I Have Neck Pain: What Are My Options? Jordan Miller, MSc PT

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1 I Have Neck Pain: What Are My Options? Jordan Miller, MSc PT McMaster University, Hamilton, Ontario For Webinar Series: Chronic Pain -Improving Life While Living It We acknowledge the financial assistance of the Province of British Columbia CIRBD2012

2 Outline: Who experiences neck pain? Why do we experience neck pain? What are some of the factors that contribute to neck pain? What are the treatment options? What is the potential benefit associated with those options? What is the potential risk associated with those options? What would I do if I had neck pain?

3 Who experiences neck pain? 1/3 adults experience neck pain each year 1 Many of the people experiencing neck pain report it as disabling 2 Neck pain is associated with more visits to a physician and more missed work days in comparison to someone without neck pain 3 1. Croft PR et al. Pain 2001; 93(3): Webb R et al. Spine 2003; 28(11): Hogg-Johnson S et al. Spine 2008; 33(4:Suppl):S51.

4 Why do we experience neck pain? Pain is a protective mechanism that your brain uses to protect you from a perception of threat or damage Pain is not necessarily to tell you that your tissue has been damaged Pain is one of many protective mechanisms that our body uses

5 Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage International Association for the Study of Pain

6 Pain Key points from this definition: Pain is unpleasant and it has to be Pain is an experience Pain can be associated with actual or potential damage

7 Pain without tissue damage

8 Tissue damage without pain

9 Neck pain depends on context

10 Neck pain depends on context

11 Neck pain depends on context

12 THOUGHTS BRAIN Pain EMOTIONS Overview STRESSES TISSUE DANGER! SPINAL CORD PROTECTION - Pain - Muscle spasm - Weakness - Run away - Lay down/freeze - Release hormones DANGER!

13 Common findings on MRI in people without neck pain Bulging disk = 73% Disk protrusions = 50% Disk extrusions = 3% Annular tears = 37% Medullary compression = 13% Osteoarthritis = >50% (depends on age) Ernst CW et al. Eur J Radiol ;55(3): J Bone Joint Surg Am 2002; 84: Webster BS & Cifuentes M (2010). Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 2010, 52 (9),

14 What are health care providers doing for people with neck pain? A series of systematic reviews and overviews suggests a multimodal approach including manual therapy and exercise may be the optimal treatment for neck pain 1-4 In current practice, there is overutilization of diagnostic testing, narcotics, and modalities, and underutilization of therapeutic exercise 5 1) Miller J et al. Manual therapy and exercise for neck pain: A systematic review. Manual Therapy 2010;15(4): ) Kay TM et al. Exercises for neck pain. Cochrane Database of Systematic Reviews ) Gross A et al. Manipulation or mobilization for neck pain. Cochrane Database of Systematic Reviews (4): ) Gross A et al. ICON overview of manual therapy and exercise for neck pain. Unpublished ) Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken ) 2010; 62(11):

15 Why use a patient decision aid? Patient centeredness is important to make sure health care decisions are made with the patients wants, needs, and preferences in mind 1 Patient decision aids have been shown to increase peoples involvement in decision making, improve knowledge of outcomes, and improve informed value-based choices 2 1) Institute of Medicine (2001).Crossing the quality chasm: A new health system for the 21st century. National Academy Press. Washington, DC. 2) Stacey D et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2011.

16 Why use a patient decision aid? In a recent qualitative study, participants with neck pain identified: a need for useful information concerns about the side effects and risks of certain treatments - neck manipulation - medication MacDermid J, Walton D, Miller J, ICON. What is the experience of receiving care for neck pain. Open Orthopaedics 2013.

17 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision Elwyn G et al, on behalf of the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

Patient Decision Aid Available here: http://www.physio-pedia.

18 Patient Decision Aid Available here: Should_I_receive_manual_therapy_and_exercise_for_my_neck_ pain%3f:_a_patient_decision_aid

Side note: For clinicians http://www.physio-pedia.

