Neck Pain: Part 2: Optimizing Treatment and Rehabilitation
Richard L. Aptaker, DOTHE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 11 - NOVEMBER 96
This is the second of two articles on neck pain. The first article, on diagnosis, appeared in the October issue.
In Brief: Most nontraumatic conditions that produce neck pain can be managed by primary care physicians, with physical therapy to augment rehabilitation. One key role the physician can often play is to reassure the patient that the injury is not serious. After that, the goal of immediate treatment is to minimize pain and inflammation with nonsteroidal medication and icing. Other options can include brief bed rest, narcotic analgesics, a cervical collar, and, depending on the condition, corticosteroids, local injections, acetaminophen, and moist heat. Rehabilitation to recover lost function should address the entire kinetic chain and include an aerobic component. Return to play must be gradual. Some injured or aging patients may have to cut back on activity or cross-train to maintain an active lifestyle.
The primary care physician must have a rational approach to nontraumatic neck and associated upper-limb pain during all phases of rehabilitation management: acute, recovery, and maintenance. Early pain control combined with appropriate rehabilitation techniques and followed by a gradual return to activity is the key in safely putting patients where they want to be: back in action. The reader is referred elsewhere (1-4) for treatment information on traumatic spine or cord injuries, burners or stingers, and transient paresis, and for participation recommendations for contact or collision sports.
General guidelines. Because a specific diagnosis of nontraumatic neck pain is sometimes difficult to make, especially if the pain is localized, the physician's key role can be in assuring the athlete that the problem is not serious. If the patient has normal strength and reflexes and a history consistent with mechanical pain, he or she can be told with confidence that no significant herniated disk or nerve injury exists, and that resolution or control of symptoms is expected without surgery or other invasive techniques. Even in the setting of a herniated intervertebral disk with radiculopathy, aggressive conservative care frequently prevents the need for surgical intervention (5).
Management of neck pain is divided into three phases: acute (immediate), recovery (rehabilitation), and maintenance (return to play) (6). In the acute phase, the goal is to minimize pain and inflammation. Initial treatment of acute injuries consists of a 4- to 6-week course of nonsteroidal anti-inflammatory drugs (NSAIDs) and frequent self-administered ice packs to the painful area for 20 to 30 minutes. The patient should discontinue activities that aggravate symptoms.
With severe pain, 1 to 2 days of bed rest may be appropriate to allow inflammation to subside. Narcotic medication such as codeine with acetaminophen can help on a time-prescribed course (eg, every 6 hours for 5 days). Physicians should avoid writing "prn" narcotic orders to prevent dependency patterns.
The patient may wear a soft cervical collar regularly for protection for up to 10 days with instructions to remove the collar several times a day to do gentle active range-of-motion exercises. For neck pain that worsens during cervical flexion, the wider part of the collar is worn anteriorly; for pain that worsens with extension, the wider part is worn posteriorly. The collar should also be worn while sleeping to prevent further injury. Long-term use of the collar, however, should be avoided, and weaning should begin as quickly as tolerated to prevent psychological dependence, muscle atrophy, and lost range of motion.
Although the literature is scarce on manual therapy for conditions that cause neck pain (7), manual therapy can be a valuable empiric adjunct to other measures during both the acute and recovery phases of treatment. Whether high-velocity manipulation, passive mobilization, muscle energy technique, or fascial release is used, the athlete may find that pain decreases and range of motion improves faster with manual therapy. A physician or physical therapist with good manual skills can assess the patient and deliver the appropriate treatment.
A patient who recovers full and painless range of motion within a few days to a week can return to sports without limitations or further treatment. A change of NSAID to a different chemical class—such as from ibuprofen (propionic acid) to diflunisal (salicylic acid)—may be helpful if there is no significant response after 2 weeks. Persistent pain or limited neck range of motion should prompt a referral to physical therapy.
Radiculopathy. In the athlete who has a cervical radiculopathy, a more prompt referral to physical therapy is warranted, in addition to the measures described above. Cervical traction, postural exercises, gentle cervical mobilization, and education are a few of the early measures a therapist might employ to help diminish radicular pain.
