Physiotherapy management of neck pain

Effects of matched vs. unmatched physical therapy interventions on pain or disability in patients with neck pain - a systematic review and meta-analysis

BACKGROUND

The interventions performed in most randomized controlled trials (RCTs) on neck pain patients are standardized, irrespective of the high heterogeneity of patients. However, clinicians tend to choose an intervention based on the patients' clinical characteristics, and thus match the treatment to the patient.

OBJECTIVES

To investigate the effectiveness of interventions matched to the clinical characteristics of patients with neck pain versus the same, but unmatched treatment for improving pain or disability.

DESIGN

A systematic review and meta-analysis conducted following Cochrane guidelines.

METHODS

Databases searches were performed from inception to September 2023. RCTs were included if the patients in the experimental group received a treatment matched to clinical presentation or to clinicians' assessment, if the patients in the control group received a similar but unmatched treatment, and if pain or disability were reported as outcome measures.

RESULTS

The literature search produced 9516 records of which 27 met the inclusion criteria. Matched exercise therapy was superior to unmatched exercise for pain (SMD -0.57; 95% CI -0.95, -0.18) and for disability (SMD -0.69; 95% CI -1.14, -0.23) at short term, but not at intermediate-term follow-up. Matched manual treatment was not superior to unmatched manual therapy for pain or for disability at short or intermediate-term follow-up.

CONCLUSIONS

Results suggest that matching exercise to movement limitation, trapezius myalgia, or forward head position may lead to better outcomes in the short term, but not in the intermediate-term. Matched manual therapy was not superior to unmatched treatment either short or intermediate-term. Further research is warranted to verify if those criteria are potentially useful matching criteria.

What are the costs of managing neck and low back pain in Brazil? Investigation of a ten-year period from the perspective of the Brazilian public health system

INTRODUCTION

Considering the prospects of increased prevalence and disability due to neck and low back pain, it is relevant to investigate the care processes adopted, to assist future public policies and decision-making for a better allocation of resources. Objective: the aim of this study was to estimate the costs arising from inpatient and outpatient care of individuals with Neck Pain (NP) and Low Back Pain (LBP) in Brazil, between 2010 and 2019.

METHODS

This is a cost-of-illness study from the perspective of the Brazilian public health system, based on health conditions with high prevalence (neck and low back pain). Data were presented descriptively using absolute and relative values.

RESULTS

Between 2010 and 2019, the health system spent more than $600 million (R$ 2.3 billion) to treat NP and LBP in adults, and LBP accounted for most of the expenses. Female had higher absolute expenses in inpatient care and in the outpatient system.

CONCLUSION

Our study showed that the costs with NP and LBP in Brazil were considerable. Female patients had higher outpatient costs and male patients had higher hospitalization costs. Healthcare expenses were concentrated for individuals between 34 and 63 years of age.

The effectiveness of cognitive functional therapy on patients with chronic neck pain: A systematic literature review

OBJECTIVE

Recently, psychological, and behavioral interventions such as cognitive functional therapy (CFT) has gained significant attention in musculoskeletal rehabilitation. We aimed to compare interventions with a CFT component in adults (>18 years old) suffering from chronic neck pain (CNP) or chronic whiplash associated disorders (>3 months) with another intervention or no intervention, in pain, disability, kinesiophobia, or any other reported outcome measure.

RESULTS

One case-study and three randomized controlled trials met the eligibility criteria. Statistically and clinically significant improvement in pain was found in favour of CFT combined with scapular exercise compared to exercise alone (MD = -19.91; 95%CI: -24.18 to -15.64) and controls (MD = -48.91; 95%CI: -53.88 to -43.94) at the very-short term follow-up. A significant difference in kinesiophobia was found at the short-term follow-up in favour of CFT and exercise compared to exercise alone (MD = -13.23; 95%CI-16.94 to -9.52) and controls (MD = -40.81 95%CI: -44.55 to -37.07). Finally, statistically and clinically significant improvement was found in favour of CFT compared to controls at the short-term follow-up in stress (MD = -36.62, 95%CI: 43.47 to -29.77), fear avoidance (MD = -35.44; 95%CI: 42.57 to -28.31), anxiety (MD = -34.43; 95%CI: 41.90 to -26.96), pain catastrophizing (MD = -25.19; 95%CI: 32.49 to -17.89), depression (MD = -30.72; 95%CI: 38.37 to -23.07), but a significant and clinically difference in favour of the control group at self-efficacy (MD = 29.56; 95%CI20.70 to 38.42).

