Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial

Therapeutic modalities in the management of nonspecific neck pain

This article has surveyed several therapeutic modalities, including physical modalities, thermal modalities, electrical modalities, exercise therapy, behavioral therapy, education, and laser therapy. Of these, exercise, mobilization, and manipulation have the greatest support in the literature, whereas thermal treatments (including therapeutic ultrasound), and electrical therapies (including TENS) have little evidence of effectiveness and no evidence for more than a transient benefit. There is a need for well-controlled studies of educational programs and behavioral interventions specifically for patients with chronic neck pain, particularly because these interventions are often employed as part of a multimodal treatment program. Low-power laser treatment and magnetic therapy require some well-controlled studies before they can be recommended to neck pain patients or discarded as worthless interventions. Cervical traction and soft collars seem to be generally ineffective for nonspecific neck pain.

Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm

OBJECTIVE

The purpose of this study was to determine the effectiveness of an individualized physical therapy intervention in treating neck pain based on a clinical reasoning algorithm. Treatment effectiveness was examined by assessing changes in impairment, physical performance, and disability in response to intervention.

DESIGN

One treatment group of 30 patients with neck pain completed physical therapy treatment. The control group of convenience was formed by a cohort group of 27 subjects who also had neck pain but did not receive treatment for various reasons. There were no significant differences between groups in demographic data and the initial test scores of the outcome measures. A quasi-experimental, nonequivalent, pretest-posttest control group design was used. A physical therapist rendered an eclectic intervention to the treatment group based on a clinical decision-making algorithm. Treatment outcome measures included the following five dependent variables: cervical range of motion, numeric pain rating, timed weighted overhead endurance, the supine capital flexion endurance test, and the Patient Specific Functional Scale. Both the treatment and control groups completed the initial and follow-up examinations, with an average duration of 4 wk between tests.

RESULTS

Five mixed analyses of variance with follow-up tests showed a significant difference for all outcome measures in the treatment group compared with the control group. After an average 4 wk of physical therapy intervention, patients in the treatment group demonstrated statistically significant increases of cervical range of motion, decrease of pain, increases of physical performance measures, and decreases in the level of disability. The control group showed no differences in all five outcome variables between the initial and follow-up test scores.

CONCLUSIONS

This study delineated algorithm-based clinical reasoning strategies for evaluating and treating patients with cervical pain. The algorithm can help clinicians classify patients with cervical pain into clinical patterns and provides pattern-specific guidelines for physical therapy interventions. An organized and specific physical therapy program was effective in improving the status of patients with neck pain.

Chiropractic in the United States: trends and issues

Chiropractic is the best established of the alternative health care professions. Although marginalized for much of the 20th century, it has entered the mainstream of health care, gaining both legitimacy and access to third-party payers. However, the profession's efforts to validate the effectiveness of spinal manipulative therapy, its principal modality, have yielded only modest and often contrary results. At the same time, reimbursement is shrinking, the number of practitioners is growing, and competition from other healing professions is increasing. The profession's efforts to establish a role in primary care are meeting resistance, and its attempts to broaden its activities in alternative medicine have inherent limitations. Although patients express a high level of satisfaction with chiropractic treatment and politicians are sympathetic to it, this may not be enough as our nation grapples to define the health care system that it can afford.

Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice

OBJECT

The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature.

METHODS

During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence. Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region.

CONCLUSIONS

Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

Evaluation of cervical range of motion and isometric neck muscle strength: reliability and validity

OBJECTIVE

To examine the test-retest reliability and construct validity of cervical active range of motion and isometric neck muscle strength as measured by the Multi Cervical Rehabilitation Unit (Hanoun Medical Inc., Ontario).

DESIGN

A cross-sectional study.

SETTING

Institutional practice.

SUBJECTS

Twenty-one patients with neck pain and 25 healthy volunteers.

METHODS

After a trial-run session, active range of motion (AROM) was measured in the subsequent two sessions, with 2-3 days in between. During each session, three measurements were taken for each direction (flexion, extension, lateral flexions and rotations). The measurement of isometric strength was after a 15-minute break following completion of the measurement of AROM. Three measurements were made for each of the six directions (flexion, extension, lateral flexions, protraction and retraction). The software of the Multi Cervical Rehabilitation Unit automatically recorded and calculated the maximum AROM and isometric strength.

