Occasionally with necks that I treat, most often with people who have suffered neck pain associated with a motor vehicle accident (Whiplash Associated Disorder), certain odd things can be reported. I have heard people describe severe worsening reactions when given strong massages (massage should feel good right?). I have heard people say that they have been unable to continue wearing collared shirts as it hurts their neck too much. I have even treated one guy who 40 years after his car accident, still hated any cold air on his neck (he would wear a scarf even in summer) because it made his neck hurt.
This is not normal, and is a feature of a malfunction of the central nervous system, which actually becomes the primary driver of chronic pain and disability in long term Whiplash Associated Disorder, and is an absolute pain (pun intended) to treat.
Increased pain sensitisation in the neck
According to a study by Rebbeck et al, “increased pain sensitisation assessed by quantitative sensory testing (QST) is associated with poor outcomes in cervical pain states…Identification of pain sensitisation in the clinic is important to not only sub-classify pain, but to inform appropriate management”
In other words, sensitivity to certain things is actually clinically measurable, and it can give us, as physios, more information to help treat your condition. The thing with this testing is that it has to happen away from the neck to be positive, meaning that the test will be on your arm and you will feel your pain in your neck.
Testable signs of pain sensitivity in the neck
The 4 most easily testable signs that confirm this pain sensitivity is present are allodynia, sharp hyperalgesia, pressure hyperalgesia and cold hyperalgesia.
Allodynia
Allodynia refers to a painful response to what would generally be considered a non-painful stimulus. Something like a light sheet at night or wearing a collared shirt causing pain. To test for this the physio will use a tissue to lightly brush the skin on various positions on your arm and shoulder, on the opposite side of your neck and finally on the side of your neck pain. The further away from the neck your symptoms are provoked, the more sensitive your central nervous system (this is the same for the following tests).
Sharp hyperalgesia
Sharp hyperalgesia refers to an exaggerated pain response to usually painful stimulus, in this case, sharp. A toothpick is usually used to determine this.
Pressure hyperalgesia
Pressure hyperalgesia, similar to sharp, is this time elicited by the therapist who will slowly increase the pressure on an area of your arm first then will re test closer to the neck. I have seen someone’s neck pain reproduced by slowly increasing the pressure on their forearm, which is absolutely crazy in real life. Wires be crossed, yo.
Cold hyperalgesia
Cold is the last, and probably most useful measure. Something cold should feel cold right? Well people with pain sensitivity feel pain when ice is used. And they can feel pain in their neck when ice is applied to their forearm.
So these things are fairly bonkers if you’ve never heard of this stuff before, but unfortunately for these people, they suffer every day. It undoubtedly means things are not normal inside their circuitry. It also unfortunately is associated with poorer prognosis, and physios will do well to consider referral to pain specialists for appropriate pharmaceutical management as commonly exercise and manual therapy tends to be less helpful in the early stages.
