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Practical advice for GPs on management of rheumatic disease Hands On Reports on the Rheumatic Diseases | Series 6 | Spring 2011 | Hands On No 8 Neck pain: management in primary care Krysia Dziedzic, Carol Doyle, Lucy Huckfield, Treena Larkin, Kay Stevenson, Panos Sargiovannis, Nadia Corp, Nadine Foster Arthritis Research UK Primary Care Centre, Keele University Introduction Editorial Neck pain is a musculoskeletal complaint com- Neck pain is a common reason for patients to monly seen in primary care. It can be disabling present in primary care to general practitioners or to varying degrees and costly in terms of visits physiotherapists. It is vital that patients are assessed to healthcare providers, sick leave and lost and managed well from the start to identify the small number of people with significant pathology, productivity. but more importantly to set patients with non- Women are affected more than men, with specific neck pain along the correct treatment path highest prevalence in middle age. Two-thirds of from the start. A confident and knowledgeable approach helps limit disability and reduces the risk people will experience neck pain at some time of the neck problem becoming chronic. in their life with half to three-quarters of these people having a recurrence of their neck pain This report has been written by physiotherapists based at the Arthritis Research UK Primary Care within 5 years.1 As neck pain can be recurrent Centre. They not only present the latest evidence and can vary in disability it is important that base but also bring to the report their considerable healthcare professionals provide simple, clear practical experience in managing patients with advice on management at an early stage. non-specific neck pain. Of particular interest to GPs is the inclusion of an ‘Information and exercise This report aims to provide the clinician with the sheet’ designed to be printed out and given to latest evidence-based assessment and treatment patients during consultations. This guide promotes strategies and provide practical advice on things self-help and it is to be hoped that it will reduce the people can do to help themselves for the manage- need for patients to be referred to physiotherapy. ment of non-specific neck pain. Pharmacological Simon Somerville treatment is not included in this review. Providing answers today and tomorrow Different kinds of neck pain BOX 2. Assessing neck pain. There may be no apparent reason for the onset • Exclude non-musculoskeletal causes. of neck pain and recovery is often difficult to • Assess for red flags (Box 1). predict. Common diagnoses of neck pain include • Assess range of neck movements. non-specific neck pain, whiplash (WAD – whiplash- • Perform a neurological examination (Box 3). associated disorder), cervical spondylosis and • Identify risk factors for developing neck pain, e.g. acute torticollis. Neck pain may be accompanied workplace, use of pillows. by pain radiating down the arm (radiculopathy) • Identify psychosocial factors (yellow flags) that or headaches (cervicogenic headaches). may suggest increased risk for chronicity and disability (Box 4). Non-specific neck pain, sometimes called ‘simple’ or ‘mechanical’ neck pain, is the most common type. Typical signs and symptoms include: quantitative job demands, low social support at • pain around the neck region that may spread work, job insecurity, poor job satisfaction, on- to the shoulder or scapula area or towards the going litigation relating to the neck pain, poor base of the skull computer workstation design and work posture, • associated muscle stiffness or spasm sedentary work positions, repetitive work and • pain aggravated by particular movements, precision work.2 postures and activities and relieved by others Disc degeneration has not been identified as a • associated headaches risk factor.3 • restricted range of neck movement • tenderness in neck and shoulder muscles. Assessment and screening of neck pain What are the risk factors? Screening and clinical assessment are the same Age, gender and genetics are of course non- for all patients presenting with neck pain. Red modifiable risk factors. Modifiable risk factors flags can be used to rule out signs of serious include smoking (both active and passive), lack spinal/structural pathology (Box 1) and patients of physical activity, poor posture, anxiety and with these should be investigated. depression, and psychological health. Other risk factors associated with neck pain in workers Asking questions on the history of the presenting include previous musculoskeletal pain, high neck condition, including the mechanism of onset, duration, site and type of symptoms, can help with the diagnosis and subsequent manage- BOX 1. Red flags. ment of neck pain. A physical examination (Box 2) Major structural pathologies include (but are not that includes observation and palpation, assess- limited to) fracture, vertebral dislocation, injury to ment of range of neck movements and