Manual therapy with or without physical medicine modalities for neck pain: a systematic review

Protocol for the development of a 'trustworthy' living systematic review and meta analyses of manual therapy interventions to treat neuromusculoskeletal impairments

BACKGROUND

Preprocessed research resources are believed to be highly 'trustworthy' when translating research to clinical practice. However, the overall 'trustworthiness' is unknown if this evidence contains randomized clinical trials (RCTs) where prospective has not been/cannot be verified, has low confidence in estimated effects, and if they are not up to date.

OBJECTIVES

This protocol will be used to create a baseline benchmark for a series of trustworthy living systematic reviews (SRs) regarding manual therapy interventions.

METHODS

Data will originate from RCTs related to manual therapy neuromusculoskeletal interventions, indexed in 6 search engines in English from 1 January 2010, to the present. Two blinded reviewers will identify the RCTs and extract data using Covidence. The data will be synthesized based on consensus and analyzed using the Cochrane collaboration's Review Manager.

EXPECTED OUTCOMES

It is expected that there will be a shortage of RCTs with at least a moderate confidence in estimated effects that will allow for strong practice recommendations.

DISCUSSION

Identifying evidence that can be translated into strong practice recommendations is essential to identify beneficial and harmful interventions, decrease practice variability, and identify neuromusculoskeletal manual therapy interventions that require further disciplined methodological focus.

Manual therapy for non-radicular cervical spine related impairments: establishing a 'Trustworthy' living systematic review and meta-analysis

OBJECTIVES

To establish a 'trustworthy' living systematic review (SR) with a meta-analysis of manual therapy for treating non-radicular cervical impairments.

DESIGN

SR with meta-analysis.

LITERATURE SEARCH

Articles published between January 2010 and September 2022 were included from: Cochrane Central Register of Controlled Trials (CENTRAL); CINAHL; MEDLINE; PubMed; PEDro, and ProQuest Nursing and Allied Health.

METHODS

This SR included English-language randomized clinical trials (RCTs) of manual therapy involving adults used to treat non-radicular cervical impairments. The primary outcomes were pain and region-specific outcome measures. Cervicogenic headaches and whiplash were excluded to improve homogeneity. Two reviewers independently assessed RCTs. The prospective plan was to synthesize results with high confidence in estimated effects using GRADE.

RESULTS

Thirty-five RCTs were screened for registration status. Twenty-eight were not registered or registered prospectively. In 5 studies, the discussion and conclusion did not match the registry, or this could not be determined. One study did not meet the external validity criterion, and another was rated as having a high risk of bias. One study met the inclusion and exclusion criteria, so practice recommendations could not be made. The remaining study did not identify any clinically meaningful group differences.

DISCUSSION

Only one prospectively registered RCT met this SR's strict, high-quality standards. The single identified paper provides initial high-quality evidence on this topic.

CONCLUSION

This SR establishes a foundation of trustworthiness and can be used to generate research agendas to determine the potential clinical utility of manual therapy directed at the cervical spine for non-radicular cervical complaints.

Incomplete reporting of manual therapy interventions and a lack of clinician and setting diversity in clinical trials for neck pain limits replication and real-world translation. A scoping review

INTRODUCTION

Neck pain is a leading cause of disability, and manual therapy (MT) is a common intervention used across disciplines and settings to treat it. While there is consistent support for MT in managing neck pain, questions remain about the feasibility of incorporating MT from research into clinical practice. The purpose of this scoping review was to assess the adequacy of MT intervention descriptions and the variability in clinician and setting for MT delivery in trials for neck pain.

METHODS

Medline (via PubMed), CINAHL, PEDRo, and the Cochrane Central Registry for Controlled Trials were searched for clinical trials published from January 2010 to November 2021. A 11-item tool modified from the Consensus on Exercise Reporting Template was used to assess appropriateness of intervention reporting. Clinicians, subclassifications of neck pain, and clinical settings were also extracted.

RESULTS

113 trials were included. A low percentage of studies provided the recommended level of detail in the description of how MT was delivered (4.4%), while 39.0% included no description at all. Just over half of trials included clinician's qualifications (58.4%), dose of MT (59.3%), and occurrence of adverse events (55.8%). The proportion of trials with clinicians delivering MT were physical therapists (77.9%), chiropractors (10.6%), and osteopaths (2.7%).

