Natural Tricks to Heal a Stiff Neck

Neck Pain UnPlugged

The Complete, Step-by-step Self-assessment/self-treatment System For Neck Pain Sufferers. Neck Pain UnPlugged is a simple-to-use, step-by-step system that is full of life changing benefits. Finally understand the underlying cause of your neck pain. Learn simple to follow steps for improving your neck pain. Save Time and $: Drastically reduce or eliminate your need for dangerous medications and endless trips for treatment. Changes that give you the long term neck pain relief that you deserve. Customized to You: No More generic stretches and exercises. Everyone is different. Only do what Your body needs to feel great. Wake up feeling great. Do the thing You want to do. Get your life back!

Neck Pain UnPlugged Summary


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Pathophysiology of nonspecific neck pain

Many patients with nonspecific neck pain show degenerative changes in the cervical disks with osteophyte formation and involvement of adjacent soft tissue structures. However, similar degenerative changes in the cervical spine are common in asymptomatic people over the age of 30 years, with changes being evident both on plain X-rays 3 and MRI scanning 4 . As there is such a poor correlation between symptoms and radiological findings, the boundary between normal aging and disease is difficult to define, and diagnosis is usually made on clinical grounds alone. Whiplash Patients develop symptoms soon after a sudden acceleration-deceleration of the neck, as occurs in road traffic or sporting accidents. While symptoms are often severe, the source of the pain is uncertain, and no specific pathology can be identified on detailed clinical or radiological investigation. While soft tissue injury is considered likely, this is difficult to confirm even using MRI scanning. In some patients with...

Natural history of nonspecific neck pain and whiplash with factors associated with chronic disability

Nonspecific neck pain usually resolves within days or weeks, but can recur or become chronic. Once pain becomes persistent, outcome is more unpredictable, and there is little consistency in the literature regarding the duration of symptoms and factors that influence outcome. A systematic review of the clinical course and prognostic factors in nonspecific neck pain found little consensus as to outcome or relevant prognostic factors, although this was based on poor-quality studies 19 . The systematic review found evidence that in patients with chronic pain treated in secondary care or an occupational setting, 20-78 (median 54 ) of patients remained symptomatic, irrespective of the therapy given. Six of the included studies documented prognostic factors, and the severity of pain at presentation was the best predictor of a poor outcome, although previous episodes of neck pain were also important. Three subsequent studies also considered the factors at presentation which might influence...

Box 83 Therapeutic options for acute and chronic whiplash

Acute whiplash Chronic whiplash Most neck pain appears to respond to conservative measures, although the effect size is often quite small, and the optimal therapeutic approach for uncomplicated neck pain has yet to be established. Even where an initial benefit is shown, this advantage is not sustained. Few modalities of treatment have been assessed in high-quality randomized studies, but I will try to present the best available evidence for the most commonly used modalities. The evidence is often contradictory because of the poor quality of many of the studies, use of interventions in combination, and diverse patient groups. The lack of consistency in study design makes it difficult to identify which intervention may be of use in which type of patients.

Neck pain with radiculopathy see

Neck pain with radiculopathy usually has a favorable prognosis without the need for surgical intervention, but there are very few studies looking at conservative approaches to therapy, like epidural injection or a comparison between conservative and surgical treatments. Systematic reviews 2, 73-75 identified two small poor-quality RCTs which provided insufficient evidence on the effects of cervical epidural interlaminar steroid injections for radiculopathy complicating nonspecific neck pain. One RCT (40 patients with radiculopathy confirmed by MRI and diagnostic transforaminal block) had one transforaminal injection of either steroid or saline plus local anesthetic with weekly assessments for 3 weeks. Six of 20 patients in each group reported improvement at 3 weeks, with no difference between the groups for any parameter at any time 76 . Epidural injections are more invasive in the cervical than lumbar region, and need to be used with caution. Complications, such as infection or...

Acute Neck Pain continued

Physical examination does not provide a patho-anatomic diagnosis of acute idiopathic or whiplash-associated neck pain as clinical tests have poor reliability and lack validity. Tenderness and restricted cervical range of movement correlate well with the presence of neck pain, confirming a local cause for the pain. Plain radiography is not indicated for the investigation of acute neck pain in the absence of a history of trauma, or in the absence of clinical features of a possible serious disorder. Acute neck pain in conjunction with features alerting to the possibility of a serious underlying condition is an indication for MRI. Except for serious conditions, precise identification of the cause of neck pain is unnecessary. Once serious causes have been recognised or excluded, terms to describe acute neck pain can be either 'acute idiopathic neck pain' or 'acute whiplash-associated neck pain'.

