Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. 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.

Self-stretching exercises with kinesio taping for management of chronic nonspecific neck pain in taxi drivers: A single-blind, randomized controlled trial

OBJECTIVES

Taxi drivers experience chronic neck pain owing to their posture while driving. The aim of this study was to investigate the effect of self-stretching exercises with kinesio taping on pain, stress, pressure pain threshold (PPT), disability, cervical range of motion (CROM) in this population.

DESIGN

A single-blind, randomized controlled trial SETTING: Forty-three taxi drivers with nonspecific chronic nonspecific neck pain were randomly assigned to experimental (n = 22) and control (n = 21) groups.

METHODS

In the experimental group, self-stretching exercises were performed 3 times a day, 5 days per week, for 4 weeks, with kinesio taping applied while driving. In the control group, only kinesio taping was applied while driving for 4 weeks. Pain intensity, stress intensity, PPT, neck disability, and CROM were assessed pre-intervention, post-intervention, and at 4 weeks post-intervention.

RESULTS

Significant time and group interactions were observed in pain intensity at rest (p = 0.048) and while driving (p = 0.001). In the experimental group, the Pre - Post - Follow-up mean (95% CI) was 4.41 (4.14 to 4.68) - 3.82 (3.57 to 4.07) - 3.78 (3.55 to 3.99). In the control group, the Pre - Post - Follow-up mean (95% CI) was 4.29 (4.01 to 4.56) - 3.86 (3.60 to 4.11) - 4.05 (3.82 to 4.27) for pain at rest. In the experimental group, the Pre - Post - Follow-up mean (95% CI) was 4.91 (4.63 to 5.19) - 4.00 (3.76 to 4.24) - 3.69 (3.69 to 4.22), while in the control group, the Pre - Post - Follow-up mean (95% CI) was 4.81 (4.53 to 5.09) - 4.38 (4.13 to 4.63) - 4.57 (4.30 to 4.85) for pain while driving. PPT on the right (p = 0.029) and left (p < 0.001) sides, and neck disability (p = 0.001) also showed significant time and group interactions. NDI was not clinically significant based on the minimum clinically important difference. All CROM showed significant time and group interactions (flexion, p = 0.008; right lateral flexion, p = 0.009; left lateral flexion, p = 0.004; right rotation, p = 0.001; left rotation, p = 0.001), except for extension.

CONCLUSION

This study showed that self-stretching exercises with kinesio taping provided benefits over kinesio taping alone on pain intensity, PPT, disability, and CROM in taxi drivers with nonspecific chronic neck pain.

CLINICAL TRIAL REGISTRATION

This study registered with the Clinical Research Information Service (WHO International Clinical Trials Registry Platform) on September 22, 2020 (KCT0005406).

Exercise therapy including the cervical extensor muscles in individuals with neck pain: A systematic review

OBJECTIVE

To review the use (dosage parameters and combination with other therapeutic interventions) of cervical extensor muscle exercises and their effect on pain, disability (primary outcomes), range of motion, endurance and strength (secondary outcomes) in people with neck pain.

DATA SOURCES

An extensive literature search was conducted through MEDLINE (Ovid), Scopus (Elsevier) and Physiotherapy Evidence Database (PEDro) up to May 2023. The reference lists of all included studies and relevant reviews were screened for additional studies.

REVIEW METHODS

Randomised controlled trials reporting the use of cervical extensor muscle exercises (alone or combined) applied to adults with idiopathic or traumatic neck pain were included. Study selection, data extraction and critical appraisal (PEDro assessment scale) were performed by two blinded reviewers. Data extraction included dosage parameters, other modalities combined with these exercises and outcomes.

RESULTS

Thirty-five randomised controlled trails (eight of which were complementary analyses) with 2409 participants fulfilled the inclusion criteria. Twenty-six were of moderate to high quality. In most studies, cervical extensor muscle exercises were combined with various other therapeutic modalities and applied at different dosages. Only two studies (one high and one low quality) specifically assessed their effectiveness. The high-quality study showed significant improvements in neck pain and disability, pressure point threshold and neck mobility after both low load and high load training for 6 weeks.

