Neck Pain CPG: Risk Factors, Clinical Course, Prognosis

Dr. Austin Kercheville begins our series on the 2017 neck pain Clinical Practice Guideline by covering neck pain prevalence, risk factors, clinical course, and prognosis.

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Transcript

Intro: Hello and welcome back to another episode of OCS Field Guide. I’m glad to be back with you after my brief hiatus to work on our new home and I’m excited to present to you the neck pain clinical practice guideline. Luckily, I don’t have any persistent low back or neck pain following refinishing our floors and tiling our bathroom. 

Before we get into the 2017 neck pain CPG, you should know that the 2017 CPG is an update of the previous 2008 CPG. So make sure you are studying the most recent version. Its also important to take note of this because if you studied or had material taken from CPGs in your PT program before this revision came out, you need to pay careful attention to this as some things have changed in this update. Something you’ll note at the end of each section in this CPG is a section titled “2017 summary” which gives you a convenient overall take away on how new evidence has changed what we thought in back in 2008. You may not need to memorize every detail given in a lot of sections, but I would bet the information given in those summary sections will be good to know. 

First we’ll cover the prevalence of neck pain. Prevalence data is quite varied, but here are the main things you need to know:

1.     First, neck pain is very common. Between 30 and 50% of the population will have neck pain in a given year, and up to 11% of the general population with have neck pain that causes disability.

2.     Second, like low back pain, neck pain is getting more common. In 2010, data showed that neck pain ranked 21st in global Causes of disability, while just three years later in 2013 in had moved up to 19th in global causes of disability.

3.     Finally, neck pain recurs often, and becomes chronic at a relatively high rate--as many as 30% of people with neck pain will develop chronic symptoms. 

Overall, the authors want to be sure you know that neck pain is very prevalent, is becoming more prevalent, recurs often, and is at high risk for chronicity. 

Next let’s cover risk factors for developing neck pain. Pay close attention to this because they are similar, yet distinct from low back pain risk factors, and are not always what we as PTs would expect intuitively. The 2017 CPG update points out that new high quality systematic reviews have demonstrated that the strongest and most consistent risk factors for new-onset of neck pain are female sex and prior history of neck pain in both office workers and the general population. Let me repeat that—the strongest and most consistent risk factors for new-onset of neck pain are female sex and prior history of neck pain. Low to moderate evidence indicates that the following factors that may increase risk for neck pain: Older age, high job demands, smoking history, low social/work support, and prior history of low back pain. Why might that be important to know? Let’s say you get a case on the test that describes a woman in her late 50’s with a high job stress and history of smoking. It should take some pretty strong red flags to convince you to choose to “refer out for further diagnostics” before a trial of treatment, as individuals with these factors very commonly end up with neck pain.

Let’s move on to the clinical course of neck pain and factors that determine prognosis. It is important to note that clinical course and prognosis are difficult to study and describe for most of neck pain subgroups since non-traumatic neck pain is typically of insidious onset—making it hard to determine a definite beginning. So, the most research in this area is going to be related to acute traumatic neck pain which is largely made up of patients with whiplash associated disorder since they are the fastest to receive care and a definite injury date can be determined. For this group, you can expect more severe problems initially to indicate a poorer prognosis. The clinical course with these individuals is not entirely favorable. Research suggest 3 general outcomes that I’ll describe now. About 45% of these individuals will have mild disability and posttraumatic stress, and that their problems will likely resolve quickly and completely. Another 40% of patients will have moderate disability and posttraumatic stress. These will definitely have improvement, but likely incomplete recovery. And another 15% of individuals will have severe disability and posttraumatic stress and will demonstrate chronic problems without recovery. That being said, with all cases of acute neck pain (traumatic or atraumatic), the fastest progress is made in the first 6-12 weeks following the injury, with recovery slowing significantly after 12 weeks. 

On to prognosis. Again, most data in this area is in relation to neck pain of traumatic onset, so keep in mind that these prognostic factors are MOST relevant to those cases. The authors list 5 constructs that are indicative of poorer prognosis and the best available tools for evaluating these constructs with cutoff scores--hint these are tools and values you SHOULD know for the OCS exam. Let’s list each factor first: High pain intensity, high self-reported disability, high pain catastrophizing, high acute post-traumatic stress symptoms, and cold hyperalgesia. Let’s list those again, but add in the associated tool and cut score you need to know.

