Nonspecific neck pain see

Therapies likely to be effective

1. Exercise

Systematic reviews [2,27-30] identified RCTs using different exercise strategies, but none of the reviews could perform a meta-analysis because of heterogeneity among the trials in types of exercise and study designs.

Positive studies

• Proprioceptive and strengthening exercise versus usual care: one RCT (60 people with chronic neck pain) [31] found a proprioceptive and strengthening exercise program to be significantly more effective (P < 0.004) at reducing pain at 10 weeks when compared with usual care (analgesics, nonsteroidal anti-inflammatory drugs or muscle relaxants).

• Endurance exercise versus strengthening exercise versus no specific exercise program: an RCT (180 female office workers with chronic neck pain) [32] compared a program of "endurance" (dynamic) or "strength" (isometric) exercises to a control group (no specific exercise), with exercise being carried out three times a week for 1 year. Both endurance and strength exercises significantly improved neck pain and disability after 12 months compared to the control therapy (P < 0.001 for exercise groups versus control).

• Strength training versus endurance training versus co-ordination exercises versus stress management: an RCT (103 women with chronic work-related neck pain) [33] compared three exercise regimens (strength training, endurance training, co-ordination exercises) compared to stress management over 10 weeks. It found that any type of exercise significantly reduced pain compared with stress management after 10-12 weeks (P < 0.05), but there was no significant difference in outcomes between the different exercise programs. There was also no significant difference in neck pain among the four groups after 3 years [34]. Another RCT (180 women with chronic neck pain) assessed the rate of change in neck strength, pain and disability of a 1-year training program comparing high-intensity strength training or lower intensity endurance training to a control group. The greatest improvement in strength was achieved within the first 2 months for both treated groups, but with improvement continuing to a year. The decrease in pain at 12 months was 69% for strength training, 61% for endurance training and 28% for controls, compared to baseline, all being significant (P < 0.001). The number of patients who were pain free or nearly pain free at 12 months was significantly greater for the treated groups (53% and 49% respectively) compared to the controls (20%) [35]. However, this study does not describe how randomization and blinding were achieved.

• Exercise plus infrared versus transcutaneous electrical nerve stimulation (TENS) plus infrared versus infrared alone: one RCT (218 patients with chronic neck pain) [36] compared the effects of twice-weekly therapy for 6 weeks using intensive exercise plus infrared, TENS plus infrared, and infrared alone. The RCT found that the addition of exercise or TENS significantly improved pain compared to infrared alone at 6 weeks (P = 0.02) and 6 months (P = 0.019), but with no difference between the two combination treatment groups.

• Exercise plus special pillow versus either alone versus control (hot/cold pack plus massage): an RCT (151 patients with chronic neck pain) [37] compared the effects of exercise plus a special pillow to exercise or a pillow alone or a control group and found a significant advantage for the combination group at 6 weeks, although the difference was small.

Negative study

• Dynamic muscle training versus relaxation training versus advice to continue with ordinary activity: one RCT (393 women office workers with chronic neck pain) [38] compared three interventions for 12 weeks: dynamic muscle training, relaxation training, and advice to continue with ordinary activities, and found no significant difference in outcome in pain or disability in the three groups at 3, 6, and 12 months of follow-up. However, the average number of 30-minute training sessions completed by participants over 12 weeks for both treatment groups was only 40% of the maximum available, and this might have influenced the result.

2. Manual therapy (manipulation and mobilization physiotherapy)

Systematic reviews [2, 27, 28, 39-44] identified a number of RCTs comparing manipulation and/or mobilization with each other or with other treatments.

Positive studies

• Manipulation or mobilization versus other physical treatments, versus usual care versus placebo:

one RCT (256 people with chronic neck and back pain; 64 with neck and 48 with neck and back involvement) [45] compared four treatment groups: manual treatment (mobilization, manipulation or both); physical treatments at the discretion of the physiotherapist; usual GP care; and placebo. It found that manual treatment significantly improved outcomes after 12 months compared with all the other treatments (statistical analysis for people with neck pain alone was not reported). It was not possible to directly compare the effects of mobilization versus manipulation.

• Manipulation versus mobilization versus exercise: one RCT (119 people with chronic neck pain) [46] compared three treatments: mobilization, manipulation, and intensive exercise training. It found no significant difference in pain among the three groups by the end of treatment or after 12 months, although pain score improved significantly from baseline in all groups.

