Knowledge to Action: A Challenge for Neck Pain Treatment
From: J Orthop Sports Phys Ther. 2009 May;39(5):351-63
Neck pain causes significant impairment, second only to low back pain. In a recent best-evidence synthesis, the 12-month prevalence of neck pain varied from 30% to 50%, lifetime prevalence was approximately 70%, point prevalence was 22%, and the estimated incidence was 213 per 1000 person years. Sedentary lifestyles are contributing to the prevalence of neck pain. Occupational factors play a large role in the development of neck pain as one of the most frequent causes of long-term sickness absence. Some 25% of visits to chiropractors, 15% to hospital-based physiotherapists, 2% to family physicians, and 75% of musculoskeletal disease seen by rheumatologists relate to neck pain. Combined, low back pain and neck pain have cost an estimated $90 billion per year in the United States, a figure roughly equivalent to 1% of the 2004 gross domestic product. Given the burden of neck disorders for society and individuals, it is important to maximize effective strategies to treat and prevent neck pain. Equally important is for health providers to make evidence-based treatment decisions to optimize their delivery of care. There is a wide spectrum of treatments available to people with neck pain, not all of which are equally effective.
Systematic reviews can enhance incorporation into practice of the large volumes of information emerging from research on effectiveness and risks. But the authors believe that these reviews are most useful with simplified tools to facilitate translation of this knowledge into practice. They provide a “Neck Care Tool Kit” that gives a diagrammatic approach to prioritizing intervention. The evidence from a series of 11 systematic reviews by the Cervical Overview Group is depicted in decision flow-charts and tables to enhance clinical interpretation of the overview findings. On simple visual inspection of symbols in a table, the reader can establish where there is evidence of benefit or no benefit, the strength of the recommendation, and if these data represent short or long term findings. Where possible, they guide clinicians to dosage of specific neck pain treatment methods. There is no consensus as to which outcome measures to prioritize among the large number in use. This clinical commentary guides clinicians to view the evidence in enough detail to integrate it into their clinical practice environment. They conclude by delineating research gaps and proposing future research directions for neck pain treatment.
Participants: Acute, subacute, or chronic neck pain with or without cervicogenic headache or radicular findings. The authors have used the following terms to categorize neck pain: (1) mechanical neck disorder to depict “non-specific” neck pain, (2) neck disorder with cervicogenic headache, (3) neck disorder with radicular signs and symptoms, (4) neck disorder associated with whiplash, (5) neck disorders associated with degenerative changes, and (6) neck disorders with associated myofascial pain.
They include studies using interventions consisting of manual therapy, medicinal and injection therapies, physical medicine methods, or patient education. They did not include trials addressing numerous complementary/alternative, herbal, and homeopathic therapies, or interventions that are principally psychology based.
Comparisons were: (1) Placebo (eg, mobilization versus mock/sham mobilization; mobilization versus another sham treatment [sham transcutaneous electrical nerve stimulation (TENS)]); (2) other treatment (eg, mobilization and ultrasound versus ultrasound), and (3) wait list or no treatment.
Exercise is a key component of most multimodal care programs. Direct strengthening and stabilization of the cervicothoracic region (postural muscles), including endurance training combined with neuromuscular re-education exercises and stretches, are a prominent feature for the treatment of chronic neck pain with or without cervicogenic headache. Active range-of-motion and stretching exercises are especially important for individuals with acute neck disorder associated with whiplash. For specific patient circumstances, approaches that are likely to be useful may include proprioceptive/vertigo exercises, progressive goal attainment strategies to increase function, and adaptation of exercise programs to ergonomic features of work. There is evidence that unsupervised home programs are not beneficial for individuals with chronic mechanical neck disorder and neck disorder with radicular signs and symptoms. Although the optimal dosage for exercise could not be determined from the literature, it may well be higher than most practitioners suspect. One high-quality research trial assessed a dose of 3 sets of 20 repetitions for craniocervical flexion routines. For strength or endurance training, a similar dose conclusion appears rational. Findings such as these have guided us to create an evidence based exercise routine for individuals with subacute and chronic mechanical neck disorder (with or without cervicogenic headache and associated degenerative changes) and related dosage recommendations.
Intermittent cervical mechanical traction has been found to be useful for pain and the patient’s global perceived effect of treatment for individuals with chronic neck disorder (with or without radicular features) while continuous traction has not. Intermittent traction holds promise for the treatment of individuals with chronic neck disorder with associated radicular findings.
The article has an illustrated neck exercise guide and I highly recommend this to any clinician treating neck pain.
