Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized controlled trials of a single session

The immediate effect of unilaterally applied lumbar mobilisations on the passive straight leg raise and ninety-ninety test in asymptomatic adults: A randomised crossover trial

OBJECTIVES

This study assessed the immediate effect of unilateral posterior-anterior lumbar mobilisations on trunk and lower limb flexibility in asymptomatic individuals.

STUDY DESIGN

Randomised cross-over trial.

PARTICIPANTS

Twenty-seven participants (age = 26.0 years ±6.4) with no current or recent history of lower back or leg pain/surgery completed the study.

MAIN OUTCOME MEASURES

Participants attended two sessions, receiving either grade 3 ('treatment') or grade 1 ('sham') unilateral spinal mobilisations. Outcome measures (modified-modified Schober's test [MMST], ninety-ninety test [NNT], and passive straight-leg raise [PSLR]) were assessed immediately before and after (post-1 and post-2) the intervention. An instrumented hand-held dynamometer was used to measure the change in NNT and PSLR joint angle (deg) and passive stiffness (Nm/deg) pre- and post-intervention.

RESULTS

The mean change in PSLR angle at the first (P1) and maximal (P2) point of discomfort following the treatment was 4.8° and 5.5°, and 5.6° and 5.7°, larger than the sham at post-1 and post-2, respectively. There was no effect of the treatment on the PSLR at P1 or P2 for the contralateral limb at either timepoint. There was no effect of the treatment on MMST distance, NNT angle or passive stiffness, or PSLR passive stiffness, for either limb.

CONCLUSIONS

Immediate effects of unilateral posterior-anterior lumbar mobilisations in asymptomatic individuals are isolated to treatment side and limited to a small increase in PSLR range, with no change in lumbar motion or the NNT test.

Establishing the inter-rater and test–retest reliability of the levator scapulae index in women with chronic mechanical neck pain: a reliability study

Background/aims

The levator scapulae is an important postural muscle that tends to shorten or become tight because of overactivity and bad posture, leading to neck and shoulder pain. Therefore, it is important to measure its length to effectively address dysfunction. The aim of this study was to measure the length of the levator scapulae using the levator scapulae index and examine this tool's inter-rater and test–retest reliability in women with chronic mechanical neck pain.

Methods

A total of 130 women aged between 18 to 30 years, with a body mass index between 18.5 and 24.9 kg/m2 and experiencing chronic mechanical neck pain, participated in this study. The length of the participants' levator scapulae was measured with a digital Vernier calliper and with the women in a standing position. Measurements were taken twice on the same day in the afternoon, with a 1 hour resting time between trials. The test–retest reliability of the levator scapulae index was measured for each participant. The procedure was repeated by two researchers after a 1-hour interval, and a mean value was obtained. Variability in body height was normalised by using the levator scapulae index (levator scapulae length [cm]/subject's height [cm]×100)

Results

Spearman's rank correlation coefficient test was used to establish the test–retest reliability (rho=0.96). Inter-rater reliability was established by intra-class correlation coefficient (rater A: 1.0, rater B: 0.98) with Cronbach's alpha (0.99).

Conclusions

The findings demonstrated the excellent reliability of the levator scapulae index for the measurement of levator scapulae length in females with chronic mechanical neck pain. This study helps to establish a reliable method for levator scapulae length measurement, which helps clinicians to plann more efficient treatment protocols for patients with chronic mechanical neck pain.

Is Cervical Stabilization Exercise Immediately Effective in Patients with Chronic Neck Pain and Upper Cervical Spine Dysfunction? Randomized Controlled Trial

Purpose: To compare the effectiveness of a single exercise session with manual therapy techniques in the segments of the upper cervical spine (C0−1, C1−2 and C2−3), against a single exercise session in patients with chronic neck pain and mobility deficits in the upper cervical spine. Methods: A single-blind randomized controlled trial was performed. Fifty-eight patients were recruited (29 for the manual therapy and exercise group and 29 for the exercise group) who presented chronic neck pain and upper cervical spine dysfunction. The exercise focused on the deep muscles. The manual therapy combined manipulations and mobilizations with these exercises. Cervical range of motion, flexion-rotation test, pressure pain threshold and pain intensity were measured by a blind evaluator before and after the intervention. Results: Compared to pre-intervention, after intervention, the exercise group was significantly lower in terms of the range of motion, flexion-rotation test, and pressure pain threshold (p < 0.05). The manual therapy and exercise group improved in upper cervical flexion, the flexion-rotation test and intensity of pain (p < 0.05). Conclusions: It may be necessary to normalize the mobility of the upper cervical spine before cervical stabilization training, in patients with chronic neck pain and mobility deficits in the upper cervical spine.

