FROM:
J Occupational and Environmental Medicine 2010 (Apr); 52 (4): 424–427 ~ FULL TEXT
Scott Haldeman, DC, MD, PhD, FRCP(C), Linda Carroll, PhD, and J. David Cassidy, DC, PhD, DrMedSc
Department of Neurology,
University of California,
Irvine, Calif, USA.
Haldemanmd@aol.com
OBJECTIVE:
To summarize the key findings of a best-evidence synthesis on neck pain.
METHODS:
A systematic search, critical review, and best-evidence synthesis of the literature on the burden and determinants of neck pain, its assessment and intervention, and its course and prognostic factors.
RESULTS:
There were 552 studies judged to have adequate internal validity to form the basis of the best-evidence synthesis. Neck pain is common across populations and age groups. Most do not experience a complete resolution of symptoms, and its course of recovery is similar across populations. In the absence of trauma and "red flags," routine imaging is not needed. Treatments emphasizing activity and return to normal function are more beneficial than those without such a focus.
CONCLUSION:
Neck pain is common, and its determinants and prognosis are multifactorial.
KEYWORDS:
From the FULL TEXT Article:
Background
The Bone and Joint Decade 2000 to 2010 Task Force on Neck
Pain and Its Associated Disorders began its work in 2000, with
the mandate to study neck pain and disorders associated with neck
pain and make recommendations that would reduce the health
consequences of neck pain. The Neck Pain Task Force completed
its deliberations and published its findings as a supplement in the
journal Spine in 2008. [1] The report was republished (with permission
from Spine) as supplements in the European Spine Journal and
the Journal of Manipulative and Physiological Therapeutics. [2, 3] In
2002, the Neck Pain Task Force was given official status by the
Steering Committee of the Bone and Joint Decade, an initiative of
the United Nations and the World Health Organization, and over its
life span, the Task Force consisted of a five-member Executive
Committee, a 13–member Scientific Secretariat, a 17–member Advisory
Committee, and 18 research associates and graduate students.
Task Force members originated from nine countries and
represented 14 clinical and scientific disciplines or specialties. The
Task Force was affiliated with eight collaborating universities and
research institutes in four countries. There were 15 financial sponsors
from government agencies, private companies, and professional
associations from multiple countries. Thirteen professional
associations provided nonfinancial support for the Task Force and
allowed their names to be published as sponsors.
MATERIALS AND METHODS
The Neck Pain Task Force undertook two phases of investigation.
These were a) a systematic search, critical review, and
synthesis of the literature on neck pain (using best-evidence synthesis
methodology) [4, 5] and b) original research on neck pain. The
literature published from 1980 to 2006 was searched using a
sensitive rather than specific search strategy. This yielded 31,878
citations, and after screening these citations for relevance to the Neck
Pain Task Force mandate, 1,203 articles were found, which met the
relevance criteria. Briefly, these criteria were studies on frequency, risk
or prevention of neck pain, studies related to the course and prognostic
factors in neck pain, studies related to the assessment or treatment of
neck pain, and studies related to the economic costs of neck pain. We
excluded studies if they were about neck pain caused by pathology or
systematic disease, if they provided no neck pain-specific findings, if
they had fewer than 20 subjects with neck pain (or at risk for neck
pain), and if they used cadavers, non-human subjects (eg, crash test
dummies or animals) or if they were laboratory simulations. Each
relevant study was subjected to a thorough critical review (described in
more detail elsewhere). [6]
The 552 studies judged to have adequate internal validity
were entered into evidence tables, from which we developed our
best-evidence syntheses on the following: the burden and determinants
of neck pain in the general population, [7] in workers, [8] and in
whiplash-associated disorders (WAD) [9]; the course and prognostic
factors for neck pain in the general population, [10] in workers, [11] and in WAD [12]; assessment of neck pain [13]; and surgical and nonsurgical interventions in neck pain. [14, 15]
The original research consisted of a population-based, casecontrol,
and case-crossover study on the risk of vertebrobasilar
stroke with chiropractic care [16]; a study on the epidemiology of
vertebrobasilar stroke in two Canadian provinces [17]; a decision
analysis to identify the best treatment among common nonsurgical
neck pain treatments [18]; and a study of the prevalence and incidence
of work absenteeism associated with neck pain from a cohort of
Ontario workers’ compensation claimants. [19] Informed by these
findings and by extensive discussions over the course of the Neck
Pain Task Force, a conceptual model of neck pain was developed
that seeks to link the onset, course, and care of neck pain [20] and
summarized the clinical practice implications of our findings. [21]
Finally, we outline what we believe to be some of the research
priorities and make recommendations to improve future research in
this area. [22]
RESULTS
Key Findings From the Task Force
Epidemiology of Neck Pain and Risk Factors
Most people can expect to experience some neck pain in their
lifetimes, although for the majority, neck pain will not seriously
interfere with normal activities. Nevertheless, a significant minority
will develop recurrent neck pain, and some will develop
associated disability. [7–9]
Reported prevalence depends greatly on the definitions used.
