Original Editors - Chad Adams, Jacob Melnick, & Tyler Shultz Show
Lead Editors
Tyler Shultz, Cindy John-Chu, Kim Jackson,
Alexandra Malzer, Eric Robertson, Dorian Mars,
Admin, Jacob Melnick, Evan Thomas, Zachary Cooper, Scott Buxton, WikiSysop, Albert Alabaster, Chad
Adams, Simisola Ajeyalemi, Agoro Bukola Zainab, Rachael Lowe and
Tony Lowe Discussion & Background[edit | edit source]The purpose of these clinical guidelines is to describe the new evidence based physical therapy practices including pathoanatomical features, examination, diagnosis/classification, intervention and treatment recommendations for musculoskeletal disorders related to neck pain. In 2017, The Orthopaedic Section of the American Physical Therapy Association (APTA) revised the previous clinical practice guidelines of neck pain from 2008 and produced a new summary of recommendations and guidelines from current peer-reviewed literature[1]. Neck pain lacks a common clinical definition[2]. The most common type is non-specific neck pain defined as ‘’pain with a postural or mechanical basis, often called cervical spondylosis’’[3]. The 7 most common types of neck pain are: muscle pain, muscle spasm, headache, facet joint pain, nerve pain, referred pain and bone pain each with their own causation, diagnosis and treatment[4]. Neck pain is becoming increasingly common throughout the world[5] with around two thirds of people experiencing neck pain at one moment in their life. The prevalence of neck pain varies largely between studies with a ‘’mean point prevalence of 7.6% and mean lifetime prevalence of 48.5%’’[3]. Most studies indicate a higher incidence of neck pain among women[5], if you suffer from anxiety or depression[6] and if you are an office worker with poor position of the screen and keyboard[7]. Anatomy[edit | edit source]Bones and Joints- The neck consists of 7 bones C1-C7. The most common neck pain caused by problems to the bone is osteoarthritis with wear in cartilage between the joints causing the bones to rub together producing pain and stiffness[8]. These bones are linked together by facet joints which are small joints between your vertebrae. Muscles, Tendons and Ligaments- Large muscles of the neck such as the sternocleidomastoid and the trapezius enable gross motor movements in the neck. The most common pain produced by these structures is a neck strain which affects the cervical muscles and tendons or a sprain which affects the ligaments, both involving overstretching or tearing these structures. Nerves- Cervical spine nerves provide functional control and sensation to different parts of the body based on the spinal level at which they sit. There are 8 cervical nerves: C1,C2 and C3 help control the head and neck, including movements forward, backward, and to the sides[9]. C4 helps to control upward shoulder movement and helps to power the diaphragm, C5 helps to control the deltoids and the biceps . C6 helps to control the wrist extensors and provides some innervation to the biceps[10], C7 helps control the triceps and wrist extensors and finally C8 helps control the hands, such as finger flexion[9][10]. Pain can be caused when a nerve branching away from the spinal cord is compressed or irritated and sensation such as tingling is often felt in the upper extremities aiding identification of the damaged nerve. Nerves, muscles and bones of the neck. Diagnoses/Causes[edit | edit source]The neck is responsible for supporting the weight for the head and is flexible to allow rotation, flexion, extension and lateral flexion to occur. The neck is also vulnerable to conditions that cause pain and restrict motion. There are a variety of causes that can contribute to neck pain, these include[11];
Eliminating the Red flags[edit | edit source]Clinicians should ensure that they carry out thorough subjective screening for patients who present with neck pain. Subjective assessments should be used to eliminate possible red flags or serious pathology such as[12];
Clinicians should use limitation of motion in the cervical and upper thoracic regions, presence of cervical pain related headache, history of trauma, and referred or radiating pain into an upper extremity as useful clinical findings for classifying a patient with neck pain into the following categories[1]:
Neck Pain with Mobility Deficits
Interventions: Neck Pain with Movement Coordination Impairments
Interventions: Neck Pain with Headaches
Interventions: Neck Pain with Radiating Pain[13] The following tests can be used to determine if the patient has cervical radiculopathy
When all of these clinical features are present, the post-test probability of cervical radiculopathy is 90% Differential Diagnosis of patients with neck pain Examination Recommendations[edit | edit source]The use of Outcome Measures (Grade: A) Outcome tools can be used for evaluations, monitoring change over time, diagnosis and prognosis of neck pain. Validated self-report questionnaires should be used with patients complaining of neck pain. The Neck Disability Index and the Patient Specific Functional Scale are two examples of these questionnaires. The main reason for this recommendation is that these tools establish a baseline status for pain, function, and disability that can be used later in intervention selection and goal tracking. Easily reproducible measures for activity and participation