Natural history of nonspecific neck pain and whiplash with factors associated with chronic disability

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Nontraumatic causes

Nonspecific neck pain usually resolves within days or weeks, but can recur or become chronic. Once pain becomes persistent, outcome is more unpredictable, and there is little consistency in the literature regarding the duration of symptoms and factors that influence outcome. A systematic review of the clinical course and prognostic factors in nonspecific neck pain found little consensus as to outcome or relevant prognostic factors, although this was based on poor-quality studies [19]. The systematic review found evidence that in patients with chronic pain treated in secondary care or an occupational setting, 20-78% (median 54%) of patients remained symptomatic, irrespective of the therapy given. Six of the included studies documented prognostic factors, and the severity of pain at presentation was the best predictor of a poor outcome, although previous episodes of neck pain were also important. Three subsequent studies also considered the factors at presentation which might influence outcome at 1 year, and found older age, and concomitant low back pain [10, 20] and severity and duration of the pain [21] to be significant. Patients with chronic spinal conditions were also found to have other chronic pain syndromes (69%), chronic physical conditions (55%) or psychologic problems (35%)[22, 23].

Neck pain with neurological complications

Many patients with neurological abnormality as a result of nonspecific neck pain will require MRI scanning of the cervical spine at an early stage, particularly if there is progressive myelopathy or intractable pain. Radiculopathy generally has a favorable outcome, although recovery can be slow. The result of decom-pressive surgery for myelopathy complicating nonspecific neck pain is often disappointing. While the rate of progression of the neurological loss may be slowed by the surgery, the lost function may not recover or symptoms may progress at a later date. The poor outcome following surgery may reflect the irreversible damage to the cervical cord or compromise to the vascular supply to the cord immediately or subsequently.

Whiplash

The prognosis for whiplash is also generally favouable [12] but as already mentioned, shows great variability as to the frequency, severity and duration of disability. This variability in outcome is at least in part related to the culture of litigation and compensation [1] but this cannot explain all the differences, particularly within the same population. Two comprehensive systematic reviews [12, 13] found little consistency as to factors influencing outcome, although societal factors like litigation and compensation culture were most important [1, 24, 25]. How other societal factors influence outcome is complex and even more poorly understood [26]. Systematic reviews of prognostic factors following whiplash injury [12, 13, 17] found conflicting evidence for pre-existing physical or psychologic factors, or crash-related factors. The most consistent predictors of an unfavorable outcome from the systematic reviews and subsequent studies were severity of pain, headache and disability at presentation.

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