Effectiveness of posture-correction interventions for mechanical neck pain and posture among people with forward head posture: protocol for a systematic review

INTRODUCTION

Forward head posture (FHP) is the most common postural deviation of the upper back. It is believed to be one of the predisposing factors for the development of mechanical neck pain (MNP). We propose doing a systematic review to find the effectiveness of interventions targeted on FHP with MNP and assess implementation fidelity associated with these interventions.

METHODS AND ANALYSIS

Medline (PubMed), Web of Science (Social Science Citation Index), EMBASE, Scopus, PEDro and CINAHL databases will be searched for studies published in English from their inception. Forward and backward citations of the included studies will be investigated for identifying additional records. We will include randomised controlled trials and non/quasi-experimental studies with two groups assessing the effectiveness of interventions targeted on FHP with MNP. Observational studies, non-randomised studies with single group and reviews will be excluded. We will consider the following outcome measures: postural variables of FHP, neck pain, performance-based functional disability scores of the neck, quality of life, basic activities of daily living and work-related outcomes. The unique citations will be screened by titles/abstracts and full texts, independently. The Cochrane Risk of Bias 2 tool will be used to critically appraise the included studies. The risk of bias and data abstraction of included studies will be undertaken independently. A qualitative synthesis will be conducted and, if sufficient studies with comparable outcome measures are available, we will statistically pool the result.

ETHICS AND DISSEMINATION

We will undertake a systematic review of primary studies, and will not directly recruit participants hence, ethical clearance is not applicable. We will aim to present the findings of the completed systematic review at an international conference and subsequently submit the manuscript in a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42021250310.

Evaluation and Treatment of Trigeminal Symptoms of Cervical Origin After a Motor-Vehicle Crash: A Case Report With 9-Month Follow-up

Objective

The purpose of this case report is to describe the management of a patient with trigeminal symptoms of cervical origin after a motor-vehicle crash (MVC).

Clinical Features

After a head-on MVC, a 65-year-old woman presented with complaints of dizziness, headaches, facial tingling, visual disturbance, tinnitus, loss of cervical motion, and pain in the cervical spine.

Intervention and Outcome

The intervention applied was manipulation of the left C1-C2 and right C2-C3, with targeted exercise to strengthen the cervical musculature. After 4 weeks of treatment, the patient reported improvement in functional tasks and reduction in overall pain, headaches, facial tingling, tinnitus, and dizziness. At a 9-month follow-up, the patient had no report of facial tingling, tinnitus, loss of motion, or eye pain.

Conclusion

This patient with trigeminal symptoms of cervical origin after an MVC responded well to manual therapy to the cervical spine as part of a combination of services.

Mechanical Parameters and Trajectory of Two Chinese Cervical Manipulations Compared by a Motion Capture System

Objective: To compare the mechanical parameters and trajectory while operating the oblique pulling manipulation and the cervical rotation–traction manipulation.

Methods: An experimental research measuring kinematics parameter and recording motion trajectories of two cervical manipulations were carried out. A total of 48 healthy volunteers participated in this study, who were randomly divided into two groups of 24 representing each of the two manipulations. A clinician performed two manipulations in two groups separately. A motion capture system was used to monitor and analyze kinematics parameters during the operation.

Results: The two cervical manipulations have similar thrust time, displacement, mean velocity, max velocity, and max acceleration. There were no significant differences in active and passive amplitudes between the two cervical rotation manipulations. The thrust amplitudes of the oblique pulling manipulation and the cervical rotation–traction manipulation were 5.735 ± 3.041° and 2.142 ± 1.742°, respectively. The thrust amplitudes of the oblique pulling manipulation was significantly greater than that of the cervical rotation–traction manipulation (P < 0.001).

Conclusion: Compared with the oblique pulling manipulation, the cervical rotation–traction manipulation has a less thrust amplitudes.

Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial

Neck pain is a frequent health problem. Manual therapy (MT) and transcutaneous electrical nerve stimulation (TENS) are recommended techniques for treatment of mechanical neck disorders (MND) in Spanish Public Primary Care Physiotherapy Services. The aim of this study was to compare the efficacy of MT versus TENS in active mobility and endurance in cervical subacute or chronic neck pain. Ninety patients with MND were randomly allocated to receive ten 30-min sessions of either MT or TENS, in a multi-centered study through 12 Primary Care Physiotherapy Units in the Madrid community. Active cervical range of motion (CD-ROM) and endurance (Palmer and Epler test) were evaluated pre- and post-intervention and at 6-month follow-up. A generalized linear model of repeated measures was constructed for the analysis of differences. Post-intervention MT yielded a significant improvement in active mobility and endurance in patients with subacute or chronic MND, and at 6-month follow-up the differences were only significant in endurance and in sagittal plane active mobility. In the TENS group, no significant improvement was detected. With regard to other variables, MT improved mobility and endurance more effectively than TENS at post-intervention and at 6-month follow-up in the sagittal plane. Only MT generated significant improvements in cervical mobility and endurance in the three movement planes.

Results of a self-management program added to standard physical therapy in chronic neck pain

OBJECTIVE

To evaluate the effectiveness of a self-management treatment added to a physical therapy program compared to a physical therapy program in patients with chronic neck pain.

METHODS

Fifty-three patients with chronic neck pain were randomly allocated to a physical therapy intervention (control group) or an individualized self-management combined with physical therapy intervention (experimental group). Both interventions were developed over a four-week period. Outcome measures included were Disability, Fear-Avoidance Beliefs, Health-Related Quality of Life, Pain, and Anxiety and Depression. All outcomes were measured before and after the treatment and at three-month follow-up.

RESULTS

There were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).

CONCLUSIONS

An individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.

PRACTICAL IMPLICATIONS

This study indicates that physical therapy for patients with chronic neck pain preferably should include self-management education.

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.

[Manual therapy in non-specific neck pain]

AIM

To investigate the effectiveness of manual therapy (MT) in patients with nonspecific neck pain (NNP).

MATERIAL AND METHODS

Ninety two patients with NNP, aged from 18 to 60 years (41,1±10,2 years), 64 (69,6%) women, 28 (30,4%) men, were examined. Treatment duration was 3 weeks with 6 sessions (2 sessions per week). The effectiveness of treatment was evaluated by measuring the decrease of pain intensity, improvement of daily activity, and patient-related recovery measured with the 11-point Numerical Rating Scale (NRS), the Neck Disability Index (NDI) and the 7-point Global Perceived Effect scale (GPE). Size effect was assessed using Cohen's d.

RESULTS

In the end of treatment, pain was reduced by 3,4±2,3 points (from 4,5±2,5 to 1,1±1,0 points; Cohen's d 1,98); disability was improved by 9,5±5,0 points (from 15,2±5,6 to 5,8±4,0 points; Cohen's d 1,97); patients assessed mean global improvement as «improved» and «much improved» (the improvement by 2-3 points on GPE scale).

CONCLUSION

MT in NNP is effective method of treatment that decreases pain syndrome, improves daily activity and is positively assessed by the patients.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial

OBJECTIVE

To determine the effect of mobilization and routine physiotherapy on pain, disability, neck range of motion (ROM) and neck muscle endurance (NME) in patients having chronic mechanical neck pain (NP).

METHODS

Sixty eight patients with chronic mechanical NP were randomly allocated into two groups by using a computer generated random sequence table with 34 patients in the multi-modal mobilization group and 34 patients in the routine physiotherapy group. Baseline values for pain, disability, NME, and neck ROM were recorded using visual analogue scale (VAS), neck disability index (NDI), neck flexor muscle endurance test and universal goniometer respectively, before the treatment. Each patient received 10 treatment sessions over a period of four weeks and at the end of four weeks all the outcome measures were recorded again.

RESULTS

A paired t-test revealed significant pre to post treatment differences for all outcome measures in both groups (p ≤ 0.001 in all instances). An independent t-test revealed statistically significant differences for pain, disability, NME, and neck ROM in favor of the multi-modal mobilization group with a between group difference of 1.57 cm for VAS (p < 0.001), 11.74 points for NDI (p = 0.001), 18.45 s for NME (p < 0.001) and 6.06-8.24° for neck ROM (p < 0.05).

