Start of open season on GPs' future
A laptop user who has developed neck pain
Forty-eight-year-old Mr T is a rep and uses a laptop. He says his neck has been painful for the past fortnight and although he has managed to work round it, he has come to see you because it is disturbing his sleep.
Dr Melanie Wynne-Jones discusses.
Why is neck pain so common?
Our heads weigh at least 10 pounds, and although the cervical spine and its supporting structures are strong and flexible, the demands we make on our necks produce frequent minor damage.
Most of us have experienced an acute but self-limiting stiff neck and up to half of us will suffer a neck problem at some time.
Sprains (or 'whiplash' injuries) are also common; pain and stiffness in the neck and/or lower back develop over a few hours and can take several weeks to settle. Immediate neck pain following an RTA or other injury may mean serious damage. The spine should be stabilised and the patient referred to A&E.
Other causes of neck pain include:
·muscle/ligamentous strains, soft tissue or facet joint injuries, often the result of poor posture or misusing the neck
·cervical spondylosis, a degenerative condition
·prolapsed cervical intervertebral disc
·rheumatoid arthritis, ankylosing spondylitis
·polymyalgia rheumatica, fibromyalgia
·infections, including osteomyelitis and TB
·meningitis or subdural haematoma
·bony metastases or myeloma
·referred pain from upper thoracic spine.
What symptoms and signs are important?
·Contributory injury or occupational/ recreational factors
·Site of pain and any associated weakness/paraesthesiae
·Muscle wasting or reduced power/ reflexes/sensation in the arms/hands this suggests nerve root compression
·Stiffness, grating noises or dizziness this suggests cervical spondylosis
·Nature of the pain constant unremitting pain suggests a serious cause
·Prolonged morning stiffness (polymyalgia rheumatica and other inflammatory conditions)
·Systemic upset sweats, weight loss and so on (infection, PMR or malignancy)
·Associated symptoms suggesting inflammatory arthritis or a possible primary malignancy (lung, breast, kidney, prostate and thyroid cancers commonly metastasise to bone).
What investigations should you perform?
None are required if there are no worrying features, but you may need to consider:
·full blood count
·ESR and/or C-reactive protein
·calcium, proteins, protein electrophoresis and/or Bence-Jones protein
·rheumatoid factor /HLAB27
·X-ray cervical spine and/or chest
·referral for MRI scan and/or further investigation
How can Mr T help himself?
Assuming he has no significant pathology, simple measures and proper care of his neck should relieve his symptoms and reduce the chances of recurrence.
·Painkillers such as paracetamol or NSAIDs; codeine at bedtime facilitates sleep
·Some people find relief from topical anti-inflammatory creams
·Local heat a hot water bottle, wheat bag or standing in a hot shower
·Ice or frozen peas wrapped in a tea towel; applied for 10 minutes every four hours
·Gently massaging neck, shoulder and scalp muscles to soothe and release tension
·Prevention of further stiffening by putting the neck through its comfortable range of movements every couple of hours, gradually increasing the range
Prevention of further pain
Bad habits and bad posture are often linked to the wrong chair, bed or pillow, driving position, computer workstations or using a laptop, heavy lifting, sport and other activities that involve twisting or straining the neck.
Mr T should:
·Maintain his neck's natural lordosis when standing, sitting and walking this involves chin tucked in and shoulders pulled gently backwards.
·Turn smoothly from the hips instead of twisting his neck to look over his shoulder this includes times when he is reversing the car.
·Use his computer at a desk (not in the car or on a coffee table) to avoid slumping. The screen should be slightly lower than his eyeline with his hands resting easily on the keyboard. His hips, knees and ankles should all form right-angles, using a footrest if necessary. Telephone and
heavy files should be within easy reach,
and he should get up and move around for five minutes in every hour. His
employer has a responsibility to ensure the correct equipment is provided and used safely.
·Use a single firm pillow or a special neck pillow.
·Lift by bending his knees without jutting out his neck; carry heavy items close to his body.
·Get up from a chair by putting one foot slightly in front of the other, keeping the neck tucked in (not jutting out), leaning the shoulders forwards over the knees, then pushing up with the legs, using the armrests for balance, not support.
Robin McKenzie's self-help book can also be recommended to patients.
What treatments can you offer?
Depending on the severity, duration and aetiology of the pain, local availability, or Mr T's ability to pay, you may be able to refer him for physiotherapy, acupuncture or to use a TENS machine.
Many patients prefer to refer themselves to a chiropracter or osteopath; advise patients to ensure they are properly registered, and remember that if you recommend a practitioner you may be liable for any adverse consequences.
Yoga, the Alexander Technique and Pilates all focus on improving posture and muscle use and may prevent recurrence of neck pain.
Early trials with Botox injections suggest they may be helpful in relieving some types of chronic neck pain.
·Most neck problems are triggered by poor posture and bad habits
·Careful history and examination should identify neck pains that need to be taken seriously
·Most neck problems respond to simple self-help measures
·Some patients benefit from physical treatments
·Prevention is better than cure
·Treat Your Own Neck;
Robin McKenzie, Spinal Publications. ISBN 0-473-00209-4. Around £8.99
·The Arthritis Research Campaign
·Chartered Society of Physiotherapy
·British Medical Acupuncture Society
·General Osteopathic Council www.osteopathy.org.uk
·British Chiropractic Association
·The Society of Teachers of the Alexander Technique
Melanie Wynne-Jones is a GP in Marple, Cheshire