RESULTS

There was a good to high level of reliability in the measurement of AROM for both groups of subjects, with intraclass correlation coefficients (ICCs) ranging from 0.81 to 0.96. Results also demonstrated very good to excellent reliability in isometric strength measurement (ICCs ranged from 0.92 to 0.99). Moreover, there was a significant difference in isometric neck muscle strength (p = 0.001) and in AROM (p = 0.034) between the two groups.

CONCLUSIONS

The Multi Cervical Rehabilitation Unit was found to be reliable and valid for testing the cervical active range of motion and isometric neck muscle strength for both normal and patient subjects.

Maximal isometric muscle strength of the cervical spine in healthy volunteers

OBJECTIVE

To describe the maximal isometric neck muscle strength in healthy Chinese volunteers, in six different directions, as measured by a Multi Cervical Rehabilitation Unit.

DESIGN

A standardized cross-sectional observational study.

SETTING

A university rehabilitation unit.

SUBJECTS

Ninety-one healthy volunteers aged 20-84.

METHODS

During the measurement the subject was instructed to do three consecutive steady contractions as hard as possible, with a 10-second rest in between each contraction and a 2-minute rest between different directions. The peak isometric strength for each of the six directions (flexion, extension, lateral flexions, protraction and retraction) was calculated.

RESULTS

No significant difference was found in muscle strength between different age groups. Isometric muscle strength in the direction of right lateral flexion was significantly greater than that to the left in men (p = 0.030), but no difference was found in women (p = 0.297). Isometric strength in all directions in men was 1.2-1.7 times that in women (all p < 0.028). Correlations between physical measurements (height and weight) and strength values were all insignificant in both genders.

CONCLUSION

Men have approximately 20-70% greater isometric neck muscle strength than women. Both men and women can maintain high levels of cervical muscle strength in six different directions up to their seventh decade. There is no significant correlation between physical measurements and isometric neck muscle strength.

Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the effects of spinal manipulation combined with low-tech rehabilitative exercise, MedX rehabilitative exercise, or spinal manipulation alone in patient self-reported outcomes over a two-year follow-up period.

SUMMARY OF BACKGROUND DATA

There have been few randomized clinical trials of spinal manipulation and rehabilitative exercise for patients with neck pain, and most have only reported short-term outcomes.

METHODS

One hundred ninety-one patients with chronic neck pain were randomized to 11 weeks of one of the three treatments. Patient self-report questionnaires measuring pain, disability, general health status, improvement, satisfaction, and OTC medication use were collected after 5 and 11 weeks of treatment and 3, 6, 12, and 24 months after treatment. Data were analyzed taking into account all time points using repeated measures analyses.

RESULTS

Ninety-three percent (178) of randomized patients completed the 11-week intervention phase, and 76% (145) provided data at all evaluation time points over the two-year follow-up period. A difference in patient-rated pain with no group-time interaction was observed in favor of the two exercise groups [F(2141) = 3.2; P= 0.04]. There was also a group difference in satisfaction with care [F(2143) = 7.7; P= 0.001], with spinal manipulation combined with low-tech rehabilitative exercise superior to MedX rehabilitative exercise (P = 0.02) and spinal manipulation alone (P < 0.001). No significant group differences were found for neck disability, general health status, improvement, and OTC medication use, although the trend over time was in favor of the two exercise groups.

CONCLUSION

The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.

Professional responsibility in relation to cervical spine manipulation

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.

A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study

OBJECTIVES

This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain.

METHODS

Neck-pain patients were randomized to the following conditions: manipulation with or without heat, manipulation with or without electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle stimulation.

RESULTS

Of 960 eligible patients, 336 enrolled in the study. Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months.

CONCLUSIONS

Cervical spine manipulation and mobilization yield comparable clinical outcomes.

