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Neck pain
Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 93e108, 2007 doi:10.1016/j.berh.2006.10.003 available online at http://www.sciencedirect.com
6 Neck pain Irene Jensen*
PhD
Psychologist Department of Clinical Neuroscience, Section of Personal Injury Prevention, Karolinska Institutet, Sweden
Karin Harms-Ringdahl
PhD, RPT
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Sweden Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden
The aim of this article was to summarise the existing evidence concerning interventions for nonspecific neck pain. Neck-and-shoulder pain is commonly experienced by both adolescents and adults. Although the prevalence appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. Explanations for the wide variation in incidence and prevalence include various methodological issues. Back and neck disorders represent one of the most common causes for both short- and long-term sick leave and disability pension. Evidenced risk factors for the onset and maintenance of non-specific neck and back pain include both individual and work-related psychosocial factors. Based on the existing evidence different forms of exercise can be strongly recommended for at-risk populations, as well as for the acute and chronic non-specific neck pain patient. Furthermore, for symptom relief this condition can be treated with transcutaneous electric nerve stimulation, low level laser therapy, pulse electromagnetic treatment or radiofrequency denervation. Key words: neck pain; mechanical neck pain; whiplash-associated disorder (WAD); systematic review; guidelines; intervention; evidence-based medicine; RCT.
INTRODUCTION This aim of this article is to summarise the evidence for interventions for non-specific neck pain. In non-specific neck pain we include the terms neck strain, neck sprain, mechanical neck disorders, whiplash, neck disorders and neck-and-shoulder pain. We exclude specific diagnoses such as e.g. infections, osteoporosis and rheumatoid arthritis. * Corresponding author. E-mail address: [email protected] (I. Jensen). 1521-6942/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.
94 I. Jensen and K. Harms-Ringdahl
The temporal definition of the condition suggested by Nachemson & Jonsson1 is as follows:
Acute neck pain: 0e3 weeks’ duration of pain and/or disability. Sub-acute neck pain: 4e12 weeks’ duration of pain and/or disability. Chronic neck pain: more than 12 weeks’ duration of pain and/or disability. Recurrent problems: patients seeking help after at least 1 month of not seeking care or being on sick leave after at least 1 month of working.
However, this classification may be problematic to employ since many reviews comprise a mixture of patients in terms of pain duration. Many of the patients with recurrent pain episodes are also classified as having a chronic condition. Thus, for practical reasons it is easier to use the terms acute and chronic. Furthermore, many studies also comprise patients with low back pain, as well as patients who are sick listed and those who are not. Also, an aspect of work ability is very often used as one of the inclusion criteria for patients in randomised controlled trial (RCT) studies. This criterion is used more often in studies of patients with chronic or long lasting pain, the latter concept being more challenging from a rehabilitative viewpoint. Only rarely is sub-grouping of the patients done and targeted interventions applied. SIZE OF THE PROBLEM Neck-and-shoulder pain is commonly experienced by both adolescents and adults, as summarised by Nachemson & Jonsson.1 Although the prevalence of back and neck disorders appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. The most probable explanations for the wide variation include the way in which questions are asked, how back problems are defined and the difficulty in validating an individual’s subjective experience of problems. The variation and, thereby, the unreliability of the various prevalence rates reported, is confirmed, at least in part, by the large differences found by different studies within the same country. Population-based epidemiological studies show a lifetime prevalence of around 67% and 71% in a Canadian2 and a Finnish population3, respectively. While the point prevalence in the Finnish population was 13.4%, a meta-analysis from 21 published studies focusing on different occupational groups4 showed that the point prevalence for cervical spondylosis in dentists was 42e50%, that for miners was 54e76% while for meat carriers it was 84%, suggesting a relationship between cervicobrachial pain and some occupational exposures. Prevalence of neck-and-shoulder pain with pressure tenderness in the muscles was studied in a Danish survey of workers performing monotonous, repetitive work. The prevalence was 7% among participants performing repetitive work and 3.8% among the referents. An association was seen with high repetitiveness (prevalence ratio (PR) ¼ 1.8), high force (PR ¼ 2.0), high repetitiveness and high force (PR ¼ 2.3), high job demands (PR ¼ 1.8), neck/shoulder injury (PR ¼ 2.6), female gender (PR ¼ 1.8) and low-pressure pain threshold (PR ¼ 1.6), revealing the multi-factorial nature of neck/shoulder pain.5 In a review by Linton6 concerning risk factors for neck and back pain it was concluded that psychosocial factors are related to the onset of pain and to acute, sub-acute and chronic pain. Work-related psychosocial risk factors for
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neck pain have been shown to be high quantitative job demands, low social (coworker) support, low job control, high and low skill discretion and low job satisfaction.7 Back and neck disorders represent one of the most common causes for both shortand long-term sick leave and disability pension.8 In a Norwegian study of 156,644 subjects taking sick leave for longer than 14 days due to musculoskeletal and connective tissue disorders, 20% was attributed to neck-and-shoulder pain.9 In a recent systematic review concerning risk factors for sick leave and disability pension due to back and neck pain it was shown that: (1) heavy physical workload, bent or twisted working position, and low work satisfaction increased the risk for short- and long-term sick leave; (2) specific back diagnoses and previous sick leave due to back disorders increased the risk for short- and long-term sick leave; (3) self-reported pain and activity limitations were associated with a high risk for long-term sick leave; (4) female gender and higher age increased the risk for disability pension.8 These risk factors are related to sick leave and the possibilities for being at work despite neck pain. Such risk factors tell us something about the consequences of neck pain for both the individual and society. However, it is not yet possible to identify those in the community who are at greater risk of developing neck pain with sufficient sensitivity or specificity to make any recommendations.10 TREATMENT GOALS AND HOW DO WE MEASURE THEM? One of the most important things to think about when implementing and evaluating an intervention is to be clear about the purpose of that intervention, which could relate to a wide variety of aspects ranging from more symptom focused, e.g. pain relief and increased mobility, to more health economic aspects such as a return to work. Some of the confusions about the effects of specific interventions are related to this issue. It is evident in the research literature that, in outcome studies, a wide range of measures attempting to cover most of the different aspects of living with non-specific pain are commonly applied. Many psychosocial factors can be viewed as factors mediating the outcome of the intervention and should, thus, not be treated as outcome measures but rather as factors of importance that should be addressed within the treatment (Table 1).
Table 1. Examples of the relationship between the treatment targets, potential mediating factors and outcome measures. Targets of treatment
Mediating factors
Outcome measures
Reduction of pain and other symptoms
Fear of pain Kinesophobia Catastrophising
Pain Disability Depression
Prevention of disability
Fear of pain Kinesophobia Catastrophising
Activity of daily living Disability Range of motion
Maintaining work capacity
Insurance system Physically demanding job Job satisfaction
Sick leave Disability pension Return to work
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Catastrophising and fear of pain11 are two such cognitive factors shown to hinder improvements in functioning and return to work. When deciding the key outcome of the intervention, it is important to distinguish between the effect on the mediating factors and the potential effect of altering the mediating factors, otherwise one runs the risk of drawing the wrong conclusions about the effect of the intervention. Thus, when treating non-specific neck pain, clinicians should not only treat the disability itself but also the factors mediating change in the outcome measure. It is also important to bear in mind the time span between the intervention and the hypothesised effect when evaluating the intervention. Many outcome studies have short follow-up times and commonly no statements are made about the expected timeframe for change. Instead it is implicitly stated in the study design with short follow-up time that the effect is immediate upon the start of intervention and will be maintained after that. In cases where the timeframe can not be theoretically derived it is wise to have a study design with repeated measures during several years of follow-up when evaluating the effectiveness of an intervention. In non-specific back pain, interventions targeted at behavioural change have been proven effective. Establishing and maintaining new behaviours takes time and if the effect on the targeted outcome is dependent on the maintenance of behavioural changes a long term follow-up is essential in determining the effectiveness of such an intervention. Interventions cost money. The costeeffectiveness of the treatment depends on how well the target as been defined so that the results can be assessed in relation to the targeted outcome. When applying interventions to symptoms such as non-specific back and neck pain, where multidisciplinary factors have been shown to influence onset and outcome, it can be tempting to ‘pull out the canons and shoot’. This can be done by either applying as many treatment modalities as possible, or by measuring the effect using as many outcome measures as possible, or both. But the costeeffectiveness can be seriously violated when applying this method, with devastating consequences for patients. The possibilities for comparing interventions will be facilitated if the purpose of the intervention is stated more clearly than is commonly done today and, furthermore, if the outcome parameters are selected in accordance with that purpose. In addition, subgroups suitable for the targeted intervention need to be identified. Any health condition affects an individual in a variety of ways, each of which may need a different approach to prevention and management. The patient expects the caregiver to ‘make him well’ and by that every single patient can mean a variety of things and expect it to happen within a very short timeframe. In this chapter, when summarising the evidence for interventions for non-specific neck pain, modified groups of the key outcomes used in Chapter 5 (Non-specific low back pain) and based on the concepts of the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) have been used. Disability and generic health measures are included in ‘Symptoms’, which is not in accordance with other chapters where they are included in ‘Activity and participation’. This modification serves the purpose of clearly separating the results from interventions that have been evaluated in terms of symptom reduction from those evaluating maintainance of/return to work. The outcome measures used are: For symptoms: Pain, disability, generic health For tissue damage: The definition of non-specific neck pain excludes the presence of tissue damage of relevance to the problem. Activity and participation: Sick leave, disability pension, return to work, work ability.
