Research-Based Treatment of Patients with Neck Pain

Evidence from randomized controlled trials and systematic reviews supports the use of therapeutic massage and physical therapy interventions in the treatment of patients with neck pain.

Cervical Mobilization and Manipulation
A recent systematic review from the Cochrane database reviewed 27 randomized controlled trials with a total of 1522 subjects that compared manipulation or mobilization against no treatment, sham (pretend) treatments, other treatments (such as medication, acupuncture, heat, electrotherapy, soft tissue massage), or each other. (20) There was moderate quality evidence from 2 trials (369 participants) which showed there to be little to no difference between manipulation and mobilization for pain relief, function and patient satisfaction for those with sub-acute or chronic neck pain at short-term and intermediate-term follow-up. (20)  Manipulation or mobilization were not as effective alone as when combined with neck exercises.    The authors noted that the optimal techniques and dose of mobilization and manipulation are unresolved and further research is needed to determine this.  In another systematic review, reviewers reported that cervical mobilization and manipulation provided patients with significant clinical improvements at 6, 12 and up to 104 weeks post-treatment.(21) The authors also concluded that thoracic mobilization may decrease neck pain and improve function.

Thoracic Mobilization and Manipulation
Thoracic spine mobilization and manipulation may have a positive effect on neck pain and cervical function due to its biomechanical relationship with the cervical spine.  Several randomized clinical trials have looked at the effects of thoracic manipulation on neck pain and dysfunction. (22,23) These studies reported that patients who received thoracic manipulation had statistically significant improvements in their neck pain and disability. (22,23)

Research-Based Massage Therapy for Neck Pain

A number of studies have shown the efficacy of massage therapy for the treatment of patients with neck pain.

A study published in 2013 in the Journal of Bodywork and Movement Therapy compared Swedish massage to Myofascial Release for the treatment of Fibromyalgia Syndrome.(41) Although both groups showed improvement based on their Nordic Musculoskeletal Questionnaire scores, the Myofascial Release group reported more consistent pain reductions in the neck and upper back regions compared to the Swedish massage group.(41)

In a recent systematic review, twelve high-quality randomized controlled trials on the massage for neck pain were examined and meta-analyzed.(42) In immediate effects, massage therapy showed significant decrease in neck pain and shoulder pain and in the short term effects, subjects also reported decreases in neck and shoulder pain.(42)

PLEASE, READ THIS RESEARCH STUDY BY CLICKING THIS LINK Massage Therapy for Neck and Shoulder Pain: A Systematic Review and Meta-Analysis.

In a Cochrane systematic review, 15 studies were examined.(43) As a stand-alone treatment, massage was found to provide immediate and short term relief of neck pain and tenderness.(43)

The Ottawa Panel performed a literature review to update evidence-based clinical practice guidelines for the use of massage therapy in the treatment of neck pain.(44) A total of 8 positive recommendations were given from 10 different research studies. Therapeutic massage can be used to decrease immediate and short term neck pain and tenderness. Massage can be used to improve cervical range of motion for sub-acute and chronic neck pain sufferers.(44)

A recent study compared therapeutic massage to physical therapy.(45) Sixty patients with neck pain were placed into a physical therapy group or therapeutic massage group. At the end of the study, both groups received benefit. Using the Neck Disability Index questionnaire, the therapeutic massage group reported a significant decrease in pain and improved performance and function.(45)

Therapeutic massage was reported to have a positive physiological and clinical effects.(46) This study assessed neurologic response of the Hoffman reflex, upper trapezius tonus and cervical range of motion on 16 subjects. The Hoffman reflex is a way to assess the alpha motoneuron pool excitability by testing the flexor carpi radialis muscle. Electromyograph analysis of muscle activity shows potential for muscle spasm and neurologic tone. The therapeutic massage group had a decreased neurologic excitability of both the flexor carpi radialis and upper trapezius muscles. The therapeutic massage group also showed an increased cervical range of motion in all directions.(46)

Strengthening Exercises
A number of randomized clinical trials have demonstrated the effectiveness of cervical strengthening exercises in the treatment of patients with neck pain and cervical dysfunction.(24-31)

