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In the introduction to this report of the “Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders,” Haldeman et al1 state that “most people can expect to experience some degree of neck pain in their lifetime.” Summarizing the epidemiology of neck pain is a natural starting point in any investigation of neck pain. We want to describe who gets neck pain and why. Many reports describing the incidence, prevalence, risk, and associated factors of neck pain appear in the scientific literature. From these, we can better understand the magnitude of the condition to plan and provide appropriate health care. Knowledge about risk and associated factors may also suggest preventive strategies and help to identify and target important subgroups of the population at greatest risk for neck pain.
The main objective of the Neck Pain Task Force report was to systematically search the scientific literature on neck pain and produce a best evidence synthesis on the epidemiology (incidence, risk factors, prevalence and factors associated with prevalent neck pain), diagnosis, treatment, and course and prognosis of neck pain. In this article, we present the results of a systematic review of the scientific literature and our best evidence synthesis on the incidence, risk factors, prevalence, and associated factors for neck pain in the general population.
Materials and Methods
Design and Data Collection
The literature search and critical review strategy is outlined in detail elsewhere.2 We systematically searched the electronic database Medline for literature published from 1980 through 2005 on neck pain and its associated disorders; we also systematically checked reference lists of relevant articles and updated the search to include key articles for 2006 and early 2007.
We screened each citation for relevance to the Neck Pain Task Force mandate, using a priori inclusion and exclusion criteria; however, we made no attempt to assess the scientific quality of each study when establishing its relevance. Screening criteria are reported in more detail in Carroll et al2 Studies were considered relevant if they pertained to the assessment, incidence, prevalence, determinants or risk factors, prevention, course, prognosis, treatment and rehabilitation, or economic costs of neck pain; if they contained data and findings specific to neck pain and/or disorders associated with neck pain; if they included at least 20 persons with neck pain or at risk for neck pain; or if they described a systematic review of the literature on neck pain. We excluded studies on neck pain that was associated with serious local pathology or systemic disease, such as neck pain from fractures or dislocations (except where such studies inform differential diagnosis in neck pain); myelopathy; rheumatoid arthritis and other inflammatory joint diseases; or tumors.
Rotating pairs of Scientific Secretariat members performed independent, in-depth critical reviews of each article, identifying methodologic strengths and weaknesses, and made decisions about the article's scientific merit after discussions of each article. (The criteria used in the methodologic appraisal of the studies can be viewed by going to Article Plus). Our methodologic appraisal focused on sources of potential selection bias, information bias, confounding; and consideration of whether these biases would likely result in erroneous or misleading conclusions. Studies judged to have adequate internal validity were considered “scientifically admissible” and were included in our best evidence synthesis.
In the current article, we report our best evidence synthesis of scientifically admissible studies related to incidence, risk factors, prevalence, and factors associated with prevalent neck pain in the general population, pertaining to any age and including groups participating in leisure activities such as sports. The best evidence synthesis of studies pertaining to the risk of neck pain in particular occupational groups, or risk or associated factors for neck pain arising at work are reported elsewhere,3 as are studies pertaining to risk of traffic-related whiplash-associated disorders (WAD).4
In this best evidence synthesis, we classified studies according to whether they provided information about incidence and/or risk factors (cohort, case/control, and twin studies) or about prevalence and/or factors associated with prevalent neck pain (cross-sectional studies). Whereas risk factors predict future neck pain, factors associated with prevalent neck pain (identified from cross-sectional studies) coexist with neck pain and therefore might be risk factors for neck pain, prognostic factors for neck pain or consequences of neck pain.
Further grouping was driven by the content of the identified evidence. For instance, several cohort and case-control studies of neck injury in sports were grouped together. Similarly, it was practical to divide the cross-sectional studies into those concentrating on children or adolescents and those including adults.
Studies of risk factors—cohort studies and case-control studies—were further classified using a methodology proposed for prognostic factors,5–7 but also previously adapted for studies of risk.8,9 This classification distinguishes 3 types of study:
- Phase I studies are exploratory, hypothesis generating studies characterized by descriptive exploration and demonstration of crude (unadjusted) associations.
- Phase II studies are also exploratory, but employ multivariable techniques or stratification to identify risk factors related to the onset of neck pain while adjusting for other factors.
- Phase III studies are confirmatory studies of a priori hypotheses which verify one or more factors as independent risk factors for the incidence of neck pain after adjusting for confounding.
In accordance with our conceptual frame work on the course and care of neck pain,10 risk and associated factors for neck pain were organized into categories, namely Demographics/Socioeconomic Factors, Prior Health/Prior Pain/Comorbidities, Collision/Workplace Factors, Psychological and Social Factors, Compensation/Laws/Societal Factors, Genetics, Health Behaviors, and Cultural Factors.
