Neck Pain Clinical Presentation

Click for referral info for MSK Refer urgently to Click for triage RED FLAGS! History more appropriate specialist info Click for more info

Consider measuring neck Click for disability index (NDI) more http://www.physio-pedia.com/ info Neck_Disability_Index

Click for Examination more info

Consider causes of neck Click for more pain info

Vertebrobasilar symptoms Refer to neurology Click for more info

Click for Click for Click for Click for Whiplash injury more Non-specific neck pain more Acute torticollis more Cervical radiculopathy more info info info info

Initial Self-management Click for Initial Self-management Click for Click for See pathway for 6 months after more more Self-management more for 6 weeks exclusion of red flags info info info Cervical Radiculopathy

If pain persists after 6 If unresolved after 6 months of initial self- Click for weeks refer to more management refer to MSK physiotherapy TRIAGE info

No resolution after 12 Weeks of physio, physiotherapy to refer to MSK triage

MSK triage service Further assessment, investigations and MDT discussion with secondary care as appropriate Back to History pathway Pain: • Is there a history of trauma? · characteristics of pain • effects of pain – including occupation and recreational activities • risk factors for developing neck pain: • advancing age causing degenerative disc disease • bad posture • workplace associated risk e.g. poor positioning at a computer screen • inappropriate seating • sleeping without adequate neck support • carrying heavy, unbalanced loads, e.g. briefcase or shopping bags • workplace associated risk, e.g. duration of sitting and neck posture • behaviour or incident with the potential to cause a whiplash injury, such as: • diving • motor vehicle accident • osteoporosis risk factors • inquire about neurological symptoms

If the patient was involved in a motor vehicle accident: • was the collision a simple rear-end? • can the patient sit now? • could the patient walk after the injury? • has there been delayed onset of neck pain?

Psychosocial factors which increase risk of chronicity and disability: • unrealistic expectations of treatment • disabling sickness behaviour • problems with compensation, work, family, mood, and emotions • stress, anxiety, depression or poor concentration Back to RED FLAGS pathway If any of the following conditions are suspected, refer urgently for investigations and further assessment: • new symptoms before age 20 years or after age 55 years • weakness involving more than one myotome or loss of sensation involving more than one dermatome • intractable or increasing pain

Myelopathy (compression of the spinal cord) • insidious progression • neurological symptoms – e.g. gait disturbance, clumsy or weak hands • sensory changes

Malignancy, inflammation or infection • fever • pain that is increasing, unremitting, or disturbs sleep • history of inflammatory arthropathy e.g. RA, ankylosing spondylitis • severe trauma or skeletal injury • unexplained weight loss, malaise, fever • history of cancer, inflammatory arthritis, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection • lymphadenopathy • exquisite tenderness over a vertebral body

Trauma or skeletal injury • history of trauma or fall from a height • history of neck surgery • risk factors for osteoporosis, such as premature menopause and use of systemic steroids – minor trauma may cause compression fractures in those with osteoporosis

Vascular conditions • drop attacks • dizziness and blackouts on movement, especially extension of the neck when gazing upwards

Seek immediate specialist advice if the person has severe or progressive motor weakness, or severe or progressive sensory loss.

NB if objective neurological deficit/red flag refer urgently to secondary care/A&E

Neck trauma

If a fracture or subluxation of the cervical vertebrae is suspected, refer immediately to A&E: The RCEM recommend imaging of the Cervical spine in the following patients that have been subjected to blunt trauma with a mechanism that may have injured the neck: · GCS<15 on assessment · Paralysis, focal neurological deficit, or paraesthesia in the extremities · Patients with abnormal vital signs (systolic BP<90mmHg or respiratory rate outside of the range 10-24 breaths per minute) · Urgent requirement to identify a cervical spine fracture (e.g. prior to surgery) · Severe neck pain ( ≥ 7/10 severity) (level four evidence) · Patients with neck pain and any of the following high risk factors: · a fall from greater than one metre or five stairs · an axial load to the head e.g. diving · a high-speed motor vehicle collision (combined speed >60mph) · a rollover motor vehicle accident · ejection from a motor vehicle · an accident involving motorised recreational vehicles · a bicycle collision · age 65 years or more · injured more than 48 hours earlier · re-attending with the same injury · known vertebral disease (e.g. ankylosing spondylitis, rheumatoid arthritis, spinal stenosis, or previous cervical surgery) · Patients with a dangerous mechanism of injury (see above) and either a visible injury above the clavicles or a severely painful ( ≥ 7/10 severity) thoracic injury even if there is no neck pain or tenderness

