty with activities; separate from this, head pulling is also a source   
      of some (less than half) disability 
    5=Pain is the major source of disability; without it, most impaired activities could be performed quite    
      satisfactorily despite head pulling 
 
Reference: Consky ES. Clinical assessments of patients with cervical dystonia. In: 
Jankovic J, Hallett M, eds. Therapy With Botulinum Toxin. New York, NY: Marcel 
Dekker; 1994:211-237 
 
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