Chronic Neck Pain: Difference between revisions

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== Search Strategy ==
== Introduction ==
[[File:Neck pain1.jpg|right|frameless]]
The International Association for the Study of Pain (IASP) in its classification of Chronic Pain defines cervical spinal pain as "pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process".&nbsp;The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders describes Neck pain as "pain located in the anatomical region of the neck with or without radiation to the head, trunk, and upper limbs".


Databases Searched: Pubmed, PEDro<br>Keyword Searches:[[Neck Pain Tool-kit: Step 1|Chronic neck pain&nbsp;]]AND [[PhysicalTherapy.com|Physical therapy]],[[Neck Pain Tool-kit: Step 1|Chronic neck pain]] AND [[Manual Therapy|Manual Therapy]], [[Neck Pain Tool-kit: Step 1|Chronic neck pain]] AND stretching,[[Neck Pain Tool-kit: Step 1|Chronic neck pain ]]AND [[Massage]],[[Neck Pain Tool-kit: Step 1|Chronic neck pain]]AND yoga<br>  
Pain is classified as chronic when it has a duration of 12 weeks or more. Chronic neck pain often presents as widespread hyperalgesia on palpation and in both passive and active movements in neck and shoulder area<ref name="Misailidou et al.">Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G, Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools; Journal of Chiropractic Medicine Jun 2010; 9(2): 49–59. (5)</ref>. 


== Definition/Description ==
Considerable research has shown that psychosocial factors are an important prognostic indicator of prolonged disability in individuals with neck pain<ref>Childs MJ, Fritz JM, Piva SR, Whitman JM. [http://www.jospt.org/doi/pdf/10.2519/jospt.2004.34.11.686 Proposal of a classification system for patients with neck pain.] Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.</ref>.  It is well known that chronic pain is often associated with anatomical, psychological, social, and professional factors. This is consistent with the [[Biopsychosocial Model|biopsychosocial model]], which considers pain to be a dynamic interaction between biological, psychological, and social factors unique to each individual.  


[[Image:Cervical spine.png|right|200px]]
== Epidemiology  ==


The International Association for the Study of Pain (IASP) in its classification of [[Chronic Pain|Chronic Pain]] defines cervical spinal pain as pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process.<ref name="Misailidou et al.">Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G, Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools; Journal of Chiropractic Medicine Jun 2010; 9(2): 49–59. (5)</ref>&nbsp;The Bone and Joint Decade 2000-2010 Task Force on [[Neck Pain Tool-kit: Step 1|Neck Pain]] and Its Associated Disorders describes [[Neck Pain Tool-kit: Step 1|Neck pain]] as pain located in the anatomical region of the neck with or without radiation to the head, trunk, and upper limbs (Guzman J. et al., 2008). It defines the posterior neck region from the superior nuchal line to the spine of the scapula and the side region down to the superior border of the clavicle and the suprasternal notch.<ref name="Misailidou et al." /> [[Neck Pain Tool-kit: Step 1| Step 1]]<br>
Although the natural history of neck pain appears to be favourable, rates of recurrence and chronicity are high<ref name=":0">Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. [http://www.jospt.org/doi/pdf/10.2519/jospt.2017.0302 Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.] Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83</ref>. Blanpied et al reviewed the literature and found that:
* 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater than 6 months in duration affecting 14% of all individuals who experience an episode of neck pain.
* 37% of individuals who experience neck pain will report persistent problems for at least 12 months. Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.
* Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.
The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures


[[Neck Pain Tool-kit: Step 1|Chronic neck pain]] is described as an often-widespread sensation with hyperalgesia in the skin, ligaments, and muscles on palpation and in both passive and active movements in neck and shoulder area (Ylinen J, 2007).<ref name="Misailidou et al." /> Another type of classification proposed by IASP is based on the duration of [[Neck Pain Tool-kit: Step 1|Neck pain]]. [[Neck Pain Tool-kit: Step 1|Acute neck pain]] usually lasts less than 7 days, [[Neck Pain Tool-kit: Step 1|subacute neck pain]] lasts more than 7 days but less than 3 months, and [[Neck Pain Tool-kit: Step 1|chronic neck pain]] has duration of 3 months or more.  
Individuals with chronic neck pain are largely middle aged and the majority are female<ref name=":0" />. Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain<ref name=":0" />. 


== Clinically Relevant Anatomy  ==
== Clinical Course ==
The overall balance of evidence supports a variable view of the clinical course of neck pain. Recovery appears to occur most rapidly in the first 6 to 12 weeks post injury, with considerable slowing after that and little recovery after 12 months<ref name=":0" /><ref>Sterling M, Hendrikz J, Kenardy J. Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: a prospective study. Pain. 2010;150:22-28. <nowiki>https://doi.org/10.1016/j</nowiki>. pain.2010.02.013</ref>.  Once considered chronic, the course may be stable or fluctuating, but in most cases can be best classified as recurrent, characterised by periods of relative improvement followed by periods of relative worsening.