In a randomized clinical trial by Ylinen et al, researchers investigated the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles in rehabilitation of women with chronic, nonspecific neck pain.(24) The subjects were 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain.  To measure pain and disability outcomes, the researchers used a visual analog scale, the neck and shoulder pain and disability index, and the Vernon neck disability index.  Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures.  The authors included reference citations that reported the reliability and validity for all of these outcome measures.  The subjects were randomly assigned to one of three groups: endurance training group, strength training group or control group.  The endurance training group (ETG) exercised the cervical flexor muscles by performing 3 sets of 20 repetitions of supine-lying head lifts.  The strength training group (STG) primarily strengthened the cervical flexor muscles by performing resistance exercises in sitting using a Theraband.  The STG performed 15 repetitions at each angle – flexion, obliquely left and obliquely right flexion and extension with a force graded at 80% of their maximal isometric strength.  The subjects in the two training groups performed their exercises under supervision 5 times per week for a total of 9 treatment sessions and then were discharged to perform these exercises at home 3 times per week for one year.  The subjects were to keep exercise diaries that would be examined by the researchers.  The subjects’ exercise intensity and technique were re-evaluated at 2 months, 6 months and at the end of the year.  The control group subjects were given written information regarding neck stretches and were told to perform the neck stretches along with aerobic exercise 3 times per week for 20 minutes.  The study showed that both training groups had a considerable reduction in average neck pain and disability compared with the control group.  Neck function, including neck strength and ROM, was improved significantly in both training groups compared with the control group.  The findings of this research study are summarized in Table 2 below.

Research Review Table 2.
Summary of the study by Ylinen et al (24)

Intervention

Outcome Measures

Results

Comments

 

Endurance training group (n=60) performed 3 sets of 20 repetitions of supine lying head lifts.

Strength training group (n=60) performed exercises for the cervical flexor and extensor muscles in sitting using an elastic band at 80% of maximum isometric strength.

Control group (n=60)
All groups, including control group, practiced aerobic exercise and neck stretching 3x /week.

 

Visual Analog Scale for pain

The neck and shoulder pain and disability index

The Vernon neck disability index. 

Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures.

 

At 12 month intervention
All the outcome measures were significantly lower in the 2 training groups compared with the control group.

There was no statistically discernible difference between the endurance and strength training groups.

 
  • RCT with control group.

 

  • Subjects equal at baseline.
  • Good sample size (N=180)

 

  • Low drop-out (1.7%)
  • Good subject compliance due to exercise diaries

 

  • Lack of control due to home program

In another single-blinded randomized controlled trial, Chiu et al evaluated the efficacy of a neck exercise program in patients with chronic neck pain.(25)  The researchers assessed the benefits of an exercise program that focused both on motor control training of the deep cervical flexor muscles and dynamic strengthening.  The dynamic strengthening consisted of strengthening the cervical flexors and extensors using a Multi-Cervical Unit.  The authors gave detailed descriptions of how all of the exercises were administered and explained that exercises were administered in a controlled environment.  A total of 145 patients with chronic neck pain were randomly assigned to either an exercise or a non-exercise control group.  At week 6, the exercise group had improved significantly in pain levels, disability scores and isometric neck muscle strength.  At the 6 month follow-up, significant differences between the 2 groups were found in pain and patient satisfaction only. The findings are summarized in Table 3 below.

Research Review Table 3.
Summary of the study by Chiu, et al. (25)

Intervention

Outcome Measures

Results

Comments

 

Exercise Group (n=67)
performed activation of the deep cervical flexor muscles using the Stabilizer pressure sensor for feedback. 
Dynamic strengthening of the deep neck flexors and extensors using a Multi Cervical Rehabilitation Unit.

Control Group (n=78)
received infrared radiation and neck care advice.

 

Northwick Park Neck Pain Questionnaire to measure neck disability.

Verbal Numerical Pain Scale (0=no pain, 10=worst pain) to measure neck pain.

Peak isometric strength measured with the Multi Cervical Rehabilitation Unit.

Perceived satisfaction (11-point scale: 0=very disappointed, 10=very satisfied).

 

At 6 weeks:
Significant improvement in disability scores.

Significant decrease in neck pain.

