Neck Pain LEARNING NEEDS? Case Study On call – telephone consultation 8 year old daughter with left sided neck pain Woke up this am Won’t move her neck Examination Tenderness is often diffuse Trigger points Restricted or painful movement Acute Torticollis Sudden onset Severe and unilateral Deviation of neck – neck feels stuck Referral to head or shoulder History of prolonged or unusual positioning of neck Differential diagnosis • Acute disc prolapse • Cervical spine injury • Drug reactions e.g. metoclopramide, antipsychotics • Cervical lymphadenopathy (infection/cancer) • Retropharyngeal abscess • Vertebral infection • Ocular disorders • Neurological with dystonia e.g. cva/encephalitis Management • 1-7 days • Recurrence is common • Analgesia • Gentle exercise • Heat/cold • Good posture • No collar • Beware of driving Features of pain Site - Where is the pain? Onset - When/how did the pain start (e.g. sudden, gradual?) Character - Describe the pain (e.g. dull ache, sharp stabbing) Radiation - Does the pain move anywhere Associations - Any symptoms/signs associated with the pain? Timing - How has the pain changed over time? Exacerbating/Relieving factors - Does anything worsen/relieve the pain? Severity - How bad is the pain on a scale of 1(mild) to 10 (worst ever). Case Study 2 32 year old man involved in RTA this morning Driver of vehicle Head on collision combined speed 50-60mph Seat belt Head restraints Air bag deployed Pins and needles in right hand Cervical spine immobilisation and XR Falls > 1 metre Altered mental status (GCS < 15) Neurological deficit (including subjective symptoms) Drug or alcohol intoxication Spinal pain Extremity fracture Is the spine clear? • GCS 15 • Neurologically intact (including subjective symptoms) • No distracting injuries • No neck pain or tenderness • FROM cervical spine • Best practice (BMJ Nov 2012) Acute Whiplash Confirm accurate history for medico-legal reasons Neck pain, head pain, Fatigue, dizziness, paraesthesiae, nausea, jaw pain MANAGEMENT? Management Reassurance about self-limiting Early return to normal activities Discourage rest and soft collars Outlook varies with culture, payment for health services, compensation More pain, symptoms initial disability is assoc with delay Management Analgesia Physiotherapy Yellow flags – intervene early Correct erroneous beliefs CBT Pain clinic Yellow flags (New Zealand Guidelines Group) • Belief that pain and activity harmful • Sickness behaviours like extended rest • Social withdrawal • Emotional problems e.g. depression anxiety and stress • Work problems Yellow flags (New Zealand Guidelines Group) • Problems with time off work • Compensation? • Overprotective family • Lack of support • Inappropriate expectations of treatment Resist Chronicity? Resist prescriptions Resist investigations Encourage normality Diagnose co-morbidity (e.g. depression) Do not corroborate poor prognosis Continue education about behaviour / beliefs Pain clinic early? So Far: Importance of history Torticollis Acute whiplash Yellow flags Now: anatomy, posture, movement testing anatomy, posture, movement testing Red Flags New symptoms <20 or >55 Weakness > 1 myotome or loss of sensation > 1 dermatome Intractable or increasing pain Myelopathy Insidious progression Neuro symptoms e.g. gait, clumsy hands, sex/bladder/bowel Neurological signs e.g. UMN in lower limbs or LMN signs in upper limbs Cancer infection or inflammation • Malaise • Fever • Weight loss • Increasing, unremitting, sleep disturbing • History - inflamm arth, cancer, TB, immunosuppression, AIDS • Lymphadenopathy • Exquisite local tenderness over a vertebral body Severe trauma / skeletal injury History of violent trauma e.g. fall from height, RTA, but watch for osteoporosis History of neck surgery Risk factors for osteoporosis e.g. menopause early or steroids Vascular insufficiency Dizziness and blackouts e.g. Sistine Chapel Drop attacks Case Study 3 45 year old man 2 weeks of neck pain Works in warehouse – some IT some labour Worse at the end of the day Radiates down both arms Arms feel numb at times Non – Specific neck pain 2% GP consultations Prevalence in middle age, women > men Point prevalence of 8% Lifetime prevalence of about 50% (clinical evidence 2008) Non-specific neck pain • Varies with different activity – rest may aggravate OR rest may relieve pain • Radiates on non-segmental distribution • May be sensory symptoms without signs • Varies with time • Related to • OR poor posture • OR overuse • OR non of these awkward movement Examination of non-sp neck pain • Positional asymmetry – a change in the most comfortable resting position • Unequal restriction in range of movement (although this is common in degenerative disease) • Tenderness in hypertonic muscles • Poorly localised tenderness • Localised areas of inc muscle tone? – nodules or tender bands Risk factors • Workplace or workstation • Duration of position • Hand-arm vibration • Twisting/bending of trunk • Excessive use of pillows Management < 4 weeks Identify risk factors Identify psychological factors Imaging not usually required Reassurance Encouragement of activity and normality One firm pillow in the hollow of the neck Analgesia Management > 4 weeks As previously PLUS: Physiotherapy Address psychosocial factors ?occupational health Acupuncture Management > 12 weeks As previously PLUS: Trial of amitriptyline or gabapentin/pregabalin Pain clinic ? Case Study 4 58 year old man – Scaffolder 1 month of increasing discomfort in neck Radiation down left arm Shakes left hand when holding things Arm feels tight/numb Cervical radiculopathy Symptoms Usually unilateral Neck shoulder or arm in a dermatome Sensory symptoms Weakness Pain or no pain Nocturnal pain interfering with sleep Symptoms Usually gradual but may be