For a structure to be a potential source of pain, it must be innervated. The posterior neck muscles and the cervical zygapophysial joints are innervated by the cervical dorsal rami. The lateral atlanto-axial joint is innervated by the C2 ventral ramus, and the atlanto-occipital joint is supplied by the C1 ventral ramus. The median atlanto-axial joint and its ligaments are supplied by the sinuvertebral nerves of C1-3. These nerves also supply the dura mater of the cervical spinal cord. The innervation of the prevertebral and lateral muscles of the neck are innervated by branches of the cervical ventral rami.  
Pain intensity, level of self-rated disability, pain-related catastrophising, post traumatic stress symptoms (traumatic onset only), and cold hyperalgesia may indicate a potential for chronicity<ref name=":0" />.
== Assessment  ==


Because they are innervated, all of the muscles, synovial joints, and intervertebral disks of the neck are potential sources of neck pain, along with the cervical dura mater and the vertebral artery. It has been shown that noxious stimulation of the cervical zygapophyseal joints causes [[Neck Pain Tool-kit: Step 1|neck pain]] and [[Referred Pain|referred pain]] (Dwyer A. et al., Aprill C. et al.). Pain from muscles innervated by a particular segment should be perceived in the same location as pain from articular structures innervated by the same segment. A study showed that stimulation of upper cervical muscles could produce pain in the head (Cyriax J.)<ref>Bogduk N,  The anatomy and pathophysiology of neck pain; Physical Medicine and  Rehabilitation Clinics North America 14, 2003, 455-472 (5)</ref>
Assessment of chronic neck pain should follow the usual [[Cervical Examination|examination for the cervical spine]]. However it is important to be aware of the differing impairments that individuals with chronic pain may present:
 
* Chronic conditions often have a lower degree of irritability<ref name=":0" />.
== Epidemiology /Etiology  ==
* Individuals with chronic neck pain often display impaired proprioception. A high-quality review by Stanton et al<ref>Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Evidence of impaired proprioception in chronic, idiopathic neck pain: systematic review. Phys Ther. 2016;96:876-887</ref> concluded that these individuals are worse than asymptomatic controls at head-to-neutral repositioning tests.
 
* Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain<ref name=":0" />
[[Neck Pain Tool-kit: Step 1|Chronic neck pain]] is a common disease in general population and employees. [[Neck Pain Tool-kit: Step 1|Chronic neck pain]] can occur one year after the initial episodes and it has been found in 60% to 80% of employees. The incidence of [[Neck Pain Tool-kit: Step 1|chronic neck pain]] was higher in women (15%) than men (9%). Women have the highest incidence at the age of 45 and men at the age of 60. <ref name="Kääria et al.">Kääria S, Laaksonen M, Rahkonen O, Lahelma E, Leino-Arjas P, Risk factors of chronic neck pain: A prospective study among middle-aged employees, 2011, European Journal of Pain (2B)</ref> Fejer et al also found that the prevalence is higher in women. Scandinavian people reported more [[Neck Pain Tool-kit: Step 1|neck pain]] than Europe or Asia. <ref>Fejer R, Kyvik KO, Hartvigsen J, The prevalence of neck pain in the world population: a systematic critical review of the literature, 2006, European Spine Journal (1A)</ref>  
It is well know that [[The Flag System|Psychosocial factor]]<nowiki/>s may contribute to an individuals persistent pain and disability, and the transition of an acute condition to a chronic, disabling condition. Certain outcome measures can be used to evaluate psychosocial factors:
 
* [[Fear Avoidance Belief Questionnaire|Fear Avoidance Questionnaire]]
According to S. Kääriä et al, the strongest predictors for women are earlier [[Neck Pain Tool-kit: Step 1|acute neck pain]] and [[Chronic Low Back Pain|chronic low back pain]]. Other predictors are:<br>
* Beck Depression Inventory
 
* Depression Anxiety Screening Scale
*high physical workload
* [[Pain Catastrophizing Scale]]
*intermediate and high work-related emotional exhaustion
*experiencing and having earlier experienced bullying at work
*common mental disorders
*rare to occasional and frequent sleep problems
*overweight and obesity
 
The predictors for men are:<br>
 
*[[Chronic Low Back Pain|chronic low back pain]]
*[[Neck Pain Tool-kit: Step 1|acute neck pain]]
*manual class as compared with managers and professionals
*high work-related emotional exhaustion
*frequent sleep problems <ref name="Kääria et al." /><br>
 