Manual therapy for mechanical neck disorders: a systematic review

Neck disorders are common, disabling and costly. Randomized trials were reviewed using a Cochrane format, to determine if manual therapy improves pain, function and patient satisfaction in adults suffering from neck disorders with and without radicular findings or headache. Sequenced computerized searches ended in December 1997. Two independent reviewers extracted data while three assessed trial quality. Standard mean difference and relative risks were translated to number needed to treat (NNT) and the percent treatment advantage. The 20 selected trials' quality was 2.4 (SD: 1.04) on the 5-point scale described by Jadad. Trials were clinically heterogenous. Manipulation alone, mobilizations alone, manipulation/mobilization and treatments including massage consistently showed similar effects to placebo, wait period or control. Multimodal manual therapy care including exercise were superior to a control, to certain physical medicine methods and to rest for pain and patient satisfaction. The NNT for a clinically important reduction in pain varied from 2 to 11 and treatment advantage from 6% to 41% at the cost of benign transient side-effects. While results remain inconclusive, some clinical themes have emerged. For mechanical neck disorder with or without headache, it appears that to be most beneficial, manual therapies should be done with exercise for improving pain and patient satisfaction. Manipulation and mobilization alone appear to be less effective. Factorial design would help delineate the magnitude of effect for each component of care.

Effects of training on female trapezius Myalgia: An intervention study with a 3-year follow-up period

STUDY DESIGN

A prospective randomized clinical trial was conducted.

OBJECTIVE

To evaluate the long-term effects of three training interventions on women with work-related trapezius myalgia.

SUMMARY OF BACKGROUND DATA

Studies with long-term follow-up evaluation of interventions for neck pain are scarce and usually cover fewer than 12 months.

METHODS

For this study, 126 women with work-related trapezius myalgia were randomized into strength, muscular endurance, or coordination training or into a nontraining reference group. Intervention training occurred three times a week for 10 weeks. Assessment of pain intensity, pressure pain thresholds, symptom frequency, perceived health, and work and exercise habits was performed before and immediately after interventions, then at clinical examinations 8 months and 17 months after the interventions. Participation rates at these follow-up assessments were 84% and 81%. At 3 years after the interventions, a questionnaire was answered by 94% of the participants, 17 of whom were dropouts that never participated in any of the four intervention groups.

RESULTS

All the training programs showed similar pain reducing effects immediately after the interventions. Pain reductions were maintained at follow-up evaluations, but at the 8-month follow-up assessment, there were no differences between the training groups and the reference group on any variable. At 3 years after the interventions, the intervention groups did not differ from the dropout group. Almost half (49%) of the women had persistent symptoms at the 3-year follow-up assessment.

CONCLUSIONS

The long-term effect of all the training programs was low. Pain in neck and shoulder muscles was persistent in a large proportion of the women over the 3 years.

A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial

OBJECTIVE

To evaluate a new 3-point bending type of cervical traction.

DESIGN

Nonrandomized controlled trial of prospective, consecutive patients compared with control subjects. Follow-up patient data were obtained at 3 and 15(1/2) months, and 8 1/10 months for controls.

SETTING

Data were collected at a spine clinic in Nevada.

PATIENTS

Volunteer subjects consisted of 30 patients and 24 controls. Subjects had cervicogenic pain (neck pain, headaches, arm pain, and/or numbness). Subjects were included if their Ruth Jackson radiographic stress lines measured less than 25 degrees but were excluded if they had suspected disk herniation or canal stenosis. All subjects completed the first follow-up examinations, and 25 of 30 patients completed the long-term follow-up examination.

INTERVENTIONS

Spinal manipulation for pain and a new form of 3-point bending cervical traction to improve lordosis. Cervical manipulation was provided for the first 3 to 4 weeks of treatment. Traction treatment consisted of 3 to 5 sessions per week for 9 +/- 1 weeks.

MAIN OUTCOMES MEASURES

Besides pain visual analog scale (VAS) ratings, pre- and posttreatment lateral cervical radiographs were analyzed.

RESULTS

Control subjects reported no change in the pain VAS ratings and had no statistically significant change in segmental or global radiographic alignment. For the traction group, VAS ratings were 4.3 pretreatment and 1.6 posttreatment. Traction group radiographic measurements showed statistically significant improvements (P <.008 in all instances of statistical significance), including anterior head weight bearing (improved 6.2mm), Cobb angle at C2-7 (improved 12.1 degrees ), and angle between posterior tangents at C2-7 (improved 14.2 degrees ). For the treatment group, at 15(1/2)-month follow-up, only minimal loss of C2-7 lordosis (3.5 degrees ) was observed.