DISCUSSION/CONCLUSION

These results reveal incomplete reporting of essential treatment parameters, and a lack of clinician diversity. To foster reproducibility, researchers should report detailed descriptions of MT interventions. Future research should incorporate a variety of MT practitioners to improve generalizability.

Effects of Cervical Rotatory Manipulation on Hemodynamics and Plaque Stability of Atherosclerotic Internal Carotid Artery in Rabbits

OBJECTIVE

The purpose of this study was to investigate the effects of cervical rotatory manipulation (CRM) on hemodynamics and plaque stability of atherosclerotic internal carotid artery (ICA) in rabbits.

METHODS

Forty rabbits were randomly divided into 4 groups: (1) internal carotid atherosclerosis (ICAS) rabbits treated with CRM (ICAS-CRM group); (2) ICAS rabbits treated without CRM (ICAS group), (3) Normal-CRM group (normal rabbits treated with CRM), and (4) blank control group. In the ICAS-CRM group and ICAS group, the ICAS model was induced by ICA balloon injury combined with a high-fat diet for 12 weeks. CRM was applied to rabbits in the ICAS-CRM and the Normal-CRM groups. During the study, an ultrasonography examination was performed for detecting plaque and hemodynamics on the ICAs. At the end of the study, all atherosclerotic ICAs were removed for histological and immunohistochemical detection.

RESULTS

The hemodynamics (especially end-diastolic velocity, resistance index, and pulsatility index) through the ICAs were adversely affected by atherosclerosis while not adversely affected by CRM. Compared with the ICAS group, the micro-vessel density and average integrated optical densities of macrophages in the ICAS-CRM group were significantly increased. Compared to the ICAS group, in the ICAS-CRM group, the atherosclerosis was more serious, and the tunica intima was more unstable.

CONCLUSIONS

Although CRM did not affect the hemodynamic index of ICA, it was observed to decrease the stability of severe ICAS plaques in rabbits, which may increase the plaque vulnerability.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Upper cervical and upper thoracic spine mobilization versus deep cervical flexors exercise in individuals with forward head posture: A randomized clinical trial investigating their effectiveness

BACKGROUND

Although commonly utilized treatments, no study has directly compared the effectiveness of joint mobilization and stabilization exercise in individuals with forward head posture (FHP).

OBJECTIVE

This study aimed to investigate the effects of upper cervical and upper thoracic spine mobilization versus deep cervical flexors exercise (DCFE) in individuals with FHP.

METHODS

Thirty-one participants with FHP were randomized into the mobilization (n= 15) or exercise (n= 16) group. The treatment period was 4 weeks with follow-up assessment at 4 weeks and 6 weeks after the initial examination. Outcomes assessed included the craniovertebral angle (CVA), numeric pain rating scale (NPRS), respiratory function, and the global rating of change (GRC).

RESULTS

Participants in the mobilization group demonstrated significant improvements (p< 0.05) in CVA, NPRS, and respiratory function, as compared to those in the exercise group. In addition, 9 of 15 (60%) participants in the mobilization group, as compared to 4 of 16 participants (25%) in the exercise group, had a GRC score of +4 or higher.

CONCLUSIONS

The combination of upper cervical and upper thoracic spine mobilization indicated better overall short-term outcomes in CVA, NPRS, respiratory function, and GRC compared with DCFE in individuals with FHP.

Comparing the effectiveness of integrating ergonomics and motor control to conventional treatment for pain and functional recovery of work-related neck-shoulder pain: A randomized trial

BACKGROUND

Work-related neck and shoulder pain (WRNSP) is highly prevalent among patients who seek physiotherapy treatment. Clinicians may tend to focus on teaching home exercises and provide general advice about workplace improvement. The present study investigates the short- and long-term impact of an intervention approach that emphasizes on integrating the motor control re-education with ergonomic advice.

METHODS

Participants diagnosed with WRNSP (n = 101) were randomly assigned into two groups in this randomized controlled trial. The Ergo-motor Group (EM, n = 51) received an integrated intervention with ergonomic advice/modifications and motor control training individualized for each participant based on their specific work demands. Control Group (CO, n = 50) received treatment for pain relief and general exercises of their necks at a designated physiotherapy clinic. Neck pain intensity and functional outcome measures were assessed before, immediately and 1-year after the 12-week intervention programmes. Global Rating of Change Score was used to evaluate the perceived recovery at 1-year follow-up.

