The Nonoperative Treatment of Cervical Pain

Evan W. Rivers

Christine M. Gagnon

Norman R. Harden

Neck pain is associated with multiple etiologies, including injury, biomechanical factors, occupational overuse, and anatomic pathology. Additionally, neck pain can accompany tumors, inflammatory conditions, infections, or bony abnormalities. It is clear that injuries that result in spinal cord injury or bony and ligamentous damage with impending neurologic compromise must be addressed with surgical stabilization. Progressive instability or compression from infection or malignancy must also be assessed for surgical intervention. However, neck pain is more commonly associated with minor injuries or overuse syndromes without any threat of progressive neurologic damage. Most neck pain resolves spontaneously within days, but occasionally the pain persists. Chronic musculoskeletal pain, including neck pain, is one of the most common causes of long-term disability. Chronic neck pain makes up a significant plurality of chronic musculoskeletal pain cases. This chapter addresses the topic of neck pain among patients with nonmalignant neck disorders who do not require surgical intervention, and specifically addresses the challenge of treating chronic neck pain.

Neck pain affects nearly everyone at some point in their lives and affects patients of all ages. Incidence of self-reported neck pain is reported to be as high as 213 of 1,000 per year. Estimates of the incidence of neck pain vary greatly depending on the source of the data, with hospitaldiagnosed pain from specific injury or tissue pathology reported much less than clinic-reported pain or self-report of pain and specific diagnoses reported less than nonspecific neck pain. Prevalence is also variable, with nonspecific neck pain that does not limit function reported more than specific diagnoses or pain that limits function. Neck pain is very common, with a 12-month prevalence among adults of 30% to 50% (20% to 40% among children), but functionally limiting pain occurs only in 2% to 11% of adults. Psychosocial factors (including parent-child interactions, workplace satisfaction, self-assessed health, and presence of psychological disorders) contribute to prevalence and incidence of neck pain and complicate the presentation, prognosis, and treatment (1).

Most neck pain is short-lived and spontaneously resolves. A small portion of neck pain (12-month prevalence 12% to 14%) leads to functional limitation. Chronic neck pain as a general diagnosis is a persistent, relapsing condition. Most patients who report neck pain report it again within 5 years. Of patients presenting with nondisabling neck pain, about 10% will develop disability, and 40% will have persistent nondisabling pain. Of those with disabling neck pain, 23% remain disabled after 5 years (2).

Neck pain is related to cigarette smoking, poor selfassessed health, presence of psychological conditions, and other musculoskeletal complaints like low back pain. Gender is a poor predictor of both prevalence and prognosis. Neck pain is more prevalent and has a worse prognosis among patients 45 to 59 years of age, and as age increases, the prognosis for recovery worsens. Good prognosis after initial presentation of neck pain is related to good psychological health and good social support. This finding reinforces the importance of addressing psychosocial and biomechanical factors that contribute to the presentation of neck pain as part of an interdisciplinary approach to management. It is important to note that neck pain does not seem to be directly related to radiologic findings of degenerative changes in cervical spinal structures, including intervertebral discs (1,2).

The literature on neck pain is incompletely developed, but much of the literature for musculoskeletal pain, spine pain, and chronic pain syndrome applies with only minimal adaptation. Consequently, many of the recommendations for the treatment of acute and chronic neck pain can be made for any spine pain, and some of the following recommendations are adapted from literature on low back pain, musculoskeletal pain, and chronic pain syndrome, and informed by our clinical experience.

ACUTE MUSCULOSKELETAL NECK PAIN

The evaluation of acute neck pain is fairly simple: Evaluate the likelihood of serious pathology and if there are no “red flags,” educate the patient on the favorable prognosis,
prescribe an analgesic medication, and perhaps physical therapy that addresses the patient’s symptoms. Appropriate pharmacologic management, early return to work or activity, and encouragement of active coping strategies are part of the initial conservative management of acute musculoskeletal neck pain. It is important to address the patient’s concerns about prognosis and function and to establish a care plan that the patient will participate in. Setting up a specific timeframe for follow-up is essential to evaluate the patient’s progress and to reassess red flags and risk factors for development of chronic pain. A plan for acute exacerbations should be discussed and may include analgesic medications, return to office, or physical therapy interventions (3).

