Bone and Joint Decade task force issues new report on neck pain

The group saw no evidence supporting a correlation between degenerative changes and pain in patients without serious pathology.

The latest findings from the Bone and Joint Decade's Task Force on Neck Pain and Its Associated Disorders shed new light on neck pain and whiplash-associated disorder onset, suggesting that there may be more factors that contribute to pain than what was once believed.

The group also recommends a new classification system for neck pain.

In a review of more than 1,200 scientific papers from throughout the world, the task force found a 1-year prevalence of neck pain of between 12.1% and 71.5% for the general population. However, only 1.7% to 11.5% will have disabling neck pain, the group wrote.

Task force members also identified several risk factors for neck pain, including increased age, smoking and gender.

"Motor vehicle crashes, trauma and certain work-related conditions may precipitate and be a risk factor for neck pain," task force member Scott Haldeman, MD, PhD, DC, told Orthopedics Today. "[But] although many activities or events may trigger neck pain, it does not appear that workers or people who have been in car crashes have a substantially higher risk for long-term neck pain than the general population."

The research also revealed that neck pain often does not resolve, or it can reoccur, Haldeman noted.

"About 30% to 60% of the people who complain of neck pain will continue to have neck pain a year or two later, and the likelihood of ongoing neck pain is not markedly different if it was precipitated by work factors or just came on without an obvious precipitating event," he said.

Seeking validity

In patients without serious pathology, the group found that many common diagnostic tests lacked validity.

"There does not appear to be a good correlation between the presence or degree of degenerative changes and the presence or severity of neck pain," Haldeman said. "A black disc, disc protrusion or degenerative changes do not appear to give information on the cause of neck pain. It's convenient to make the association between findings on imaging and neck pain, but unfortunately the evidence for this association does not exist."

The group discovered some evidence supporting less-expensive therapies such as mobilization, exercises and education, but found little evidence for intra-articular injections and radiofrequency neurotomy.

"There is no treatment approach that has a large impact on neck pain," Haldeman said. "There are a number of treatments that appear to be useful, but the interesting thing is that none of them stand out as being so much better than the other effective treatments."

Early research indicates that prolonged treatment, especially if ineffective, can prolong disability. "Ongoing treatment that does not give relief is probably detrimental," he said.

The research also revealed an increase incidence in whiplash-associated disorders in the past 30 years. Moreover, nearly 50% of people who have neck pain after a car crash will continue to experience neck pain about a year later.

"If you have legal involvement, then you're more likely to have a prolonged period of disability, and that does not appear to relate to the amount of pain that you have at the time of injury," Haldeman said. "Litigation is a risk factor for prolonging the period of disability."

Pain grades

The task force also advocated use of a new classification system for neck pain based on the following grades:

Grade I for patients with neck pain without serious pathology and which does not interfere with activities;
Grade II for those with pain without serious pathology that interferes with activities of daily living;
Grade III for patients with radiculopathy; and,
Grade IV for patients with serious structural pathology and red flags for disorders such as infection, fracture, tumor or myelopathy.

Grade I patients may find relief in minimal interventions. Patients with Grade II pain are likely to benefit from one or more of the effective nonsurgical interventions. Grade III patients may expect short-term relief following epidural injections and often respond to surgical intervention, while Grade IV cases need immediate investigation and appropriate treatment, the task force wrote.

Given the findings, clinicians should inform patients who do not have major pathology that there is no "magic bullet" for their pain, and inform them about various treatment options.

"The end point is that as physicians and clinicians, we have to be very careful what claims we make, what we tell patients and what we personally believe. Many of our beliefs are not upheld by the science," Haldeman said.

"I think that as clinicians, we have to be more informed and we have to be more critical of our own thinking."

For more information:
Scott Haldeman, MD, PhD, DC, is a neurologist. He can be reached at the University of California-Irvine, 801 N. Tustin Ave., Suite 202, Santa Ana, CA 92705, U.S.A.; e-mail: haldemanmd@aol.com.
Haldeman SDC, Carroll L, Cassidy DJ, et al. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive summary. Spine. 2008;33(4S):S5-S7.