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The Clinical Course of Neck Pain

A recent study correlates muscle-fat infiltration of multifidi with decreased physical ability among seniors with low back pain (LBP). This adds to previous studies finding that asymmetrical multifidus atrophy predicts low back pain recurrence and that lower muscle quality predicts decreased physical function among people without LBP. The persistence of multifidus atrophy and fat infiltration, even among so-called spontaneous resolvers, and its causal role in chronicity underscore the importance of active approaches toward LBP treatment.

Last July, the Journal of Orthopaedic & Sports Physical Therapy updated clinical guidelines containing the latest evidence on the course of neck pain. Understanding the clinical course of conditions can help with treatment decisions and advice to patients. However, aggregated information must be interpreted with the understanding that subjects observed may have received no treatment or participated in any of a range of treatments. In the case of neck pain, this may include physiotherapy, surgery, pharmacological treatments, chiropractic, etc. That being said, Roy Altman MD and colleagues, the authors of the latest guidelines, generalise the clinical course of neck pain as “variable and not entirely favourable.” 


The good news is that for acute cervical radiculopathy specifically, the natural course appears favourable, with resolution in weeks to months in most cases. The systematic review of Thoomes, et al. finds that physiotherapy shows “promising results at short-term follow-up.” Studies find that active rehabilitation gets better results than wait-and-see or advice to remain active.


For the remainder of neck pain categories, the clinical course proves less favourable. For acute, nontraumatic (idiopathic) neck pain, most cases become recurrent, characterised by periods of relative improvement followed by periods of worsening. This pattern underscores the importance of focusing treatment goals on minimising recurrence, rather than labelling the closure of one pain episode as recovery. Additionally, the majority of improvement occurs within the first six weeks. Improvement after the first six weeks slows considerably.


Acute, traumatic neck conditions can be considered to follow one of three trajectories: mild problems with rapid recovery; moderate problems with incomplete recovery; and severe problems with limited recovery. The approximate likelihood of each trajectory is 45%, 40%, and 15%, respectively. Unfortunately, the majority of patients with acute, traumatic neck conditions (approximately 55%) realise incomplete to no recovery. Recovery occurs most rapidly in the first six weeks following the injury, with considerable slowing afterwards.


The importance of the first six weeks in the recovery process stands out as a recurring theme and challenges the practice of watchful waiting. This is consistent with previous studies demonstrating that greater and more cost-effective outcomes are achieved in spine conditions the sooner physical therapy begins. When Rosenfeld et al. compared whiplash patients receiving advice, active care at 96 hours, or active care at 14 days, only the 96-hour group had cervical range of motion approaching that of uninjured controls at three-year follow-up. Active treatment groups also experienced less pain at six-month and three-year follow-ups.


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