Research Review by Dr. Kent Stuber©

Date:

June 2008

Study Title:

Treatment of neck pain: noninvasive interventions. Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders

Authors:

Hurwitz EL, Carragee EJ, van der Velde G, et al.

Authors’ Affiliations: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
  • Hurwitz – Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawaii at Manoa
  • Carragee – Department of Orthopaedic Surgery, Stanford University School of Medicine; Orthopaedic Spine Center and Spinal Surgery Service, Stanford University Hospital and Clinics
  • van der Velde – Department of Health Policy, Management and Evaluation, University of Toronto; Institute for Work and Health, Toronto; Centre for Research Excellence in Improved Disability Outcomes (CREIDO) University Health Network Rehabilitation Solutions, Toronto Western Hospital; Division of Health Care and Outcomes Research, Toronto Western Hospital Research Institute

Publication Information:

Spine 2008; 33(4S): S123-S152.

Summary:

The Neck Pain Task Force (NPTF) evaluated articles on noninvasive treatments for neck pain and associated disorders for two main clinical presentations:
  1. The post-motor vehicle accident patient with neck pain
  2. The neck pain patient that is not subsequent to MVA
To review, the NPTF recommend classifying neck pain into four grades similar to those used in WAD as set out in the Quebec Task Force Classification. They are as follows:
  • Grade I neck pain is neck pain and associated disorders with no signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living.
  • Grade II neck pain indicates no signs or symptoms of major structural pathology, but major interference with activities of daily living.
  • Grade III neck pain indicates no signs or symptoms of major structural pathology, but presence of neurologic signs or nerve compression such as decreased deep tendon reflexes, weakness, or sensory deficits.
  • Grade IV neck pain indicates signs or symptoms of major structural pathology.
The NPTF accepted 156 articles related to noninvasive treatments of neck pain including 80 primary studies. Of these, 70 were RCTs with the remainder including 3 cohort studies and 5 non-randomized clinical trials. 17 of the studies focused on whiplash, 46 were on non-traumatic neck pain, and 11 were on radiculopathy patients (grade III neck pain). 30 systematic reviews relating to noninvasive treatments for neck pain were also included in the analysis.

In this summary, each different treatment modality reviewed by the NPTF in this article will be discussed in order.

Education or Advice:
Education or advice are almost always mandated in the treatment of any condition, unfortunately a treatment arm containing this intervention does not often appear in clinical trials, and even then the definition of education or advice can vary considerably (from pamphlets to videos, etc). Educational videos have been shown to be associated with reduced pain levels in acute whiplash associated disorders (WAD). In non-specific neck pain there does not appear to be any superior form of advice or educational intervention.

Exercise Interventions:
In WAD the evidence supporting the use of exercise as the only intervention is inconsistent. Exercise has compared favorably with passive modalities or soft collars in acute or subacute WAD, but not as much as when compared with simple education or usual care. Supervised physical training appears to improve numerous outcomes when compared with instructions for home exercise in the short term. For nonspecific neck pain, exercise therapy seems to be helpful either by itself or as an adjunct to manipulation for non-acute neck pain and disability in the short term when compared to manipulation alone, TENS, or usual general practitioner care.

Endurance and strength training are better for neck pain and disability than exercise advice alone. Exercise and TENS have performed comparably when compared with infrared irradiation for neck pain and disability. Exercises that focus on eye-neck coordination and proprioception result in greater pain reduction and perceived improvement when compared with symptomatic care alone. Low-load exercise appears helpful for cervicogenic headache.

Manual Therapy:
In whiplash, mobilizations were found to be more effective in reducing pain than usual care, soft collars, or advice. Manual therapy and relaxation treatment as a multimodal plan resulted in high satisfaction and quicker return to work rates than passive modalities. For non-specific neck pain there were numerous studies on manual therapy accepted into the Task Force analysis (17 studies in 27 articles).

Studies on different forms of manual therapy (manipulation, mobilization, and massage) have been conducted comparing those therapies alone or in combination with other therapies against other treatments. Unfortunately results between studies are inconsistent. This could be partially due to variances in forms of manual therapy, the number of treatment sessions, etc. Mobilizations have compared favorably against usual care, pain medications, and advice.

