Anita Gross

Exercises for mechanical neck disorders.

BACKGROUNDnNeck pain is common, disabling and costly. Exercise is one treatment approach.nnnOBJECTIVESnTo assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.nnnSEARCH METHODSnWe 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).nnnSELECTION CRITERIAnWe 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.nnnDATA COLLECTION AND ANALYSISnTwo 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.nnnMAIN RESULTSnTwenty-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.nnnAUTHORS CONCLUSIONSnNo 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.

Conservative management of mechanical neck pain: systematic overview and meta-analysis

Abstract Objective: To review the efficacy of conservative management of mechanical neck disorders. Methods: Published and unpublished reports were identified through computerised and manual searches of bibliographical databases, reference lists from primary articles, and letters to authors, agencies, foundations, and content experts. Selection criteria were applied to blinded articles, and selected articles were scored for methodological quality. Effect sizes were calculated from raw pain scores and combined by using meta-analytic techniques when appropriate. Results: Twenty four randomised clinical trials met the selection criteria and were categorised by type of intervention: nine used manual treatments; 12 physical medicine methods; four drug treatment; and three education of patients (four trials investigated more than one form of intervention). The intervention strategies were summarised separately. Pooling of studies was considered only within each category. Five of the nine trials that used manual treatment in combination with other treatments were combined. One to four weeks after treatment the pooled effect size was −0.6 (95% confidence interval −0.9 to −0.4), equivalent to an improvement of 16 (6.9 to 23.1) points on a 100 point scale. Sensitivity analyses on study quality, chronicity, and data imputation did not alter this estimate. For other interventions, studies could not be combined to arrive at pooled estimates of effect. Conclusions: There is little information available from clinical trials to support many of the treatments for mechanical neck pain. In general, conservative interventions have not been studied in enough detail to assess efficacy or effectiveness adequately. Key messages Many treatments are available and accepted as standard forms of practice Systematic literature searching finds a limited number of clinical trials There is early evidence to support the use of manual treatments in combination with other treatments for short term pain relief, but in general, conservative interventions have not been studied in enough detail to assess efficacy or effec- tiveness adequately Further clinical trials are needed to determine optimal treatment approaches

A cochrane review of manipulation and mobilization for mechanical neck disorders

Study Design and Objectives. Our systematic review of randomized trials assessed whether manipulation and mobilization relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders. Summary of Background Data. Neck disorders are common, disabling, and costly. Methods. Computerized bibliographic databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled effect measures were calculated using a random effects model. Results. Of the 33 selected trials, 42% were high quality trials. Single or multiple (3–11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences −0.85 (95% CI: −1.20 to −0.50)], improvement in function [pooled SMD −0.57 (95% CI: −0.94 to −0.21)] and global perceived effect [standardized mean differences −2.73 (95% CI: −3.30 to −2.16)] for subacute/chronic mechanical neck disorders with or without headache. Conclusions. Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active agent(s) within a treatment mix.

A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain

Study Design. A criteria-based appraisal of review articles on neck pain. Objectives. To assess the methodologic quality, conclusions, and extent of concordance among reviews on the conservative treatment of neck disorders. Summary of Background Data. During the past decades there has been an increasing interest in summarizing and analyzing the available evidence on the effectiveness of conservative management of neck pain. Considering the growing number and quality of reviews, consumers may question which reviews to read and believe. Methods. Computerized bibliographic databases were searched without language restriction. The reviews assessed had been published before January 1998, included neck pain and evaluated conservative therapies, and reported at least one controlled clinical trial. Identification, selection, and quality assessment were performed independently by two investigators. Results. Of the 108 identified articles, 25 review articles were selected, of which 12 were systematic reviews. The reviews differed in their reporting of study population, interventions, and outcomes. Statistical pooling was performed in two high-quality systematic reviews, whereas in other reviews, the investigators explicitly decided not to pool data. The results of the current study show that the concordance among reviews varied. Regarding manipulation and traction, there is inconclusive evidence among reviews. Concordance regarding the effectiveness of other conservative interventions was absent. Many of the reviews displayed major methodologic flaws. Conclusions. Consumers should consider reports of reviews both carefully and critically, given the wide variety of review methodology, descriptive information, and final conclusions. There is a paucity of evidence from primary studies on neck pain. Therefore, more research is needed to allow systematic reviews to formulate stronger conclusions.

Manipulation or mobilisation for neck pain: A Cochrane Review

Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain. This review assesses if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults experiencing neck pain with or without cervicogenic headache or radicular findings. A computerised search was performed in July 2009. Randomised trials investigating manipulation or mobilisation for neck pain were included. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardised mean differences (pSMD) were calculated. 33% of 27 trials had a low risk of bias. Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control (pSMD -0.90 (95%CI: -1.78 to -0.02)). Low quality evidence also supported thoracic manipulation for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and immediate pain reduction in chronic neck pain (NNT 5; 29% treatment advantage). Optimal technique and dose need to be determined.