RESULTS

Both groups reported significant reductions in pain and functional disability scores at post-intervention (EM, n = 44; CO, n = 42) and 1-year follow-up (EM, n = 40; CO, n = 38); however, no significant between-group differences were found (p > 0.05). Significantly higher rating in global recovery score was reported in EM group at 1-year follow-up (p < 0.05).

CONCLUSIONS

Intervention integrating ergonomic advice/modification with motor control exercise was found to be equally effective as pain relief and general exercise for pain and functional recovery. However, at 1-year follow-up, such integrated approach resulted in significantly better global recovery perceived by people with WRNSP.

SIGNIFICANCE

Integrating ergonomic intervention and motor control training achieved similar reduction in pain and functional outcomes compared to conventional physiotherapy at post-intervention and at 1-year follow-up, for patients with moderate level of work-related neck-shoulder pain and mild degree of functional disability. The Ergo-motor Group reported significantly better perceived overall recovery at 1-year follow-up.

Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions

OBJECTIVE

To identify potentially effective complementary approaches for musculoskeletal (MSK)-mental health (MH) comorbidity, by synthesising evidence on effectiveness, cost-effectiveness and safety from systematic reviews (SRs).

DESIGN

Scoping review of SRs.

METHODS

We searched literature databases, registries and reference lists, and contacted key authors and professional organisations to identify SRs of randomised controlled trials for complementary medicine for MSK or MH. Inclusion criteria were: published after 2004, studying adults, in English and scoring >50% on Assessing the Methodological Quality of Systematic Reviews (AMSTAR); quality appraisal checklist). SRs were synthesised to identify research priorities, based on moderate/good quality evidence, sample size and indication of cost-effectiveness and safety.

RESULTS

We included 84 MSK SRs and 27 MH SRs. Only one focused on MSK-MH comorbidity. Meditative approaches and yoga may improve MH outcomes in MSK populations. Yoga and tai chi had moderate/good evidence for MSK and MH conditions. SRs reported moderate/good quality evidence (any comparator) in a moderate/large population for: low back pain (LBP) (yoga, acupuncture, spinal manipulation/mobilisation, osteopathy), osteoarthritis (OA) (acupuncture, tai chi), neck pain (acupuncture, manipulation/manual therapy), myofascial trigger point pain (acupuncture), depression (mindfulness-based stress reduction (MBSR), meditation, tai chi, relaxation), anxiety (meditation/MBSR, moving meditation, yoga), sleep disorders (meditative/mind-body movement) and stress/distress (mindfulness). The majority of these complementary approaches had some evidence of safety-only three had evidence of harm. There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP, and manual therapy/manipulation for neck pain, but few SRs reviewed cost-effectiveness and many found no data.

CONCLUSIONS

Only one SR studied MSK-MH comorbidity. Research priorities for complementary medicine for both MSK and MH (LBP, OA, depression, anxiety and sleep problems) are yoga, mindfulness and tai chi. Despite the large number of SRs and the prevalence of comorbidity, more high-quality, large randomised controlled trials in comorbid populations are needed.

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE

To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

RESULTS

We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

DISCUSSION

Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.

Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: a randomized clinical trial

Background

Although upper cervical and upper thoracic spine mobilization plus therapeutic exercises are common interventions for the management of forward head posture (FHP), no study has directly compared the effectiveness of cervical spine mobilization and stabilization exercise with that of thoracic spine mobilization and mobility exercise in individuals with FHP.

Methods

Thirty-two participants with FHP were randomized into the cervical group or the thoracic group. The treatment period was 4 weeks, with follow-up assessment at 4 and 6 weeks after the initial examination. Outcome measures including the craniovertebral angle (CVA), cervical range of motion, numeric pain rating scale (NPRS), pressure pain threshold, neck disability index (NDI), and global rating of change (GRC) were collected. Data were examined with a two-way repeated-measures analysis of variance (group × time).

Results

Participants in the thoracic group demonstrated significant improvements (p < .05) in CVA, cervical extension, NPRS, and NDI at the 6-week follow-up compared with those in the cervical group. In addition, 11 of 15 (68.8%) participants in the thoracic group compared with 8 of 16 participants (50%) in the cervical group showed a GRC score of +4 or higher at the 4-week follow-up.

Conclusions

The combination of upper thoracic spine mobilization and mobility exercise demonstrated better overall short-term outcomes in CVA (standing position), cervical extension, NPRS, NDI, and GRC compared with upper cervical spine mobilization and stabilization exercise in individuals with FHP.

