Neck Pain

Neck Pain

Treatment Options

R = Risk      E = Effectiveness      S = Self-Care

C = Cost     U = Usefulness (overall rating)

1 = Least Favorable     5 = Most Favorable

R

E

S

C

U

(overall rating)

Ice/Heat

 5 

 3 

 5 

 5 

5

Manipulation

4

5

1

4

5

Acupuncture

5

3

1

5

4

Cortisone

Injection

1

2

0

3

1

NSAIDs

2

3

5

3

2

TENS

5

3

5

5

5

Laser

5

2

0

4

3

 

It goes without saying that the type of treatment you receive for your back pain will largely depend on whom you see. Your M.D. will likely provide anti-inflammatory medications, muscle relaxants and pain medications initially. If those fail to resolve the problem, he or she may refer you for physical therapy, and more and more frequently these days for chiropractic care or acupuncture. If conservative care fails to resolve the

Neck pain can come from a wide variety of tissues: muscles, joints, nerves, bones, tendons and ligaments in the neck itself, but also can be referred (meaning felt in the neck from problems in the jaw, shoulder or upper arm. ) Neck pain is often associated with headaches.

There are many causes of neck pain: whiplash injuries from car accidents and trauma are not uncommon. Repeated minor traumas can also cause neck pain, such as prolonged poor posture (like at a desk where the positioning of the monitor or desk top is not set for the user), looking down at cell phones too often or for too long, and over time can lead to neck pain, and ultimately even arthritis in the neck, where the discs or joints begin to degenerate. There are also other systemic medical conditions that can cause neck pain, though these are less common. They include polymyalgia rheumatica, ankylosing spondylitis, rheumatoid arthritis, tumors, and infections.

Causes of Neck Pain

Most neck pain is described as “non-specific” or mechanical in nature, and can have a variety of causes, as noted below. Neck pain can be “acute” or of recent onset, “cumulative”, meaning it developed over time, or “chronic,” meaning it has lasted for some time, typically more than 3 months. Treating neck pain appropriately requires understanding what caused it.

Sprain/stain injuries: these include trauma like whiplash or football injuries, but also includes activities over time which overload the muscles, joints and ligaments, like spending hours in front of a computer monitor or reading data on a cell phone, or holding the neck in awkward positions for long periods of time. Other factors can include stress, depression, certain occupations and sports injuries, among others.

Degenerative joint disease (DJD), also called osteoarthritis and spondylosis: this includes “wear and tear” arthritis of the discs and joints of the neck due to overuse, prior trauma and other causes. It is often influenced by genetic factors that make some patients more likely to develop arthritis than others according to some recent studies. Joints respond to the pressure put on them, and joints under stress develop more bone, which leads to “spurs” or bony outgrowths at the joints or disc margins. Depending on where they grow they can produce localized pain or even press on nerves in the area, sending pain and altered sensation (pain, numbness, tingling and loss of muscle strength) into the arm, hand and fingers.

Neck Disc herniations and related issues: Over time, wear and tear (stress) on the disc (the “cushion”) between the bones of the neck, called “vertebra” can cause the disc structures to wear down and allow the disc material to release irritating chemicals and move and touch sensitive structures. Discs are made up of a fibrous outer layer (think of a very tough donut made of thick fiber strands) and an inner soft gel (like a jelly filled donut.) If the fibers of the outer disk begin to wear out and tear, the “jelly” or “nucleus” can move from the inside of the “donut” to the outside, release painful chemicals, and even press on nerves. That will irritate the nerves or even cut them off and can result in pain, numbness, weakness and other sensations where that nerve travels. This is called “radiculopathy.” It can range from numbness and tingling (meaning it is affecting the outermost layers of the nerve) to loss of muscle strength or even loss of the ability to use one or more muscles if the pressure is enough to press deeper into the nerve to cut off nerve flow to those muscles.