Typical 12–month prevalence estimates range from 30% to
50% in the general population and in workers. Among children
and adolescents, prevalence rates were similar (typically
20% to 40%).
Neck pain with associated disability was less common: 12–month
prevalence estimates ranged from 2% to 11% in the general
population, and between 11% and 14% of workers reported being
limited in their activities because of neck pain. Neck pain was
common in all occupational categories. Of note, the results of the
Ontario cohort study (described in more detail later in this
article) suggest that worker’s compensation data significantly
underestimate the burden of neck pain in workers.
The number of persons seeking health care in emergency rooms
for traffic-related WAD has been increasing over the past three
decades.
Analyses of risk factors for neck pain suggest that this disorder
has a multifactorial etiology. Nonmodifiable risk factors for neck
pain included age (the incidence of neck pain peaks in the middle
years, then decreases), female gender, and genetics. There is no
evidence that common degenerative changes in the cervical spine
are a risk factor for neck pain.
Modifiable risk factors for neck pain include psychologic health,
smoking, exposure to environmental tobacco, and physical activity
participation (protective). In the workplace, repetitive and
precision work, sedentary work position (ie, prolonged standing,
sitting, or doing computer work), working with the cervical spine
in flexion for prolonged periods of time, poor keyboard position
(eg, keyboard positioned too close to the desktop edge), mouse
position requiring flexion of shoulders of more than 25 degrees),
use of chairs without armrests, using telephone shoulder rests,
using a computer monitor requiring poor head posture (eg, a head
tilt of more than 3 degrees), high levels of psychologic job strain,
low coworker social support, and job insecurity increased the risk
of neck pain. Nevertheless, there is a lack of evidence that
workplace interventions aimed at modifying workstations and
worker posture were effective in reducing the incidence of neck
pain in workers.
Eliminating insurance payments for pain and suffering is associated
with a lower incidence of whiplash claims and faster
recovery from symptoms.
Motor vehicle head restraint devices aimed at limiting head
extension during rear-end collisions were found to have a preventive
effect, especially for women.
Course and Prognosis of Neck Pain
Most people with neck pain do not experience a complete
resolution of symptoms. Between 50% and 85% of those who
experience neck pain at some initial point will report neck pain
again 1 to 5 years later. These numbers appear to be similar in the
general population, in workers, and in patients after motor
vehicle crashes. [10–12]
The prognosis for neck pain also seems to be multifactorial.
Younger age was associated with a better prognosis in general
population samples with neck pain and in WAD recovery,
although age appears unimportant in neck pain recovery in
workers.
Poor health and prior neck pain episodes were associated with a
poorer prognosis in workers and in the general population. In the
general population, poor psychologic health, worrying, and becoming
angry or frustrated in response to neck pain were all
associated with poorer prognosis, and greater optimism and a
coping style that involves self-assurance and having less need to
socialize were all associated with better prognosis. Passive coping,
depressed mood, feelings of helplessness, fear of movement,
catastrophizing, and postinjury anxiety were also associated with
poorer recovery in WAD. Few of these factors have been well
studied in workers with neck pain.
