Exercises for mechanical neck disorders

Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. Randomized controlled trial

Background

Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction.

Purpose

To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction.

Methods

Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0–10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise.

Results

The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range: 0.003–0.000).

Conclusion

Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

Self-Kinematic Training for Flight-Associated Neck Pain: a Randomized Controlled Trial

BACKGROUND: Flight-associated neck pain (FANP) is a serious problem in fighter pilots. Despite the high impact of FANP there is little evidence for effective management. However, self-kinematic training showed a positive effect in the general population. The purpose of this study was to investigate the effectiveness of a self-kinematic training program using virtual reality in improving neck pain in fighter pilots.METHODS: There were 45 pilots with FANP who were randomized to a control group (N 23) or a training group (N 22). Training participants were instructed to exercise using a personalized self-training program, for 20 min/wk, for 4 wk. Primary outcome measures were neck disability (NDI%) and mean velocity ( s¹), and secondary were pain, health status, accuracy, and isometric strength. Assessments were conducted by a blinded assessor and intention-to-treat analysis by a blinded statistician.RESULTS: There were 40 pilots who completed the postintervention assessments, and 35 completed the 6-mo follow-up. Baseline measurements showed mild pain and disability (mean VAS 43 22.73, NDI 17.76 9.59%) and high kinematic performance. Compliance with self-training was poor. No differences were observed in self-reported measures and strength. Exercise duration was correlated with NDI% improvement.DISCUSSION: This self-kinematic training promoted kinematic performance, but was ineffective in engaging the pilots to exercise, and consequently did not improve pain and disability. Poor compliance was previously reported in self-training for FANP, suggesting further studies should prioritize supervised training. Considering the high baseline kinematic performance, kinematics does not seem to be a key factor in FANP, and future exercise research should aim for intense strengthening to increase endurance to the high G_z pilots experience.Sarig Bahat H, German D, Palomo G, Gold H, Frankel Nir Y. Self-kinematic training for flight-associated neck pain: a randomized controlled trial. Aerosp Med Hum Perform. 2020; 91(10):790797.

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short- and Mid-Term? A Randomized Controlled Trial

Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

Systematic Review and Meta-Analysis Suggest Strength Training and Workplace Modifications May Reduce Neck Pain in Office Workers

OBJECTIVE

Neck pain is a burdensome musculoskeletal disorder in office workers. Workplace interventions aim to prevent and minimize the effect of neck pain and improve work quality. However, the summed effect of workplace interventions on neck pain in office workers remains unclear. This systematic review with meta-analysis and meta-regression evaluated the summed effect of workplace interventions on neck pain in office workers.

METHODS

We searched 7 electronic databases to January 2020 for randomized clinical trials. We selected studies, independently extracted data, and assessed risk of bias. Meta-analyses were carried out along with normalized trend plots.

RESULTS

Twenty-nine trials, including 8 of high quality, met our inclusion criteria. Normalized trend plots indicate that neck strengthening demonstrated the sharpest decrease in pain scores. The results of pre- and post-outcome measurement of the effect of activity performance and workplace modification showed significant improvements in self-reported neck pain (P ≤ 0.001). Meta-regression was used to evaluate the effect of time, but it was not significant.

CONCLUSIONS

There is low-quality evidence that neck strengthening and tailored workstation modifications are effective at reducing neck pain in office workers. Further high-quality research methodology, including clinicians, is important to evaluate this summed effect.

Concussion part II: Rehabilitation - The need for a multifaceted approach

INTRODUCTION

While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit.

PURPOSE

The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion.

IMPLICATIONS

Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.

The Chinese Association for the Study of Pain (CASP): Expert Consensus on the Cervicogenic Headache

Cervicogenic headache is a relatively common but unique form of headache, and in China, as well as in several other countries, both diagnosis and a clear evidence-based treatment plan remain controversial. Therefore, the Chinese Association for the Study of Pain organized a meeting of pain management experts and created an expert consensus on the diagnosis and treatment of cervicogenic headache in China. This article summarizes the conclusions of the consensus group regarding the epidemiology, etiology, clinical features, diagnosis, differential diagnosis, treatment, and rehabilitation of cervicogenic headache in China.

Orofacial pain of cervical origin: A case report

BACKGROUND

The etiopathogenesis of orofacial pain remains complex and a number of pain referral patterns for this region have been reported in the literature. The purpose of this report is to describe the assessment and successful clinical management of orofacial pain possibly attributable to cervical origin.

CASE DESCRIPTION

A 55-year-old male teacher with a 3-year history of pain in the right lower jaw, radiating to the ear, consulted our institute for assessment and management. The patient was unsuccessfully treated for dental pain and trigeminal neuralgia. The patient's functioning was grossly limited and the patient was unable to sleep because of severe pain. Current and previous medical and physical examinations revealed no infection, malignancies, or sinusitis. Palpation revealed no temporomandibular disorder, tenderness or myofascial trigger points. Examination of the cervical range of motion showed a reduction in rotation to the right side. The patient was treated for upper cervical joint dysfunction involving mobilization of the first three cervical vertebrae and motor control exercises. The patient had an almost complete resolution of symptoms and reported significant improvement in the Patient Specific Functional Scale (PSFS) and the Global Rating of Change (GRC) scale.

CONCLUSION

This case study demonstrates the importance of considering, assessing and treating the cervical spine as a possible source of orofacial pain, and the positive role of cervical mobilization on these disorders.

Neck-specific exercises with internet-based support compared to neck-specific exercises at a physiotherapy clinic for chronic whiplash-associated disorders: study protocol of a randomized controlled multicentre trial

Background

Globally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness.

Methods

This prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness.

Discussion

The study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society.

Trial registration

ClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016.

