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Hands On


									                                                                          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

  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

   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.

                                                      Referral to
                                                    secondary care

                                                 therapy and exercise

                                                 Assess for red ags
                                                 First-line pain relief
     Injection                                 Advice to remain active
      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.

                         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.
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.
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–
2010 Task Force on Neck Pain and Its Associated Disorders.
Spine 2008;33(4 Suppl):S39-S51.
                                                                   [Quick reference guide:
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.
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.
6. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM.
Efficacy of low-level laser therapy in the management of           • Neck pain – acute torticollis.
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.
Lancet 2009;374(9705):1897-908.                                       neck_pain_whiplash_injury#352389001.

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