Research Review By Dr. Ceara Higgins©


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Date Posted:

June 2016

Study Title:

Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders by the OPTIMa collaboration


Wong JJ, Shearer HM, Mior S, et al.

Author's Affiliations:

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation; University of Ontario Institute of Technology (UOIT); Canadian Memorial Chiropractic College (CMCC); Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital; Toronto Health Economics and Technology Assessment (THETA) Collaborative; Leslie Dan Faculty of Pharmacy, University of Toronto; Institute for Work and Health; Alberta Centre for Injury Control and Research and School of Public Health, University of Alberta; Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal; Institute of Health Policy, Management and Evaluation, University of Toronto; Clinical Research, Kingston General Hospital; Department of Emergency Medicine, School of Medicine, Queen’s University; Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Centre, NYU School of Medicine, New York University.

Publication Information:

The Spine Journal 2016; 16: 1598-1630.

Background Information:

Neck pain is a common problem that has been associated with disability, reduced health-related quality of life and substantial costs to the health care system (1). In 2008, the Neck Pain Task Force presented evidence on the effectiveness of manual therapies, passive physical modalities, and acupuncture for the treatment of whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) (2). Their key findings included:
  1. Manipulation and mobilization demonstrate similar clinical effectiveness.
  2. Manipulation and mobilization also showed similar outcomes compared to other conservative interventions for subacute and chronic neck pain.
  3. Western massage was equivalent to sham acupuncture, but less effective than acupuncture in treating chronic neck pain.
  4. There was an extremely low risk of adverse events associated with spinal manipulation.
  5. Low-level laser therapy (LLLT) showed short-term improvement in subacute or chronic neck pain.
  6. Pulsed electromagnetic therapy was more effective than placebo.
  7. Magnetic necklaces showed similar outcomes to placebo interventions.
  8. Collars, transcutaneous electrical nerve stimulation (TENS), ultrasound, heat, and electrical muscle stimulation were equally or less effective than other interventions.
  9. Acupuncture may be effective for treating neck pain.
The Neck Pain Task Force identified a number of gaps in the research and outlined important research priorities, including:
  1. Comparing the use of cervical manipulation, thoracic manipulation, and traction for WAD; and
  2. examining the effectiveness of conservative interventions for cervical radiculopathy.
Since the 2008 Neck Pain Task Force findings were published, the IDEAL framework has been published and has allowed the classification of studies according to their stage of development, allowing the evidence to be better organized (3). Studies are classified within this framework as “exploratory studies”, which assess interventional efficacy, collect short-term outcomes, and help prepare for designing evaluation studies; or “evaluation studies”, which provide evidence of an intervention’s effectiveness, or comparative effectiveness to a standard of care (3). The purpose of this project was to update findings from the Neck Pain Task Force examining the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD.

Pertinent Results:

Literature Search Results:
22 studies were included. Of these, all were RCTs – 7 were categorized as exploratory studies and 15 as evaluation studies. 21 evaluated adults with NAD and one evaluated adults with WAD. All studies used clear research questions, appropriate randomization, valid and reliable outcome measures, and intention to treat analysis where applicable. 20 used proper allocation concealment and proper blinding procedures, while 17 showed similarity at baseline across groups. All but one study had a follow-up rate above 75%.

Exploratory Studies

WAD: No exploratory studies were found

Grades I-II NAD of Variable Duration:
Klein et al. compared a single strain-counterstrain session (passive neck positioning aimed to induce minimal-to-moderate muscle tension for 90 seconds) to a sham treatment (digital pressure adjacent to the spinous process of C4 with 30 degrees of passive neck rotation for 90 seconds) and found no between-group differences in neck pain intensity, cervical motion, or self-perceived recovery (4).

Recent-onset Grades I-II NAD:
Masaracchio et al. found that patients receiving two sessions of thoracic manipulation showed clinically significant improvements in neck pain (NRS), disability (NDI) and self-rated recovery when compared to patients receiving two sessions of cervical mobilization and home exercises (13). Cleland et al. found that patients receiving two thoracic manipulations showed clinically significant reductions in neck pain (NRS) and disability (NDI) compared to patients treated with thoracic mobilizations (14).

