Neck pain is one of the most common musculoskeletal disorders and is associated with a high economic burden.  Persistent or recurrent neck pain may be associated with biomechanical function proprioceptive and postural changes as well as psychosocial factors such as anxiety catastrophic depression and fear).  This page discusses a patient with recurrent neck pain.
Freddy is a 22-year-old male fresh out of college. He hasn’t started working yet. Currently, he works out at the gym twice a week and plays a lot of cricket, although it’s not strenuous. He’s also played hockey before and might want to come back here. his fitness class is Mainly focused on cardiovascular fitness (stationary bike treadmill rowing machine). The weights are primarily machine-based, with an emphasis on the legs, back, arms, chest, and core.
History of presenting condition
Freddy first broke his neck at the age of 13 in a football scramble game. At that time he had significant neck pain (VAS = 9/10). The pain from this injury went away quickly without treatment and he has been problem free for 3 years.
At 16, Freddy started bowling cricket and developed neck pain (VAS 8-9/10). He noticed a pinching sensation in the lower cervical spine. Because of this pain, he was unable to continue bowling and become a goaltender.
Since then, he has had neck pain. Although he was able to perform all activities of daily living and most sports, he reported persistent mild neck pain. This pain is aggravated by prolonged poor posture (i.e. sitting in front of a computer/device (VAS 4/10) or playing games for long periods of time) In a sport like hockey, he has to adopt a bent stance. Note: Freddy doesn’t mention a specific 24-hour pattern – sometimes neck pain sufferers report increased pain with a stiff neck in the morning or muscle fatigue at the end of the day. 
He noticed that he often had the urge to knock his neck. Movement feels “bumpy and stiff” rather than “smooth.”
While his pain levels have decreased over the past few years, the inconvenience continues.
Over the past few years, Freddy has seen 3 different osteopaths. When his neck feels particularly sore, he tends to seek treatment.
Every osteopath offers a different diagnosis, and their treatments provide short-term pain relief, but no long-term results. Manual techniques have been shown to be an important part of diagnosing neck pain and to be effective in reducing pain, but they are detrimental to neuromuscular and sensorimotor function.  A randomized controlled trial by Sremakaew et al. 2022. found that while manual therapy and exercise were able to reduce neck pain in the short and long term, including sensorimotor training helped maintain pain and disability in the long term. 
Possible diagnoses from osteopaths:
- Leg length differences and a focus on quadriceps nerve firing. Freddy noted that this provided the longest benefit, with significant pain reduction for about 6 months.
- Alignment issue
- Pain associated with the first injury – provides manual techniques that help the most in the short term. Freddie noted that he had seen the osteopath several times, with his last appointment being 10 months ago.
Freddy is now looking for a longer-term solution. He has no particular self-management plan other than trying to improve his posture.
Past medical history
Freddie is reported to be in good health. He has had no surgery for major illnesses and is not taking any medications. His weight is stable. He reported no binocular collapse/fainting pins and needles or numbness. He reported that during his initial injury or his The pain got worse again.
He notes that he occasionally feels dizzy when standing up quickly. This symptom may be related to sensorimotor dysfunction, but Freddy reported that his mother had the same problem.
There is substantial research to support the idea that cervical afferent nerve dysfunction can lead to dizziness, instability, visual disturbances, and altered balance, as well as head and eye movements following neck trauma.  This is especially true in patients with persistent symptoms.  Therefore, an objective evaluation of this patient must include a neck and shoulder examination as well as head control and balance.
Neck pain can also lead to changes in sensorimotor function, but these changes do not always go away as the pain decreases.  Therefore, a detailed evaluation needs to include an examination of sensorimotor function.  Please click here for an overview of sensorimotor impairment due to neck pain.
Assessing muscle performance is also important because people with neck pain have reduced strength, reduced endurance, and they fatigue more quickly.  Please click here for an overview of cervical muscle performance testing.
The diagnosis in this case study was probably facet joint dysfunction with some allergies. Cervical facet joints are recognized as a common cause of neck pain headaches and upper extremity referred pain.  estimated the prevalence of chronic axial facet joint dysfunction Neck pain occurs in 25% to 66%.  Although there is limited evidence to support the use of clinical trials in assessing the cervical spine in adults with neck pain, a recent systematic review by Lemeunier and colleagues suggests that the extension-rotation test may be reliable and that it Possesses sufficient effectiveness to rule out pain arising from facet joints.  And. A panel of three tests was found to be sensitive (94%) and specific (84%) in diagnosing cervical facet joint dysfunction. These tests are the Stretch Rotation Test Manual Spine Examination and Palpate segmental tenderness. 
Freddy’s balance and postural control tests were unremarkable. When testing proprioception on the right side, he showed a deviation greater than 6.5 cm, which is a positive test (see video below for tips on how to perform this test)  Testing on the left side did not show any significant difference Impairment – eye movement test also absent (he had no dizziness/blurred vision or saccades). Sensorimotor dysfunction is worse when neck pain originates in the facet joints of the upper cervical spine, as this region contains more muscle spindles than The visual and vestibular systems, which have more reflex activity than the lower areas. 
