Research Review by Dr. Stephen Burnie©

Date:

Sept. 2007

Study Title:

Conservative management of mechanical neck disorders: A systematic review

Authors:

Gross A, Goldsmith C, Hoving J, Haines T, Peloso P, Aker P, Santaguida P, Myers C, and the Cervical Overview Group

Publication Information:

The Journal of Rheumatology 2007;34:1083-1102.

Summary:

About 70% of the population experiences neck pain at some point in their lives, however optimal treatment continues to be hotly debated. The Cervical Overview Group (COG) is a multidisciplinary group of clinicians and researchers that was created with the intent of monitoring neck pain research, and creating regular systematic review updates on conservative management for patients with neck pain.

This extensive review presents the most up-to-date compilation of randomized controlled trials (RCTs) examining the use of conservative treatment for neck pain that the COG has published.

The COG performed a thorough and well-described literature search, including RCTs from journals not listed in mainstream medical databases. Subjects in these studies were classified as acute (<30 days), subacute (30-90 days), or chronic (>90 days) with neck disorders classified as:
  1. mechanical neck disorders, including whiplash associated disorders (WAD I and WAD II), myofascial neck pain, and degenerative changes or osteoarthritis
  2. neck disorder with headache
  3. neck disorder with radicular findings, including WAD III
Interventions included in this review were medication, medical injections, acupuncture, electrotherapy, exercise, low-level laser therapy, orthoses, thermal agents, traction, massage, mobilization, manipulation, and patient education. Control groups in these RCTs were placebo, wait-list/no-treatment control, active treatment control (e.g. exercise and ultrasound vs. ultrasound alone), or inactive treatment control (e.g. simulated transcutaneous electrical nerve stimulation). Outcomes of interest were pain, disability and function including work related outcomes, patient satisfaction, and global perceived effect.

Methodological quality of each paper was evaluated using Jadad criteria and van Tulder criteria, which are both commonly used and validated methods for evaluating RCTs. Using these tools, 59% of the selected papers were classified as “acceptable” in methodological quality. Although it may be surprising that so many RCTs were rated poorly, it is important to note that manual therapy studies in particular are prone to poor ratings with these scales, as it is difficult to adequately blind the patients and care providers to the treatment being given.

Due to the ambitious nature of this review, a wide range of therapies were examined and reported on. Below is an executive summary of the authors’ findings, grouped by the strength of evidence provided by the studies.

Strong evidence of benefit
  • Multimodal approaches - that include stretching or strengthening exercises and mobilization or manipulation reduced pain, improved function, and resulted in favourable global perceived effect over the long term for each type of neck pain.
Moderate evidence of benefit
  • Exercise - with direct neck strengthening and stretching was found to be beneficial in 7 trials for chronic neck disorder with headache and chronic neck pain. Stretching and strengthening of only the shoulder region plus general conditioning did not alter pain but had short term benefits in function for patients with chronic neck pain. Active range of motion exercises for acute pain reduction of WAD provided short-term benefit in one study. 2 studies found that cervical proprioceptive training and eye-fixation exercises provide benefits in all outcomes for each type of neck pain, however the reductions in pain were not maintained long term.
  • Medication - was found to have long-term benefits in 2 trials, however it may be argued that these therapies are not “conservative”. Intravenous glucocorticoid (a corticosteroid) resulted in pain reduction and reduced sick leave in patients with acute WAD, and epidural injections provided pain reduction and improved function for patients with chronic neck pain with radiculopathy.
  • Low-level laser therapy (830 or 904 nm wavelength) - was useful for pain reduction and function improvement for acute/subacute and chronic neck pain with osteoarthritis. The authors were not able to make recommendations on dosage (power, frequency, duration) as each trial used different laser protocols.
  • Electrotherapy - in the form of low-frequency pulsed electromagnetic field therapy was helpful in reducing pain for acute WAD I and II, acute neck pain, and chronic neck pain with osteoarthritis post-treatment, however this benefit was not carried even into the short-term.
  • Intermittent traction - provided short-term pain reduction for chronic neck pain, neck disorder with radiculopathy, and neck pain with degenerative changes.
  • Acupuncture - provided immediate and short-term pain relief for chronic neck pain and neck disorder with radiculopathy. These benefits were not found to continue into the intermediate and long term. One high quality study of the traditional Chinese medicine procedure of dry needling to trigger points and a low quality study on local “standard points” demonstrated no relief of pain in the short term.
Limited evidence of benefit
Limited low quality studies suggested that there might be benefit in the use of the below therapies, however further high-quality research must been done before recommendations for their use can be made.
  • traditional Chinese massage
  • repetitive magnetic stimulation
  • orthopedic pillows
  • intramuscular injections of local anesthetic (lidocaine)
Evidence of no benefit
The following therapies were found to have compelling evidence to suggest that they are not useful in the treatment of neck pain. It is important to remember, however, that future studies with different designs may detect benefits from these treatments not found in studies to date.
  • home exercise
  • hot packs
  • ultrasound
  • combination of manipulation/mobilization/modalities for chronic neck pain without exercise
  • manipulation alone
  • Botox (botulinum-A)
  • morphine added to an epidural injection
  • various massage techniques
  • laser for myofascial pain
  • infrared light
  • static traction
  • spray and stretch
  • oral splint
  • neck school
  • advice (to rest for acute WAD pain relief was inferior to active treatments; advice to activate; or on pain and stress and coping skills)
Conflicting evidence
The following therapies were found to have conflicting evidence of benefit for neck pain, perhaps due to differences in study design. Until further high quality evidence is published, the COG group is not able to make recommendations on their use.
  • multimodal massage (combined with electrotherapy or exercise)
  • mobilization and manipulation alone
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Interferential current (IFC)
  • oral psychotropic agents (cyclobenzaprine, diazepam, tetrazapam, eperison hydrochloride, phenobarbital, and meprobamate)
  • oral anti-inflammatory medications and oral analgesics
  • nerve block injections

Conclusions & Practical Application:

There are many findings from this review that are important for chiropractors, physical therapists, and other manual therapy providers. For patients with subacute and chronic neck pain or neck pain with headaches, evidence was found to support a multimodal strategy including exercise and mobilization or manipulation; exercise alone; intramuscular lidocaine injection; and low level laser therapy for pain, function, and global perceived effect in the short and long term. Acupuncture, cervical orthopedic pillow, low-frequency pulse electromagnetic field, repetitive magnetic stimulation, and traditional Chinese massage are beneficial for either immediate or short-term pain management. Other commonly used treatments were either not studied or the results were unclear and thus not included in the review.

The take-home message from this review is that manual therapy providers are ideally trained to provide neck pain treatment for which the highest level of evidence exists. Perhaps most encouraging, invasive techniques or expensive modalities are not required to provide pain relief from neck pain.