Massage for mechanical neck disorders

BACKGROUNDnThe prevalence of mechanical neck disorders (MND) is known to be both a hindrance to individuals and costly to society. As such, massage is widely used as a form of treatment for MND.nnnOBJECTIVESnTo assess the effects of massage on pain, function, patient satisfaction, global perceived effect, adverse effects and cost of care in adults with neck pain versus any comparison at immediate post-treatment to long-term follow-up.nnnSEARCH METHODSnWe searched The Cochrane Library (CENTRAL), MEDLINE, EMBASE, MANTIS, CINAHL, and ICL databases from date of inception to 4 Feburary 2012.nnnSELECTION CRITERIAnStudies using random assignment were included.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently conducted citation identification, study selection, data abstraction and methodological quality assessment. Using a random-effects model, we calculated the risk ratio and standardised mean difference.nnnMAIN RESULTSnFifteen trials met the inclusion criteria. The overall methodology of all the trials assessed was either low or very low GRADE level. None of the trials were of strong to moderate GRADE level. The results showed very low level evidence that certain massage techniques (traditional Chinese massage, classical and modified strain/counter strain technique) may have been more effective than control or placebo treatment in improving function and tenderness. There was very low level evidence that massage may have been more beneficial than education in the short term for pain bothersomeness. Along with that, there was low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction. The clinical applicability assessment showed that only 4/15 trials adequately described the massage technique. The majority of the trials assessed outcomes at immediate post-treatment, which is not an adequate time to assess clinical change. Due to the limitations in the quality of existing studies, we were unable to make any firm statement to guide clinical practice. We noted that only four of the 15 studies reported side effects. All four studies reported post-treatment pain as a side effect and one study (Irnich 2001) showed that 22% of the participants experienced low blood pressure following treatment.nnnAUTHORS CONCLUSIONSnNo recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.As a stand-alone treatment, massage for MND was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.

Acupuncture for neck disorders

Study Design. Systematic review. Objective. To determine the effects of acupuncture for individuals with neck pain. Summary of Background Data. Neck pain is one of the 3 most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are the perceptions of benefits. Methods. We searched CENTRAL (2006, issue 1) and MEDLINE, EMBASE, MANTIS, Cumulative Index to Nursing and Allied Health Literature from their beginning to February 2006. We searched reference lists and the acupuncture database TCMLARS in China. Any published trials using randomized (RCT) or quasi-randomized (quasi-RCT) assignment to the intervention groups, either in full text or abstract form, were included. Results. We found 10 trials that examined acupuncture treatments for chronic neck pain. Overall, methodologic quality had a mean of 2.3 of 5 on the Jadad scale. For chronic mechanical neck disorders, there was moderate evidence that acupuncture was more effective for pain relief than some types of sham controls, measured immediately posttreatment. There was moderate evidence that acupuncture was more effective than inactive, sham treatments measured immediately posttreatment, and at short-term follow-up (pooled standardized mean difference, −0.37; 95% confidence interval, −0.61 to −0.12). There was limited evidence that acupuncture was more effective than massage at short-term follow-up. For chronic neck disorders with radicular symptoms, there was moderate evidence that acupuncture was more effective than a wait-list control at short-term follow-up. Conclusions. There is moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the treatment. There is moderate evidence that those who received acupuncture reported less pain at short-term follow-up than those on a waiting list. There is also moderate evidence that acupuncture is more effective than inactive treatments for relieving pain posttreatment, and this is maintained at short-term follow-up.