Trial registration

KCT0002307, April 11, 2017 (retrospectively registered).

Effectiveness of manual therapy for cervical radiculopathy, a review

Manual therapy is often used for patients with neck pain with or without radicular symptoms. There is sparse evidence on the effectiveness in cervical radiculopathy. The aim of this study was to assess current levels of evidence on the effectiveness of manual therapy interventions for patients with cervical radiculopathy. Electronic data bases were systematically searched for clinical guidelines, reviews and randomised clinical trials (RCTs) reporting on the effectiveness of manual therapy for patients with cervical radiculopathy. Eight relevant reviews, two guidelines and two recent RCTs, that had not yet been included in either, were retrieved. The overall quality of the evidence of included studies was evaluated using the GRADE method. Most interventions were only studied in one single RCT. There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions. There is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy. There is low level evidence of the effectiveness of cervical mobilisation with a neurodynamical intent as unimodal intervention, on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and global perceived effect compared to a wait-and-see policy. There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR. There is low level evidence that traction is no more effective than placebo traction.

Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD).

PURPOSE

To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD.

STUDY DESIGN/SETTING

Systematic review and best-evidence synthesis.

PATIENT SAMPLE

We included randomized controlled trials (RCTs), cohort studies, and case-control studies.

OUTCOME MEASURES

Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events.

METHODS

We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles.

RESULTS

We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD.

CONCLUSIONS

Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nonfunctioning pituitary macroadenoma: a case report from the patient perspective

BACKGROUND

Nonfunctioning pituitary macroadenoma (NFPA) is a tumour of the endocrine system that is virtually always benign and can be difficult to detect. This case report is presented from the patient's perspective to highlight experiences that led to the eventual diagnosis of this condition.

CASE PRESENTATION

A 48 year-old male experienced prolonged and unexplained reduced athletic performance worsening over five years. The patient reported decreased libido, which initiated a testosterone blood test. This confirmed reduced testosterone levels and resulted in an endocrinology referral. A subsequent dynamic contrast MRI of the pituitary region revealed a mass. The most frequent symptoms of NFPA are visual field defects, headaches and features of hypopituitarism (includes fatigue, dizziness, dry skin, irregular periods in women and sexual dysfunction in men).

CONCLUSION

Clinicians should consider this differential diagnosis in middle-aged athletes with diminished athletic performance from an unknown cause, test visual fields and inquire if symptoms of headaches or hypopituitarism are present.

Mechanism of Action of Spinal Mobilizations: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To review the evidence regarding the mechanism of action of mobilizations.

SUMMARY OF BACKGROUND DATA

Spinal mobilizations-low velocity passive oscillatory movements-reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations' mechanism(s) of action are unclear.

METHODS

Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool.

RESULTS

Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness.

CONCLUSION

These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms.

LEVEL OF EVIDENCE

3.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations

Background

There is controversy surrounding the risk of manipulation, which is often used by chiropractors, with respect to its association with vertebrobasilar artery system (VBA) stroke. The objective of this study was to compare the associations between chiropractic care and VBA stroke with recent primary care physician (PCP) care and VBA stroke.

Methods

The study design was a case–control study of commercially insured and Medicare Advantage (MA) health plan members in the U.S. population between January 1, 2011 and December 31, 2013. Administrative data were used to identify exposures to chiropractic and PCP care. Separate analyses using conditional logistic regression were conducted for the commercially insured and the MA populations. The analysis of the commercial population was further stratified by age (<45 years; ≥45 years). Odds ratios were calculated to measure associations for different hazard periods. A secondary descriptive analysis was conducted to determine the relevance of using chiropractic visits as a proxy for exposure to manipulative treatment.

Results

There were a total of 1,829 VBA stroke cases (1,159 – commercial; 670 – MA). The findings showed no significant association between chiropractic visits and VBA stroke for either population or for samples stratified by age. In both commercial and MA populations, there was a significant association between PCP visits and VBA stroke incidence regardless of length of hazard period. The results were similar for age-stratified samples. The findings of the secondary analysis showed that chiropractic visits did not report the inclusion of manipulation in almost one third of stroke cases in the commercial population and in only 1 of 2 cases of the MA cohort.

Conclusions

We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

Experimental integrative muscular movement technique enhances cervical range of motion in patients with chronic neck pain: a pilot study

INTRODUCTION

Neck pain presents a tremendous physical and financial burden. This study compared the efficacy of the complementary and alternative medical treatments of integrative muscular movement technique (IMMT) and Swedish massage on neck pain in women of occupation age, the largest demographic group with neck pain.