If the patient does not respond to 2 to 4 days of rest, ice, NSAIDs, and a soft collar in 2 weeks, or if pain prevents participation in physical therapy, corticosteroids should be considered. However, any patient who is in too much pain to participate in physical therapy or demonstrates neuromotor weakness on examination should be seen by a spine or rehabilitation specialist as soon as possible for further evaluation.
Although there are no controlled studies, oral corticosteroids given in a tapering dose over 7 to 10 days (eg, prednisone 60 mg once daily for 3 days, 40 mg a day for 2 days, then 20 mg a day for 2 days) can significantly diminish the pain associated with radiculopathy. The complications associated with long-term use of oral steroids are essentially nonexistent in a short course, although side effects are occasionally reported (8). The most devastating of these is avascular necrosis of bone, usually at the femoral head. Patients, therefore, should be warned of the remote chance of this permanently disabling condition.
Oral steroids should be used with great caution in patients who have a history of diabetes, peptic ulcer disease, hypertension, smoking, or excessive alcohol consumption. Epidural steroid injections may be used before oral steroids when they are readily available, or when oral agents are contraindicated or ineffective. Cervical epidurals are most effective when upper-extremity pain rather than neck pain is the predominant feature and neuromotor findings are present (9).
Localized pain. In athletes who demonstrate discrete trigger or tender points on palpation, vapocoolant spray techniques ("spray and stretch" (10)) or the judicious use of local injections may augment other treatments during the acute phase to make the patient more comfortable. Studies have shown that corticosteroid and anesthetic combinations (11), saline or anesthetic alone (12), and vapocoolant spray or dry needling (13) can all be effective. The injections, however, should not be used to mask pain in an attempt to rush the patient's rehabilitation.
Chronic injury. In degenerative cervical pain syndromes, the initial treatment for exacerbations has some similarities to the acute pain treatment. A short course of NSAIDs may be used for periodic flares, although if a regular pain medication is needed, plain acetaminophen (3,000 to 4,000 mg per day) should be tried to lessen possible gastrointestinal and renal side effects. For patients who risk losing their active lifestyle because of neck pain of well-documented mechanical origin, nonescalating doses of a narcotic medication can be used judiciously, preferably prescribed by one physician. Moist heat applied before activity, and ice packs after, can help provide symptomatic relief.
Some athletes acknowledge their chronic condition and merely seek suggestions about modifying their activity. A 60-year-old male swimmer who has a degenerative disease, for example, can turn his head to the uninjured side during the crawl or switch to the back stroke to prolong the "life" of his neck. Education about mechanics such as proper form, posture, and exercises is greatly enhanced by a knowledgeable physical therapist.
Rehab and Recovery
As pain and inflammation are being controlled, the athlete is advanced to the recovery phase of rehabilitation, where the goal is to recover lost function. Physical therapy is appropriate for any athlete who has acute neck pain and is slow to recover, or for a patient who has chronic neck symptoms but has never had a thorough physical therapy evaluation and treatment. The primary principle that the physician and therapist should understand when treating neck pain is that of the kinetic chain (6). The essence of this principle is that a functional and/or biomechanical deficit or injury anywhere in the musculoskeletal system can lead to injury elsewhere in the system.
For example, a tennis player who has poor thoracic and lumbar mobility and abnormal scapulothoracic and glenohumeral mechanics will stress her cervical spine more often during serving and overhead shots as she tries to maximize her reach and power. This can result in a cervical overuse syndrome. Thus the physical therapist must address rehabilitation at all appropriate levels of the kinetic chain for a successful outcome. Cole et al (14) provide a more detailed description of kinetic chain rehabilitation in sports-related cervical spine injuries.
The patient should also work on aerobic conditioning during the acute and recovery phases because maintaining overall fitness will facilitate return to activities. Aerobic exercise can include stationary biking, brisk walking, using a stair-climbing machine, or some other nonimpact activity. Upper- and lower-extremity strengthening and stretching should also be maintained, provided the exercises do not exacerbate the cervical condition. If at any time during the acute or recovery phases the athlete does not respond as expected, he or she should be referred to a specialist for further evaluation.