NB: the negative predictive value of red flag symptoms is high and if none are present it is unlikely that a serious spinal abnormality has been missed NB: interpret positive findings with caution as the positive predictive value for diagnosing disease is poor Back to Consider measuring neck disability index (NDI) pathway Ask the patient to self-evaluate their level of pain using the neck disability index (NDI): http://www.physio-pedia.com/Neck_Disability_Index: • neck pain associated with musculoskeletal dysfunction, whiplash-associated disorders (WADs), and cervical radiculopathy • score is out of 50 (as recommended by the developer) - caution should be used when reading clinical reports to ascertain which metric was used (may be given as percentage)

• Vernon and Mior suggest that a score between: • 0-4 represents no disability • 5-14 represents mild disability • 15-24 represents moderate disability • 25-34 represents severe disability • > 35 represents complete disability Back to Examination pathway • should include neck examination and neurological examination: • palpate for areas of spasm or tenderness and identification of trigger points

Neurological examination: • evaluate muscle strength, sensation, and tendon reflexes • assess for: • upper motor neuron signs, e.g. Babinski's sign – up-going plantar reflex, hyperreflexia, clonus, spasticity • lower motor neuron signs such as atrophy and hyporeflexia • sensory changes – vibration, soft/sharp touch, proprioception (e.g. joint position) Back to Consider causes of neck pain pathway First consider RED FLAG causes

Then consider the following common causes of neck pain:

• acute torticollis – if neck pain is due to spasm with no obvious underlying cause • whiplash injury – if neck pain occurred following a recent sudden or excessive episode of hyperextension, flexion, or rotation • non-specific neck pain: • if neck pain varies with different physical activities and with time; or • is related to awkward movement, poor posture, or overuse • consider cervical radiculopathy if there is evidence of: • unilateral neck, shoulder, or arm pain that is approximately related to a dermatome • altered sensation or numbness, or weakness in related muscles • NB: the presence of pain or paraesthesia radiating into the arm is not specific for nerve root pain and may be present in those with non-specific neck pain • consider other causes, including fibromyalgia or inflammatory arthropathies such as rheumatoid arthritis Back to Vertebrobasilar symptoms pathway Vertebrobasilar Insufficiency: Occlusion or impairment of the vertebrobasilar blood supply affects the medulla, cerebellum, pons, midbrain, thalamus and occipital cortex. This results in a number of clinical syndromes and is caused primarily by atherosclerosis.

The presence of dizziness is the most common presenting symptom of Vertebrobasilar Insufficency (VBI). If dizziness is present, other symptoms associated with VBI should be sought, including: • Visual disturbances such as diplopia (double vision), blurred vision and transient hemianopia • Dysarthria (difficulty with speech) • Dysphagia (difficulty with swallowing) • Drop attacks (sudden loss of power with no loss of consciousness) • Nausea and vomiting • Lightheadedness and fainting • Disorientation or anxiety • Hearing disturbances such as tinnitus • Facial or oral paraesthesia or anaesthesia • Pallor, tremors and sweating • Other neurological symptoms

If any suspicion of Vertebrobasilar insufficiency refer to neurology. Back to Whiplash injury pathway Whiplash is caused by an acceleration-deceleration mechanism which commonly occurs in: • rear-end or side-impact motor vehicle collisions • other activities and mishaps, e.g. diving

Confirm a history of sudden or excessive neck extension, flexion, or rotation.

