Joint protection program for the neck

INTRODUCTION — The management of neck pain includes joint protection, active treatment, and rehabilitation. A joint protection program can provide guidance to help people maintain function and minimize neck pain through changing habits and movement patterns. A joint protection program for the neck is indicated for any patients predisposed to neck pain due to rheumatologic disorders involving the neck, or for those whose work or recreational activities put them at risk of neck strain.

The principles and guidelines for joint protection programs for the neck will be reviewed here. An overview of joint protection and the evaluation and treatment of neck pain are discussed separately. (See "Overview of joint protection" and "Evaluation of the adult patient with neck pain" and "Management of nonradicular neck pain in adults".)

PRINCIPLES OF JOINT PROTECTION — The following principles are the foundation of patient education in joint protection and apply most directly to the neck:

●Respect pain

●Avoid maintaining the same joint position for prolonged periods

●Reduce excess body weight

●Use good posture and body mechanics

●Use the minimum amount of force necessary to complete the job

●Simplify work by using efficiency principles: plan, organize, and balance work with rest

●Remain active to maintain and increase strength and range of motion

These principles are derived from the simple, practical application of proper body mechanics, posture, and positioning of joints. Joint protection reduces local joint stress and preserves joint integrity. (See "Overview of joint protection".)

Aggravating factors — Aggravating factors are those habits and activities that can initiate and/or perpetuate soft tissue pain and disability. The initial step in evaluation includes a detailed assessment of the patient's routine at work, at home, and in sports and other activities. This evaluation should identify aggravating factors such as habits and activities that have the potential to initiate and/or perpetuate soft tissue pain and disability. Examples of such aggravating factors include use of computers, frequent texting or gaming, job stress, ergonomic deficiencies in workplace design and use, and insufficient rest or breaks from work. Similar factors can be present both in the home and in the workplace.

A systematic review from 2020 of neck pain in young adults found that there were many potential risk factors, but none showed consistent associations with neck pain, and studies were of low quality [1]. A subsequent systematic review in 2023 identified 11 main risk factors affecting college students’ neck pain, including factors related to neck position (improper use of the pillow, improper sitting posture, longer length of time spent with a bowed head, longer use of electronics on a daily basis), lack of exercise, history of neck and shoulder trauma, senior grade, staying up late, high stress, emotional problems, and female gender [2].

Office work is highly correlated with musculoskeletal symptoms in the neck, along with other areas. Factors that were most strongly associated with neck pain included awkward posture, higher body mass index (BMI), job demand, and infrequent rest breaks (once every four to six hours) [3]. A study of healthy but high-risk office workers found that those taking active breaks or using postural shifts to reduce sitting discomfort experienced a 50 percent reduction in incidence of neck pain and recovery time compared with participants in a control group [4].

Job-specific risk factors in other professions should be considered. Awkward postures and sustained positions, such as neck rotation to the left side with the side bending to the right; sustained neck flexion; and sustained upper arm abduction, such as for mirror use, put dental workers at risk for neck injuries [5,6]. Use of prismatic spectacles can reduce neck pain and improve the ability to work [7,8].

Surgeons are at high risk for musculoskeletal complaints. Performing minimally invasive surgeries increases the risk of neck pain compared with traditional open techniques. A scoping review reported a prevalence of neck pain of 74 percent among surgeons [9]. Physicians performing lengthy endoscopic procedures in awkward positions with leaded protective gear are also at increased risk of neck pain [10]. Addressing workplace ergonomic factors during surgery is recommended when patients are surgeons.

Job strain is a subjective measure that increases when job demands are high and when job decision latitude is low. Increased job strain may predispose to neck pain. As an example, a prospective observational study of job strain (determined by questionnaire) among computer users compared pain and other musculoskeletal symptoms at baseline and after six months [11]. Self-reported job strain was associated with future musculoskeletal symptoms when compared with those who did not perceive job strain. Among those reporting job strain, computer users in the highest strain ratio category were at increased risk of neck and shoulder symptoms when compared with those in the lowest strain ratio category. Those with limited previous computer work also had more frequent symptoms.

Ergonomic deficiencies in computer workstation design and use are common and have a deleterious effect on the user. Examples include the use of nonadjustable chairs, sitting in bent and unsupported postures, and use of office tables instead of computer workstations. Attention to good workplace design helps to reduce posture-related pain [12].

Similar problems, including poor resting posture, the act of lying with the head propped forward on too-high pillows or the arm of a sofa, positions with the arms extended, or improper height of the computer terminal, are present in the home and in the workplace. Prolonged needlework, improper eyeglasses, and improper lighting may contribute to neck pain. Falling asleep while reading and allowing the head to drop forward may also cause symptoms.

The rapid increase in use of mobile devices, such as touchscreen smartphones and tablets, may be associated with neck symptoms. A systematic review found a high prevalence of musculoskeletal complaints among mobile device users, with neck complaints having the highest prevalence rates, ranging from 17.3 to 67.8 percent. Neck flexion appeared to be one of the strongest risk factors [13]. Neck flexion angles have been found to be greater (p<0.05) during text messaging than during other tasks such as web browsing and significantly larger in sitting than in standing [14]. The mechanical demand on the neck muscles during seated tasks, such as using a tablet, have been shown to be approximately three to five times that of a neutral neck posture [15]. Compared with desktop computers, the use of laptops and tablets have been shown to increase neck flexion [16].

