Findings of the Bone and Joint Decade Neck Pain Task Force: Interview with Scott Haldeman, DC, MD, PhD
SOURCE: Health Insights Today
An Interview by Daniel Redwood, DC
Scott Haldeman chaired the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Related Disorders, the most comprehensive multidisciplinary review on neck pain ever undertaken.
As with similar projects, the Task Force reviewed and evaluated all existing research on the diagnosis and treatment of neck pain. But it went further, initiating original research in insufficiently explored areas, including the now-renowned study by David Cassidy and colleagues which demonstrated that strokes are no more likely after a visit to a chiropractor than after a visit to a medical doctor. In this Health Insights Today interview, Dr. Haldeman discusses the major findings of the Neck Pain Task Force and their implications for the management of this challenging condition.
Dr. Haldeman holds the positions of Clinical Professor, Department of Neurology, University of California, Irvine; Adjunct Professor, Department of Epidemiology, School of Public Health, University of California, Los Angeles; and Adjunct Professor, Department of Research, Southern California University of Health Sciences. He is Past President of the North American Spine Society, the American Back Society, the North American Academy of Manipulative Therapy, and the Orange County Neurological Society. He served on the Executive Council of the International Society for the Study of the Lumbar Spine.
He was appointed International Ambassador for the Bone and Joint Decade and serves as President of World Spine Care, a non-profit organization endorsed by the Bone and Joint Decade, an initiative of the WHO. This Foundation has the goal of helping people in underserved regions of the world who suffer from spinal disorders. He sits on the editorial boards of eight journals. He has published over 195 articles or book chapters and over 70 scientific abstracts, and has authored or edited 8 text books. He is certified by the American Board of Neurology and Psychiatry, is a Fellow of the Royal College of Physicians of Canada and a Fellow of the American Academy of Neurology. He is a Diplomate of the American Board of Electrodiagnostic Medicine, the American Board of Electroencephalography and Neurophysiology and the American Board of Clinical Physiology. He served on the US department of Health AHCPR Clinical Guidelines Committee on Acute Low Back Problems in Adults as well as 4 other Clinical Guidelines Committees.
Dr. Haldeman is currently chairman of the Research Council of the World Federation of Chiropractic. He was awarded the David Selby Award by the North American Spine Society, the Patenge Distinguished Lecturer Award from Michigan State University, an honorary Doctor of Humanities degree from the Southern California University of Health Sciences and an honorary Doctor of Science degree from the Western States Chiropractic College.
You chaired the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Who initiated this and why was there a need for such a project?
It was initiated by David Cassidy and myself. The Quebec Task Force on Whiplash Injuries published its findings in 1995 and was the first major international, multidisciplinary task force on neck pain. It, however, had limited its mandate solely to whiplash related injuries. The Quebec Task Force recommended a repeat look at the scientific literature be considered within ten years’ time and expected that its findings would likely change with new research. In 1999, we realized that this needed to be done. David Cassidy and I formed a committee with the help of Linda Carroll to convene a new task force. We decided to that the task force would not limit itself to whiplash but would look at the scientific literature on all forms of neck pain and its associated disorders.
What role did other groups, such as the World Health Organization, play in this?
Initially, none to set it up. The Bone and Joint Decade (BJD) is an initiative of the United Nations and the World Health Organization. Their goal was to advance musculoskeletal health throughout the world. We presented them with the proposal to establish the Neck Pain Task Force and explained our plans and goals. The steering committee of the BJD felt that the Task Force goals were in line with their mandate and agreed with our suggestion that the official name would be The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
From a chiropractor’s perspective, it has always been quite striking to me how relatively little research has been done on spinal manipulation, or chiropractic care, for neck pain, in contrast to the larger quantity of research on low back pain. Why do you think this has been the case, and is the situation changing?
That’s true of all forms of treatment for neck pain. In fact, there are probably as many studies now on spinal manipulation for neck pain as for any other treatment approach to neck pain. But neck pain has always been the stepchild of the spinal pain syndromes—if one ignores thoracic pain, for which there is essentially no research at all. Neck pain has always taken a second position after low back pain, mostly because low back pain is such a devastating, work-related injury and has such a huge socioeconomic impact.
Research into treatments for low back pain became a priority for everybody’s research—surgeons, nonsurgeons, chiropractors, and other clinicians—way back in the 1970s and 1980s. That’s when the International Society for the Lumbar Spine was formed. This organization was the first major international spine society. Shortly after that the journal, Spine, was founded to publish articles on the low back. The editors of Spine, however, decided to include research on the entire spine including the neck. Now that there is a great deal of research on the low back, researchers have started focusing more on the neck. While the quantity of neck pain research is still behind that of the low back, the quality and quantity of neck research has been increasing.
What reasonable conclusions can we draw from the research that currently exists regarding the effectiveness of manual interventions of the type delivered by chiropractors for neck pain? How does this compare to the effectiveness of other approaches?
