Are Manual Therapies, Passive Physical Modalities, Or Acupuncture Effective for the Management of Patients With Whiplash-Associated Disorders or Neck Pain and Associated Disorders

Accepted ManuscriptTitle: Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? an update of the bone and joint decade task force on neck pain and its associated disorders by the optima collaboration Author: Jessica J. Wong, Heather M. Shearer, Silvano Mior, Craig Jacobs, Pierre Côté, Kristi Randhawa, Hainan Yu, Danielle Southerst, Sharanya Varatharajan, Deborah Sutton, Gabrielle van der Velde, Linda J. Carroll, Arthur Ameis, Carlo Ammendolia, Robert Brison, Margareta Nordin, Maja Stupar, Anne Taylor-Vaisey PII: DOI: Reference: S1529-9430(15)01234-6 http://dx.doi.org/doi: 10.1016/j.spinee.2015.08.024 SPINEE 56530 To appear in: The Spine Journal Received date: Revised date: Accepted date: 14-11-2014 5-6-2015 11-8-2015 Please cite this article as: Jessica J. Wong, Heather M. Shearer, Silvano Mior, Craig Jacobs, Pierre Côté, Kristi Randhawa, Hainan Yu, Danielle Southerst, Sharanya Varatharajan, Deborah Sutton, Gabrielle van der Velde, Linda J. Carroll, Arthur Ameis, Carlo Ammendolia, Robert Brison, Margareta Nordin, Maja Stupar, Anne Taylor-Vaisey, Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplashassociated disorders or neck pain and associated disorders? an update of the bone and joint decade task force on neck pain and its associated disorders by the optima collaboration, The Spine Journal (2015), http://dx.doi.org/doi: 10.1016/j.spinee.2015.08.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. 1 Are manual therapies, passive physical modalities, or acupuncture effective for 2 the management of patients with whiplash-associated disorders or neck pain and 3 associated disorders? An update of the Bone and Joint Decade Task Force on 4 Neck Pain and its Associated Disorders by the OPTIMa Collaboration 5 6 Jessica J. Wong, BSc, DC, FCCS(C)1,2; Heather M. Shearer, DC, MSc, FCCS(C)1,3; 7 Silvano Mior, DC, PhD3; Craig Jacobs, BFA, DC, MSc, FCCS(C)1,4; Pierre Côté, DC, 8 PhD1,5,6; Kristi Randhawa, BHSc, MPH1,4; Hainan Yu, MBBS, MSc1,4; Danielle 9 Southerst, BScH, DC, FCCS(C)1,7; Sharanya Varatharajan, BSc, MSc1,4; Deborah 10 Sutton, BScOT, MEd, MSc1,4; Gabrielle van der Velde, DC, PhD8,9,10; Linda J. Carroll, 11 PhD11; Arthur Ameis, FRCPC, DESS, FAAPM&R12; Carlo Ammendolia, DC, PhD10,13; 12 Robert Brison, MD, MPH14,15; Margareta Nordin, Dr. Med. Sci.16; Maja Stupar, DC, 13 PhD1; Anne Taylor-Vaisey, MLS1 14 15 1 UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University 16 of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College 17 (CMCC) 18 19 20 2 Department of Graduate Studies, Canadian Memorial Chiropractic College 3 Division of Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC) 21 1 Page 1 of 89 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 4 Division of Clinical Education, Canadian Memorial Chiropractic College, Canada 5 Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) 6 Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT) 7 Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital 8 Toronto Health Economics and Technology Assessment (THETA) Collaborative 9 Leslie Dan Faculty of Pharmacy, University of Toronto 10 Institute for Work and Health 11 Alberta Centre for Injury Control and Research and School of Public Health, University of Alberta 12 Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal 13 Institute for Health Policy, Management and Evaluation, University of Toronto 14 Clinical Research, Kingston General Hospital 15 Department of Emergency Medicine, School of Medicine, Queen’s University 16 Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University 19 2 Page 2 of 89 manual therapy. neck pain and associated disorders. Phone: +1 3 (416) 482-2340 x170. M2H 3J1. acupuncture 7 8 Systematic Review Registration Numbers: CRD42013004372. UOIT-CMCC Centre for the Study of Disability 2 Prevention and Rehabilitation. Toronto. CRD42013005167. ON. email: jessica. 9 CRD42013004301. CRD42013004395 10 11 12 13 14 15 16 17 18 ABSTRACT 3 Page 3 of 89 . passive physical modalities. 6100 Leslie Street. whiplash- 6 associated disorders.ca 4 5 Keywords: systematic review.1 Corresponding Author: Jessica Wong.wong@uoit. passive physical modalities. or acupuncture 4 for the management of whiplash-associated disorders (WAD) or neck pain and 5 associated disorders (NAD). passive physical modalities. case-control studies 11 comparing manual therapies. 9 Study Design/Setting: Systematic review and best evidence synthesis. 15 Methods: We systematically searched five databases from 2000 to 2014. cohort studies. or acupuncture to other 12 interventions. Funding was provided by the 20 Ministry of Finance. pain intensity. health-related 14 quality of life. Random 16 pairs of independent reviewers critically appraised eligible studies using the Scottish 17 Intercollegiate Guidelines Network (SIGN) criteria. the Bone and Joint Decade 2000-2010 Task Force on 2 Neck Pain and its Associated Disorders (Neck Pain Task Force) found limited evidence 3 on the effectiveness of manual therapies. passive physical modalities. or no intervention. psychological outcomes. 6 Purpose: To update findings of the Neck Pain Task Force examining the effectiveness 7 of manual therapies. 13 Outcome measures: Self-rated or functional recovery.1 Background Context: In 2008. 10 Sample: Randomized controlled trials (RCTs). placebo/sham. Studies with a low risk of bias were 18 stratified by the intervention’s stage of development (exploratory versus evaluation) and 19 synthesized following best evidence synthesis principles. or adverse events. and acupuncture for the management 8 of WAD or NAD. 4 Page 4 of 89 . It also suggests that 20 electroacupuncture. Western 12 acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture. 2) for persistent 4 NAD I-II: technical parameters of cervical mobilization (e. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II: 8 cervical and thoracic manipulation provides no additional benefit to high-dose 9 supervised exercises. 17 Conclusions: Our review adds new evidence to the Neck Pain Task Force and 18 suggests that mobilization. and 4) for recent NAD III: a semi-rigid cervical collar with rest and 16 graded strengthening exercises lead to similar outcomes. 13 needle acupuncture provides similar outcomes to sham-penetrating acupuncture.. Swedish/clinical massage adds benefit to self-care advice. hydrotherapy. Evidence from seven exploratory studies suggests that: 1) for recent but not 3 persistent NAD I-II: thoracic manipulation offers short-term benefits. ultrasound) are not effective 22 and should not be used to manage neck pain. 23 5 Page 5 of 89 . and some passive 21 physical modalities (heat. while one session of cervical manipulation is similar to 6 Kinesiotaping. 38 studies were relevant. strain-counterstrain. direction or site of manual 5 contact) do not impact outcomes. cold. diathermy.1 Results: We screened 8551 citations.g. low-level laser therapy (LLLT) does not offer benefits. 2) for 10 persistent NAD I-II: home-based cupping massage has similar outcomes to home- 11 based muscle relaxation. LLLT does not offer benefits. and 3) for NAD I-II: strain-counterstrain treatment is no better than 7 placebo. and clinical massage are effective 19 interventions for the management of neck pain. relaxation massage. manipulation. 3) for 14 WAD I-II: needle electroacupuncture offers similar outcomes as simulated 15 electroacupuncture. and 22 had a low risk 2 of bias. 7 8 Findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and 9 Its Associated Disorders (Neck Pain Task Force) 10 In 2008. 4 including manual therapies. 6]. few interventions have been 6 demonstrated to be effective and most are associated with short-term benefits [5]. 5]. and substantial health care system costs [1-3]. However. Numerous treatments. the Neck Pain Task Force synthesized evidence on the effectiveness of 11 manual therapies.1 INTRODUCTION 2 Neck pain is a public health problem associated with disability. and 21 22 23 Western massage was equivalent to sham acupuncture but less effective than  The risk of serious adverse events associated with manipulation was extremely low. and acupuncture for the management of 12 whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) 13 (Table 1) [5. passive physical modalities. 14 15 For manual therapies. 20  acupuncture for chronic neck pain. reduced health-related 3 quality of life. the Neck Pain Task Force [5] found that: 16  Manipulation and mobilization had similar effectiveness. 6 Page 6 of 89 . low-level laser therapy (LLLT)] for subacute and chronic 19 neck pain. 17  Manipulation and mobilization led to similar outcomes as other conservative 18 interventions [exercise. passive physical modalities. and acupuncture. are 5 commonly used to treat neck pain [4. heat. the Neck Pain Task Force reported that acupuncture may be effective for treating neck pain [5]. In contrast. and 6  Collars. The recent publication of the IDEAL framework. evaluation 23 studies provide confidence in the intervention’s effectiveness or comparative 7 Page 7 of 89 . ultrasound. These priorities included trials comparing cervical manipulation. 16 17 In 2008. collect short-term outcomes. 3 4  Pulsed electromagnetic therapy was more effective than placebo. 19 which classifies studies according to their stage of development. 9 10 Finally. and prepare for designing evaluation studies. 14 thoracic manipulation. the Neck Pain Task Force did not organize their findings according to the 18 stages of development of interventions. transcutaneous electrical nerve stimulation (TENS). the Neck Pain Task Force [5] found that:  LLLT was efficacious for short-term improvement of subacute or chronic neck pain. 11 12 The Neck Pain Task Force identified important gaps in the literature and outlined 13 research priorities. 9]. 7 and electrical muscle stimulation were equally or less effective than other 8 interventions. provides a useful 20 framework to organize the evidence [8. 22 Exploratory studies do not provide evidence of effectiveness. 5  Magnetic necklaces led to similar outcomes as placebo.1 2 For passive physical modalities. Exploratory studies assess interventional 21 efficacy. and traction for WAD and trials examining the effectiveness of 15 conservative interventions for cervical radiculopathy [7]. 1 effectiveness to a standard of care [8. Therefore. 16 17 Eligibility Criteria 18 Population: Our review targeted studies of adults and children with WAD or NAD 19 grades I-III. respectively (Table 2 . 11]. CRD4201300XXXX. 9]. passive physical modalities.online) [10. Moreover. 5 6 The purpose of our systematic review was to update the findings of the Neck Pain Task 7 Force [5] on the effectiveness of manual therapies. 9 10 METHODS 11 12 Registration 13 We registered our protocol with the International Prospective Register of Systematic 14 Reviews 15 CRD4201300XXXX. and 8 acupuncture for the management of WAD and NAD. the findings of exploratory studies need to 4 be validated in evaluation studies. (PROSPERO) in 2013 (CRD4201300XXXX. exploratory studies do not provide 2 evidence of effectiveness and need to be considered separately when synthesizing 3 evidence in a systematic review. CRD4201300XXXX). as previously classified by the Quebec Task Force and the Neck Pain Task 20 Force. We excluded studies of neck pain due to 8 Page 8 of 89 . 7 and soft tissue therapy) as the application of hands-on and/or mechanically-assisted 8 treatments. spinal cord injury. 2 neoplasms.online). We defined acupuncture as 14 body needling. or indirectly facilitate function). Physico-chemical modalities have a common intention to treat using a 11 thermal or electromagnetic effect. fractures. traction..1 major structural pathology (e. We defined manual therapy (i. 17 18 Comparisons: We included studies that compared manual therapies. manipulation. 20 placebo/sham intervention. Structural modalities include non-functional assistive 12 devices (to encourage a state of rest in anatomic positions) and functional assistive 13 devices (to align.. 3 4 Interventions: We restricted our review to studies evaluating the specific effectiveness 5 of manual therapies. support. dislocations. or acupressure (application of pressure at 16 acupuncture points) [12]. 21 9 Page 9 of 89 . passive physical 19 modalities. passive physical modalities. waiting list (wait and see). or no intervention.g. mobilization. laser acupuncture. systemic disease). or acupuncture to other interventions. We defined a passive physical modality as a physical treatment (physico- 9 chemical or structural) involving a device that does not require active participation by 10 the patient. microsystem 15 acupuncture (e.g.. ear acupuncture). or acupuncture (Table 3 – in text. infection. 6 Table 4 . moxibustion. electroacupuncture.e. meeting abstracts. and/or adverse events. or 4) studies already included in the Neck Pain Task Force 19 Report [5]. 4 5 Study characteristics: Eligible studies met the following criteria: 1) English language. disability). studies not reporting on methodology. 3 administrative outcomes. lectures and addresses. government reports. 15 consensus development statements.g. A sample size of 9 30 is conventionally considered the minimum needed for non-normal distributions to 10 approximate the normal distribution [13]. cohort studies. We excluded the following: 1) guidelines. 3) 18 cadaveric or animal studies. books and 14 book chapters. 20 21 Information Sources 10 Page 10 of 89 . narrative reviews.1 Outcomes: Studies had to include one of the following outcomes to be elgigiSelf-rated 2 or functional recovery. 2) cross-sectional studies. conference proceedings. non-systematic and systematic reviews. 