Returning to Activity
Few things are more frustrating for an athlete than to be out of sports because of an injury, but one of them is reinjury as a result of a premature return. To minimize the chance of reinjury, the athlete is promoted to the maintenance phase of rehabilitation only after certain criteria have been met. The goal in this phase is to ensure a graduated return to sports while maintaining the gains made during the recovery phase.
For the athlete who periodically has neck pain only in connection with an acute injury, one goal is pain-free cervical range of motion before full return to sports. On the other hand, an athlete who has a chronic cervical pain syndrome, such as degenerative disk disease, and who sustains a flare-up or superimposed neck injury, will return to full activities when he or she reaches the "familiar" level of pain. Cervical rotation and lateral bending should approach symmetry, with right and left values within about 10% of one another. The range of cervical flexion and extension cannot be compared with values from an uninjured side, so clinical judgment based on normal ranges of motion must be used.
Motor strength of the neck muscles, another return-to-play criterion, is difficult to quantify in the clinician's office, but a good qualitative attempt should be made. The patient should offer strong, pain-free cervical resistance to the examiner's hand in flexion, extension, lateral bending, and rotation. Rotation and lateral bending should be relatively symmetrical side to side. Extension should be more powerful than flexion. Return to full athletic participation should be delayed if a gross side-to-side discrepancy is noted.
In patients who have cervical radiculopathy, the examiner should note side-to-side differences in extremity range of motion and strength. The involved limb should be pain-free in motion with no further dysesthesias, and have at least 80% to 85% of the range of the uninvolved side. Motor strength in the myotome of the affected limb should have recovered to at least 75% of that of the opposite side before the patient begins a gradual return to sports (6).
The athlete should resume his or her sport at a level or intensity that allows pain-free participation, then increase the time, distance, weight, number of throws, etc, by approximately 10% each week. For example, if the 60-year-old swimmer mentioned previously had swum 30 laps per session prior to a flare of his symptoms, he might start at 15 laps and increase by 1.5 to 2 laps each week until he reached his previous level. If the patient's symptoms return at any point, he or she must drop back to the previous pain-free level and continue working on strength, flexibility, and good mechanics before attempting to advance. A qualified coach can be invaluable in helping many athletes develop proper technique, which will facilitate injury-free participation.
Whether the patient is a recreational or professional athlete, at some point aging may dictate an alteration in activity. Some patients by the age of 30 or 40, many by the age of 50, and most by the age of 60 will have to spend more and more time working to maintain neck flexibility and strength for sports that require significant cervical movement.
For the young athlete who finds cervical injuries occurring more frequently, or the older athlete who has chronic cervical pain, the primary care physician must ensure that appropriate radiologic studies (usually plain radiographs) have ruled out a serious problem, and that the rehabilitation program has been pushed to its maximum benefit. If a complete and well-rounded exercise program is not preventing or minimizing neck pain during sports, the athlete must consider other options. These may include tolerating a certain amount of discomfort or taking periodic breaks of 1 to 3 months from a sport to allow the neck to recover, much as a professional athlete does during the off-season.
Although not recommended routinely, cervical manipulation, sports massage, or acupuncture can be a valuable adjunct to control pain for some patients. These passive treatments, however, should not be in lieu of an active rehabilitation program.
Another reasonable approach would be to help the patient understand the ideas of conservation (cutting back intensity and/or frequency to improve longevity) and cross-training. For example, our swimmer with chronic neck pain who swims freestyle 5 days a week for 30 minutes may benefit from mixing the backstroke into his routine, limiting sessions to 20 minutes 3 days a week, and working out on a cross-country ski machine the other 2 days. The use of alternative training techniques will allow injured or aging patients to maintain an active lifestyle.
Dr Aptaker is the chief of the Department of Physical Medicine, the director of the Spine Clinic, and a staff physician at the Sports Medicine Clinic at Kaiser Permanente Medical Center in San Francisco. He is a member of the Physiatric Association of Spine, Sports, & Occupational Medicine and the American Osteopathic Academy of Sports Medicine. Address correspondence to Richard L. Aptaker, DO, Kaiser Permanente Medical Center, 1635 Divisadero St, Suite 300, San Francisco, CA 94115.