Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

Expectations of Qigong and Exercise Therapy in Patients With Long-term Neck Pain: An Analysis of a Prospective Randomized Study

OBJECTIVE

The aim of the present study was to study differences in treatment expectations after participating in qigong and exercise therapy among participants with long-term neck pain, the impact of total group expectations on treatment outcomes, and the relationship between these treatment expectations and pain and disability.

METHOD

Reliable questionnaires were used. Differences between qigong and exercise was studied in a randomized, controlled, multicenter trial (n = 122). The impact of total group expectations on treatment outcomes and the association between these treatment expectations and pain and disability were studied with nonparametric statistical analysis and Spearman's correlation coefficient.

RESULTS

The exercise group had higher expectations than the qigong group before the intervention on how logical treatment seemed to be and after the intervention on treatment credibility (ie, that the treatment would reduce/eliminate neck pain). The exercise group was also more confident that the treatment could reduce neck pain and significantly increased their expectations of reduced neck pain over the 3-month intervention period. Both treatment groups had high expectations of the assigned treatment. Those with high expectations had better treatment outcomes in pain and disability. The relationship between treatment expectations and credibility, pain, and disability was weak.

CONCLUSIONS

The current findings support the role of assessment of expectation/credibility for positive treatment results. An understanding of each patient's treatment expectations may be helpful in guiding patients with respect to appropriate interventions and as an indication of risk of poor outcome.

Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial

Background

Manual therapy according to the School of Manual Therapy Utrecht (MTU) is a specific type of passive manual joint mobilization. MTU has not yet been systematically compared to other manual therapies and physical therapy. In this study the effectiveness of MTU is compared to physical therapy, particularly active exercise therapy (PT) in patients with non-specific neck pain.

Methods

Patients neck pain, aged between 18–70 years, were included in a pragmatic randomized controlled trial with a one-year follow-up. Primary outcome measures were global perceived effect and functioning (Neck Disability Index), the secondary outcome was pain intensity (Numeric Rating Scale for Pain). Outcomes were measured at 3, 7, 13, 26 and 52 weeks. Multilevel analyses (intention-to-treat) were the primary analyses for overall between-group differences. Additional to the primary and secondary outcomes the number of treatment sessions of the MTU group and PT group was analyzed. Data were collected from September 2008 to February 2011.

Results

A total of 181 patients were included. Multilevel analyses showed no statistically significant overall differences at one year between the MTU and PT groups on any of the primary and secondary outcomes. The MTU group showed significantly lower treatment sessions compared to the PT group (respectively 3.1 vs. 5.9 after 7 weeks; 6.1 vs. 10.0 after 52 weeks).

Conclusions

Patients with neck pain improved in both groups without statistical significantly or clinically relevant differences between the MTU and PT groups during one-year follow-up.

Trial registration

ClinicalTrials.gov Identifier: NCT00713843.

A commentary on the implications of medication prescription rights for the chiropractic profession

There is a growing desire within the chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine / musculoskeletal disorders. However, if the chiropractic profession wishes to lobby to expand the scope of practice to include limited prescriptive authority, several issues must first be addressed. These would include changes to chiropractic education and legislation, as well as consideration of how such privileges could impact the chiropractic profession on a more theoretical basis. In this commentary, we examine the arguments in favour of and against limited medication prescription rights for chiropractors and discuss the implications of such privileges for the profession.

Identifying and treating the causes of neck pain

Future studies are needed to further understand the pathophysiology of mechanical neck pain. Robust scientific evidence is sparse on which noninvasive treatments are the most beneficial and how to better select patients for particular noninvasive or invasive treatments.

[Neck pain with and without affection of nerve roots]

BACKGROUND

The prevalence of neck pain is 30-50 %, and those most affected are women and people in working age. Neck pain and other musculoskeletal complaints are among the most common causes for sick leave and disability pension in Norway, which emphasises the need for guidelines on diagnostic assessment and treatment of these patients.

MATERIAL AND METHODS

This paper is based on a review of "The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorder", Cohrane overviews and some additional sources.

RESULTS

A classification of neck pain into grades I-IV is recommended as a tool for daily clinical work. Unspecific neck pain (grades I and II) is still a challenge and the various underlying conditions are not well defined. Diagnostics and assessment of neck pain is mainly directed towards nerve root affection (grade III) or serious neck disease (grade IV).