Incidence rates, estimates of prevalence, and relative risks with confidence intervals (CIs) are presented in the tables as reported in the original articles, or when possible, as calculated from raw data provided in those articles. Exact CIs were calculated using SAS V9.1.11
We critically appraised 469 studies related to the epidemiology of neck pain (incidence, risk factors, prevalence, and factors associated with prevalent neck pain), and judged 249 of these to be scientifically admissible.2 Of these, 17 studies were related to incidence and risk factors for neck pain and its associated disorders in the general population, and are summarized below.
Incidence and Risk Factors for Neck Pain in the General Population
Seventeen studies were related to incidence and risk factors in the general population and scientifically admissible for inclusion in our best evidence synthesis.12–28 (These are summarized in Evidence Table 1 and can be viewed online through Article Plus.)
Nine cohort studies (below) provided estimates of incidence rates for neck pain in the general population. Target populations, based in northern European countries, Canada, and the United States, were most often defined by catchment area or by the registration lists of individual health care facilities.
Different methods were used to identify cases of neck pain. Some studies13–15,23,25,28 identified cases when people sought care for their symptoms; 3 others16,17,27 used survey methods involving questionnaires. Case definitions for neck pain were disparate; they included self-reported pain lasting at least a day, a diagnosis of neck sprain/ strain (ICD-9 code 847.0) by a physician, neck pain/symptoms prompting a visit to a health center, neck injury prompting a visit to a hospital emergency department or hospital, and a diagnosis of soft disc protrusion demonstrated by myelography or surgery. Variations in population and setting, inclusion/exclusion criteria, method of ascertainment, and case definition likely accounted for the variability in estimated incidence rates.
Table 1 shows the incidence rates per 1000 person years (PY) or the cumulative incidence per 1000 persons ordered roughly from lowest to highest range.13–17,23,25,27,28 The lowest rates pertain to neck injuries presenting to a hospital or emergency department, or to specific conditions such as disc protrusion/herniation. Intermediate rates arise from studies of visits for health care, while the highest rates come from self-reports of neck pain via survey questionnaires.
Risk Factors for Neck Pain
Evidence regarding age as a risk factor for neck pain varied. The only Phase II study to consider age as a risk factor reported no association between age and incidence of neck pain after controlling for other factors: compared to people aged 18 to 29 years, the relative risk (RR) for those aged 30 to 44 years was 1.0 (95% CI, 0.7–1.4); for those aged 45 to 59 years, it was 0.9 (95% CI, 0.6–1.3); and for those aged 60 or greater, it was 0.7 (95% CI, 0.5–1.1).17
However, 3 phase I cohort studies14,23,25 showed that the risk for neck pain increased with age up to a peak and decreased thereafter. Peak incidence of neck pain coincided with middle-age groups peaking at ages 40 to 49,14 and ages 35 to 44.25 For diagnosed protrusion with radicular syndrome, the peak incidence was at 45 to 54 years.23 On the other hand, when dichotomizing age into 20 to 46 years and >46 years, Côté et al16 found the crude incidence of neck pain was lower for the older age group [incidence rate ratio (IRR) 0.60, 95% CI, 0.38–0.93].
The relationship between gender as a risk factor and neck pain varied depending on case definition for pain. Two Phase I cohort studies23,28 showed higher incidence rates for men; one study included cases of non-MVC neck sprain/strain injuries presenting to hospital (“incidence over the whole age range showed a male predominance, statistically significant Z-values ranged from 2.2 to 3.6 P < 0.05)”28); the other included cases of disc protrusion with radicular syndrome (IRR = 1.41; 95% CI, 0.84–2.39; for men vs. women).23 One phase I cohort study15 showed similar incidence rates for men and women of minor/moderate neck injury identified in emergency departments (IRR, 1.14; 95% CI, 0.67–1.94). Women showed higher rates of visits to a health care center for neck pain (2.6 visits per 1000 for men 95% CI, 2.1–3.0, and 3.5 visits per 1000 for women 95% CI, 3.0–4.025). Finally, women showed increase risk of neck pain reported via questionnaire17,27 in one Phase II (RR, 1.2; 95% CI, 0.9–1.5) and one Phase I cohort (IRR, 1.98, 95% CI, 1.53–2.58), while women were at higher risk only for mild (i.e., nonintense, nondisabling) neck pain in a Phase I cohort (IRR, 2.30; 95% CI, 1.27–3.87).16
One Phase II cohort17 found that the risk of neck pain in adults increased with how many children they had [this emerged as an independent risk factor for neck pain; odds ratios (OR) and 95% CI relative to no children are 1.2 (0.9–1.8) for one child, 1.2 (0.9–1.7) for 2 children, 1.5 (1.0–2.1) for 3 children and 1.6 (1.1–2.4) for 4 or more children]. In the same study, marital status and car ownership were considered, but were not found associated with neck pain in adults.
