Manipulation or mobilisation for neck pain

Efficacy of cervical mobilization with post-isometric relaxation in managing mechanical neck pain, ROM, and functional limitations associated with myofascial trigger points

BACKGROUND

Sedentary lifestyle, age-related degenerative changes or traumatic injuries leads to cervical spine structural mal-alignment, which results in neck pain and other symptoms. Various therapeutic exercises and manual techniques have been proven to be beneficial in terms of managing these symptoms. This study aimed to determine the combined effects of cervical mobilization and post-isometric relaxation (PIR) technique on managing neck pain, cervical side flexion range of motion, and functional limitation in participants with mechanical neck pain linked with myofascial trigger points.

METHODS

This study followed a 2-arm, parallel-group, pretest-posttest randomized comparative design. Thirty participants with mechanical neck pain associated with myofascial trigger points aged 30.87 ± 4.45 years were randomly allocated to Groups 1 and 2. Group 1 received conventional intervention, PIR, and cervical mobilization techniques while Group 2 received conventional intervention and PIR technique only. Neck pain, muscle tenderness, cervical range of motion, and functional limitations were assessed using a visual analog scale, pressure pain threshold (PPT), goniometer, and neck disability index (NDI) questionnaire, respectively at baseline on day 1 and post-intervention on day 7, 14, and 21. Wilcoxon signed-rank test and the Mann-Whitney U test evaluated within-group and between-group analyses, respectively. Statistical significance was established at a 95% confidence interval, indicated by P < .05.

RESULTS

Significant differences (95% confidence interval [CI], P < .05) were observed within each group for all the outcomes scores when compared to the baselines across multiple time points. Significant variations were observed between the groups when comparing visual analog scale and NDI scores at weeks 1, 2, and 3 post-interventions. In contrast, insignificant differences (95% CI, P > .05) were observed for side flexion range of motion and PPT compared at weeks 1, 2, and 3 post-interventions except for PPT at week 3 post-intervention (95% CI, P < .05). Additionally, Cohen d test revealed the superiority of group 1 over group 2 in reducing pain and functional limitations and improving cervical side flexion range of motion and PPT.

CONCLUSION

The combination of cervical mobilization and Post-isometric relaxation techniques was discovered to effectively alleviate neck pain and enhance functional abilities when contrasted with the application of post-isometric relaxation alone in patients with mechanical neck pain linked with myofascial trigger points.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

Osteopathic Medicine in Four Chronic Musculoskeletal Pain Diseases: An Observational Trial with Follow-Up

BACKGROUND AND AIM

Patients with chronic musculoskeletal pain diseases (CMPDs) often use osteopathic medicine (OM), although the changes in patients with pain diseases are still insufficiently investigated. This study aimed to observe changes along and after OM in addition to routine care on pain, functioning, and quality of life in patients with four CMPDs.

METHODS

In this observational trial with follow-up, patients suffering from chronic neck pain (CNP, n = 10), chronic low back pain (CLBP, n = 10), chronic shoulder pain (CSP, n = 10), or chronic knee pain (CKP, n = 10) received up to six OM sessions in addition to routine care.

RESULTS

A total of 40 patients (73% female, mean age 47.7 ± 8.3 years, mean pain intensity 59.4 ± 12.5 mm, measured by a visual analog scale [VAS] 0-100 mm) were included. After 26 weeks, there was an improvement in the VAS pain score in the whole population (mean difference to baseline -33.1 mm [95% CI -40.5 to -25.7]), as well in the patients with the four diseases: CNP (-33.7 mm [-54.7 to -12.6]), CLBP (-28.2 mm [-47.9 to -8.4]), CSP (-32.4 [-46.8 to -18.0]), and CKP (-38.1 mm [-49.1 to -27.0]). Regarding disease-specific outcomes, we found improvements in CNP, as measured by the neck disability index (scale 0-50; mean difference -3.6 [-9.0 to 1.9]), CLBP, as measured by the low back pain rating scale (scale 0-60; -3.4 [-12.5 to 5.7]), CSP, as measured by the disabilities of the arm, shoulder and hand score (scale 0-100; -13.4 [-23.1 to -3.7]), and CKP, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (scale 0-96; -13.0 [-23.5 to -2.5]). These improvements persisted through week 52. No adverse events were observed.

CONCLUSION

The study observed beneficial changes along and after the OM treatment in addition to routine care in patients with four different CMPDs. High-quality, multicenter randomized controlled trials are strongly needed to compare the effectiveness of OM and standard care interventions in treating CMPDs in the future. We have provided sufficient data for sample size calculations for these trials.

The effect of osteopathic medicine on pain in musicians with nonspecific chronic neck pain: a randomized controlled trial

Background:

Nonspecific chronic neck pain (cNP) is common in adult violinists and violists and is often treated with osteopathic medicine (OM), although the effectiveness of this treatment has not been determined to date. This study aimed to evaluate the effectiveness and safety of OM in adult violinists and violists with cNP.

Methods:

In a two-armed randomized controlled single-center open trial, adult violinists and violists, including music students, with cNP (⩾12 weeks) were randomized to either five individualized OM sessions (OM group) or to no intervention (control group, CG) in the outpatient clinic for integrative medicine, Charité - Universitätsmedizin Berlin, Germany. All patients received a musicians’ medicine consultation and paracetamol on demand. The primary outcome parameter was the neck pain intensity on a visual analog scale (VAS, 0–100 mm, 0 = no pain, 100 = worst imaginable pain) after 12 weeks. Secondary outcomes included neck pain disability (Neck Disability Index, NDI, 0–100%) after 12 weeks. The last follow-up visit was after 52 weeks. Statistical analysis included analysis of covariance adjusted for respective baseline value.

