Mechanical Neck Pain: Difference between revisions

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== Introduction ==
== Introduction ==
Neck pain is a common musculoskeletal problem, worldwide. Just like low back pain, neck pain is episodic in nature. It defined as pain between superior nuchal line and imaginary transverse line through the tip of the first thoracic spinous process and laterally by sagittal planes tangential to lateral borders of the neck.<ref>Cleland JA, Dommerholt J, Oostendorp RA, Vleeming A. Manual therapy for musculoskeletal pain syndromes: an evidence-and clinical-informed approach. Elsevier,; 2016.</ref>  
[[File:3d-medical-image-with-female-holding-neck-pain.jpg|right|frameless]]
 
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.<ref>Fernández-de-las-Peñas C., Cleland J.A., Dommerholt J. [https://www.elsevier.com/books/manual-therapy-for-musculoskeletal-pain-syndromes/978-0-7020-5576-8 Manual therapy for musculoskeletal pain syndromes: an evidence-and clinical-informed approach.] Elsevier e-Book, 2015.</ref> Pain in the neck may be local and/or referred into the head, and/or one or both upper limbs. <ref name=":3">Guzman J., Hurwitz E., Carroll L., Haldeman S., Côté P., Carragee E., et al. [https://pubmed.ncbi.nlm.nih.gov/18204387/ 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. </ref> <ref name=":9" /> Apart from its anatomical definition, NP can also be defined based on its duration (acute, subacute, [https://www.physio-pedia.com/Chronic_Neck_Pain chronic]) or reason for onset.  
Individuals with neck pain that lack an identifiable pathoanatomic cause for their symptoms are usually classified as having mechanical neck pain. Direct pathoanatomic cause of mechanical neck pain is rarely identifiable<ref name=":1" />.  Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown<ref name=":1">Childs, J.D., Cleland, J.A., Elliott, J.M., Teyhen, D.S., Wainner, R.S., Whitman, J.M., Sopky, B.J., Godges, J.J., Flynn, T.W., Delitto, A. and Dyriw, G.M., 2008. [http://www.jospt.org/doi/pdf/10.2519/jospt.2008.0303 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'', ''38''(9), pp.A1-A34.</ref>
 
Neck pain persisting since 12 weeks or more comes under the heading of [[Chronic Neck Pain]].
 
Mechanical neck pain commonly arises insidiously and is generally multifactorial in origin, including one or more of the following: poor posture, anxiety, depression, neck strain, and sporting or occupational activities<ref name=":0">Heintz MM, Hegedus EJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2716155/ Multimodal management of mechanical neck pain using a treatment based classification system]. Journal of Manual & Manipulative Therapy. 2008 Oct 1;16(4):217-24.</ref>.  


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. <ref name=":1" />  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. <ref name=":1">Childs J., Cleland J., Elliott J., Teyhen D., Wainner R., Whitman J., Sopky B., Godges J., Flynn T., Delitto A., Dyriw G. [http://www.jospt.org/doi/pdf/10.2519/jospt.2008.0303 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.</ref>
== Epidemiology ==
== Epidemiology ==
Rate of recurrence is high for neck pain along with its chronicity. The economic burden to neck pain is also high. Highest incidence of neck pain is found in computer workers. Prevalence is high among women, high income countries and high in urban report. The prevalence in overall population is 16.7% to 75.1%.<ref>Genebra CV, Maciel NM, Bento TP, Simeão SF, 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.</ref>
NP is a common musculoskeletal problem worldwide. <ref>Shin DW., Shin J., Koyanagi A., Jacob L., Smith L., Lee H., Chang Y., Song T-J. [https://www.frontiersin.org/articles/10.3389/fneur.2022.955367/full 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.  
 
