Algoritma Neck Pain
Algoritma Neck Pain
Algoritma Neck Pain
P R I M A R YC A R E M A N A G E M E N T O F
Neck Pain
f ti s care process model (CPM) was created by the Functional Restoration/Chronic Pain Development Team of
Intermountain H ealthcares Pain Management Service. Based on national guidelines,APTA,DOU emerging evidence,
and expert opinion, this CPM provides guidance for primary care providers on diagnosis and treatment of acute
and chronic neck pain. f ti s document presents an evidence-based approach that is appropriate for most
patients; it should be adapted to meet the needs of individual patients and situations, and should not replace
clinicaljudgment.
WHATS INSIDE?
Why Focus ON NECK PAIN? ALGORITHM AND NOTES . . . . . . . . . . 2
Prevalence and cost .In the general population, the lifetime prevalence ACUTE MECHANICAL NECK PAIN . . . . 4
of neck pain is as high as 71%. Between 10% and 22% of adults Etiology of neck pain . . . . . . . . . . . . . . . .4
have neck pain at any given time.CLIN Neck pain is second only to low Core treatment ....................4 Appropriate
back pain in annual workerscompensation funds expenses in the pain medication . . . . . . . . . . 5 Patient
U.S.APTA
expectations for PT ...........5 Nonsurgical
Recurrence and chronicity rates .Neck pain is often a self-limiting spine specialist referral . . . . 6 Further
problem; however, recurrence and chronicity rates are high. One psychosocial evaluation .......6
study found that 30%
CHRONIC NECK PAIN AND/OR
of patients with neck pain develop chronic symptoms, and 14% of
CERVICOGENIC NECK PAIN . . . . . . . .7
patients with an episode of neck pain will have pain for 6 months or
Pain assessment ....................7 Psychosocial
longer.APTA One critical challenge is predicting which patients are at
risk for chronic neck pain and intervening appropriately. evaluation ..............7 Patient education &
management plan . . 7 Medication
Key Points IN THIS CPM management ............7 Considering other
treatmentoptions . . .8
In most cases, imaging tests are NOT needed to diagnose acute neck pain .
Diagnostic imaging on neck pain can be misleading; imaging often SPINE SPECIALIST TREATMENT . . . . 10
identifies abnormalities that are not contributing to current REFERENCES . . . . . . . . . . . . . . . . . .11
symptoms. One study found abnormalities on the radiographs of RESOURCES . . . . . . . . . . . . . . . . . . . 12
79% of asymptomatic patients (disk space narrowing, endplate
sclerosis, or osteophytes).D O U If there are no red flags(signs of serious GOALS
pathology or injury), avoid imaging tests. Improve efficiency of neck pain care, using a
For most neck pain, conservative treatment and self-care is adequate team approach where appropriate.
and effective. f t e core treatment for acute neck pain includes Reduce the use of ineffective imaging and
therapeutic procedures.
education and reassurance, encouragement to remain active, a short
Increase the patients understanding of
course of medications, and a course of physical therapy. effective neck pain management.
Psychosocial factors can complicate the course of neck pain .If neck pain Improve the patients pain management,
persists beyond 3 to 6 weeks despite core treatment, consider function, and satisfaction with care.
psychosocial issues and evaluation (see page 6).
MEASUREMENTS
Identifying neurological signs and symptoms that indicate myelopathy early Pain prescriptions for neck pain
and immediate referral to a spine surgeon is critical. If myelopathy is Patients with a neck pain
present, optimal neurological recovery depends on early surgical diagnosis referred for radiology
decompression.UT D1 Comorbidities diagnosed with neckpain
Physical therapy is best for patients with neck pain persisting beyond 6
weeks .In the treatment of chronic neck pain and cervicogenic
headache,
physical therapy treatment that focuses on the neck and shoulder
blade region is helpful.KAY
Chronic neck pain that persists despite conservative treatment should be
N E CK PA I N D E C EMB E R 2014
Recent trauma with suspected cervical spine fracture CT scan (more sensitive than x-rays)NPTF URGENT referral to ortho/neuro
or dislocation Standard 3-view x-ray.NPTFStart with an spine surgeon or emergency dept
upright lateral view to rule out fracture or
dislocation. Avoid flex extension views
until unstable neck ruled out. Best
reviewed in emergency dept or bysurgeon.
