Neck Pain: Revision 2017

The Effectiveness of Mulligan's Techniques in Non-Specific Neck Pain: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Mulligan's techniques, such as Sustained Natural Apophyseal Glides (SNAGs) and Natural Apophyseal Glides (NAGs), are commonly applied by physiotherapists when treating patients with non-specific neck pain (NP). However, there has been no comprehensive synthesis of their effects in NP. This review aimed to assess the effectiveness of Mulligan's techniques in reducing pain, improving disability, and enhancing cervical range of motion (CROM) in adults with acute, subacute, or chronic NP.

METHODS

A systematic review with meta-analysis was conducted on randomized controlled trials (RCTs) comparing Mulligan's techniques with other interventions in adults with NP. Two reviewers independently conducted study selection, data extraction, and risk of bias (RoB) assessment. Meta-analyses were performed when clinical homogeneity was present; otherwise, a narrative synthesis was used. Certainty of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Thirty-three studies were included. For acute and mixed (acute/subacute/chronic) NP, Mulligan's techniques were no more effective than other interventions for pain reduction, disability improvement, or CROM enhancement. However, in patients with chronic or uncertain chronicity NP, SNAGs combined with other interventions demonstrated superior outcomes-both statistically and sometimes clinically-compared to certain treatments like exercises and muscle-energy techniques, for reducing pain and disability and improving CROM. The certainty of evidence was rated very low.

DISCUSSION

Mulligan's techniques appear to be safe, simple, and potentially beneficial for managing mixed or chronic NP when combined with other interventions, presenting results that may be comparable or occasionally superior to other standard techniques.

IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE

Physiotherapists may consider incorporating Mulligan's techniques, especially SNAGs, within broader NP treatment strategies, as they offer a feasible, low-risk option for improving patient outcomes, particularly for chronic NP cases when used alongside other therapies.

Effectiveness of Telerehabilitation Exercise Programme on Disability and Pain in Patients With Chronic Non-Specific Neck Pain: Randomised Controlled Trial Assessor-Blinded

INTRODUCTION

Chronic neck pain is an important public health problem. Telerehabilitation has emerged as an important tool for individuals with musculoskeletal conditions.

OBJECTIVES

The study aims to identify the effectiveness of a telerehabilitation exercise programme compared with a digital self-care booklet on non-specific neck pain.

METHODS

A randomised controlled trial assessor-blinded, 3 months follow-up. 70 patients were randomised into two groups of 35. The telerehabilitation group received 6 weeks of individualised training through vídeo calls and an online booklet. The control group received an online booklet. The primary outcome was functional disability. Secondary outcomes included pain intensity, global perceived effect, self-efficacy, quality of life, and kinesiophobia. All outcomes were assessed at baseline, 6 weeks, and a 3-month follow-up.

RESULTS

There was a significant difference between groups for functional disability (Mean 10.3, CI 95% 4.8-15.7), pain intensity (Mean 2.8, CI 95% 1.4-4.1), global perceived effect (Mean -2.3, CI 95% -3.7 to -0.9), and self-efficacy (Mean -24.7, CI 95% -41.0 to -8.4) at the 6-week. At the 3-month follow-up, statistically significant differences were observed for perceived overall effect (Mean -2.0, CI 95% -3.4 to -0.6) and self-efficacy (Mean -26.3, CI 95% -42.8 to -9.8).

CONCLUSIONS

Telerehabilitation is effective in improving disability and pain intensity compared with self-care booklets only in individuals with non-specific chronic neck pain.

TRIAL REGISTRATION

This trial is registered at https://ensaiosclinicos.gov.br/rg/RBR-10h7khvk under the registration number RBR10h7khvk at 09/16/2022.

Adherence to neck and low back pain clinical practice guidelines based on clinical specialization: a survey of physical therapists

OBJECTIVE

To investigate physical therapist adherence to the Academy of Orthopaedic Physical Therapy's (AOPT) clinical practice guidelines (CPGs) for the management of neck and low back pain (LBP) and to compare adherence among varying clinical specializations.

DESIGN

Electronic cross-sectional survey.

METHODS

The survey was sent to 17,348 AOPT members and 7,000 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) members. Participants selected the best diagnosis and intervention(s) for six case vignettes based on the current AOPT CPGs for neck and LBP. Diagnostic and intervention adherence rates were reported as total percentages and delineated by the highest level of clinical specialization - fellowship training (PTFs), orthopedic residency training (PTRs), Board Certified Clinical Specialist in Orthopaedic Physical Therapy (PTSs), orthopedic background without clinical specialization (PTOs). Binary logistic regression analyses were performed to determine the effects of clinical specialization (PTFs, PTRs, or PTSs) compared to PTOs on the likelihood of guideline adherence for all six cases.

RESULTS

Of the 159 participants who responded to the survey, 152 were eligible and 145 completed demographic data. Participant responses declined as the survey progressed from 125 completing case one to 106 completing case six. The odds ratio from binary logistic regression analyses were not significant for any specialization in all six cases (OR = 0.16; 95% CI: 0.02, 1.11; p = 0.064).

CONCLUSIONS

The results of this manuscript demonstrated variable adherence rates across subgroups of patients with neck and LBP with no significant association between clinical specialization and adherence. Adherence to CPGs is dependent on the clinical presentation of various patient cohorts.

Understanding degenerative cervical myelopathy in musculoskeletal practice

BACKGROUND

Degenerative cervical myelopathy (DCM) is a clinical syndrome characterized by a progressive compression of the spinal cord. DCM often looks like common symptoms of aging or bilateral carpal tunnel syndrome in its early stages, requiring careful differential diagnosis. Identifying DCM is a real challenge as no validated screening tools are available for making the DCM diagnosis. Potentially, individuals with DCM may experience misdiagnosis or substantial diagnostic delays, with an enhanced risk of irreversible neurological consequences if not promptly addressed. Despite the increasing prevalence, there is a lack of awareness about DCM among both the public and healthcare professionals. However, patients may seek physiotherapy to obtain a diagnosis or access treatment.

METHODS

A comprehensive (non-systematic) review of the literature about DCM epidemiology, pathophysiology, clinical presentation, diagnostic methods, and management was conducted.

RESULTS

A guide and essential knowledge to facilitate clinicians to understand DCM and to enhance clinical reasoning skills, performance and interpretation of the examination are provided. Interdisciplinary collaboration and optimal referral methods are also handled.

CONCLUSION

The aim of this article is to summarize and enhance physiotherapists' essential knowledge of the differential diagnosis and management of patients with DCM.

