We’ve had a recent rush of patients coming in with neck pain – something to do with added work stress, perhaps? I was irritated by how vague we are on neck pain and how difficult it was to describe in effective ‘lay’ (but not patronising) terms what the hell was going on. And this got me thinking….
How common is neck pain?
Well, you are certainly not alone – Hill and co-workers report that in the UK many as 31% of adults have had neck pain in the last month (the adult population of the UK has got to be over 50 million people so, as hey say in the US, “Go do the math”) and 48% of neck pain patients report persistent pain a year later.
- Hill J, Lewis M et al. (2004) Predicting Persistent Neck Pain. Spine 29:1648-1654
What’s going wrong?
Well, this is trickier. Liebenson, Skaggs et al. say that it is ‘difficult to pinpoint the specific pain-generating tissue’ of neck pain and even if you can the reasons why ‘are often elusive’. Now, in my experience the most common neck problem we see is ‘Posterior Facet Syndrome’, one of the mechanical neck pains, and it is caused by compression of the facet joints as a result of anterior head carriage commonly aggravated by peering into the computer for eight hours a day.
Though, try Googleing ‘Posterior Facet Syndrome’ and see what comes up as it is a hotly debated subject with some denialists saying it doesn’t exist though how can this be as I treat it daily and it responds very well.
In trying to describle what I am treating I say that PFS is similar to an ankle sprain but of the neck joints and that, like an ankle sprain, a whole raft of different tissues may be involved in the injury depending on how it was done. This seems pretty plausible to me and covers all the bases and, as long as we are treating these tissues, we should have some impact on the problem – yes?
There are some even stranger things happening out there in neck land. Up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.
- Michael Freedman Dec 2001.
Not surprisingly, I suspect that this has some impact on the way things progress in a neck but, surprisingly, there may well be nothing that can be done about it and that even if the information was available it would not change the way the neck was managed anyway.
Neck pan can be split into these broad categories:
Grade 1 – neck pain with little or no interference with daily activity.
Grade 2 – limits daily activity.
Grade 3 – neck pain with accompanied radiculopathy (pinched nerve pain, weakness and/or numbness in the arm)
Grade 4 – neck pain with serious pathology – tumour, infection or systemic disease.
(Clearly, along with mechanical neck pain there are some real nasties out there; neck pain may be a symptom of meningitis and if any of the following symptoms occur, dial 999 or seek medical attention urgently:
• A rash develops that does not fade when you press it with a glass tumbler or a finger.
• You feel ill or are running a fever as well as feeling neck pain.
• It is to painful to bend the neck forward and put your chin on your chest.
• Light hurts.
• Your neck pain is accompanied by severe headache or continuous vomiting.
• Neck pain is accompanied by severe pain in the back.
And in some cases, neck pain can be a symptom of head injury or disc trouble in the neck, so. If any of the following symptoms occur, dial 999 or seek medical attention urgently:
• Neck pain is the result of a recent head injury and you are becoming drowsy, confused or are vomiting.
• Neck pain is accompanied by headache.
• If there is pain behind one eye.
• Vision, hearing, taste or balance are affected.
• Severe vomiting.
• The muscle power in your arms or legs is reduced.)
Treatment
Here’s the science bit:
Cleland et al. showed that manipulation of the thoracic spine produces immediate analgesic effects in patients with mechanical neck pain.
- Cleland JA, Childs JD et al. (2005) Immediate Effects of Thoracic Manipulation in Patients with Neck Pain: A Randomized Clinical Trail, Manipulative Therapy 10:127-135.
And Liebenson recommends manual therapy with some rehabilitation exercises. This has been supported by one of the strongest research trials in this field carried out by Bronfort, Evans et al. In this trial 191 patients were split into three treatment groups, like this:
• Spinal manipulation and low-tech exercise,
• Spinal manipulation and MedX exercise – receiving dynamic progressive resistance exercises on MedX machines,
• Spinal manipulation.
Outcomes were measured at 5 and 11 weeks and 3, 6 and 12 months after the trial. At the one year follow up the group that were receiving exercises and manipulation did significantly better than the group undergoing manipulation alone.