Suspected cancer: A prior history of malignancy, history CBC, ESR, CRP X-ray (evaluate in context with ESR) URGENT referral to spine
of cancer, multiple cancer risk factors, or strong clinical MRI of the neck (T1, T2)w/gadolinium specialist or emergency dept if
suspicion/constitutional symptoms patient exhibits severe pain,
myelopathy orradiculopathy
Suspected infection or recent spinal procedure: CBC, ESR, CRP Consider MRI* with gadolinium Referral to surgeon, or, if recent
fever, weight loss, night sweats, other systemic symptoms, or bone scan spinal injection or procedure,
immunocompromised patient, UTI, IV drug use, pain with rest or at referral back to treating physician;
night, or chronic steroiduse consider infectious disease consult
Suspected rheumatic causes, such as rheumatoid arthritis that CBC, ESR, CRP, RF, Referral torheumatologist
frequently presents as neck pain, morning stiffness that improves anti-CCP, HLA, B27
over the course of the day, redness/swelling in joints, joint
deformation, extended morning stiffness, recent history (within 6
months) of chlamydia, red hot joints or jointdeformity
Rheumatoid arthritis: aching and morning stiffness in the CBC, ESR, CRP, RF, Referral torheumatologist
shoulders, hip girdle, and neck anti-CCP, HLA, B27
Downs Syndrome: concern of C1C2, joint instability Cervical spine x-ray with flexion/extension
*Ensuring a high-quality MRI . To reduce the need for a repeat MRI, ensure that the imaging center uses a 1.5 tesla magnet. Large bore and standard MRIs usually provide
better image quality than open MRIs. Order sedation if necessary to get a high-quality MRI. See page 6 for details on Intermountains Spinal MRI Order Guidelines.
C2
C2
C3
C3
C4
C5
C6
C7
C8 C6 C6
Core treatment
T1
T1
C7
C8
C7 f ti s CPM recommends core treatment elements based on national
guidelinesand a method for stratifying treatment based on a patients risk
C8
Staying active helps your neck recover in whiplash-associated disorder (WAD) . PATIENT EDUCATION
Research shows that an early return to regular activities acts as a The Krames patient education library has
means of pain control and recovery for WAD.APTA,D O U several HealthSheets that can support patient
Imaging tests are NOT needed at this stage (unless trauma indicated). An x-ray or education. Materials appear in iCentra based
on diagnosis code, or you can access them
MRI isntnecessary to know what to do, and imaging may lead to
through intermountain .netor
expensive, unnecessary treatment.DO U For example, most of us have intermountainphysician .org. See page 12for
bulging discs that cause no symptoms. more information.
Posture modifications are critical to your treatment . Keep your neck straight, The following HealthSheets are available to
avoid heavy loads and straps over your shoulders, sleep with your neck support patienteducation:
supported, continue to exercise (see note (e) page 3), and so on, to reduce Understanding Neck Problems
pain and speed recovery. Neck Problems: Relieving YourSymptoms
Know Your Neck: The CervicalSpine
Avoid prolonged sitting in slouched positions such as watching TV in
bed, hunching over a laptop computer, or reading a mobile phone.
Referral considerations
A multidisciplinary spine care program is the best option .ftese programs
integrate nonsurgical treatment (injections, exercise, medications),
SPINAL MRI GUIDELINE physical therapy, surgical treatment, mental health, and other
modalities. (For spine interventions, the procedure suite should have
Spinal MRI Order Guidelines A UG US T 2 0 14
Imaging
mechanicalconsiderations
conservative treatment (see LBP CPM) for 4 to 6 weeks. ICD-9:
Avoidinimaging
mind thatfor patients whoatdothe
not have signs ofnot
serious outcomes(see
pathology
additional E code to identify the cause. osteoporosis risk. ICD-9: pathological fracture 733.13.
2 0 14 INTERMOUNTAIN HEALTHCARE. All rights reserved. These guidelines apply to common clinical circumstances, and may not be appropriate for certain patients and situations. The treating clinician must use judgment in
red flags, page 3), unless pain has persisted longer than 6 weeks.
applying guidelines to the care of individual patients. Primary Care Clinical Program approval 07/17/2014. CPM009e - 08/14 (Patient and Provider Publications 801-442-2963)
Intermountain has developed guidelines Common questions about imaging tests as part of areferral:
for when to order a spinal MRI exams at Should I order imaging tests as part of a nonsurgical spine specialist referral?
Intermountain facilities. These guidelines
include a list of appropriate indications for
In most cases, no unless there are obvious signs of radiculopathy or
spinal MRI imaging for back andneck red flagsfor serious pathology. Inappropriate imaging can lead to
pain, which enables you to identify medical unnecessary radiation and cost.
necessity and can assist with preauthorization.