If you look at the key points in the reports from the Neck Pain Task Force, you’ll find that there is no therapy that stands out as being particularly effective. The bottom line is that if you have neck pain, you are likely to continue to have neck pain. It will fluctuate throughout your life, from “no pain” to “a little bit of pain” to “a lot of pain,” or what was called interfering pain, of the sort that interferes with your life. For the average person with neck pain, the pain will fluctuate through these stages throughout their life. There are treatments that are available which can give relief to people with neck pain but we are not sure if they shorten the length of the episodes or change the long term prognosis significantly. It is possible to at least give relief when someone is having a bad episode of neck pain.
There are relatively few treatments that have been shown to be of value and worth trying if a person presents with neck pain. Amongst them are the manual therapies (manipulation and mobilization), NSAIDs (nonsteroidal anti-inflammatories), exercise, and maybe acupuncture and a few other therapies that have somewhat less research. But essentially, when you’re talking about the management of neck pain now, you’re talking about giving some form of analgesia (it could be NSAIDs, or it could be using a heating pad at home), giving some form of manual therapy to increase the motion of the joints and relax the muscles, and exercises to increase functional capacity and avoid disability. That is what the current research suggests should be the primary approach to managing uncomplicated neck pain, that is neck pain that does not involve radiculopathy or serious pathology.
How extensive is our current knowledge about what diagnostic and therapeutic approaches are effective for acute neck pain versus chronic or subacute neck pain?
It’s not much better. We are pretty good at looking at fractures. CT scans can find a fracture in 99 percent of the cases. This is far better than x-rays, by the way, which are probably a waste of money if a CT scan is available. If you really suspect a fracture, you should do a CT scan. If you have a red flag for serious pathology, then testing for that red flag (cancer, infection, inflammatory joint disease, etc.) using widely used and available diagnostic testing is relatively good. Red flags have a high sensitivity but a low specificity for neck pathology. They screen for these serious disorders pretty well. If you have radiculopathy, neurologic deficits, or myelopathy, then testing is available to document whether there is a lesion compressing the spinal cord or a nerve root. There are pretty good studies for this purpose and these are generally accepted, although we don’t know how good their sensitivity and specificity is.
Once you leave radiculopathy and serious pathology, right now there is no test that can be considered valid to tell us what is causing your pain.
In the Task Force reports, there was extensive discussion about assessment of neck pain. One of the conclusions was that, in the absence of signs of nerve root compression, it might make more sense to just describe the condition rather than to try to formulate a tissue-specific diagnosis. Could you expand on that?
It became obvious that there is no test that has been shown to be able to identify the tissue causing the pain. I recently was asked to write a commentary in The Spine Journal (2011), in which I asked whether it is time to discard the concept of diagnosis when dealing with uncomplicated neck pain. This was an expansion of what the Task Force on Neck Pain found and the conceptual model that was developed.
The point is that if we cannot find the pathology, what is the most useful way of looking at neck pain and determining how to treat it? After considerable discussion the Task Force elected to expand on the Quebec Whiplash Task Force criteria of describing neck pain into Grades depending on severity. It was felt that this classification system would be of value, because it can influence how neck pain should be treated and also influence the prognosis. We used a zero to four scale. Grade 4 was red flags; the first goal of any clinician is to rule out red flags. Grade 3 is determined by the presence of radiculopathy and should be the second goal of a clinician. Having done that, the next goal is to determine whether the person’s neck pain is interfering (Grade 2) or noninterfering (Grade 1). In other words, is it serious or is it mild neck pain?
So Grade 1, noninterfering neck pain, is a situation where you have some pain but you are able to carry on your normal life activities.
Yes. The Task Force also described a Grade 0, when a person has no neck pain but is at risk for getting it in the future. One hundred percent of the population is at risk of getting neck pain and most will fluctuate between Grade 0, Grade 1 and lesser number Grade 2 and Grade 3 neck pain.
What do we currently know about how to prevent neck pain, or to prevent its recurrence?
We don’t know a lot. We know almost nothing about prevention but we do have some knowledge about risk factors that make it more likely. [Statistically], those include trauma, being a female, middle age, and lack of physical activity. There are also work-related risk factors, which the Task Force report described in some detail—how you sit, your posture, how you hold your arms, and so on.
Theoretically at least, if you reduce the risk factors you are less likely to get neck pain, although even that has not yet been demonstrated by research.
How important is it for chiropractors, or other practitioners, to include exercise as part of their recommendations for neck pain care?
It is crucial. It should be an intimate part of what they recommend. For chiropractors, it’s also philosophically correct. If you look at old-time chiropractic philosophy, they recommended that you maintain good health through good diet, regular exercise and good psychological support. Those are three important principles that have survived throughout the history of chiropractic. Psychological factors are also important risk factors for neck pain and identifying and dealing with psychological stress should be part of every clinician’s approach to neck pain.
What does research tell us about the differences in effect, and the issues chiropractic clinicians should consider, with regard to the effects of manipulation, mobilization and massage. Are there times when one is more appropriate for neck pain than the other?
We don’t know. It comes down to your clinical skill, clinical knowledge and clinical experience. There’s no research which can give guidance in this regard and it remains very controversial.
