The effectiveness of Long's manipulation on patients with chronic mechanical neck pain: a randomized controlled trial

The majority of clinical trials assessing mobilization and manipulation for neck pain lack a pragmatic approach: a systematic review of 174 trials

BACKGROUND

Disorders of the cervical spine are some of the costliest musculoskeletal conditions to manage globally. Joint mobilization and manipulation have been shown to be an effective treatment for neck pain. However, the generalizability and clinical translation depends on the nature of the trial designs that inform its use. The extent to which randomized control trials (RCTs) assessing manual therapy treatments for cervical spine disorders fall on the efficacy (explanatory) -effectiveness (pragmatic) spectrum often informs how the findings are translated into clinical practice.

OBJECTIVE

The aim of this systematic review was to determine where RCTs of manual therapy for neck disorders fall on the efficacy-effectiveness spectrum.

METHODS

A search of three electronic databases including PubMed, CINAHL, and CENTRAL were completed for trials published from inception to May 2023. RCTs in which joint mobilization or manipulation were used to treat cervical spine disorders were assessed on the effectiveness-efficacy spectrum using the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool and risk of bias using the Revised Cochrane Risk of Bias tool.

RESULTS

A total of 174 trials met eligibility. RITES domain two trial setting (71.3% vs 16.1%), domain three flexibility of intervention(s) (62.1% vs 23%), and domain four clinical relevance of experimental and comparison intervention(s) (51.7% vs 29.3%) all favored efficacy over effectiveness. Domain one participant characteristic(s) had a slightly greater emphasis on effectiveness compared to efficacy (36.8% vs 44.8%). Most studies (96%) had at least some risk of bias.

CONCLUSION

Over half of the RCTs assessing the treatment effect of joint mobilization and manipulation for neck pain favor efficacy (explanatory) over effectiveness (pragmatic) designs. Future RCTs on this topic should consider a greater emphasis on pragmatic trial design components in order to better reflect real-world translation to clinical practice.

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.

Experimental and numerical analysis of biomechanical effects in cervical spine positioning rotation manipulation

Unlocking the biomechanical effects of cervical spine positioning rotation manipulation in the treatment of patients with neck pain. In this paper, the safety of the cervical positioning rotation manipulation is analyzed by experimentally obtaining head kinematic data, importing them into a finite element model that has been developed and validated, and calculating and analyzing the angular displacements, disc pressures, and articular surface contact forces in the normal and pathological models. The results show that the cervical spine positioning rotation technique is more effective in adjusting the position and applying force to the cervical spine C5-C6 "tendon out of the groove and bone misalignment" pathological model. Also, the cervical positioning rotation manipulation is applied with less variation in disc nucleus pulposus pressure than in the non-positioning situation. Thus, in patients with disc degeneration, cervical positioning rotational manipulation has a more direct mechanical effect and is safer than non-positioning rotational manipulation. The cervical spine positioning rotation manipulation is a safe method that can effectively treat patients with neck pain. It has been well demonstrated in the computational analysis of the pathological model.

Effects of manual therapy on body posture: Systematic review and meta-analysis

BACKGROUND

Several clinical trials investigated the effectiveness of MT on body posture, but a systematic review grouping the results of these studies was not found in the literature.

RESEARCH QUESTION

Does manual therapy (MT) cause postural changes?

METHODS

Inclusion criteria were: randomized controlled trials in any population; studies in which the primary intervention was the use of any MT technique; studies that evaluated the immediate, short, medium, or long-term effects of interventions on body posture; and studies published in peer-reviewed scientific journals in any year and language. In March 2022, we conducted a search in the PUBMED, Cinahl, Embase, PEDro, and Cochrane Central databases that yielded 6627 articles, of which 38 including 1597 participants were eligible; of these, 35 could be grouped into 12 meta-analyses. The risk of bias was assessed using the PEDro scale and the certainty in the scientific evidence rated through the GRADE system.