Croft et al17 also investigated employment status as a potential risk factor for neck pain and found no relationship after adjusting for other factors of interest—except for a higher rate of incident neck pain among those not working due to ill health and/or disability at baseline (compared to those working full time, unadjusted RR, 1.9; 95% CI, 1.2–2.9).
Prior Health/Prior Pain/Comorbidities.
A Phase III cohort found that health care visits for a variety of health issues were predictive of neck pain 25 years later.18 One phase II cohort17 identified a history of neck pain (RR, 1.7; 95% CI, 1.2–2.5), poor self-assessed health (compared to excellent health, RR for good health 1.0; 95% CI, 0.7–1.4; fair health 1.3; 95% CI, 0.9–1.9; poor health 1.3; 95% CI, 0.7–2.3) and a history of low back pain (RR, 1.7; 95% CI, 1.3–2.1) as independent risk factors for neck pain. Body mass index (BMI) was not identified as an independent risk factor in one Phase II study.17
Collision and workplace factors as they pertain to neck pain are considered elsewhere in the Neck Pain Task Force report.3,4 However, we included one finding from Berglund et al about collisions as it relates to neck pain in the general population and not specifically to whiplash-associated disorders (WAD). Previous trauma to the neck via exposure to a motor vehicle collision was associated with subsequent neck pain prevalence at 7-year follow-up only when there had been a report of WAD following the collision (RR, 2.7; 95% CI, 2.1–3.5). Those who had been involved in a collision but did not report WAD as a result of that collision had no higher prevalence of neck pain 7 years later than those who had not been in a collision (RR, 1.3, 95% CI, 0.8–2.0).12
Psychological and Social Factors.
There was consistent evidence from 2 cohorts that psychological factors are risk factors for neck pain. Siivola et al26 found psychosomatic symptoms in adolescence predictive of newly reported neck pain in young adulthood (for one unit change in psychosomatic score OR 1.0; 95% CI, 1.0–1.1). One Phase II cohort17 identified poor psychological status, as measured by the General Health Questionnaire (GHQ), as an independent risk factor for neck pain (compared to GHQ score 0–7, RR of GHQ 8–12, 1.1; 95% CI, 0.8–1.5; GHQ 13–17, 1.6; 95% CI, 1.1–2.3; GHQ 18–36, 1.5; 95% CI, 1.0–2.7).
We found no study or studies that reported on compensation factors, laws or societal factors as risk factors for neck pain in the general population.
Three twin studies provided evidence about genetics showing an interaction between the heritability of neck pain and age. MacGregor et al24 showed excess concordance of neck pain in monozygotic as compared to dizygotic twins aged 45 to 79. Heritability was estimated at 48% (95% CI, 29–67) for any lifetime neck pain and 35% (95% CI, 9–61) for severe disabling neck pain. Hartvigsen et al21 reported that dominant genetic or common environmental effects did not affect the overall occurrence of neck pain among Danish twins aged 75 years and over. Finally, Fejer et al20 reported overall heritability of lifetime neck pain as 45% (95% CI, 40–49) in young and middle-aged Danish twins; however, heritability was negligible in the oldest age group.
A Phase III cohort19 found that Norwegian nurses' aides exposed to environmental tobacco smoke in childhood had an increased risk of neck pain compared to those with no such exposure (adjusted odds ratios of 1.37 (95% CI, 1.03–1.84) and 1.32 (95% CI, 1.00–1.74) for those sometimes and often exposed, respectively).
Two Phase II cohorts17,22 investigated a variety of health behaviors including cigarette smoking, other kinds of tobacco use, alcohol consumption, time spent in automobiles or on motorcycles and the wearing of high-heeled shoes. There was consistent evidence from 2 studies for current smoking as a risk factor for neck pain. One study of disc herniation (confirmed by radiograph of myelogram)22 reported an elevated risk for current smokers compared to those who had never smoked (age- and sex-matched controls; OR = 2.1, 95% CI, 0.9–5.0); another study of self-reported neck pain17 found an age- and sex-adjusted RR for current smokers of 1.2 (95% CI, 0.9–1.5) compared to those who never smoked.
Kelsey et al22 reported an increased risk for neck pain related to motorcycle riding (cases 0.5 hours/wk vs. controls 0.04 hours/wk, P value 0.06). Finally, there was no increased risk of neck pain associated with wearing high-heeled shoes.22
Cultural Factors and Neck Pain.
We found no study or studies reporting on cultural risk factors for neck pain in the general population.