== Diagnostic Procedures  ==
 
The most common [[Neck Pain Tool-kit: Step 1|neck pain]] in a physician’s office is nonspecific and it is usually caused by daily activities. The differential diagnosis of [[Neck Pain Tool-kit: Step 1|neck pain]] is focused on mechanical and non-mechanical. [[Neck Pain Tool-kit: Step 1|Chronic neck pain]] is when the complaints are longer than three months and this can be a mechanical or non-mechanical cause. Possible factors that can lead to chronicity are: fear, catastrophizing, depression and anxiety.<ref>Wang C. K, Factors contributing to pain chronicity, Current pain and headache reports, 2009  (2C)</ref> The table below shows the possible causes of [[Neck Pain Tool-kit: Step 1|neck pain]]. <ref>Philip D. Sloan, Essentials of the family medicine , Chapter 37 introduction , Wolters kluwer , 6th edition.</ref>
 
<br>
 
{| width="650" cellspacing="1" cellpadding="1" border="1" align="center"
|-
| '''Mechanical'''
| '''Infections'''
|-
| &nbsp; &nbsp; &nbsp; Nontraumatic
| &nbsp; &nbsp; &nbsp; [[Osteomyelitis|Osteomyelitis]]&nbsp;
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Neck Strain
| &nbsp; &nbsp; &nbsp; Discitis&nbsp;
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Postural
| &nbsp; &nbsp; &nbsp; [[Meningitis|Meningitis]]
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Tension
| &nbsp; &nbsp; &nbsp; [[Herpes Zoster|Herpes Zoster]]
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Adult-onset Idiopathic Torticollis|Torticollis]] (acquired)
| &nbsp; &nbsp; &nbsp; [[Lyme Disease|Lyme Disease]]
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Cervical Spondylosis|Spondylosis]]* (degenerative arthritis)
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Cervical Myelopathy|Myelopathy]]*
| '''Neurologic'''
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Cervical Fracture* (see neoplasm)
| &nbsp; &nbsp; &nbsp; Peripheral Entrapment&nbsp;
|-
| <br>
| &nbsp; &nbsp; &nbsp; Brachial Plexitis
|-
| '''Traumatic'''
| &nbsp; &nbsp; &nbsp; Neuropathies
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Whiplash Associated Disorders|Whiplash]] Syndromes*  
| &nbsp; &nbsp; &nbsp; Reflex Sympathetic Dystrophy
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Disc Herniation|Disc Herniation]]*  
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Neck Sprain
| '''Referred'''
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Sports (Stinger*)
| &nbsp; &nbsp; &nbsp; [[Thoracic Outlet Syndrome (TOS)|Thoracic Outlet Syndrome]]
|-
| <br>
| &nbsp; &nbsp; &nbsp;[[Pancoast Tumor|Pancoast Tumor]]
|-
| '''Non Mechanical'''
| &nbsp; &nbsp; &nbsp; Esophagitis
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Rheumatologic/Inflammatory
| &nbsp; &nbsp; &nbsp; Angina
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Rheumatoid Arthritis|Rheumatoïd Arthritis]]
| &nbsp; &nbsp; &nbsp; Vascular Dissection
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Ankylosing Spondylitis|Ankylosing Spondylitis]]
| &nbsp; &nbsp; &nbsp; Carotidynia
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; [[Fibromyalgia|Fibromyalgia]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; [[Polymyalgia Rheumatica|Polymyalgia Rheumatic]]
| '''Miscellaneous'''
|-
| [[Reiter's Syndrome|&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Reiter's Syndrome]]
| &nbsp; &nbsp; &nbsp; [[Sarcoidosis|Sarcoidosis]]
|-
| &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; [[Psoriatic Arthritis|Psoriatic Arthritis]]
| &nbsp; &nbsp; &nbsp; [[Paget's Disease|Paget Disease]]
|-
| <br>
| <br>
|-
| '''Neoplastic'''
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Osteoblastoma|Osteoblastoma]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Osteochondroma|Osteochondroma]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Giant Cell Tumor|Giant Cell Tumor]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Metastases
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Hemangioma
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Multiple Myeloma
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Chondrosarcoma|Chondrosarcoma]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Glioma
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;[[Syringomyelia|Syringomyelia]]
| <br>
|-
| &nbsp; &nbsp; &nbsp; &nbsp;Neurofibroma
| <br>
|-
|
|-
|*With or without [[Radiculopathy|radiculopathy]]
|}
 
== Outcome Measures  ==
 
== Examination  ==
 
Please see [[Cervical Examination|this page]] for information of examination of the cervical spine<br>


== Medical Management  ==
== Medical Management  ==


There is a lack of trials and evidence for medical therapies commonly used in [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. For chronic [[Whiplash Associated Disorders|WAD]] , there is strong evidence against the use of botulinum-A to reduce pain, improve disability or global perceived effect after short term follow-up. For chronic facet joint pain and related disability, the evidence suggest against the use of medial branch block with steroids from short- to long-term follow-up. There is only one muscle relaxant (psychotropic agent) for chronic neck pain that the evidence supports, eperison hydrochloride. There is limited efficacy with this agent, however, as it will help one in 37 people achieve immediate pain relief and evidence for longer-term benefits is not available. <ref>Peloso P.M., Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON§ Project , 2013 , The open orthopedics journal, 473-493 (1A)</ref><br>
There is a lack of evidence for medical management of chronic neck pain. Trials testing the use of botulinum injections, steroid injections and muscle relaxants have not proven to be efficacious.  