INTERPRETATION

Treatment of neck pain is not sufficiently evidence-based, as there are few high-quality publications within this field. Research within the field is clearly needed and should be prioritized nationally.

Findings from the bone and joint decade 2000 to 2010 task force on neck pain and its associated disorders

OBJECTIVE

To summarize the key findings of a best-evidence synthesis on neck pain.

METHODS

A systematic search, critical review, and best-evidence synthesis of the literature on the burden and determinants of neck pain, its assessment and intervention, and its course and prognostic factors.

RESULTS

There were 552 studies judged to have adequate internal validity to form the basis of the best-evidence synthesis. Neck pain is common across populations and age groups. Most do not experience a complete resolution of symptoms, and its course of recovery is similar across populations. In the absence of trauma and "red flags," routine imaging is not needed. Treatments emphasizing activity and return to normal function are more beneficial than those without such a focus.

CONCLUSION

Neck pain is common, and its determinants and prognosis are multifactorial.

Neck pain patients' preference scores for their current health

Purpose

To elicit neck pain (NP) patients’ preference scores for their current health, and investigate the association between their scores and NP disability.

Methods

Rating scale scores (RSs) and standard gamble scores (SGs) for current health were elicited from chronic NP patients (n = 104) and patients with NP following a motor vehicle accident (n = 116). Patients were stratified into Von Korff Pain Grades: Grade I (low-intensity pain, few activity limitations); Grade II (high-intensity pain, few activity limitations); Grade III (pain with high disability levels, moderate activity limitations); and Grade IV (pain with high disability levels, several activity limitations). Multivariable regression quantified the association between preference scores and NP disability.

Results

Mean SGs and RSs were as follows: Grade I patients: 0.81, 0.76; Grade II: 0.70, 0.60; Grade III: 0.64, 0.44; Grade IV: 0.57, 0.39. The association between preference scores and NP disability depended on type of NP and preference-elicitation method. Chronic NP patients’ scores were more strongly associated with depressive symptoms than with NP disability. In both samples, NP disability explained little more than random variance in SGs, and up to 51% of variance in RSs.

Conclusion

Health-related quality-of-life is considerably diminished in NP patients. Depressive symptoms and preference-elicitation methods influence preference scores that NP patients assign to their health.

What is 'manipulation'? A reappraisal

Due primarily to its colloquial function, 'manipulation' is a poor term for distinguishing one healthcare intervention from another. With reports continuing to associate serious adverse events with manipulation, particularly relating to its use in the cervical spine, it is essential that the term be used appropriately and in accordance with a valid definition. The purpose of this paper is to identify empirically-derived features that we propose to be necessary and collectively sufficient for the formation of a valid definition for manipulation. A final definition is not offered. However, arguments for and against the inclusion of features are presented. Importantly, these features are explicitly divided into two categories: the 'action' (that which the practitioner does to the recipient) and the 'mechanical response' (that which occurs within the recipient). The proposed features are: 1) A force is applied to the recipient; 2) The line of action of this force is perpendicular to the articular surface of the affected joint; 3) The applied force creates motion at a joint; 4) This joint motion includes articular surface separation; 5) Cavitation occurs within the affected joint.

Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study

STUDY DESIGN

Population-based, case-control and case-crossover study.

OBJECTIVE

To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.

SUMMARY OF BACKGROUND DATA

Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.

METHODS

Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.

RESULTS

There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.

CONCLUSION

VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To provide evidence-based guidance to primary care clinicians about how to best assess and treat patients with neck pain.

SUMMARY OF BACKGROUND DATA

There is a need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians.

METHODS

Based on best evidence syntheses of published studies on the risk, prognosis, assessment, and management of people with neck pain and its associated disorders, plus additional research projects and focused literature reviews reported in this supplement, the 12-member multidisciplinary Scientific Secretariat of the Neck Pain Task Force followed a 4-step approach to develop practical guidance for clinicians.

RESULTS

The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-spine rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology.

CONCLUSION

The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain (Grade I and Grade II) might be offered the listed noninvasive treatments if short-term relief is desired.

A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders.

OBJECTIVE

To provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help organize and interpret existing knowledge, and to highlight gaps in the current literature.

SUMMARY OF BACKGROUND DATA

The wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual model for appropriate interpretation of the research evidence.

METHODS

The 12-member Scientific Secretariat of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved by the group.

RESULTS

Our new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short- and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies based on how subjects were recruited into each study.

CONCLUSION

The Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions.