Prognosis of Acute Idiopathic Neck Pain is Poor: A Systematic Review and Meta-Analysis

doi:10.1016/j.apmr.2010.12.025

Archives of Physical Medicine and Rehabilitation

Volume 92, Issue 5, May 2011, Pages 824-829

Presented to the International Association for the Study of Pain World Pain Congress, September 2, 2010, Montreal, QC, Canada.

https://doi.org/10.1016/j.apmr.2010.12.025 Get rights and content

Abstract

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis.

Objective

To conduct a systematic review and meta-analysis on the prognosis of acute idiopathic neck pain and disability.

Data Sources

EMBASE, CINAHL, Medline, AMED, PEDro, and CENTRAL were searched from inception to July 2009, limited to human studies. Reference lists of relevant systematic reviews were searched by hand. Search terms included: neck pain, prognosis, inception, cohort, longitudinal, observational, or prospective study and randomized controlled trial.

Study Selection

Eligible studies were longitudinal cohort studies and randomized controlled trials with a no treatment or minimal treatment arm that recruited an inception cohort of acute idiopathic neck pain and reported pain or disability outcomes. Eligibility was determined by 2 authors independently. Seven of 20,085 references were included.

Data Extraction

Pain and disability data were extracted independently by 2 authors. Risk of bias was assessed independently by 2 authors.

Data Synthesis

Statistical pooling showed a weighted mean pain score (0–100) of 64 (95% confidence interval [CI], 61–67) at onset and 35 (95% CI, 32–38) at 6.5 weeks. At 12 months, neck pain severity remained high at 42 (95% CI, 39–45). Disability reduced from a pooled weighted mean score (0–100) at onset of 30 (95% CI, 28–32) to 17 (95% CI, 15–19) by 6.5 weeks, without further improvement at 12 months. Studies varied in length of follow-up, design, and sample size.

Conclusions

This review provides Level I evidence that the prognosis of acute idiopathic neck pain is worse than currently recognized. This evidence can guide primary care clinicians when providing prognostic information to patients. Further research to identify prognostic factors and long-term outcomes from inception cohorts would be valuable.

Section snippets

Data Sources and Searches

We conducted this systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were identified through searches of the following databases from their inception to July 2009: EMBASE, CINAHL, Medline, AMED, PEDro, and CENTRAL. Searches were limited to human studies. Key search terms used to identify the study population of interest were: neck pain, neck injury, neck muscles, cervical, or cervical vertebrae. Search terms used to

Results

The search retrieved 20,085 references, of which 6 studies, published in 7 articles, fulfilled our inclusion criteria (table 1).18, 19, 20, 21, 22, 23, 24 Two articles20, 22 reported the same participant population and were considered a single study. Three of the included studies used an inception cohort design, following the course of acute neck pain in participants recruited from chiropractic,²¹ physiotherapy,²³ and general practice20, 22 clinics. The remaining 3 studies were randomized

Discussion

In this study, to our knowledge the first systematic review about the course of acute idiopathic neck pain from its inception, we report that outcomes for acute neck pain are surprisingly poor and resolution is incomplete. There is a rapid decrease in pain by 45% and disability by 43% during the first 6.5 weeks. While this degree of symptom reduction may be clinically worthwhile to some patients,²⁵ the severity and duration of symptom persistence (between 37–42 on a 0–100 scale up to 1y) are

Conclusions

To our knowledge, this study provides the first systematic review and meta-analysis of acute idiopathic neck pain prognosis from its inception. The results show that the prognosis of acute idiopathic neck pain is markedly worse than previously recognized and that resolution is incomplete. This level 1 evidence may be useful for the allocation of health resources by policy makers and can be incorporated into future clinical practice guidelines to guide primary care clinicians when providing

Acknowledgements

We thank research assistant Angie Johnson, BAppSc(Phty), for her excellent technical assistance with this study.