a neuro- the spinal cord, infection, neoplasm, or systemic logical examination to identify any possible radicu- disease including inflammatory arthropathies. lopathy (Box 3) should be performed. If the neck Red flags for neck pain: trauma, osteoporosis risk, pain varies with different activities and time, or is myelopathy, history of cancer, unexplained weight associated with poor posture, injury or overuse, loss, fever, infections and any of the following signs suspect non-specific neck pain. and symptoms: • new symptoms below age 20 or above age It is important to identify patients who are at risk 55 years of developing long-term pain and disability, i.e. • constant, progressive, non-mechanical pain to assess for yellow flags (Box 4) and address • cauda equina syndrome/widespread neurologi- these as soon as possible. cal symptoms, gait disturbance, clumsy or weak hands, loss of sexual, bladder or bowel function Investigations • Lhermitte’s sign (flexion of the neck producing an electric shock sensation down the spine and into Cervical x-rays and other imaging studies and the limbs) investigations are not routinely required to diag- • dizziness, drop attacks, blackouts. nose or assess neck pain with radiculopathy or non-specific neck pain. In primary care, triage 2 BOX 3. Neurological examination. • Check for upper motor neurone lesion – brisk reflexes, clonus, up-going plantar reflexes. • Check for lower motor neurone lesion – loss of sensation, power and reflexes. Commonly affected nerve roots are as follows: Root Dermatome Myotome Reflex C5 Lateral upper arm Shoulder abduction Biceps C6 Lateral forearm and thumb Elbow flexion, wrist extension Brachioradialis C7 Middle finger Elbow extension, wrist flexion Triceps C8 Little finger Finger flexion T1 Medial aspect of forearm Finger abduction Fingers L4 Anterior shin, medial foot Ankle dorsiflexion Knee L5 Hallux Hallux extension S1 Lateral foot, heel, calf Knee flexion, eversion of foot Ankle should be based on history and physical exam- is common and that symptoms are likely to ination alone, including screening for red flags resolve. Patients may ask about or have already plus a neurological examination for signs of tried non-NHS treatments such as alternative or radiculopathy. It is best to be open about the complementary treatments which are often ex- limitations of investigations for the assessment of pensive and encourage dependency. It is import- non-specific neck pain while reassuring patients ant therefore to provide good, clear advice to that they can still be helped without such patients on how best to manage their neck pain investigations. from the start. Encourage the patient to: How to treat non-specific • remain as active as possible neck pain • restore their neck movements as pain allows For the vast majority of patients, appropriate (see ‘Information and exercise sheet’) advice with simple analgesia is the best way to • correct poor posture if precipitating or treat non-specific neck pain. The choice of aggravating the neck pain analgesia will depend on the chronicity and • sleep with one pillow which provides lateral severity of pain, personal preference, tolerability support and also gives support to the hollow and risk of adverse effects. of the neck. Two pillows may force the head Neck pain has commonly been labelled by the into an unnatural position. duration of symptoms: acute, subacute, chronic. Discourage the patient from: Acute neck pain • prolonged absence from work • wearing a cervical collar (which paradoxically During its acute phase (within the first 3–4 weeks) may hinder recovery). it is important to give reassurance that neck pain Subacute neck pain BOX 4. Yellow flags. If symptoms persist from 3 or 4 weeks to 12 weeks, in addition to the above advice: Risks of developing long-term pain and disability: • Refer to physiotherapy for a multimodal treat- • belief that pain and activity are harmful ment strategy that includes postural advice, • excessive concerns about the neck pain exercises and manual therapy. Acupuncture • low or negative moods and emotions may be included at this stage. • unrealistic expectations of treatment • Promote positive attitudes to activity and work. • problems at work • Address any psychosocial factors – ‘yellow • overprotective family or lack of support flags’ (Box 4). • ongoing problems with compensation and claims relating to the neck pain. • Consider referral to a psychologist or occu- pational health clinician. 