CONCLUSION

The results suggest cervical extensor muscle exercises may reduce neck pain and disability; however firm conclusions cannot be drawn because of the few studies that addressed this question and the heterogeneity of the dosage parameters.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

Resistance, Motor Control, and Mindfulness-Based Exercises Are Effective for Treating Chronic Nonspecific Neck Pain: A Systematic Review With Meta-Analysis and Dose-Response Meta-Regression

OBJECTIVE: We aimed to analyze the effects and dose-response relationship of the most effective exercises for improving pain and disability in people with chronic nonspecific neck pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched the PubMed, PEDro, and CENTRAL databases from their inception to September 30, 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials that involved people with chronic neck pain adopting a longitudinal exercise intervention and assessed one pain and/or disability outcome. DATA SYNTHESIS: Restricted maximum-likelihood random-effects meta-analyses were modeled separately for resistance, mindfulness-based, and motor control exercises; standardized mean differences (Hedge's g, standardized mean difference [SMD]) were effect estimators. Meta-regressions (dependent variable: effect sizes of the interventions; independent variables: training dose and control group effects) were conducted to explore the dose-response relationship for therapy success of any exercise type. RESULTS: We included 68 trials. Compared to true control, effects on pain and disability were significantly larger for resistance exercise (pain: SMD, -1.27; 95% confidence interval [CI]: -2.26, -0.28; |2 = 96%; disability: SMD, -1.76; 95% CI: -3.16, -0.37; |2 = 98%), motor control exercise (pain: SMD, -2.29; 95% CI: -3.82, -0.75; |2 = 98%; disability: SMD, -2.42; 95% CI: -3.38, -1.47; |2 = 94%), and Yoga/Pilates/Tai Chi/Qui Gong exercise (pain: SMD, 1.91; 95% CI:-3.28, -0.55; |2 = 96%; disability: SMD, -0.62; 95% CI: -0.85, -0.38; |2 = 0%). Yoga/Pilates/Tai Chi/Qui Gong exercise was more effective than other exercises (SMD, -0.84; 95% CI: -1.553, -0.13; |2 = 86%) for reducing pain. For disability, motor control exercise was superior to other exercises (SMD, -0.70; 95% CI: -1.23, -0.17; |2 = 98%). There was no dose-response relationship for resistance exercise (R2 = 0.32). Higher frequencies (estimate = -0.10) and longer durations (estimate = -0.11) of motor control exercise had larger effects on pain (R2 = 0.72). Longer sessions (estimate = -0.13) of motor control exercise had larger effects on disability (R2 = 0.61). CONCLUSION: Resistance, mindfulness-based, and motor control exercises were effective for reducing neck pain (very low- to moderate-certainty evidence). Higher frequencies and longer duration of sessions had a significant effect on pain for motor control exercise. J Orthop Sports Phys Ther 2023;53(8):1-41. Epub: 20 June 2023. doi:10.2519/jospt.2023.11820.

A systematic review and meta-analysis of randomized controlled trials of manipulative therapy for patients with chronic neck pain

BACKGROUND

An increasing number of people suffer from chronic neck pain due to increased telecommuting. Manual therapy is considered a safe and less painful method and has been increasingly used to alleviate chronic neck pain. However, there is controversy about the effectiveness of manipulation therapy on chronic neck pain. Therefore, this systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to determine the effectiveness of manipulative therapy for chronic neck pain.

METHODS

A search of the literature was conducted on seven databases (PubMed, Cochrane Center Register of Controlled Trials, Embase, Medline, CNKI, WanFang, and SinoMed) from the establishment of the databases to May 2022. This study included RCTs on chronic neck pain managed with manipulative therapy compared with sham, exercise, and other physical therapies. The retrieved records were independently reviewed by two researchers. Further, the methodological quality was evaluated using the PEDro scale. All statistical analyses were performed using RevMan V.5.3 software. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment was used to evaluate the quality of the study results.