Modalities:
  • Physical Modalities: Passive modalities (TENS, ultrasound, diathermy) alone or combined with mobilizations were not associated with better pain outcomes when compared with exercise and manual therapy for acute or sub-acute WAD. For non-specific neck pain, modalities alone or in combination with other treatments or medication do not lead to clinically important pain and functional outcome improvements when compared with mobilizations, other modalities, usual care or sham interventions. Percutaneous neuromodulation therapy was associated with post-treatment decreases in pain and improved sleep and with more physical activity than placebo.
  • Laser Therapy: Low level laser therapy is associated with pain level and functional improvements when compared with placebo for non-specific neck pain.
  • Acupuncture: For nonspecific neck pain there is inconsistent evidence as to whether acupuncture is superior to sham acupuncture for short and long term outcomes, however it has outperformed massage in one study in terms of pain outcomes, but was not associated with better outcomes than mobilization and traction
Combined Approach:
There is evidence from one study that a coordinated multidisciplinary treatment of WAD is positively associated with quicker claim closure and lower average costs when compared with usual care; however referrals to fitness training or rehabilitation plus usual care are not associated with faster recovery rates in acute WAD when compared with usual care alone. A multimodal treatment package consisting of psychological support, manual therapy, eye fixation exercises, relaxation and postural training resulted in greater patient satisfaction and faster return to work when compared with physical modalities (pain scores between the groups were similar however).

For nonspecific neck pain there is inconsistent evidence that multimodal interventions are associated with improved outcomes in the short or long term when compared with usual care or other single interventions.

Collars:
Collars have been used in a few acute whiplash studies, but have been found to be of no benefit or less benefit than other treatments with respect to reduction of pain or disability levels in either the short or long term. One study on cervicobrachial pain patients showed that those in collars for 3 months did not improve when compared with multimodal or surgical intervention.

Medications:
In many studies, medications of various forms (pain-killers, anti-inflammatories, muscle relaxants) are considered part of “usual care”. Neither corticosteroids nor methylprednisone appear to be of benefit in patients with WAD when compared with placebo. For non-specific neck pain analgesics (orphenadrine) combined with muscle relaxants (paracetamol) have shown effectiveness when compared with placebo. Salicylates in combination with advice and mobilizations appear to be associated with greater short-term pain reduction than salicylates alone or in combination with other physical therapy modalities.

Other medications including botulinum toxin A, keterolac tromethamine (im) do not appear to be helpful in non-specific neck pain, and there is no evidence to support or refute the use of other NSAIDS, narcotic, or anti-depressants in the treatment of non-specific neck pain.

Workplace Interventions:
In non-specific neck pain, computer programs that encourage more regular work breaks (that included rest or exercise) appear ineffective in reducing neck pain intensity or frequency or resulting sick leave, however it appears to help facilitate recovery and encourage productivity. Multiple ergonomic interventions produce only minor reductions in neck pain intensity and frequency. Physical training and stress management have not been proven more effective in preventing or reducing neck and shoulder pain than no intervention at all. In Saskatchewan at the presentation of the NPTF findings, it was commented that ergonomic and workplace interventions were one of the most disappointing areas, as there is no strong evidence to support the use of any single workplace intervention in the treatment or prevention of neck pain.

Patterns or Course of Care:
In WAD, there is consistent evidence that high health care utilization in the month following a traffic accident is associated with slower times to claim closure. No particular course of care using any combination of treatments for WAD has been shown to be superior.

Intervention Safety:
No serious adverse effects of any noninvasive treatment have been noted in whiplash trials. The NPTF has concluded that the potential risk associated with cervical spinal manipulative therapy for causing vertebrobasilar artery strokes is very small but similar to rates in those seeing their medical physician, as has been highlighted in other Research Review Service reviews.

Transient minor discomfort appears to occur more commonly when manipulation is used as compared to mobilization, in one study where keterolac (im) was compared with manipulation, the keterolac patients reported more minor side effects. Botulinum toxin A was studied in one placebo-controlled trial and botulinum patients had increased rates of adverse reactions. No single or combination of noninvasive treatments are associated (positively or negatively) with clinically important adverse outcomes (short or long term) when compared with other treatments for non-specific neck pain.

Prevention:
There is no evidence of any single or combination of interventions that are associated with the prevention, incidence, or recurrence of WAD (other than not getting into an accident in the first place) or non-specific neck pain or associated disorders

Cost and Cost-Benefit:
Coordinated multidisciplinary treatment with active interventions was associated with fewer costs than usual treatment in one study. There have been studies that indicate an association between high health care utilization and slower WAD recovery rates. For non-specific neck pain, manual therapy (mobilizations) is less costly and more effective than physiotherapy or general practitioner care alone when considering cost effectiveness and cost utility ratios for subacute or chronic neck pain.

Brief physiotherapy intervention resulted in lower costs and lower quality adjusted life years when compared with usual physiotherapy, making usual physiotherapy less cost effective. Costs for acupuncture were higher than routine care but adding it to routine medical care was still considered cost effective when considering quality adjusted life years.

