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By Nancy Walsh, Staff Writer, MedPage Today
Published: October 28, 2010
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Patients with chronic neck pain are overutilizing unproven and questionable therapies and underusing modalities for which there is evidence, a telephone survey found.
For instance, almost one-third of patients were taking strong narcotics, despite the fact that the evidence for medications in neck pain is "extremely limited," wrote Adam P. Goode, DPT, of Duke University, and colleagues.
In contrast, only about half had been prescribed therapeutic exercises during the past year -- a treatment for which a Cochrane review found good evidence, the researchers observed online in Arthritis Care & Research.
"Like chronic low back pain, chronic neck pain is often unresponsive to treatment and costly in regard to direct and indirect costs," the researchers noted.
Because few data are available on healthcare usage for chronic neck pain, they conducted a telephone survey in North Carolina, contacting 5,357 households with 9,924 adults, querying them about family members with chronic, impairing neck pain.
This was defined as pain and interference with activities almost every day for the past three months, or more than 24 episodes of pain persisting for at least a day during the past year.
They identified 135 patients who met the criteria, giving a point prevalence for North Carolina of 2.2% (95% CI 1.7 to 2.6).
This meant that there could be almost 195,000 adults in the state who had neck pain severe enough to interfere with their activities, according to the researchers.
More than half of the patients were women, the majority were non-Hispanic white, and mean age was 48.9 years. Fewer than 10% had less than a high school education.
Mean pain score on a 10-point scale for the past three months was 6.2 (95% CI 5.7 to 6.6), and mean duration of pain was 6.9 years (95% CI 5.4 to 8.3).
The mean neck disability index score was 31.5 (95% CI 28.9 to 34.1) out of a possible 50.
On the physical component of the short form-12 evaluation of health status, the mean score was 38.6, while the mean score on the mental component was 50.3.
A total of 55.6% reported having had depressed mood.
With regard to healthcare utilization, 79.3% had consulted at least one provider for their neck pain during the previous year, and among these patients, more than 90% had seen a physician: Primary care physician, 72%Orthopedic surgeon, 31.6%Neurosurgeon, 29.1%Neurologist, 22.8%
In addition, 40% saw a chiropractor, 35.2% consulted a physical therapist, and 41% visited an alternative medicine specialist such as a massage therapist.
Frequent consultation with multiple types of providers was common, with an average of five providers per patient and 21 visits.
Imaging tests also were prevalent, with 45% of patients having had x-rays, often more than once, as well as 24% having CT scans and 30% undergoing MRI.
The researchers commented that this use of diagnostic imaging techniques did not appear to be in line with recommendations for clinical decision-making.
"One may also question the value of imaging techniques for subjects with an average duration of symptoms of 6.9 years, as this duration of symptoms may decrease the likelihood that findings would lead to clinically important inferences," they wrote.
The strong narcotics used included oxycodone, fentanyl, and methadone, while weaker narcotics such as codeine and propoxyphene had been taken by 23.1% (95% CI 15 to 33.7). Almost one-third used muscle relaxants.
Other treatment modalities favored by patients included heat, cold, and massage, which were reported by 57%, 47.7%, and 28.1%, respectively -- despite there being little or no evidence in their favor.
In contrast, rehabilitation conditioning/work hardening and acupuncture -- both of which have some positive evidence -- were used by the fewest patients, at 2.7% and 3.9%, respectively.
The authors noted that there are various possible explanations for the discrepancies between treatments used and available evidence, including the complexity of neck pain, patients' high expectations of technology, reimbursement problems, and inadequate knowledge of evidence by providers.
Potential shortcomings of the study include its limitation to patients with chronic neck pain without lower back pain, which commonly occur together.
It also included only participants from one state, and was cross-sectional in design.
In addition, it relied on patient recall for tests and treatments, which could have resulted in over- or underestimations.
The researchers concluded that this patient population exhibits high use of healthcare resources, yet continues to have considerable disability.
The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
The authors had no other financial disclosures.
