Overhaul needed in procedures for diagnosing and deciding treatment for axial neck pain
Lack of uniformity in clinicians' approaches leads to controversy
Neck pain is generally classified into three categories: axial neck pain, radiculopathy and myelopathy. Axial pain is musculoskeletal, meaning it affects both muscles and bones, and is limited to pain in the neck only (examples are whiplash and neck strain). When it comes to axial neck pain, a great deal of variation exists in the method spine-care clinicians choose for diagnosing and treating it. Since most clinicians consider their approach to be superior, this lack of consistency has led to heated debates between parties, with each firmly standing by their methods. To seek out the best possible diagnosis, a plethora of examination procedures have emerged, utilized by clinicians intent on finding a specific cause of the neck pain. Some of these include imaging tests (e.g. X-ray and magnetic resonance imaging [MRI]), manual examinations, and psychological and functional tests to factors contributing to pain or disability. Consequently, a lot of money can be spent searching for the cause of a patient's pain, yet it's not entirely certain that these tests are informative to clinicians or beneficial to patients. Though many of the tests are considered to have some value, this overall system, especially the lack of consistency, is incredibly flawed and requires an overhaul.
Flaws with system can be categorized into four major problems
1) The first and most glaring problem with clinicians' approach is the lack of agreed-upon gold standard for diagnosing axial neck pain. All the tests for diagnosing it mentioned above have produced high false-positives, meaning they produce findings assumed to be abnormal (and reserved to those with neck pain) in people without any symptoms. Without a universal gold standard, however, it's impossible to determine what the specific false-negative rates are for any of these studies, and it's extremely difficult to rate their usefulness.
2) The second major problem is that clinicians from different specialties still fail to follow a uniform approach in searching for a diagnosis. The unfortunate truth is most clinicians only perform a specific set of diagnostic procedures that are likely to justify whichever treatment approach they see fit, and they could overlook other important procedures as a result. With such a variety of diagnostic techniques and a clear favoritism towards tests that will appear supportive of an agenda, it's apparent that more uniformity across the board is needed so everyone is on the same page.
3) The third problem and part of the reason there is no general consensus is the fact that many times there's minimal or no correlation between findings from procedures like MRI and actual clinical findings. This means the MRI may show an abnormality that's not the cause of the pain, which can be misinterpreted by the patient and sometimes even the physician. Almost all studies comparing multiple diagnostic tests have shown results that don't match up with each other, which only complicates matters further.
4) The fourth and most important problem is with diagnostic labeling itself. Studies have shown that labeling a patient with a specific diagnosis has not been proven to have a positive impact on the prognosis or long-term outcome after treatment, and some suggest it may actually have a negative one. The general goal of a diagnosis is to justify specific treatments that, even under the best circumstances, have only a moderate impact on pain and disability. This leads to the question of whether the process of searching for a diagnosis in patients is even useful in the first place, and perhaps it's time to consider an alternate model for examination.
A possible shift away from diagnoses
One approach that's been gaining popularity is to move away from diagnoses altogether and establish some clinical prediction rules instead. The intention here is to identify characteristics in patients who are likely to respond positively or negatively to particular treatment approaches, then administer the ones that seem they'll be the most effective. Though the early results of this type of approach have been mixed, the prospect of a shift in the system would be extremely beneficial to patients, and is worthy of the focus of clinicians. By decreasing emphasis on diagnostic terms when appropriate, patients can be spared extensive and expensive tests that don't correlate and may not even allow for a specific treatment approach. In doing so, the emphasis could become more geared towards identifying specific factors for each patient and offering them treatments that have the greatest likelihood for a successful outcome.
-Summarized by Greg Gargiulo
-As reported in the March '11 edition of The Spine Journal