Incidence of Sports-Related Neck Pain
Seventeen studies (on 15 separate cohorts of subjects) reporting incidence and risk of neck pain related to participation in sports were judged scientifically admissible and are described in Evidence Table 2 (available online through Article Plus).22,29–43
Twelve studies (10 distinct cohorts of study participants)30–38,40,41 provided incidence rate estimates for neck pain while people were participating in some kind of sports activity. All but one of these studies38 were based in North America. These included 4 cohorts of people playing ice hockey30–33 and one each of those engaged in football,34,35 lacrosse,36 luge,37 Tae-kwon-do,40 wrestling,41 and car racing.38 Incidence rates of neck pain, ordered roughly from lowest to highest, are noted in Table 2.
Risk Factors for Sports-Related Neck Pain
Information about neck pain risk associated with age and gender during sports is sparse because most studies included a narrow age range, and some included only male athletes. However, Lorish et al41 in a phase I cohort noted an increased risk of injury with increasing age among young wrestlers (aged 6–16 years), after controlling for body weight (from logistic regression, P value for age 0.01). Hinton et al36 reported a higher risk of neck injury among male versus female high school lacrosse players (a Phase I cohort, IRR, 3.89; 95% CI, 1.13–20.73).
Prior Health/Prior Pain/Comorbidities.
A Phase II cohort study found that varsity football players with a history of neck injury were more likely to sustain a new neck injury than were players with no previous neck injury (RR, 5.04; 95% CI, 3.1–8.2).34
Collision and workplace factors as they pertain to neck pain are considered elsewhere in the Neck Pain Task Force report.3,4
Psychological and Social Factors.
We found no study or studies that examined psychological or social factors as risk factors for neck pain during sporting activities.
One Phase I cohort study33 showed a large reduction in risk for neck injury (from 2.37 to 0.56 neck injuries per 1000 player games) among people who played hockey after officials implemented a new system of stiffer penalties on players who checked other players from behind (IRR 0.24, 95% CI, 0.05–1.08). No other scientifically admissible studies considered legal or rule changes in sport.
We found no study or studies that examined genetic factors as risk factors for neck pain during sporting activities.
Three studies investigated the relationship between neck injury and sporting equipment, and generally found no increase in neck pain associated with the equipment under study. In a Phase I cohort study of bicyclists with injuries, neck sprain was not associated with helmet use (OR, 0.9; CI, 0.6–1.5).29 Helmet use was also investigated in a Phase III study of skiers to see whether helmet use would reduce head injuries without any concurrent rise in neck injuries.39 The odds of sustaining a head injury were reduced with a helmet; the odds ratio of sustaining a neck injury with a helmet, compared to no helmet, was 0.62 (95% CI 0.33–1.19). A Phase III study of ice hockey players found the risk of neck injury was similar, whether players wore a full face-shield or a half face-shield (RR of half-shield 1.16; 95% CI, 0.43–3.16).30 However, the risk for facial and dental injuries was greatly reduced among players who wore the full face-shields (RR of half-shield 2.52; 95% CI, 1.73–3.68).
Three studies investigated whether participation in a range of physical activities is a protective factor for neck pain,22,42,43 and the evidence varies. The Phase III study43 found that regular participation in a sport for at least 10 months a year was protective for neck pain (OR, 0.82; 95% CI, 0.67–0.99). This was a strong study with a sophisticated analysis; however, the sample at baseline included those with and without neck pain at baseline, raising the possibility of prevalence-incidence bias, and so it should be interpreted with caution. The other two studies—small case-control studies, both Phase II, and very similar in population, design, and measurement—reported conflicting findings on whether participation in sports activities was associated with risk of disc herniation.
We found no study or studies that examined cultural factors as risk factors for neck pain during sporting activities.
The Prevalence of Neck Pain and Associated Factors in the General Population
Evidence is presented separately for studies of adults or entire populations (i.e., children and adults) (Evidence Table 3 available online through Article Plus) and for those which focused on children and adolescents (Evidence Table 4 available online through Article Plus). For adult general populations, we judged 54 studies (reporting on 45 separate samples of participants) to be scientifically admissible.20,24,45–96 For children/adolescents, we judged 18 studies (13 separate samples of participants) to be scientifically admissible.26,53,97–112 Studies of adults came from countries around the world, although the vast majority were from North America, Scandinavian and northern European countries. Except for one study from New Zealand and one from Canada, all studies of children and/or adolescents were based in Scandinavian or northern European countries.
Studies relating to the general population show large variations in prevalence estimates. Variations in population, inclusion/exclusion criteria, case definition and case ascertainment all likely contributed to these differences. Case definitions varied with respect to the time period of interest (point prevalence, 1-month, 6-month, 12-month, or lifetime). The studies also varied in the intensity, frequency and duration of neck pain, the types of symptoms included, and whether or not neck pain interfered with daily activities. Finally, studies differed on how data were collected—for example, whether neck pain was the main focus of study or one of a long list of conditions, whether data were collected via questionnaire, and whether cases were confirmed by physical examination.
