Evidence Based Interventions for Neck Pain

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Top Contributors - Rachael Lowe, Kim Jackson, Simisola Ajeyalemi, Jess Bell and Nupur Smit Shah  

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. 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. 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. The identification of a homogeneous patient population would likely enhance the potential to initiate targeted interventions and to specifically assess treatment responses.

Current trends in research support the use of manual therapy in combination with exercise

Education

Education plays a great role in the management of individuals with neck pain 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 and providing biomechanical information about the spine that is not evidence-based can add to their concerns. 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. 

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.

Exercise Therapy

Exercise-based neck/shoulder rehabilitation can be an effective way of managing cervicogenic disorders. No one exercise regime stands out although there is some evidence that both strengthening and endurance regimes have superior benefits over other forms of activity, such as stretching programmes or returning to normal activity. 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

Motor control

Sensorimotor

Passive Treatments

Manual Therapy

Evidence suggests that mobilisation/ manipulation is beneficial for at least some patients with neck pain. Hoving et al reported in a high quality randomised clinical trial that manual therapy consisting of mobilisations performed by a physical therapist was more effective in improving outcomes and more cost effective than a physical therapy intervention that did not incorporate a manual therapy approach, or than continued care by a general practitioner. It is also suggested that patients with restricted cervical range of motion and symptoms isolated to the neck (ie, no upper extremity symptoms) may also be more likely to benefit from mobilisation/manipulation. Evidence also suggests that manual therapy is more effective when used in combination with exercise.

Traction

A recent study performed by Cleland et al which included patients with cervical radiculopathy reported drastic reductions in disability following a conservative management strategy that included intermittent cervical traction, manual therapy, and deep neck flexor muscle strengthening. However, further research is needed on traction which is frequently used with the intent of symptom centralizationhas not been proven to be effective.

Psychosocial Aspects

There is evidence that psychosocial factors (yellow flags) are more important than biomechanical factors in influencing the development of neck pain. Psychosocial factors play an important role in persisting symptoms and disability, and influence the response to treatment and rehabilitation. Barriers to recovery need to be identified and addressed.

cognitive–behavioural interventions can be successful but the extent of training and the resulting skill levels that are required to deliver an effective cognitive behavioural intervention may be critical.