Combined chiropractic care and Tai Chi for chronic neck pain: A protocol for a pilot randomized trial

Background

Neck pain presents a personal and socioeconomic burden globally. Despite increasing prevalence, research on chronic neck pain (CNP) is limited and management relies on generalized approaches. There is growing interest in non-pharmacological interventions, however their efficacy remains uncertain due to the multifactorial etiology of CNP. Two interventions, multimodal chiropractic care (MCC) and Tai Chi, have shown promise individually in managing CNP, and when combined may offer synergistic benefits. This pilot study aims to assess the feasibility of combining these interventions for CNP.Methods/design: Forty-eight adults, aged 18-65y, with CNP defined as occurring ≥5 days a week for ≥3 consecutive months, severity of ≥3 on the numeric rating scale, and a score of ≥5 on the Neck Disability Index will be recruited. Participants will be randomized 1:1:1 to one of the three treatment groups (MCC plus Tai Chi and Enhanced Usual Care (EUC), MCC plus EUC, or EUC alone). The MCC was validated using a modified Delphi approach. Primary outcomes relate to feasibility (recruitment, retention, and adherence) and secondary outcomes include clinical measures of neck pain severity and disability, health-related quality-of-life, psychosocial well-being, and physical function. Outcomes will be assessed at baseline, 16-weeks (post-intervention), and 24-weeks. Qualitative interviews will be conducted.

Discussion

Results of this study will provide preliminary evidence regarding the feasibility and clinical evaluation of pragmatically delivered MCC, alone or in combination with Tai Chi, for individuals with CNP. These data will be used to inform the design of a fully powered, factorial trial evaluating two promising non-pharmacological therapies for CNP.

Trial registration

This study is registered in ClinicalTrials.gov (NCT05726331).

Caution is necessary in interpreting musculoskeletal physiotherapy intervention outcomes: a methodological review of physiotherapy neuromusculoskeletal reviews

OBJECTIVES

The physiotherapy literature lacks high-quality, registered systematic reviews (SRs) and 'trustworthy' randomized controlled trials (RCTs). It is unknown whether considering quality and 'trustworthiness' impact publication bias, heterogeneity, and the certainty of clinical recommendations observed in the literature.

METHODS

We performed a methodological review of SRs investigating physiotherapy treatment of neuromusculoskeletal conditions indexed by MEDLINE, between 1 January 2018, and 25 October 2023. Blinded reviewers examined the prospective intent and quality of SRs and the 'trustworthiness' of RCTs included therein. Blinded reviewers extracted data for the variables of interest (Numeric Pain Rating Scale and Visual Analog Scale).

RESULTS

Of the SRs identified (N = 677), 13 were included in the final review. These included a total of 109 RCTs, including duplicates. Only eight of these trials were deemed 'trustworthy.' Publication bias was identified, and heterogeneity across the trials (N = 55) included in the quantitative analysis was high (I2 = 80.11%, 95% CI [75.88, 83.60]). Publication bias and heterogeneity were eliminated (I2 = 0%, 95% CI [0.00, 37.44]) upon considering those prospectively registered (N = 14). Statistical significance, assessed via the p-value at baseline (<.001), was eliminated (p = .746) once prospective, external, and internal validity was considered. Statistical inference through estimation, evaluated via effect size, confidence intervals, and minimal detectable change, was not present at baseline and reduced throughout the screening process.

DISCUSSION

Trials of musculoskeletal interventions to manage pain in patients with neuromusculoskeletal conditions lack certainty and confidence in their treatment effects and exhibit high heterogeneity. Statistically significant effects and heterogeneity are eliminated when considering 'trustworthy' quality evidence.

CONCLUSIONS

Consistent with previous findings, null effects, and low heterogeneity arise when considering the best available evidence. Meaningful effects are likely rare when assessed holistically using statistical inference through estimation and the confidence and certainty of the estimated effect.

Knowledge, Attitude and Practice of Italian Physiotherapists When Prescribing Exercise for People With Non-Specific Neck Pain: A National Survey

BACKGROUND AND OBJECTIVE

Exercise is a crucial component of a multimodal treatment for improving function and reducing pain in patients with non-specific neck pain. This study aims to investigate the knowledge, attitudes, practices and the influence of professional characteristics of Italian specialised musculoskeletal physiotherapists compared with non-specialised physiotherapists. The influence of professional characteristics on exercise prescription for individuals with non-specific neck pain was also investigated.

MATERIALS AND METHODS

This observational study was reported according to the CHERRIES checklist. A 30-question survey was conducted from August 2023 until January 2024.

RESULTS

A total of 446 Italian physiotherapists participated; 57.3% were Orthopaedic Manipulative Physical Therapists (OMPTs). Most (84%) reported being trained in exercise prescription for neck pain, but many were unfamiliar with certain muscular assessment tests which have been described in the literature (e.g., cervical extensor endurance test [35%], scapular holding test [41%]). 79% of the OMPTs and 56% of non-specialised physiotherapists (non-OMPTs) prescribed exercise for patients with neck pain, with 84% of the OMPTs and 68% of non-OMPTs agreeing that exercise should be part of neck pain management. 81% of the OMPTs and 63% of non-OMPTs reported being trained in the prescription of resistance training for patients with neck pain. However, OMPTs prescribed it less frequently.

CONCLUSIONS

Italian physiotherapists are trained in exercise prescription for neck pain but lack familiarity with key muscle assessment tests. There is a need for enhanced training in aerobic and resistance exercise prescription to align with international guidelines and ultimately improve patient outcomes.

Effects of an artificial intelligence-based exercise program on pain intensity and disability in patients with neck pain compared with group exercise therapy: A cohort study

OBJECTIVES

This study compares the effects of an artificial intelligence app-based exercise program with group exercise therapy on pain intensity and neck-related disability in patients with neck pain.

PARTICIPANTS

84 patients with neck pain. 70 fulfilled the study requirements. 52 were in the intervention and 18 in the comparison group.

INTERVENTION

The intervention group utilized an AI-based exercise program accessible via digital devices. The AI provided 3-5 daily exercises tailored to individual feedback, pain intensity, and well-being. The exercise duration was up to 15 min per day. The comparison group attended up to two 45-min group exercise sessions weekly.

METHODS

Pain intensity and neck-related disability were assessed using an 11-point numerical rating scale and the Neck Disability Index via online questionnaires at baseline, 4 weeks, and 8 weeks. The non-parametric Mann-Whitney U test was used to test for between group differences.

RESULTS

After 8 weeks, the intervention group showed a significantly lower pain intensity than the comparison group (U = 287, Z = -2.447, p = 0.042, r = 0.3). Compared to baseline, the intervention group showed a significant reduction in neck pain (Chi2 (2) = 15.775, p < 0.001, W = 0.15) and an improvement in neck-related disability (Chi2 (2) = 25.094, p < 0.001, W = 0.24). The comparison group showed no significant change over time.

CONCLUSION

The app-based exercise program demonstrated promising results for the reduction of pain intensity and neck-related disability, offering a personalized and mobile alternative to group exercise therapy for patients with neck pain.

Manual therapy and neck-specific exercise are equally effective for treating non-specific neck pain but only when exercise adherence is maximised: A randomised controlled trial

OBJECTIVE

To assess the effectiveness of manual therapy versus a progressive, tailored neck-specific exercise program with high adherence for treating non-specific chronic neck pain (NSNP) and to examine the relationship between exercise adherence and treatment outcome.

DESIGN

Single-blind, parallel, randomized clinical trial with two treatment arms, adhering to CONSORT guidelines.

METHODS

65 NSNP participants were randomly allocated to manual therapy or exercise. They received four treatment sessions of either manual therapy or neck-specific exercise, once a week for four weeks. Outcomes measured at baseline, two weeks, four weeks, and 12 weeks post-treatment included pain intensity, disability, patient-perceived improvement, quality of life, kinesiophobia and the craniocervical flexion test (CCFT) performance. In addition to evaluating each individual outcome, patients were categorized into either responders or non-responders according to pain intensity, disability and patient-perceived improvement. Exercise adherence was recorded.

