The CORE Neck TOOL: An Organized Approach to Neck Pain · motor neuron signs and should include deep tendon reflexes, myotomes and dermatomes but also include upper motor neuron tests

The CORE Neck TOOL: An Organized Approach to Neck Pain

BACK HEALTH

ABSTRACTNeck pain is a common presentation in primary care with an estimated one-year incidence ranging from 10.4-21.3% and a 25-50% recurrent rate.1 Guidelines have not included a specific approach to assessment although treatment recommendations have advised non-pharmacological and pharma-cological management for optimal results. The CORE Neck Tool was designed as a comprehensive, user-friendly approach to clinical decision making for primary care providers assessing patients with neck pain. The key components of the tool include a high yield history, physical examination and a management matrix providing evidence-based recommendations for acute and chronic neck domi-nant and arm dominant pain patterns. Criteria is clearly described for investigations and referral man-agement and patient key messages are embedded in the tool. This tool has been incorporated into the Ontario Quality Based Spine Pathway and is endorsed by the Ontario College of Family Physicians and the Nurse Practitioners Association of Ontario. A clinical case will be used to demonstrate the ap-plication of the tool to practice and instruct the reader on the key features.

KEYWORDS: Spinal lesion, tumour, imaging characteristics, primary bone tumours

BackgroundWith the success of the Core Back Tool in helping primary care providers to assess spine pain, the committee defining the Quality Based Pathway for Spine care and the Ontario College of Family Physicians concurrently recommended the develop-ment of a Neck Tool. This tool development process was managed by the Centre for

CME

Pre-test Quiz

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

Pierre Côté DC, PhD, Canada Research Chair in Disability Prevention and Rehabilitation; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation.

Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

22 Journal of Current Clinical Care Volume 8, Issue 3, 2018


Effective Practice and the meth-odology included provider focus groups to identify common gaps in practice and engagement of knowledge experts to ensure an evidence-based approach, which supports clinical decision making and enhances health care provider knowledge and attitudes.

As with low back pain, we usu-ally cannot find a specific anatomi-cal cause for neck pain and the presence of degenerative changes on imaging do not correlate with patient’s symptoms of pain or interference with function.2 In low back pain we strive to ensure that a cauda equina lesion is never missed; in neck pain, espe-cially in the early and emergent stages there may be a delayed or overlooked diagnosis of cervical myelopathy. In the neck there are no validated mechanical pain pat-terns associated with movement direction as there are in low back pain. There are dominant areas of pain in the neck, arm or shoulder that can guide the clinician toward a clinically useful classification. Risk factors for mechanical neck pain include genetics, poor psy-chological health and previous musculoskeletal pain.3 Low physi-cal capacity, poor posture and job insecurity are common among patients with neck pain.3

The presence of headache associated with neck pain can pre-sent a confusing clinical picture and there are potentially more

serious pathologies associated with headache. Therefore, the clinician using the Core Neck Tool starts the assessment by asking if the patient is experiencing a headache related to this episode of neck pain. If the answer is yes, the clinician is advised to use the Headache Navi-gator4 to assess the symptoms in more detail.

Case Details:Sarita is a 37-year-old woman with a 3-week history of intermittent right sided neck pain that radiates into her right shoulder and occa-sionally down the inner border of her right shoulder blade. She recalls this starting after she got a new bicycle and rode daily to work for a month. Her commute was 60 min-utes twice a day. She has been a migraine sufferer for 10 years and has not noticed any change in head-aches. Her job is sedentary, but she has three children at home aged 8, 5 and 3 years. She has tried some ice and some topical diclofenac which she applies at night. She feels that massage would help her as she carries a lot of tension in her trape-zius muscles. On examination, there were no neurological findings and her pain was reproduced with neck extension.

Sarita does experience head-aches but they are pre-existing to her neck pain and have been previously diagnosed. It is recom-mended that you would still ask the question; Are you experienc-



ing a headache related to your visit for today? In this case, she would answer no, but if she did answer yes, then you would proceed with the Headache Navigator tool.

Questions 2 and 3, “Where is your pain the worst?” and “Is your pain constant or intermittent?” (See Diagram 1) help you determine if her pain is mechanical and the likely source of her symptoms. When you are determining the patient’s domi-nant area of pain, consider where they describe their most intense and bothersome symptoms. Neck dominant is most intense in the sub-occipital, trapezius and par-ascapular regions. Arm dominant

pain is most intense in the upper arm below the deltoid, forearm and hand. Neck dominant symp-toms are usually referred pain while arm dominant pain should be considered radicular. It can be challenging to identify shoulder dominant pain since both neck and arm pain can have coexisting shoulder pain but if you can deter-mine that the worse pain is over the deltoid or anterior shoulder then the patient’s most dominant pain would be classified as shoul-der. If shoulder pain is dominant, you should exit the tool to perform a full shoulder examination. Sarita may have both shoulder and neck pathology since during cycling she

Diagram 1:



has been weight bearing on her upper extremity while holding her neck in sustained extension.