This guideline is not designed to limit your Who should recommend interventions based on imaging tests? A nonsurgical
ability to order cervical spine MRI exams; it spine specialist can evaluate imaging to identify which interventions (if
facilitates appropriate use of spinal imaging. any) may be helpful. It is not generally recommended for primary care
Click the image above to open the guideline, or providers to order interventions directly. However, it may be
see page 12 for information on accessing it. appropriate for a PCP to order an intervention for established patients
who have been helped by a specific procedure in the past, if the same
symptoms recur.
Exercise therapy A systematic review and best evidence analysis found that combined programs (coordination, strength and endurance,
range of motion, flexibility, coordination, and supervised qigong) are effective for the management of neck pain.SOU
Traction A randomized clinical trial found that adding mechanical traction to a standard exercise program for patients with signs of
cervical radiculopathy lowered self-reported disability and reduced neck and arm pain. These improvements were
particularly notable at 6-month and 12-month follow-ups.FRI(Many insurers may not cover home traction therapy.)
Injection therapy Cervical epidural cortisone is indicated for cervical radicular pain. Studies do not clearly support epidural
steroids for axial neck pain. Consider other injections to diagnose other pain generators(e.g., facets).DOU
Radiofrequency rhizotomy
(RF)
The majority of axial neck pain is caused by facet joints.YINThe best proven procedure to effectively treat the facet joints is
radiofrequency rhizotomy, which causes a heat lesion to the small nerves that innervate the facet joints. Before RF is performed,
diagnostic anesthetic blocks are performed to diagnose facet pain and predict outcomes of the RF. Evidence supports RF.BOG
Team-based programs Functional restoration programsthat integrate medical and psychosocial treatment have been found to improve
function and reduce pain in patients with chronic pain.GUZ If a functional restoration program is not available, consider
incorporating as many features of team-based care within your clinic as possible such as incorporating MHI and
planning for consistent communication with physical therapists and other specialists.
Cognitive behavioral
therapy (CBT)
In a randomized trial of CBT versus no CBT in 91 patients with whiplash, those randomly assigned to CBT were more likely to
report resolution of pain (23% versus 9%) or improvement of pain symptoms (53% versus42%) at 3-month follow-up.PAT
? Mobilization/manipulation With manipulation, risk of stroke or spinal cord injury is <1 in 1,000,000, but stroke and injury do
occur.The most beneficial manipulative interventions for patients with mechanical neck pain with or
without headaches should be combined with exercise to improve patient satisfaction.APTA
? Surgery for radiculopathy Radiculopathy: Surgery mayrelieve otherwise intractable signs and symptoms related to cervical radiculopathy, although no data
exist to guide optimal timing of the intervention.CAR
? Trigger point injections Although widely used, evidence is currently lacking. A single, randomized trial for low back
pain showed no difference in pain response between saline injection, anesthetic injection,
needle insertion without injection, and vapocoolant spray with acupressure.DOU
? Complementary and
alternative medicine
Evidenceis inconclusive regardingthe benefits and harmsof CAM therapies in patients with pain. While there is
insufficient data to support the effects or benefit of CAM treatments; some patients report improvement in
function and severity of pain with their use. Additional research is needed in this area of treatment.
therapies (CAM)
? Acupuncture No reviews show clear demonstration of effectiveness. A review of outcomes of 14 trials were equally balanced between positive
and negative outcomes. Another review found either no effect or negative effect. No major recommending body currently
recommends acupuncture for neck pain.DOU
TENS Research shows limited benefits and/or treatment is not recommended in major guidelines.
Immobilization Cervical collars have little effect on cervical range of motion in healthy adults. Three reviews found inconclusive or no evidence of
benefit in neck pain.DOU
Key to symbols:
= Research shows good outcomes and/or treatment is recommended in majorguidelines.
? = Research is uncertain on outcomes.
= Research shows limited benefits and/or treatment is not recommended in majorguidelines.
