Evidence Based Interventions for Neck Pain

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Introduction

Once any signs of potentially serious disease are excluded, the physiotherapist can confidently consider the condition to be suitable for physiotherapy management. When managing individuals with neck pain clinicians should consider implementing approaches based on risk, impairment, or response to treatment when choosing their interventions.

Unfortunately the literature fails to provide sufficient, high-quality evidence to effectively guide the conservative treatment of individuals with neck pain. This lack of quality evidence largely stems from the poorly understood clinical course of neck pain in conjunction with the inconclusive results related to the efficacy of commonly used interventions[1]. One reason the outcomes in the literature may be less than impressive is that many of the studies looking at conservative treatments for the management of neck pain use a heterogeneous subject population[2][3]. Many studies also combine clinical manifestations (such as acute whiplash, subacute and chronic mechanical disorders, and chronic cervical headache) into the same case mix during clinical trials[4]. The identification of a homogeneous patient population would likely enhance the potential to initiate targeted interventions and to specifically assess treatment responses[1][3].

Education

Education plays a great role in the management of individuals with neck pain[5] and this may be the most important and most challenging part of the treatment. The physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient[6] and providing biomechanical information about the spine that is not evidence-based can add to their concerns[7]. It is important to avoid reinforcing individuals fears about the threatening processes that might be going on in their spine as these fears or concerns can act as a barrier to recovery and need to be properly addressed[7]

An essential component of treatment for individuals with neck pain is to encourage active self-management. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. Advice can be effectively supported by offering simple evidence-based educational materials.

Key messages[5]:

  • Stay active and return to normal activities - there is evidence that remaining active has, in general, resulted in better outcomes than the alternative (immobilization)[5] however in some cases such as in people with high levels of pain, rest may be recommended for a few days to reduce pain.
  • Provide information about the nature of the injury - specific pathoanatomic sources of pain cannot be identified in most individuals with neck pain[8][9][10] therefore information that can be provided is limited and often restricted to the “absence of severe pathology"[5].
  • Provide information about course of recovery - positive expectations of recovery are associated with less pain and disability which highlights the importance of a positive message. However many individuals with neck pain report ongoing pain and disability after 12 months, it remains to be tested as to whether a differential message about the course of recovery should be provided to those at high risk[5].
  • Provide information about coping strategies and address unhelpful beliefs - individuals should be provided with information about how to cope with pain and disability, particularly as their symptoms transition to the chronic phase. Key concepts to address are reducing catastrophic thought,60 giving active coping strategies, and addressing fear of movement
  • Pain education - pain neurophysiology education can be effective in changing pain behaviours.

Simple therapist led patient education has been shown to be more effective in comparison to more comprehensive exercise in individuals with both acute[11] and chronic[12] whiplash.

Exercise Therapy

Exercise is recommended as an effective way of managing neck pain disorders and has been shown to be more effective in comparison to more passive interventions[5][13]. There is also evidence that both strengthening and endurance regimes have superior benefits over other forms of activity, such as stretching programmes or returning to normal activity[5]. In WAD neck postural/stabilisation exercises are more effective then a cervical collar for reducing pain[13].

A range of exercise approaches may be employed, these include exercises to improve range of motion (ROM), to reduce pain (eg, McKenzie method), to improve cervical proprioception, to address cervical muscle impairments, and to improve function. No one exercise regime stands out however clinical guidelines and clinical experts recommend the selection of exercises is based on 2 factors: first the presence of specific physical impairments where exercises should be selected accordingly, and second do related symptoms improve as a result of implementing exercises addressing identified impairments.

Multimodal treatment approaches that include the use of exercise therapy appear to be more effective than single treatments alone for the management of neck pain. Education and exercise have the highest evidence for their role in the management of individuals with whiplash[14]. Manual therapy is more effective when used in combination with exercise for individuals with chronic neck pain[3][15][16][17].

Available adherence strategies for adoption and maintenance of home exercise should be integrated to maximise clinical benefit over the long term[13].

Passive Treatments

Passive therapies are not always recommended as first line interventions[5]. Low or conflicting evidence of effectiveness leads to recommendations that passive therapies should be provided as part of a multimodal package that includes active treatment, provided there is evidence of benefit[13].