CONCLUSIONS

Very low certainty evidence suggests that CFT alone or in combination with exercise may produce better outcomes than no treatment or exercise alone. The results should be interpreted with caution, given that the number of studies assessing CFT in CNP is limited.

Effect of thoracic manipulation on neck pain in the mobility group: A randomized controlled trial

Background and aims

Thoracic spine manipulation (TSM) increases the thoracic spine's range of motion (ROM), effectively reducing pain intensity and disability in patients with mechanical neck pain. We aimed to determine the effect of TSM on neck pain intensity and functional impairment in patients classified under the "mobility" category in Childs' classification.

Methods

In this randomized controlled trial, patients with mechanical neck pain who met the inclusion criteria were randomly assigned to either the TSM (n = 21) or sham manipulation (n = 20) group. The primary outcomes were pain during neck rotation and subjective improvement assessed using the Numerical Pain Rating Scale (NPRS) and Global Rating of Change (GROC), respectively. The secondary outcomes were NPRS at rest, disability (assessed using the Neck Disability Index [NDI]), and ROM of the cervical and thoracic spine rotation. Outcome measurements were performed at baseline, immediately after treatment, 1 week after treatment, and at the 4-week follow-up. Linear mixed models were used to analyze the NPRS, NDI, and ROM. The GROC was analyzed using a chi-square test for the percentage recording ≥+4; the means of each group were compared using an unpaired t-test.

Results

The NPRS with neck rotation, neck and thoracic ROM, and NDI showed significant interactions between the groups. The NPRS with neck rotation was significantly lower in the TSM group than in the sham group at all time points after the treatment (p < 0.001). There was no difference between the groups in the proportion showing moderate (≥+4) improvement according to the GROC; however, there was a significant difference in the mean values (p = 0.013).

Conclusion

Incorporating TSM into treatment protocols may improve clinical outcomes in patients with neck pain, potentially leading to better pain management and functional recovery. Therefore, physiotherapists should consider TSM as a viable and effective intervention to improve patient outcomes in neck pain rehabilitation.

Physical modulation of mesenchymal stem cell exosomes: A new perspective for regenerative medicine

Mesenchymal stem cell-derived exosomes (MSC-Exo) offer promising therapeutic potential for various refractory diseases, presenting a novel therapeutic strategy. However, their clinical application encounters several obstacles, including low natural secretion, uncontrolled biological functions and inherent heterogeneity. On the one hand, physical stimuli can mimic the microenvironment dynamics where MSC-Exo reside. These factors influence not only their secretion but also, significantly, their biological efficacy. Moreover, physical factors can also serve as techniques for engineering exosomes. Therefore, the realm of physical factors assumes a crucial role in modifying MSC-Exo, ultimately facilitating their clinical translation. This review focuses on the research progress in applying physical factors to MSC-Exo, encompassing ultrasound, electrical stimulation, light irradiation, intrinsic physical properties, ionizing radiation, magnetic field, mechanical forces and temperature. We also discuss the current status and potential of physical stimuli-affected MSC-Exo in clinical applications. Furthermore, we address the limitations of recent studies in this field. Based on this, this review provides novel insights to advance the refinement of MSC-Exo as a therapeutic approach in regenerative medicine.