Results:

Altogether, 62 outpatients were included [OM group (n = 28), CG (n = 34); 81% female; mean age, 41.6 ± 11.1 years; mean baseline neck pain, 55.9 ± 11.6 mm]. After 12 weeks, OM was associated with an improvement in the OM group versus the CG in neck pain on the VAS [14.6 mm (95% confidence interval 8.0; 21.2) versus 40.8 mm (34.7; 46.9), p < 0.001, Cohen’s d = 1.4], and neck pain disability as determined by the NDI [8.8% (6.7; 10.8) versus 17.2% (15.3; 19.1), p < 0.001]. Some improvements were maintained until 52 weeks of follow-up. No serious adverse events were observed.

Conclusions:

The results of this study suggest that OM might be effective in reducing pain intensity in adult violinists and violists with nonspecific cNP. Further studies should investigate the efficacy of OM in comparison with a sham procedure and with other effective therapy methods in high-quality multicenter trials.

Trial registration:

WHO Trial Registration https://apps.who.int/trialsearch/NoAccess.aspx?aspxerrorpath=/trialsearch/Trial2.aspx by German Clinical Trials Register DRKS00009258, Universal Trial Number (UTN): U1111-1173-5943.

Local and Widespread Pressure Pain Hyperalgesia Is Not Side Specific in Females with Unilateral Neck Pain that Can Be Reproduced during Passive Neck Rotation

Current evidence for widespread hyperalgesia in non-specific neck pain (NSNP) is unclear. It is currently recommended to group NSNP patients according to pain-provoking movements. The aim of this study was to investigate local and widespread pain sensitivity in females with unilateral NSNP that is reproducible during passive neck rotation compared with matched controls, and to compare the side specific effect of pain location on pressure pain sensitivity among females with unilateral NSNP. Thirty-six females with unilateral NSNP evoked during passive ipsilateral (n = 20) or contralateral (n = 16) rotation toward the painful side were compared with 20 controls. Participants reported their pain intensity at rest and during passive neck rotation and completed the Neck Disability Index. Pressure pain thresholds (PPTs) were assessed bilaterally over the anterior scalene; the sternocleidomastoid; the levator scapulae; lateral to the spinous process of C6; the median, ulnar, and radial nerves; and the tibialis anterior. The ANOVA revealed lower PPTs in females with unilateral NSNP compared with the controls (all at p < 0.001), but no differences were found between the sides, nor was there any Group × side interaction. Among females with NSNP, those with higher pain intensity during ipsilateral rotation toward the painful side showed lower PPTs over the anterior scalene, median nerve, ulnar nerve, and tibialis anterior (all, p < 0.05) than females with higher pain intensity during contralateral rotation toward the painful side. These findings demonstrated bilateral local and widespread pressure pain hyperalgesia in females with unilateral NSNP that was reproducible during passive neck rotation compared with controls. There was no side specific effect of pain location on PPTs among females with unilateral NSNP.

A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review

Cervical artery dissection refers to a tear in the internal carotid or the vertebral artery that results in an intramural haematoma and/or an aneurysmal dilatation. Although cervical artery dissection is thought to occur spontaneously, physical trauma to the neck, especially hyperextension and rotation, has been reported as a trigger. Headache and/or neck pain is the most common initial symptom of cervical artery dissection. Other symptoms include Horner's syndrome and lower cranial nerve palsy. Both headache and/or neck pain are common symptoms and leading causes of disability, while cervical artery dissection is rare. Patients often consult their general practitioner for headache and/or neck pain, and because manual-therapy interventions can alleviate headache and/or neck pain, many patients seek manual therapists, such as chiropractors and physiotherapists. Cervical mobilization and manipulation are two interventions that manual therapists use. Both interventions have been suspected of being able to trigger cervical artery dissection as an adverse event. The aim of this review is to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection. Key messages Cervical mobilization and/or manipulation have been suspected to be able to trigger cervical artery dissection (CAD). However, these assumptions are based on case studies which are unable to established direct causality. The concern relates to the chicken and the egg discussion, i.e. whether the CAD symptoms lead the patient to seek cervical manual-therapy or whether the cervical manual-therapy provoked CAD along with the non-CAD presenting complaint. Thus, instead of proving a nearly impossible causality hypothesis, this study provide clinicians with an updated step-by-step risk-benefit assessment strategy tool to (a) facilitate clinicians understanding of CAD, (b) appraise the risk and applicability of cervical manual-therapy, and (c) provide clinicians with adequate tools to better detect and exclude CAD in clinical settings.

Tai chi for treating osteopenia and primary osteoporosis: a meta-analysis and trial sequential analysis

Purpose

The aim of this meta-analysis was to evaluate the efficacy of Tai chi (TC) as an adjuvant treatment for osteopenia and primary osteoporosis.

Methods

We went through eight databases to identify relevant randomized controlled trials that compared TC with a control group. The primary outcome was osteoporosis-related fractures (fracture incidence). Meta-analyses and trial sequential analyses (TSA) were conducted using RevMan 5.3 and TSA 0.9.

Results

Fifteen randomized controlled trials involving a total of 857 patients were included in the analyses. No trials reported primary outcome; however, bone mineral density (BMD) values differed significantly in subgroup 1 (TC vs no treatment; weighted mean difference [WMD] =0.05 g/cm², 95% CI 0.03 to 0.07; P<0.00001; P for heterogeneity =0.22, I²=22%) and subgroup 2 (TC vs conventional treatments; WMD =0.16 g/cm², 95% CI 0.11 to 0.21; P<0.00001; P for heterogeneity =0.008, I²=75%). In addition, two trials compared TC with conventional treatments, which found a significant difference in bone gla protein (standardized mean difference =−1.18, 95% CI −1.66 to −0.70; P<0.00001; P for heterogeneity =0.58, I²=75%). The results of the BMD were confirmed by TSA. Also, TC may have a certain effect on the relief of osteoporotic pain (WMD = −2.61, 95% CI −3.51 to −1.71; WMD = −1.39, 95% CI −2.01 to −0.77). However, it did not promote the quality of life, level of serum calcium, serum phosphorus, and also had no effect on bone turnover markers.

Conclusion

Although there is no study monitoring fracture incidence, TC may be beneficial for patients in improving BMD values, level of bone gla protein, and relieving osteoporotic pain. However, due to the low methodological quality, current evidence for treating osteopenia and primary osteoporosis through TC is insufficient.

Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions

Thanks to advances in neuroscience, biopsychosocial models for diagnostics and treatment (including physical, psychological, and pharmacological therapies) currently have more clinical support and scientific growth. At present, a conservative treatment approach prevails over surgery, given it is less aggressive and usually results in satisfactory clinical outcomes in mild–moderate temporomandibular disorder (TMD). The aim of this review is to evaluate the recent evidence, identify challenges, and propose solutions from a clinical point of view for patients with craniofacial pain and TMD. The treatment we propose is structured in a multi-modal approach based on a biobehavioral approach that includes medical, physiotherapeutic, psychological, and dental treatments. We also propose a new biobehavioral model regarding pain perception and motor behavior for the diagnosis and treatment of patients with painful TMD.

[Manual therapy in non-specific neck pain]

AIM

To investigate the effectiveness of manual therapy (MT) in patients with nonspecific neck pain (NNP).

MATERIAL AND METHODS

Ninety two patients with NNP, aged from 18 to 60 years (41,1±10,2 years), 64 (69,6%) women, 28 (30,4%) men, were examined. Treatment duration was 3 weeks with 6 sessions (2 sessions per week). The effectiveness of treatment was evaluated by measuring the decrease of pain intensity, improvement of daily activity, and patient-related recovery measured with the 11-point Numerical Rating Scale (NRS), the Neck Disability Index (NDI) and the 7-point Global Perceived Effect scale (GPE). Size effect was assessed using Cohen's d.

RESULTS

In the end of treatment, pain was reduced by 3,4±2,3 points (from 4,5±2,5 to 1,1±1,0 points; Cohen's d 1,98); disability was improved by 9,5±5,0 points (from 15,2±5,6 to 5,8±4,0 points; Cohen's d 1,97); patients assessed mean global improvement as «improved» and «much improved» (the improvement by 2-3 points on GPE scale).

CONCLUSION

MT in NNP is effective method of treatment that decreases pain syndrome, improves daily activity and is positively assessed by the patients.

Qianggu capsule for the treatment of primary osteoporosis: evidence from a Chinese patent medicine

BACKGROUND

Qianggu Capsule, a Chinese patent medicine, has been widely applied in the clinical practice of primary osteoporosis (POP) in recent years. This study aims to summarize the effectiveness and safety of Qianggu Capsule in treating POP.

METHODS

We searched seven electronic databases, all searches ended in 30 September, 2015. All randomised controlled trials comparing the efficacy of Qianggu Capsule treatment with no treatment, placebo or conventional therapy for POP were included. Combined therapies of Qianggu Capsule were also included. Cochrane risk of bias tool was used to assess methodological quality of primary studies. Revman 5.2.0 software was used for data analysis.

RESULTS

Ten trials were enrolled. The combined effect showed that Qianggu Capsule plus Caltrate D was better than Caltrate D on lumbar spine bone mineral density (BMD) (MD = 0.05 g/cm²; 95% CI: 0.02-0.07; P = 0.0004), femoral neck BMD (MD = 0.03 g/cm²; 95% CI: 0.01-0.05; P = 0.001), femoral great trochanter BMD (MD = 0.04 g/cm²; 95% CI: 0.03-0.06; P < 0.001). Meta-analysis exhibited a significant antiosteoporosis effect of Qianggu Capsule on femoral neck BMD (MD = 0.03 g/cm²; 95% CI: 0.01-0.05; P = 0.003) and femoral trochanteric BMD (MD = 0.07 g/cm²; 95% CI: 0.02-0.12; P = 0.006) compared with α-D3 capsule. However, the methodological quality of included studies was low. Constipation and dry mouth were the most common adverse drug reactions of Qianggu Capsule. Finally the evidence level was evaluated to be low or very low.

CONCLUSIONS

The effect of Qianggu Capsule for POP was supported in improving BMD. Due to the methodological drawbacks of the included studies, the conclusions should be treated with caution for future research.

Effect of lumbar spinal manipulation on local and remote pressure pain threshold and pinprick sensitivity in asymptomatic individuals: a randomised trial

BACKGROUND

The mechanisms of clinical pain relief associated with spinal manipulative therapy (SMT) are poorly understood. Our objective was to determine whether lumbar high-velocity low-amplitude SMT altered pressure pain threshold (PPT) and pinprick sensitivity (PPS) locally and remotely, how long any change lasted (up to 30 min), and whether changes related to the side of SMT.

METHODS

Thirty-four asymptomatic participants (mean age 22.6 years ±4.0) received a right- or left-sided lumbar SMT. PPT and PPS were measured bilaterally at the calf, lumbar spine, scapula, and forehead before and immediately, 10, 20, and 30 min after intervention. Data were collected between October 2014 and June 2015.

RESULTS

Bilateral calf and lumbar spine PPT increased significantly after 10 - 20 min and was maintained at 30 min (7.2-11.8 % increase). PPS decreased significantly in all locations at various times (9.8 - 22.5 % decrease). At the calf and lumbar spine, PPT increased slightly more ipsilateral to the SMT than contralateral.

CONCLUSIONS

Lumbar SMT reduced deep pressure sensitivity locally and in the lower limbs for at least 30 min, whereas sensitivity to pinprick was reduced systemically. These findings suggest that SMT specifically inhibits deep pressure sensitivity distally. These findings are novel compared to other lumbar SMT studies, and may reflect a local spinal or complex supraspinal analgesic mechanism.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000682640).

Treatment success in neck pain: The added predictive value of psychosocial variables in addition to clinical variables

BACKGROUND AND AIMS

Identification of psychosocial variables may influence treatment outcome. The objective of this study was to prospectively examine whether psychosocial variables, in addition to clinical variables (pain, functioning, general health, previous neck pain, comorbidity), are predictive factors for treatment outcome (i.e. global perceived effect, functioning and pain) in patients with sub-acute and chronic non-specific neck pain undergoing physical therapy or manual therapy. Psychosocial factors included treatment outcome expectancy and treatment credibility, health locus of control, and fear avoidance beliefs.

