Chronic Neck Pain
Original Editor - Axel Antoine
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Search Strategy[edit | edit source]
Databases Searched: Pubmed, PEDro
Keyword Searches:Chronic neck pain AND Physical therapy,Chronic neck pain AND Manual Therapy, Chronic neck pain AND stretching,Chronic neck pain AND Massage,Chronic neck painAND yoga
Definition/Description[edit | edit source]
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.[1] 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 (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.[1] 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).[1] Another type of classification proposed by IASP is based on the duration of Neck pain. Acute neck pain usually lasts less than 7 days, subacute neck pain lasts more than 7 days but less than 3 months, and chronic neck pain has duration of 3 months or more.
Clinically Relevant Anatomy[edit | edit source]
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.
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 and 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.)[2]
Epidemiology /Etiology[edit | edit source]
Chronic neck pain is a common disease in general population and employees. 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 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. [3] Fejer et al also found that the prevalence is higher in women. Scandinavian people reported more neck pain than Europe or Asia. [4]
According to S. Kääriä et al, the strongest predictors for women are earlier acute neck pain and chronic low back pain. Other predictors are:
- high physical workload
- 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:
- chronic low back pain
- acute neck pain
- manual class as compared with managers and professionals
- high work-related emotional exhaustion
- frequent sleep problems [3]
Diagnostic Procedures[edit | edit source]
The most common neck pain in a physician’s office is nonspecific and it is usually caused by daily activities. The differential diagnosis of neck pain is focused on mechanical and non-mechanical. 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.[5] The table below shows the possible causes of neck pain. [6]
| Mechanical | Infections |
| Nontraumatic | Osteomyelitis |
| Neck Strain | Discitis |
| Postural | Meningitis |
| Tension | Herpes Zoster |
| Torticollis (acquired) | Lyme Disease |
| Spondylosis* (degenerative arthritis) | |
| Myelopathy* | Neurologic |
| Cervical Fracture* (see neoplasm) | Peripheral Entrapment |
| Brachial Plexitis | |
| Traumatic | Neuropathies |
| Whiplash Syndromes* | Reflex Sympathetic Dystrophy |
| Disc Herniation* | |
| Neck Sprain | Referred |
| Sports (Stinger*) | Thoracic Outlet Syndrome |
| Pancoast Tumor | |
| Non Mechanical | Esophagitis |
| Rheumatologic/Inflammatory | Angina |
| Rheumatoïd Arthritis | Vascular Dissection |
| Ankylosing Spondylitis | Carotidynia |
| Fibromyalgia | |
| Polymyalgia Rheumatic | Miscellaneous |
| Reiter's Syndrome | Sarcoidosis |
| Psoriatic Arthritis | Paget Disease |
| Neoplastic | |
| Osteoblastoma | |
| Osteochondroma | |
| Giant Cell Tumor | |
| Metastases | |
| Hemangioma | |
| Multiple Myeloma | |
| Chondrosarcoma | |
| Glioma | |
| Syringomyelia | |
| Neurofibroma | |
| *With or without radiculopathy |
Outcome Measures[edit | edit source]
Examination[edit | edit source]
Please see this page for information of examination of the cervical spine
Medical Management[edit | edit source]
There is a lack of trials and evidence for medical therapies commonly used in chronic neck pain. For chronic 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. [7]
Physical Therapy Management[edit | edit source]
In the literature, there are different treatments that have been investigated for chronic neck pain. We found treatment consisted of manual therapy, massage, stretching, strength training but also alternative therapy such as yoga.
Stretching in treatment of chronic neck pain[edit | edit source]
Ylinen J. et al compared the effects of stretching exercises with manual therapy in the treatment of 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
- Mobilization of the jaw joint
- 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.
After the mobilization, the patients received 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. [8]
Strength Training[edit | edit source]
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 chronic neck pain but people must be motivated to perform training for a long period. [9]
Ylinen J. et al also investigated if this neck muscle training in the treatment of 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. [10]
Sudarat Borisut investigated if strength and endurance training of the superficial and deep neck muscles improved pain and disability in 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).
