Neck Pain Treatment

A pain in the Neck!

Neck pain may be attributed to a variety of causes such as muscle strain, ligament sprains, arthritis of neck joints, or a “pulled or strained” nerve. An estimated 10 percent of adults experience neck pain at any given time. Fortunately, most patients, regardless of the cause of pain, recover with conservative therapy.

Structures in the neck

In order to better understand your neck pain, it is useful to identify some basic structures that it comprise of. The neck, or cervical spine, is formed by seven square-shaped bones (cervical vertebrae), which are stacked one on top of another. The vertebrae are named for their position in the cervical spine, beginning at the top with C1 down to C7. Together with the supporting ligaments and the overlying long neck muscles, the cervical vertebrae form a spinal canal that surrounds and protects the spinal cord (Figure 1).

In between the neck bones are discs, which function as shock absorbers, cushioning one bone from another. Directly over the bones and the discs is a layer of strong ligaments. These thick tissues are attached directly to the bones and function to limit the movement of one vertebra against the other. Car accidents and injuries to the head or body can cause injury to these ligaments and the joints that it supports.

Overlying the small muscles that support the vertebrae, the major muscles of the neck form the next protective layer. These muscles are responsible for holding the head up, maintaining normal posture, and supporting the neck. Overuse and irritation of these larger muscles is often called neck strain.

Causes of neck pain

There are a number of factors causing neck pain which can be identified after detailed clinical examination and imaging tests by a neck pain specialist in Singapore.

1. Cervical strain — Cervical muscle strain can happen when there is an injury to the muscles of the neck, causing spasm of the cervical and upper back muscles. Typically, cervical strain symptoms are pain, stiffness, and tightness in the upper back or shoulder, which can last for six weeks.
2. Cervical spondylosis — Cervical spondylosis is a common term used by doctors to refer to degenerative changes (wear and tear) of the cervical spine. Wear-and-tear causes gradual narrowing of the disc space, a loss of the normal square-shaped bone, and growth of the edges of the bone (bone spurs). These spurs can increase pressure on the surrounding tissues. A small amount of wear and tear is normal with aging, although severe degenerative changes are abnormal. In other words, having neck pain as a result of degenerative changes does not mean it cannot be treated. Hence, a specialised cervical spondylosis treatment is required to alleviate muscle strain.
3. Cervical discogenic pain — Cervical discogenic pain may be one of the most common cause of neck pain. It is caused by changes in the structure of one or more of the cervical intervertebral discs. Common symptoms of discogenic pain include pain in the neck when turning or tilting the head. Pain may be worsened when the neck is held in one position for prolonged periods, such as occurs with driving, reading, or working at a computer. Discogenic pain can also refer pain or uncomfortable sensations into the arm or shoulder.
4. Cervical facet syndrome — The facet joint, which is located on the left and right side of the vertebrae, is the most commonly affected area in whiplash-related neck pain and headaches. Another potential cause of cervical facet syndrome includes a job that requires a person to repeatedly extend the neck (tilt the head backwards). Symptoms of cervical facet syndrome include pain in the middle or side of the neck; some people also notice pain in the shoulders, around the shoulder blades, at the base of the head, or in one arm.
5. Whiplash injury — The cervical whiplash syndrome is caused by a traumatic event that causes an abrupt forward/backward movement of the cervical spine. The most common cause of whiplash is a motor vehicle accident.
6. Cervical myofascial pain — Myofascial pain refers to tight and tender muscular type pain that are often very sensitive to touch and pressure.
7. Cervical stenosis — Cervical stenosis occurs when there are degenerative changes that narrow the central (middle) spinal canal. This narrowing can injure the cervical spinal cord or cause it to function improperly. Weakness, difficulty walking or coordinating movement, inability to empty or control the bowels or bladder, and sexual dysfunction (eg, erectile dysfunction) may occur as a result of irritation or compression of the spinal cord.
8. Cervical radiculopathy — Cervical radiculopathy occurs when a nerve root is irritated by a protruding disc, arthritis of the spine, or a mass that compresses a nerve. Signs of radiculopathy can include pain, weakness, or changes in sensation (eg, numbness, pins and needles) in the arms.
9. Cervical “slipped” disc – This is a severe neck pain condition where excessive pressure to the disc causes the inner gelatin-like material to protrude through its outer capsule; this is called a herniated or “slipped” disc. Other variations of disc injury include “bulging,” “protruding,” or “rupture.” It can resulted in sudden pain down the arm with or without numbness or weakness.