Imaging Studies in Neck Pain

With a history of trauma, cervical spine x-ray in an AP, lateral, odontoid view may be helpful. History suggestive of infection or tumor also warrants urgent x-ray of the cervical spine. Cervical spine x-ray is not generally indicated if the patient is alert, does not have neurological deficits, and does not have midline tenderness posteriorly. CT is best for bone changes and MRI is best for soft tissue evaluation. Both CT and MRI are not required initially in neck pain that appears uncomplicated.

Treatment of Neck Pain Acute Neck Pain

The natural history for acute neck pain is recovery within 3 months. Reassure patient that serious causes, which are rare, are ruled out. Patient should be encouraged to maintain normal activities. The most effective treatment may be simple neck exercises to keep the neck mobile and increase range of motion. If there is no improvement, patient should be further evaluated with imaging (e.g., MRI). There is no evidence that analgesics, non-steroidal anti-inflammatory agents, or muscle relaxants are effective in acute neck pain, although they are often prescribed. In general opioids are not indicated in acute neck pain. Studies have reported long-term relief in up to 60 of patients with cervical epidural steroid injections using the interlaminar or transforaminal approach. Rare but serious complications can occur with these injections, (particularly with the transforaminal approach), including spinal cord or brainstem infarction and death.

Epidemiology of nonspecific neck pain

Epidemiological studies of neck pain are based on questionnaires and surveys, which may overestimate the frequency of the condition. Nevertheless, it is clear that nonspecific neck pain including whiplash places a heavy burden on individuals, employers, and healthcare services. About two-thirds of the population will experience neck pain at some time in their lives 7, 8 , with the condition being most common in middle age, and in women 9 . The reported prevalence of neck pain varies widely between studies, but has a mean point prevalence of 7.6 (range 5.9-38.7 ) and a mean lifetime prevalence of 48.5 (range 14.2-71 ) 9 . A UK survey found that 18 of 7669 adults had neck pain at the time of the survey, but when symptomatic people were re-questioned 1 year later (58 responded), half were still symptomatic 10 . A Norwegian survey of 10,000 adults also reported that 34 of responders had experienced neck pain in the previous year 11 . Neck pain is second only to back pain in frequency of...

Acute neck pain

For the treatment of acute neck pain, the Australian Acute Musculoskeletal Pain Guidelines Group found evidence that collars were ineffective, and found evidence to be lacking or insufficient on the effectiveness of acupuncture, analgesics, manipulation, passive mobilization, electrotherapy, gymnastics, multidisciplinary biopsychosocial rehabilitation, muscle relaxants, neck school, nonsteroidal anti-inflammatory drugs, patient education, spray and stretch, traction, or transcutaneous electrical nerve stimulation (TENS).100 I The literature pertaining to this evidence is reviewed in detail elsewhere.100,101 The Australian Guidelines Group recommended that the treatment of acute neck pain be based on explanation and reassurance, activation, and exercises.100 I These recommendations were consonant with the results of an earlier systematic review of conservative therapy for neck pain.102,103 I In support of these recommendations, the literature is positive but limited. Contentious is how...

Neck Pain

Just as with back pain, the cause of common neck pain is often not apparent. Neck pain of less than 3 months duration is considered acute neck pain, while neck pain that has been present for more than 3 months is generally considered chronic neck pain. Neck pain can arise from the cervical spine and surrounding anatomical structures. These structures include the facet or zygapophysial joints, the intervertebral disks, the vertebral bodies, the anterior and posterior ligaments, the prevertebral muscles, and the posterior neck muscles. Serious but rare causes of neck pain include tumors (vertebral body, spinal cord) and infection (e.g., epidural abscess, meningitis, discitis, and osteomyelitis). Abnormal neurological findings associated with neck pain can be found in patients with cervical radiculopathy, cervical myelopathy, spinal cord tumor, and thoracic outlet syndrome (Carette 2005). Risk factors for neck pain differ from those for back pain. There appears to be no consistent...


This is a term for an event that occurs in a rear end collision in a motor vehicle accident, sometimes leading to in neck pain. Studies have shown that whiplash is not a flexion-extension or acceleration-deceleration injury as popular belief would have it. It appears that the cervical spine is subjected to a compression injury in which the trunk is forced upward into the cervical spine, resulting in possible strain and injury to the disk and facet joints. According to epidemiological data not all patients sustain injury, and most injuries are minor from which the majority of patients recover (Bogduk and McGuirk 2006c).

Chronic Neck Pain

In chronic neck pain, there is no solid evidence that the use of the following is effective traction, use of cervical collar, TENS, acupuncture, botulinum toxin injections, conventional physical therapy, and manipulation therapy. Exercises appear to be as effective as manual therapy or physical therapy in reducing pain. There is evidence that percutaneous radiofre-quency neurotomy for cervical facet pain provides pain relief for chronic neck pain. Pain from the facet joints can be diagnosed by diagnostic blocks of the medial branches that innervate the joints.