Effects of yoga, strength training and advice on back pain: a randomized controlled trial

Background

Among the working population, non-specific low-back pain and neck pain are one of the most common reasons for sickness absenteeism. The aim was to evaluate the effects of an early intervention of yoga - compared with strength training or evidence-based advice - on sickness absenteeism, sickness presenteeism, back and neck pain and disability among a working population.

Methods

A randomized controlled trial was conducted on 159 participants with predominantly (90%) chronic back and neck pain. After screening, the participants were randomized to kundalini yoga, strength training or evidence-based advice. Primary outcome was sickness absenteeism. Secondary outcomes were sickness presenteeism, back and neck pain and disability. Self-reported questionnaires and SMS text messages were completed at baseline, 6 weeks, 6 and 12 months.

Results

The results did not indicate that kundalini yoga and strength training had any statistically significant effects on the primary outcome compared with evidence-based advice. An interaction effect was found between adherence to recommendations and sickness absenteeism, indicating larger significant effects among the adherers to kundalini yoga versus evidence-based advice: RR = 0.47 (CI 0.30; 0.74, p = 0.001), strength training versus evidence-based advice: RR = 0.60 (CI 0.38; 0.96, p = 0.032). Some significant differences were also found for the secondary outcomes to the advantage of kundalini yoga and strength training.

Conclusions

Guided exercise in the forms of kundalini yoga or strength training does not reduce sickness absenteeism more than evidence-based advice alone. However, secondary analyses reveal that among those who pursue kundalini yoga or strength training at least two times a week, a significantly reduction in sickness absenteeism was found. Methods to increase adherence to treatment recommendations should be further developed and applied in exercise interventions.

Trial Registration

Clinicaltrials.gov NCT01653782, date of registration: June, 28, 2012, retrospectively registered.

The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE

The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder.

METHODS

We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias.

RESULTS

We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections.

CONCLUSIONS

The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated.

A therapist-focused knowledge translation intervention for improving patient adherence in musculoskeletal physiotherapy practice

Background

Nonadherence to treatment remains high among patients with musculoskeletal conditions with negative impact on the treatment outcomes, use of personal and cost of care. An active knowledge translation (KT) strategy may be an effective strategy to support practice change. The purpose of this study was to deliver a brief, interactive, multifaceted and targeted KT program to improve physiotherapist knowledge and confidence in performing adherence enhancing activities related to risk, barriers, assessment and interventions.

Methods

We utilised a 2-phase approach in this KT project. Phase 1 involved the development of an adherence tool kit following a synthesis of the literature and an iterative process involving 47 end-users. Clinicians treating patients with musculoskeletal conditions were recruited from two Physiotherapy and Occupational therapy national conferences in Canada. The intervention, based on the acronym SIMPLE TIPS was tested on 51 physiotherapists in phase 2. A pre- and post-repeated measures design was used in Phase 2. Graham’s knowledge-to-action cycle was used as the conceptual framework. Participants completed a pre—intervention assessment, took part in a 1-h educational session and completed a post—intervention assessment. A questionnaire was used to measure knowledge of evidence—based treatment adherence barriers, interventions and measures and confidence to perform evidence—based adherence practice activities. Data was analysed using descriptive statistics (frequency and percentage), Fisher’s exact test and Wilcoxon Sign-Ranked tests.

Results

Barriers and facilitators of adherence were identified under three domains (therapist, patient, health system) in phase 1. Seventy percent of the participants completed the questionnaire. Results indicated that 46.8% of respondents explored barriers including the use of behaviour change strategies and 45.7% reported that they measured adherence but none reported the use of validated outcomes. A significant improvement in post-self-efficacy scores for the four adherence enhancing activities was observed immediately after the workshop.

Conclusion

The use of a multi-modal KT intervention is feasible in an educational setting. A brief interactive educational session was successfully implemented using a toolkit and caused a significant increase in physiotherapists’ knowledge and confidence at performing adherence enhancing activities in the very short-term. Further testing of SIMPLE TIPS on long-term adherence practices could help advance best practices specific to treatment adherence in MSK practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s40945-016-0029-x) contains supplementary material, which is available to authorized users.

Craniosacral Therapy for the Treatment of Chronic Neck Pain: A Randomized Sham-controlled Trial

Objectives:

With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study therefore aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients.

Materials and Methods:

A total of 54 blinded patients were randomized into either 8 weekly units of CST or light-touch sham treatment. Outcomes were assessed before and after treatment (week 8) and again 3 months later (week 20). The primary outcome was the pain intensity on a visual analog scale at week 8; secondary outcomes included pain on movement, pressure pain sensitivity, functional disability, health-related quality of life, well-being, anxiety, depression, stress perception, pain acceptance, body awareness, patients’ global impression of improvement, and safety.

Results:

In comparison with sham, CST patients reported significant and clinically relevant effects on pain intensity at week 8 (−21 mm group difference; 95% confidence interval, −32.6 to −9.4; P=0.001; d=1.02) and at week 20 (−16.8 mm group difference; 95% confidence interval, −27.5 to −6.1; P=0.003; d=0.88). Minimal clinically important differences in pain intensity at week 20 were reported by 78% within the CST group, whereas 48% even had substantial clinical benefit. Significant between-group differences at week 20 were also found for pain on movement, functional disability, physical quality of life, anxiety and patients’ global improvement. Pressure pain sensitivity and body awareness were significantly improved only at week 8. No serious adverse events were reported.

Discussion:

CST was both specifically effective and safe in reducing neck pain intensity and may improve functional disability and the quality of life up to 3 months after intervention.

The Effect of Physical Therapy Treatment in Patients with Subjective Tinnitus: A Systematic Review

Background: Tinnitus is a very common symptom that often causes distress and decreases the patient's quality of life. Apart from the well-known causes, tinnitus can in some cases be elicited by dysfunctions of the cervical spine or the temporomandibular joint (TMJ). To date however, it is unclear whether alleviation of these dysfunctions, by physical therapy treatment, also decreases the tinnitus complaints. Such physical therapy could be an interesting treatment option for patients that are now often left without treatment.

