review article evidence of physiotherapy interventions for patients with...
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Hindawi Publishing CorporationISRN PainVolume 2013, Article ID 567175, 23 pageshttp://dx.doi.org/10.1155/2013/567175
Review ArticleEvidence of Physiotherapy Interventions forPatients with Chronic Neck Pain: A Systematic Review ofRandomised Controlled Trials
Pia Damgaard,1,2 Else Marie Bartels,3 Inge Ris,1
Robin Christensen,1,3 and Birgit Juul-Kristensen1,4
1 Research Unit of Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics,University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
2Department of Rehabilitation, Aeroe Municipality, 5970 Aeroeskoebing, Denmark3The Parker Institute, Department of Rheumatology, Copenhagen University Hospital, 2000 Frederiksberg, Copenhagen, Denmark4 Bergen University College, Institute of Occupational Therapy, Physiotherapy and Radiography, Department of Health Sciences,5020 Bergen, Norway
Correspondence should be addressed to Birgit Juul-Kristensen; [email protected]
Received 12 February 2013; Accepted 13 March 2013
Academic Editors: A. Blumenfeld and A. Nackley
Copyright © 2013 Pia Damgaard et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Chronic neck pain (CNP) is common and costly, and the effect of physiotherapeutic interventions on the condition is unclear. Wereviewed the literature for evidence of effect of physiotherapy interventions on patients with CNP. Five bibliographic databases(MEDLINE, EMBASE, CINAHL, Cochrane Library, and PEDro) were systematically searched. Randomised, placebo and active-treatment-controlled trials including physiotherapy interventions for adults with CNP were selected. Data were extracted primaryoutcome was pain. Risk of bias was appraised. Effect of an intervention was assessed, weighted to risk of bias. 42 trials reportingon randomised comparisons of various physiotherapy interventions and control conditions were eligible for inclusion involving3919 patients with CNP. Out of these, 23 were unclear or at high risk of bias, and their results were considered moderate- or low-quality evidence. Nineteen were at low risk of bias, and here eight trials found effect on pain of a physiotherapy intervention. Onlyexercise therapy, focusing on strength and endurance training, andmultimodal physiotherapy, cognitive-behavioural interventions,massage, manipulations, laser therapy, and to some extent also TNS appear to have an effect on CNP. However, sufficient evidencefor application of a specific physiotherapy modality or aiming at a specific patient subgroup is not available.
1. Introduction
Musculoskeletal disorders are threatening quality of life byhaving the potential to restrict daily activities, cause absencefrom work, and result in a change or discontinuation inemployment. These disorders are expensive for society andfor patients and are responsible for the highest number ofhealthy years lost [1–4]. The prevalence of chronic neck painvaries. The 12-month prevalence of pain typically rangesbetween 30% and 50%; the 12-month prevalence of activity-limiting pain is 1.7% to 11.5% [5].The annual incidence of neckpain associated with whiplash varies greatly. Although 50%of whiplash victims recover in three to six months, 30% to40% have persisting mild to moderate pain and 10% to 20%
retain more severe pain [6]. It is a multifaceted phenomenonwith physical impairment, psychological distress, and socialdysfunction, which calls for an evidence-based, cost-effectiverehabilitation treatment [7–11].
According to a Dutch study, 44% of patients with chronicneck pain visited their general practitioner (GP) with thecondition during a twelve-month period; 51% of these werereferred to physiotherapy treatment [12]. Knowledge of theactual effect of physiotherapy is therefore important and isanticipated to be reflected in the awareness of evidence-basedpractice among physiotherapists.
The Cochrane Collaboration has provided systematicreviews on the effect of massage for mechanical neck disor-ders [13], patient education for neck pain [14], electrotherapy
2 ISRN Pain
for neck pain [15], mechanical traction for neck pain withor without radiculopathy [16], and conservative treatmentfor whiplash [17]. The overall conclusion has been that theevidence for these treatments is low and that no definitestatements on the efficacy and clinical usefulness of thesetreatments can be made. A further Cochrane Review on theeffect of manipulation and mobilisation of neck pain foundlow quality evidence that cervical and thoracicmanipulationsmay provide pain reduction [18]. An additional CochraneReview on the effect of exercises for mechanical neck dis-orders concluded that the summarised evidence indicatesthat there is a role for exercises in the treatment of acuteand chronic mechanical neck pain plus headache but thatthe relative benefit of each type of exercise needs extensiveresearch [19].
However, none of these reviews have covered themajorityof commonly used physiotherapy modalities in one in orderto get an overview of the subject. Besides, the effect ofspecific physiotherapy treatments in specific subgroups ofchronic pain patients is an important topic which has not yetbeen examined. Clinicians and policy makers need evidencefrom research to inform and guide clinical practice andpolicy. Patients and researchers also need such informationto support shared decisions and to set priorities for futureresearch.
The aim of this study was to review the literature sys-tematically and discuss the quality of evidence of commonlyused physiotherapy interventions (exercise, manual therapy,and electrotherapy) aimed at improving outcomes (on pain,function, and quality of life) important for patients withchronic neck pain [20]. Neck pain was defined as pain locatedin the anatomical region of the neck [21]. Pain was consideredchronic if it had persisted for more than three months, asdefined by the International Association of the Study of Pain.
2. Methods
Weperformed a systematic review of all available randomisedcontrolled trials on the subject of physiotherapy for neckpain to determine the effects of physiotherapy interventionson pain, function, and quality of life in neck-pain patientsand to explore whether beneficial effects could be explainedby biases affecting individual trials [22]. Study selection,assessment of eligibility criteria, and data extraction werecarried out based on a predefined, peer-reviewed protocolaccording to the Cochrane Collaboration’s guidelines [23].This paper was prepared in accordance with the PRISMAstatement [24].
2.1. Literature Search. We searched five bibliographic data-bases (MEDLINE, EMBASE, CINAHL, Cochrane Library,and PEDro) from January 1990 to January 2012 with astructured, pre-defined, search strategy [25]. The searchstrategy was “Neck Pain AND Physiotherapy Intervention.”For neck pain, the following terms were combined with OR:“whiplash/WAD,” “neck injury,” “neck sprain/strain,” “neckache,” “cervical sprain/strain,” “cervical disorder/syndrome,”
“cervical spondylosis/itis,” “cervical osteoarthritis”, “cervico-dynia”, “cervicobrachial pain/disorder/syndrome”, “myofas-cial pain/disorder/syndrome,” “trapezius myalgia,” “postu-ral syndrome,” and “nonspecific neck pain.” For physio-therapy interventions, the following terms were combinedwith OR: “physiotherapy,” “physical therapy,” “rehabilitation,”“intervention studies,” “exercise,” “exercise therapy,” “exer-cise movement techniques,” “manual therapy,” “manipula-tive medicine,” “mobilisation/mobilization,” “musculoskele-tal techniques,” and “electric/electro stimulation therapy.” Allterms were searched as free text as well as keywords, wherethis was applicable. Limitations were human studies in theEnglish, German, Dutch, Danish, Norwegian, and Swedishlanguages, in the time span of January 1990 to January 2012.To assure that the included studies followed scientificallysoundmethods and the data thereforewerewell documented,we set a limit for inclusion to publications from 1990 andonwards.
Reference lists of review articles and included studieswere searched to identify other potentially eligible studies.An additional search was conducted via the scientificsearch machine http://www.scirus.com/, using the followingsearch terms combined with AND: “chronic neck pain,”“physiotherapy.”
2.2. Selection Criteria. Studies were included if participantswere older than 18 years of age and had chronic neck painfor more than three months (therefore considered chronic).Chronic neck pain was defined as (i) chronic whiplash-associated disorders (WAD); (ii) chronic non-specific neckpain, includingwork-related neck pain,myofascial neck pain,upper trapezius myalgia, chronic neck pain associated withdegenerative findings with or without radicular findings, orother surrogate terms.
Eligible interventions were physiotherapy interventionscommonly used in the treatment of musculoskeletal pain:(i) exercise therapy, including specific types of exercises,for example, neuromuscular training, strength training, andendurance training; (ii) manual therapy, for example, mas-sage, manipulations, and mobilisations; (iii) electrotherapy,for example, TENS, low-level laser, or other surrogate terms.Acupuncture was not considered a physiotherapy techniquesince this technique is not part of physiotherapy in allcountries. Comparison of the therapy had to be made withno treatment (e.g., waiting list controls), or other conservativeactive therapies called “care as usual,” or sham therapy.Anticipating that only a limited number of trials availableused placebo/sham control, we decided also to include trialsin which an active control was used as a cointervention.
To be eligible for inclusion, a studymust apply at least onepain measurement prior to and following the intervention,which was an outcome considered to be of major importanceto the patients. Self-reported function and disability [26],self-reported quality of life [27], objective physical function,and clinical tests were considered minor outcomes andtherefore not considered necessary inclusion criteria [28–30].Only randomised controlled trials were accepted. Exclusioncriteria were studies with participants with acute or subacute
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Records identified by searchstrategy
(𝑛 = 1236)
Records for further assessment(𝑛 = 760)
Full-text articles assessed foreligibility(𝑛 = 151)
Studies included in qualitativesynthesis(𝑛 = 42)
Full-text articles not fulfilling inclusion criteria
pain that could not be separated from data on otherpatient groups + 10 not commonly usedphysiotherapy interventions + 2 intervention notreported + 2 primary outcome not available + 4 pilotstudies + 2 conference papers + 2 dissertations + 1
Records excluded(𝑛 = 476; 303 not fulfilling inclusion criteria + 173
reviews or guidelines)
Records excluded(𝑛 = 609; 593 not fulfilling inclusion criteria + 16
parallel publications)
(𝑛 = 109; 11 not randomised/groups notcomparative + 41 no chronic condition + 16 neck
test sensitivity study + 18 parallel publications)
Figure 1: Flow diagram of the selection process of included studies.
neck pain, neck pain with definite or possible long tractsigns, neck pain due to specific pathological conditions (e.g.,fractures, tumours, infections, inflammatory processes, anky-losing spondylitis, and rheumatoid arthritis), and headache.
We created a reliable process through consequently tworeviewers who independently conducted the study selectionand assessment of eligibility criteria. Similarly, two reviewersindependently conducted data abstraction and assessed therisk of bias. Disagreements were resolved through consensuswith a third reviewer being consulted if there was disagree-ment.
2.3. Data Extraction and Evidence Synthesis. Data regard-ing publication status, trial design, patient characteristics,treatment regimens, outcome methods, results, and fundingwere extracted on a standardised form using a custom-madeMicrosoft Excel spreadsheet.