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We conducted an explorative prospective cohort study with 6 months follow-up to 1) identify different pain and disability trajectories following an episode of acute neck pain, and 2) assess whether neuroimmune/endocrine, psychological, behavioral, nociceptive processing, clinical outcome, demographic and management-related factors differ between these trajectories. Fifty people with acute neck pain (ie, within 2 weeks of onset) were included. At baseline, and at 2, 4, 6, 12, and 26 weeks follow-up, various neuroimmune/endocrine (eg, inflammatory cytokines and endocrine factors), psychological (eg, stress symptoms), behavioral (eg, sleep disturbances), nociceptive processing (eg, condition pain modulation), clinical outcome (eg, trauma), demographic factors (eg, age), and management-related factors (eg, treatment received) were assessed. Latent class models were performed to identify outcome trajectories for neck pain and disability. Linear mixed models or the Pearson chi-square test were used to evaluate differences in these factors between the trajectories at baseline and at each follow-up assessment and over the entire 6 months period. For pain, 3 trajectories were identified. The majority of patients were assigned to the “Moderate pain – Favourable recovery” trajectory (n = 25; 50%) with smaller proportions assigned to the “Severe pain – Favourable recovery” (n = 16; 32%) and the “Severe pain – Unfavourable recovery” (n = 9; 18%) trajectories. For disability, 2 trajectories were identified: “Mild disability – Favourable recovery” (n = 43; 82%) and “Severe disability – Unfavourable recovery” (n = 7; 18%). Ongoing systemic inflammation (increased high-sensitive C-reactive protein), sleep disturbances, and elevated psychological factors (such as depression, stress and anxiety symptoms) were mainly present in the unfavorable outcome trajectories compared to the favorable outcome trajectories.
Using exploratory analyses, different recovery trajectories for acute neck pain were identified based on disability and pain intensity. These trajectories were influenced by systemic inflammation, sleep disturbances, and psychological factors.
External validation and updating of prognostic models for predicting recovery of disability in people with (sub)acute neck pain was successful: broad external validation in a new prospective cohort
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Can existing post-treatment prognostic models for predicting neck pain recovery (primarily in terms of disability and secondarily in terms of pain intensity and perceived improvement) be externally validated and updated at the end of the treatment period and at 6 and 12 weeks of follow-up in a new Dutch cohort of people with neck pain treated with guideline-based usual care physiotherapy?
External validation and model updating in a new prospective cohort of three previously developed prognostic models.
People with (sub)acute neck pain and registered for primary care physiotherapy treatment.
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Discriminative performance (c-statistic) of the disability model at 6 weeks was 0.73 (95% CI 0.69 to 0.77) and reasonably well calibrated after intercept recalibration. The disability model at 12 weeks and at the end of the treatment period showed discriminative c-statistic performance values of 0.69 (95% CI 0.64 to 0.73) and 0.68 (95% CI 0.63 to 0.72), respectively, and was well calibrated. Pain models and perceived recovery models did not reach acceptable performance. Cervical mobility added value to the disability models and pain catastrophising to the disability and pain models at 6 weeks.
Broad external validation of the disability model was successful in people with (sub)acute neck pain and clinicians may use this model in clinical practice with reasonable accuracy. Further research is required to assess the disability model’s clinical impact and generalisability, and to identify additional valuable model predictors.
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The primary outcomes were pain intensity and disability. The secondary outcome was adverse events.
Overall, 119 RCTs (12,496 patients; 32 interventions) were included. Risk of bias was low in 50.4% of trials, unclear in 22.7% and high in 26.9%. Compared with inert treatment, a combination of active and/or passive multimodal non-pharmacological inventions (eg, exercise and manual therapy) were effective for pain on a 0-to-10 scale at 1 month (MD range 0.84 to 3.74) and at 3 to 6 months (MD range 1.06 to 1.49), and effective on disability on a 0-to-100 scale at 1 month (MD range 10.26 to 14.09) and 3 to 6 months (MD range 5.60 to 16.46). These effects ranged from possible to definite clinical relevance. Compared with inert treatment, anti-inflammatory drugs alone or in combination with another non-pharmacological treatment did not reduce pain at 1 month or 3 to 6 months. At 12 months, no superiority was found over inert treatment on both outcomes. Most mild adverse events were experienced following acupuncture/dry needling intervention. On average, the evidence varied from low to very low certainty.
While multimodal non-pharmacological interventions may reduce pain and disability for up to 3 to 6 months of follow-up when compared with inert treatment, the evidence was very uncertain about their effects. Better quality and larger trials are needed to improve the certainty of evidence.
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Non-serious adverse events do not influence recovery in patients with neck pain treated with manual therapy; an observational study
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Only duration of NP at baseline had prognostic value to predict recovery, whereas the remaining prognostic factors did not contribute to the model. The significant influence of duration of NP on outcome is in accordance with existing evidence; patients suffering from NP less than six weeks have better chance of recovery than patients with chronic NP (Hush et al., 2011). Adverse events do not seem to be uniquely assigned to MT. Recent studies by Paanalahti et al. and Tabell et al. showed that NSAE are commonly reported in the treatment of NP, regardless whether the intervention consisted of manipulation or other modalities.
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The global point prevalence of neck pain has been estimated to be 4.9%, and it is the fourth-ranked condition in terms of years lived with disability.1 Idiopathic neck pain is characterized by incomplete resolution and recurrent pain episodes.2 It has been suggested that impaired cervicocephalic proprioception (CCP) is associated with persistent neck pain3 as well as dizziness, imbalance, and falls.4
The purpose of this systematic review was to determine the reliability and, where possible, the validity of cervicocephalic proprioceptive (CCP) tests in healthy adults and clinical populations.
A systematic search, utilizing 7 databases from the earliest possible date to April 14, 2021, identified studies that measured reliability of CCP tests. Studies were screened for eligibility, and included studies were appraised using Quality Appraisal Tool for Studies of Diagnostic Reliability (QAREL) and Quality Assessment and Diagnostic Accuracy Studies-2 Tool (QUADAS-2) tools. Validity outcomes were assessed for included studies.
Of 34 included studies, 29 investigated reliability for sense of position tests, 10 involved sense of movement tests, and 1 used a sense of force test. The head to neutral test was reliable and valid when 6 or more repetitions were performed within the test, discriminating between those with and without neck pain. Head tracking tests were reliable with 6 repetitions, and 1 study found discriminative validity in a whiplash population. Studies that found discriminative validity in sense of position reported mean joint position error generally >4.5° in the neck pain group and <4.5° in the asymptomatic group. No sense of force test was applied to a clinical population. Convergent validity analysis showed that these proprioceptive tests have low correlations with each other.
The reliability and validity of CCP tests for sense of position and movement are dependent upon equipment and repetitions. Six repetitions are generally required for good reliability, and joint position error >4.5° is likely to indicate impairment in sense of position.
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LBP and NP have been reported to be the 4th and 19th leading causes of disability in 2019 (Vos et al., 2020), with current estimates of years lived with disability reported to be a combined total of 94 million years (Hurwitz, Randhawa, 2018). Most new episodes of spinal pain recover rapidly within the first 6 to 12 weeks from onset (Costa et al., 2012, Hush et al., 2011), although up to 30% of individuals report incomplete recovery after one year (Henschke et al., 2008). The societal and economic costs of spinal pain disorders are high, driven largely by a small fraction of individuals with persistent pain (Carroll et al., 2008).
The purpose of this narrative review is to provide a critical reflection of how analytical machine learning approaches could provide the platform to harness variability of patient presentation to enhance clinical prediction. The review includes a summary of current knowledge on the physiological adaptations present in people with spinal pain. We discuss how contemporary evidence highlights the importance of not relying on single features when characterizing patients given the variability of physiological adaptations present in people with spinal pain. The advantages and disadvantages of current analytical strategies in contemporary basic science and epidemiological research are reviewed and we consider how analytical machine learning approaches could provide the platform to harness the variability of patient presentations to enhance clinical prediction of pain persistence or recurrence. We propose that machine learning techniques can be leveraged to translate a potentially heterogeneous set of variables into clinically useful information with the potential to enhance patient management.

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: Supported by the National Health and Medical Research Council, Australia; and an Australian Postgraduate Award provided by the Australian Commonwealth Government.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Published online April 1, 2011 at www.archives-pmr.org.

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Review article (meta-analysis)Prognosis of Acute Idiopathic Neck Pain is Poor: A Systematic Review and Meta-Analysis

Abstract

Objective

Data Sources

Study Selection

Data Extraction

Data Synthesis

Conclusions

Section snippets

Data Sources and Searches

Results

Discussion

Conclusions

Acknowledgements

Risk factors for neck pain: a longitudinal study in the general population

Pain

The annual incidence and course of neck pain in the general population: a population-based cohort study

Pain

Regional musculoskeletal painThe neck

Baillieres Best Pract Res Clin Rheumatol

Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Spine

Neck pain

Cost-of-illness of neck pain in The Netherlands in 1996

Pain

Evidence-based management of acute musculoskeletal pain

Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders: from concepts and findings to recommendations

Spine

Patient satisfaction with management of back pain: part 1: what is satisfaction?Review of satisfaction with medical management

Physiotherapy

Patient satisfaction with management of back pain: part 2: an explorative, qualitative study into patients' satisfaction with physiotherapy

Physiotherapy

Satisfaction with outpatient physiotherapy: focus groups to explore the views of patients with acute and chronic musculoskeletal conditions

Physiother Theory Pract

Acute low back pain: systematic review of its prognosis

BMJ

Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

BMJ

Review article (meta-analysis)
Prognosis of Acute Idiopathic Neck Pain is Poor: A Systematic Review and Meta-Analysis