Objectives: The aim of this review was to investigate the current evidence regarding physical therapy treatment in patients with tinnitus.

Data sources: The online databases Pubmed, Web of Science, Cochrane, and Embase were searched up to March 2016. Two independent reviewers conducted the data extraction and methodological quality assessment.

Study eligibility criteria: Only randomized controlled trials and quasi-experimental trials were included in the review. Studies had to be written in English, French, Dutch, or German.

Participants and interventions: The included studies investigated the effect of physical therapy treatment modalities on tinnitus severity in patients suffering from subjective tinnitus.

Results: Six studies were included in this review, four investigating cervical spine treatment and two investigating TMJ treatment. These studies show positive effects of cervical spine treatment (manipulations, exercises, triggerpoint treatment) on tinnitus severity. Additionally, decrease in tinnitus severity and intensity was demonstrated after TMJ treatment, following splints, occlusal adjustments as well as jaw exercises.

Limitations: The risk of bias in the included studies was high, mainly due to lack of randomization, lack of blinding of subjects, therapists, and/or investigators. Additionally, risk of bias is present due to incomplete presentation of the data and selective reporting. A major issue of the reviewed papers is the heterogeneity of the included study populations, treatments and outcome measures, which inhibit data pooling and meta-analysis.

Conclusions: Despite the methodological issues in the included studies and the consequent low quality evidence, it is noteworthy that all included studies show positive treatment effects. Before recommendations can be made, these results need to be confirmed in larger, high quality studies, using unambiguous inclusion criteria, state-of-the-art treatment, and high quality outcome measures.

Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain? A randomized controlled trial

BACKGROUND

The evidence for the effect of treatments of neck pain is modest. In the absence of causal treatments, a possibility is to tailor the treatment to the individuals' functional limitations and symptoms. The aim was to evaluate treatment effects of a tailored treatment versus a non-tailored treatment. Our hypothesis was that tailored treatment (TT) would have better effect on pain intensity and disability than either non-tailored treatment (NTT) (same treatment components but applied quasi-randomly) or treatment-as-usual (TAU) (no treatment from the study, no restrictions). We further hypothesized that TT and NTT would both have better effect than TAU.

METHOD

One hundred twenty working women with subacute and chronic non-specific neck pain were allocated to 11 weeks of either TT, NTT or TAU in a randomized controlled trial with follow-ups at 3, 9 and 15 months. The TT was designed from a decision model based on assessment of function and symptoms with defined cut-off levels for the following categories: reduced cervical mobility, impaired neck-shoulder strength and motor control, impaired eye-head-neck control, trapezius myalgia and cervicogenic headache. Primary outcomes were pain and disability. Secondary outcomes were symptoms, general improvement, work productivity, and pressure pain threshold of m. trapezius.

RESULTS

Linear mixed models analysis showed no differences between TT and NTT besides work productivity favoring TT at 9- and 15-months follow-ups. TT and NTT improved significantly more than TAU on pain, disability and symptoms at 3-month follow-up. General improvement also favored TT and NTT over TAU at all follow-ups.

CONCLUSION

Tailored treatment according to our proposed decision model was not more effective than non-tailored treatment in women with subacute and chronic neck pain. Both tailored and non-tailored treatments had better short-term effects than treatment-as-usual, supporting active and specific exercise therapy, although therapist-patient interaction was not controlled for. Better understanding of the importance of functional impairments for pain and disability, in combination with a more precise tailoring of specific treatment components, is needed to progress.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 49348025. Registered 2 August 2011.

Change in Health-Related Quality-of-Life at Group and Individual Levels Over Time in Patients Treated for Chronic Myofascial Neck Pain

BACKGROUND

This study evaluated change in health-related quality of life at the group and individual levels in a consecutive series of patients with chronic myofascial neck pain.

METHODS

Fifty patients with chronic neck pain self-administered the Short Form-36 Version 2 (SF-36 v2) before treatment and 6 weeks later. Internal consistency reliability was estimated for the 8 scale scores and Mosier's formula was used to estimate reliability of the physical and mental health composite scores. Significance of group-level change was estimated using within-group t statistics. Significance of individual change was evaluated by reliable change index.

RESULTS

Statistically significant ( P < .05) group mean improvement over time was found for all SF-36 scores. At the individual level, 20% of the possible changes were statistically significant (17% improvement, 3% decline).

CONCLUSIONS

Estimating the significance of individual change in health-related quality of life adds important information in comparing different treatment modalities for chronic myofascial neck pain.

Exercises for mechanical neck disorders: A Cochrane review update

BACKGROUND

Neck pain (NP) is disabling and costly.

OBJECTIVES

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP.

METHODS

We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence.

MAIN RESULTS

The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

AUTHORS' CONCLUSIONS

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial

Background:

Mechanical neck pain is one of the common musculoskeletal disorders. Muscle energy technique (MET) may be a useful intervention for treating such disorder.

Objective:

The aim of this study was to compare the effect of MET with passive stretching on pain and functional disability in people with mechanical neck pain.

Methods:

A randomized controlled trial was undertaken. Sixty patients with mechanical neck pain were randomly allocated to either the MET group or control group. The former group received MET, and the latter group received static stretching. Both groups received conventional therapy. Treatment was given once a day for 6 days. A visual analogue scale (VAS) was used to measure the intensity of pain, and functional disability was assessed using the neck disability index (NDI) was immediately before treatment and again on the 6^th day.

Results:

VAS and NDI scores showed a significant improvement in both MET and stretching groups on the 6^th day postintervention (p < 0.05). However, both VAS and NDI scores showed better improvement in the MET group as compared to the stretching group (p < 0.025).

Conclusion:

Muscle energy technique was better than stretching technique in improving pain and functional disability in people with mechanical neck pain.