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WHAT CAN BE DONE: THE EVIDENCE FOR DIFFERENT INTERVENTIONS In everyday practice a variety of interventions are used when treating neck pain. Upon reviewing the literature, it was evident that high quality research concerning outcome studies on the effects of interventions applied to non-specific neck pain is sparse. Several systematic reviews have been conducted investigating the evidence for different types of interventions. In this summary of evidence we will present results from existing systematic reviews. The purpose with this summary is to provide an upto-date tool for clinicians in their treatment strategy decision-making. Procedure We performed searches in two high quality libraries for systematic reviews e The Cochrane library and The Centre for Reviews and Dissemination DARE library e and in MEDLINE. The search terms used were: neck pain, neck strain, neck sprain, mechanical neck disorders, whiplash and systematic reviews published 2000e2005. All systematic reviews (1) using at least two independent reviewers, (2) having a specified search procedure and (3) having predefined quality assessment criteria, were included. In total, 17 systematic reviews of relevance were identified. All of these reviews were then appraised for evidence. Appraising the evidence The evidence presented in the reviews is summarised below. We apply the same grading system as in the European Action Towards Better Musculoskeletal Health report10 shown in Table 2. Since grading of the strength of the evidence can vary between different systematic reviews the grading system reveals the type of source indicating that the meta-analytic approach of RCTs is superior. Therefore, the evidence of effect presented includes evidence from limited to strong. When results from reviews were contradictory the evidence was interpreted as being inconsistent if the conclusions were based on the same studies. If one review was conducted several years later and included more evidence, then the results were interpreted in accordance with the updated review. Summary of evidence In the tables below, ‘symptoms’ includes measures of pain, disability and generic health. ‘Activity and participation’ includes measures of sick leave, disability pension and return to work. Lifestyle interventions Table 3 summarises the level of evidence from selected and appraised systematic reviews for lifestyle interventions on the target outcomes. Two systematic reviews were identified that investigated interventions for preventing neck pain. Moderate evidence was found for exercise in the prevention of neck pain. Further results show that fitness training at the work place was effective in
98 I. Jensen and K. Harms-Ringdahl
Table 2. The grading of evidence. Grading of evidence Categories of evidence Ia Ib IIa IIb III
# IE
Evidence from meta-analysis of randomised controlled trials Evidence from at least one randomised controlled trial Evidence from at least one controlled study without randomisation Evidence from at least one other type of quasi-experimental study Evidence from descriptive studies, i.e. comparative studies, correlation studies and caseecontrol studies Evidence from expert committee reports or opinion, or clinical experience of a respected authority or both Inconsistent findings Inadequate evidence from which to make a grading
The nature of effect þ 0
Positive effect Evidence of no effect Negative effect
IV
Source: European Action Towards Better Musculoskeletal Health report.10
reducing the prevalence of neck and back pain. Other reviews did not find any conclusive evidence regarding fitness training for acute and chronic neck pain. However, more specific types of exercises have been shown to be effective (see below Table 5). In the reviews, authors have pointed out the lack of consistency in defining the different types of exercise interventions. Contrary to back pain, where evidence shows that education is effective in increasing function and activity, the evidence for neck pain and education programmes is inconclusive. Pharmacological interventions Table 4 summarises the level of evidence from selected and appraised systematic reviews for pharmacological interventions on the target outcomes. Table 3. Summary of evidence for lifestyle interventions. Lifestyle interventions
Aims of intervention Symptom
Fitness training At risk populations Acute Chronic Education programmes At risk populations Acute Chronic 1,12e15
Sources. For gradings, see Table 1.
Iaþ
IE
Activity and participation
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Table 4. Summary of evidence for pharmacological interventions. Pharmacological interventions
Aims of intervention Symptom
Oral psychotropic agents Acute Chronic
Ia# Ia#
NSAIDs Acute Chronic
Ia0 Ia0
Intra-muscular injections of multivitamins Acute Chronic
IE
Melatonin Acute Chronic
Ia0
Local treatment with anaesthetic Acute Chronic
Iaþ
Treatment with epidural steroids Acute Chronic
Ia#
Local treatment with Botulinum Acute Chronic
Ia0
Subcutaneous injections Acute Chronic
Ia0
Intravenous glucocorticoid Acute Chronic
Iaþ
Activity and participation
Ia#
Iaþ
Sources.1,16e18 For gradings, see Table 1. NSAIDs, non-steroidal anti-inflammatory drugs; WAD, whiplash-associated disorder.
Most of the investigated pharmacological treatments either lack effect or have inconsistent findings in meta-analyses of RCTs (level Ia). Intra-muscular injection of lidocaine provides short-term effects on pain in chronic neck pain. Intravenous methylprednisolone and lidocaine is effective in reducing pain in short term and in reducing long term sick both leave for acute whiplash-associated disorder (WAD). Surgical intervention There is insufficient evidence of effectiveness for surgical interventions for non-specific neck pain to make recommendations since the long-term effects are unclear.
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Table 5. Summary of evidence for rehabilitative interventions. Rehabilitative interventions
Aims of intervention Symptom
Cold spray Acute Chronic
IE
Laser (LLLT) Acute Chronic
Ibþ Ibþ
Pulse electromagnetic treatment (PEMS ) Acute Chronic
Ibþ Ibþ
Radiofrequency denervation Acute Chronic
Ibþ
Transcutaneous electric nerve stimulation (TENS) Acute Ia# Chronic Ia# Electric muscle stimulation (EMS ) Acute Chronic
Ib0
Acupuncture Acute Chronic
IE Ib0
Traction Acute Chronic
IE Ib0
Mobilisation Acute Chronic
Ia0 Ia0
Manipulation Acute Chronic
Ia0 Ia0
Neck collar Acute Chronic
Ia0 Ia0
ROM exercise Acute Chronic
Iaþ IE
Strengthening exercise Acute Chronic
Iaþ
Proprioceptive exercise Acute Chronic
Iaþ
Activity and participation
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Table 5 (continued ) Rehabilitative interventions
Aims of intervention Symptom
Individualised instructions for home exercise Acute Chronic
Iaþ Iaþ
Multimodal intervention combining physical agents Acute Chronic
Iaþ Iaþ
Multimodal intervention combining physical agents and CBT Acute Chronic
Ibþ
Activity and participation
Ibþ
Sources.1,12,15,19e30 For grading, see Table 1. LLLT, low level laser therapy; ROM, region of movement; CBT, cognitive behavioural therapy.