CONCLUSIONS

Sagittal cervical traction with transverse load at midneck (2-way cervical traction) combined with cervical manipulation can improve cervical lordosis in 8 to 10 weeks as indicated by increases in segmental and global cervical alignment. Magnitude of lordosis at C2-7 remained stable at long-term follow-up.

The CAM movement and the integration of quality health care: the case of chiropractic

High and increasing consumer demand for complementary and alternative medicine (CAM) services necessitates a concerted focus to determine the effectiveness of such practices and to ensure that future possible integration of CAM with conventional medicine is founded on sound evidence-based principles of quality health care delivery. The example of chiropractic provides useful insights to guide further research and integration of evidence-based CAM into mainstream health care in the United States. A critical point of departure for this area of inquiry is identifying and addressing barriers to conducting scientifically sound and meaningful cross-disciplinary, practice-based research.

The Bournemouth Questionnaire: a short-form comprehensive outcome measure. II. Psychometric properties in neck pain patients

OBJECTIVE

To modify an existing outcome measure (Bournemouth Questionnaire [BQ]) for use in patients with nonspecific neck pain and test its psychometric properties.

DESIGN

Prospective longitudinal study in which the questionnaire was administered on 3 occasions (pretreatment, retest, and posttreatment).

SETTING

Anglo-European College of Chiropractic outpatient clinic and 8 field chiropractic practices.

METHOD

Seven core items relating to the biopsychosocial model of pain were included in the original questionnaire (back BQ). The wording of one of these items (disability in activities of daily living) was modified to include activities likely to be affected by neck pain. Testing of the neck BQ was carried out in 102 patients with nonspecific neck pain.

RESULTS

The instrument demonstrated high internal consistency on 3 administrations (Cronbach's alpha = 0.87, 0.91, 0.92). All 7 items were retained on the basis that they each significantly contributed to the total score (item-corrected total score correlations >0.43) and to the instrument's responsiveness to clinical change (item change-corrected total change score correlations >0.42). The instrument was reliable in test-retest administrations in stable subjects (ICC = 0.65). The instrument demonstrated acceptable construct validity and longitudinal construct validity with established external measures. The treatment effect size of the instrument was found to be high (1.67).

CONCLUSION

The neck BQ covers the salient dimensions of the biopsychosocial model of pain, is quick and easy to complete, and has been shown to be reliable, valid, and responsive to clinically significant change in patients with nonspecific neck pain. Its use as an outcome measure in clinical trials and outcomes research is recommended.

Chiropractic patients in Denmark: a short description of basic characteristics

BACKGROUND

The vast majority of information on chiropractic and chiropractic patients originates from English-speaking countries. Lately, however, reports describing chiropractic patients and practice in other European countries have emerged.

OBJECTIVE

To describe basic characteristics of Danish chiropractic patients.

DESIGN

Survey questionnaire. All chiropractic clinics in Denmark were asked to collect information on new patients during 1 randomly assigned week in 1999.

SETTING

Private chiropractic practice and a nonprofit research institution.

OUTCOME MEASURES

Age and sex, location and duration of chief complaint, pain intensity, limitation of activities of daily living from chief complaint, and mode of referral.

RESULTS

Eighty-eight percent of all chiropractic clinics in Denmark participated in the study. Out of 2020 patients from the participating clinics, 1897 (94%) filled out a self-administered questionnaire. The mean age of participants was 42 years, and slightly more women than men returned the questionnaire. By far the most frequent area of complaint was pain related to the lower back (50%) followed by pain related to the neck (15%). The majority of patients had complaints in the subacute or chronic category (duration 1-6 months). Patients with sciatica had significantly higher pain scores and limitation in activities of daily living (ADL) than any other group, whereas patients with neck pain tended to score lower. Patients in the subacute category had the highest pain scores and limitation in ADL. For complaints lasting more than 6 months, limitation in ADL remained constant at a low level. Twenty-three percent of all patients were referred to the chiropractor, most frequently by a general medical practitioner. More than half of all patients had previously been treated for the same or similar problems, most frequently by a chiropractor. Fifty-one percent had also received chiropractic care for other types of problems.

