Neck Pain

Sean Mackay: Today I’d like to welcome back to the PodMd studio Nathan Rickard.
Nathan Rickard is a Physiotherapist with over 20 years’ experience. He has worked in both the public and private sector, leading large teams that care for musculoskeletal patients. He currently owns and operates two community-based physiotherapy clinics in Melbourne with a team of 14 Physios and Exercise Physiologists.

We have physiotherapist, Nathan Rickard and spinal surgeon, Yi Yang talking about the full spectrum of neck pain patients and how to best help them
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

What are the most common causes of neck pain?

In our physio clinic, the most common ones are cervical posture syndrome, which is what we call the syndrome or pain syndrome when a patient presents and get generalized neck pain, usually from sitting and when they’re stressed as well.

So, I say, look, I carry my tension in my shoulders. That’s how I tend to flag this particular kind of pain. So, it gets worse. Whereas we’re sitting for long periods, hence the posture syndrome, uh, definition, um, the second most common or one of the most other common ones we see is a cervical facet, joint dysfunction. Uh, that’s typically pain on one side of the neck and it’s pretty much always associated with a lack of range of motion usually to that side of the neck, but also with looking down or looking up, cause the facet joint on that side is just not opening or closing properly.

Nathan, have you seen an increase in these two presentations during the COVID?

Yeah. Good question. Not so much the second one, but definitely the first one. So, you know, people set up at home desks and home desk is probably a nice way of putting it or, or might a couch, a couch that’s up on their knees for eight hours or even worse lying in bed.

So now to absolutely there’s been an increase that and running injuries. Um, but, uh, yeah, but the third, most common would be a cervical radicular apathy and usually caused by a disc bulge or uh, or at least an inflamed disc, which is irritating a nerve root. Uh, and probably one that I just flag. It’s one that we don’t see commonly, but I’m just bringing it up because if you miss it, it can, or just, I like to diagnose it. It can kind of mess a patient around for quite a while. And that’s neck pain caused by an inflammatory condition, a systemic one. Uh, cause if you miss that, it just ends up many people end up doing a treatment or exercise for prolonged periods without any real results. Uh, so I usually always back to GP for, um, bloods or rheumatologists, uh, referral

What about yourself when it comes to who you see for neck pain?
I’ve certainly been seeing a lot more pain in relation to the posture. I actually had a lady who operated on her back and she went to work, or she went back to work at home, herniated, a disc in her neck, herniated this down in her thoracic spine and ended up spending a few days in hospital. So definitely home offices have been a massive cause of increased neck pain for me recently. But roughly for, for me, the pain that I see in regard to the cervical spine is divided into two general areas. One is musculoskeletal, so that’s the muscular symptoms and the joint symptoms that you’ve touched on. So, I won’t really talk too much about them. I would say one thing is that, um, I do actually get referred pain on occasions. So, rotator cuff tears that can manifest as neck pain and vice versa. A lot of shoulder pain is actually from the cervical spine and in that region of radiation. So, um, it’s not uncommon that, um, I have a lot to do with shoulder surgeons or upper limb surgeons because of these referred pains.

How do you differentially diagnose those kinds of concerns?

Great question. So often the examination is difficult because they do have pain in their shoulders and they do have pain in the neck and the same degenerative process that’s occurring in their neck can also be occurring in their shoulders, such as arthritis. So often a sensitive way to diagnose it as way imaging in the end. But certainly, there are, there are aspects of the pain, um, such as nerve type pain, which is the second large group that I see, which differentiate the shoulder paint, which doesn’t usually travel. So, shoulder pain is usually local, maybe goes down occasionally to the elbow, goes up to one side of the neck, but that’s about it. Whereas the neck pain with radicular apathy will go straight down to your fingers on a lot of occasions. So that’s a great segue into the second part, which is nerve type pain or the radicular pain that we see or that I see.

