Acute Neck Pain

Introduction

Acute neck pain is characterised by its sudden onset, typically lasting less than three months. This discomfort can manifest as localised pain or radiate to the head, shoulders, and arms. According to NICE guidelines, the prevalence of condition-specific acute neck pain ranges from 40 to 70%. Various factors such as injury, disease, wear and tear, or poor biomechanics can stress the spine and lead to this type of pain. However, pinpointing the exact source of discomfort can be challenging. Potential contributing factors may include nerve damage, tissue scarring, arthritis, and the emotional effects of pain.

Functional Anatomy

The cervical spine consists of several structural group:

1. Muscles - anterior muscles, posterior muscles, lateral muscles, muscles that feed into the neck
2. Ligaments - anterior and posterior longitudinal ligament, intertransverse ligaments, nucheal ligament, alar ligaments, apical ligaments of dens, yellow ligaments
3. Neurological structures - arteries, nerves, glands, and 2 passageways

These three structural groups in the cervical spine works together to serve the three main functions of the cervical spine:

1. Protect spinal cord
2. Support the head and allow movements
3. Provide a safe passageway for vertebral arteries
   

Mechanism of injury and Differential Diagnosis

Understanding the mechanism of acute neck pain and differential diagnosis are the key parts of a physiotherapy assessment process. Various sources can contribute to acute neck pain:

• Cervical muscle sprain - Most common cause of acute neck pain, usually caused my overuse of the musculature e.g., sitting hunched over in a chair

• Muscle weakness - Training muscles asymmetrically can cause pain i.e., training upper traps more than lower traps can lead to overstimulation of the upper traps, the difference can cause pain
• Concussion - After a concussion, people may experience head and neck pain, it can start quickly after and last anywhere from a few days to months/years. Any symptoms that last longer than 3 months after is considered post-concussion syndrome
• RTA - Symptoms can occur suddenly or within a few days following an accident , similar to a concussion, how long the symptoms last can range
• Whiplash- This can occur within a RTA or from another type of trauma e.g., a fall   

Risk Factors

Identifying and understanding risk factors is crucial for prevention and early diagnosis, as acute neck pain can potentially evolve into chronic conditions. Potential contributing risk factors include:

1. Advanced age
2. Female
3. History of neck, shoulder, and pelvis trauma
4. Psychological factors
5. Lifestyle

Classification

According to the updated neck pain revision of the Orthopaedic Section of the American Physical Therapy Association (APTA) in 2017, these are the revised clinical guidelines for neck pain classification:

• Neck pain with mobility deficits
• Neck pain with movement coordination impairments
• Neck pain with headaches
• Neck pain with radiating pain

Clinical Presentation

Every acute neck pain present differently, it often present with more than a simple pain in the neck. Typically, it is accompanied by:

• Referred pain - headache, shoulder pain, upper or lower back pain, radiated pain with upper extremity numbness. These pain can be explained by refereed or widespread pain from innervated cervical spine structure.
• Mobility deficit (reduce range of motion)
• Coordination impairment
• Muscle tightness and spasm
• Dizziness, nausea (patients with cervical vertigo may encounter these symptoms)
• Fever (might indicate an infection extending into the brain)

Ruling out Red Flags

Red flags are signs and symptoms found in the patient's history and clinical examination, which could warn us the possibility of life-threatening disorders. Identification of red flags is crucial, it should be carried out before any assessment. Once identified, depending on which one will determine the course of action. Red flags might include:

• Symptoms pattern - worsening of symptoms, recent bladder or bowel issue, sensory changes, unsteady gait, age above 50, previous history of cancer, unexplained weight loss, severely limiting range of motion (ROM) or pain, 5 D’s or 3 N’s, boy temperature over 36 degree, blood pressure (BP) above 160/95, and resting pulse higher than 100bpm
• Family history - Any history of cardiovascular disease or any relevant pathology
• Cranial Nerves - If applicable i.e., you have suspicion they may be involved, test all 12 nerves
• Mechanism of injury - e.g., car crash or big trauma

• Psychosocial factors (factors that stop individual from sleeping, returning to activity, or causes extreme pain), despite not including in red flags, should also be taken into consideration.

Subjective Assessment

Subjective assessment involves a series of questions to understand patients' problems and goals. It helps to direct and guide further objective assessment, as well as provides information for accurate diagnosis. Questions you may ask in subjective assessment include:

• Onset​ - acute/recurring/sudden/chronic
• Nature of the pain​ - type of pain, pain severity, timing when pain occurs, and what triggers aggravation/eases of symptoms
• Pain location​ - or if there is any radiating pain
• Past medical history​ - such as previous injury or infection, not just red flags for example cancer
• Occupational history​ - if their job is physically strenuous or sedentary. Gives an idea if this impacts their pain
• Current presence of a fever​
• Symptoms of anxiety or depression​ - on occasion pain may be made worse by the psychological state of the patient
• Yellow flag questions - this may increase the patient's risk of developing a long term condition