Comparison of Short-Term Effects of Different Spinal Manipulations in Patients with Chronic Non-Specific Neck Pain: A Randomized Controlled Trial

Spinal manipulations for chronic non-specific neck pain (CNNP) include cervical, cervicothoracic junction, and thoracic spine (CCT) manipulations as well as upper cervical spine (UCS) manipulations. This study aimed to compare the short-term effects of UCS manipulation versus a combination of CCT spine manipulations on pain intensity, disability, and cervical range of motion (CROM) in CNNP patients. In a private physiotherapy clinic, 186 participants with CNNP were randomly assigned to either the UCS (n = 93) or CCT (n = 93) manipulation groups. Neck pain, disability, and CROM were measured before and one week after the intervention. No significant differences were found between the groups regarding pain intensity and CROM. However, there was a statistically significant difference in neck disability, with the CCT group showing a slightly greater decrease (CCT: 16.9 ± 3.8 vs. UCS: 19.5 ± 6.8; p = 0.01). The findings suggest that a combination of manipulations in the CCT spine results in a slightly more pronounced decrease in self-perceived disability compared to UCS manipulation in patients with CNNP after one week. However, no statistically significant differences were observed between the groups in terms of pain intensity or CROM.

The effectiveness of cervical rehabilitation interventions for pain in adults with myogenic temporomandibular disorders: A systematic review and meta-analysis

OBJECTIVE

Little evidence exists for the most effective conservative treatment approach for adults with myogenic temporomandibular disorders (MTMD). We aim to assess the effectiveness of cervical rehabilitation interventions on pain intensity and sensitivity in adults with MTMD compared to comparison intervention such as placebo, sham treatment, education or no intervention.

METHODS

For this systematic review and meta-analysis, we searched PubMed, EMBASE, Medline, PEDro databases, forward and backward citations and grey literature studies through PROSPERO, clinical trials and data registries without language or date restrictions between inception and 1 December 2021. We selected randomised controlled trials (RCTs) based on adult populations with MTMD who had a cervical rehabilitation intervention which was defined as any conservative intervention targeting the anatomical structures of the cervical spine. The primary outcome measures for pain were self-reported pain intensity and pain sensitivity through the pressure pain threshold (PPT) of the masseter and temporalis muscles. Secondary outcome measures of maximal mouth opening (on MMO) were included. Included studies were assessed for bias with the Cochrane risk of bias tool for randomised trials. Evidence from RCTs was synthesised to determine treatment effect size as differences between standardised mean difference (SMD) for changes in pain intensity, PPT and MMO comparing adults with MTMD who were treated with cervical rehabilitation interventions compared to a control group. This study is registered on Prospero, number CRD 42021289299.

RESULTS

Our general search yielded 2647 studies where seven RCTs met eligibility criteria with low to some concerns in their risk of bias. Pain intensity (five studies, n = 223, SMD -0.98, 95% CI -1.67 to -0.28, I2 = 79%), PPT of the masseter muscle (six studies, n = 395, SMD 0.64, 95% CI 0.43 to 0.86, I2 = 90%) and the temporalis muscles (five studies, n = 295, SMD 0.76, 95% CI 0.07 to 1.45, I2 = 84%) showed large treatment effect estimates favouring cervical rehabilitation interventions compared to no treatment, sham cervical treatment, patient education or non-cervical neuromuscular techniques. Compared to control interventions, one type of cervical rehabilitation intervention, cervical manual therapy alone or in combination with a neck exercise program was associated with statistically significant, large treatment effect estimates on pain intensity (four studies, n = 203, SMD -1.52, 95% CI -2.50 to -0.55).

CONCLUSIONS

This review found that in the short-term, cervical rehabilitation interventions especially upper cervical MT alone or in combination with a neck exercise program are effective in improving multiple pain outcomes in adults with MTMD. However, further research is needed to measure the long-term effects of this type of intervention.

Description of massage interventions in randomised clinical trials for neck pain; a review using the TIDieR checklist

OBJECTIVE

How interventions are reported can impact the ability to implement these intervention in clinical practice. Therefore, our aim is to assess the reporting of massage interventions in randomised controlled trials for patients with neck pain.