So, the most common would be cervical radicular apathy. So, where you have a cervical disc herniation and it impinges on the nerve, which then causes traveling pain all the way down the arm and into the fingers. And that can cause both a combination of pain and weakness. So, um, that’s probably the most common nerve type pain. There are other presentations of nerve type pain, such as pain that’s going to the back of the scalp is a very common one that I see and name for that is the occipital neuralgia. Typically, it’s because of the upper cervical levels being compressed, but you’ll find that the most common levels would be six and C6 seven. And those typically are hand symptoms that you would get. And then finally, the last one is actually not painful at all, which is my lot of feet. And that’s where your spinal cord becomes compressed upon. And the spinal cord itself doesn’t actually have innovation. So, it’s just like, this is how people can do brain surgery because the brain itself doesn’t actually carry any nerve fibres. And the symptoms of my law Kathy are actually mostly in the hands in the legs, upper motor in your own science. So, hyperreflexia and balancing. So that’s rarer. However, it’s an important one to be aware of.

How did they typically come to you? Those kinds of patients, you can actually bilateral symptoms that have been picked up by a GP.

Well, I think a lot of it is actually a decline in general function. So, the last one I picked up was because they came to see me because of back pain. And the first thing they did was walk in the door. Um, they walked into the doorframe because they had a balance. Yeah. So, they, you know, the door was open, open the door for them and boom, straight into the doorframe that they go because they just don’t have the proprioception. They lose all of the biggest fibres or the biggest nerve fibres in their body. So, they start to lose balance appropriate ception and as a result become severely disabled. So, it’s a, uh, really a silent problem, which can become very significant. Yeah, for sure. Interesting.

When should you refer to radiology?

Look, I basically try not to refer to radiology as much as possible. Um, simply because there’s a fair bit of evidence now, probably more on the lower back than the, the neck, but there’s quite a bit of evidence that shows that, um, the more you refer to radiology and the more people get told about this age related changes, the more they believe they’ve got a problem and the more they believe they’ve got a problem, the more pain they have and the more it tends to stay with them. So really, I always avoid referring for radiology unless there are red flags present. So, if I’ve been the first contact for that patient and there’s red flags present, um, all then refer for radiology, um, or back to their GP. And then the other time really is if I think surgery might be indicated. Um, and I explained to the patient, I said, look, you know, what you’ve got is, you know, very normal. We see this all the time and it recovers with XYZ. Um, but so therefore, unless I think you probably need surgery, well then there’s no real point referring at this stage. Um, then let’s just say, if someone’s three months down the track and they’ve got persistence, persistent, peripheral pain, that’s referring from a nerve root denim, you know, I’m much more likely to refer, um, or I might just, you know, send on to a surgeon like yourself or touch base with someone like yourself to, to go from there. Um, what about yourself know, I

Think what you bring up is an excellent point in that we know asymptomatic, these degenerations occur in basically everyone and the latest studies, um, show that this generation starts occurring in teenagers. And so essentially signed people up to this ongoing cycle of needing more and more imaging until they’ve had every investigation under the sun. And because we don’t have actually a scan to show pain and what we can see on the scans don’t necessarily correlate with where the patient has pain. Um, and so I think that’s where the clinical now sort of comes in. But in terms of my practice, I tend to image people, uh, based on time or symptoms either. They’ve had their symptoms for a long time. And usually by the time they get to see me, they’ve been to see a physio. They’ve been to see their GP and it’s been six to eight weeks.

So, I think that’s the sort of cut-off window when they start to come out of that acute phase and going to a semi acute or chronic phase. Now, alternatively, if they’ve got really bad symptoms, so basically if they can’t move their arm or their leg because of weakness or pain, and a lot of weakness is caused by pain inhibition, like you’re not going to be able to walk on a broken foot. So therefore, I think that, um, deserves some sort of investigation or imaging. And then finally you have the small, but uh, very serious group of traumas, tumours, infections, rheumatoid, all that sort of thing. Yeah. They all definitely need to be investigated.

Are there any tell-tale signs when it comes to who might need surgery just for the benefit of myself or GPS referring to a surgeon?

