ALLAN BINDER, M.D., Lister Hospital, Stevenage, United Kingdom
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The evidence is available at http://www.clinicalevidence.com/ceweb/conditions/msd/1103/1103.jsp.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Klara Brunnhuber (email@example.com). The complete text for this topic also is available in HTML and PDF format. This series is part of the AFP’s CME. See «Clinical Quiz on page 31.
What are the effects of treatments for uncomplicated neck pain without severe neurologic deficit?
likely to be beneficial
Manual Treatments (Mobilization and Manipulation). Systematic reviews and randomized controlled trials (RCTs) found limited evidence that manipulation or mobilization improved symptoms compared with other or no treatment in people with neck pain.
Physical Treatments (Active Physiotherapy, Exercise, Pulsed Electromagnetic Field Treatment). Systematic reviews and RCTs have found that active physiotherapy reduces pain compared with passive treatment, and that exercise programs reduce pain compared with management that does not include exercise programs. One RCT provided limited evidence that pulsed electromagnetic field treatment reduced pain compared with sham treatment.
Drug Treatments (Analgesics, Nonsteroidal Anti-inflammatory Drugs [NSAIDs], Antidepressants, or Muscle Relaxants). We found insufficient evidence on the effects of analgesics, NSAIDs, antidepressants, or muscle relaxants for neck pain, although they are widely used. Several drugs used to treat neck pain are associated with well-documented adverse effects.
Multidisciplinary (Multimodal) Treatment. RCTs provided insufficient evidence to compare effects of multimodal treatments with other treatment in people with uncomplicated pain.
Physical Treatments (Heat or Cold, Traction, Biofeedback, Spray and Stretch, Acupuncture, Laser). Systematic reviews found insufficient evidence about the effects of these physical treatments.
Soft Collars and Special Pillows. We found no RCTs of sufficient quality on the effects of soft collars or special pillows.
unlikely to be beneficial
Patient Education. Three RCTs found no significant difference between patient education (advice or group instruction) with or without analgesics compared with no treatment, stress management, placebo, or usual care.
What are the effects of treatments for acute whiplash injury?
likely to be beneficial
Early Mobilization. Systematic reviews and subsequent RCTs provided limited evidence that early mobilization reduced pain compared with immobilization or rest plus a collar.
Early Return to Normal Activity. Systematic reviews and subsequent RCTs provided limited evidence that advice to «act as usual plus anti-inflammatory drugs improved mild symptoms compared with immobilization plus 14 days of sick leave.
Electrotherapy. One small RCT provided limited evidence that electromagnetic field treatment reduced pain after four weeks but not after three months compared with sham treatment.
Multimodal Treatment. One RCT found that multimodal treatment reduced pain at the end of treatment and after six months compared with physical treatment.
Drug Treatments. We found no RCTs of drug treatments in acute whiplash injury.
Home Exercise Programs. One RCT found no significant difference between different home exercise programs in pain or disability.
What are the effects of treatments for chronic whiplash injury?
likely to be beneficial
Percutaneous Radiofrequency Neurotomy. One RCT provided limited evidence that percutaneous radiofrequency neurotomy reduced pain compared with sham treatment after 27 weeks.
Multimodal Treatment (Physiotherapy Plus Cognitive Behavior Treatment). One RCT found no significant difference between multimodal treatment (physiotherapy plus cognitive behavior treatment) in disability, pain, or range of movement at the end of treatment or at three months.
Physiotherapy. One RCT found no significant difference between physiotherapy alone and multimodal treatment (physiotherapy plus cognitive behavior treatment) in disability, pain, or range of movement at the end of treatment or at three months.
What are the effects of treatments for neck pain with radiculopathy?
Drug Treatments (Epidural Steroid Injections, Analgesics, NSAIDs, or Muscle Relaxants). We found no RCTs on the effects of epidural steroid injections, analgesics, NSAIDs, or muscle relaxants.
Surgery Versus Conservative Treatment. One RCT found no significant difference between surgery and conservative treatment in symptoms after one year.
In this topic, we have differentiated uncomplicated neck pain from whiplash, although many studies, particularly in people with chronic pain (duration more than three months), do not specify which types of people are included. Most studies of acute pain (duration less than three months) are confined to whiplash. We have included under radiculopathy those studies involving people with predominantly radicular symptoms arising in the cervical spine. Neck pain often occurs in combination with limited movement and poorly defined neurologic symptoms affecting the upper limbs. The pain can be severe and intractable, and can occur with radiculopathy or myelopathy.
About two thirds of people will experience neck pain at some time in their lives.1,2 Prevalence is highest in middle age. In the United Kingdom, about 15 percent of hospital-based physiotherapy, and in Canada 30 percent of chiropractic referrals are for neck pain.3,4 In the Netherlands, neck pain contributes up to 2 percent of general practitioner consultations.5
Most uncomplicated neck pain is associated with poor posture, anxiety and depression, neck strain, occupational injuries, or sporting injuries. With chronic pain, mechanical and degenerative factors (often referred to as cervical spondylosis) are more likely. Some neck pain results from soft tissue trauma, most typically seen in whiplash injuries. Rarely, disc prolapse and inflammatory, infective, or malignant conditions affect the cervical spine and present as neck pain with or without neurologic features.
Neck pain usually resolves within days or weeks but can recur or become chronic. In some industries, neck-related disorders account for as much time off work as low back pain.6 The percentage of people in whom neck pain becomes chronic depends on the cause but is thought to be about 10 percent,1 similar to low back pain. Neck pain causes severe disability in 5 percent of affected people.2
Whiplash. Whiplash injuries were more likely to cause disability than neck pain from other causes; up to 40 percent of sufferers reported symptoms even after 15 years of follow-up.7 Factors associated with a poorer outcome after whiplash are not well defined.8 The incidence of chronic disability after whiplash varies among countries, although reasons for this variation are unclear.9
Clin Evid Concise 2004;11:1534-50.