Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain? A randomized controlled trial

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis

BACKGROUND

Cervicogenic headache is a secondary headache, and manual therapy is one of the most common treatment choices for this and other types of headache. Nonetheless, recent guidelines on the management of cervicogenic headache underlined the lack of trials comparing manual and exercise therapy to sham or no-treatment controls. The main objective of this systematic review and meta-analysis was to assess the effectiveness of different forms of manual and exercise therapy in people living with cervicogenic headache, when compared to other treatments, sham, or no treatment controls.

METHODS

Following the PRISMA guidelines, the literature search was conducted until January 2022 on MEDLINE, CENTRAL, DOAJ, and PEDro. Randomized controlled trials assessing the effects of manual or exercise therapy on patients with cervicogenic headache with headache intensity or frequency as primary outcome measures were included. Study selection, data extraction and Risk of Bias (RoB) assessment were done in duplicate. GRADE was used to assess the quality of the evidence.

RESULTS

Twenty studies were included in the review, with a total of 1439 patients. Common interventions were spinal manipulation, trigger point therapy, spinal mobilization, scapulo-thoracic and cranio-cervical exercises. Meta-analysis was only possible for six manual therapy trials with sham comparators. Data pooling showed moderate-to-large effects in favour of manual therapy for headache frequency and intensity at short-term, small-to-moderate for disability at short-term, small-to-moderate for headache intensity and small for headache frequency at long-term. A sensitivity meta-analysis of low-RoB trials showed small effects in favor of manual therapy in reducing headache intensity, frequency and disability at short and long-term. Both trials included in the sensitivity meta-analysis studied spinal manipulation as the intervention of interest. GRADE assessment showed moderate quality of evidence.

CONCLUSION

The evidence suggests that manual and exercise therapy may reduce headache intensity, frequency and disability at short and long-term in people living with cervicogenic headache, but the overall RoB in most included trials was high. However, a sensitivity meta-analysis on low-RoB trials showed moderate-quality evidence supporting the use of spinal manipulation compared to sham interventions. More high-quality trials are necessary to make stronger recommendations, ideally based on methodological recommendations that enhance comparability between studies. Trial registration The protocol for this meta-analysis was pre-registered on PROSPERO under the registration number CRD42021249277.

Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review

OBJECTIVE

The aim of this study was to identify the manual therapy (MT) methods and techniques that have been evaluated for the treatment of cervicogenic headache (CH) and their effectiveness.

BACKGROUND

MT seems to be one of the options with the greatest potential for the treatment of CH, but the techniques to be applied are varied and there is no consensus on which are the most indicated.

METHODS

A systematic search in Scopus, Medline, PubMed, Cinahl, PEDro, and Web of Science with the terms: secondary headache disorders, physical therapy modalities, musculoskeletal manipulations, cervicogenic headache, manual therapy, and physical therapy. We included articles published from 2015 to the present that studied interventions with MT techniques in patients with CH. Two reviewers independently screened 365 articles for demographic information, characteristics of study design, study-specific intervention, and results. The Oxford 2011 Levels of Evidence and the Jadad scale were used.

RESULTS

Of a total of 14 articles selected, 11 were randomized control trials and three were quasi-experimental studies. The techniques studied were: spinal manipulative therapy, Mulligan's Sustained Natural Apophyseal Glides, muscle techniques, and translatory vertebral mobilization. In the short-term, the Jones technique on the trapezius and ischemic compression on the sternocleidomastoid achieved immediate improvements, whereas adding spinal manipulative therapy to the treatment can maintain long-term results.

CONCLUSIONS

The manual therapy techniques could be effective in the treatment of patients with CH. The combined use of MT techniques improved the results compared with using them separately. This review has methodological limitations, such as the inclusion of quasi-experimental studies and studies with small sample sizes that reduced the generalizability of the results obtained.

The Unknown Prevalence of Postrandomization Bias in 15 Physical Therapy Journals: A Methods Review

OBJECTIVES

To determine the prevalence of prospective clinical trial registration and postrandomization bias in published musculoskeletal physical therapy randomized clinical trials (RCTs).

DESIGN

A methods review.

LITERATURE SEARCH

Articles indexed in MEDLINE and published between January 2016 and July 2020 were included.

STUDY SELECTION CRITERIA

Two independent blinded reviewers identified the RCTs using Covidence. We included RCTs related to musculoskeletal interventions that were published in International Society of Physiotherapy Journal Editors member journals.

DATA SYNTHESIS

Data were extracted independently for the variables of interest from the identified RCTs by 2 blinded reviewers. The data were presented descriptively or in frequency tables.

