Physiotherapy for Neck Pain| Assessment & Treatment

Prognosis & Course

Neck pain has a lifetime prevalence of 70% with a point-prevalence of 20% amongst the dutch population.
It’s important to differentiate between a normal and abnormal course of neck pain:

• Normal: 45% pain reduction within 6 weeks after onset
• Abnormal: Less than 45% reduction within 6 weeks after onset

Neck pain has a high recurrence with 50-85% within 5 years after the first episode. The guideline categorizes neck pain according to different grades:

• Grade I: Neck pain without signs & symptoms of serious pathology and no or mild influence on activities of daily living (ADLs)
• Grade II: Neck pain without signs & symptoms of serious pathology and strong influence on activities of daily living (ADLs)
• Grade III: Neck pain without signs & symptoms of serious pathology, but neurological signs & symptoms
• Grade IV: Neck pain with serious signs & symptoms

There are several factors that can impair the recovery, which are summarized in thefollowing table :

Screening

Red flags are signs & symptoms that might indicate serious pathology. In the cervical spine, the following specific red flags will have to be excluded first, before you can continue with your patient history taking:

Diagnosis

During your diagnosing part, the guideline recommends the following steps:

1) In- or exclusion of Grade III neck pain (signs & symptoms of neck pain with neurological signs & symptoms):

• Sensory symptoms like paresthesia, loss of feeling, or diminished touch sense
• Impaired CROM: <60° of rotation or pain
• Decreased muscle strength
• Radiating pain in the arm

2) Interference with ADLs with the help of the Patient Specific Complaint Questionnaire(PSC) to differentiate between neck pain grade I or grade II

3) Course: Normal or abnormal?

4) Is your patient experiencing work- or trauma-related neck pain?

5) Prognostic factors, co-morbidities, current treatment, medication, social background

Physical Examination

The guideline recommends sticking to the following steps during your physical examination:

1) In- or exclusion of Grade III neck pain (signs & symptoms of neck pain with neurological signs & symptoms) if your patient complained of neurological symptoms during patient-history taking:

• Test for a diminished biceps- and triceps reflex, diminished touch sense in the dermatomes, reduced muscle strength in the myotomes,
• To confirm cervical radiculopathy, the guideline recommends the Spurling’s test and/or the traction/distraction test (see in a later section)
• To exclude radiculopathy, the guideline recommends performing the ULTT1

2) Examination of the cervical and thoracic spine, shoulder joint, and shoulder girdle on the following points:

• Range of Motion (ROM), the direction of movement, resistance, end-feel
• Provocation or reduction of pain and radiation

3) Muscle Examination:

• Length, elasticity, end-feel, sensibility on contraction/stretch, tonus
• Strength and endurance of the deep neck flexors with the help of the deep neck flexor endurance test

The guideline further recommends the following clinimetric tools:

• Numeric Pain Rating Scale (NPRS) for an average of the experienced pain in the last24 hours from 0 to 10
• PSC scale to evaluate the impairment in ADLs

These two tools should be used at the beginning and the end of the whole treatment. It should be noted that an improvement of at least 2 points on these scales is considered clinically relevant. Other clinimetric tools like the Neck Disability Index (NDI) might be used according to the physiotherapist’s own opinion. Due to the moderate validity and the risk of false positive results, the general use of x-rays, MRI, CT scans, or ultrasound is not advised.

Analysis

After your patient-history taking and physical examination, you should be able to give answers to the following questions:

1) Which grade of neck pain (I-IV) is present in this patient?

2) Course: Normal or abnormal?

3) Is this patient experiencing work- or trauma-related neck pain?

4) Are any prognostic factors present that I can influence?

5) Is the relationship between the reported limitations of daily living and participation consistent with the patient’s neck pain?

The answers to the abovementioned 5 questions enable you to categorize your patient in the following treatment profiles:

Treatment

The treatment for neck pain depends on the different profiles that the patient was categorized in after the analysis.

