TREATMENT OF NECK PAIN: NONINVASIVE INTERVENTIONS: RESULTS OF THE BONE AND JOINT DECADE 2000–2010 TASK FORCE ON NECK PAIN AND ITS ASSOCIATED DISORDERS
 
   

Treatment of Neck Pain: Noninvasive Interventions:

Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther 2009 (Feb);   32 (2):   S141–S175 ~ FULL TEXT
Republished from:   Spine (Phila Pa 1976). 2008 (Feb 15);   33 (4 Suppl):   S123–152


Eric L. Hurwitz, DC, PhD, Eugene J. Carragee, MD, FACS, Gabrielle van der Velde, DC,
Linda J. Carroll, PhD, Margareta Nordin, PT, DrMedSci, Jaime Guzman, MD,
Paul M. Peloso, MD, MSc, FRCP(C), Lena W. Holm, DrMedSc, Pierre Côté, DC, PhD,
Sheilah Hogg-Johnson, PhD, J. David Cassidy, DC, PhD, DrMedSc, Scott Haldeman, DC, MD, PhD

Department of Public Health Sciences,
John A. Burns School of Medicine,
University of Hawaii at Manoa,
Honolulu, HI, USA.
ehurwitz@aii.edu


Researchers reviewed literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders. The researchers found that for whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. Researchers also found that therapies involving manual therapy and exercise were effective for patients with neck pain.

THE OBJECTIVE of this best-evidence synthesis was to perform a critical appraisal and synthesize literature on non-invasive therapies for neck pain and associated disorders.

THIS STUDY conducted a Medline search of literature published between 1980 and 2006 on the use, effectiveness and safety of non-invasive neck pain interventions. The results were screened and rated for relevance, yielding 139 papers that were analyzed in detail.

RESULTS

  • For “non-specific” neck pain, the evidence shows that manual therapy, supervised exercise and low-level laser therapy provide a therapeutic benefit and are more effective than alternative treatments. Acupuncture may also be helpful.

  • For whiplash-associated disorders, there is evidence that mobilization, exercise and educational videos that include exercises and focus on restoring patients’ ability to work and perform activities of daily life are more beneficial than conventional medical care or care involving passive modalities (TENS, ultrasound, diathermy), collars or general advice.

  • For neck pain without radicular symptoms, therapies that aim at restoring function as soon as possible are more effective than types of therapy that do not have that focus.


STUDY DESIGN:   Best evidence synthesis.

OBJECTIVE:   To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders.

SUMMARY OF BACKGROUND DATA:   No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade.

METHODS:   We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis.

RESULTS:   Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.

CONCLUSION:   Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.



From the FULL TEXT Article:

Introduction

Since publication of the Québec Task Force on whiplash-associated disorders (WAD) best evidence synthesis in 1995, [1] several additional systematic reviews of interventions for whiplash and other types of neck pain have been published. However, no comprehensive reviews have been published on the utilization, safety, effectiveness, and cost effectiveness of noninvasive interventions, for both WAD and for nonspecific neck pain and associated disorders. Instead, the reviews typically focus on a specific type of treatment (e.g., manual therapy) or a specific patient population (e.g., those with WAD). Given the recent explosive growth of the neck pain literature and a lack of synthesis, this is an appropriate time to critically examine the evidence and to offer informed judgment about the current state of knowledge regarding noninvasive interventions for neck pain.

The primary objective of this study was to identify, critically appraise, and synthesize the literature published between 1980 and 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and its associated disorders. The review of invasive interventions, including injection therapies and surgery, is described in a separate article. [2] The secondary objectives of this review were

(1) to identify gaps in and problems with the literature, and

(2) to suggest areas where resources should be expended in an effort to reduce the individual and societal burden of neck pain and its associated disorders.

We begin with a brief discussion about how and where noninvasive interventions fit into our conceptual model of the course and care of neck pain. We then describe our methods and the results of the literature search and screening. Finally, we discuss the accepted studies according to their type: health-care utilization, effectiveness of interventions, safety of interventions, systematic reviews, cost and cost-benefit, and workplace interventions. The chapter ends with our thoughts on the study's limitations, our recommendations for future research, and evidence statements drawn from the best evidence synthesis.

