_________________________________________________________________________ Neck Pain in Adults
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
Traction is popular among patients with cervical radiculopathy, but it is contraindicated with tumor, infection, fracture, or dislocation [103]. Mechanical traction is widely used to promote cervical immobilization and widen the foraminal openings. Cervical traction may relieve radicular pain from nerve root compression, but it does not improve pain from soft-tissue injury. Hot packs, massage, or electrical stimulation should be applied before traction to relieve pain and relax muscles [65]. IMMOBILIZATION Immobilization limits neck motion to reduce nerve or soft tissue irritation, and soft cervical collars are the most widely used device. For acute soft-tissue neck injuries, cervical collar use should not exceed three to four consecutive days to avoid risks of losing cervical range of motion and neck strength from muscle disuse and atrophy [51]. In radiculopathy caused by foraminal stenosis, the wide part of the collar is placed posteriorly, with the thin part placed anteriorly to promote neck flexion, discourage extension, and open the intervertebral foramina. Cervical collars can be worn during sleep or distance-driving [51]. In severe cervical spondylosis with evidence of myelopathy, cervical spine immobilization is the mainstay of conservative treatment. Soft cervical collars do not sufficiently limit cervical spine motion and should only be used in daytime. More rigid orthoses adequately immobilize the cervical spine; isometric cervical exercises may help limit loss of muscle tone [65]. PASSIVE ASSISTIVE DEVICES Passive assistive devices inhibit or prevent movement [8]. Molded cervical pillows can better align the spine during sleep and provide symptom relief for some patients [65]. THERMOTHERAPY Thermotherapy applies heat or cold to superficial or deep tissue. Superficial thermotherapy applies heat or cold to raise or lower skin tissue temperatures. This approach is indicated for reducing acute pain, edema, muscle spasm, and inflammation, or for promoting stretching/flexibility. Heat packs or hydrotherapy can apply heat, while cold packs or vapocoolant spray can apply cold. Cold and heat packs can be used at home [8; 103]. Deep tissue thermotherapy is applied to affect structures beneath the skin surface and includes low-level laser, electrical muscle stimulation, pulsed electromagnetic therapy, and ultrasonic heat [8]. Electrical muscle stimulation is indicated for muscle spasm or atrophy with varying frequencies, from twice daily to once weekly. A home unit should be purchased, if effective. Short-wave diathermy applies an electromagnetic field to soft tissues to reduce muscle guarding, inflammation, or edema, typically two to three times per week for three to five weeks [103].
Indications for TENS therapy in patients with neck pain include muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width, and amplitude modulation. In patients with pain relief using TENS, also consider functional improvement before prescribing for purchase of a home unit [103].
PHYSICAL AND EXERCISE THERAPIES Functional Restoration Programs
Functional restoration programs assist patients disabled by chronic cervical pain to overcome obstacles to recovery, such as deconditioning, secondary gain, poor motivation, and psychopathology. Patients should receive education on cervical anatomy, biomechanics, pathology, and ergonomics, and develop preventive strategies that protect against further injury during daily activities. These medically directed interdisciplinary programs have been successful in helping workers’ compensation patients return to work and in reducing recurrent injury, new surgeries, and healthcare use in patients with chronic cervical pain who successfully complete a program [51]. The McKenzie Approach For most cervical disk disorders, studies support conservative treatment, such as the McKenzie approach or cervicothoracic stabilization programs combined with aerobic conditioning. The McKenzie system identifies three mechanical syndromes that cause pain and compromise function [51]: • The postural syndrome: Provokes pain when normal
soft tissues are loaded statically at end-range of motion. Treatment aims to correct posture.
• The dysfunction syndrome: Produces pain when the patient attempting full movement mechanically deforms contracted scarred soft tissue. Therapy involves stretching and remodeling of such contracted tissue. • The derangement syndrome: Produces intermittent pain with certain movements or postures from activity-dependent displacement of intradiscal material. Therapy attempts to correct derangement by promoting activity that centralizes pain. The McKenzie theory recognizes that patients may demonstrate similar signs and symptoms, but one movement (i.e., cervical extension) may help some patients and aggravate symptoms in others. In McKenzie therapy, treatment individualization plays a key role [51].
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