Well, I think weakness, uh, or severe pain is always a consideration. Um, and also it depends on the duration and how other treatments or how, what are the treatments they might’ve tried? So, I don’t think many people out there would be signing people up for surgery if they only had symptoms for two to three weeks, you know, unless it was something like they couldn’t pee or they couldn’t move their arm and it’s completely paralysed. And usually those people end up in emergency anyways. So, I think for the great number of GPS or physicians or fair family doctors out there, they would see someone at maybe the four-week Mark, six-week Mark. And if they’re still symptoms are not getting better or they’re continually to be, or they continue to be severe. And then they send them to me, we obviously try conservative management and then assess them based on their symptoms. So, duration of symptoms, severity of symptoms, um, and also the effect of the symptoms themselves.

So, if someone’s got weakness, that’s not just playing inhibition, but it’s weakness due to nerve root impingement. How long is too long if their motor power is affected to answer your question and then, you know, if you, if they’re not operated on sooner enough, they’re left with the permanent weak?

Yeah. That’s a great quote. And I think look to some extent, um, pain also is like that as well because motor function and pain function are not necessarily carried by the same fibres of the note is extremely complex. It’s far more than what we give it credit for. It’s not just the wire, a nerve itself actually has its own physiology. And so those, we S uh, it’s fairly commonly accepted that if we say, look, you’ve had weakness for a long time, there’s very good chance you don’t get a complete recovery because of chronic weakness by that same token, a lot of patients also get chronic pain, but never get better. In fact, there is some good studies to show that neck pain is not as benign as we used to think it was, you know, especially in an older population. Um, we find that people with neck pain that started acute, we used to think that they all got better maybe after six months, 12 months. And the reality is that that study showed about 60% don’t actually improve. Um, and they get ongoing neck pain.

So, do you suspect Yi, that when it comes to pain, it’s due to the, effect on that nerve root itself, or do you think it’s due to more central pain, sensitisation and psychosocial factors?

We’re starting to get outside of the boundaries understanding, but what I can say is that nerves themselves and also the brain in the way that we perceive pain has a certain amount of plasticity and memory. And this is why people can get Phantom limb pain after they don’t have that limit anymore. So, it makes no sense, right? Someone’s like is no longer there yet. They can still very much feel neuropathic pain down their leg. And so, I’m sure that the actual physiology of the nerve, the way interacts with your brain is extremely complex. And it’s not as simple as well. This nerve connects your brain to your muscle. So, I guess coming back to your original question of how long we should wait before we do something, it depends on how bad the symptoms are and how long those symptoms have gone on for, for, for me, you know, a grade four or a slight amount of weakness is not a huge deal. However, they come in, um, and they can’t lift their foot and they’ve got a drop foot, or you can hear them down the Cardinal slapping their foot down, then that represents a much more significant issue

Individually assess them, I guess. But in general terms, you probably don’t want weakness to be more than three months. Yeah, for sure. Would you say that’s what you experience has been?

Yeah. Look, I don’t like anything going on for more than three months. I mean, in general, when you look at your typical healing, even if there’s like inflammation present, pigging it two to three days tailing off and being gone by two weeks, if you reduce other factors that should be causing them ongoing pain, um, you know, if they’re not right by three months and you’ve tried all the things that need to be done from a conservative point of view yeah. They need to be sent on at that point, for sure. If not a bit sooner. Yeah.

Yeah. And that, again comes back to how bad their symptoms are as well. Like you’ve got the grade one grade, two can barely lift the foot versus, you know, it does most things don’t worry, but you know, can’t do a hundred-star jumps. That’s a different group of patients.

Nathan, uh, there seems to be a broad range of conservative treatment options. So, what do you actually do?

Yeah, it’s a good question. And I think sometimes as physios, we forget that everybody doesn’t actually know what we do because it can be quite broad. Um, but a simple way of putting it is that we don’t heal people. Um, I’m always telling clients that I’m not Jesus, I’m not going to heal you. I can’t do that. Um, because they will heal on their own. What we do is, and what I think is the most important thing is reduce the risk of repeated episodes and also reduce the risk of developing chronic pain. Um, because that’s where the real problems lie when it comes to how neck pain can impact on someone’s life. Um, so in order to reduce the risk of repeated episodes and chronic pain, it’s important to identify and remove the behaviours that cause neck pain. Um, and that might be honestly, sometimes someone comes in and they’ve got neck pain and I asked them why. And I say, well, I get it. After watching Netflix on my laptop for two hours in bed, I go, well, you know, you don’t need to see me. You just need to stop watching Netflix on your laptop

In order to understand. That’s why I don’t identify that.

