Assessing and managing the patient with neck pain
Several clinical features predict sickness absence among workers consulting with neck pain. These include short duration, high pain intensity, report of continuous pain, and certain physical signs (pain in the upper limb during rotation of the head and pain in the shoulder during abduction of the arm).51 Previous sickness absence attributed to neck pain is also predictive of future absence spells from this cause.52
Further investigations (e.g. radiology and MRI) are not indicated except in rare circumstances. Changes of osteoarthritis will often be found, but the correlation between symptoms and x-ray appearance is inconsistent, and the predictive performance of such tests for future incapacity is low.
Guidelines on managing neck pain are less developed than those on managing LBP. In principle, and by analogy, the optimal approach should be similar to that for LBP: initial assessment by triage, followed by advice to maintain activity and coping within the limits of pain for simple mechanical neck pain. However, direct evidence on this is sparse.
Complex versions of such advice have been embedded in programmes of multidisciplinary biopsychosocial rehabilitation but there is little evidence at present to justify the effort. Specific exercise programmes, involving strength and endurance training, muscle training, stretching, and relaxation are also of uncertain benefit. Thus, strength and endurance training decreased pain and disability in women with chronic neck problems in one trial, where stretching did not.53 In another randomized trial, dynamic muscle and relaxation training did not lead to better relief or recovery than continuation of ordinary activity.54
Perhaps the best that can be said at present is that most neck pain, like most LBP, does not have a serious underlying cause; that triage is a means of identifying the few cases needing further investigation; that such investigations will rarely aid fitness assessment in the work setting; and that symptomatic relief and advice to remain active is a sensible pragmatic approach, likely in most cases to be followed by an early return to work. Jobs that require workers to crane and twist their necks to an unusual degree (e.g. to inspect overhead electrical equipment in a confined space) and those that require full neck movements to ensure unrestricted field of view in safety critical situations may justify a temporary fitness restriction. However, research evidence is currently lacking to support the view that workplace interventions will reduce the incidence of neck