The first factor, high pain intensity, should be evaluated with the numeric pain rating scale. A cut score of 6 or greater on the NPRS should indicate a poorer prognosis.

Second, high self-reported disability should be assessed with the Neck Disability Index, and a cut score of greater than 30% disability should indicate poorer prognosis

Third, high pain catastrophizing should be assessed with the Pain Catastrophizing Scale and a score of 20 or greater should indicate poorer prognosis

Fourth, high post traumatic stress symptoms should be assessed with the Impact of Events scale-revised, and a cut score of 33 or greater should indicate poorer prognosis. The authors remind us that this tool is not intended to assess for posttraumatic stress disorder, but rather to predict symptom chronicity as high post traumatic distress is common in acute injuries. This is also the only construct that is exclusive to traumatic–onset neck pain, for obvious reasons.

Fifth and final, cold hyperalgesia, for this they recommend you whip out your TSA-II – NeuroSensory Analyzer which is the gold-standard. Just kidding. Obviously, only researchers would have access to that kind equipment. The CPG recommends alternative tests such as a cold pressor test in which the patient would put a hand in ice water and record time to initial pain and time to pain intolerance, or simply placing an ice cube on their skin and doing the same. However there are no cut scores, so this would be a hard construct to test. The most you should need to know is that positive cold hyperalgesia does indicate poorer prognosis for neck pain. 

To recap, high pain, high self reported disability, high pain catastrophizing, high post traumatic stress, and cold hyperalgesia can each indicate a poorer prognosis with neck pain.

Similarly important are the factors listed that do NOT impact prognosis in traumatic-onset neck pain because many of them seem plausible factors. These include: (1) angular deformity of the neck (eg, scolio- sis, flattened lordosis), (2) impact direction, (3) seating position in the vehicle, (4) awareness of the impending collision, (5) having a headrest in place at the time of collision, (6) stationary versus moving when hit, and (7) older age. So lookout for OCS question writers to include answers or information that sound plausible, but that have either not been studied or have been shown NOT to impact prognosis.

 Let’s make this a little more practical and go through a practice question:

A 33-year-old female presents to an outpatient physical therapy clinic 2 weeks after being involved in a motor vehicle accident. She reports 8 out of 10 pain on the NPRS. Radiographs performed in the emergency department revealed moderate degenerative disc disease at C5-C6 and C6-C7 with mild facet arthrosis. Clinical exam reveals:

-       Cervical rotation AROM 45 deg to L and 50 deg to R with pain throughout ROM 

-       Grossly 4/5 strength throughout upper extremities

-       Normal dermatomes and myotomes

-       Hypomobility and pain with UPA a R C5 

Which of the following additional pieces of information would indicate a poorer prognosis for this patient:

a.     Positive deep neck flexor endurance test

b.     Previous history of neck pain

c.     Pain catastrophizing scale of 22

d.     Neck Disability Index score of 25%

Hopefully, having just heard this information, this is an easy question. But there are a couple of tricky options. Answer A, positive deep neck flexor endurance test, is helpful in classifying this patient as neck pain with movement coordination impairments, but this is not helpful in forming prognosis. “B” –previous History of neck pain—is a significant risk factor for developing neck pain, but is does not impact prognosis. C, the correct answer, pain catastrophizing scale of 22 is one of the prognostic factors that does meet the cut score to indicate poorer prognosis. “D”—NDI score of 25%--is tricky because the NDI is one of the prognostic factors, however a score of 25% does not reach the cut score that would indicate a poor prognosis. 

So that wraps up our first episode in our neck pain clinical practice guideline. If you liked that practice question head on over to Physiofieldguide.com to sign up to get free, high quality practice questions to your inbox. If you found this podcast helpful, please subscribe and give us a review on your podcast platform. Then share it with your colleagues. Friends don’t let friends waste time studying for the OCS.