The importance of intermittent or constant pain is to determine if further consideration should be given to potential red flags. To have truly intermittent pain the patient must report times (no matter how brief) when the pain has completely disappeared. If pain is constant, you must con-sider pathologies such as cervical,

myelopathy, inflammatory arthri-tis, fracture or tumour in your dif-ferential diagnosis. (See Diagram 2) The initiation of investigations should only occur if red flags are present in the history and validated in the physical examination.

In Questions 4, 5, 6 and 7, the clinician can quickly screen for other significant non-mechanical pathologies and promptly embark on further evaluation to avoid a delay in diagnosis. (See Diagram 3) If the pain spreads to the upper-left anterior chest, it is important to determine if the patient is expe-riencing cardiac symptoms such as shortness of breath, chest pres-sure or dizziness. When the chest pain is referred from the neck this is called “cervical angina” and fur-ther cardiac investigations are not required.5 The patient can be assured that their symptoms are related to their neck pain.

Cervical myelopathy is a poten-tially devastating condition that should not be missed. It is impor-tant to assess gait disturbance, incoordination and loss of fine motor control in the hands such as doing up buttons. The modified Japanese Orthopedic Association (mJOA) score is a valuable tool used by surgeons to better adju-dicate the urgency of the referral.6 Primary care clinicians may receive consultation reports noting the mJOA score. A higher score 15-17 is indicative of a mild myelopathy, a moderate score 12-14 indicates

Diagram 2:



moderate involvements and severe myelopathy affecting functional ability and quality of life is scored from 0-11.

In Question 6, “Did your neck pain begin with a trauma?” the clinician consid-ers the possibility of fracture and/or concussion if the neck pain is associated with a recent fall or acci-dent. Question 7, “Are you expe-riencing morning stiffness for longer than 60 minutes?” is aimed at early identification of patients who may have inflamma-tory and not mechanical neck pain. In Sarita’s case if she was experi-encing prolonged morning spinal

stiffness we might consider rheu-matoid arthritis in the differential diagnosis

Question 8, Is there any-thing you cannot do now that you could do before the onset of your neck pain? is the same question that is used in the Core Back tool. It provides valuable insight into the level of function or dysfunction and can reveal high levels of perceived patient disabil-ity, which may be indicative of yel-low flags; psychosocial risk factors for developing chronicity.7 The yel-low flags are commonly described as fear of activity, dependency on passive treatment and low or

Diagram 3:



negative mood. (See Diagram 4) Patients demonstrating significant yellow flags may benefit from cog-nitive behavioural therapy or other psychosocial intervention(s) and support.7

The recommended physical examination (See Diagram 5) is designed to confirm or refute the suspected mechanical patterns identified on history while ensuring

that there are no undetected signs of sinister pathology. The examina-tion consists of observation, range of motion, neurological assess-ment and provocation of possible radicular signs. The clinician will observe gait to determine imbal-ance or unsteadiness that could suggest cord compression. The neck position and general postural habitus are good insights into usual postural stresses on the spine or to positions that relieve pain. Gently palpate the cervical lymph nodes checking for any prominences. This could be an early indicator of infec-tion and/or tumor and lead the examiner to more detailed evalua-tions. Range of motion is assessed actively in flexion, extension, rota-tion and side bending to determine the effect they have on pain levels. The range of movement is not use-ful for initial interpretation but may be recorded to demonstrate progress on follow-up in the acute phase.

Radicular pain can be dem-onstrated by the reproduction of arm dominant pain on the Spurl-ing’s cervical compression test and the alleviation of arm domi-nant pain with the cervical dis-traction test.8 Spurling’s test has a high specificity of 93% but a low sensitivity of 30% while cervical distraction has a high specific-ity of 97% and a low sensitivity of 44%.9 Using the combination of two tests, the clinician is more

Diagram 4:



likely to identify the patients who do not have radiculopathy (true negative rate). A neurologi-cal screen should look for lower motor neuron signs and should include deep tendon reflexes, myotomes and dermatomes but also include upper motor neuron

tests such as Hoffman’s test and the extensor plantar response.