Prevalence estimates for lifetime, 12-month and 1-month prevalence of neck pain are presented in Figure 1. Prevalence estimates for other periods are presented in the evidence tables (Evidence Tables 3 and 4, available online through Article Plus).
- As the period of time increased, from point-prevalence to lifetime-prevalence, the prevalence of neck pain generally increased.
- Measures of any pain not qualified by frequency, duration and/or accompanying interference with activities tended to be larger than estimates for pain that had been qualified in some way.
- For each period, the prevalence of neck pain which interfered with activities was much lower than the prevalence of any neck pain.
- Finally, prevalence estimates of very specific diagnoses such as cervicogenic headache or spondylotic radiculopathy were very much lower than prevalence estimates of any pain or of pain interfering with activity.
To illustrate findings on neck pain prevalence, we might consider 1-month and 12-month prevalence:
- One-month prevalence estimates of any neck pain ranged from 15.4% to 45.3% among adults and from 4.5% to 8.5% among children/adolescents.
- When pain was qualified as frequent (e.g., weekly) or of specified duration (at least a week), estimates ranged from 12% to 14% among adults and 8% among adolescents.
- One-month prevalence interfering with activities among adults ranged from 7.5% to 14.5%.
- One-month prevalence of cervicogenic headache among adults was estimated as 2.5%.
There were similar patterns for 12-month prevalence:
- The 12-month prevalence of any neck pain among adults ranged from 12.1% to 71.5% and among children ranged from 34.5% to 71.5%.54,57,60,64,78,84,86,94,98,105 Most estimates of 12-month prevalence were between 30% and 50%.
- The 12-month prevalence of neck pain-limiting activities among adults was estimated as 1.7% (limited ability to work due to neck pain)57; 2.4% (limited social activities due to neck pain)57; and 11.5% (limited activities due to neck pain).84
Factors Associated With the Prevalence of Neck Pain in the General Population
Complete statistical documentation such as measures of effect (odds ratios, risk ratios) and their significance or precision for associations described here can be found in Evidence Tables 3 and 4 (available online through Article Plus).
The preponderance of evidence on neck pain prevalence by age group among adults shows increasing prevalence with age (to a peak during the middle years and declining prevalence thereafter).46,51,52,66,68,76,86,88,90,92 Gordon et al65 noted a similar peaking during middle age for men, but not for women, whereas Urwin et al91 noted this trend for women, but not for men. Ciancaglini et al,60 Hasvold et al,72 and Webb et al93 reported increasing prevalence with increasing age. Chiu et al57 reported no significant association between neck pain prevalence and age, although crude prevalence showed highest values for the middle-age group. Findings by Côté et al61 showed the familiar decline in prevalence in later years for any neck pain; however, when neck pain was stratified by intensity and disability, low intensity, nondisabling neck pain, declined markedly with increasing age, whereas high intensity neck pain and neck pain with disability had more consistent prevalence across age groups.
Among children and adolescents, the relationship between age and prevalence reported in 8 studies varied. In 4 studies, the prevalence of neck pain increased with age,100,104,106,109 whereas 2 studies showed similar prevalence at different ages,105,112 and 2 studies showed reduced prevalence with age.108,110
The preponderance of evidence showed higher prevalence for women than men 46,50,57,60–62,66,68,72,75,76,81,86,88,91,93,94 and for girls over boys 53,98,100,102,103,105,107–110,112 with ratios ranging from 1.2 to 2.0 for 1-month prevalence and 1.1 to 3.4 for 12-month prevalence. There were some exceptions: one study found no gender association,52 another found higher prevalence among men than women (31% vs. 27%)78 and another found higher prevalence for women under 40 years, but higher prevalence for men at older ages.65 Most of these are reports of crude (unadjusted) prevalence.
The preponderance of evidence showed no association between neck pain and socioeconomic status (SES) or its correlates (education, income, home ownership, social deprivation)47,57,62,71,78,91,93,94,98 although three52,68,81 of 7 studies47,52,57,62,68,71,81 that considered education reported increased neck pain prevalence with lower education.
Five studies examined the relationship between employment status and neck pain prevalence among adults, with varied findings. In 2 studies, there was no association.62,81 However, one study52 reported a higher prevalence of neck pain among retired versus employed persons. Another study68 reported lower prevalence for pensioners and those on sick leave, whereas Chiu et al57 reported lower neck pain prevalence for housewives, unemployed and retired persons compared to employed managers and professionals. The single study considering employment among adolescents97 found higher neck pain prevalence among working adolescents compared to those not working.