6 2) randomized controlled trials (RCTs).. and 3) an 7 inception cohort of a minimum of 30 participants per treatment arm for RCTs or 100 8 subjects per exposed group for cohort studies or case-control studies. 17 biomechanical studies. 13 commentaries. case series. guideline statements. letters. 16 case reports. The assumption that data is normally 11 distributed is required to ascertain a difference in sample means between treatment 12 arms. case-control studies. pain. dissertations. qualitative studies. clinical outcomes (e. psychological symptoms. unpublished manuscripts. laboratory studies. editorials. and acupuncture. The same paired reviewers 21 independently reviewed the manuscripts of possibly relevant studies in phase two 22 screening to make a final determination of eligibility. IC. The search terms included subject headings (e.g. Phase one screening resulted in studies being 20 classified as relevant. CINAHL. Reviewers met to resolve 11 Page 11 of 89 . IB. and Cochrane Central 2 Register of Controlled Trials from January 1. random pairs of independent reviewers screened citation titles and abstracts 19 to determine the eligibility of studies. EMBASE. possibly relevant. In phase one 18 screening. PsycINFO. and traction. ID). 5 We developed four distinct search strategies with a health sciences librarian (Appendix 6 IA. 2000 to: 1) March 21. 2013 for passive physical modalities. 2013 for 3 manipulation.. 8 9 The search strategy was first developed in MEDLINE and subsequently adapted to the 10 other bibliographic databases. which were reviewed by a second librarian using the Peer Review of 7 Electronic Search Strategies (PRESS) Checklist [14]. 2013 for acupuncture. 2) February 27. 2014 for soft tissue therapy. MeSH 11 for MEDLINE) specific to each database and free text words relevant to WAD or NAD 12 (grades I-III). We used 13 EndNote X6 reference management software to create a database containing the 14 search results [15]. manual therapies. or irrelevant.1 We searched MEDLINE. 15 16 Study Selection 17 We used a two-phase screening process to select eligible studies. 3) 4 April 9. and 4) January 31. passive physical modalities. mobilization. We did not 16 use a quantitative score or a cutoff point to determine the internal validity of studies [17]. cohort studies. information bias. the SIGN criteria were used to assist reviewers in making an informed overall 18 judgment on the internal validity of studies. and confounding on the results of a study. we critically appraised the following methodological aspects of a study: 1) 21 clarify of the research question. 13 14 The SIGN criteria were used to qualitatively evaluate the presence and impact of 15 selection bias. 3) concealment of treatment 12 Page 12 of 89 . After critical appraisal. trained 7 reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for 8 RCTs. with an independent third reviewer if necessary. All reviewers were trained in the 9 evaluation studies using the SIGN criteria. 17 Rather. 19 20 Specifically. studies with 12 a low risk of bias were included in our evidence synthesis. 3 4 5 Assessment of Risk of Bias 6 Eligible studies were critically appraised by random pairs of independent. and case-control studies [16]. We involved a third 2 reviewer if consensus could not be reached. 2) randomization method. Authors 11 were contacted if additional information was needed.1 disagreements and reach consensus on the eligibility of studies. Consensus between paired reviewers was 10 reached through discussion. 7) validity and 3 reliability of outcome measures.e..1 allocation.e. 4) blinding of treatment and outcomes. we stratified studies according to the IDEAL framework 21 (exploratory versus evaluation studies) [8. 13 Page 13 of 89 . WAD or NAD grades I-III) and 18 duration [i. 9]. variable duration (study does 19 not distinguish between recent and persistent)].e. evidence) synthesis. persistent (≥3 months). interventions. and outcomes. We 14 performed a qualitative synthesis of findings from the studies with a low risk of bias to 15 develop evidence statements using best evidence synthesis principles [18]. 9) analysis according to intention to 4 treat principles. and 10) comparability of results across study sites (where applicable). Exploratory studies investigate the short- 22 term efficacy (1-2 days) of interventions provided in 1-2 sessions. 5) similarity of baseline characteristics 2 between/among treatment arms. To facilitate translation of evidence into 20 clinically relevant findings. 16 17 We stratified our results by the type of disorder (i. 8) follow-up rates. Meta-analysis 12 was not performed due to the heterogeneity of scientifically admissible studies with 13 respect to patient populations. comparators. without high risk of bias) and were included in our data 7 (results. 8 9 Data Extraction and Synthesis of Results 10 The lead author extracted data from studies with a low risk of bias to build evidence 11 tables and the data were independently checked by a second reviewer. 5 After critical appraisal.. studies judged to have adequate internal validity were deemed 6 scientifically admissible (i. 6) co-intervention contamination. recent (<3 months). 10/100 mm on the Visual 15 Analogue Scale (VAS) [23]. 16 17 Reporting 18 This systematic review was organized and reported based on the Preferred Reporting 19 Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [26]. We calculated the percentage 5 agreement for classifying studies into low or high risk of bias following independent 6 critical appraisal. The computation of the 9 95% CI for the difference in mean change was based on the assumption that the pre- 10 and post-intervention outcomes were highly correlated (r=0. and 5/50 on the Neck Disability Index (NDI) [23-25]. 21]. 11 12 We used standardized cut-off values to determine if clinically important changes were 13 reached in each trial for common outcome measures. To quantify the effectiveness of interventions. These include a between-group 14 difference of 2/10 on the Numeric Rating Scale (NRS) [22]. 20 14 Page 14 of 89 . we used data from 7 studies with a low risk of bias by computing the relative risk or difference in mean 8 change and its 95% CI where this information was available.8) [20.1 2 Statistical Analyses 3 We computed the inter-rater reliability for the screening of articles using the kappa 4 coefficient (ĸ) and 95% confidence intervals (CI) [19]. 3) k=0. 11 12 Study Characteristics 13 All 22 studies with a low risk of bias were RCTs (Table 5 . valid and reliable outcome measures. appropriate 20 randomization. 2) k=0. 0.93 9 (95% CI 0.98) 7 for manipulation.00) for acupuncture. IB. IC. we 14 categorized seven studies as exploratory studies [27.97) for passive physical modalities. The percentage agreement for article admissibility 10 during independent critical appraisal was 84.online). 0. ID . Of these.91. 41.91 (95% CI 0. of which 22 had a low risk of bias [27-49]. 37. 17 18 Risk of Bias within Studies 19 All studies with a low risk of bias used clear research questions.94 (95% CI 0. and traction. 5 6 The inter-rater agreement for screening of articles was: 1) k=0. and 4) k=0.1 RESULTS 2 Study Selection 3 We screened 8551 citations (Figures IA.95 (95% CI 0.86. Most studies adequately fulfilled the following 15 Page 15 of 89 . 1.90. and intention to treat analysis 21 where applicable (Table 5 . 50-53] and 15 as 15 evaluation studies [28-35.online) [27-49].online). Thirty-eight articles were 4 critically appraised. mobilization. 0. 43-49].84. Most studies (21/22) evaluated adults with NAD and 16 one targeted adults with WAD [46].2% (32/38).99) for soft tissue 8 therapy. 16 17 Grades I-II NAD of Variable Duration 18 A single strain-counterstrain session is no more effective than sham strain-counterstrain 19 in patients were neck pain of one month to five years duration [27].online). The follow-up 3 rate was above 75% in all but one study [31] (Table 5 .1 criteria: proper allocation concealment (20/22). 10 11 Summary of the Evidence Published After the Neck Pain Task Force Report 12 13 Exploratory Studies (Table 6 . likely attrition bias. and similarity at baseline across groups (17/22) [27-49]. and no report of intention to treat analysis [54-66]. poor or unknown allocation concealment. Participants 20 randomized to strain-counterstrain received passive neck positioning aimed to induce 16 Page 16 of 89 . proper blinding procedures where 2 possible (20/22).online) 14 WAD 15 We found no exploratory studies with a low risk of bias for the management of WAD. 4 5 The main methodological limitations of studies with a high risk of bias included: poor or 6 unknown randomization methods. We 9 contacted the authors of five RCTs for additional information but none responded. clinically 7 important differences in baseline characteristics with no statistical adjustment in the 8 analysis. Sham strain-counterstrain involved 2 digital pressure adjacent to the spinous process of C4 with 30 degrees of passive neck 3 rotation for 90 seconds. Cleland et al.1 minimal-to-moderate muscle tension for 90 seconds. intensity. Similarly. disability 10 (NDI). found that 12 individuals who received two thoracic manipulations had clinically important reductions 13 in neck pain (NRS) and disability (NDI) compared to those treated with thoracic 14 mobilization [38]. cervical motion or self-perceived recovery [27]. 40]. reported that patients who received two sessions of thoracic 9 manipulation reported clinically important improvements in neck pain (NRS). 38]. and self-rated recovery compared to those randomized to two sessions of 11 cervical mobilization and home exercise [37]. There were no between-group differences in neck pain intensity 4 (Neck Pain Disability Scale). there were 19 no differences in pain (VAS) or range of motion (ROM) immediately after one session of 20 targeted cervical mobilization targeted to the symptomatic side compared to one 21 session of non-targeted cervical mobilization [39]. In patients with persistent unilateral neck pain. 5 6 Recent-onset Grades I-II NAD 7 Thoracic manipulation is efficacious for the management of recent NAD I-II [37. 8 Masaracchio et al. patients receiving central 22 posterior-anterior cervical mobilization had statistically significant but not clinically 17 Page 17 of 89 . Similarly. 15 16 Persistent Grades I-II NAD 17 The type of neck mobilization has little impact on the outcomes of patients with 18 persistent NAD I-II [39. 7 disability (NDI). Finally.online) 15 Grades I-II WAD of Variable Duration 16 A 6-week course of needle electroacupuncture or simulated electroacupuncture 17 provides similar disability (NDI) and health-related quality of life (SF-36) outcomes for 18 WAD grade I-II [46]. Needle electroacupuncture led to statistically but not clinically 19 significant changes in pain intensity (VAS) at three and six months follow-up [46]. 13 14 Evaluation Studies (Table 6 . one session of upper thoracic manipulation and placebo 10 thoracic manipulation (applied manipulative force to an open hand contact at the upper 11 thoracic spine) provide similar outcomes for pain (VAS) in patients with persistent NAD 12 I-II [42]. there were no post-intervention differences in cervical ROM 3 or global perceived recovery [40]. 6 There were no clinically or statistically significant differences in pain intensity (NRS). 4 5 The efficacy of spinal manipulation for the management of persistent NAD I-II is unclear.1 important reductions in pain (VAS) compared to those receiving randomly-directed 2 mobilization [40]. 20 Electroacupuncture involved needle electroacupuncture at specific points while 21 simulated electroacupuncture involved deactivated electroacupuncture on needled 22 points 20-30 mm away from these specific points. Moreover. 18 Page 18 of 89 . and a 7-day application of KinesioTape over the 9 cervical extensors [41]. and ROM outcomes between administration of one mid-cervical and 8 one cervico-thoracic manipulation. Cervical manipulation with 21 traditional Chinese massage is superior to traditional Chinese massage (relaxation. there were no differences in pain (NRS). disability 19 (NDI). 14 15 Persistent Grades I-II NAD 16 The effectiveness of spinal manipulation may be dependent on the treatment modalities 17 that are provided with manipulation. disability (NDI). 6 7 A soft tissue therapy intervention combining ischemic compression. strain-counterstrain. 8 and muscle energy technique is associated with statistically but not clinically significant 9 differences in pain (VAS). range of motion. ischemic compression. One group received integrated neuromuscular inhibition 11 technique (i. global perceived effect.. strength or satisfaction up to 52 weeks 20 post-intervention in patients with persistent NAD I-II [43]. disability (NDI). and lateral flexion compared to muscle 10 energy technique alone [28].1 Recent-onset Grades I-II NAD 2 In comparing a course of neck manipulation and neck mobilization (four treatments over 3 two weeks) for recent NAD I-II. strain-counterstrain. 22 provocative. 4 and health-related quality of life (SF-12) immediately and up to 12 weeks post- 5 intervention for recent NAD I-II [44]. Adding cervical and thoracic manipulation to a high- 18 dose supervised exercise program provides no additional improvement in pain. and muscle energy 12 technique) to the upper trapezius while the other group received muscle energy 13 technique alone to the upper trapezius.e. and gentle massage techniques) alone in reducing neck pain intensity 19 Page 19 of 89 . 