CONCLUSIONS

Most Danish chiropractic patients complain of pain related to the low back or neck of between 1 and 6 months' duration. This study confirms that chiropractic is fairly well integrated in the Danish primary health care system. There are differences between the chiropractic patient population in Denmark compared with that of Sweden and Holland.

French translation and validation of 3 functional disability scales for neck pain

OBJECTIVE

To translate and assess the reliability and the construct validity of 3 functional disability scales for neck pain.

DESIGN

Reliability and validity study.

SETTING

Tertiary care teaching hospital and outpatient clinic.

PARTICIPANTS

One hundred one patients (mean age, 49 y).

INTERVENTION

French translations were obtained by using the "translation-backward translation" method. Adaptations were made after a pilot study.

MAIN OUTCOME MEASURES

Impairment outcome measures (visual analog scale [VAS] pain, neck range of motion, morning stiffness, score of neck sensitivity, radiologic score of Kellgren) and patients' perceived handicap (VAS) were recorded at the baseline visit. Three functional disability scales (Neck Disability Index [NDI], Neck Pain and Disability Scale [NPDS], Northwick Park Neck Pain Questionnaire [NPQ]) were recorded twice, at baseline visit and 24 hours later. Reliability was assessed by using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct (convergent and divergent) validity was investigated by using the Spearman rank correlation coefficient and a factor analysis was performed.

RESULTS

Test-retest was excellent for the NPDS and NDI (ICC =.91,.93, respectively) and good for the NPQ (ICC =.84). The Bland and Altman method showed no systematic trend. Expected convergent and divergent validity were observed only for the NPDS; 3 main factors were extracted by factor analysis and explained 78% of the cumulative variance.

CONCLUSION

The 3 translated scales are valid, but the NPDS seems to have the best construct validity.

Importance of psychiatric intervention in intolerances in endoscopic procedures

Despite the fact that pre-medication, in a number of different drug combinations, has been used for a long time in endoscopy units, and has been subject to extended clinical studies, it is still not possible to claim that it has attained an ideal state with regard to patient tolerance to endoscopy procedures. In this clinical study, we have investigated the effects of psychological intervention in addition to medication, which we used on patients with intolerance to endoscopy. Intolerance was very high in all endoscopic procedures (15.8% total). It was observed that average midazolam doses were significantly higher in intolerant than in tolerant patients. It was found that in patients who had received psychiatric intervention, the decrease in midazolam dose was statistically significant in a subsequent endoscopy procedure.

Manual and manipulation techniques for rheumatic disease

Table 1 summarizes many of the studies cited in this article. Can we specifically answer the question, "Does manipulation effectively treat musculoskeletal disorders and arthritis?" It is apparent that many individuals make decisions to see therapists who use manual techniques for pain relief and improved function even though few third-party payers cover such treatments. If this question could unequivocally be answered in the affirmative, these treatments would likely be reimbursed by the payers. The studies noted in Table 1 show mixed results for several conditions. Each study has its strengths and weaknesses, but the most powerful ones indicate that manual techniques are beneficial for back and neck pain when compared with no treatment or "placebo." Comparative studies against other techniques such as physical therapy, education, or exercise do not show a clear superiority for manual therapy, however. Thus, one would have to conclude that these techniques have usefulness, primarily as adjuncts to a comprehensive treatment program. Particularly, manual techniques are useful for painful conditions as a means to break the pain cycle and increase tolerance of exercise and other educational approaches. Although clinical trials do provide important information, they do not provide information on the mechanism by which the therapy assists in the healing process. Further work is needed to understand the mechanism by which manipulation affects pain and motion. Such research should clarify the discrepancies reported in the clinical trials and provide better designs for future studies.

Subjective health measure used on Chinese patients with neck pain in Hong Kong

STUDY DESIGN

A prospective observational study was conducted on the use of the Chinese version of the Northwick Park Neck Pain Questionnaire.

OBJECTIVE

To examine the reliability, validity, and responsiveness of the Chinese version of the Northwick Park Neck Pain Questionnaire in Chinese patients with neck pain in Hong Kong.