Prior Health/Prior Pain/Comorbidities.
Consistent associations were reported between neck pain and a number of other health factors including other musculoskeletal aches and pains,103,104,109 previous trauma to the neck,56,62,63,78,81 headache,62,69,71,72 disability,56,80 poorer general or self-rated health,62,64,71 sleep disturbances47,76,104 and restricted range of motion.56 Two studies109,111 reported no association between neck pain prevalence and age at puberty. One study53 investigated the relationship between parental musculoskeletal pains in various body regions and neck pain in adolescent offspring; they found an association between neck pain in the mother and/or father and neck pain in the offspring. Associations between parental musculoskeletal pain and adolescent neck pain could reflect genetic mechanisms, shared environments or psychosocial issues.
The preponderance of evidence suggests no relationship between body mass index (BMI) and prevalent neck pain.47,61,71,81,93,105,109
Findings for a relationship between radiographic evidence of degeneration and neck pain prevalence varied. One study85 reported no significant difference in amount of pain and disability between neck-pain patients with and without radiographic evidence of cervical spine degeneration. Another study92 showed increasing prevalence of neck pain with increasing grade of disc degeneration; however, after controlling for age, this relationship remained statistically significant only for men. Finally, one study96 showed increasing prevalence of neck pain with increasing grade of degenerative change related to atlanto-odontoid osteoarthritis.
Collision and workplace factors are considered in 2 other articles within the Neck Pain Task Force report.3,4
Psychological and Social Factors.
The preponderance of evidence for adults, adolescents and children showed an association between prevalent neck pain and poor psychological health, although the specific psychological factors measured varied across studies. Indexes of psychological health included mental distress, any mental disorder, depression, depressed mood, anxiety and general mental health.64,81,87,92,97–99,101,104,106,108,109 Only one study examining this factor found no such associations.47
We found no study or studies that examined the association between compensation, law or societal factors and neck pain prevalence in the general population.
We found no study or studies that examined the association between genetic factors and neck pain prevalence although Borge and Nordhagen53 explored the relationship between musculoskeletal complaints in parents and their adolescent offspring (reported above).
Eight studies investigated smoking and neck pain prevalence. Four reported no association.47,71,108,109 Two studies specifically focused on exposure to smoking84,102 and both reported associations between current smoking and neck pain. For adults, the reported effect sizes were of low magnitude (odds ratios for neck pain = 1.1; 95% CI, 1.1–1.2; and OR for neck pain restricting activity 1.5; 95% CI, 1.3–1.6),84 whereas for adolescents, the odds ratios were 3.1 (95% CI, 2.4–4.0) for boys and 2.5 (95% CI, 2.0–3.1) for girls.102 Côté et al62 reported associations between smoking and neck pain of OR = 1.66 (95% CI, 0.93–2.98) for high intensity low disability neck pain, and 1.82 (95% CI, 0.76–4.36) for disabling neck pain, whereas Makela et al81 reported a small consistent relationship between current smoking and neck pain (adjusted OR 1.25; 95% CI, 0.99–1.57; and adjusted OR 1.23; 95% CI 0.72–2.11 for people younger than and older than 65 years, respectively).
Six studies considered exercise and participation in sporting activities, but most reported no association with neck pain prevalence.47,61,62,97,108,109 However, neck pain prevalence was lower among girls who took part in sports that involved dynamic use of the upper extremity, as compared to girls doing other types of physical activity.105
Two studies investigated school bags (weight, type, style of carrying); both reported no association with prevalent neck pain.108,112
We found no study or studies that examined the association between cultural factors and the prevalence of neck pain in the general population.
Main Findings on the Burden of Neck Pain
In this best evidence synthesis on the epidemiology of neck pain we found that neck pain, like other musculoskeletal conditions, is common in the general population. Although neck pain is common, when we start to qualify it (i.e., by duration, by frequency, by intensity, by whether health care was sought) we see the typical “iceberg of burden” that has been reported for other musculoskeletal conditions. That means we observe many cases of some pain, but fewer cases of any significant duration, fewer cases that lead to utilization of the health care system, and fewer still that are disabling.
Neck pain is experienced by people of all ages, including children and adolescents.27,53,97,98,100,102–110,112 There is consistent evidence that previous neck pain or trauma is predictive of both incident and prevalent neck pain, suggesting that neck pain often follows an episodic course similar to low back pain.
Risk Factors and Factors Associated With Neck Pain
A variety of risk factors and associated factors have been considered, with key findings highlighted here. Here we compare our findings with those in other chapters of this best evidence synthesis.