Specific workplace or physical job demands were not linked with
recovery from neck pain in workers. The evidence suggests that
workers who engaged in general exercise and sporting activities
were more likely to experience improvement in neck pain,
although this needs more study.
There is also evidence that neck injury claims that involve tort
compensation systems (ie, payment for pain and suffering) and
legal representation factors have a poorer prognosis for recovery
from WAD.
Assessment and Diagnosis of Neck Pain
For patients seeking emergency medical care for neck pain after
blunt trauma to the neck (for example, for neck pain after a motor
vehicle crash), it is important to identify those with serious
injury, which includes fracture, dislocation, and subluxation or
spinal cord injury or both. Two screening protocols, the
Canadian C-spine Rule (CCR) and the NEXUS Low-Risk Criteria, can be
used to identify low-risk patients who do not need radiographic
investigations (for a full description of “low-risk” criteria, please
see the Canadian C-Spine and the NEXUS protocols, as referenced).
For alert, medically stable “low-risk” patients, these
screening protocols have high sensitivity and excellent negative
predictive values in ruling out serious injury and, thus, ruling out
the need for radiography. Where radiography is indicated, computerized
tomography scan has better prediction and accuracy to
detect serious injury than standard radiography. [13]
There is currently no validated set of “red flags” to be used to
rule out serious pathology when triaging patients with no exposure
to blunt trauma. The Neck Pain Task Force suggests an
extrapolation of existing recommendations for ruling out serious
conditions affecting the lumbar spine. Serious diseases to consider
include (but are not limited to) pathologic fractures (eg,
resulting from decreased bone density caused by osteoporosis or
corticosteroid treatment); neoplasms (eg, previous history of
cancer, unexplained weight loss); failure to improve after a
month of evidence-based therapy; cervical myelopathy; systemic
diseases (eg, inflammatory arthritis); infections; intractable pain
or tenderness over the vertebral body; and prior neck surgery.
The clinical-physical examination is generally better at ruling out
a structural lesion or neurologic compression than at diagnosing
any specific etiologic condition in patients with neck pain. For
patients with neck pain and suspected cervical radiculopathy,
manual provocation tests that involve elongation of the nerves to
elicit a pain response (eg, contralateral rotation of the head and
extension of the arm and fingers to elicit radiating pain) have
high predictive value, when compared with gold standards of
magnetic resonance imaging, nerve conduction/magnetic resonance
imaging, and myelography. For those with positive manual
provocation tests, a combination of history, physical examination,
modern imaging techniques, and needle electromyography
can be used to diagnose the cause and site of cervical radiculopathy.
For those patients seeking care in nonemergency situations and
in the absence of acute trauma and red flags, there is no evidence
to support the validity or utility of diagnostic procedures such as
routine imaging, anesthetic facet or medial branch blocks, surface
electromyography, dermatomal somatosensory-evoked responses,
or quantitative sensory testing for the diagnosis of
radiculopathy.
Reliable and valid self-assessment questionnaires given to patients
with neck pain can provide useful information for management
and prognosis.
The finding of degenerative changes on imaging has not been
shown to be associated with neck pain.
Treatments for Neck Pain (Noninvasive and Invasive)
A number of nonsurgical treatments (listed below) seemed to be
more beneficial than usual care, sham, or alternative interventions, but none of the active treatments were clearly superior to
any other in the short- or long-term. There is no evidence that a
particular course of care with any intervention improves the
prognosis for WAD or non-WAD neck pain, although there is
evidence that high health care utilization in the first month after
a traffic collision may slow down recovery in WAD. [14, 15]
For WAD, educational videos, mobilization, and exercises seem
more beneficial than usual care or passive modalities alone.
There is evidence that educational pamphlets, corticosteroid
injections, passive modalities (such as transcutaneous electrical
nerve stimulation, ultrasound, diathermy), and use of collars are
not effective.