WITHDRAWN: Botulinum toxin for subacute/chronic neck pain

Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy

The editorial group responsible for this previously published document have withdrawn it from publication.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians

Playing a musical instrument at an elite level is a highly complex motor skill. The regular daily training loads resulting from practice, rehearsals and performances place great demands on the neuromusculoskeletal systems of the body. As a consequence, performance-related musculoskeletal disorders (PRMDs) are globally recognized as common phenomena amongst professional orchestral musicians. These disorders create a significant financial burden to individuals and orchestras as well as lead to serious consequences to the musicians’ performance and ultimately their career. Physical therapists are experts in treating musculoskeletal injuries and are ideally placed to apply their skills to manage PRMDs in this hyper-functioning population, but there is little available evidence to guide specific injury management approaches. An Australia-wide survey of professional orchestral musicians revealed that the musicians attributed excessively high or sudden increase in playing-load as major contributors to their PRMDs. Therefore, facilitating musicians to better manage these loads should be a cornerstone of physical therapy management. The Sound Practice orchestral musicians work health and safety project used formative and process evaluation approaches to develop evidence-informed and clinically applicable physical therapy interventions, ultimately resulting in favorable outcomes. After these methodologies were employed, the intervention studies were conducted with a national cohort of professional musicians including: health education, onsite injury management, cross-training exercise regimes, performance postural analysis, and music performance biomechanics feedback. The outcomes of all these interventions will be discussed alongside a focussed review on the existing literature of these management strategies. Finally, a framework for best-practice physical therapy management of PRMDs in musicians will be provided.

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.

Function in patients with cervical radiculopathy or chronic whiplash-associated disorders compared with healthy volunteers

OBJECTIVE

The purposes of this study were to examine whether any differences in function and health exist between patients with cervical radiculopathy (CR) due to disk disease scheduled for surgery and patients with chronic whiplash-associated disorders (WADs) and to compare measures of patients' physical function with those obtained from healthy volunteers.

METHODS

This is a cross-sectional study of patients with CR (n = 198) and patients with chronic WAD (n = 215). Patient data were compared with raw data previously obtained from healthy people. Physical measures included cervical active range of motion, neck muscle endurance, and hand grip strength. Self-rated measures included pain intensity (visual analog scale), neck disability (Neck Disability Index), self-efficacy (Self-Efficacy Scale), and health-related quality of life (EuroQol 5-dimensional self-classifier).

RESULTS

Patient groups exhibited significantly lower performance than the healthy group in all physical measures (P < .0005) except for neck muscle endurance in flexion for women (P > .09). There was a general trend toward worse results in the CR group than the WAD group, with significant differences in neck active range of motion, left hand strength for women, pain intensity, Neck Disability Index, EuroQol 5-dimensional self-classifier, and Self-Efficacy Scale (P < .0001).

CONCLUSIONS

Patients had worse values than healthy individuals in almost all physical measures. There was a trend toward worse results for CR than WAD patients.

Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol)

BACKGROUND

Exercise programmes are frequently advocated for the management of musculoskeletal disorders; however, adherence is an important pre-requisite for their success. The assessment of exercise adherence requires the use of relevant and appropriate measures, but guidance for appropriate assessment does not exist. This research will identify and evaluate the quality and acceptability of all measures used to assess exercise adherence within a musculoskeletal setting, seeking to reach consensus for the most relevant and appropriate measures for application in research and/or clinical practice settings.

METHODS/DESIGN

There are two key stages to the proposed research. First, a systematic review of the quality and acceptability of measures used to assess exercise adherence in musculoskeletal disorders; second, a consensus meeting. The systematic review will be conducted in two phases and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a robust methodology. Phase one will identify all measures that have been used to assess exercise adherence in a musculoskeletal setting. Phase two will seek to identify published and unpublished evidence of the measurement and practical properties of identified measures. Study quality will be assessed against the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. A shortlist of best quality measures will be produced for consideration during stage two: a meeting of relevant stakeholders in the United Kingdom during which consensus on the most relevant and appropriate measures of exercise adherence for application in research and/or clinical practice settings will be sought.

DISCUSSION

This study will benefit clinicians who seek to evaluate patients' levels of exercise adherence and those intending to undertake research, service evaluation, or audit relating to exercise adherence in the musculoskeletal field. The findings will impact upon new research studies which aim to understand the factors that predict adherence with exercise and which test different adherence-enhancing interventions. PROSPERO reference: CRD42013006212.

Outcome of physiotherapy after surgery for cervical disc disease: a prospective randomised multi-centre trial

BACKGROUND

Many patients with cervical disc disease require leave from work, due to long-lasting, complex symptoms, including chronic pain and reduced levels of physical and psychological function. Surgery on a few segmental levels might be expected to resolve disc-specific pain and reduce neurological deficits, but not the non-specific neck pain and the frequent illness. No study has investigated whether post-surgery physiotherapy might improve the outcome of surgery. The main purpose of this study was to evaluate whether a well-structured rehabilitation programme might add benefit to the customary post-surgical treatment for cervical disc disease, with respect to function, disability, work capability, and cost effectiveness.

METHODS/DESIGN

This study was designed as a prospective, randomised, controlled, multi-centre study. An independent, blinded investigator will compare two alternatives of rehabilitation. We will include 200 patients of working age, with cervical disc disease confirmed by clinical findings and symptoms of cervical nerve root compression. After providing informed consent, study participants will be randomised to one of two alternative physiotherapy regimes; (A) customary treatment (information and advice on a specialist clinic); or (B) customary treatment plus active physiotherapy. Physiotherapy will follow a standardised, structured programme of neck-specific exercises combined with a behavioural approach. All patients will be evaluated both clinically and subjectively (with questionnaires) before surgery and at 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. The main outcome variable will be neck-specific disability. Cost-effectiveness will also be calculated.

DISCUSSION

We anticipate that the results of this study will provide evidence to support physiotherapeutic rehabilitation applied after surgery for cervical radiculopathy due to cervical disc disease.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01547611.

