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Dolor de Cuello logy

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Published by: Jorge Campillay Guzmán on Nov 21, 2009
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4Neck pain
Robert Ferrari*
Anthony S. Russell
Department of Rheumatic Diseases, University of Alberta, Edmonton, Alberta, Canada
Neck pain is second only to low back pain as the most common musculoskeletal disorder inpopulation surveys and primary care, and, like low back pain, it poses a significant health andeconomic burden, being a frequent source of disability. While most individuals with acute neck pain do not seek health care, those that do account for a disproportionate amount of health carecosts. Furthermore, in the setting of the whiplash syndrome, neck pain accounts for significantcosts to society in terms of insurance and litigation, and days lost from work. Much neck pain isnot attributable to a specific disease or disorder and is labelled as ‘soft-tissue’ rheumatism ormuscular/mechanical/postural neck pain. Most chronic neck pain is attributed to whiplash injury,another enigmatic diagnosis. Despite decades of research and posturing to explain chronic neck pain on the basis of a specific disease or injury, and despite increasingly sophisticated radiologicalassessment, little advance has been made in either achieving a specific structural diagnosis or,more importantly, in reducing the health and economic burden of chronic neck pain. There issome evidence, however, that measures which address the psychosocial factors that promotepain chronicity, and shift the patient’s view away from injury and disease to more benignperspectives on their condition, may be helpful. This chapter considers briefly the magnitude of the neck pain problem, our limitations in understanding it from a traditional medical perspective,and suggestions for therapeutic and societal approaches that appear more likely to be helpful.
Key words:
neck pain; whiplash injuries; chronic pain.
The problem with neck pain is that it does not end there. Neck pain, especially chronicneck pain, is often accompanied by a host of other symptoms whose association isdifficult to explain on a physiological basis alone. Neck pain is often just one feature of nebulous syndromes like chronic whiplash, myofascial pain syndrome, fibromyalgia,cervicobrachial syndrome, et cetera. Chronic neck pain also brings with it the spectreof litigation (e.g. whiplash issues) and disability claims. In addition there is a tendencyfor over-investigation and over-treatment, often as a result of the level of a patient’sdistress at the failure of the medical community to provide helpful answers. In thischapter, we deal with the fact that the epidemiology of neck pain clearly indicates thisto be a major health and economic burden, but the traditional diagnostic approachbased on history, physical examination, and investigations provides little solution formost patients. We argue that much of this endemic musculoskeletal problem is
1521-6942/03/$ - see front matter
2003 Elsevier Science Ltd. All rights reserved.Best Practice & Research Clinical RheumatologyVol. 17, No. 1, pp. 57–70, 2003
doi:10.1053/yberh.2003.269, www.elsevier.com/locate/jnlabr/yberh
*Corresponding author.
fostered by psychosocial factors, including personality traits, social status (or lacthereof), iatrogenic and legal factors, and an excessive reliance on the ‘injury or diseasemodel’. The reader is referred to a previous review in this journal for the discussionand approach to neck pain in general.
In addition to providing an update to this, wefocus on certain aspects that deal more with how the current medical approach toneck pain – and whiplash in particular – is unhelpful and requires a re-evaluation infavour of a new paradigm.
Neck pain is generally defined as stiffness and/or pain felt dorsally in the cervical regionsomewhere between the occipital condyles and the C7 vertebral prominence. Neck pain, however, is often accompanied by pain in the occiput (a headache), the upperthoracic region, and the jaws. Clinically, it is recognized that even in subjects with noevidence of nerveroot irritation orcompression, neck pain may be associated with painreferred along myotomal patterns to the anterior chest, arm, and dorsal spine regions.The neurological examination would, of course, be normal.The less common causes of neck pain include tumours, systemic arthropathy (e.g.rheumatoid arthritis, ankylosing spondylitis), infections, thyroid disorders, oesophagealobstruction or reflux disease. Additionally, the neck is a site for referred pain fromcardiac, gastric and diaphragmatic disease processes. Yet, perhaps 95% of neck painpatients will receive a more benign diagnosis, for example, neck sprain, mechanicalneck pain, muscular neck pain, myofascial pain syndrome, postural neck pain, etcetera.These latter diagnoses are both a blessing and a curse for the patient. While theyreflect a benign aspect in terms of mortality, the vagueness of the diagnosis oftenleaves the patient searching for a more definitive pathological understanding of theirpain, and they soon encounter many who are willing to creatively ascribe the pain tofacet joint and other subluxations, trigger points and muscle bands, chronicmusculoligamentous injury, etcetera – the non-specificity of most neck pain is fodderfor the imaginative therapist to produce a remarkable array of unprovable anduntestable explanations.The most remarkable aspects of the aetiology of neck pain, acute as well as chronic,are how seldom we know or can tell the patient we have identified the source of pain.The corollary is, how often obvious pathology exists in entirely asymptomatic patients.A population-based best estimate of the outcome of acuteneck pain is that at least80% of all acute neck pain resolves within days to weeks.
