neck pain - Ask Dr. P - The Pain Doc

Pain With No Apparent Cause

by Pain Doc | Jul 2, 2012 | Uncategorized

It’s strange, but you would think that for someone experiencing neck, back, shoulder or any other type of musculoskeletal pain in his body, he would know exactly when it started, and how.

But surprisingly, this is not the case for a majority of patients I have seen over the years. Most cases of pain I see are idiopathic; meaning, “with no apparent cause (at least in the eyes of the patient).”

A typical history of such a patient goes something like this:

Me: “Ok Sue, I understand you are experiencing pain in your upper back, right side. When did it start, and how, to your knowledge?”

Patient: “At least the past five or so years. I don’t know what started it; it just seemed to have appeared gradually. It is good some days, then bad, and lately it has been getting worse, so I decided to get it checked.”

At this point, I continue with the history by asking questions related to the patient’s occupational, social/recreational, and past medical history. Usually there is something in the history that can be linked to the complaint, like a past car accident, a particular sports activity during college, or something about the physical requirements of her occupation. But in some cases, there still is nothing in the history that can explain the pain.

But where there is a problem, there is an answer. It’s just that sometimes the answer requires some smart detective work.

If you suffer from pain that can’t seem to be traced to a specific cause, realize that musculoskeletal pain, aside from systemic related disorders such as rheumatoid arthritis, lupus, bone disease, and others, develops from some kind of mechanical breakdown in the musculoskeletal system. It can be something obvious like a hard fall that injures and misaligns a joint; something seemingly innocuous like sleeping on your right side for most of your adult life; or something very subtle, like a subluxated heel bone that does its damage via a drip effect.

So, your best bet is to find a practitioner who is very experienced in human biomechanics. Chiropractors or physical therapists such as Craig Liebenson, DC who emphasize body kinematics and targeted exercise rehabilitation will typically have a keen eye for abnormal or dysfunctional movement. The course of treatment will involve identifying and acknowledging the problem; aggressive rehabilitative exercise regimen, and lifestyle modifications. Manual therapies may be employed, such as spinal manipulation; and orthotics may be required, at least during the initial phase of treatment.

This applies to conditions including unilateral hip or knee pain, TMJ pain, neck pain with right or left rotation, rib or sternum pain, and many others. Oftentimes the condition is secondary to a primary cause, so the doctor should not jump to conclusions and direct all treatment to the site of pain. A thorough investigation and inspection is required.

What Should You Do For Neck Pain?

by Pain Doc | Jan 8, 2012 | Neck Pain

A recent study in the Annals of Internal Medicine compared the effectiveness of chiropractic spinal manipulation, pain medications, and home exercise and advice in treating biomechanical neck pain.

The study participants were 272 people between the ages of 18 and 65 who complained of non-specific neck pain for 2-12 weeks. They were divided into three groups, one of which took medicine only; one which received spinal manipulation to the neck only, and a third group that was just given home exercises and self-care advice. Participants were asked to rate their pain at 2 weeks, 1 month, 2 months, 3 months, 6 months, and one year. The method the study used to grade the pain was subjective rating (probably using a visual pain scale between 0 to 10, with 0 being no pain and 10 being the worst pain) and a Health Status questionnaire asking them their level of ability to engage in certain activities.

The patients treated by a chiropractor experienced the highest rate of success with 32 percent saying they were pain free, compared to 30 percent of those who exercised. Only 13 percent of patients treated with medication said they no longer experienced pain.

The conclusion of the study was that for participants with acute (recent onset) and subacute (usually meaning lasting more than two weeks) neck pain, chiropractic spinal adjustments were more effective than medication in both the short and long term. However, a few instructional sessions of home exercises and advice resulted in similar outcomes at most time points.

My comments:

Biomechanical neck pain can lower the quality of life significantly. Imagine having to struggle to turn your neck all the time, and having to avoid exercise, sports and many recreational activities due to neck pain. According to the researchers, neck pain affects 70% of adults at one point in their lives.

From my experience, biomechanical neck pain typically arises from some type of past trauma, and it doesn’t have to be major. Examples include car accidents, sports injuries/impacts, horseplaying as kids; and hard impact generating activities such as running, horseback riding, parachuting, gymnastics, boxing, martial arts, and cheer leading.