Three-dimensional computerized mobilization of the cervical spine for the treatment of chronic neck pain: a pilot study

BACKGROUND

Manual therapies for chronic neck pain are imprecise, inconsistent, and brief due to therapist fatigue. A previous study showed that computerized mobilization of the cervical spine in the sagittal plane is a safe and potentially effective treatment of chronic neck pain.

OBJECTIVE

To investigate the safety and efficacy of computerized mobilization of the cervical spine in a three-dimensional space for the treatment of chronic neck pain.

DESIGN

Pilot, open trial.

SETTING

Physical therapy outpatient department.

PARTICIPANTS

Nine patients with chronic neck pain.

INTERVENTIONS

A computerized cradle capable of three-dimensional neck mobilizations was used. Treatment sessions lasted 20 minutes, biweekly, for six weeks.

MAIN OUTCOME MEASURES

Visual analog scale (VAS) for pain, cervical range of motion (CROM), neck disability index (NDI), joint position error (JPE), and muscle algometry.

RESULTS

Comparing baseline at week one with week six (end of treatment), the VAS scores dropped by 2.9 points (P < 0.01). The six directions of movement studied by the CROM showed a combined increase of 11% (P = 0.01). The NDI decreased significantly from 16 to 10 (P = 0.03), and the JPE decreased significantly from 3.7° to 1.9° (P = 0.047). There was no change in the pressure pain threshold in any muscle tested. There were no significant adverse effects.

CONCLUSIONS

These preliminary results demonstrate that this novel, computerized, three-dimensional cervical mobilization device is probably safe. The data also suggest that this method is effective in alleviating neck pain and associated headache, and in increasing the CROM, although the sample size was small in this open trial.

Guideline-based development and practice test of quality indicators for physiotherapy care in patients with neck pain

RATIONALE, AIMS AND OBJECTIVES

Little is currently known about the quality of physiotherapy care for patients with musculoskeletal pain. Neck pain was used as an example. The aim is to develop a set of quality indicators, including a practice test.

METHODS

A systematic method is used to develop potential process and outcome indicators. An expert and user panel is used to appraise the potential quality indicators regarding clarity, relevancy, feasibility, acceptability and improvement potential. An invitation to participate in the practice test was sent to physiotherapy practices. The resulting algorithm is used to calculate the degree to which physiotherapists met these indicators (0-100%). Differences in valid outcomes are tested for significance (Student's t-test; α = 0.05) and compared with established values for clinical relevance [minimal clinically important change (MCIC)].

RESULTS

A representative set of 40 quality indicators (28 process indicators and 12 outcome indicators) is selected from 44 initial guidelines and literature-based recommendations. The process indicators (n = 28) are classified per step of the clinical reasoning process of physiotherapy care. Of the 106 potential participants from 27 practices, 38 physiotherapists (35.8%) submitted data on 96 patients with non-specific neck pain. On average, the participating physiotherapists showed a 55.6% adherence to process indicators with a great variation in scores per step of the clinical reasoning process. The outcomes for 'pain', 'headache' and 'daily functioning' were significantly better compared with baseline, and the mean differences exceeded established values for MCICs.

CONCLUSION

Guardedly, we can conclude that a systematic approach is a valuable means to develop a preliminary set of process and outcome indicators for physiotherapy care for patients with non-specific neck pain, and a practice test should be an intrinsic part of such a systematic approach as it provides valuable information on the key attributes of the set indicators.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

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

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

What does 'recovery' mean to people with neck pain? Results of a descriptive thematic analysis

OBJECTIVES

To describe the meaning of being recovered as perceived by people with chronic mechanical neck pain.

METHODS

To determine the way people with neck pain would describe a recovered state a descriptive thematic approach was used. A nominal focus group technique, written reflections, and one-on-one semi-structured interviews were used to collect sufficient data. Data from the focus groups were analyzed both through vote tallying and thematic analysis. Reflections and interviews were analyzed thematically by two independent researchers. Triangulation and member-checking were employed to establish trustworthiness of results.

RESULTS

A total of 35 people, primarily females with neck pain of traumatic origin, participated in this study. Thematic analysis identified 6 themes that adequately described the data: absent or manageable symptoms, having the physical capacity one ought to have, participation in life roles, feeling positive emotions, autonomy & spontaneity, and re-establishing a sense of self. Member checking and triangulation suggested data saturation and accuracy of the generated themes.

DISCUSSION

Recovery from neck pain appears to be informed by factors that fit with existing models of health, quality of life and satisfaction. Basing recovery solely on symptom or activity-level measures risks inaccurate estimates of recovery trajectories from traumatic or non-traumatic neck pain.

Effects of strength and endurance training of superficial and deep neck muscles on muscle activities and pain levels of females with chronic neck pain

[Purpose] To compare muscle activities and pain levels of females with chronic neck pain receiving different exercise programs. [Subjects and Methods] One hundred females with chronic neck pain participated in this study. They were randomly allocated into 4 groups (n = 25) on the basis of the exercises performed as follows: strength-endurance exercise, craniocervical flexion exercise, combination of strength-endurance and craniocervical flexion exercise and control groups. Pain, disability levels and changes in the muscle activities of the cervical erector spinae (CE), sternocleidomastoid (SCM), anterior scalenes (AS) and upper trapezius (UT) muscles were evaluated before and after the interventions. [Results] After 12 weeks of exercise intervention, all three exercise groups showed improvements in pain and disability. The muscle activities during the typing task were significantly different from the control group in all three exercise groups for all muscles except those of the extensor muscles in the craniocervical flexion exercise group. [Conclusion] The results of this study indicate that exercises for the cervical muscles improve pain and disability. The exercise programs reduced the activities of almost all cervical muscles.