RESULTS

Seventeen RCTs, including 1190 participants, were included in this meta-analysis. Manipulative therapy showed better results regarding pain intensity and neck disability than the control group. Manipulative therapy was shown to relieve pain intensity (SMD = -0.83; 95% confidence interval [CI] = [-1.04 to -0.62]; p < 0.0001) and neck disability (MD = -3.65; 95% CI = [-5.67 to - 1.62]; p = 0.004). However, the studies had high heterogeneity, which could be explained by the type and control interventions. In addition, there were no significant differences in adverse events between the intervention and the control groups.

CONCLUSIONS

Manipulative therapy reduces the degree of chronic neck pain and neck disabilities.

Are there differences between a real C0-C1 mobilization and a sham technique in function and pressure pain threshold in patients with chronic neck pain and upper cervical restriction? A randomised controlled clinical trial

BACKGROUND

Chronic neck pain is one of the main reasons for visiting a healthcare professional. In recent years, it has been shown that upper cervical restriction may be a factor involved in neck pain.

OBJECTIVE

To compare the immediate effects of a real cervical mobilization technique versus a sham cervical mobilization technique in patients with chronic neck pain and upper cervical restriction.

METHODS

This was a randomised, controlled, double-blind clinical trial. Twenty-eight patients with chronic neck pain were recruited and divided into two groups (14 = real cervical mobilization; 14 = sham mobilization). Both groups received a single 5-minute treatment session. Upper cervical range motion, flexion-rotation test, deep cervical activation and pressure pain threshold were measured.

RESULTS

In the between-groups comparison, statistically significant differences were found in favour of the real cervical mobilization group in upper cervical extension (p= 0.003), more restricted side of flexion-rotation test (p< 0.001) and less restricted side of flexion-rotation test (p= 0.007) and in the pressure pain threshold of the right trapezius (p= 0.040) and right splenius (p= 0.049). No differences in deep muscle activation were obtained.

CONCLUSION

The real cervical mobilization group generates improvements in upper cervical spine movement and pressure pain threshold of right trapezius and right splenius compared to the sham group in patients with chronic neck pain and upper cervical restriction.

Effects of isometric training on the treatment of patients with neck pain: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to evaluate the effects of isometric training interventions on the treatment of patients with neck pain.

METHODS

Electronic databases, including PubMed, The Cochrane Library, Web of Science, etc., were retrieved and screened by computer, and 18 articles with a total of 868 samples were included. Review Manager 5.4 software was used for the meta-analysis.

RESULTS

The meta-analysis results showed that isometric training can reduce visual analogue scale scores of patients[weighted mean difference (95% confidence interval) = -0.80(-0.88, -0.73), P < .00001]; decrease patients neck disability index score, isometric training was better than the control group [weighted mean difference (95% confidence interval) = 5.55 (4.57, 6.53), P < .0001]; in improving patients' motion of the sagittal plane [weighted mean difference (95% confidence interval) = 1.53 (-0.40, 3.63), P = .12], coronal plane [weighted mean difference (95% confidence interval) = 2.12 (0.56, 3.68), P = .008], horizontal plane [weighted mean difference (95% confidence interval) = 3.58 (1.56, 5.59), P = .0005], isometric training was superior to the control group. More than 20 isometric training interventions had more significant effects on visual analogue scale and range of motion. And isometric training for more than 8 weeks had more significant effects on the visual analogue scale and neck disability index scores.

CONCLUSION

Isometric training has significant effects on relieving neck pain, improving neck dysfunction, and improving joint mobility. However, the two indicators of visual analogue scale and neck disability index had more influential factors; the sample size of most studies was relatively small, and the intervention measures in the control group were relatively simple. It is expected that more abundant research will expand and deepen in the future, laying the foundation for meta-analysis.

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.