DATA SOURCES

This manuscript concerns a secondary analysis of trials evaluating massage for neck pain selected for a scoping review. An updated literature search was completed using four databases to 31 July 2023.

REVIEW METHODS

Trials were selected that evaluate massage interventions. Two independent assessors extracted descriptive information, methodological quality (PEDro-scale) and assessed completeness of reporting of the intervention using the Template for Intervention Description and Replication (TIDier-checklist). We present frequencies of the extracted data.

RESULTS

We included 35 trials (2840 patients) with neck pain. Most trials (n = 23) included patients with chronic non-specific neck pain. We found a wide variety of massage interventions from Chinese massage, Swedish massage to myofascial release. In addition, the dose, number of sessions and the duration of the intervention varied widely. The methodological quality overall was fair to good (varied between 4-8/10), and we found a moderate completeness of reporting. All trials provided the name of the intervention, 30 (86%) provided a rationale and 26 (74%) trials described details of the massage intervention.

CONCLUSION

The massage interventions were moderately described in trials in patients with neck pain, but provided enough information to guide the decision making for designing future Network Meta-analysis as to what trials need to be considered when grouping massage interventions in a clinically relevant way.

Clinical validation of grouping conservative treatments in neck pain for use in a network meta-analysis: a Delphi consensus study

BACKGROUND

A network meta-analysis aims to help clinicians make clinical decisions on the most effective treatment for a certain condition. Neck pain is multifactorial, with various classification systems and treatment options. Classifying patients and grouping interventions in clinically relevant treatment nodes for a NMA is essential, but this process is poorly defined.

OBJECTIVE

Our aim is to obtain consensus among experts on neck pain classifications and the grouping of interventions into nodes for a future network meta-analysis.

DESIGN

A Delphi consensus study involving neck pain experts worldwide.

METHODS

We invited authors of neck pain clinical practice guidelines published from 2014 onwards. The Delphi baseline questionnaire was developed based on the findings of a scoping review, including four items on classifications and 19 nodes. Participants were asked to record their level of agreement on a seven-point Likert scale or using Yes/No/Not sure answer options for the various statements. We used descriptive analysis to summarise the responses on each statement with content analysis of the free-text comments.

RESULTS

In total, 18/80 experts (22.5%) agreed to participate in one or more Delphi rounds. We needed three rounds to reach consensus for two classification of neck pain: one based on aetiology and one on duration. In addition, we also reached consensus on the grouping of interventions, including a definition of each node, with the number of nodes reduced to 17.

CONCLUSION

With this consensus we clinically validated two neck pain classifications and grouped conservative treatments into 17 well-defined and clinically relevant nodes.

Effect of a telerehabilitation exercise program versus a digital booklet with self-care for patients with chronic non-specific neck pain: a protocol of a randomized controlled trial assessor-blinded, 3 months follow-up

BACKGROUND

Neck pain is the fourth worldwide leading cause of disability and represents 22% of musculoskeletal disorders. Conservative intervention has been strongly recommended to treat chronic neck pain and Telerehabilitation is the alternative for the treatment of musculoskeletal conditions. There is a lack of high-quality research on the effects of telerehabilitation in patients with neck pain and functional disability. Therefore, this study aims to evaluate the effect of a telerehabilitation exercise program versus a digital booklet only with self-care information in individuals with non-specific chronic neck pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomized controlled trial comparing a telerehabilitation exercise program versus a digital booklet with self-care information. Seventy patients will be recruited with non-specific chronic neck pain. Follow-ups will be conducted post-treatment, 6 weeks, and 3 months after randomization. The primary outcome will be disability at post-treatment (6 weeks) measured using neck pain disability. Secondary outcomes will be pain intensity levels, global perceived effect, self-efficacy, quality of life, kinesiophobia, and adherence to treatment. In our hypothesis, patients allocated to the intervention group experience outcomes that are similar to those of those assigned to the self-care digital booklet. Our hypothesis can then be approved or disapproved based on the results of the study.