limitations related to neck pain should be used (Grade: F). This is to assess the change in function throughout the episode of care. An example of a tool to carry this out is the spinal function sort tool which like many other measures are more specific to low back pain and is part of the reasons for this recommendation being grade F. A study reports that the modified spinal function sort tool has good reliability and validity for assessing perceived self efficacy of work related tasks and the authors recommend this for patients with chronic musculoskeletal (MSK) disorders[14]. The consideration of certain risk factors that can predispose a patient to chronic neck pain (Grade: B) On the first instance treating a patient with acute neck pain it may be useful to consider if the patient has any risk factors for developing chronic neck pain. Early detection of risk factors can allow the clinician to implement strategies to decrease the likelihood of developing chronic pain[15]. These risk factors include:
Physical Impairment Measures (Grade: B) Physical examination should be undertaken to establish baselines and monitor changes over time. Physical assessments can also be useful in the ruling in/out of conditions/causes of neck pain. Algometric assessment of pressure pain threshold should be used for classifying pain. Below are examination recommendations for different types of neck pain patients.
Patient Classification (Grade: C) From examination, clinicians should categorise neck pain patients into one of the four previously mentioned groups in order to deliver the most appropriate treatment plan. To group patients, the clinician should carry out an appropriate subjective and objective examination. Below are the key findings to assess when placing patients into these categories. However, the classifications outlined are not exhaustive and therefore designating patients requires individual clinical judgement based on the examination findings. Neck pain with mobility deficits:
Intervention & Treatment Recommendations[edit | edit source]Interventions: Neck Pain with Mobility Deficits[1] Acute Acute neck pain with mobility deficits can be managed in a variety of different ways. Recommended interventions include: thoracic manipulations, neck ROM exercises (such as movement through restricted range with increases in range to progress), scapulothoracic and UL and upper extremity strengthening, and cervical manipulation and/or mobilisation (such as AP glide of cervical spine). Practitioners should also aim to enhance program adherence, which has been shown to improve with the inclusion of thoracic manipulation, neck ROM exercises and scapulothoracic and Upper extremity strengthening. Subacute For subacute management of neck pain with mobility deficits the following has been advised: neck and shoulder girdle endurance exercises (e.g. chin tuck endurance exercises. With gravity, against gravity, etc.), thoracic manipulation, and cervical manipulation and/or cervical mobilisation. Chronic Chronic neck pain with mobility deficits benefit more from a multimodal management technique, to include: thoracic manipulation and cervical manipulation or mobilisation; mixed exercises for cervical/scapulothoracic regions: neuromuscular exercise (e.g. coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements; or intermittent mechanical/manual traction. Dry needling can also be used as an intervention. It has been shown to be effective in short-term and long-term follow-ups when measuring its effect on: pain intensity, mechanical hyperalgesia, neck active range of motion, neck muscle strength, and perceived neck disability[16]. Low-effect laser therapy can provide relief from chronic neck pain for 2-6 months, with no serious side effects or complications being reported[17]. Furthermore, patient education should be provided in order to recommend an active lifestyle and address cognitive and affective factors – e.g. help to arrange a suitable weekly activity schedule. Lastly, neck, shoulder girdle and trunk endurance exercises should be used – e.g. plank, side plank, shoulder shrugs, etc. Interventions: Neck Pain with Movement Coordination Impairments[1] Acute Acute management of neck pain with movement coordination impairments should be managed with a strong focus on education, to include: return to nonprovocative pre-accident activities as soon as they are able to; minimise use of cervical collar; encourage postural and mobility exercises to decrease pain and increase ROM; reassure the patient of average recovery times of up to 2-3 months Furthermore, a multimodal approach is favoured, to include: manual mobilisation techniques alongside exercise (e.g. strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises). If a patient is at low risk of progressing towards chronicity then the intervention applied should be focused around patient independence and involvement through education and a home exercise programme (HEP): a single session consisting of early advice, exercise instruction, and education; along with a comprehensive exercise program (to include strength and/or endurance with/without coordination exercises); and Transcutaneous electrical nerve stimulation (TENS) It has been found that an effective HEP has a strong correlation with reduced neck pain, increased function, decreased disability and improved