Manual Therapy

Evidence suggests that mobilisation/manipulation is beneficial for at least some patients with neck pain (neck pain alone or with mobility deficits or headaches)[3][13]. There is no evidence for manual therapy techniques alone for individuals with WAD[13]. Evidence also suggests that manual therapy is more effective when used in combination with exercise[3][15][16][17].

Traction

Traction is frequently used with the intent of symptom centralisation particularly in radicular pain however research on it's effectiveness is inconclusive. Cleland et al[18] reported drastic reductions in disability in indivudlas with cervical radiculopthy following a conservative management strategy that included intermittent cervical traction, manual therapy, and deep neck flexor muscle strengthening. However Young et al[19] suggested that traction plus manual therapy and exercise does not improve short-term outcomes in patients with radiating neck pain compared to manual therapy and exercise alone.

Physical Modalities

Electrothermal therapy has often been used as the comparison group where manual therapy has been show to be more effective. There may be short term benefits of laser, dry needling, and intermittent traction for chronic neck pain with mobility deficits[13]. Intermittent traction combined with other interventions such as manual therapy and strengthening exercises can be used for reducing pain and disability in patients with neck and neck-related arm pain[13]. There is conflicting evidence for the use of dry needling[13]. There is evidence for the use of TENS in WAD[13]. The use of collars can be detrimental[13].

Behavioural Interventions

Psychosocial factors play an important role in persisting symptoms and disability, and influence the response to treatment and rehabilitation. If relevant psychosocial factors are identified, the rehabilitation approach may need to be modified. An emphasis on active rehabilitation and positive reinforcement of functional accomplishments is recommended. Graded exercise programs that direct attention towards attaining certain functional goals and away from the symptom of pain have also been recommended. Finally, graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform may be helpful.

Cognitive Behavioural Therapy (CBT) is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner. The CBT approach to LBP can be as effectively applied to neck pain and can be included in your education strategy. The extent of training and the resulting skill levels that are required to deliver an effective cognitive behavioural intervention may be critical[20].

References

  1. 1.0 1.1 Heintz MM, Hegedus EJ. Multimodal management of mechanical neck pain using a treatment based classification system. Journal of Manual & Manipulative Therapy. 2008 Oct 1;16(4):217-24.
  2. Lewis M, James M, Stokes E, et al. An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial. Rheumatology (Oxford) 2007;46:1701–1708.
  3. 3.0 3.1 3.2 3.3 3.4 Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
  4. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine. 2001;26:788–797. discussion 798–799
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Rebbeck T. The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-32.
  6. Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med 2004; 164:1365–8.
  7. 7.0 7.1 Moffett J, McLean S. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology. 2005 Dec 6;45(4):371-8.
  8. Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a systematic review. Pain. 1998;77:1-13
  9. Fritz, J. M., & Brennan, G. P. (2007). Preliminary Examination of a Proposed Treatment-Based Classification System for Patients Receiving Physical Therapy Interventions for Neck Pain. Physical Therapy, 87(5), 513-524.
  10. Hush JM, Maher CG, Refshauge KM. Risk factors for neck pain in office workers: A prospective study. BMC Musculoskelet Disord. 2006;7:81
  11. Lamb SE, Gates S, Williams MA, et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. Lancet. 2013;381:546-556
  12. Michaleff ZA, Maher CG, Lin CW, et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet. 2014;384:133-141
  13. 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK, Altman RD, Beattie P, Boeglin E. Neck Pain: Revision 2017: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jul;47(7):A1-83
  14. Rebbeck T. The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-32.
  15. 15.0 15.1 Walker M, Boyles R, Young B, Strunce J, Garber M, Whitman J, Deyle G, Wainner R. The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain. SPINE. 2008;33(22):2371-2378
  16. 16.0 16.1 Cleland J, Mintken P, Carpenter K, Fritz J, Glynn P, Whitman J, Childs J. Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical Range of Motion Exercise: Multi-Center Randomized Clinical Trial. Phys Ther. 2010;90(9):1239-1250
  17. 17.0 17.1 Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. Cervical overview group. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database Syst Rev. 2004;(1):CD004249
  18. Cleland JA, Fritz JM, Whitman JM, Heath R. Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Phys Ther. 2007;87:1619–1632
  19. Young I, Michener L, Cleland J, Aguilera A, Snyder A. Manual Therapy, Exercise and Traction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial. Phys Ther. 2009;89(7):1-11
  20. Moffett J, McLean S. The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology. 2005 Dec 6;45(4):371-8.