In a study of 56 young adults, neck symptoms were more common in the group that sat with the head bent forward and without forearm support. Electromyography (EMG) activity of the trapezius muscles was decreased when the forearms were supported [17].

GUIDELINES FOR APPLYING JOINT PROTECTION PRINCIPLES TO THE NECK — The following guidelines may be used to help prevent further or recurrent neck symptoms in patients with disorders such as arthritis, cervical pain syndromes, cervical nerve root impingement, and thoracic outlet syndrome.

Time on task

●Taking frequent rest breaks during tasks in which the body is in a static posture (eg, computer use, knitting) has been shown to reduce neck pain [18-20]. Patients may benefit from self-monitoring symptoms to identify early signs of discomfort to determine tailored rest breaks or position changes. Although it is generally agreed that prolonged periods in a static position can induce neck strain, the evidence is very low quality and does not support specific time frames.

●Activity pacing involves taking rest breaks and doing tasks at a slower pace, to avoid overactivity-underactivity cycling (fluctuating between high and low levels of activity) [21]. Pacing does not reduce the severity of pain; however, it can assist in lessening fatigue and joint stiffness and allow more regular participation in physical activity [22].

Role of exercise

●Although the quality of evidence is not strong, specific cervical and scapulae stretching and strengthening exercises help alleviate chronic neck pain. If symptoms do not improve, or if pain further increases, patients should be referred to a physical therapist for individualized treatment [23]. Strengthening the spinal extensor muscles has been shown to delay the progression of kyphosis that may occur in middle-aged females and that may contribute to neck pain [24].

●Manual therapy in the form of cervical spine mobilizations, when combined with low-load cervical muscle training exercises, produced greater reductions in neck pain and disability in patients with chronic nonspecific neck pain, compared with usual care [25,26]. Manipulation or mobilization combined with stabilization exercise is also more effective than exercise alone in improving disability, night pain, and quality of life [27].

●Intensive isometric neck strength training and endurance training of neck muscles, in addition to regular aerobic and stretching exercises, is effective in decreasing neck pain and disability and in increasing neck range of motion in female office workers with chronic neck pain [28]. While a general stretching and strengthening program is beneficial, it may not help chronic neck pain when done alone [23]. Specific exercises targeting muscle control, endurance, and strength in the neck and scapulae improved neck pain and posture in a group of female dentists with chronic neck pain compared with a control group [29].

●Workplace exercise may be effective in providing therapeutic relief of existing neck and shoulder symptoms. A review of studies examining the efficacy of workplace exercise interventions to control neck and shoulder pain symptoms found evidence in support of specific resistance training (SRT) exercise targeting the neck and shoulders as a tertiary prevention approach for reducing existing symptoms, at least in the short term [30].

●A combination of ergonomic intervention with neck-specific exercise produced greater reductions in severity of neck pain intensity compared with the same ergonomic intervention with health promotion in a large group of office workers. The exercises were carried out for 12 weeks, and pain reduction was not maintained at 12 months, suggesting that continuing exercises for longer would help to maintain the benefits [31].

●Remaining active helps maintain strength and range of motion. Being physically active was cited by the Neck Pain Task Force as one of the few prognostic factors for controlling neck pain [32]. Regular physical activity may also decrease the risk of developing neck pain for patients who are at high risk of developing it (eg, dentists) [8].

Posture and body mechanics

●Correct posture in sitting has been found to reduce muscle activity, particularly in the jaw and posterior neck, compared with forward head positioning [33]. Although these approaches have biologic plausibility, their effectiveness alone in prevention or treatment of work-related symptoms is uncertain. As an example, attention to posture did not produce a statistically significant difference in musculoskeletal symptoms in a prospective trial in which computer users were the subjects [34].

●There is very little evidence for any specific sleeping position, although low-quality evidence found that side lying generally decreased waking pain and stiffness [35]. Avoid stressful head positions (eg, lying on a sofa with the head propped up, falling asleep in a chair and allowing the head to drop forward, and using more than one pillow). Patients may have less pain when they use rubber or spring pillows as compared with feather pillows, although the type of pillow does not change neck alignment when lying on one's side [36].

●When using mobile devices such as cell phones or tablet computers, sit with the trunk and neck erect and try to limit the frequency of use [13,17]. When texting on a mobile phone, try standing instead of sitting [14].

●When working at a computer, the top of the monitor should be at or below eye level, and use a "draft holder" to place work at eye level next to the screen (Occupational Safety and Health Administration [OSHA] computer workstations eTool).

●When swimming, look directly downward rather than forward, and avoid breathing only on one side. Wearing swim goggles may assist in maintaining the correct form. Extending the head too high when taking a breath increases the load on the neck and can cause pain.