Yeah. It looks some people; some people are quite intuitive, and they do. And some people just don’t, it’s, it’s sometimes quiet, uh, quite astounding. Um, also identifying and eliminating environmental factors that causes someone’s pain. And the most common, one of that is a poor desk set up. And like we were saying earlier, you know, home desk set up. So, it’s not the behaviour that’s putting constant and continual pressure and stress on the neck. It’s the actual environment that they’re living in that isn’t encouraging certain postures or forcing certain postures. Um, we, uh, restore range of motion because if someone’s got limited movement and tension in their neck, whether it’s global through muscles or more specific through particular joints, um, that pressure with use of the neck is going to cause mechanical pain and eventually inflammatory pain and Fe you know, if they, if it’s severe enough to cause tissue breakdown. Uh, so we restore range of motion using manual therapy techniques, such as, uh, massage and joint mobilizations and, um, teach people how to stretch as well.

So, can you go into what you do versus say manipulations of the neck?

Yeah, for sure. Um, so immobilization, just to, I guess define it is low, large amply or relatively large amplitude pressure on a facet joint or on the whole vertebrae via the spine central Spanish process to basically loosen the joint. Um, and manipulation is commonly. What was, what is commonly referred to as cracking a joint or in a more accurate description? It’s a high velocity thrust techniques. So it’s taking a joint that’s restricted in range and taking it to its end of its restricted range and then doing a high velocity, but small amplitude thrust to basically open the joint very quickly or close it very quickly and kind of get past that barrier of restriction. Um, I asked that it causes a reflex that allows the overlying muscles to relax, and then it’s quite handy to restore the, the movement in that joint. Um, you know, I’ve sort of looked at this more recently and I can’t find any studies that show that manipulations are more successful than mobilizations. And so, given that they’re, you know, they can be some danger associated with, with cracking joints, with the high velocity thrust. Um, I tend to stay away from them myself. Um, sometimes if a joint yeah, can very easily cracking feels like a once again on the patient, says it and takes it

In front of you and they crack it themselves and they feel better afterwards. Yeah. Which I think is probably fine. Everyone cracks, knuckles and misses. If you can do it yourself makes you feel better than who am I to argue.

Yeah. As long as you know, I guess, I guess where the real dangers come with cracking someone’s neck when you’re enjoying it, because you’re providing the force, they’re not controlling it internally. You know, someone who’s been on steroids for long periods or someone that’s kind of in that age bracket way, they’ve still got a good range of motion and then neck, but the carotid artery, I’m sorry, the vertebral basil artery is sort of starting to thin out and weaken a little bit, get plaques, and then you can, and then if you pop that, you know, you’re not going to be

Check manipulations in general, uh, should be very, very cautious because the potential for something bad to happen is high. Whereas in the fingers, for example, the worst thing you can do is sort of cause a bit of pain and perhaps dislocated joint. And so that’s a very different thing. And I’ve certainly seen patients who’ve become worse with a cervical disc herniation, although those are rare. And I don’t think that that is a commonly done thing. What I would say is that, and this is to echo your, your last point is that there have been large scale studies to show that, um, traction can help temporarily. And this is a very thing is that people go and have their neck traction and pulled. And you can know, even by these devices on the internet now, but sort of neck traction, and they will help for a day or two and generally your pain will come back afterwards. And I think it’s that process of elongating or providing traction to the joints that makes people feel better. Yeah.

