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The amount of neck pain and disability suffered by patients varies greatly from very low pain levels and virtually no disability to high pain levels which interfere significantly with activities of daily living. The underlying reasons for this are likely to be related to the pathological and neurological mechanisms at work in the differing neck pain syndromes. Initial focus was on identifying pathology in the cervical spine which could be responsible but this approach has not led to a complete understanding. Attention has moved towards the underlying pain mechanisms potentially responsible.

One way to allow more accurate whiplash treatment to be identified is to clarify which diagnosis and which pain syndrome in present in an individual patient\’s neck pain problem. Neck injury can consist of long term postural abnormality, repeated small trauma in activity or an obvious event such as whiplash injury. Any inflammation which is present in these cases in known to significantly change the ways pain is processed both in the central nervous system of the brain and the spinal cord and in the locally damaged area. Even though most research has been performed on animals this can be taken seriously when considering pain in humans.

An injury sets off a chain of events in the local area, the spinal cord and in the brain which leads to the central nervous system developing increased sensitivity to all incoming stimuli, making it react more strongly. A reduction both in the pain threshold and the tolerance to pain in the neck has been found in patients with generalised neck pain of unknown origin and in those who have suffered whiplash. This is known as hyperalgesia which is defined as an exaggerated painful response to a normally painful stimulus.

Neck hyperalgesia occurs to some extent in all people after whiplash injury but this decreases steadily in two to three months in patients who recover or report mild symptoms. This abnormal pain reaction continues however in patients with worse pain and those who become chronic. Damaged local neck and head structures have been identified after whiplash injury, potentially causing local sensitivity changes. However, central nervous system mechanisms could also be responsible, causing a heightened reaction to incoming feelings and being the reason why pain is maintained over time.

The internal nerve mechanisms of the central nervous system are very likely important in neck pain problems but there is evidence of ongoing pain sources in the shape of damaged neck structures. Investigation of the facet joints of the neck by injection blocks has indicated they are a pain source in some chronic whiplash pain patients. Referred pain is also a typical phenomenon, with pain being perceived away from the site of its generation. This may be because the nervous system interprets pain inputs from bodily structures such as joints and discs as related to other areas linked with the same sensory nerve pathways.

The upper three main neck segments may refer pain into the head and the lower ones down to the first thoracic segment may refer pain into the arm. In some cases an increased response to stimulation may be present in areas of the body or limbs where the patients are reporting no symptoms. An increase in the responses to mechanical stimuli (hyperalgesia) is present in typical neck pain and in people who have whiplash, but the latter may have more complex disturbances of neurological functioning. They may react more strongly also to pressure, heat and cold, the reasons for this not being clear.

With more widespread symptoms and a higher pain level also comes a wider sensitivity response to incoming stimuli, typical findings in patients with chronic neck and arm pain from nerve root problems and with whiplash. Whiplash and cervical radiculopathy (a condition where the nerve root in the spinal cord is compromised by for example compression as it exits the spinal canal) may both cause complex excitation changes in the way the nervous system processes incoming pain signals. But this may not be the only mechanism as it might be maintained by incoming pain from damaged or injured neck muscles, joints, ligaments or discs in the neck.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Glasgow, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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