Significant increase in peak isometric strength in all directions.

At 6 month follow-up:
Significant between-group differences in neck pain.
Significant between- group difference  in perceived satisfaction.

 

 

Single-blinded RCT with control group.

Subjects equal at baseline.

Good sample size (n=145).

Dropouts were statistically analyzed as if in the study.

All exercises were administered in clinical setting by physical therapist using specific protocol.

Dynamic strengthening exercises worked on cervical flexors and extensors.

Nikander et al evaluated the effectiveness of strengthening exercises in a randomized, controlled, examiner-blinded, 12-month intervention trial with two treatment groups and one control group.(26)  The subjects were female office workers between the ages of 25 and 55 years with chronic neck pain, which matched my patient very well.  The subjects underwent an initial 12 day rehabilitation program where they were taught the proper way to perform the exercises.  The exercises that the endurance training group performed were 3 sets of 20 repetitions of supine head lifts to strengthen the deep cervical flexor muscles.  The strength training group performed resisted cervical flexion, oblique right/left flexion and extension using an elastic band of strength approximating 80% of the subject’s maximal cervical isometric strength.  The subjects were then asked to practice the training regimens at home and keep a diary of their exercise training sessions for 1 year.  The control group subjects were asked to perform aerobic exercise and given cervical stretches to do 3 times per week.  The subjects were measured at baseline and at the end of the 12-month intervention period.  Based on questionnaires and the diaries, metabolic rate equivalents (MET) were determined by using specific software (MetPro 2.03.7, Sci Reha, Jyva¨skyla¨, Finland) to establish the correlation between exercise dose and response.  The authors reported that the measurement of MET levels has been shown to have an acceptable level of reliability.  The results showed a clear dose–response relationship for two cervical exercise programs.  One MET-hour of training per week accounted for a 0.8-mm decrease of neck pain on the visual analog scale (VAS) and a 0.5-mm decrease on the neck and shoulder pain and disability index.  The visual analog scale and the neck and shoulder pain and disability index were reported to have an acceptable level of reliability.  The study showed that if the training program was performed twice per week, it was ineffective in reducing pain and increasing function, but if the exercises were performed three times per week, the program was effective.  The authors reported that the effective dose of either of the specific cervical exercise training programs to decrease chronic neck pain was 8.75 MET-hour (525 MET-minutes) per week.  The amount of training required to effectively reduce pain and disability was feasible and safe to perform among these female office workers. The findings are summarized in Table 4 below.

Research Review Table 4.
Summary of the study by Nikander, et al. (26)

Intervention

Outcome Measures

Results

Comments

 

Endurance training group (n=60) performed 3 sets of 20 repetitions of supine lying head lifts.

Strength training group (n=60) performed exercises for the cervical flexor and extensor muscles in sitting using an elastic band at 80% of maximum isometric strength.

Control group (n=60)
All groups, including control group, practiced aerobic exercise and neck stretching 3x /week.

 

Visual analog scale for neck pain.

Neck and shoulder pain and disability index.

Measured at baseline and at the end of 1 year intervention period.

 

At 12 months:
All the outcome measures were significantly lower in the 2 training groups compared with the control group.

There was no statistically discernible difference between the endurance and strength training groups.

There was a positive correlation between dose of exercise and effectiveness.

 
  • RCT with control group.

 

  • Women office workers between 25-55 y.o.
  • Good sample size (N=180).

 

  • Low drop-out rate.
  • Good adherence due to exercise diaries.

 

Visual Analog Scale has good reliability.

Neck and shoulder disability index has good reliability.