20 21 LLLT is not effective in reducing pain (VAS) or disability (NDI) compared to an 22 inactivated laser device for the management of persistent cervical myofascial pain 20 Page 20 of 89 . pain perception. relieve muscle tension. psychological outcomes and quality of life (SF- 14 36) in patients with persistent NAD [30]. Swedish and/or clinical massage with self-care advice is 5 superior for reducing neck disability (NDI) and symptom bothersomeness (NRS) in the 6 short-term and for reducing symptom bothersomeness in the long-term for patients with 7 persistent neck pain [29]. The massage group received various Swedish and clinical 8 massage techniques at the discretion of the practitioner with verbal self-care advice. 9 while the control group received information on neck pain causes. associated 10 symptoms. exercises. Both groups 19 continued independent home care twice per week for 12 weeks. Participants randomized to cupping massage 15 attended a one-hour workshop on the home-based cupping massage technique (using 16 a cupping glass and massage oil). but not neck pain-related disability immediately post-intervention in patients with 2 persistent NAD I-II [31]. 11 12 Cupping massage and progressive muscle relaxation lead to similar changes in pain 13 (VAS). and treatment options. Progressive muscle relaxation involved one hour of 17 instruction by a psychologist on home-based techniques to achieve deep muscle 18 relaxation. disability (NDI). 3 4 Compared to a self-care book. and improve general well-being.1 (NRS). posture. 48]. Western 21 acupuncture provides statistically but not clinically significant improvements in pain 22 (VAS). strain- 11 counterstrain). There were statistically significant but not clinically 19 important differences in pain (VAS) and disability (Northwick Park Questionnaire) 20 favouring traditional Chinese medicine acupuncture [47. or 2) multimodal therapy that included a neuromuscular 10 technique. 48]. Both groups received a home program consisting of postural skills and 12 exercises. disability (NDI). dose 7J per point) or a device that was not activated. and strain-counterstrain) lead to similar changes 7 in pain (VAS). Two studies found that traditional Chinese medicine acupuncture 16 and sham-penetrating acupuncture (same procedure as the needle acupuncture group 17 but needles were superficially inserted 1cm lateral to traditional acupuncture points) 18 lead to similar outcomes [47. post- 6 isometric stretching. post-isometric stretching. 13 14 The evidence does not support the use of needle acupuncture for the management of 15 persistent NAD I-II.e. Western 21 Page 21 of 89 . spray and stretch. spray and stretch. 4 5 TENS and a multimodal soft tissue therapy program (neuromuscular technique. Jones technique (i. disability (NDI). and health-related quality of life (SF-12) at one or six 8 month follow-up for persistent NAD I-II [33]. and health-related quality of life (SF-36) compared to non- 23 penetrating placebo electroacupuncture for persistent NAD I-II [49]. frequency 1000 Hz. Moreover. 3 power output 58mW/cm2.. Participants were randomized to: 1) TENS 9 (80 Hz.1 syndrome [32]. ≤150μs pulse duration). Participants were randomized to receive LLLT to three trigger points 2 bilaterally using either an active device (wavelength of 830-nm. neck 22 pain (VAS). and physical health-related quality of life (SF-12) compared 22 Page 22 of 89 . 20 21 LLLT leads to statistically but not clinically significant improvements in arm pain. disability (NDI).1 acupuncture involved needling of locally tender and traditional points.2 10 weeks. while the placebo 2 group received inactivated electrodes to acupuncture points. or 3) six weeks of supervised graded 19 strengthening exercises for the neck and shoulder. neck pain 15 (VAS). or disability (NDI) to patients with recent NAD III [35]. 11 12 Recent-onset Grade III NAD 13 Participating in a graded strengthening exercise program or wearing a semi-rigid 14 cervical collar for six weeks provide similar improvements in arm pain (VAS). Participants were randomized to: 1) three weeks of wearing a semi- 17 hard cervical collar and prescribed rest followed by three weeks of weaning from the 18 collar. exercise and home exercise) provides no 7 additional benefits in pain (NRS) or disability (NDI) compared to sham cervical traction 8 with the same multimodal care up to four weeks follow-up for the management of NAD 9 grade III [45]. Both treatments were 16 superior to advice. 3 4 Grade III NAD of Variable Duration 5 Adding intermittent cervical traction to a multimodal program of care (postural 6 education. Patients were treated an average of seven visits over an average of 4. manipulation or mobilization. 2) advice to continue daily activities. 50]. and 96. Most studies had a rate of minor adverse events ranging from 9 zero to about 30% [33. 21 mobilization. and acupuncture for neck pain has advanced. but were reported as unrelated to treatment by the 14 attending medical specialists (one participant had a cardiac event and one developed 15 severe arm pain and weakness three days after the mobilization session) [44]. One study [43] reported mild and 10 transient adverse events in 98. 35-37.1 to placebo LLLT (deactivated laser treatment) for the management of recent NAD III 2 [34]. 40. 44. 33.9% of patients who received high dose strengthening 11 exercise therapy and spinal manipulation. 68]. There are 22 recent studies with a low risk of bias investigating the effectiveness of a cervical collar. 48. 43. 16 17 DISCUSSION 18 Since 2008. soft tissue therapies. 36-41. 3 4 Adverse Events 5 Sixteen of the 22 studies with a low risk of bias addressed the occurrence of adverse 6 events [27. 34. 39. 29-31. and taping for NAD grades I-II. No serious neurovascular adverse 8 events were reported. Two serious adverse events in patients allocated to cervical mobilization 13 were reported in one study. manipulation. Most adverse events were mild to 7 moderate and transient (Table 6 and Table 7).6% who received the same exercise 12 therapy alone. LLLT. the literature on the effectiveness of manual therapies. Our review adds to the 20 existing knowledge base by clarifying the effectiveness of acupuncture. passive physical 19 modalities. 23 Page 23 of 89 . 42-48. 67. 14 15 Evaluation studies: 16 We found that strain-counterstrain and ischemic compression provide no added benefit 17 to muscle energy technique for recent NAD grades I-II. However. For persistent NAD grades I-II. investigated progressive muscle 24 Page 24 of 89 . but is no better than placebo for treating 9 persistent NAD grades I-II. we found that strain- 13 counterstrain is not efficacious for NAD. but 19 not to high-dose supervised exercises. We found that the type of neck mobilization may not impact 10 the outcomes of patients. We also found that home-based cupping 20 massage leads to similar outcomes to home-based progressive muscle relaxation for 21 persistent NAD grades I-II. 3 4 New Findings since the Publication of the Neck Pain Task Force Report 5 6 Exploratory studies: 7 Based on exploratory evidence.1 LLLT. the trial by Lauche et al. Key findings from our 2 synthesis of the evidence are outlined in Table 8. it is important to note that the progressive muscle 22 relaxation used in this study does not reflect how the intervention would be delivered in 23 clinical practice. and traction for the management of NAD grade III. We also found that one session of cervical and cervico- 11 thoracic manipulation is as effective as one week of kinesiotape over the neck in the 12 short-term for persistent NAD grades I-II. we found that thoracic manipulation provides benefit to 8 individuals with recent NAD grades I-II. Specifically. 18 we found that manipulation provides added benefit to traditional Chinese massage. For soft tissue therapy. We did not find 12 any studies that compared different techniques of cervical manipulation. therefore. 5 6 Results that are Consistent with Findings of the Neck Pain Task Force 7 8 Evaluation studies: 9 We found that cervical manipulation and cervical mobilization lead to similar outcomes 10 in individuals with recent NAD grades I-II. While these results may appear contradictory. We also found that there were no serious 11 adverse events reported in randomized clinical trials on manipulation. we found that LLLT was not effective for recent- 3 onset NAD grade III and traction does not provide added benefit to a multimodal 4 program for NAD III. it is 25 Page 25 of 89 . In 2008.1 relaxation performed by patients at home after they were instructed by a psychologist 2 during a one hour session [30]. the Neck 21 Pain Task Force reported that relaxation massage was not effective (equal to sham 22 acupuncture) for chronic neck pain. Finally. 14 15 16 Results that are not Consistent with Findings of the Neck Pain Task Force 17 18 Evaluation studies: 19 We found that relaxation and/or clinical massage added benefit to self-care advice when 20 compared to self-care advice alone for persistent NAD grades I-II. it is 13 unclear if specific cervical manipulation techniques are more effective than others. However. Overall. the preponderance of evidence suggests that clinic-based 7 LLLT is effective for persistent NAD. 12 13 For acupuncture. 74. the Neck 18 Pain Task Force warned that this result may be attributed to favourable patients’ 19 expectations. while 14 Western acupuncture and needle acupuncture is not effective for persistent NAD I-II. However. 75]. the updated evidence suggests that acupuncture may not be 21 effective for the management of recent or persistent neck pain. 26 Page 26 of 89 . we found that electroacupuncture is not effective for WAD I-II.1 possible that the clinical (not relaxation) massage provides benefit to patients with 2 persistent neck pain. 16 which found that needle acupuncture. graded strengthening exercises and cervical collar with 10 rest were equally effective. when combining the new evidence with Neck Pain Task Force findings 6 from five studies [69-73]. However. when added to routine general medical care. since all participants in this study were patients of physicians who practice 20 acupuncture [75]. 8 9 We found that for NAD grade III. 3 4 We found new evidence suggesting that LLLT is not effective for persistent NAD grades 5 I-II. 15 These new findings contradict the evidence available to the Neck Pain Task Force [75]. caution should be taken when considering the use 11 of cervical collars because of the potential for iatrogenic disability [13. may 17 provide short-term benefits to patients with persistent neck pain [68]. It is important to note 22 that acupuncture was compared to needling interventions where skin was penetrated. as the 10 effectiveness of this multimodal program of care is unknown. Our review differentiates studies by the 19 nature of their design for the purpose of contextualizing the dose and duration of 20 outcomes to reflect clinical practice. or magnetic necklaces. policy makers. Overall. since they 22 provide confidence in the intervention’s effectiveness or comparative effectiveness to a 27 Page 27 of 89 . this new evidence cannot 11 be used to support or refute the findings of the Neck Pain Task Force. Our review found new evidence that TENS provides similar outcomes to a 9 multimodal program of care focused on soft tissue therapy. 3 4 Findings of the Neck Pain Task Force that We Cannot Support or Clarify 5 We did not find new evidence on the effectiveness of ultrasound. 9]. 8 76]. 13 14 Unlike previous systematic reviews. However. diathermy. and 21 patients to place more emphasis on the results of the evaluation studies. electrical muscle stimulation. It is important for clinicians. we stratified admissible studies into exploratory 15 (efficacy) and evaluation (comparative effectiveness) according to the IDEAL framework 16 to facilitate the clinical interpretability of results [8. Exploratory studies are used to 17 develop well-informed hypotheses about the effectiveness of promising interventions 18 that need to be tested in evaluation studies. there is a 12 lack of evidence supporting the effectiveness of TENS in this population. heat 6 therapy. The Neck Pain Task 7 Force found that TENS provides no clinically important benefit compared to placebo [75.1 which may have a physiological effect. studies with non-penetrating sham/placebo 2 interventions are needed. this review cannot comment on how patients valued and experienced their 20 exposure to manual therapies. inclusion 8 criteria. We conducted a rigorous search of the literature and 7 the search strategy was peer reviewed.1 standard of care. and outcomes [20]. when heterogeneity exists across patient populations. our conclusions were based on the best evidence 11 synthesis method to minimize the risk of bias associated with using low quality studies 12 [20]. or acupuncture. There should be caution in including results from exploratory studies 2 into clinical guidelines or practice pending more robust evaluation studies. We used the SIGN criteria to standardize the critical 10 appraisal process [19]. A best evidence synthesis is considered an appropriate alternative to a meta- 13 analysis 14 comparisons. and exclusion criteria for the selection of studies and only considered studies 9 with adequate sample sizes. 19 Thus. but this is an unlikely source of bias [77-81]. We used clear case definitions. 18 Qualitative studies that explored the lived experience of patients were not included. 15 16 Our review also has limitations. We only searched the English literature. 21 22 CONCLUSIONS 28 Page 28 of 89 . interventions. passive physical modalities. 3 4 Strengths and Limitations 5 6 There are strengths to our review. which may 17 have excluded some relevant studies. Lastly. Michel Lacerte. hydrotherapy. or drafting of the manuscript. 8 9 Acknowledgement 10 11 This study was funded by the Ontario Ministry of Finance and the Financial Services 12 Commission of Ontario (RFP No. thanks to funding from the Canada Research Chairs program to Dr. 20 Mike Paulden. 