We assessed the risk of bias by using the CochraneCollaboration’s tool for assessing risk of bias as presentedin [23]. Each of the following domains would be consideredadequate—that is, presumably with a low risk of bias (i) “ade-quate sequence generation”; (ii) “allocation concealment”;(iii) “blinding”; (iv) “incomplete outcome data addressed”;(v) “free of selective outcome reporting”; (vi) “free of otherbias (i.e., whether a study sponsor would benefit eco-nomically from a positive outcome). Each of these keycomponents of methodological quality was assessed on anAdequate/Unclear/Inadequate basis. We used The CochraneCollaboration’s approach for summary assessments of the riskof bias for each important outcome across domains within atrial [23].
Due to the limited number of studies investigating eachof the specific interventions, it was decided that both meta-analytical and level of evidence approaches would be inap-propriate.Therefore, a narrative approachwherewe evaluatedthe study and results between groups within a trial was usedto summarise the findings. To formulate conclusions, onlyresults from trials at low risk were considered as evidence foran intervention.
3. Results
The literature search identified 4921 relevant studies (1110from EMBASE, 1568 from MEDLINE, 1239 from CINAHL,and 491 from PEDro), of which 3685 were duplicates, leaving1236 potentially eligible studies to be screened (see Figure 1).Following screening of titles and abstracts, 151 potentially rel-evant studies were identified and retrieved in full text. Finally,42 randomised controlled trials, involving 3919 patients,fulfilled the selection criteria andwere considered suitable forinclusion.The selection process and reasons for exclusions arepresented in Figure 1.
3.1. Study Characteristics. Study characteristics and studyresults are presented under the categories exercise therapy (25trials, 18 regarding chronic non-specific neck pain, and sevenregarding chronic neck pain related to whiplash); manualtherapy (six trials, all related to chronic non-specific neckpain); and electrotherapy (11 trials, all related to chronic non-specific neck pain) in Appendix A, Tables 1–4.
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The trials covered the following intervention topics: (i)exercise therapy: various types of dynamic and isomet-ric exercises, general aerobic exercises, exercises with afocus on strength, endurance, proprioception and coordina-tion, specific neck stabilising exercises, craniocervical-flexionexercises, posture, behavioural graded activity, relaxation,body awareness, myo-feedback training, and multimodalphysiotherapy; (ii) manual therapy: massage, manipulation,and traction; (iii) electrotherapy: laser, transcutaneous nervestimulation (TENS), ultrasound, and repetitive magneticstimulation (rMS).
Sham therapy or waiting list controls were used ascontrol groups in 12 trials; 10 trials used a control groupconsisting of a self-management book, health-counselling,or other interventions, clearly distinguished from the activeintervention group; six trials used active-treatment controlreported as “treatment as usual”; active-treatment control wasused in 14 trials.
Primary outcome measures were self-reported painand/or self-reported pain and disability in 41 trials; whenprimary outcome measures were not reported, all outcomemeasures were considered. One trial had an objective test asprimary outcome, yet pain was included in the secondaryoutcome measures.
3.2. Risk of Bias. Risk of bias is presented in Appendix B,Table 5.
Overall, the quality of reporting onmethodological issuesvaried. Table 5 shows the judgements (“Adequate,” “Unclear,”and “Inadequate”) for each of the domains. As can beseen, 28 of 42 trials succeeded in reporting on adequatesequence generation; 18 trials described adequate allocationconcealment; four trials adequately reported on attemptsto blind participants, personnel, and outcome assessors; 22trials adequately reported on missing outcome data, usingintention-to-treat analysis; three trials adequately reportedon selective outcome reporting by referring to a publishedand available protocol for comparisons; and 25 trials ade-quately reported on funding and the role of funding.
The summary assessment of risk of bias revealed 19 trialsat low risk of bias [34–39, 45, 47–49, 51, 55–60, 63, 64] and 23trials as unclear or at high risk of bias [31–33, 40–44, 46, 50,52–54, 61, 62, 65–72], and for this reason their results were notconsidered as evidence. Of these 19 trials at low risk of bias,11 trials found no difference between intervention groups [34,36–39, 45, 48, 49, 56, 58, 60], and eight trials found an effecton pain of the intervention [35, 47, 51, 55, 57, 59, 63, 64].
All studies are described in detail in Appendix A, Tables1–4. All trials at low risk of bias, showing an effect on pain, are,furthermore, presented in the following section. According tothe described criteria, the evidence for each intervention willfollowing be summarised at the end of each section.
3.3. Effect of Physiotherapy Interventions
3.3.1. Exercise
Effect of Exercise on Pain in Patients with Chronic Nonspe-cific Neck Pain. As shown in Appendix A, Table 1, 18 trials
examined the effect of various types of exercise in patientswith chronic neck pain; nine of these were at unclear orhigh risk of bias [31–33, 40–44, 46], and nine were atlow risk of bias [34–39, 45, 47, 48]. Seven of the trials atlow risk examined the effect of different types of exercise,including proprioception exercises (eye-head coordination),craniocervical flexion exercises (C-CF), neck stabilisationexercises, stretching, strengthening, and behavioural gradedactivity programme, but did not find statistically significantdifference on pain between groups following intervention[34, 36–39, 45, 48]. Two of the trials at low risk of biassucceeded in finding an effect on pain from the intervention,and for this reason, their results were considered evidence ofuse of exercise.
(1) Gustavsson et al. [35] examined a multicomponentpain and stress self-management group intervention(PASS) versus a control group receiving individuallyadministered physiotherapy (IAPT). There was astatistically significant effect on ability to control pain(𝑃 < 0.001) and on neck-related disability (NDI) (𝑃 <0.001) in favour of PASS at the 20-week followup.
(2) Ylinen et al. [47] examined three interventions: int-ensive isometric strength training versus lighterendurance training versus a control group. The twotraining groups had an additional 12-day institutionalrehabilitation programme. At the 12-month followup,both neck pain and disability had decreased in bothtraining groups compared with the control group(𝑃 < 0.01).
No trials with low risk of bias supported single use ofproprioception exercises (eye-head co-ordination), cranio-cervical flexion exercises (C-CF), or neck stabilisation exer-cises for pain. No trials with low risk of bias support the useof stretching.
Effect of Exercise on Pain in Patients with Chronic Whiplash-Associated Disorder. As shown in Appendix A, Table 2, seventrials examined the effect of various types of exercise inpatients with chronic WAD; three of these were at low riskof bias [49, 51, 55], and four were at unclear or high risk ofbias [50, 52–54]. One of the trials at low risk of bias examinedthe effect of adding biofeedback training to a rehabilitationprogramme, but found no difference in effect between groups[49]. Two trials at low risk of bias succeeded in finding aneffect on pain from the intervention, and for this reason, theirresults were considered evidence of use of exercise.
(1) Jull et al. [51] examined a multimodal physiother-apy programme (including exercises, education, andergonomics) versus a self-management programme.The multimodal physiotherapy programme groupattained a statistically significant greater reduction inreported neck pain and disability (NDI) posttreat-ment (𝑃 = 0.04).
(2) Stewart et al. [55] examined exercise (e.g., endurance,strength, aerobic, coordination, and cognitivebehavioural therapy) versus advice alone. Exerciseand advice were more effective than advice alone at
ISRN Pain 5
Table1:Ex
ercise
therapy—
patie
ntsw
ithchronicn
onspecificn
eckpain.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Cunh
aetal.[31]
Wom
en,aged35–6
0,with
diagno
sedprim
arymechanical
myogeno
usor
arthrogeno
us,n
eck
pain
lasting>12wks
(𝑁=33)
(1)G
PRgrou
p(𝑛=15),manualtherapy
for
stretching
fasciaefor
30min,m
uscle
stretching
intheform
ofglob
alpo
sture
reeducation(G
PR)
for3
0min
(2)C
onventionalstre
tching
grou
p(𝑛=16),
manualtherapy
forstre
tching
fasciaefor
30min,
muscle
stretching
throug
hconventio
nal
stretching
exercisesfor
30min
All:twoweeklyph
ysiotherapysessions
durin
ga
6wkperio
d
VAS,RO
M,SF-36
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psaft
ertre
atmentand
at6w
kfollo
wup
Dellvee
tal.[32]
Wom
en,aged35–6
0,with
work
disability(atleast50%)a
ndpain
inthen
eck(diagn
osed
cervicob
rachial
pain
synd
rome)fora
tleast1y
ear
(𝑁=60)
(1)M
yofeedback
training
(𝑛=20),min
8ho
urs/wk,registe
redthem
uscle
activ
ity(EMG)
ofup
pertrapezius
muscle
sand
gave
alarm
ifthe
presetlevelofm
uscularrestw
asno
treached.
Person
alvisit
once/w
kfro
map
hysio
therapist
brow
singEM
Gprofi
lesw
ithreferencetodiary
entries
(2)Intensiv
emuscularstre
ngth
training
(𝑛=20),as
tructured5–10min
program
tobe
perfo
rmed
twicea
dayfor6
days/w
k.A
physiotherapist
coachedby
twoperson
alvisits
andadditio
nalpho
necalls
twice/wk
(3)C
ontro
lgroup
(𝑛=20)
All:kept
adiary
6days/w
krecordingactiv
ities,
discom
fort,pain,
andsle
epingdistu
rbances.All
interventio
nslaste
d1m
th
Workabilityindex(W
AI)
Sing
leitem
onwo
rkability,w
orking
degree,changed
workability
Pain,N
RSCop
enhagenPsycho
social
Questionn
aire
Cutlery
wipingperfo
rmance
test,
dexterity,m
ax.grip
streng
th
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psaft
er1m
thandatfollo
wup
after
3mths
Falla
etal.[33]
Patie
ntsw
ithchronicn
onsevere
neck
pain
(>3m
ths),score<16
(out
ofpo
ssible50)inNDI(𝑁=58)
(1)E
ndurance-stre
ngth
training
ofthec
ervical
spinefl
exor
muscle
s(𝑛=29)
(2)R
eferentexercise
interventio
n,low-lo
adcraniocervicalexercise
(𝑛=29)
All:instructionandsupervision
once
awkfor
6wk,supp
liedwith
anexercise
diary
EMGmeasureso
fmaxim
umvoluntarycontractionforceo
fste
rnocleido
mastoid
andanterio
rscalenem
uscle
,NRS∗∗
,NDI∗∗
Therew
eren
ostatisticallysig
nificant
differences
betweengrou
psforc
hange
inpain
(NRS
)ord
isability(N
DI)
measuredin
thew
eekim
mediately
after
interventio
n(w
eek7)
Griffi
thse
tal.[34]
Chronicn
eckpain
(diagn
osed
spon
dylosis,w
hiplash,no
nspecific
neck
pain,and
discogenicpain),age
18andover
(𝑁=74)
(1)S
pecific
neck
stabilisatio
nexercises(𝑛=37)
inadditio
nto
thes
amep
rogram
mea
sgroup
2(2)G
eneralneck
exercise
programme(𝑛=37),
postu
recorrectio
ntechniqu
e,andactiv
erange
ofmovem
entexercise
All:max.fou
r30m
intre
atmentsessio
nswith
inthefi
rst6
wks,advicetoperfo
rmexercises5
–10
times
daily,w
rittensheets,
after
6wks
the
therapist
coulddischargethe
patie
ntor
continue
NPD
S,NPQ
,VAS∗∗
Therew
eren
osig
nificant
between-grou
pdifferences
inthe
NPD
Sateither
6wks
or6m
ths
6 ISRN Pain
Table1:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Gustavssonetal.