Acetaminophen scheduled at regular intervals can be used for the treatment of mild to moderate acute neck pain whether neuropathic or musculoskeletal. Nonsteroidal anti-inflammatory drugs (NSAIDs) maybe considered, but no evidence directly supports the use of one NSAID over another (4). A short tapering course of steroids may be indicated for many cases of acute neuropathic or musculoskeletal pain if more profound anti-inflammatory effects are desired (5,6), though the benefit does not seem remarkable in acute whiplash injuries (4). Opioids, benzodiazepines, and medications marketed as “muscle relaxants” should be avoided in the treatment of mild to moderate pain (3,5,6).

Opioids may be considered for severe acute neck pain alongside a regimen of acetaminophen and NSAIDs but should be prescribed in scheduled doses and only for a short duration. Persistent requirement for opioid analgesics may be indicative of developing chronicity, may represent evolving pain behavior, and should lead to reevaluation of the treatment plan and contributing psychosocial factors. Benzodiazepines and “muscle relaxants” are not typically indicated for acute pain due to limited evidence of effectiveness, risk of dependence and abuse potential, and adverse effects that limit social and occupational participation (3,5,6).

Physical therapy is indicated for acute neck pain of all causes. Strengthening and stretching exercises are effective ways to treat acute neck pain, and active involvement by the patient leads to the best outcome. A brief course of physical therapy is often adequate, and outcomes seem comparable to longer courses (4). Goals for physical therapy are patient self-efficacy in strengthening, stretching, and pain relief during exacerbations. Occupational therapy and ergonomic advice should be considered when a patient complains of work-related neck pain but is only likely to help carefully selected patients with neck pain of other causes.

Education that is given in face-to-face meetings either individually or with a group can substantially improve outcomes in neck pain. Videotapes with educational material including prognosis and general exercises lead to improved outcomes in patients with acute whiplash injuries. Pamphlets and handouts alone do not seem to be an effective way to communicate the important points of prognosis and self-care in patients with neck pain (4).

Though spine surgery can result in rapid relief of pain from cervical radiculopathy, evidence indicates no significant benefit in functional outcome after 1 year among patients with radiculopathy treated surgically or conservatively. There is no evidence to support the surgical treatment of nonradicular neck pain without serious underlying pathology (7). Conservative management is often a safe and cost-effective alternative to surgical intervention.

Red flags in the patient’s history and examination direct the clinician to suspect serious pathology and order the appropriate confirmatory tests. Less familiar, but crucial for the management of musculoskeletal pain, “yellow flags” indicate that the patient has psychological, social, occupational, and behavioral characteristics that may predispose them to the development of chronic pain. Yellow flags include (a) belief that pain is harmful or disabling; (b) avoidance of activity due to anticipation of pain; (c) depressed mood and social withdrawal; (d) history of back pain or time off for pain; (e) problems with disability claims or compensation; and (f) poor work satisfaction, difficult work tasks, or difficult work hours. It is the clinician’s responsibility to screen for these factors at the initial and each follow-up visit and direct management appropriately. Dialog with the treating physical therapist can sometimes help identify yellow flags when they are not elicited during the office visit (8,9).

Just as red flags lead the clinician to pursue additional radiologic and laboratory tests to rule out pathology, yellow flags should direct the physician to consider psychosocial interventions that can help modify beliefs and behaviors that lead to chronic pain. Referral to a chronic pain specialist at this time can help address psychosocial factors that lead to chronic pain. The single factor that most clearly predicts the response of pain to any kind of treatment is the duration of the pain (3,10). Addressing risk factors for chronic pain early in the treatment of acute pain may help prevent its development (3).

CHRONIC NECK PAIN

Chronic neck pain may be defined as cervical pain with no serious underlying pathology lasting longer than 3 months and sometimes causing severe disability. Chronic neck pain results from accumulated maladaptive compensatory behaviors and central neurophysiologic sensitization that develop as a response to persistent or recurrent acute pain. Emotions and beliefs also contribute to and result from chronic pain (3,11). Chronic pain can present with or without contributing mood and sleep disturbance. Mood disorders can contribute to the presentation of chronic pain, so appropriate psychological treatment is an important part of chronic pain management (11).

