_________________________________________________________________________ Neck Pain in Adults
Sleep Assessment Sleep quality and pain are intimately linked, making sleep important to assess. For every 1-point decrease in sleep quality (on a 0–3-point scale), pain intensity increased 2.08 points (on a 0–10-point scale) among 1,246 patients with acute low back pain [105]. This large effect of poor sleep on subsequent pain intensity was unrelated to depression or other common factors. Among 1,016 patients with chronic low back pain or neck pain, 42.22% experienced sleep deprivation (less than six hours per night) and 19.88% experienced serious sleep impairment (less than four hours per night), even when using analgesics. Severity of sleep impairment strongly correlated with pain intensity score and pain chronification grade but did not differ between low back pain and neck pain [106]. PHYSICAL EXAMINATION The physical exam supports patient history findings, screens for serious pathology, informs further diagnostic work-up, and guides treatment selection. Neck pain origin is important to identify (when possible) and document, but underlying pathology of neck pain is seldom curable, and its treatment targeting has led to inadequate outcomes. Specific pathologies can generate different pain types, and the importance of pain type assessment and treatment is now stressed. Characterizing neuropathic pain and identifying neuropathic components in chronic nociceptive neck pain are essential tasks during the physical exam. Sensory, motor, and reflex testing during the physical exam, assessment, and provocative tests assist in this task [2; 19; 29; 41; 94; 103]. General Visual Inspection Observe patient to identify nonverbal facial or behavioral pain expressions. Gait abnormalities can reflect spinal cord (myelopathy) or brain injury. Note traumatic or developmental abnormalities. Assess gait, posture, stance, rapid walking, balance, and visible deformities. Palpation Palpate the spine, facets, and paravertebral muscles for tenderness, muscle spasm, myofascial tightness, and trigger points. Painful facets can reflect osteoarthritis or post-traumatic irritation of the joint capsule. Thoracic Spine and Shoulder Examine shoulder for range of motion impingement and rotator cuff function. Motor and Sensory Examination Evaluate upper muscle groups with specific nerve root focus; assess sensation to light touch, pin prick, temperature, position, and vibration. A >2 cm difference in circumference of two upper extremities may indicate muscle atrophy; motor and sensory differences may implicate a specific nerve root.
Reflex Testing Asymmetry of deep tendon reflexes may indicate pathology. Inverted reflexes (e.g., arm flexion or triceps tap) may indicate nerve root or spinal cord pathology at the tested level. Pathologic reflex tests include wrist clonus, grasp reflex, and Hoffman sign. In patients with suspected malingering or who report severe pain in the absence of pain-related behaviors, reflexes may be the only objective exam tool. Cervical Range of Motion During rotation, flexion, and extension, assess quality of motion and for presence of muscle spasm. Motion evaluation of specific joints may be indicated. Do not assess in acute trauma cases until fracture and instability are ruled out. Cervical range of motion is often limited in all patients with neck pain, but aggravating and alleviating factors and specific exacerbating movements may provide clues to the pain origin and inform decisions to concerning further work-up. Pain- exacerbating movements and suggested pain origin include [2; 14]: • Turning or bending head ipsilateral to source: Radicular or facet pain • Contralateral turning of head: Myofascial origin • Arm pain aggravated by neck extension: Spinal stenosis • Arm pain aggravated by neck flexion toward affected side: Foraminal stenosis and/or radiculopathy • Forward flexion: Diskogenic origin • Morning stiffness: Facet joint pain due to arthritis • Severe unrelenting pain unaffected by rest or position changes: Assess for “red flags” (e.g., malignancy, primary neurologic disorder, infection) Neuropathic Neck Pain Cervical radiculopathy is the most common neuropathic neck pain. Distribution of abnormal sensations or pain can follow patterns specific to the innervated skin (dermatome) of the involved nerve root, and less commonly, other innervated structures that include muscles (myotome), joints, or ligaments (sclerotome) [22]. Symptom distribution with mechanical stimulation of nerve roots (dynatome) differs from dermatomal patterns (although they may overlap). Cervical disk herniation may induce thermal distributions (thermatome). Radiculopathy can occur without pain, and distribution patterns vary among patients [51]. Cervical radiculopathy can result from nerve root irritation (chemical radiculopathy) or compression (e.g., disk herniation, foraminal stenosis, cord compression in myelopathy) [2; 29; 51].
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