And that’s from nice little segue probably into my last point. So as physios, whilst we do that, those manual therapy techniques, they really are just focusing on the symptoms and treating the symptom, not the cause of the problem. Um, so as well as, you know, improving behaviour and modifying environments, um, to take the pressure off that person’s neck, the most important thing is to actually strengthen the person’s neck, postural muscles and also their shoulder and upper limb muscles to improve the capacity of that person’s neck to perform what they need in life. Um, and I reckon this is becoming more and more important all the time, because as a general rule, we’re all becoming more sedentary and less active, which means that what a lot of us have weaker, stiffer necks through lack of views. And that means that we’ve got less capacity when we then go and garden or, um, you know, start going to the gym or go on holidays and start lugging, um, baggage around. And therefore, we actually hurt our necks more easily. So, in order to reduce ongoing episodes and help reduce the risk for chronic pain, we focus on postural strengthening in general strengthening. So, the neck can handle more.

Yeah, completely agree. The NIC is seven kilos in most people. So, it’s the weight of a bowling ball balanced on top of the stick. So, your muscles have to be really strong. And I do have patients come in and their Collins and their colours actually help with acute neck pain. Again, in the same way as traction does for maybe a day or two, it’s very temporary that it will make the patient feel a bit better. But what they do is that, that we can they’re there because you cannot move your neck and your neck is very much supportive or your head is very much supported by Nicole it’s. So, I’m generally not a huge advocate of them. I

Liked the description, like a bowling ball on a stick

Around thing on top of, and you know, if it’s my head, then it’s solid on the inside, like a bowling pool.

Uh, actually it probably something I listen to is relevant that gets missed a lot too, is sometimes people just focused on strengthening the, the neck muscles, where as you look at all the muscles that are attached to the neck, upper traps, um, lower down your rhomboids, Luvata scab for all of those muscles attached to your scapula. And so, you need the general strength and postural control through your shoulder blades and your arms. It’s not just about focusing on neck muscles. It’s about all those other upper limb and scapula muscles too.

Absolutely. And even putting a patient in a soft collar for a short period of time, I noticed that they showed us stiff. So, I always send my patients to have say neck strengthening or next range of motion, but also range of motion of their shoulders. Yeah. That’s a big thing. And vice versa. I’ve seen people we’ve had shoulder surgery then get you neck pain as well. So, there’s, we’re very connected parts of us.

What things best predict ongoing neck pain?

Uh in people that don’t need surgery. So, it’s the non-specific neck pain. Um, the biggest risk respect is, uh, actually I’m always psycho-social risk factors. Um, there things such as, you know, high perceived job demands, you know, conflict at work, um, low perceived support at work from co-workers and management. Um, again, you it’s just high demand at work. The workplace is a massive place. Yeah, definitely. Um, depression, the more depressed someone is psychologically and not just upset on and off, but actual clinical depression, um, and everything leading up to that, they’re more likely to have ongoing issues and ongoing pain just because of the pie and their brain perceives from their body. Um, and then, and then history of neck pain, one of the biggest risk factors for ongoing neck pain is having had it in the past. And I think that there’s going to be some, uh, what you kind of touched on before you with this, you know, with the central factors where people are in pain and the nerves, aren’t just a wire, having repeated pain in the past is likely to lead them to ongoing pain, but also, um, just in terms of that person believing they’re going to have ongoing problems.

Um, it’s like a self-fulfilling prophecy to would agree.

I completely agree with those statements and there’s actually been very good studies to show that those are very major risk factors. Although we have to be a little careful about talking about causation versus association, because those things like you say, you know, the people who are more depressed will probably experience more anxiety and as a result, more spasms and B was it, there’s a job that’s actually causing that stress in the first place. So, they’re all probably associated with each other in some ways. And it’s no surprise that people who are depressed and anxious suffer from higher degrees of chronic pain. So, they are both more prevalent and they also suffer more severe with chronic pain and chronic pain being defined as more than six months of ongoing pain or more than three of ongoing pain, depending on what you want to read. Um, and there’s no surprise that the use of common antidepressants helps with chronic neck pain a lot. And so, you know, I often prescribe in-depth, um, for patients and there is very good level, one evidence to show that it does actually help. And now it may not completely help to the point that they, uh, able to function normally, but it will reduce their pain to a certain degree. So, um, definitely

That’s funny. I had a patient just two days ago, um, who said ended up, she was prescribed, ended up a couple of years ago, her neck pain cleared up. She really, uh, quite raved about it.

