Welcome to the latest installment of our blog series. This month we will be taking a look at neck pain, and what we as Physiotherapists can do to help patients, specifically in relation to work.
Neck pain is a commonly seen condition and can sometimes lead to substantial time off work. The prevalence of neck pain is higher in industrialised countries, but there are many factors to consider, in terms of the physical work tasks, the fitness of the worker, and the multiple factors involved in a patient’s perception of their problem and how they feel they are being supported in the workplace.
This blog will aim to briefly provide an overview of the causes of neck pain with a particular bias towards the workplace. This will include a basic recap of anatomy, the essential screening of red flag symptoms and then looking into what, as physiotherapists, we can do to both treat and prevent this condition in the longer term.
PRESENTATION OF NECK PAIN IN THE WORKPLACE
As previously mentioned neck pain is very common in the workplace. There are numerous psychosocial and physical aspects that may contribute to its development, as well as its progression into a chronic condition. Literature clearly linking causation to any one specific factor is lacking. However, both gender and age have been shown to affect the prevalence of neck pain. It has been reported that women have higher prevalence of neck pain compared with men, which is partly explained by differences in work task exposure between men and women. Neck pain has also been reported as being more prevalent among older workers, which makes sense, in terms of the contribution of normal age related changes to the structures of the neck to symptoms.
It has been shown that workers with a high level of physical work demands have a higher risk of work-related disability, compared with workers in less physically demanding jobs. Manual handling, and repetitive work are commonly reported as causes for work-related neck disorders. Prolonged sitting is also thought to be associated with an increased risk of developing musculoskeletal disorders in the back, neck, shoulders, arms and legs. Psychosocial factors such as high job demands, low support from supervisors and co-workers, and low job control are also recognised as important contributors to musculoskeletal problems.
The neck contains a number of overlapping muscles, blood vessels, nerves and bony structures, all contained within limited space and all susceptible to stresses or injury. The neck also contains the thyroid and parathyroid glands, oesophagus, larynx, trachea, and also a number of lymph glands. Conditions involving any of these structures can cause neck pain and/or visual deformities of the neck. Injury to the neck can result in spasm and pain in the muscles and lead to referred pain experienced as headaches, shoulder or arm pain. Structural problems or injury within the vertebrae, discs, and nerves can also be experienced as neck pain, referred pain, headaches, paraesthesia and loss of strength. More serious pathology may lead to injury of the spinal cord. A thorough subjective and objective assessment is essential, to determine the best course of management and also to ensure patient safety.
As MSK physio’s we tend sometimes to focus only on those structures we usually refer to in the MSK system (joints, ligaments, muscles, nerves etc.).
It is surprising however, how many other visceral structures such as lymph, salivary and thyroid glands are closely integrated within these neck structures. This is a really important consideration when undertaking physiotherapy assessment and treatment techniques. A pathology in the lymph and glandular structures can present as neck pain. Physical assessment techniques, such as anterior palpation of the cervical facets will be directly compressing these tissues and may account for some of the levels of discomfort expressed by patients and physio models alike, when this is being undertaken.
THE VASCULAR STRUCTURES
It is not possible to leave the anatomy of the neck, without making reference to the red flag questioning for the cervical spine: Cervical Artery Dysfunction (CAD) which includes Vertrbrobasilar Insufficiency (VBI) as well as upper cervical instability and internal / vertebral artery dysfunction must be excluded using the 5D’s & 3N’S!
The vertebral artery is relatively fixed at the foramen magnum and at C2. Between these 2 points, the artery goes through an “S” bend as it passes behind the lateral mass of the atlas. This section of the artery is subjected to large stretching forces during rotation and is at risk of injury during inappropriate manual therapy techniques and end range movements,
There is great guidance available from the MACP and IFOMPT on the assessment of the cervical spine and this has been added to the resources for this blog. In the interests of brevity, the 5 D’s are:
VBI causes ischaemia in the areas of the brain supplied by the basilar artery: the pons, medulla and cerebellum, as well as the central and peripheral vestibular system. A variety of signs and symptoms can therefore be generated by disruption of the artery, however the most commonly reported symptoms associated with VBI is dizziness.