• Manipulation versus mobilization: three RCTs compared manipulation to mobilization. The first RCT (100 people with acute or chronic neck pain)

[47] compared a single manipulation treatment versus a single mobilization treatment and found no significant difference between them in immediate improvement in pain (85% with manipulation, 69% with mobilization). In this study, there was a transient increase in pain in 5% of people receiving manipulation and 6% receiving mobilization. The second RCT (336 people with acute or chronic neck pain) [48] found no significant difference between manipulation and mobilization in "average" pain, "severe" pain and neck disability scores between a variable number of chiropractic mobilizations and a variable number of manipulations after 6 months. In this RCT, only 35% of eligible people agreed to participate, and this may reduce the external validity of the study. A follow-up questionnaire of adverse effects at 2 weeks [49] found that 30% of the 280 people who responded reported at least one minor adverse effect such as increased pain or headache associated with manipulation and less commonly with mobilization. In the third RCT (70 patients with chronic neck pain) [50], patients received one manipulation or one mobilization with assessment before the therapy and 5 minutes after treatment. Both groups showed significant improvement in pain and range of movement, but with a greater benefit for the manipulation group.

• Mobilization versus exercise versus usual care: one RCT (183 people with neck pain for >2 weeks) [51] compared three 6-week courses of treatment with mobilization, exercise or usual care, with treatment "success" being defined as "much improved" or "completely recovered." The RCT found "success" to be significantly more common at 7 weeks with mobilization compared to exercise or usual care, but there was no difference between exercise and usual care. Long-term follow-up of this RCT [52] found that mobilization was still superior at 26 weeks, but not at 1 year.

Negative studies

• Manipulation versus diazepam, anti-inflammatory drugs or usual care: one review [40] performed a meta-analysis of three RCTs (155 people with chronic neck and back pain) comparing manipulation to diazepam, anti-inflammatory drugs or usual care. It found no significant difference in improvement in pain at 3 weeks between manipulation and other treatments, although all treatments improved pain. However, the meta-analysis may have been underpowered to detect a clinically important difference.

• McKenzie mobilization versus general exercise versus placebo: one small low-quality RCT (77 people) [53] compared McKenzie mobilization, exercise and placebo, and found no significant difference in pain between the groups at 6 months and 12 months.

• Adverse events associated with manipulation: manipulation has been associated with occasional serious neurologic complications and the estimated risk from case reports of cerebrovascular accident is 1-3/million manipulations [54], while the estimated risk of all serious adverse effects (such as death or disk herniation) is 5-10/10 million manipulations [40].

3. Manual therapy plus exercise Two systematic reviews by the same Cochrane group reviewed exercise therapy [30] and manual therapy [41] in patients with nonspecific neck pain, neck pain with radiculopathy and whiplash, and found the best evidence of efficacy was for the combination of manual therapy (mobilization or manipulation) with exercise when compared with any other treatments. However, the review did not provide a subgroup analysis in people with uncomplicated nonspecific neck pain.

Positive study

• Manipulation plus strengthening exercises versus either treatment alone: one RCT (191 people with chronic neck pain) [55] compared three treatments: low-technology strengthening exercises plus manipulation (combined treatment), high-technology MedX strengthening exercises (exercise), and manipulation alone (manipulation). The RCT found that the combined treatment significantly improved patient satisfaction, objective strength, and range of movement (P < 0.05) compared with manipulation after 11 weeks. The RCT also found that both the combined treatment and exercise significantly improved pain and patient satisfaction compared to manipulation after 1 year, although it found no significant difference among treatments in health status, neck disability or medication use. The 2-year follow-up to this RCT (data available for 76% of the original patients) [56]

found superior pain reduction for the combined treatment or exercise groups compared to manipulation (P = 0.04).

Negative study

• Manipulation, mobilization or shortwave diathermy plus exercise and advice: one pragmatic multicenter RCT (350 patients with chronic neck pain) [57] found no benefit from the addition of manual therapy (63% had mobilization physiotherapy) or pulsed shortwave diathermy to advice plus exercise at 6 weeks or 6 months.

Therapies likely to be ineffective

1. Patient education alone

Two RCTs in people with chronic neck, back or shoulder pain found no significant benefit from patient education (individual advice, pamphlets or group instruction) with or without analgesics, stress management or cognitive behavioral therapy.

• Educational pamphlet versus more extensive information versus cognitive behavioral therapy (CBT): the first RCT (243 people with neck and back pain) [58] compared three interventions: an educational pamphlet, a more extensive information program, and six sessions of CBT, and found no significant difference among treatments. However, post hoc analysis suggested that CBT significantly reduced time off work compared with an educational pamphlet (P = 0.05).