DISCUSSION

This randomized clinical trial will provide reliable information on the use of telerehabilitation to treat patients with chronic non-specific neck pain.

TRIAL REGISTRATION

The study was prospectively registered at the Brazilian Registry of Clinical Trials (number: RBR-10h7khvk). Registered on 16 September 2022.

Recognition of Prodromal Hypoglossal Nerve Palsy Presenting with Neck Pain as Primary Complaint: Findings from a Rare Case Report in Direct Access Physiotherapy during the COVID-19 Pandemic

Neck pain (NP) is the second most common musculoskeletal disorder. Spinal cysts (SCs) are cystic dilatations of the synovial sheaths in joints and tendons. SCs are extremely rare in the cervical spine. Typically, patients are unaware of having an SC due to its asymptomatic nature; however, when cervical SC extends, its volume could compress the surrounding structures, such as the hypoglossal nerve. Isolated hypoglossal nerve palsy (HNP) is very rare and typically presents with unilateral atrophy of the musculature of the tongue and contralateral tongue deviation. Often, patients with HNP also report occipital/neck pain. A 75-year-old man with occipital/neck pain as a primary complaint. Although difficult to observe because of the filtering facepiece two mask, difficulties in articulation and sialorrhea during the interview were noticed. These latter were cues to consider CN examination that revealed CN XII palsy. This prompted a referral for further examination that revealed an SC compressing the right hypoglossal canal. The patient was not considered a surgical candidate and was managed conservatively. This case report outlines the relevant findings relating to the triage of a rare isolated hypoglossal nerve palsy from the physiotherapist's perspective within a complex setting because of the COVID-19 pandemic. Although referred with a diagnosis of cervical radiculopathy, our case highlights that skilled physiotherapists may play a fundamental role in both the recognition and, when applicable, subsequent novel management of a non-musculoskeletal presentation.

Do people with musculoskeletal pain differ from healthy cohorts in terms of global measures of strength? A systematic review and meta-analysis

OBJECTIVE

It is currently unknown if people with musculoskeletal pain display different multi-joint strength capacities than healthy cohorts. The aim was to investigate whether people with musculoskeletal pain show differences in global measures of strength in comparison to healthy cohorts.

DATA SOURCES

A systematic review was conducted using three databases (Medline, CINAHL and SPORTDiscus) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

REVIEW METHODS

Studies involving participants with painful musculoskeletal conditions and multi-joint strength assessment measured at baseline were included. A meta-analysis was also performed to compute standardized mean differences (± 95% confidence intervals), using Hedge's g, and examined the differences in multi-joint strength at baseline between participants with painful musculoskeletal conditions and healthy participants.

RESULTS

In total, 5043 articles were identified, of which 20 articles met the inclusion criteria and were included in the qualitative analysis. The available evidence revealed that multi-joint strength values were limited to knee osteoarthritis, fibromyalgia, chronic low back pain, and rheumatoid arthritis. Only four studies were included in the quantitative synthesis and revealed that only small differences in both chest press (g = -0.34, 95% CI [-0.64, -0.03]) and leg press (g = -0.25, 95% CI [-0.49, -0.02]) existed between adult women with fibromyalgia and active community women.

CONCLUSION

There is a paucity of multi-joint strength values in participants with musculoskeletal pain. Quantitative comparison with healthy cohorts was limited, except for those with fibromyalgia. Adult women with fibromyalgia displayed reduced multi-joint strength values in comparison to active community women.

Risk factors for neck pain-induced disability among primary healthcare workers: A pilot study

BACKGROUND

Neck pain (NP) is associated with high disability rates among healthcare workers.

OBJECTIVE

To determine the potential risk factors associated with disability due to NP among healthcare staff working in primary care settings.

METHODS

This 30-day prospective cross-sectional study involved a survey of 63 healthcare personnel (55 women and 8 men aged 45.30±12.34 years) of two primary healthcare centers in Serbia, who completed a general questionnaire developed for this purpose along with the Neck Disability Index (NDI), whereby the potential predictors of NP-related disability were assessed using the statistical package SPSS ver. 24.