Rehabilitative interventions Table 5 summarises the level of evidence from selected and appraised systematic reviews for rehabilitative interventions on the target outcomes. Differences in evidence are revealed when comparing acute and chronic neck pain. The strongest evidence (level Ia) is evident for region of movement (ROM)-exercises in reducing pain in acute neck pain in the short term and for multimodal interventions combining physical agents in reducing pain and improving functioning in both acute and chronic neck pain. Furthermore, for chronic neck pain the strongest evidence (level Ia) is evident for all types of exercise except ROM exercise. This summary of evidence shows that for acute and chronic neck pain low level laser therapy (LLLT) is effective in reducing pain (level Ib). Pulse electromagnetic treatment (PEMS) is effective in reducing pain in the short term only in acute WAD and in chronic non-specific neck pain. Radiofrequency denervation is effective in reducing pain in chronic neck pain. Individualised instruction for home exercise is effective in reducing pain and increasing patient satisfaction compared to written information alone in both acute and chronic neck pain. Multimodal interventions with cognitive behavioural intervention are effective for sub-acute WAD in reducing symptoms in the short term and sick leave in the long term. Manual therapy (traction, manipulation and mobilisation) has no evidenced effect. However, although not effective alone, evidence shows that combining manual therapy techniques and exercise therapy in a multimodal intervention is effective, even though it is not possible from the evidence to draw conclusions on how much the manual therapy contributes when compared to exercise alone. Description of the interventions Fitness training: includes physical fitness exercises for flexibility, aerobics, co-ordination, muscular strength and endurance. Examples are endurance training such as running, swimming, cycling or aerobic training.
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Education programmes: in the form of ‘back schools’ that aim to provide education about neck pain with the purpose of increasing coping ability. Oral psychotropic agents: cyclobenzaprine, diazepam, tetrazepam and others aim to reduce muscle spasm and, thereby, pain. Non-steroidal anti-inflammatory drugs (NSAIDs): oral anti-inflammatory and analgesic medication. Intra-muscular injections of multivitamins: injection of the multivitamin ‘Neurotrat’. Melatonin: oral medication aiming to improve sleep and reduce pain. Local treatment with anaesthetic: intra-muscular injections of lidocaine. Local treatment with epidural steroids: epidural injections with methylprednisolone and lidocaine. Local treatment with Botulinum toxin: intra-muscular injections of Botox A. Subcutaneous injections: injections of carbon dioxide, aiming to reduce pain by vasodilatation. Intravenous glucocorticoid: methylprednisolone and lidocaine. Cold spray: aims to decrease nerve conduction velocity. Low level laser therapy (LLLT ): aims to reduce pain by applying light with a less than 0.5 C increase in temperature on the exposed tissue. The international standard classes IeIIIb are included in this evaluation. Pulse electromagnetic treatment (PEMS ): induces electric current within the tissue and aims to enhance bone and tissue healing. Radiofrequency denervation: aims to de-activate the nerve responsible by applying electric current in to the disc to cauterise the nerve with the purpose of pain relief. Transcutaneous electric nerve stimulation (TENS ): electrical impulses are applied through rubber plates on the skin over nerves and muscles using an apparatus where currency and frequency can be adjusted. Can be used for 20e30 minutes daily in order to stimulate endorphin production and reduce pain.10 Electric muscle stimulation (EMS ): most characteristics are comparable to those of TENS. Acupuncture: very thin needles are applied for 25e30 minutes at a defined depth in specific acupuncture points in order to produce impulses that will stimulate endorphin production and reduce pain. Sometimes electrical impulses are applied through the needles in order to increase the effect.10 Traction: the spine is pulled in a longitudinal direction, sometimes with a component of lateral rotation, with the aim of increasing nerve root space and mobility.10 Mobilisation: mobilising techniques, provided by a therapist specialised in manual therapy (chiropractor, osteopath, naprapath, physiotherapist, physician), use a precise, directed force or thrust and aim to increase mobility between specified vertebrae and their muscles within their physiological motion range.10 Manipulation: As for mobilisation (see above), but with a short thrust applied very fast and distinctly. Neck collar: a soft collar is applied around the neck with the aim of supporting the neck and serving as a reminder not to perform excessive movements. Range of motion (ROM ) exercises: training aimed at increasing joint range of motion. Movements are guided in specific directions depending on the symptoms of the patient, e.g. Mckenzie-exercises.10 Strengthening exercises: aim to increase muscle performance such as muscle activation, endurance and strength.10 Proprioceptive exercises: neck exercises aiming to improve proprioceptive sense. Proprioceptive sense refers to the sensory input and feedback that tells us about movement and body position.
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Multimodal intervention combining physical agents: a comprehensive, multi-professional programme with a combination of treatment modalities, education, strengthening exercises and fitness training. Usually the programme is conducted during full or half days for at least 4 weeks. Multimodal intervention combining physical agents and cognitive behavioural therapy (CBT ): a comprehensive, multi-professional programme with a combination of treatment modalities, education, strengthening exercises and cognitive behavioural treatment. Usually the programme is conducted during full or half days for at least 4 weeks sometimes combined with work-related measures.10 Effects on key outcomes Table 6 provides a summary of those interventions that have evidence for a positive effect on the key target outcomes. Adverse events Negative side effects of treatments are rarely reported in studies. In systematic reviews, the authors commonly state that nothing on adverse effects has been reported in the majority of studies. This could be due to reporting bias or it could be a true statement that no side effects are evident. In the reviews appraised in this chapter, 50% did not address adverse effects. When addressed, those reviews reporting adverse effects recorded that a range of 0e71% with a mean of 33% of the reviewed studies reported on this. Authors of the reviews mainly concluded that adverse effects are reported but the evidence is too scarce to allow for estimation of risks. Cost and effectiveness In this summary no aspects of cost or effectiveness have been taken into consideration. The research concerning this is still in its infancy. None of the systematic reviews were able to make statements about cost and effectiveness. Cost and effectiveness can be evaluated using different approaches mainly depending on what outcome parameters are used. In costeeffectiveness and costebenefit analyses, comparisons between treatments can be made using the same outcome parameters and/or by measuring the monetary values.31 Very few studies have used parameters that can be evaluated in monetary terms, e.g. sick leave or return to work. One systematic review was identified that evaluated the costeeffectiveness of multimodal interventions, but no conclusions could be made due to lack of evidence.32 In one RCT study from Sweden evaluating the different components in multidisciplinary interventions for non-specific back and neck pain, it was shown that a full-time multidisciplinary intervention programme combining exercise therapy and CBT was costeeffective for women when compared with a no treatment control group.33 Over 3 years the sum of about V138 000 per treated female was gained, based on a calculation of production losses.33 In a costeutility analysis RCT study of manipulation, comparing standard care to spinal manipulation from a general practitioner (GP) who was a registered osteopath34, the results revealed slightly improved effects on health-related quality of life for the osteopathic alternative but at a higher cost. Similar results were presented in a Finnish RCT study comparing the same types of interventions.35
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Table 6. Interventions with evidence of positive effects on key outcomes. Key outcomes
Interventions
Symptoms
Acute/sub acute
Chronic
Pain
Low level laser therapy (LLLT) Transcutaneous electric nerve stimulation (TENS) Individualised instruction for home exercise ROM-exercises Multimodal interventions combining physical agents Pulse electromagnetic treatment (PEMS)a Multimodal intervention including CBTa Intravenous injections with Methylprednisol and lidocainea
Low level laser therapy (LLLT) Transcutaneous electric nerve stimulation (TENS) Pulse electromagnetic treatment (PEMS) Radiofrequency denervation Individualised instruction for home exercise Strengthening exercise Proprioceptive exercises Multimodal interventions combining physical agents Intra-muscular injections of lidocainea Proprioceptive exercises Strengthening exercises Multimodal interventions combining physical agents
Disability (self reported measures)
Multimodal interventions combining physical agents
Physical functioning (objective measures e.g. ROM) Psychosocial functioning (e.g. depression, social participation) Global perceived effect (e.g. generic health)
Multimodal interventions combining physical agents
Proprioceptive exercises Strengthening exercises Multimodal interventions combining physical agents
Multimodal intervention including CBTa Intravenous injections with methylprednisol and lidocainea
Proprioceptive exercises
Activity and participation Maintaining work (i.e. sick leave, disability pension, work ability)
a
Evidence for whiplash associated disorders (WAD) only.