== Physical Therapy Management  ==
== Physical Therapy Management  ==


In the literature, there are different treatments that have been investigated for [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. We found treatment consisted of [[Manual Therapy|manual therapy]], [[Massage|massage]], stretching, strength training but also alternative therapy such as yoga.
=== Treatment Based Classification Approach ===
 
The treatment based classification approach to neck pain revision in 2017<ref name=":0" /> (CLINICAL PRACTICE GUIDELINE) separately listed interventions for chronic neck pain: (level of evidence 1a)  
=== '''Stretching in treatment of chronic neck pain'''  ===
 
Ylinen J. et al compared the effects of stretching exercises with manual therapy in the treatment of [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. Low-velocity osteopathic type mobilization of cervical joints for 10 minutes. Mobilization was based on eight osteopathic-type mobilization techniques, which were all performed while the patient was lying supine:
 
#Mobilization of upper cervical joints<br>
#Mobilization of the jaw joint<br>
#Translation upwards
#Translation sideways
#Side bending
#Rotation and side bending in the same direction
#Rotation and side bending in the opposite direction
#Rotation with small ROM
 
The second to eighth mobilization treatments started at the level of the fourth vertebra and each vertebra is moved 2-3 times. When the head is reached the direction is reversed and then the vertebra below it, is mobilized 2-3 times and this until the seventh cervical vertebra is reached.<br>
 
After the mobilization, the patients received [[Massage|massage]] of the neck, shoulder and back muscles for 15 minutes. At the end the patients received 5 minutes of passive stretching. The stretched structures were scalene, upper trapezius, and pectoralis minor muscles, interspinous muscles and ligamentum nuchae. These were all stretched during 30 seconds.
 
The stretching group received the same treatment but in reverse order. In addition they were taught stretching exercises, each of which were held for 30 seconds and performed three times each for a total of 10 minutes, five times per week.
 
After a treatment of four weeks, pain and disability significantly decreased in both groups and there was no significant difference between both groups. Both groups were followed over 12 weeks and after 12 weeks there was still a significant effect in both groups. Both treatments are recommended to decrease pain, at least on short term. <ref name="Ylinen et al.">Ylinen J, Kautiainen H, Wirén K, Häkkinen A. Stretching exercises vs manual therapy in treatment of chronic neck pain: a randomized, controlled cross-over trial, 2007, Journal of Rehabilitation Medecine, (1B)</ref>
 
=== '''Strength Training'''  ===
 
P. K. Salo et al. investigated if a long-term strengthening program had a positive effect on the health-related quality of life. The group was divided into three sub-groups; one strength training group, one endurance training group and one control group. Both groups received a 12 day rehabilitation program in a rehabilitation centre and this program was then performed as a home training program for one year.
 
The strength training group used a rubber band to train the neck muscles. The patients sat in an upright position. One end of the rubber was attached to the patients’ head and the other end to a sturdy stand. They had to bend from the hips directly forward, obliquely to the right and left and finally backwards. In addition, a single adjustable dumbbell was used to perform upper body exercises. These were dumbbell shrugs, presses, curls, bent-over rows, flies and pullovers. During each exercise, the erect posture of the spine was maintained. Each exercise had to be done 15 times. If the patients could repeat the exercise for 20 times, weight was added.
 
The endurance training group trained their neck muscles by lifting the head up from supine position in three sets of 20 repetitions. They performed the same exercise for the upper body as the strength training group but they used a pair of dumbbells, each of 2 kg and they had to do three sets of 20 repetitions.
 
In addition to 20 minutes of stretching exercises, both groups had to perform a single series of squats, sit-ups and back extension exercise. The both groups had to train three times per week.
 
The control group received written information and one guidance session concerning the same stretching exercises that the training groups were performing. Each group was encouraged to perform aerobic exercises three times a week.
 
This training program of strength and endurance training showed a significant effect on the health-related quality of life in these patients. A training program consisted of strength and endurance training is recommended for people with [[Neck Pain Tool-kit: Step 1|chronic neck pain]] but people must be motivated to perform training for a long period. <ref name="Salo et al.">Salo PK, Häkkinen AH, Kautiainen H, Ylinen JJ. Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study, 2010, Health and Quality of Life Outcomes (1B)</ref>
 
Ylinen J. et al also investigated if this neck muscle training in the treatment of [[Neck Pain Tool-kit: Step 1|chronic neck pain had]] a long term effect. The patients received strength or endurance training three times per week. The endurance group trained the neck muscles by lifting the head up while lying down. The strength training group performed isometric neck resistance training with an elastic rubber band in the sitting position. Both groups performed dynamic exercises for the shoulders, upper and lower extremities and the trunk. At the end of the training they had to stretch the neck, shoulder and upper limb muscles.
 