How is neck pain diagnosed?

The evaluation of neck pain often starts by assessing the person’s ability to turn the head to the left and right, forward and backward, and side to side. Your specialist doctor will examine the posture and movement of the neck and shoulders. He will touch the muscles in the neck, head, upper back, and shoulders to find spots of pain, weakness, or tension. If weakness or sensory complaints are present, strength and sensation in the extremities will also be examined.

For some, more tests, such as an x-ray, magnetic resonance imaging (MRI) or electrodiagnostic testing (EMG or electromyography) will be recommended. Even though most cases of chronic neck pain can be treated with traditional options, it is mandatory to see your specialist for anyone with a head or neck injury, inability to control the bowels or bladder, severe pain, numbness or changes in sensation in the arms or legs, or if pain remains after one week with treatment at home.

What is the prognosis for neck pain?

The outlook for neck pain depends on the precise cause. Most forms of pain in the neck can resolve with conservative measures including rest, avoiding re-injury, and gradual rehabilitation.

Can neck pain be prevented?

Neck pain can really only be prevented by avoiding injury to the neck. This would include minimizing the risks of injury during sports activities. However, there are some neck stretching and strengthening exercises that will benefit almost everyone who suffers from the occasional neck tightness.

Stretching exercises — Apart from maintaining flexibility, stretching exercises can also help to decrease pain from muscle injury. Exercises can be performed in the morning to relieve stiffness and again at night before going to bed.  Sharp or electric like pain in the shoulder or arm is not normal and should be reported to your specialist doctor.

The most useful stretching exercises for the neck include the following:

• Neck bending — Tilt the head forward and try to touch your chin to your neck. Hold for a few seconds, breathe in gradually, and exhale slowly with each exercise. Exhaling with the movement helps relax the muscles. Repeat 10 to 15 times. Relax the neck and back muscles with each neck bend.
• Shoulder rolls — In the sitting or standing position, hold the arms at the side with the elbows bent. Try to pinch the shoulder blades together. Roll the shoulders backwards 10 to 15 times, moving in a rhythmic, rowing motion. Rest. Roll the shoulders forwards 10 to 15 times.
• Neck rotation — Slowly look to the right. Hold for a few seconds. Look to the center. Rest for a few seconds between movements. Repeat 10 to 15 times. Perform on the left side.
• Neck tilting — Look straight forward, then tilt the top of the head to the right, trying to touch your right ear to the right shoulder (without moving the shoulder). Hold in place for a few seconds. Return the head to the center. Repeat 10 to 15 times. Repeat on the left side.
• Vertical shoulder stretches — In the sitting or standing position, use the right hand to hold the left wrist and pull the arm (and shoulder) up and over the head, towards the right. Hold for five seconds. Keep the left shoulder and back muscles relaxed. Rest and repeat 10 to 15 times. Repeat using left hand to hold right wrist.
• Upper back stretches — In the standing position, lean forward from the hips and rest both hands on a low counter with the elbows straight. Exhale, relax the neck and shoulders, and allow the head to fall forward as you round the upper back. This requires the shoulder blades to spread apart and mimics the motion of a cat stretching its back. Exhaling with the motion helps to relax the muscles. Return to the standing position with hands on a counter. Repeat slowly 10 times.
• Basic neck strengthening — In the same forward positioning as the upper back stretches, after allowing the head to fall forward, raise the head by looking forwards keeping the neck in a straight line as the upper back and hold for 10 seconds. This trains the neck muscles that keep the neck upright. Repeat slowly 10 to 15 times. 

