FINDINGS FROM THE BONE AND JOINT DECADE 2000 TO 2010 TASK FORCE ON NECK PAIN AND ITS ASSOCIATED DISORDERS
 
   

Findings From the Bone and Joint Decade 2000 to 2010
Task Force on Neck Pain and its Associated Disorders

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org
 
   

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.



References:

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