METHODS

A total of 38 women were assigned to IMMT (n=28) or Swedish massage (n=10) in a blinded manner. Both groups received eight 30-minute treatments over 4 weeks. Cervical range of motion (ROM) in flexion, extension, sidebending, and rotation was measured before and after treatment. Each patient's pain was assessed by using an analogue pain scale of 0-10.

RESULTS

Compared with the Swedish massage group, patients receiving IMMT experienced a significant increase in ROM in cervical flexion (p<0.001), extension (p<0.001), sidebending (p<0.05), and rotation (p<0.001). Absolute change in pain for IMMT was -1.75 units compared with -0.3 units for Swedish massage (p<0.05).

CONCLUSION

Patients receiving the IMMT demonstrated significantly improved cervical ROM in every movement measured compared with Swedish massage. Inclusion of the IMMT 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 in patients with neck pain.

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

Background

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

Methods

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

Results

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

Conclusions

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

Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial

STUDY DESIGN

Randomized clinical study.

OBJECTIVES

To compare the effects of trigger point (TrP) dry needling (DN) and TrP manual therapy (MT) on pain, function, pressure pain sensitivity, and cervical range of motion in subjects with chronic mechanical neck pain.

BACKGROUND

Recent evidence suggests that TrP DN could be effective in the treatment of neck pain. However, no studies have directly compared the outcomes of TrP DN and TrP MT in this population.

METHODS

Ninety-four patients (mean ± SD age, 31 ± 3 years; 66% female) were randomized into a TrP DN group (n = 47) or a TrP MT group (n = 47). Neck pain intensity (11-point numeric pain rating scale), cervical range of motion, and pressure pain thresholds (PPTs) over the spinous process of C7 were measured at baseline, postintervention, and at follow-ups of 1 week and 2 weeks after treatment. The Spanish version of the Northwick Park Neck Pain Questionnaire was used to measure disability/function at baseline and the 2-week follow-up. Mixed-model, repeated-measures analyses of variance (ANOVAs) were used to determine if a time-by-group interaction existed on the effects of the treatment on each outcome variable, with time as the within-subject variable and group as the between-subject variable.

RESULTS

The ANOVA revealed that participants who received TrP DN had outcomes similar to those who received TrP MT in terms of pain, function, and cervical range of motion. The 4-by-2 mixed-model ANOVA also revealed a significant time-by-group interaction (P<.001) for PPT: patients who received TrP DN experienced a greater increase in PPT (decreased pressure sensitivity) than those who received TrP MT at all follow-up periods (between-group differences: posttreatment, 59.0 kPa; 95% confidence interval [CI]: 40.0, 69.2; 1-week follow-up, 69.2 kPa; 95% CI: 49.5, 79.1; 2-week follow-up, 78.9 kPa; 95% CI: 49.5, 89.0).

CONCLUSION

The results of this clinical trial suggest that 2 sessions of TrP DN and TrP MT resulted in similar outcomes in terms of pain, disability, and cervical range of motion. Those in the TrP DN group experienced greater improvements in PPT over the cervical spine. Future trials are needed to examine the effects of TrP DN and TrP MT over long-term follow-up periods.

LEVEL OF EVIDENCE

Therapy, level 1b.

Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey

Background

Clinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens.

Aim

To describe the utilization of interventions in patients with neck pain by clinicians.

Methods

A cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain.

Results

The survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41-66%) working in private practice (69-95%). Exercise and manual therapies were consistently (98-99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and ‘other’ interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics).

Conclusions

This survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.

Beliefs and practice patterns in spinal manipulation and spinal motion palpation reported by canadian manipulative physiotherapists

PURPOSE

This practice survey describes how Fellows of the Canadian Academy of Manipulative Physiotherapy (FCAMPT) use spinal manipulation and mobilization and how they perceive their competence in performing spinal assessment; it also quantifies relationships between clinical experience and use of spinal manipulation.

METHODS

A cross-sectional survey was designed based on input from experts and the literature was administered to a random sample of the FCAMPT mailing list. Descriptive (including frequencies) and inferential statistical analyses (including linear regression) were performed.