●Avoid prolonged work below knee level. A small study found that cervical extension angle and upper trapezius (uTP) muscle activity were significantly increased during below-knee work compared with overhead work, which could cause neck pain [37].

Reduce muscle tension and force

●Increased activity has been demonstrated in sternocleidomastoid (SCM), uTP, and middle trapezius (mTP) muscles during jaw clenching while performing computer typing tasks [38]. Use of relaxation techniques or a bite spacer to prevent clenching of the jaw may assist in decreasing muscle tension.

●Work settings with high psychological stress promote negative mood and awkward posture; such settings increase the risk for neck and upper extremity symptoms [39].

●Supporting the forearms during assembly tasks and when texting decreases activity of the uTP muscles and may decrease symptoms [17].

Assistive technology and devices

●Ergonomic training together with the use of an armrest was more effective in reducing the one-year incidence of neck and shoulder disorders in call center employees compared with ergonomic training alone [40]. There is moderate-quality evidence that using an arm support with an alternative computer mouse reduced the incidence of neck pain in data entry workers [20].

●Organize workstations with adjustable chair, keyboard, and armrests, and consider an additional keyboard for portable (laptop) computers to improve neck and back posture and to reduce pain [41].

●Consider a sit-stand workstation. In a randomized trial of 60 young male office workers, musculoskeletal symptoms were reduced without loss of data entry efficiency [42]. Use of a 12 degree incline on a fixed-height desk improved head and neck posture with decreased discomfort during laptop computer use [43].

●Use of an inclined work surface decreased neck symptoms in 75 percent of 215 assembly workers [44]. Tasks included repetitive soldering and screwing of components on a level surface. Introducing the inclined work surface reduced the amount of neck flexion required.

●Using hands-free headsets decreased neck pain compared with handheld phones among call center operators and should be considered for anyone who uses a phone for prolonged or frequent telephone use [45].

●When driving, the automobile should be equipped with side-curtain airbags [46]; head restraints should be in a high and forward position [47].

RESOURCES

Dorsey J, Ehrenfried H, Finch D, Jaegers LA. Work. In: Willard and Spackman's Occupational Therapy, 13^th ed, Boyt Schell BA, Gillen G (Eds), Wolters Kluwer 2018. p.779.

Computer Workstations eTool

Occupational Safety and Health Administration (OSHA)

US Department of Labor

Website: https://www.osha.gov/etools/computer-workstations

Applied Ergonomics

Elsevier

Langford Lane

Kidlington

Oxford, OX5 1GB,UK

Website: https://www.sciencedirect.com/journal/applied-ergonomics

Job Accommodation Network

809 Allen Hall

PO Box 6080

West Virginia University

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Website: https://askjan.org/

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (See "Patient education: Neck pain (The Basics)".)

●Beyond the Basics topics (See "Patient education: Neck pain (Beyond the Basics)".)

SUMMARY AND RECOMMENDATIONS

●Principles of joint protection for the neck – A joint protection program can provide guidance to help people maintain function and minimize neck pain through changing habits and movement patterns. A joint protection program for the neck is indicated for any patients predisposed to neck pain due to rheumatologic disorders involving the neck, or for those whose work or recreational activities put them at risk of neck strain. Principles of joint protection are derived from the application of proper body mechanics, posture, and positioning of joints. (See 'Introduction' above and 'Principles of joint protection' above.)

●Aggravating factors – The initial step in evaluation includes a detailed assessment of the patient's routine at work, at home, and in sports and other activities. This evaluation should identify aggravating factors, such as habits and activities that have the potential to initiate and/or perpetuate soft tissue pain and disability. Examples of such aggravating factors include use of computers, frequent texting or gaming, job stress, ergonomic deficiencies in workplace design and use, and insufficient rest or breaks from work. Similar factors can be present both in the home and in the workplace. (See 'Aggravating factors' above.)

●Time on task and exercise – Patients should limit time on task in one position, whether sitting or standing; taking regular breaks from activities in a single body position; and performing activities involving movement. Being physically active is associated with control of neck pain. (See 'Time on task' above and 'Role of exercise' above.)

●Posture and body mechanics – Maintaining good posture and alignment of the head, neck, and trunk during rest and activities is important. Patients should attempt to maintain postural alignment when using mobile devices for phone calls, gaming, web browsing, and particularly for texting. Proper body mechanics should be maintained in activities at home and in the workplace, including attention to proper lifting and positioning for physically stressful activities. Shoulder strengthening and spine extension exercises are also beneficial. (See 'Posture and body mechanics' above.)

●Reducing muscle tension and force – Although there is conflicting evidence that exercise can prevent neck pain, both isometric strength training and dynamic endurance training can decrease pain and disability in females with chronic neck pain. Additionally, relaxation techniques or a bite spacer can be used to prevent clenching of the jaw, which can cause muscle spasms in the neck. (See 'Reduce muscle tension and force' above and 'Role of exercise' above.)

●Assistive technology and devices – Assistive technology and devices such as "hands-free" headsets for prolonged or frequent telephone use and inclined surfaces for prolonged close work should be used to limit neck strain. (See 'Assistive technology and devices' above.)