The interesting thing is women are from large-scale studies tend to suffer more. Um, I can’t really, no one knows why, but, um, there seems to be a slight preponderance, but one thing that’s good is that being young is very predictive against Nick Bay. We almost never see young people with chronic neck pain, and no one knows and maybe has to do with that plasticity of the brain in that the brain is able to more than brand and all the nerves are able to accommodate for this. And so that’s an extremely unusual presentations to have long standing, neck pain, young people. Um,

That’s probably a good one to actually flag just for someone to look at carefully and refer on because it’s when it’s unusual, you start thinking, well, is there a sinister cause for it? Or there must be some something that really needs to be addressed because this person is unusually young. Yeah.

Distribution of back pain in kids is actually very interesting. Then they be well below the age of 10 back pain is extremely uncommon between sort of teenage years to adult or to sort of the young twenties back pain is extremely common. And again, no one knows quite why, but it’s an interesting thing. So, if I see a young kid like that five- or four-year-old with back pain, then I’m looking for something. Whereas if I see a 15- or 14-year-old kid with back pain, I’m generally telling them to stop, you know, chatting to their friends on their options or whatever.

When are steroid injections indicated for neck pain?

So, there is quite good evidence to show that steroid injections and by steroid injections, this is a wide range of injections, but in general, they do help with acute pain. Um, they can help with chronic pain that they do help a lot more in the acute situation. Um, and the common ones in the neck are in love with injection or a facet joint injection. And they target two different things. So, then over injections, but Vicky apathy, which we talked about and the facet joint injection is more for the somatic type or musculoskeletal pains, um, is sort of much less common. You can do epidurals, although that is done extremely unusually because, you know, you can obviously become quadriplegic off the bat. That’s not something which is desirable. So, I think the two most common ones are over injections and also facet joint injections. And I think it’s a worthwhile first-line treatment. So, I generally offer patients medications and or injections if I think they have true science and a bad long-standing sort of facet type pains. And I think facet, joint injections or blocks are also very good and they help to both localize the problem as well as treat. Yeah.

Is there a classic patient you can just describe that would respond always best to refer for the facet joint injection?

So, that’s an interesting point because facet joints or facet arthropathy, or for cytogenic pain actually presents across a very wide range of, um, different ways, uh, that in that they present some people complain of a lot of headache or radiated scalp type pains, the occipital neuralgia, which I touched upon, I find that facet, joint injections, and actually work really well in these people. Um, so I have the patient that comes in with a very stiff neck, has trouble sleeping at night. Can’t lie on my side, can’t lie sort of on their back, just struggles with pain. Whenever they turn their head, they get these sharp, tight pain. Sometimes it feels like a migraine to them, even though they’ve never had migraines before and on their investigations, you see that they have a lot of facet, joint degeneration. I think those patients benefit a lot because in addition has the benefit of sometimes making the headaches and scalp pain better.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on flat feet.
1) first one is to identify and address the causes of the person’s neck pain, not the symptoms.
2) secondly, you know, exercise is the best medicine, you know, particularly strengthening exercises for the neck and shoulders, uh, because it addresses the physical often the physical cause of someone’s neck pain, particularly when it’s repeated. But it also has so many psychological benefits as well.

Great. And for me, I guess, um, the, my take home messages are
3) be aware of pain, which is neurogenic and origin. So, ones that started in the neck that travelled down the arm that cause weakness to the hands or the arms, those ones, we have to keep a close eye on.
4) And the other one I’ll interesting is be aware of the patient with no pain, but a lot of problems. And so, we’re talking about silent myelopathy there, they’re the ones that has trouble balancing CA do that buttons up, you know, drop things on the ground with their hand and because that implicates a serious neurologic shoe line.

Thanks again for your time and the insight’s you’ve provided.

Thanks very much for having me