RESULTS

There were no differences between groups in individual outcomes. Treatment outcome in the exercise group was associated with exercise adherence. Patients receiving manual therapy were more likely to be classified as responders than those receiving exercise at all measured time points (odds ratio, 2 weeks: 0.14; 95 % CI: 0.02-0.79; treatment completion: 0.31; 95 % CI: 0.12-0.82; 12 weeks after treatment completion: 0.19; 95 % CI: 0.05-0.65), however these differences were no longer present when only patients whose exercise adherence was ≥95 % were analysed. Exercise was more effective than manual therapy in improving CCFT performance but only if patients with ≥95 % adherence were considered.

CONCLUSION

A four-week intervention of manual therapy was more effective than exercise, however when exercise adherence was ≥95 %, the interventions were equally effective. Manual therapy may only be superior to specific-exercise when high exercise adherence cannot be assured.

Effectiveness of Jingjin Therapy for Non-Specific Chronic Neck Pain with Extension Dysfunction: A Randomised Controlled Trial

Purpose

To evaluate whether Jingjin therapy, a distal manual intervention, could accelerate extension dysfunction for non-specific chronic neck pain (NCNP).

Patients and Methods

In this single-centre, two-arm randomised controlled trial, we enrolled Chinese patients aged 20-60 years with active neck extension disorder, regardless of prior exposure to manual therapy. We randomly assigned 160 patients to one of the following two arms: Jingjin therapy or general manual therapy. Both groups underwent six treatment sessions: the first three sessions were administered daily, and the last three sessions were administered every other day. The primary outcome was the between-group difference in the angle of active neck extension after the sixth treatment and 1 week after treatment. A repeated-measures linear mixed-effects model was used to assess between-group differences in outcome indices, with group allocation and treatment time points treated as fixed effects and participants as random effects.

Results

The change in the angle of active neck extension from baseline to the sixth treatment session was significant for Jingjin therapy (mean: 29.75° to 51.97°) and general manual therapy (mean: 28.18° to 52.49°). Further, the between-group difference was minimal (mean -0.26°, 95% confidence interval, -2.62°, 2.09°) and not statistically significant (P = 0.828).

Conclusion

Jingjin therapy for 9 days significantly improved neck extension function in patients with NCNP, with no significant difference compared to general manual therapy.

Clinical Trial Registry Id

ChiCTR2300068892.

Effects of simultaneous soft tissue mobilization and capacitive and resistive electric transfer therapy using bracelet electrodes in women with chronic non-specific neck pain: A randomized clinical trial

BackgroundChronic non-specific neck pain (CNSNP), persisting for over 12 weeks, is commonly associated with myofascial trigger points. Soft tissue mobilization techniques (STMT) and capacitive and resistive electric transfer therapy (TECAR) may reduce pain and improve function.AimTo evaluate the effectiveness of combining STMT with TECAR using resistive bracelet electrodes in women with CNSNP.MethodA parallel-group, assessor-blinded randomized controlled trial (RCT) was conducted in accordance with CONSORT guidelines. Eighty women were randomly assigned to an experimental group (STMT + TECAR) or control (STMT only). TECAR was applied at 500 kHz: 10 min of capacitive mode with a conventional electrode, followed by simultaneous STMT and resistive mode using bracelet electrodes. Participants received 15 sessions over five weeks. NPRS, pressure pain thresholds (PPT), cervical range of motion (ROM), and Neck Disability Index (NDI) were assessed at baseline, week 5, and 6-month follow-up.ResultsThe experimental group showed significantly greater improvements at week 5 in NPRS, NDI, all PPT areas, lateral flexion, and right rotation ROM (p < .05). Clinically meaningful improvements in NPRS and NDI were observed only in the experimental group, while both groups achieved clinically significant gains in PPT. Improvements were sustained at six months; left rotation ROM differed only at follow-up. No differences were found in neck flexion or extension.ConclusionsCombining STMT with TECAR using bracelet electrodes resulted in superior improvements in pain, function, and ROM in women with CNSNP versus STMT alone, likely due to the synergistic mechanical and thermal effects of the intervention.

A description of serious adverse events following spinal manipulative therapy for adults with history of spine surgery: a single institution retrospective chart review

OBJECTIVES

The purpose of this study was to describe patient demographics and medical history, clinical care characteristics, and short-term serious adverse events associated with SMT in adults with prior spine surgery.

METHODS

This study was a retrospective chart review of adult (at least 18 years of age) patients with any prior spine surgery who underwent SMT between January 2010 and December 2021 at an academic medical center in the United States. Eligible charts were reviewed, and data were extracted and transcribed onto an a priori Microsoft Excel data extraction tool. Adverse events were defined as vertebral artery dissection, cauda equina syndrome, fracture in the location of SMT, or spine surgery hardware failure in the same spinal region of SMT within 10-days following SMT.

RESULTS

A total of 418 unique patient's charts were eligible for review. The mean patient age was 50.6 years. The majority of patients were female (52.6%), White (90.7%), and non-Hispanic (97.8%). The most common types of spine surgeries were lumbar fusion (28.7%), cervical fusion (27.8%), and lumbar discectomy with laminectomy/foraminotomy (34.7%). The median time after surgery to first SMT was 311 days. There were no short-term incidents of vertebrobasilar/cervical artery injury, acute cauda equina, fractures in the same region of SMT application, or hardware failure.

CONCLUSION

There were no incidents of serious adverse events in the short-term following SMT in individuals with prior spine surgery in this study. Findings from this study aid in evaluating the safety profile of SMT for patients with prior spine surgery. In addition, findings contribute to the development of future high-quality study designs for investigating the clinical effectiveness of SMT in this patient population.

Cervical manipulation accelerates recovery and further correction of cervical alignment in mechanical neck pain (MNP) patients with neck exercise: A randomized controlled trial

BACKGROUND

Mechanical neck pain (MNP) is often associated with changes in cervical sagittal alignment, causing pain and functional limitations.

OBJECTIVE

This study evaluated the additional effects of cervical manipulation in patients with MNP undergoing neck retraction exercise.

METHODS

Patients with MNP were randomly assigned to either the cervical manipulation plus neck retraction exercise group (CM + NRE) or the neck retraction exercise group (NRE). Both groups completed their respective regimens over an 8-week period. Primary outcomes include visual analogue scale (VAS) and cervical range of motion (CROM). Secondary outcomes include neck disability index (NDI), neck muscle strength, and cervical sagittal alignment (relative rotation angles [RRA]; absolute rotation angles [C2-7ARA]; cervical sagittal vertical axis [c2-7SVA]). The statistical analysis applied intention-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS

In the ITT analysis, the CM + NRE group demonstrated more pronounced changes in VAS and CROM after the first treatment (VAS: d = 1.83, P = 0.001; CROM: d = 1.92, P = 0.001), at 4 weeks (VAS: d = 0.98, P = 0.001; CROM: d = 1.05, P = 0.001), 8 weeks (VAS: d = 1.05, P = 0.001; CROM: d = 0.93, P = 0.001), and at a 4-week follow-up (VAS: d = 1.16, P = 0.001; CROM: d = 0.91, P = 0.001). In the assessments of NDI, RRA, and C2-7ARA, the CM + NRE group showed significantly greater changes compared to the NRE group (p < 0.05). These results were consistent with the PP analysis.