CONCLUSION

The results suggest that a combination of cervical mobilization with routine physiotherapy is more effective for reducing pain and disability and improving NME and neck ROM in patients with chronic mechanical NP compared to routine physiotherapy alone.

Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States

Study Design Cross-sectional survey. Objective To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. Background Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. Methods A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). Results The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). Conclusion Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. J Orthop Sports Phys Ther 2017;47(3):200-208. Epub 30 Oct 2016. doi:10.2519/jospt.2017.6914.

Exercise, especially combined stretching and strengthening exercise, reduces myofascial pain: a systematic review

QUESTION

Among people with myofascial pain, does exercise reduce the intensity of the pain and disability?

DESIGN

Systematic review of randomised and quasi-randomised controlled trials.

PARTICIPANTS

People with myofascial pain of any duration.

INTERVENTION

Exercise versus minimal or no intervention and exercise versus other intervention.

OUTCOME MEASURES

Pain intensity and disability.

RESULTS

Eight studies involving 255 participants were included. Pooled estimates from six studies showed statistically significant effects of exercise when compared with minimal or no intervention (support and encouragement or no treatment) on pain intensity at short-term follow-up. The weighted mean difference in pain intensity due to exercise was -1.2 points (95% CI -2.3 to -0.1) on a 0 to 10 scale. Pooled estimates from two studies showed a non-significant effect of exercise when compared with other interventions (electrotherapy or dry needling) on pain intensity at short-term follow-up. The weighted mean difference in pain intensity due to exercise instead of other therapies was 0.4 points (95% CI -0.3 to 1.1) on a 0 to 10 scale. Individual studies reported no significant effects of exercise on disability compared with minimal intervention (-0.4, 95% CI -1.3 to 0.5) and other interventions (0.0, 95% CI -0.8 to 0.8) at short-term follow-up. Sensitivity analysis suggested that combining stretching and strengthening achieves greater short-term effects on pain intensity compared with minimal or no intervention (-2.3, 95% CI -4.1 to -0.5).

CONCLUSION

Evidence from a limited number of trials indicates that exercise has positive small-to-moderate effects on pain intensity at short-term follow-up in people with myofascial pain. A combination of stretching and strengthening exercises seems to achieve greater effects. These estimates may change with future high-quality studies. [Mata Diz JB, de Souza JRLM, Leopoldino AAO, Oliveira VC (2016) Exercise, especially combined stretching and strengthening exercise, reduces myofascial pain: a systematic review.Journal of Physiotherapy63: 17-22].

Manual and Instrument Applied Cervical Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare the effects of 2 different cervical manipulation techniques for mechanical neck pain (MNP).

METHODS

Participants with MNP of at least 1 month's duration (n = 65) were randomly allocated to 3 groups: (1) stretching (control), (2) stretching plus manually applied manipulation (MAM), and (3) stretching plus instrument-applied manipulation (IAM). MAM consisted of a single high-velocity, low-amplitude cervical chiropractic manipulation, whereas IAM involved the application of a single cervical manipulation using an (Activator IV) adjusting instrument. Preintervention and postintervention measurements were taken of all outcomes measures. Pain was the primary outcome and was measured using visual analogue scale and pressure pain thresholds. Secondary outcomes included cervical range of motion, hand grip-strength, and wrist blood pressure. Follow-up subjective pain scores were obtained via telephone text message 7 days postintervention.

RESULTS

Subjective pain scores decreased at 7-day follow-up in the MAM group compared with control (P = .015). Cervical rotation bilaterally (ipsilateral: P = .002; contralateral: P = .015) and lateral flexion on the contralateral side to manipulation (P = .001) increased following MAM. Hand grip-strength on the contralateral side to manipulation (P = .013) increased following IAM. No moderate or severe adverse events were reported. Mild adverse events were reported on 6 occasions (control, 4; MAM, 1; IAM, 1).

CONCLUSION

This study demonstrates that a single cervical manipulation is capable of producing immediate and short-term benefits for MNP. The study also demonstrates that not all manipulative techniques have the same effect and that the differences may be mediated by neurological or biomechanical factors inherent to each technique.

