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Neck pain - non-specific - Management
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How should I manage someone with non-specific neck pain?
- Manage any comorbidities, such as other chronic pain conditions, chronic physical conditions, anxiety, and mood disorders.
- During the first 3–4 weeks (acute phase):
- Reassure the person that neck pain is a very common problem and that the symptoms are likely to resolve.
- Encourage the person to remain active and return to a normal lifestyle.
- Discourage the person from wearing a cervical collar. Neck supports, if used, should be worn for as short a time as possible (2–4 days) and under supervision (e.g. by a physiotherapist), to ensure that mobilization is started as soon as possible.
- Strongly discourage prolonged absence from work.
- Poor posture should be corrected if it is thought to precipitate or aggravate the neck pain.
- Advise the person not to drive if the range of motion of the neck is restricted.
- A firm pillow may provide comfort at night:
- The pillow should provide lateral support and support the hollow of the neck.
- A position of comfort should be found before trying to go to sleep.
- Using two pillows may force the head into an unnatural position.
- Offer limited courses of analgesia to relieve symptoms. Choice of analgesia depends on the severity, personal preferences, tolerability, and risk of adverse effects (see Prescribing information on NSAIDs). Options include:
- Paracetamol or ibuprofen taken as required — this will be sufficient for many people, or
- Paracetamol taken regularly, or
- Ibuprofen taken regularly, or
- Paracetamol and ibuprofen taken regularly, or
- Codeine taken in addition to regular paracetamol or ibuprofen if the response to either drug is insufficient. Codeine should be prescribed separately to allow flexibility of dosing and titration of analgesic effect. Combination products, such as co-codamol, are not recommended.
- If symptoms persist from 3 or 4 weeks to 12 weeks (subacute phase), in addition to the above:
- Refer to a physiotherapist for a multimodal treatment strategy that includes exercise and some form of manual therapy.
- Look for and address any psychosocial factors:
- Fear or avoidance beliefs.
- Associated anxiety and depression.
- Medico-legal issues.
- Family dynamics.
- Promote positive attitudes to activity and work.
- Consider referral:
- To a psychologist or occupational health clinician.
- For acupuncture.
- If symptoms persist for more than 12 weeks (chronic phase), in addition to the above:
- Continue physiotherapy if helpful, discontinue if not. Avoid passive interventions, such as massage or electrotherapy.
- Consider a trial of a low-dose tricyclic antidepressant (for example, start with amitriptyline 10–25 mg and titrate accordingly) if the pain is unresponsive to full-dose standard analgesics. For further information on tricyclic antidepressants (including dose titration), see the CKS topic on Neuropathic pain - drug treatment.
- Re-examine psychosocial factors periodically.
- Consider referral to a pain clinic.
- For people with chronic pain or nerve root symptoms that are poorly controlled, consider referring for assessment for invasive treatment, including surgery.
Basis for recommendation
- It is not possible to treat neck pain solely on the basis of current evidence, as few treatments have been assessed in high-quality randomized controlled trials [Binder, 2007b]. These recommendations are based on expert advice in a primary care textbook [Williams and Hoving, 2004].
- Comorbidity is common in people with chronic neck or back pain [Cote et al, 2001]. Most people (87%) with chronic spinal pain report at least one other comorbid condition, including other chronic pain conditions (69%), chronic physical conditions (55%), mental disorders (35%), anxiety disorders, and mood disorders [Von Korff et al, 2005].
- Although acute non-specific neck pain tends to resolve over a few weeks, evidence indicates that it can progress into a chronic disabling condition.
- Although there is no trial evidence, expert opinion in review articles [Barry and Jenner, 1995; Binder, 2007b] recommends that:
- Postural aspects in daily activities, work, and sport should be identified and corrected where possible.
- A reduction from several pillows at night to one pillow will help many people.
- The evidence is insufficient to assess the effectiveness of drug treatments, electrotherapy, massage, multidisciplinary biopsychosocial rehabilitation, education, physical treatment, special pillows, and traction.