METHODS

This study reports a secondary analysis of a primary care-based pragmatic randomized controlled trial. Potential predictors were measured at baseline and outcomes, in 181 patients, at 7 weeks and 26 weeks.

RESULTS

Hierarchical logistic regression models showed that treatment outcome expectancy predicted outcome success, in addition to clinical and demographic variables. Expectancy explained additional variance, ranging from 6% (pain) to 17% (functioning) at 7 weeks, and 8% (pain) to 16% (functioning) at 26 weeks. Locus of control and fear avoidance beliefs did not add significantly to predicting outcome.

CONCLUSIONS

Based on the results of this study we conclude that outcome expectancy, in patients with non-specific sub-acute and chronic neck pain, has additional predictive value for treatment success above and beyond clinical and demographic variables.

IMPLICATIONS

Psychological processes, health perceptions and how these factors relate to clinical variables may be important for treatment decision making regarding therapeutic options for individual patients.

Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain

BACKGROUND CONTEXT

Chronic neck pain is a prevalent and disabling condition among older adults. Despite the large burden of neck pain, little is known regarding the cost-effectiveness of commonly used treatments.

PURPOSE

This study aimed to estimate the cost-effectiveness of home exercise and advice (HEA), spinal manipulative therapy (SMT) plus HEA, and supervised rehabilitative exercise (SRE) plus HEA.

STUDY DESIGN/SETTING

Cost-effectiveness analysis conducted alongside a randomized clinical trial (RCT) was performed.

PATIENT SAMPLE

A total of 241 older adults (≥65 years) with chronic mechanical neck pain comprised the patient sample.

OUTCOME MEASURES

The outcome measures were direct and indirect costs, neck pain, neck disability, SF-6D-derived quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) over a 1-year time horizon.

METHODS

This work was supported by grants from the National Center for Complementary and Integrative Health (#F32AT007507), National Institute of Arthritis and Musculoskeletal and Skin Diseases (#P60AR062799), and Health Resources and Services Administration (#R18HP01425). The RCT is registered at ClinicalTrials.gov (#NCT00269308). A societal perspective was adopted for the primary analysis. A healthcare perspective was adopted as a sensitivity analysis. Cost-effectivenesswas a secondary aim of the RCT which was not powered for differences in costs or QALYs. Differences in costs and clinical outcomes were estimated using generalized estimating equations and linear mixed models, respectively. Cost-effectiveness acceptability curves were calculated to assess the uncertainty surrounding cost-effectiveness estimates.

RESULTS

Total costs for SMT+HEA were 5% lower than HEA (mean difference: -$111; 95% confidence interval [CI] -$1,354 to $899) and 47% lower than SRE+HEA (mean difference: -$1,932; 95% CI -$2,796 to -$1,097). SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95% CI 0.23 to 0.92) and SRE+HEA (0.41; 95% CI 0.05 to 0.76). Differences in disability and QALYs favored SMT+HEA. The probability that adding SMT to HEA is cost-effective at willingness to pay thresholds of $50,000 to $200,000 per QALY gained ranges from 0.75 to 0.81. If adopting a health-care perspective, costs for SMT+HEA were 66% higher than HEA (mean difference: $515; 95% CI $225 to $1,094), resulting in an ICER of $55,975 per QALY gained.

CONCLUSION

On average, SMT+HEA resulted in better clinical outcomes and lower total societal costs relative to SRE+HEA and HEA alone, with a 0.75 to 0.81 probability of cost-effectiveness for willingness to pay thresholds of $50,000 to $200,000 per QALY.

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study

OBJECTIVES

The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy.

METHODS

A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%.

RESULTS

The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients.

DISCUSSION

Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Is manipulative therapy clinically necessary for relief of neck pain? A systematic review and meta-analysis

OBJECTIVE

To summarize and critically assess the effificacy of Eastern and Western manipulative therapies for the treatment of neck pain in adults.

METHODS

A search of PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, EMBASE, etc. from their inception date to January 2014 with Chinese, Japanese, and Korean databases. Two reviewers independently selected randomized controlled trials (RCTs) with negative control or blank control, extracted data and assessed methodological quality. Meta-analysis and levels of evidence were performed by Revman5.1 and Grades of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Nineteen clinical trials with adequate randomization were included in this review, 11 of them had a low risk of bias. The primary outcome for short-term pain had no significant differences, however, the secondary outcome, only the Numerical Pain Rating Scale (NPRS) score of intermediate-term [n=916, pooled mean differences (MD) =-0.29, P=0.02], the Neck Disability Index (NDI) score of short-term (n=1,145, pooled MD=-2.10, P<0.01), and intermediate-term (n=987, pooled MD=-1.45, P=0.01) were signifificantly reduced with moderate quality evidence. However, it supported the minimally clinically important difference (MCID) of the Visual Analogue Scale and NPRS pain score to be 13 mm, while NDI was 3.5 points. The meta-analysis only suggested a trend in favor of manipulative therapy rather than clinical signifificance.

CONCLUSIONS

The results do not support the existing evidences for the clinical value of Eastern or Western manipulative therapy for neck pain of short-term follow-up according to MCIDs. The limitations of our review related to blinding, allocation concealment and small sample size.

Complementary medicine in chronic pain treatment

This article discusses several issues related to therapies that are considered "complementary" or "alternative" to conventional medicine. A definition of "complementary and alternative medicine" (CAM) is considered in the context of the evolving health care field of complementary medicine. A rationale for pain physicians and clinicians to understand these treatments of chronic pain is presented. The challenges of an evidence-based approach to incorporating CAM therapies are explored. Finally, a brief survey of the evidence that supports several widely available and commonly used complementary therapies for chronic pain is provided.

Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review

OBJECTIVES

Non-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP.

METHODS

This review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990-2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilised outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardised form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison.

RESULTS

Over 912 articles were retrieved: three RCTs, one single-arm trial and three pre-post test studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre-post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre-post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT.