      Noninvasive Intervention and the Conceptual Model
      of the Course and Care of Neck Pain


Although much of the literature focuses on what “we” (health-care practitioners and scientists) do in the area of neck pain treatment, we have tried to keep our primary perspective focused on the person who is experiencing neck pain or who may be at risk for neck pain.

With the person with neck pain firmly in mind, one always seeks the most effective interventions. Such interventions, whether therapeutic, diagnostic, or preventive, favorably influence the natural history of illness. Because most of the interventions described in the literature are treatments applied by health-care practitioners, the vast majority of those discussed in this chapter are by definition health-care interventions.

However, effective interventions, such as health promotion programs and policies applied at the community or regional level, are not necessarily health-care interventions. Our conceptual model vividly illustrates that many other factors and systems (beyond the health care system) impact the person with or at risk of neck pain. This means there are many potential places and points in time for intervention to occur and for intervention effects to be realized (Fig 1, available online through doi:10.1016/j.jmpt.2008.11.017). Furthermore, intervention can be conceptualized as just one of many possible prognostic factors. Indeed, some interventions themselves may actually become risk factors for prolonging symptoms and/or side effects; thus, an intervention intended to solve a problem may actually create a need for further treatment.

The experience of being diagnosed—undergoing various examinations and tests and then receiving a “label”—may itself be therapeutic (or harmful), and thus “prognostic.” In other words, the place where diagnosis ends and intervention begins is not clear-cut. Diagnosis and intervention need not take place within a health-care environment: self-diagnosis and self-care have their own therapeutic potential, and it is likely that people with neck pain understand this fact.

The line between diagnosis and intervention becomes even more blurred if we consider a prognostic criterion as a reference standard for diagnosis. Given the lack of a “gold standard” assessment for neck pain, a prognostic criterion seems reasonable and most relevant to the person with neck pain. In this case, the outcome measures used in so-called “outcomes” studies would also be used in diagnostic studies with prognostic criteria. The patient may not care what his or her diagnosis is; what's important is the outcome. For example, regardless of diagnosis, patients want answers to questions like: “Am I going to get better? How long will it take to get better? Will I be able to return to work and my usual activities?”

Interventions may have different effects in different populations (e.g., workers vs. nonworkers, claimants vs. nonclaimants, litigants vs. nonlitigants). Intervention effects may also vary by type of outcome measure (e.g., pain, disability, global improvement, return to work) and by follow-up time (e.g., days, weeks, months, years). In addition, access to and preferences for certain types of care and treatment expectations may also influence outcomes. For example, patients who have had favorable results with manual therapy may prefer manual therapy for subsequent episodes of neck pain. Not receiving a favored therapy may adversely affect outcomes, and conversely, it is possible that receiving a preferred therapy may enhance patients' response to therapies. Although this could have important clinical and policy implications, it is an understudied topic.



Discussion

We identified 156 articles reporting on 80 primary studies and 30 systematic reviews that were deemed scientifically admissible and accepted in our best evidence synthesis of interventions for neck pain and associated disorders. Our synthesis shows that neck pain is one of the most commonly reported symptoms in primary medical care and among chiropractic patients. Complementary therapies are frequently used, either alone or in conjunction with conventional treatments, although many persons with neck pain do not seek care. Of those who do seek care, many have non-neck musculoskeletal pain and episodes of care for pain in other sites.

Persons with neck pain or one of its associated disorders have the option of dealing with it on their own (self-care) or seeking treatment. Our literature screening did not identify and our synthesis did not include any studies designed to evaluate the efficacy or relative effectiveness of self-care approaches (e.g., over-the-counter medications) used by persons who do not seek care. Similarly, we did not identify or accept any studies of community-based interventions for the prevention or amelioration of neck pain or associated disorders. We accepted only 1 prevention study and only a handful of studies designed to estimate the costs, cost effectiveness, and frequencies of complications associated with noninvasive interventions.

The vast majority of scientifically admissible studies included persons with “nonspecific” or “mechanical” neck pain (Grades I or II) who sought care or were recruited via advertisements for participation. Thirteen studies comprised workers, although only 2 studies evaluated workplace interventions per se. Persons with possible neurologic signs (Grade III neck pain) or headache were included in only 5 and 3 studies, respectively, and only 1 study had patients with definite Grade III neck pain. [52] Cervicogenic headache and radiculopathy are vastly underrepresented in the accepted noninvasive intervention literature.