RESULTS

The results allowed us to conclude with moderate certainty in the evidence that, when compared to no intervention or sham, in the short and medium term, MT reduced the forward head posture (14 studies, 584 individuals, 95%CI 0.38, 1.06), reduced thoracic kyphosis (5 studies, 217 individuals, 95%CI 0.37, 0.94), improved lateral pelvic tilt (5 studies, 211 individuals, 95%CI 0.11, 0.67) and pelvic torsion (2 studies, 120 individuals, 95%CI 0.44, 1.19) and increased plantar area (3 studies, 134 individuals, 95%CI 0.04, 0.74). With moderate certainty, there was no significant effect on shoulder protrusion (5 studies, 176 individuals, 95%CI -0.11, 0.61), shoulder alignment in the frontal plane (3 studies, 160 individuals, 95%CI -0.15, 0.52), scoliosis (2 studies, 26 individuals, 95%CI -1.57, 2.19), and pelvic anteversion (5 studies, 233 individuals, 95%CI -0.02, 0.51). With low certainty, MT had no effect on scapular upward rotation (2 studies, 74 individuals, 95%CI -0.76, 2.17). With low to very low certainty, it is possible to conclude that MT was not superior to other interventions in the short or medium term regarding the improvement of forward head posture (5 studies, 170 individuals, 95%CI -1.39, 0.67) and shoulder protrusion (3 studies, 94 individuals, 95%CI -4.04, 0.97).

SIGNIFICANCE

MT can be recommended to improve forward head posture, thoracic kyphosis and pelvic alignment in the short and medium term, but not shoulder posture and scoliosis. MT reduces the height of the plantar arch and this must be taken into account in physical therapy planning. PROSPERO registration number: CRD42021244423.

Effects of Acupressure on Pain, Flexibility, and Substance P in Middle-Age Women with Chronic Neck Pain

Introduction: Acupressure is known to be effective for some types of chronic pain. However, the effect of acupressure on chronic neck pain has not been investigated. Accordingly, the authors aimed to evaluate effects of the 4-week acupressure treatment on pain, neck function, and substance P in women with chronic neck pain. Methods: The acupressure treatment was performed two times a week for 4 weeks in an acupressure group (n = 24), meanwhile a control group (n = 26) was untreated. Before and after intervention, pain intensity and physical disability were measured by visual analogue scale (VAS) and neck disability index (NDI), respectively. In addition, cervical range of motion (CROM) and serum substance P were evaluated. Results: Results of two-way analysis of variance with repeated measures revealed that time × group interactions were significant in all outcomes (all p < 0.001) except substance P. These results indicate that after 4 weeks, VAS and NDI significantly decreased in the acupressure group compared with those changes in the control group. The CROM values for six cervical movements significantly increased in the acupressure group compared with those changes in the control group. Serum substance P did not change significantly in both groups. However, when the pre- and postintervention data from all subjects were pooled, substance P was significantly correlated with VAS (r = 20; p < 0.05; n = 100). Conclusions: The 4-week acupressure intervention showed significant reduction in pain and improvement in neck disability and flexibility, suggesting that acupressure intervention is an effective treatment for chronic neck pain. This study was registered with the Korean Clinical Trial Registry and WHO Clinical Trial Registry (KCT0005363).

Osteopathic care for spinal complaints: A systematic literature review

The aim of the current study was to evaluate the literature examining the impact of osteopathic care for spinal complaints. The bibliographic databases Medline (Pubmed), Web of Science, Embase, and PEDro were searched. In addition, a number of grey literature sources were searched. Only randomized controlled trials conducted in high-income Western countries were considered. Two authors independently screened the titles and abstracts. Primary outcomes included ‘pain’ and ‘functional status’, while secondary outcomes included ‘medication use’ and ‘health status’. It was examined if differences existed related to the treatment protocol and geography (European vs. US studies). Study quality was assessed using the risk of bias tool of the Cochrane Back Review Group. Nineteen studies were included and qualitatively synthesized. Nine studies were from the US, followed by Germany with seven studies. The majority of studies (n = 13) focused on low back pain. In general, mixed findings related to the impact of osteopathic care on primary and secondary outcomes were observed. For the primary outcomes, a clear distinction between US and European studies was found, in favor of the latter ones. Studies were characterized by substantial methodological differences in sample sizes, number of treatments, control groups, and follow-up. In conclusion, there is some evidence suggesting that osteopathic care may be effective for people suffering from spinal complaints. Further studies with larger study samples and assessment of long-term impact are required to further increase the evidence-based knowledge of the potential of osteopathic care for individuals suffering from spinal complaints.

Acupoint Embedding of Polyglactin 910 Sutures in Patients with Chronic Pain due to Cervical Spondylotic Radiculopathy: A Multicenter, Randomized, Controlled Clinical Trial

Objective

We aimed to investigate the effectiveness of acupoint polyglactin 910 (PGLA) embedding in patients with cervical spondylotic radiculopathy (CSR).

