Review article

The anatomy and pathophysiology of neck pain

Our aim is to provide an overview of how neck pain is classified in the literature, define and group conservative interventions into ‘nodes’, and develop draft networks of interventions in preparation for a network meta-analysis (NMA).

We performed a scoping review. For feasibility reasons, we searched for randomized clinical trials (RCTs) via neck pain clinical practice guidelines (CPGs) published from 2014. We used standardized data extraction forms to extract data about classification of neck pain and interventions evaluated in the included RCTs. We calculated frequencies of neck pain classifications and grouped interventions into nodes based on the definitions used in Cochrane reviews. Draft network graphs comparing interventions were constructed using the online Shiny R application CINEMA.

We included 242 RCTs from seven CPGs, evaluating 28,581 patients. We found three different classification systems of which The Neck Pain Task Force classification was used most often. We defined and grouped all interventions into 19 discrete potential nodes.

We found a wide variation in neck pain classifications and conservative interventions. Grouping the interventions was challenging and needs further evaluation before conducting a final NMA.

The investigation of this study was to compare the effect of adding motor imagery training to neck stabilization exercises on pain, disability, and kinesiophobia in patients with chronic neck pain.

After screening, seventy-two volunteers with chronic neck pain were randomly allocated to 3 groups: neck stabilization exercises alone, n = 24, combined ( neck stabilization exercises + motor imagery training), n = 24, and a control group, n = 24. Pain intensity, disability, and kinesiophobia before and after the intervention exercises were measured by the Visual Analog Scale, Neck Disability Index, and the Tampa Scale of Kinesiophobia , respectively.

Statistically significant differences in pain intensity, the neck disability index, and kinesiophobia were found when a combined intervention group including neck stabilization and motor imagery training was compared with neck stabilization training alone at 6 weeks ) p ≤ 0.005). Also, there were significant between-group differences favoring experimental groups versus control for all outcomes (p ≤ 0.001).

neck stabilization exercises in combination with motor imagery training was superior to neck stabilization exercises alone in decreasing pain, disability, and kinesiophobia in patients with chronic neck pain.

Neck Pain can be related to the disorders of other adjacent areas such as the Temporomandibular Joint (TMJ). This study aimed to investigate whether there is value in adding TMJ treatments to routine physiotherapy in patients with non-specific chronic neck pain compared with a control group.

A randomized, single-blind, clinical study desined including two groups of patients. Group A (20 people) received routine physiotherapy for neck pain and group B (20 people) received TMJ manual therapy plus exercise therapy in addition to routine physiotherapy for neck pain. The Treatment program included six sessions for two days a week over a period of 21 days. Assessments were performed during the first session, in the last session and one month after treatment as a follow-up. Outcome measures included neck range of motion (ROM), neck disability index (NDI) and visual analogue scale (VAS). Before starting the study, the reliability of methods for measuring neck ROM was evaluated.

Participants were 21 women and 19 men. Initially, a pilot study was carried out on the 40 volunteers to assess the reliability of the measurement methods, and the results were acceptable. With both the control group and the intervention group, the indexes showed significant improvement (p < 0.001), although the intervention group showed more improvement (p < 0.001).

This result means adding treatments of TMJ to routine neck physiotherapy can magnify the effect of the intervention, a significant change still in evidence at follow up. Moreover, given the clinically important differences, our results for VAS and NDI were acceptable.

Low back pain has become a costly burden to society. It is currently the leading cause of disability worldwide. It is extremely common and affects all age groups throughout the world. Despite the steep rise in cost in the diagnosis and treatment of low back pain, outcomes have gotten worse, with more patients disabled than ever before. The physiatric approach to low back pain could reverse some of these worldwide trends. There are some serious causes of back pain in which a clear pathology can be identified, but for the vast majority of patients with low back pain, a specific cause cannot be found. Most people with new back pain recover quickly, but for a few, pain becomes persistent and costly. This chapter outlines the anatomy and biomechanics of the lumbar spine and our current understanding of the physiology of low back pain. Then, the clinical evaluation and treatment of various etiologies of low back pain and leg pain caused by lumbar spine disease are discussed. Information about how to recognize serious causes of low back pain so that they can be diagnosed early is covered. The evidence for various treatments of low back pain, and benefits and risks of treatment are thoroughly described so that physicians can protect patients from unproven or harmful approaches to management and deliver patient-centered care that focuses on self-management and healthy lifestyles. An overview of the treatment of low back pain in special populations, such as during pregnancy and back pain in children, is also covered.

Successful treatment of painful cervical spine disorders hinges on the accurate assessment of the underlying tissue injury, which can involve a broad range of biomechanical and biochemical disorders. The clinician needs to conceptualize a process of diagnosis and treatment that incorporates an understanding of the pathophysiology of cervical spine injury and the associated potential symptom manifestations, an awareness of the advantages and disadvantages of the myriad of diagnostic tools, and knowledge of the potential therapeutic options. The initial step in this process is the history taking. It is important that one distinguish between cervical axial pain (neck pain) and upper limb pain. Evaluating and treating common cervical spine disorders requires the completion of a probability analysis of what injured structure is most likely responsible for the patient’s presentation. An astute spine clinician recognizes individual symptom composites to accurately diagnose and treat these injuries. This chapter is intended to be a foundation for approaching common painful cervical spine disorders, and provides a view of a tiered treatment algorithm, which incorporates appropriate therapeutic interventions across a spectrum of care.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of “red flag” symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.