[35]
Patie
ntsw
ithmusculoskele
tal
tension-type
neck
pain
ofpersistent
duratio
n(>3m
ths),age
18–6
5(𝑁=156)
(1)M
ultic
ompo
nent
pain
andstr
ess
self-managem
entg
roup
interventio
n(PASS)
(𝑛=77),relaxatio
ntraining
,bod
yaw
areness
exercises,lectures
andgrou
pdiscussio
ns,seven
1.5hsessions
over
a7wkperio
d,andab
ooste
rsessionaft
er20
wks
(2)C
ontro
lgroup
receivingindividu
ally
administered
physiotherapy(IA
PT)(𝑛=79)
Question
naire
comprising
the
self-effi
cacy
scale,NDI,coping
strategies
questio
nnaire,hospital
anddepressio
nscale,fear-avoidance
beliefsqu
estio
nnaire,and
questio
nsregardingneck
pain,analgesics,and
utilisatio
nof
health
care
Therew
asas
tatistic
allysig
nificant
effecto
nabilityto
controlp
ain
(𝑃<0.001),andon
neck
related
disability(N
DI)(𝑃<0.001)infavour
ofPA
SSatthe2
0wks
follo
wup
Hakkinenetal.
[36]
Non
specificn
eckpain
ofmorethan
6mths,age2
5–53,pain>29
mm
onVA
S(𝑁=101)
(1)S
treng
thtraining
andstretching
(𝑛=49).
Sessions
once
awkfor6
wks
andthereafte
rone
sessioneverysecond
mth
for12m
ths
(2)S
tretching
grou
p(𝑛=52)inas
ingleg
roup
sessioninstr
uctio
nsAll:encouraged
toperfo
rmho
metraining
regimen
threetim
esaw
kandto
keep
weekly
exercise
diary
VAS,neck
andshou
lder
disability
index,NDI,RO
M,isometric
strength
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psaft
ertwoand12mon
thsm
easured
with
VASandNDI
Jordan
etal.[37]
Patie
ntsw
ithchronicn
eckpain
(>3m
ths),non
radiculare
xtremity
pain
was
perm
itted,age
20–6
0(𝑁=119)
(1)Intensiv
etrainingof
then
eckandshou
lder
musculature
(𝑛=40)
(2)Ind
ividualphysio
therapytre
atment(𝑛=39)
(3)H
igh-velocity,low
-amplitu
despinal
manipulationperfo
rmed
byac
hiropractor
(𝑛=40)
All:abovetraining/tre
atmentsessio
nstwicea
wk
for6
wks,besides
asinglen
eckscho
olgrou
psession
Self-repo
rted
disabilityandpain
on11-po
intb
oxscales,m
edicationuse,
patie
ntsp
erceived
effect,ph
ysicians
glob
alassessment
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psat
4and12mthsfollowup
Julletal.[38]
Females
with
chronicn
eckpain
ofidiopathicor
traumaticorigin
and
abno
rmalmeasureso
fjoint
position
sense(𝑁=64)
(1)P
roprioceptivee
xercise
interventio
n(𝑛=28)
(2)C
raniocervicalspine
flexion
exercise
interventio
n(𝑛=30)
All:person
alinstructionandsupervision
once
awkfor6
wks
Jointp
osition
error,NDI,NRS
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psmeasuredin
thew
eekim
mediately
after
interventio
n(w
eek7)
Julletal.[39]
Females
with
chronic,no
nsevere
neck
pain
(>3m
ths),score<15/50
onNDI(𝑁=46)
(1)C
raniocervicalspine
flexion
training
(𝑛=23),lowload
(2)S
treng
thtraining
(𝑛=23)
All:person
alinstructionandsupervision
once
awkfor6
wks
(NDI,NRS
)∗∗
,EM
Gam
plitu
deof
deep
cervical
spinefl
exor
muscle
s,ste
rnocleido
mastoid
andanterio
rscalenem
uscle
andRO
M
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psmeasuredin
thew
eekim
mediately
after
interventio
n(w
eek7)
ISRN Pain 7
Table1:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
O’Leary
etal.[40
]
Females
with
chronicn
eckpain
(>3m
ths),havingin
theh
ighere
ndof
mild
tomod
eratep
ainand
disability,score>
4/50
onNDI
(𝑁=48)
(1)C
ranio-cervicalspinefl
exioncoordinatio
nexercise
(CCF
)(𝑛=24)
(2)C
ervicalspine
flexion
endu
rancee
xercise
(CF)
(𝑛=24)
All:on
eexp
erim
entalsessio
n
VAS
Therew
eren
ostatisticallysig
nificant
differences
betweengrou
pson
VAS
Rand
løvetal.[41]
Females
with
chronicn
eck/shou
lder
pain
(>6m
ths),age
18–6
5(𝑁=77)
(1)L
ight
training
(𝑛=41)
(2)Intensiv
etraining(𝑛=36)
All:threetim
esperw
k,in
total36sessions
Pain
measuresw
ithtwo11-po
int
boxscales,activities
ofdaily
living,
strength,endu
rance
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psaft
ersix
andtwelv
emthsfollowup
Reveletal.[42]
Patie
ntsw
ithchronicn
eckpain
(>3m
ths),age>15
(𝑁=60)
(1)R
ehabilitatio
ngrou
p(𝑛=30),receiving
common
symptom
atictre
atment,besid
eseye-head
exercisesimprovingneck
prop
rioceptionin
individu
alexercise
sessions
twicea
wkfor8
wks
(2)C
ontro
lgroup
(𝑛=30),receivingon
lysymptom
atictre
atmentw
ithou
trehabilitatio
n
Headrepo
sitioning
accuracy,V
AS,
medicationintake,R
OM
Sign
ificant
differenceb
etweengrou
psforthe
rehabilitationgrou
pon
VAS
pain
(−21.8±25.2)(𝑃=0.04)at10w
kfollo
wup
Taim
elae
tal.[43]
Patie
ntsw
ithchronic,no
nspecific
neck
pain
(>3m
ths),halfh
adlocal
pain
andhalfreferred
pain
below
thee
lbow
,age
30–6
0(𝑁=76)
(1)A
ctivetreatment(𝑛=25),prop
rioceptive
exercises,relaxatio
nandbehaviou
ralsup
port,24
sessions
(2)H
omer
egim
en(𝑛=25),neck
lecturea
ndtwosessions
ofpractic
altraining
forh
ome
exercisesa
ndinstructions
form
aintaining
adiary
(3)C
ontro
lgroup
(𝑛=26),alecture
regarding
care
ofthen
eckwith
arecom
mendatio
nto
exercise
VAS,RO
M,P
PT
TheV
ASscores
after
theintervention
at3m
thsw
eres
ignificantly
lower
inthea
ctivetreatment(22
mm)a
ndho
mer
egim
en(23m
m)g
roup
sthanin
thec
ontro
lgroup
(39m
m)(𝑃=0.018)
after
3mths.Nostatisticallysig
nificant
differences
betweentheg
roup
swere
notedat12mths
Viljanenetal.[44
]Femaleo
ffice
workerswith
chronic
non-specificn
eckpain
(>12wks),
age3
0–60
(𝑁=393)
(1)D
ynam
icmuscle
training
(𝑛=135)
(2)R
elaxationtraining
(𝑛=128)
(3)C
ontro
lgroup
,ordinaryactiv
ity(𝑛=130)
Group
s1and2wereinstructedandtrained3
times
awkfor12w
ksfollo
wed
byon
ewkof
reinforcem
ent6
mthsa
fterrando
misa
tion
Pain
ratedon
ascale0(nopain)–10
(unb
earablep
ain),pain
questio
nnaire
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psat
3,6,and12mthsfollowup
Vonk
etal.[45]
Patie
ntsw
ithchronicn
on-specific
neck
pain
(>3m
ths),age
18–70
(𝑁=139)
(1)B
ehaviour
graded
activ
ityprogramme
(𝑛=68),biop
sychosocialm
odelguided
bythe
patie
nt’sfunctio
nalabilities
(2)C
onventionalexercise
(𝑛=71),reflected
usualcare,exercises,massage
andmob
ilisatio
nandtractio
nAll:tre
atmentp
eriod9w
ks
Globalp
erceived
effect,NDI,NRS
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psat
4,9,26,and
52wks
8 ISRN Pain
Table1:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Walingetal.[46
]
Wom
enwith
chronicw
ork-related
trapeziusm
yalgia(>1ye),not
onsic
kleavem
orethan1m
thdu
ring
lastyear,age<45
ye(𝑁=103)
(1)S
treng
thtraining
grou
p(𝑛=29),loaded
toallow12
rep.maxim
um(RM)
(2)E
ndurance
training
grou
p(𝑛=28),
arm-cyclin
gintensity
light
(11)—somew
hath
ard
(13)
onRP
Ealternatingwith
exercisesloadedto
30–35RM
(3)C
oordinationtraining
(𝑛=25).
Body-awarenesstherapy
andtraining
.(4)C
ontro
lgroup
:non
training
.Group
stress
andbo
dilyreactio
nsdu
etostr
essw
eres
tudied.
Two-ho
ursessions
once
awkfor10w
ksGroup
s1–3:one-hou
rsessio
ns,three
times
awk
for10w
ks
VAS,threes
cales:pain-in
-general,
pain-at-w
orst,
pain-at-p
resent.
Pain
threshold
Sign
ificant
effecto
fstre
ngth
training
andendu
rancetrainingVA
Spain-at-w
orstaft
er10wks
(𝑃<0.05).