In a multi-center randomized clinical trial, Jull et al recruited 200 patients with cervicogenic headaches.(27) The patients were randomized into four different groups: a mobilization/manipulation group, an exercise group, a combined manual therapy and exercise group and a control group.  The initial benefit was a reduction in headaches.  At the twelve-month follow-up, all the groups except the control group had decreased headache frequency and intensity.  The group that received manipulation/mobilization and exercise had the greatest improvement.(27)  In another study by Jull et al, researchers compared craniocervical flexion exercise to cervical proprioceptive training patients with chronic neck pain.(28) The main outcome that was studied was cervical joint position.  At the end of 6 weeks of training, both groups had decreased cervical joint position error.(28)  A recent systematic review assessed the effects of exercise therapy on pain, function, patient satisfaction, and global perceived effect in adults suffering from mechanical neck pain.(29) The authors selected 31 trials for the review, of which 19%-35% were considered high quality. The reviewer concluded that “there is strong evidence of benefit favoring a multimodal care approach of exercise combined with mobilizations or manipulations for sub-acute and chronic mechanical neck disorders, with or with headache in the short and long term. (29) In a randomized clinical trial by Bronfort et al, researchers reported that a combined program of manipulation, cervical strengthening exercises and endurance exercises lead to increases in strength, muscular endurance, cervical range of motion and patients’ long-term decreases in neck pain.(30)  Taimela et al compared proprioceptive exercise training to a control group of patient education and home exercises in 76 patients with chronic non-specific neck pain.(31) The patients in the proprioceptive exercise training group had decreased neck pain and increased ability to work.(31)  In a randomized clinical trial by Dusunceli et al, researchers divided 60 neck pain patients into 3 groups: a physical therapy agents (ultrasound, TENS, infra-red radiation) control group, a stretching group (plus physical agents) and a neck stabilization exercise group (plus physical agents). (32) The researchers concluded that the neck stabilization exercises (plus physical agents) provided greater benefit in reduced neck pain and disability than the other two groups.(32)

Stretching Exercises
In a randomized clinical cross-over trial, Ylinen et al compared cervical stretching exercises to manual therapy in 125 female patients with chronic neck pain.(33)  The stretching exercises were performed by participants 5 times per week and the manual therapy was performed by clinicians 2 times per week.  The patients in both groups reported a significant decrease in neck pain, neck stiffness and disability at 4 weeks and 12-week follow-up.(33) Although the manual therapy group reported more benefit, the difference was not clinically significant.  The researchers recommended including cervical stretching exercises in the treatment of chronic neck pain.(33)

Cervical Traction
In a systematic review, researchers reviewed 7 randomized clinical trials and found that there was “no statistically significant difference (SMD -0.16: 95% CI: -0.59 to 0.27) between continuous traction and placebo traction in reducing pain or improving function for chronic neck disorders with radicular symptoms.”(35)  In another systematic review, researchers reported that there was moderate evidence to support the use of intermittent cervical traction to decrease neck pain and improve function.(34) 

Nerve Mobilization
For patients that present with referred symptoms into their upper extremity, there is some evidence to support nerve mobilization techniques to reduce neural tension.  The Upper Limb Tension Test, described earlier in this article, has a high predictive accuracy for identifying patients with upper extremity neural tension.  In a randomized clinical trial pilot study, Allison et al compared a nerve mobilization technique to a cervical/upper quadrant mobilization technique on patients with cervicobrachial syndrome.(36) After 8 weeks of treatment, both manual therapy groups had improvements in pain and function and the neural mobilization group had significantly less pain than the group that received cervical/upper quadrant mobilization.(36)  In another randomized clinical trial, researchers compared cervical mobilization with the upper extremity in a neural tension position (see Upper Limb Tension Test on page 2) to ultrasound.(37) The mobilization group reported significant decreases in pain and exhibited increased elbow range of motion compared to the ultrasound group.(37)

Patient Education

The current research supports counseling patients in early active interventions and return to normal activities as opposed to long periods of rest and inactivity.  In a randomized controlled trial of 108 patients with neck injury from motor vehicle accidents, patients were assigned to either an early intervention exercise group or to wear a soft collar for 3 weeks and then initiate exercises.(38) The researchers found that the soft collar provided no benefit to the patients’ injury rehabilitation and that patients who used the collar had prolonged periods off work.(38)  In another randomized controlled trial, researchers showed the efficacy of early patient education in active home exercise intervention over the use of cervical collars.(39) Patients who use active exercises and return to normal activities report reduced pain and disability.(39) Brison, et al used a video presentation to educate patients with whiplash associated disorders in pain management, exercises, posture and how to return to normal activities.(40) The patients reported decreased severity of their whiplash associated disorders, especially decreased pain in their neck, upper back and shoulders.

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