Non-specific neck pain: diagnosis and treatment - KCE

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ii non-specific neck pain KCE reports 119C INTRODUCTION Executive summary This study aims to provide a systematic review of the scientific literature on diagnosis, prognosis and treatment of acute and chronic non-specific neck pain. The objective is to propose evidence-based key messages to diagnose and to treat adults who suffer from non-specific neck pain. Neck pain is a wide entity which includes e.g. non-specific neck pain and neck pain associated disorders. Symptoms vary with physical activity and over time. Each form of acute, subacute or chronic neck pain, where no abnormal anatomic structure as cause of pain can be identified, is non-specific neck pain. In the literature, no generally accepted definition exists for the concept acute, sub-acute or chronic. METHODOLOGY The literature search covered the period from 1998 to 2008 and included (systematic) reviews, meta-analyses, guidelines, RCTs and clinical trials. The researchers screened the scientific literature in Medline, Embase, Cochrane and Pedro databases. Moreover, existing guidelines were searched in specific databases. All papers were screened by a team of two reviewers. A multidisciplinary panel of experts joined the research team to define the evidence level of the conclusions using the “GRADE” system: • Grade A (high level of evidence): RCTs without important limitations or overwhelming evidence from observational studies; • Grade B (moderate level of evidence): RCTs with important limitations (inconsistent indirect, or imprecise results; methodological flaws) or exceptionally strong evidence from observational studies; • Grade C (low level of evidence): Lower level of evidence. Finally, the conclusions of this review were compared to those of two high quality guidelines identified during the search.
KCE reports 119C non-specific neck pain iii RESULTS The search for evidence on diagnosis and prognosis yielded 135 possibly relevant publications, of which 11 publications of good quality were selected. The search on treatment yielded 564 references, including 55 reviews: 24 of them were selected after the quality appraisal. Finally, 13 RCTs published after the most recent good quality reviews were also included after quality appraisal. ASSESSMENT OF NECK PAIN AND DISABILITY The “Neck Disability Index” is a validated instrument widely used for assessing selfrated disability in patients with neck pain. It has been used effectively in both clinical and research settings and has been translated in Dutch (but not in French). DIAGNOSIS OF NON SPECIFIC NECK PAIN No systematic review or primary studies was identified examining the diagnostic accuracy of history-taking or diagnostic imaging in patients with non-specific neck pain. Exclusion of “red flags” and nerve-root disorders “Red flags” are clinical signs or symptoms that make a serious underlying cause more likely. It is important to exclude the “red flags” (see table 1 in the scientific report) as well as nerve-root pain (radicular pain/radiculopathy) in order to confirm the diagnosis of “Non-specific Neck Pain”. The presence of radicular pain/radiculopathy (disease involving a spinal nerve root which may result from compression and other conditions) can be clinically demonstrated by the Spurling’s test, traction/neck distraction, shoulder abduction test and a Valsalva’s manoeuvre (low level of evidence). The absence of radicular pain/radiculopathy is supposed after a negative upper limb test (low level of evidence). Diagnosis of facet joint pain PROGNOSIS Local anesthetic block might be useful in diagnosing facet joint spinal pain as the underlying structure causing the pain (low level of evidence). However, this invasive technique should only be used when the clinical diagnosis remains uncertain: this technique has a high false positive rate and there is a lack of consensus on the definition of “a successful anaesthetic block” for cervical facet joints pain. There is a limited number of publications regarding prognostic factors for non-specific neck pain. A few indicators of a less favourable prognosis (more pain, lower level of functionality or less general improvement, more health care utilization, more lost days of work) were identified e.g. age, concomitant low back pain, severe pain and a history of previous attacks (low level of evidence). Research suggest that pathologic radiological findings (e.g. degenerative changes in discs or joints) are not associated with a worse prognosis (low level of evidence).
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