Efficiency and equity

These studies are useful as reference points for subsequent economic analyses,32 but rely heavily on estimates and underlying assumptions and should be treated with caution.33 In addition, there are theoretical debates about the most appropriate method for estimating productivity and indirect costs.33 The human capital approach considers the value of potentially lost production resulting from a disease in terms of absenteeism, reduced productivity, and disability or premature death at a specific age until the age of retirement. The alternative, friction cost method, assumes that production losses are confined to the period needed to replace the sick worker.34 The differences in results can be highly significant. For example, the indirect nonmedical costs of neck pain in the Netherlands in 1996 were estimated at US 530 million, using the human capital approach and US 96 million using the friction cost method.35 Similarly, the indirect cost of back pain in the UK in 1998 was estimated...

Disorders of unknown pathology

The remaining rubrics listed in Table 12.7 concern the differential diagnosis of spinal pain. Some require and invite no investigations. Acceleration-deceleration injury of the neck is the formal rubric for whiplash - a diagnosis made on the basis of history alone. Similarly, spinal pain of unknown origin pertains to pain whose cause cannot be or has not been pursued. The gluteal and piriformis syndromes are diagnosed clinically, and do not require special investigations.

Skeletal Muscle Relaxants

There was fair evidence that cyclobenzaprine, carisoprodol, orphenadrine, and tizanidine were effective compared to placebo in patients with musculoskeletal conditions (primarily acute back or neck pain). Cyclobenzaprine has been evaluated in most clinical trials and has consistently been found to be effective. There are very limited or inconsistent data regarding the effectiveness of metaxalone, methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo in patients with musculoskeletal conditions. There was insufficient evidence to determine the relative efficacy or safety of cyclobenzaprine, carisoprodol, orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone. Dantrolene and, to a lesser degree chlorzoxazone, have been associated with rare serious hepatotoxicity (Chou et al. 2004).

Herpes simplex virus type

The most common central nervous system (CNS) complication of HSV-2 infection is aseptic meningitis (headache, fever, and stiff neck). Aseptic meningitis may follow recurrent genital infection. HSV-2 aseptic meningitis occurs any time of year and can recur.9 The CSF contains a mononuclear pleocytosis. Unlike HSV-1 in encephalitis, HSV-2 can readily be isolated from CSF during aseptic meningitis.10 Infection is

Clinical Aspects Of Bacterial Meningitis

Bacterial meningitis is clinically characterized by stiff neck, headache, fever, photophobia, malaise, vomiting, alteration of consciousness, seizures, confusion, irritability, and, rarely, acute psychosis. Cerebrospinal fluid (CSF) usually reveals an elevated white blood cell count of more than 1000 white blood cells l, consisting of more than 60 polymorphonuclear leukocytes, an elevated total protein content and a decreased CSF serum glucose ratio. A CSF white blood cell count of less than 1000 cells l may be found early in the disease, in partially treated bacterial meningitis, in overwhelming bacterial meningeal infection ('apurulent bacterial meningitis') and in immunosuppressed and leukopenic patients.

Regional Anesthesia and Other Interventions

Traumatic brain injury (TBI) is another common cause of chronic pain and disability, affecting nearly 1.5 million Americans per year. The prevalence of pain following TBI varies dramatically, ranging from 18 to over 90 depending on the surveillance method, severity, and associated trauma (Cohen et al. 2004). The most common pain complaints in patients with mild TBI (Glasgow Coma Scale 13-15, loss of consciousness < 1 h) are headache (69 ), neck pain (40 ), and back pain (32 ). First-line treatments for headache prophylaxis include tricyclic antidepressants, topiramate, and gabapentin. The most frequent cause of neck pain after trauma is facet arthropathy, which may be treated with radiofrequency denervation (Lord et al. 1996, Cohen et al. 2007). Other causes of chronic neck pain after trauma include occipital neuralgia, which may respond to nerve blocks and pulsed radiofrequency, cervical discogenic pain, and myofascial pain.

Magnetic resonance imaging

In patients with acute neck pain, but with no clinical indicators of any serious cause, magnetic resonance imaging (MRI) offers little prospect of a positive diagnosis. The only indication for MRI is as a screening test for rare and clinically occult disorders in patients with persistent or chronic neck pain. Yet even in that context, the use of MRI is questionable. By definition, rare conditions are unlikely to be evident, and in the absence of clinical indicators they are even more unlikely. The cardinal indicators are a past history of cancer, risk factors for infection, or signs of systemic illness. In patients with risk factors for aneurysm (see Chapter 12, Diagnostic procedures in chronic pain), magnetic resonance angiography is indicated. and with increasing frequency with age.74,75 Finding such abnormalities does not provide a diagnosis. In patients with neck pain after whiplash, multiple studies have shown that MRI reveals nothing but normal age changes, with the same...