The effect of manual therapy with augmentative exercises for neck pain: a randomised clinical trial

OBJECTIVES

To compare the effect of manual therapy (MT) and an augmentative exercise programme (AEP) versus MT and general neck range of motion (ROM) on functional outcomes for patients with neck pain. A secondary objective was to examine changes in self-report measures and quantitative sensory testing (QST) following MT and AEP.

METHODS

This was a randomised clinical trial. Seventy-two patients with neck pain were recruited. All patients received a single session of MT. Patients were randomly assigned to MT+AEP or MT+ROM. Clinical self-report outcome measures for disability and pain, and QST measures (pain and vibration thresholds) were collected at baseline, post MT treatment, at ∼48 hours, and at ∼96 hours. Repeated measures ANOVA and MANOVA were used to analyse within and between-group effects for clinical and QST measures.

RESULTS

There were no between-group differences for disability, pain and QST measures. There was, however, a significant difference between groups for Global Rating of Change (GRoC) scores (P = 0.037). Patients in both groups showed improvements in pain, disability and trapezius pressure-pain threshold (PPT) (all P < 0.001).

DISCUSSION

Augmentative exercise programme does not significantly improve disability, pain or QST measures in patients with chronic neck pain although it may enhance their GRoC scores. Over a 96-hour period, patients benefitted from MT plus exercise whether the exercise was general or specific.

The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis

STUDY DESIGN

Systematic literature review and meta-analysis.

OBJECTIVE

IN SYMPTOMATIC SUBJECTS TO: (1) examine the effects of a single session of joint mobilization on pain at rest and with most painful movement, and (2) compare the effects when joint mobilization is provided to a specific or non-specific spinal level.

BACKGROUND

Joint mobilization is routinely used for treating spinal pain in conjunction with other interventions, but its unique effect is not well understood. Further, there is controversy about the role of 'specific level' techniques in producing benefit.

METHODS

Searches were performed for randomized controlled trials (RCTs) using electronic databases (MEDLINE, CINAHL, and PEDro) from 1966 through November 2010. Methodological quality was assessed using previously detailed criteria. Meta-analysis and meta-regression were conducted on eligible studies.

RESULTS

Eight RCTs with a mean methodological score of 10/12 were included. Significant heterogeneity (P = 0.075) was found in the overall meta-analysis estimate. When stratified by body location, no significant individual effect was found for pain at rest. However, there was a statistical mean difference [0.71 (95% confidence interval: 0.13-1.28)] between pain at rest for the cervical and lumbar individual means.

CONCLUSIONS

We found multiple studies which provided evidence that a single session of joint mobilization can lead to a reduction of pain at rest and with most painful movement. When using joint mobilization, the need for specific versus non-specific level mobilization may be influenced by anatomical region; the direction of effect in the cervical spine was toward specific mobilization and in the lumbar spine towards non-specific mobilization.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

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.

A randomized, placebo-controlled double-blinded comparative clinical study of five over-the-counter non-pharmacological topical analgesics for myofascial pain: single session findings

OBJECTIVES

To investigate the effects of topical agents for the treatment of Myofascial Pain Syndrome (MPS) and Myofascial Trigger Point (MTRP).

METHODS

Subjects with an identifiable trigger point in the trapezius muscle, age 18-80 were recruited for a single-session randomized, placebo-blinded clinical study. Baseline measurements of trapezius muscle pressure pain threshold (PPT: by pressure algometer) along with right and left cervical lateral flexion (rangiometer) were obtained by a blinded examiner. An assessor blinded to the outcomes assessments applied one of 6 topical formulations which had been placed in identical plastic containers. Five of these topicals were proposed active formulations; the control group was given a non-active formulation (PLA). Five minutes after the application of the formula the outcome measures were re-tested. Data were analyzed with a 5-way ANOVA and Holms-adjusted t-tests with an alpha level of 0.05.

