Neck and Upper Back Disorders
Julie Adkins and Jill C. Cash
Definition
A.Nonspecific disorders: Self-limited, usually benign disorders with unclear etiology, such as regional upper back and neck pain and shoulder pain adjacent to the neck.
B.Degenerative disorders: Consequences of aging or repetitive use, or a combination thereof, such as degenerative disc disease and osteoarthritis.
C.Potentially serious neck or upper back disorders: Fractures, dislocation, infection, tumor, progressive neurologic deficit, or cord compression.
Incidence
A.Exact numbers are unknown.
Pathogenesis
A.Cervical strain is irritation and spasm of the upper back and cervical muscles. The upper portion of the trapezius and the levator scapulae muscles, rhomboid major and minor muscles, and the long cervical muscles are most often affected.
Predisposing Factors
A.Whiplash-like injuries.
B.Cervical strain.
C.Cervical arthritis.
D.Holding your head in a forward posture or odd position. Frequently seen in patients who regularly use computers, cell phones/texting, laptops, and iPads.
E.Sleeping on a pillow too high or too flat.
F.Stress/tension.
Common Complaints
A.Aching neck.
B.Tightness and tenderness in neck area.
C.Stiffness and tightness in shoulders.
D.Stiff neck and a headache upon awakening.
Other Signs and Symptoms
A.Limited range of motion (ROM).
B.Back pain: Guarding with cervical motion.
C.Numbness in upper extremities.
D.Muscle weakness.
Subjective Data
A.What are presenting symptoms? Note pain, numbness, weakness, or stiffness.
B.Was there any type of injury, either recently or in the past?
C.Is the pain located primarily in the neck, upper back, or shoulder? Is there any radiation noted?
D.How do these symptoms limit the patient’s activity?
E.How long can the patient sit, stand, walk, or do overhead work?
F.Is the patient able to lift? If so, how much weight is bearable? Compare to normal weight.
G.How long has the patient had these symptoms?
H.How have the symptoms evolved, from the beginning of discomfort until now?
I.If the patient has a previous history of similar or the same pain, what therapy was used in the past and what were the results?
J.Does the patient have any medical problems?
Physical Examination
Infection may include severe cervical spasms (nuchal rigidity), elevated temperature, chills, hypotension, and tachycardia.
A.Check temperature, blood pressure, and pulse.
B.Inspect: Observe stance and gait. Note the patient’s coordination and use of extremities.
C.Palpate:
1.Palpate trigger points in upper back, paracervical, and rhomboid muscles.
2.Palpate for any bony tenderness in neck, shoulders, and upper back.
3.Perform ROM tests.
4.Assess the patient for reduced ipsilateral and contralateral bending of the neck.
5.Check for fracture, or inability to move neck due to pain, and severe cervical midline vertebral pain. Note tenderness, the patient holding head for stability; look for possible neurologic deficits.
D.Assess deep tendon reflexes (DTRs), bilaterally:
1.Biceps reflex tests fifth and sixth cervical nerve root.
2.Brachioradialis reflex tests fifth and sixth cervical nerve root.
3.Triceps reflex tests seventh and eighth cervical nerve root.
E.Test muscle strength in shoulders.
F.Abduction, elbow flexion, or supination tests fourth and fifth cervical discs.
G.Check for weakness of radial wrist extension, indicating fifth and sixth cervical disc problems. Check for weakness of elbow extension and ulnar wrist flexion, indicating seventh cervical nerve impairment. Check weak finger abduction and adduction, indicating seventh and eighth cervical nerve impairment. Measure circumference at forearm and upper arm for muscle atrophy. Dominant arm is 1/4 inch greater than nondominant arm.
H.Sensory: Test light touch, pinprick, pressure sensations in forearm and hand. Possible cervical spinal cord compromise is indicated by paresthesia of upper extremities, weakness of upper or lower extremities, and difficulty walking.
I.Percuss back, spine, and neck areas. Tumor is indicated by tenderness to vertebral percussion, cachexia.
J.Auscultate heart and lungs.
Diagnostic Tests
A.Radiography of cervical spine.
Differential Diagnoses
A.Regional neck pain.
B.Cervical strain.
C.Cervical arthritis.
D.Cervical nerve root compression with radiculopathy.
E.Rotator cuff tendinitis.
F.Rotator cuff tendon tear.
G.Postlaminectomy syndrome.
H.Spinal stenosis.
I.Torticollis (which may be present at birth or caused by injury or disease).
Plan
A.General interventions:
1.Correct posture and lifestyle modifications (exercise, strengthening, etc.) are imperative for the patient to remain free of pain. Patient education and therapy depend on individual diagnosis.
B.Patient teaching:
1.Teach the patient to use local applications of cold packs during the first 3 days of acute complaints and hot pack applications thereafter.
2.Encourage the following changes in lifestyle:
a.Sitting straight with shoulders held high.
b.Sleeping with the head and neck aligned with the body and a small pillow under the neck.
c.Driving with arms slightly shrugged, using arm rests.
d.Avoiding carrying objects with a strap over shoulders.
e.Making ergonomic changes in computer, cell phone, iPad use, and so on.
3.Suggest adjustments in tasks at work and at home.
4.Encourage daily stretching exercises, including shoulder roll, scapular pinch, and neck stretches.
5.Have the patient perform ROM exercises daily.
6.Tell the patient to avoid extremes of ROM, prolonged periods in one position, and any other aggravating activity.
7.Explain relaxation techniques and stress reduction.
8. 
See Section III: Patient Teaching Guide RICE Therapy and Exercise Therapy.
C.Pharmaceutical therapy:
1.Nonprescription medications: Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).
2.Prescription medications: NSAIDs and/or muscle relaxants for nighttime use.
Follow-Up
A.Evaluate the patient after 2 weeks of conservative treatment. If pain continues after 2 to 3 weeks despite adequate therapy, order radiography, and physical therapy, including ultrasonography, massage, and gentle cervical traction beginning at 5 pounds for 5 to 10 minutes once a day. Soft cervical collar may be worn while doing physical work.
Consultation/Referral
A.Consult or refer the patient to a physician if there is still no improvement after adequate time for healing and no relief is noted with physical therapy and medications.
Individual Considerations
A.Geriatrics:
1.Geriatric neck and upper back pain are most often caused from the natural aging process of degenerative discs, falls (60%), forced hyperextension/hyperflexion injuries, poor body mechanics with reading/computer or sleeping (posture and improper pillows), or pathological fractures.
2.Geriatric treatment management options include physical therapy, Tylenol, short-term NSAIDs/steroids, rigid collar immobilization, halo cast with reduction, or surgical disc fusion for severe cases (uncontrolled pain). Meta-analysis research studies that compared elder and younger adults with the latter treatment options found no differences in morbidity, complications, or mortality.