Persistent Grades I-II NAD:
Kanalayanaphotporn & Vachalathiti showed no differences in pain (VAS) or range of motion (ROM) in patients with persistent, unilateral neck pain, receiving a single session of targeted cervical mobilization compared with a single session of non-targeted cervical mobilization (15). Patients receiving central posterior-anterior cervical mobilization showed no clinically significant changes in pain (VAS), cervical ROM, or global perceived recovery when compared to patients receiving randomly directed mobilization (16). In a comparison of one mid-cervical and one cervico-thoracic manipulation to a 7-day application of Kinesio Tape over the cervical extensors, no clinically significant differences were seen in pain intensity (NRS), disability (NDI), and ROM (17). Finally, similar changes in pain (VAS) were found in patients treated with one session of upper thoracic manipulation compared with those receiving placebo thoracic manipulation (18).

Evaluation Studies

Grades I-II WAD of Variable Duration:
In a comparison of 6-weeks of needle electroacupuncture and simulated electroacupuncture, similar changes in disability (NDI) and health-related quality of life (SF-36) were seen in both groups, while statistically, but not clinically significant changes were seen in pain intensity (VAS) in patients receiving needle electroacupuncture at three and six months follow up (22).

Recent-onset Grades I-II NAD:
Leaver et al. compared neck manipulation to neck mobilization (four treatments over two weeks) and found no difference in pain (NRS), disability (NDI), and health-related quality of life (SF-12) immediately, or up to 12-weeks post treatment (20). Nagrale et al. examined a soft tissue therapy intervention that combined ischemic compression, strain-counterstrain, and muscle energy technique and showed statistically, but not clinically significant differences in pain (VAS), disability (NDI), and lateral flexion when compared to muscle energy technique alone (5).

Persistent Grades I-II NAD:
No additional improvements in pain, disability (NDI), global perceived effect, range of motion, strength, or satisfaction were found when cervical and thoracic manipulations were added to a high-dose supervised exercise program up to 52-weeks post-intervention (19). However, when cervical manipulation was added to traditional Chinese massage, patients reported greater reductions in pain, but no difference in neck pain related disability immediately post-intervention (8). When compared to a self-care book, the combination of Swedish and/or clinical massage and self-care advice was superior for reducing disability (NDI) and symptom bothersomeness (NRS) in the short-term and in reducing symptom bothersomeness in the long-term (6).

Lauche et al. compared a group given a one-hour workshop on home-based cupping techniques with a group given a one-hour workshop on progressive muscle relaxation techniques. Both groups were asked to carry out independent home care twice per week for 12 weeks. Both groups showed similar changes in pain (VAS), pain perception, disability (NDI), psychological outcomes, and quality of life (SF-36) (7).

Dundar et al. compared LLLT (wavelength of 830-nm, frequency of 1000Hz, power output of 58mW/cm2, dose of 7J per point) with a device that was not activated, both applied to three trigger points bilaterally and found neither to be effective in reducing pain (VAS) or disability (NDI) (9). When TENS was compared to a multimodal soft tissue therapy program, similar changes were found in pain (VAS), disability (NDI), and health-related quality of life (SF-12) at one and six months post-treatment (10).

Two studies on needle acupuncture found that traditional Chinese medicine acupuncture and sham-penetrating acupuncture (needles inserted superficially 1cm lateral to traditional acupuncture points) showed statistically, but not clinically significant differences in pain (VAS) and disability (Northwick Park Questionnaire) favouring traditional Chinese medicine acupuncture (23, 24). Western acupuncture showed statistically, but not clinically significant improvements in pain (VAS), disability (NDI), and health-related quality of life (SF-36) when compared to non-penetrating placebo electroacupuncture (inactivated electrodes placed on acupuncture points) (25).

