Mechanical Neck Pain

Introduction[edit | edit source]

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Neck pain (NP) is most commonly defined as pain between the superior nuchal line, an imaginary transverse line through the tip of the first thoracic spinous process, and laterally by sagittal planes peripheral to the lateral borders of the neck.[1] Pain in the neck may be local and/or referred into the head, and/or one or both upper limbs. [2] [3] Apart from its anatomical definition, NP can also be defined based on its duration (acute, subacute, chronic) or reason for onset.

Individuals with NP may lack an identifiable pathoanatomic source for their symptoms; this patient group is classified as having mechanical or non-specific NP because a direct pathoanatomic cause is rarely identifiable. [4] Although the cause of NP may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s NP is usually unknown. [4]

Epidemiology[edit | edit source]

NP is a common musculoskeletal problem worldwide. [5] Just like low back pain (LBP), NP is episodic, with high rates of recurrence and chronicity, and variable recovery between episodes over a lifetime. [2] Mechanical NP commonly arises insidiously and is generally multifactorial in origin. Some of the modifiable factors that have been identified for mechanical NP onset are smoking, [6] poor posture, anxiety, depression, neck strain, and sporting or occupational activities.[7] NP is considered an important societal burden. The prevalence in the overall population may range from 16.7% to 75.1%.[8] Prevalence is high among women in high-income countries and in urban reports. [9] A high incidence is found in the office workers and especially computer users.[10] You can find more information in Epidemiology of Neck Pain.

Triage Classification[edit | edit source]

Classification for NP aims to break down the large entity of NP presentations into homogeneous groups that can be linked with specific management recommendations. Clinical practice guidelines on the assessment and treatment of NP [11][12] propose to initially start with triaging patients into four broad categories:

Grade 1: There are no evident physical examination findings that suggest any structural/major pathology and minimal or no involvement of activities of daily living. Neck pain is present.

Grade 2: The patient is not able to do activities of daily living properly and there are no signs and symptoms of any structural involvement.

Grade 3:Patient represents neurologic signs (sensory deficits/ reduced DTR/weakness). No signs/symptoms of any major structural pathology.

Grade 4: Signs/symptoms of a major structural pathology like fracture/dislocation/spinal cord injury/metastasis/neoplasm or any systemic disease.

Patients with Grade 1 and 2 NP fall into the non-specific NP group and can be managed with physiotherapy treatments. Grade 3 should be further diagnosed and might benefit from other interventions. Grade 4 patients require referral for specialised treatment based on their serious pathology diagnosis.

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Ruling out serious pathology[edit | edit source]

NP is not always mechanical in origin. In some cases, NP may mask a serious pathology. Clinicians must be aware of serious pathological neck conditions and screen for key signs and symptoms - red flags - that may be associated with serious neck pathology (Level 4). Detailed information can be found in Serious Cervical Spine Conditions and Red Flags in Spinal Conditions.

Red flag Diagnosis
Dizziness on neck movements, headache, facial numbness especially on prolonged postures or even drop attacks.[13] [14] Congenital Basilar Impression/Basilar Invagination (craniovertebral abnormality where the odontoid process projects above the foramen magnum) [13] [14] If asymptomatic, it may not be recognized till adulthood.
Pain on activity, which doesn't alleviate after positional or postural changes. Pain ceases once the activity is stopped.[15] Angina
Prolonged use of corticosteroids, osteoporosis, history of trauma, old age. Sudden onset of symptoms [16] Fracture
Early symptoms may resemble those of NP. Unresolved sensory issues in arms and legs, loss of muscle strength in limbs, or bladder-bowel dysfunction should be treated with suspicion.[17] Spinal Cord Injury /Cervical Myelopathy Most common myelopathy detected after 55 years of age.[17]
History of tumor/neoplasm with night neck pain, unexplained weight loss, loss of appetite, dysphagia, headache, failure to improve with treatment.[18] Malignancy
Persistent fever / night sweats [11] Infection
Recent trauma, vascular pathology, smoking (dissecting). Hypertension, high cholesterol, smoking, (non-dissecting). Presenting with headache, visual disturbances, dizziness, paresthesia, unsteadiness, confusion etc. [19] Vascular pathologies of the neck

