The epidemiology of neck pain: what we have learned from our population-based studies
From: JCCA 2003; 47(4):284–290
Background: There are few population-based studies on the epidemiology of neck pain in the general population. Since the mid 1980’s, we have witnessed a slow, but constant
increase in the amount of attention paid to the problem of neck pain in the general population. The growing interest in neck pain is mainly linked to the escalating disability burden and compensation costs associated with neck pain related to automobile collisions and occupational injuries. As a result, epidemiologists started to investigate the magnitude, causes and prognosis of neck pain in the population.
Purpose: To synthesize the findings of two large population-based studies of the epidemiology of neck pain and whiplash.
Study Design and Methods: We conducted two population-based cohort studies of neck pain and its related disability. First, the Saskatchewan Health and Back Pain Survey was designed to determine the prevalence and factors associated with neck pain in randomly selected adults. Second, we conducted a cohort study of the incidence and prognosis of whiplash and studied whether a change in the insurance system from tort to no-fault was related to a reduction in the number of whiplash claims and faster recovery.
Results: In 1995, the six-month prevalence of neck pain was 54.2% and 4.6% of adults experienced disabling neck pain in the previous six-months. Neck pain was associated with education, comorbidities, smoking, self-reported general health and a history of neck injury in a motor vehicle collision. The incidence of treated and/or compensated whiplash injury was reestimated at 834/100,000 adults in 1994, and dropped by 28% to 98/100,000 adults in 1995, after tort reform. Compared to tort, the median time-to-recovery was more than 230 days faster under no-fault. The strongest predictors of recovery were age, gender, education, injury severity, lawyer involvement and type of initial care provider.
Conclusion: Neck pain is a public health problem. The incidence and prognosis of whiplash injuries are greatly influenced by compensation for pain and suffering, legal factors, injury severity and sociodemographic characteristics. Overall, neck pain is a multifaceted disabling problem that deserves more attention. When treating patients with neck pain,
clinicians need to recognize that it is more than a physical problem and that its prognosis is influenced by broader determinants of health.
Our specific objectives are: 1) to present the prevalence and factors associated with neck pain and its related disability and 2) to present the incidence and prognosis for whiplash under two different insurance systems.
We measured the point, six-month and lifetime prevalence of neck pain. Neck pain was defined as pain located between the occiput and the third thoracic vertebra. The six month prevalence of neck pain was classified by grades of severity according to the Chronic Pain Questionnaire. The questionnaire provides five ordered grades derived
from the severity of pain and disability reported by a subject Grade I corresponds to mild, non-disabling pain. Grade II refers to high intensity pain that does not limit activities. Grades III-IV refers to disabling neck pain.
Overall, 66.7% of the subjects reported that they had experienced neck pain during their
lifetime and 22.2% suffered from neck pain on the day of the survey.9 Moreover, 54.2%
of the sample experienced neck pain in the six months before the survey. The majority of
subjects (39.7%) had suffered from mild (Grade I) neck pain, and 10.1% of the sample had suffered from intense (Grade II) neck pain during the previous six months. More importantly, disabling (Grades III–IV) neck pain affected 4.6% of the study sample in the previous six months. Finally, the six-month prevalence of mild neck pain gradually decreased from the 20–29 year-old age group to the 60–69 group. The prevalence of intense and disabling neck pain did not significantly vary with age. All grades of neck pain were more common in women (58.8%) than men (47.2%). These figures suggest that while neck pain is very common in the population, most is mild in nature and does not interfere with activities of daily living.
Our analysis showed that Grades II, III and IV neck pain were independently and strongly associated with depressive symptomatology suggesting that those who suffer from disabling pain are more likely to also suffer from clinical or sub-clinical depression. Furthermore, we found that increasing severity of pain and disability was positively associated with greater use of passive coping strategies. In other words, subjects who reported Grade III-IV neck pain were more likely to cope passively with their pain. We did not find independent associations between neck pain and active coping. Therefore, encouraging patients to limit the use of passive coping strategies may be helpful when managing disabling neck pain.
We studied early predictors for recovery separately under the tort and no-fault systems of insurance. Under both systems, older age, higher neck pain intensity, greater percentage of the body in pain, lawyer involvement and initial health-care provision by chiropractors or combinations of chiropractors, physical therapists and physicians were detrimental for recovery. In addition, not being at fault for the collision (i.e., being a victim) slowed recovery under the tort system only, since fault is not an issue in a no-fault plan. Also, the presence of reduced or painful jaw movement and concentration problems slowed recovery for tort claimants. Overall, pain intensity and spread was more
important in delaying recovery under tort, and this might be explained by the benefits paid for pain and suffering under tort laws. No-fault claimants with minor fractures,
memory problems and numbness or pain in the upper extremities also had a poor prognosis. These findings indicate that recovery is determined by a range of factors,
some of which are related to the insurance system.
So, what have we learned about the epidemiology of neck pain from our population based studies? Obviously, what is often viewed as a simple clinical problem can rapidly develop into a complex disorder where physical, psychological, compensation, legal and other
societal forces all interact to cause disability. Although complex, the prevention of chronic neck pain and its related disability could be accomplished by designing clinical,
legal and insurance policies that address the various factors that impact on its development. For these policies to be successful, clinicians, researchers and policy makers need to consider the broader causes of disability, rather than focus only on the clinical and individual issues.