Grade III NAD of Variable Duration:
Patients receiving intermittent cervical traction along with a multimodal program of care, including postural education, manipulation or mobilization, exercises and home exercise showed no additional benefits to pain (NRS) or disability (NDI) when compared to the same multimodal program of care with sham cervical traction up to 4-weeks post-treatment (21).

Recent-Onset Grade III NAD:
Kuijper et al. investigated three interventions:
  1. Three weeks of wearing a semi-hard cervical collar with rest, followed by three weeks of weaning from the collar;
  2. advice to continue daily activities; or
  3. six weeks of supervised graded strengthening exercises for the neck and shoulder.
They found that both the strengthening program and the semi-rigid collar showed similar improvements in arm pain (VAS), neck pain (VAS), and disability (NDI) and were both superior to advice (12).

When Konstantinovic et al. compared LLLT to placebo LLLT (deactivated laser treatment) they found statistically, but not clinically significant improvements in arm pain, neck pain (VAS), disability (NDI), and physical health-related quality of life (SF-12) with LLLT (11).

Adverse Events:
Of the 22 studies evaluated, 16 addressed adverse events. Most reported adverse events were mild to moderate and transient, with reported rates ranging from 0% to about 30%. No serious neurovascular events were reported. Only two serious adverse events were reported, both in patients allocated to cervical mobilization, and neither was reported as related to treatment. One patient experienced a cardiac event and one developed severe arm pain and weakness three days after mobilization (20).

Comparison with the 2008 Neck Pain Task Force Report

New findings since the Neck Pain Task Force Report:

The exploratory studies found thoracic manipulation to be beneficial to individuals with recent NAD grades I-II but no better than placebo for individuals with persistent NAD grades I-II. One session of cervical and cervico-thoracic manipulation was found to be as effective as one week of Kinesio Tape in the short term for persistent NAD grades I-II, while strain-counterstrain soft tissue therapy was not found to be beneficial for NAD.

Evaluation studies showed that manipulation provided additional benefits compared to traditional Chinese massage, but not to high-dose supervised exercise in individuals with persistent NAD grades I-II. Home-based cupping and home-based progressive muscle relaxation showed similar results for persistent NAD grades I-II, however, the interventions in this study were different from those that would be delivered in clinical practice and may affect the external applicability of the study. Finally, LLLT was not effective for recent-onset NAD grade III and traction did not provide any additional benefit to a multimodal program for NAD III.

Findings consistent with the Neck Pain Task Force Report:

Evaluation studies showed similar outcomes with cervical manipulation and cervical mobilization in individuals with recent NAD grades I-II. No serious events were reported. No studies were found that compared different cervical manipulative techniques, so it is unclear if specific technique is more effective than others.

Findings inconsistent with the Neck Pain Task Force Report:

Evaluation studies showed additional benefit to patients with persistent NAD grades I-II when relaxation and/or clinical massage was added to self-care advice. The 2008 Neck Pain Task Force reported that relaxation massage was not effective in treating chronic neck pain, however, it is possible that the clinical massage provided benefit in the current study.

New evidence assessed in this article suggested that LLLT was not effective for persistent NAD grades I-II, however, when combined with evidence from the Neck Pain Task Force, most evidence supports the effectiveness of LLLT for treatment of persistent NAD. For grade III NAD, graded strengthening exercises and the use of a cervical collar with rest were both effective. However, due to the potential for iatrogenic disability, caution should be taken when using cervical collars.

Although the Neck Pain Task Force reported that needle acupuncture added to routine general medical care was able to provide short-term benefits to individuals with persistent neck pain, this article found that electroacupuncture was not effective in treating WAD I-II and Western acupuncture and needle acupuncture was not effective in treating persistent NAD I-II. Where acupuncture was compared to needling interventions where the skin was penetrated, it is possible that the control group also received a physiological effect. Therefore, studies with non-penetrating sham/placebo treatments are needed.

Findings from the Neck Pain Task Force Report that cannot be supported or clarified:

No new evidence was found on the effectiveness of ultrasound, diathermy, heat therapy, electrical muscle stimulation, magnetic necklaces, or TENS.