For non-WAD, “nonspecific” neck pain without radiculopathy,
supervised exercises, mobilization, manipulation, and low-level
laser therapy appear to have some benefit. The evidence for
acupuncture was less clear (ie, some studies reported a benefit,
whereas others reported no benefit). Overall, there seems to be
some benefit of acupuncture in treatment of neck pain, although
this should be further assessed in large, well-conducted intervention
studies.
For both WAD and other neck pain without radicular symptoms,
the evidence supports interventions involving active therapy,
combined with education emphasizing self-management and return
to normal function as soon as possible, rather than interventions
without such a focus.
There is a lack of evidence about the harms or benefits of
noninvasive interventions for neck pain with radiculopathy.
There is evidence for short-term symptomatic improvement of
radicular symptoms with epidural or selective root injections
with corticosteroids, but these treatments did not appear to
decrease the rate of surgery for decompression of cervical nerve
roots.
Evidence is lacking to support intraarticular steroid injections or
radiofrequency neurotomy for cervical radiculopathy. There is
evidence that surgical treatment of cervical radiculopathy because
of nerve root impingement results in relatively rapid and
substantial relief of pain and impairment in the short-term (6 to
12 weeks after surgery). However, it is not clear from the
evidence that long-term outcomes are improved with the surgical
treatment of cervical radiculopathy compared with nonoperative
measures.
Early results from trials of cervical disc arthroplasty (artificial
disc replacement) appear to show 1– to 2–year outcomes for
radicular symptoms that are similar to outcomes for anterior
fusion surgery. There is no evidence to support the use of
cervical disc arthroplasty in patients with neck pain who do not
have primary radicular pain.
Vertebrobasilar Artery Stroke Study Findings
Vertebrobasilar artery (VBA) stroke is a rare event. [16, 17]
There was an association between receiving chiropractic care and
subsequent VBA stroke in persons younger than 45 years of age.
There was a similar association between receiving care from
general practitioners and subsequent VBA stroke in this age
group. This is likely explained by patients with VBA dissectionrelated
neck pain and/or headache seeking health care from
chiropractors and general practitioners before having their stroke.
Thus, there is no additional risk associated with chiropractic care.
Decision Analysis Study Findings
A decision analysis, performed to compare relative effectiveness
of those nonsurgical treatments that were found to be effective
for treatment of neck pain, concluded the following. When the
goal is to maximize quality-adjusted life expectancy and consider
treatment-related harms and benefits, a comparison of common
nonsurgical neck pain treatments (standard nonsteroidal antiinflammatory
drugs, Cox-2 nonsteroidal antiinflammatory drugs,
exercise, mobilization, and manipulation) suggests no important
differences among the five treatments. [18]
Work Absenteeism Involving Neck Pain
Although surveys of workers identify neck pain as an important
source of activity limitations, workers’ compensation statistics
would suggest that work-related neck pain represents only a
minor health burden, with fewer than 5% of claims involving
soft-tissue disorders of the neck. This study suggests that this low
estimate is due to workers’ compensation statistics not accurately
reflecting the burden of neck pain in workers because of the
coding protocols. After reexamining Ontario workers’ compensation
lost-time claim data files for “injured part of body” and
“nature of injury” codes that related to neck pain, 11.3% workers
receiving lost-time benefits had neck pain associated with their
claim. [19]
These findings suggest that traditional application of workers’
compensation statistics greatly underestimate the burden of neck
pain in workers.
A New Conceptual Model for Neck Pain
The Neck Pain Task Force proposes a new conceptual model for
the course and care of neck pain. The model is centered on
persons with neck pain or persons who are at risk for developing
neck pain. The model describes neck pain as an episodic occurrence
over a lifetime with variable recovery between episodes. [20]
The model comprised five major components. These are factors
affecting the onset and course of neck pain: the “care” complex
(including no care, self-care, and entry into the health care
system for diagnosis or treatment or both); the “participation”
complex (ie, how involvement in life situations such as employment,
family responsibilities, etc, are affected); the “claim”
complex (ie, not making a claim, making a claim for health care,
and making a claim for disability); and the short- and long-term
impacts and outcomes of neck pain (eg, resolution, readjustment,
chronic pain etc).
