Introduction: The Neck

Problems with the neck are very common, with pain and often limitation of movement that affects many everyday activities. Neck pain often spreads into the shoulder and neck problems can cause pins and needles and numbness in the hands. For this reason, it is often necessary to assess both the neck and the shoulder when dealing with a neck problem. However we shall consider the neck and shoulder separately, for simplicity.

Anatomy of the Neck

The neck is the upper part of the spine and is sometimes referred to as the cervical spine. The spinal column is comprised of a number of small bones or vertebrae (singular vertebra) separated by intervertebral discs. The cervical spine comprises seven vertebrae, which are numbered C1 to C7, starting at the skull and numbering towards the shoulder region. C1 is called the Atlas bone and C2 is the Axis. Each vertebra has a spinous process, which can easily be palpated in the midline posteriorly.

The nerves that supply the shoulders, arms and hands leave the spinal cord between the vertebrae of the neck. Therefore, problems with the vertebrae that cause pressure on, or trapping of, the nerve can be accompanied by pain or tingling in the shoulders, arms or fingers and, less commonly, may cause muscular weakness in the arms or hands, and rarely in the legs.

Neck Pain

The neck moves almost constantly during waking hours. Neck pain is common, over two thirds of the population experience some kind of neck pain that lasts for three or more months during their lives.

Neck problems can present with pain and stiffness in the neck and sometimes an accompanying headache. The pain can spread across to a shoulder and down the arm. These symptoms can be due to disorders in the neck itself or from the muscles going into spasm. Neck problems can also result in pins and needles in the hand and forearm if a nerve that is bringing sensation from the hand and forearm is pressed on or irritated as it passes through the forearm into the cervical spine.

Fig N-5

Neck pain may be due to:

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Cervical spondylosis with degeneration of the discs and osteoarthritis of the joints in the neck	Pain often spreads across into a shoulder and upper arm. May be associated with headache at the back of the head (often confused with migraine). Can be associated with irritation of the nerves to the arms with pins and needles in a hand as a result. Sometimes osteoarthritis of the joints can cause pressure on the nerves with tingling or pins and needles (parasthesiae) in the hand. If the pressure is more severe, there may be loss of feeling and of power.
Whiplash	Caused by a sudden jerking, for example the sudden stopping of a car, whiplash can result in acute neck pain with muscle spasm. It is self-limiting in most people but in a few it can take a long time to settle.
Poor posture or straining the neck	This often affects people in sedentary jobs that involve holding the neck in one position for long periods, for example looking at a computer screen. Also tasks which involve overhead work can provoke neck pain.
A prolapsed intervertebral disc	Prolapsed discs can cause pain that may spread down the back or arm. The disc may protrude into the spinal canal where it presses on nerves and can cause pain with tingling, loss of feeling and weakness. This is not very common in the neck and more often happens in the lower back.
Inflammatory arthritis including rheumatoid arthritis	The neck can be affected in ankylosing spondylitis and other similar types of arthritis with inflammation of the tissues around the joint. Rheumatoid arthritis can also affect the joints of the neck and can make the neck unstable (subluxation) – this is not seen so often now with the more effective treatment of RA.

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Giving a History of Neck Problems

Invite the doctor to carry out a consultation by first asking you about your history related to the experience you have of your condition. This will then be followed by the physical examination.

The doctor should first ask you ‘What is the problem?’ and you should give a short response describing your symptoms and their effect on your quality of life.

Develop a script based on your own experience. You may still have the symptoms or you may be describing an episode you have had as if it were still present.

Describe as fully as you can your own symptoms, including where in the neck you feel/felt pain or discomfort and whether you have/had any tingling in your arms and/or hands. Say if you have any stiffness, swelling or other symptoms. Mention if you have/had any headaches and how the problem is having/had an impact on your daily life, your work or your sleep.

Remember to describe how your condition affects/affected your quality of life using the framework covered in the earlier section of this manual. Consider self care (e.g. ability to wash, dress, toilet and feed), domestic care (e.g. ability to cook, clean, launder, shop), work (e.g. ability to stand, sit, type), leisure (e.g. ability to play sports, walk, go out for meals). Explain about the way it limits/limited your activities and restricts/restricted your participation in normal life.

Do not tell him everything spontaneously – just the important part. He will then need to ask further questions to fully characterise your problem. Develop a set of answers with your trainer to the following points. Prompt them if they omit important questions.

Pain is usually present and questions should establish:

• How the pain started and developed.
• The nature of the pain.
• The exact distribution of the pain.
• Whether the pain has increased or decreased over time.
• Whether it affects sleep.
• Whether anything exacerbates or relieves the pain. Stiffness may be a symptom and questions should establish:
• If you are stiff at all?
• When it is worse?
• What improves it?

Swelling may be a symptom and questions should establish:

• If you have noticed any swelling and where.
• If it is always present.
• If it is painful or tender.
• If it is increasing.

They need to ask about the pattern of all the symptoms – where they started and if they have spread anywhere.

You may  prompt the doctor (if you have  not already told  them)  to make sure that they include the following information:

• Your hand dominance.
• Your age, occupation and  hobbies.
• Whether you have injured or strained your neck.
• Your past medical history.
• Whether you have   any  symptoms such   as  tingling,   numbness  or weakness in your arms/hands/fingers.
• Whether there is any  impairment of function and  how  this impacts on your daily activities and  quality  of life.