== Causes ==
 
=== Poor Posture/Muscle Imbalance ===
Most common abnormal posture seen in the region of neck is forward head posture. There is shortening(tightness) of the postural muscles like upper trapezius, levator scapulae and pectoral muscles and weakness in deep neck flexors, rhomboids and serratus anterior. This leads to restricted neck mobility. Such kind of muscle imbalance and abormal posture is found in the population who work on laptops/computers for long hours. This creates stress and pain in the cervical region.<ref>Mahajan R, Kataria C, Bansal K. Comparative effectiveness of muscle energy technique and static stretching for treatment of subacute mechanical neck pain. Int J Health Rehabil Sci. 2012 Jul;1(1):16-21.</ref>Poor posture is considered the greatest cause of mechanical neck pain when there is no trauma or major injury.<ref>Chaudhery JK, Dabholkar A. Efficacy of spinal mobilization with arm movements (SMWAMs) in mechanical neck pain patients: Case-controlled trial. International Journal of Therapies and Rehabilitation Research. 2017;6(1):18.</ref>Measuring the Craniovertebral (CV) angle is one of the method used to measure the forward head posture.<ref>Contractor ES, Shah SS, Shah SJ. To study correlation between neck pain and cranio-vertebral angle in young adults. Int Arch Integr Med. 2018;5(4):81-6.</ref>
 
The therapist's role is to provide appropriate office ergonomics to reduce the chances of recurrence. For more information on this click on [[Office Ergonomics and Neck Pain]]
 
=== Alteration in Thoracic Alignment ===
The cervical ,thoracic and the lumbar spine are interrelated biomechanically. There has to be proper motion (concomitant motion) occurring at the thoracic spine in order to get full ROM at the cervical spine. Thoracic spine acts as the supporting base for the cervical spine and it has an influence on cervical joint kinematics via the cervicothoracic junction. Because of the close kinetic link, any mechanical dysfunction at the thoracic spine will create associated effect on the cervical spine.<ref>Joshi S, Balthillaya G, Neelapala YR. Thoracic posture and mobility in mechanical neck pain population: A review of the literature. Asian spine journal. 2019 Oct;13(5):849.</ref>
 
== Classification (Neck Pain Task Force Classification) ==
Level 1 : There are no evident physical examination findings which suggest of any structural pathology and minimal or no involvement of activities of daily living. Neck pain is present.
 
Level 2 :  Patient is not able to activities of daily living properly and there are no signs and symptoms of any structural involvement.
 
Level 3 :Presence of neurologic signs(sensory deficits/ reduced DTR/weakness). No signs/symptoms of any major structural pathology
 
Level 4: Signs/symptoms of a major structural pathology like fracture/dislocation/spinal cord injury/metastasis/neoplasm or any systemic disease.<ref name=":2">Bier JD, Scholten-Peeters WG, Staal JB, Pool J, van Tulder MW, Beekman E, Knoop J, Meerhoff G, Verhagen AP. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Physical therapy. 2018 Mar 1;98(3):162-71.</ref>
 
== Red Flags ==
 
=== Congenital Basilar Impression/Basilar Invagination ===
Neck pain may mask a serious pathology. It is possible to encounter life threatening condition such as craniovertebral anomalies. Basilar invagination is an abnormality where the odontoid process projects above the foramen magnum. The prevalence is 1%.This is the most common malformation of the craniocervical junction.<ref>Donnally III CJ, Munakomi S, Varacallo M. Basilar invagination.</ref>
 
Congenital basilar impression may not be recognized till adulthood if it is asymptomatic.
 
The patient of mechanical neck pain might complain of dizziness on neck movements, headache, facial numbness specially on prolong postures or even drop attacks. All these features are an indication of a red flag which are to be ruled out by the physiotherapist refer to the neurosurgeon when necessary. <ref>Mourad F, Giovannico G, Maselli F, Bonetti F, de las Peñas CF, Dunning J. Basilar impression presenting as intermittent mechanical neck pain: a rare case report. BMC musculoskeletal disorders. 2016 Dec;17(1):1-5.</ref>
 
=== Angina ===
The patient can have pain on weight lifting in the gym, which doesn't alleviate after positional or postural changes and the pain is ceased once the activity is stopped. This is an indication of a red flag and further investigations are needed.<ref>Mathers JJ. 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.</ref>
 
=== Fracture ===
Prolonged use of corticosteroids, osteoporosis, history of trauma or old age are the corresponding red flags to be ruled out.
 
