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STUDY DESIGN: Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders. OBJECTIVE: To provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help organize and interpret existing knowledge, and to highlight gaps in the current literature. SUMMARY OF BACKGROUND DATA: The wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual model for appropriate interpretation of the research evidence. METHODS: The 12-member Scientific Secretariat of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved by the group. RESULTS: Our new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short- and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies based on how subjects were recruited into each study. CONCLUSION: The Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions.

STUDY DESIGN Best evidence synthesis. OBJECTIVE To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease. SUMMARY OF BACKGROUND DATA There have been no comprehensive systematic literature or evidence-based reviews published on this topic. METHODS We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis. RESULTS Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (

Study design Best evidence synthesis. Objective To critically appraise and synthesize the literature on assessment of neck pain. Summary of background data The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature. Methods The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain. Results We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain. Conclusion The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

Study design Best-evidence synthesis. Objective To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in workers. Summary of background data Knowledge of the course of neck pain in workers guides expectations for recovery. Identifying prognostic factors assists in planning effective workplace policies, formulating interventions and promoting lifestyle changes to decrease the frequency and burden of neck pain in the workplace. Methods The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working populations. Between 60% and 80% of workers with neck pain reported neck pain 1 year later. Few workplace or physical job demands were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis. Conclusion The Neck Pain Task Force presents a report of current best evidence on course and prognosis for neck pain. Few modifiable prognostic factors were identified; however, having some influence over one's own job and being physically active seem to hold promise as prognostic factors.

Best evidence synthesis. To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades I–III whiplash-associated disorders (WAD). Knowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning management and intervention strategies and effective compensation policies to decrease the burden of WAD. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD. The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.

STUDY DESIGN: Best evidence synthesis. OBJECTIVE: To undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated disorders in the general population. SUMMARY OF BACKGROUND DATA: The evidence on burden and determinants of neck has not previously been summarized. METHODS: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting criteria for scientific validity were included in a best evidence synthesis. RESULTS: We identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years (disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing. CONCLUSION: Neck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain. Language: en

Best evidence synthesis. To undertake a best evidence synthesis on the burden and determinants of whiplash-associated disorders (WAD) after traffic collisions. Summary of Background Data. Previous best evidence synthesis on WAD has noted a lack of evidence regarding incidence of and risk factors for WAD. Therefore there was a warrant of a reanalyze of this body of research. A systematic search of Medline was conducted. The reviewers looked for studies on neck pain and its associated disorders published 1980 –2006. Each relevant study was independently and critically reviewed by rotating pairs of reviewers. Data from studies judged to have acceptable internal validity (scientifically admissible) were abstracted into evidence tables, and provide the body of the best evidence synthesis. The authors found 32 scientifically admissible studies related to the burden and determinants of WAD. In the Western world, visits to emergency rooms due to WAD have increased over the past 30 years. The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during rear-end collisions had a preventive effect on reporting WAD, especially in females. WAD after traffic collisions affects many people. Despite many years of research, the evidence regarding risk factors for WAD is sparse but seems to include personal, societal, and environmental factors. More research including, well-defined studies with accurate denominators for calculating risk, and better consideration of confounding factors, are needed.

Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders. To provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help organize and interpret existing knowledge, and to highlight gaps in the current literature. The wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual model for appropriate interpretation of the research evidence. The 12-member Scientific Secretariat of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved by the group. Our new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short- and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies based on how subjects were recruited into each study. The Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions.

Study design Best evidence synthesis. Objective To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders. Summary of background data No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade. Methods We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis. Results Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus. Conclusion Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.