Radiofrequency neurotomy

Percutaneous radiofrequency (RF) neurotomy is the one surgical procedure that has withstood scientific scrutiny. In this procedure, the nerves that innervate the cervical zygapophysial joints are coagulated in an effort to relieve pain stemming from these joints.140 Under double-blind, controlled conditions, the procedure has proven not to be a placebo.141 II Moreover, it is the only treatment for neck pain that has been shown to achieve complete relief of pain, and restoration of activities of daily living.141,142 II , III Furthermore, relief of pain is attended by complete resolution of psychological distress.143 III A limitation of the procedure is that pain recurs as the treated nerves regenerate, but in that event, the procedure can be repeated and the pain once again completely relieved. Long-term studies have shown that continued, repeated relief can be sustained for up to 2000 days.142 III In the context of whiplash, it has repeatedly been shown that the outcomes following RF...

Severity and Characteristics of the Pain

Somatic pain is generally described as a dull, aching pain. Pain that is shooting or lancinating is usually indicative of a neurogenic origin. The level of pain reported by the patient is useful information. Severe acute neck pain requires urgent evaluation. In patients with chronic neck pain, assessment of the level of pain may be useful in guiding effectiveness of various treatment modalities. Factors that relieve or exacerbate pain may include specific patient or activities, although none are specific for any source of pain.

Physical Examination

The cause of common neck pain is not usually determined on physical examination. Range of motion of the neck and areas of tenderness in the neck and shoulder girdle muscles are noted. In patients with neurologic symptoms, a neurological examination including motor, sensory, and reflex testing in upper and lower extremities may help narrow findings to specific nerve roots (Table 26.7). The presence of hyperreflexia, clonus, Babinski's sign, and abnormal gait may indicate myelopathy.

Pain from Cervical Spine

Pain from cervical structures referred to the head is called cervicogenic headache. It can be experienced in the occipital, parietal, frontal, or orbital regions. The sensory axons from C1, 2, and 3 converge on dorsal horn neurons that also receive afferent supply from the trigeminal nerve. Hence pain mediated by the C1, 2, and 3 nerves is perceived in areas supplied by the trigeminal nerve. A common cause of cervicogenic headache, particularly in patients after whiplash injury, is pain from the C2-3 facet joint mediated by the third occipital nerve. The source of pain can be diagnosed using controlled diagnostic blocks. Facet intra-articular injection with steroid and more so radiofrequency neurotomy is effective in relieving pain.

Somatic Chest Pain Referred

Chronic thoracic pain.113 It has been estimated that 15 percent of spinal pains originate in the thoracic spine.114 Of those, it has been suggested that nearly half originated in the zygoapophyseal joints.115,116 Painful cervical facets were the cause of the pain in 55 percent of patients with neck pain and 42 percent patients with thoracic pain.116 Manchikanti et al.116 found this to be more prevalent in people with sedentary jobs. The diagnosis is made by exclusion of other pathologies and a high index of suspicion since there are no defined clinical or radiological features.117 There have been descriptions of patterns of distribution of this pain in healthy volunteers, and these are mainly centered on the back.118,119

Measurement of costs and benefits

There is also debate as to whether the human capital approach (where a year of working time lost is measured by average salary) or the friction method (where production losses are dealt with by transferring work lost to other workers) should be used in measuring indirect costs. The differences in results may be highly significant. For example, the indirect non-medical cost of neck pain in the Netherlands in 1996 was

Generalized anxiety disorder

Improvement in anxiety was more important than changes in physical capacity in predicting outcome.36 Similar benefits when reducing anxiety in patients with back pain were shown in a Finnish study.37 In a recent World Health Organization (WHO) survey, people with back and neck pain were over 2.5 times more likely to have GAD than controls without this condition.38 This survey was not able to show the temporal relationship between pain and anxiety, but other studies have strongly suggested that anxiety sensitivity is a feature in this population.27'36

Physiological Influences

Investigated, but the findings to date in the elderly suggest genetic factors are not important. A study looking at the development of neck pain in the elderly failed to demonstrate a significant influence of genetic factors.11 IV Similar work on back pain in the over 70 age group suggests a small genetic effect in men but not women. Significant predictors for back pain found in this latter study included previous or current diagnosis of osteoporosis, arthritic or lumbar disk disease, as well as environmental effects.12 IV