SUMMARY OF BACKGROUND DATA

There is increasing recognition that patient perspectives are essential both in making medical decisions and in judging the treatment outcomes. A valid Chinese version of a neck disability index questionnaire is urgently needed for effective and reliable evaluation of the treatment outcomes for patients with neck pain.

METHODS

Two samples with 532 consecutive adult patients with neck pain from seven physiotherapy outpatient departments in Hong Kong who completed the Northwick Park Neck Pain Questionnaire were observed and measured at different intervals: at the beginning of physiotherapy, at 7 days, at 3 weeks, and 6 weeks after physiotherapy.

RESULTS

The questionnaire had good content validity, very good test-retest reliability, and internal consistency (intraclass correlation coefficient, 0.95; Cronbach's alpha, 0.87). It also had good validity (Spearman correlation coefficient of 0.59 when the score was correlated with that of a generic 42-item Chinese health questionnaire) and good responsiveness (effect size of 1.11 at week 6 after treatment began).

CONCLUSIONS

The Chinese version of the Northwick Park Neck Pain Questionnaire has been shown to demonstrate very good content validity, a high degree of test-retest reliability, and internal consistency. It also exhibited good construct validity and high sensitivity to changes in severity over time.

A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction

OBJECTIVE

To determine the relative effect of instrument-delivered thrust cervical manipulations in comparison with traditional manual-delivered thrust cervical manipulations in the treatment of cervical spine dysfunction.

DESIGN

Prospective, randomized, comparative clinical trial.

SETTING

Outpatient chiropractic clinic, Technikon Natal, South Africa.

PATIENTS

Thirty patients diagnosed with neck pain and restricted cervical spine range of motion without complicating pathosis for at least 1 month were included in the study.

INTERVENTIONS

The patients were randomized into 2 groups. Those in one group received mechanical force, manually assisted (MFMA) manipulation to the cervical spine, delivered by means of a hand-held instrument (Activator II Adjusting Instrument). Those in the other group received specific contact high-velocity, low-amplitude (HVLA) manipulation consisting of standard Diversified rotary/lateral break techniques to the cervical spine. Each group received only the specific therapeutic intervention, no other treatment modalities or interventions (including medication) being used, until asymptomatic status was achieved or a maximum of 8 treatments had been received.

MAIN OUTCOME MEASURES

Both treatment groups were assessed through use of subjective (Numerical Pain Rating Scale 101, McGill Short-Form Pain Questionnaire, and Neck Disability Index) and objective (goniometer cervical range of motion) measurement parameters at specific intervals during the treatment period and at 1-month follow-up. The data were assessed through use of 2-tailed nonparametric paired and unpaired analysis, descriptive statistics, and power analysis of the data.

RESULTS

The results indicate that both treatment methods had a positive effect on the subjective and objective clinical outcome measures, no significant difference being observed between the 2 groups (P < .025). The subjective data from all 3 questionnaires showed statistically significant changes from initial to final consultations as well as from initial consultation to 1-month follow-up (P < .025). The objective range of motion measures showed statistically significant changes in the MFMA group for left and right rotation and left and right lateral flexion from initial consultation to final consultations and for right rotation and right lateral flexion from initial consultation to 1-month follow-up. The HVLA group showed only the change in left rotation from initial to final consultations and from initial consultation to 1-month follow-up to be statistically significant.

CONCLUSIONS

The results of this clinical trial indicate that both instrumental (MFMA) manipulation and manual (HVLA) manipulation have beneficial effects associated with reducing pain and disability and improving cervical range of motion in this patient population. A randomized, controlled clinical trial in a similar patient base with a larger sample size is necessary to verify the clinical relevance of these findings.

A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain

STUDY DESIGN

A randomized, parallel-group, single-blinded clinical trial was performed. After a 1-week baseline period, patients were randomized to 11 weeks of therapy, with posttreatment follow-up assessment 3, 6, and 12 months later.

OBJECTIVES

To compare the relative efficacy of rehabilitative neck exercise and spinal manipulation for the management of patients with chronic neck pain.

SUMMARY OF BACKGROUND DATA

Mechanical neck pain is a common condition associated with substantial morbidity and cost. Relatively little is known about the efficacy of spinal manipulation and exercise for chronic neck pain. Also, the combination of both therapies has yet to be explored.