RESULTS

The response rate was 82% (278/338 eligible FCAMPTs). Most (99%) used spinal manipulation. Two-thirds (62%) used clinical presentation as a factor when deciding to mobilize or manipulate. The least frequently manipulated spinal region was the cervical spine (2% of patients); 60% felt that cervical manipulation generated more adverse events. Increased experience was associated with increased use of upper cervical manipulation among male respondents (14% more often for every 10 years after certification; β, 95% CI=1.37, 0.89-1.85, p<0.001) but not among female respondents. Confidence in palpation accuracy decreased in lower regions of the spine.

CONCLUSION

The use of spinal manipulation/mobilization is prevalent among FCAMPTs, but is less commonly used in the neck because of a perceived association with adverse events.

Retention of blinding at follow-up in a randomized clinical study using a sham-control cervical manipulation procedure for neck pain: secondary analyses from a randomized clinical study

OBJECTIVE

Participants in clinical trials of spinal manipulation have not been rigorously blinded to group assignment. This study reports on secondary analyses of the retention of participant blinding beyond the immediate posttreatment time frame following a single-session, randomized clinical study. A novel control cervical manipulation procedure that has previously been shown to be therapeutically inert was contrasted with a typical manipulation procedure.

METHODS

A randomized clinical study of a single session of typical vs sham-control manipulation in patients with chronic neck pain was conducted. Findings of self-reported group registration at 24 to 48 hours posttreatment were computed. The Blinding Index (BI) of Bang et al was then applied to both the immediate and post-24- to 48-hour results.

RESULTS

Twenty-four to 48 hours after treatment, 94% and 22% of participants in the typical and control groups, respectively, correctly identified their group assignment. When analyzed with the BI of Bang et al, the immediate posttreatment BI for the group receiving a typical manipulation was 0.22 (95% confidence interval [CI], -0.03 to 0.47); for the group receiving a control manipulation, it was 0.19 (95% CI, -0.06 to 0.43). The BI at post-24 hours was as follows: typical = 0.75 (95% CI, 0.59-0.91) and control = -0.34 (95% CI, -0.58 to -0.11).

CONCLUSIONS

This study found that the novel sham-control cervical manipulation procedure may be effective in blinding sham group allocation up to 48 hours posttreatment. It appears that, at 48 hours posttreatment, the modified form of the typical cervical manipulation was not. The sham-control procedure appears to be a promising procedure for future clinical trials.

Proprioception interventions to improve cervical position sense in cervical pathology

Background:

Non-specific cervical pain is a common pathology and is difficult to treat. Various types of treatment interventions have been used individually or in combination. Proprioception training has been suggested as an aspect of intervention for cervical pathology but no systematic review has been conducted to evaluate the effectiveness of cervical proprioception retraining on reposition sense.

Methods:

A systematic review of the literature was performed to evaluate the effectiveness of proprioception interventions to improve cervical position sense (PS) in patients with pathology. A modified American Academy of Cerebral Palsy and Developmental Medicine method was used to systematically grade the level of evidence. In addition, a meta-analysis was performed on the intervention effects on PS or pain.

Findings:

PS was measured in 11 studies; seven used a laser pointer while four used motion detection instrumentation. Various treatment interventions, including deep cervical flexor activation, eye-head neck coordination exercises, mobilisation, manipulation and a multi-behavioural exercise approach were used individually or in combination to affect proprioception. Pain was measured in six studies using various outcome measures. The meta-analyses showed high heterogeneity of results in favour of treatment interventions for flexion/extension and for right/left rotation to improve PS as well as for pain reduction for the pain outcome measures.

Conclusions:

All the treatment interventions activated proprioceptors through muscle activation and joint or skin sensory receptors. The use of eye-head-neck coordination exercises produced moderate and large treatment effects for improving PS. This type of exercise links the sensory/motor (proprioception) systems of the neck with the oculomotor and vestibular systems to improve PS. Pain was also reduced (moderate effect size) with the use of these techniques. Clinicians targeting improvements in cervical PS may use this evidence, but further research is needed.

Validation of a novel sham cervical manipulation procedure

BACKGROUND CONTEXT

No clinical trial of spinal manipulation for chronic neck pain (NP), for either single or multiple intervention session(s), has used an effective manual sham-manipulation control group.

PURPOSE

Validate a practical sham cervical high-velocity low-amplitude spinal manipulation.

STUDY DESIGN/SETTING

Randomized experimental validation study in an institutional clinical research laboratory.