Prevention and Posture — Activities and body positions that prevent or reduce neck pain include those that emphasize a neutral neck position and minimize tension across the supporting muscles and ligaments of the neck. Extremes of range of motion, activities, and body positions that cause constant tension should be minimized or avoided:

• Avoid sitting in the same position for prolonged periods of time. Take periodic five minute breaks from the desk, work station, etc. Avoid looking up or down at a computer monitor; adjust it to eye level.
• Avoid placing pressure over the upper back with backpacks, over-the-shoulder purses, or children riding on your shoulders
• Do not perform overhead work for prolonged periods at a time.
• Maintain good posture by holding your head up and keeping your shoulders back and down.
• Use the car or chair arm rests to keep the arms supported.
• Sleep with your neck in a neutral position by sleeping with enough pillows to keep your neck straight in line with your body. Avoid sleeping on the stomach with the head turned.
• Carry heavy objects close to your body rather than with outstretched arms.

NECK PAIN TREATMENTS IN SINGAPORE

What most patients do not realise is that most cases of chronic neck pain can be treated conservatively with over-the-counter pain medications, ice, heat and massage, and strengthening and/or stretching exercises at home.

Ice — For some people, ice can reduce the severity of neck pain. It can be applied directly to the sore area of the neck. Ice can be frozen in a paper cup, and then the upper edge of the cup can be torn away. The ice should be moved continuously in strokes on the neck muscles for five to seven minutes.

To control sudden onset muscle tightness, place a bag of ice, bag of frozen peas, or a frozen towel wrapped in a dry towel, on the painful area. The ice should be left in place for 15 to 20 minutes to deeply penetrate the tissues; this can be repeated every two to four hours until symptoms improve.

Heat — Heat can help to reduce pain in the neck muscles. Moist heat can be applied for 10 to 15 minutes in a shower, hot bath, or with a moist towel warmed in a microwave. However, acute injuries should utilize ice as the initial treatment. Heat may be used initially for patients who have cold intolerance to ice.

Massage — Massage can be helpful for relieving muscle spasm and can be performed after heating or icing the neck. Massage can be done with the hands by applying pressure to both sides of the neck and the upper back muscles, or with an electric hand-held vibrator. The neck muscles should be relaxed during massage by supporting the head or lying down.

Reduce stress — Emotional stress can increase neck tension and interfere with or delay the recovery process. Reducing stress may help to prevent a recurrence of neck pain. Relaxation techniques can relieve musculoskeletal tension. An example of a relaxation exercise is to take a deep breath in, hold it for a few seconds, and then exhale completely. Breathe normally for a few seconds, and then repeat.

Many patients may have also attempted acupuncture, biofeedback, cervical collars, cervical traction and other forms of physical therapy. In particular, some studies have found that treatments that include quick “thrusting” of the neck are associated with serious injury. Aggressive manipulation or adjustments to the cervical spine should be discouraged in elderly patients and those with cervical stenosis. Cervical traction involves the use of weights to realign or pull the spinal column into alignment.  Clinical studies have shown that there is no benefit of traction in the treatment of neck pain.

IS SURGERY THE NEXT STEP?

Most practitioners will agree that surgery may not be useful for treating most types of neck pain. However, surgery does have a role in relieving symptoms related to a pinched nerve caused by a moderately large herniated disc after a trial of conservative therapy (eg, stretching exercises, physical therapy). Most patients however, will only consider surgery as their last option and as a result, they end up enduring a significant amount of pain in the process.

The good news is that today, modern medicine has a much greater understanding of neck pain than previously. As there are many varied causes of neck pain, there are also as many options of non-surgical interventions that act as the “missing link” between conservative care and surgical options. As a matter of fact, there are many more options for resolving pain, even for people who think — or have been told — that “nothing else can be done.”

Minimally invasive procedures that target these sources include trigger point injections,  diagnostic nerve root blocks, facet joint blocks or radiofrequency ablation, and discography. The choice of procedures will ultimately depend on what is diagnosed as the main cause of neck pain in the individual patient.

Dr G himself is a general practitioner but attributed his neck pain to degenerative changes in his cervical spine. As a result he suffered from chronic neck pain for close to 4 years before deciding to come for treatment. One of the reasons that prompted him to do so was that he started developing gastritis as a result of the painkillers he had been taking. Dr G underwent radiofrequency facet joint treatment, performed under X-ray guidance. He had since then stopped taking his pain medications and had also resumed playing golf again. 