Grade III Neck Pain (includes radicular symptoms or cervical radiculopathy):
There is no evidence of a superior noninvasive treatment or combination of treatments for radiculopathy or Grade III neck pain.

Cervicogenic Headache:
A water pillow has been associated with increased pain relief and improved sleep quality in patients with neck pain with or without cervicogenic headache when compared with a roll or normal pillow. Therapeutic exercise with or without manipulation/mobilization was associated with reductions in headaches and overall better outcomes in patients with cervicogenic headaches when compared with no intervention.

Conclusions & Practical Application:

Certainly the NPTF had to sort through a mountain of information to generate any conclusions. They provide an evidence table that can allow the reader to determine some treatments to potentially apply or not apply for different patients presentations as seen below. Please note that the “DO USE” below represents interventions that the NPTF has deemed likely (denoted with a *) or possibly helpful. Those deemed likely to be helpful are worthy considerations for the practicing clinician interested in evidence based practice.

The “DO NOT USE” group includes treatments that the NPTF has either found will likely not be helpful or there is insufficient evidence from which they can base an opinion. Those in the likely not helpful category (denoted with a *) are ones whose use a clinician may find themselves having a hard time justifying down the road.

WHIPLASH (Grade I or II WAD)

DO USE (Deemed Likely or Possibly Helpful by the NPTF):
  • Educational video*
  • Mobilization*
  • Exercises*
  • Exercises and mobilization*
  • Pulsed electromagnetic therapy
  • Coordinated multidisciplinary care (in non-acute WAD)
DON’T USE (Deemed Likely Not Helpful or Not Enough Evidence by the NPTF):
  • Pamphlet / neck booklet alone*
  • Cervical collars*
  • Passive modalities*
  • Referral to fitness or rehab program*
  • Frequent early health care use*
  • Methylprednisone*
  • Corticosteroid injections*
  • Manipulation
  • Traction
  • NSAIDS or other drugs
NECK PAIN NOT ASSOCIATED WITH WAD (Grade I or II)

DO USE (Deemed Likely or Possibly Helpful by the NPTF):
  • Manipulation*
  • Mobilization*
  • Supervised exercises*
  • Manual therapy plus exercise*
  • Acupuncture*
  • Low-level laser therapy*
  • Analgesics*
  • Percutaneous neuromodular therapy
  • Brief intervention using cognitive behavioral principles
DON’T USE (Deemed Likely Not Helpful or Not Enough Evidence by the NPTF):
  • Advice alone*
  • Collars*
  • Passive modalities*
  • Exercise instruction*
  • Botulinum toxin A*
  • Magnetic stimulation
  • Massage
  • Traction
  • NSAIDS or other drugs
NECK PAIN WITH RADIATION OR CERVICAL RADICULOPATHY (Grade III)

DO USE (Deemed Likely or Possibly Helpful by the NPTF):
  • No intervention of choice
DON’T USE (Deemed Likely Not Helpful or Not Enough Evidence by the NPTF):
  • All interventions found to have insufficient evidence
CERVICOGENIC HEADACHE

DO USE (Deemed Likely or Possibly Helpful by the NPTF):
  • Water pillow
  • Supervised exercise
  • Manipulation / Mobilization
  • Manipulation or mobilization plus supervised exercise
DON’T USE (Deemed Likely Not Helpful or Not Enough Evidence by the NPTF):
  • Passive modalities
  • Traction
  • NSAIDS or other drugs
WORKERS WITH NECK PAIN (Grade I or II)

DO USE (Deemed Likely or Possibly Helpful by the NPTF):
  • Supervised exercise plus strength or endurance training and/or relaxation training with behavioral support
DON’T USE (Deemed Likely Not Helpful or Not Enough Evidence by the NPTF):
  • Ergonomic interventions*
  • Forced work breaks*
  • Rehabilitation programs*
  • Stress management programs*
  • Relaxation training*
  • Physical training*
  • Exercise instruction*
It is imperative for the clinician to correctly diagnose their patient and sort them into the correct patient presentation (Grades I-IV, cervicogenic headache, etc) to help them select the most efficacious treatments for that particular presentation.

It will be of interest to manual therapy practitioners to see how often some form of manual therapy is recommended by the NPTF. Mobilizations were deemed likely helpful in Grade I and II whiplash, manipulation and mobilizations were both deemed likely helpful in Grade I and II non-specific neck pain and both deemed possibly helpful in cervicogenic headache.

It is interesting to note that only laser and acupuncture were the only modality based treatments found to be likely to help for non-specific neck pain.

It is unfortunate that cervical radiculopathy has not been better studied for non-invasive interventions as there is no clearly recommended treatment for this type of neck pain.