DISCUSSION

Thoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.

Clinical practice in line with evidence? A survey among primary care physiotherapists in western Sweden

RATIONALE, AIMS AND OBJECTIVES

Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables.

METHODS

419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire.

RESULTS

The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1-16). The most common treatment interventions across the three conditions were advice on posture (reported by 82-94%), advice to stay active (86-92%), and different types of exercise (65-92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29-96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience.

CONCLUSIONS

Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Development of an attention-touch control for manual cervical distraction: a pilot randomized clinical trial for patients with neck pain

Background

Manual cervical distraction (MCD) is a traction-based therapy performed with a manual contact over the cervical region producing repeating cycles while patients lie prone. This study evaluated a traction force-based minimal intervention for use as an attention-touch control in clinical trials of MCD for patients with chronic neck pain.

Methods

We conducted a mixed-methods, pilot randomized clinical trial in adults with chronic neck pain. Participants were allocated to three traction force ranges of MCD: low force/minimal intervention (0-20 N), medium force (21-50 N), or high force (51-100 N). Clinicians delivered five treatments over two weeks consisting of three sets of five cycles of MCD at the C5 vertebra and occiput. Traction forces were measured at each treatment. Patient-reported outcomes included a pain visual analogue scale (VAS), Neck Disability Index (NDI), Credibility and Expectancy Questionnaire (CEQ), and adverse effects. A qualitative interview evaluated treatment group allocation perceptions.

Results

We randomized 48 participants, allocating an average of five each month. Forty-five participants completed the trial with three participants lost to follow-up. Most participants were women (65 %) and white (92 %) with a mean (SD) age of 46.8 (12.5) years. Mean traction force values were within the prescribed force ranges for each group at the C5 and occiput levels. Neck pain VAS demonstrated a benefit for high traction force MCD compared to the low force group [adjusted mean difference 15.6; 95 % confidence interval (CI) 1.6 to 29.7]. Participants in the medium traction force group demonstrated improvements in NDI compared to the low force group (adjusted mean difference 3.0; 95 % CI 0.1 to 5.9), as did participants in the high traction force group (adjusted mean difference 2.7; 95 % CI -0.1 to 5.6). CEQ favored the high force group. Most low force participants correctly identified their treatment allocation in the qualitative interview. No serious adverse events were documented.

Conclusions

This pilot study demonstrated the feasibility of a clinical trial protocol and the utility of a traction-based, minimal intervention as an attention-touch control for future efficacy trials of MCD for patients with neck pain.

Trial registration

ClinicalTrials.gov NCT01765751 (Registration Date 30 May 2012)

Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis

Background

Neck pain (NP) and low back pain (LBP) are common symptoms bothering people in daily life. Traditional Chinese medicine (TCM) has been used to treat various symptoms and diseases in China and has been demonstrated to be effective. The objective of the present study was to review and analyze the existing data about pain and disability in TCM treatments for NP and LBP.

Methods

Studies were identified by a comprehensive search of databases, such as MEDLINE, EMBASE, and Cochrane Library, up to September 1, 2013. A meta-analysis was performed to evaluate the efficacy and safety of TCM in managing NP and LBP.

Results

Seventy five randomized controlled trials (n = 11077) were included. Almost all of the studies investigated individuals experiencing chronic NP (CNP) or chronic LBP (CLBP). We found moderate evidence that acupuncture was more effective than sham-acupuncture in reducing pain immediately post-treatment for CNP (visual analogue scale (VAS) 10 cm, mean difference (MD) = -0.58 (-0.94, -0.22), 95% confidence interval, p = 0.01), CLBP (standardized mean difference = -0.47 (-0.77, -0.17), p = 0.003), and acute LBP (VAS 10 cm, MD = -0.99 (-1.24, -0.73), p< 0.001). Cupping could be more effective than waitlist in VAS (100 mm) (MD = -19.10 (-27.61, -10.58), p < 0. 001) for CNP or medications (e.g. NSAID) for CLBP (MD = -5.4 (-8.9, -0.19), p = 0.003). No serious or life-threatening adverse effects were found.

Conclusions

Acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with CNP or CLBP in the immediate term. Gua sha, tai chi, qigong, and Chinese manipulation showed fair effects, but we were unable to draw any definite conclusions, and further research is still needed. The efficacy of tuina and moxibustion is unknown because no direct evidence was obtained. These TCM modalities are relatively safe.

Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck, or trunk after an office visit for chiropractic spinal manipulation compared with office visit for evaluation by primary care physician.

SUMMARY OF BACKGROUND DATA

The risk of physical injury due to spinal manipulation has not been rigorously evaluated for older adults, a population particularly vulnerable to traumatic injury in general.

METHODS

We analyzed Medicare administrative data on Medicare B beneficiaries aged 66 to 99 years with an office visit in 2007 for a neuromusculoskeletal complaint. Using a Cox proportional hazards model, we evaluated for adjusted risk of injury within 7 days, comparing 2 cohorts: those treated by chiropractic spinal manipulation versus those evaluated by a primary care physician. We used direct adjusted survival curves to estimate the cumulative probability of injury. In the chiropractic cohort only, we used logistic regression to evaluate the effect of specific chronic conditions on likelihood of injury.

RESULTS

The adjusted risk of injury in the chiropractic cohort was lower than that of the primary care cohort (hazard ratio, 0.24; 95% confidence interval, 0.23-0.25). The cumulative probability of injury in the chiropractic cohort was 40 injury incidents per 100,000 subjects compared with 153 incidents per 100,000 subjects in the primary care cohort. Among subjects who saw a chiropractic physician, the likelihood of injury was increased in those with a chronic coagulation defect, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection, or long-term use of anticoagulant therapy.

CONCLUSION

Among Medicare beneficiaries aged 66 to 99 years with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck, or trunk within 7 days was 76% lower among subjects with a chiropractic office visit than among those who saw a primary care physician.

LEVEL OF EVIDENCE

3.