Methods

A total of 102 CSR patients with neck and shoulder pain were recruited and assigned randomly into three groups: the sham acupoint embedding (SAE) group, the middle-layer acupoint PGLA embedding (MAPE) group, and the deep-layer acupoint PGLA embedding (DAPE) group. The primary outcomes were Visual Analog Scale (VAS) scores showing the analgesic effects of treatment. Secondary outcomes included clinical symptoms (evaluated by the Yasuhisa Tanaka 20 (YT-20) score and the neck disability index (NDI)) and patient health status (evaluated by the 36-item short-form survey (SF-36)) as reported in the trial.

Results

Compared with the SAE group, VAS scores were significantly reduced at 1, 2, 3, 4, and 10 weeks after the first treatment in both the DAPE and MAPE groups (P < 0.001). Moreover, there were statistically significant increases in the weekly YT-20 scores and significant reductions of the weekly NDI scores compared with baseline values in both the DAPE and MAPE groups (P < 0.001). Compared with baseline values, both the physical component summary (PCS) and the mental component summary scores of the SF-36 at 2, 3, 4, and 10 weeks were significantly higher in the DAPE and MAPE groups (P < 0.001). There were significant lower VAS scores (P < 0.01), higher PCS scores (P < 0.05) at 3 weeks, and lower NDI scores (P < 0.05) at 4 weeks in the DAPE group compared with the MAPE group.

Conclusions

Both DAPE and MAPE showed significant and long-lasting effects on alleviating pain and improving clinical symptoms as well as quality of life in CSR patients with neck and shoulder pain. A more intense effect was seen in the DAPE group compared with the MAPE group.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.

Shi-style cervical manipulations for cervical radiculopathy: A multicenter randomized-controlled clinical trial

BACKGROUND

There is a lack of high-quality evidence supporting the use of manipulation therapy for patients with cervical radiculopathy (CR). This study aimed to evaluate the effectiveness of Shi-style cervical manipulations (SCMs) versus mechanical cervical traction (MCT) for CR.

METHODS

This was a randomized, open-label, controlled trial carried out at 5 hospitals in patients with CR for at least 2 weeks and neck pain. The patients received 6 treatments of SCM (n = 179) or MCT (n = 180) over 2 weeks. The primary outcome was participant-rated disability (neck disability index), measured 2 weeks after randomization. The secondary outcomes were participant-rated pain (visual analog scale) and health-related quality of life (36-Item Short Form Health Survey [SF-36]). Assessments were performed before, during, and after (2, 4, 12, and 24 weeks) intervention.

RESULTS

After 2 weeks of treatment, the SCM group showed a greater improvement in participant-rated disability compared with the control group (P = .018). The SCM group reported less disability compared with the control group (P < .001) during the 26-week follow-up. The difference was particularly important at 6 months (mean -28.91 ± 16.43, P < .001). Significant improvements in SF-36 were noted in both groups after 2 weeks of treatment, but there were no differences between the 2 groups.

CONCLUSION

SCM could be a better option than MCT for the treatment of CR-related pain and disability.

Therapeutic Effects and Finite Element Analysis of a Combined Treatment Using Laser Needle-Knife with Supine Repositioning Massage on Patients with Cervical Spondylotic Vertebral Arteriopathy

Objective: To investigate the effectiveness of combined laser needle-knife and massage on cervical spondylotic vertebral arteriopathy patients. Summary of background data: With the recent rise of electronic businesses, the incidence of cervical spondylosis has also risen rapidly. Methods: Cervical spondylotic vertebral arteriopathy patients were treated using laser needle-knife with massage, and compared to patients who only received the massage. A 3D anatomical and hemodynamic model was developed. Results: The symptomatic and functional overall scores were reduced by 71.43% after the combined treatment. Results from the finite element analysis indicated that the maximum flow rate of the left vertebral artery was improved by 47.52% and the right was improved by 38.67%. Conclusion: A combined treatment of cervical spondylotic vertebral arteriopathy using laser needle-knife and massage is an effective approach with a therapeutic mechanism closely related to hemodynamics.

Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration

BACKGROUND CONTEXT

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

PURPOSE

This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD.

STUDY DESIGN/SETTING

This is a systematic review and best evidence synthesis.

SAMPLE

The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention.

OUTCOME MEASURES

The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events.

METHODS

We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance.

RESULTS

We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I-II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I-II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I-II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I-II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I-II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits.

CONCLUSIONS

Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS

This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1

Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2

Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3

Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4

For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5

For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6

For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

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.

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.