PATIENT SAMPLE

Eligible subjects were males and females, 18 to 60 years of age with mechanical NP (as defined by the International Association for the Study of Pain Classification) of at least 3 months' duration. Subjects with arm pain, any pathologic cause of NP, or any contraindication to spinal manipulation were excluded.

OUTCOME MEASURES

The primary outcome was the patient's self-report or registration of group allocation after treatment. Secondary outcomes were numerical rating scale-101 for NP, range of motion (ROM; by goniometer), and tenderness (by pressure algometry).

METHODS

Eligible subjects were randomly allocated to one of two groups: real cervical manipulation (RM) or sham cervical manipulation (SM). All subjects were given two procedures in sequence, either RM+SM or SM+SM. Immediately after the two procedures, subjects were asked to register any pain experienced during the procedures and to identify their treatment group allocation. Force-time profiles were recorded during all procedures. Secondary clinical outcome measures were obtained at baseline, 5 and 15 minutes after the intervention, including ROM, self-report of pain, and local spinous process tenderness. Data for each variable were summarized and tested for normality in distribution. Summary statistics were obtained for each variable and statistically tested.

RESULTS

Sixty-seven subjects were randomized. Data from 64 subjects (32 per group) were available for analysis. There were no significant differences between the groups at baseline. One adverse event occurred in the "real" group, which was a mild posttreatment pain reaction lasting less than 24 hours. In the RM group, 50% of subjects incorrectly registered their treatment allocation; in the sham group, 53% did so. For the SM group, none of the procedures resulted in cavitation, whereas in the RM group, 87% of procedures resulted in cavitation. There were no significant changes between groups on pain, tenderness, or ROM. Force-time profiles of the RM and SM procedures demonstrated fidelity with significant differences between components as intended.

CONCLUSIONS

The novel sham procedure has been shown to be effective in masking subjects to group allocation and to be clinically inert with respect to common outcomes in the immediate posttreatment stage. Further research on serial applications and for multiple operators is warranted.

A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up

OBJECTIVE

We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up.

METHODS

In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale).

RESULTS

Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention.

CONCLUSIONS

At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted.

Therapy recommendation "act as usual" in patients with whiplash injuries QTF I°

Up to now no therapy study has used the classification system of the Quebec Task Force (QTF) to differentiate between patients with (QTF II°) and without functional disorders (QTF I°). This differentiation seems meaningful, as this difference may be relevant for the correct treatment planning. In this context the effect of the therapy recommendation “act as usual” has been evaluated in a homogeneous patient collective with whiplash injuries QTF I°.

470 patients with acute whiplash injuries had been catched in this study and classified according to the QTF. 359 patients (76.4%) with QTF I° injuries could be identified. Out of that 162 patients were enrolled to the study and received the therapy recommendation “act as usual” and the adapted pain treatment with non-steroidal anti-inflammatory drugs (NSAID). After six months the outcome was evaluated by phone.

After injury the median pain score assessed by a visual analogue scale (VAS) was 5.4 (min = 3.3; max = 8.5). After six months 5 of the 162 patients complained intermittent pain symptoms (VAS values < 2). This is consistent with a chronification rate of 3.1%. After injury, the median pain disability index (PDI) was 3.9 (min = 1.9; max = 7.7). After six months 3 of the 162 patients stated persisting disability during sporting and physical activities (VAS values < 1).

The therapy recommendation “act as usual” in combination with an adapted pain treatment is sufficient. Usually patients with whiplash injuries QTF I° do not need physical therapy. An escalation of therapy measures should be reserved to patients with complicated healing processes.

A structured review of spinal stiffness as a kinesiological outcome of manipulation: its measurement and utility in diagnosis, prognosis and treatment decision-making

PURPOSE

To review and discuss the methods used for measuring spinal stiffness and factors associated with stiffness, how stiffness is used in diagnosis, prognosis, and treatment decision-making and the effects of manipulative techniques on stiffness.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted. Included studies addressed one of four constructs related to stiffness: measurement, diagnosis, prognosis and/or treatment decision-making, and the effects of manipulation on stiffness. Spinal stiffness was defined as the relationship between force and displacement.

