Now, that said, even for
cervical radiculopathy, whiplash,
the management of these
different causes of neck pain
really should follow about the same
order because it's usually going to be
a time-limited type of symptom.
More time will improve things.
I like acetaminophen as a first-line analgesic.
Because it tends to be a little bit safer than others
and usually better tolerated overall.
But it may not be enough
and may not be as effective.
Therefore, think about NSAIDs, second line,
not a great difference in terms of superiority of NSAIDs
versus acetaminophen for musculoskeletal pain,
but they might be more effective,
but they do –
you have to watch.
They can promote gastrointestinal bleeding.
You have to be careful in patients with heart
disease or renal disease and taking NSAIDs too.
I really don't feel like there's much
of a place for muscle relaxants.
They don't have a specific therapeutic target.
They do tend to make people very tired.
There is some risk of abuse
associated with these agents as well.
So, don't really seem to have as much of a role.
Tramadol is a mu opioid receptor agonist, and so
therefore does activate the natural opioid system.
It doesn't have the addictive
potential as other opiates,
but still has some addictive potential.
Can be used –
particularly when used with acetaminophen,
can be more effective than either alone.
And then opiates are really a last line.
Generally, Center for Disease Control in the US
recommends they shouldn’t be
used for more than seven days,
most cases three days at most.
So, a short course of opiates for
somebody who's really suffering,
but not prolonging therapy down
the road, I think, is important.
Other treatments that you may see
recommended for neck pain.
Cervical collars are not helpful.
So, immobilization does not help and,
therefore, that may come up on your exam.
Do not recommend it.
Home exercises, in and of
themselves, they’re really –
it’s unclear whether they're effective or not.
Physical therapy, on the other hand,
can be effective for these patients.
I’ll usually reserve it for patients
who are in a prolonged course of pain,
more than several weeks where
it just seems to be not getting better,
yet they have got negative imaging studies.
Physical therapy can be a good option for those patients.
They may also think about spinal manipulation.
Overall, there really isn't enough
data to recommend nor refute
the use of spinal manipulations for cases of neck pain.
So, just a little bit more about whiplash.
About half of whiplash patients
continue to have neck pain at one year.
So, if you're that severe that you have this –
that severe stiffness,
the severe muscle tension with headache
that indicates whiplash after an acute injury,
unfortunately, half will go on
to continue to have symptoms,
but there is a link between financial compensation
or time off work and the duration
of neck pain in these cases.
And with that –
so with that,
what we did today was
really kind of differentiate
a little bit of whiplash versus
We went through a very typical algorithm for the management of
musculoskeletal pain that
I'll probably return to a couple of times
when we talk about other issues
such as back pain, for example, or arthritis.
But I think that is very important to keep in mind
as you move forward,
starting with your more safe drugs with a proven record,
and then really holding opiates out for the patients who need them
and then trying to keep that course as short as possible.
that was very helpful for you today.
Look forward to seeing you next time.