CONCLUSION

Cervical manipulation enhances the effectiveness of neck retraction exercise, which promotes rapid recovery from neck pain and stiffness and further facilitates the correction of cervical sagittal alignment in patients with MNP.

Efficacy and safety of spinal manipulative therapy in the management of acute neck pain: a systematic review and meta-analysis

BACKGROUND

Spinal manipulative therapy (SMT) is frequently used to manage neck pain; however, its efficacy and safety in treating acute neck pain (ANP) remain uncertain and require further investigation.

OBJECTIVES

This study aims to comprehensively evaluate the efficacy and safety of SMT in the treatment of ANP.

DATABASES AND DATA TREATMENT

A thorough search was conducted in PubMed, Embase, Web of Science, PEDro, and Cochrane Library databases, covering all studies from inception to March 20, 2023. Mean differences (MD) with 95% confidence intervals (CIs) were calculated to assess outcomes such as pain intensity, cervical range of motion (CROM), and disability. The PEDro Scale and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were utilized to evaluate the methodological quality and strength of evidence.

RESULTS

Eight randomized controlled trials (RCTs) with 965 patients were included. Their PEDro scores ranged from 4-9 (mean: 6.38, SD: 1.25). Forest plot analysis showed SMT was better than the control in reducing pain (MD = -1.53, 95% CI [-2.22, -0.83]) and improving CROM in all measured aspects. It also significantly reduced disability scores (MD = -6.20, 95% CI [-9.81, -2.59]). No serious adverse events were reported.

CONCLUSIONS

The evidence supports the use of SMT as an effective and safe intervention for reducing pain, improving CROM, and decreasing disability in patients with ANP. These findings provide valuable insights for clinical practitioners and highlight the potential of SMT as a viable therapeutic option in managing ANP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021264411.

The efficacy of manual therapy and therapeutic exercise for reducing chronic non-specific neck pain: A systematic review and meta-analysis

BackgroundChronic non-specific neck pain (CNSNP) is a highly prevalent musculoskeletal disorder associated with significant disability, resulting in growing recourse to healthcare providers, huge cost for society and a great number of workdays lost.ObjectiveBy this systematic review and metanalysis we aimed to assess the effects of different physical therapy techniques in patients with CNSNP.MethodsPubMed, Scopus, and Web of Science databases were regularly used to search for articles published from 1st January 2010 until 31st January 2024. All RCTs were assessed for eligibility, including studies on: patients with diagnosis of CNSNP; physical therapy approaches such as manual therapy (MT) and therapeutic exercise (TE); waiting list, sham treatments, as comparison; Visual Analogue Scale, Numerical Rating Scale, Numerical Pain Rating Scale, and Numerical Pain Scale, as outcomes.ResultsAt the end of the search, 14025 studies were identified. After the removal of duplicates, 10,852 were considered eligible according to title and abstract screening, while 10,557 papers were excluded after this process. Therefore; a total of 11 RCTs were included in this systematic review. A decrease of pain intensity was observed in all groups, albeit in patients being treated with TE and MT. Besides this, the combination of TE and MT demonstrated a 91% of probability to be the best choice in patients with CNSNP at the first visit. Only the combination of TE plus MT/cognitive behavioral therapy and MT as a single treatment showed a reduction in pain score. Overall, 3 studies (27.2%) showed a low risk of bias, 6 (54.5%) showed some concerns in bias assessment, and 2 (19%) a high risk of bias.ConclusionCollectively, the findings of this systematic review showed that MT and TE might be considered as effective rehabilitation approaches for treatment of pain in patients with CNSNP.

Number of physiotherapy sessions in work-related absenteeism due to musculoskeletal disorders, by gender, age and occupation: A retrospective cohort study

BackgroundThe number of physiotherapy sessions needed to treat musculoskeletal conditions varies in the literature; age and gender may partly explain the discordant reports. However, no research has analysed whether occupation may influence this outcome in the working population.ObjectivesTo assess the number of physiotherapy sessions performed for low back pain (LBP), cervicalgia (CG), and whiplash syndrome (WS) in workers on sickness absence, according to gender, age, and occupation.MethodsIn this retrospective cohort study, the outcome variable was the number of physiotherapy sessions needed to recover from LBP, CG, and WS. Explanatory variables were sex, age, occupation, year when physiotherapy ended, and treatment centre. The adjusted median differences in the number of sessions (MDa) were calculated.ResultsOlder workers (55-65 years) needed a median of 2.6 additional sessions for LBP, 3.0 more sessions for CG, and 3.6 for WS. Men underwent fewer sessions than women (LBP and CG: MDa -0.9 sessions; WS: MDa -1.7 sessions). Compared to crafts and related trades workers, plant and machine operators and assemblers required more sessions to recover from LBP (MDa 0.7), as did service and sales workers (MDa 0.7). In CG and WS, differences were observed for technicians and associate professionals (MDa 1.3 and MDa 1.7, respectively), and for professionals (MDa 2.4 and MDa 1.6). Clerical support workers also needed significantly more sessions for CG.ConclusionsThe number of sessions required to recover from LBP, CG, and WS in workers on work-related sickness absence is different according to gender, age, and occupation.

Optimizing safety in conservative physical management of the cervical spine: A modified Delphi study

BACKGROUND

Conservative cervical spine treatment is generally safe, but serious adverse events (SAEs) still occur despite various available clinical guidelines. There have been several challenges in understanding the specific circumstances of these events to direct prevention such as inconsistent reporting, misuse of professional titles, and incomplete data. There are also differences in opinions between professions. It is now important to understand expert views and consensus across professions regarding prevention strategies and minimum requirements for reporting standards for future SAEs.

METHODS

A modified Delphi method was used, involving 28 international experts from various allied health professions, including chiropractic, physiotherapy, osteopathy, and medicolegal fields. The experts took part in three rounds of online surveys to reach a consensus on reporting, characteristics, risk factors, and prevention of SAEs associated with neck treatments. An agreement of >74 % was required before consensus was reached.

RESULTS

Consensus was reached for more standardised reporting of SAEs across different types of treatments and professions. Addressing underlying health conditions and improving the recognition of potential risks, precautions, and contraindications during treatment were highlighted. Recommendations for strategies to improve safety, including early identification of risk factors and careful application of techniques, especially in vulnerable populations were also provided.

CONCLUSION

Experts called for the development of universally accepted clinician friendly clinical guidelines that focus on improving SAE reporting, early identification of SAEs, and safer technique application, particularly in special populations. Implementing these recommendations will help reduce the occurrence of SAEs and improve the safety of conservative cervical spine management across professions.

A cross-sectional study on ChatGPT's alignment with clinical practice guidelines in musculoskeletal rehabilitation

BACKGROUND

AI models like ChatGPT have the potential to support musculoskeletal rehabilitation by providing clinical insights. However, their alignment with evidence-based guidelines needs evaluation before integration into physiotherapy practice.