RESULTS

One hundred thirty-eight RCTs were identified. One third of RCTs were consistent with their prospectively registered intent (49/138); consistency with prospectively registered intent could not be determined for two thirds (89/138) of the RCTs. Four RCTs (8%)reported inconsistent results with the primary aims and 7 (14%) with the outcomes from the prospective clinical trial registry, despite high methodological quality (Physiotherapy Evidence Database [PEDro] scale score). Differences between prospectively registered and non-prospectively registered RCTs for PEDro scale scores had a medium effect size (r = 0.30). Two of 15 journals followed their clinical trial registration policy 100% of the time; in 1 journal, the published RCTs were consistent with the clinical trial registration.

CONCLUSION

Postrandomization bias in musculoskeletal physical therapy RCTs could not be ruled out, due to the lack of prospective clinical trial registration and detailed data analysis plans. J Orthop Sports Phys Ther 2021;51(11):542-550. Epub 21 Sep 2021. doi:10.2519/jospt.2021.10491.

Expert consensus on the important chronic non-specific neck pain motor control and segmental exercise and dosage variables: An international e-Delphi study

BACKGROUND

Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity.

OBJECTIVE

To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain.

METHODS

An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1-5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics.

RESULTS

Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions.

CONCLUSION

Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.

Measuring upper limb disability for patients with neck pain: Evaluation of the feasibility of the single arm military press (SAMP) test

BACKGROUND

Non-specific neck pain (NSNP) is frequently associated with upper limb disability (ULD). Consequently, evaluation of ULD using an outcome measure is necessary during the management of patients with NSNP. The Single Arm Military Press (SAMP) test is a performance-based ULD measure developed for populations with neck pain. During the SAMP test, patients are asked to repeatedly lift a weight above their head for 30 s. The number of repetitions is counted. Its clinical utility in a patient group is still unknown.

OBJECTIVE

This study investigates the feasibility of the SAMP test from patients and clinicians' perspectives.

METHODS

Seventy female patients with NSNP were randomly allocated into one of three groups. Participants in each group completed the SAMP test using one of three proposed weights (½kg, 1 kg or 1½kg). The feasibility of the SAMP test was established using structured qualitative exit feedback interviews for patients and administrating clinicians.

RESULTS

Participants using ½kg achieved the highest number of repetitions, but a high proportion reported the weight as extremely light, whereas those who tested using the 1½kg achieved the lowest number of repetitions and participants reported the weight as being heavy. Participants tested using 1 kg achieved an average number of repetitions and a high proportion reported the weight as acceptably heavy. Clinicians and patients reported that the SAMP test was efficient and convenient.

CONCLUSION

The 1 kg SAMP test is feasible for use in female patients with NSNP. The measurement properties of the SAMP test should be determined in a patient group.

Patients' perceptions with musculoskeletal disorders regarding their experience with healthcare providers and health services: an overview of reviews

Objectives

This overview of reviews aimed to identify (1) aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system, and (2) which mechanisms are used to measure aspects of the patient experience.

Data sources

Four databases were searched from inception to December 20th, 2019.

Review methods

Systematic or scoping reviews examining patient experience in seeking care for musculoskeletal from healthcare providers and the healthcare system were included. Independent authors screened and selected studies, extracted data, and assessed the methodological quality of the reviews. Patient experience concepts were compiled into five themes from a perspective of a) relational and b) functional aspects. A list of mechanisms used to capture the patient experience was also collected.

Results

Thirty reviews were included (18 systematic and 12 scoping reviews). Relational aspects were reported in 29 reviews and functional aspects in 25 reviews. For relational aspects, the most prevalent themes were “information needs” (education and explanation on diseases, symptoms, and self-management strategies) and “understanding patient expectations” (respect and empathy). For functional aspects, the most prevalent themes were patient’s “physical and environmental needs,” (cleanliness, safety, and accessibility of clinics), and “trusted expertise,” (healthcare providers’ competence and clinical skills to provide holistic care). Interviews were the most frequent mechanism identified to collect patient experience.

Conclusions

Measuring patient experience provides direct insights about the patient’s perspectives and may help to promote better patient-centered health services and increase the quality of care. Areas of improvement identified were interpersonal skills of healthcare providers and logistics of health delivery, which may lead to a more desirable patient-perceived experience and thus better overall healthcare outcomes.

Trial registration

Systematic review registration: PROSPERO (CRD42019136500).

Is a combined programme of manual therapy and exercise more effective than usual care in patients with non-specific chronic neck pain? A randomized controlled trial

OBJECTIVE

The aim of this study was to compare the effectiveness of a combined intervention of manual therapy and exercise (MET) versus usual care (UC), on disability, pain intensity and global perceived recovery, in patients with non-specific chronic neck pain (CNP).

DESIGN

Randomized controlled trial.

SETTING

Outpatient care units.

SUBJECTS

Sixty-four non-specific CNP patients were randomly allocated to MET (n = 32) or UC (n = 32) groups.