Case 2 Gareth Suneil Ramessur Mbbs Bsc Hons FRCA DipHEP

Gareth, 40-year-old man, is referred to you with persistent pain and tingling around his neck and upper limbs. The pain started following a road traffic accident during which he sustained whiplash injury several months ago. He has tried various pain killers and physiotherapy without much benefit. The attending neurologist has requested you to see Gareth. A recent MRI of cervical spine is showing arthritic changes in the cervical facet joints. Though the presentation and investigations indicate pain secondary to the whiplash injury and cervical facet joint arthropathy, it essential that a detailed first-hand history and clinical assessment are performed. In whiplash injury, pain course can be difficult to predict. Pain can persist for many years. There could be periods of remission and exacerbation. Regular medications and interventions such as physiotherapy, trigger point injections, and acupuncture have all been tried with variable success. Another interesting aspect of pain in such...

Lymphomatous Meninigitis

CNS lymphoma may present as lymphomatous meningitis, a condition characterized by headache, fever, stiff neck and mental status changes with cranial or spinal nerve palsies. CSF white blood cell count, protein and glucose can be normal or elevated. CSF cytological analysis may reveal malignant cells. Brain imaging reveals atrophy with or without meningeal enhancement. The mean survival from the time of diagnosis of lymphomatous meningitis is only 5 weeks. At this stage, treatment is not usually helpful.171

Which of the following is true about the use of antidepressants and their analgesic effects

Mary is a 35-year-old female who has been suffering from a headache following whiplash injury. She says that her pain starts from the back of her head and radiates to the forehead and into both of her eyes. On examination, she has tenderness over the posterior occiput. The following statement is not correct

Sreekumar Kunnumpurath Mbbs Md Fcarcsi Frca Ffpmrca

Andrew is 75-year-old man who has been very active until about a year ago. He used to play golf twice a week. One year ago, he slowly started to get persistent lower back pain which gradually began to worsen. A few months later he noted that he was getting pain in his thigh and to his dismay his neck was becoming painful too. Finally, he had to stop playing golf altogether. He was seen by his PCP who after a careful examination made a diagnosis of non-specific back pain. Andrew was started on acetaminophen and ibuprofen, which reduced his back pain to such an extent that he could play some golf again. However, a few months later during a routine checkup his PCP noticed edema of his ankles. On further investigation, he was found to have elevated blood urea and crea-tinine. Ibuprofen was promptly stopped with resulting recurrence of back and neck pain. Andrew was then prescribed regular codeine phosphate and diazepam before bedtime for Can you correlate neck pain and back pain

Diagnostic blocks

Among the possible sources of low back pain are the lumbar zygapophysial joints and the sacroiliac joints. Among the sources of neck pain and headache are the cervical zygapophysial joints, the lateral atlantoaxial joints, and the atlantooccipital joints. For these joints, a variety of diagnostic blocks has been devised and implemented in some circles. Yet their use has met with acrimonious dissidence. Even though the validity of these blocks has been established in double-blind, controlled studies, they have been decried as amounting to no more than placebos.81 The irony is that the same critics extol the virtues of sympathetic blocks, which lack doubleblind, controlled studies.81 In the pursuit of neck pain, the atlantooccipital and lateral atlantoaxial joints can be anesthetized using intraarticular injections of local anesthetic agents.82,83,84, 85, 86, 87 The cervical zygapophysial joints can be anesthetized using intraarticular blocks or blocks of the medial branches of the...

List of Tables

6.1 Acute Neck Pain as the Principal Presenting Feature Possible Causes 90 6.2 Medical, Social and Occupational Risk Factors Shown Not To Be Aetiological Risk Factors for Neck Pain 93 with Neck Pain 93 6.4 Psychosocial Risk Factors Shown Not To Be Related to Neck Pain 93 with Acute Neck Pain 96 6.6 Factors Associated with Chronic Neck Pain After Whiplash with Chronic Neck Pain After Whiplash 103


Literature searches on therapeutic options for treating mechanical neck pain were carried out using the following databases Chirolars (now called Mantis), Bioethicsline, CINAHL, Current Contents, and Medline, with data being used to prepare and update an article in Clinical Evidence 2 . I will summarize the evidence on treatment modalities currently in use, with an indication of questions which still need to be answered. Studies relating to specific conditions like fibromyalgia and disk prolapse will not be discussed. Data on therapy will be considered for patients with (uncomplicated) nonspecific neck pain, neck pain plus radiculopathy, and whiplash. Therapies will then be categorized as likely to be effective, where there is at least one high-quality RCT suggesting benefit and reasonable consensus from other studies likely to be ineffective, where there is at least one high-quality study suggesting a lack of benefit from the treatment and unknown effectiveness, where there is...