QoL[18]. Specifically, HEPs were more effective when they utilised self-mobilisation techniques, strengthening exercises, endurance exercises, and when the HEPs were designed to address a specific spinal level. The current research on TENS in relation to neck pain is fairly sparse. Although effects have been seen, they have been limited to short-term effects, that usually recur; and show no sign of responding to treatment in the long-term. It’s also been shown that TENS is more effective than placebo, and seems to have an effect in reducing the intensity of acute and chronic cervical pain[19][20]. Patients who are showing signs of progressing towards chronicity or delayed rehabilitation outcomes should be identified and monitored as early as possible, in order to provide them with a more intensive rehabilitation and an early pain education program. Chronic Management of Chronic Neck Pain with Movement Coordination Impairments follows a similar emphasis on education and advice, focusing on assurance, encouragement, prognosis, and pain management. Furthermore, mobilisation combined with an individualised, progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioural therapy is advised. This can be used alongside TENS. Interventions: Neck Pain with Headaches[1] Acute For management of acute neck pain with headaches, an emphasis should be mainly placed on mobilisation. Active mobility exercises should be provided along with supervised instruction to be given by the practitioner. Furthermore, C1-C2 self-sustained natural apophyseal glide (self-SNAG) exercises should also be provided to be completed independently. C1-C2 self-sustained natural apophyseal glide rotation exercises have shown improved results when combined with C1-C2 self-SNAG exercises, in comparison to C1-C2 self-SNAG exercises alone. This presented as a strong effect on pain intensity, physical function, CFRT and pain catastrophising. Furthermore, moderate improvements were seen in active Cervical range of movement, kinesiophobia and fear-avoidance beliefs[21]. Subacute Subacute neck pain with headaches should also be managed with an emphasis on mobilisation, both independent and passively employed by a practitioner. This is to include:
Chronic Chronic neck pain with headaches should be managed through an intervention of cervical or cervicothoracic manipulation or mobilisations. This can be paired with shoulder girdle and neck stretching, alongside strengthening and endurance exercises for the shoulder girdle and neck. migrainecanada.org - headache and neck pain is it possible that nerve compression is to blame Interventions: Neck Pain with Radiating Pain[1] Acute Acute management of neck pain with radiating pain focuses on a few different modalities. One intervention available to practitioners is mobilising and stabilising exercises. Another intervention available to practitioners for acute management of neck pain with radiating pain, is laser intervention. Finally, practitioners may employ use of a cervical collar, but only in the short-term. Chronic Management of chronic neck pain with radiating pain, completely differs from acute management. Mechanical intermittent cervical traction can be used as an intervention in chronic patients, in conjunction with stretching and strengthening exercises, and cervical and thoracic mobilisation and/or manipulation. Traction should be used in conjunction with other interventions, because on its own it has found limited success. It has been shown that traction has no specific benefits as an intervention for chronic neck pain in adults when compared to standard physiotherapy interventions[22]. However, the research suggests exercise as a more relevant therapeutic management strategy. Alongside other interventions, education and counselling to encourage participation in exercises and occupational activities are recommended. Further advice (NICE, 2018): Acute: · For people with acute neck pain (lasting less than 6 weeks) or subacute neck pain (lasting for 6–12 weeks):
Chronic:
References[edit | edit source]
Which device should you use to move a seated stable patient who is complaining of neck pain?The Kendrick Extrication Device (shown in Figure 1 with a yellow arrow) is used in the pre-hospital environment to stabilize patients complaining of neck or back pain after car collisions. The KED is a low-flexibility device that is secured to the patient's torso, legs and head to prevent movement.
Which emergency move technique is appropriate for a patient with a neck injury?The rapid extrication technique is designed to move a patient in a series of coordinated movements from the sitting position to the supine position on a long backboard while always maintaining stabilization and support for the head/neck, torso, and pelvis.
What is the most appropriate device to use when immobilizing a patient with a suspected spinal injury?SAFELY TRANSPORTING PATIENTS WITH KNOWN SPINAL INJURIES
The EMS cot is a safer, more comfortable and more appropriate spinal immobilization device. These patients should be secured to the EMS cot as if they were being secured to the backboard.
Which is the most appropriate method to use when moving a patient?The most recognized technique is the use of the stretcher. EMS and stretchers go together like peanut butter and jelly.
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