Clinical Application & Conclusions:

In summary, this update to the Neck Pain Task Force suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain, while electroacupuncture, strain-counterstrain, relaxation massage, and other passive physical modalities are not as effective and should not be considered first line options in the treatment of neck pain.

Study Methods:

Search Strategy:
MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials were searched for relevant NAD/WAD studies from January 1st, 2000 to:
  • March 21st, 2013 for manipulation, mobilization, and traction
  • February 27th, 2014 for soft tissue therapy
  • April 9th, 2013 for passive physical modalities
  • January 31st, 2013 for acupuncture
A two-phase screening process was utilized. In phase one, random pairs of independent reviewers screened citation titles and abstracts classifying the citations as relevant, possibly relevant, or irrelevant. In phase two, the full text of the possibly relevant articles was reviewed to make a final determination of eligibility. In cases where consensus was not reached, a third reviewer was involved.

Inclusion Criteria for Studies:
  • Subjects were adults and/or children with WAD or NAD grades I-III as classified by the Quebec Task Force and the Neck Pain Task Force.
  • Studies had to evaluate the specific effectiveness of manual therapies (application of hands-on and/or mechanically assisted treatments), passive physical modalities (physical treatment involving a device that does not require active participation by the patient), or acupuncture (body needling, moxibustion, electroacupuncture, laser acupuncture, microsystem acupuncture, or acupressure).
  • Studies had to compare manual therapies, passive physical modalities, or acupuncture to other interventions, waiting list, placebo/sham intervention, or no intervention
  • Inclusion of a relevant outcome measure including self-rated or functional recovery, clinical outcomes, psychological symptoms, administrative outcomes, and/or adverse events.
  • English language publication.
  • Study design had to be a randomized controlled trial (RCTs), cohort or case-controlled.
  • Sample size had to be an inception cohort of a minimum of 30 subjects per treatment arm for RCTs, or 100 subjects per exposed group for cohort or case-controlled studies
Exclusion Criteria:
  • Studies of neck pain due to major structural pathology.
  • Guidelines, narrative reviews, letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, and guideline statements.
  • Cross-sectional studies, case reports, case series, qualitative studies, non-systematic and systematic reviews, biomechanical studies, laboratory studies, and studies not reporting on methodology.
  • Cadaveric or animal studies.
  • Studies already included in the prior Neck Pain Task Force Report.
Eligible studies were appraised using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for risk of bias. Studies with a low risk of bias were included in the evidence synthesis. Studies were specifically appraised for the clarity of the research question, randomization methods, concealment of treatment allocation, blinding of treatment and outcomes, similarity of baseline characteristics between/among treatment arms, co-intervention contamination, validity and reliability of outcome measures, follow-up rates, analysis according to intention to treat principles, and comparability of results across study sites (where applicable).

A qualitative synthesis of findings was performed using best evidence synthesis principles (18). Results were separated by the type of disorder (i.e. WAD or NAD grades I-III), duration (i.e. recent [< 3 months], persistent [≥ 3 months], variable duration [study does not differentiate]), and into exploratory versus evaluation studies according to the IDEAL framework. Standardized cut-off values were used to determine clinically important changes in outcome measures. These included a between-group difference of 2/10 on the Numeric Rating Scale (NRS), 10/100 mm on the Visual Analogue Scale (VAS), and 5/50 on the Neck Disability Index (NDI).

Study Strengths / Weaknesses:

  • Search strategies were developed with a health sciences librarian and reviewed by a second librarian using the Peer Review of Electronic Search Strategies (PRESS) (14).
  • Clear case definitions, inclusion criteria, and exclusion criteria were used.
  • Only studies with an adequate sample size were accepted.
  • The SIGN criteria was used to standardize the critical appraisal of the literature.
  • The best evidence synthesis method was used to form conclusions while minimizing the risk of bias associated with using low quality studies.
  • No explanation for the differing search dates applied for each treatment was provided (as mentioned, the searches were completed up to 2013 or 2014, depending on the treatment).
  • Only English literature was searched, which may have excluded some important papers.
  • Qualitative studies were not included, therefore no comments can be made on how the patients valued and experienced their treatments.

