Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.

Cleland JA, Abbott JH, Kidd MO, Stockwell S, Cheney S, Gerrard DF, Flynn TW.

OBJECTIVE:

To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain.

BACKGROUND:

There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects.

METHODS:

Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes of interest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time).

RESULTS:

Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups.

CONCLUSION:

The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs.

Journal of  Orthopedic Sports Physical Therapy. 2009 Aug;39(8):573-85. – abstract

Power point presentation of the main outcome charts- here

Filed under: Exercise therapy, Foot and ankle, Manual therapy , iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis

Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group

Furlan, AD; Imamura, M; Dryden, T; Irvin, E

Abstract

Study Design. Systematic Review.

Objectives. To assess the effects of massage therapy for nonspecific low back pain.

Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.

Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.

Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.

Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.

Spine: 15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684 - abstract

doi: 10.1097/BRS.0b013e3181ad7bd6

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Exercise therapy, Lumbar spine, Massage, Patient education, Topic review , Low back, Lumbar spine, massage therapy, nonspecific low back pain, pain, Systematic review

Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program

Deyle, Allison, Matekel, Ryder et al

Background and Purpose. Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteo-arthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program.

Subjects. One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [±SD]=64±10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [±SD]=62±9 years).

Methods. Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results. Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group.

Discussion and Conclusion. Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Physical Therapy, Vol. 85, No. 12, December 2005, pp. 1301-1317

Full text PDF

Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee

Deyle, Henderson, Matekel, Ryder et al

Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.

Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.

Design: Randomized, controlled clinical trial.

Setting: Outpatient physical therapy department of a large military medical center.

Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).

Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm² with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.

Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.

Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.

Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

Annals of Internal Medicine, 1 Feb 2000, Vol 132 Issue 3, 173-181

Full text PDF

Filed under: Exercise therapy, Knee, Manual therapy, Osteoarthritis

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Methods Group: Brosseau, Wells, Tugwell, Egan et al

BACKGROUND AND PURPOSE: Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management of adult patients (>18 years of age) with a diagnosis of OA. All stages of the disease were included in the analysis, and studies of patients who had recent surgery or other rheumatologic, musculoskeletal, or spinal problems or of subjects without known pathology or impairments were excluded.

METHODS: The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises for OA that were identified, 113 were considered potentially relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used.

RESULTS: Sixteen positive recommendations of clinical benefit were developed for therapeutic exercises, especially strengthening exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined with exercises also is recommended in the management of patients with OA.

DISCUSSION AND CONCLUSION: The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 13 grade A and 3 grade C+. The Ottawa Panel recommends the use of therapeutic exercises because of the strong evidence (grades A, B, and C+) in the literature.

Physical Therapy, Vol. 85, No. 9, September 2005, pp. 907-971

Full text PDF

Filed under: Exercise therapy, Manual therapy, Osteoarthritis, Treatment guidelines

Investigation of Clinical Effects of High- and Low-Resistance Training for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Mei-Hwa Jan et al

Background and Purpose: Muscle strength training is important for people with knee osteoarthritis (OA). High-resistance exercise has been demonstrated to be more beneficial than low-resistance exercise for young subjects. The purpose of this study was to compare the effects of high- and low-resistance strength training in elderly subjects with knee OA.

Subjects and Methods: One hundred two subjects were randomly assigned to groups that received 8 weeks of high-resistance exercise (HR group), 8 weeks of low-resistance exercise (LR group), or no exercise (control group). Pain, function, walking time, and muscle torque were examined before and after intervention.

Results: Significant improvement for all measures was observed in both exercise groups. There was no significant difference in any measures between HR and LR groups. However, based on effect size between exercise and control groups, the HR group improved more than the LR group.

Discussion and Conclusion: Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance strength training appear to be larger than those of low-resistance strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant.

Physical Thrapy, Vol. 88, No. 4, April 2008, pp. 427-436
DOI: 10.2522/ptj.20060300

Full text available in through MTABC member only website

Filed under: Exercise therapy, Knee, Osteoarthritis

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

Zhang, Moskowitz, Nuki, Abramson et al

PURPOSE: To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS: Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS: Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION: Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

Osteoarthritis and Cartilage, Volume 16, Issue 2, February 2008, Pages 137-162

Full text PDF

Filed under: Exercise therapy, Hip, Knee, Osteoarthritis, Patient education, Treatment guidelines

A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

A Kirkley, TB Birmingham, RB Litchfield, JR Giffin et al.

ABSTRACT

Background – The efficacy of arthroscopic surgery for the treatment of osteoarthritis of the knee is unknown.

Methods – We conducted a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. Patients were randomly assigned to surgical lavage and arthroscopic débridement together with optimized physical and medical therapy or to treatment with physical and medical therapy alone (for details please see “details of physical therapy provided” below) . The primary outcome was the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (range, 0 to 2400; higher scores indicate more severe symptoms) at 2 years of follow-up. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score (range, 0 to 100; higher scores indicate better quality of life).