=== Spinal Cord Injury /Cervical Myelopathy ===
The therapist has to look for signs of radiculopathy like sensory issues in arms and legs  ,loss of muscle strength in limbs or bladder-bowel dysfunction. Cervical spondylotic myelopathy is the most common myelopathy detected after 55 years of age usually. The early symptoms are similar to those of mechanical neck pain.<ref>Smith BE, Diver CJ, Taylor AJ. Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report. Manual therapy. 2014 Aug 1;19(4):360-4.
 
</ref>
 
=== Malignancy ===
History of tumor/neoplasm, Unexplained weight loss, sudden loss of appetite, dysphagia, headache, failure to improve after the treatment of one month.
 
=== Infection ===
The therapist has to look for signs of infection like fever /night sweats.<ref name=":2" />
 
== Differential Diagnosis ==


=== Cervical Spondylosis ===
</ref> Just like low back pain (LBP), NP is episodic, with high rates of recurrence and chronicity, and variable recovery between episodes over a lifetime. <ref name=":3" /> 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, <ref>Siivola S., Levoska S., Latvala K., Hoskio E., Vanharanta H., Keinänen-Kiukaanniemi S. [https://pubmed.ncbi.nlm.nih.gov/15284513/ Predictive factors for neck and shoulder pain: a longitudinal study in young adults.] Spine (Phila Pa 1976). 2004 Aug 1;29(15):1662-9. </ref> poor posture, anxiety, depression, neck strain, and sporting or occupational activities.<ref name=":0">Heintz M., Hegedus E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2716155/ Multimodal management of mechanical neck pain using a treatment based classification system]. Journal of Manual & Manipulative Therapy. 2008 Oct 1;16(4):217-24.</ref> NP is considered an important societal burden. The prevalence in the overall population may range from 16.7% to 75.1%.<ref>Genebra C., Maciel N., Bento T., Simeão S., De Vitta A. [https://pubmed.ncbi.nlm.nih.gov/28602744/ Prevalence and factors associated with neck pain: a population-based study.] Brazilian journal of physical therapy. 2017 Jul 1;21(4):274-80.</ref> Prevalence is high among women in high-income countries and in urban reports. <ref>Hoy D.G., Protani M., De R., Buchbinder R. [https://pubmed.ncbi.nlm.nih.gov/21665126/ The epidemiology of neck pain.] Best Pract Res Clin Rheumatol. 2010 Dec;24(6):783-92. </ref> A high incidence is found in the office workers  and especially computer users.<ref>Verma T., Verma R., Bameta D., Sharma V., Saroha S., Taneja A.  [https://ijop.net/index.php/mlu/article/download/2488/2187/4839 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-</ref> You can find more information in [https://www.physio-pedia.com/Epidemiology_of_Neck_Pain#cite_note-:0-1 Epidemiology of Neck Pain].
It is a degenerative disease which is progressive in nature. It affects IV disc, facet joints, ligamentum flavum and joints of Luschka. It is natural aging process which happens after fifth decade of life. Symptoms include neck pain , neck stiffness and can have radicular symptoms.
== Triage Classification  ==
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 <ref name=":2">Bier J., Scholten-Peeters W., Staal J., Pool J., van Tulder M., Beekman E., Knoop J., Meerhoff G., Verhagen A. [https://pubmed.ncbi.nlm.nih.gov/29228289/ Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain.] Physical therapy. 2018 Mar 1;98(3):162-71.</ref><ref>Guzman J., Haldeman S., Carroll L., Carragee E., Hurwitz E., Peloso P., et al. [https://pubmed.ncbi.nlm.nih.gov/18204393/ 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. </ref> propose to initially start with triaging patients into four broad categories:


Long term mechanical neck pain can lead to [[Cervical Spondylosis|Cervical spondylosis.]]
'''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.