Future research

The benefit of most therapeutic interventions for nonspecific neck pain is small, and many patients improve with limited or even no treatment 97 . It is therefore important that future studies set predetermined minimum differences, which are considered to be clinically relevant. This approach should avoid the current difficulty that many studies, while showing statistically significant differences in outcome, may have little clinical importance.


Nonspecific neck pain including whiplash is a very common cause of disability, and places a heavy burden on individuals, employers and society. However, there are many aspects regarding etio-pathogenesis and treatment which remain poorly understood. Furthermore, if the factors that influence the progression from acute to chronic pain were better understood, it might be possible to reduce the frequency and severity of chronic disability for both whiplash and other causes of nonspecific neck pain. Most studies of acute neck pain are in patients following whiplash injury, and it is not clear if the findings from those studies can be generalized to neck pain from nontraumatic causes. There have been some higher quality randomized controlled trials of therapy in patients with nonspecific neck pain, which suggest that exercise 32, 33 and manual therapy (mobilization physiotherapy or manipulation) 45, 46, 48 are the treatments of choice, and are more effective than less active therapies, but...


There are three forms of encephalitis produced by measles virus. The most common form is a post-infectious encephalomyelitis characterized by the acute onset of headache, fever, stiff neck, seizures and focal deficit, usually within 14 days of rash. Mortality is about 10-20 ,222 and survivors are often left with seizure disorders, impairment of cognitive function and deafness. Pathological changes are found mainly in white matter and are indistinguishable from the inflammatory demyelination seen in fatal cases of post-vaccinial encephalomyelitis due to rabies immunization or smallpox vaccination. Measles virus is not found in the brains of patients who die of measles post-infectious encephalo-myelitis.223


An additional tract that may be lesioned is the quintothala-mic tract. It is located superomedial to the spinothalamic tract. This decreases transmission of extralemniscal emotional suffering. The best results have been using stereotactic approaches for the treatment of nociceptive head and neck pain secondary to malignancy and neuropathy. The main untoward side effects are dysesthesias and oculomotor dysfunction (Fig. 13.41).

Value and efficacy

In 2003, Assendelft et al.69 I performed a meta-analysis of 39 randomized controlled trials evaluating spinal manipulation in low back pain. They concluded that spinal manipulation was superior to sham therapy and to therapies that have been judged to be ineffective or harmful, but it had no advantage when compared with general practitioner care, analgesics, physical therapy, exercises, or back school. Results were similar for acute and chronic low back pain. A Cochrane review by Gross et al.70 I concluded that manipulation and or gentle mobilization were not beneficial when performed alone, but they were beneficial when used with exercise. The review also concluded that neither was superior to the other and that there was insufficient evidence about their effects with radicular findings. The review acknowledged the methodological limitations of many of the underlying trials. Fernandez et al.71 I published a meta-analysis evaluating whether manual therapies have proven efficacy in...

Tensiontype headache

Peripheral factors have traditionally been considered of major importance in TTH. Numerous studies have reported increased tenderness of pericranial myofascial tissues in these patients.43,44 Moreover, TTH patients are more liable to develop shoulder and neck pain in response to static exercise than healthy controls.45 The increased myofascial pain sensitivity in TTH could be due to release of inflammatory mediators resulting in excitation and sensitization of peripheral sensory afferents.43,44 A recent study demonstrated normal in vivo interstitial concentrations of inflammatory mediators and metabolites in a tender point of patients with CTTH.46 Concomitant psychophysical measures indicated that a peripheral sen-sitization of myofascial sensory afferents was responsible for the muscular hypersensitivity in these patients,47 but firm evidence is still lacking.


Neck pain is pain perceived in a region bounded laterally by the margins of the neck, superiorly by the superior nuchal line, and inferiorly by an imaginary transverse line According to this definition, neck pain is perceived in the back of the neck, and this is typically where patients indicate neck pain. It is unusual for a patient to indicate neck pain anteriorly. In such cases, neck pain needs to be distinguished from pain in the throat or elsewhere in the visceral column of the neck. If a patient complains of visceral pain it should be so described and recorded, and not confused with neck pain. Conceptually, anterior neck pain would be pain perceived behind the visceral structures of the neck. Accordingly, the term anterior neck pain'' should be reserved strictly for those patients who can identify pain at the front of their neck, but not in the pharynx, larynx, trachea, or esophagus, or their adnexae. Little has been published about this type of pain. The evidence base for neck...

Risk factors

Many factors have been studied as risk factors for the development of neck pain. Some have been refuted others have only a weak or moderate association, with odds ratios less than 3.0 (Table 36.1 ).17 The most pervasive risk factors for neck pain relate to the work environment. They include high job demands,18, 19 low decision authority,19,20 little influence over the work situation21 or low job control,22 low coworker social support,19,22,23 high psychological demand,23 and low decision latitude.23 Although psychosocial in nature, these factors stem from the patient's work circumstances, and do not constitute personal psychological factors. Specific and classical psychological variables have failed to emerge as determinants of neck pain. Distinctly unrelated to neck pain are variables such as social support, depression, anxiety, coping ability, self-confidence, ability to solve problems, sense of humor, irritability, impatience, psychosis, extroversion, and lying, on the Eysenck...