Table 5 shows the noninvasive interventions for whiplash and other neck-associated disorders, by type of population and, based on our synthesis of the literature, the likelihood of each intervention being helpful in the short-term. For all interventions, treatment courses were generally short (12 weeks or less), effects (if any) were small, and clear evidence of effectiveness in the long-term (6 months or longer) is lacking for all noninvasive interventions. There is no evidence of “dose-response” (i.e., the greater the frequency of care, the greater the effect) or “duration-response” (i.e., the longer the duration of care, the better the effect) with any noninvasive treatment. In fact, there is some evidence that excessive treatment may be counter-productive for those with a recent whiplash injury, although it is unclear exactly what amount of treatment is optimal. This evidence suggests that the best course for patients seeking treatment for a recent WAD may be to start with minimal treatment. This treatment could consist of a brief course of mobilization and/or the other treatments for which there is evidence of effectiveness (see summary below). Since both the risks and the benefits among these treatment options are very similar, it seems reasonable that patient preference should be an important guide in choice of treatment.



Summary of Results

      Whiplash-Associated Disorders

  • Pulsed Electromagnetic Therapy (PEMT) was found in a single study to be of short-term benefit compared with placebo for patients with WAD.

  • Corticosteroids were largely ineffective in 2 placebo-controlled studies.

  • Combined interventions involving mobilization and exercises or supervised training and rehabilitation demonstrated short-term effectiveness when compared with conventional medical care or care involving physical modalities, collars, or simple advice or referral to exercise.

  • Educational videos that included exercises and aimed at getting patients back to work and other daily activities as soon as possible after acute whiplash injury also proved effective.

  • High health-care utilization within a month of whiplash injury may result in slower recovery. There is no evidence that a longer course of care or care initiated earlier versus later improves prognosis.

  • Lack of scientifically acceptable evidence precludes summary statements on cervical and thoracic manipulation, traction, and NSAIDS and other medications in the treatment of WAD.


      “Nonspecific” Neck Pain and Associated Disorders

  • Medications (orphenadrine/paracetamol, piroxicam, indomethicin, benorylate/chlormezanone), per-cutaneous neuromuscular therapy, mobilization, and LLLT were found efficacious in the short-term when compared with placebo or sham interventions.

  • Evidence from placebo-controlled trials for acupuncture in treating “nonspecific” neck pain was inconsistent; botulinum toxin A was found ineffective and harmful in 1 placebo-controlled trial. Strength or endurance training with dynamic exercises, mobilization, and acupuncture appeared to be beneficial in the short-term, compared with primary medical care or care involving unspecified interventions.

  • Physical modalities, ergonomic interventions, and physical and stress management programs have not been proven effective for “nonspecific” neck pain.

  • Active exercise, combined with education emphasizing self management and return to normal function, was more beneficial than manual therapy, TENS, neck collar, or simple advice (singly or as part of a multimodal intervention) for patients with “nonspecific” neck pain. There were few if any differences between the effectiveness of endurance versus strength training, manipulation versus mobilization, manual therapies versus acupuncture, and various passive multimodal approaches without active exercise components.

  • There is no information to suggest that one medication is superior to any other medication or to other nonmedication interventions for “nonspecific” neck pain.

  • Finally, there is no evidence that a longer versus shorter duration of care or particular course of care with any intervention improves prognosis for neck disorders.

  • Limited or no acceptable evidence precludes summary statements on magnetic stimulation, massage, and traction in the treatment of “nonspecific” neck pain or cervicogenic headache. Acceptable evidence regarding the effectiveness of any noninvasive interventions for persons with radicular symptoms or neurologic signs (Grade III neck pain) is entirely lacking.



Limitations of the Literature

      Methodologic Considerations

Most of the intervention studies identified but not included in our best evidence synthesis were case series or small clinical cohorts, which cannot be used to estimate effectiveness or relative effectiveness. Other studies were not accepted because of likely bias due to selection, information, or confounding. Possibly because of introduction of the CONSORT guidelines for clinical trials in 2001, [152] the proportion of intervention studies rated as scientifically admissible has increased dramatically in the past 10 years, from 25% in 1995 to 66% for studies published in 2005. [153] Because confounding is less likely to occur in large randomized clinical trials (vs. small randomized or nonrandomized intervention studies, cohort studies, and case-control studies), large RCTs are the most appropriate design for testing the safety and effectiveness of interventions in primary study populations. Therefore, the RCT is the most prevalent study design in our best evidence synthesis.
But even among the accepted randomized studies, there are several problems that limit their usefulness. For example:

  • unclear source, target, and study populations

  • heterogeneity of interventions (e.g., different modes, durations, and intensities of care)

  • failure to account for baseline differences in prognosis

  • no apparent distinction between primary versus other outcomes (pain, functional status, overall health, global improvement, participation, range of motion, resource use)

  • cointerventions and compliance not monitored

  • proportions and differences in proportions of patients with clinically meaningful levels of improvement not considered or reported


      Clinical Considerations

In addition to the problems mentioned above, several issues affecting the clinical interpretation of findings deserve greater attention. For example:

  • Various packages of interventions preclude estimation of effects of each package component.

  • There is heterogeneity of outcome measures.

  • Diagnostic criteria are unclear.

  • Side effects are not monitored.

  • There is a lack of clarity on the clinical relevance of effect estimates.

  • There is heterogeneity of follow-up times (immediate to 3+ years).


      Reporting Considerations

The way studies were reported and outcomes described precluded pooling of data. Even though many of the most recently published trials followed CONSORT guidelines when reporting results, [152] there remains much room for improvement. For example, the following reporting flaws were frequent in the literature we appraised:

  • diagnostic criteria not reported

  • description, frequency and duration of interventions, and length of episodes of care not reported

  • raw data with estimates of variability not reported

  • use of histograms and other figures instead of tables for reporting outcome data (which often don't include specific estimates with measures of variability)

  • data on side effects and adverse events not consistently reported154

  • external validity not discussed


      Gaps in the Literature

Although many noninvasive interventions for neck pain and its associated disorders are well studied, there is a dearth of literature on many others. Gaps are most apparent in the following areas:

  • self-diagnosis and self-care of neck pain

  • preventive interventions

  • the effects of societal and environmental factors on access to interventions and on care-seeking decisions among people with neck pain

  • patient preferences for neck pain treatment

  • cultural factors influencing perceptions of pain and perceived effectiveness of interventions

  • safety and risk-benefit of neck pain interventions

  • cost benefit and cost effectiveness of neck pain interventions

  • interventions for neck pain with radiation into upper extremities and neurologic signs (Grade III neck pain)

  • interventions for cervicogenic headache

  • clinical prediction rules for risks and benefits of neck pain interventions



Research Recommendations

Given the gaps in—and problems with—the current nonsurgical neck-pain intervention literature, we suggest more high-quality experimental and observational research be done in the following areas: the use and effectiveness of self-care approaches in the treatment of neck disorders; the effectiveness of strategies designed to prevent incident and recurrent neck pain and associated disorders; treatment for neck pain with radicular signs or symptoms (Grade III neck pain); interventions for cervicogenic headache; and research involving clinically homogenous subgroups.

Considering the mostly small differences between interventions in terms of efficacy, effectiveness and relative effectiveness, especially in the long-term, future work should focus on patients' preferences, cost and cost-benefit, risk and risk-benefit, and on developing and evaluating novel preventive and therapeutic interventions appropriate to the community and workplace. Because influential societal and environmental factors vary across communities, interventions successfully applied in 1 locale may not be effective in others. For example, as the conceptual model illustrates, workers' compensation and litigation issues play roles in care-seeking decisions and may influence outcomes. However, these issues are relevant mainly in certain industrialized countries and much less relevant in other nations and in less developed parts of the world. In all parts of the world, the relative roles of health-care interventions applied to individuals versus interventions and policies applied at the population level need much greater elucidation.

To date, clinical interventions have received the lion's share of attention and resources. Perhaps, it is now appropriate to devote more time and energy to strategies that can be applied at the population level and that may have a larger impact on the community vis-à-vis reducing risk and improving prognosis (i.e., decreasing incidence and prevalence, and thus the burden of neck pain and its associated disorders on society).

For example, the current neck-pain literature provides little evidence for or against potential primary preventive approaches. Yet evidence in the literature on back pain suggests that a population-based intervention can favorably influence beliefs, both among the general population and among clinicians, and that such an intervention may have a sustained impact on related disability. [155–157]

Similarly, we know the provision of health services is affected by local health policies, but we know little about how these policies influence utilization, costs, and outcomes at the population level. We do know, however, that certain health-care strategies may prolong recovery. Uncharted territory includes the roles of preferences, expectations, and diagnostic labels, and the provision of care consistent with patients' health goals and values.