They found that the training program had a long term effect. The decrease in pain and disability as well as the functional improvements remained at the three year follow-up. <ref name="Ylinen et al. 2">Ylinen J, Häkkinen A, Nykänen M, Kautiainen H, Takala EP, Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study, 2007, Europa Medicophysica (1B)</ref>  
 
Sudarat Borisut investigated if strength and endurance training of the superficial and deep neck muscles improved pain and disability in [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. There were three groups. The strength-endurance group received a progressive resistance training for the neck muscles (the superficial flexor and extensor muscles of the neck, the sternocleidomastoideus, the anterior scalenes and the cervical erector spinae). <br>The craniocervical flexion group received exercises of a low load for the cranio-cervical flexor muscles, the deep flexors of the upper cervical region, the longus capitis and colli. <br>The combined exercise group performed both strength-endurance and cranio-cervical flexion exercises. First, patients performed the cranio-cervical flexion exercise and after a rest of 5 minutes they performed the strength-endurance exercise. <br>The three groups showed an improvement of the pain and disability after performing the exercises. These exercise programs reduced the activities of almost all cervical muscles. <ref name="Borisut et al.">Borisut S, Vongsirinavarat M, Vachalathiti R, Sakulsriprasert P, Effects of strength and endurance training of superficial and deep neck muscles on muscle activities and pain levels of females with chronic neck pain, Journal of Physical Therapy Science (2B)</ref>
 
Bertozzi L et al also supports the use of therapeutic exercises in the management of [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. This group investigated different randomized controlled trials and found a positive effect for therapeutic exercises on pain and disability. <ref name="Bertozzi et al.">Bertozzi L, Gardenghi I, Turoni F, Villafañe JH, Capra F, Guccione AA, Pillastrini P, Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials, 2013, Physical Therapy, (1A)</ref>
 
=== '''Manual Therapy for chronic neck pain'''  ===
 
As already said above Ylinen J. et al compared the effects of stretching exercises with [[Manual Therapy|manual therapy]] in the treatment of [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. They found that a treatment with [[Manual Therapy|manual therapy]] had a positive effect at least in the short-term. <ref name="Ylinen et al." /><br>In the treatment of chronic neck pain, H. M.C. Lau et al investigated the effect of thoracic manipulation in patients with [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. There were two groups.
 
Group A received thoracic manipulation during 8 sessions, 2 times a week, including infrared radiation therapy for 15 minutes on the painful site. The patients also received a standard set of educational materials illustrating the simple pathology of neck pain and general advice on neck care. Group B was the control group and received 8 sessions, 2 times a week, of infrared radiation therapy and also the set of educational materials. <br>Thoracic manipulation showed a positive effect in reducing [[Neck Pain Tool-kit: Step 1|neck pain]], it improved the dysfunction, neck posture and the neck ROM. These effects were lasting after 6 months follow-up. <ref name="Lau et al.">Lau HM, Wing Chiu TT, Lam TH. The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain - a randomized controlled trial, 2013, Manual Therapy, (1B)</ref>
 
Another author, T.Suvarnnato et al compared the effect of thoracic manipulation and mobilization in the treatment of [[Neck Pain Tool-kit: Step 1|chronic neck pain]]
 
There were 3 groups. The patients in the single level thoracic manipulation group were asked to lie in a prone position on a examination table. The patients had to perform deep inhalation and exhalation. At the end of the exhalation the thoracic manipulation were performed, the screw thrust technique, at T6-T7. If the popping sound wasn’t heard, a second attempt was made, which was the maximum. <br>The patients in the single level thoracic mobilization group were asked to lie in the prone position on the examination table. Then Grade III unilaterally poster-anterior mobilization was performed at T6-T7 on the left and right side. This technique has been used to improve the ROM.<br>The patients in the control group were asked to lie in the prone position on the examination table. Then clinician placed their hands on both sides of T6-T7 without compressive pressure of the joints and this for 2 minutes. <br>There was a significant reduction in pain at rest and the cervical ROM increased in al movements of the cervical spine after the single level thoracic manipulation at T6-T7. The single thoracic mobilization at T6-T7 showed a reduction in pain at rest and increased cervical ROM in some directions. Both have a short term effect. <ref name="Suvarnnato et al.">Suvarnnato T., Puntumetakul R, Kaber D, Boucaut R, Boonphakob Y, Arayawichanon P, Uraiwan C, The Effects of Thoracic Manipulation Versus Mobilization for Chronic Neck Pain: a Randomized Controlled Trial Pilot Study, 2013, Journal of Physical Therapy science (1B)</ref>
 