Objective Assessment

From subjective assessment, a clear picture of patient's presenting issue should starting to be developed. Your objective assessment might include:

*first thing is to rule out red flags

• Carry out Canadian C-spine rule if it applies, i.e. if there is a specific trauma to determine if an x-ray is needed to rule out a fracture
• Oculomotor tests
• Neurological exam - Dermatomes, myotomes, reflexes and cranial nerves
• Observation
• Palpation
• Cervical RoM - Active and Passive
• Muscle Strength
• Special Tests
• Neck Disability Index (NDI)

Treatment and Management

If any red flags have been identified, patient must be referred immediately or have an urgent appointment for investigation. When it comes to treatment, should the patient not present with any red flags, the NICE guidelines and other research advise management for acute neck pain as following:

1. Reassurance
2. Initial early exercises - Depending on the objective findings of an assessment, the NHS recommends some initial, early exercises such as ROM exercises can be given followed by later exercises that include more resistance exercises
3. Advice and education - e.g. a firm pillow can help support the head, maintain activity
4. Manual therapy

Example Case Study

Treatment varies from person to person depending on a variety of things, therefore this case study provides a clear idea on how you may treat a patient with acute neck pain.

A Clinical Perspective Subjective

A 28-year-old male complains of decreased range of motion and cervical pain. He was involved in an accident 2 weeks ago where he suffered a whiplash mechanism injury in a road traffic accident (RTA).

He visited the emergency department the same day and was found to have symptoms of whiplash associated disorder (WAD) in line with the Grade II classification on the Quebec Task Force of WAD. The doctor ruled out the presence of a fracture with an x-ray.

Upon entering the clinic, in addition to the decreased ROM, the patient presents with right-sided neck pain (4/10) with poor concentration and coordination. Aggravation include work as he is a teacher so he had to look around a lot, and eases include not moving. Pain does not wake him up at night as he usually sleeps on his back.

Red flags and Yellow Flags

The first thing to do is ruling out red flags. Several main red flags have been rule ruled out from the case as listed:

• Cauda equina ❌

• Neurological symptoms ❌

• Family history  ❌

However there are some yellow flags to consider:

1. Career –  does the injury affect his ability to work?
2. Income – does he have a family or carers that rely on him?
3. Free time? - does the patient play any sports?
4. Psychological and social well-being

In this case study, our patient will be affected by his inability to work as a teacher and therefore income, which includes mobilising his head throughout the day. Besides, our patient enjoys playing golf in his free time. Unfortunately, due to his WAD, he is unable to enjoy his hobby. Furthermore, psychological and social wellbeing could significantly impact patient's pain, hence consideration should also be taken.

Objective Assessment

After considering red and yellow flags, objective assessment is performed on patient:

1. Intermittent pain - 4/10
2. Neurological testing - No need to perform due to no neurological symptoms
3. Oculomotor tests - No need to perform since patient didn't present with headache ( if headache presents, saccadic eye movement and smooth pursuit with neck torsion will be performed )
4. Observation- No obvious swelling/bruising, posture (less lordosis in cervical spine than usual)
5. Palpation- Tenderness/pain in upper trapezius and neck
6. Active and passive Range of Motion (ROM) (Perform all RoM to compare differences) - limited active and passive RoM in all movements (flexion, extension, side flexion, and rotation)
7. Strength test (neck and shoulder muscles) - Weak strength limited by pain (require reassess when pain improves)
8. Neck Disability Index (NDI) - 60% activity limitation

Treatment and Management

When it comes to treatment, our patient’s aims were to return to normal activities such as work and golf. To achieve such aim, our physio aims would be to increase ROM and reduce pain. In the initial stage of the treatment, we will begin with RoM exercise with gravity. Progression exercises will be slowly introduced in later stage of the rehabilitation, as listed below:

1. RoM exercise with gravity as assistance - e.g. being sat up with flexion, extension, side flexion, and rotation
2. RoM exercise against gravity - progress with minimal gravity resistance
3. Isometric holds - then we will progress to isometric holds and strengthening exercises, such as using therabands
4. Sport specific - In later stage of the treatment, we would then combine with sport specific exercises, such as holding a golf club and practicing a swing slowly to begin with, then progress to using a ball etc. ​

Take Home Messages

There are a few important messages for you to take home, it is important to remember these when treating any patient:

1. Red Flags - The first thing to do when seeing a patient is to identify and rule out any red flags, this is crucial as it might lead to adverse impact on patients later on if you failed to identify any existing red flags.
2. Having a holistic approach throughout - Psychological well being can pose a significant influence on pain, especially when patient's job or daily life is affected. Remember to consider any yellow flags when planning your management.
3. Treatment and Management - You cannot take the same views into every patient. Even though 2 patients may present the same injury, the treatment and management might not be the same for both, you can't decide on your exact treatment until you do the subjective and objective assessment. It all requires clinical judgement, be critical!!