_________________________________________________________________________ Neck Pain in Adults
Higher body mass index increases risk of chronic neck and shoulder pain. Obese persons may be predisposed to neck pain due to systemic inflammation, deleterious structural changes, increased mechanical stress, diminished muscle strength, greater number of psychosocial factors, and greater kinesiophobia-related disability [2; 12]. Treatments used in low back pain are considered applicable to neck pain. The presumptive similarity is generally true, but features of cervical anatomy and physiology make some neck pain conditions distinct from those of other spinal locations. WAD and some collision-related sports injuries (e.g., related to American football, rugby) are unique risk factors for neck pain [2; 9]. In one study, risk of cervical spine injury was evaluated in roller-coaster riders [13]. In 656 neck and back injuries during roller-coaster riding, 72% considered significant were cervical disk injuries. Lumbar spine injuries also included disk herniation or vertebral compression fracture. Passenger testing showed that peak g-force for vertical or axial acceleration (4.5–5.0) and lateral acceleration (1.5) both occurred within 1/10 second (100 ms). The authors concluded a minimum threshold of significant spine injury is not established. Individual susceptibility largely explains the injuries from traumatic loading [13]. PERSONAL AND SOCIETAL IMPACT As noted, neck pain is the fourth leading cause of disability in the United States (behind low back pain, depression, and arthritic disorders), and in some industries, it accounts for as much time off work as low back pain [1; 2; 14]. In many patients, neck pain becomes chronic, with life-impairing symptoms that severely decrease quality of life and restrict work productivity and daily activities [8]. However, neck pain has received a fraction of the research funding and attention directed to back pain. This reflects a wider underappreciation of its negative physical and psychological impact, and of the associated high economic burden from medical visits, physiotherapy, pharmacologic and surgical treatments, lost work days, and compensation expenditure [2; 4]. SPECIFIC NECK PAIN CONDITIONS Whiplash Injury and Whiplash-Associated Disorders WADs result from rapid acceleration/deceleration, typically involving rear-end or side-impact motor vehicle collisions, and represent 75% of all survivable motor vehicle collision injuries [15]. WAD can also occur from falls, diving, or collisions in contact sports. The “limit of harmlessness” with rear-end collision is 5 to 10 miles per hour (MPH); many whiplash injuries involve rear-end motor vehicle collision at speeds of 14 MPH or less [16; 17; 18; 19]. WAD is associated with significant economic costs from lost work productivity, medical care, legal services, and other disability-related expenses, mostly incurred by patients with chronic symptoms [20].
INTRODUCTION Acute neck pain can be minor and self-limiting or develop into chronic pain that adversely affects quality of life. Neck pain is the fourth leading cause of disability in the United States, but its negative physical, psychological, and socioeconomic impact on patients continues to be underappreciated [1; 2]. Primary care clinicians may find neck pain practice guidelines confusing, because recommended approaches are shaped by the training and specialty of guideline authors. This reflects the broader problem of failing to recognize pain medicine as a medical specialty, which has historically fragmented research and practice guidance and made standards of care elusive [3]. With pharmacotherapy studies in neck pain lacking, the focus of neck pain guidelines is nonpharmacologic treatment [4]. A subset of patients experience significant pain relief when structural tissue pathology is identified and treated. However, cervical spine pathology (e.g., disk bulges, degenerative changes) is common in asymptomatic persons, and the longstanding treatment focus on tissue pathology has contributed to poor pain outcomes in these patients. The diverse pain mechanisms produced by specific pathologies are suggested as a treatment focus in chronic neck pain. By combining the best available evidence from diverse sources, this course can greatly assist healthcare providers in optimizing the care of patients with acute or chronic neck pain. EPIDEMIOLOGY Neck pain is very common in the general population, with an annual incidence of 10.4% to 21.3% and lifetime prevalence of 23%. Neck pain can occur repeatedly, and 50% of neck pain seen in primary care settings is in recurrent cases. More than 50% of the middle-aged population shows clinical or radiologic signs of cervical spine disease, which is often asymptomatic [5; 6; 7]. Neck pain encompasses a variety of associated disorders, including whiplash pain and associated disorders (WAD) and other non-traumatic, traumatic, and work-related neck pain [8]. Neck pain and associated disorders account for 10.2 million physician and hospital outpatient visits in the United States each year [8]. Neck pain prevalence is slightly higher in women in their fifth decade of life, and a higher incidence is found in office/computer workers, manual laborers, and healthcare workers. Chronic neck pain is associated with psychological factors (e.g., anxiety, poor coping skills, somatization), sleep disorders, smoking, sedentary lifestyle, and genetics [9; 10; 11]. Common neck pain comorbidities include headache, back pain, arthralgias, and depression [2; 9].
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