Differential Diagnosis[edit | edit source]

Cervical Spondylosis[edit | edit source]

Cervical spondylosis includes all progressive degenerative conditions of the cervical spine. [20] It may affect the IV disc, facet joints, ligamentum flavum, and joints of Luschka. [20] It is often linked to the natural aging process that happens after the fifth decade of life. [20] Symptoms may include neck pain and stiffness, and radicular symptoms. [21]

Cervical Nerve Root Lesion (Radiculopathy)[edit | edit source]

Common causes for cervical nerve root lesion are disc herniation, stenosis, osteophytes /swelling with trauma. The affected nerve root may have depressed DTR. Numbness, pins, needles in affected dermatomes (paresthesia). Cervical traction may reduce the symptoms. [22]More information is available in Cervical Radiculopathy.

Brachial Plexus Injury[edit | edit source]

Branchial Plexus Injury can occur due to stretching of the cervical spine, compression of the cervical spine, or depression of the shoulder. Contributing factor can be thoracic outlet syndrome. The clinical presentation is variable; there may be pain over the trapezius along with a sharp burning sensation or more severe paralysis symptoms.[23]

Management[edit | edit source]

There are many different management strategies for mechanical NP. Significant gaps in the literature often result in lack of sufficient, high-quality evidence to effectively guide the conservative treatment of this patient population. [7] [24] Heintz et al. [7] once suggested that this lack of quality evidence largely stems from the poorly understood clinical course of NP and the inconclusive results for the efficacy of the most commonly used interventions. Nevertheless, there have been several attempts to provide evidence-based clinical information [24], see Neck Pain: Clinical Practice Guidelines.

Physiotherapy management[edit | edit source]

Physiotherapy management of mechanical neck pain may involve various modalities, such as advice and education, massage, thermotherapy, electrical stimulation, ultrasound, [25] acupuncture, low-level laser therapy, exercise, manual therapy, traction. [26] [27] To date, neck pain guidelines (6 in total) have provided consistent weak or moderate strength recommendations for reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. [24]

Further information on physiotherapy management of mechanical NP can be found in Evidence-Based Interventions for Neck Pain and Treatment‐based classification approach to neck pain.

Physiotherapy protocols are usually multimodal, customised and decided after a detailed assessment of the patient, to suit the individual needs/goals. Validated self-report questionnaires for patients with NP, should be used to identify a patient’s baseline status and to monitor changes relative to pain, function, disability, and psychosocial functioning. [3]

Ergonomic advice and modifications at the workplace might also be given to reduce the chances of recurrence, although this is currently supported by evidence only for back pain.[24] For more information on this click on Office Ergonomics and Neck Pain.

References[edit | edit source]