7 ultrasound) are not effective and should not be used to manage neck pain. interpretation of the data. J. and acupuncture informing their use for the management of 3 neck pain. It also suggests that electroacupuncture. Gail Lindsay. Pierre Côté. and Shawn Marshall. David Cassidy. Doug Gross. and clinical massage are effective interventions for the management of 5 neck pain. Poonam Cardoso. Our update of the Neck Pain Task Force suggests that mobilization. The authors also thank Trish Johns-Wilson at the 22 University of Ontario Institute of Technology for her review of the search strategy. data analysis. Murray Krahn. relaxation 6 massage. John Stapleton. Patrick Loisel. diathermy. The funding agencies were not involved in the collection 16 of data. strain-counterstrain. Richard Bohay. there is new scientific evidence on the effectiveness of manual therapies.1 Since 2008. 14 Canada Research Chair in Disability Prevention and Rehabilitation at the University of 15 Ontario Institute of Technology. and other passive physical modalities (heat. cold. in 13 part. 29 Page 29 of 89 . This research was undertaken. 4 manipulation. Roger 21 Salhany. 17 18 The authors acknowledge the invaluable contributions to this review from: Angela 19 Verven.: OSS_00267175). 2 passive physical modalities. Miller J. 17 Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated 18 Disorders: from concepts and findings to recommendations. 6 2. 16 6. Treatment of neck pain: Guzman J. Cote P. 21 implications: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its 22 Associated Disorders. The Saskatchewan Health and Back Pain Survey. 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Goldsmith C. whiplash-associated disorders. 2003. exp Neck Pain/ 18 4. Report of the International Paris Task Force on Back Pain. whiplash. exp Whiplash Injuries/ 16 2. Development of a taxonomy Med 2006. Thompson D.ti. 8 88. BMC Complement Altern 10 Graham N. 4 acute musculoskeletal pain. exp Radiculopathy/ 21 7.6:24. 5 87. and manual therapy 15 1. exp Cervical Vertebrae/in [Injuries] 20 6. Cherkin DC. 41 Page 41 of 89 .25:1S-33S.38:145-52. J Rehabil Med 2006. Evidence-based management of Abenhaim L.ab. Rossignol M. 3 86. The role of activity in the therapeutic Sherman KJ. 6 management of back pain. exp Brachial Plexus Neuropathies/ 22 8. Dixon MW. exp Torticollis/ 23 9. 9 to describe massage treatments for musculoskeletal pain.1 85. Neck Muscles/in [Injuries] 19 5. et al. 2 disorders: a systematic review. exp Neck Injuries/ 17 3. 11 12 13 14 Appendix IA: MEDLINE search strategy for neck pain and associated disorders. Valat JP. 22 31.ti.ti.ab. Double-Blind Method/ 19 28. 5 14. controlled clinical trial.ab.ab. 8 17.ab. (meta analys* or meta-analys* or metaanalys*). (random* adj4 (control* or clinical or allocat*)).ab. "neck pain*".ti. single-blind method/ 20 29. "radiculopath*". exp case-control studies/ 17 26.ab. 2 11.ti.ti.ti. 11 20. exp Cohort Studies/ 18 27. exp consensus development conferences as topic/ 15 24. 4 13. 10 19. ("headache*" adj4 (whiplash or WAD or neck pain)). "neck injur*".pt. Placebos/ 21 30. 24 33. "brachial plexus neuropath*". 16 25.pt.ti.ti.ti. 3 12.ab.1 10. "neck ache*".ti. "cervical pain*".ab.ab.ti. 12 21. "cervicodynia*". 23 32.ab.ti. 42 Page 42 of 89 . 7 16. 25 34. (cohort adj4 (study or studies or analys*)). "neckache*".ab. Randomized Controlled Trials as Topic/ 13 22.ab. 9 18.ab.ab. exp Controlled Clinical Trials as Topic/ 14 23. 6 15.ti. "cervicalgia*". torticollis. randomized controlled trial.pt.ti. meta-analysis. (traction and (manual or passive or mechanical or non-surgical or nonsurgical)). 25 58. 16 50. Motion Therapy. 18 52. Orthopedic/ 10 44.ti. ((double or single) adj3 blind*).ab.ab.ti.ti. 23 56.ab.ti. Continuous Passive/ 12 46.ti. (case adj control*).ti. (mobili?ation adj4 (spinal or lumbar or thoracic or cervical)). 24 57.ab. Osteopathic/ 11 45. "placebo*".ab. (mobli?ation adj4 (chiropract* or osteopath* or orthopedic* or orthopaedic*)). or/1-20 5 39.ab.ab.ab. 17 51. (manipulat* and (instrument assisted or instrument-assisted)). 43 Page 43 of 89 .ab. Manipulation. Musculoskeletal Manipulations/ 7 41. (adjustment* adj4 (chiropract* or spinal or lumbar or cervical or thoracic)). 21 54.ti. (flexion-distraction or flexion distraction).ab. (HVLA or high velocity low amplitude). Chiropractic/ 9 43.ti.1 35. (manipulat* adj4 (spinal or lumbar or thoracic or cervical)). (manipulat* adj4 (chiropract* or osteopath* or orthopedic* or orthopaedic*)). Spinal/ 8 42. Manipulation. (manipulat* and (physiotherap* or physical therap*)). Manipulation.ab.ab.ti. Manipulation. 19 20 53. 3 37.ab.ti.ti.ab. 2 36.ti. (mobili?ation and (physiotherap* or physical therap*)).ti. 15 49.ti. Muscle Stretching Exercises/ 13 47. or/21-37 6 40.ab.ti. 14 48. (therap* adj4 (manual or manipulat* or mobili?at*)). 22 55. 4 38. Muscle Stretching Exercises/ 16 8. 38 and 39 and 60 4 62. (musculoskeletal and (physiotherap* or physical therap*)).ti.ab. Manipulation. "Anma massage*". Chiropractic/ 12 4. Acupressure/ 10 2. limit 61 to (english language and yr="2000 -Current") 5 6 7 8 Appendix IB: MEDLINE search strategy for neck pain and associated disorders. Massage/ 15 7. active release. Complementary Therapies/ 11 3. Manipulation. 25 17. Osteopathic/ 14 6. Vibration/tu [Therapeutic Use] 22 14.ti. Reflexotherapy/ 19 11. Manipulation.ab.ab. 2 60. Musculoskeletal Manipulations/ 17 9. exp Medicine. Chinese Traditional/ 21 13. Therapeutic Touch/ 20 12.ti.ab.ti. acupressure. 23 15. Orthopedic/ 13 5. and soft tissue therapy 9 1. 24 16. "Alexander technique*".1 59. or/40-59 3 61. whiplash-associated disorders.ti.ab. 44 Page 44 of 89 . Physical Therapy Modalities/ 18 10. ab. 21 38. 14 31. 15 32. Jin Shin.ab. 19 36.ab.ab. Cyriax friction.ti.ti.ab.ti.ti. "deep tissue therap*".ti. 18 35.ti.ti. Chih Ya. (craniosacral and (massage or therap*)).ab.ti. "neuromuscular therap*". "manual therap*".ab. (instrument assisted and (massage* or soft tissue or soft-tissue)). "Ayurvedic massage*". (instrument-assisted and (massage* or soft tissue or soft-tissue)). Feldenkrais method.ti. 5 22. 3 20. 10 27.ti. 12 29.ab. 7 24. Gua Sha.ab.ab. bodywork. 23 40.ab.ab.ti. 8 25.ab. Nimmo.ab. 11 28. 4 21. 45 Page 45 of 89 . "Hot stone massage*".1 18. Aston patterning.ab. 16 33. (cranio-sacral and (massage or therap*)).ti.ab. 6 23. Graston.ab. "muscle energy technique*".ti.ab.ab. 24 41. "friction massage*".ab. "massage*".ti.ti.ti.ti.ti. 13 30. 2 19. Hakomi method.ab. 17 34. myofascial release.ab.ab.ti.ti. 9 26.ab.ti.ti. Guasha. 25 42.ti.ti. cranial release.ti. 22 39. 20 37.ab. ti. Vibromax. 15 57.ti. Tui Na. ((post isometric or post-isometric) and relaxation). "trigger point* therap*".ti.ti.ab.ti.ti. 20 62.ab. 19 61. Reiki. 23 65. 24 66.ab. TCM. 18 60. (soft tissue and (mobili?ation or therap*)). "therapeutic touch*". 13 55.1 43.ab.ti.ab.ab.ti.ab.ab.ab.ti.ab.ti.ti.ti.ti. Trager psychophysical.ab.ti. 14 56.ab. 17 59. 7 49. 8 50. "sports massage*".ab.ab.ab.ti.ti. 2 44. 5 47. 12 54.ab.ti. 16 58. 21 63.ti.ab. traditional Chinese medicine.ab.ab.ab.ti. "Thai massage*". 46 Page 46 of 89 . 22 64.ti. 11 53. "polarity therap*". "pressure point* therap*". "Pfrimmer therap*".ab.ti.ab. 25 67.ti. 6 48. 3 45.ti. "reflexotherap*". "Swedish massage*".ti.ab. Shiat?u. "vibration therap*". Rolfing.ti. 10 52. 4 46. 9 51. Tuina. (soft-tissue and (mobili?ation or therap*)).ab. reflexology. Thumper. proprioceptive neuromuscular facilitation.ab. Zhi Ya. Low Back Pain/ 9 76. exp Lumbosacral Plexus/ 14 81.ti. Sacrococcygeal Region/ 20 87.ab. or/1-70 5 72. Spine/ 16 83. VMTX. Lumbar Vertebrae/in [Injuries] 13 80. Spinal Stenosis/ 25 92. 4 71. 47 Page 47 of 89 . exp Back Injuries/ 7 74. Coccyx/in [Injuries] 10 77.ti.ti. (avulsed lumbar and (disc* or disk*)). Sciatica/ 23 90. 2 69. Polyradiculopathy/ 18 85. Osteoarthritis. Intervertebral Disc Displacement/ 12 79.ab. Back Pain/ 8 75. 3 70. Sacroiliac Joint/ 21 88. Piriformis Muscle Syndrome/ 17 84.1 68. Spinal Diseases/ 24 91. Radiculopathy/ 19 86.ab.ti. exp Back/ 6 73. Intervertebral Disc Degeneration/ 11 78. "Zone therap*". Sacrum/ 22 89. Lumbosacral Region/in [Injuries] 15 82.ab. 2 94. 12 102.ti.ti. coccyx. coccydynia.ab.ab.ti.ti. "lumbosacr*".ti. "sciatic*". "low* back pain". radiculalgia.ab.ab. (lumbar disk* and (extruded or degenerat* or herniat* or prolapse* or sequestered or slipped)). 21 110.ab.ab.ab.ab. 25 114.ab.ti.ti.ti.ti.ab. 6 98. "lumbarsacr*".ti.ti.ab.ab. dorsalgia. 13 14 103.ab.ab. 48 Page 48 of 89 . SI joint.ti.ti.ti. 7 8 99. 16 105.ti.ab. (back pain or back-pain).ab.ti. "low*-back-pain*". (lumbar and (pain or facet or nerve root* or osteoarthritis or radicul* or spinal stenosis or spondylo* or zygapophys*)). 22 111. (sacroiliac or sacro-iliac). 3 95. (lumbar disc* and (extruded or degenerat* or herniat* or prolapse* or sequestered or slipped)). spinal stenos?s.ti. lumboischialgia.ab. 24 113. 18 107. "Piriformis syndrome*".ti.ab.ab. (back and (ache* or injur* or pain*)).ti. 15 104. 5 97. 20 109.ab.1 93.ti. 11 101. 23 112.ab. 17 106. sacrococcygeal pain*. 26 115.ti. spondylosis. (backache* and (injur* or pain*)). 4 96.ab.ti. 19 108. 9 10 100.ab. sacral pain*.ti. exp Brachial Plexus Neuropathies/ 11 126. or/119-138 25 140. 16 131.ti. 19 134. "cervicalgia*". whiplash. "vertebrogenic pain*".ab. "radiculopath*".ti.ti. 20 135. "cervical pain*". 3 118. 15 130.ti.ab. "neck pain*". Torticollis/ 12 127. 14 129.ti.ti. Neck Pain/ 7 122. "neckache*". "neck injur*". "cervicodynia*". exp Cervical Vertebrae/in [Injuries] 9 124.ab.1 116. Neck Muscles/in [Injuries] 8 123.ti.ab.ab. Radiculopathy/ 10 125. "neck ache*".ab. 2 117.ti.ab. Neck Injuries/ 6 121. Whiplash Injuries/ 5 120.ti. 23 138.ab. "tailbone pain*". "brachial plexus neuropath*". 18 133.ab.ti.ab.ab.ti. or/72-117 4 119. 24 139.ti. 13 128.ab. torticollis. 22 137. 21 136.ab.ab.ti.ti. 118 or 139 49 Page 49 of 89 . 17 132. "headache* and (whiplash or WAD or neck pain*)". 1 141.pt.ti. 13 153. 10 150. Placebos/ 9 149. 17 157. 14 154.pt. 18 158.ab. controlled clinical trial.ab.ab.ti. 20 160. (case adj control*). Clinical Trials as Topic/ 4 144.pt.ab.ab.ti.ab. 19 159. exp Case-Control Studies/ 5 145.ti. 12 152. Randomized Controlled Trials as Topic/ 2 142.ti. (meta analys* or meta-analys* or metaanalys*).ab. limit 162 to (english language and humans and yr="2000 -Current") 24 25 50 Page 50 of 89 . 21 161. ((double or single) and blind*). or/141-160 22 162. (random* and (control* or clinical or allocat*)). randomized controlled trial. 71 and 140 and 161 23 163. (comparative and (study or studies)). (case adj control*).ti. Single-Blind Method/ 8 148.ti.ti. (meta analys* or meta-analys* or metaanalys*). (cohort and (study or studies or analys*)).ti. Controlled Clinical Trials as Topic/ 3 143. "placebo*". exp Cohort Studies/ 6 146. 16 156.ab. Double-Blind Method/ 7 147. 15 155. comparative study. 11 151.ab. and passive physical modalities 4 1.ti. Self-Help Devices/ 20 17. 26 27 21. (heat* and (therap* or pack* or compress or massage or lamp or pad or bath or soak or tub or bottle or superficial or therapeutic)). (ice and (therap* or pack* or compress or massage or immersion or soak or treatment or therap*)). High-Energy Shock Waves/tu [Therapeutic Use] 17 14. Fluid Therapy/ 14 11. Cryotherapy/ 7 4.ab.ti. exp Orthotic Devices/ 10 7. exp Electric Stimulation Therapy/ 9 6. Laser Therapy. 24 25 20.ab. Magnetic Field Therapy/ 8 5. "Bedding and Linens"/ 16 13. exp Diathermy/ 11 8. exp Hydrotherapy/ 5 2.ti. (cold and (therap* or pack* or compress or massage or immersion or soak or treatment or therap*)). Casts. Low-Level/ 6 3. Magnetics/tu [Therapeutic Use] 15 12. Hot Temperature/tu [Therapeutic Use] 12 9. or/1-17 22 23 19. Surgical/ 13 10. Bed Rest/ 18 15.ab. 51 Page 51 of 89 . whiplash-associated disorders.1 2 3 Appendix IC: MEDLINE search strategy for neck pain and associated disorders. Restraint. Rest/ 19 16. Physical/ 21 18. galvanic stimulation.ab.ab. 11 30.1 2 22. "electromodalit*".ti. (athletic and (tape or taping)). "hydrocollar*".ab. (electric* and (stimulation or EMS or heating pad*)).ab.ti. 6 25.ti. 52 Page 52 of 89 .ab. 17 36.ti.ti.ti.ti. 8 27.ti. (braces or brace or bracing). (collar or collars). 12 31.ab. "assistive device*".ab. 21 40. 3 4 23. "hydrotherap*".ab. (H-Wave Device Stimulation or HWDS). (corset or corsets). 7 26. 24 43.ab.ti. 13 32. (electrogalvanic stimulation or EGS). 10 29.ti.ab. (hot and (therap* or pack* or compress or massage or lamp or pad or bath or soak or tub or bottle or superficial or therapeutic)).ti.ab. 9 28. (electromagnet* and (radiation or therap*)).ab.ab. (cast or casts). 19 38. (high energy shock wave* or high-energy shock wave* or HESW). 18 37.ti. "fluidotherap*".ti.ti.ab.ti. 20 39.ti. "back belt*".ab.ti.ab. 25 44.ab.ab. ((shockwave* or shock wave* or shock-wave*) and (ultrasonic or therap* or radiation)).ab. electroanalgesia.ti.ab.ti. electrotherapy.ab. 26 45.ti. 15 34.ti. 5 24. 23 42.ti.ab.ab. 16 35. "cryotherap*". (guard* and (teeth or night or mouth or wrist or knee)).ti. 14 33. 22 41.ab.ti. diathermy. ti. muscle activation. iontophoresis.ti. (paraffin and (treatment* or therap*)). 20 65.ti. (Neuromuscular Electrical Stimulation or NMES). 7 52. 12 57. "seat cushion*". 16 61.ti.ti.ab.ab.ti. 22 67.ab. myofascial release.ab. "orthotic*". (interferential current* or ICS or IFC).ab.ti.ab.ab. (pulsed and (electromagnetic or magnetic or radio frequency or energy)). 53 Page 53 of 89 . radiant light.ti. "Percutaneous Electric* Nerve Stimulation".ti. "moist air bath*".ab. 6 51.ab.ti. 19 64.ab.ti. 14 59.ab.ab.ab.ti. 9 54. (magnetic and (necklace* or therap* or bracelet*)).1 46. "lumbar support*".ab. "microwave*". 18 63. 13 58. 15 60.ti. 4 49. "passive modalit*".ab. (short wave* or short-wave*). 