• Individualized education plus exercise program versus stress management versus no intervention: the second RCT (282 nurses with neck, shoulder or back pain in the preceding 12 months) [59] compared three interventions: an individualized education and exercise program, stress management, and no intervention. The RCT found no significant difference in pain among the groups immediately after treatment, or at 12 and 18 months.

2. Heat

Systematic reviews [2, 27, 28] identified two RCTs suggesting that heat was less effective than other therapies in people with uncomplicated neck pain. One RCT of people with chronic neck and back pain [45] found that heat combined with other physical treatment was less effective in improving outcomes than manipulation or mobilization (see "Manual therapy"). The second RCT [36] found infrared less effective when used alone than when combined with exercise or TENS (see "Exercise").

Therapies of unknown effectiveness

1. Multimodal treatment

Systematic reviews [2, 60] identified two RCTs which provided insufficient evidence to assess the benefit or cost-effectiveness of multimodal treatment in people with uncomplicated neck pain.

• Multimodal treatment versus CBT versus minimal treatment: one RCT (185 patients with nonspecific neck [87%] and/or back [91%] pain) [61] compared minimal therapy (advice to keep active), CBT (six sessions of structured CBT), and CBT plus physical therapy (same regimen as CBT group plus physical training). The RCT found that minimal treatment significantly increased the risk of being off work for 15 or more days compared with CBT plus physical training. It found no significant difference in sick leave between CBT and CBT plus physical therapy. However, the RCT included people with neck pain, back pain or both, and did not separately report results for those with neck pain alone.

• Different forms of multimodal therapy: the second RCT (66 people with chronic neck and shoulder pain) [62] compared exercise plus behavioral modification (patient education and advice, with a psychologist acting as an advisor to other staff) to exercise plus CBT (with CBT administered by a psychologist). It found no significant difference between the interventions in pain or time off work after 6 months.

2. Traction

Systematic reviews [2, 27, 28, 63, 64] identified two RCTs comparing traction versus sham traction, placebo tablets, exercise, acupuncture, heat, collar, and analgesics. The RCTs found no consistent difference in pain between traction and any of the other interventions.

3. Acupuncture

Systematic reviews [2, 27, 28, 65-67] identified 14 RCTs comparing needle or laser acupuncture with different control procedures (sham acupuncture, sham TENS, diazepam, traction, short-wave diathermy, and mobilization) in people with acute or chronic neck pain. None of the reviews was able to perform a meta-analysis, and the RCTs found no consistent difference in pain between acupuncture and any of the other interventions. The quality of the studies was considered "disappointing."

4. Pulsed electromagnetic field treatment (PEMF) Systematic reviews [2, 27, 28, 68] identified one RCT of moderate quality comparing PEMF versus sham PEMF in people with chronic neck pain. The RCT (81 people with neck pain and 86 people with osteo-arthritis of the knee) [69] compared true to sham PEMF. Subgroup analysis in people with chronic neck pain found that PEMF significantly reduced pain (P < 0.04) and pain on passive motion (P = 0.03), compared with sham PEMF, but there was no difference in a range of other parameters. Although randomization was conducted appropriately, baseline characteristics of treated and placebo groups were, by chance, different and it is not clear how much of the observed effect was caused by bias introduced by the baseline differences.

5. Transcutaneous electrical nerve stimulation (TENS)

Systematic reviews [2, 27, 28, 68] identified one RCT [36] that found that TENS plus infrared was equally effective to infrared plus exercise, and superior to infrared alone at 6 weeks (see "Exercise").

6. Drug treatments (analgesics, NSAIDs or muscle relaxants, tricyclic antidepressants)

No systematic review or RCTs examining the effects of drug treatments in people with nonspecific neck pain were found.

7. Facet joint injection

Two systematic reviews [70, 71] found moderate evidence of efficacy for facet joint block using medial branch blocks, but no evidence for cervical intra-articular facet joint blocks. One RCT of medial branch blocks of the facet joints (60 patients with facet joint disease confirmed by diagnostic medial branch block) were randomized to receive one of four preparations with the medial branch blocks: bupi-vacaine alone, bupivacaine plus sarapin, bupivacaine plus betamethasone, or all three agents together, with the same injections being repeated as required over the next year. Significant pain relief (>50%) and improved disability were observed in 80-87% of all patients at 3 months, 80-93% at 6 months and 8793% at 12 months, but with no difference between the treatment groups or patients who did or did not receive the steroid. The average number of treatments per patient was 3.8 +/—0.7 in the nonsteroid groups, and 3.4 +/ —1.0 in the steroid groups, with no significant difference among the groups [72].

8. Soft collars, special pillows, biofeedback, spray and stretch

There are no data on these measures in patients with nonspecific neck pain.

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