Other symptoms that have been commonly reported with VBI are:
THE MANAGEMENT OF NECK PAIN:
SUBJECTIVE EXAMINATION PART 1 – EXCLUDING THE NASTY CAUSES!
I am not going to spend a lot of time explaining the subjective examination, apart from the screening of red flags and then the bias towards screening within an Occupational Health setting. It goes without saying, that serious causes of acute neck pain may be identified from the nature and mode of pain onset, its intensity and alerting features such as the red flags. The history distinguishes serious causes of acute and chronic neck pain from non-threatening causes.
In the Neck, in addition to the 5 D’s and an 3Ns, reported above, the following factors would raise suspicion that there may be serious underlying pathology:
With regards to pathways for stratifying the care of patients with acute neck pain, the Canadian C-Spine Rule is a simple tool to use when assessing patients with neck pain.
Generally, in the absence of trauma, suspicion of sinister pathology, or progressive neurology, imaging is not indicated, as it will not change the management of the condition.
During the subjective assessment, from an Occupational Health Physiotherapy perspective, it is imperative that all of the other “flags” are considered during the assessment. It is stated in the literature regarding psychosocial flags that psychosocial factors start to become increasingly important between two and six weeks of onset of the problem. I would argue that patients’ belief systems are influential on their symptoms from the time of onset and that consideration of these flags and the physio’s ability to deal with these is relevant from the very first point of contact.
There are several useful methods for assessing flags in Occupational Health, which could be talked about in great depth. All of this information is to be found in the resources for this blog, as this is a topic in itself. In essence, the mainstay of assessment is:
1. Observation: of the way the employee behaves, interacts with others, and talks about their condition and work.
2. Key questions: these will give you an idea for the flags that may be present. These can be aimed towards the patient’s beliefs with regards to whether work has caused/contributed to their symptoms and how keen they would be to return.
3. Screening questionnaires: a number of screening questionnaires exist that can help to identify flags in more detail. These do have a place in assessment and can help in arguing the case for referral for additional input. However, questionnaires are just one part of the overall assessment process and should be used alongside other methods as well.
There are many other questionnaires available for assessing fear avoidance, fear of movement and self-efficacy, and can be useful where indicated.
4. Structured interviews: ABCDEFW (nice and easy to remember!) if the methods already discussed have confirmed the presence of psychosocial flags, then the structured interview is the next step in getting more information about particular issues and flags. An acronym has been developed to help remember which areas to ask more about: ABCDEFW. A for attitudes and beliefs, B for behaviours, C for compensation, D for diagnosis and treatment, E for emotions, F for family and W for work.
5. Workplace visit: this is not always possible, but is an excellent additional method of assessing flags. This can be conducted as an informal visit for physios who work onsite, or as a more structured visit for ergonomic assessment. This can help obtain a large amount of information with regards to psychosocial flags.
All of the information gathered with regards to the patient’s work beliefs can help enable the design of a suitable plan for rehabilitation, involving the employee and the other stakeholders in the process. Dealing with psychosocial issues will result in better functional outcomes for the employee. The presence of psychosocial flags should never be a reason to exclude people from treatment programmes or rehabilitation, or to write them off as people who will not recover. The identification of these flags however, will provide the opportunity to arrange suitable support, to give the patient every opportunity to recover.
Depending on the flags that have been identified, a few relevant parties may need to be involved in the action plan, to overcome the obstacles and return someone to work. It may be necessary to make referrals for health treatment, for medical investigations, to organise case meetings with the workplace, and even possibly arrange advice from external support agencies, such as debt or relationship counselling.
Following a thorough subjective examination, there should already be a reasonable hypothesis as to what you feel is contributing to the symptoms and what the probable underlying mechanism of the pain symptoms is.
The physical examination is also an opportunity to further identify or exclude the features of potentially serious conditions.
Bearing in mind the SIN factors of the presenting issue and the subjective history, it is really important that the objective assessment is appropriate and doesn’t unnecessarily aggravate symptoms further.