The evidence on whether age is a risk factor for incident neck pain is equivocal. However, as with other musculoskeletal conditions,113 most data show that prevalence of neck pain increases with older age, peaking in the middle years and declining in later life. This should be interpreted in light of findings from general population studies that younger persons with neck pain have a better prognosis,114 and it may be this factor, rather than differences in incidence rates, which “drives” the relationship between age and prevalent neck pain.
There was consistent evidence that neck pain coexists with other health problems, including other musculoskeletal complaints like low back pain, headache and poorer self-rated health. There was also generally consistent evidence that neck pain is both predicted by and coexists with different types of psychological health conditions. Of note is that our best evidence synthesis of prognostic factors for neck pain in the general population also identifies health problems, musculoskeletal complaints and poor psychological health as prognostic of poor outcome.114
We did not identify any evidence demonstrating that disc degeneration is a risk factor for neck pain. Longitudinal studies are required to demonstrate disc degeneration as a risk factor, and there were no such studies judged scientifically admissible. This is an important finding to note, given the existing body of literature based on the assumption that persistent and disabling neck pain is associated with cervical degenerative changes.115–118 The lack of evidence identified here is consistent with findings reported elsewhere in the Neck Pain Task Force report around the use of diagnostic imaging.119 Nordin et al119 also concluded there is “no evidence that common degenerative changes on cervical MRI are strongly correlated with neck pain symptoms” and that “common degenerative changes in the cervical spine identified by MRI are at best fair to moderately reproducible.”
Modifiable Risk Factors and Prevention of Neck Pain
Most of the identified literature addressed nonmodifiable factors such as gender, a history of neck pain and genetics. Poor psychological health was identified as both a risk factor and an associated factor for neck and low back pain,9 although to date, there is no evidence that treating psychological conditions will lead to reductions in neck pain or other musculoskeletal complaints.
Smoking was investigated as a risk factor or associated factor in several studies,17,22,47,62,71,81,84,102,108,109 with many studies reporting no statistically significant relationship with neck pain. However, in 5 studies22,62,81,84,102 low-magnitude relationships between smoking and neck pain were identified and reported. Exposure to second-hand smoke during childhood was also identified as a risk factor for neck pain later in life.19 Thus, attempts to reduce smoking in general may have potential benefits for preventing neck pain.
The evidence on exercise and physical activity varied. Many studies showed no association, although most of these relied on a single summary self-report measure of activity participation. One study with a more thorough assessment of activity participation suggested that certain levels of participation provided a protective effect against neck pain.43 Although this study must be interpreted with caution (because of the possibility of prevalence-incidence bias), their findings generally support evidence cited elsewhere in this Neck Pain Task Force report; that exercise was found to be an effective intervention for neck pain,120 and that workers who exercised had a better prognosis for recovery from neck pain,121 although preliminary evidence suggests that general physical activity is not associated with prognosis in the general population.114
The State of the Literature
Our search identified 469 articles that were relevant to our investigation of neck pain epidemiology, and 249 were judged scientifically admissible and 101 of these studies related to the burden and determinants of neck pain in the general population. These articles drew on results from 86 different groups of study participants conducted in countries around the world.
The accepted studies varied widely in their design:
- Most of the scientifically admissible studies (52 of 86) were cross-sectional and provided evidence about prevalence and/or factors associated with neck pain.
- There were also 27 cohort studies, although for our purposes, 3 of these were analyzed in a cross-sectional manner.56,97,103,104 Of the remaining 24 cohorts, 5 produced estimates of incidence rates only, and 19 examined risk factors for neck pain or injury. Of these 19 studies, 13 were Phase I investigations; there were only 2 Phase II and 4 Phase III investigations.
- In addition, there were 3 Phase II and one Phase III case-control studies which examined risk factors for neck pain or neck injury.
- Finally, there were 3 twin studies examining the inheritability of neck pain.
Cross-sectional studies investigating prevalence are useful starting points for understanding the burden of neck pain. But in order to advance this field of study, we need more high-quality cohort studies and case-control studies to identify and investigate both risk and protective factors. Assembling cohorts of people before any episodes of neck pain may prove difficult or inefficient, given the reports of high prevalence seen in children and adolescents.27,53,97,98,100,102–110,112 However, the evidence points to an episodic, recurrent course for neck pain,12,17,34,56,62,63,78,81,114 much like other musculoskeletal conditions.122–131 Therefore, studies integrating investigations into risk and prognosis are likely to be most fruitful.
The studies which comprise our best evidence synthesis on burden and determinants of neck pain in the general population showed geographically distinct patterns of distribution. All but 2 of the 15 sports-related studies were based in North America. The remaining studies were predominantly from northern European countries (Scandinavia, Netherlands and the U.K.). Some more varied geographical distribution appeared in the cross-sectional studies with studies from Australia, Asia and the Middle East, partially due to the Community Oriented Programme for Control of Rheumatic Disease (COPCORD), an initiative first planned by the International League of Associations of Rheumatology (ILAR) and the World Health Organization (WHO) in 1981 to assess the global burden of rheumatic diseases.132,133 Still, more than half of the cross-sectional studies were from northern Europe.