=== Cervical Nerve Root Lesion ===
'''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.
The cause of cervical nerve root lesion is disc herniation ,stenosis ,osteophytes /swelling with trauma. Affected nerve root may have depressed DTR.  Numbness , pins, needles in affected dermatomes (paresthesia). Cervical traction reduces the symptoms.


== Brachial Plexus Lesion ==
'''Grade 3:'''Patient represents neurologic signs (sensory deficits/ reduced DTR/weakness). No signs/symptoms of any major structural pathology.
It can occur due to stretching of cervical spine , compression of cervical spine or depression of shoulder. Contributing factor can be thoracic outlet syndrome. There is pain over trapezius along with sharp burning sensation.<ref>Magee DJ. Orthopedic physical assessment-E-Book. Elsevier Health Sciences; 2019 Mar 25.</ref>


== Management ==
'''Grade 4:''' Signs/symptoms of a major structural pathology like fracture/dislocation/spinal cord injury/metastasis/neoplasm or any systemic disease.
Despite the prevalence, less-than optimal prognosis, associated risk of disability, and economic consequences of individuals suffering from mechanical neck pain, there remains a significant gap in the literature, which fails to provide sufficient, high-quality evidence to effectively guide the conservative treatment of this patient population<ref name=":0" />.  Heintz et al<ref name=":0" /> suggest that this lack of quality evidence largely stems from the poorly understood clinical course of neck pain in conjunction with the inconclusive results related to the efficacy of commonly used interventions.


== Physiotherapy management ==
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. [[File:Red-flag-waving.jpg|right|frameless]]
Physiotherapy approach the management of mechanical neck pain is with a plethora of interventions such as manual therapy, therapeutic exercises, modalities, massage, and functional training. You can find the information on [[Evidence Based Interventions for Neck Pain|Evidence Based Interventions for Neck Pain.]]
=== Ruling out serious pathology ===
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 [https://www.physio-pedia.com/Serious_Cervical_Spine_Conditions Serious Cervical Spine Conditions] and [https://www.physio-pedia.com/Red_Flags_in_Spinal_Conditions Red Flags in Spinal Conditions].
{| class="wikitable"
|+
!'''Red flag'''
!'''Diagnosis'''
!
|-
|Dizziness on neck movements, headache, facial numbness especially on prolonged postures or even drop attacks.<ref name=":4" />  <ref name=":5" />
|'''Congenital Basilar Impression/Basilar Invagination''' (craniovertebral abnormality where the odontoid process projects above the foramen magnum) <ref name=":4">Donnally III C.J., Munakomi S., Varacallo M. [https://pubmed.ncbi.nlm.nih.gov/28846299/ Basilar Invagination. 2022 Nov 19.] In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. </ref>  <ref name=":5">Mourad F., Giovannico G., Maselli F., Bonetti F., de las Peñas C.F., Dunning J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707768/ Basilar impression presenting as intermittent mechanical neck pain: a rare case report.] BMC musculoskeletal disorders. 2016 Dec;17(1):1-5.</ref>
|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.<ref>Mathers J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500134/ 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.</ref>
|'''Angina'''
|
|-
|Prolonged use of corticosteroids, osteoporosis, history of trauma, old age. Sudden onset of symptoms <ref>Cox J., DeGraauw C., Klein E. Pa[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807678/ thological burst fracture in the cervical spine with negative red flags: a case report]. J Can Chiropr Assoc. 2016 Mar;60(1):81-7.</ref>
|'''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.<ref name=":6">Smith B., Diver C., Taylor A. [https://pubmed.ncbi.nlm.nih.gov/24815593/ Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report.] Manual therapy. 2014 Aug 1;19(4):360-4.
</ref>
|'''Spinal Cord Injury /Cervical Myelopathy''' 
|Most common myelopathy detected after 55 years of age.<ref name=":6" />
|-
|History of tumor/neoplasm with night neck pain, unexplained weight loss, loss of appetite, dysphagia, headache, failure to improve with treatment.<ref>Sowa G., Weiner D., Camacho-Soto A. [https://www.sciencedirect.com/science/article/pii/B9780323401968000413 Chapter 41 - Geriatric Pain.] Essentials in Pain Medicine 4th ed. 2018; 357-370.</ref>
|'''Malignancy'''
|
|-
|Persistent fever / night sweats <ref name=":2" />
|'''Infection'''
|
|-
|Recent trauma, vascular pathology, smoking  (dissecting). Hypertension, high cholesterol, smoking,  (non-dissecting). Presenting with headache, visual disturbances, dizziness, paresthesia, unsteadiness, confusion etc. <ref>Rushton A., Carlesso L.,  Flynn T., Hing W., Rubinstein S., Vogel S., Kerry R. [https://www.jospt.org/doi/10.2519/jospt.2022.11147 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.</ref>
|'''Vascular pathologies of the neck'''
|
|}
=== Differential Diagnosis ===