25 70. 2 47. 3 48. 23 68.ab. 10 55.ti.ti.ti.ab. "kinesiotap*".ab.ti. (laser* and (phototherapy or irradiation or biostimulation or light or therap*)).ab.ti. "low level laser*". infrared. Microcurrent Electrical Neuromuscular Stimulation. 24 69. "pillow*".ti. 21 66.ab. 11 56.ti. (sling or slings). 8 53.ab.ti.ti. 5 50. Russian stimulation.ab.ti.ab.ti.ab.ti.ab. 17 62. 2 72.1 71.ab.ab. Radiculopathy/ 19 89. 9 79.ab. 22 92. (splint or splinting or splints).ab.ti.ti.ab. Neck Injuries/ 15 85.ti. 54 Page 54 of 89 .ti. 8 78. "cervical pain*". 7 77. "neck injur*". 25 95. whiplash.ti.ti. "neck pain*". exp Brachial Plexus Neuropathies/ 20 90.ab.ti. 5 75. exp Cervical Vertebrae/in [Injuries] 18 88. 3 73.ti. (tape or taping).ab. 10 80. whirlpool.ti.ti. Neck Muscles/in [Injuries] 17 87.ti. 4 74.ab. "wax treatment*".ti. "vibration therap*". 18 or 81 13 83.ab.ti.ab. "warm compress*". ultrasound. 24 94. Torticollis/ 21 91. vapocoolant spray.ab. or/19-80 12 82.ab.ti. "neck ache*".ti. 6 76.ab. 11 81. 23 93. Whiplash Injuries/ 14 84.ab. "spray and stretch". Neck pain/ 16 86.ab. (transcutaneous electrical stimulation or TENS). Randomized Controlled Trials as Topic/ 11 105. 18 112. "cervicalgia*".ti. or/83-102 9 10 104.ab. single-blind method/ 16 110. "brachial plexus neuropath*".pt. (cohort adj4 (study or studies or analys*)). 4 99. (case adj control*).ab. "neckache*".ab. exp case-control studies/ 13 107.ti. (headache* adj4 (whiplash or WAD or neck pain)).pt. 7 102.1 96.ti.ti. "cervicodynia*".ab.ti.ti.ab.ab.ti.pt. Controlled Clinical Trials as Topic/ 12 106. 5 100.ti. 20 114. 25 119. torticollis. ((double or single) adj3 blind*).ti. randomized controlled trial.ab. Placebos/ 17 111. (meta analys* or meta-analys* or metaanalys*).ti.ti.ab. exp cohort studies/ 14 108. 19 113. 3 98. 55 Page 55 of 89 . (cohort adj4 (study or studies or analys*)). 21 115. 23 117.ab. 24 118.ab.ab.ab. 6 101. 22 116. 2 97.ti.ti.ab. "radiculopath*". controlled clinical trial. double-blind method/ 15 109. 8 103. meta-analysis. (random* adj4 (control* or clinical or allocat*)). "placebo*". and acupuncture 9 1. 24 16.ab. "radiculopath*". limit 122 to (english language and yr="2000 -Current") 5 6 7 8 Appendix ID: MEDLINE search strategy for neck pain and associated disorders. exp Radiculopathy/ 15 7. "cervicalgia*". "cervical pain*". 2 121.ti. 20 12. exp Cervical Vertebrae/in [Injuries] 14 6.ab. "neck pain*". "neck injur*". or/104-120 3 122.ti.ab.ti.ti.ab.1 120.ab.ab.ti. 56 Page 56 of 89 .ab.ti.ti. "neck ache*". Neck Muscles/in [Injuries] 13 5. "neckache*". 25 17.ti. whiplash. 18 10. 21 13.ab. exp Torticollis/ 17 9.ab. "cervicodynia*". exp Whiplash Injuries/ 10 2.ab.ti.ti. whiplash-associated disorders. exp Neck Injuries/ 11 3. exp Brachial Plexus Neuropathies/ 16 8. 22 14. 19 11. 23 15. exp Neck pain/ 12 4. 82 and 103 and 121 4 123. 13 30.pt.ab. 6 23.ab.pt. 18 35. Double-Blind Method/ 9 26. 12 29. (random* adj4 (control* or clinical or allocat*)). Acupuncture/ 22 39.ti. exp Cohort Studies/ 8 25. exp Acupuncture Therapy/ 20 37. exp Controlled Clinical Trials as Topic/ 5 22. 2 19. ((double or single) adj3 blind*).ti. (meta analys* or meta-analys* or metaanalys*). Acupressure/ 25 42.ti. exp Auriculotherapy/ 57 Page 57 of 89 . 14 31. randomized controlled trial. (case adj control*).ab.ab. single-blind method/ 10 27. exp case-control studies/ 7 24. Electroacupuncture/ 24 41. (cohort adj4 (study or studies or analys*)).pt.1 18. controlled clinical trial. 3 20. 16 33. Acupuncture Points/ 21 38. 15 32.ti.ab.ab.ti. Randomized Controlled Trials as Topic/ 4 21.ab. Placebos/ 11 28. 17 34. meta-analysis.ti. "brachial plexus neuropath*". 19 36.ti.ti.ab. torticollis. "placebo*". Electric Stimulation Therapy/ 23 40. (Shiatsu or Shiatzu or Zhi Ya or Chih Ya). "acupuncture*". Japanese Meridian Therapy.ab. electrical stimulation.1 43.ab. or/36-56 18 60.ab.ab.ab. 8 50. Mobilization.ti. 57 and 58 and 59 19 61.ti. 15 57.ti. or/1-19 16 58.ti.ab. or/20-35 17 59. 9 51.ab.ti. 14 56.ti. intramuscular stimulation.ti.ab. 10 52.ab. auriculotherapy.ti. 13 55.ti.ti. (Ching Lo or Jing Luo or Jingluo).ab. 4 46. Lemington Five Elements. (needling and (dry or body or "trigger point*")).ab. acupressure. French Energetic.ti. or Traction for the Management of Neck Pain 58 Page 58 of 89 . limit 60 to (english language and humans and yr="2000 -Current") 20 21 22 Figure Captions: 23 Figure 1A: Selection and Critical Appraisal of Studies on the Effectiveness of 24 Manipulation.ti.ab.ab.ti. 6 48. 3 45. Korean Constitutional. moxibustion. 12 54. 5 47.ab. 2 44. artemisia vulgaris. 7 49. 11 53.ti. 1 Figure 1B: Selection and Critical Appraisal of Studies on the Effectiveness of Soft 2 Tissue Therapy for the Management of Neck Pain 3 Figure 1C: Selection and Critical Appraisal of Studies on the Effectiveness of Passive 4 Physical Modalities for the Management of Neck Pain 5 Figure 1D: Selection and Critical Appraisal of Studies on the Effectiveness of 6 Acupuncture for the Management of Neck Pain 7 8 9 10 11 12 13 14 15 16 17 59 Page 59 of 89 . heat. ultrasound. heat Pain/short term therapy. Passive Physical Modalities. electrical muscle stimulation ≤ other interventions Recent/persistent/variable Magnetic necklace = sham Pain/short term Acupuncture** Pain. TENS. disability or global improvement/ short term 5 1 There was insufficient evidence to make a determination on all interventions for the 6 management of WAD or NAD grade III. **The Neck Pain Task Force reported 7 that acupuncture may be effective. but this was based on inconsistent evidence 8 NAD – neck pain and associated disorders. and 3 Acupuncture for the Management of Neck Pain and Associated Disorders 4 and Whiplash-associated Disorders [6]1 Origin/Grade WAD Grade Duration Recent I-II Intervention and Comparison Pulsed electromagnetic therapy > Outcome/Follow-up Pain/short term sham NAD or WAD Recent/persistent/variable Collars.1 Table 1: Summary of the Findings from the Neck Pain Task Force on the 2 Effectiveness of Manual Therapies. WAD – whiplash-associated disorders 9 60 Page 60 of 89 . cold ≤ other interventions Pain/short term Manipulation = mobilization Pain or disability/ short Grade I-II term Recent and persistent NAD Grade I- Persistent II Recent/persistent/variable Manipulation/mobilization = other Pain or disability/ short conservative interventions term Low level laser therapy > sham Pain/short term Western massage < acupuncture Pain/short term Western massage = sham acupuncture Pain/short term Cervical collar. decreased or limited sensation. but major interference with activities of II daily living III 1 IV 3 [5] No signs or symptoms of major structural pathology. weakness or sensory deficits Signs or symptoms of major structural pathology 1 Grade IV was excluded from this systematic review 4 5 6 7 61 Page 61 of 89 . but presence of neurologic signs such as decreased deep tendon reflexes.1 Table 2: Classification of Grades for Whiplash-associated Disorders [10] and Neck Pain and Associated Disorders [11] 2 Grade Definition Québec Task Force Classification of Grades of Whiplash-associated Disorders [13] I Subjects with neck pain and associated symptoms in the absence of objective physical signs Subjects with neck pain and associated symptoms in the presence of objective physical signs II and without evidence of neurological involvement Subjects with neck pain and associated symptoms with evidence of neurological involvement III including decreased or absent reflexes. or muscular weakness 1 IV Subjects with neck pain and associated symptoms with evidence of fracture or dislocation The Neck Pain Task Force Classification of Grades of Neck Pain and Associated Disorders No signs or symptoms suggestive of major structural pathology and no or minor interference I with activities of daily living No signs or symptoms of major structural pathology. Definition and Categories of Manual Therapies. fluidotherapy). low amplitude impulse or thrust applied at or near the end of a joint’s passive range of motion [82] Mobilization Mobilization includes techniques incorporating a low velocity and small or large amplitude oscillatory movement. hydrotherapy. Passive Physical 2 Modalities. and Acupuncture Intervention Definition Category Manual Therapies Manipulation Manipulation includes techniques incorporating a high velocity. Examples of passive applications to the skin surface include but are not limited to heat applications (hot packs/compresses/pads. 85] Soft Tissue Therapy Soft tissue therapy is defined as a mechanical form of therapy where soft tissue structures are passively pressed and kneaded. 83] Traction Traction is defined as a manual or mechanically assisted application of an intermittent or continuous distractive force [84. heat or light application affecting the body at the skin level. Passive Physical Modalities Physico-chemical Physico-chemical modalities have a common intention to treat using either a thermal or electromagnetic effect: including cold. within a joint’s passive range of motion [82. and cryotherapy 62 Page 62 of 89 .1 Table 3. Exercise is defined as any series of active movements aiming to train or develop the body by routine practice or physical training to promote good physical health [87]. or light. We used this definition of exercise to exclude interventions that were not considered soft tissue therapy. Soft tissue techniques using acupuncture points and exercise (such as active stretches) were not considered soft tissue therapy. using physical contact with the hand or mechanical device [86]. ultrasonic or electromagnetic radiation affecting structures beneath the skin. collars.). 1 2 3 4 5 6 7 63 Page 63 of 89 .. taping. corsets. microcurrent. support. and ultrasonic shockwave therapy. tenodesis splints.. trigger point needling. casts. vapocoolant spray). we defined acupuncture of acupuncture) 8 interventions as body needling (traditional. modern.(cold packs. dry needling. electrotherapy (transcutaneous electrical stimulation (TENS). shoe orthotics.g. electroacupuncture. seat cushions) or actively inhibit or prevent movement (e. pulsed electromagnetic therapy. Functional assistive devices (e.g. and assistive braces) may align. and acupressure (application of pressure at acupuncture points). etc. and rest splints). laser acupuncture. microsystem acupuncture (such as ear acupuncture). Structural Structural modalities include non-functional assistive devices that may either encourage a state of rest in anatomic positions (e. pillows. ice massage.g. moxibustion (burning of herbs). electrical muscle stimulation. Acupuncture Acupuncture (all forms In accordance with the World Health Organization [12]. medical. electrogalvanic stimulation. or otherwise indirectly facilitate function in the affected region.. slings. Examples of passive applications affecting structures beneath the skin surface include but are not limited to LLLT. microwave. ultrasound. ease and blockages promote wellness releasing muscle lightness in body spasms Additional Nourish cells. energy in the body from cells. Accomplish specific Induce sense of Free energy move body fluids.1 Table 4: Taxonomy of Soft Tissue Therapies [88] Principal Relaxation Goals of Massage Clinical Massage Movement Re- Energy Work education Treatment Intention Relax muscles. relieve pain enhance posture. or relax body focused therapeutic function Treatment 1 goals Commonly - 2 - Myofascial - Proprioceptive - Acupressure massage trigger point neuro-muscular - Reiki - Spa massage therapy facilitation - Polarity - Sports Strain - Therapeutic Used Styles (examples ) Swedish - Myofascial - release massage - Strain counterstrain 4 touch - Trager - Tuina - Direction of Counterstrain Commonly - Gliding - Direct pressure - Contract-relax Used - Kneading - Skin rolling - Passive Techniques - Friction - Resistive - Holding stretching - energy stretching - Smoothing Resistive - Direct 64 Page 64 of 89 . and restricted body awareness. use movement. diminish pain. Focus on muscle or Use movement to Assist the flow of Goals of remove wastes fascia. goals such as freedom. motion. many of them can be used in massages with different principal treatment goals.3 (examples ) - Percussion - Vibration - stretching - 1 2 3 4 5 6 Passive stretching - Rocking pressure - Holding Cross-fiber - Rocking friction - Traction 1 Additional goals of treatment were retrieved from the body of the paper by Sherman et al. some may be used to address several distinct treatment goals. [88] 2 While some styles of massage are commonly used in addressing one of the four principal treatment goals. 3 By varying the intent (or purpose) for a technique. 4 Acupressure was considered an acupuncture technique in our review (not a soft tissue therapy) 7 8 9 10 11 12 13 14 15 16 17 65 Page 65 of 89 . Year Research Randomiz.6% MMT: 23. 2007 Y Y Y CS N CS Y Y Y CS Y Y Y Y [32] 2 to 4 days postintervention: none 4 weeks: 0% for both groups Escortell- Y Y Y Y N CS Y Intervention completion: Mayor et al.. 2007 [50] Dundar et al..3% 6 months: TENS: 18.Concealment Blinding Similarity Similarity Outcome Percent drop-out Question ation at baseline 1 between measures Intention Comparable to treat arms results between sites 6 months: Cameron et al. 2011 [33] TENS: 2. ET: 66 Page 66 of 89 .1 Table 5: Risk of Bias for Accepted Randomized Controlled Trials on Neck Pain 2 based on Scottish Intercollegiate Guidelines Network (SIGN) Criteria [16] Author.4% Evans et al. 2012 [43] Y Y Y Y Y Y Y 12 weeks: ET+SMT:6..6%.. 2011 [46] Electroacupuncture: Y Y Y Y N CS Y 0% Y NA Y CS NA NA Y CS Y NA Simulated acupuncture: 8% Cleland et al.3% MMT: 4.. 2010 [34] 3 weeks: LLLT: 6.39% Control group: N 2 NA NA NA NA NA Y CS Y NA Y CS 3/58=5. ET: 12.4%. HEA: 14. ET: 16.6% 26 weeks: ET + SMT:13.9%.7.2%. 