Symptoms – may be delayed for hours or days after the injury: • the two most common are disabling neck pain, with or without referral to the shoulder or arm, and headache • other features include: • fatigue • dizziness • paresthesia • nausea • jaw pain • posterior cervical sympathetic syndrome – headaches or facial formication (sensation of ants crawling over face)

Alarming presenting symptoms include: • visual disturbance • impairment of the proprioceptive control of head and neck position • impaired cognitive function

'Late whiplash syndrome' is characterized by a variety of symptoms that persist for more than 6 months after an acute whiplash injury.

Prognostic factors of delayed functional recovery include high initial pain intensity, a greater number of symptoms, and greater initial disability. Back to Initial Self-management for 6 months pathway Self-care advice: • provide reassurance that whiplash-associated disorder is usually benign and self-limiting • encourage early return to usual activities and early mobilization – these may be painful initially but they are not harmful or indicative of ongoing damage • discourage rest, immobilisation, and use of soft collars

Offer analgesia: • paracetamol and/or ibuprofen taken regularly, or as required • codeine may be added to regular paracetamol or ibuprofen – prescribe separately for flexible dosing and titration of analgesic effect (combination products, e.g. co-codamol, are not recommended) • escalate analgesia depending on severity and other symptoms

Consider psychosocial factors such as depression and anxiety, and manage as appropriate.

Patient information links:

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HHCCTT NNeecckk ppaaiinn -- hhttttppss::////wwwwww..hhcctt..nnhhss..uukk//mmeeddiiaa//22225577//nneecckk--ppaaiinn--mmaayy--22001177..ppddff BBrriittiisshh PPaaiinn SSoocciieettyy lleeaafflleett,, MMaannaaggiinngg yyoouurr ppaaiinn eeffffeeccttiivveellyy uussiinngg oovveerr--tthhee--ccoouunntteerr mmeeddiicciinneess -- hhttttpp::////wwwwww..sseellffccaarreeffoorruumm..oorrgg//ffaacctt--sshheeeettss//

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Chartered Society of Physiotherapy - https://www.csp.org.uk/publications/neck-pain-exercises Back to IIff ppaaiinn ppeerrssiissttss aafftteerr 66 mmoonntthhss ooff iinniittiiaall sseellff--mmaannaaggeemmeenntt pathway IIff wwhhiippllaasshh iinnjjuurryy ssyymmppttoommss ppeerrssiissttss ffoorr mmoorree tthhaann 66 mmoonntthhss ccoonnssiiddeerr tthhee ffoolllloowwiinngg::

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Clinical Features: • aggravated by particular movements, posture, and/or activities, and relieved by others • commonly, exercise makes the pain worse and rest relieves it, but the opposite may also be true • typically radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae • commonly associated with muscle stiffness and spasm • may also be associated with: • odd sensations, e.g. temperature change, subjective weakness • paraesthesia • hyperaesthesia • cervical stiffness • headache or dizziness • pain in the spine • not usually associated with objective loss of sensation or muscle strength/power • very rarely, it may be associated with: • dysphagia (due to large anterior osteophytes) • syncope • triggering of migraine • pseudo-angina

Typical signs include: • positional asymmetry – degree of asymmetry varies, e.g. a small positional change from normal resting position of the neck, to torticollis where the neck is pulled to one side • unequal restriction or limited range of movement (common with ageing) • tenderness in hypertonic muscles or intervertebral joints – usually poorly localized • soft-tissue signs – localised areas of increased muscle tone that can be palpated as nodules or tender bands Back to Acute torticollis pathway • common condition also known as 'wry neck' or 'a twisted neck' – occasionally pain may be in the middle of the neck or referred to the head or shoulder region • thought to be due to minor local musculoskeletal irritation causing pain and spasm in neck muscles • cause of torticollis is often not known, but it may be due to: • bad posture • poor positioning at a computer screen • inappropriate seating • sleeping without adequate neck support • carrying heavy, unbalanced loads, e.g. briefcase or shopping bags