Profile A

Goal: Educate and facilitate active coping

• Explain the normal course of neck pain: Normal course of neck pain is favorable and neck pain is not damaging or reflects the level of tissue damage
• Advise and motivate the patient to gradually increase his activity, participation and exercise level and to return to work
• If the neck pain is work-related: Adjust the workspace and explain how different work-related prognostic factors can negatively influence the recovery
• If your patient is on sick leave you can suggest your patient to contact a physiotherapist that is specialized in work-related issues
• N.B. Maximal number of treatment sessions should be 3!

Profile B

Goal: Influence prognostic factors

• Education and advice like in profile A
• Provide exercise therapy (in line with the patient‘s needs, limitations, and goals) with cervical and/or thoracic mobilization / manipulation
• If the above-mentioned treatment is not successful, the therapist can consider the following optional treatment options: cervical pillow, cognitive behavioral therapy, kinesiotaping in case of trauma-related neck pain to decrease pain in the short-term, massages in combination with other therapies to decrease pain in the short-term, heat and cryotherapy also in combination with other forms of therapy
• The guideline discourages the use of dry needling, electrotherapy, ultrasound, or laser therapy
• If the neck pain is work-related: Like profile A + motivate your patient to contact a physiotherapist that is specialized in work-related issues or the company’s general practitioner to evaluate treatment options
• If your patient is on sick leave or is less productive for not longer than 4 weeks: Ask the patient about arrangements being made with the company’s physician or ask him to get in touch with a physiotherapist that is specialized in work-related issues to coordinate further management• Evaluate the content of your treatment, commitment to treatment and the results with an NP(R)S and PSC scale
• N.B. Terminate the treatment if goals have been reached or if no improvement is achieved after 6 weeks of treatment. If the treatment has not had any effect on pain or activity level, contact the general practitioner to evaluate further treatment options.

Profile C

Goal: Influence psychosocial prognostic factors

• Approach like in Profile B
• Focus less on your patient’s pain as this can lead to increased attention to your patient’s pain and pain behavior
• Explain to your patient how psychosocial prognostic factors like fear, depression, restlessness, kinesiophobia, and catastrophizing can have a negative influence on recovery
• In the case of kinesiophobia, you should explain that activity is promoting recovery and motivate them to move more
• Continually discuss the influence of psychosocial factors that lead to a delayed recovery in order to evaluate if those factors have changed or if their influence on neck pain has become less
• If psychosocial factors are the main reason that your patient is not recovering, you should advise your patient to discuss further treatment options with their general practitioner, a psychologist, or a psychosomatic physiotherapist• During the exercise part of the treatment, you should stress behavioral principles and graded exposure to movement
• Other treatment options as those mentioned in profile B can be taken into consideration aswellN.B. Terminate the treatment if goals have been reached or if no improvement is achieved after 6 weeks of treatment. If the treatment has not had any effect on pain or activity level, contact the general practitioner to evaluate further treatment options.

Profile D

Goal: Management according to a clear time path

• Approach like in profile B with the following differences:
• Explain the diagnosis to your patient and reassure them that neurological signs in the arm often diminish on their own
• Promote an active physical lifestyle and an active coping style but at the same time your patient should avoid movements that worsen the radiating pain or other complaints in the arm
• Exercise therapy with mobilizations and manipulations combined with nerve mobilization
• Optional: Semi-rigid neck brace to reduce pain in the short-term (effect should be evaluated after 2 weeks to prevent dependence, except in trauma-related cases)
• Traction can be considered if the above-mentioned exercise approaches do not have sufficient effects
• N.B. Refer the patient back to their general practitioner if treatment is ineffective (within the agreed time frame or at 6 weeks maximum) or if complaints worsen.6 weeks of treatment is considered the maximum time of treatment in all profiles, due to the fact that the chance of improvement after this time period severely decreases.

5 ESSENTIAL MOBILIZATION / MANIPULATION TECHNIQUES EVERY PHYSIO SHOULD MASTER

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References

Bier, J. D., Scholten-Peeters, W. G., Staal, J. B., Pool, J., van Tulder, M. W., Beekman, E., … & Verhagen, A. P. (2018). Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Physical therapy, 98(3), 162-171.