Results – Of the 92 patients assigned to surgery, 6 did not undergo surgery. Of the 86 patients assigned to control treatment, all received only physical and medical therapy. After 2 years, the mean (±SD) WOMAC score for the surgery group was 874±624, as compared with 897±583 for the control group (absolute difference [surgery-group score minus control-group score], –23±605; 95% confidence interval [CI], –208 to 161; P=0.22 after adjustment for baseline score and grade of severity). The SF-36 Physical Component Summary scores were 37.0±11.4 and 37.2±10.6, respectively (absolute difference, –0.2±11.1; 95% CI, –3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery.

Conclusions – Arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy

the New England Journal of Medicine. 2008 Sep 11;359(11):1169-70.

Details of physical therapy provided: Optimized physical and medical therapy was initiated within 7 days after surgery and followed an identical program in both groups. Physical therapy was provided for 1 hour once a week for 12 consecutive weeks. The intervention was standardized and based on a review of the literature and a formal survey of university physical therapists.³¹ Information regarding a home exercise exercises program that emphasized range-of-motion and strengthening was provided to all patients. Individualized exercises were recommended on the basis of the severity of osteoarthritis, the patient’s age, and the patient’s specific needs. Instruction was also provided regarding activities of daily living, walking, use of stairs, and methods of treatment involving cold and heat. The patients were asked to perform the exercises twice daily and once on the day of a scheduled physical-therapy session. After the patients had completed 12 weeks of supervised activity, they continued an unsupervised exercise program at home for the duration of the study. The patients received additional education from attendance at local Arthritis Society workshops, from a copy of The Arthritis Helpbook³² that was provided to them, and from an educational videotape.

Filed under: Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Objectives: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

Methods: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

Results: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

Conclusion: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswere

Final set of 10 recommendations based on both evidence and expert opinion    (table 6)
1.     The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
2.     The treatment of knee OA should be tailored according to:
(a) Knee risk factors (obesity, adverse mechanical factors, physical activity)
(b) General risk factors (age, comorbidity, polypharmacy) (c) Level of pain intensity and disability
(d) Sign of inflammation—for example, effusion
(e) Location and degree of structural damage
3.     Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
4.     Paracetamol (acetaminophen) is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
5.     Topical applications (NSAID, capsaicin) have clinical efficacy and are safe
6.     NSAIDs should be considered in patients unresponsive to paracetamol (acetaminophen). In patients with an increased gastrointestinal risk, non-selective
NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
7.     Opioid analgesics, with or without paracetamol (acetaminophen), are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
8.     SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
9.     Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
10.     Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability

Annals of the Rheumatic Disease. 2003 December; 62(12): 1145–1155.

doi: 10.1136/ard.2003.011742.

Full text PDF

Filed under: Arthritis, Exercise therapy, Knee, Osteoarthritis, Patient education, Surgery

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive Summary

Haldeman, S; Carroll, L; Cassidy, J D; Schubert, J; Nygren, Å

This Task Force consisted of a 5-member Executive Committee, a 13-member Scientific Secretariat, a 17-member Advisory Committee, and 18 research associates and graduate students. Committee members originated from 9 countries and represented 19 clinical and scientific disciplines or specialties. The Task Force was affiliated with 8 collaborating universities and research institutes in 4 countries, and 11 professional organizations agreed to become nonfinancial sponsors.

Key Findings From the Task Force

Epidemiology of Neck Pain

* Most people can expect to experience some neck pain in their lifetimes, although for the majority, neck pain will not seriously interfere with normal activities.

* Depending on the case definitions used, the 12-month prevalence of neck pain ranged from 12.1% to 71.5% in the general population, and from 27.1% to 47.8% in workers. However, neck pain with associated disability was less common: 12-month prevalence estimates ranged from 1.7% to 11.5% in the general population.

* Each year, between 11% and 14.1% of workers reported being limited in their activities because of neck pain. Neck pain was common in all occupational categories, and the results of the Ontario cohort study suggest that worker’s compensation data significantly underestimate the burden of neck pain in workers.

* The number of persons seeking health care in emergency rooms for traffic-related Whiplash-associated disorders (WAD) has been increasing over the past 3 decades.

Risk Factors for Neck Pain

* Analysis of risk factors for neck pain suggest that this disorder has a multifactorial etiology. Nonmodifiable risk factors for neck pain included age, gender, and genetics. There is no evidence that common degenerative changes in the cervical spine are a risk factor for neck pain.

* Modifiable risk/protective factors for neck pain include smoking, exposure to environmental tobacco, and physical activity participation. In the workplace high quantitative job demands, low social support at work, sedentary work position, repetitive work, and precision work increased the risk of neck pain. However, there is a lack of evidence that workplace interventions were effective in reducing the incidence of neck pain in workers.

