There is perhaps no more challenging situation for a clinician than getting a brand-new patient who is in substantial pain, asking for help right before they have to leave for a trip and not return for multiple weeks. Of course, you want to be of service and provide them with immediate relief, but often the odds are stacked against you as you need to calm them down from a heightened state of irritability, establish some sort of rapport, gather as much information as possible through the paperwork they filled out and their verbal history, and thoroughly and precisely extrapolate information from your physical exam. By the end of your hour together, the treatment provided hopefully moves the needle enough so that the patient feels better, enough for them to follow up with you when they get back. In addition, the patient’s presentation of pain may be one that is not a quick fix, not your usual run-of-the-mill mild disc irritability. There are a lot of factors that must line up right. Neck pain, in particular, can be extremely difficult to treat because of its proximity to your head. If you wanted to find out all the factors that your therapist is taking into consideration with this scenario, here is your chance.
Mechanical Pain: Can You Fix Yourself?
It should be known that serious conditions or “Red Flag” symptoms should be ruled out prior to progression to treatment. As mentioned before, neck pain is especially jarring due to its proximity to the head. Our ability to concentrate or get through the day requires that our attention be as focused as possible, and this is quite a challenge when pain is in that close of proximity to the part of the body (your brain) that handles our ability to focus and make decisions. The dilemma is always, do I make the patient just feel good for only that moment, which isn’t lasting by just doing soft tissue work, in addition, not really have any clue on what is going on, OR go balls to the wall to find out if the pain can be lessened substantially through exercise, positioning, or other appropriate treatment. It may sound counterintuitive, but I believe the latter is what you shoot for because if the patient still has no answers after trying other prior treatments (paid massage or a Theragun) that have given no explanation, you owe it to them to understand what the issue is, to the best of your ability, and provide them a plan on how to best progress forward. It’s important to determine whether a condition can be resolved quickly through mechanical means (e.g., exercises, positioning) because if the patient can self-correct, that ability helps them feel at ease, which is the first step toward getting their life back to normal. That is the plan, but nothing is ever foolproof. There is a possibility that seeking the truth of the matter could temporarily make things worse.
The Presentation
Many patients come in with neck pain that travels into the shoulder, down the arm, or even into the forearm, with tingling and numbness. This is radiating — pain coming from an inflamed cervical nerve root, the capsule of the facet joints, or disc (with or without compression of the spinal cervical nerve root). This knowledge has been around for years, dating back to 1959, when Dr. Ralph Cloward began pressurizing different areas of cervical spine discs via spinal injections, yielding specific patterns of pain that patients confirmed verbally.
Pain patterns that are well-defined (we call this a cervical dermatome) and the location of your symptoms can tell us a lot about which spinal nerve root level is involved. The 7th spinal nerve root, for example, classically produces symptoms that radiate into the middle finger in both pictures above. The pain distribution pattern helps clinicians deduce which specific cervical spinal nerve root they come from. We can hypothesize (propose until proven wrong) that the nerve root is being irritated by something (thought to be typically the disc, but not always). The great thing is that we can further confirm the level by checking specific items related to that spinal level such as sensation (do both sides of the same areas feel the same), reflexes (does the joint jerk appropriately when hitting the right tendon that flexes the joint with a reflex hammer), and strength (is a specific muscle that is supplied by that spinal nerve level able to resist the clinician’s pressure on both sides of the body equally) which not only helps to pinpoint the level, but also allows us to determine if improvement is occurring; not just because the patient is saying, “I think I feel better.” This is how we hypothesize what nerve level is irritated and if a spinal nerve is involved.
What Do You Mean By “If A Spinal Nerve Level Is Involved?“
Great question. Bogduk et al.’s and Cooper et al.’s work further emphasized that the referring pain is not necessarily coming from an irritated spinal nerve root but from facet joints (the joint area where one cervical vertebra contacts another). In fact, in Bogduk’s study, individuals with post-traumatic neck pain (whiplash injuries) showed that symptomatic disc and symptomatic facet joints were both found at the same level in 41% of patients, discs were symptomatic alone in 20% of patients, facet joints were symptomatic alone in 23%, and 17% had neither disc nor facet identified as the sources of pain at the segments studied. So what does that mean? It means that referred pain to the shoulder, arm, forearm, and hand does not have to come from an irritated cervical spinal nerve or a cervical spinal disc pressing on a spinal nerve. The way to rule out an irritated spinal nerve root is to observe that sensation, reflexes, and strength are intact. An irritated spinal nerve root would show deficits in these areas.
Assessment
Something to note, the thoracic spine and first rib can be the cause of referring pain down the arm and should be delineated out in its potential contribution to your radiating pain. Without those areas being able to move normally, resolving neck pain and improving movement is unlikely to happen quickly. The main question, however, is whether the neck pain is mechanical (does it improve with movement, positioning, or exercise)? Potentially, yes — and here’s how you know. If there are specific movements, positions, or exercises that cause your arm or hand pain to move closer to the neck (we call that centralization; see below), that is a very good sign and can reduce your pain by 50% or more within the same session. We have observed this repeatedly in patients with the right presentation.
It means the condition has a mechanical component (very likely, your pain involves a cervical disc that is either compressing a nerve or is injured but doesn’t compress the spinal nerve root at that level) and can be influenced by the right exercises. If, however, your pain does not change positively (intensity of pain decreasing, size of area of pain getting smaller, range of motion of your neck improving in all directions) with movement, positioning, exercises, or centralization just isn’t happening, that tells us there’s more going on beneath the surface that needs to be addressed, perhaps inflammation, that may need time to calm down through anti-inflammatory medications, icing, or even a local anti-inflammatory/analgesic injection to a specific spinal level of the neck by a physician. This is why ruling out a purely mechanical cause first matters, and why there is a lot to consider when in a position where positive results are wanted quickly. There is no doubt that irritability can increase with assessment, especially if the patient’s presentation deviates from a straightforward case. Balancing your patient’s expectations while progressing with the assessment is a fine line, especially when a not-so-straightforward presentation is involved. This provides some context for what a clinician is sifting through when assessing a patient with neck pain seeking immediate relief in a single visit, with a not-straightforward presentation.
It’s a tough and disconcerting time, but we’ll guide you through! If you are seeking help for neck pain, feel free to reach out sooner rather than later so you do not have to experience this any longer than necessary. Stay well and be well, Mobile Spine Family!
Sources:
Bogduk, N., & Aprill, C. (1993). On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain, 54(2), 213-217.
Cloward, R.B. (1959) ‘Cervical diskography: a contribution to the etiology and mechanism of neck, shoulder and arm pain’, Annals of Surgery, 150(6), pp. 1052–1064.
Cooper, G., Bailey, B., Bogduk, N., 2007. Cervical Zygapophysial Joint Pain Maps. Pain Med 8, 344–353.