Conclusion

For WAD,

(a) mobilization and exercises appear more beneficial than usual care or physical modalities,

(b) collars and high health-care utilization may delay recovery, and

(c) an educational video focusing on self efficacy in addition to usual medical care appears promising.

For other neck disorders without radicular signs or symptoms (Grades I and II), the evidence suggests that manual (manipulation or mobilization) and exercise interventions, LLLT, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of these treatments is clearly superior to any other in either the short- or long-term.

For both WAD and neck disorders without trauma, the evidence favors supervised exercise sessions with or without manual therapy over usual or no care. Of the manual therapies, manipulation and mobilization yield comparable clinical outcomes. The risk of minor transient adverse effects appears higher with cervical manipulation than with mobilization. Of more concern, however, are major adverse events. Of specific concern are VBA strokes, which are extremely rare, but have been reported to be associated with chiropractic visits. [20, 54] However, the association between chiropractic visits (which frequently include cervical manipulation) and VBA stroke is similar to the association between physician visits and VBA stroke. This suggests that, on average, patients who seek chiropractic care for neck pain or headaches, and who then developed a VBA stroke may have actually been in the prodromal phase of a stroke when consulting the chiropractor; that is, the neck pain or headaches, which lead them to seek care were early symptoms of a VBA stroke. [54] This, in turn, suggests that the choice between mobilization or manipulation should depend on patient preference. It should be noted that the safety and efficacy of thoracic manipulation as a promising alternative to cervical manipulation has recently been investigated and deserves further examination. [35]

The risk for serious side effects from NSAIDs is negligible; however, minor side effects may be much more frequent. There is no evidence that a particular course of care (longer vs. shorter, early vs. late) with any intervention improves prognosis or appreciably affects the natural history of neck disorders, and some evidence that “less is more” when it comes to WAD care. The evidence does not support episodes of care longer than 6 to 8 weeks with any 1 or combination of noninvasive interventions.

Because of the lack of scientifically acceptable studies on acute nontraumatic neck disorders and disorders with radiation and neurologic signs (Grade III neck pain), we cannot make any conclusions regarding the risks and benefits of noninvasive interventions for these conditions. Evidence for the effectiveness of neck-pain prevention strategies in the workplace and elsewhere is lacking. Future efforts should focus on the design and evaluation of neck-pain prevention strategies, and on intervention strategies for persons with acute nontraumatic neck disorders, disorders with radicular symptoms, and cervicogenic headache.



Evidence Statements

Whiplash-Associated Disorders

      Education or Advice

1.   There is evidence from one RCT that an educational pamphlet was not associated with recovery in persons with acute WAD when compared with usual care alone. [90]

2.   There is consistent evidence from one RCT89 and one nonrandomized study [12] that an educational video in combination with usual emergency or urgent care was positively associated with lower pain ratings at 24 to 26 weeks in persons with acute WAD when compared with usual care alone.


      Exercise Interventions

3.   There is inconsistent evidence from 5 RCTs and a cohort study that interventions including an exercise component were positively associated with more favorable prognoses in the short- or long-term in persons with acute or subacute WAD when compared with passive interventions including education, or to primary care. [8, 92–97]

4.   There is evidence from one RCT that supervised and home exercise plus advice was marginally more effective than advice alone in the short-term (6 weeks) but not in the long-term (12 months) in persons with WAD-related neck pain and disability of between 3 and 12 months. [98]


      Medications

5.   There is evidence from one placebo-controlled RCT that cervical zygapophysial joint corticosteroid injections were not associated with greater pain reduction in the short-term (20 weeks) in persons with post-WAD of more than 3 months. [99]

6.   There is evidence from one placebo-controlled RCT that infusion of methylprednisolone was not associated with greater pain reduction or recovery in the short-term (2–26 weeks) in persons with acute WAD. [100]


      Manual Therapies

7.   There is consistent evidence from 4 RCTs that active therapies involving mobilization were associated with greater pain reduction in the short-term among persons with acute WAD when compared with usual care, soft collars, passive modalities, or general advice. [93–96, 101]

8.   There is evidence from one RCT that immobilization in a rigid collar for 2 weeks followed by active mobilization or active mobilization within 72 hours of injury was as effective as usual care (focused on reducing fear and staying active) for persons with acute WAD after 12 months of follow up. [91]