Electrotherapy for neck pain

BACKGROUNDnNeck pain is common, disabling and costly. The effectiveness of electrotherapyxa0as a physiotherapeutic option remains unclear. This is an update of a Cochrane review first published in 2005 and previously updated in 2009.nnnOBJECTIVESnThis systematic review assessed the short, intermediate and long-term effects of electrotherapy on pain, function, disability, patient satisfaction, global perceived effect, and quality of life in adults with neck pain with and without radiculopathy or cervicogenic headache.nnnSEARCH METHODSnWe searched CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, without language restrictions, from their beginning to August 2012; handsearched relevant conference proceedings; and consulted content experts.nnnSELECTION CRITERIAnRandomized controlled trials (RCTs), in any language, investigating the effects of electrotherapy used primarily as unimodal treatment for neck pain. Quasi-RCTs and controlled clinical trials were excluded.nnnDATA COLLECTION AND ANALYSISnWe used standard methodological procedures expected by The Cochrane Collaboration. We were unable to statistically pool any of the results, but we assessed the quality of the evidence using an adapted GRADE approach.nnnMAIN RESULTSnTwenty small trials (1239 people with neck pain) containing 38 comparisons were included. Analysis was limited by trials of varied quality, heterogeneous treatment subtypes and conflicting results. The main findings for reduction of neck pain by treatment with electrotherapeutic modalities were as follows.Very low quality evidence determined that pulsed electromagnetic field therapy (PEMF) and repetitive magnetic stimulation (rMS) were more effective than placebo, while transcutaneous electrical nerve stimulation (TENS) showed inconsistent results.Very low quality evidence determined that PEMF, rMS and TENS were more effective than placebo.Low quality evidence (1 trial, 52 participants) determined that permanent magnets (necklace) were no more effective than placebo (standardized mean difference (SMD) 0.27, 95% CI -0.27 to 0.82, random-effects model).Very low quality evidence showed that modulated galvanic current, iontophoresis and electric muscle stimulation (EMS) were not more effective than placebo.There were four trials that reported on other outcomes such as function and global perceived effects, but none of the effects were of clinical importance. When TENS, iontophoresis and PEMF were compared to another treatment, very low quality evidence prevented us from suggesting any recommendations. No adverse side effects were reported in any of the included studies.nnnAUTHORS CONCLUSIONSnWe cannot make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain. Since the evidence is of low or very low quality, we are uncertain about the estimate of the effect. Further research is very likely to change both the estimate of effect and our confidence in the results. Current evidence for PEMF, rMS, and TENS shows that these modalities might be more effective than placebo. When compared to other interventions the quality of evidence was very low thus preventing further recommendations.Funding bias should be considered, especially in PEMF studies.xa0Galvanic current, iontophoresis, EMS, and a static magnetic field did not reduce pain or disability. Future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics.

Physical medicine modalities for mechanical neck disorders

OBJECTIVESnMultiple physical medicine modalities are commonly included as part of therapeutic interventions for mechanical neck disorders (neck pain). The objective of this review was to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders.nnnSEARCH STRATEGYnWe searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services and reference lists of the retrieved articles from 1985 to December 1993 and we contacted content experts.nnnSELECTION CRITERIAnRandomised trials and controlled trials of physical medicine modalities in adults with mechanical neck disorder.nnnDATA COLLECTION AND ANALYSISnThree reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain information or data that could not be found in the published reports.nnnMAIN RESULTSnThirteen trials were included. The overall quality of the included trials was generally good. Two trials using electromagnetic therapy produced a significant reduction in pain (p <0.01) with three to four weeks of daily (eight hours per day) therapy sessions; and three using laser therapy did not differ significantly from a placebo (p=0.20) for six to 10 sessions of treatment. Not enough scientific testing exists to clearly determine the effectiveness of other therapies. This includes treatments such as exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic pain / cognitive behavioural rehabilitation strategies.nnnREVIEWERS CONCLUSIONSnThere is little information available from trials to support the use of physical medicine modalities for mechanical neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy with respect to pain reduction.

Massage for mechanical neck disorders: A systematic review

Study Design. Systematic review. Objective. To assess the effects of massage on pain, function, patient satisfaction, cost of care, and adverse events in adults with neck pain. Summary of Background Data. Neck pain is common, disabling, and costly. Massage is a commonly used modality for the treatment of neck pain. Methods. We searched several databases without language restriction from their inception to September 2004. We included randomized and quasirandomized trials. Two reviewers independently identified studies, abstracted data, and assessed quality. We calculated the relative risks and standardized mean differences on primary outcomes. Trials could not be statistically pooled because of heterogeneity in treatment and control groups. Therefore, a levels-of-evidence approach was used to synthesize results. Results. Overall, 19 trials were included, with 12/19 receiving low-quality scores. Descriptions of the massage intervention, massage professional’s credentials, or experience were frequently missing. Six trials examined massage as a stand-alone treatment. The results were inconclusive. Results were also inconclusive in 14 trials that used massage as part of a multimodal intervention because none were designed such that the relative contribution of massage could be ascertained. Conclusions. No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain. Pilot studies are needed to characterize massage treatment (frequency, duration, number of sessions, and massage technique) and establish the optimal treatment to be used in subsequent larger trials that examine the effect of massage as either a stand-alone treatment or part of a multimodal intervention. For multimodal interventions, factorial designs are needed to determine the relative contribution of massage. Future reports of trials should improve reporting of the concealment of allocation, blinding of outcome assessor, adverse events, and massage characteristics. Standards of reporting for massage interventions, similar to Consolidated Standards of Reporting Trials, are needed. Both short and long-term follow-up are needed.