The association between asymmetric hip mobility and neck pain in young adults

OBJECTIVE

The objective of this cross-sectional observational study was to determine whether asymmetric hip mobility was associated with neck pain in young adults.

METHODS

Three hundred twenty-seven freshmen students were recruited from an urban university and underwent the Patrick's flexion, abduction, external rotation, extension (FABERE) test for comparison of the functional mobility of bilateral hip joints during the health examination. A logistic regression model was constructed to determine whether the asymmetry measured by the Patrick's FABERE test was associated with neck pain after adjusting for factors of sex and exercise habits.

RESULTS

The frequency of asymmetric results of the Patrick's FABERE test among the students who reported neck pain was significantly higher than that of those without neck pain (54.2% vs 26.5%; P < .001). After adjusting for the above confounders, the odds ratio of asymmetric results of a Patrick's FABERE test was 2.99 (95% confidence interval, 1.57-5.72; P < .001).

CONCLUSIONS

Imbalanced mobility of the hip joints might be associated with an increased incidence of neck pain.

Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: a randomized controlled study

BACKGROUND

Although exercise can be effective for relief of neck pain, little is known about the effect of exercise on the neural control of neck muscles.

METHODS

A randomized controlled trial was conducted on 46 women with chronic neck pain to investigate the immediate effectiveness of an 8-week exercise programme on pain and directional specificity of neck muscle activity. At baseline, the patients completed questionnaires including the neck disability index (NDI) and performed a circular contraction of their head in the horizontal plane at 15 N force, with continuous change in force direction in the range 0-360°. Electromyography (EMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SCap) muscles. Tuning curves of the EMG amplitude were computed, which depicts muscle activity over a range of force directions. The mean point of the tuning curves defined a directional vector, which determined the specificity of muscle activity. Patients were randomly assigned either to a training or control group.

RESULTS

A significant between-group difference in the change in NDI was observed. A reduction in NDI was observed following training (pre: 18.2 ± 7.4; post: 14.1 ± 6.5; p < 0.01) but not for the control group (pre: 17.5 ± 6.3; post: 16.6 ± 7.4). The training group showed higher specificity of muscle activity post-intervention (pre: 18.6 ± 9.8%, post: 24.7 ± 14.3%; p < 0.05), whereas no change occurred for the control group (pre: 19.4 ± 11.9%, post: 18.2 ± 10.1%).

CONCLUSION

An exercise programme that aims to enhance motor control of the cervical spine improves the specificity of neck muscle activity and reduces pain and disability in patients with neck pain.

Evidence of Physiotherapy Interventions for Patients with Chronic Neck Pain: A Systematic Review of Randomised Controlled Trials

Chronic neck pain (CNP) is common and costly, and the effect of physiotherapeutic interventions on the condition is unclear. We reviewed the literature for evidence of effect of physiotherapy interventions on patients with CNP. Five bibliographic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PEDro) were systematically searched. Randomised, placebo and active-treatment-controlled trials including physiotherapy interventions for adults with CNP were selected. Data were extracted primary outcome was pain. Risk of bias was appraised. Effect of an intervention was assessed, weighted to risk of bias. 42 trials reporting on randomised comparisons of various physiotherapy interventions and control conditions were eligible for inclusion involving 3919 patients with CNP. Out of these, 23 were unclear or at high risk of bias, and their results were considered moderate- or low-quality evidence. Nineteen were at low risk of bias, and here eight trials found effect on pain of a physiotherapy intervention. Only exercise therapy, focusing on strength and endurance training, and multimodal physiotherapy, cognitive-behavioural interventions, massage, manipulations, laser therapy, and to some extent also TNS appear to have an effect on CNP. However, sufficient evidence for application of a specific physiotherapy modality or aiming at a specific patient subgroup is not available.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Ultrasound imaging with speckle tracking of cervical muscle deformation and deformation rate: isometric contraction of patients after anterior cervical decompression and fusion for cervical disc disease and controls

There is currently a lack of information regarding neck muscle activity during specific exercises. The purpose of the present study was to investigate deformation and deformation rate in different layers of dorsal and ventral neck muscles during isometric neck muscle contraction in individuals after anterior cervical decompression and fusion and in healthy controls. This study included 10 individuals (mean age 60 years; SD 7.1) with a verified, long-standing neck disorder and 10 healthy, age- and sex-matched controls. Ultrasonography and post-process speckle tracking analysis was used to investigate the degree and the rate of neck muscles motions at the C4 segmental level during sub-maximal, isometric resistance of the head in a seated position. None of the analyses performed showed significant differences between groups (p > 0.05). In the dorsal muscles, both groups exhibited a higher deformation rate in the multifidus than in the trapezius, splenius, and semispinalis capitis (p ≤ 0.01). In the neck disorder group, the multifidus also showed a higher deformation rate compared to the semispinalis cervicis (p = 0.02). In the ventral muscles of patients with neck disorders, the longus colli had a higher deformation rate than the sternocleidomastoid (p = 0.02). Among the healthy controls, the multifidus showed a higher degree of deformation (p = 0.02) than the trapezius. In conclusion, our results showed no significant differences between the two groups in mechanical neck muscle activation. Larger studies with different exercises, preferably with a standardized measure of resistance, are needed to investigate whether patients and controls show differences in deformation and deformation rates in neck muscles.

Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests. A study protocol of a randomized controlled trial

Background

A major problem with rehabilitation interventions for neck pain is that the condition may have multiple causes, thus a single treatment approach is seldom efficient. The present study protocol outlines a single blinded randomised controlled trial evaluating the effect of tailored treatment for neck-shoulder pain. The treatment is based on a decision model guided by standardized clinical assessment and functional tests with cut-off values. Our main hypothesis is that the tailored treatment has better short, intermediate and long-term effects than either non-tailored treatment or treatment-as-usual (TAU) on pain and function. We sub-sequentially hypothesize that tailored and non-tailored treatment both have better effect than TAU.