19 Side note: For clinicians _Exercise_for_Neck_Pain:_Clinical_Treatment_Toolkit

20 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision Elwyn G et al, on behalf of the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

21 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision Elwyn G et al, on behalf of the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

22 What happens if I don t get treatment? Every person s experience with neck pain is different Most people with non-specific neck pain experience a large decrease in pain and disability during the first 6-7 weeks after first noticing the pain 1 Average decrease in pain intensity: from 62/100 at the start to 34/100 after 6-7 weeks Average decrease in disability: from 30/100 at the start to 17/ weeks later Hush JM et al. Arch Phys Med Rehabil 2011; 92: Kamper SJ et al. Pain 2008;138: Carroll L et al. Spine 2008;33(4S):S Sterling M et al. Pain 2006;122(1-2): Sterling M et al. Pain 2010;150(1):22-8.

23 What happens if I don t get treatment? In neck pain from a whiplash injury, pain and disability will usually improve during the first 12 weeks 2 Average decrease in pain intensity: from 41/100 at the start to 24/100 six months later Average decrease in disability: from 41/100 at the start to 24/100 after six months Hush JM et al. Arch Phys Med Rehabil 2011; 92: Kamper SJ et al. Pain 2008;138: Carroll L et al. Spine 2008;33(4S):S Sterling M et al. Pain 2006;122(1-2): Sterling M et al. Pain 2010;150(1):22-8.

24 What happens if I don t get treatment? The majority of people who experience whiplash have recovered or have only mild symptoms remaining at 3-6 months after injury out of every 10 people who experience whiplash recover within 3-6 months 3-4 out of every 10 people have mild to moderate pain at 3-6 months 1-2 out of 10 people continue to have more severe pain at 3-6 months Hush JM et al. Arch Phys Med Rehabil 2011; 92: Kamper SJ et al. Pain 2008;138: Carroll L et al. Spine 2008;33(4S):S Sterling M et al. Pain 2006;122(1-2): Sterling M et al. Pain 2010;150(1):22-8.

25 Some people get better and others don t can we predict who recovers and who does not? Not really, but we know some contributing factors

26 Predictors of a poor outcome after a whiplash injury High baseline pain intensity (greater than 5.5/10) High level of disability at onset Headache, neck pain, or low back pain at onset Catastrophizing Depression Anxiety Less than postsecondary education Female sex WAD 3 (pain, weakness or numbness travelling down arm) Walton DM et al. JOSPT 2013;43(2): Hill JC et al. Clin J Pain 2007; 13(8):

27 Predictors of a positive outcome High expectations of recovery Wearing a seatbelt Walton DM et al. JOSPT 2013;43(2): Hill JC et al. Clin J Pain 2007; 13(8): Bishop MD et al. 2013;43(7):457-65

28 Not predictors of outcome Collision intensity Type of collision (ex: rear end vs. front end) Age Prior neck pain Prior headache Walton DM et al. JOSPT 2013;43(2): Hill JC et al. Clin J Pain 2007; 13(8):

29 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision Elwyn G et al, on behalf of the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

30 What are my treatment options? What are your options? Option #1: Exercise Option #2: Manual therapy Option #3: A combination of manual therapy and exercise Option #4: Other options Option #5: Do nothing or continue with current strategy

31 ICON ICON 2012 Medicine Physical Medicine Modalities Exercise & Manual Therapy Psychological Care Patient Education Injections Low Level Laser Exercise Patient Education Medication Traction Mobilization Psychology Electrotherapy Massage Orthotics Heat & Cold Manipulation Ergonomics Sonic Agents Prevention Acupuncture

32 ICON Results Whiplash Associated Disorder acute subacute/chronic Cervical manip or mob + cervical ROM and strengthening exercises vs traditional care for pain Ultrasound vs placebo for pain, function,gpe Botulinum-A injection vs placebo for pain, disability, GPE Education Video in ER vs placebo for pain Key: Moderate GRADE; High GRADE Benefit: IP; ST; IT; LT No Benefit: IP; ST; IT; LT (IP immediate post; ST short term, IT intermediate term, LT long term)