METHODS

Altogether, 191 patients with chronic mechanical neck pain were randomized to receive 20 sessions of spinal manipulation combined with rehabilitative neck exercise (spinal manipulation with exercise), MedX rehabilitative neck exercise, or spinal manipulation alone. The main outcome measures were patient-rated neck pain, neck disability, functional health status (as measured by Short Form-36 [SF-36]), global improvement, satisfaction with care, and medication use. Range of motion, muscle strength, and muscle endurance were assessed by examiners blinded to patients' treatment assignment.

RESULTS

Clinical and demographic characteristics were similar among groups at baseline. A total of 93% of the patients completed the intervention phase. The response rate for the 12-month follow-up period was 84%. Except for patient satisfaction, where spinal manipulative therapy and exercise were superior to spinal manipulation with (P = 0.03), the group differences in patient-rated outcomes after 11 weeks of treatment were not statistically significant (P = 0.13). However, the spinal manipulative therapy and exercise group showed greater gains in all measures of strength, endurance, and range of motion than the spinal manipulation group (P < 0.05). The spinal manipulation with exercise group also demonstrated more improvement in flexion endurance and in flexion and rotation strength than the MedX group (P < 0.03). The MedX exercise group had larger gains in extension strength and flexion-extension range of motion than the spinal manipulation group (P < 0.05). During the follow-up year, a greater improvement in patient-rated outcomes were observed for spinal manipulation with exercise and for MedX exercise than for spinal manipulation alone (P = 0.01). Both exercise groups showed very similar levels of improvement in patient-rated outcomes, although the spinal manipulation and exercise group reported greater satisfaction with care (P < 0.01).

CONCLUSIONS

For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.

Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training

OBJECTIVES

To study whether isometric shoulder endurance was more advantageous than isometric shoulder strength training in reducing pain and perceived exertion and to increase shoulder function through improved muscle endurance and strength.

DESIGN

Randomized trial.

SETTING

Three occupational health care centers.

PARTICIPANTS

Women industrial workers with nonspecific neck-shoulder pain. The International Classification of Diseases, 10th Revision (ICD-10) diagnosis was "cervicobrachial syndrome" (M53.1). Thirty-eight patients completed the isometric shoulder endurance training and 31 patients completed the isometric shoulder strength training.

INTERVENTION

Twelve weeks of training.

MAIN OUTCOME MEASURES

Self-reported pain and rating of perceived exertion (RPE), arm motion performance test, shoulder muscle strength, shoulder muscle endurance, and shoulder functional tests, as well as follow-up after supervised training had ended.

RESULTS

The isometric shoulder strength training resulted in an almost one-scale step decrease in RPE at work and a 5% to 15% improvement of arm motion performance compared with the endurance training. The isometric shoulder strength training more effectively improved left side shoulder abduction strength (p < .026), but no major differences were found for the other strength measurements. The isometric shoulder endurance training was not more successful than the strength training in the endurance test (p .51 to .81).

CONCLUSIONS

Physical training programs for neck-shoulder pain may include isometric shoulder muscular strength exercise in addition to isometric shoulder endurance training, rather than endurance training only.

Active treatment of chronic neck pain: a prospective randomized intervention

STUDY DESIGN

A randomized comparative study with single-blind outcome assessments.

OBJECTIVES

To compare the efficacy of a multimodal treatment emphasizing proprioceptive training (ACTIVE) with activated home exercises (HOME) and recommendation of exercise (CONTROL) in patients with nonspecific chronic neck pain.

SUMMARY OF BACKGROUND DATA

The efficacy of active exercises and passive physiotherapy for neck trouble has been somewhat disappointing in the previous few studies.

METHODS

Seventy-six patients (22 men, 54 women) with chronic, nonspecific neck pain participated. Sixty-two participated the 1-year follow-up. Subjective pain and disability, cervical ranges of motion, and pressure pain threshold in the shoulder region were measured at baseline, at 3 months, and at 12 months. The ACTIVE treatment consisted of 24 sessions of proprioceptive exercises, relaxation, and behavioral support. The HOME regimen included a neck lecture and two sessions of practical training for home exercises and instructions for maintaining a diary of progress. The CONTROL treatment included a lecture regarding care of the neck with a recommendation to exercise.