OBJECTIVE

To evaluate the performance of ChatGPT (GPT-4 model) in generating responses to musculoskeletal rehabilitation queries by comparing its recommendations with evidence-based clinical practice guidelines (CPGs).

DESIGN

This study was designed as a cross-sectional observational study.

METHODS

Twenty questions covering disease information, assessment, and rehabilitation were developed by two experienced physiotherapists specializing in musculoskeletal disorders. The questions were distributed across three anatomical regions: upper extremity (7 questions), lower extremity (9 questions), and spine (4 questions). ChatGPT's responses were obtained and evaluated independently by two raters using a 5-point Likert scale assessing relevance, accuracy, clarity, completeness, and consistency. Weighted kappa values were calculated to assess inter-rater agreement and consistency within each category.

RESULTS

ChatGPT's responses received the highest average score for clarity (4.85), followed by accuracy (4.62), relevance (4.50), and completeness (4.20). Consistency received the lowest score (3.85). The highest agreement (weighted kappa = 0.90) was observed in the disease information category, whereas rehabilitation displayed relatively lower agreement (weighted kappa = 0.56). Variability in consistency and moderate weighted kappa values in relevance and clarity highlighted areas requiring improvement.

CONCLUSIONS

This study demonstrates ChatGPT's potential in providing guideline-aligned information in musculoskeletal rehabilitation. However, due to observed limitations in consistency, completeness, and the ability to replicate nuanced clinical reasoning, its use should remain supplementary rather than as a primary decision-making tool. While it performed better in disease information, as evidenced by higher inter-rater agreement and scores, its performance in the rehabilitation category was comparatively lower, highlighting challenges in addressing complex, nuanced therapeutic interventions. This variability in consistency and domain-specific reasoning underscores the need for further refinement to ensure reliability in complex clinical scenarios.

CLINICAL TRIAL NUMBER

Not applicable.

Effects of health qigong on cervical spondylosis: A systematic review

AIM

Exercise therapy is a widely utilized intervention for the prevention and rehabilitation of cervical spondylosis. As a distinctive form of traditional exercise therapy in China, Health Qigong has been empirically validated to exert beneficial effects across 17 physiological systems, with particularly pronounced efficacy in addressing musculoskeletal disorders. This systematic review aims to critically evaluate the impact of Health Qigong on cervical spondylosis.

METHODS

According to the literature search principles, works published from the publication date to November 2024 were searched. The databases used were the China National Knowledge Infrastructure, Scopus, PubMed, Web of Science, and EBSCOhost (SPORTDiscus). The study quality was evaluated using the Physiotherapy Evidence Database (PEDro) scale. The search process was documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)2020.

RESULTS

A total of 10 studies were selected from an initial pool of 702 studies, comprising 656 participants. The PEDro scores of the 10 studies ranged from seven to eight. The findings indicate that Health Qigong exerts its therapeutic effects on cervical spondylosis primarily in four key areas: alleviating neck pain, improving cervical dysfunction, restoring cervical curvature, and enhancing cervical mobility. Specifically, for pain relief, the Visual Analog Scale(VAS) scores showed a mean reduction of 2.8-4.15 points, while the Neck Disability Index (NDI) scores significantly decreased from 6.10 to 1.4. And after intervention, the prevalence of abnormal cervical curvature decreased by 10.97 %, cervical range of motion (CROM) improved by 19.78° to 67.4° on average. Furthermore, according to the Traditional Chinese Medicine (TCM) Diagnostic and Treatment Criteria, five studies reported an overall effectiveness rate exceeding 90 %, with a maximum of 97.14 %. Short-term intervention outcomes indicated that Ba Duan Jin showed a recurrence rate of 0 %, whereas interventions using Yi Jin Jing and Wu Qin Xi exhibited recurrence rates ranging from 11.2 % to 13.33 %.

CONCLUSION

As an exercise-based intervention, Health Qigong not only helps alleviate cervical spondylosis-related pain and improve cervical dysfunction but also promotes the restoration of cervical curvature and enhances cervical mobility, thereby addressing limitations in neck function. However, current research exhibits certain limitations and research gaps in areas such as populations, cervical spondylosis classification, intervention design, and outcome assessment criteria.Therefore, there is an urgent need to develop more targeted intervention strategies, establish standardized outcome evaluation systems, and conduct in-depth mechanistic studies to further validate the clinical efficacy and practical application of Health Qigong in the management of cervical spondylosis.

Comparative effectiveness of six biophysical agents on neck pain rehabilitation: a systematic review and network meta-analysis

PURPOSE

This systematic review and network meta-analysis aims to investigate the comparative effectiveness of six biophysical agents, including Transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), extracorporeal shockwave therapy (ESWT), therapeutic ultrasound, low-level laser therapy (LLLT), and high-intensity laser therapy (HILT) on neck pain rehabilitation.

METHODS

Three bibliographic databases, PubMed, Embase, and Scopus were searched from inception to July 30, 2024. Randomized controlled trials comparing a single biophysical agent with placebo control or another biophysical agent on neck pain intensity as an outcome were selected. Two independent reviewers independently conducted study selection, data extraction, and quality assessment. The methodological quality of included randomized controlled trials was assessed using the Physiotherapy Evidence Database scale.

RESULTS

A total of 34 randomized controlled trials with 2141 patients with neck pain were included, and all included studies had good or above quality. A random-effects frequentist network meta-analysis, assuming a common random-effects standard deviation for all comparisons in the network. Effects of biophysical agents on neck pain intensity were estimated as mean differences with 95% confidence intervals. League tables were created to display the relative degree of neck pain for all comparisons among the six biophysical agents.

CONCLUSION

This study suggests that rehabilitation of neck pain using biophysical agents should be prioritized in the following ranks: HILT, ESWT, IFC, TENS, LLLT, and therapeutic ultrasound. The results clarified how different biophysical agents may influence neck pain outcomes and provided proper evidence to inform clinicians to select biophysical agents prudently for neck pain management.

Predicting Work Disability Related to Spinal Pain: A Systematic Review of the Most Clinically Relevant Tools

PURPOSE

Musculoskeletal disorders, especially spinal conditions, are leading causes of disability, contributing significantly to work absenteeism and socio-economic burden. Rehabilitation is essential for promoting sustainable return to work (RTW). However, clinicians need reliable tools with appropriate psychometric properties to determine patients' risk of persistent work disability and tailor interventions. This systematic review objectives were to (1) identify clinically useful questionnaires that enable clinicians to identify individuals with spinal pain (back or neck pain) at risk of work disability, and (2) document the psychometric properties of the identified questionnaires.

METHODS

A systematic search was conducted in three databases from inception to 01/10/2025, to retrieve relevant studies. Studies were included if they reported self-administered questionnaires with ≤ 15 items predicting RTW outcomes in spinal disorders. Tools were evaluated based on psychometric properties (calibration, discrimination), and pragmatic characteristics (number of items, readability).

