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Pain in the neck is a common complaint. It
is the product of a fast, mechanical life full of
tension, lack of exercise and bad posture, use of cushy
pillows and a soft bed. It may also be due to an injury.
No specific cause can be pin-pointed. Some patients
develop a stiff neck due to the incorrect positioning of
the head in bed, especially while lying on the tummy with
the head turned to one side. Sometimes the pain in the
neck lasts for a few days and wears off on its own. But
when it persists for a long time, it presents greater
problems.
The cervical vertebrae have many peculiarities. They
protect the spinal chord which carries practically all
the nerves to the whole body. A disease of the cervical
spine can have much wider effect than a similar
disturbance in the dorsal or lumbar spine. The neck has
to be mobile and yet it has no support like the ribs in
the dorsal spine or the pelvis in the lumbar spine. It
has to support the head and a considerable strain is
borne by the neck when the arm muscles are put to
vigorous use. It carries its own blood supply through the
vertebral arteries and veins. These vessels are well
protected in transverse processes, but they still
experience mechanical problems.
Limitation of movement is one of three main problems. It
may occur due to osteoarthritis of the cervical spine,
which is called spondylosis. As a person grows old, there
is always some generalised wear and tear of bones,
including the cervical spine. The most common complaints
mentioned are those of pain and stiffness in the neck.
These generally occur in the three lowest cervical
vertebrae. Patients are not able to turn their necks and
look behind. This pain may radiate to the posterior part
of the head or upper back between the two shoulder blades
and to both shoulders. It is likely that only referred
pain is prominent – that is, the patient may not
complain of pain in the neck but pain between his
shoulder blades only. These patients, especially women,
often have swelling in the lower part of the neck. As the
swelling subsides there is improvement of mobility and
the pain is also reduced or relieved.
In this condition, there is degeneration of the disc
between the vertebral bodies. A few osteophytes can be
seen at the joint margins in an X-ray. These osteophytes
may encroach upon the intervertebral foramen (the
passages between the vertebrae) and reduce their size.
This causes pressure on the cervical nerves. There may be
numbness, tingling and a feeling of pins and needles in
the hands. There is a tenderness over the muscles of the
neck. Occasionally creaking sounds can be heard while
moving the neck.
The therapeutic result of manipulation cannot be judged
by changes seen in the X-ray. In advanced osteoarthritis
excellent results are achieved with the spine recovering
its normal range of movement and the pain completely
subsiding. On other occasions, minor changes may take
much longer to respond. When osteoarthritis involves
facet joints, the results of manipulation are less
satisfactory. In such cases manipulation which is too
brisk should not be used; the technique must be gentle
with a steady progress.
The patient should not be manipulated in an acute phase.
A clear cut distinction must be made as to whether the
problem is mechanical or inflammatory. In an inflammatory
condition movement in al directions is painful. Cases of
rheumatoid arthritis should not be manipulated. A
preliminary test and examination of the patient will
provide enough indication about the therapeutic success
of manipulative treatment. In a majority of cases
treatment is possible and induces immediate beneficial
results upon the mobility of the spine. The pain and
other complaints start getting better. Manipulative
treatment of cervical spondylosis is therefore helpful. A
few select exercises after the cure diminish any chance
of recurrence.Brachial Neuralgia
Sometimes the arm
becomes painful. The pain shoots down one of the arms,
accompanied by numbness and a tingling sensation in one
or more fingers. This is due to irritation in the nerve
roots emerging between the fourth cervical and the second
thoracic vertebrae.
There are two factors
which cause this pain:
First, pressure of the
disc on the nerve root;
Second , inflammation of the nerve sheath or tissue
contained in the intervertebral foramen. The pain may be
in the entire upper arm or in a localised area depending
upon the site of pressure. It may be a severe pain or a
dull pain. It may increase during certain movements of
the neck or on laughing. It usually increases when the
patient is in bed and is relieved by certain movements,
for example, placing one’s hand behind one’s
head.
The patient usually complains of stiffness of the neck
and pain between the shoulder blades for years before the
disc begins to protrude. When the pain becomes acute,
spreading over the upper limb, and the movements get
restricted, it is then that the diagnosis of a disc
prolapse can be made. A couple of more clinical tests
confirm the diagnosis:
- When the lower part
of the neck is involved, movement in the painful
side of the neck increases the pain, leading to a
numbness in the arm.