Methods/Design

120 working women with minimum six weeks of nonspecific neck-shoulder pain aged 20–65, are allocated by minimisation with the factors age, duration of pain, pain intensity and disability in to the groups tailored treatment (T), non-tailored treatment (NT) or treatment-as-usual (TAU). Treatment is given to the groups T and NT for 11 weeks (27 sessions evenly distributed). An extensive presentation of the tests and treatment decision model is provided. The main treatment components are manual therapy, cranio-cervical flexion exercise and strength training, EMG-biofeedback training, treatment for cervicogenic headache, neck motor control training. A decision algorithm based on the baseline assessment determines the treatment components given to each participant of T- and NT-groups. Primary outcome measures are physical functioning (Neck Disability Index) and average pain intensity last week (Numeric Rating Scale). Secondary outcomes are general improvement (Patient Global Impression of Change scale), symptoms (Profile Fitness Mapping neck questionnaire), capacity to work in the last 6 weeks (quality and quantity) and pressure pain threshold of m. trapezius. Primary and secondary outcomes will be reported for each group with effect size and its precision.

Discussion

We have chosen not to include women with psychological ill-health and focus on biomedical aspects of neck pain. Future studies should aim at including psychosocial aspects in a widened treatment decision model. No important adverse events or side-effects are expected.

Trial registration

Current Controlled Trials registration ISRCTN49348025.

Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial

PURPOSE

Although there is growing evidence in favour of the bio-psychosocial approach to the treatment of persistent neck pain, it is questioned whether treating psychological factors can improve patient perceptions of disability, pain and quality of life. This randomised, controlled study with 12 months' follow-up was conducted to evaluate the efficacy of adding cognitive-behavioural principles to exercises for chronic neck pain.

METHODS

Eighty patients were randomly assigned to the usual neck exercises plus cognitive-behavioural treatment (PTcb group, 40 subjects) or to treatment based on neck exercises alone (PT group, 40 subjects). Before treatment (T1), at the end of treatment (T2) and 12 months later (T3), all of the patients completed a booklet including the Neck Pain and Disability Scale, a numerical rating scale, and the Short-Form Health Survey Questionnaire (SF-36).

RESULTS

The present trial failed to demonstrate its primary end point: the pre- and post-treatment difference in total NPDS scores was not statistically different between groups. Disability improved similarly in both groups over time, remaining stable until T3 in the PTcb group and slightly increasing at the same time in the PT group. Pain trends were comparable, with both groups showing an improvement between T1 and T2, and a slight worsening between T2 and T3. There were significant increases in all of the SF-36 domains except for health in general, and vitality in both groups by the end of treatment. SF-36 showed a between-group difference only for the physical activity domain (10.4; 95% CI 2.4-18.5).

CONCLUSION

Disability, pain and quality of life improved at the end of treatment in both groups, without differences between them.

An educational and physical program to reduce headache, neck/shoulder pain in a working community: a cluster-randomized controlled trial

BACKGROUND

Noninvasive physical management is often prescribed for headache and neck pain. Systematic reviews, however, indicate that the evidence of its efficacy is limited. Our aim was to evaluate the effectiveness of a workplace educational and physical program in reducing headache and neck/shoulder pain.

METHODOLOGY/PRINCIPAL FINDINGS

Cluster-randomized controlled trial. All municipal workers of the City of Turin, Italy, were invited to participate. Those who agreed were randomly assigned, according to their departments, to the intervention group (IG) or to the control group and were given diaries for the daily recording of pain episodes for 1 month (baseline). Subsequently, only the IG (119 departments, 923 workers) began the physical and educational program, whereas the control group (117 departments, 990 workers) did not receive any intervention. All participants were again given diaries for the daily recording of pain episodes after 6 months of intervention. The primary outcome was the change in the frequency of headache (expressed as the proportion of subjects with a ≥50% reduction of frequency; responder rate); among the secondary outcomes there were the absolute reduction of the number of days per month with headache and neck/shoulder pain. Differences between the two groups were evaluated using mixed-effect regression models. The IG showed a higher responder rate [risk ratio, 95% confidence interval (CI)] for headache (1.58; 1.28 to 1.92) and for neck/shoulder pain (1.53; 1.27 to 1.82), and a larger reduction of the days per month (95% CI) with headache (-1.72; -2.40 to -1.04) and with neck/shoulder pain (-2.51; -3.56 to -1.47).

CONCLUSIONS

The program effectively reduced headache and neck/shoulder pain in a large working community and appears to be easily transferable to primary-care settings. Further trials are needed to investigate the program effectiveness in a clinical setting, for highly selected patients suffering from specific headache types.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00551980.

Avoidable costs of physical treatments for chronic back, neck and shoulder pain within the Spanish National Health Service: a cross-sectional study

BACKGROUND

Back, neck and shoulder pain are the most common causes of occupational disability. They reduce health-related quality of life and have a significant economic impact. Many different forms of physical treatment are routinely used. The objective of this study was to estimate the cost of physical treatments which, despite the absence of evidence supporting their effectiveness, were used between 2004 and 2007 for chronic and non-specific neck pain (NP), back pain (BP) and shoulder pain (SP), within the Spanish National Health Service in the Canary Islands (SNHSCI).

METHODS

Chronic patients referred from the SNHSCI to private physical therapy centres for NP, BP or SP, between 2004 and 2007, were identified. The cost of providing physical therapies to these patients was estimated. Systematic reviews (SRs) and clinical practice guidelines (CPGs) for NP, BP and SP available in the same period were searched for and rated according to the Oxman and AGREE criteria, respectively. Those rated positively for ≥70% of the criteria, were used to categorise physical therapies as Effective; Ineffective; Inconclusive; and Insufficiently Assessed. The main outcome was the cost of physical therapies included in each of these categories.