RESULTS

Seventeen studies were retrieved including 16 unique questionnaires of which four demonstrated sufficient discrimination capability. From these, the Örebro musculoskeletal pain questionnaire 10-items (ÖMPQ- 10), STarT Back screening tool (SBST), and a single item from the ÖMPQ- 25 demonstrated acceptable to excellent discrimination for low back pain populations, but showed lower discrimination for mixed or neck pain populations.

CONCLUSION

The SBST, ÖMPQ- 10, and single items from the ÖMPQ- 25 performed best in predicting RTW outcomes for low back pain. No questionnaire had sufficient discriminatory capability for neck pain. These results should be interpreted with caution, as the overall risk of bias assessment remains unclear for the OMPQ- 10 and high for the SBST. Further research is necessary to develop or validate tools specific to neck pain and mixed populations.

The response to individualized treatment after a standardized treatment protocol among neck pain sufferers: a secondary analysis of a randomized controlled trial

BACKGROUND

Manual therapy and exercise are recommended for patients with neck pain. In a recent randomized controlled trial, home stretching exercises with or without manual therapy were offered to subjects with persistent or recurrent neck pain. No difference in pain or disability between the treatment groups were found after the two-week intervention period. We aimed to investigate whether these patients had a better outcome after individual tailoring of the treatment content two months after the initial structured intervention period.

METHODS

This manuscript is a secondary analysis of a previous clinical trial where 131 patients with persistent or recurrent neck pain received treatments over two weeks (the intervention period). Pain and disability were assessed for two months following the intervention period. During this period, the treating therapists could recommend further individualized tailored treatment, including any treatment modality, regardless of the intervention group and whether the participants responded to the intervention (responders) or not (non-responders). Responders from the intervention period were defined as reporting a minimal clinical improvement on the numeric rating scale (NRS-11) at a 20-percentage points improvement (2 increments), regardless of group belonging in the original trial. All other participants were considered non-responders. We also evaluated the number of treatments, differences in disability, quality and affective component of pain, and quality of life during the individualized care period.

RESULTS

For responders to a randomized trial of manual therapy and stretching exercises, a significant worsening in pain was associated with an increasing number of treatments during a two-month individualized care period. Among non-responders to the initial intervention period, improvement in neck pain disability was observed with individually tailored treatments.

CONCLUSIONS

For responders to a randomized trial of manual therapy and stretching, worsening pain in the individualized care period was associated with increasing numbers of individually tailored treatments. Among non-responders to the initial intervention period, improvement in neck pain disability was observed with individually tailored treatments.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov, registration number NCT03576846, on 23rd of June 2018.

Efficacy of Yijinjing for Soft Tissue Improvement in Patients with Non-specific Chronic Neck Pain: Study Protocol for a Multicenter Randomized Controlled Trial

INTRODUCTION

As a mind-body exercise, Yijinjing has shown benefits in enhancing the effects of manual therapy for the treatment of pain, disability and soft tissue status associated with non-specific chronic neck pain (NCNP). The efficacy of Yijinjing as an independent exercise regimen for the treatment of NCNP has not been established. This study is designed to assess the efficacy of Yijinjing in patients with NCNP, compared with cervical function training (CFT).

METHODS AND ANALYSIS

A total of 132 consenting NCNP participants will be randomly assigned in a 1:1 ratio to either the Yijinjing group or the CFT group (three times a week for 8 weeks). Both groups will undergo an 8-week intervention phase. Outcome variables will be assessed at baseline and at 4-week, 8-week and 12-week follow-up. The primary outcome measure is the change in visual analogue scale scores at week 8. Secondary outcomes include neck disability index, cervical range of motion and soft tissue status parameters.

ETHICS AND DISSEMINATION

This study has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki, local laws and regulations. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ITMCTR2024000323.

Physician referrals of patients with neck and low back pain for physical therapy in outpatient clinics: a cross-sectional study

BACKGROUND

Patients commonly seek outpatient physical therapy services for musculoskeletal disorders. Understanding these patient groups in Israel provides valuable insights into the healthcare system. We aimed to investigate physician referral patterns for physical therapy across different age and sex groups, focusing on neck and low back pain. Additionally, we sought to explore the therapeutic interventions provided by physical therapists for these conditions.

METHODS

For this retrospective, cross-sectional study we utilized data from a national health maintenance organization covering > 4 million people at 100 physical therapy outpatient clinics. We measured the prevalence rates of physicians' referral patterns for neck and low back pain according to age and sex, as well as therapeutic interventions prescribed by physical therapists. We used Z-tests to assess the differences in prevalence rates between women and men within the same age group. Logistic regression analyses were used to evaluate the likelihood of patients of a specific age group being referred to physical therapy compared with the total sample. We analyzed prevalence rates of different treatment protocols used by physical therapists according to these referrals.

RESULTS

Overall, 1,593,592 physician referrals for physical therapy were made over 6 years for all musculoskeletal conditions. Of those, 32.4% were for spine disorders, with 21.2% for low back pain and 11.1% for neck pain, mostly chronic (80.6% and 72.7%, respectively). Women were more likely than men to be referred for both low back pain (odds ratio = 1.36, 95% confidence interval = 1.34-1.38, p < 0.001) and neck pain (1.40, 1.37-1.43, p < 0.001). All referral rates increased with age. The most common treatment provided by physical therapists for neck and low back pain was education and advice for an active lifestyle.

CONCLUSIONS

This study provides comprehensive data that highlight significant trends related to age, acuteness, and sex. Chronic low back and neck pain are the predominant reasons for physical therapy referrals, particularly among women and older adults. Physician referrals for neck and low back pain aligned with the epidemiology of such conditions in the Israeli population, underscoring the need for targeted rehabilitation strategies, early intervention programs, and effective healthcare service planning.

The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain

Study DesignObservational Cohort Study.ObjectivesThis study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain.MethodsData from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression.ResultsOf 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up.ConclusionsThis study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Promoting longus colli muscle activation: Force direction in sitting matters

BACKGROUND

There is limited evidence to inform exercise prescription for deep neck flexor activation out of supine.

OBJECTIVE

To compare activation of longus colli (LC) and sternocleidomastoid (SCM) from supine to sitting, and to compare the effect of craniocervical flexion (CCF) exercises in sitting on activation.

METHODS

Twenty-four individuals without neck pain (mean age 28.8 years, 12 females) completed 7 isometric CCF exercises (1 supine CCF, 6 sitting with applied head resistance through an elastic band in straight or oblique planes from the contra- or ipsilateral sides) while muscle activation was captured using ultrasound imaging. A 2-way analysis of variance examined the effects of exercise and muscle on percent change activation using planned post-hoc comparisons and Cohen's D to establish effect sizes.

RESULTS

Supine CCF was equivocal to sitting CCF with resistance for LC activation (p = 0.758). The LC muscle was most robustly activated by applying an ipsilateral oblique resistance force compared to a straight lateral force (p = 0.002, Cohen's d = -0.82). LC activation was higher when oblique resistance was applied from the ipsilateral than contralateral side (p = 0.002, Cohen's d = -0.84). SCM activation was higher resisting an ipsilateral lateral force compared to a contralateral force (p = 0.0006, Cohen's d = 1.06).

CONCLUSIONS

Craniocervical flexion in supine and sitting activate LC equally but in sitting, applying oblique resistance during lateral flexion with extension enhances LC activation most effectively. Care should be taken with straight laterally applied forces since this can promote unwanted SCM activation.