Freddie had segmental pain on palpation. Additionally, his muscle performance tests revealed weakness and loss of endurance/control. He was able to achieve 30mmHg on a craniocervical flexion test. This test is considered a reliable and valid clinical test, but is recommended only with Caution as a discriminatory test or as an outcome measure.  Freddie found this too irritating to hold for 10 seconds, which is typical for people with neck pain.  Muscle performance problems are most evident in neck flexor endurance tests (see video below for an overview of how to perform this test). Freddy can only hold the position for 15 seconds and reports a VAS of 3-4/10. Domenech et al (2011) found that male subjects without neck pain had an average endurance retention time of 38.9 ± 20.1 seconds (mean of 29.4 ± 20.1 seconds for female subjects) 13.7 seconds). After the assessment Freddy noticed that his neck felt weak and fragile rather than strong. He felt consistent pain in all muscle performance tests.
Neck Flexor Endurance Test Video by Clinically Relevant
Treatment should focus on strengthening and improving muscle performance. Of particular relevance to Freddy is the discovery that deep neck flexor training can reduce pain.  In addition to his usual gym workouts, possible exercises included shoulder shrugs and lateral raises. Discussed in detail Neck Muscle Strengthening click here.
- ↑ Kazeminasab S, Nejadghaderi SA, Amiri P, Pourfathi H, Araj-Khodaei M, Sullman MJM, et al. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord. 2022 Jan 3;23(1):26.
- ↑ Mendes-Fernandes T, Puente-González AS, Márquez-Vera MA, Vila-Chã C, Méndez-Sánchez R. Effects of global postural reeducation versus specific therapeutic neck exercises on pain, disability, postural control, and neuromuscular efficiency in women with chronic nonspecific neck pain: study protocol for a randomized, parallel, clinical trial. Int J Environ Res Public Health. 2021 Oct 12;18(20):10704.
- ↑ Jump up to:3.0 3.1 3.2 Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. journal of orthopaedic & sports physical therapy. 2009 May;39(5):364-77. [Accessed 26 June 2018] Available from: http://www.neckcare.com/wp-content/uploads/Sensorimotor-function-and-dizziness-in-neck-pain_Implication-for-assessment-and-management.pdf
- ↑ Jull, G. Non-specific neck pain: The case for specific treatment (Webinar). IFOMPT. 2019.
- ↑ Sremakaew M, Jull G, Treleaven J, Uthaikhup S. Effectiveness of adding rehabilitation of cervical related sensorimotor control to manual therapy and exercise for neck pain: A randomized controlled trial. Musculoskeletal Science and Practice. 2022:102690.
- ↑ Jump up to:6.0 6.1 6.2 Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502.
- ↑ Sterling, M, Jull, G, Vicenzino B, Kenardy, J, Darnell, R. Development of motor system dysfunction following whiplash injury. Pain. 2003; 103(1-2): 65-73.
- ↑ Reid, SA, Rivett, DA, Katekar, MG, Callister, R. Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Physical Therapy. 2014; 94(4): 466-476.
- ↑ Jull, G, Trott, P, Potter, H, Zito, G, Niere, K, Shirley, D et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002; 27(17): 1835-43.
- ↑ Jump up to:10.0 10.1 Blomgren J, Strandell E, Jull G, Vikman I, Röijezon U. Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review. BMC Musculoskelet Disord. 2018;19(1):415.
- ↑ Jull, G. Non-specific neck pain: The case for specific treatment (Webinar). IFOMPT. 2019.
- ↑ Manchikanti L, Kosanovic R, Cash KA, Pampati V, Soin A, Kaye AD et al. Assessment of Prevalence of Cervical Facet Joint Pain with Diagnostic Cervical Medial Branch Blocks: Analysis Based on Chronic Pain Model. Pain Physician. 2020;23(6):531-40.
- ↑ Kirpalani, D. Mitra, R. Cervical Facet Joint Dysfunction: A Review. Archives of Physical Medicine and Rehabilitation. 2008; 89(4): 770-4.
- ↑ Lemeunier N, da Silva-Oolup S, Chow N, Southerst D, Carroll L, Wong JJ et al. Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1-A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. Eur Spine J. 2017;26(9):2225-41.
- ↑ Schneider, GM, Jull, G, Thomas K, Smith, A, Emery, C, Faris, P et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil. 2014; 95(9): 1695-701.
- ↑ Chris Worsfold Assessing proprioception of the neck – YouTube. Available from: https://www.youtube.com/watch?v=SFjAMaAdqXY[last accessed 28/06/18]
- ↑ Araujo FX, Ferreira GE, Scholl Schell M, Castro MP, Ribeiro DC, Silva MF. Measurement Properties of the Craniocervical Flexion Test: A Systematic Review. Phys Ther. 2020;100(7):1094-117.
- ↑ Brukner P. Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill; 2012.
- ↑ Domenech, MA, Sizer, PS, Dedrick, G, McGalliard, MK. The Deep Neck Flexor Endurance Test: Normative Data Scores in Healthy Adults, PM&R. 2011; 3(2): 105-110.
- ↑ Jull GA, O’leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. Journal of Manipulative & Physiological Therapeutics. 2008 Sep [Accessed 7 Jun 2018] 1;31(7):525-33. Available from: https://scholar.google.com/scholar_url?url=http://portalsaude.dominiotemporario.com/doc/teste_cranio_cervical.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=i1IZW_DMNYGnywSN4o3ABQ&scisig=AAGBfm3AjnSQA5jlgWBbIawh20NsI2sFmA