In a literature review published by Hurwitz, Aker et al. in Spine and Aker, Gross et al. in the British Medical Journal, so hardly slack journals I’d suggest, manipulation and mobilization were both more effective than muscle relaxants and usual medical care in providing pain relief for patients with sub-acute or chronic neck pain. In a study (2003) in Spine Giles and Muller compared acupuncture, joint manipulation and standard medication (NSAIDs). Patients in the acupuncture and medications groups had no significant improvement during the trial on any of the outcome measures and the manipulation group showed significant improvement on all measures with no patient made worse or experiencing side effects. Giles and Muller then followed up their patients a year later and reported that the manipulation group gained ‘significant broad-based beneficial…long-term outcomes’ (I like Giles and Muller).
In a great study by Haneline at Palmer College of Chiropractic, 79% of the patients improved to the point they had only minimal or minor restriction of movement and their satisfaction rates were an astounding 94% – and I suspect few trials can report the same, with 70% indicating they were very satisfied. When asked which provider helped the most 83% replied the chiropractor (this all sounds too much like a dodgy ‘election’ in North Korea for it to sit comfortably with me but….)
However, and there’s always one, here’s what the GP’s advise on http://www.patient.co.uk/:
Exercise your neck and keep active
Aim to keep your neck moving as normally as possible. At first the pain may be quite bad, and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able. You should not let it ‘stiffen up’. Gradually try to increase the range of the neck movements. Every few hours gently move the neck in each direction. Do this several times a day. As far as possible, continue with normal activities.
In the past, some people have worn a neck collar for long periods when a bout of neck pain developed. The problem with collars is that they prevent you from moving your neck properly. Studies have shown that you are more likely to make a quicker recovery if you do regular neck exercises, and keep your neck active rather than resting it for long periods in a collar. Also, if you keep the neck active during a bout of neck pain, it is thought to help prevent chronic (persistent) neck pain from developing.
(So good, reasonable advice so far but then…)
Medicines
Painkillers are often helpful. It is best to take painkillers regularly until the pain eases. This is better than taking them now and again just when the pain is very bad. If you take them regularly, it may prevent the pain from getting severe, and enable you to exercise and keep your neck active.
• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic need a prescription. Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is sometimes prescribed for a few days if your neck muscles become tense and make the pain worse.
(Awww, and they were doing so well. The problem in your neck has nothing to do with a lack of pain-killer in your blood so don’t do it. The evidence doesn’t support it so why advise it unless there is some other reason and I am not going to suggest that we are a drug reliant NHS, oh no. I will suggest that the muscle tightness has a purpose and is not a trick that your neck is doing just to irritate you, perhaps; just perhaps, your brain wants to immobilize the injured joints, just like an ankle sprain then, and is using the muscles surrounding the joint to do this. So why would you want to take a muscle relaxant to stop this happening, why would you want to over ride your clearly stupid brain and let your neck move freely during an acute phase?)
Other advice
Some other advice which is commonly given includes:
• A good posture may help. Brace your shoulders slightly backwards, and walk ‘like a model’. Try not to stoop when you sit at a desk. Sit upright.
• A firm supporting pillow seems to help some people when sleeping.
• Physiotherapy. It is not clear whether this makes much difference to the outcome of mechanical neck pain. Therapies such as traction, heat, cold, manipulation, etc, may be tried, but the evidence that these help is not strong. However, what is often helpful is the advice a physiotherapist can give on neck exercises to do at home. A common situation is for a doctor to advise on painkillers and gentle neck exercises. If symptoms do not begin to settle over a week or so, you may then be referred to a physiotherapist to help with pain relief and for advice on specific neck exercises.
So, manipulation gets one word. Yet the recent report from the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and Its Associated Disorders (made up by a staggering 50 researchers in 9 countries comprising of 14 different clinical disciplines and looking at over 31,000 research criterion and over 1000 met relevant criteria.) recommended that neck manipulation, acupuncture and massage are better choices for managing most common neck pain. It also recommended exercises, education and neck mobilization but to be less effective than adjustment.
I know which one I’d chose.