      Physical Modalities

9.   There is evidence from 2 RCTs that passive modalities (TENS, ultrasound, diathermy) alone or in combination with mobilization were not associated with better pain outcomes in the short-term (4–26 weeks) when compared with care involving exercises and manual therapies for persons with acute or subacute WAD. [94, 101]


      Collars

10.   There is consistent evidence from 2 RCTs and one nonrandomized study [9] that soft or rigid collars alone or in combination with other treatments were not associated with greater pain or disability reduction in the short- or long-term (up to 1 year) in persons with acute WAD when compared with advice to rest, exercises, and mobilization, and usual or no care. [9, 91, 103]


      Combined Approaches

11.   There is evidence from one nonrandomized intervention study that a coordinated multidisciplinary management approach was positively associated with quicker claim closure in persons with WAD when compared with usual care. [13]

12.   There is evidence from one nonrandomized intervention study that referrals to fitness training or in- or out-patient rehabilitation plus usual care was not associated with quicker self-reported recovery rates in persons with acute WAD when compared with usual care alone. [8]

      Patterns/Course of Care

13.   There is consistent evidence from 2 population-based cohort studies that high health-care utilization in the 30 days after a traffic collision was associated with slower times to claim closure in persons with WAD. [32, 33]

14.   There is no evidence from any studies that a particular course of care (e.g., longer vs. shorter, early vs. late) with any one or combinations of noninvasive interventions for WAD is associated with a better short- or long-term prognosis.


      Safety of Interventions

15.   There is no evidence from any studies that any one or combinations of noninvasive interventions for WAD are positively or negatively associated with clinically important adverse outcomes in the short- or long-term when compared with other noninvasive interventions for neck pain.


      Cost and Cost-Benefit

16.   There is evidence from one nonrandomized intervention study that a coordinated multidisciplinary management approach with active interventions were less costly than “usual care” for patients with acute WAD. [13]


      Prevention

17.   There is no evidence from any studies that any one or combinations of noninvasive interventions were associated with the prevention of incident or recurrent WAD.



“Nonspecific” Neck Pain


      Education or Advice

1.   There is no evidence from any studies that any one type of advice or educational intervention is better than any other advice or educational intervention or other noninvasive intervention in the short- or long-term for persons with “nonspecific” neck pain.


      Exercise Interventions

2.   There is consistent evidence from 3 RCTs that a neck exercise program alone or in combination with spinal manipulation was positively associated with reduced pain and disability in the short- term (6 to 13 weeks) in persons with subacute or chronic or recurrent neck pain when compared to spinal manipulation alone, TENS, or usual GP care. [36, 78, 106, 108, 109, 115, 116]

3.   There is evidence from one RCT that manual therapy or pulsed shortwave diathermy in addition to neck exercises and advice about coping with neck pain and staying active was not associated with reduced pain-related disability or greater global improvement in the short-term (6–26 weeks) in patients with subacute or chronic “nonspecific” neck pain when compared to exercise and advice alone. [105]

4.   There is consistent evidence from 2 RCTs that, compared with endurance exercises, strengthening exercises were not associated with better clinical outcomes in the short- or long-term in female workers with subacute, chronic, or recurrent neck pain. [43, 117]


      Medications

5.   There is evidence from one placebo-controlled RCT that orphenadrine and paracetamol were associated with greater pain reduction in the short-term (8 days) in patients with subacute or chronic neck pain. [121]

6.   There is evidence from one RCT that piroxicam did not reduce pain more than indomethicin in the short-term (1–2 weeks) in patients with cervicobrachial syndrome pain. [123]

7.   There is evidence from one RCT that advice and mobilization, in addition to salicylates, was associated with greater pain reduction in the short-term (3–4 weeks) in patients with cervical pain when compared to salicylates alone or to salicylates with advice, massage, electrical stimulation, and traction. [120]

8.   There is evidence from one placebo-controlled RCT that botulinum toxin A was not associated with better short-term (16 weeks) pain and disability outcomes in people with subacute or chronic neck pain. [150]

9.   There is evidence from one RCT that intramuscular ketorolac tromethamine (30 mg) was not associated with greater pain reduction or patient perception of pain relief 1 hour post-treatment for neck pain of less than 3 weeks' duration. [122]

10.   There is no evidence from any studies that other medications including NSAIDs (other than salicylates, indomethicin, and ketorolac), narcotics, or antidepressant medications are positively or negatively associated with clinically important outcomes in the short- or long-term when compared with other medications, to other noninvasive interventions, or to no treatment or sham interventions.