Spinal Stenosis: the spinal cord is the consistency of boiled spaghetti and transmits nerve signals from the body (touch, heat, cold, vibration, movement, etc) to the brain, and the brain sends messages down to the muscles to coordinate movement and balance. The spinal cord is like a large cable of interconnecting nerves, with messages flowing up to the brain from our sensory organs, including the skin, and down to the muscles and organs (although nerve supply to the organs does not come from spinal nerves.) The spine forms a sort of bony tube that protects the spinal cord, and the nerves that pass out from the cord to various body parts. Remember, the spine and the nerves are soft and vulnerable to pressure or trauma. Anything that narrows the bony tube formed by the vertebrae and joints can squeeze and put pressure on the spinal cord or nerves as they exit the spinal cord. Some people are born with a narrow spinal canal and others develop narrowing because of bony growth in arthritis. This is called “ spinal stenosis.”

Neck Pain Related Conditions

While neck pain from relatively straightforward causes, such as a muscle strain, whiplash or even mild arthritis is often mild and may resolve without any treatment at all, other conditions can cause more serious and disabling problems

Radiculopathy: Radiculopathy (often called a “pinched nerve”) refers to pretty much what it sounds like: a nerve in the neck is being pinched, irritated or compressed. This can occur from a herniated disc pressing against the nerve, or from an arthritic growth or spur at the joints between the neck bones, called “facets.” Excessive bony growth around the facets can cause narrowing of the hole (neuroforamen) where the nerves pass from the spinal cord to other body areas. Other causes include trauma, instability or even tumors.

Radiculopathy can range from mild tingling or numbness which can be confused with localized nerve compression problems like carpal tunnel syndrome, to severe pain and loss of motor function of the affected nerves.
There are 7 vertebrae in the neck, but 8 cervical nerve roots (Cervical nerve 1 or C1 starts between the skull and first cervical vertebra.) These nerves pass through openings called “foramen” from the spinal cord on both sides of the neck to various areas including the neck, trapezius muscles and out to the arms. Symptoms can vary, but the spinal nerve or “root” being pinched will determine what part of the body is affected.

http://www.eurospine.org/cervical-spine.htm

Segmental Dysfunction: Chiropractors may refer to this condition as a “subluxation” or “joint dysfunction”, osteopathic physicians call it “somatic dysfunction” and practitioners of manual medicine call it “fixation” or “functional blockage.” Significant progress in clinical treatment using various forms of manipulation for this condition have been made, but the exact biomechanical basis for these conditions is unclear. Nevertheless, chiropractors alone treat 35 million patients each year using manipulation to address joint dysfunction, which can be associated with the other conditions listed here.

How Common is Neck Pain?

Studies show 2 out of 3 of us will experience neck pain in our lifetimes, and half the population in the US had neck pain in the last 6 months.

What are the Symptoms of Neck Pain

Neck pain can vary from a slight nagging discomfort to severe pain, and depends on what is causing the pain. Simple strains may resolve with little or no treatment, while more severe conditions can cause symptoms ranging from numbness, pain in the arm “like a toothache”, to weakness and loss of function. Strains and sprains typically produce localized pain, but may also be associated with other symptoms, such as headache. Disc herniations and degeneration (spondylosis) may produce no symptoms, severe radiating pain and weakness, or something in between.

Other serious conditions can produce neck pain which require immediate evaluation and treatment, including spinal meningitis or cancer, so neck pain that does not resolve within a short period of time with reasonable conservative measures should be evaluated by a licensed healthcare provider. (See red flags.)

How Is Neck Pain Evaluated or Diagnosed?

History: Your health care provider will first obtain a history by asking a series of questions, like these:

  • How did the condition begin? Was there trauma or did the pain come on slowly?
  • What is the quality of the pain: sharp, dull, aching, electric, stabbing etc. how often, how bad, does it come or go? What makes it better or worse?
  • Does it radiate is it localized only? If it radiates, where?
  • Severity: how bad is the pain?(Often rated on a 0-10 scale, where 0 is “no pain.”.)
  • Timing: is it worse at a particular time of day or associated with certain activities?
  • Your clinician is also likely to ask you to fill out various forms, such as the Neck Disability Index, which helps to document difficulties with activities of daily living, such as reading, driving, sleeping, lifting or other activities.
  • The answers to these questions, and others, will help guide the clinician in terms of a preliminary diagnosis, which is then confirmed with a physical examination and perhaps additional studies like xray, MRI or other tests.