RESULTS

8,308 chronic cases of NP, 4,693 of BP and 5,035 of SP, were included in this study. Among prescribed treatments, 39.88% were considered Effective (physical exercise and manual therapy with mobilization); 23.06% Ineffective; 13.38% Inconclusive, and 23.66% Insufficiently Assessed. The total cost of treatments was € 5,107,720. Effective therapies accounted for € 2,069,932.

CONCLUSIONS

Sixty percent of the resources allocated by the SNHSCI to fund physical treatment for NP, BP and SP in private practices are spent on forms of treatment proven to be ineffective, or for which there is no evidence of effectiveness.

The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study

Introduction. Cupping has been used since antiquity in the treatment of pain conditions. In this pilot study, we investigated the effect of traditional cupping therapy on chronic nonspecific neck pain (CNP) and mechanical sensory thresholds. Methods. Fifty CNP patients were randomly assigned to treatment (TG, n = 25) or waiting list control group (WL, n = 25). TG received a single cupping treatment. Pain at rest (PR), pain related to movement (PM), quality of life (SF-36), Neck Disability Index (NDI), mechanical detection (MDT), vibration detection (MDT), and pressure pain thresholds (PPT) were measured before and three days after a single cupping treatment. Patients also kept a pain and medication diary (PaDi, MeDi) during the study. Results. Baseline characteristics were similar in the two groups. After cupping TG reported significantly less pain (PR: −17.9 mm VAS, 95%CI −29.2 to −6.6; PM: −19.7, 95%CI −32.2 to −7.2; PaDi: −1.5 points on NRS, 95%CI −2.5 to −0.4; all P < 0.05) and higher quality of life than WL (SF-36, Physical Functioning: 7.5, 95%CI 1.4 to 13.5; Bodily Pain: 14.9, 95%CI 4.4 to 25.4; Physical Component Score: 5.0, 95%CI 1.4 to 8.5; all P < 0.05). No significant effect was found for NDI, MDT, or VDT, but TG showed significantly higher PPT at pain-areas than WL (in lg(kPa); pain-maximum: 0.088, 95%CI 0.029 to 0.148, pain-adjacent: 0.118, 95%CI 0.038 to 0.199; both P < 0.01). Conclusion. A single application of traditional cupping might be an effective treatment for improving pain, quality of life, and hyperalgesia in CNP.

Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: design of a randomised controlled trial

BACKGROUND

Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.

METHODS/DESIGN

The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg - 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.

DISCUSSION

The perspectives of this study are discussed, in addition to the strengths and weaknesses.

TRIAL REGISTRATION

The study is registered in http://www.ClinicalTrials.gov identifier NCT01431261.

A novel massage therapy technique for management of chronic cervical pain: a case series

Background:

Neck pain is a generalized condition resulting from a complex etiology with presentation of a wide variety of symptoms. Neck pain is most often accompanied by decreased range of motion (ROM), muscle and joint stiffness, and limitations in functional capabilities. This condition may result in significant personal and societal burden.

Purpose:

We evaluated the effectiveness of a novel massage therapy intervention by following the treatment regimen and outcomes of two patients experiencing chronic neck pain.

Participants:

Two patients (46 and 53 years old) experienced chronic (>5 years) neck pain. Both patients reported pain, limited ROM, and muscle and joint stiffness. Additionally, the first patient reported a lack of sleep, and both patients stated their pain interfered with their quality of life and activities of daily living.

Intervention:

Patients received the Integrative Muscular Movement Technique (IMMT) intervention approximately twice a week for a total of eight treatments, each approximately 20 minutes in duration.

Results:

Both patients experienced a reduction in pain and an increase in cervical ROM in flexion, extension, rotation, and sidebending. The first patient also reported an increased ability to sleep. Both patients reported an increased ability to perform activities of daily living, including work-related responsibilities.

Conclusions:

For the two patients included in this report, therapist observations and patient reports indicate that inclusion of the IMMT treatment in a treatment regimen for chronic neck pain may lead to decreased pain and increased cervical ROM. These positive effects of the IMMT intervention may have a role in enhancing functional outcomes of these patients.

The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain--a randomised controlled pilot study

Background

In this preliminary trial we investigated the effects of dry cupping, an ancient method for treating pain syndromes, on patients with chronic non-specific neck pain. Sensory mechanical thresholds and the participants' self-reported outcome measures of pain and quality of life were evaluated.

Methods

Fifty patients (50.5 ± 11.9 years) were randomised to a treatment group (TG) or a waiting-list control group (WL). Patients in the TG received a series of 5 cupping treatments over a period of 2 weeks; the control group did not. Self-reported outcome measures before and after the cupping series included the following: Pain at rest (PR) and maximal pain related to movement (PM) on a 100-mm visual analogue scale (VAS), pain diary (PD) data on a 0-10 numeric rating scale (NRS), Neck Disability Index (NDI), and health-related quality of life (SF-36). In addition, the mechanical-detection thresholds (MDT), vibration-detection thresholds (VDT), and pressure-pain thresholds (PPT) were determined at pain-related and control areas.

Results

Patients of the TG had significantly less pain after cupping therapy than patients of the WL group (PR: Δ-22.5 mm, p = 0.00002; PM: Δ-17.8 mm, p = 0.01). Pain diaries (PD) revealed that neck pain decreased gradually in the TG patients and that pain reported by the two groups differed significantly after the fifth cupping session (Δ-1.1, p = 0.001). There were also significant differences in the SF-36 subscales for bodily pain (Δ13.8, p = 0.006) and vitality (Δ10.2, p = 0.006). Group differences in PPT were significant at pain-related and control areas (all p < 0.05), but were not significant for MDT or VDT.

Conclusions

A series of five dry cupping treatments appeared to be effective in relieving chronic non-specific neck pain. Not only subjective measures improved, but also mechanical pain sensitivity differed significantly between the two groups, suggesting that cupping has an influence on functional pain processing.

Trial registration

The trial was registered at clinicaltrials.gov (NCT01289964).