Additional References:

  1. Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther 2010;15: 334-354.
  2. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33: S123-152.
  3. Ergina PL, Barkun JS, McCulloch P, et al. IDEAL framework for surgical innovation 2: observational studies in the exploration and assessment stages. BMJ 2013; 346: f3011.
  4. Klein R, Bareis A, Schneider A, Linde K. Strain-counterstrain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomized trial. Complement Ther Med 2013; 21: 1-7.
  5. Nagrale AV, Glynn P, Joshi A, Ramteke G. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial. J Man Manip Ther 2010; 18: 37-43.
  6. Sherman KJ, Cherkin DC, Hawkes RJ, et al. Randomized trials of therapeutic massage for chronic neck pain. Clin J Pain 2009; 25: 233-238.
  7. Lauche R, Materdey S, Cramer H, et al. Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain- a randomized controlled trial. PLoS One 2013; 8: e65378.
  8. Lin JH, Shen T,Chung RC, Chiu TT. The effectiveness of Long’s manipulation on patients with chronic mechanical neck pain: a randomized controlled trial. Man Ther 2013; 18: 308-315.
  9. Dundar U, Evcik D, Samli F, et al. The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: a double blind, placebo-controlled study. Clin Rheumatol 2007; 26: 930-934.
  10. Escortell-Mayor E, Riesgo-Fuertes R, Garrido-Elustondo S, et al. Primary care randomized clinical trial: manual therapy effectiveness in comparison with TENS in patients with neck pain. Man Ther 2011; 16: 66-73.
  11. Konstantinovic LM, Cutovic MR, Milovanovic AN, et al. Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Pain Med 2010; 11: 1169-1178.
  12. Kuijper B, Tans JT, Beelan A, et al. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomized trial. BMJ 2009; 339: b3883.
  13. Masaracchio MC, Hellman M, Hagins M, et al. Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther 2013; 43: 118-127.
  14. Cleland JA, Whitman J, Eberhart S, et al. Short-term response of thoracic spine thrust versus non-thrust manipulation in patients with mechanical neck pain: preliminary analysis of a randomized clinical trial. J Manual Manip Ther 2007; 14: 172.
  15. Kanlayanaphotporn RC, Vachalathiti R. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Archives of physical medicine and rehabilitation [serial on the Internet]. 2009; 90(2).
  16. Kanlayanaphotporn RC, Vachalathiti R. Immediate effects of the central posteroanterior mobilization techniques on pain and range of motion in patients with mechanical neck pain. Dis Rehab 2010; 32: 622-628.
  17. Saavedra-Hernandez M, Castro-Sanchez AM, Arroyo-Morales M, et al. Short-term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther 2012; 42: 724-730.
  18. Sillevis RC, Hellman M, Beekhuizen K. Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial. J Man Manip Ther 2010; 18: 181-190.
  19. Evans R, Bronfort G, Schulz C, et al. Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain: a randomized controlled trial. Spine 2012; 37: 903-914.
  20. Leaver A, Herbert R, Latimer J, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil 2010; 91(9).
  21. Young I, Cleland J, Aguilera A, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: A randomized clinical trial. Phys Ther 2009; 89: 632-642.
  22. Cameron ID, Wang E, Sindhusake D. A randomized trial comparing acupuncture and simulated acupuncture for subacute and chronic whiplash. Spine 2011; 36: E1659-1665.
  23. Fu WL, Zhu X, Yu P, et al. Analysis on the effect of acupuncture in treating cervical spondylosis with different syndrome types. Chinese J Integrative Med 2009; 15: 426-430.
  24. Liang ZZ, Yang X, Fu W, Lu A. Assessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomized controlled study. Complement Ther Med 2011; 19 Suppl 1: S26-32.
  25. White PL, Prescott P, Conway J. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized controlled trial. Annals Intern Med 2004; 141: 911-919.