In terms of “must”, “should” and “could” elements of the assessment, neurology needs to be assessed. I would argue that neurology needs to be assessed in all patients presenting with spinal pain, regardless of the subjective assessment findings. It is good practice, establishes a baseline and only takes a minute. This would include upper motor neurone lesion tests, such as Hoffman’s/Babinski as well as standard dermatome, myotome and reflex testing. Without doing this at baseline, it is impossible to know, at follow up, if symptoms of neural compromise start to be reported, whether there was a deficit to begin with. It is also relevant to assess a patient’s movement capacity in terms of active and passive ranges of movement where possible.). Palpation, PPIVMs, PAIVMs and muscle length testing can be undertaken as appropriate. As a rule of thumb, upper limb neural tension testing and its accompanying latency of pain symptoms wouldn’t tend to be a first assessment priority, unless hunting for symptoms in a low SIN case.
On the whole, there is much less available evidence in terms of research studies on which to base treatment decisions for neck pain than for back pain. Current thinking, with the evidence available, is that it should be managed with a similar approach to that advocated in back pain guidance. The following approach is based on the general treatment approach for neck pain, but with a bias towards patients presenting with neck pain in Occupational Health.
Develop a management plan ensuring that patients know what to expect, and understand their role and responsibilities in their own management. Adapt methods of communication as needed, to meet the needs and abilities of each patient. Terms that are used to describe the problem need to be “neutral” and avoid diagnostic labels and jargon.
It is important that the patient is provided with a comprehensive explanation of their presenting problem, to avoid inappropriate expectations, fears or mistaken beliefs about their condition or its management. Written information can be really useful for communicating this, if you have this available. Arthritis Research UK has some brilliant evidence based resources available for information about the causes of neck pain, the advice regarding analgesia, investigations and also the exercises available.
The physiotherapist needs to check that any information provided has been understood. Any barriers to understanding need to be explored and addressed.
With regards to work, agree a return to work plan, which is time specific and clearly states any relevant modifications to work tasks or other activities. To facilitate the patient’s presence at work, it is important to seek agreement to involve the employer, if necessary, to help enable the patient be present in work to some extent, not just inform the employer of the recommendations you are advising. Informed consent to involve the patient’s employer in their management plan needs to be documented as written consent.
It is important to avoid attributing problems to a specific injury or mechanical derangement, unless there is a clear cause. For conditions where there is evidence, consider using treatment modalities to reduce pain and disability early.
Pink flags are unofficial in terms of a recognised phenomenon, but have been referred to in this blog as they can be useful in practice. Pink flags were first described by pain specialist physiotherapist Louis Gifford, in 2005, to reflect his concern at the constant focus of medicine on the things that make people worse, rather than looking for factors that can help make people better.
The idea of focussing on pink flags is the concept of focussing on the “positives”. In medicine, the focus tends to be put on the psychosocial factors that contribute to a poor outcome. Louis Gifford presented the idea that we should look for attitudes or ideas that promote a good outcome, as well as document the negatives. Pink flags are the positive factors that should be looked out for and emphasised. These are the beliefs that give people the chance of a better outcome. Examples would be of someone who enjoys their job and is keen to work with the team, to find a way back to work, or an employee who has discovered that activity helps them feel better, so has expressed that they want to stay active at home and at work.
Physiotherapists can influence pink flags by giving reassurance and educating patients appropriately. This helps prevent any unhelpful beliefs developing and also supports and promotes confidence in the planning process, with regards to return to work, or undertaking treatment. An accommodating workplace is a pink flag, and the right sort of work is good for peoples’ health and wellbeing. As physiotherapists, we can be the facilitators in this process.
The mainstay for treatment of neck symptoms is always going to be exercise and self-management. Exercise has both physical and mental benefits through its effects on numerous systems including the cardiovascular, immune, neurologic and musculoskeletal systems. Central to these benefits are the stages of change, encompassing health beliefs and cognitive behaviour models. A 2016 Cochrane review of exercise for neck pain found that specific strengthening exercises for the neck, scapula-thoracic and the shoulder for chronic neck pain are beneficial, demonstrating a moderate improvement in symptoms and function.
Advice to stay active and resume normal activities and movements of the neck is standard advice, which is similar to that of the back pain guidelines. It also correlates with the advice from the CSP Move More campaign.