      Manual Therapies

11.   There is consistent evidence from 4 RCTs that cervical spine manipulation alone or with advice and home exercises was not associated with greater pain or disability reduction in the short- or long-term in persons with subacute or chronic neck pain when compared with mobilization with or without traction, to strengthening exercises, or to instrumental manipulation. [77, 106, 110, 126, 137]

12.   There is consistent evidence from 4 RCTs that mobilization or exercise sessions alone or in combination with medication was positively associated with better pain and functional outcomes in the short-term (4–13 weeks) in people with subacute or chronic neck pain when compared to usual GP care, pain medications, or advice to stay active. [36, 48, 108, 109, 112, 120]

13.   There is evidence from 2 RCTs that manipulation or mobilization was not associated with better pain or disability outcomes (3–12 months) in people with subacute or chronic neck pain when compared with exercises alone or to exercise combined with massage or passive modalities. [36, 79, 108, 109, 130–134]


      Physical Modalities

14.   There is consistent evidence from 6 RCTs that passive modalities alone or in combination with other passive treatments or medication were not associated with clinically better pain and functional outcomes in the short- or long-term in people with subacute or chronic neck pain when compared with mobilization, to other modalities, to GP care, or to sham interventions. [79, 107, 115, 116, 120, 126, 130–134, 138]

15.   There is evidence from one randomized, placebo-controlled crossover study that percutaneous neuromodulation therapy was associated with greater immediate post-treatment decreases in pain and improved sleep and with more physical activity after 3 weeks in cervical disc disease patients experiencing chronic pain. [139]


      Acupuncture

16.   There is inconsistent evidence from 3 RCTs and a double-blind crossover trial that acupuncture was associated with better short- and long-term clinical outcomes in people with subacute or chronic neck pain when compared with sham acupuncture. [44, 45, 129, 141, 142]

17.   There is evidence from one RCT that acupuncture was associated with better short-term (4–16 weeks) pain outcomes in patients with subacute or chronic neck pain when compared with massage. [129]

18.   There is evidence from one RCT that acupuncture was not associated with better short-term (6–26 weeks) pain and disability outcomes in patients with subacute or chronic neck pain when compared with mobilization and traction. [125]


      Laser Therapy and Magnetic Therapy

19.   There is consistent evidence from 4 double-blind placebo-controlled RCTs that LLLT was associated with improvements in pain and function in the short-term (10 days to 12 weeks) in persons with subacute or chronic neck or shoulder pain. [145–148]

20.   There is evidence from one RCT that magnetic stimulation was associated with better pain and disability outcomes in the short-term (4–13 weeks) in patients with myofascial pain syndrome when compared with placebo or TENS. [138]


      Combined Approaches

21.   There is inconsistent evidence from 5 RCTs and a cohort study that multimodal interventions (including combinations of exercises, manual therapies, and education) were positively associated with reduced sick leave or better pain and disability outcomes in the short- or long-term in people with subacute or chronic neck or cervicobrachial pain when compared to usual or GP care, surgery, cervical collar, or advice to stay active. [37, 42, 49, 52, 79, 104, 107, 130–134]


      Workplace or Employee Interventions

22.   There is evidence from one cohort study that multiple ergonomic interventions were not associated with reduced neck pain intensity or frequency over a 2 to 6-year period in video display unit users. [6, 7]

23.   There is evidence from one RCT that computer software-stimulated work breaks, which included rest or exercises, was associated with perceived recovery and productivity, but not associated with pain reduction or sick leave over an 8-week period in computer users with neck, shoulder or upper extremity symptoms. [15]

24.   There is consistent evidence from 2 RCTs and a cohort study42 that active neck exercise programs alone or in combination with education, relaxation, and behavioral support were not associated with better 1-year pain and disability outcomes or reduced sick leave in employees with subacute, chronic, or recurrent neck pain when compared with advice and information, ordinary activity, relaxation training, or to physiotherapy and medications. [42, 49, 51]

25.   There is evidence from one RCT that endurance or strength training in combination with dynamic exercises involving upper and lower extremities was associated with better 1-year pain and disability outcomes in female office workers with chronic or recurrent neck pain when compared with advice to perform exercises. [117]

26.   There is evidence from one RCT that physical training and stress management programs were not associated with prevention of neck or shoulder pain in the short- or long-term (12–18 months) in female home-care nursing aides and assistants when compared with a nonintervention control. [46]


      Patterns/Course of Care

27.   There is no evidence from any studies that a particular course of care (e.g., longer vs. shorter, early vs. late) with any one or combinations of noninvasive interventions for “nonspecific” neck pain was associated with a better short- or long-term prognosis.