RESULTS

Female healthcare workers achieved a higher score on the NDI scale (Me = 8.00, p < 0.05), as did older respondents (r = 0.260, p < 0.05), those with longer work experience (r = 0.323, p < 0.05), and those that wear prescription glasses (Me = 9.00, p < 0.01). Higher NDI scores were also achieved by respondents that suffered from neck pain at the time of the study (Me = 12.50, p < 0.001), especially if they relied on pain medication (Me = 13.00, p < 0.05), and topical analgesic creams (Me = 12.50, p < 0.05) for treating neck pain.

CONCLUSION

Female sex, older age, greater work experience, current neck pain, use of pain-relieving medications and creams, and need for prescription glasses to correct vision increase the risk of disability due to pain in the cervical spine among healthcare workers.

Prevalence Of Neck and Back Pain Among Gynecologists and Obstetrics in Tertiary Care Hospital of Lahore

Neck pain is identified as the ache, irritation and discomfort in the area below your head up to third Thoracic vertebrae. It can radiate to shoulders, arms and fingers also. The presenting complaints of cervical patients include headache, stiff neck, stress, muscle pain, fever, and tenderness, radiating pain, weakness in the arm and difficulty in lifting or gripping activities. Patients may also present with numbness, tingling and weakness of the arm. Objective: To determine the prevalence of neck and back pain among gynecologists and obstetrics in different tertiary care hospitals of Lahore. Methods: The cross-sectional study included 310 gynecologist and obstetrics that were recruited using non-probability convenience sampling. The cases of the neck pain were recruited from the obstetrics and gynecology department of different hospitals including: Fatima Memorial Hospital, Shalimar Hospital, Services Hospital, Mayo Hospital and Sir Ganga Ram Hospital, Lahore. Research was completed within six months from 23 October 2021 to 30th April 2022. Results: Among 310 participants, 196 (63.2%) reported neck pain among which; 153 (44.4%) gynecologists reported pain two times per week. Out of total, 306 (98.7%) reported fatigue especially on long days. Results regarding pain area showed that 196 (63.2%) had neck pain, 64 (24.6%) had back pain and 50 (16.1%) had shoulder pain. Results regarding frequency of pain showed that out of 310 (100%), 153 (49.4%) had pain 2 times per week and 105 (33.9%) had pain 0-2 times per month. Conclusions: Prevalence of low back pain was 20.65% whereas prevalence of neck pain in gynecologists was 63.23%. The study suggests that neck pain and fatigue were common in gynecologists and obstetrics. They lack of postural awareness and don’t follow ergonomics principles during surgical procedures. 

Dry needling in active or latent trigger point in patients with neck pain: a randomized clinical trial

The purpose was to determine the efficacy of deep dry needling (DDN) applied on an active myofascial trigger point (MTrP) versus a latent-MTrP versus a non-MTrP location, on pain reduction and cervical disability, in patients with chronic neck pain. A randomized, double-blind clinical trial design was used. A sample of 65 patients was divided into non-MTrP-DDN, active-MTrP-DDN and latent-MTrP-DDN groups. The visual analog scale (VAS), reproduction of the patient's pain, number of local twitch responses, pressure pain threshold (PPT) and Neck Disability Index (NDI) were assessed before, during and after the intervention and up to 1 month post-intervention. The active-MTrP-DDN-group reduced pain intensity more than non-MTrP-DDN-group after a week and a month (P < 0.01), as well as showing the greatest improvement in tibialis muscle PPT. The treatment of both Active and Latent MTrPs was associated with the reproduction of the patient's pain. The application of DDN on an active-MTrP in the upper trapezius muscle shows greater improvements in pain intensity after 1 week and 1 month post-intervention, compared to DDN applied in latent-MTrPs or outside of MTrPs in patients with neck pain.