2009 [47] Y Y Y Y Y Y Y 2/59= 3...9%.15.. PT: 67 Page 67 of 89 .4% Treatment group: Fu et al..7% Placebo: 0% Kuijper et al. 2009 [51] Kanlayanaphotporn et al.4%.4%.6% 52 weeks: ET + SMT.0% Sham SCS – 0% Y Y Y Y Y Y Y al. 2009 [35] Y Y Y CS Y Y Y 6 weeks: Collar: 1. HEA: 5. HEA: 15... 2013 [32] Konstantinovic et Y Y Y Y Y CS Y Y Y Y Y Y Y Y Immediately postintervention: none Immediately postintervention: none Post-intervention: Y Y Y Y Y CS Y SCS .17% Kanlayanaphotporn et al. 2010 [52] Klein et al. 2011[48] Acupuncture group: Y Y Y Y CS Y Y 5/93 = 5. 2010 [41] Y Y Y Y Y Y Y 2 and 4 weeks: INIT . 2010 [44] Y Y Y Y Y Y Y Manipulation: 2....3% At 3 months: Liang et al.3% Immediately postintervention: Masaracchio et al.7%. Comparison: 3. 2013 [44] Y Y CS Y Y CS Y LM – 6.2% Post-intervention: Lin et al.9%.2%. PT: 2.7% 12 weeks: Leaver et al.2. Control: 7..1% Nagrale et al. 2013 [37] Y Y Y N Y Y Y Experimental: 2. Mobilization: 3. 2013 [43] Y Y Y Y Y Y Y CM: 13.0% 68 Page 68 of 89 .9%.4% 2 N NA Y CS Y NA Y NA Placebo group: 7/97 = 7..5% 6 months: Collar: 8.6% Post-intervention: Lauche et al.3% Y NA Y CS PMR: 9.. Control: 1.9%.1% TCM – 13. Placebo: 2.7% Placebo: 7/65 = 10. Y NA Y CS NA NA Y Y Kinesio Taping: 0% 4 weeks: M+SCA – 3% SCB – 9% Sherman et al. 2004 [49] Placebo: 4/65 = 6% Y Y Y Y Y CS Y 8 weeks: Acupuncture: 11/70 = 15. 2010 [53] Y Y Y Y Y Y Y intervention: Manipulation: 0%. Y Y Y Y Y CS Y 2012 [41] Manipulation: 10%. 2009 [42] 10 weeks: Y Y Y Y Y CS Y M+SCA – 3% SCB – 12% 26 weeks: M+SCA – 6% SCB – 12% Immediately postSillevis et al..MET – 0% 1 week: SaavedraHernandez et al....8% 69 Page 69 of 89 .0% 4 weeks: Acupuncture: 7/70 = 10% White et al. SMT: spinal 6 manipulative therapy. SCB – self-care book.6% Placebo: 11/65 = 16. TCM – Traditional Chinese massage. MMT: multimodal therapy.. Y – yes. TENS: transcutaneous electrical nerve 7 stimulation 8 9 2 Although these studies did not perform an intention to treat analysis. no crossover between groups occurred in these studies [47. Y CS Sham: 16. 10 11 12 13 70 Page 70 of 89 . 48]. 2009 [45] Y Y Y Y N CS Y Traction: 13. LM – Long’s manipulation.6 months: Acupuncture: 13/70 = 18. CS – can’t say. SCS – strain-counterstrain.1% Placebo: 12/65 = 18. NA – not 2 applicable. PMR – progressive muscle 5 relaxation. LLLT: low-level laser therapy. N – no. 4 M – massage. SCA – self-care advice. MET – muscle energy technique. HEA – home exercise and advice.9% 12 months: Acupuncture: 16/70 = 23.7% 1 1 Includes participant withdrawal and loss to follow-up. CM – cupping massage. ET – exercise therapy. INIT – 3 integrated neuromuscular inhibition technique.3%.5% 4 weeks: Young et al. . Number (n) of Follow-up Subjects Exploratory Studies Non-thrust mobilization/ manipulation provided by trained physical therapists: 30 second grade III or IV central posterioranterior non-thrust (T1-T6). usual activities. or contralateral unilateral PA) to the cervical spine. and global perceived effect between groups. (n=30) Statistically significant mean difference (thrust mobilization/manipulation – nonthrust mobilization/manipulation: Secondary outcomes: Pain (NPRS) 0-10). About. active CROM.e. (n=30) Key Findings Primary outcome: Pain (VAS 0-100).6° (95% CI 0.48. current medication. (NH.7) Pain: 2. usual activities.14. Passive Physical Modalities. and Acupuncture for Neck Pain and Associated Disorders and Whiplash-associated Disorders Author(s). (n=60). Mean difference (preferred -random mobilization) Active CROM in Flexion: 2. 4. ipsilateral unilateral PA. ẋ=804 days Comparisons.7) GROC: 1. Number (n) Enrolled Interventions. Year Cleland et al. 30% patients in both groups experienced mild –moderate side effects lasting <24 hrs.47) No significant difference in pain. Evidence Table for Accepted Randomized Controlled Trials on Manual Therapies.83) No reported adverse events 71 Page 71 of 89 .03% (95% CI 5. ipsilateral to pain. (n=30) 2-4 days after one intervention Outcomes Random mobilization by physical therapist (1 session): mobilizations randomly directed pressure (i. MA.o.A. 3. general cervical mobility exercise.) from primary care physicians to 1 of 5 outpatient orthopedic physical therapy clinics in the U. 2.39.5 (95% CI 0. Neck pain at rest >20 on 100mm VAS. ẋ=56 days Patients (20-70 y. 2. Selfperceived Disability: 10.17(95% CI 0. 2007 [50] Kanlayanaph otporn et al. Active CROM. Number (n) of Subjects Patients (18-60 y. current medication.03 (95% CI 1. (n=30) Case definition: neck pain (NDI score > 10%) with or without unilateral upperextremity symptoms. Global perceived effect 1-7 Adverse events No serious side effects. CA) between June 2005 and July 2006.o.38.. (n=60).4. Thrust mobilization/ manipulation by physical therapists: thrust to upper thoracic (T1-T4) & mid thoracic spine (T5-T8) spine.3.) Case definition: unilateral mechanical neck pain ≥1 week. central PA.S.5) (50% in manipulation group reported moderate change in status vs 10% in mobilization group Global rating of change (GROC) -7 to 7 5 minutes after treatment 2 Primary outcome: Disability (NDI-0100%) Adverse events Preferred mobilization by physical therapist (1 session): unilateral PA pressure. CO. OR of experiencing side effect for manipulation = 1. with the exception of flexion. general cervical mobility exercise. 2009 [51] Setting and Subjects. MN.1 2 Table 6. 1.). Germany between February and August 2011. ẋ=1575 days Adults (18-65 y.3. 2010 [52] Klein et al.2 (95% CI 0.o.) with acute nonspecific neck pain referred from private general practice in Bavaria.94) 72 Page 72 of 89 . much better) Adverse events Neck pain (NPRS 0-10). Case definition: nonspecific pain. Number (n) of Subjects Random mobilization by trained physical therapist (1 session): mobilizations randomly directed pressure (i.e.o. 18.3% Sham: 3.2% Statistically significant mean differences between groups (experimental minus comparison)* Neck pain: 1. Strain-counterstrain by GP (1 session): Neck positioned by therapist away from restricted cervical segment for 90 seconds then slowly repositioned to neutral. right unilateral PA. unchanged.) who presented to physical therapy or Follow-up 5 minutes after treatment 2 Outcomes Key Findings Primary outcome: Pain (VAS 0-100). slightly better.06. (n=30) Thoracic thrust manipulation + cervical nonthrust manipulations and Sham straincounterstrain by GP (1 session): Neck passively rotated 30˚ to the left and held for 90 seconds as therapist placed finger slightly right of the C4 spinous process. No statistically significant difference between groups for neck pain intensity or cervical motion. Neck then slowly repositioned to neutral.o.Author(s). (n=31) Immediately after intervention Cervical nonthrust manipulation and home exercises by physical therapist (2 2-3 days after intervention Primary outcome: Cervical motion (goniometer) Secondary outcomes: Neck pain intensity (from NPDS). Active CROM (assessed with CROM device). or left unilateral PA. Year Kanlayanaph otporn et al. 2013 [32] Setting and Subjects. Number (n) of Subjects Central PA mobilization by physical therapists (1 session): PA pressure over the spinous process of the cervical vertebra. Neck pain at rest >20 on 100mm VAS.. central PA. (n=60). Global rating No adverse events reported. slightly worse. Global perceived effect No significant differences between groups in neck pain at rest or CROM. 2013 [37] Comparisons. Number (n) Enrolled Patients (20-70 y. Disability (NDI 050).. selfperceived global assessment (much worse.e.5 (95% CI 1. except for pain intensity on most painful movement: Mean difference (central PA mobilization – random mobilization): Pain intensity on the most painful movement: 9. pain and/or dizziness): Strain-counterstrain: 13.0) Adverse events No difference between groups in patients rating of global perceived effect. (n=61) Interventions. (n=30) Patients (18-60 y.. (n=30) Case definition: Acute episode of nonspecific neck pain and cervical joint restrictions Masaracchio et al. exacerbated by neck movements or by sustained neck postures. Self-perceived recovery (strain-counterstrain versus sham): Slightly worse: 3% versus 3% Unchanged: 37% versus 55% Slightly better: 53% versus 36% Much better: 7% versus 7% Mild transient adverse events reported (i. cervical flexion.. extension and right or left lateral flexion.0 (95% CI 1. or palpation of cervical musculature.o.21.39. Spain. Case definition: neck pain (<3 months) without symptoms distal to the shoulder.8 (95% CI 6. Patients (18-65 y.8 (95% CI: 3.) with idiopathic mechanical neck pain referred to a physical therapy clinic in Almeria. (n=34) Kinesio Taping: Tape applied over the cervical extensors from T1-T2 to C1-C2 spinal segments after initial examination for 7 days.) recruited from five outpatient physical therapy Interventions. 10. Number (n) of Subjects sessions): cervical nonthrust oscillating manipulation and instruction on active neck ROM exercises at home.o. (n=66) Patients (18-55 y..35. Year SaavedraHernández et al.(n=32) Cervical Manipulation (SMT): one applied to the mid C/S and one to the C/T junction after initial examination. Secondary No statistically significant change in pupil 73 Page 73 of 89 . Primary outcome: Neck pain intensity (NPRS). NDI≥20%. Secondary 0utcomes: Disability (NDI). Difference in mean change (degree) for range of motion (Tape . 2010 [53] Setting and Subjects. 2012 [41] Sillevis et al.9 (95% CI: 3.Author(s). 10.SMT)*: Right rotation: 6.5% of SMT group had minor increase in neck pain or fatigue 5% of taping group had cutaneous irritation Primary outcome: Pain (VAS) No statistically significant differences between groups for pain.46) Adverse events High velocity midrange thoracic manipulation by physical therapist (1 Key Findings No serious adverse events: 7. disability. 3) Adverse events No adverse events reported other than soreness that resolved 24-48 hours after treatment. 11.21) Left rotation: 6. (n=40) Follow-up 7 days Outcomes Placebo thoracic manipulation by physical therapist (1 session): applied Immediately post intervention 2 of change (GROC 7 to 7) Disability: 8. Number (n) Enrolled volunteered from 2009-2011. No difference between groups for pain. Nonthrust cervical manipulation and home exercises same as comparison group. (n=80) Case definition: Mechanical neck pain defined as generalized neck or shoulder pain provoked by sustained neck postures.39) GROC: 2. CROM (goniometer). neck movement. (n=40) Comparisons. Number (n) of Subjects home exercises by physical therapist (2 sessions):2 thrust manipulations to the upper and 2 to mid thoracic spine. o.3% No clinical or statistical difference between groups for any outcomes at 4 weeks.5 (95% CI 0. Evaluation Studies Cameron et al.1. provoked with neck movements.. GB 20. Electrical output: Frequency=2-5 Hz. HRQoL and Pain Rating Index.SE) Pain: 0. Year Setting and Subjects.0) Restriction in activities of daily living: 0. Case definition: non-specific pain (≥3 months) in cervical and cervicothoracic region down to T4. 1. LI 14 and S I6.3.2) Restriction in activities of daily living: 0. 1.1. 2011 [46] Participants (18-65 y. needles at two acupuncture points in the cervical area.Author(s).o.6 (95% CI 0.1. and At 6 months Mean difference (RE . disability (NDI). Electrical output inactivated.0) No statistically significant difference in disability. (n=51) Follow-up Outcomes Key Findings 2 outcome: puplliometric measure (Friedman Test) diameter in manipulation group. wrists and ankles.3%.. 1. statistically significant change in placebo group over time. HRQoL (SF-36) At 3 months Mean difference (RE . Primary outcomes: pain intensity (VAS).6 (95% CI 0. movement. HRQoL and Pain Rating Index.5 volts. (n=60) 3 and 6 months Secondary outcomes: restriction in activities of daily living (VAS). Number (n) of Subjects manipulative force to an open hand contact at the upper thoracic spine (T3-4). 74 Page 74 of 89 .4 (95% CI 0.) recruited through newspaper in Australia. Number (n) Enrolled clinics in the USA in 2008. intensity=1. Adverse reactions: No serious adverse events RE: 6. however.1) No statistically significant difference in disability. SE: 3. Pain Rating Index (Total of the Short Form McGill pain Questionnaire) Adverse events Dundar et al. Number (n) of Subjects session): applied manipulative force to a closed hand contact at the upper thoracic spine (T3-T4). 1.SE) Pain : 0. (n=64) Simulated Electroacupuncture (SE) by same acupuncturist (2 30min sessions per week/6 weeks): similar procedures as RE but treatment points 20-30mm away from selected points. (n=124) Case Definition: WAD I-II (>1 month duration) Real Electroacupuncture (RE) by acupuncturist (2 30-min sessions per week/6 weeks): bilaterally selected treatment points to GB 39. (n=108) Interventions.) with chronic Low-level (Ga-As-Al) laser therapy (LLLT) by Placebo: low-level gallium arsenide 4 weeks Pain at rest. (n=50) Comparisons. 2007 [32] Patients (20-60 y. 12. Interventions.. EscortellMayor et al. or health-related quality of life in the short or medium term. daily cervical isometric and stretching exercises supervised by a physiotherapist. 2012 [43] Patients (18-60 y. postisometric stretching. Spain from May 2005 to May 2007. global perceived effect. Year Setting and Subjects. Number (n) of Subjects physiotherapist (15 sessions / 3 weeks) pulse frequency = 1000 Hz. dose = 7J/point.).. each point. No significant adverse events. home program of postural skills and exercises. spray and stretch and Jones technique. (n=43) SMT by chiropractor + exercise therapy (ET) supervised by exercise therapist: 20 sessions Comparisons. Health-related quality of life (SF12). medication use and satisfaction at each 75 Page 75 of 89 . home program of postural skills and exercises. (n=47) Postintervention.) with subacute or chronic mechanical neck disorders treated in 12 primary healthcare physiotherapy units in Madrid.Author(s). quality of life scores.o. Adverse events Primary outcome: pain: (NRS) Secondary No statistically significant differences between SMT+ET and ET in pain. 26. active cervical range of motion (inclinometer and goniometer). 