Chronic Neck Pain

Original Editor - Axel Antoine

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

Introduction

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.

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. Pain is classified as chronic when it has a duration of 3 months or more.

Considerable research has shown that psychosocial factors are an important prognostic indicator of prolonged disability in individuals with neck pain. 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

Although the natural history of neck pain appears to be favorable, rates of recurrence and chronicity are high. 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. 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. 

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. 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.

Assessment

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.
• Individuals with chronic neck pain often display impaired proprioception. A high-quality review by Stanton et al 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

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:

• Fear Avoidance Questionnaire
• Beck Depression Inventory
• Depression Anxiety Screening Scale
• Pain Catastrophizing Scale

Medical Management

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.

Physical Therapy Management

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. Mobilization combined with an individualized, progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioral 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

Behavioural Interventions

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.