The importance of “case definition” in public health and clinical inquiry have been duly noted in the literature,134–140 particularly for symptom-based conditions; this has also been true of other methodologic issues when it comes to measuring prevalence.113 In out exploration of neck pain epidemiology and risk, we saw that summarizing the evidence and making comparisons across populations and settings was especially challenging due to extensive between-study variations in the case definitions of “neck pain/neck injury.” This has led the Neck Pain Task Force to propose a framework for case definitions.10
We found that case definitions and sampling frames used by researchers varied in many different ways:
- Some studies only included specific conditions such as prolapsed disc22,42 or disc protrusion or herniation resulting in radicular syndrome.23 Others included any self-reported pain in the neck region.
- Some studies included only those people with neck pain who were presenting for health care; others surveyed general populations and generally yielded higher estimates of neck pain incidence or prevalence.
- The actual location of symptoms also varied. Some investigators only considered pain felt in a very clearly delimited part of the body24,78; others included “neck/shoulder” pain within their case definition. Generally, the more extensive the area(s) of the body, the higher the prevalence of neck pain.139
- There were also differences in the period under consideration for measures of prevalence (from point prevalence to lifetime) and also in the frequency, duration, and severity of symptoms captured by different case definitions, as previously described in a framework presented by Beaton et al135 Some case definitions also specified pain with disability or interference with activities of daily living.
Generally, the fewer conditions placed on duration, period, frequency and intensity, the higher the incidence or prevalence of neck pain. We also noted that some studies were specifically focused on neck pain, and so only neck pain statistics were gathered, whereas other studies included information on a wide variety of musculoskeletal complaints in different parts of the body.
Typically, estimates of neck pain prevalence were lower in the broader investigations. The unified framework for case definitions proposed elsewhere in the Neck Pain Task Force report,10 if used consistently by researchers, would provide a flexible and comprehensive set of approaches to case definition and facilitate future literature synthesis.
Limitations of Our Review
Our findings on the epidemiology and risk factors for neck pain in the general population are, of course, limited by the available literature. There were far fewer studies of incidence and risk in neck pain compared to studies looking at prevalence and associated factors. We found limited evidence on risk factors and even more limited evidence on “modifiable” risk factors. No admissible evidence was found for some categories of factors, such as societal level factors and cultural factors. For practical reasons, we restricted our literature search to articles appearing in Medline; we only searched for publications in English, French and Swedish; and we limited publication to a specific time frame (between 1980 and 2005). Thus, it is possible that we might have missed relevant literature not indexed by these databases or which fell outside these restrictions.2
- Neck pain is common in the adult general population, with typical 12-month prevalence estimates from 30% to 50%. Among children and adolescents, 12-month prevalence estimates range from 21% to 42%.
- Neck pain which limits activities is less common, with 12-month prevalence estimates ranging from 2% to 11%.
- There is no evidence to support the assumption that degenerative disc changes are a risk factor for neck pain without radiculopathy.
- Poor psychological health is a risk factor for neck pain and is often associated with it.
- Helmet use during activities such as bicycling, skiing, and hockey may reduce some types of injuries without increasing the risk of neck injury.
Tables available online through Article Plus.
We are indebted to Ms. Oksana Colson and Ms. Leah Phillips, MA, for their administrative assistance and to Mr. Stephen Greenhalgh, MA, MLIS, Ms. C. Sam Cheng, MLIS, and Ms. Lori Giles-Smith, MLIS, research librarians, for their assistance in the work of the Neck Pain Task Force. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders was supported by grants from the following: National Chiropractic Mutual Insurance Company (USA); Canadian Chiropractic Protective Association (Canada); State Farm Insurance Company (USA); Insurance Bureau of Canada; Länsförsäkringar (Sweden); The Swedish Whiplash Commission; Jalan Pacific Inc. (Brazil); Amgen (USA). All funds received were unrestricted grants. Funders had no control in planning, research activities, analysis or results. The report was not released to grantors prior to publication and no approval was required from funders regarding the final report. Dr. Côté is supported by the Canadian Institutes of Health Research through a New Investigator Award and by the Institute for Work & Health through the Workplace Safety and Insurance Board of Ontario. Dr. van der Velde is supported by the Canadian Institutes of Health Research through a Fellowship Award. Dr. Carroll is supported by a Health Scholar Award from the Alberta Heritage Foundation for Medical Research. Dr. Cassidy is supported by an endowed research chair from the University Health Network.
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