Chiropractic treatment approaches for spinal musculoskeletal conditions: a cross-sectional survey

Background

There are several chiropractic spinal manipulative technique systems. However, there is limited research differentiating the efficacy of these techniques. Additionally, chiropractors may also use ancillary procedures in the treatment of musculoskeletal pain, a variable that also needs to be considered when measuring the efficacy of chiropractic therapy. No data is currently available regarding the frequency of usage of chiropractic technique systems or ancillary procedures for the treatment of specific musculoskeletal conditions. Knowing which technique systems and ancillary procedures are used most frequently may help to direct future research. The aim of this research was to provide insight into which treatment approaches are used most frequently by Australian chiropractors to treat spinal musculoskeletal conditions.

Methods

Cross-sectional survey design. The survey was sent online to the members of the two main Australian chiropractic associations between 30^th June 2013 and 7^th August 2013. The participants were asked to provide information on treatment choices for specific spinal musculoskeletal conditions.

Results

280 respondents. Diversified manipulative technique was the first choice of treatment for most of the included conditions. Diversified was used significantly less in 4 conditions; cervical disc syndrome with radiculopathy and cervical central stenosis were more likely to be treated with Activator; flexion distraction technique was used almost as much as Diversified in the treatment of lumbar disc syndrome with radiculopathy and lumbar central stenosis. More experienced Australian chiropractors use more Activator and soft tissue therapy and less Diversified technique compared to their less experienced peers. The majority of responding chiropractors used ancillary procedures such as soft tissue techniques and exercise prescription in the treatment of spinal musculoskeletal conditions.

Conclusion

This survey provides information on commonly used treatment choices to the chiropractic profession. Treatment choices changed based on the region of disorder and whether neurological symptoms were present rather than with specific diagnoses. Diversified technique was the most commonly used spinal manipulative therapy, however, ancillary procedures such as soft tissue techniques and exercise prescription were also commonly utilised. This information may help direct future studies into the efficacy of chiropractic treatment for spinal musculoskeletal disorders.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-014-0033-8) contains supplementary material, which is available to authorized users.

Short term treatment versus long term management of neck and back disability in older adults utilizing spinal manipulative therapy and supervised exercise: a parallel-group randomized clinical trial evaluating relative effectiveness and harms

Background

Back and neck disability are frequent in older adults resulting in loss of function and independence. Exercise therapy and manual therapy, like spinal manipulative therapy (SMT), have evidence of short and intermediate term effectiveness for spinal disability in the general population and growing evidence in older adults. For older populations experiencing chronic spinal conditions, long term management may be more appropriate to maintain improvement and minimize the impact of future exacerbations. Research is limited comparing short courses of treatment to long term management of spinal disability.

The primary aim is to compare the relative effectiveness of 12 weeks versus 36 weeks of SMT and supervised rehabilitative exercise (SRE) in older adults with back and neck disability.

Methods/Design

Randomized, mixed-methods, comparative effectiveness trial conducted at a university-affiliated research clinic in the Minneapolis/St. Paul, Minnesota metropolitan area.

Participants

Independently ambulatory community dwelling adults ≥ 65 years of age with back and neck disability of minimum 12 weeks duration (n = 200).

Interventions

12 weeks SMT + SRE or 36 weeks SMT + SRE.

Randomization

Blocked 1:1 allocation; computer generated scheme, concealed in sequentially numbered, opaque, sealed envelopes.

Blinding

Functional outcome examiners are blinded to treatment allocation; physical nature of the treatments prevents blinding of participants and providers to treatment assignment.

Primary endpoint

36 weeks post-randomization.

Data collection

Self-report questionnaires administered at 2 baseline visits and 4, 12, 24, 36, 52, and 78 weeks post-randomization. Primary outcomes include back and neck disability, measured by the Oswestry Disability Index and Neck Disability Index. Secondary outcomes include pain, general health status, improvement, self-efficacy, kinesiophobia, satisfaction, and medication use. Functional outcome assessment occurs at baseline and week 37 for hand grip strength, short physical performance battery, and accelerometry. Individual qualitative interviews are conducted when treatment ends. Data on expectations, falls, side effects, and adverse events are systematically collected.

Primary analysis

Linear mixed-model method for repeated measures to test for between-group differences with baseline values as covariates.

Discussion

Treatments that address the management of spinal disability in older adults may have far reaching implications for patient outcomes, clinical guidelines, and healthcare policy.

Trial registry

www.ClinicalTrials.gov; Identifier: NCT01057706.

Indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain: protocol of an inter-examiner reliability study among manual therapists

BACKGROUND

Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.

METHODS

This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists' decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen's kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.

DISCUSSION

This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Is manipulative therapy more effective than sham manipulation in adults : a systematic review and meta-analysis

BACKGROUND

Manipulative therapy is widely used in the treatment of spinal disorders. Manipulative techniques are under debate because of the possibility of adverse events. To date, the efficacy of manipulations compared to sham manipulations is unclear. The purpose of the study is: to assess the efficacy of manipulative therapy compared to sham in adults with a variety of complaints.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Bibliographic databases (PubMed, EMBASE, CINAHL, PEDro, Central) along with a hand search of selected bibliographies were searched from inception up to April 2012.

RESULTS

In total 965 references were screened for eligibility and 19 RCTs (n = 1080) met the selection criteria. Eight studies were considered of low risk of bias. There is moderate level of evidence that manipulative therapy has a significant effect in adults on pain relief immediately after treatment (standardized mean difference [SMD] - 0.68, 95% confidence interval (-1.06 to -0.31). There is low level of evidence that manipulative therapy has a significant effect in adults on pain relief (SMD - 0.37, -0.69 to -0.04) at short- term follow-up. In patients with musculoskeletal disorders, we found moderate level of evidence for pain relief (SMD - 0.73, -1.21 to -0.25) immediate after treatment and low level of evidence for pain relief (SMD - 0.52, -0.87 to -0.17) at short term-follow-up. We found very low level of evidence that manipulative therapy has no statistically significant effect on disability and perceived (asthma) recovery. Sensitivity analyses did not change the main findings. No serious adverse events were reported in the manipulative therapy or sham group.

