Advances in the diagnosis and management of neck pain
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3221 (Published 14 August 2017) Cite this as: BMJ 2017;358:j3221All rapid responses
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I realise that this is a narrative review rather than systematic. It is disappointing that the myth of muscle-relaxants is perpetuated in the absence of evidence of benefit and with a significant risk of harm. It is also disappointing that exercise is viewed as a complimentary or alternative therapy. Most spine specialists in Europe would not consider surgery for neck pain, unless there was serious spine pathology , myelopathy or unresolved radicular pain. Maybe it is the difference between the fiscal based healthcare of North America and that of Northern Europe.
Competing interests: No competing interests
Again neck pain is considered a disease,when it is only a symptom that needs a diagnosis of a disease or syndrome.
One of the common causes of neck pain is Thoracic Outlet Syndrome that can be diagnosed in physicians' offices by performing a diagnostic triad during the physical examination.
The differentiation from cervical radiculophaties is not complicated, C8 -T1 radiculopathies are very rare,and have obvious image abnormalities. C4-C5-C6 and C7 radiculopathies do not have a positive Diagnostic Triad and have cervical spine radiological abnormalities.
Treating a symptom without knowing the physiopathological origin is illogical and wasteful.
Competing interests: No competing interests
I read with a particular interest the review “Advances in the diagnosis and management of neck pain” by Steven P. Cohen and W. Michael Hooten.[1] It represents an excellent state of the art of diagnosis and treatment of neck pain, except for work adaptation required among patients who are working.[2,3] Indeed, the authors stated the potential occupational factors involved in neck pain by differentiating:
- the axial non-radicular cause corresponding to perceived stress at work (“low job satisfaction and poorly perceived work support”), both associated with onset and poor prognosis and sometimes prolonged active posture (also called tension neck syndrome, or non-specific neck pain).[4,5]
- from the radicular cause that might be related only to extreme biomechanical factors (athletes, aviators/astronauts) or trauma, but not to minor repetitive trauma or carrying loads.[2,6] Stress at work might also be a poor prognosis factor.
Taking these factors into account, the authors should include them in the treatment to avoid recurrence and improve outcomes. In non-radicular cause, management of stress at work is probably effective,[7] as the opposite of decreasing biomechanical loads is not (except for some cases of posture). For radicular cause, considering that work is not a major risk factor, work adaptation should not be recommended, except for extreme conditions where prevention of trauma is important and sometimes a short decrease of constraints for pain management purposes.
References
1 Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. BMJ 2017;358:j3221.
2 Cote P, van der, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine Phila Pa 1976 2008;33:S60–74.
3 Roquelaure Y, Petit A. Surveillance médico-professionnelle du risque lombaire pour les travailleurs exposés à des manipulations de charges. Recommandations de Bonne Pratique. ArchMalProfEnviron 2014.
4 Sluiter BJ, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. ScandJ Work EnvironHealth 2001;27 Suppl 1:1–102.
5 McLean SM, May S, Klaber-Moffett J, et al. Risk factors for the onset of non-specific neck pain: a systematic review. J Epidemiol Community Health 2010;64:565–72. doi:10.1136/jech.2009.090720
6 Nouri A, Tetreault L, Singh A, et al. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine 2015;40:E675-693. doi:10.1097/BRS.0000000000000913
7 Despréaux T, Saint-Lary O, Danzin F, et al. Stress at work. BMJ 2017;357:j2489.
Competing interests: No competing interests
Re: Advances in the diagnosis and management of neck pain
Stretching or strengthening exercises for neck pain.
The most common exercises recommended for axial neck pain in the UK are stretching exercises. A set of exercises jointly developed by Arthritis Research UK and the Chartered Society of Physiotherapists are found on their respective websites 1, 2.
However, a Cochrane review3 published in 2015, regarding Exercise for Neck Pain, states "using specific strengthening exercises as part of a routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. However, when only stretching exercises were used no beneficial effects may be expected."
A previous Randomised Controlled Study conducted in Finland by Ylinen4 and Salo5 compared strengthening vs stretching exercises. In their study, they used a theraband to perform strengthening exercises and their results showed that strengthening was better than stretching. Stretching increases the risk of further pain and thereby decreases compliance. However, with strengthening exercises, the range of motion should naturally increase once the stability of the neck is improved by the increased strength.
1. http://www.arthritisresearchuk.org/arthritis-information/common-pain/nec...
2. http://www.csp.org.uk/publications/neck-pain-exercises
3. http://www.cochrane.org/CD004250/BACK_exercise-for-neck-pain
4. Ylinen J, Takala EP, Nykänen M, Häkkinen A, Mälkiä E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA. 2003 May 21;289(19):2509-16.
5. Salo PK, Häkkinen AH, Kautiainen H, Ylinen JJ. Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study. Health Qual Life Outcomes. 2010 May 14;8:48.
Competing interests: No competing interests