6 months Home exercise with advice (HEA) by physical therapists with in-person (2 -1- 4. No difference between groups for pain. disability (NDI) Multimodal therapy by physical therapists (Ten 30 minute sessions on alternate days): neuromuscular technique. ≤150μs pulse duration. time = 2 min. and 52 weeks Primary outcome: Pain intensity (VAS). daily cervical isometric and stretching exercises supervised by a physiotherapist. Number (n) Enrolled cervical MPS. wavelength = 830-nm. 2011 [33] Evans et al. (n=90) Case definition: Subacute or chronic mechanical neck disorders based on Quebec Task Force classification grades I-II Residents from Minnesota (18-65 y. Secondary outcomes: Disability (NDI). Number (n) of Subjects aluminum (Ga-As-Al) laser therapy applied by same physiotherapist in the same manner as LLLT group. disability. (n=32) Transcutaneous electrical nerve stimulation (TENS) by physical therapists (Ten 30 minute sessions on alternate days) at 80 Hz. power = 58 mW/cm2. disability.o. (n=64) Case definition: Cervical myofascial pain based on the major and minor criteria of Simons et al. (n=32) Follow-up Outcomes Key Findings 2 at night (VAS). 0. infrared irradiation provided. ET: 25.) diagnosed in a Guangzhou hospital.3%. (n=59) Sham acupuncture (9 20-min sessions/18 days): sham points 1cm lateral to (ExHN15 and SI15. needles inserted superficially without manipulation. 1 and 3 months Outcomes: disability (NPQ). Year Setting and Subjects.. 0.1) Additional health care reported at 52weeks: ET + SMT: 25. 20 sessions in 12 wks (n=89) Fu et al.08.93) 1 month Mean difference (acupuncture .51 (0. (n=117) Case Definition: cervical spondylosis according to "Standard for diagnosis and efficacy evaluation of traditional Chinese medicine syndromes and diseases" ≥6 months duration.48 (95% CI 0. HEA: 33. 76 Page 76 of 89 . satisfaction.sham acupuncture)* Neck disability: 5.8% Non-serious adverse events (mild and transient): ET + SMT: 98. ET: 96.sham acupuncture)* Neck disability: 5. Number (n) of Subjects hr sessions): individualized program of neck and shoulder selfmobilization.Author(s). 9. No statistically significant differences in CROM and strength except for static flexion endurance at 12wks: 62. Number (n) Enrolled Case definition: NAD I/II (≥12 weeks) and neck pain intensity ≥ 3/10.51 (95% CI 3. Ex-HN15 and SI15. Number (n) of Subjects over 12 wks. China.6%. 8.35) Adverse events not reported. global perceived effect. med use.sham acupuncture)* Neck disability: 6.51.52. 8.o.09. (n=58) Outcomes Adverse event 18 days (post intervention).54.7 (95%CI-32. 0. quality of life (SF36). light soft tissue massage if necessary) (n=91) Comparisons.77) Pain: -0. pain intensity (VAS) Key Findings 2 assessment period at 12 and 52 wks. (n=90) Follow-up outcomes: disability (NDI). infrared radiation provided.88) 3 months Mean difference (acupuncture . additional care visits.38) Pain: 0.3% Moderate adverse event in 1 patient in ET group.64 (95% CI 2. 2009 [47] Patients (18-60 y. Post intervention Mean difference (acupuncture .6. ROM & strength ET: Same as Intervention group.45. ET: high dose strengthening exercise program SMT: cervical and thoracic spine (max 5 mins. (n=270) Interventions.50) Pain: 0.9%. and needles manipulated to Deqi. 158. Acupuncture (9 20-min sessions/18 days): selected acupuncture points DU14. change expectations in neck pain.05 (95% CI -0.46 (95% CI 2. education and advice regarding posture and daily activities. 6 weeks. duration =120 seconds/ trigger point over 6 points. and 6 months Primary outcomes: neck pain intensity (VAS).(n=69) Physiotherapy (PT): 2 x/week for 6 weeks.11) Disability (NDI): 4. power density = 12 mW/cm². education to do home exercises. arm pain intensity (VAS). 11..80. persistent nausea: 3. 19. (n=66) 3 weeks. neck mobility (mm) Adverse events: LLLT group: transitional worsening pain: 20%.o. (n=30) Follow-up 3 weeks 2 Outcomes Key Findings Primary outcome: Neck and arm pain intensity (VAS). frequency = 5000 Hz. opioid use. moderate/severe disability Patients (18-75 y. Secondary outcomes: treatment satisfaction. 2010 [34] Setting and Subjects. disability (NDI).33%. Pain killers allowed. 25. Placebo group: no adverse events. health-related quality of life (SF12).28) Arm pain (VAS): 5.2 (95% CI 0.04) Neck pain (VAS) Differences in mean changes (collar – control)* 3 weeks: 18..70.90 (95% CI -1. 8. intensity = 2 J/cm².8 (95% CI 12.5 (95% CI 5.40. (standardized graded neck strengthening exercises.97.) with cervical radiculopathy (< 1 month)from 3 Dutch hospitals (n=205) Case definition: Acute cervical radiculopathy with arm pain (>40/100 VAS) reproduced by Cervical collar: Rest and a semi-hard cervical collar during the day for 3 weeks.45.37. work Arm pain (VAS) Differences in mean changes (collar – control):* 3 weeks: 6.09 (95% CI 3. 28.07. increased blood pressure: 3. Difference in mean change at 3 weeks (LLLT Placebo)*: Neck pain (VAS): 4. Number (n) Enrolled Patients with acute neck pain and unilateral radiculopathy (< 4 weeks and ≤ 3 previous episodes) treated at the Belgrade university rehabilitation clinic in Serbia from January 2005 to September 2007. 7. Number (n) of Subjects Placebo: Inactive LLLT applied by the same therapist in the same manner as LLLT group. (n=60) Interventions.20) 6 weeks: 21. Then weaned off during weeks 3-6. (n=70) Wait and see: Advice to continue daily activities.9 (95% CI 15.Author(s).63. Number (n) of Subjects Low-level laser therapy (LLLT) by therapist (5 times/week over 3 weeks): 1 cm² diode surface. Year Konstantinov ic et al.71 (95% CI 2.62) PCS (SF-12): -0.35) 77 Page 77 of 89 . 6.43) Secondary outcomes: Disability (NDI).77) 6 weeks: 12. Adverse events Kuijper et al.49 (95% CI 0. (n=30) Comparisons. -0. wavelength = 905 nm. 2009 [35] Case definition: Unilateral radiculopathy defined as neck and/or unilateral arm pain with neurological signs.3%. or sensory changes.56) No statistically significant difference in mean change between groups post intervention for the outcomes pain. psychological distress (HADS. days of interference in past 3 78 Page 78 of 89 .50) Inner peace (FEW16): 1.55 (95% CI: 6. 9. (n=30) Progressive muscle relaxation (PMR) instructed by a psychologist (PMR taught during a one hour session). relieve muscle tension and improve general well-being.18 (-4.26. or disability at 6 months Lauche et al. pain perception. Interventions. diminished deep tendon reflexes.94) Pressure pain threshold at site of maximum pain (algometer): 63.50) Vitality (FEW16): 1. or sick leave at 3 and 6 weeks Difference in mean change at post 1 intervention (CM . could attend refresher session. or muscle weakness.out of 50): -2.76 (95% CI: 0. health-related quality of life (SF36).76 (0.27) No significant difference in disability (collarcontrol) at 3 weeks* No significant differences in disability. Follow-up Outcomes status.33. Number (n) Enrolled neck movements (≥1 time). 3.PMR): Disability (NDI . (n=61) Case definition: Persistent nonspecific neck pain occurring a minimum of 5 Cupping massage (CM) instructed by experienced teacher (taught during one workshop) and done by partner at home twice a week for 12 weeks (10-15 min each): Cupping massage technique using cupping glass and massage oil. 2013 [43] Patients (18-75 y.21) Psychological Outcomes: Stress resistance (FEW16): 1. 3. 2011 and May 2012. neck pain.01. Given written information and CD on relaxation Postintervention (12 weeks) Primary outcomes: pain (VAS. stress No significant differences between groups for treatment satisfaction. Germany between Dec. NSAID use.01.Author(s). neckrelated disability (NDI).56. -0. Given written information. Number (n) of Subjects All patients were allowed to use pain killers.60 (95% CI: -0. depression 0-21). 121. opioid use. pain at motion. arm or neck pain (collar-PT) at 3 or 6 weeks* No significant difference between groups for median arm pain. affective perception of pain (Pain Description List [SBL]).13.) with persistent neck pain (≥3 months) were recruited via a local newspaper advertisement in Essen.2 (95% CI 1.o. 2. anxiety 0-21. 2 independent home sessions/week for 12 weeks): aimed to achieve deep relaxation. Year Setting and Subjects. Key Findings 2 Disability (NDI) Differences in mean changes (collar – control)* 6 weeks: 5. Number (n) of Subjects Comparisons.100mm).. 3% or 1/30).3% or 1/30 considered serious but not a consequence of cupping massage). pressure pain threshold (digital algometer. Quality of life (SF-12) Key Findings 2 months. (n=182) Interventions. Primary outcome: Time to recovery (7 consecutive days with NRS <1/10). or continued exercise program as indicated. reassurance. Pain (NRS). 2010 [44] Setting and Subjects. 2. and quality of life. global perceived effect. Function (Specific Functional Scale). interference in daily life.0% of subjects). Global perceived effect. or health-related quality of life at any follow-up point. disability. prolapsed intervertebral disc (3.o. anxiety. psychological wellbeing (FEW16). 4. No statistically significant differences in incidence of minor adverse effects between groups.) recruited from 12 private physiotherapy. 4 treatments over 2 weeks unless recovery occurred or serious adverse event. Case definition: Recent onset of neck pain (≥2 NRS) for <3 months and preceeded by 1 month without neck pain. or osteopath: Manual low-velocity oscillating passive movement directed at the cervical joints. increments of 40kPa/s. function.3% or 1/30). Advice. Advice. (n=31) Neck mobilization by physiotherapist. and 12 weeks Adverse events. or continued exercise program as indicated. lowamplitude thrust techniques directed at the cervical joints. Adverse events: No adverse events reported in PMR group. No statistically significant difference in Kaplan-Meier recovery curves between groups for recovery from neck pain and recovery of normal activity. chiropractor. or osteopath: Manual high-velocity. Year Leaver et al. (n=91) Follow-up Outcomes perception (PSQ20). Number (n) Enrolled days/week with an intensity of ≥45 mm on VAS Patients (18-70 y. depression. 79 Page 79 of 89 . Australia from 2006-2008. and osteopathy clinics in Sydney. Three patients reported adverse events in CM group: muscular tension and pain (3. locus of control beliefs (Health Related Control Beliefs). chiropractor. Number (n) of Subjects Neck manipulation by physiotherapist. (n=91) Comparisons. Minor adverse events of increased neck pain (29. No statistically significant differences between groups for pain. reassurance.4% of subjects) and headache (22.. chiropractic. Secondary outcomes: Time to recovery of normal activity (7 consecutive days with no activity interference). pain in shoulder area (3. 4 treatments over 2 weeks unless recovery occurred or serious adverse event.Author(s). Number (n) of Subjects training. Disability (NDI). No serious neurovascular events. o.1% 80 Page 80 of 89 .02.89.55 (95% CI -0.03.98) VAS: 0.63.38.14) No statistically significant difference in other domains in in SF-36.55 (95% CI -2. 5.18.14 (95% CI 1. (n=93) Comparisons.56.1) No statistically significant difference in other domains in in SF-36.72) Mental health: 2.04.71) Vitality: 3. Interventions.63. no needle manipulation. 5. pain intensity (VAS) Secondary outcome: HRQoL (SF-36) Adverse events Key Findings 2 Immediately after 3-week intervention Mean difference (TA -SA)* NPQ: 3. (n=190). Case definition: neck pain or stiffness in neck and shoulder (>once per month for ≥6 months) and neck pain between 3-7/10.39).03. 5. needles manipulated.58 (95% CI -0. 4.5 (95% CI -1. 0. 4.35 (95% CI 0. 3 month after 3 week intervention Mean difference (TA .SA)* NPQ: 3.69) Social functioning: 2. infrared irradiation on the cervical region.11. VAS: 0.69 (95% CI 1. Number (n) Enrolled Participants (18-60 y. 5.72.SA)* NPQ: 4.) recruited from leaflet dissemination in Guangzhou. 6) Social functioning: 6.12) No statistically significant difference in other domains in in SF-36. 0.72) Mental health: 1. Fainting: TA 3. infrared irradiation on the cervical region..42) Vitality: 3. 1 month after 3 week intervention Mean difference (TA . 6.17) VAS: 0. 2011 [48] Setting and Subjects. Year Liang et al. 3. 5.Author(s). Adverse reactions: No serious adverse events.2%.67) Social functioning: 2. Number (n) of Subjects Sham acupuncture (SA) by acupuncturists (9 20min sessions / 3 weeks): sham points 1cm lateral to selected acupuncture points.02. PA 4.12 (95% CI -0. 9. SI15 and Ex-HN15 bilaterally. 0.11.85 (95% CI 1. China.95) Mental health: 0.41 (95% CI 0.89.55 (95% CI -0.34 (95% CI 0.03 (95% CI 0.36 (95% CI 1.79 (95% CI 3.66) Vitality: 2.1 month and 3 months post intervention Outcomes Adverse events Primary outcomes: disability (NPQ). Number (n) of Subjects Traditional acupuncture (TA) by acupuncturists (9 20min sessions / 3 weeks): acupuncture points DU14. (n=97) Follow-up Immediately. 5. 2010 [41] Adults (18-65 y. degrees of cervical lateral flexion (goniometer). cervical range of motion (CROM). Difference in mean change (INIT .13 (95% CI 2.61) Neck disability (out of 50) 4. Number (n) of Subjects Comparisons. perceived satisfaction (11point scale) Difference in mean change (LM . 20 minutes each): Relaxation massage to release tension or spasm. craniovertebral angle (electronic head posture instrument).76. Number (n) Enrolled Interventions.93) Cervical lateral flexion 3. Case definition: Mechanical neck pain without neurologic or vascular deficit.14 (95% CI 1.Author(s).72 (95% CI 2. 