CONCLUSIONS

Manipulative therapy has a clinical relevant effect on pain, but not on disability or perceived (asthma) recovery. Clinicians can refer patients for manipulative therapy to reduce pain.

Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project

OBJECTIVES

To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched from 2006 to 2012.

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review.

MAIN RESULTS

We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability;

REVIEWERS' CONCLUSIONS

While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.

An ICON Overview on Physical Modalities for Neck Pain and Associated Disorders

INTRODUCTION

Neck pain is common, can be disabling and is costly to society. Physical modalities are often included in neck rehabilitation programs. Interventions may include thermal, electrotherapy, ultrasound, mechanical traction, laser and acupuncture. Definitive knowledge regarding optimal modalities and dosage for neck pain management is limited.

PURPOSE

To systematically review existing literature to establish the evidence-base for recommendations on physical modalities for acute to chronic neck pain.

METHODS

A comprehensive computerized and manual search strategy from January 2000 to July 2012, systematic review methodological quality assessment using AMSTAR, qualitative assessment using a GRADE approach and recommendation presentation was included. Systematic or meta-analyses of studies evaluating physical modalities were eligible. Independent assessment by at least two review team members was conducted. Data extraction was performed by one reviewer and checked by a second. Disagreements were resolved by consensus.

RESULTS

Of 103 reviews eligible, 20 were included and 83 were excluded. Short term pain relief - Moderate evidence of benefit: acupuncture, intermittent traction and laser were shown to be better than placebo for chronic neck pain. Moderate evidence of no benefit: pulsed ultrasound, infrared light or continuous traction was no better than placebo for acute whiplash associated disorder, chronic myofascial neck pain or subacute to chronic neck pain. There was no added benefit when hot packs were combined with mobilization, manipulation or electrical muscle stimulation for chronic neck pain, function or patient satisfaction at six month follow-up.

CONCLUSIONS

The current state of the evidence favours acupuncture, laser and intermittent traction for chronic neck pain. Some electrotherapies show little benefit for chronic neck pain. Consistent dosage, improved design and long term follow-up continue to be the recommendations for future research.

Low Level Laser Therapy (LLLT) for Neck Pain: A Systematic Review and Meta-Regression

PURPOSE

This systematic review update evaluated low level laser therapy (LLLT) for adults with neck pain.

METHODS

Computerized searches (root up to Feb 2012) included pain, function/disability, quality of life (QoL) and global perceived effect (GPE). GRADE, effect-sizes, heterogeneity and meta-regression were assessed.

RESULTS

Of 17 trials, 10 demonstrated high risk of bias. For chronic neck pain, there was moderate quality evidence (2 trials, 109 participants) supporting LLLT over placebo to improve pain/disability/QoL/GPE up to intermediate-term (IT). For acute radiculopathy, cervical osteoarthritis or acute neck pain, low quality evidence suggested LLLT improves ST pain/function/QoL over a placebo. For chronic myofascial neck pain (5 trials, 188 participants), evidence was conflicting; a meta-regression of heterogeneous trials suggests super-pulsed LLLT increases the chance of a successful pain outcome.

CONCLUSIONS

We found diverse evidence using LLLT for neck pain. LLLT may be beneficial for chronic neck pain/function/QoL. Larger long-term dosage trials are needed.

A description of the methodology used in an overview of reviews to evaluate evidence on the treatment, harms, diagnosis/classification, prognosis and outcomes used in the management of neck pain

BACKGROUND

Neck Pain (NP) is a common musculoskeletal disorder and the literature provides conflicting evidence about its management.

OBJECTIVE

To describe the methodology used to conduct an overview of reviews (OvR) and to characterize the distribution and risk of bias profiles across the evidence for all areas of NP management.

METHODS

Standard systematic review (SR) methodology was employed. MEDLINE, CINAHL, EMBASE, ILC, Cochrane CENTRAL, and LILACS were searched from 2000 to March 2012; Narrative and SR and clinical practice guidelines (CPG) evaluating the efficacy of treatment (benefits and harms), diagnosis/classification, prognosis, and outcomes were eligible. For treatment, articles were limited to SRs from 2005 forward. Risk of bias of SR was assessed with the AMSTAR; the AGREE II was used to critically appraise the CPGs.

RESULTS

From 2476 articles, 508 were eligible for full text screening. A total of 341 articles were included. Treatment (n=117) had the greatest yield. Other clinical areas had less literature (diagnosis=54, prognosis=16, outcomes=27, harms=16). There were no SR for classification and narrative reviews were problematic for this topic. There was great overlap across different databases within each clinical area except for those for outcome measures. Risk of bias assessment using the AMSTAR of eligible SRs showed a similar trend across different clinical areas.

CONCLUSION

A summary of methods used to review the literature in five clinical areas of NP management have been described. The challenges of selecting and synthesizing eligible articles in an OvR required customized solutions across different areas of clinical focus.

What are the clinical criteria justifying spinal manipulative therapy for neck pain?- a systematic review of randomized controlled trials

OBJECTIVE

Manipulation and mobilization are used to treat neck pain. However, little is known about the diagnostic criteria used to determine the need for manipulation in cases of neck pain. The primary aim of this study was to determine what diagnostic criteria are used to identify which neck pain sufferers should receive spinal manipulation or mobilization.

DESIGN

We systematically reviewed randomized controlled trials (RCT) involving mobilization or manipulation for neck pain. A data extraction pro forma was developed and trialled before two independent assessors extracted data sets from each RCT. A descriptive analysis was undertaken.

RESULTS

Thirty RCTs met the inclusion criteria. Acute and chronic "Mechanical" neck pain was the most common (43%) diagnosis at recruitment to the RCTs but some (10%) included patients with cervicogenic headache. Clinical criteria were used to determine the need for neck manipulation in over half (63%) of the RCTs. This usually involved exclusion of serious conditions, manual examination for tenderness on palpation, and/or altered vertebral motion in the neck or upper thoracic region which are known to lack validity. The remainder of the RCTs did not report a diagnostic strategy. All RCTs lacked detail descriptions of diagnostic criteria or interventions used.