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joseph biundo - Oct 29, 2010
It is unfortunate that the two specialities that might be able to better evaluate and treat chronic neck pain are not even mentioned, and these are Rheumatology and also Physical Medicine & Rehabilitation. These two specialities are more likely to identify such problems as fibromyalgia, polymyalgia rheumatica or inflammatory arthritis, which also cause chronic neck pain. Too, these specialities are more likely to prescribe physical therapy and rely less on narcotics for treatment. Joseph Biundo, MDEric Robertson, PT, DPT - Oct 29, 2010
The discrepancy between evidence-supported interventions and the actual interventions performed is certainly a problem for many musculoskeletal conditions. Congratulations to the authors for bringing attention to this issue. In addition to the Cochrane review which supports therapeutic exercise for neck pain, there is also a clinical practice guideline publicly available which highlights those examination and intervention strategies supported by high quality evidence. This guideline can be found at http://www.guidelines.gov/content.aspx? id=14703. Furthermore, a recent high-quality randomized clinical trial by Walker et al. published in Spine (October 2008), highlighted the effectiveness of joint mobilization and manipulation added to an exercise program. Not only did the hands-on treatment prove more effective in reducing neck pain, those individuals who received manual therapy had a much lower utilization of other health resources. Research like this study from Goode et al., certainly brings to light the over-allocation of high- cost medical resources and supports increased ease of access to providers like physical therapists who provide evidence-based interventions for patients with neck pain.Janet Peterson, Chronic Pain Patient - Oct 29, 2010
Thankfully, I don't have neck pain. I have back pain. T-8 thru T-12/L-1 hernations. I don't see in here any mention of questions related to, or breakdown of reasons WHY these people may have neck pain. I'd love to know why that is? Most certainly, until we have actually unraveled the truly complex process called pain, there will be "high use of healthcare resources, yet continues to have considerable disability." This can be for a great number of reasons. The one that comes to mind that seems to be skewed here, is the number of diagnostic tools used. MRI, CT, XRAY etc. These are not being done at 6.9 mean years of having had the pain, they were done within the first year of the pain not subsiding with exercise, physical therapy, nsaids, and other common remedies first tried when a patient presents with pain. Now, back to the reasons behind the pain. No mention of what's been found with all the diagnostics. How many have hernieated cervical vertebrae? How many have pinched nerves? How many have tried surgical intervention without resolution? How many have this neck pain as a result of trauma such as a car crash? I can say as a patient with pain not easily identifiable by swelling or blood present, that ALL of these are what is prescribed as the Dr's try to find not only the reason for the pain, but the relief of that pain. All of the diagnostics mentioned, all of the possible physical exercises encompassed by both the orthodox and unorthodox western medicine, from physical therapy to accupunture, all of the relief measures such as hot, and cold, exercises, physical rehab, narcotics, everything, is how modern medicine tries to treat a chronic pain patient. Any patient taking most of the higher narcotics mentioned are visiting their Dr's anywhere from once a month to once every three months, in compliance with measures put in place to protect both the Dr. and the patient. There was no mention of the diagnosis given to all of these patients either. How many have been told by thosee neurosurgeons that this is it. There is no surgery, there is not treatment, there is nothing more to be done accept to treat the pain as best they can, and for the patient to put in place any measures that they have found seem to help them personally, such as heat or cold. They encourage the exercises given by the physical therapists, but they also know that those patients have met their health care insurance's limits on actual visits to those professionals. I guess what surprised me the very most, is that being what I considered a patient very interested in my own health and healthcare, I have done everything mentioned in here, and more, with my health care providers opinion being a very large factor, and my own research into my own condition, and yet I'm reading that none of this is either in line, or effective? At least for neck pain? I find it so surprising because I believe that this is how most pain that isn't acute IS treated by our health care providers, regardless of pain site, or cause, i.e. trauma, deterioration, etc. Now my case may be different, in that there is no surgery, no cure, no treament for the problem itself, but it sounds as if the way my healthcare professionals approached this, is exactly the same. Please let me say that no, I am not a doctor. I may not have been able to read this particular article correctly, but this is what I did take away from it. If I've been mistaken in what I understood, I apologize, and I won't need any more than one doctor to let me know how much I don't understand lol. Please?joseph biundo - Oct 29, 2010