3 Referral to secondary care Manual therapy and exercise General Laser exercises Assess for red ags First-line pain relief Injection Advice to remain active Surgery therapy Posture and seating Address psychosocial factors Patient ‘Information and exercise sheet’ Acupuncture Ergonomics Local agencies e.g. exercise in the community Pain management and cognitive behavioural therapy FIGURE 1. Core treatment recommendations for non-speci c neck pain. The inner core represents treatment approaches o ered to all; the outer core illustrates adjunctive treatment that could be o ered. • Exercises, manual therapy, analgesics, acupuncture and low-level laser therapy have been shown to provide some degree of short-term relief of neck pain without trauma. • Manual therapy is often used with exercise to treat neck pain for pain reduction and improved quality of life.4 • There can be short-term bene t with acupuncture.5 • Low-level laser therapy reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain.6 • Exercises and mobilisation have been shown to provide some degree of short-term relief after a whiplash- associated disorder. • Referral to secondary care will be necessary for certain people. Chronic pain management, corticosteroid injection and surgery may be indicated. Chronic neck pain Conclusion If symptoms persist for more than 12 weeks, in This report provides a practical overview of neck addition to the above advice: pain seen in primary care. It has focused on the • Continue physiotherapy if it is helping, appropriate assessment and management of discontinue if not. non-specific neck pain. Key messages have been • Avoid passive interventions, e.g. electrotherapy presented and core treatments highlighted. and massage. • Reassess psychological factors. The management of this condition has great • Consider referral to a pain clinic for people similarities to that of low back pain with regard to with chronic pain or nerve root symptoms the assessment and management of the majority where there is poor control. of patients. Many of these patients require Core treatment recommendations are outlined reassurance, simple primary care management in Figure 1. and minimal investigations. 4 Key messages • Neck pain is very common. • Neck pain may be related to poor posture. • Serious structural injury is unlikely. • Self-management is key. • Encourage patient to remain as active as possible and avoid immobilisation of the neck. • Clinical management is important: to identify and address yellow flags, to exclude red flags and to provide reassurance and information. • Don’t x-ray for non-specific neck pain. References Further reading 1. Carroll LJ, Hogg-Johnson S, van der Velde G et al. Course Map of Medicine (MoM) Clinical Editorial team and and prognostic factors for neck pain in the general popu- independent reviewers invited by MoM. London: MoM; lation: results of the Bone and Joint Decade 2000–2010 2010. http://eng.mapofmedicine.com/evidence/map/ Task Force on Neck Pain and Its Associated Disorders. neck_pain1.html. Spine 2008;33(4 Suppl):S75-S82. National Institute for Health and Clinical Excellence (NICE). 2. Côté P, van der Velde G, Cassidy JD et al. The burden and Spinal cord stimulation for chronic pain of neuropathic or determinants of neck pain in workers: results of the Bone ischaemic origin. Technology Appraisal 159. London: NICE; and Joint 2000–2010 Task Force on Neck Pain and Its 2008. http://www.nice.org.uk/TA159. Associated Disorders. Spine 2008;33(4 Suppl):S60-S74. 3. Hogg-Johnson S, van der Velde G, Carroll LJ et al. The Moore A, Jackson A, Jordan J et al. Clinical guidelines for the physiotherapy management of whiplash-associated burden and determinants of neck pain in the general disorder. London: Chartered Society of Physiotherapy; population: results of the Bone and Joint Decade 2000– 2005. http://www.csp.org.uk/uploads/documents/csp_ 2010 Task Force on Neck Pain and Its Associated Disorders. whiplash_guideline.pdf. Spine 2008;33(4 Suppl):S39-S51. [Quick reference guide: http://www.csp.org.uk/uploads/ 4. Miller J, Gross A, D’Sylva J et al. Manual therapy and documents/csp_WAD_QRG.pdf] exercise for neck pain: a systematic review. Man Ther 2010;15(4):334-54. Clinical Knowledge Summaries (CKS). London; CKS; 2009: 5. Fu LM, Li JT, Wu WS. Randomized controlled trials of • Neck pain – non-specific. http://www.cks.nhs.uk/neck_ acupuncture for neck pain: systematic review and meta- pain_non_specific#344100001. analysis. J Altern Complement Med 2009;15(2):133-45. • Neck pain – cervical radiculopathy. http://www.cks.nhs. uk/neck_pain_cervical_radiculopathy#377267001. 6. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy in the management of • Neck pain – acute torticollis. http://www.cks.nhs.uk/ neck pain: a systematic review and meta-analysis of ran- neck_pain_acute_torticollis#352387001. domised placebo or active-treatment controlled trials. • Neck pain – whiplash injury. http://www.cks.nhs.uk/ Lancet 2009;374(9705):1897-908. neck_pain_whiplash_injury#352389001. 5 Would you prefer to read our reports in electronic format? If you enjoy Hands On, Synovium or Topical Reviews but would prefer to view them electronically you can now opt to receive a free email notification as soon as new issues are published. Please sign up via www.arthritisresearchuk.org/medical-professional-info and follow the link on the right-hand side. Once you have entered your work or home email address, name, and the address at which you currently receive our reports, we will take you off our postal list for paper copies. 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