Physiotherapy management is decided after detailed assessment of the patient. Hence the protocol is set as per individual needs/goals of the patient.
==== Cervical Spondylosis ====
[https://www.physio-pedia.com/Cervical_Spondylosis Cervical spondylosis] includes all progressive degenerative conditions of the cervical spine. <ref name=":7">Kuo DT, Tadi P. [https://pubmed.ncbi.nlm.nih.gov/31855384/ Cervical Spondylosi]s. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.</ref> It may affect the IV disc, facet joints, ligamentum flavum, and joints of Luschka. <ref name=":7" /> It is often linked to the natural aging process that happens after the fifth decade of life. <ref name=":7" /> Symptoms may include neck pain and stiffness, and radicular symptoms. <ref>Theodore N. [https://pubmed.ncbi.nlm.nih.gov/32640134/ Degenerative Cervical Spondylosis]. N Engl J Med. 2020 Jul 9;383(2):159-168. </ref>


Physiotherapy treatment:
==== Cervical Nerve Root Lesion (Radiculopathy) ====
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. <ref>Iyer S., Kim H.J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958381/ Cervical radiculopathy.] Curr Rev Musculoskelet Med. 2016 Sep;9(3):272-80</ref>More information is available in [https://www.physio-pedia.com/Cervical_Radiculopathy Cervical Radiculopathy].


* Pain  management :
==== Brachial Plexus Injury ====
[https://www.physio-pedia.com/Brachial_Plexus_Injury 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.<ref>Magee DJ. Orthopedic physical assessment-E-Book. Elsevier Health Sciences; 2019 Mar 25.</ref>