How to identify those who will benefit most from intervention? Non-specific neck pain conditions are commonly conditions of a multidimensional nature. Since we do not fully understand the causal relationships between occurrence, reoccurrence and pain maintenance, interventions that focus on the mediators mentioned above seem to be important for development and/or progression and long term outcome. That means that we need to be able to identify those with a specific condition,
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for which proper treatment is available, without discourage the remainder by telling them that we do not know why this painful condition has occurred. A proper investigation addressing ‘red’ and ‘yellow’ flags constitutes an important basis for this. Fear avoidance beliefs, catastrophising, self-efficacy and beliefs about the future situation are all thoughts that both care-seekers and care-providers may have in mind, sometimes shared with each other and sometimes not, and all of which seem to influence outcome.6,11 Maintaining physical activity despite acute or subacute back pain seems to shorten the length of the pain episode and it is reasonable to believe that this is also the case for episodes of neck pain. On a background of public awareness, healthcare professionals should be good informants of the importance of physical activities and should guide patients on how to achieve this, despite pain episodes. Furthermore, healthcare providers should be careful with advice that restricts a patient’s activities and participation. The only restriction given should be to avoid bed rest. It seems likely that workplace improvements reducing risk factors for the development of neck pain would result in a healthier working population. However, good-quality evidence on the effectiveness of risk factor modification on neck pain is lacking.36 Despite considerable research on return to work (RTW), there has been little change in overall rates of work disability in developed countries. In a recent review, 30 RTW researchers, representing over 20 institutions, reviewed the current state of the art in RTW research and identified promising areas for further development and future investigations.37 Six priority areas were identified: (1) early risk prediction; (2) psychosocial, behavioural and cognitive interventions; (3) physical treatments; (4) implementing evidence in the workplace context; (5) effective methods for engaging multiple stakeholders; and (6) identification of outcomes that are relevant to both RTW stakeholders and different phases of the RTW process. What strategies (care pathways) should be used for prevention and treatment based on this evidence? Since people with neck pain are frequent visitors to primary health care centres, hospitals, paramedical institutions (e.g. for physiotherapy and chiropractice) and occupational health care centres, strategies must be developed to reach these care providers with Clinical Guidelines. However, little research has been done on the implementation and dissemination of evidence-based methods (EBM) of care.38 Accordingly evidence for strategies that effectively enhance compliance and thus change clinical practice is lacking. Recent research on the effects of EBM on clinical practice shows that although the knowledge is acquired, the clinical practice is not equally effective when measured in terms of behavioural change.39 From the evidence summarised in this chapter it is clear that there is also a shift in the responsibility for the health of the individual from the care provider to the patient. To be physically active at a moderate level for at least 30 minutes per day as part of ordinary life and to modify work postures, movements and organisation, requires much more effort than does passive treatment and taking a pill. More research is needed on how to coach patients to have a healthy lifestyle without violating the integrity of that patient. At an occupational and societal level, strategies are needed to provide possibilities for closer collaboration between care providers and workplaces, including school health care and teachers, in order to enhance physical activities.
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Practice points Based on the existing evidence, the following is recommended for the targeted groups: Risk population: since non-specific neck pain is a common condition, the risk population should be considered to be the whole population. It is recommended that measures be taken to enhance physical activity in the population. The degree of exercise is not clear, but based on the evidence, physical activity should take place regularly several times a week. Acute and sub-acute conditions: it is recommended that people with this condition should exercise regularly. Specific range of motion (ROM) exercise is beneficial. The degree of exercise is not clear but based on the physical activity should take place regularly several times a week. Individually tailored information about exercise should be given. A supplement for short term symptom reduction is to use transcutaneous electric nerve stimulation (TENS) or low level laser treatment (LLLT). For acute whiplash-associated disorder(WAD) only: it is recommended that intravenous glucocorticoid and pulse electromagnetic treatment (PEMS) be used. It is further recommended that multimodal intervention including non-excessive ROM exercise and cognitive behavioural therapy be used for sub-acute WAD. Chronic conditions: for comprehensive treatment results, exercise and multimodal intervention is effective. Individually tailored information about exercise should be given. For pain reduction there are some effective alternatives to exercise and it is recommended that people with this condition can be treated with TENS, LLLT, PEMS or radiofrequency denervation. For chronic WAD only: intra-muscular injections of lidocaine can be used.
Research agenda In order to establish safe and effective treatments more research should be devoted to the following: evaluating the common interventions used in everyday clinical practice including alternative and complementary medicine for non-specific neck pain researchers should be more aware of the importance of reporting adverse effects to facilitate the costeeffective use of resources, efforts should be made to invest in high quality studies on costeeffectiveness/utility.
REFERENCES 1. Nachemson AL & Jonsson E (eds). Neck and Back Pain. The Scientific Evidence of Causes, Diagnosis and Treatment. Philadelphia: Lippincott Williams & Wilkins, 2000. 2. Cote´ P, Cassidy J & Carroll L. The Saskatchewan health and back pain survey: the prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998; 23: 1689e1698.
Neck pain 107 3. Makela M, Heliovaara M, Sievers K et al. Prevalence, determinants, and consequences of chronic neck pain in Finland. American Journal of Epidemiology 1991; 134(11): 1356e1367. 4. Hagberg M & Wegman DH. Prevalence rates and odds ratios of shoulder-neck diseases in different occupational groups. British Journal of Industrial Medicine 1987; 44(9): 602e610. 5. Andersen JH, Kaergaard A, Frost P et al. Physical, psychosocial, and individual risk factors for neck/ shoulder pain with pressure tenderness in the muscles among workers performing monotonous, repetitive work. Spine 2002; 27(6): 660e667. 6. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000; 25(9): 1148e1156. 7. Ariens GA, van Mechelen W, Bongers PM et al. Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial Medicine 2001; 39(2): 180e193. 8. Hansson T & Jensen I. Swedish Council on Technology Assessment in Health Care (SBU). Chapter 6. Sickness absence due to back and neck disorders. Scandinavian Journal of Public Health. Supplement 2004; 63: 109e151. 9. Brage S, Nygard JF & Tellnes G. The gender gap in musculoskeletal-related long-term sickness absence in Norway. Scandinavian Journal of Social Medicine 1998; 26(1): 34e43. 10. European Action Towards Better Musculoskeletal Health: A Public Health Strategy to Reduce the Burden of Musculoskeletal Conditions. A Bone and Joint Decade Report, 2004. The European Bone and Joint Health Strategies Project. The Bone and Joint Decade, Lund, Sweden. Available at: http://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion_2000_frep_15_en.pdf. 11. Vlaeyen JW & Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000; 85(3): 317e332. *12. Kay TM, Gross A, Goldsmith C et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews 2006; (3): CD004250. 13. Linton SJ & van Tulder MW. Preventive interventions for back and neck pain problems: what is the evidence? Spine 2001; 26(7): 778e787. 14. Proper KI, Koning M, van der Beek AJ et al. The effectiveness of worksite physical activity programs on physical activity, physical fitness, and health. Clinical Journal of Sport Medicine 2003; 13(2): 106e117. 15. Seferiadis A, Rosenfeld M & Gunnarsson R. A review of treatment interventions in whiplash-associated disorders. European Spine Journal 2004; 13(5): 387e397. 16. Chou R, Peterson K & Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. Journal of Pain and Symptom Management 2004; 28(2): 140e175. *17. Peloso P, Gross A, Haines T et al. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database of Systematic Reviews 2005; (2): CD000319. 18. Sycha T, Kranz G, Auff E & Schnider P. Botulinum toxin in the treatment of rare head and neck pain syndromes: a systematic review of the literature. Journal of Neurology 2004; 251(supplement 1): I19eI30. *19. Gross AR, Hoving JL, Haines TA et al. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews 2005; (1): CD004249. 20. Sarig-Bahat H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy 2003; 8(1): 10e20. 21. Kroeling P, Gross AR, Goldsmith CH & Cervical Overview Group. Electrotherapy for neck disorders. The Cochrane Library Database of Systematic Reviews 2005; (2): CD004251. *22. Niemisto L, Kalso E, Malmivaara A, Seitsalo S et al. Radiofrequency denervation for neck and back pain. The Cochrane Library 2006; (1): CD004058. 23. Clare HA, Adams R & Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Australian Journal of Physiotherapy 2004; 50(4): 209e216. *24. Ernst E. Chiropractic spinal manipulation for neck pain: a systematic review. Journal of Pain 2003; 4(8): 417e421. *25. Chow RT & Barnsley L. Systematic review of the literature of low-level laser therapy (LLLT) in the management of neck pain. Lasers in Surgery and Medicine 2005; 37(1): 46e52. 26. Graham N, Gross AR & Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. Journal of Rehabilitation Medicine 2006; 38(3): 145e152. 27. Gemmell H & Miller P. Comparative effectiveness of manipulation, mobilisation and the activator instrument in treatment of non-specific neck pain: a systematic review. Chiropractic & Osteopathy 2006; 14: 7.