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.
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.
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. [11]
Bertozzi L et al also supports the use of therapeutic exercises in the management of chronic neck pain. This group investigated different randomized controlled trials and found a positive effect for therapeutic exercises on pain and disability. [12]
Manual Therapy for chronic neck pain[edit | edit source]
As already said above Ylinen J. et al compared the effects of stretching exercises with manual therapy in the treatment of chronic neck pain. They found that a treatment with manual therapy had a positive effect at least in the short-term. [8]
In the treatment of chronic neck pain, H. M.C. Lau et al investigated the effect of thoracic manipulation in patients with 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.
Thoracic manipulation showed a positive effect in reducing neck pain, it improved the dysfunction, neck posture and the neck ROM. These effects were lasting after 6 months follow-up. [13]
Another author, T.Suvarnnato et al compared the effect of thoracic manipulation and mobilization in the treatment of 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.
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.
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.
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. [14]
Vernon H et al, investigated the effect of manual therapy on subjects with 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. [15]
Massage for chronic neck pain[edit | edit source]
Massage is a common treatment in chronic neck pain but there has not been done a lot of investigation to date. Sherman KJ et al investigated the effect of massage in the treatment of 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 chronic neck pain but in the short term. [16] He also investigated the optimal dose of massage therapy. He found that a treatment of 60 minutes per week was more effective than shorter sessions of 30 minutes. [17]
Alternative therapy for chronic neck[edit | edit source]
Another, more alternative, treatment is yoga. Cramer et al. investigated the effects of a nine-week yoga intervention on nonspecific chronic neck pain 12 months after completion. The 51 subjects with 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 and disability for at least 12 months after completion of the yoga intervention. [18]
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 relief. The result of this study was that there was significantly less 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. [19]
Key Research[edit | edit source]
One level 1B RCT [8] studied the effect of stretching and manual therapy in patients with chronic neck pain, which reported a significant decreasing in pain and disability in subjects with chronic neck pain. Two other RCT’s [13],[14] studied the effect of thoracic manipulation and mobilization in subjects with 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 [15]. Two level 1B RCT’s [9],[10] and a Level 2B cohort study [11] 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 chronic neck pain [12]. The effect of massage was investigated and two level 1B RCT’s found a positive effect. One RCT suggests 10 massages over 10 weeks [16] and the other RCT suggests that 60 minutes of massage has a greater effect than 30 minutes of massage in subjects with chronic neck pain. [17] Two level 1B RCT’s [18],[19] found that yoga has a positive effect on chronic neck pain.
Resources[edit | edit source]
Clinical Bottom Line
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 1.2 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)
- ↑ Bogduk N, The anatomy and pathophysiology of neck pain; Physical Medicine and Rehabilitation Clinics North America 14, 2003, 455-472 (5)
- ↑ 3.0 3.1 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)
- ↑ 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)
- ↑ Wang C. K, Factors contributing to pain chronicity, Current pain and headache reports, 2009 (2C)
- ↑ Philip D. Sloan, Essentials of the family medicine , Chapter 37 introduction , Wolters kluwer , 6th edition.
- ↑ 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)
- ↑ 8.0 8.1 8.2 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)
- ↑ 9.0 9.1 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)
- ↑ 10.0 10.1 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)
- ↑ 11.0 11.1 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)
- ↑ 12.0 12.1 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)
- ↑ 13.0 13.1 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)
- ↑ 14.0 14.1 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)
- ↑ 15.0 15.1 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)
- ↑ 16.0 16.1 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)
- ↑ 17.0 17.1 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)
- ↑ 18.0 18.1 Cramer H, Lauche R, Hohmann C, Langhorst J, Dobos G. Yoga for chronic neck pain: a 12-month follow-up, 2013 , Pain medicine (1B)
- ↑ 19.0 19.1 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)