–  Neck    problems  typically  cause   difficulty   driving,    reading, sleeping, looking  up  to  change a  light  bulb,  or  performing any activity  requiring the  head to be  held  up  or in the  same  position for a length  of time. Working with the arms raised  above shoulder height  is often  difficult as you look up to do this.

• Whether you have  had  previous treatment and  if so whether it was successful.

The  effect  of  any  problem depends on  your  personal circumstances. The  doctor needs to  know  about what  you  need to  do  in  the  home, at work,  your leisure  interests  and  your expectations.

You may  have  symptoms affecting  other  parts  of your  musculoskeletal system.  You may prompt the doctor to ensure he has asked  whether you have  any other  problems affecting  your muscles, joints,  neck  or back.

You may go into further  details  about how  your problem affects your life and  the  treatment you  have  received at  the  end  of the  session  when discussing the findings.

Example of a Script

You should develop something like this, based on your own  story. First you need to ask me:

“What is your problem?”

“I have  had  neck  pain  for several  years  which is worse  when  I wake  up, and I also get pins and needles in my hands. It sometimes wakes  me and I cannot do things  that need me to look upwards for a long time.”

You should then  respond to questions, guiding  and prompting the doctor through the information as listed  above.

Neck Examination Script

Describe  the   examination  to  the   doctor  using   the   anatomical and directional  terms   you   have   learnt. You  can   use   your   knowledge   of anatomy  best  when   the  doctor  is  feeling   the  joint  and   periarticular structures.

“I  would now   like  to  invite  you  to  find  out  a  little  bit  more  about my problems, by role play, using me as your patient and examining me.”

Examination of the  cervical spine  must  be  gentle,   especially in  those with  severe  rheumatoid arthritis.  Some  people with  rheumatoid arthritis have  an unstable spine  because of joint damage and if the spine  is forced to  move  beyond its  limits  neurological damage or  subluxation   of the cervical spine  could occur. (Subluxation is partial  dislocation of a joint so that the bones are still in contact but are not properly aligned).

Look

Inspect  the patient’s  posture and the alignment of the head and neck. The head and  neck   should be  erect   and  perpendicular to  the  shoulders. Redness  and  swelling  are rarely  seen  in the neck.

What do you see?

Feel

Feel  for  tenderness over  the  cervical spinous processes by  palpating down the  vertebrae using  the  index  and/or middle fingers  or  thumbs. The patient may like to place their hands on a table  or chair  for support.

Feel  for tenderness or spasm  in the  muscles approximately 1”  (2.5cm) either  side of the spinous processes. Move  the flat surface  of your finger tips in a circular motion and  keep  fingers  in contact with  the skin so as not to miss any findings.

What do you feel?

Move

Rotation: Evaluate  rotation by asking  the patient to sit facing  you on the edge  of the examining table  or in a chair.  Ask them  to turn their head to the right as far as they can  and  estimate the angle.  Repeat  this to the left. Look  for  full  or  limited   range  of  motion (ROM);  remember  flexibility diminishes with age.

Figure N-6. Rotation of neck

Lateral flexion:  Lateral  flexion  can  be  assessed by asking  the  patient to angle  their head to the right trying to touch their shoulder with their ear and  then  repeating this  to  the  left. You  may  need to  demonstrate the movement to them.  Ask if this is the patient’s  normal range  of motion or whether they feel it is restricted.

Fig N-7

Flexion and extension: Assess flexion and extension by asking the patient to bend  their  head forward  as far as they  can.  Then  ask  the  patient to perform  the reverse  movement and to look up as far as possible. Estimate whether this  is the  full ROM  or  seems  restricted; remember  flexibility decreases with  age.  Ask the  patient if the  current range  of  motion  is normal for them  or if it has changed.

Fig N-8

What have you found?

Stress

It is very important that stress is never  used  when  examining the neck.

Listen

Crepitus may  be heard on movement. It tends  to occur quite  frequently in older  people, even  when  they have  no significant neck  problem.

Special tests

As neck  problems can  be  associated with  irritation or  pressure on  the nerves   to  the  arm,  a  neurological examination should also  be  done, especially if there  are any symptoms of tingling,  numbness or weakness in the arms or hands.

Lightly touch the  arms  and  the  palmar and  dorsal  surfaces  of the  hands and  fingers  and  ask  if sensation is normal. Test grip  strength  by asking them  to wrap  their fingers around two of yours and then  to squeeze hard. Test pinch grip by asking  them  to pinch together their  thumb and  index finger  hard  and  you  seeing  if you  can  break  the  circle.  Tell them  they should now  test  the  reflexes  in the  arms  (triceps,  biceps and  supinator jerks).

“We  have  now  come to the  end  of this mock  consultation. You should have    learned   quite    a    bit    about   my    condition   from    taking my  history  and  examining my  joints,  however, I would be  happy to provide you  with  a bit more  detail  about the  progress of my condition and  how  it affects my life, if you would find this useful.”

[Please give a brief description of your  condition:

• When and how  it started.
• Physical and psychological affects  on you.
• Treatments offered.
• How your  condition progressed.
• How this affected your life: Home, education, work,  leisure,  ability to travel, relationships etc.]

“Does anyone have  any further  questions?”

“Thank   you  again   for  attending this  session. I hope   you  have   found it useful.”