CONCLUSIONS

This systematic review highlights the absence of reliable and valid diagnostic protocols to determine the need for spinal manipulation in persons presenting with non-serious, idiopathic, or whiplash-associated (grade II) neck pain. Guidelines requiring the reporting of valid diagnostic criteria are needed to improve the quality of RCTs concerning manual therapy.

Spinal accessory neuropathy in patients with chronic neck pain

AIM: To assess the presence of spinal accessory neuropathy in patients with chronic neck pain.

METHODS: Patients with pain either regional or focal in the neck or shoulders for at least 6 mo (chronic neck pain) were recruited randomly from the Rheumatology and Rehabilitation Outpatient Clinic at the Faculty of Medicine-Suez Canal University. Two groups were compared: 30 patients with chronic neck pain with mean age (36.97 ± 12.45 years) and 10 apparently healthy controls. Trapezius muscle examination including inspection and range of motion both active and passive was performed. A full clinical neurological examination was carried out to exclude peripheral neuropathy and motor neuron disease. According to the subject’s type of work, cases were categorized into labor-intensive and non-labor intensive tasks. A nerve conduction study (NCS) was performed on spinal accessory nerves at both sides for all patients and controls. Parameters including latencies and amplitudes of compound motor action potential (CMAP) were compared with the chronicity of neck pain using the neck disability score. This cross sectional study was carried in the Rheumatology and Rehabilitation Department, at Suez Canal University Hospital, Ismailia, Egypt.

RESULTS: Physical examination revealed that 80% of cases had spinal trapezius muscle spasm. Restricted neck motion was present in 16.6% of cases. No one suffered from muscle wasting or weakness. Pain was bilateral in 18 patients (60%), localized to the right side in six patients (20%) and localized to the left side in six patients (20%). The causes of neck pain in the patients studied were nonspecific, due to physical stresses, cervical spondylosis and mild cervical disc herniation. Mean disease duration in patients with labor-intensive tasks was (3.9 ± 2.1 years), which was longer than that in patients with non-labor intensive tasks (3.1 ± 1.9 years); however, this difference was statistically insignificant. Spinal accessory NCSs were performed while subjects were in sitting positions and relaxed with naturally suspended arms to minimize muscular movement. The results of electrophysiological studies revealed that mean right and left latencies of the spinal accessory nerve were 2.96 ± 0.69 ms, 2.98 ± 0.61 ms in the patient group and 2.44 ± 0.38 ms, 2.33 ± 0.36 ms in control group respectively. These differences were statistically significant with P = 0.028 and 0.006 respectively. Spinal accessory NCS showed normal CMAP amplitude in both patients and controls. Comparing the results of the neck disability index (NDI) to different characteristics in patients with chronic neck pain, showed that patients with labor-intensive work had a higher NDI score mean (34.7 ± 9.5) compared to those with non-labor-intensive work, with significant statistical difference (P = 0.011). In addition, mean NDI scores were higher in males, and patients aged over 40 years and this difference was statistically significant (P = 0.007 and P = 0.009 respectively). Correlation studies between right and left spinal accessory nerve latencies and disability percent calculated using the NDI revealed a positive correlation. Moreover, there was a positive correlation between age and disability percent.

CONCLUSION: This study demonstrates electrophysiological evidence of demyelination in a significant proportion of patients with chronic cervical pain.

Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

STUDY DESIGN

Systematic review of randomized clinical trials.

OBJECTIVE

Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy.

BACKGROUND

Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population.

RESULTS

Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising.

CONCLUSION

Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.

Manipulative practice in the cervical spine: a survey of IFOMPT member countries

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) aims to achieve worldwide promotion of excellence and unity in clinical and academic standards for manual and musculoskeletal physical therapists. To this end, IFOMPT has sponsored several conference panel sessions and a survey of Member Organizations (MOs) and Registered Interest Groups (RIGs) regarding current cervical spine manipulation and pre-manipulative screening practice in each country. The purpose of this study was to determine common elements of cervical spine manipulative practice and pre-manipulative screening between countries. In late 2007, a questionnaire investigating recommended pre-manipulative screening protocol/guideline use, informed consent regarding risks, screening procedures, and treatment/manipulation technique was sent to all twenty MOs and five RIGs. The response rate was 88%. The main findings of the survey included: 77% of respondent organizations use pre-manipulative guidelines, with Australian guidelines the most frequently adopted internationally (36%); recommendations concerning the provision of information about the possibility of serious adverse events is not standard practice in all countries (50%); positional tests for vertebrobasilar insufficiency are used by all respondent organizations; craniovertebral ligament testing is sometimes taught as a pre-manipulative screening tool (36%); the use of upper cervical spine manipulation has declined in some countries (41%); and of the respondent organizations that continue to teach upper cervical manipulation, most (70%) minimize the rotation component. The findings of this research will inform an IFOMPT international standard for screening the cervical region prior to orthopaedic manual therapy intervention. The development of an IFOMPT endorsed document will be of assistance to manual therapy clinicians worldwide in safely managing disorders of the cervical spine.

The role of manual therapies in equine pain management

Manual therapy includes a diverse array of techniques, such as touch therapies, massage, physical therapy, osteopathy, and chiropractic, that were originally developed for use in humans and have been gradually applied to horses. All forms of manual therapy have variable reported levels of effectiveness for treating musculoskeletal issues in humans, but mostly only anecdotal evidence exists in horses. This article explores the scientific literature for evidence of efficacy, safety, and common mechanisms of action of the different forms of manual therapies for potential use in managing acute or chronic pain syndromes in horses. Currently, there is limited evidence supporting the effectiveness of spinal mobilization and manipulation in reducing pain and muscle hypertonicity. Further research is needed to assess the efficacy of specific manual therapy techniques and their contribution to multimodal protocols for managing specific somatic pain conditions in horses.