Neck Pain in Adults _________________________________________________________________________
• Radiating symptoms ‒ Presence and distribution of upper/lower extremity numbness, paresthesia, or weakness ‒ Percentage of axial versus peripheral pain (e.g., 90% neck versus 10% upper limb) ‒ Precipitated by coughing or sneezing, or alleviated by raising the affected arm over the head • Initial treatment of present complaint ‒ Emergency department ‒ Acute care or clinic evaluation ‒ Imaging ‒ Analgesics given and symptom response Spinal pain history should include information regarding: • Known neck or back disorders (e.g., osteoporosis, osteoarthritis, disk disorders, recent or remote injury) • Specific prior treatment, including surgery • Chronic or recurrent symptoms • Functional limitations • History of motor vehicle collisions (if whiplash suspected) • Risk factors for:
• Pain severity: High pain intensity (NRS or VAS score ≥6 on a 1–10 scale) • Interference with daily activities: Evaluates pain impact on personal care, lifting,reading, concentration, work, driving, sleeping and recreation; pain intensity, and headaches. High self-reported disability is defined as an NDI score of ≥30%. • Pain catastrophizing: Belief that pain is to be feared or may be severely disabling. High pain catastrophizing is defined as a PCS score of ≥20. • Acute post-traumatic stress symptoms: The IES-R evaluates post-traumatic stress symptoms, not post-traumatic stress disorder (PTSD). High acute post-traumatic stress symptoms is defined as an IES-R score of ≥33. “Yellow Flag” Assessment The Tampa Scale of Kinesiophobia (TSK), the Fear Avoidance of Pain Scale (FAPS), the Patient Health Questionnaire-9 (PHQ-9), and the Hospital Anxiety and Depression Scale (HADS) measure “yellow flags,” psychosocial conditions that may predispose the patient to a more complex clinical course, chronicity, or disability [8; 19; 103]. The following psychological factors should be identified and measured using the associated tools: • Pain catastrophizing: PCS • Kinesiophobia, or avoiding activities due to fear of pain (fear-avoidance behavior): TSK or FAPS • Passive coping: PCS • Depressed mood or feelings of depression about pain: PHQ-9 or HADS • Anxiety or fear about pain: TSK or FAPS • Pessimism and poor recovery expectation: Ask the patient: Do you think that your injury will…
‒ Back disorders (e.g., cancer, osteoporosis) ‒ Aneurysm (e.g., smoking, hypertension)
‒ Infection (e.g., immunosuppression, IV drug use, recent surgery, hemodialysis, penetrating trauma) • Extra-articular features of an underlying systemic disorder (e.g., diarrhea, abdominal pain, uveitis, psoriasis) Medication use, smoking history, and diabetes risk should also be assessed. ASSESSMENT OF PROGNOSTIC FACTORS Clinicians should perform functional assessments during initial contact and all follow-ups and a psychosocial (“yellow flag”) assessment during initial or follow-up visit to obtain important information about baseline status, trajectory, and prognosis of recovery. Both assessments are easily conducted using validated self-report questionnaires. Functional Assessment The Visual Analog Scale (VAS), the Numerical Pain Rating Scale (NRS), the NDI, the Neck Pain and Disability scale (NPAD), the Pain Catastrophizing Scale (PCS), and the Impact of Events Scale-Revised (IES-R) measure clinical variables with significant prognostic value in acute neck pain; all may be used for the initial assessment and follow-up. Patients with high initial scores are at much greater risk of persistent pain and disability and may require treatment of greater intensity or focus. Clinical factors and cutoff scores for poorer prognosis include [22; 29; 39; 104]:
‒ Get better soon ‒ Get better slowly ‒ Never get better ‒ Don’t know
• High levels of frustration or anger about pain. Ask the patient to quantify (on a 0–10 scale) how frustrated (angry) he or she feels about the pain. Obtain during history: ‒ Past/current social or financial problems ‒ Past/current multiple medical diagnoses, unresolved musculoskeletal conditions ‒ Past/current history of physical abuse, emotional abuse, chronic pain ‒ Past/current active substance abuse
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MDKY1626
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