Joint Pains 

Chronic non-cancer pain is typically defined as pain lasting longer than 3 months or beyond the expected healing of tissue pathology. Prevalence studies on chronic pain report rates ranging from 10.1% to 55.2%. In fact, the World Health Organisation estimates that some 20% of individuals worldwide have some degree of chronic pain. The prevalence rate in Singapore, using the definition of pain for at least 3 out of past 6 months, was 8.7% which translates to more than 300,000 adults currently having chronic pain. This is likely to be an underestimation of the actual prevalence. The data available reflect a higher prevalence of chronic pain among females. 

Reference:

Nicholas HL Chua. QST Observations in Chronic Neck Pain: Towards a mechanism-oriented approach to Cervicogenic Headache. 2013. 1: 10-34. ISBN: 978-981-07-5529-4.

In Singapore, main sites of chronic pain were in the lower limbs (knee 30% and leg 21%), low back (19%) and neck pain (10%).

Reference:

Pain Prevalence in Singapore. Ann Acad Med Singapore 2009;38:937-42

A joint is the point at which the ends of two bones meet to allow a body part to move. A normal joint consists of bones that are separated by cartilage that act as support for the adjacent bones. Ligaments connect bone to bone around the joint. Bursae are fluid-filled sacs that give a gliding surface for surrounding tendons. Tendons connect muscle to bone around the joint. Joint pain can be caused by injury or disease of the joint or adjacent tissues. It is not always the internal joint tissue that is the cause of joint pain as commonly thought. Joint pain can result from injury or disease affecting any of the ligaments, bursae, or tendons surrounding the joint. Injury or disease can also affect the ligaments, cartilage, and bones within the joint, causing pain in . Pain is also a feature of joint inflammation (arthritis) and infection and can be a symptom of rare tumors of the joint.

In Singapore, its mainly the elderly who suffer from joint pains. After the age of 65, the incidence of joint pain increases steeply. About 30-40% increase in sports related joint injuries have been observed over the past 3-4 yrs. However, this number may be a conservative estimate as such patient may consult a variety of specialists including sport physicians, orthopaedic surgeons, physiotherapists and even chiropractioners.

Injuries to joints can often be prevented by proper sports gear and training. Joint disease on the other hand is generally not avoidable, but once medical treatment programs have been initiated, they can be essential to preventing recurrent pain in the joints.

Treatment options for joint pain

Firstly, if you have pain in the joint that persists after one week, it should be evaluated by your doctor. More importantly, severe pains in the joint should be medically evaluated as soon as possible.

The treatment of joint pain is targeted towards the exact underlying cause. Should the problem be an injury, the main treatment normally entails rest, cold applications, and anti-inflammatory medications. Further medications for controlling pain is usually not required at this juncture. Patients may require gradual rehabilitation physical therapy.

Should there be a form of arthritis causing the joint pain, doctors may suggest anti-inflammatory medications. However, prolonged usage of anti-inflammatory medications can have adverse effects in some organs such as the stomach and kidneys. In some specific forms of arthritis, other more specific medications aimed at the cause of the arthritis may be required. If the bone, ligament, or cartilage is diseased, surgical procedures may sometimes also be required.

Some studies, but not all, have suggested that the food supplements glucosamine, chondroitin and collagen II can relieve symptoms of pain and stiffness for some people with osteoarthritis. These supplements are available in pharmacies and health-food stores without a prescription, although there is no certainty about their effectiveness (even doubts). Their initial research demonstrated only a minor benefit in relieving pain for those with osteoarthritis. Fish oil supplements have also been shown to have some anti-inflammation properties, and increasing the dietary fish intake and/or taking fish oil capsules (omega-3 capsules) can sometimes help reduce the inflammation of arthritis. There are also many other types of topical gels that help with joint pains, most of which contains anti-inflammatory medications as well. Others contain small particles which is believed to cross the skin and migrate through various tissues to reach the target joint. Once inside the joint, these small particles are believed to accumulate on the damaged cartilage forming a lubricating layer. Further studies however, are needed clarify many issues regarding dosing, safety, and effectiveness of these products for osteoarthritis. 

Dr Nicholas Chua, Ph.D

MBBS(S’pore), MMed(Anaes), FIPP(USA) Dipl.AAPM(USA), FAMS(Anaes)

Consultant, Anaesthesiology & Pain Medicine

Medical Director

Specialist Pain International Clinic

Mt Elizabeth Hospital