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Neck pain

Neck pain is a common worldwide ailment and can potentially lead to disability, resulting in significant costs. It is estimated that only about one in five individuals with neck pain seeks help for their problem. Pain can be short-term, referred to as acute neck pain, or long-lasting, termed chronic neck pain. Currently, we understand that the causes of neck pain are multifactorial. Factors underlying the pain can broadly be categorized into physical, psychosocial, and individual-related risk factors. In the realm of science, neck pain is somewhat similar to lower back pain. We know of factors related to neck pain and anatomical structures that may potentially cause problems, but we usually lack the means to pinpoint a specific structure responsible for the pain. Thus, the diagnosis often becomes nonspecific neck pain. If there is a clear cause for neck pain, which is much rarer, it may be termed specific neck pain.

In any case, unfortunately, there is no silver bullet for neck pain that works for all cases (though there are many good treatment options that work for many people, we cannot yet say that one specific treatment is clearly the best). For example, social media is full of various "treatments" promising to cure neck pain and often all other pains and problems as well. It is advisable to approach these promises with a healthy dose of skepticism.

In Finland's Current Care Guidelines, neck pain is classified as 1) local neck pain, 2) radiating neck pain, 3) whiplash injury, 4) myelopathy, or 5) other neck pain. In international studies, four groups have been created: 1) neck pain with restricted motion, 2) neck pain with coordination problems, 3) neck pain with headaches, and 4) neck pain with radiating pain. This article reviews the current scientific understanding of risk factors, examination, and treatment of nonspecific neck pain in adults.

Risk factors

Psychological factors - There is a clear connection between psychological factors such as anxiety, depression, stress, and neck pain. However, it is currently difficult to determine causality. For example, the relationship between depression and neck pain is believed to be bidirectional, meaning that depression worsens neck pain and neck pain can worsen depression. Poor job satisfaction, low social support from coworkers, and working in a poor posture for extended periods can also increase the risk of neck pain. (3,4)
Cognitive factors - Attitudes and behaviors such as fear-avoidance behavior (the patient avoids using their neck/back) have been found to be associated with neck pain. Catastrophizing pain and low self-efficacy are also common phenomena that can intensify the perception of pain. (3)
Sleep problems - The relationship between neck pain and sleep problems appears to be bidirectional, meaning that neck pain can lead to sleep problems and vice versa. (3,5)
Whiplash injury - Often resulting from a car accident or sports injury, whiplash involves sudden movements of the neck, resulting in neck pain, headaches, dizziness, and nausea. (3)
Fibromyalgia - A chronic musculoskeletal disorder often associated with neck pain. (3)
Radicular pain (often due to a herniated disc) - A condition where pressure or irritation occurs on the nerve roots originating from the spinal cord, often causing neck pain and numbness/tingling in the arm if it involves a cervical disc herniation. Good news for those suffering from radicular pain: over 85% of acute radicular pain cases resolve on their own within 8-12 weeks, with significant improvement observed in some studies as early as 4 weeks. (2,3)
Autoimmune diseases - Some autoimmune diseases can cause neck pain, including various rheumatic diseases, multiple sclerosis, psoriatic arthritis, and myositis, an inflammatory muscle disease. It is important to note that autoimmune diseases are rare causes of neck pain. (3)
Gender - Women seem to experience more neck pain. (3,6)
Age - Neck pain is most common among middle-aged individuals, aged 45-54. (3,6)
Genetics - Twin studies have shown a connection between genetics and neck pain, but more research is needed in this area. (3)

Examination

When investigating neck pain, the first step is to determine whether there is a specific cause of pain (e.g., as a result of physical trauma) and to rule out any possible serious causes. If there is suspicion of infection, autoimmune disease (e.g., rheumatoid arthritis), tumor, or myelopathy (compression of the spinal cord), further tests such as various laboratory tests and imaging are usually needed. Nerve root-related conditions, such as herniated discs, should also be ruled out if the patient experiences numbness/radiating symptoms and/or other neurological symptoms in addition to neck pain. Fortunately, these aforementioned causes are relatively rare contributors to neck pain. In summary, when assessing someone with neck pain, one first looks for "red flags," which are signs/symptoms of something unusual and potentially more serious. If no red flags are found, the diagnosis is nonspecific neck pain. What kind of examinations can a person with neck pain expect during a consultation?

1. Initial interview - the patient's history is thoroughly investigated, and various questionnaires may be used for this purpose.

2. Neck function and palpation - range of motion/painful directions are examined, muscles and spine in the neck and shoulder are palpated manually, and neck muscle strength levels should also be assessed.

3. Neurological examination - if a herniated disc is suspected, provocative tests (e.g., Spurling's test, nerve tension tests), muscle strength tests, reflexes, and sensory testing are performed.

Imaging and laboratory tests as needed - note that findings such as disc degeneration in the cervical spine can be detected in magnetic resonance imaging (MRI) scans of asymptomatic individuals as young as 20 years old (in about 15% of cases). Imaging is therefore not usually beneficial in nonspecific neck pain; in fact, it can often lead to unnecessary worry and negatively impact an individual's thoughts and behavior. When a person sees images showing various injuries and "defects" in their body (which are present in almost everyone), these incidental findings can cause undue concern and worsen pain.

Management

Although there is not much reliable information available regarding the prognosis of nonspecific neck pain, it can generally be said that the prognosis is usually good. As mentioned earlier, there is no one-size-fits-all treatment for neck pain. Therefore, treatment measures should always be tailored to each individual suffering from pain to achieve the best possible outcome. The following list includes different treatment modalities recommended based on research, and often a good outcome is achieved by combining various treatments: (7):

1. Therapeutic exercise/physical activity - may include various exercises for the neck, shoulders, arms, and upper back, and/or aerobic forms of exercise such as walking. Often, even small amounts of exercise yield a good response (e.g., 1-3 exercises, 2-3 times per week). Important for both acute and chronic pain management. Among individual treatment modalities, exercise has the most convincing research evidence for the treatment of neck pain.

2. Education - patients should be encouraged to remain active; bed rest is not advisable, and returning to normal activities as soon as possible is recommended. Additionally, advice on managing pain in daily life is provided, and monitoring the situation is important. For example, in the case of a herniated disc, certain movements are often best avoided to prevent pain exacerbation.

3. Manual therapy - effective for some as pain relief alongside other treatment interventions, including massage, joint mobilizations, joint manipulations ("cracking"), acupuncture, and TENS.