Butn
odifferenceo
nVA
Spain-at-p
resent
oratVA
Spain-at-g
eneral
Ylinen
etal.[47]
Femaleo
ffice
worker,age2
5–53,
with
constant
orfre
quently
occurringneck
pain
ofmorethan
6mths.Motivated
tocontinue
working
andrehabilitation
(𝑁=180)
(1)E
ndurance
grou
p(𝑛=60),endu
rance
training
,dyn
amicneck
exercises
(2)S
treng
thgrou
p(𝑛=60),streng
thtraining
,high
-intensity
isometric
neck
streng
theningand
stabilisatio
nexercises
Group
s1and2:12-day
institu
tional
rehabilitationprogrammew
ithtraining
lesson
s,behaviou
ralsup
port,4
sessions
ofph
ysical
manualtherapy,advicetocontinue
exercise
3tim
esaw
katho
me
(3)C
ontro
lgroup
(𝑛=60):3-dayinstitutio
nal
rehabilitationprogrammew
ithrecreatio
nal
activ
ities
All:advice
toperfo
rmaerobice
xercise
3tim
esa
wkforh
alfanho
uratho
me.
VAS,neck
andshou
lder
pain
and
disabilityindex,vernon
neck
disabilityindex
Atthe12m
thfollo
wup
,bothneck
pain
anddisabilityhaddecreasedin
both
training
grou
pscomparedwith
the
controlgroup
(𝑃<0.01).Decrease
Pain
VASin
thee
ndurance
grou
p:−35
((−42)–(−28));inthes
treng
thgrou
p:−40
((−48)–(−32))
Ylinen
etal.[48]
Female,age2
5–53,w
ithconstant
orfre
quently
occurringneck
pain
ofmorethan6m
thsd
uration,
pain>
44mm
onVA
S(𝑁=125)
Crossovertria
l,aft
er4w
ks(1)M
anualtherapy
grou
p(𝑛=62),low-velo
city
osteop
athic-type
mob
ilisatio
nof
cervicaljoints,
tradition
almassage,passiv
estre
tching
,two
treatmentsaw
kfor4
wks
(2)S
tretching
exercisesg
roup
(𝑛=63)con
sisted
ofinstructionto
perfo
rmneck
stretching
exercisesa
thom
efor
4wks
VAS,neck
andshou
lder
pain
and
disabilityindex,NDI,
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psat
theo
ne-a
ndthree-year
follo
wup
∗
Inordertoshow
aneffecto
faninterventio
nandhereby
supp
ortthe
interventio
n,itrequ
iressho
wingsta
tisticalsig
nificantd
ifference
betweengrou
ps.
∗∗
Second
aryou
tcom
emeasure.
VAS:visualanalogue
scale;NRS
:num
ericalratin
gscale;VNPS
:verbaln
umericpain
scale;NPQ
:NorthwickPark
neck
pain
questio
nnaire;N
DI:neck
disabilityindex;NPD
I:neck
pain
anddisabilityindex;NPD
S:neck
pain
anddisabilityscale;NPD
VAS:neck
pain
anddisabilityvisualanalogue
scale;PS
FS:p
atient
specificfunctio
nalscale;N
PI:N
orthwickPark
neck
pain
index;SF-36:
short-form
36;P
PT:p
ressurepain
threshold;RO
M:range
ofmovem
ent;RP
E:ratin
gof
perceivedexertio
n;EM
G:electromyographic,HRQ
oL:health
-rela
tedqu
ality
oflife.
ISRN Pain 9
Table2:Ex
ercise
therapy—
patie
ntsw
ithchronicw
hiplash-associated
disorder.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Ehrenb
organd
Archenh
oltz
[49]
Patie
nts,aged
17–58,with
pain
after
whiplashinjury
(>3m
ths),and
referred
tothep
ainun
itfor
outpatient-based,interdisciplin
ary
rehabilitation(𝑁=65)
(1)B
iofeedback
training
(𝑛=36),eightsessio
ns(tw
ice/wk
forfou
rwk)
whilebeingactiv
einas
elf-c
hosenhand
icraft.
(2)B
eing
activ
einas
elf-c
hosenhand
icrafton
thes
ame
term
sasg
roup
1but
with
outb
iofeedback
(𝑛=29).
All:4–
6wkrehabilitationprogrammec
onsistin
gof
acombinatio
nof
education,
ergono
micinterventio
ns,
physicaltraining
,rela
xatio
ntechniqu
es,bod
yaw
areness
training
,and
interventio
nsby
psycho
logistand/or
social
workerifn
eeded
Canadian
occupatio
nal
perfo
rmance
measure,
Multid
imensio
nalP
ain
Inventory,Sw
edish
version
Therew
eren
ostatisticallysig
nificant
differences
ineffectb
etweengrou
psat
6mthsfollowup
Fitz-Ritson
[50]
Patie
ntsw
ithchronicp
ainin
cervicalspinem
usculature
follo
wingmotor
vehicle
accident
(WAD),age19–
57,stillh
aving
symptom
safte
rreceiving
chiro
practic
treatmentsand
rehabilitationexercisesfor>12mths
(𝑁=30)
(1)C
ontin
uedchiro
practic
treatmentsandsta
ndard
rehabilitationexercises(𝑛=15)
(2)C
ontin
uedchiro
practic
treatmentsandwerea
dvise
dto
do“phasic
neck
exercises”(eye-headco-ordination)
(𝑛=15)
All:exercises5
days
awkfor8
wks
NPD
ITh
eautho
rsdo
notreportany
dataon
statisticallysig
nificantd
ifferences
betweengrou
psaft
er8w
k
Julletal.[51]
Patie
ntsw
ithchronic
whiplash-associated
disorder
(>3m
ths,<2y
rs),cla
ssified
WADII,
age18–65
(𝑁=71)
(1)M
ultim
odalph
ysiotherapyprogramme(MPT
)(𝑛=36),low-lo
adexercise
forreedu
catin
gmuscle
control
ofthen
eckflexora
ndextensor
muscle
sand
scapular
muscle
s,po
sture
exercises,kinaestheticexercisesa
ndmob
ilisatio
ntechniqu
es,edu
catio
ninclu
ding
ergono
mics,
daily
livingadvice,hom
eexercise
(2)S
elf-m
anagem
entp
rogram
me,education,
advice
and
exercise
(SMP)
(𝑛=35)
All:interventio
nperio
d10wks
NPI,V
AS∗∗
TheM
PTgrou
pattained
astatistic
ally
significantg
reater
redu
ctionin
repo
rted
neck
pain
anddisability(N
PI)(𝑃=0.04),
effectsize0
.48,measuredim
mediately
follo
wingtre
atment
Pato
etal.[52]
Patie
ntsw
ithwhiplashinjury
grade
IorII(QuebecT
askFo
rce
Classifi
catio
n),w
ithpersistentn
eck
pain
orheadache
6–12mthsa
fter
thea
ccident(𝑁=91)
(1)L
ocalanestheticinfiltrationof
tend
erpo
intsin
the
neck
2×aw
k,in
8wks,(𝑛=30)
(2)P
hysio
therapy,2×aw
k,in
8wks:m
assage,relaxation
techniqu
esof
myogelotic
muscle
s,instr
uctedin
adetailed
homeprogram
ofiso
metric
andlow-in
tensity
activ
eiso
tonictrainingof
neck
muscle
s(𝑛=29)
(3)M
edication:
200m
gflu
rbiprofenin
itsslo
wrelease
preparationon
cead
ay.Patientsw
eres
eentwicea
wkby
thes
ames
tudy
physiciandu
ringthe8
wks
(𝑛=28)
All:furtherm
ore,in
each
treatmentg
roup
patie
ntsw
ere
rand
omlyallocatedto
additio
nalcognitiv
e-behavioral
therapy(C
BT)o
rnoCB
T.CB
Ttwicea
wkfor8
wks
Each
sessionlaste
d60
minutes
Subjectiv
eoutcomer
ating
(free
ofsymptom
s,im
proved,unchanged,
worse),McG
illpain
questio
nnaire,V
AS),
working
capacity
Therew
eren
ostatisticallysig
nificant
differences
betweenthe3
different
treatmentg
roup
smeasuredat8w
kandat
6mthsfollowup
.Therew
asas
tatistically
significanteffectin
thes
hortterm
infemalep
atientsintheg
roup
swith
additio
nalC
BT(𝑃=0.024)a
fter8
wks
oftre
atmentinthes
ubjectiveo
utcome,bu
tno
tat6
mthsfollowup
10 ISRN Pain
Table2:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Ryan
[53]
Patie
ntsw
ithchronicW
AD,
duratio
nof
pain
notreported
(𝑁=103)
(1)S
treng
thtraining
grou
p(𝑛
=no
treported)
(2)E
ndurance
training
grou
p(𝑛
=no
treported)
All:twicea
wkfor8
–12w
ksVA
S,SF-36,streng
thTh
erew
eren
ostatisticallysig
nificant
differences
betweengrou
pspo
sttreatment
Soderlu
ndand
Lind
berg
[54]
Patie
ntsw
ithchronicW
AD,
(>3m
thsa
fterinjury),age
18–6
0(𝑁=33)
(1)P
hysio
therapywith
cogn
itive
behaviou
ralcom
ponents,
learning
andapplicationof
basic
physicaland
psycho
logicalskills
ineveryday
activ
ities,besides
physiotherapyas
ingrou
p2(𝑛=16)
(2)P
hysio
therapy,individu
alise
dexercisesa
thom
eand
/or
indepartmentsgym,various
pain-relievingmetho
ds(i.e.,
TENS,heat)(𝑛=17)
All:max.12individu
alsessions
with
thep
hysio
therapist
PDI,NRS
,physic
almeasureso
fpain,
disability,coping
and
self-effi
cacy
Results
revealed
nosta
tistic
ally
significantd
ifferencesb
etweengrou
psin
self-ratin
gsof
disabilityor
pain
intensity
posttre
atmento
rat3
mthsfollowup
Stew
artetal.
[55]
Patie
ntsw
ithchronicW
AD
(>3m
ths,<12mths),classified
WAD
I–III,having
significantp
ainor
disability(𝑁=134)
(1)A
dvicea
lone
grou
p(𝑛=68),received
education,
reassurancea
ndencouragem
enttoparticipateinlight
activ
ityalon
e,advice
givenin
onec
onsultatio
nandtwo
follo
w-upph
onec
ontacts
(2)A
dvicea
ndexercise
grou
p(𝑛=66),individu
alise
d,progressive,subm
axim
alprogrammed
esignedto
improve
functio
nalactivities,end
urance,stre
ngth,aerob
ic,speed,
coordinatio
n,principles
ofcogn
itive
behavioraltherapy
(i.e.,
setting
goals),12sessions
durin
g6w
ks
Pain
intensity
andpain
bothersomenessrated
ona0
–10bo
xscale,PS
FC
Exercise
andadvice
werem
oree
ffective
than
advice
alon
eat6
wks
fora
llprim
ary
outcom
esbu
tnot
at12
mon
ths.Th
eeffect
ofexercise
onthe0
–10pain
intensity
scalew
as−1.1
(95%
CI−1.8
to−0.3,
𝑃=0.005)at6
wks
and−0.2(0.6to−1.0
,𝑃=0.59)at12m
ths;on
the
bothersomenessscalethee
ffectwas−1.0
(−1.9
to−0.2,𝑃=0.003)at6
wks
and0.3
(−0.6to
1.3,𝑃=0.48)at12m
ths
∗
Inordertoshow
aneffecto
faninterventio
nandhereby
supp
ortthe
interventio
n,itrequ
iressho
wingsta
tisticalsig
nificantd
ifference
betweengrou
ps.