For each of these components, the model considers that demographic
and socioeconomic factors, health characteristics, psychologic
and social factors, environmental/societal factors (such as
workplace or collision characteristics, compensation systems, laws,
etc), genetics, health behaviors, and cultural factors form the context
and have an influence at each point. The onset, course, and consequences
of neck pain cannot be understood without understanding
these environmental and contextual factors.
A New Classification System for Neck Pain
The Neck Pain Task Force found few major differences
between trauma-related neck pain and neck pain with a nontraumatic
etiology. Thus, for the subset of individuals who seek clinical
care, the Neck Pain Task Force recommends a four-grade classification
system of neck pain severity that is intended to help in the
interpretation of scientific evidence. The new system will also help
people with neck pain, researchers, clinicians, and policymakers in
framing their questions and decisions [21]:
Grade I neck pain: No signs of pathology and no significant
disability; will likely respond to minimal intervention such as
reassurance and pain control; does not require intensive investigations
or ongoing treatment. In the absence of blunt trauma,
diagnostic testing is not indicated in the initial assessment. When
choosing treatments for pain relief, patients and their clinicians
should consider potential side effects and personal preferences
regarding treatment options. Acceptable treatments include those
evidence-based treatments listed in an earlier section in this
document.
Grade II neck pain: No signs of pathology but significant disability;
requires pain relief and early activation aimed at preventing
long-term disability. In the absence of blunt trauma, diagnostic
testing is not indicated in initial assessments. When
choosing treatments for pain relief, patients and their clinicians
should consider potential side effects and personal preferences
regarding treatment options. Acceptable treatments include those
evidence-based treatments listed in an earlier section in this
document.
Grade III neck pain: Neurologic signs of nerve compression;
might require investigation and, occasionally, more invasive
treatments. Those with suspected grade III pain may benefit from
further investigation. Those with confirmed nerve compression
and severe persistent radicular symptoms might benefit from
corticosteroid injections or surgery. There is a paucity of evidence
for or against noninvasive interventions for neck pain with
radicular signs.
Grade IV neck pain: Neck pain with signs of pathology such as
fracture, infection, myelopathy, neoplasm, or systemic disease;
requires prompt investigation and treatment.
Research Priorities and Methodological Implications
Research should be methodologically and conceptually
sound, and theory driven. The theoretical frameworks used to
understand neck pain should recognize the multifactorial etiology
and complex causal pathways involved. Further research on risk
and prognosis should focus on modifiable factors. The knowledge
gained in these research endeavors should be used to inform novel
prevention, diagnostic, and intervention strategies. There are important
gaps in our knowledge about neck pain. Among those topics
needing urgent attention are risk factors and preventive measures
for neck pain in children; emergency department screening criteria
to rule out serious injury in children with blunt trauma to the neck;
and management of neck pain in children. In addition, there is a
need for studies exploring the impact of culture and social policies
on neck pain, because changes in public policy that address these
risk factors may significantly reduce the burden and cost of neck
pain in society. Finally, because no one particular treatment is best
for neck pain, there is a need for better designed randomized
controlled trials that target those patients who are most likely to
benefit from care. [22]
SUMMARY AND CONCLUSIONS
Neck pain and neck pain disability have a huge impact on
individuals and their families, health care systems, and society as a
whole. Neck pain is common across populations and in all age
groups, including children. In the hopes of providing information
aimed at decreasing the burden of neck pain, the international and
multidisciplinary Bone and Joint 2000 to 2010 Task Force on Neck
Pain and Its Associated Disorders completed and published a body
of work that consists of best-evidence synthesis, original research,
a new model for conceptualizing the complexities of the onset,
course, care, and outcomes of neck pain, and clinical and research
implications of these findings.
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