33 Non-specific mechanical neck pain acute subacute/chronic continuous traction vs placebo for pain and function (for neck pain of mixed duration) Manip or mob & Exercise vs exercise for pain in the short term but not for pain, function, GPE long term ; vs manip or mobilization alone for pain & QOL ; vs advice for pain Cervical / scapulothoracic ROM & strengthening exercise vs varied adjuncts for pain in the intermediate term but not long term function, PS, not GPE or QoL Nerve block injections with varying combinations of steroid and sarapin vs cntl for cervical facet joint pain for pain Qigong exercises vs wait-list control for pain and function Botulinum-A injecton vs placebo for pain ultrasound vs mobilization for pain Infrared light vs sham TENS for pain heat as an adjunct to mobilization, manipulation or EMS for pain, function, patient satisfaction Exercise, pulsed ultrasound, and massage vs no treatment for pain Low level laser therapy vs placebo for pain, function and QOL Acupuncture vs sham acupuncture, other placebo or no treatment for pain Intermitent traction vs no treatment or placebo for pain Oral eperison hydrochloride, a psychotropic agent vs placebo for pain manipulation vs mobilization for pain and function upper extremity stretching and endurance training vs normal activities for pain and function continuous traction vs placebo for pain and function (for neck pain of mixed duration)

34 Neck pain with cervicogenic headache acute subacute/chronic cervical mobilizations plus cervical and scapulothoracic endurance training vs no treatment for pain, function,gpe cervical and scapulothoracic endurance training vs no treatment for pain, function,gpe

35 Neck pain with radiculopathy acute subacute/chronic Intermitent traction vs no treatment or placebo for pain

36 There are a lot of options In the patient decision aid, emphasis is placed on manual therapy and exercise as that is where the strongest evidence of benefit exists

37 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the Elwyn treatment G et al, on behalf of decision the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

38 Steps to making an informed decision

39 Manual therapy and exercise provides.

40 Manual therapy and exercise provides.

41 Manual therapy and exercise provides.

42 Exercise alone is effective

43 Exercises can t be focused at just the arms and shoulders

44 Manipulation = mobilization in terms of effectiveness

45 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision

46 What are the risks?

47 What are the risks?

48 What are the risks?

49 That was a lot of info! Summary: For people with chronic neck pain: MT + EX provides greater short term pain relief than EX alone, but no difference in pain or function in long term MT + EX provides greater short- and long-term pain relief and improved function versus MT alone EX is effective in the short- and long- term Manipulation and mobilization appear to have similar effects on pain and function

50 That was a lot of info! Summary: MT + EX are both associated with a risk of shortterm increases in pain or worsening of current symptoms Manipulations also has a very small risk of more serious side effects such as long-lasting pain or stroke EX is effective in the short- and long- term

51 A choice to be made: Most people will choose exercise given the benefits and risks Some may choose to take the added risk of shortterm pain for the short-term benefit of reduced pain with mobilizations Others may choose to take the small, but more serious risk of manipulation for short-term pain relief despite evidence of equal effectiveness of manipulation and mobilization

52 Patient decision aid Key information needed to make an informed decision Description of the condition Natural history of the condition Description of treatment options Evidence of benefits for treatment options Evidence of risks associated with treatment options Patient asked to consider their own values in the treatment decision Elwyn G et al, on behalf of the International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal Aug 26;333(7565):417

53 Encouraging patients to consider their own values

54 What would I do if I had neck pain? For an acute episode of neck pain: I would educate myself on pain neurophysiology I would keep moving and stay involved in my usual life activities I would be confident that I will get better within 12 weeks if I keep active

55 What would I do if I had neck pain? If I have chronic neck pain: I would arm myself with as many tools for self-management as I can This would include a set of exercises to perform regularly I might get help from a physiotherapist if I was not confident in my knowledge of which exercises to perform Personally, I would not choose hands on or passive approaches to treat my neck pain, knowing that these are not likely to make a difference in the long-term I would consider other factors that may be contributing to my pain and address those Overly focused on my symptoms Stressed Depressed Anxious I would stay active and involved in my usual life activities

56 ICON Acknowledgements Grant Support: Meeting, Planning, Dissemination Grant: Knowledge Translation Supplement University Partners: Research Partners: Industry Partners: COG 11 Reviews

57 Thank you for attending. QUESTIONS? Contact us: Jordan Miller CIRDP We acknowledge the financial assistance of the Province of British Columbia PAIN BC CANADIAN PAIN COALITION

How to use movement and graded exposure to reduce pain. Jordan Miller, MSc PT

How to use movement and graded exposure to reduce pain Jordan Miller, MSc PT McMaster University, Hamilton, Ontario For Webinar Series: Chronic Pain Improving Life While Living It We acknowledge the financial