INTERVENTIONS

Participants in the MET group received 12 sessions of mobilization and exercise, whereas the UC group received 15 sessions of usual care in physiotherapy.

MAIN MEASURES

The primary outcome was disability (Neck Disability Index). The secondary outcomes were pain intensity (Numeric Pain Rating Scale) and global perceived recovery (Patient Global Impression Change). Patients were assessed at baseline, three weeks, six weeks (end of treatment) and at a three-month follow-up.

RESULTS

Fifty-eight participants completed the study. No significant between-group difference was observed on disability and pain intensity at baseline. A significant between-group difference was observed on disability at three-week, six-week and three-month follow-up (median (P₂₅-P₇₅): 6 (3.25-9.81) vs. 15.5 (11.28-20.75); P < 0.001), favouring the MET group. Regarding pain intensity, a significant between-group difference was observed at six-week and three-month follow-up (median (P₂₅-P₇₅): 2 (1-2.51) vs. 5 (3.33-6); P < 0.001), with superiority of effect in MET group. Concerning the global perceived recovery, a significant between-group difference was observed only at the three-month follow-up (P = 0.001), favouring the MET group.

CONCLUSION

This study's findings suggest that a combination of manual therapy and exercise is more effective than usual care on disability, pain intensity and global perceived recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE

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

Impact of Workplace Exposure and Stress on Neck Pain and Disabilities in Women-A Longitudinal Follow-up After a Rehabilitation Intervention

Introduction

The aim was to evaluate if pain, disability, and work productivity are influenced by physical and psychosocial work exposures as well as by stress, up to 1 year after a randomized controlled trial treatment intervention, and to determine whether any such association differed between treatment and control groups.

Methods

Ninety-seven working women suffering non-specific neck pain (n = 67 treatment group, n = 30 control group) were followed from end of treatment intervention and at 9- and 15-month follow-ups, respectively. Physical and psychosocial exposures, as well as perceived stress, were assessed after the treatment intervention. Pain, neck disability, and work productivity were assessed at baseline, after intervention 3 months later and at 9- and 15-month follow-ups. Longitudinal assessment was conducted using the exposure level at 3 months as predictor of pain, disability, and work productivity at 3, 9, and 15 months, respectively. Mixed models were used to estimate longitudinal associations, accounting for within-individual correlation of repeated outcome measures by incorporation of a random intercept. Age and duration of neck pain were adjusted for in all models. To evaluate group differences, interactions between exposures and treatment groups were estimated.

Results

High perceived stress was associated with more neck pain, more neck disability, and decreased work productivity in both cross-sectional and longitudinal analyses. High 'control of decision' was associated with less neck pain, less neck disability, and higher work productivity in cross-sectional analyses but only to less disability and higher productivity in longitudinal analyses. Shoulder/arm load was the only physical exposure variable that was significantly associated with work productivity in the univariate analyses. Only small differences were observed between treatment and control groups.

Conclusion

High perceived stress and low 'control of decision' were associated with more neck pain, increased neck disability, and decreased work productivity. Treatment interventions for individuals with neck pain should take into account psychosocial workplace exposures and stress to improve intermediate and long-term results.

Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain

BACKGROUND

Impaired proprioception, increased pain sensitivity, higher levels of anxiety and catastrophizing are present in adults with chronic idiopathic neck pain. Despite the high prevalence of neck pain, studies in adolescents are scarce.

OBJECTIVES

The main aim was to compare pressure pain thresholds (PPTs) and joint repositioning error (JRE) between adolescents with chronic idiopathic neck pain and adolescents without neck pain. Secondary aims were to compare these groups for catastrophizing and anxiety and to investigate the association between PPTs, JRE and psychosocial variables and pain characteristics.

METHODS

80 adolescents (40 with and 40 without chronic neck pain) were assessed for: neck repositioning error, neck, upper trapezius and tibialis anterior PPTs, anxiety and catastrophizing. Neck pain was characterized in terms of intensity, frequency, duration and associated disability. MANCOVA was used for between group comparisons and Pearson and Spearman coefficients for correlational analysis.

RESULTS

Adolescents with neck pain showed higher levels of catastrophizing (p < 0.001) and anxiety (trait: p < 0.001; state: p = 0.028), lower PPTs (p < 0.001) and higher JRE (p < 0.001) than asymptomatic controls. Pain intensity, frequency and duration were moderately correlated with anxiety, and disability was moderately correlated with anxiety (r between 0.43 and 0.50, p < 0.05) and catastrophizing (r = 0.40, p < 0.05).

CONCLUSIONS

This study suggests that functional changes and maladaptive cognitive processes are present in adolescents with neck pain aged 16-18 years old. These findings need to be replicated in future studies.