  1. Fernández-de-las-Peñas C., Cleland J.A., Dommerholt J. Manual therapy for musculoskeletal pain syndromes: an evidence-and clinical-informed approach. Elsevier e-Book, 2015.
  2. 2.0 2.1 Guzman J., Hurwitz E., Carroll L., Haldeman S., Côté P., Carragee E., et al. Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S14-23.
  3. 3.0 3.1 Blanpied P., Gross A., Elliott J., Devaney L., Clewley D., Walton D., Sparks C., Robertson E., Altman R., Beattie P., Boeglin E., Cleland J., Childs J., DeWitt J., Flynn T., Ferland A., Kaplan S., Killoran D., Torburn L., 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. JOSPT 2017; 47(7):A1-83.
  4. 4.0 4.1 Childs J., Cleland J., Elliott J., Teyhen D., Wainner R., Whitman J., Sopky B., Godges J., Flynn T., Delitto A., Dyriw G. Neck pain: 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 2008; 38(9): A1-A34.
  5. Shin DW., Shin J., Koyanagi A., Jacob L., Smith L., Lee H., Chang Y., Song T-J. Global, regional, and national neck pain burden in the general population, 1990–2019: An analysis of the global burden of disease study 2019. Front. Neurol. 2022; September 1:13.
  6. Siivola S., Levoska S., Latvala K., Hoskio E., Vanharanta H., Keinänen-Kiukaanniemi S. Predictive factors for neck and shoulder pain: a longitudinal study in young adults. Spine (Phila Pa 1976). 2004 Aug 1;29(15):1662-9.
  7. 7.0 7.1 7.2 Heintz M., Hegedus E. Multimodal management of mechanical neck pain using a treatment based classification system. Journal of Manual & Manipulative Therapy. 2008 Oct 1;16(4):217-24.
  8. Genebra C., Maciel N., Bento T., Simeão S., De Vitta A. Prevalence and factors associated with neck pain: a population-based study. Brazilian journal of physical therapy. 2017 Jul 1;21(4):274-80.
  9. Hoy D.G., Protani M., De R., Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):783-92.
  10. Verma T., Verma R., Bameta D., Sharma V., Saroha S., Taneja A. Prevalence of Work from Home on Female-it Workers, on Neck Pain and its Psycho-Social Effects During Epidemic Period. Medico-legal Update, January-March 2021; 21(1): 1240-
  11. 11.0 11.1 Bier J., Scholten-Peeters W., Staal J., Pool J., van Tulder M., Beekman E., Knoop J., Meerhoff G., Verhagen A. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Physical therapy. 2018 Mar 1;98(3):162-71.
  12. Guzman J., Haldeman S., Carroll L., Carragee E., Hurwitz E., Peloso P., et al. Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S199-213.
  13. 13.0 13.1 Donnally III C.J., Munakomi S., Varacallo M. Basilar Invagination. 2022 Nov 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
  14. 14.0 14.1 Mourad F., Giovannico G., Maselli F., Bonetti F., de las Peñas C.F., Dunning J. Basilar impression presenting as intermittent mechanical neck pain: a rare case report. BMC musculoskeletal disorders. 2016 Dec;17(1):1-5.
  15. Mathers J. Differential diagnosis of a patient referred to physical therapy with neck pain: a case study of a patient with an atypical presentation of angina. Journal of Manual & Manipulative Therapy. 2012 Nov 1;20(4):214-8.
  16. Cox J., DeGraauw C., Klein E. Pathological burst fracture in the cervical spine with negative red flags: a case report. J Can Chiropr Assoc. 2016 Mar;60(1):81-7.
  17. 17.0 17.1 Smith B., Diver C., Taylor A. Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report. Manual therapy. 2014 Aug 1;19(4):360-4.
  18. Sowa G., Weiner D., Camacho-Soto A. Chapter 41 - Geriatric Pain. Essentials in Pain Medicine 4th ed. 2018; 357-370.
  19. Rushton A., Carlesso L., Flynn T., Hing W., Rubinstein S., Vogel S., Kerry R. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. JOSPT 2023; 53(1):7-22.
  20. 20.0 20.1 20.2 Kuo DT, Tadi P. Cervical Spondylosis. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
  21. Theodore N. Degenerative Cervical Spondylosis. N Engl J Med. 2020 Jul 9;383(2):159-168.
  22. Iyer S., Kim H.J. Cervical radiculopathy. Curr Rev Musculoskelet Med. 2016 Sep;9(3):272-80
  23. Magee DJ. Orthopedic physical assessment-E-Book. Elsevier Health Sciences; 2019 Mar 25.
  24. 24.0 24.1 24.2 24.3 Corp N., Mansell G., Stynes S., Wynne-Jones G., Morsø L., Hill J., van der Windt D. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain 2021; 25;275-295.
  25. Qing W., Shi X., Zhang Q., Peng L., He C., Wei Q. Effect of therapeutic ultrasound for neck pain: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2021 Mar 17; 102(11):2219-2230.
  26. Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Phys Ther. 2001 Oct;81(10):1701-17.
  27. Hurwitz E., Carragee E., van der Velde G., Carroll L., Nordin M., Guzman J., et al. Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S123-52.