Physical Examination for Neck Pain: The history will typically guide the physical examination, which will also vary somewhat based on the type of provider you are seeing. Most providers should do the following:

  • Touch or “palpate” the area(s) of pain and movement of the specific joints
  • Evaluation how well you can move your neck or “range of motion.”
  • Test your sensation
  • Check your reflexes
  • Test the strength of the various major muscles, especially the arms. In some cases the lower extremities should also be tested, particularly in suspected cases of spinal stenosis.

Red Flags For Neck Pain

The presence of “Red Flags” means additional information should be obtained, as they may be signs of a more serious medical condition. You should contact your physician or other health practitioner if any of these signs or symptoms accompany your neck pain. Neck pain with fever for example may be an indication of meningitis, a serious and potentially life threatening condition.

  • Significant history of trauma or neck surgery
  • Unexplained weight loss, night sweats, fevers
  • Severe pain
  • Pain at night
  • Relatively young (<20) or old (>55)
  • Signs of spinal cord compression
  • Significant vertebral body tenderness
  • History of tuberculosis, HIV, cancer or inflammatory arthritis

Other signs or symptoms will also require additional investigation. For example, a sudden onset of neck pain and headaches, especially if also accompanied by other neurological signs may indicate a serious condition called “vertebral artery dissection.” While quite rare, it can lead to stroke and even death.

Associated neurological signs of potential neck artery injury include but are not limited to:

  • Nausea
  • Nystagmus (rapid uncontrolled eye movements)
  • Dizziness
  • Difficulty swallowing
  • Difficulty speaking
  • Drop attacks (fainting or loss of consciousness)
  • Difficulty with movements or falling
  • Double vision

Signs such as facial drooping or numbness, blurred vision, difficulty speaking, walking or moving, or trouble swallowing may indicate a potential stroke and should be taken seriously. If there is any possibility that a patient may be undergoing a vertebral artery dissection or stroke, emergency medical care should be sought.

Neck Pain - Whiplash

Whiplash and Whiplash Associated Disorders (WAD) are the most common injury associated with motor vehicle collisions and is a major cause of disability and litigation. It is caused by a sudden acceleration and deceleration, typically from rear-end or side impact crashes. In rear-end crashes, the patient’s body is first pushed back into the seat and the head and neck are thrown backward relative to the car. The neck is then thrown forward as the vehicle continues to move forward.

The Quebec task force (QTF) on whiplash associated disorders (WAD) defined whiplash as “bony or soft tissue injuries” resulting “from rear-end or side impact, predominantly in motor vehicle accidents, and from other mishaps” as a result of “an acceleration-deceleration mechanism of energy transfer to the neck” . Whiplash is associated with a wide variety of clinical manifestations including neck pain, neck stiffness, arm pain and paresthesias (tingling or numbness), problems with memory and concentration, and psychological distress. This group of symptoms and signs are collectively termed WAD.

In addition to the suffering WAD produces, it is also associated with significant costs, including treatment, lost work time, disability and litigation. It was commonly thought that most whiplash symptoms resolve within 3 months of injury, but more recent studies suggest up to half of patients still had issues a year later.

Whiplash injuries are categorized under the Quebec Task Force depending on the severity of the injury, ranging from 0 to IV:

QTF classification of whiplash-associated disorders
Grade Classification
0 No complaint about the neck. No physical signs
I Neck complaint of pain, stiffness or tenderness only. No physical signs
II Neck complaint and musculoskeletal signs. Musculoskeletal signs include decreased range of motion and point tenderness
III Neck complaint and neurological signs. Neurological signs include decreased or absent deep tendon reflexes, weakness and sensory deficits
IV Neck complain and fracture or dislocation