Assess for typical features, such as: • sudden onset (often on waking) of severe unilateral pain with deviation of the neck to that side • neck feels stuck in one position and any attempted movement to free it results in sharp spasms of pain • no history of trauma or strain • history of: • localised exposure to prolonged cold • unusual positioning of the neck • unusual posture, e.g. holding the neck in an unusual position whilst working, sleeping, or reading • on examination there is usually unilateral diffuse tenderness with palpable spasm and restricted or painful movement Back to Cervical radiculopathy pathway • commonly caused by degenerative disc disease • radiculopathy occurs as a result of nerve root compression, whereas myelopathy occurs due to compression of the spinal cord • NB: myelopathy is a red flag and if suspected should be referred urgently for investigations and further assessment • can cause: • loss of disc space height • loss of foraminal area • herniated intervertebral disc • protruding osteophytes • can result in significant pain, instability, radiculopathy, myelopathy, or a combination of symptoms Back to Initial self-management pathway • Cervical X-rays are not routinely required to diagnose or assess acute non-specific neck pain • NB if objective neurological deficit/red flag refer urgently to secondary care/A&E

Initial management (if no red flags): • reassure the patient that neck pain is common and often resolves within a few weeks • encourage the patient to stay active and return to a normal lifestyle, including work, as soon as possible: • advise them not to drive if their neck range of motion is restricted • discourage the use of cervical collars because this restricts mobility and may prolong symptoms • advise the patient that 1 firm pillow may provide additional comfort during the night, whereas 2 pillows can force the head into an unnatural position • offer analgesia: • paracetamol and/or ibuprofen taken regularly, or as required • codeine may be added to regular paracetamol or ibuprofen – prescribe separately for flexible dosing and titration of analgesic effect (combination products, e.g. co-codamol, are not recommended) • Escalate depending on severity and other symptoms

Patient information links:

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BBrraaiinn aanndd SSppiinnee FFoouunnddaattiioonn -- hhttttppss::////wwwwww..bbrraaiinnaannddssppiinnee..oorrgg..uukk//iinnffoorrmmaattiioonn--aanndd--ssuuppppoorrtt//

CChhaarrtteerreedd SSoocciieettyy ooff PPhhyyssiiootthheerraappyy -- hhttttppss::////wwwwww..ccsspp..oorrgg..uukk//ppuubblliiccaattiioonnss//nneecckk--ppaaiinn--eexxeerrcciisseess Back to Self-Management pathway Explain to the patient that: • acute torticollis usually resolves within 24-48 hours • occasionally symptoms take up to a week to resolve • recurrence is common

Advise the patient of general measures which they can do to relieve symptoms: • gentle exercise (within comfort zone) • intermittent heat or a cold pack to help reduce pain and spasm • sleeping on a low firm pillow • maintaining a good posture • routine use of a soft cervical collar is not recommended: • if there is severe pain on moving the neck then wearing a soft collar for a few days may help • consider driving ability – may be difficult to rotate the head to view traffic

Patient information links:

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BBrraaiinn aanndd SSppiinnee FFoouunnddaattiioonn -- hhttttppss::////wwwwww..bbrraaiinnaannddssppiinnee..oorrgg..uukk//iinnffoorrmmaattiioonn--aanndd--ssuuppppoorrtt//

CChhaarrtteerreedd SSoocciieettyy ooff PPhhyyssiiootthheerraappyy -- hhttttppss::////wwwwww..ccsspp..oorrgg..uukk//ppuubblliiccaattiioonnss//nneecckk--ppaaiinn--eexxeerrcciisseess Back to RReeffeerrrraall iinnffoorrmmaattiioonn ffoorr HHCCTT MMSSKK TTrriiaaggee SSeerrvviiccee pathway

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