Management of neck pain
The January issue of the Journal of Physiotherapy contains plenty of top-notch research papers, including an Invited Topical Review on physiotherapy management of neck pain. Here is a Q&A with Arianne Verhagen.
How common is neck pain?
Neck pain is very common. After low back pain, neck pain is the second most leading musculoskeletal condition, even more common than osteoarthritis. Up to 70 per cent of people will experience some neck pain in their lifetime.
In most cases neck pain will not seriously interfere with daily activities and participation. The risk that neck pain is caused by serious pathology is probably less than two per cent.
Is it worth trying to categorise specific types of neck pain and do we know whether doing so improves the accuracy of prognosis or the effects of treatment?
That’s a good question. In clinical practice, physiotherapists want to categorise patients to tailor their treatment. This is a really good thing.
Treatments should be tailored to specific patient needs as that enhances compliance with the advice given by the physiotherapist, or the exercises they ask people to do at home.
Unfortunately, in research we have as yet been unable to validly categorise patients.
Having said this, there is some evidence that people who report a trauma as a possible cause of their neck pain, and have a lot of pain, have a poorer prognosis than other people with neck pain.
People whose neck pain is work related, meaning working makes the pain worse and the pain decreases during time off, are also known to have a poorer prognosis.
In general, several factors have been identified in the literature that are likely related to a poorer prognosis: previous episodes of neck pain, concurrent low back pain, concurrent headaches, poor health, psychological factors (such as anxiety, worry, frustration and depression) and work-related symptoms (such as low job satisfaction, high physical job demands and little influence on work situation).
In contrast, younger age, an active coping style and optimistic outlook appear to be related to a favorable prognosis.
Do people just use the same red flags that are used for back pain, or is there evidence specific to neck pain?
The review mentions neck pain specific red flags ruling out a fracture.
These are the only red flags for neck pain patients specifically that have been reported in the literature.
In the case of absence of neck pain specific red flags, for instance to rule out malignancy,
I think using the ones for low back pain makes sense. Please bear in mind that there are just two red flags found in the literature to be of relevance for low back pain and malignancy.
In one study we found that only a ‘history of malignancy’ and ‘strong clinical suspicion’ were found to be of acceptable diagnostic accuracy (Verhagen et al Pain 2017).
Which physiotherapy treatments are effective?
In general, we found education, exercise, manipulations and mobilisations, preferably combined, to be effective treatments.
The benefit of education (or advice) is not frequently evaluated, as it is regarded an essential part of the communication between the physiotherapist and the patient.
Nevertheless, based on the evidence available, guidelines recommend reassuring patients that the pain is not a serious condition; providing information on pain and prognosis, including information that imaging is not recommended; advising to stay active; and educating about self- care, exercises and (stress) coping skills.
Exercises should be an important part of a physiotherapy treatment. Fortunately, no specific exercise was found to be superior to any other kind of exercise. This is good to know as this enables physiotherapists to tailor the exercises to each specific patient.
Thoracic manipulations are equally, if not more, effective compared to cervical manipulations, although the evidence is not very strong. Also, mobilisations are considered as effective as manipulations.
Therefore, the advice would be to refrain from cervical manipulations as these have a risk of severe adverse effects, and there are other, equally effective treatment options.
What about clinical prediction rules?
Clinical prediction rules are the way to go in the future, especially when these prediction rules are developed in combination with targeted treatments.
At the moment research in this area is emerging, but not yet mature enough to be able to draw firm conclusions.
Nevertheless, according to promising clinical prediction rules, it seems that age (< 35 years old) and no or minor disability (a score less than 32 per cent on the Neck Disability Index) seem relevant in predicting a good outcome on pain for patients with trauma-related neck pain.
Do physiotherapists also need to be aware about the evidence regarding surgery and medication?
I certainly think they should. Being aware of the evidence of treatments from other disciplines, like pharmacy or surgery, helps physiotherapists to provide accurate information to patients.
It also helps physiotherapists put their own contribution to improve patient outcomes into perspective.
It is good to know that physiotherapy care is equally effective compared to surgery. This knowledge boosts your self-confidence and can help in reassuring patients that the pain is not a serious condition.
In addition, when patients are in a lot of pain and ask whether it is okay to use some over-the-counter medication for a day or two, it is good to know what the evidence is as it helps the conversation.
Nevertheless, physiotherapists need to be aware that they cannot prescribe medication or refer to surgery.
>> Arianne Verhagen is professor and head of department of the School of Physiotherapy at the University of Technology Sydney. Her main areas of interest are research in the neck pain area and diagnostic research, including systematic reviews.
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