6.) with mechanical neck pain (> 3 months) recruited from an outpatient clinic in Hong Kong between February 2011 and March 2012 (n=63).MET) at 2 1 weeks : Neck pain intensity (out of 10) 0. 0. abnormal changes of cervical curve and alignment on radiographs Adults (18-55 y.52. followed by provocative massage techniques (pinching. 3.3%. restriction of movement of a motion segment. 3 months Neck pain (Northwick Park Neck Pain Questionnaire 0100).73 (95% CI 0.55. Traditional Chinese massage was the same as comparison group (n=33). Immediately after intervention. 4 weeks postintervention Outcomes: Neck pain intensity (VAS 10 cm). rubbing) to the neck (n=30). 20 minutes each): A high velocity low amplitude manipulation to the cervical spine. Number (n) of Subjects Follow-up Outcomes Key Findings 2 Numbness and aching: TA 4.o.68) 81 Page 81 of 89 . then gentle massage techniques (stroking. 13..) with nonspecific neck pain (<3 months) referred by health care providers or recruited through advertising in Long’s manipulation (LM) and traditional Chinese massage (TCM) by manual therapist (1 session every 3 days for 8 sessions total. 2.17) NPRS (out of 10) 2. No serious adverse events reported except increased neck pain reported by 1 patient receiving TCM (3%) Adverse events Integrated Neuromuscular Inhibition Technique (INIT) by therapist to upper trapezius (3 sessions/week for 4 weeks): Ischemic compression over Muscle Energy Technique (MET) by therapist to upper trapezius (3 sessions/week for 4 weeks): Passive positioning of neck away from affected 2 weeks. 2013 [44] Nagrale et al.65 (95% CI 4.o.13.16 (95% CI 0. pain intensity (NPRS 010). 1.65. Year Setting and Subjects. Traditional Chinese massage (TCM) by manual therapist (1 session every 3 days for 8 sessions total. PA 2% Lin et al.TCM) 1 immediately after intervention : NPQ (out of 100) 8.69) No statistically significant differences in craniovertebral angle or cervical ranges of motion between groups immediately after intervention.73) Satisfaction (out of 10) 1.63. plucking). possible discomfort with joint challenge/pressure.. 78.68) At 4 weeks Difference in mean change (Massage .. India between June 2007 and April 2008.5) Neck functional disability (out of 30) 1. Number (n) of Subjects muscle.15.Author(s). Self-care advice included advice to exercise and drink more water. (n= 64) Case definition: Persistent neck pain (>12 weeks and ≥3/10 on bothersome scale) Interventions. Number (n) Enrolled newspapers and health magazines in Dhamtari.6 (95%CI 0. Year Sherman et al.6 (0. 1.1 (95%CI 0. (n=32) Follow-up Outcomes neck disability (NDI out of 50) 4.03. 2. Number (n) of Subjects trigger points (≤ 90 seconds). 10. (n=30) Massage and self-care advice by licensed massage practitioners (maximum 10 sessions over 10 weeks): Massage included a variety of Swedish and clinical massage techniques. enrolled in Group Health in Washington State and Idaho. self-perceived global Key Findings 2 1 Mean difference (INIT . 2.15. first aid for intermittent flareups. 2009 [42] Setting and Subjects.self1 care book) : Neck disability (out of 50) 2.8) 82 Page 82 of 89 . 3.18) Cervical lateral flexion 5. conventional and complementary treatment.24. healthrelated quality of life (SF-36).98 (95% CI 0.75 (95% CI 2.1. Muscle then stretched passively for 30 seconds. (n=32) Comparisons.7 (95% CI -0. 6. (n=30) Self-care book sent by mail: “What to do for a pain in the neck” with information on neck pain causes.18 (95% CI 4. 4.3 (95% CI -0.) with persistent neck pain and who received primary care for neck pain at least 3 months prior.o.2 (95% CI -0. straincounterstrain with digital pressure over trigger points for 2030s with 3-5 repetitions. exercises.0) Symptom bothersomeness (out of 10) 1. 4. (n=60) Case definition: Nonspecific neck pain (<3 months) and active trigger points in upper trapezius muscle Patients (20-64 y. neckrelated headache. United States. 2. and 26 weeks after randomization Primary outcomes: Neck disability (NDI out of 50).4) At 10 weeks Difference in mean change (Massage . 3-5 repetitions.82. symptom bothersomeness (NRS 0-10) Secondary outcomes: Neck functional disability (Copenhagen Neck Functional Disability Scale 030).self1 care book) : Neck disability (out of 50) 2.7. and MET same as comparison group. medication use in the last week. whiplash. posture.69.5) Neck functional disability (out of 30) 0.7) Symptom bothersomeness (out of 10) 1.MET) at 4 weeks : Neck pain intensity (out of 10) 0. then submaximal isometric contraction of trapezius for 7-10 seconds against practitioner’s hand.67) Neck disability (out of 50) 4. 5. Number (n) of Subjects Follow-up Outcomes improvement (7point Likert scale from completely gone to much worse) Adverse events Key Findings 2 At 26 weeks Difference in mean change (Massage .2) 26 weeks: 1.5.8. 14.8 (95% CO 0.3) 10 weeks: 2. 1.9 (95% CI -0. 3. 21.5) 26 weeks: 1.99. 4.self1 care book) : Neck disability (out of 50) 1. 9 83 Page 83 of 89 .Author(s). 2.2.5 (95% CI 2.2. Medication use (baseline to 26 weeks): Massage: no change Self-care book: increased by 14% RR for improvement of ≥5 points on NDI with massage: 4 weeks: 5.8 (95% CI 0. Number (n) Enrolled Interventions.5) RR for improvement of >30% on symptom bothersomeness with massage: 4 weeks: 4.7.4) Symptom bothersomeness (out of 10) 0. 3.0) RR for ‘better’ or ‘much ‘better’ on global improvement with massage: 4 weeks: 8. Year Setting and Subjects.63.2 (95% CI 1.5) 26 weeks: 1.0.5) 10 weeks: 2. 4.97.1 (95% CI 1.04. 4.4) 10 weeks: 2.7 (95% CI 0. Number (n) of Subjects Comparisons.7 (95% CI 1.1 (95% CI 0. 35.5) No statistically significant difference between groups for quality of life. 3.8) No moderate or severe adverse events.14 (95% CI -1.1 (95% CI 1.1. Adverse reactions: No serious adverse events Acupuncture: 11. HRQoL or acetaminophen use at 1 week. manual therapy. HRQoL (SF-36).Author(s). Type and location of symptoms (Pain Diagram).o.. home exercise and sham intermittent cervical traction. No significant differences between groups in disability. Case definition: cervical radiculopathy of unspecified duration diagnosed through positive tests of clinical prediction rule (n=81) Interventions. subjects reported non-disruptive mild adverse experiences likely attributable to massage.55) Secondary outcomes: pain (VAS) at various time points.3% No significant differences between groups for primary and secondary outcome measures with or without addition of cervical traction.4% .77. 8 weeks. Number (n) Enrolled Patients (18-80 y. 3 months. (n=70) Posture education. Acetaminophen allowed for pain relief. 6 months and 12 months postintervention 2. Pain (NPRS). manual therapy. or 6 months post intervention.) recruited from orthopedic physical therapy clinic in the USA.. Placebo: 12. VAS). Year White et al. Fear 84 Page 84 of 89 . 2004 [49] Setting and Subjects. provided by trained physical therapists. needle manipulation. points selected in the same manner as acupuncture group.79 (95% CI 1. (n=135) Case definition: chronic neck pain (> 2 months and > 30/100 in VAS) Young et al. acetaminophen use (diary). activity limitations (Patient-Specific Functional Scale). 10. Number (n) of Subjects Placebo electroacupuncture by same practitioner (2 20-min sessions/week over/4weeks): inactivated electroacupuncture stimulator.) referred by rehumatologists. Number (n) of Subjects Western acupuncture (2 20-min sessions/ week/4 weeks): acupuncture points selected according to pain distribution and palpitation of ah-shi or tender points.o. 4 weeks 2 Outcomes Key Findings Primary outcome: average pain at one week posttreatment (daily pain diary. exercise. Adverse events. No significant differences between groups in average weekly pain at 6 months or 12 months post intervention. Primary outcomes: Neck disability (NDI). 2009 [45] Patients (18-70 y. Mean difference in pain (acupuncture minus placebo)*1 week post intervention: 5.. home exercise and intermittent cervical traction (average of 7 visits). acetaminophen allowed for pain relief. family physicians or physiotherapy waiting lists in the UK. (n=36) Follow-up 1 week. provided by trained physical therapists.26) 8 weeks post intervention: 1.39 (95% CI -2. Secondary outcomes: GROC. disability (NDI). exercise. 8 weeks. 5.32. (n=45) Comparisons. (n=65) Posture education. SCA – self-care advice. CM – cupping massage. SF-36 – short-form-36. Grip strength. RR – relative risk. Statistically and/or clinically significant results were reported. – years old 5 6 7 8 9 10 11 12 85 Page 85 of 89 . LM – Long’s manipulation. NPDS – Neck Pain Disability Scale. CI – confidence interval.o. PMR – progressive muscle relaxation. Number (n) of Subjects Comparisons. MET – muscle energy technique. TCM – traditional Chinese massage. VAS – visual analogue scale. Year 1 2 3 4 Setting and Subjects.Author(s). INIT – integrated neuromuscular inhibition technique. Number (n) of Subjects Follow-up Outcomes Key Findings 2 and avoidance beliefs (FearAvoidance Beliefs Questionnaire). GP – general practitioner. NDI – Neck Disability Index. y. Number (n) Enrolled Interventions. patient satisfaction. 1 2 Recalculated data from study. 36]. Additionally. 40] to about 30% [37. Soft tissue Four of the five RCTs with low risk of bias reported on adverse events and none reported serious adverse events [27. Most therapy adverse events were mild. but were considered unrelated to treatment by the attending medical specialists as reported by the authors (one participant had a cardiac event and one developed severe arm pain and weakness three days after the mobilization session) [44]. In one RCT.. transient. 44]. and prolapsed intervertebral disc (1/30. The rate of adverse events reported in six of the nine studies varied from zero [39.5% of participants receiving manipulative therapy physical reported mild adverse events (minor increase in neck pain and fatigue) while 5% in the Kinesio tape group reported cutaneous modalities irritation [36]. Adverse Events Reported in the Accepted Randomized Controlled Trials on Manual Therapies. 34. Passive Three of the five RCTs reported on adverse events [33. one individual reported increased blood pressure while another had persistent nausea [34]. 7. 41.1 Table 7. Twenty percent of those in the LLLT group reported a transient worsening of pain that occurred after the first three treatments. 29]. Two serious adverse events in patients allocated to cervical mobilization were reported in one study. and Acupuncture for Neck Pain Intervention Adverse Events Manipulation. Two studies 86 Page 86 of 89 .6% who received the same exercise therapy alone. 31]. muscular tension that resolved hours later (1/30). One study [43] reported mild and transient adverse events in 98. Most adverse mobilization. 38. events were mild to moderate and transient. In one study.e. however. Passive 2 Physical Modalities. and affected a small percentage of patients [27. 10% (3/30) of subjects reported minor adverse events with cupping massage [i. increased pain in shoulder area (1/30.9% of patients who or traction received high dose strengthening exercise therapy and spinal manipulation. considered serious but not a direct consequence of cupping massage)] [30]. and 96. No serious neurovascular adverse events were reported. this patient had history of shoulder problems). 29. Common minor side effects were slight pain. 1 2 3 4 Table 8: The Effectiveness of Manual Therapies. 49]. 48. and local bleeding. 11. No serious adverse events were related to acupuncture. 12. cold. Acupuncture Three of the four studies reported on adverse events [46.4% of the acupuncture group reported minor adverse events. swelling. acupuncture* 87 Page 87 of 89 . 93]. dizziness. passive modalities Manipulation. diathermy. sweating. bruising. and Acupuncture for the 5 Management of Neck Pain Based on Preponderance of Evidence from the Neck Pain Task Force [5.2% to 11.reported no significant adverse events occurred [33].3% of the placebo group also reported minor adverse events [49]. fainting. therapy (heat. Similar side effects were reported for the placebo/sham groups. traction. Passive Physical Modalities. The incidence of non-serious events in the acupuncture groups varied among studies ranging from 3. 74] and Our 6 Update Grade of Neck Duration Likely Helpful (Worth Possibly Helpful (Might Likely Not Helpful (Not Not Enough or Pain of Neck Considering) Consider) Worth Considering) Inconsistent Evidence to Pain WAD Grade I-II 1 Recent Make Determination Mobilization Pulsed electromagnetic Collars. In the RCT by White et al.4% [48. however. ultrasound).hydrotherapy). laser therapy electrical muscle acupuncture* Manipulation*. low level (heat therapy. traction. mobilization*. passive modalities Magnetic stimulation. straincounterstrain* NAD Grade III Recent - Short-term use of cervical 2 collar* . massage. electroacupuncture* Persistent - - Passive modalities (TENS. - stimulation). massage. mobilization*. passive modalities Magnetic stimulation. straincounterstrain* Persistent Collars. relaxation Manipulation*. low level laser All other interventions therapy* All interventions 88 Page 88 of 89 . traction. traction. Persistent - - Traction*. TENS. low level (heat therapy. - massage*. laser therapy*. clinical electrical muscle acupuncture* massage* stimulation). TENS. Manipulation. acupuncture* electroacupuncture* NAD Grade I-II Recent Collars. WAD: whiplash-associated 5 disorders 6 89 Page 89 of 89 . 75] 4 NAD: neck pain and associated disorders. persistent refers to ≥ 3 months. TENS: transcutaneous electrical nerve stimulation. 1Recent refers to < 3 months. 2Caution should be taken when considering the use 3 of cervical collars because of the potential for iatrogenic disability [10.1 *Italicized interventions refers to interventions for which we found new evidence in our update of the Neck Pain Task 2 Force. 74.