Neck pain treatment

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Do not give neck pain treatment, give treatment of whole patient

Reassurance of patient is the first striking point in neck pain treatment. Then we have to find out the cause of neck pain and treat accordingly. Here are some neck pain treatment guidelines.

Education of patient

Patient education is paramount and should emphasize that pain does not imply harm to the underlying structures and that exercise is helpful rather than damaging. Return to work and normal activity should take place as soon as possible. Bed rest is not helpful and may increase the risk of chronic disability.

Rest

Rest is recommended for only short periods, typically 12 to 24 hours. After that you can go for active and passive exercises. Cervical collar or neck brace are helpful to provide rest to neck.

Manual Therapy

Passive Manipulation and Mobilization:

Manipulation is a sudden movement of low amplitude. It is performed at the end of the joint range at such a speed that the patient is unable to prevent it. Mobilization is a passive movement technique that is performed so that the patient can control the movements at all times. Manipulation and mobilization are performed as low-velocity, small-amplitude or large-amplitude passive movement techniques. The aim of these techniques is to restore joint function.

Trigger Point Therapy:

Acute or chronic muscle pain is a frequent problem in rehabilitation and is often diagnosed as a myofascial pain syndrome that is associated with discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. Often a twitch response can be elicited in the muscle by palpation of the most of the tender spots of the taut band. These so-called trigger points may generate referred pain that is felt in different, usually distal sites. Chronic muscle overload, repetitive microtrauma, direct trauma to the region, and stress may lead to the activation of trigger points. Several hypotheses have been proposed to explain trigger points. The most recent theory is that trigger points are “overactive” muscle spindles.

Treatment techniques consist of ischemic compression and are often accompanied by isotonic contractions of the affected muscle, local manual stretching of the affected muscle, myofascial release technique, and instruction of muscle-specific self-stretches. Trigger points also can be inactivated by inserting a needle into them (Acupuncture). A local twitch response, provocation of referred pain, and subsequent relaxation of the taut band indicate the successful application. In chronic conditions, the factors causing the twitch response must be addressed and if possible corrected

Massage and Lymph Drainage:

It can relieve muscle spasms and reduce pain and stiffness. Additionally, a massage decreases blood pressure, relaxes muscles, and increases the blood flow in muscles and the lymph flow. Massage can be used in a classic form with gliding movements, kneading, and percussion. Lymph drainage is a special form of massage to increase lymph flow and to decrease edema. Massage also can be applied as deep friction massage to break up adhesions in muscles, tendons, or ligaments or as soft tissue mobilization or myofascial release techniques.

A special type of massage is the connective tissue massage (Bindegewebsmassage), which is mostly used in European countries. Connective tissue massage is applied to facilitate changes in the autonomic nervous system over cutaneovisceral reflexes. With this special technique, the therapist tries to influence organs whose innervation corresponds to cutaneous dermatomes.

Massages are contraindicated over malignant tumors, open wounds, thrombophlebitis, and infected tissues. Lymph drainage should be avoided in patients with congestive heart failure.

Neck pain exercises

The rationale for advocating exercise is to overcome the consequences of prolonged rest. Pain intensity is used as a guideline to determine exercise intensity. Such low-intensity exercise may not provide the required training stimuli to achieve an improvement in strength and joint function.

Exercise techniques can be classified into nonresistive and resistive exercises. Nonresistive exercises include range-of-motion exercise and aerobic exercise. Resistive exercises are strengthening exercises that may be isotonic, isometric, or isokinetic.

Range-of-Motion Exercise

Range-of-motion exercise can be progressed from passive to active assisted to active exercises. With passive exercises, a therapist or assistive device moves the joint without any muscle contraction exerted by the patient. In active-assisted exercises, the patient exerts some muscle contraction while attempting joint movement, but is assisted in achieving the desired range. In active exercises, the individual exerts his or her own muscle activity to achieve the desired range of motion.

Strengthening Exercises

In strengthening exercises, a force from a therapist, free weights, or a machine applies resistance in opposition to the attempted movement of a specific muscle group by the subject. Resistance can be increased in strengthening exercises over time as muscle strength improves. The types of strengthening exercises are isometric or dynamic isotonic and isokinetic.

