Non-Specific Neck Pain - the Case for Specific Treatment

Neck pain and low back pain were the leading cause of global disability in 2015 in most countries.[1] In most instances, neck pain is considered to be non-specific as there is no known patho-anatomical cause.[2]

However, according to Professor Jull, there are inherent risks in using the “non-specific” label for neck pain.[2] These risks include:

  • Physiotherapists failing to appreciate variations within and between the domains of the biopsychosocial framework for individual patients
  • Physiotherapists prescribing generic treatment across all domains of the biopsychosocial framework rather than considering each patient’s unique presentation

What do we know about neck pain?[edit | edit source]

Most people get better from an episode of neck pain. Moreover, education and advice are usually sufficient for people who have neck pain.[3] However, 50-75% of people who experience neck pain will experience another episode within 1-5 years or they will have continuing neck pain.[4]

Jull therefore poses the question whether reducing pain during a specific episode of neck pain should be our main aim. She suggests that focusing only on pain relief, fails to consider the burden generated by repeat acute events over the years.[2] These include:

  • Loss of quality of life
  • Loss of productivity
  • Cost of treatments
  • Cost of harm (ie side effects of drug treatments)

Like any condition, it is important to consider the biopsychosocial model when assessing and treating patients with neck pain.

The Psychological Domain[edit | edit source]

Pain is a significant sensory and emotional experience and patients with neck pain may present with a number of psychological symptoms (Jull Webinar), including depression or anxiety.[5][6]

However, there is no strong evidence that psychological interventions for acute or chronic neck pain or whiplash result in clinically relevant changes to neck pain and disability.[7]

Why aren't psychological interventions helping?[edit | edit source]

Jull suggests that these interventions are failing in part because they are not being applied specifically - ie not everyone will respond to the same intervention and, in some instances, applying a psychological intervention may have no effect.[2]

While recent research has shown a link between neck pain and psychological symptoms, these symptoms are more significant in some patients than others. A study by Park and Kim found that 28% of patients with chronic neck pain attending a pain clinic were depressed.[8] Thus 72% had no symptoms of depression al all.[2]

Moreover, a study by Nazari et al. found that psychological responses often decrease as pain decreases.[5] In fact, many psychological symptoms or emotions are a natural response to injury and pain, so as Jull notes we should not pathologise normal human reactions.[2]

Thus, while it is important to recognise psychological features and try to incorporate psychological awareness into our treatment, it doesn’t mean that this should be our primary focus.[4] However, it is essential to recognise the need to refer on to mental health practitioners if it is warranted.[2]

The Biological Domain[edit | edit source]

Manual therapy[edit | edit source]

Manual examination and therapy have been de-popularised in some quarters, but according to Jull, the scientific basis for this is poor.  While there are many things that manual therapy cannot do (ie it has little effect on neuromuscular and sensorimotor function), it remains useful.[2]

  • Manual examination is vital in the diagnosis of neck pain. The Flexion Rotation Test, for instance, has face validity,[9] as well as 90% sensitivity and 88% specificity to distinguish cervicogenic headache with C1-2 dysfunction.[10]
  • Similarly, a cluster of three tests has even shown to be a sensitive (94%) and specific (84%) means of diagnosing cervical facet joint dysfunction. These tests are:
    • the extension-rotation test
    • manual spinal examination
    • palpation for segmental tenderness[11]
  • Manual therapy is effective in reducing neck pain as a single modality or as part of a multimodal programme[2]

However, like psychological interventions, manual assessment/therapy needs to be specific. A lack of skills in these areas, risk non-specific diagnosis and treatment for neck pain.[2]

  1. ↑ Vos et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injures, 1990-2015: a systematic analysis for the Global Burden of Disease. The Lancet. 2016 388(10052), 1545-1602.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Jull, G. Non-specific neck pain: The case for specific treatment (Webinar). IFOMPT. 2019.
  3. ↑ Bier, J, Scholten-Peeters, G, Staal, JB, Pool, J, Tulder, M, Beekman, E et al. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Physical Therapy. 2018; 98(3): 162-171.
  4. ↑ 4.0 4.1 Carroll, LJ, Hogg-Johnson, S, van der Velde, G, Haldeman S, Holm, LW, Carragee, EJ et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008; 33(4 Suppl): S77-82.
  5. ↑ 5.0 5.1 Nazari, G., Bobos, P, Billis E, MacDermid JC. Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study. Physiother Res Int. 2018; 23(3): e1712.
  6. ↑ Falla, D, Peolsson, A, Peterson, G, Ludvigsson, ML, Soldini, E, Schneebeli, A et al. Perceived pain extent is associated with disability, depression and self-efficacy in individuals with whiplash-associated disorders. Eur J Pain. 2016; 20(9): 1490-501.
  7. ↑ Monticone, M, Ambrosini E, Cedraschi C, Rocca B, Fiorentini, R, Restelli, M. Cognitive-behavioural treatment for subacute and chronic neck pain (Cochrane review). Cochrane Database Syst Rev. 2015: CD10664
  8. ↑ Park, SD, Kim, SY. Clinical feasibility of cervical exercise to improve neck pain, body function, and psychosocial factors in patients with post-traumatic stress disorder: a randomized controlled trial. J Phys Ther Sci. 2015; 27(5): 1369-1372.
  9. ↑ Takasaki, H, Hall, T, Oshiro, S, Kaneko, S, Ikemoto, Y, Jull G. 2011. Normal kinematics of the upper cervical spine during the Flexion-Rotation Test - In vivo measurements using magnetic resonance imaging. Man Ther. 2011;16(2): 167-71.
  10. ↑ Hall, TM, Robinson, KW, Fujinawa, O, Akasaka, K. Pyne, EA. Intertester reliability and diagnostic validity of the cervical flexion-rotation test. J Manipulative Physiol Ther. 2008;31(4): 293-300.
  11. ↑ Schneider, GM, Jull, G, Thomas K, Smith, A, Emery, C, Faris, P et al. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil. 2014; 95(9): 1695-701.
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