Neck pain by Gwen Jull, Part I
A current direction in research into cervical (neck) disorders is towards investigating the value of a "mechanisms" approach to diagnosis. Professor Gwendolen Jull, a renowned musculoskeletal physiotherapist, has reviewed some of the research investigating the pathophysiological features of neck pain, in terms of changes in the articular (joint), muscle, sensorimotor and sensory systems. Changes have been found in patterns of cervical (neck) muscle activation in cognitive, functional and automatic tasks in neck pain patients. In addition, some patients have been found to have disturbances in features of the postural control system in association with their neck disorders. Altered responses to sensory testing have also been determined, particularly in some patients with whiplash-induced neck pain. The value of this mechanisms approach to diagnosis is in its ability to direct specific treatment strategies to address the precise impairments presenting in the individual neck pain patient. It supports the evidence that indicates that a multimodal approach to management is likely to be most efficacious.
Up to 60% of persons can expect some degree of ongoing pain for many years following their first episode of neck pain (Gore D, Sepic S Gardner G, et al. Neck pain: a long-term follow-up of 205 patients. Spine 1987; 12:1-5) . In the Western medical model, diagnosis has traditionally been driven by the desire to obtain a pathoanatomical diagnosis. This approach has failed for neck pain, as for most patients, definitive pathology cannot be identified. Patients often receive a diagnosis of non-specific neck pain, which does not provide strong directives for treatment. Recent clinical guidelines for the management of acute neck pain have recommended (in the absence of identifiable, relevant pathology and other features suggestive of red-flag conditions) that neck pain be classified merely as either idiopathic (unknown) or whiplash-induced (Australian acute Musculoskeletal Pain Guidelines. Evidence Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press, 2003). However, as with the pathoanatomical model, this classification does not recognize neck pain as a potentially complex biological and psychological event and also fails to direct management. There is a need for different directions or diagnosis and classification, and this change is beginning to happen internationally, with an increasing amount of research being directed towards understanding the pathophysiology of neck pain. Thus, the direction is towards developing a "mechanisms"-based diagnosis that has the potential to direct specific interventions. This fits well with the clinical reasoning model used by physiotherapists in their physical examination of the neck pain patient.
Luck LI
Musculoskeletal Physiotherapist
Up to 60% of persons can expect some degree of ongoing pain for many years following their first episode of neck pain (Gore D, Sepic S Gardner G, et al. Neck pain: a long-term follow-up of 205 patients. Spine 1987; 12:1-5) . In the Western medical model, diagnosis has traditionally been driven by the desire to obtain a pathoanatomical diagnosis. This approach has failed for neck pain, as for most patients, definitive pathology cannot be identified. Patients often receive a diagnosis of non-specific neck pain, which does not provide strong directives for treatment. Recent clinical guidelines for the management of acute neck pain have recommended (in the absence of identifiable, relevant pathology and other features suggestive of red-flag conditions) that neck pain be classified merely as either idiopathic (unknown) or whiplash-induced (Australian acute Musculoskeletal Pain Guidelines. Evidence Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press, 2003). However, as with the pathoanatomical model, this classification does not recognize neck pain as a potentially complex biological and psychological event and also fails to direct management. There is a need for different directions or diagnosis and classification, and this change is beginning to happen internationally, with an increasing amount of research being directed towards understanding the pathophysiology of neck pain. Thus, the direction is towards developing a "mechanisms"-based diagnosis that has the potential to direct specific interventions. This fits well with the clinical reasoning model used by physiotherapists in their physical examination of the neck pain patient.
Luck LI
Musculoskeletal Physiotherapist