∗∗
Second
aryou
tcom
emeasure.
VAS:visualanalogue
scale;NRS
:num
ericalratin
gscale;VNPS
:verbaln
umericpain
scale;NPQ
:NorthwickPark
neck
pain
questio
nnaire;N
DI:neck
disabilityindex;NPD
I:neck
pain
anddisabilityindex;NPD
S:neck
pain
anddisabilityscale;NPD
VAS:neck
pain
anddisabilityvisualanalogue
scale;PS
FS:p
atient-specific
functio
nalscale;N
PI:N
orthwickPark
neck
pain
index;SF-36:
short-form
36;P
PT:p
ressurepain
threshold;RO
M:range
ofmovem
ent;RP
E:ratin
gof
perceivedexertio
n;EM
G:electromyographic,HRQ
oL:health
-rela
tedqu
ality
oflife.
ISRN Pain 11
Table3:Manualtherapy—patie
ntsw
ithchronicn
onspecificn
eckpain.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
nbetweengrou
ps
Bron
fortetal.
[56]
Patie
ntsw
ithmechanicaln
eckpain
lasting>12wks,age
20–6
5(𝑁=191)
(1)S
pinalm
anipulationandlow-te
chno
logy
rehabilitative
neck
exercise
(𝑛=63)
(2)H
igh-techno
logy
MedXrehabilitativen
eckexercise
(𝑛=60)
(3)S
pinalm
anipulation(𝑛=64)
All:attend
ed20
one-ho
urvisitsd
uringthe11w
kstu
dy
Pain
ratin
gscale(0–
10),
NDI,SF-36,glob
alim
provem
ento
fsatisfactionwith
care,
medicationuse
Nostatisticallysig
nificant
differences
betweengrou
psin
patie
ntratedou
tcom
esat11wk
andat12mth
follo
wup
Lauetal.[57]
Patie
ntsw
ithad
iagn
osisof
chronic
mechanicaln
eckpain
(>3m
ths),age
18–55(𝑁=120)
(1)Th
oracicmanipulations
TM,anterior-po
sterio
rapp
roachin
supine
lying(𝑛=60)
(2)C
ontro
l(𝑛=60)
All:8sessions
infrared
radiation(2/w
k)for15m
inover
painful
site.Ed
ucationalp
amph
letinvolving
activ
eneckmob
ilisatio
n,iso
metric
neck
muscle
stabilisation,
stretching,po
stural
correctio
nexercise
NPR
S,NPQ
,SF-36,
cervicalRO
M,
craniovertebralang
le
Statisticallysig
nificantd
ifferences
infavour
ofTM
post-
treatmento
npain
intensity
(𝑃=0.043)a
ndNPQ
(𝑃=0.018).Im
provem
ents
werem
aintainedat3and6m
ths
follo
wup
Marteletal.[58]
Patie
ntsw
ithpain
ofmechanical
origin
locatedin
thea
natomicalregion
ofthen
eck,with
orwith
outradiatio
nto
theh
ead,trun
k,or
limbs>12wks;
between18
and60
yrs(𝑁=98)
All:spinalmanipulation10–15tre
atmentsin
5-6w
k(sym
ptom
aticph
ase)aft
erthat3different
interventio
ns(preventivep
hase).
(1)S
pinalm
anipulationcervicalandthoracicun
tilTh
4,on
ceperm
onth,4
times
(𝑛=36)
(2)S
pinalm
anipulationcervicalandthoracicun
tilTh
4,on
ceperm
th,4
times
AND20–30min.hom
eexercise
s3×perw
k:inclu
ding
rangeo
fmotionexercises,4str
etching/mob
ilisatio
n,and4str
engthening
exercises.Th
rees
erieso
feachexercise.
Tenmths(𝑛=33)
(3)A
ttentioncontrolgroup
:notre
atment(𝑛=29)
VAS,cervicalRO
M,
NPD
I,Bo
urnemou
thqu
estio
nnaire,SF-12
questio
nnaire,
fear-avoidance
behaviou
rquestionn
aire
Nostatisticallysig
nificant
differences
werefou
ndbetween
grou
ps
Sherman
etal.
[59]
Patie
ntsw
ithchronicn
eckpain
(>3m
ths),age
20–6
4(𝑁=64)
(1)Th
erapeutic
neck
massage
(𝑛=32),common
lyused
Swedish
andclinicalm
assage
techniqu
es,allo
wed
typical
self-care
recommendatio
ns,upto
10tre
atmentsover
a10w
kperio
d(2)S
elf-careb
ook(𝑛=32),they
werem
ailedac
opyof
aself-care
book
with
inform
ationandrecommendatio
n
NDI,NRS
Statisticallysig
nificanteffecton
massage
after
four
wks
measured
byNDI,−2.1(−4.00–0
.03)
(𝑃=0.047),bu
tnot
inlong
-term
follo
wup
at10
and26
wks
Sillevise
tal.[60]
Patie
ntsb
etween18
and65
from
outpatientsp
hysio
therapyclinicw
ithno
n-specificp
ainin
thec
ervicaland
cervicotho
racicr
egiondo
wnto
T4,
provoked
with
neck
movem
ents,
presentfor
atleast3
mths(𝑁=100)
(1)O
netim
ethrustm
anipulationatT3
-T4(𝑛=50)
(2)P
lacebo
manipulationatT3
-T4(𝑛=50)
VAS,pu
pild
iameter
Nostatisticallysig
nificant
differences
betweengrou
psim
mediatelyaft
erthetreatment
12 ISRN Pain
Table3:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
nbetweengrou
ps
Yagcietal.[61]
Patie
ntsw
ithchronicc
ervical
myofascialp
ainsynd
rome(>6m
ths),
age2
1–44
(𝑁=40)
(1)S
pray-stre
tchtechniqu
e(𝑛=20),ethylchlorides
prayed
onmuscle
with
triggerp
oint
inmuscle
stretchedpo
sition,
6sessions
(2)C
onnectivetissue
massage
(𝑛=20),15
sessions
All:follo
wed
activ
eexercise
stobe
carriedou
tthree
times
aday
VAS,pain
threshold,
ROM,stre
ngth,
endu
rance
Nostatisticallysig
nificant
differences
betweengrou
pswere
foun
don
pain
posttreatment
∗
Inordertoshow
aneffecto
faninterventio
nandhereby
supp
ortthe
interventio
n,itrequ
iressho
wingsta
tisticalsig
nificantd
ifference
betweengrou
ps.
VAS:visualanalogue
scale;NRS
:num
ericalratin
gscale;VNPS
:verbaln
umericpain
scale;NPQ
:NorthwickPark
neck
pain
questio
nnaire;N
DI:neck
disabilityindex;NPD
I:neck
pain
anddisabilityindex;NPD
S:neck
pain
anddisabilityscale;NPD
VAS:neck
pain
anddisabilityvisualanalogue
scale;PS
FS:p
atient-specific
functio
nalscale;N
PI:N
orthwickPark
neck
pain
index;SF-36:
short-form
36;P
PT:p
ressurepain
threshold;RO
M:range
ofmovem
ent;RP
E:ratin
gof
perceivedexertio
n;EM
G:electromyographic,HRQ
oL:health
-rela
tedqu
ality
oflife.
ISRN Pain 13
Table4:Electro
therapy—
patie
ntsw
ithchronicn
onspecificn
eckpain.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Altanetal.[62]
Patie
ntsw
ithchronicc
ervical
myofascialp
ainsynd
rome
(>3m
ths),havingtend
erpo
ints
(𝑁=53)
(1)L
aser
treatment(𝑛=23),appliedover
four
trigger
pointsbilat.,fre
quency
1000
Hzfor
2min
over
each
point.