Even though we believethat there should be a structural cause for neck pain that lasts a short period like this,we can seldom identify a source. In chronic neck pain, that lasts for at least 6 weeks, weagain do not know the structural basis in most cases. When pain is referred to the neck from other sites (i.e. myocardial ischaemia), although we have a general theory of thisreferral pattern from an anatomical understanding of nerve root embryology we donot know why some patients with myocardial ischaemia have neck pain and others donot. Finally, we know from clinical experience and radiological studies, for example,that patients with rheumatoid arthritis can have extensive inflammatory destruction of the atlantoaxial structure with no symptoms at all. In other studies (see below)individuals may have large osteophytes and marked degenerative changes, again with nosymptoms.
58 R. Ferrari and A. S. Russell
Chronic neck pain is perhaps second only to chronic low back pain as the mostcommon musculoskeletal disorder associated with injury and disability claims, both inthe work place and after motor vehicle collisions. At any given time, approximately 10%of the population reports having neck pain on at least 7 days per month, andneck pain(of unspecified duration) occurs in at least 80% of the population at some time
, witha 20–30% annual incidence of acute neck pain in population-based studies.
Thesefigures hold for a number of different countries, although there are limited data thatneck pain may be less common in Asia.
Linton recentlyexamined studies dealing with psychosocial risk factors in acute necand back pain.
Factors cited include preceding stressful life events or depression. It isnot clear why these associations evolve, whether psychological distress causesindividuals to notice, amplify, and focus on life’s ordinary and minor aches and pains orwhether psychological distress can manifest itself as spinal pain. Independent risk factors for incident neck pain also include poor general health at baseline, femalegender, obesity, a previous historyof neck injury or of concomitant pain elsewhere, andhigher numbers of children.
These are,interestingly, the same risk factors forother regional musculoskeletal pain disorders.
Other risk factors for incident neck pain which have a more ‘mechanical’ or‘occupational’ flavour include duration of sitting, duration of twisting and bending thetrunk in working postures.
Studies thus far, however, have failed to find neck flexion,neck extension, neck rotation, arm force and posture, handarm vibration, workplacedesign, or sports/exercise to be risk factors for incident neck pain.
There has beenonly one prospective study to assess the relation between work-related psychosocialfactors and incident neck pain, with appropriate adjustment for both work-related andnon-work-related physicalfactors and individual characteristics. This study, reportedrecently by Ariens et al
, indicates that high quantitative job demands (e.g. workingunder time pressure or working with deadlines) and low co-worker support areindependent risk factors for neck pain. Not surprisingly, givenrelatively fewphysical risk factors for acute neck pain, many mechanical interventions studied for prevention of neck pain in theworkplace havefailed to demonstrate anybenefit, except forexercises,which modestly reduce the future incidence of neck pain and work absenteeism.
Neck pain thus remains costly, a common cause of disability, andresponsible for asignificant proportion of work absenteeism, and lost productivity.
There have been various studies showing, however, that not everyone with neck (orback) pain seeks health care providers, and these individuals who thereby become‘patients’are a self-selected subgroup. There are awide array of independent predictorsas to who will seek a health care provider.
Cote et al, for example, studiedapproximately 800 subjects from a population-based sample in Saskatchewan, Canada,these subjects having experienced neck or back pain in the previous 4 weeks. Theyfound that approximately 25% of subjects sought some form of health care provider.While it is encouraging that 75% were not attending a health care provider, the fact thatspinal pain is so common means that the 25% who did still account for a large healthcare expenditure for the treatment of acute neck pain. As expected, various factorssuch as neck pain severity, duration, and presence of co-morbidities were predictors of who sought health care. Cote et al further found, however, that even if one controls forpain severity, pain duration, socio-economic status, co-morbidities and various otherfactors known to modify health care seeking (i.e. medicalization), spinal pain thatoccurred in the setting of a traffic collision or that was attributed to an occupational
Neck pain 59

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