Exercise Therapy and Self-management Techniques for Persistent Neck Pain (Part 1)

Neck pain accounts for 15% of the musculoskeletal soft tissue injuries presented in the general practice clinics. Most people have experienced an episode of neck pain in their lifetime. It is reported that the incidence of neck pain in women is more than men.

There are multiple factors that may contribute to neck pain and immediate medical attention is required to screen for red flags (medical emergency).1

Causes of neck pain

Sinister underlying causes are infrequent, and acute symptoms of most neck pain episodes generally resolve over a few days. 1, 2

Neck pain may occur due to different reasons. It may be a result of post traumatic (force related) injuries such as whiplash or may be caused by atraumatic (without external force) injuries such as postural stress syndromes (soft tissue sprains) or neuropathic in nature e.g. tingly feeling, burning shoulder pain among athletes.

However, the exact pathophysiology of chronic neck pain remains obscure in patients with complaints of frequent flare ups.3 In the absence of any specific disease detected as the underlying cause of the complaints, persistent neck pain is termed as non-specific chronic neck pain (CNSNP).4

Recurrence of neck pain

People may have multiple relapses of neck pain since their first episode. It is reported that 50% of individuals with history of neck pain continue to experience some degree of pain and recurrence.2

According to a Canadian study in 2004, among people with prevalent neck pain at baseline, in their one year follow up with their GP’s (local doctors), 37.3 % of the population have reported to develop persistent problems and 9. 9% of the population have reported further aggravation of their baseline complaint. 3

Recurrence of neck pain contributes to absenteeism from work and disability as the injury progresses to a chronic stage. Therefore, appropriate treatment of neck pain in the initial stages of injury may be required in order to stop the progression of the ailment from an acute stage to a chronic stage.

Treatment of neck pain 

Traditionally neck pain has been managed symptomatically by using pain medication. The “wait and watch” approach by GP have resulted in good short-term outcomes 2, but one third of neck pain patients develop chronic symptoms lasting more than 6 months, particularly in patients with CNSNP.4  Since there does not seem to have one particular intervention that may stop the recurrence of neck pain, other treatment alternatives need to be explored.

In recent years, physiotherapy interventions have gained momentum in treating neck pain because of its several therapeutic benefits on pain relief, musculoskeletal disability, and overall health.

A physiotherapist may choose from several interventions in treating musculoskeletal pain.  They may include manual therapy, exercise-based rehabilitation, pain management techniques and many other modalities.  Up to now, no one specific treatment method has gained consensus in the treatment of chronic neck pain.

The choice of treatment modalities in clinical practice is highly variable. This may be due to presentation of injury or practitioner preferences (routine, treatment bias, time constraints, etc.) rather than what is supported by hard evidence. There may also be other factors contributing to the treatment choices such as lack of “knowledge translation’, practicality, clinical set-up. But investigation of clinical decision making is outside the scope of this narrative.

Here, in this narrative we will look at some of the treatment modalities that are supported by current evidence.

First, while Exercise Therapy in the acute phase (first 24 to 48 hours of onset) may not be recommended due to high chances of flare-up, there is high quality of evidence that supports the use of both manual therapy and exercises for pain relief in the sub-acute stages. A combination of both manual therapy and exercise therapy for pain reduction and disability has been recommended over manual therapy alone for treatment of chronic neck pain.5

Second, many studies have reported significant benefits of therapeutic exercise (TE) on pain in the short-term (more than six months).  Yet the long-term effects of TE on pain are not well reported. This could be due to the lack of long-term follow ups in most studies. Research studies suggest moderate benefit of TE on disability at 6 months to 1 year follow up and small long-term benefits of TE in individuals with chronic neck pain. Thus, current evidence is inclined towards supporting the benefit of TE in the management of chronic neck pain.4

Third, recent advancements in our understanding of perceived pain suggest that chronic pain is complex and multifactorial in nature. Long term treatment and management of persistent neck pain should be adopted by looking at its complexity through a biopsychosocial lens. For example, biological factors (e.g. tissue inflammation), psychological reactions (e.g. anxiety, stress), social factors such as situation at home and family situation affecting quality of sleep, and occupational factors (e.g. poor ergonomics) should all be considered when treating persistent neck pain.

Biological (mechanical) factors, which play a crucial part in chronic neck pain, may be addressed using exercise-based rehabilitation and self-help techniques. Some of these modalities are often overlooked in clinical practice and therefore these modalities will be the focus of this chronic neck pain narrative.

The psychosocial factors may not be the same for everyone and are dependent on individual circumstances; therefore, a multidisciplinary health care approach should be considered.

Recommendations, in this narrative should not replace physiotherapy or medical advice.  On the contrary, these modalities may be beneficial as an adjunct to professional advice for patients suffering from ongoing neck pain. Some of the treatment modalities and self-help strategies that will be presented to you are as follows:

  • Ergonomics and breathing pattern
  • Mobility exercises
  • Motor control strategies
  • Strength training

In part 2 of this narrative, we will discuss when and how these interventions could be applied in the management and treatment of chronic neck pain. We will suggest an action plan for these interventions by using the stages of healing as our guide.

Key takeaway: Recurrence of neck pain is common and can lead to musculoskeletal disability. Treatment of neck pain should be multifactorial in nature. Therapeutic exercise and self-management modalities are key to treatment of persistent neck pain.

Reference:

  1. Hackett, G. I., Bundred, P., Hutton, J. L., O’Brien, J., & Stanley, I. M. (1993). Management of joint and soft tissue injuries in three general practices: value of on-site physiotherapy. The British journal of general practice: the journal of the Royal College of General Practitioners, 43(367), 61–64.
  1. Cohen, S. P. (2015, February). Epidemiology, diagnosis, and treatment of neck pain. In Mayo Clinic Proceedings(Vol. 90, No. 2, pp. 284-299). Elsevier.
  1. Côté, P., Cassidy, J. D., Carroll, L. J., & Kristman, V. (2004). The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain112(3), 267-273.
  1. Bertozzi, L., Gardenghi, I., Turoni, F., Villafañe, J. H., Capra, F., Guccione, A. A., & Pillastrini, P. (2013). Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Physical therapy93(8), 1026-1036.
  1. Miller, J., Gross, A., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., … & Hoving, J. L. (2010). Manual therapy and exercise for neck pain: a systematic review. Manual therapy15(4), 334-354.

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