Laserp
aram
eters:infrared
27GaA
sdiode,904
nm,
frequ
ency
range5
–700
0Hz,max
power
of27
W,50W
,or
27×4W
was
used
(2)P
lacebo,sham
lasertreatment(𝑛=25)
All:tre
atmento
ncea
dayfor10days
durin
gap
eriodof
14days,instructedto
perfo
rmiso
metric
exercisesa
ndstretching
atho
me
VAS,algometric
measurements,
ROM
Therew
eren
osig
nificantd
ifferences
betweengrou
psim
mediatelyaft
er(w
k2)
andat12wks
follo
wup
Chiu
etal.[63]
Patie
ntsw
ithchronic
interm
ittentn
eckpain
(>3m
ths),
age2
0–70
(𝑁=218)
(1)T
ENSgrou
p(𝑛=73):infrared
radiation,
advice
onneck
care,T
ENSto
then
eckregion
for3
0min.T
ENS
parameters:du
al-chann
elTE
NSun
it(130
Z),con
tinuo
us150𝜇
ssqu
arep
ulsesa
t80H
z,four
surfa
ceelectro
des,
intensity
ofTE
NSwas
adjuste
dto
prod
ucea
tingling
sensation
(2)E
xercise
grou
p(𝑛=67):infrared
radiation,
advice
onneck
care,intensiv
eneckexercise
programme
(3)C
ontro
lgroup
(𝑛=78):infrared
radiation,
advice
onneck
care
All:twosessions
awkforsixwks
VNPS
,NPQ
,NPI,
strength
Therew
eren
ostatisticallysig
nificant
differences
betweenthethree
grou
pson
VNPS
pain
after
6wkandat6m
ths
follo
wup
,but
theT
ENSgrou
pandthe
exercise
grou
phadas
ignificantly
bette
rim
provem
entinNPQ
than
thatof
the
controlgroup
(𝑃=0.034and𝑃=0.02,
resp.)aft
er6w
ksandat6m
thsfollowup
Chow
etal.[64
]Patie
ntsw
ithchronicn
eckpain
(>3m
ths),age>18
(𝑁=90)
(1)L
aser
treatment(𝑛=45),appliedto
tend
erpo
intsfor
30sp
erpo
intw
ithup
to50
pointsbeingtre
ated.L
aser
parameters:cla
ss3B
,diolase
devices,wavelength830n
m,
power
of300m
Win
continuo
uswavem
odea
tapo
wer
density
of0.67
W/cm
2
(2)S
ham
lasertreatment(𝑛=45)
All:14
treatmentsover
7wks
VAS
Theimprovem
entinrawVA
Swas
statisticallysig
nificantly
greaterinthe
laser-tre
atmentg
roup
than
inthes
ham
laser
treatmentg
roup
(−2.7comparedwith
+0.3,
𝑃<0.001).at12wkfollo
wup
Dun
dare
tal.[65]
Patie
ntsw
ithchronicc
ervical
myofascialp
ain,
having
spot
tend
ernessalon
gtaut
band
,age
20–6
0(𝑁=64)
(1)L
aser
treatment(𝑛=32),appliedover
threetrig
ger
pointsbilat.,fre
quency
1,000
Hzfor
2min
over
each
point,
power
output
58mW/cm
2by
1,000
Hz.Dosep
erpo
int7
J,totalp
ertre
atment4
2J.L
aser
parameters:infrared
Ga-As
-Ald
iode,w
avelength830n
m,m
axpo
wer
output
of450m
W(2)P
lacebo,sham
laser(𝑛=32)
All:on
cead
ayfor15days
durin
g3w
ks,instructedin
daily
isometric
exercise
andstr
etchingexercise
VAS,RO
M,N
DI
Therew
eren
ostatisticallysig
nificant
differences
betweengrou
psaft
er4w
ks
14 ISRN Pain
Table4:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Esenyeletal.[66]
Patie
ntsw
ithchronicm
yofascial
triggerp
oints(du
ratio
n6mon
ths
to7y
rs)inon
esideo
fthe
upper
trapeziusm
uscle
s(𝑁=102)
(1)U
ltrasou
ndtherapy(𝑛=36),do
se1.5
W/cm
2 ,6m
in.,
10sessions
(2)T
riggerp
oint
injections
(1%lid
ocaine)(𝑛=36)
(3)C
ontro
l(𝑛=30)
All:neck-stre
tching
exercises
VAS,PP
T,RO
M
Statisticallysig
nificantand
equalreductio
nin
VASpain
from
ultrasou
ndandinjection
grou
pscomparedwith
controls(𝑃<0.001)
after
treatmentand
at3m
thfollo
wup
.There
weren
ostatisticallysig
nificantd
ifferencesin
outcom
emeasuresb
etweengrou
ps1and
2
Gam
etal.[67]
Patie
ntsw
ithchronictrig
ger
pointsin
then
eckandwith
anintensity
distu
rbingno
rmaldaily
activ
ity,age
18–6
0(𝑁=67)
(1)U
ltrasou
nd,m
assage,exercise
(𝑛=18),do
se100H
z,pu
lse=2:
8,3W
/cm
2 ,3m
in(2)S
ham
ultrasou
nd,m
assage,exercise
(𝑛=22)
(3)C
ontro
lgroup
(𝑛=18)
Group
s1and2weretreated
2sessions
perw
kin
4wks
VAS,measure
oftrigger
points
Therew
eren
osig
nificantd
ifferences
betweengrou
pspo
sttre
atmentand
at6m
thfollo
wup
Gur
etal.[68]
Patie
ntsw
ithchronicm
yofascial
pain
synd
romeinthen
eck
(>1yr),affectingqu
ality
oflife,
with
1–10
tend
erpo
intsin
shou
lder
girdle(𝑁=60)
(1)L
aser
treatment(𝑛=30),2J/cm
2ateach
triggerp
oint
(max.20J/cm
2 ).L
aser
parameters:Ga-As
laser,20
Wmax
output
perp
ulse,904
nm,200
nano
second
smax
duratio
npu
lse,2,8kH
zpulse
frequ
ency,11.2
mW
averagep
ower,
1cm
2surfa
ce(2)P
lacebo,sham
lasertreatment(𝑛=30)
All:tre
atment3
min
ateach
triggerpoint,5
times
awkfor
2wks,instructedin
correctp
osture,ergon
omicsa
ndto
avoidactiv
ityexacerbatedpain
NPD
S,VA
S
Statisticallysig
nificantd
ifference
onpain
infavour
oflasertreatmentat2nd
wkand3rd
wkon
pain
VAS(2nd
wk:VA
Spain
atrest
3.11±2.29,𝑃=0.01;V
ASpain
atmovem
ent
2.67±2.58,𝑃=0.01)a
ndNPD
S,andat12
wkfollowup
maintainedatNPD
S(41.14±28.34)(𝑃=0.01)
Ozdem
iretal.[69]Patie
ntsw
ithchronicn
eckpain
relatedto
osteoarthritis(𝑁=60)
(1)L
ow-le
vellaser
therapy(𝑛=30),appliedto
12po
ints,
0.90
Jfor
each
1cm
2 ,each
pointfor
15s.Laserp
aram
eters:
endo
laser4
76,G
a-As
Al,po
wero
utpu
tof50m
W,
wavele
ngth
830n
m,diameter
beam
1mm.,0.90
Jfor
each
1cm
2
(2)P
lacebo,sham
laser(𝑛=30)
All:tre
atmentin10
consecutived
ays
VAS,ph
ysician
assessmento
fpressure
pain,ang
leof
lordosis,
ROM,N
PDS
Thea
utho
rsdidno
treportany
dataon
statisticallysig
nificantd
ifferenceso
npain
betweengrou
psaft
ertre
atment
Seideland
Uhlem
ann[70]
Patie
ntsw
ithchronicc
ervical
pain
synd
rome(>6m
ths)
(𝑁=51)
(1)P
lacebo,sham
lasertreatment(𝑛=13)
(2)L
aser
treatment(𝑛=12),ou
tput
7mW,stim
ulationto
meridianpo
ints,
1min
perp
oint,totally15
points.
Laser
parameters:cw
-IR-GaA
IAs-Laser,830n
m,L
asotronic,
energy
density
0J/cm
2 ;21J/c
m2 ;90
J/cm
2 ,irr
adiatio
narea
0.02
cm2 ,laserskindifference8
mm
(3)L
aser
treatment(𝑛=13),ou
tput
30mW,stim
ulationto
meridianpo
ints,
1min
perp
oint,totally15
points.
Laser
parameters:cw
-IR-GaA
IAs-Laser,830n
m,L
asotronic,
energy
density
0J/cm
2 ;21J/c
m2 ;90
J/cm
2 ,irr
adiatio
narea
0.02
cm2 ,laserskindifference8
mm
(4)N
eedlea
cupu
ncture
(𝑛=13)
All:8tre
atmentsin
4wk
VAS,PP
T,RO
MTh
eautho
rsdidno
treportany
dataon
statisticallysig
nificantd
ifferenceso
npain
betweengrou
psaft
er4w
k
ISRN Pain 15
Table4:Con
tinued.
Author
Participants
Interventio
nsMainou
tcom
emeasures
Stud
yresults
oneffect∗of
interventio
non
pain
Smaniaetal.[71]
Patie
ntsw
ithchronicm
yofascial
pain
synd
romeo
fthe
superio
rtrapeziusm
uscle
(and
inno
other
muscle
),age18–80
(𝑁=53)
(1)R
epetitive
magnetic
stim
ulation(rMS)
(𝑛=17),
stim
ulationto
triggerp
ointsw
ithfig
ure-eight-s
hapedcoil
until
coiltemperature
reached40
degreesa
ndthen
replaced
bycircular
coil,pu
lsedmagnetic
stim
uli(40
00)
each
20min
sessionin
5-second
trains
at20
Hzs
eparated
by25-secon
dpause
(2)T
ranscutaneou
selectric
alstimulation(TEN
S)(𝑛=18),100H
z,pu
lsewidth
250𝜇
s,asym
metric
alrectangu
larb
iphasic
waveform,intensitysettopatie
nts
comfortun
tilsig
nificantlocalsensation
(3)P
lacebo
(𝑛=18),sham
-ultrasou
ndtherapy
All:tre
atmentsessio
ns,2
times
awkfor2
wks
NPD
VAS,VA
S,PP
T,RO
M
Ther
MSgrou
pandtheT
ENSgrou
pshow
edas
tatistic
allysig
nificantimprovem
entinthe
NPD
VAScomparedto
thep
lacebo
grou
p:differences
toplacebogrou
pin
NPD
VAS,
rMSgrou
p:pre-po
st𝑃<0.01;pre-1mth
𝑃<0.001;pre-3mths𝑃=0.038.D
ifferences
toplacebogrou
pin
NPD
VAS,TE
NSgrou
p:pre-po
st𝑃<0.01;nodifferencein
pre-1m
thsa
ndpre-3m
thstest.Difference
ineffecto
nNPD
VASbetweenrM
SandTN
Sin
favour
ofrM
Son
lyin
pre-1m
thstest,
𝑃<0.001,and
inpre-3m
thstest,𝑃<0.001
Thorsenetal.[72]
Femalelaboratoryworkerswith
chronicp
ain(>1yr)fro
mneck
andshou
lder
girdle,
pain
affectin
gtheq
ualityof
workor
daily
living,1–10
tend
erpo
ints,
age18–65
yrs(𝑁=49)
Crossoverstudy,6
sessions
over
2wks
follo
wed
byon
ewk
pauseb
efore6
newtre
atmentsessio
nsover
2wks
inother
grou
p.(1)L
aser
treatment(𝑛=25)0
.9Jp
ertre
ated
pointm
ax9J
pertreatment.Laserp
aram
eters:endo
laser4
65cla
ssno
.B,
830n
m±0.5n
m,30m
W,
GaAIAs
diod
e,beam
divergence
4degrees,prob
ehead
2.5m
m2
(2)P
lacebo,sham
lasertreatment(𝑛=22)
All:6sessions
over
a2wkperio
d
VAS
Therew
eren
ostatisticallysig
nificant
differences
betweengrou
pspo
sttre
atment
∗
Inordertoshow
aneffecto
faninterventio
nandhereby
supp
ortthe
interventio
n,itrequ
iressho
wingsta
tisticalsig
nificantd
ifference
betweengrou
ps.
VAS:visualanalogue
scale;NRS
:num
ericalratin
gscale;VNPS
:verbaln
umericpain
scale;NPQ
:NorthwickPark
neck
pain
questio
nnaire;N
DI:neck
disabilityindex;NPD
I:neck
pain
anddisabilityindex;NPD
S:neck
pain
anddisabilityscale;NPD
VAS:neck
pain
anddisabilityvisualanalogue
scale;PS
FS:p
atient-specific
functio
nalscale;N
PI:N
orthwickPark
neck
pain
index;SF-36:
short-form
36;P
PT:p
ressurepain
threshold;RO
M:range
ofmovem
ent;RP
E:ratin
gof
perceivedexertio
n;EM
G:electromyographic,HRQ
oL:health
-rela
tedqu
ality
oflife.