Isometric (or static) exercise is performed without a change in joint range or muscle length. Isometric exercise causes the least strain on joints and places less strain on the cardiovascular system than dynamic exercise. Isotonic exercise consists of muscle shortening (concentric) and muscle lengthening (eccentric) contractions. This form of strengthening has not been recommended for patients with inflamed joints. In view of the newly emerging scientific evidence of the usefulness of high-intensity exercise, however, these recommendations must be reviewed. Isokinetic exercise involves movement through a fixed range of motion at a fixed rate of motion (velocity) against variable resistance that matches exactly the force generated by the patient at any point in the range. The stronger the force applied by the user, the greater is the resistance supplied. Equipment providing the latter type of accommodating resistance (e.g., Cybex system) is highly sophisticated and expensive. This equipment also can provide a printout of the torque developed during the exercise activity.

Home-based Exercises

The term self-management emphasizes the responsibility of the individual patient in the management of the disease. Home-based self-care emphasizing exercise is part of the self-management process. Patients receiving this advice significantly improved self-efficacy for exercise, self-reported mobility, and levels of exercise, and revealed a tendency to improve function compared with a control group

Aquatic Exercise

Bathing in water (balneotherapy or spa therapy) has a long-standing tradition in the management of musculoskeletal disorders. Its effect is attributed to the physical properties of water resulting in biomechanical changes, such as joint unloading and relaxation. Further expected effects are physiologic changes, such as increased diuresis and hemodilution. Aquatic therapy is a subgroup of balneotherapy and consists of exercises in a hot water pool. The recommended water temperature is 33°C to 34°C (92°F to 94°F). The additional benefit of the water could be an explanation for the improved muscle strength in the lower limbs of women with fibromyalgia exercising in waist-high water, while the strength of other muscles did not change. Additional benefits were improvements in pain and health-related quality of life. Patients with osteoarthritis achieved more functional gains with water-based and land-based exercise programs than a control group.

High-Intensity versus Low-Intensity Exercise

The applicability of high-intensity exercises for patients with rheumatoid arthritis and osteoarthritis has long been questioned because of concerns about accelerating joint damage. Treatment recommendations for these patients traditionally consisted of exercise restriction or exercise programs limited to non–weight-bearing isometric exercises and range-of-motion exercises. There is growing evidence, however, that intensive exercise programs are more effective than conservative treatment in improving the muscle strength and functional ability of patients with RA. Patients with preexisting extensive large joint damage should be advised to refrain from activities that excessively strain the damaged joints because high-intensity, weight-bearing exercises seem to accelerate joint damage. There is insufficient evidence to draw any conclusions regarding the intensity of an exercise therapy program for individuals with osteoarthritis.

Physical Modalities

Heat and Cold

Heat and cold modalities have been used for many years in the treatment of neck pain. Heat can be applied by radiation (infrared light), conduction (hot packs, paraffin, or water) or conversion of another form of energy to heat (diathermy or ultrasound). Radiation and conduction are forms of superficial heat, whereas deep heating is achieved by conversion. These techniques must be used with caution to avoid burns. Hot water bottles should be filled with warm, but not boiling, water. Timers should be used with heating pads; application of the heating pad should not exceed 20 minutes. A suggested approach is to alternate between 20 minutes using heating pads and 20 minutes without a heating pad. Superficial heat can increase the threshold for pain, produce analgesia by acting on free nerve endings, and decrease muscle spasm. A more recent review of the effects of superficial heat is short-term reduction in pain and disability.

For patients with degenerative joint diseases or with soft tissue syndromes without prominent inflammation, heat is usually well tolerated and helpful. Heat therapy is contraindicated for patients with acute arthritis because it causes increased and sustained inflammation and pain. Nevertheless, heat may be helpful for patients with moderate joint inflammation, where it can reduce pain and muscle spasm and increase joint mobility by decreasing adhesive processes in the joint capsules. Paraffin wax baths might be a suitable treatment method for these patients. Heat therapy is also contraindicated or precautions have to be taken in patients with acute trauma or hemorrhage, insensitivity, severe ischemia in peripheral occlusive disease and varicose veins, and for patients who cannot communicate feelings of discomfort (comatose or demented patients).