A second, possible cause of biomechanical neck pain is ergonomic in nature; meaning, related to positioning of the body. Long hours of desk work keeps the head relatively stationary (static) in a single position, allowing gravity to pull down on the head, over time altering the weight distribution on the joint surfaces of the bones that make up the neck. Such an “activity” also promotes muscle deconditioning around the neck. The term “deconditioned” means that the muscle is slower to respond to nerve commands, so it loses some ability to support, guard and protect the cervical spine (neck).

The worst combination is someone who has a history of impact trauma to the neck who later gets a job that involves working at a desk for long hours at a time. The trauma history sets the stage for neck pain, and the static positioning of the head accelerates the process over time.

The pain in biomechanical neck pain frequently originates in the joint surfaces of one or several cervical vertebrae, commonly the posterior facet joints (also called the zygapophyseal joints). This is where most of the movement occurs when turning and bending the neck. Orthopedic surgeons sometimes prescribe a facet block for neck pain, which is an injection of pain medications directly into the joint, usually guided by video fluoroscopy. If the patient has degenerative disc disease, pain can emanate from the intervertebral discs, either as a disc herniation or internal tear of the disc. If this is the case, neck surgery is typically the last hope. The disc herniation may be able to be reduced by surgery, but if the surgeon feels that the disc is beyond repair, discectomy (total disc removal) with surgical fusion is usually performed. However, this is like trading one evil for another. Surgeons know that when you fuse two vertebrae together, the vertebrae above and below the fusion bear an increased burden of providing the movement lost by the two fused vertebrae. This will lead to accelerated degenerative changes to those areas as well, over time.

Neck pain can also emanate from the surrounding muscles and fascia. Myofascial trigger points are focal, tender spots along a muscle that are believed to develop from trauma or microtrauma. They may actually be a concentration of nerve endings on the muscle that developed following an injury. These are best handled through manual therapies such as chiropractic, massage, exercises and stretches.

Some people get inexplicable muscle spasms of the neck. This is usually accompanied with a migraine or tension headache. A muscle spasm occurs when the nerves that control the muscle misfire, causing the muscle to maintain a constant state of hypertonus (involuntary contraction). This results in muscle pain, fatigue and low grade inflammation. Sometimes the spasm can be so intense that anti-spasmodic medications, ice, heat, and rest have no effect. In cases like this, botox injections are sometimes used. Botox injections are comprised of a weakened strain of the Botox bacteria, which has the effect of muscle paralysis.

Lastly, it should be mentioned that a poor, nutrient-deficient diet and smoking can make neck pain worse by denying the body critical nutrients needed for repair and maintenance of muscles, ligaments, tendons, nerves and bones.

The study, while emphasizing that chiropractic manipulation was superior to medications in reducing neck pain among participants, also mentions that home exercises and advice were just as effective. It therefore seems natural that a combination of spinal manipulation and home exercises would be a good strategy to reduce or eliminate biomechanical neck pain.

If you are experiencing non-specific neck pain (don’t really know what caused it) for over two weeks and desire to try chiropractic, it’s important to choose a good, qualified chiropractor. Some of the signs of a good, reputable chiropractor are:

1. Doesn’t try to convince you to purchase a long-term treatment program involving multiple adjustments per week.

2. Asks you about your complaint: the nature of your symptoms, how they started, how long you’ve had these symptoms, how they affect your ability to do certain things; and questions regarding your general health.

3. Gives you his/her diagnosis and uses standard orthopedic terminology that is consistent with what you are coming in for (doesn’t go off subject). It meshes with the information you provided in #2 above. You feel that the chiropractor listened to you, and responded with a meaningful solution that is clear to you.

4. Gives you a treatment recommendation the same day: the type of treatment and a brief description of it (spinal adjustments, modalities, supports); what to expect from the treatment, and approximately how long it will take. The chiropractor should also disclose potential risks and side effects of the treatment. In my opinion, six treatments followed by a re-evaluation is a sensible treatment approach for most cases of subacute, musculoskeletal pain.

A chiropractor like this may or may not have a lot of reviews on the internet. Use your judgement, ask friends and co-workers for referrals, and by all means, don’t be afraid to change chiropractors if your first choice turned out to be bad.

Regarding home exercises and advice for treating biomechanical neck pain, stay tuned! I will be putting up an information-packed neck pain relief video on this topic shortly.