Reflections of a rehabilitation professional: A pain in the neck

We have all used the expression “a pain in the neck” on occasions. Google describes this as ‘someone or something that is annoying or difficult to deal with’.

‍It was not long after I became a consultant that I realised that neck pain (NP) was very common even though it is the ‘poor cousin of back pain [1, 2]. Not only is it common, but it can be severe and disabling. It soon became clear that we needed some method of describing firstly what was happening in the body, and secondly how disabling it was.For the first objective, we decided to utilise the method described for low back pain (LBP). After excluding those with non-mechanical/degenerative spinal conditions, six groups were modelled on those of Spitzer et al [3] and the categories modified for cervical pain as follows: -1 - Neck pain including trapezius & interscapular pain2 - Arm pain / paraesthesiae / numbness3 - Probable root compression4 - Confirmed root compression with imaging5 - Cord compression6 – Other [2].

Potential causes were classified as due to road traffic accidents, other trauma, occupationally related or idiopathic. Patients were categorised as acute, acute on chronic and chronic as was described previously [4].

The assessment of disability was more taxing and in the absence of any well-established tool, we modified the Oswestry low back pain disability questionnaire [5] to create the Northwick Park neck pain and disability questionnaire (NPQ) [6] which has subsequently been translated into French, Spanish and Chinese. Interestingly another group of researchers did almost the same study [7] and published it just before we did – giving rise to claims that we had hijacked their research – but luckily we had presented the work at a conference earlier so we could not have plagiarised their research – however, a lesson was learned that one should always check the literature between any early presentations and the final one!Of course, these early questionnaires did not try and distinguish between the physical and emotional components of the pain, but they did provide a useful screening test - those scoring highly needing a more vigorous assessment that could include the emotional components – e.g. [8, 9].The study by Leak et al [2] looked at potential work-related factors which were noted in 13% of the 141 subjects with non-specific NP (that due to mechanical or degenerative factors). The mean total duration of NP in the idiopathic group was 76, sd 93, range 1-530 months). Of those of working age (up to 65) the majority were (self) employed and working, 71% were working normally although nearly half had taken sickness absence (totalling 3.6 years) at some time.  The factors thought to be contributing to the NP were prolonged sitting, standing or repetitive lifting. Almost 90% of the subjects had a comorbidity, the commonest of which was LBP noted in 26% and a spinal deformity in 10%. Depression was thought to be present in 9% whilst those with post-traumatic psychological distress was noted in 2% [2].

The NPQ was significantly higher for those who:-

• were not working due to disability
• were employed but off sick
• had one comorbidity
• had LBP
• had a sleep disturbance
• were tearful or felt tearful [2].

Not surprisingly a significant group (13%) had post-traumatic pain and for many seen over the years, they provided my introduction to post-traumatic psychological distress – often with many symptoms of post-traumatic stress disorder. It was in this group of individuals with NP that I started to investigate sleep disorders and nightmares – how, for example, a mother of young children, who were not in the car at the time of an accident, will nevertheless experience nightmares which picture them in the car at the time of the accident! Apart from the psychological sequelae of accidents (which were often missed in primary care in my early years as a consultant), trauma can lead to structural damage and one individual presented to the clinic with NP due to a missed fracture of C1[2].

It may be the fact that NP can be prolonged and nagging that has given rise to the expression – a pain in the neck!

Conclusions

Individuals presenting with spinal pain from one part of the spine must have a full spinal assessment. Structural anomalies may well be present – a common one in the neck pain clinic being a thoracic kyphus (either degenerative or osteoporotic) which tilts the head forwards and forces the individual to extend the neck for good visibility. Disorders of mood will often be present although the diagnostic criteria for e.g. depression may well be missing.

My next reflection will take a look at the conservative management of NP which is not well covered in the literature.I am happy to discuss any of the issues raised in these reflections with colleagues who can email me and head the email VRA – professional reflections.

Andrew FrankTrustee and Past-Chair, VRA

References

1. Bogduk, N., The neck. Best Practice & Research in Clinical Rheumatology, 1999. 13(2): p. 261-285.
2. Frank, A., L. De Souza, and C. Frank, Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. Int J Clin Pract, 2005. 59(doi: 10.1111/j.1742-1241.2004.00237.x): p. 173-182.
3. Spitzer, W., F. LeBlanc, and M. Dupuis, Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Spine, 1987. 12(Suppl 1): p. S1-S59.
4. Frank, A., et al., A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force Classification. Int J Clin Pract, 2000. 54(10): p. 639-644.
5. Fairbank, J., et al., The Oswestry low back pain disability questionnaire. Physiotherapy, 1980. 66: p. 271-273.
6. Leak, A., et al., The Northwick Park Neck Pain Questionnaire, devised to measure neck pain and disability. Br J Rheum, 1994. 33: p. 469-474.
7. Vernon, H. and S. Mior, The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther, 1991. 14(7): p. 409-415.
8. Zigmond, A.S. and R.P. Snaith, The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 1983. 67(6): p. 361-370.
9. Main, C., et al., The distress and risk assessment method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine, 1992. 17(1): p. 42-52.