Monday, November 1, 2010

Chronic Neck Pain Can Be Real “Pain in the Neck”

Neck PainPast research has reported that a third to half of all adults may suffer acute or chronic neck pain in any given year. Now, a new survey paints a rather dismal picture when it comes to chronic neck pain, with patients seeking care from multiple practitioners, over a long period of time, and often receiving numerous inadequate therapies.

Researchers at Duke University and the University of North Carolina — reporting in the upcoming November issue of Arthritis Care & Research — surveyed 5,357 North Carolina households, questioning respondents aged 21 or older about “chronic impairing neck pain” [Goode et al. 2010]. This was described as (1) neck pain and activity limitation nearly every day for the past 3 months, or (2) greater than 24 episodes of neck pain in the previous year with each episode limiting activity for a day or more. Cases of neck pain with concurrent low back pain were excluded.

This approach identified 141 cases of chronic, impairing neck pain for analysis and, weighted to the North Carolina population, it represented a 2.2% annual prevalence rate. Subjects with neck pain were typically middle-aged (mean age 49 years), female (56%), and non-Hispanic white (81%). On average and in rounded numbers, they had suffered disabling neck pain for nearly 7 years, consulted 5 different healthcare providers on 21 different occasions, received 16 treatments, and underwent 2 diagnostic tests. These included spinal radiographs (45% of subjects), magnetic resonance imaging (30%), and computed tomography scans (24%). In the year prior to the survey, those who were X-rayed had an average of 2 different sets taken, which the authors note to be inconsistent with clinical decision-making guidelines for diagnostic imaging in patients with such a long disease duration.

Subjects had received a wide variety of treatments — including electrotherapy stimulation (30%), corsets or braces (21%), massage (28%), ultrasound (27%), heat (57%) and cold (47%) — which all have unclear or little benefit based on current evidence reviews, according to the researchers. More than half of subjects in the study (56%) used over-the-counter medications (eg, NSAIDs), 32% received muscle relaxants, 29% reported being prescribed strong opioids (MS Contin, oxycodone), and 23% weak opioids (codeine, propoxyphene). Based on prior systematic reviews, the authors suggest that medical evidence for the effectiveness of medications in the treatment of chronic neck pain is quite limited.

COMMENTARY: The researchers propose that, among all persons suffering neck pain, symptoms do not completely resolve in roughly 50% to 80% of cases. In their study, which must be recognized as being potentially biased by the limited geographic scope, they believe that opioids and diagnostic testing were overused in treating chronic, debilitating neck pain. However, it must be recognized that this opinion may reflect a lack of current research evidence, and neck pain can be excruciating and/or signal a potentially deteriorating neurologic condition, justifying both careful diagnosis and strong analgesics at least on a short-term basis.

Unfortunately, this study does little to help determine what does work best for chronic neck pain. The authors note that clinicians may overlook more effective treatments for neck pain, such as therapeutic exercise. According to reviews cited in the study, evidence to support the effectiveness of therapeutic exercise in treating chronic neck pain is good, yet only about half of subjects in this study (53%) were prescribed such therapy. Of further interest, rehabilitation conditioning and acupuncture were reportedly used only about 3% and 4% of the time, respectively, and both have some evidence of efficacy for treating neck pain in the clinical literature.

Finally, an important limitation of this study was that it specifically targeted cases of chronic, debilitating neck pain without chronic, impairing low back pain, which the authors concede is a common comorbidity and an independent risk factor for neck pain. Still, it is disconcerting that patients with neck pain appeared to have such difficulty finding a practitioner and a treatment to help ameliorate their problem; potentially making such conditions a real “pain in the neck” from human suffering, disability, and economic impact perspectives.

REFERENCE: Goode AP, Freburger J, Carey T. Prevalence, Practice Patterns, and Evidence for Chronic Neck Pain. Arth Care Res. 2010(Nov); ahead of print [abstract here].