- Few randomized controlled trials have specifically tested drug treatments for neck pain. Although evidence is insufficient to assess the effects of drugs to treat neck pain, it is reasonable to extrapolate evidence from trials of these drugs for back pain and other painful musculoskeletal conditions:
- Paracetamol is a good first-line choice for pain relief and is not associated with gastrointestinal toxicity [SIGN, 2000]. It is suitable for the treatment of mild-to-moderate pain, and it is well tolerated at the recommended daily dose. It is more likely to be effective for neck pain when used regularly rather than 'as required'.
- Codeine 60 mg plus paracetamol has been shown to provide more pain relief than either codeine 60 mg alone or paracetamol 1000 mg alone [Moore et al, 1997].
- Codeine can also be combined with an NSAID, or paracetamol can be combined with an NSAID, but there is less evidence to support this.
- No evidence suggests that any particular NSAID is more effective than another for neck pain. Ibuprofen is generally preferred because of its lower risk of gastrointestinal adverse effects [CSM, 2002].
- The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders recommended that people with common neck pain (grade 1 neck pain with no signs of major abnormality and no or little interference with daily activities, or grade 2 neck pain with no signs of major abnormality but interference with usual daily activities) should be offered non-invasive treatments if short-term relief is needed [Guzman et al, 2008].
- Strong evidence favours a multimodal care approach using exercise combined with mobilization or manipulation in people with subacute or chronic neck pain. The relative benefit of different exercise approaches and which subgroups may benefit is unclear. A best-evidence synthesis by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders concluded that the evidence suggests that manual and supervised exercise interventions are more effective than sham treatments, no treatment, or alternative treatments and that interventions that focussed on regaining function as soon as possible were more effective than interventions that did not have such a focus [Hurwitz et al, 2008].
- Moderate evidence indicates that acupuncture has clinical treatment benefits, but the effects are short term.
- Magnetic resonance imaging (MRI) should be done in the presence of widespread neurological symptoms or signs [Williams and Hoving, 2004].
When should I refer someone with non-specific neck pain?
- If 'red flags' (suggesting a serious spinal abnormality) are present, refer urgently or arrange immediate assessment, depending on the severity of the clinical findings.
- If symptoms persist from 3 or 4 weeks to 12 weeks (subacute phase):
- Refer to a physiotherapist for a multimodal treatment strategy that includes exercise and some form of manual therapy.
- Consider referral to a psychologist or occupational health clinician.
- Consider referral for acupuncture.
- If symptoms persist for more than 12 weeks (chronic phase):
- Refer if the person has not had a course of physiotherapy and spinal manipulation.
- Consider referral to a pain clinic.
- For people with chronic pain or nerve root symptoms that are poorly controlled, consider referral for assessment for invasive treatment. Surgery and other invasive treatments are rarely indicated.
Basis for recommendation
- These recommendations are based on expert opinion in a primary care textbook [Williams and Hoving, 2004] and review articles [Binder, 2007a; Binder, 2007b].
- Moderate evidence indicates that acupuncture has clinical treatment benefits, but the effects are short term.
- Magnetic resonance imaging (MRI) should be done in the presence of widespread neurological symptoms or signs [Williams and Hoving, 2004]. The result should be interpreted with care because although MRI is the investigation of choice when a more serious abnormality is suspected, normal people also have abnormalities on MRI [Binder, 2007b]. For example, asymptomatic disc protrusions are present in 10–15% of the population [Williams and Hoving, 2004].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Paracetamol +/- codeine
Age from 16 years onwards
Paracetamol tablets: 500mg to 1g up to four times a day
Paracetamol 500mg tablets
Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Add on if severe pain: codeine tablets
Codeine 30mg tablets
Take one to two tablets every 4 to 6 hours when required for additional pain relief. Maximum of 8 tablets in 24 hours.
Supply 28 tablets.
Ibuprofen
Age from 16 years onwards
Ibuprofen tablets: 400mg three times a day
Ibuprofen 400mg tablets
Take one tablet three times a day.
Supply 21 tablets.
Tricyclic antidepressants: initiation (for neck pain)
Age from 18 years onwards
Amitriptyline tablets: 10mg at night
Amitriptyline 10mg tablets
Take one tablet at night.
Supply 28 tablets.
Amitriptyline tablets: 25mg at night
Amitriptyline 25mg tablets
Take one tablet at night.
Supply 28 tablets.
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