Vernon H et al, investigated the effect of manual therapy on subjects with [[Neck Pain Tool-kit: Step 1|chronic neck pain]] not due to whiplash or without arm pain and headaches. They investigated different randomized controlled trials and have found that pinal mobilization and manipulation showed important improvements even at longer term. <ref name="Vernon et al.">Vernon H, Humphreys K, Hagino C. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials, 2007, Journal of Manipulative and Physiological Therapeutics (1A)</ref>
 
=== '''Massage for chronic neck pain'''  ===
 
[[Massage|Massage]] is a common treatment in [[Neck Pain Tool-kit: Step 1|chronic neck pain]] but there has not been done a lot of investigation to date. Sherman KJ et al investigated the effect of [[Massage|massage]] in the treatment of [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. He found that a treatment of 10 massages over 10 weeks had a positive effect on chronic neck pain. It is safe and has clinical benefits for treating [[Neck Pain Tool-kit: Step 1|chronic neck pain]] but in the short term. <ref name="Sherman et al.">Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. 2009, The Clinical Journal of Pain(1B)</ref> He also investigated the optimal dose of [[Massage|massage]] therapy. He found that a treatment of 60 minutes per week was more effective than shorter sessions of 30 minutes. <ref name="Sherman et al. 2">Sherman KJ, Cook AJ, Wellman RD, Hawkes RJ, Kahn JR, Deyo RA, Daniel C. Cherkin DC, Five-Week Outcomes From a Dosing Trial of Therapeutic Massage for Chronic Neck Pain, 2014, Annals of Familiy Medecine (1B)</ref>


=== '''Alternative therapy for chronic neck''' ===
'''Neck pain with mobility deficits'''


Another, more alternative, treatment is yoga. Cramer et al. investigated the effects of a nine-week yoga intervention on [[Neck Pain Tool-kit: Step 1|nonspecific chronic neck pain]] 12 months after completion. The 51 subjects with [[Neck Pain Tool-kit: Step 1|chronic nonspecific neck pain received]] a 9-week yoga group intervention. After the intervention was there a 12 month follow-up. The conclusion of this study was a significant improvement in [[Neck Pain Tool-kit: Step 1|neck pain]] and disability for at least 12 months after completion of the yoga intervention. <ref name="Cramer et al.">Cramer H, Lauche R, Hohmann C, Langhorst J, Dobos G. Yoga for chronic neck pain: a 12-month follow-up, 2013 , Pain medicine (1B)</ref>
Clinicians should provide a multimodal approach of the following:  
# Thoracic manipulation and cervical manipulation or mobilization 
# Mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (eg, coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements 
# Dry needling, laser, or intermittent mechanical/manual traction
# Clinicians may provide neck, shoulder girdle, and trunk endurance exercise approaches and patient education and counseling strategies that promote an active lifestyle and address cognitive and affective factors.  
'''Chronic neck pain with movement coordination impairments (including WAD)'''


Another study of Cramer et al. investigated the comparison of yoga and home-based exercises. The 51 subjects were randomly assigned to either yoga or home-based exercises. The yoga group attended a nine-week yoga course and the home-based exercise group received a self-care manual on home-based exercises for [[Neck Pain Tool-kit: Step 1|neck pain]]&nbsp;relief. The result of this study was that there was significantly less [[Neck Pain Tool-kit: Step 1|neck pain]] intensity compared with the exercise group. The yoga group reported less disability and better mental quality of life. Range of motion and proprioceptive acuity were improved and the pressure pain threshold was elevated in the yoga group. It seems that yoga does influence the functional status of neck muscles as indicated by improvement of physiological measures of [[Neck Pain Tool-kit: Step 1|neck pain]]. <ref name="Cramer et al. 2">Cramer H, Lauche R, Hohmann C, Lüdtke R, Haller H, Michalsen A, Langhorst J, Dobos G. Randomized-controlled trial comparing yoga and home-based exercise for chronic neck pain, 2013 , The clinical journal of pain (1B)</ref><br>
Clinicians may provide the following:
# Patient education and advice focusing on assurance, encouragement, prognosis, and pain management
# Mobilisation combined with an individualised, progressive sub maximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioural therapy
# TENS
'''Chronic neck pain with headache'''


== Key Research  ==
Clinicians should provide cervical or cervicothoracic manipulation or mobilisations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.