The two main contributing biomedical triggers for chronic neck pain are neuropathic pain and myofascial pain. It is now widely accepted that peripheral neuropathic pain causes neurophysiologic changes in the central nervous system (CNS), but studies and clinical experience now also support the assertion that musculoskeletal pain sources can produce similar alteration in CNS function through the same mechanisms. Changes in the receptor sensitivity in the in the dorsal horn, conduction pathways, and sensory cortex, as well as efferent facilitation, have been implicated in the development of central sensitization and chronic pain for both neuropathic and
musculoskeletal pain. The final result is the “chronic pain syndrome” that has certain recognizable qualities and is refractory to medical or surgical intervention, but which may respond to rehabilitation (10,12).

Myofascial pain syndrome (MPS) is a special case of chronic musculoskeletal pain that often affects the neck. It is characterized by regional pain, the presence of painful muscular “trigger points” within taut bands of muscle that replicate symptoms in predictable referral patterns and respond with a twitch response to mechanical or percutaneous stimulation, and the absence of abnormal neurologic findings. It can also present with palpable ropiness or nodularity of the muscle trigger points, decreased range of motion, and relief of symptoms with injection of local anesthetic into muscle trigger points or to “spray and stretch” techniques (5). It seems that most cases of chronic musculoskeletal neck pain, including occupational neck pain and whiplash-associated disorder (WAD), are presentations of MPS (10).

Two presentations of neck pain that require a high index of suspicion for associated psychosocial abnormalities are briefly mentioned below.

OCCUPATIONAL NECK PAIN

Each year, 5% of the working population experience frequent or persistent neck pain, and 60% of those will still report it 1 year later. The etiology of workplace neck pain is multifactorial, with individual and work-related contributors. Individual factors include age, gender, ethnicity, history of musculoskeletal pain or headache, and poor conditioning. Individual psychologic factors also contribute and include poor social support, poor job security, passive coping strategies, job satisfaction, and emotional distress. Work-related factors include poor ergonomics of workstation, sedentary job, high-force work, repetitive work, and precision work. No single factor seems to lead to neck pain, but complex interactions between these factors result in “occupational neck pain” (13).

Poor prognosis of occupational neck pain is related to prior musculoskeletal pain, prior sick leave, type of work, and having little influence over the work environment. Exercise is generally associated with improved outcome, with the notable exception of bicycling. The likelihood that a patient will return to work has less to do with pain characteristics than with job satisfaction (14). It is informative to note that chronic occupational neck pain cases often present with findings indistinguishable from MPS (10). Addressing the many contributing factors using an interdisciplinary team approach gives the best results in the treatment of occupational neck pain.

CHRONIC WHIPLASH ASSOCIATED DISORDER

Chronic WAD is persistent neck pain after rapid flexionextension injury in the absence of demonstrable anatomic lesion or neurologic deficit, most often reported after automobile collision (12,15). Pain after whiplash injury typically resolves within weeks, and any pain that persists after several months should be evaluated as chronic pain. While it is normal to experience decreased range of motion in the cervical spine immediately after whiplash injury, there is rarely restriction of motion several months later, even when pain persists. WAD often involves associated complaints, such as headache, dizziness, poor concentration, and fatigue. Some of these complaints may result from demonstrable alterations in motor control and impaired cervico-ocular and vestibulo-ocular reflexes, but others are less easily explained (12).

WAD is reported more frequently now than 30 years ago, and reported WAD seems to coincide with the availability of payable insurance claims. In medicolegal systems without payable claims for neck pain after automobile accident, the reported incidence is extremely low. When Saskatchewan changed its laws to allow fewer payable claims, the rate of reported persistent neck pain decreased (12,15).

As opposed to occupational pain or pain in the general population, WAD is associated with younger age. There is no evidence that degenerative disease of the cervical spine is associated with the development of chronic WAD (15). Chronic WAD leads to long-term pain and disability: About 50% of those with WAD report neck pain 1 year later, and 10% to 20% of patients with WAD develop chronic pain and disability. High health care utilization in the first month after injury, high initial symptom severity, passive coping mechanisms, and psychological distress are associated with worse outcomes. Most studies support removal of neck orthosis and return to regular activity as soon as possible after injury to prevent the development of WAD from early whiplash pain (16). It is informative to note that almost all chronic WAD cases also present with findings indistinguishable from MPS (12).

Only gold members can continue reading. Log In or Register to continue