Study design Systematic review and best evidence synthesis. Objectives To describe the prevalence and incidence of neck pain and disability in workers; to identify risk factors for neck pain in workers; to propose an etiological diagram; and to make recommendations for future research. Summary of background data Previous reviews of the etiology of neck pain in workers relied on cross-sectional evidence. Recently published cohorts and randomized trials warrant a re-analysis of this body of research. Methods We systematically searched Medline for literature published from 1980-2006. Retrieved articles were reviewed for relevance. Relevant articles were critically appraised. Articles judged to have adequate internal validity were included in our best evidence synthesis. Results One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible. The annual prevalence of neck pain varied from 27.1% in Norway to 47.8% in Quebec, Canada. Each year, between 11% and 14.1% of workers were limited in their activities because of neck pain. Risk factors associated with neck pain in workers include age, previous musculoskeletal pain, high quantitative job demands, low social support at work, job insecurity, low physical capacity, poor computer workstation design and work posture, sedentary work position, repetitive work and precision work. We found preliminary evidence that gender, occupation, headaches, emotional problems, smoking, poor job satisfaction, awkward work postures, poor physical work environment, and workers' ethnicity may be associated with neck pain. There is evidence that interventions aimed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers. Conclusion Neck disorders are a significant source of pain and activity limitations in workers. Most neck pain results from complex relationships between individual and workplace risk factors. No prevention strategies have been shown to reduce the incidence of neck pain in workers.

Study design Best evidence synthesis. Objective To provide a detailed description of the methods undertaken in a systematic search and perform a best evidence synthesis on the frequency, determinants, assessment, interventions, course and prognosis of neck pain, and its associated disorders. Summary of background data Neck pain is an important cause of health burden; however, the published information is vast, and stakeholders would benefit from a summary of the best evidence. Methods The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders conducted a systematic search and critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain. Citations were screened for relevance to the Neck Pain Task Force mandate, using a priori criteria, and relevant studies were critically reviewed for their internal scientific validity. Findings from studies meeting criteria for scientific validity were synthesized into a best evidence synthesis. Results We found 31,878 citations, of which 1203 were relevant to the mandate of the Neck Pain Task Force. After critical review, 552 studies (46%) were judged scientifically admissible and were compiled into the best evidence synthesis. Conclusion The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders undertook a best evidence synthesis to establish a baseline of the current best evidence on the epidemiology, assessment and classification of neck pain, as well as interventions and prognosis for this symptom. This article reports the methods used and the outcomes from the review. We found that 46% of the research literature was of acceptable scientific quality to inform clinical practice, policy-making, and future research.

STUDY DESIGN Best evidence synthesis. OBJECTIVE To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. SUMMARY OF BACKGROUND DATA Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. METHODS The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. RESULTS We found 226 articles on the course and prognostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psychosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prognostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. CONCLUSION The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.

STUDY DESIGN: Decision analysis. OBJECTIVE: To identify the best treatment for nonspecific neck pain. SUMMARY OF BACKGROUND DATA: In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects. METHODS: (Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial. RESULTS: There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days. CONCLUSION: When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior

Context Coronary heart disease (CHD) mortality has declined substantially in Canada since 1994. Objective To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments. Design, Setting, and Patients Prospective analytic study of the Ontario, Canada, population aged 25 to 84 years between 1994 and 2005, using an updated version of the validated IMPACT model, which integrates data on population size, CHD mortality, risk factors, and treatment uptake changes. Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and (1) evidence-based therapies in 8 distinct CHD subpopulations (acute myocardial infarction [AMI], acute coronary syndromes, secondary prevention post-AMI, chronic coronary artery disease, heart failure in the hospital vs in the community, and primary prevention for hyperlipidemia or hypertension) and (2) population trends in 6 risk factors (smoking, diabetes mellitus, systolic blood pressure, plasma cholesterol level, exercise, and obesity). Main Outcome Measures The number of deaths prevented or delayed in 2005; secondary outcome measures were improvements in medical treatments and trends in risk factors. Results Between 1994 and 2005, the age-adjusted CHD mortality rate in Ontario decreased by 35% from 191 to 125 deaths per 100 000 inhabitants, translating to an estimated 7585 fewer CHD deaths in 2005. Improvements in medical and surgical treatments were associated with 43% (range, 11% to 124%) of the total mortality decrease, most notably in AMI (8%; range, −5% to 40%), chronic stable coronary artery disease (17%; range, 7% to 35%), and heart failure occurring while in the community (10%; range, 6% to 31%). Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed (48% of total; range, 28% to 64%), specifically, reductions in total cholesterol (23%; range, 10% to 33%) and systolic blood pressure (20%; range, 13% to 26%). Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6% (range, 4% to 8%) and 2% (range, 1% to 4%), respectively. Conclusion Between 1994 and 2005, there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments, each explaining about half of the decrease.