108 I. Jensen and K. Harms-Ringdahl *28. Karjalainen K, Malmivaara A, van Tulder M et al. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Cochrane Database of Systematic Reviews 2003; (2): CD002194. *29. Schonstein E, Kenny DT, Keating J & Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain. Cochrane Database of Systematic Reviews 2003; (1): CD001822. 30. Geurts JW, van Wijk RM, Stolker RJ & Groen GL. Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials. Regional Anesthesia and Pain Medicine 2001; 26(5): 394e400. 31. Hansson E. The Treatment of Back and Neck Pain. Cost and Utility. Go¨teborg: Department of Orthopaedics, Sahlgrenska Academy, 2005. 32. Ospina M & Harstall C. Multidisciplinary Pain Programs for Chronic Pain: Evidence from Systematic Reviews. Edmonton: Alberta Heritage Foundation for Medical Research (AHFMR), 2003. 33. Jensen IB, Bergstrom G, Ljunqquist T & Bodin L. A 3-year follow-up of a multidisciplinary rehabilitation programme for back and neck pain. Pain 2005; 115(3): 273e283. 34. Williams NH, Edwards RT, Linck P et al. Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial. Family Practice 2004; 21(6): 643e650. 35. Niemisto L, Rissanen P, Sarna S et al. Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine 2005; 30(10): 1109e1115. 36. Linton SJ, Gross D, Schultz IZ et al. Prognosis and the identification of workers risking disability: research issues and directions for future research. Journal of Occupational Rehabilitation 2005; 15(4): 459e474. *37. Pransky G, Gatchel R, Linton SJ & Loisel P. Improving return to work research. Journal of Occupational Rehabilitation 2005; 15(4): 453e457. *38. Breen AC, van Tulder MW, Koes BW et al. Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care? European Spine Journal 2006; 15(5): 641e647. 39. Overmeer T, Linton SJ, Holmquist L et al. Do evidence-based guidelines have an impact in primary care? A cross-sectional study of Swedish physicians and physiotherapists. Spine 2005; 30(1): 146e151.
6 Neck pain Irene Jensen*
PhD
Psychologist Department of Clinical Neuroscience, Section of Personal Injury Prevention, Karolinska Institutet, Sweden
Karin Harms-Ringdahl
PhD, RPT
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Sweden Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden
The aim of this article was to summarise the existing evidence concerning interventions for nonspecific neck pain. Neck-and-shoulder pain is commonly experienced by both adolescents and adults. Although the prevalence appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. Explanations for the wide variation in incidence and prevalence include various methodological issues. Back and neck disorders represent one of the most common causes for both short- and long-term sick leave and disability pension. Evidenced risk factors for the onset and maintenance of non-specific neck and back pain include both individual and work-related psychosocial factors. Based on the existing evidence different forms of exercise can be strongly recommended for at-risk populations, as well as for the acute and chronic non-specific neck pain patient. Furthermore, for symptom relief this condition can be treated with transcutaneous electric nerve stimulation, low level laser therapy, pulse electromagnetic treatment or radiofrequency denervation. Key words: neck pain; mechanical neck pain; whiplash-associated disorder (WAD); systematic review; guidelines; intervention; evidence-based medicine; RCT.
INTRODUCTION This aim of this article is to summarise the evidence for interventions for non-specific neck pain. In non-specific neck pain we include the terms neck strain, neck sprain, mechanical neck disorders, whiplash, neck disorders and neck-and-shoulder pain. We exclude specific diagnoses such as e.g. infections, osteoporosis and rheumatoid arthritis. * Corresponding author. E-mail address: [email protected] (I. Jensen). 1521-6942/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.
94 I. Jensen and K. Harms-Ringdahl
The temporal definition of the condition suggested by Nachemson & Jonsson1 is as follows:
Acute neck pain: 0e3 weeks’ duration of pain and/or disability. Sub-acute neck pain: 4e12 weeks’ duration of pain and/or disability. Chronic neck pain: more than 12 weeks’ duration of pain and/or disability. Recurrent problems: patients seeking help after at least 1 month of not seeking care or being on sick leave after at least 1 month of working.
However, this classification may be problematic to employ since many reviews comprise a mixture of patients in terms of pain duration. Many of the patients with recurrent pain episodes are also classified as having a chronic condition. Thus, for practical reasons it is easier to use the terms acute and chronic. Furthermore, many studies also comprise patients with low back pain, as well as patients who are sick listed and those who are not. Also, an aspect of work ability is very often used as one of the inclusion criteria for patients in randomised controlled trial (RCT) studies. This criterion is used more often in studies of patients with chronic or long lasting pain, the latter concept being more challenging from a rehabilitative viewpoint. Only rarely is sub-grouping of the patients done and targeted interventions applied. SIZE OF THE PROBLEM Neck-and-shoulder pain is commonly experienced by both adolescents and adults, as summarised by Nachemson & Jonsson.1 Although the prevalence of back and neck disorders appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. The most probable explanations for the wide variation include the way in which questions are asked, how back problems are defined and the difficulty in validating an individual’s subjective experience of problems. The variation and, thereby, the unreliability of the various prevalence rates reported, is confirmed, at least in part, by the large differences found by different studies within the same country. Population-based epidemiological studies show a lifetime prevalence of around 67% and 71% in a Canadian2 and a Finnish population3, respectively. While the point prevalence in the Finnish population was 13.4%, a meta-analysis from 21 published studies focusing on different occupational groups4 showed that the point prevalence for cervical spondylosis in dentists was 42e50%, that for miners was 54e76% while for meat carriers it was 84%, suggesting a relationship between cervicobrachial pain and some occupational exposures. Prevalence of neck-and-shoulder pain with pressure tenderness in the muscles was studied in a Danish survey of workers performing monotonous, repetitive work. The prevalence was 7% among participants performing repetitive work and 3.8% among the referents. An association was seen with high repetitiveness (prevalence ratio (PR) ¼ 1.8), high force (PR ¼ 2.0), high repetitiveness and high force (PR ¼ 2.3), high job demands (PR ¼ 1.8), neck/shoulder injury (PR ¼ 2.6), female gender (PR ¼ 1.8) and low-pressure pain threshold (PR ¼ 1.6), revealing the multi-factorial nature of neck/shoulder pain.5 In a review by Linton6 concerning risk factors for neck and back pain it was concluded that psychosocial factors are related to the onset of pain and to acute, sub-acute and chronic pain. Work-related psychosocial risk factors for
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neck pain have been shown to be high quantitative job demands, low social (coworker) support, low job control, high and low skill discretion and low job satisfaction.7 Back and neck disorders represent one of the most common causes for both shortand long-term sick leave and disability pension.8 In a Norwegian study of 156,644 subjects taking sick leave for longer than 14 days due to musculoskeletal and connective tissue disorders, 20% was attributed to neck-and-shoulder pain.9 In a recent systematic review concerning risk factors for sick leave and disability pension due to back and neck pain it was shown that: (1) heavy physical workload, bent or twisted working position, and low work satisfaction increased the risk for short- and long-term sick leave; (2) specific back diagnoses and previous sick leave due to back disorders increased the risk for short- and long-term sick leave; (3) self-reported pain and activity limitations were associated with a high risk for long-term sick leave; (4) female gender and higher age increased the risk for disability pension.8 These risk factors are related to sick leave and the possibilities for being at work despite neck pain. Such risk factors tell us something about the consequences of neck pain for both the individual and society. However, it is not yet possible to identify those in the community who are at greater risk of developing neck pain with sufficient sensitivity or specificity to make any recommendations.10 TREATMENT GOALS AND HOW DO WE MEASURE THEM? One of the most important things to think about when implementing and evaluating an intervention is to be clear about the purpose of that intervention, which could relate to a wide variety of aspects ranging from more symptom focused, e.g. pain relief and increased mobility, to more health economic aspects such as a return to work. Some of the confusions about the effects of specific interventions are related to this issue. It is evident in the research literature that, in outcome studies, a wide range of measures attempting to cover most of the different aspects of living with non-specific pain are commonly applied. Many psychosocial factors can be viewed as factors mediating the outcome of the intervention and should, thus, not be treated as outcome measures but rather as factors of importance that should be addressed within the treatment (Table 1).