One level 1B RCT <ref name="Ylinen et al." /> studied the effect of stretching and [[Manual Therapy|manual therapy]] in patients with [[Neck Pain Tool-kit: Step 1|chronic neck pain]], which reported a significant decreasing in pain and disability in subjects with [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. Two other RCT’s <ref name="Lau et al." />,<ref name="Suvarnnato et al." />&nbsp;studied the effect of thoracic manipulation and mobilization in subjects with [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. Both had a significant effect on pain and dysfunction in these subjects. One Level 1A systematic review confirmed the positive effect of [[Manual Therapy|manual therapy]] <ref name="Vernon et al." />. Two level 1B RCT’s <ref name="Salo et al." />,<ref name="Ylinen et al. 2" /> and a Level 2B cohort study <ref name="Borisut et al." /> investigated the effect of strength exercises for the neck muscles. They found that strength training has a short and long term effect and decreases pain and dysfunction. These findings were also found in a Level 1A systematic review which confirms the decreasing in pain and disability in subjects with [[Neck Pain Tool-kit: Step 1|chronic neck pain]] <ref name="Bertozzi et al." />. The effect of [[Massage|massage]] was investigated and two level 1B RCT’s found a positive effect. One RCT suggests 10 [[Massage|massages]] over 10 weeks <ref name="Sherman et al." /> and the other RCT suggests that 60 minutes of [[Massage|massage]] has a greater effect than 30 minutes of [[Massage|massage]] in subjects with [[Neck Pain Tool-kit: Step 1|chronic neck pain]]. <ref name="Sherman et al. 2" /> Two level 1B RCT’s <ref name="Cramer et al." />,<ref name="Cramer et al. 2" /> found that yoga has a positive effect on [[Neck Pain Tool-kit: Step 1|chronic neck pain]].
'''Chronic neck pain with radiating pain'''
# Clinicians should provide mechanical intermittent cervical traction, combined with other interventions such as stretching and strengthening exercise plus cervical and thoracic mobilisation/ manipulation.  
# Clinicians should provide education and counselling to encourage participation in occupational and exercise activities 


== Resources ==
== Chronic Whiplash Clinical Care Pathway==
<ref name=":1">Rebbeck T. [http://www.jospt.org/doi/pdf/10.2519/jospt.2017.7138 The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary.] Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-32.</ref> (LOE 5) ==
[[File:Chronic whiplash clinical care pathway.png|frameless|668x668px]]


== Clinical Bottom Line<br>  ==
=== Behavioural Interventions ===
Education is a key component of managing individuals with chronic neck pain and behavioural interventions should play a role in the management of people with chronic whiplash<ref name=":1" /> (LOE 5). Guidelines recommend that individuals be provided with information about how to cope with pain and disability, particularly as their symptoms transition to the chronic phase. Key concepts to address include reducing catastrophic thought, addressing unhelpful beliefs, addressing fear of movement and providing active coping strategies to assist patients to cope with pain<ref name=":1" /> (LOE 5).  There is some preliminary evidence that pain neurophysiology education in chromic WAD improves both pain behavior and pain thresholds<ref name=":1" /> (LOE 5). 


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
Cognitive Behavioural Therapy (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner. The [[CBT Approach to Chronic Low Back Pain|CBT approach to LBP]] can be as effectively applied to neck pain and can be included in your [[The Inclusion of CBT in Physiotherapy Education|education strategy]].  
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1PcHN4WG_QmjBJdF8OEyVyNfZJuiovHE038E0eRcjBe953094R|charset=UTF-8|short|max=10</rss>
</div>
== References ==


<references />
If relevant psychosocial factors are identified, the rehabilitation approach may need to be modified. An emphasis on active rehabilitation and positive reinforcement of functional accomplishments is recommended. Graded exercise programs that direct attention towards attaining certain functional goals and away from the symptom of pain have also been recommended. Finally, graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform may be helpful.


[[Category:Cervical_Spine]] [[Category:Pain]] [[Category:Musculoskeletal/Orthopaedics]]
== References ==
<references />
[[Category:Occupational Health]]
[[Category:Pain]]  
[[Category:Conditions]]
[[Category:Cervical Spine]]
[[Category:Cervical Spine - Conditions]]
[[Category:Mental Health]]
[[Category:Mental Health - Conditions]]

Latest revision as of 11:50, 15 November 2023

Original Editor - Axel Antoine

Top Contributors - Axel Antoine, Laura Ritchie, Kim Jackson, Rachael Lowe, Simisola Ajeyalemi, Jess Bell, Olajumoke Ogunleye, Admin, Evan Thomas, George Prudden, Joris Servranckx, Eva Roose1, WikiSysop, Claire Knott and Lauren Lopez

Introduction[edit | edit source]

Neck pain1.jpg

The International Association for the Study of Pain (IASP) in its classification of Chronic Pain defines cervical spinal pain as "pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process". The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders describes Neck pain as "pain located in the anatomical region of the neck with or without radiation to the head, trunk, and upper limbs".

Pain is classified as chronic when it has a duration of 12 weeks or more. Chronic neck pain often presents as widespread hyperalgesia on palpation and in both passive and active movements in neck and shoulder area[1].

Considerable research has shown that psychosocial factors are an important prognostic indicator of prolonged disability in individuals with neck pain[2]. It is well known that chronic pain is often associated with anatomical, psychological, social, and professional factors. This is consistent with the biopsychosocial model, which considers pain to be a dynamic interaction between biological, psychological, and social factors unique to each individual.