RESULTS

120 subjects were entered into the study (63 females; ages 16-82); 20 subjects randomly allocated into each group. The pre- and post-treatment results for pressure threshold did show significant intra-group increases for the Ben-Gay Ultra Strength Muscle Pain Ointment (BG), the Professional Therapy MuscleCare Roll-on (PTMC roll-on) and Motion Medicine Cream (MM) with an increased threshold of 0.5 kg/cm2 (+/-0.15), 0.72 kg/cm2 (+/-0.17) and 0.47 Kg/cm2 (+/-0.19) respectively. With respect to the inter-group comparisons, PTMC roll-on showed significant increases in pressure threshold compared with Placebo (PLA) (p = 0.002) and Icy Hot Extra Strength Cream (IH) (p = 0.006). In addition, BG demonstrated significant increases in pressure threshold compared with PLA (p = 0.0003).

CONCLUSIONS

With regards to pressure threshold, PTMC roll-on, BG and MM showed significant increases in pain threshold tolerance after a short-term application on a trigger points located in the trapezius muscle. PTMC roll-on and BG were both shown to be superior vs placebo while PTMC was also shown to be superior to IH in patients with trigger points located in the trapezius muscle on a single application.CMCC Research Ethics Board Approval # 1012X01, 2011.

Ultrasonographic analysis of the neck flexor muscles in patients with chronic neck pain and changes after cervical spine mobilization

OBJECTIVE

The purpose of this study was to analyze changes in the recruitment of the muscles longus colli (Lco) and sternocledomastoid (SCM) as measured by ultrasonography in patients with chronic neck pain before and immediately after a single cervical Maitland's posterior-anterior central mobilization technique.

METHODS

This was a cross-sectional, case-control research design study. Ultrasonographic images of Lco and SCM were taken in 31 patients with chronic neck pain and matched controls during the 5 phases of the craniocervical flexion test before and after a Maitland's posterior-anterior central mobilization session at the cervical spine. Changes in muscle thickness during the test were calculated to infer muscle recruitment. Separate analysis of variance models for each muscle was built.

RESULTS

Both groups showed increases in Lco and SCM recruitment between phases (F = 7.95, P < .001; F = 21.29, P < .001), with patients with chronic neck pain demonstrating lesser increases for Lco changes in thickness compared with controls, mainly at phase 5 (-0.09, P = .004; 95% confidence interval [CI], 0.03-0.15). After the mobilization, Lco recruitment increased more significantly in patients with chronic neck pain, and previous difference between groups in phase 5 was no longer significant (-0.07, P = .07; 95% CI, -0.14 to 0.01). The SCM recruitment decreased in phase 1 for patients with chronic neck pain (P = .01; 95% CI, -0.06 to -0.01).

CONCLUSION

Cervical mobilization appeared to modulate neck muscles function by increasing deep muscle and reducing superficial muscles recruitment.

Effects of high-velocity, low-amplitude manipulation on catalase activity in men with neck pain

OBJECTIVE

The aim of this study was to identify the influence of high-velocity, low-amplitude (HVLA) manipulation on lipid peroxidation and catalase activity in subjects with neck pain who answered the Neck Disability Index and quadruple visual scale questionnaires.

METHODS

Twenty-two men (mean age, 38 years) with neck pain were recruited through radio and newspaper advertisements in the local media. Every patient received 6 sessions of HVLA manipulation, 3 times a week for 2 weeks. Blood samples were drawn from the cubital vein before treatment in the first session and after the third and sixth sessions. The quadruple visual scale was used with the same scheme. The Neck Disability Index questionnaire was applied before the beginning of treatment and after the last session. Catalase activity and lipoperoxidation were measured in erythrocyte samples.

RESULTS

Results showed no change in lipid peroxidation. Nevertheless, the catalase activity was increased by HVLA manipulation. The same treatment reduced pain perception and disability in these subjects.

CONCLUSION

The present study has shown that catalase activity of the erythrocytes, but not lipoperoxidation, increased after 6 sessions of HVLA manipulation treatment in men with neck pain. The results support the beneficial role of HVLA in the treatment of patients with neck pain.