Table 1. Examples of the relationship between the treatment targets, potential mediating factors and outcome measures. Targets of treatment
Mediating factors
Outcome measures
Reduction of pain and other symptoms
Fear of pain Kinesophobia Catastrophising
Pain Disability Depression
Prevention of disability
Fear of pain Kinesophobia Catastrophising
Activity of daily living Disability Range of motion
Maintaining work capacity
Insurance system Physically demanding job Job satisfaction
Sick leave Disability pension Return to work
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Catastrophising and fear of pain11 are two such cognitive factors shown to hinder improvements in functioning and return to work. When deciding the key outcome of the intervention, it is important to distinguish between the effect on the mediating factors and the potential effect of altering the mediating factors, otherwise one runs the risk of drawing the wrong conclusions about the effect of the intervention. Thus, when treating non-specific neck pain, clinicians should not only treat the disability itself but also the factors mediating change in the outcome measure. It is also important to bear in mind the time span between the intervention and the hypothesised effect when evaluating the intervention. Many outcome studies have short follow-up times and commonly no statements are made about the expected timeframe for change. Instead it is implicitly stated in the study design with short follow-up time that the effect is immediate upon the start of intervention and will be maintained after that. In cases where the timeframe can not be theoretically derived it is wise to have a study design with repeated measures during several years of follow-up when evaluating the effectiveness of an intervention. In non-specific back pain, interventions targeted at behavioural change have been proven effective. Establishing and maintaining new behaviours takes time and if the effect on the targeted outcome is dependent on the maintenance of behavioural changes a long term follow-up is essential in determining the effectiveness of such an intervention. Interventions cost money. The costeeffectiveness of the treatment depends on how well the target as been defined so that the results can be assessed in relation to the targeted outcome. When applying interventions to symptoms such as non-specific back and neck pain, where multidisciplinary factors have been shown to influence onset and outcome, it can be tempting to ‘pull out the canons and shoot’. This can be done by either applying as many treatment modalities as possible, or by measuring the effect using as many outcome measures as possible, or both. But the costeeffectiveness can be seriously violated when applying this method, with devastating consequences for patients. The possibilities for comparing interventions will be facilitated if the purpose of the intervention is stated more clearly than is commonly done today and, furthermore, if the outcome parameters are selected in accordance with that purpose. In addition, subgroups suitable for the targeted intervention need to be identified. Any health condition affects an individual in a variety of ways, each of which may need a different approach to prevention and management. The patient expects the caregiver to ‘make him well’ and by that every single patient can mean a variety of things and expect it to happen within a very short timeframe. In this chapter, when summarising the evidence for interventions for non-specific neck pain, modified groups of the key outcomes used in Chapter 5 (Non-specific low back pain) and based on the concepts of the World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) have been used. Disability and generic health measures are included in ‘Symptoms’, which is not in accordance with other chapters where they are included in ‘Activity and participation’. This modification serves the purpose of clearly separating the results from interventions that have been evaluated in terms of symptom reduction from those evaluating maintainance of/return to work. The outcome measures used are: For symptoms: Pain, disability, generic health For tissue damage: The definition of non-specific neck pain excludes the presence of tissue damage of relevance to the problem. Activity and participation: Sick leave, disability pension, return to work, work ability.
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WHAT CAN BE DONE: THE EVIDENCE FOR DIFFERENT INTERVENTIONS In everyday practice a variety of interventions are used when treating neck pain. Upon reviewing the literature, it was evident that high quality research concerning outcome studies on the effects of interventions applied to non-specific neck pain is sparse. Several systematic reviews have been conducted investigating the evidence for different types of interventions. In this summary of evidence we will present results from existing systematic reviews. The purpose with this summary is to provide an upto-date tool for clinicians in their treatment strategy decision-making. Procedure We performed searches in two high quality libraries for systematic reviews e The Cochrane library and The Centre for Reviews and Dissemination DARE library e and in MEDLINE. The search terms used were: neck pain, neck strain, neck sprain, mechanical neck disorders, whiplash and systematic reviews published 2000e2005. All systematic reviews (1) using at least two independent reviewers, (2) having a specified search procedure and (3) having predefined quality assessment criteria, were included. In total, 17 systematic reviews of relevance were identified. All of these reviews were then appraised for evidence. Appraising the evidence The evidence presented in the reviews is summarised below. We apply the same grading system as in the European Action Towards Better Musculoskeletal Health report10 shown in Table 2. Since grading of the strength of the evidence can vary between different systematic reviews the grading system reveals the type of source indicating that the meta-analytic approach of RCTs is superior. Therefore, the evidence of effect presented includes evidence from limited to strong. When results from reviews were contradictory the evidence was interpreted as being inconsistent if the conclusions were based on the same studies. If one review was conducted several years later and included more evidence, then the results were interpreted in accordance with the updated review. Summary of evidence In the tables below, ‘symptoms’ includes measures of pain, disability and generic health. ‘Activity and participation’ includes measures of sick leave, disability pension and return to work. Lifestyle interventions Table 3 summarises the level of evidence from selected and appraised systematic reviews for lifestyle interventions on the target outcomes. Two systematic reviews were identified that investigated interventions for preventing neck pain. Moderate evidence was found for exercise in the prevention of neck pain. Further results show that fitness training at the work place was effective in
98 I. Jensen and K. Harms-Ringdahl
Table 2. The grading of evidence. Grading of evidence Categories of evidence Ia Ib IIa IIb III
# IE
Evidence from meta-analysis of randomised controlled trials Evidence from at least one randomised controlled trial Evidence from at least one controlled study without randomisation Evidence from at least one other type of quasi-experimental study Evidence from descriptive studies, i.e. comparative studies, correlation studies and caseecontrol studies Evidence from expert committee reports or opinion, or clinical experience of a respected authority or both Inconsistent findings Inadequate evidence from which to make a grading
The nature of effect þ 0
Positive effect Evidence of no effect Negative effect
IV
Source: European Action Towards Better Musculoskeletal Health report.10
reducing the prevalence of neck and back pain. Other reviews did not find any conclusive evidence regarding fitness training for acute and chronic neck pain. However, more specific types of exercises have been shown to be effective (see below Table 5). In the reviews, authors have pointed out the lack of consistency in defining the different types of exercise interventions. Contrary to back pain, where evidence shows that education is effective in increasing function and activity, the evidence for neck pain and education programmes is inconclusive. Pharmacological interventions Table 4 summarises the level of evidence from selected and appraised systematic reviews for pharmacological interventions on the target outcomes. Table 3. Summary of evidence for lifestyle interventions. Lifestyle interventions
Aims of intervention Symptom
Fitness training At risk populations Acute Chronic Education programmes At risk populations Acute Chronic 1,12e15
Sources. For gradings, see Table 1.