Natural history

Some 14 percent of the population experience a new episode of neck pain in a given year, with 0.6 percent experiencing disabling pain.27 Approximately 37 percent of those affected progress to complete resolution, with the passage of time and a further 33 percent experience improvement but neck pain persists in the remainder.27 Some 23 percent of individuals suffer a recurrence within the year. In effect, neck pain persists in about half of those initially afflicted.28 Some 25 percent of patients have moderate symptoms after ten years, and some 7 percent remain or become severely disabled.29,30 Table 36.1 Refuted and weak to moderate risk factors for the development of neck pain.17 Table 36.1 Refuted and weak to moderate risk factors for the development of neck pain.17 Systematic reviews have found few studies that reported on prognostic factors for neck pain.31,32 None provided a statistical analysis that yielded either the relative risk or odds ratio for any association....

Prognostic factors

Persistence of neck pain after whiplash is not related to factors such as age, gender, psychological response, or compensation.54 It is weakly related to sleep disturbance, cognitive impairments, poor concentration, neuroticism, past history of headache, and being unprepared for the collision.54 The cardinal determinant of poor outcome is the initial intensity of pain and other symptoms.54, 55, 56, 57 Patients least likely to recover exhibit hyperalgesia, both in the cervical region and in regions remote from the neck, as well as psychological distress in the face of their symptoms.58,59,60,61,62 Evidence has also emerged that, independent of the initial intensity of pain, engaging a lawyer is a predictor of poor outcome.56,57


The favorable natural history of neck pain after whiplash indicates that most patients suffer no substantive injury. Perhaps they suffer a minor muscle strain, or a minor injury to a joint in the neck, which spontaneously resolves. A pathology is required only to explain the minority of cases in which pain becomes chronic. Rare injuries include disruption of the alar ligaments, prevertebral hematoma, perforation of the esophagus, tears of the sympathetic trunk, damage to the recurrent laryngeal nerve, spinal cord injury, periplymph fistula, thrombosis or traumatic aneurysms of the vertebral or internal carotid arteries, retinal angiopathy, and anterior spinal artery syndrome.51,58 Fractures after whiplash are so uncommon as to be rare. Such fractures as have been attributed to whiplash have been reported only in case studies or small, descriptive series. These fractures may be difficult to detect on conventional investigations, and special attention needs to be paid to their...

Clinical assessment

A comprehensive history of neck pain can be recorded by noting the standard features of any type of pain, as listed in Table 36.3. Asking the duration of illness establishes if the condition is acute or chronic. The circumstances of onset identify if the cause was spontaneous or traumatic, or associated with an illness or intervention. The mode of onset is usually unremarkable, but a sudden, spontaneous onset of severe neck pain should warn of a red flag condition. The site of pain and its radiation may be helpful in indicating, prima facie, the likely segmental origin of pain, but widespread neck pain offers no localizing clue. Neck pain should be dull and aching in quality lancinating or sharp pain suggests a possible neurogenic cause. Asking about frequency and duration establishes if the pain is episodic or constant, but lends little to establishing the cause, nor does the timing of the pain. Pain precipitated and aggravated by neck movement suggests an articular or muscular...

Plain radiography

The only valid indication for plain radiography in a patient with neck pain is a history of trauma. In that context, radiography is used as a screening test for fractures. However, the pretest likelihood of fracture is low, even in patients with a history of trauma.70 The Canadian C-spine rules define the responsible use of radiography in such patients71 (see Chapter 12, Diagnostic procedures in chronic pain). Radiography is indicated if the patient is older than 65 has suffered a dangerous injury, such as a fall or high speed collision or expresses neurological symptoms. A simple rear-end motor vehicle collision does not qualify as a dangerous injury, and is not an indication for radiography. Otherwise, if the patient has been ambulatory and is able to rotate their neck by 45 to the left and right, radiography is not indicated. Under these rules, the chances of missing a significant fracture by failing to undertake radiography are essentially nil. In patients with neck pain but no...