Cervicocephalic force steadiness and force sense in people with and without neck pain

BACKGROUND

Proprioceptive and motor control impairments have been identified in people with neck pain, but there is limited data regarding deficits and reliability of cervical force steadiness and force sense.

OBJECTIVES

To evaluate between-group differences and test-retest reliability of cervical force steadiness and force sense in people with and without neck pain.

DESIGN

Cross-sectional comparative study.

METHOD

Fourteen people with chronic neck pain (CNP) and 15 healthy participants of comparable age range completed a force-matching protocol of randomised isometric contractions for cervical flexion, extension, rotation (left and right), and lateral flexion (left and right) at intensities of 10% and 25% of their maximal voluntary contraction (MVC). Twenty-four participants completed a second session 4-7 days later to evaluate reliability. Force was converted to coefficient of variation (COV) to measure force steadiness, and absolute error (AE), constant error (CE), and variable error (VE) for force sense.

RESULTS

CNP participants demonstrated worse total VE at 10% MVC (mean difference 36.96%, p < .001). Reliability of force sense varied between poor to good, with best reliability shown for CE (ICC estimates 0.21-0.88). Force steadiness was significantly worse in the CNP population for 10% MVC (mean difference 42.26%, p < .001) and 25% MVC (mean difference 23.97%, p < .001), and reliability was moderate-good for all contractions (ICC estimates 0.53-0.87) except two.

CONCLUSIONS

People with CNP demonstrated impairments in force steadiness and force sense, particularly at 10% MVC intensity contractions. Reliability was varied for force sense and most contractions demonstrated moderate-good reliability for force steadiness.

Differences in the clinical presentation of chronic whiplash-associated disorders and nontraumatic neck pain: a systematic review and meta-analysis

ABSTRACT

Health outcomes may be worse for individuals with whiplash-associated disorders (WAD) compared to nontraumatic neck pain (NTNP), and clinical characteristics may differ. This systematic review examined evidence comparing WAD and NTNP in terms of pain, disability, psychological status, quality of life, measures of nociceptive processing, movement, sensorimotor, and muscle function. Studies were identified through electronic database searches and included after screening against predefined eligibility criteria. Standardized mean differences (SMD) or mean differences (MD) and 95% confidence intervals (CI) were calculated. Associations between MDs with demographics and study characteristics were explored using meta-regression. Certainty of evidence was assessed using Grades of Recommendation, Assessment, Development, and Evaluation. Sixty-one studies were eligible with 45 included in meta-analysis. Individuals with WAD reported clinically relevant higher disability (100-point Neck Disability Index MD [95% CI] 11.15 [8.63, 13.68]), greater remote cold sensitivity (SMD 0.89 [0.57, 1.21]), lower quality of life (SMD -0.96 [-1.77, -0.16]), greater depression (SMD 0.60 [0.27, 0.93]), greater local (SMD -0.56 [-1.00, -0.13]) and remote (SMD -0.50 [-0.81, -0.19]) pressure sensitivity, less cervical flexion (MD -5.30° [-7.44, -3.16]) and extension (MD -5.43° [-9.31, -1.55]), higher pain intensity (100-point numerical rating scale: MD 8.15 [5.80, 10.50]), and greater kinesiophobia (SMD 0.35 [0.11, 0.59]). No between-group differences were found for dizziness symptoms, stress, anxiety, balance, and local cold sensitivity. Meta-regression indicated that disability differences were negatively associated with age (R2 = 29.6%, P = 0.006). Certainty of evidence was mostly moderate. Individuals with chronic WAD have a worse clinical presentation compared to those with chronic NTNP, which has implications for patient assessment and management.

The diagnostic validity of the cervical side bend-rotation test for C 1/2 dysfunction

INTRODUCTION

Neck pain and headaches are common, with a reported lifetime prevalence of up to 66%. Upper cervical segmental dysfunction has been implicated as meaningful in neck pain and multiple headache types. Several tests have been described to assess upper cervical joint dysfunction, including the flexion-rotation test (FRT), the side bend-rotation test (SBRT), and joint play assessment (PA). The purpose of this study was to determine the diagnostic validity of the SBRT to detect C1-2 dysfunction in a sample of people with medically diagnosed sinus headaches and controls.

METHODS

Design: prospective diagnostic accuracy study, occurring during an observational case-control study in a sample of individuals with medically diagnosed sinus headaches. All participants were assessed using the SBRT, FRT, and C1-2 joint play assessments. The diagnostic accuracy of the SBRT was assessed using a reference standard of concurrent positive FRT (a loss of at least 10° from expected ROM (≤34°)) and restriction of C1-2 joint play. Cut-off scores for the SBRT were determined using ROC curve analysis, and tests of diagnostic accuracy were calculated using 2 × 2contingency tables.

RESULTS

A total of 80 individuals (40 headache, 64 female, mean age 32.9 ± 13.8 yrs.) were included in the study. Mean ROM for the tests was: SBRT 31.4 ± 9.4°, FRT 44.9 ± 9.5°, and C1-2 mobility 22 hypomobile/58 normal. An SBRT cutoff score of <25° was confirmed using ROC curves. Using this cutoff score, the SBRT demonstrated 100% sensitivity and 62% specificity to detect C1-2 hypomobility.

DISCUSSION/CONCLUSION

The SBRT, using a cutoff score of ≤25°, appears to be a sensitive test to detect C1-2 dysfunction. Based on the strong sensitivity and negative predictive values, scores greater than 25° may effectively rule-out C1-2 dysfunction. The SBRT should be considered as part of a sequential clinical decision-making process when screening for C1-2 dysfunction, although further research is required to improve generalizability of these findings.

Association among clinical severity indicators, psychological health status and elastic properties of neck muscles in patients with chronic mechanical neck pain

BACKGROUND

Since objective stifness measures are not consistent with the patients' perception and its correlation with the clinical severity of neck pain is not clear, novel studies assessing the clinical relevance of muscle stiffness are needed.

OBJECTIVES

To analyze the correlation among psychological factors, clinical severity indicators, and muscle stiffness in neck muscles in patients with chronic mechanical neck pain, and compare these factors with asymptomatic controls.

METHODS

A cross-sectional observational study was conducted. Participants included cases with chronic neck pain and asymptomatic controls, assessed for muscle stiffness using shear wave elastography, psychological health (anxiety and kinesiophobia), and clinical severity. Data analysis involved correlation matrices and comparison between groups.

RESULTS

Although no significant differences in levator scapulae stiffness were observed between groups (p > 0.05), patients exhibited significantly increased stiffness in the anterior scalene and cervical multifidus muscles (p = 0.009 and p = 0.040, respectively). STAI scores were significantly higher in patients for both subscales (STAI-S p = 0.002 and STAI-T p < 0.001), but no kinesiophobic behaviors differences were found (p > 0.05). Significant correlations between pain chronicity, intensity, disability, and psychological factors were confirmed. Notably, the levator scapulae stiffness was positively associated with disability, anxiety, and kinesiophobia (all p < 0.01). However, the anterior scalene and cervical multifidus stiffness, even if significantly associated with demographic factors (p < 0.05), were not associated with clinical or psychological outcomes.