* Eliminating insurance payments for pain and suffering, and improving benefits disability costs were both associated with a lower incidence of whiplash claims and faster recovery from symptoms. Devices aimed at limiting head extension during rear-end collisions were found to have a preventive effect.

Course and Prognosis

* Most people with neck pain do not experience a complete resolution of symptoms. Between 50% and 85% of those who experience neck pain at some initial point will report neck pain again 1 to 5 years later. These numbers appear to be similar in the general population, in workers and after motor vehicle crashes.

* The prognosis for neck pain also appears to be multifactorial. Younger age was associated with a better prognosis, whereas poor health and prior neck pain episodes were associated with a poorer prognosis. Poorer prognosis was also associated with poor psychological health, worrying, and becoming angry or frustrated in response to neck pain. Greater optimism, a coping style that involved self-assurance, and having less need to socialize, were all associated with better prognosis.

* Specific workplace or physical job demands were not linked with recovery from neck pain. Workers who engaged in general exercise and sporting activities were more likely to experience improvement in neck pain. Postinjury psychological distress and passive types of coping were prognostic of poorer recovery in WAD. There is evidence that compensation and legal factors are also prognostic for poorer recovery from WAD.

Assessment of Neck Pain

* The assessment for fracture in the emergency room and the diagnosis of neck pain with radiculopathy are of value, but there is little evidence that diagnostic procedures for neck pain without severe trauma or radicular symptoms have validity and utility.

* Screening protocols to alert low-risk patients with blunt trauma to the neck have high predictive values in detecting cervical spine fracture. Computerized tomography scan has better validity and utility in cervical trauma for high-risk or multi-injured patients. The clinical physical examination is more predictive at excluding a structural lesion or neurologic compression than at diagnosing any specific etiologic condition in patients with neck pain. All other assessment tools such as electrophysiology, imaging, injections, discography, functional tests, and bloods test lack validity and utility.

* Reliable and valid self-assessment questionnaires given to neck pain patients can provide useful information for management and prognosis.

* The finding of degenerative changes on imaging has not been shown to be associated with neck pain.

Treatments for Neck Pain (Noninvasive and Invasive)

* A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions but none of the active treatments were clearly superior to any other in the short or long term. Educational videos, mobilization, manual therapy, exercises, low-level laser therapy, and perhaps acupuncture appeared to have some benefit. For both WAD and other neck pain without radicular symptoms, interventions that focused on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus.

* There is evidence for short-term symptomatic improvement of radicular symptoms with epidural or selective root injections with corticosteroids, but these treatments did not appear to decrease the rate of open surgery.

* Evidence is lacking to support intra-articular steroid injections or radiofrequency neurotomy. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared with nonoperative measures. However, relatively rapid and substantial relief of pain and impairment in the short term (6-12 weeks after surgery) after surgical treatment appears to have been reliably achieved.

* Early results from trials of cervical disc arthroplasty appear to show 1- to 2-year outcomes for radicular symptoms that are similar to outcomes for anterior fusion surgery. There is no evidence to support the use of cervical disc arthroplasty in patients with neck pain who do not have primary radicular pain.

Decision Analysis Study Findings

* Quality of life years (QALYs) associated with standard NSAIDs, Cox-2 NSAIDs, exercise, manipulation, and mobilization were compared in a decision-analytic model. None of the active treatments was found to be clearly superior to any other in the short or long term when estimates of the course of neck pain, adverse event risks, treatment effectiveness and risk, and patient-preferences for health outcomes were considered.

A New Conceptual Model for Neck Pain

The Neck Pain Task Force proposes a new conceptual model for the course and care of neck pain. The model is centered on persons with neck pain or who are at risk for neck pain. The model describes neck pain as an episodic occurrence over a lifetime with variable recovery between episodes. It outlines the options available to deal with neck pain; the factors that determine available options, choices, and consequences; and the short- and long-term impacts of neck pain.

A New Classification System for Neck Pain

For the subset of individuals who seek clinical care, the Neck Pain Task Force recommends a 4-grade classification system of neck pain severity that is intended to help in the interpretation of scientific evidence. The new system will also help people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions:

* Grade I neck pain: No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living; will likely respond to minimal intervention such as reassurance and pain control; does not require intensive investigations or ongoing treatment.

* Grade II neck pain: No signs or symptoms of major structural pathology, but major interference with activities of daily living; requires pain relief and early activation/intervention aimed at preventing long-term disability.

* Grade III neck pain: No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness, and/or sensory deficits; might require investigation and, occasionally more invasive treatments.

* Grade IV neck pain: Signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment.

When choosing treatments to relieve grades I and II neck pain, patients and their clinicians should consider the potential side effects and personal preferences regarding treatment options.

Spine:Volume 33(4S) Supplement15 February 2008pp S5-S7

Full text PDF

Filed under: Cervical, Exercise therapy, Manual therapy, Patient education, Spine, Whiplash Injuries , The Bone and Joint Decade 2000-2010 Task Force on Neck Pain