Primary care randomized clinical trial: manual therapy effectiveness in comparison with TENS in patients with neck pain

This study investigated effectiveness of manual therapy (MT) with transcutaneous electrical nerve stimulation (TENS) to reduce pain intensity in patients with mechanical neck disorder (MND). A randomized multi-centered controlled clinical trial was performed in 12 Primary Care Physiotherapy Units in Madrid Region. Ninety patients were included with diagnoses of subacute or chronic MND without neurological damage, 47 patients received MT and 43 TENS. The primary outcome was pain intensity measured in millimeters using the Visual Analogue Scale (VAS). Also disability, quality of life, adverse effects and sociodemographic and prognosis variables were measured. Three evaluations were performed (before, when the procedure finished and six months after). Seventy-one patients (79%) completed the follow-up measurement at six months. In more than half of the treated patients the procedure had a clinically relevant "short term" result after having ended the intervention, when either MT or TENS was used. The success rate decreased to one-third of the patients 6 months after the intervention. No differences can be found in the reduction of pain, in the decrease of disability nor in the quality of life between both therapies. Both analyzed physiotherapy techniques produce a short-term pain reduction that is clinically relevant.

Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points: a double blind randomised placebo-controlled trial

OBJECTIVE

The purpose of this study was to investigate the immediate effect of electric point stimulation in treating latent upper trapezius trigger points compared to placebo.

DESIGN

Double blind randomised placebo-controlled trial.

SETTING

Anglo-European College of Chiropractic.

PARTICIPANTS

Sixty participants with latent upper trapezius trigger points.

INTERVENTIONS

Electric point stimulator type of TENS, or detuned (inactive) electric point stimulator type of TENS.

MAIN OUTCOME MEASURES

The three outcome measures were pressure pain threshold at the trigger point, a numerical rating scale for pain elicited over the trigger point, and lateral cervical flexion to the side opposite the trigger point.

RESULTS

On the outcome of pressure pain threshold the electric point stimulator group had a mean change of 0.49 (0.99) kg/cm(2), while the placebo group had a mean change of 0.45 (0.98) kg/cm(2) (t = 0.16, df = 58, p = 0.88). For change in pain over the trigger point, the electric point stimulator group had a mean decrease of 0.93 (0.87) points, while the placebo group had a mean decrease of 0.23 (0.97) points (t = 0.70, df = 58, p = 0.005). On the outcome of change in lateral cervical flexion the electric point stimulator group had a mean increase of 2.87 (4.55) degrees, while the placebo group had a mean increase of 1.99 (2.49) degrees (t = 0.92, df = 58, p = 0.36).

CONCLUSION

Electric point stimulator type of TENS is superior to placebo only in reduction of pain for treating latent upper trapezius trigger points.

The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis

STUDY DESIGN

Secondary analysis of a randomized clinical trial (RCT).

OBJECTIVES

To perform a secondary analysis on the treatment arm of a larger RCT to determine differences in treatment outcomes, adverse reactions, and effect sizes between patients who received cervical thrust manipulation and those who received only nonthrust manipulation as part of an impairment-based, multimodal treatment program of manual physical therapy (MPT) and exercise for patients with mechanical neck pain.

BACKGROUND

A treatment regimen of MPT and exercise has been effective in patients with mechanical neck pain. Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient population, and no studies have investigated the added benefit of cervical thrust manipulations as part of an overall MPT treatment plan.

METHODS

Treatment outcomes from 47 patients in the treatment arm of a larger RCT, with a primary complaint of mechanical neck pain, were analyzed. Twenty-three patients (49%) received cervical thrust manipulations as part of their MPT treatment, and 24 patients (51%) received only cervical nonthrust mobilizations. All patients received up to 6 clinic sessions, twice weekly for 3 weeks, and a home exercise program. Primary outcome measures were the Neck Disability Index (NDI), 2 visual analog scales for cervical and upper extremity pain, and a 15-point global rating of change scale. Blinded outcome measurements were collected at baseline and at 3-, 6- and 52-week follow-ups.

RESULTS

Consistent with the larger RCT, both subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and disability scores. Low statistical power (beta< or =.28) and the resultant small effect size indices (-0.21 to 0.17) preclude the identification of any between-group differences. No serious adverse reactions were reported by patients in either subgroup.

CONCLUSIONS

Clinically meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation, as part of the MPT treatment plan, did not influence the results of the treatment arm of the larger RCT from which this study was drawn. Although no between-group differences can be identified, the small observed effect sizes in this study may benefit future studies with sample size estimation for larger RCTs and indicate the need to incorporate clinical prediction rule criteria as a means to improve statistical power.

LEVEL OF EVIDENCE

Therapy, level 4.