RESULTS

One hundred and four studies are discussed in this review, with the majority of studies focused on the measurement of stiffness, most often in asymptomatic persons. Eight studies investigated spinal stiffness in diagnosis, providing limited evidence that practitioner-judged stiffness is associated with radiographic findings of sagittal rotational mobility. Fifteen studies investigated spinal stiffness in prognosis or treatment decision-making, providing limited evidence that spinal stiffness is unlikely to independently predict patient outcomes, though stiffness may influence a practitioner's application of non-thrust manipulative techniques. Nine studies investigating the effects of manipulative techniques on spinal stiffness provide very limited evidence that there is no change in spinal stiffness following thrust or non-thrust manipulation in asymptomatic individuals and non-thrust techniques in symptomatic persons, with only one study supporting an immediate, but not sustained, stiffness decrease following thrust manipulation in symptomatic individuals.

CONCLUSIONS

The existing limited evidence does not support an association between spinal stiffness and manipulative treatment outcomes. There is a need for additional research investigating the effects of manipulation on spinal stiffness in persons with spinal pain.

Ottawa Panel evidence-based clinical practice guidelines on therapeutic massage for neck pain

OBJECTIVE

To update evidence-based clinical practice guideline (EBCPG) on the use of massage compared to a control or other treatments for adults (>18 years) suffering from sub-acute and chronic neck pain.

METHODS

A literature search was performed from January 1, 1948 to December 31, 2010 for relevant articles. The Ottawa Panel created inclusion criteria focusing on high methodological quality and grading methods. Recommendations were assigned a grade (A, B, C, C+, D, D+, D-) based on strength of evidence.

RESULTS

A total of 45 recommendations from ten articles were developed including 8 positive recommendations (6 grade A and 2 grade C+) and 23 neutral recommendations (12 grade C and 11 grade D).

DISCUSSION

Therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain.

CONCLUSION

The Ottawa Panel was able to demonstrate that the massage interventions are effective for relieving immediate post-treatment neck pain symptoms, but data is insufficient for long-term effects.

A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain

Background. Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain. Data Sources. Records without language restriction from various databases up to February 2010. Data Extraction. The efficacy outcomes of interest were pain intensity and disability. Data Synthesis. Reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature. Conclusions. CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.

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

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

Systematic review of clinical trials of cervical manipulation: control group procedures and pain outcomes

Objective

To characterize the types of control procedures used in controlled clinical trials of cervical spine manipulation and to evaluate the outcomes obtained by subjects in control groups so as to improve the quality of future clinical trials

Methods

A search of relevant clinical trials was performed in PubMed 1966-May 2010 with the following key words: "Chiropractic"[Mesh] OR "Manipulation, Spinal"[Mesh]) AND "Clinical Trial "[Publication Type]. Reference lists from these trials were searched for any additional trials. The reference lists of two prior studies, one review and one original study were also searched. Accepted reports were then rated for quality by 2 reviewers using the PEDro scale. Studies achieving a score of >50% were included for data extraction and analysis. Intra-group change scores on pain outcomes were obtained. For determining clinically important outcomes, a threshold of 20% improvement was used where continuous data were available; otherwise, an effect size of 0.30 was employed

Results

The PubMed search yielded 753 citations of which 13 were selected. Eight (8) other studies were identified by reviewing two systematic reviews and through reference searches. All studies scored >50% on the PEDro scale. There were 9 multi-session studies and 12 single-session studies. The most commonly used control procedure was "manual contact/no thrust". Four (4) studies used a placebo-control (patient blinded). For two of these studies with VAS data, the average change reported was 4.5 mm. For the other control procedures, variable results were obtained. No clinically important changes were reported in 57% of the paired comparisons, while, in 43% of these, changes which would be considered clinically important were obtained in the control groups. Only 15% of trials reported on post-intervention group registration.

Conclusions

Most control procedures in cervical manipulation trials result in small clinical changes, although larger changes are observed in 47% of paired comparisons. The vast majority of studies do not result in subject blinding; the effect of unmasking of control subjects in these studies makes the interpretation of the existing clinical trials challenging. The greatest majority of trials do not report on post-intervention blinding. A small number of candidate procedures for effective control interventions exist. Much more research is required to improve this important aspect of clinical trial methodology in cervical manipulation studies.

Spinal manipulation or mobilization for radiculopathy: a systematic review

In this systematic review, we present a comprehensive and up-to-date systematic review of the literature as it relates to the efficacy and effectiveness of spinal manipulation or mobilization in the management of cervical, thoracic, and lumbar-related extremity pain. There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low. At present, no evidence exists for the treatment of thoracic radiculopathy. Future high-quality studies should address these conditions.