In terms of recommended exercises, gentle neck exercises are advised. With regards to these, there is no specific advice in the literature and, despite there being various courses and articles advocating specific exercise regimes, there is no compelling evidence that would make me want to advocate very specific testing and fine motor control rehabilitation, versus basic ROM exercises and deep neck flexor strengthening, with an emphasis on functional tasks.
It has been found in clinical trials that exercises performed at home, are as effective for neck pain as tailored outpatient treatments at two months and appear more effective two years after treatment. This does add to the argument for providing home based exercise regimes.
In a study examining the feasibility of a smartphone-based exercise programme for office workers with neck pain, the patients conducted individualised exercise programmes, depending on their conditions and symptoms. In particular, young office workers were targeted in this study, because young office workers have an increasingly high incidence of neck pain and a smartphone app is a highly accessible method for this generation. As a result, there were significant improvements in pain intensity, functional disability, and perceived physical health. There were no improvements however, in perceived mental health, fear avoidance, or cervical ROM.
Manual therapy can be useful for both pain relief and increasing range of movement. In terms of manual therapy techniques for the painful neck, there are various schools of thought and algorithms that can be used to support the mechanism by which the technique is selected and then used.
The manual techniques chosen need to be able to be modified and adapted, in response to the treatment effect and taken into the context of all of the other factors influencing the patient’s presentation. The screening of red flags is essential prior to commencing any manual therapy techniques, and in addition to the “red flag” symptoms listed previously, there needs to be specific screening with regards to any other pathology that may influence the patient’s safety for undertaking manual therapy: Pathologies such as Rheumatoid Arthritis, Downs’ Syndrome, Ehlers Danlos syndrome and other conditions that affect collagen structure, such as long term steroid use, may effect upper cervical stability and predispose the patient to risk. In addition, cardiac conditions such as high blood pressure and atherosclerosis or history of previous TIA or stroke may prevent end of range neck movements or determine patient position for techniques.
Manipulations or HVLA techniques can be used by appropriately trained clinicians, with informed consent and with prior VBI testing. There is literature on the protocol and evidence for this in the IFOMPT guidelines in the resources for this blog.
Patient selection for the appropriateness of manual therapy – particularly HVLA techniques – is essential. The following headline appeared as I was writing this blog!:
Chiropractor is arrested on suspicion of manslaughter after retired bank manager, 80, 'passes out during a treatment for lower backache' then dies from 'traumatic spinal cord injury'
“A chiropractor has been arrested on suspicion of manslaughter after a retired bank manager died following treatment for backache.
John Lawler, 80, was undergoing routine treatment at a private clinic when he lost consciousness and appeared to have become paralysed from the shoulders down.
He was taken straight to hospital but died the next day as a result of a 'traumatic spinal cord injury. He died the following day. His family said his death certificate gave the cause of death as respiratory depression caused by traumatic spinal cord injury”
This article is not included to frighten clinicians. Rather, it is a reminder that, whatever treatment modality we use, has to be used appropriately, within the context of the thorough assessment, that has occurred beforehand.
Manual therapy is one of the treatment approaches advocated for use in patients with neck pain that can be attributed to a mechanical cause.
Cervical side glides are a commonly used treatment for neuropathic referred arm pain. However, in a large trial RCT in 2016, there was no significantly different outcomes for patients who were treated with cervical side glides alongside self-management, versus self-management alone, however, there was an 11% increase in the reporting of “minor harm” in the group receiving the manual therapy. It was also more expensive as a service to provide.
In an RCT of 51 patients in 2013, HVLA, mobilisations and SNAGs were compared in patients with chronic neck pain. No significant differences were found at 3, 6 and 12 months post intervention between the different techniques in terms of disability, ROM and pain. Pain was reduced with all 3 techniques to a clinically significant level. It was noted by the researcher that the SNAG is a much safer treatment technique, with much less risk or vascular injury.
Studies looking at the effects of exercise and manual therapy combined have shown a small and not statistically significant difference compared with exercise therapy alone.
Interestingly, there is greater patient satisfaction for patients who undergo manual therapy alongside exercise therapy and/or other interventions, but clinically, the effects appear to be the same.