Iaþ
IE
Activity and participation
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Table 4. Summary of evidence for pharmacological interventions. Pharmacological interventions
Aims of intervention Symptom
Oral psychotropic agents Acute Chronic
Ia# Ia#
NSAIDs Acute Chronic
Ia0 Ia0
Intra-muscular injections of multivitamins Acute Chronic
IE
Melatonin Acute Chronic
Ia0
Local treatment with anaesthetic Acute Chronic
Iaþ
Treatment with epidural steroids Acute Chronic
Ia#
Local treatment with Botulinum Acute Chronic
Ia0
Subcutaneous injections Acute Chronic
Ia0
Intravenous glucocorticoid Acute Chronic
Iaþ
Activity and participation
Ia#
Iaþ
Sources.1,16e18 For gradings, see Table 1. NSAIDs, non-steroidal anti-inflammatory drugs; WAD, whiplash-associated disorder.
Most of the investigated pharmacological treatments either lack effect or have inconsistent findings in meta-analyses of RCTs (level Ia). Intra-muscular injection of lidocaine provides short-term effects on pain in chronic neck pain. Intravenous methylprednisolone and lidocaine is effective in reducing pain in short term and in reducing long term sick both leave for acute whiplash-associated disorder (WAD). Surgical intervention There is insufficient evidence of effectiveness for surgical interventions for non-specific neck pain to make recommendations since the long-term effects are unclear.
100 I. Jensen and K. Harms-Ringdahl
Table 5. Summary of evidence for rehabilitative interventions. Rehabilitative interventions
Aims of intervention Symptom
Cold spray Acute Chronic
IE
Laser (LLLT) Acute Chronic
Ibþ Ibþ
Pulse electromagnetic treatment (PEMS ) Acute Chronic
Ibþ Ibþ
Radiofrequency denervation Acute Chronic
Ibþ
Transcutaneous electric nerve stimulation (TENS) Acute Ia# Chronic Ia# Electric muscle stimulation (EMS ) Acute Chronic
Ib0
Acupuncture Acute Chronic
IE Ib0
Traction Acute Chronic
IE Ib0
Mobilisation Acute Chronic
Ia0 Ia0
Manipulation Acute Chronic
Ia0 Ia0
Neck collar Acute Chronic
Ia0 Ia0
ROM exercise Acute Chronic
Iaþ IE
Strengthening exercise Acute Chronic
Iaþ
Proprioceptive exercise Acute Chronic
Iaþ
Activity and participation
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Table 5 (continued ) Rehabilitative interventions
Aims of intervention Symptom
Individualised instructions for home exercise Acute Chronic
Iaþ Iaþ
Multimodal intervention combining physical agents Acute Chronic
Iaþ Iaþ
Multimodal intervention combining physical agents and CBT Acute Chronic
Ibþ
Activity and participation
Ibþ
Sources.1,12,15,19e30 For grading, see Table 1. LLLT, low level laser therapy; ROM, region of movement; CBT, cognitive behavioural therapy.
Rehabilitative interventions Table 5 summarises the level of evidence from selected and appraised systematic reviews for rehabilitative interventions on the target outcomes. Differences in evidence are revealed when comparing acute and chronic neck pain. The strongest evidence (level Ia) is evident for region of movement (ROM)-exercises in reducing pain in acute neck pain in the short term and for multimodal interventions combining physical agents in reducing pain and improving functioning in both acute and chronic neck pain. Furthermore, for chronic neck pain the strongest evidence (level Ia) is evident for all types of exercise except ROM exercise. This summary of evidence shows that for acute and chronic neck pain low level laser therapy (LLLT) is effective in reducing pain (level Ib). Pulse electromagnetic treatment (PEMS) is effective in reducing pain in the short term only in acute WAD and in chronic non-specific neck pain. Radiofrequency denervation is effective in reducing pain in chronic neck pain. Individualised instruction for home exercise is effective in reducing pain and increasing patient satisfaction compared to written information alone in both acute and chronic neck pain. Multimodal interventions with cognitive behavioural intervention are effective for sub-acute WAD in reducing symptoms in the short term and sick leave in the long term. Manual therapy (traction, manipulation and mobilisation) has no evidenced effect. However, although not effective alone, evidence shows that combining manual therapy techniques and exercise therapy in a multimodal intervention is effective, even though it is not possible from the evidence to draw conclusions on how much the manual therapy contributes when compared to exercise alone. Description of the interventions Fitness training: includes physical fitness exercises for flexibility, aerobics, co-ordination, muscular strength and endurance. Examples are endurance training such as running, swimming, cycling or aerobic training.
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Education programmes: in the form of ‘back schools’ that aim to provide education about neck pain with the purpose of increasing coping ability. Oral psychotropic agents: cyclobenzaprine, diazepam, tetrazepam and others aim to reduce muscle spasm and, thereby, pain. Non-steroidal anti-inflammatory drugs (NSAIDs): oral anti-inflammatory and analgesic medication. Intra-muscular injections of multivitamins: injection of the multivitamin ‘Neurotrat’. Melatonin: oral medication aiming to improve sleep and reduce pain. Local treatment with anaesthetic: intra-muscular injections of lidocaine. Local treatment with epidural steroids: epidural injections with methylprednisolone and lidocaine. Local treatment with Botulinum toxin: intra-muscular injections of Botox A. Subcutaneous injections: injections of carbon dioxide, aiming to reduce pain by vasodilatation. Intravenous glucocorticoid: methylprednisolone and lidocaine. Cold spray: aims to decrease nerve conduction velocity. Low level laser therapy (LLLT ): aims to reduce pain by applying light with a less than 0.5 C increase in temperature on the exposed tissue. The international standard classes IeIIIb are included in this evaluation. Pulse electromagnetic treatment (PEMS ): induces electric current within the tissue and aims to enhance bone and tissue healing. Radiofrequency denervation: aims to de-activate the nerve responsible by applying electric current in to the disc to cauterise the nerve with the purpose of pain relief. Transcutaneous electric nerve stimulation (TENS ): electrical impulses are applied through rubber plates on the skin over nerves and muscles using an apparatus where currency and frequency can be adjusted. Can be used for 20e30 minutes daily in order to stimulate endorphin production and reduce pain.10 Electric muscle stimulation (EMS ): most characteristics are comparable to those of TENS. Acupuncture: very thin needles are applied for 25e30 minutes at a defined depth in specific acupuncture points in order to produce impulses that will stimulate endorphin production and reduce pain. Sometimes electrical impulses are applied through the needles in order to increase the effect.10 Traction: the spine is pulled in a longitudinal direction, sometimes with a component of lateral rotation, with the aim of increasing nerve root space and mobility.10 Mobilisation: mobilising techniques, provided by a therapist specialised in manual therapy (chiropractor, osteopath, naprapath, physiotherapist, physician), use a precise, directed force or thrust and aim to increase mobility between specified vertebrae and their muscles within their physiological motion range.10 Manipulation: As for mobilisation (see above), but with a short thrust applied very fast and distinctly. Neck collar: a soft collar is applied around the neck with the aim of supporting the neck and serving as a reminder not to perform excessive movements. Range of motion (ROM ) exercises: training aimed at increasing joint range of motion. Movements are guided in specific directions depending on the symptoms of the patient, e.g. Mckenzie-exercises.10 Strengthening exercises: aim to increase muscle performance such as muscle activation, endurance and strength.10 Proprioceptive exercises: neck exercises aiming to improve proprioceptive sense. Proprioceptive sense refers to the sensory input and feedback that tells us about movement and body position.