You were the lead author on a Task Force paper called “The Empowerment of People with Neck Pain.” Why is it important to empower patients?
There’s a growing body of literature, or at least consensus, that suggests that patients, right now, have a tendency to believe that neck pain is a disease for which there is a diagnosis and a cure. So they will go from one doctor to another, throughout their lives, looking for this magical cure. This can be very frustrating as nobody can provide more than temporary relief. Patients going on this merry-go-round often become more depressed, more anxious and the pain gets worse, it becomes more debilitating, they think they’re sicker and they demand more imaging and other studies.
The general feeling is that it may be possible to avoid this cycle if a patient is aware of the nature of the neck pain. The assumption is that knowledgeable patients can learn how to deal with it, they will start doing the things that are necessary to control the neck pain and stop doing the things that actually make the neck pain worse. For example, there is a growing amount of evidence that extended medical care prolongs disability and if patients become aware of the limitations of current treatment approaches they can avoid excessive and unnecessary care.
In that paper, you and your colleagues noted that clinicians often order multiple diagnostic tests, which in many cases are expensive, in what is often a fruitless effort to find a pathological source of the pain. And that the insurance companies then get upset at the costs of these inconclusive tests, and as a result will sometimes delay or deny reasonable care. What’s the solution to this serious problem?
One of the ways that this problem can be dealt with is to have strict criteria for when tests are ordered. That is what evidence-based guidelines are all about. They attempt to describe under which circumstances testing is likely to provide information that will change the way that patients are treated. Under some circumstances, there’s evidence that testing provides information that causes you to change the patient for the worse, to make them sicker. Under other circumstances, testing can cause changes in treatment that are likely to result in improvement of the patient. So what you’re looking for is those situations in which testing causes a clinician to change his or her approach to the benefit of the patient.
Regarding the use of x-rays after trauma, when I was in chiropractic school a generation ago we were taught to perform a 7-view x-ray series on whiplash patients. I saw that the Task Force reached a different conclusion about that. Our college currently uses Canadian guidelines that have a specific checklist of criteria needed to justify taking x-rays. What can you add?
There is no evidence that a 7-view series is of any benefit to anybody, and the information that is available suggests the contrary. If there is a true serious injury, then the proper approach is to use the Canadian c-spine rule, or the NEXIS c-spine rule. I would like to see chiropractors document that they have used the Canadian or NEXIS rule, and then if it is negative, not take an x-ray unless there are other red flags for serious pathology.
Do you think there are circumstances in which x-ray guidelines should be different for medical physicians than for chiropractors, who may be utilizing thrusting adjustments?
No, not really. They are either of value or not of value. In most of the world, chiropractors do not take x-rays. But, if you’re not taking x-rays, you must do a proper examination, use the NEXIS or Canadian C-spine rule whenever there is trauma and be sure to test for red flags and for radiculopathy. Because positive findings from such an evaluation may be indications for x-rays. Never taking an x-ray can also be a problem, in the same way that taking an x-ray every time is a problem. X-ray is a tool that has to be used judiciously, based on the history and clinical examination.
Are there other key points that you would want people to be aware of regarding the findings of the Bone and Joint Decade Neck Pain Task Force?
The Task Force put out a series of key points, which are at the end of each chapter. Those are the main messages that the Task Force wished to convey to readers.
One final question. What do you see as the most important next steps in research related to chiropractic? Overall, not just with regard to neck pain.
If you look at my recent article on diagnosis, it looks like we are not going to be able to determine a diagnosis when dealing with uncomplicated neck and back pain, but maybe we can develop a prediction rule. There is some research leading in that direction. The suggestion is that it would be very good for all of us to know which patients are likely to respond to a treatment, and which aren’t. And we don’t know that yet. Patients come in and virtually everyone gets treatment. Some respond and some don’t. It would be very nice to be able to have a prediction rule and that’s going to require a period of research.
The second question that it would be very nice to have an answer to is whether one treatment works with certain kinds of patients and whether another kind of treatment works with others. As you mentioned, within the manual therapies there’s manipulation and mobilization and massage, but within each of those there are a series of subdivisions and named techniques. It would be very nice for all of us to say that this type of patient is more likely to respond to this particular type of manual therapy, and a different kind of patient is likely to respond to a different kind of manual therapy. We teach it, but what we teach is based solely on experience. It is not based on anything except personal opinion.
The only study that comes to mind comparing two types of chiropractic approaches was the 2009 study by Maria Hondras and colleagues, in which they compared flexion-distraction to diversified adjustments.
Yes, and they found no major difference between the two. But more of those studies may give us some feel for whether we can offer specific types of care to specific patients. A problem with that study is that they didn’t look at prediction rules. It’s possible that if half of the patients responded to one treatment and half of the patients responded to the other, that the net outcome would be that they appeared equal in effect. It’s possible, if we had a good prediction rule, we could say, “Patients who look like this respond this way, and patients who look like that respond a different way to each of the specific treatment approaches.”
Thank you, Dr. Haldeman.
Daniel Redwood, DC, the interviewer, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.