- When traction of the
neck provides relief, it confirms the diagnosis.
A symptom frequently
accompanying the pain may be in the form of weakness of
the neck muscles. Sometimes the pain may be so severe
that the patient has to hold his head while sitting. Even
while turning his head in bed he may have to support it.
If the pain has started following an injury, the patient
may complain of pain several hours after the injury.
The site of pain, numbness, tingling, a feeling of pins
and needles, weakening of the neck muscles, decrease in
the muscle power and altered reflexes – all depend
upon the level of the disc lesion. Clinical and
neurological examination can determine the approximate
site of the level of disc protrusion.
Treatment
In many cases of
brachial neuralgia manipulation is quite effective. When
there is acute pain and almost no movement of the neck is
possible, manipulation should not be attempted. Prior to
manipulation, immobilisation of the neck in a collar,
rest and shortwave diathermy may be tried. In some cases
where only a little movement is possible, manoeuvres to
relax the muscles and gradual mobilisation are helpful.
Manipulative manoeuvres should only be attempted when
considerable movement in the neck is achieved.
Sometimes manipulation of the upper dorsal spine is also
necessary along with cervical manipulation. In moderate
cases manipulation can be immediately. The treatment must
be conducted gently. This is more important in the region
of the neck that in any other region.
Selective and gentle
treatment is more effective. Thus treatment is given in
the following order:
- Relaxation of the
cervical region, shoulders, muscles and upper
back.
- Mobilisation prior to
manipulation.
Before manipulation,
traction can be utilised, but in cases where traction has
failed, manipulation must be given a fair trial.
Following the reduction of disc herniation by
manipulation, the patient can use the collar as a
protection against strain.
Once the muscle spasm has subsided, the collar can be
removed. Other physiotherapy methods may also be used.
Patients should sleep on a hard bed without a pillow.
Neck exercises should be started when the pain has
completely subsided.
Case
Histories
- A bankman aged
forty-two years suffered for one and a half
months from pain in the neck, which radiated to
the right arm. He also felt numbness and a
tingling sensation in the right arm. He
experienced relief by raising his arm but felt
more pain when the right arm was hanging down. He
had a similar attack six years before but then
the pain used to radiate to the left arm and
subside with cervical traction. The pain, at that
time, had lasted for one month. A similar pain
had occurred six months ago, which had subsided
in fifteen days with the same treatment.This time
the pain was radiating in the right arm and
nothing seemed to work in spite of medication and
cervical traction. Manipulative treatment was
started. He experienced considerable relief and
the numbness and tingling completely subsided. By
the third session of the treatment, he was ninety
percent better. In six weeks he had no pain at
all and has had no attack since.
- A cloth merchant aged
forty-eight years complained of neck pain for six
months. The pain radiated to the right arm. It
was severe for three months. It started without
any injury and went on increasing, being present
all the time. He felt more pain during the
evening after working the whole day. He felt
stiffness in the neck when he got up in the
morning. Medication and traction of the neck did
not help. The X-ray showed no abnormality in the
cervical spine. The laboratory tests were all
normal. He felt a lot of relief for 2-3 days
after the first manipulative treatment. The
treatment was repeated again after one week and
the improvement was remarkable. After four weeks
he was free of pain. Now two years have passed
and he has had no repetition of pain.
- A young housewife
from kanpur, aged twenty-four, had been suffering
from pain in the neck for four years. It started
without any apparent cause and went on
increasing, radiating to both arms, especially
when she worked without wearing a collar. She
consulted an orthopaedic surgeon and was advised
medication and traction, and then given a collar
which she used for three years. When she came to
me, an X-ray of her cervical spine was taken
again and it showed no change from the previous
X-ray. Her laboratory tests were all normal.
Manipulative treatment was started for her
cervical and upper dorsal spine. Her pain started
getting less from the very first day of
treatment. She was advised to use the collar for
shorter periods, and that too only when she felt
the pain. Within a month, she stopped using the
collar. The pain was seventy-five per cent
better. She obtained complete relief in two
months. A year later I received greetings from
her giving me the good news that she no longer
suffered from any pain.
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