Evidence Based Interventions for Neck Pain

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Introduction[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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]. 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].

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[13]. Manual therapy is more effective when used in combination with exercise[3][14][15][16].

Passive Treatments[edit | edit source]

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.

Manual Therapy[edit | edit source]

Evidence suggests that mobilisation/ manipulation is beneficial for at least some patients with neck pain[3]. Hoving et al[17] 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[3]. Evidence also suggests that manual therapy is more effective when used in combination with exercise[3][14][15][16].

Traction[edit | edit source]

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.

Soft Tissue Mobilisation[edit | edit source]

Physical Modalities[edit | edit source]

Behavioural Interventions[edit | edit source]

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[20].

References[edit | edit source]

  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 3.5 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. ↑ 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.
  14. ↑ 14.0 14.1 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
  15. ↑ 15.0 15.1 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
  16. ↑ 16.0 16.1 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
  17. ↑ Hoving JL, Koes BW, de Vet HC, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med. 2002;136:713-722.
  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.
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