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Multimodal intervention combining physical agents: a comprehensive, multi-professional programme with a combination of treatment modalities, education, strengthening exercises and fitness training. Usually the programme is conducted during full or half days for at least 4 weeks. Multimodal intervention combining physical agents and cognitive behavioural therapy (CBT ): a comprehensive, multi-professional programme with a combination of treatment modalities, education, strengthening exercises and cognitive behavioural treatment. Usually the programme is conducted during full or half days for at least 4 weeks sometimes combined with work-related measures.10 Effects on key outcomes Table 6 provides a summary of those interventions that have evidence for a positive effect on the key target outcomes. Adverse events Negative side effects of treatments are rarely reported in studies. In systematic reviews, the authors commonly state that nothing on adverse effects has been reported in the majority of studies. This could be due to reporting bias or it could be a true statement that no side effects are evident. In the reviews appraised in this chapter, 50% did not address adverse effects. When addressed, those reviews reporting adverse effects recorded that a range of 0e71% with a mean of 33% of the reviewed studies reported on this. Authors of the reviews mainly concluded that adverse effects are reported but the evidence is too scarce to allow for estimation of risks. Cost and effectiveness In this summary no aspects of cost or effectiveness have been taken into consideration. The research concerning this is still in its infancy. None of the systematic reviews were able to make statements about cost and effectiveness. Cost and effectiveness can be evaluated using different approaches mainly depending on what outcome parameters are used. In costeeffectiveness and costebenefit analyses, comparisons between treatments can be made using the same outcome parameters and/or by measuring the monetary values.31 Very few studies have used parameters that can be evaluated in monetary terms, e.g. sick leave or return to work. One systematic review was identified that evaluated the costeeffectiveness of multimodal interventions, but no conclusions could be made due to lack of evidence.32 In one RCT study from Sweden evaluating the different components in multidisciplinary interventions for non-specific back and neck pain, it was shown that a full-time multidisciplinary intervention programme combining exercise therapy and CBT was costeeffective for women when compared with a no treatment control group.33 Over 3 years the sum of about V138 000 per treated female was gained, based on a calculation of production losses.33 In a costeutility analysis RCT study of manipulation, comparing standard care to spinal manipulation from a general practitioner (GP) who was a registered osteopath34, the results revealed slightly improved effects on health-related quality of life for the osteopathic alternative but at a higher cost. Similar results were presented in a Finnish RCT study comparing the same types of interventions.35
104 I. Jensen and K. Harms-Ringdahl
Table 6. Interventions with evidence of positive effects on key outcomes. Key outcomes
Interventions
Symptoms
Acute/sub acute
Chronic
Pain
Low level laser therapy (LLLT) Transcutaneous electric nerve stimulation (TENS) Individualised instruction for home exercise ROM-exercises Multimodal interventions combining physical agents Pulse electromagnetic treatment (PEMS)a Multimodal intervention including CBTa Intravenous injections with Methylprednisol and lidocainea
Low level laser therapy (LLLT) Transcutaneous electric nerve stimulation (TENS) Pulse electromagnetic treatment (PEMS) Radiofrequency denervation Individualised instruction for home exercise Strengthening exercise Proprioceptive exercises Multimodal interventions combining physical agents Intra-muscular injections of lidocainea Proprioceptive exercises Strengthening exercises Multimodal interventions combining physical agents
Disability (self reported measures)
Multimodal interventions combining physical agents
Physical functioning (objective measures e.g. ROM) Psychosocial functioning (e.g. depression, social participation) Global perceived effect (e.g. generic health)
Multimodal interventions combining physical agents
Proprioceptive exercises Strengthening exercises Multimodal interventions combining physical agents
Multimodal intervention including CBTa Intravenous injections with methylprednisol and lidocainea
Proprioceptive exercises
Activity and participation Maintaining work (i.e. sick leave, disability pension, work ability)
a
Evidence for whiplash associated disorders (WAD) only.
How to identify those who will benefit most from intervention? Non-specific neck pain conditions are commonly conditions of a multidimensional nature. Since we do not fully understand the causal relationships between occurrence, reoccurrence and pain maintenance, interventions that focus on the mediators mentioned above seem to be important for development and/or progression and long term outcome. That means that we need to be able to identify those with a specific condition,
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for which proper treatment is available, without discourage the remainder by telling them that we do not know why this painful condition has occurred. A proper investigation addressing ‘red’ and ‘yellow’ flags constitutes an important basis for this. Fear avoidance beliefs, catastrophising, self-efficacy and beliefs about the future situation are all thoughts that both care-seekers and care-providers may have in mind, sometimes shared with each other and sometimes not, and all of which seem to influence outcome.6,11 Maintaining physical activity despite acute or subacute back pain seems to shorten the length of the pain episode and it is reasonable to believe that this is also the case for episodes of neck pain. On a background of public awareness, healthcare professionals should be good informants of the importance of physical activities and should guide patients on how to achieve this, despite pain episodes. Furthermore, healthcare providers should be careful with advice that restricts a patient’s activities and participation. The only restriction given should be to avoid bed rest. It seems likely that workplace improvements reducing risk factors for the development of neck pain would result in a healthier working population. However, good-quality evidence on the effectiveness of risk factor modification on neck pain is lacking.36 Despite considerable research on return to work (RTW), there has been little change in overall rates of work disability in developed countries. In a recent review, 30 RTW researchers, representing over 20 institutions, reviewed the current state of the art in RTW research and identified promising areas for further development and future investigations.37 Six priority areas were identified: (1) early risk prediction; (2) psychosocial, behavioural and cognitive interventions; (3) physical treatments; (4) implementing evidence in the workplace context; (5) effective methods for engaging multiple stakeholders; and (6) identification of outcomes that are relevant to both RTW stakeholders and different phases of the RTW process. What strategies (care pathways) should be used for prevention and treatment based on this evidence? Since people with neck pain are frequent visitors to primary health care centres, hospitals, paramedical institutions (e.g. for physiotherapy and chiropractice) and occupational health care centres, strategies must be developed to reach these care providers with Clinical Guidelines. However, little research has been done on the implementation and dissemination of evidence-based methods (EBM) of care.38 Accordingly evidence for strategies that effectively enhance compliance and thus change clinical practice is lacking. Recent research on the effects of EBM on clinical practice shows that although the knowledge is acquired, the clinical practice is not equally effective when measured in terms of behavioural change.39 From the evidence summarised in this chapter it is clear that there is also a shift in the responsibility for the health of the individual from the care provider to the patient. To be physically active at a moderate level for at least 30 minutes per day as part of ordinary life and to modify work postures, movements and organisation, requires much more effort than does passive treatment and taking a pill. More research is needed on how to coach patients to have a healthy lifestyle without violating the integrity of that patient. At an occupational and societal level, strategies are needed to provide possibilities for closer collaboration between care providers and workplaces, including school health care and teachers, in order to enhance physical activities.
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Practice points Based on the existing evidence, the following is recommended for the targeted groups: Risk population: since non-specific neck pain is a common condition, the risk population should be considered to be the whole population. It is recommended that measures be taken to enhance physical activity in the population. The degree of exercise is not clear, but based on the evidence, physical activity should take place regularly several times a week. Acute and sub-acute conditions: it is recommended that people with this condition should exercise regularly. Specific range of motion (ROM) exercise is beneficial. The degree of exercise is not clear but based on the physical activity should take place regularly several times a week. Individually tailored information about exercise should be given. A supplement for short term symptom reduction is to use transcutaneous electric nerve stimulation (TENS) or low level laser treatment (LLLT). For acute whiplash-associated disorder(WAD) only: it is recommended that intravenous glucocorticoid and pulse electromagnetic treatment (PEMS) be used. It is further recommended that multimodal intervention including non-excessive ROM exercise and cognitive behavioural therapy be used for sub-acute WAD. Chronic conditions: for comprehensive treatment results, exercise and multimodal intervention is effective. Individually tailored information about exercise should be given. For pain reduction there are some effective alternatives to exercise and it is recommended that people with this condition can be treated with TENS, LLLT, PEMS or radiofrequency denervation. For chronic WAD only: intra-muscular injections of lidocaine can be used.
Research agenda In order to establish safe and effective treatments more research should be devoted to the following: evaluating the common interventions used in everyday clinical practice including alternative and complementary medicine for non-specific neck pain researchers should be more aware of the importance of reporting adverse effects to facilitate the costeeffective use of resources, efforts should be made to invest in high quality studies on costeeffectiveness/utility.
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