# Transcutaneous electrical nerve stimulation (TENS) , IFT (interferential therapy) depending on the radicular symptoms.
== Management  ==
# Ultrasound therapy: Therapeutic ultrasound is found to be effective in neck pain patients.<ref>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.</ref> It can be applied on trigger points over the trapezius muscle. Many of the clients have associated trapezitis(upper trapezius) with mechanical neck pain where ultrasound can be applied. It is associated with myofascial pain syndrome where ultrasound is used to inactivate the trigger points and reduce the tension of the tissue. <ref>Yildirim MA, Kadriye ÖN, Gökşenoğlu G. Effectiveness of ultrasound therapy on myofascial pain syndrome of the upper trapezius: randomized, single-blind, placebo-controlled study. Archives of rheumatology. 2018 Dec;33(4):418.</ref>Trapezitis is commonly seen in upper fibers of trapezius and is also known as [[Trapezius Myalgia|trapezius myalgia]]
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. <ref name=":0" /> <ref name=":8" /> Heintz et al. <ref name=":0" /> 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 <ref name=":8">Corp N., Mansell G., Stynes S., Wynne-Jones G., Morsø L., Hill J., van der Windt D. [https://www.fysmedupdate.no/wp-content/uploads/2022/02/Rygg-og-nakke-Euro-guidel-anbefalinger-SR-Corp-20.pdf Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines.] Eur J Pain 2021; 25;275-295.     </ref>, see [https://www.physio-pedia.com/Neck_Pain:_Clinical_Practice_Guidelines#cite_note-:5-1 Neck Pain: Clinical Practice Guidelines].
# Neck mobilization/ Thoracic mobilization/High velocity thrust: Central Maitland Mobilization or Sustained Natural Apophyseal Glide on cervical spine. Single cervical high amplitude thrust is applied in the cases of intervertebral joint dysfunction.<ref>Martínez-Segura R, Fernández-de-las-Peñas C, Ruiz-Sáez M, López-Jiménez C, Rodríguez-Blanco C. Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial. Journal of manipulative and physiological therapeutics. 2006 Sep 1;29(7):511-7.</ref>
# MET : Muscle energy technique is a form of active stretching technique is proved to be effective in mechanical neck pain.<ref>SACHDEVA S, YADAV J, GULATI M. Comparing the Efficacy of First Rib Maitland Mobilisation and Muscle Energy Technique on Pain, Disability and Head Position Sense in Patients with Chronic Mechanical Neck Pain. Journal of Clinical & Diagnostic Research. 2019 Dec 1;13(12).</ref>
# Deep neck flexor endurance training : DNF endurance training combined with thoracic mobilisation is found to be effective in chronic neck pain patients.<ref>Lee KS, Lee JH. Effect of Maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain. Journal of physical therapy science. 2017;29(3):531-5.</ref>


* Home program
=== Physiotherapy management ===
Physiotherapy management of mechanical neck pain may involve various modalities, such as advice and education, massage, thermotherapy, electrical stimulation, ultrasound, <ref>Qing W., Shi X., Zhang Q., Peng L., He C., Wei Q. [https://pubmed.ncbi.nlm.nih.gov/33722564/ 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.</ref> acupuncture, low-level laser therapy, exercise, manual therapy, traction. <ref>Philadelphia Panel. [https://pubmed.ncbi.nlm.nih.gov/11589644/ Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain.] Phys Ther. 2001 Oct;81(10):1701-17. </ref>  <ref>Hurwitz E., Carragee E., van der Velde G., Carroll L., Nordin M., Guzman J., et al. [https://pubmed.ncbi.nlm.nih.gov/18204386/ 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.</ref> 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. <ref name=":8" />


* Ergonomic advice: It has to be given based on the job/work of the patient. Necessary modifications of the work place is advised for long term pain relief and avoid the recurrence.
Further information on physiotherapy management of mechanical NP can be found in [[Evidence Based Interventions for Neck Pain|Evidence-Based Interventions for Neck Pain]] and [[Treatment‐based classification approach to neck pain]].
* Active Range of motion exercises : Neck ROM exercises are prescribed. Serratus anterior is the coupling muscle of upper trapezius. If there is muscle imbalance between the two, the serratus anterior muscle tends to be weak and upper trapezius tends to be tight. Hence, Stretching of upper trapezius and strengthening of serratus anterior can b given specifically.


Also refer to [[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. <ref name=":9">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., [https://www.jospt.org/doi/10.2519/jospt.2017.0302 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.</ref>


== References  ==
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.<ref name=":8" /> For more information on this click on [[Office Ergonomics and Neck Pain|Office Ergonomics and Neck Pain.]]


== References ==
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[[Category:Cervical Spine - Conditions]]  
[[Category:Cervical Spine - Conditions]]  

Latest revision as of 07:32, 5 February 2023

Original Editor - Rachael Lowe

Top Contributors - Nupur Smit Shah, Angeliki Chorti, Rachael Lowe, Kim Jackson and Wanda van Niekerk  

Introduction[edit | edit source]

3d-medical-image-with-female-holding-neck-pain.jpg

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.
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