Emerging prospects

It is possible that lesions responsible for neck pain can escape detection because of the limited resolution of conventional imaging techniques. Advanced technology has been explored for its ability to provide greater resolution. A case report illustrated that functional MRI could reveal lesions of the atlanto-axial joints and ligaments that had escaped detection by conventional means.83 A pair of studies reported that MRI could demonstrate various grades of lesions in the alar and transverse ligaments, and that such lesions were significantly more common in patients with a history of whiplash than in control subjects.84,85 Others have not yet reproduced these observations. Nor have the lesions detected been shown to correlate with pain. A study in progress issued a preliminary report to the effect that lesions affecting the zygapophysial joints, disks, and other structures could be revealed in patients after whiplash, using MRI spectroscopy.86

Surgical therapy

There is no compelling evidence of the efficacy of cervical fusion for neck pain. Such studies as have reported on this therapy claim success,135,136 IV but outcome measures are few and lacking in rigor. Some studies report disheartening results,137 IV particularly for surgical therapy of neck pain after whiplash.138 IV Some 57 percent of patients report their pain as much better after surgery, but only 10 percent are rendered free of pain.139 IV Table 36.5 The pain scores reported in various studies of exercises for chronic neck pain. All studies provide level II evidence. Table 36.5 The pain scores reported in various studies of exercises for chronic neck pain. All studies provide level II evidence.

Medical History

A careful medical history including questions regarding systemic illness, unexplained weight loss, history of neoplasm, fever, infection, neurological changes including numbness and weakness in the extremities, and history of substance abuse is important to exclude serious causes of neck pain. Just as there are red flags with the assessment of low back pain, the same red flags should be emphasized in patients with neck pain. Infection, tumor, trauma (spinal cord, epidural hematoma, fractures) are serious causes that require urgent evaluation

Litigation and Pain

Concerns naturally arise about the potential role of ongoing litigation and its effect on the experience of pain, the rehabilitation process, and allegations of disability. It is conceivable that the pursuit of litigation could have an impact on the treatment and rehabilitation of a patient's pain (Gatchel et al. 1995). It has been reported that people with whiplash injuries who were in the midst of litigation reported more pain than those who were no longer involved in litigation (i.e., whose cases were settled or resolved) (Swartzman et al. 1996). However, there was no statistically significant difference between those who were in the midst of litigation and those who were not with regard to employment status, return to work, and functional adaptation. The clinician is cautioned against making causal assumptions about the role of the litigation in influencing the patient's agenda (Swartzman et al. 1996). It is possible that for some patients, pain is exaggerated so as to increase...

Medial Branch Blocks

Cervical medial branch blocks can be used to test if a zygapophysial joint is the source of a patient's neck pain. They involve anesthetizing, under fluoroscopic control, the small nerves that innervate the target joint, each with no more than 0.3 mL of local anesthetic89 (Figure 36.5). Epidemiologic studies, using double-blind, controlled, diagnostic blocks, have shown that zygapophysial joint pain is the single most common basis of chronic neck pain, both after whiplash and in heterogeneous samples. In patients with a history of whiplash, prevalence figures (with 95 percent confidence intervals) of 54 percent (40-68 percent)94 and 60 percent (46-73 percent)95 have been reported. In patients with headache after whiplash, the prevalence of C2-3 zygapophysial joint pain was 53 percent (37-68 percent).96 Amongst drivers involved in high-speed collisions, the prevalence was as high as 74 percent (65-83 percent).97 In patients with neck pain not restricted to those with whiplash, the...

Neuronal Plasticity

Repetitive activation of muscle nociceptors leads to peripheral sensitization, therefore decreasing the excitation threshold and increasing the response to low level noxious stimuli (hyperalgesia). Wind-up occurs in the spinal dorsal horn, when repetitive input from the C-fiber nociceptors increases the response of the neurones. This causes increased release of substance P and glutamate activating the N-methyl-D-aspartic acid (NMDA) receptors by removing the magnesium block. Temporal summation studies have been carried out in FMS patients with intramuscular electrical stimulation. The results showed that temporal summation was more pronounced in FMS patients compared to controls, indicating central sensitization.54 Similar results were reported for FMS and whiplash patients,55 again supporting the hypothesis that localized pain (or trauma) can develop into FMS.


Tions or gummas) disease develops within 1-30 years after primary infection.129 Meningovascular infarcts,130 CNS gummas, and myelopathy131 may occur. Meningovascular syphilis is characterized by headache, fever, stiff neck, and focal neurological deficit. Seizures and cranial nerve deficits, particularly optic neuritis, facial weakness and hearing loss, may also develop. In fact, 20 of syphilis meningitis patients become deaf. Dementia and psychosis characterize general paresis, a late complication of neurosyphilis. The onset of memory loss, delusions of grandeur and dysarthria is insidious. Tabes dorsalis, another late complication, consists of lightning pains in the lower extremities and abdomen, diminished reflexes, severe loss of vibratory and proprioceptive sensation and bilateral Argyll-Robertson pupils (small, irregular pupils that do not react to light, but do accommodate).