TABLE 4 .Nonsurgical spine specialist approach: evaluation and treatment of neck pain
Pain generator Evaluation Treatments the specialist may consider
Facet pain Symptoms: Mechanical neck pain and possible Physical therapy
referred pain Manual therapytreatment
Physical exam: Facet tenderness and pain with Medical branch blocks and radiofrequency rhizotomy
extension androtation Cervical facet cortisone injections
Imaging: Not diagnostic; facet degeneration is a
common finding
Herniated disc Symptoms: Acute and often severe scapular and arm Education to explain the natural history of this problem
with radicular symptoms pain, usually worse when at computer, driving, (favorable toimprovement)
or moving neck Physical therapy/traction
Physical exam: Positive Spurlings test, upper limb Epidural cortisoneinjections
tension tests, distraction test; variable numbness,
Surgery referral indicated with progressive neurologic
weakness, and loss of DTR
deficit, profound weakness, or lack of improvement in 3
Imaging: MRI months
Degenerative disc: Most likely Imaging: Not helpful; disc degeneration is a Physical therapy, per treatment options on page 9
asymptomatic. Only 16% of neck normal finding Rarely indicated: Discography, intradiscal procedures,
pain is caused by degenerative disk. and surgery
Whiplash/extension injury: Symptoms: Neck pain, headache Conservative treatment with NSAIDS and physical therapy
Causes post-traumatic neck pain Physical exam: Headache and/or neck pain is triggered for 68 weeks
and can cause headaches for by neck motion or pressure applied toneck Physical therapy deep neck flexor exercises
manypatients.
Diagnostic injection: Medial branch block to evaluate If chronic neck pain or headache persist, consider
facet pain radiofrequency rhizotomy
Cervicogenic headache Diagnostic injections: Medial branch block to evaluate Physical therapy
for C2 to C3 facet injury (or less commonly, from C1 to Radiofrequency rhizotomy
C2 or C3 toC4)
Deep neck flexor exercises
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linked to the International Classification of Functioning, Disability, and pain in chronic neck pain. Pain Physician. 2002 Jul;5(3):243-249. Erratum
Health from the Orthopedic Section of the American Physical Therapy in: Pain Physician. 2002 Oct;5(4):445.
Association. J Orthop Sports Phys Ther.2008;38(9):A1-A34. NPTF Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the
CAR Carette S, Fehlings MG. Clinical practice.Cervical radiculopathy. Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its
N Engl J Med. 2005 Jul 28;353(4):392-399. Review. Associated Disorders: from concepts and findings to recommendations. J
Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S227-43.
CLIN Clin-eguide guideline: cervicalgia: Management overview. http://
clineguide.ovid.com/clinicalresource/re/displayCG?accessionPath=mdcgebd PAT Pato U, Di Stefano G, Fravi N, et al. Comparison of randomized treatments for
b/2390&dbName=mdcgeb&title=-86971944&actionIndex=1&fileName=/ late whiplash. Neurology. 2010 Apr13;74(15):1223-1230.
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ROS Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D.
Accessed June 9, 2014.
Mindfulness-based stress reduction for chronic pain conditions: variation in
DOU Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in treatment outcomes and role of home meditation practice. J Psychosom Res.
family practice. J Am Board Fam Pract. 2004 Nov-Dec;17Suppl:S13-22.
2010;68(1):29-36.
DWY Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A SOU Southerst D, Nordin MC, Ct P, Shearer HM, et al. Is exercise effective for
study in normal volunteers. Spine (Phila Pa 1976). 1990 Jun;15(6):453-7. the management of neck pain and associated disorders or whiplash-
EUB Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain associated disorders? A systematic review by the Ontario Protocol for
and radicular symptoms. Am Fam Physician. 2010 Jan 1;81(1):33-40. Traffic Injury Management (OPTIMa)Collaboration.
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FRI Fritz JM, Thackeray A, Brennan GP, Childs JD. Exercise only, exercise with
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mechanical traction, or exercise with over-door traction for patients with
cervical radiculopathy, with or without consideration of status on a UTD1 Isaac Z, Anderson B. Evaluation of the patient with neck and cervical spine
previously described subgrouping rule: a randomized clinical trial. disorders. UpToDate. http://www.uptodate.com/contents/evaluation-of-
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Published August 2008. Accessed November 11, 2014.
This CPM presents a model of best care based on the best available scientific evidence at the time
of publication. It is not a prescription for every physician or every patient, nor does it replace clinical
judgment. All statements, protocols, and recommendations herein are viewed as transitory and
iterative. Although physicians are encouraged to follow the CPM to help focus on and measure
quality, deviations are a means for discovering improvements in patient care and expanding the
knowledge base. Send feedback to Timothy Houden, MD, Intermountain Healthcare, Pain
Management Services Medical Director, (Timothy .Houden@imail .org).
12 2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM077 - 12/14