16 ISRN Pain
Table5:(a)E
xercise
therapy,(b)m
anualtherapy,and
(c)electrotherapy.
(a)
Author
Agend
aSequ
ence
generatio
nAllo
catio
nconcealm
ent
Blinding
ofparticipants,
person
nel,andou
tcom
eassessors
Incomplete
outcom
edata
Selective
outcom
erepo
rting
Other
sources
ofbias
Resultof
summary
assessmento
frisk
ofbias
Cunh
aetal.[31]
Globalp
osture
reeducation+stretching
Adequate
Unclear
Inadequate
Inadequate
Unclear
Unclear
High
Dellvee
tal.[32]
Myofeedback
training
+intensives
treng
thtraining
Unclear
Unclear
Unclear
Inadequate
Unclear
Unclear
Unclear
Ehrenb
organd
Archenh
oltz[49]
Biofeedb
acktraining
+interdisc
iplin
ary
rehabilitation
Adequate
Adequate
Inadequate
Adequate
Unclear
Unclear
Low
Falla
etal.[33]
Endu
rance-streng
thexercise
Adequate
Unclear
Inadequate
Adequate
Unclear
Adequate
Unclear
Fitz-Ritson
[50]
Prop
rioception,
eye-head-neckcoordinatio
nInadequate
Inadequate
Inadequate
Inadequate
Unclear
Unclear
High
Griffi
thse
tal.[34]
Specificn
eckstabilisatio
nexercises+
general
exercises
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Gustavssonetal.[35]M
ultic
ompo
nent
pain
andstr
essself-m
anagem
ent
grou
pinterventio
n+individu
alph
ysiotherapy
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Hakkinenetal.[36]
Streng
thtraining
+stretching
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Jordan
etal.[37]
Intensivetraining+ph
ysiotherapy+chiro
practic
manipulation
Adequate
Adequate
Inadequate
Unclear
Unclear
Adequate
Low
Julletal.[38]
Prop
rioception,
eye-head
coordinatio
n+
cranio-cervicalfl
exion
Adequate
Adequate
Inadequate
Inadequate
Unclear
Adequate
Low
Julletal.[51]
Multim
odalph
ysiotherapyprogramme
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Julletal.[39]
Cranio-cervicalfl
exionexercise
+streng
thexercises
Adequate
Unclear
Inadequate
Adequate
Unclear
Adequate
Low
O’Leary
etal.[40
]Cr
anio-cervicalfl
exion+cervicalflexion
endu
rancetraining
Unclear
Unclear
Inadequate
Unclear
Unclear
Adequate
Unclear
Pato
etal.[52]
Cognitiv
ebehaviouraltherapy+multim
odal
physiotherapy+infiltration+medication
Unclear
Unclear
Inadequate
Inadequate
Unclear
Unclear
Unclear
Rand
løvetal.[41]
Intensivetraining+light
training
Adequate
Unclear
Inadequate
Unclear
Unclear
Adequate
Unclear
Reveletal.[42]
Prop
rioception,
eye-head-neckcoordinatio
nUnclear
Unclear
Inadequate
Inadequate
Unclear
Adequate
Unclear
Ryan
[53]
Streng
thtraining
+endu
rancetraining
Unclear
Unclear
Inadequate
Inadequate
Unclear
Unclear
High
Soderlu
ndand
Lind
berg
[54]
Cognitiv
ebehaviouralprogramme
Unclear
Unclear
Inadequate
Adequate
Unclear
Adequate
Unclear
Stew
artetal.[55]
Exercise
Adequate
Adequate
Inadequate
Adequate
Adequate
Adequate
Low
Taim
elae
tal.[43]
Multim
odalprop
rioceptivetraining+ho
me
exercises
Unclear
Unclear
Inadequate
Adequate
Unclear
Adequate
Unclear
Viljanenetal.[44
]Dyn
amicmuscle
training
+relaxatio
ntraining
Adequate
Unclear
Inadequate
Adequate
Unclear
Adequate
Unclear
Vonk
etal.[45]
Behaviou
ralgradedactiv
ity+exercise
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Walingetal.[46
]Streng
th+endu
rance+
coordinatio
ntraining
Unclear
Unclear
Inadequate
Inadequate
Unclear
Adequate
High
Ylinen
etal.[47]
Intensives
treng
thtraining
+lighter
endu
rance
training
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Ylinen
etal.[48]
Stretching
exercises+
manualtherapy
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
ISRN Pain 17
(b)
Author
Agend
aSequ
ence
generatio
nAllo
catio
nconcealm
ent
Blinding
ofparticipants,
person
nel,andou
tcom
eassessors
Incomplete
outcom
edata
Selectiveo
utcome
repo
rting
Other
sources
ofbias
Resultof
summary
assessmento
frisk
ofbias
Bron
fortetal.[56]
Manipulation+exercise
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Lauetal.[57]
Thoracicmanipulation
Adequate
Adequate
Inadequate
Adequate
Unclear
Unclear
Low
Marteletal.[58]
Spinalmanipulation+ho
mee
xercise
Adequate
Adequate
Inadequate
Adequate
Adequate
Adequate
Low
Sherman
etal.[59]
Massage
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Sillevise
tal.[60]
Thoracicmanipulation
Adequate
Adequate
Inadequate
Adequate
Unclear
uncle
arLo
w
Yagcietal.[61]
Con
nectivetissue
massage
+spray-stretchtechniqu
eUnclear
Unclear
Inadequate
Unclear
Unclear
Unclear
Unclear
(c)
Author
Agend
aSequ
ence
generatio
nAllo
catio
nconcealm
ent
Blinding
ofparticipants,
person
nel,andou
tcom
eassessors
Incomplete
outcom
edata
Selectiveo
utcome
repo
rting
Other
sources
ofbias
Resultof
summary
assessmento
frisk
ofbias
Altanetal.[62]
Laser
Unclear
Unclear
Adequate
Inadequate
Unclear
Unclear
Unclear
Chiu
etal.[63]
TENS
Adequate
Adequate
Inadequate
Adequate
Unclear
Adequate
Low
Chow
etal.[64
]Laser
Adequate
Adequate
Adequate
Adequate
Unclear
Unclear
Low
Dun
dare
tal.[65]
Laser
Adequate
Unclear
Inadequate
Adequate
Unclear
Unclear
Unclear
Esenyeletal.[66]
Ultrasou
ndUnclear
Unclear
Inadequate
Unclear
Unclear
Unclear
Unclear
Gam
etal.[67]
Ultrasou
ndAd
equate
Unclear
Adequate
Inadequate
Unclear
Adequate
Unclear
Gur
etal.[68]
Laser
Adequate
Unclear
Inadequate
Unclear
Unclear
Unclear
Unclear
Ozdem
iretal.
[69]
Laser
Unclear
Unclear
Unclear
Unclear
Unclear
Unclear
Unclear
Seideland
Uhlem
ann[70]
Laser
Adequate
Unclear
Inadequate
Unclear
Unclear
Unclear
Unclear
Smaniaetal.[71]
rMS+TE
NS
Adequate
Unclear
Inadequate
Unclear
Adequate
Unclear
Unclear
Thorsenetal.[72]
Laser
Unclear
Unclear
Adequate
Inadequate
Unclear
Adequate
Unclear
18 ISRN Pain
6 weeks on pain intensity scale (𝑃 = 0.005) and on abothersomeness scale at 6 weeks (𝑃 = 0.003) and at12 months (𝑃 = 0.003).
No trials at low risk of bias support the use of EMGbiofeedback.
3.3.2. Manual Therapy
Effect of Manual Therapy on Pain in Patients with ChronicNonspecific Neck Pain. As shown in Appendix A, Table 3,six trials examined the effect of various types of manualtherapy in patients with chronic non-specific neck pain [56–61]. One of the trials was at unclear risk of bias, and for thatreason not considered evidence [61]. Three trials at low riskof bias examining the effect of spinal manipulations found nodifference between groups [56, 58, 60]. Two trials succeededin finding an effect on pain from the intervention. Both trialshad a low risk of bias, and for this reason, their results wereconsidered evidence of use of manual therapy.
(1) Lau et al. [57] examined thoracicmanipulation versusa control group. They found statistically significantdifferences in favour of thoracic manipulation post-treatment on pain intensity (𝑃 = 0, 043) and pain anddisability (NPQ) (𝑃 = 0, 018). Improvements weremaintained at 3, and 6-month followup.
(2) Sherman et al. [59] examined massage versus a self-care book.They found statistically significant effect onmassage following four weeks of treatment on neckpain and disability (NDI) (𝑃 = 0.047), but not at long-term followup at 10 and 26 weeks.
No trials at low risk of bias support the use of traction.
3.3.3. Electrotherapy
Effect of Electrotherapy on Pain in Patients with ChronicNonspecific Neck Pain. As shown in Appendix A, Table 4, 11trials examined the effect of various types of electrotherapyin patients with chronic non-specific neck pain; two of thesewere at low risk of bias [63, 64], and nine were at unclearor high risk of bias [62, 65–72]. The two trials at low risk ofbias both succeeded in demonstrating an effect on pain fromthis type of intervention and for this reason; their results wereconsidered evidence of use of electrotherapy.
(1) Chiu et al. [63] examined three interventions: TENSversus exercise versus a control group. There were nostatistically significant differences between the threegroups on pain (VNPS) after 6-week and at 6-monthfollowup, but the TENS group and the exercise grouphad a significantly better improvement in neck painand disability (NPQ) than the control group (𝑃 =0.034 and 𝑃 = 0.02, resp.) after 6-week, and at 6-month followup.
(2) Chow et al. [64] examined laser versus sham lasertreatment. The improvement in VAS was statisticallysignificantly greater in the laser treatment group than
in the sham laser treatment group (−2.7 comparedwith +0.3, 𝑃 < 0.001) at 12-week followup.
No trials at low risk of bias support the use of ultrasoundtherapy. No trials at low risk of bias support the use of rMS.
4. Discussion
4.1. General Interpretation. In this review, we assessed theeffect of various interventions for the treatment of chronicneck pain and evaluated the methodological quality of thetrials. Our findings emphasise the importance of taking therisk of bias into consideration when evaluating the evidenceof an intervention.