Whiplash Symptoms

Typically whiplash injuries can include neck pain, headaches, upper back pain, shoulder pain, and tingling, numbness or even weakness in the arms. Other frequent symptoms include fatigue, irritability, and vertigo, among other complaints. 12

Some whiplash injuries are very mild and require no treatment, while others can be life-threatening. While the type of treatment provided is determined at least in part on the severity of the injury and how long it has been since the injury, there remains some controversy about what is best to do and when. Most guidelines recommend an early return to activity and stretching or mobilization. One recently developed guideline recommended a “multimodal” (meaning multiple treatments) approach including manual therapy, self-management advice and exercise for neck pain and whiplash-associated disorders.

Seeking Help for Neck Pain

The first step in developing a plan of treatment for neck pain is understanding the nature of the problem. Most neck conditions are considered non-specific or mechanical. Providers of different types tend to look at neck pain from their own perspectives. For example, orthopedic surgeons may evaluate patients to determine if their condition will respond to surgery. Pain doctors will often suggest medications or epidural injections and family physicians typically rely on anti-inflammatory medications and muscle relaxants.

Some providers, such as chiropractors will evaluate patients to rule out more serious conditions, but tend to focus on mechanical dysfunction of the joints or muscles. Acupuncturists use a different paradigm which evaluates for blockages of Chi or energy channels in the body’s meridians.

Physical therapists evaluate for muscle or joint dysfunction or deconditioning of the muscles that support the spine. Other providers, such as naturopaths, may use a combination of natural remedies including herbs. Physical therapists and others including chiropractors, naturopaths, some physicians and acupuncturists will also use therapies, modalities and procedures to help relieve back pain. These might include electrical muscle stimulation to reduce pain and relax muscles, traction, soft tissue muscle techniques, exercise and rehab protocols and a variety of other techniques. Most providers will agree that exercise is an important component of any treatment problem for neck pain. Most chiropractors, physical and physicians will provide exercises to their neck pain patients.

Neck Pain - Red Flags

Your provider will screen you for potentially life-threatening conditions which might present as neck pain. These might include infection, fractures, and malignancies. Factors such as advanced age, heavy use of steroids and significant trauma increase the risk for fractures. Tell your provider if have any of these issues, or a previous history of malignancy.

Do I Need an MRI/XRAY?

The routine use of xrays or other imaging studies for patients presenting with neck pain is no longer recommended. However, iIf “red flags” are present, there is a history of trauma, or you don’t respond as expected, then imaging studies make sense. If your provider wants to take xrays or send you for CT or MRI, ask them why, and what they hope to learn from the study. Ask what the downside to waiting might be, and how the imaging study would change their treatment approach. If they plan to do the same thing regardless of whether a study is obtained, hold off on the study.

Treatment Approaches for Neck Pain

It goes without saying that the type of treatment you receive for your back pain will largely depend on whom you see. Your M.D. will likely provide anti-inflammatory medications, muscle relaxants and pain medications initially. If those fail to resolve the problem, he or she may refer you for physical therapy, and more and more frequently these days for chiropractic care or acupuncture. If conservative care fails to resolve the problem and there is a disc herniation, or pressure on the spinal cord or a nerve, you may be referred to a pain specialist for epidural steroid treatments or other medications. Less common problems will require various forms of care tailored to those conditions. Ultimately some conditions may require surgery if nothing else helps. Generally, it makes sense to start with the least invasive, safest and most cost-effective treatments first and work up from there. Here’s what you need to know about some of the basic forms of therapy for neck pain:

  • Acupuncture
  • Manipulation
  • Acupuncture
  • Cortisone Injection
  • Anti-inflammatory Medication (NSAIDS)
  • TENS
  • Laser

TREATMENT FOR NECK PAIN

Ice and Heat for Neck Pain

Manipulation for Neck Pain

Acupuncture for Neck Pain

Epidural Steroid Injections for Neck Pain

NSAIDs for Neck Pain

TENS for Neck Pain

Laser for Neck Pain

http://www.utoledo.edu/library/canaday/exhibits/quackery/quack2.html
Cassedy JH. Medicine in America: A Short History. Baltimore, MD. Johns Hopkins University Press; 1991.