abrupt. Often a combination Sensory more common than motor symptoms C5-T1 most commonly DERMATOMES Neurology refresher… Examination Asymmetry to help decompression of nerve root Reduced neck movements Spurling’s test Muscle weakness or sensory change Change in tendon reflexes Neural stretch tests Acute torticollis Acute whiplash Chronic whiplash Red flags Yellow flags Non-specific neck pain Cervical radiculopathy Back Pain Prevalence LBP affects 1/3 of UK population each year Only 20% of people with LBP consult GP MAINLY: non-specific and serious causes rare Prognosis Difficult to prognosticate because of irregular course of symptoms Risk factors for slower return to work: leg pain as well as back pain Repeated episodes Co-morbidities Manual work or lower socioeconomic class Longer duration off work Psychosocial factors Definitions Non-specific low back pain Specific low back pain Mechanical back pain Inflammatory back pain Non-Specific Low Back Pain pain, tension, soreness, or stiffness in the lower back which cannot be attributed to a specific cause. Sprains and strains included. best thought of as a symptom or complaint — not as a disease or homogeneous condition. Non-specific low back pain is also called simple, or uncomplicated, low back pain. Inflammatory low back pain low back pain and stiffness aggravated by rest or sleep often waking the person in the second half of the night. It lasts >30 minutes after getting up relieved by physical activity & NSAID. typical of ankylosing spondylitis and other rheumatic conditions. Mechanical LBP varies with posture or movement. E.G.: aggravated by standing and relieved by sitting or lying; in others: vice versa. Mechanical low back pain is typical of non- specific low back pain, and specific causes such as sciatica, vertebral fracture, and facet joint injury. Importance is exclusion of inflammatory back pain. Sarah…. Non-specific low back pain Diagnosis Rule out serious pathology Cauda Equina Red flags for cauda equina Saddle anaesthesia or paraesthesia Recent onset bladder dysfunction Recent onset faecal incontinence Perianal sensory loss Unexpected laxity anal sphincter Severe OR progressive neuro deficit Red flags for fracture From medical history: Sudden onset of severe central pain relieved by lying down. Major trauma e.g. RTA, fall from a height. Minor trauma, or even just strenuous lifting, in people with osteoporosis. From physical examination: Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) Red flags for cancer or infection older than 50 years, or younger than 20 years History of cancer. Recent bacterial infection (for example urinary tract infection). Intravenous drug misuse. Immune suppression. Red flags for cancer or infection Constitutional symptoms, such as fever, chills, or unexplained weight loss. Pain that remains when lying down, aching night-time pain that disturbs sleep, thoracic pain (which could also be caused by an aortic aneurysm). O/E: Structural deformity of the spine (such as scoliosis). Ruled out serious pathology… Check pain From back Is mechanical Is not inflammatory (?ESR, CRP) Check for long term prognosis Misunderstanding of the cause of back pain. The belief that pain and activity are harmful. Sickness behaviours, such as extended rest. Overprotective family. Social withdrawal, lack of support. Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress. Problems with claims for compensation or applications for social benefits. Inappropriate expectations of treatment, such as low expectations of active participation in treatment. Management positive attitude realistic expectations. Avoid ‘threatening’ language 'the normal ageing process of the spine' rather than 'wear and tear', 'crumbling discs', or 'damage to disc or joint'. Information: real physical cause disturbance of function, not by serious structural damage. Settles in most people but can recur repeatedly Analgesia, mobilise and back to work ASAP normal activities should be paced The aim is to do a little more each day. Information Care with lifting and twisting Cushion between knees when sleeping on side No need for complete resolution before work Work can help with distraction Analgesia (paracet/NSAID/opioid) ?use of diazepam x 5/7 Expect resolution <6 weeks Chronic (>6 weeks) Structured exercise programme Manual therapy Acupuncture Poor response? Check for red flags Check for yellow flags Consider other conditions Consider referral to pain mgt clinic If severe, consider specialist spinal surgical service -> ?fusion Not recommended for chronic low back pain Non-specific Less than a year Should not be treated or referred with: Not recommended for chronic low back pain Alexander technique (exercise likely to be more cost-effective) not available on NHS Massage Percutaneous electrical nerve stimulation (PENS) Transcutaneous electrical nerve stimulation (TENS) SSRI Injection of substances into the back Not recommended for chronic low back pain Laser therapy Interferential therapy Therapeutic ultrasound Lumbar supports Traction Radiofrequency electrothermal therapy Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) Neuroreflexive therapy Opioids in Back pain On the increase Some estimates 30% of LBP last >1y Cochrane review Use of opioids 4 studies 3 compared tramadol to placebo 900 patients in total… There still remains little evidence in the medical literature to address the concerns of physicians and patients regarding the effect of opioids on pain intensity, improved function and risk of drug abuse. Examination Dermatomes Myotomes Neural tension signs Examination Fingertip to floor Schober – S1 and 10cm above (9-15cm) Hoover’s test – hand under contralat. foot Waddell’s signs Tenderness, axial loading, distraction (SLR), regional disturbances, over-reaction