It is unfortunate that the two specialities that might be able to better evaluate and treat chronic neck pain are not even mentioned, and these are Rheumatology and also Physical Medicine & Rehabilitation. These two specialities are more likely to identify such problems as fibromyalgia, polymyalgia rheumatica or inflammatory arthritis, which also cause chronic neck pain. Too, these specialities are more likely to prescribe physical therapy and rely less on narcotics for treatment. Joseph Biundo, MDEric Robertson, PT, DPT - Oct 29, 2010
The discrepancy between evidence-supported interventions and the actual interventions performed is certainly a problem for many musculoskeletal conditions. Congratulations to the authors for bringing attention to this issue. In addition to the Cochrane review which supports therapeutic exercise for neck pain, there is also a clinical practice guideline publicly available which highlights those examination and intervention strategies supported by high quality evidence. This guideline can be found at http://www.guidelines.gov/content.aspx? id=14703. Furthermore, a recent high-quality randomized clinical trial by Walker et al. published in Spine (October 2008), highlighted the effectiveness of joint mobilization and manipulation added to an exercise program. Not only did the hands-on treatment prove more effective in reducing neck pain, those individuals who received manual therapy had a much lower utilization of other health resources. Research like this study from Goode et al., certainly brings to light the over-allocation of high- cost medical resources and supports increased ease of access to providers like physical therapists who provide evidence-based interventions for patients with neck pain.Janet Peterson, Chronic Pain Patient - Oct 29, 2010
Thankfully, I don't have neck pain. I have back pain. T-8 thru T-12/L-1 hernations. I don't see in here any mention of questions related to, or breakdown of reasons WHY these people may have neck pain. I'd love to know why that is? Most certainly, until we have actually unraveled the truly complex process called pain, there will be "high use of healthcare resources, yet continues to have considerable disability." This can be for a great number of reasons. The one that comes to mind that seems to be skewed here, is the number of diagnostic tools used. MRI, CT, XRAY etc. These are not being done at 6.9 mean years of having had the pain, they were done within the first year of the pain not subsiding with exercise, physical therapy, nsaids, and other common remedies first tried when a patient presents with pain. Now, back to the reasons behind the pain. No mention of what's been found with all the diagnostics. How many have hernieated cervical vertebrae? How many have pinched nerves? How many have tried surgical intervention without resolution? How many have this neck pain as a result of trauma such as a car crash? I can say as a patient with pain not easily identifiable by swelling or blood present, that ALL of these are what is prescribed as the Dr's try to find not only the reason for the pain, but the relief of that pain. All of the diagnostics mentioned, all of the possible physical exercises encompassed by both the orthodox and unorthodox western medicine, from physical therapy to accupunture, all of the relief measures such as hot, and cold, exercises, physical rehab, narcotics, everything, is how modern medicine tries to treat a chronic pain patient. Any patient taking most of the higher narcotics mentioned are visiting their Dr's anywhere from once a month to once every three months, in compliance with measures put in place to protect both the Dr. and the patient. There was no mention of the diagnosis given to all of these patients either. How many have been told by thosee neurosurgeons that this is it. There is no surgery, there is not treatment, there is nothing more to be done accept to treat the pain as best they can, and for the patient to put in place any measures that they have found seem to help them personally, such as heat or cold. They encourage the exercises given by the physical therapists, but they also know that those patients have met their health care insurance's limits on actual visits to those professionals. I guess what surprised me the very most, is that being what I considered a patient very interested in my own health and healthcare, I have done everything mentioned in here, and more, with my health care providers opinion being a very large factor, and my own research into my own condition, and yet I'm reading that none of this is either in line, or effective? At least for neck pain? I find it so surprising because I believe that this is how most pain that isn't acute IS treated by our health care providers, regardless of pain site, or cause, i.e. trauma, deterioration, etc. Now my case may be different, in that there is no surgery, no cure, no treament for the problem itself, but it sounds as if the way my healthcare professionals approached this, is exactly the same. Please let me say that no, I am not a doctor. I may not have been able to read this particular article correctly, but this is what I did take away from it. If I've been mistaken in what I understood, I apologize, and I won't need any more than one doctor to let me know how much I don't understand lol. Please?
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