Trials varied substantially regarding their internal valid-ity, although the methodological quality of the RCTs ingeneral appeared to be somewhat low with an unclear or highrisk of bias. We identified various methodological flaws thatmayhave implications for the internal validity of the trials andconsequently may result in biased outcomes. Key domains inthis context were randomisation, blinding, and incompleteoutcome data.
Our evaluation also exposes a widespread use of within-group analyses, claiming statistically nonsignificant results tobe beneficial. Results were frequently analysed and reportedas if they were uncontrolled within-group studies, whichconsequently led to misinterpretation of results. To someextent this may be due to the absence of a control groupin many trials, and the use of an active treatment as acomparative group makes the “proof ” of a truly statisticallysignificant effect more difficult to find. We believe thatattention should be paid to inadequate interpretation of a trialresult when authors inadequately interpret lack of differencein terms of efficacy [73–76].
4.2. Effect of Physiotherapy on Chronic Neck Pain. Overall,the evidence of effect of physiotherapy for chronic neck painis strengthened. Yet, for some of the treatments offered, nodefinite effect and clinical usefulness can be shown.This doesnot necessarily implicate that these treatments have no effect,only that the present evidence is not sufficient.
Physiotherapy interventions for chronic neck pain show-ing the strongest support for an effect on pain are strengthand endurance training (supported by two trials by Stewartet al. [55] and by Ylinen et al. [47], treating patients withchronic WAD and patients with chronic non-specific neckpain, resp.). In patients with chronicWAD,multimodal phys-iotherapy was also shown to have a beneficial effect by onetrial by Jull et al. [51]. In patients with chronic non-specificneck pain, the use of cognitive/behavioural components inexercise was supported by one trial by Gustavsson et al. [35].In regard to manual therapy, massage seems to have an effecton pain in patients with chronic non-specific neck pain,supported by one trial by Sherman et al. [59], and thoracicmanipulation seems to have an effect on pain, supported byone trial by Lau et al. [57]. Within the area of electrotherapy,both laser therapy and TNS seem to have an effect on painin patients with chronic non-specific neck pain. This wassupported by one trial by Chow et al. [64] and one trial
ISRN Pain 19
by Chiu et al. [63]. No trials supported the isolated useof proprioception (eye-head co-ordination), cranio-cervicalflexion training, stretching, ultrasound therapy, rMS, andtraction.
When looking deeper into the actual components of thevarious interventions in the above-mentioned trials, fourof them—despite the differences, diversity, and individualfeatures of the interventions—seem to have several charac-teristics in common: The interventions can be considered tobe rehabilitative interventions of multimodal physiotherapywith a focus on exercise, including cognitive-behaviouralcomponents. This is based on (1) the trial by Stewart et al.[55] showing effect of mixed exercises, where the interven-tion besides submaximal training, stretching, and aerobicendurance included coordination programme designed toimprove functional activities and principles of cognitivebehavioural therapy (i.e., setting goals); (2) the trial by Ylinenet al. [47] showing effect of strength training and endurancetraining, where training groups had an additional 12-dayinstitutional rehabilitation programme with training lessons,behavioural support, ergonomics, sessions of physical man-ual therapy—including massage/mobilisations—and adviceto continue exercise; (3) the trial by Jull et al. [51] showingeffect of a multimodal physiotherapy, including low-loadexercise for reeducatingmuscle control of the neck flexor andextensor muscles and scapular muscles, posture exercises,kinaesthetic exercises, and mobilisation techniques, and inaddition education including ergonomics, daily living advice,and home exercise; (4) finally, the trial by Gustavsson et al.[35] who found effect from a multi-component pain andstress self-management group intervention—including relax-ation training, body awareness exercises, and lectures andgroup discussions—regarding coping with pain in terms ofpatients’ self-reported pain control, self-efficacy, and disabil-ity. Our main results are consistent with findings of previousreviews of interventions for neck pain.The Cochrane ReviewbyKay et al. [19] on the effect of exercises formechanical neckdisorders concluded that the summarised evidence indicatesthat there is a role for exercises in the treatment of acuteand chronic mechanical neck pain plus headache, but thatthe relative benefit of each type of exercise needs extensiveresearch. Our review on chronic neck pain agrees withthe present conclusion regarding exercise, yet our findingstend to favour strength and endurance training, as well asmultimodal physiotherapy in addition to pain and stress self-management. The superior effect of strength training andendurance training may be due to the physical impairmentsfound in the chronic condition [77–80].
Our review adds new knowledge regarding the evidencefor use of massage. Our findings are in discrepancy to aCochrane Review by Haraldsson et al. [13] who concludedthat the effectiveness of massage for improving neck painand function remains. Yet the quoted review was last updatedin 2004, and the trial by Sherman et al. [59] supportingmassage was published in 2009. Our findings on the evidenceof manipulation are in line with another Cochrane Review byGross et al. [18] on the effect of manipulation and mobilisa-tion for neck pain, who found low quality evidence that cervi-cal and thoracic manipulations may provide pain reduction.
We too found evidence that thoracicmanipulationsmay havean effect on pain [57]. Regarding low-level laser therapy, ourfindings are consistent with the findings of a review by Chowet al. [81], who found that low-level laser therapy reducespain in patients with chronic neck pain. A Cochrane Reviewfrom 2007 [17] on the effect of conservative treatment forwhiplash concluded that clearly effective treatments are notfound for treatment of acute, subacute, or chronic symptoms.The findings of our newer review do support multimodalphysiotherapy and mixed exercise programmes for chronicWAD. The explanation for the difference may be that theCochrane Review by Verhagen in 2007 was not updated afterJanuary 2007, and our findings are based on more recentresearch, namely, two trials published later in 2007 [51, 55].A more recent review by Teasell et al. [82] found evidenceto suggest that exercise programmes are the most effectivenoninvasive treatments for patients with chronic WAD. Ourfindings give support to the use of cognitive-behaviouralelement, and to pain and stress self-management. This is indiscrepancy to another Cochrane Review by Gross et al. [14]on patient education for neck pain, concluding that thereis no strong evidence for the effectiveness of educationalinterventions in various neck disorders. This difference maybe due to the use of only single-modal trials in their reviewrather than multimodal trials as used in the current review.
4.3. Strengths and Weaknesses of Review Procedures. To ourknowledge, this is the first systematic review on interventionsfor chronic neck pain addressing the majority of commonlyused physiotherapeutic modalities in one study, in order toget an overview of the subject area.
The search strategy and selection criteria we used werequite strict and easy to apply and according to normalprocedures for conducting systematic reviews [23]. Yet thefollowing limitations of the literature search may have intro-duced a bias: some relevant trials may have been missedif they used other keywords, although this is not verylikely. We had limitations in language, and this may haveled to missing studies from countries in Eastern Europewith a tradition of physiotherapy research, like Poland. Wedecided to limit our search from 1990 to January 2012. Thiswas due to physiotherapists prior to this time not beingtrained in scientific methods and also that RCTs were rare.Studies earlier than 1990 would in general not be followinga strict protocol like the ones used for RCTs, but at best belongitudinal cohort studies.
The quality assessment was presented in a reproduciblemanner. However, the results may be affected by ouremphases during filtering methods for synthesis evidence.We might have chosen to exclude all trials with insufficientreporting on allocation sequence and allocation concealment.However, we chose not to, since this would have left us withvery few trials to assess. We assessed risk of bias, requiring aconvincing mechanism to be described in order for a trial tobe classified as “adequate.” Our approach to this problem wasto assume that the quality was inadequate unless informationon the contrary was provided, and in doing so, wemight havemisclassified well-conducted but badly reported trials.
20 ISRN Pain
Thepresent review succeeded in a subgroup assessment ofphysiotherapy treatment for chronic non-specific neck painand for chronicWAD. Yet the first groupwas very wide due tothemixed conditions in the group of participants.The variousinterventions were considered to be complex, multifaceted,and with various cointerventions, and by classifying theminto intervention groups according to—what we believedto be—the trial’s agenda, we may have misclassified some.On the other hand, the often used combined therapies alsohighlight a fundamental problem when assessing effect ofspecific and single physiotherapy modalities. Another issueis the quality of the intervention since the interventions wereadministered in different ways and in different settings. Itis reasonable to expect that the way in which they wereadministered including the dose-response relationship couldhave influenced the outcome. It would have been interestingand very relevant to examine this. Herbert and Bo [83]emphasise that researchers carrying out systematic reviewsshould routinely examine the quality of interventions.
4.4. Future Directions. We need to know which patients willbenefit from which intervention, built on well-conductedand well-reported trials, considering subgroups of patientswith chronic neck pain, in order to support recommendedevidence-based decisions and to set priorities for futureresearch.We also request future trial investigators to considerto what extent cointerventions are valuable, in addition topossible confounders. Another issue to consider is the extentto which the control groups ought to be given care andattention to the same extent as the intervention groups.
Appendices
A. Study Characteristics and Study Results
See Tables 1–4.
B. Risk of Bias
See Table 5.
Conflict of Interests
The authors report no conflict of interests.
Authors’ Contribution
P. Damgaard contributed to the conception, design, and writ-ing of the study protocol and the design of search strategies;she located and obtained trial reports, helped to select andassess trials, conducted the data analysis, and drafted andapproved the final paper. E. M. Bartels contributed to theconception of the study protocol and the design of searchstrategies; she helped to locate and obtain trial reports, andrevised and approved the final paper. I. Ris helped to selectand assess trials, contributed to the data analysis, and revisedand approved the final paper. R. Christensen contributed tothe conception, design, and writing of the study protocol,
conducted data analysis, and revised and approved the finalpaper. All authors acted as guarantors for the paper. B. Juul-Kristensen contributed to the conception, design, andwritingof the study protocol and the design of search strategies; shehelped to select and assess trials and revised and approved thefinal paper.
Disclosure
The funding organisations had no role in any aspect of thestudy, the paper, or the decision to publish.
Acknowledgment
The authors have completed ICMJE’s the Unified CompetingInterest form at (available on request from the correspondingauthor) and want to acknowledge. The financial support forthe submitted work by grants from The Danish Associationfor Physiotherapists, the Research Fund of the Region ofSouthern Denmark, the patient organization PTU-DanishSociety of Polio andAccident Victims and fromTheResearchUnit for Musculoskeletal Function and Physiotherapy atThe University of Southern Denmark, and the Parker Insti-tute, Musculoskeletal Statistics Unit, which is supported bygrants from The Oak Foundation, The Danish RheumatismAssociation, and Frederiksberg Hospital. The authors alsodeclare. No financial relationships with commercial entitiesthatmight have an interest in the submittedwork; no spouses,partners, or children with relationships with commercialentities that might have an interest in the submitted work;and no nonfinancial interests that may be relevant to thesubmitted work.
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