Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To quantify and compare the short- and long-term effects of manual treatment and spinal rehabilitative exercise for cervicogenic headache, classified according to the International Headache Society's (IHS) diagnostic criteria, with an active or placebo/sham comparison or wait-list control.

Spinal rehabilitative exercise or manual treatment for the prevention of tension-type headache in adults

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the short- and long-term effects of manual treatment and spinal rehabilitative exercise for the prevention of tension-type headache in adults.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

WITHDRAWN: Non-invasive physical treatments for chronic/recurrent headache

This review is out of date, but is correct at the date of publication. The review has been withdrawn from The Cochrane Library, but readers can still access previous versions in the 'Other versions' tab. The original author team is preparing three new protocols which will serve to update and replace this review: Manual treatment and spinal rehabilitative exercise for the prevention of migraine attacks in adults, Manual treatment and spinal rehabilitative exercise for the prevention of TTH in adults, and Manual treatment and spinal rehabilitative exercise for the prevention of cervicogenic headaches in adults. For further information, please contact the PaPaS CRG (details here ).

July 2017

At July 2017, the series of three new reviews intended to replace this review were withdrawn as they were not able to be completed within the available editorial resource.

The editorial group responsible for this previously published document have withdrawn it from publication.

Traction for low-back pain with or without sciatica

BACKGROUND

Traction has been used to treat low-back pain (LBP), often in combination with other treatments. We included both manual and machine-delivered traction in this review. This is an update of a Cochrane review first published in 1995, and previously updated in 2006.

OBJECTIVES

To assess the effects of traction compared to placebo, sham traction, reference treatments and no treatment in people with LBP.

SEARCH METHODS

We searched the Cochrane Back Review Group Specialized Register, the Cochrane Central Register of Controlled Trials (2012, Issue 8), MEDLINE (January 2006 to August 2012), EMBASE (January 2006 to August 2012), CINAHL (January 2006 to August 2012), and reference lists of articles and personal files. The review authors are not aware of any important new randomized controlled trial (RCTs) on this topic since the date of the last search.

SELECTION CRITERIA

RCTs involving traction to treat acute (less than four weeks' duration), subacute (four to 12 weeks' duration) or chronic (more than 12 weeks' duration) non-specific LBP with or without sciatica.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. As there were insufficient data for statistical pooling, we performed a descriptive analysis. We did not find any case series that identified adverse effects, therefore we evaluated adverse effects that were reported in the included studies.

MAIN RESULTS

We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group's 'Risk of bias' tool.For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement. This was true when traction was compared with controls and other treatments, as well as when the combination of traction plus physiotherapy was compared with physiotherapy alone. No studies reported the effect of traction on return to work.For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment. No studies reported on the effect of traction on functional status, global improvement or return to work.Adverse effects were reported in seven of the 32 studies. These included increased pain, aggravation of neurological signs and subsequent surgery. Four studies reported that there were no adverse effects. The remaining studies did not mention adverse effects.

AUTHORS' CONCLUSIONS

These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant. Implications for practice To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction. Implications for research Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Manual therapy and exercise for neck pain: a systematic review

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI: -1.69, -0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI: -0.76, -0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.

Manual therapy and exercise for neck pain: A systematic review

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:-0.76,-0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.

Manipulation or mobilisation for neck pain

BACKGROUND

Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain.

OBJECTIVES

To assess if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life, and global perceived effect in adults with acute/subacute/chronic neck pain with or without cervicogenic headache or radicular findings.

SEARCH STRATEGY

CENTRAL (The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, Manual Alternative and Natural Therapy, CINAHL, and Index to Chiropractic Literature were updated to July 2009.

SELECTION CRITERIA

Randomised controlled trials on manipulation or mobilisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.

MAIN RESULTS

We included 27 trials (1522 participants).Cervical Manipulation for subacute/chronic neck pain : Moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence showed manipulation alone compared to a control may provide short- term relief following one to four sessions (SMD pooled -0.90 (95%CI: -1.78 to -0.02)) and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache. Optimal technique and dose need to be determined.Thoracic Manipulation for acute/chronic neck pain : Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured a single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5, 29% treatment advantage).Mobilisation for subacute/chronic neck pain: In addition to the evidence noted above, low quality evidence for subacute and chronic neck pain indicated that 1) a combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) there was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; and 3) neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisation techniques were superior.

AUTHORS' CONCLUSIONS

Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.