Looking at the summaries of the evidence for different treatments after several meta-analysis studies of the available literature, the following is a summary of the main themes:
There is insufficient research evidence for micro-breaks (compared to irregular breaks), Multi-Disciplinary Biopsychosocial Rehabilitation, multi-disciplinary treatment, Neck Schools, or patient education (in isolation).
There is conflicting evidence that acupuncture is more effective compared to placebo and other treatments for neck pain in mixed populations. Cervical Manipulation or passive mobilisation, electrotherapy and gymnastics (!) do not have sufficient evidence to be recommended. Spray and stretch therapy (trigger point work with ice cold sprays, followed by stretching) appears no more effective than placebo for neck pain in mixed populations.
There is evidence that traction is of no benefit, compared to a range of other interventions for neck pain. There is insufficient evidence of benefit from TENS, compared to a collar or manual therapy in acute neck pain. Finally, soft collars are not effective for acute neck pain, compared to advice to resume normal activity and other interventions.
Given that the recommendations are made on the basis of high quality RCTs, these do not take into account patient preference and satisfaction. As mentioned in the multimodal section above, patients who were treated with both manual therapy and exercise, reported higher satisfaction than those treated with exercise alone. Some patients who are acutely painful, cannot effectively perform exercises and do not wish for their painful neck to be touched. It is an individual clinical decision in conjunction with an agreed treatment plan with the patient, as to what treatment modalities may be of benefit.
This summary is based on work by the Australian government guideline group (National Health and Medical Research Council [NHMRC], 2003) who developed a multidisciplinary, evidence-based national guideline, that addresses acute low back pain, acute thoracic spinal pain, acute neck pain, acute shoulder pain and anterior knee pain. This has since been adopted by the HSE and been the basis of the advice in the guidelines for the management of musculoskeletal disorders.
Review and modify the plan for recovery of activity and function with both the employee and employer. Review the role of all the contributing factors. If the patient is not recovering, consider initiating a rehabilitation programme at work or other work based intervention.
The prevention of symptoms occurring in the first place has to be one of the aims of providing an Occupational Health service.
Although exercise has been proven as one of the mainstay treatments for neck pain, with strong evidence for the use of muscle strengthening and endurance exercises, there is very little evidence to support the use of exercise in the prevention of neck pain.
It is often important to look at the workplace ergonomics as part of treatment and prevention of neck pain. Perhaps the placement of the desk, computer workstation and/or placement of the computer monitor and keyboard can be improved, to encourage improved upper back and neck posture.
In terms of ergonomic advice, the following would be of benefit when considering a patient’s work tasks:
If workers have a standing work station or perform other sorts of sitting or driving tasks, try to ensure that there is as much variety in repetitive tasks as possible..
It is advisable that the worker should avoid sitting in their office chair for long periods (despite the lack of research evidence for micro-breaks, there is enough physiological evidence for ligament creep and ischemic pain from prolonged positions, to warrant this advice).
Essentially, despite the need for the workstation to comply with DSE requirements, the main advice would be for the worker to avoid sitting in one place for too long, even in ergonomic office chairs that have good back support. Advise the worker to get up and walk around and stretch as needed – this can be documented as part of the work advice, if you are providing a report for a patient’s employer.
Neck pain is multi-factorial. The subjective history needs to take all of the contributing factors into consideration, particularly with regards to psychosocial flags. Work factors need to considered from the outset.
Screen for red flags!!!
Conduct an appropriate objective assessment with a view to ensuring there are no red flags and to support your working hypothesis.
Manage the presenting problem: inform the patient, provide advice, exercise and hands on techniques as appropriate alongside pain advice and work advice. Include the patient’s employer and other relevant professionals as appropriate and as agreed by the patient with written consent.
Moving regularly will help to prevent MSK disorders in the longer term.
PINK FLAGS – focus on the positives! Use the things that the patients enjoy and are keen to pursue, as the focus for treatment and ongoing management plans.
Further information is available in the resources for this blog and there are also free webinars and podcasts available with regards to the management of neck pain.
Thank you for taking the time to read this lengthy but hopefully useful blog!