Chiropractic – A Brief Overview, Part I


Agocs S. Chiropractic’s Fight for Survival. AMA Journal of Ethics. June 2011, Volume 13, Number 6: 384-388.

http://www.nytimes.com/1987/08/29/us/us-judge-finds-medical-group-conspired-against-chiropractors.html
https://www.acatoday.org/About/History-of-Chiropractic

Subluxation: dogma or science? Keating J, Charlton K, Grod J, Perle S, Sikorski D, Winterstein J. Chiropractic & Osteopathy200513:17

Hawk C. The Praeger Handbook of Chiropractic Health Care.Santa Barabara CA: ABC-CLIO; 2017.
https://ccgpp.org

Johnson C. Highlights of the basic components of evience-based practice. J Manipulative and Physiol Ther. 2008; 31(2):91-92.

Bishop PB, Quon JA, Fisher CG, Dvorak MF. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine J. 2010; 10 (2):1055-1064.

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491.

Paige MN, Miake-Lye IM, Booth MS, et al.Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460

Van TUlder MW. Michaleff ZA, Lin CW, Maher CG. Spinal manipulation epidemiology; systematic review of cost effectiveness studies. J Electromyogr Kinesiol. 2012;22(5): 655-662.

Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM. Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State. Spine. 2013;38(11):953-964. doi:10.1097/BRS.0b013e3182814ed5.

Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilization for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Sys Rev. 2015;9: CD004249.

Verhage AP, Scholten-Peeter GC, vanWijngaarden S, et al. Conservative treatment for whiplash. Cochrane Database Sys Rev. 2017;2: CD003338

Gross A, Forget M, St George K, et al. Mechanical traction for neck pain with or without radiculopathy or myelopathy. Cochrane Database Sys Rev. 2012;3: CD005106

Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: non-invasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. Spine. 2008;33:4 Suppl;S123-152.

Nikolaidis I, Fouyas IP, Sandercock PAG, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Sys Rev. 2010;1: CD001466.

Bussières, André E. et al The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. Journ Manip Phys Ther.39(8);523-564.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18:3. doi:10.1186/1746-1340-18-3.

Coulter I, Adams A, CoganP, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Altern Ther Health Med. 1998;4(5):6464-75.

Fontana RJ. Acute Liver Failure including Acetaminophen Overdose. The Medical clinics of North America. 2008;92(4):761-794. doi:10.1016/j.mcna.2008.03.005.

Wolfe MM, Lichtenstein DR, Singh G. Gatrointestinal toxicity of non-steroidal anti-inflammatory drugs. N Engl J Med. 2007;147(7):478-491.
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis

Hurwitz EL1, Morgenstern H, Vassilaki M, Chiang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. J Manipulative Physiol Ther. 2004 Jan;27(1):16-25.

Oliphant D..Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210.

Park K-W, Park J-S, Hwang S-C, Im S-B, Shin W-H, Kim B-T. Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations. Journal of Korean Neurosurgical Society. 2008;44(3):109-115

Haneline MT, Rosner AL. The etiology of cervical artery dissection. Journal of Chiropractic Medicine. 2007;6(3):110-120. doi:10.1016/j.jcme.2007.04.007.

Herzog W1, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012 Oct;22(5):740-6.

Cassidy JD, Boyle E, Côté P, et al. Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. European Spine Journal. 2008;17(Suppl 1):176-183.

Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap. 2015 Jun 16;23:19

Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ: Canadian Medical Association Journal. 2001;165(7):905-906.8,

Saeed A. B., Shuaib A., Al-Sulaiti G., Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Canadian Journal of Neurological Sciences. 2000;27(4):292–296

Senna, M K, Machaly, S A. Does Maintained Spinal Manipulation Therapy for Chronic Non-specific Low Back Pain Result in Better Long Term Outcome?Spine (Phila Pa 1976) 2011 (Aug 15); 36 (18): 1427–1437