Ice is useful to control pain and swelling because it induces a vasoconstriction of superficial and intra-articular tissues, reduces local metabolism and slows nerve conduction. It may be applied using cold packs, ice massages or ice baths and vapocoolant sprays. In knee osteoarthritis, administration of ice massages had significant effects on range of motion and the function and strength of the quadriceps muscle. Cold packs decreased knee edema

Electrotherapy

Electrotherapy is the use of electricity as a therapeutic agent to stimulate nerves and muscles and to alleviate pain. Electricity is mostly applied by surface electrodes. Only electroacupuncture and dorsal horn stimulation use needle electrodes percutaneously. The types of currents used for electrotherapy include direct continuous galvanic currents and modulated direct currents.

Galvanic currents slow down pain conduction in slow unmyelinated nerve fibers (C fibers) to reduce pain. Modulated middle-frequency electrotherapy is based on the gate control theory of pain. This current leads to an inhibition of pain-related potentials at the spinal and supraspinal levels. Basically, the electric stimulation of the fast-conducting myelinated nerve fibers can partially decrease pain through inhibition of pain impulses carried more slowly by unmyelinated fibers. The faster impulses arrive at the level of the dorsal horn first and “close the gate.” The gate control principle works with all classic forms of electrotherapy and with transcutaneous electrical nerve stimulation (TENS). The advantage of TENS devices is their small size because they can be worn by the patient and used when and where desired.

Common indications for TENS are musculoskeletal pain, post-traumatic or postsurgical pain, peripheral nerve injury, neuropathic pain, phantom limb pain, and sympathetically mediated pain. Electrotherapy should not be used on patients with cardiac pacemakers or implanted cardiac defibrillators. It can be used with caution on patients with atrophic skin. The effectiveness of TENS is still controversial.

Ultrasound

Ultrasound is a special form of heating. It interacts with skin, fat, muscles, and bones during treatment. Heating occurs mostly at tissue interfaces. The most important interfaces where heating occurs are the bone soft tissue interfaces that are well reached with ultrasound. Ultrasound may penetrate 7 to 8 cm of fat, but less than 1 mm of bone, depending on what energy level and which frequency is chosen. In practice, ultrasound with frequencies of 0.1 to 1 MHz can produce an increase of temperature of 4°C to 5°C at depths of 7 to 8 cm. Ultrasound is used for patients with localized musculoskeletal pain secondary to tendinitis or osteoarthritis of various joints. Ultrasound may be used in rheumatoid arthritis. A review found evidence that continuous ultrasound increases grip strength, decreases morning stiffness, and reduces the number of swollen and tender joints. Contraindications for a treatment with ultrasound are the same as for heat therapy. Ultrasound should not be applied over fluid-filled cavities, such as eyes and gravid uterus.

Orthotics

An orthosis may restore lost function or may help to maintain optimal function by altering biomechanics and reducing pain.  Orthotic devices such as cervical collar decrease forces passing through painful neck, stabilize subluxating joints, improve motion patterns, and maximize functional positioning

Subluxation of the atlantodental joint can occur in rheumatoid arthritis. If surgery is not applicable, cervical collars may be prescribed. Cervical collars include soft collars, the Philadelphia collar, and the sterno-occipitomandibular plaster immobilization. None of these cervical orthoses provides a high level of mechanical restriction of motion, and all are ineffective in preventing pathologic displacements. Patients with night pain resulting from a cervical disk syndrome may profit from wearing a soft collar during night.

Assistive Devices

A vast variety of assistive devices serve to reduce disability. If necessary, an experienced occupational therapist can assess which devices are appropriate for a patientVarious kitchen aids may simplify kitchen work and eating (e.g., big handles on knives, forks, and spoons; knives with vertical grip for cutting bread or meat; electric opener for bottles).

Vocational Rehabilitation

Vocational rehabilitation contains an interdisciplinary approach aimed at the maintenance of gainful employment.

Cognitive Behavioral Treatment

It also acknowledges that pain and its resulting disability are not only influenced by somatic pathology, but also by psychological and social factors. In general, three behavioral treatment approaches are distinguished: operant, cognitive, and respondent. They are helpful to reduce disability.

Neck pain relief

All the above mentioned methods reduce neck pain. Besides adequate analgesia by PARACETAMOL, NSAIDs, muscle relaxant, corticosteroids or OPIOIDs must be provided for relief of pain. Oral or intravenous or intramuscular medications used on the basis of patient’s condition.

Pain from NEOPLASIA or referred causes of neck pain should be treated according to diagnosis and neck will be if their treatment given.

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