RESULTS

The average self-experienced total benefit was highest in the ACTIVE group, and the HOME group rated over the CONTROL group (P < 0.001). Differences between the groups in favor of the ACTIVE treatment were recorded in reduction of neck symptoms and improvements in general health and self-experienced working ability (P < 0.01-0.03). Changes in measures of mobility and pressure pain threshold were minor.

CONCLUSIONS

Regarding self-experienced benefit, the multimodal treatment was more efficacious than activated home exercises that were clearly more efficacious than just advising. No major differences were noted in objective measurements of cervical function between the groups, but the content validity of these assessments in chronic neck trouble can be questioned.

Perceived pain before and after three exercise programs--a controlled clinical trial of women with work-related trapezius myalgia

The effect of exercise on neck-shoulder pain was studied in 103 women with work-related trapezius myalgia randomized into three exercise groups and a control group. One group trained strength, the second muscular endurance and the third co-ordination. The exercise groups met three times weekly for 10 weeks. Pain assessment was made on three visual analogue scales, indicating pain at present, pain in general and pain at worst. Pain thresholds were measured in the trapezius muscle with a pressure algometer. A pain drawing was completed. The rated pain decreased significantly (P<0.05) on the VAS describing pain at worst in the strength and endurance groups. Pressure sensitivity decreased significantly (P<0.05) in four triggerpoints in the exercise groups. No changes were seen in the extent of painful body area in any group. Comparison of exercisers (n=82) and controls (n=21) showed significantly larger pain reductions on VAS pain at present and VAS pain at worst among exercisers. All three exercise programs showed similar decreases of pain which indicates that the type of exercise is of less importance to achieve pain reduction.

Manual and manipulation techniques for rheumatic disease

Manipulation is practiced primarily by chiropractors and osteopaths and is one of the most commonly utilized alternative treatments for rheumatic diseases. Low back pain and neck pain are the most frequently treated disorders, but manipulation is also used to treat a broad range of rheumatic diseases. Manipulation has been shown to decrease joint pain and normalize function. The mechanisms of action, however, are not well understood. Current theories propose an imbalance of muscle activity is a source of pain that manipulation can relieve through reflexive actions. Such muscle imbalances would exacerbate rheumatic and arthritic conditions, suggesting that manipulation may be an important therapy that is appropriate for early conservative care as part of a comprehensive treatment program.

Maximal isometric strength of the cervical musculature in 100 healthy volunteers

STUDY DESIGN

A descriptive study involving maximal isometric strength measurements of the cervical musculature.

OBJECTIVES

To determine the maximal isometric strength of the flexors and extensors and of the cervical musculature in 100 healthy volunteers (50 men and 50 women).

SUMMARY OF BACKGROUND DATA

The literature contains only a few descriptive studies pertaining to strength levels of the cervical musculature. These studies include small subject populations, and measurement methods have demonstrated weak reliability.

METHODS

Testing was carried out using strain-gauge technology on a neck muscle training apparatus.

RESULTS

A reliability study demonstrated acceptable intraday and day-to-day values. Maximal isometric strength was approximately 20% to 25% higher in male subjects than female subjects in both flexion and extension from the third to the sixth decades. In the seventh decade, the women's strength levels surpassed values for men in both flexion and extension. Extension-flexion ratios were approximately 1.7 to 1 in both the men and women participants. The men demonstrated a significant decrease in maximal isometric strength with increasing age in both flexion and extension, whereas the women were able to maintain strength values in the ages tested.

CONCLUSIONS

Men and women demonstrate impressive levels of muscular strength in the flexors and extensors of the cervical spine and can maintain these values until the seventh decade of life. Successful rehabilitation of the cervical musculature will require considerable resistance for sufficient stimulation of the cervical musculature.

Chronic neck syndromes: an update

Chronic neck pain syndromes are recognized as myofascial disorders in the main. Often such syndromes follow trauma, and there are significant psychological and secondary gain issues that impact on the outcome of therapy. Comparison with cervical radicular syndromes is discussed.