      Safety of Interventions

28.   There is evidence from 2 population-based case-control studies and a case-crossover study that chiropractic care was associated with a very small increased risk of posterior circulation stroke in people under age 45; however, because this increased risk is also seen in those seeking health care from their primary care physician, this association is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. [8, 20]

29.   There is evidence from one RCT that manipulation (vs. mobilization) was associated with an increased risk of minor adverse reactions in patients with mostly subacute or chronic neck pain. [126–128]

30.   There is evidence from one RCT that intramuscular ketorolac tromethamine (30 mg) was associated with a greater frequency of reported minor adverse reactions than osteopathic manipulative treatment 1 hour post-treatment in patients with neck pain of less than 3 weeks' duration. [122]

31.   There is evidence from one placebo-controlled RCT that botulinum toxin A was associated with an increased risk of adverse reactions in people with subacute or chronic neck pain. [150]

33.   There is no evidence from any studies that any one or combinations of noninvasive interventions for neck pain are positively or negatively associated with clinically important adverse outcomes in the short- or long-term when compared with other noninvasive interventions for “nonspecific” neck pain.


      Cost and Cost-Benefit

34.   There is evidence from one RCT that manual therapy (mobilization) was more cost effective in patients with subacute or chronic neck pain when compared with physical therapy (sessions of active exercises) and usual care by a general practitioner. [36]

35.   There is evidence from one RCT that the addition of acupuncture to routine medical care for patients with chronic neck pain was cost effective. [38]

36.   There is evidence from one RCT that, compared to a brief physiotherapy intervention focusing on self efficacy, several sessions of usual physiotherapy (advice, mobilization, modalities, exercises) for subacute or chronic neck pain was not cost effective. [37]


      Prevention

37.   There is evidence from one RCT that physical training and stress management programs were not associated with prevention of neck or shoulder pain in the short- or long-term (12–18 months) in female home-care nursing aides and assistants when compared with a nonintervention control. [46]

38.   There is no evidence from any studies that any one or combinations of noninvasive interventions are associated with the prevention of incident or recurrent “nonspecific” neck pain or associated disorders.



Other Neck Pain Associated Disorders:

      Cervicogenic Headache

39.   There is evidence from one RCT that therapeutic exercise with or without manipulation or mobilization was associated with fewer headaches and a better global outcome after 1 year in patients with cervicogenic headache when compared with no treatment. [111, 113]

40.   There is evidence from one crossover trial that using a water pillow was associated with increased pain relief and improved sleep quality in patients with neck pain (with or without cervicogenic headache) when compared with using a usual or roll pillow. [149]


      Neck Pain With Radicular Symptoms or Cervical Radiculopathy

41.   There is no evidence from any studies that any one or combinations of noninvasive interventions for neck pain with radicular symptoms or cervical radiculopathy are positively or negatively associated with clinically important outcomes in the short- or long-term when compared with other noninvasive interventions or to no treatment or sham interventions.



Key Points

  • We conducted a best evidence synthesis of the literature (1980–2006) on noninvasive interventions for neck pain and associated disorders. Of the 359 intervention articles, 170 (47%) articles were deemed scientifically admissible. Of these, 139 related to noninvasive interventions and were included in the best evidence synthesis.

  • For WAD, educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities; for other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions. However, none of the active treatments is clearly superior to any other in the short- or long-term.

  • There is:

    (1)   no evidence that a particular course of care with any intervention improves the prognosis for whiplash or other neck disorders;

    (2)   some evidence that high rates of health-care use may slow recovery from whiplash; and

    (3)   little data on cost effectiveness.

  • Future research efforts should focus on neck-pain prevention strategies in the community and workplace, and on noninvasive interventions for persons with radicular symptoms



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