Epidemiology[edit | edit source]

Although the natural history of neck pain appears to be favourable, rates of recurrence and chronicity are high[3]. Blanpied et al reviewed the literature and found that:

  • 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater than 6 months in duration affecting 14% of all individuals who experience an episode of neck pain.
  • 37% of individuals who experience neck pain will report persistent problems for at least 12 months. Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.
  • Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.

The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures

Individuals with chronic neck pain are largely middle aged and the majority are female[3]. Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain[3]. 

Clinical Course[edit | edit source]

The overall balance of evidence supports a variable view of the clinical course of neck pain. Recovery appears to occur most rapidly in the first 6 to 12 weeks post injury, with considerable slowing after that and little recovery after 12 months[3][4]. Once considered chronic, the course may be stable or fluctuating, but in most cases can be best classified as recurrent, characterised by periods of relative improvement followed by periods of relative worsening.

Pain intensity, level of self-rated disability, pain-related catastrophising, post traumatic stress symptoms (traumatic onset only), and cold hyperalgesia may indicate a potential for chronicity[3].

Assessment[edit | edit source]

Assessment of chronic neck pain should follow the usual examination for the cervical spine. However it is important to be aware of the differing impairments that individuals with chronic pain may present:

  • Chronic conditions often have a lower degree of irritability[3].
  • Individuals with chronic neck pain often display impaired proprioception. A high-quality review by Stanton et al[5] concluded that these individuals are worse than asymptomatic controls at head-to-neutral repositioning tests.
  • Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain[3]

It is well know that Psychosocial factors may contribute to an individuals persistent pain and disability, and the transition of an acute condition to a chronic, disabling condition. Certain outcome measures can be used to evaluate psychosocial factors:

Medical Management[edit | edit source]

There is a lack of evidence for medical management of chronic neck pain. Trials testing the use of botulinum injections, steroid injections and muscle relaxants have not proven to be efficacious.

Physical Therapy Management[edit | edit source]

Treatment Based Classification Approach[edit | edit source]

The treatment based classification approach to neck pain revision in 2017[3] (CLINICAL PRACTICE GUIDELINE) separately listed interventions for chronic neck pain: (level of evidence 1a)

Neck pain with mobility deficits

Clinicians should provide a multimodal approach of the following:

  1. Thoracic manipulation and cervical manipulation or mobilization
  2. Mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (eg, coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements
  3. Dry needling, laser, or intermittent mechanical/manual traction
  4. Clinicians may provide neck, shoulder girdle, and trunk endurance exercise approaches and patient education and counseling strategies that promote an active lifestyle and address cognitive and affective factors.

Chronic neck pain with movement coordination impairments (including WAD)

Clinicians may provide the following:

  1. Patient education and advice focusing on assurance, encouragement, prognosis, and pain management
  2. Mobilisation combined with an individualised, progressive sub maximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioural therapy
  3. TENS

Chronic neck pain with headache

Clinicians should provide cervical or cervicothoracic manipulation or mobilisations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.

Chronic neck pain with radiating pain

  1. Clinicians should provide mechanical intermittent cervical traction, combined with other interventions such as stretching and strengthening exercise plus cervical and thoracic mobilisation/ manipulation.
  2. Clinicians should provide education and counselling to encourage participation in occupational and exercise activities

Chronic Whiplash Clinical Care Pathway[edit | edit source]

[6] (LOE 5) == Chronic whiplash clinical care pathway.png

Behavioural Interventions[edit | edit source]

Education is a key component of managing individuals with chronic neck pain and behavioural interventions should play a role in the management of people with chronic whiplash[6] (LOE 5). Guidelines recommend that individuals be provided with information about how to cope with pain and disability, particularly as their symptoms transition to the chronic phase. Key concepts to address include reducing catastrophic thought, addressing unhelpful beliefs, addressing fear of movement and providing active coping strategies to assist patients to cope with pain[6] (LOE 5). There is some preliminary evidence that pain neurophysiology education in chromic WAD improves both pain behavior and pain thresholds[6] (LOE 5).

Cognitive Behavioural Therapy (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner. The CBT approach to LBP can be as effectively applied to neck pain and can be included in your education strategy.

If relevant psychosocial factors are identified, the rehabilitation approach may need to be modified. An emphasis on active rehabilitation and positive reinforcement of functional accomplishments is recommended. Graded exercise programs that direct attention towards attaining certain functional goals and away from the symptom of pain have also been recommended. Finally, graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform may be helpful.

References[edit | edit source]

  1. ↑ Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G, Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools; Journal of Chiropractic Medicine Jun 2010; 9(2): 49–59. (5)
  2. ↑ Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83
  4. ↑ Sterling M, Hendrikz J, Kenardy J. Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: a prospective study. Pain. 2010;150:22-28. https://doi.org/10.1016/j. pain.2010.02.013
  5. ↑ Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Evidence of impaired proprioception in chronic, idiopathic neck pain: systematic review. Phys Ther. 2016;96:876-887
  6. ↑ 6.0 6.1 6.2 6.3 Rebbeck T. The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-32.
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