00:01
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.
00:15
More time will improve things.
00:18
I like acetaminophen as a first-line analgesic.
00:22
Why?
Because it tends to be a little bit safer than others
and usually better tolerated overall.
00:29
But it may not be enough
and may not be as effective.
00:32
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.
00:47
They can promote gastrointestinal bleeding.
00:49
You have to be careful in patients with heart
disease or renal disease and taking NSAIDs too.
00:54
Muscle relaxants.
00:56
I really don't feel like there's much
of a place for muscle relaxants.
00:59
They don't have a specific therapeutic target.
01:01
They do tend to make people very tired.
01:04
There is some risk of abuse
associated with these agents as well.
01:08
So, don't really seem to have as much of a role.
01:11
Tramadol is a mu opioid receptor agonist, and so
therefore does activate the natural opioid system.
01:23
It doesn't have the addictive
potential as other opiates,
but still has some addictive potential.
01:29
Can be used –
particularly when used with acetaminophen,
can be more effective than either alone.
01:36
And then opiates are really a last line.
01:39
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.
01:47
So, a short course of opiates for
somebody who's really suffering,
but not prolonging therapy down
the road, I think, is important.
01:55
Other treatments that you may see
recommended for neck pain.
01:58
Cervical collars are not helpful.
02:00
So, immobilization does not help and,
therefore, that may come up on your exam.
02:03
Do not recommend it.
02:05
Home exercises, in and of
themselves, they’re really –
it’s unclear whether they're effective or not.
02:11
Physical therapy, on the other hand,
can be effective for these patients.
02:14
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.
02:24
Physical therapy can be a good option for those patients.
02:27
They may also think about spinal manipulation.
02:30
Overall, there really isn't enough
data to recommend nor refute
the use of spinal manipulations for cases of neck pain.
02:39
So, just a little bit more about whiplash.
02:41
About half of whiplash patients
continue to have neck pain at one year.
02:45
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.
03:07
And with that –
so with that,
what we did today was
really kind of differentiate
a little bit of whiplash versus
cervical radiculopathy.
03:14
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.
03:27
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.
03:44
So, hopefully,
that was very helpful for you today.
03:46
Look forward to seeing you next time.