When deciding best manage-ment for your patient (See Diagram 6), first determine if their neck pain is acute or chronic. The designation “acute” is applied to patients whose neck pain episode is less than three

Diagram 5:



Diagram 6:



months and the term “chronic” is used to denote patients who have experienced persistent or ongoing neck pain for longer periods. The next determinant in management is to divide treatment into that for neck dominant (referred) or arm dominant (radicular) symptoms. Evidence based treatment includes both non-pharmacological and pharmacological interventions.10 The primary goal is to decrease pain through effective medication

use and recovery positioning while increasing activity through educa-tion, daily living activity and exer-cise.11 Referral to a therapist can be helpful when initial treatment does not relieve symptoms or when there is associated extensive muscle guarding, stiffness and pain irrita-bility. In chronic neck pain manage-ment medications can be advanced to anti-depressants or anti-epilep-tics. It is important to note that some commonly prescribed treat-

1. Most neck pain is benign mechanical pain and serious pathology is uncommon.

2. Always assess the patient’s headache symptoms first before proceeding with the neck assessment.

3. Cervical imaging is only required in patients with persistent arm dominant pain, positive neurological

findings or a history of significant trauma.12

4. Neck pain is considered chronic if persisting greater than three months.

5. Exercise, education and postural advice are the best evidence-based treatment.

SUMMARY OF KEY POINTS

CME

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

Post-testQuiz

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If the patient presents with shoulder dominant pain, do a complete shoulder examination versus if the patient presents with neck dominant pain, only a shoulder screen assessing range is necessary.

Palpation of the cervical nodes is a quick and necessary component of the neck examination to ensure that a red flag is not present.

Cervical myelopathy signs may include difficulty with hand fine motor tasks, tingling and/or numbness in the upper extremities and changes in gait steadiness and coordination.

Do not make the concurrent diagnosis of bilateral carpal tunnel syndrome, until cervical cord pathology has been excluded

CLINICAL PEARLS



Diagram 7:



ments are not recommended as there is no evidence to support their use and there may be evidence of associated harm. These treatments are listed under Not Recommended and in acute pain include cervical collars, neck pillows and passive modalities. In chronic pain they include cervical traction, regular opioid use and relaxation massage.

Section D, Referrals (See Dia-gram 7), provides criteria for appropriate referral to another provider. The rehabilitation crite-ria include a list of the skills that a therapist should have to effec-tively provide evidence-based care as well as a list of criteria to indi-cate patient readiness. Criteria for surgical consultation and pain management, two other frequent options, are outlined.

In summary, by using the Neck Core Tool,13 Sarita’s primary care provider would be able to deter-mine that she is having acute neck dominant non-radicular pain that would benefit from education, encouragement to resume normal activities that don’t trigger her pain, short-term active therapy and non-opioid analgesia perhaps com-bined with a non-steroidal anti-inflammatory.

References:

1. Teichthal A, McColl G. An Approach to Neck Pain for the Family Physician, Australian Family Physician, 2013, 42(11) :774-778

2. Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ, Godges JJ, Flynn TW. Neck

pain: Clinical practice guidelines linked to the Inter-national Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. 2008. J Orthop Sports Phys Ther. 38(9):A1-A34.

3. Côté P, van der Velde G, Cassidy JD, Carroll LJ, Hogg-Johnson S, Holm LW, Carragee EJ, Haldeman S, Nor-din M, Hurwitz EL, Guzman J, Peloso PM. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(Suppl):S60-74.

4. Headache Navigator Section of Core Neck Tool5. Wells P. Cervical angina. American Family Physician.

55(6): 2262-2264, 1997.6. Tetreault L, Kopjar B, Nouri A, Arnold P, Barbagallo G,

Bartels R, Qiang Z, Singh A, Zileli M, Vaccaro A, Fehlings MG. The modified Japanese Orthopaedic Association scale: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. Eur Spine J. 2017 Jan;26(1):78-84.

7. Alleyne J, Rampersaud R, Rogers J, Hall H., CORE BACK TOOL 2016: New and Improved! Journal of Current Clinical Care Volume 6, Issue 2, 2016

8. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison Sl. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003 Jan 1; 28(1):52-62.

9. Tong HC1, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy, Spine (Phila Pa 1976). 2002 Jan 15;27(2):156-9.

10. Côté P, Wong JJ, Sutton D, Shearer HM, Mior S, Rand-hawa K, Ameis A, Carroll LJ, Nordin M, Yu H, Lindsay G, Southerst D, Varatharjan S, Jacobs C, Stupar M*, Taylor-Vaisey A, van der Velde G, Gross D, Brison R, Paulden M, Ammendolia C, Cassidy JD, Loisel P, Marshall S, Bohay R, Stapleton J, Lacerte M, Krahn M, Salhany R. Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016. 25(7): 2000-2022.

11. Hall H, McIntosh G, Alleyne J, Côté P. A Pain in the Neck. Journal of Current Clinical Care Volume 5, Issue 1, 2015

12. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiog-raphy in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.

13. CORE Neck Tool and Headache Navigator. Toronto: July 2016 Centre for Effective Practice. http://thewell-health.ca/neckheadpain

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The CORE Neck TOOL: An Organized Approach to Neck Pain · motor neuron signs and should include deep tendon reflexes, myotomes and dermatomes but also include upper motor neuron tests