CONCLUSION

The findings underscore the intertwined nature of psychological factors and muscle stiffness in chronic neck pain, suggesting the need for integrated approaches in treatment that consider both physical and psychological dimensions.

Diagnosing and treating upper back pain: insights from New Zealand's manipulative physiotherapists and osteopaths

BACKGROUND

Manual therapy is routinely used in the management of upper back pain (UBP), a disabling condition. However, the approach to diagnosis and treatment techniques used by manipulative physiotherapists and osteopaths is largely unknown.

OBJECTIVES

To explore knowledge about UBP, including diagnosis and treatment, by New Zealand (NZ) osteopaths and manipulative physiotherapists and to investigate differences (if any) in the self-reported approaches to diagnosis and management of UBP between the professions.

DESIGN

A cross-sectional survey administered through an online platform (Qualtrics) between September 2023 and January 2024.

PARTICIPANTS

One hundred and ten NZ osteopaths and manipulative physiotherapists completed the survey.

RESULTS

Forty-eight percent (n = 53) of respondents identified their profession as physiotherapists and 52% (n = 57) as osteopaths. Over three-quarters of respondents (77%) 'strongly agreed' that a multimodal approach is essential for effective UBP management. Osteopaths were significantly more likely to often proffer 'wear and tear/degeneration' (p < 0.01) and 'visceral referred pain' (p = 0.02) as the cause of a patient's UBP. In terms of management, osteopaths were significantly more likely to use soft tissue techniques (p < 0.01), spinal manipulations (p < 0.01), rib manipulations (p < 0.01), rib mobilizations (p < 0.01), and visceral techniques (p < 0.01), compared to physiotherapists.

CONCLUSIONS

The survey highlights a strong consensus among respondents that a multimodal approach is essential for effective UBP management. The survey also identified profession-specific approaches to the diagnosis and management of UBP. Future research using qualitative methods is required to further explore these profession-specific differences and explore outcomes of care.

Effects of manual therapy combined with therapeutic exercise on brain structure in patients with chronic nonspecific neck pain: A randomized controlled trial

This trial aimed to investigate the effects of 10-week manual therapy combined with exercise compared to routine physical therapy on brain structure and clinical outcomes in patients with neck pain. Fifty-two participants with chronic nonspecific neck pain were randomized into either an intervention group or a control group (a 1:1 ratio). The intervention group received cervical mobilization and cervical and scapular exercises. The control group received routine physical therapy. The primary outcomes were cortical thickness and volume. Secondary outcomes were neck pain intensity, disability, psychological symptoms, cervical range of motion and cervical flexor muscle strength. Outcome measures were taken at baseline and post-treatment. There was no loss to follow-up. Compared to baseline, significant differences in cortical thickness were observed at post-treatment in both groups, including prefrontal cortex (PFC), anterior cingulate cortex (ACC), primary somatosensory cortex (S1), primary motor cortex (M1) and precuneus (p<0.05). The intervention group exhibited greater increases in cortical thickness in the ACC and M1 compared to controls (p<0.05). The secondary outcomes were improved in both groups (p<0.05). There were differences in brain structure (S1, PFC and insula) between participants who experienced ≥50% reduction in pain intensity and those with <50% reduction (p<0.05). Changes in brain structure were correlated with changes in pain intensity and neck disability (r =-0.31 to -0.44, p<0.05). The study suggests that patients with chronic nonspecific neck pain who experienced significant improvements in pain intensity exhibited greater changes in cortical structure following a 10-week intervention, particularly with a combination of manual therapy and exercise. PERSPECTIVE: A combination of manual therapy and exercise results in greater improvements in clinical outcomes and substantially alters cortical thickness compared to routine physical therapy in patients with chronic nonspecific neck pain. These findings highlight the potential impact of this intervention on both brain structure and clinical recovery.

Noncontact optical 3D strain measurements in cervical soft tissues biomechanics by digital image correlation under tensile test: an experimental approach

Background

Digital image correlation (DIC) is widely used to measure surface strain in loaded objects. When studying the deformation of the cervical spine, the complexity and non-planarity of the structure complicate the speckle pattern required for applying DIC. While this non-invasive technique has shown promise in biomechanical testing, its application to cervical spine analysis presents unique challenges, particularly in achieving dynamic full-scale multi-aspect strain measurements. The aim of this paper is to introduce a method for exploring the stress-strain relationship on cervical cadaveric specimen by optical non-contact measurement system.

Method

Cervical cadaveric specimens were selected as subjects. Before testing, anatomical exposure, embedding, and spraying were performed sequentially. Specimen preparation was optimized through transverse process removal to enhance visualization of key anatomical structures. The surface strain under tensile testing was analyzed by the Aramis non-contact measurement system.

Result

High-quality three-dimensional strain images were obtained with improved inspection points across all aspects, particularly in the lateral aspect (5397.25 ± 723.76 vs. 3268.25 ± 573.17, P < 0.05). Under 60N tensile loading, strain distribution revealed concentration in soft tissue regions while preserving clear visualization of vertebral bodies, intervertebral discs, and foramina. Quantitative analysis shown consistent deformation patterns across cervical segments (C4-C7), with no significant differences in segmental parameters (P > 0.05).

Conclusion

The application of an optical non-contact measurement system in this study of cervical spine biomechanics has been proven effective. This method potentially mitigates some of the limitations associated with previous DIC techniques when applied to cervical cadaveric specimens. As a result, it enables more available measurements of multidimensional strain, which may enhance our understanding of the mechanics of the cervical spine.

Experiences of People With Persistent Nonspecific Neck Pain Who Used Immersive Virtual Reality Serious Games in the Home Setting: A Qualitative Study

OBJECTIVE

The purpose of this study was to explore the experiences of individuals with persistent nonspecific neck pain who used immersive virtual reality (VR) serious games at home for 2 weeks.

METHODS

In this descriptive qualitative study, semi-structured one-on-one interviews were conducted at the participant's home after the 2-week period. Interviews were analyzed using qualitative content analysis. Sample size was determined using the information power concept (where "information power" refers to the amount of relevant information the sample provides for addressing the research question).

RESULTS

Eleven adults with continuous or recurrent nonspecific neck pain participated in the study. Three main categories were identified. The first revolves around the home environment, revealing that participants had mixed perceptions about being at home, yet held a positive perspective on the utilization of immersive VR in that setting. The second pertains to immersive VR as a novel technology, indicating its overall comfort, user-friendliness, and varying degrees of immersion and presence experienced by the participants. The third focuses on exercising in immersive VR, drawing comparisons with conventional exercises, exploring the facilitators and barriers to usage, and addressing various aspects of integrating this technology into rehabilitation.

CONCLUSION

Immersive VR was deemed comfortable for almost all participants and easy to use. Participants found exercising in immersive VR motivating and enjoyable, compared to conventional exercises. The home environment proved suitable for using immersive VR, though challenges included autonomy and reduced human contact. Participants highlighted facilitators and barriers in using immersive VR serious games, as well as immersive VR's rehabilitation potential. They also underscored the crucial role of physical therapists for guidance, remote supervision, and personalized treatment.

IMPACT

These findings could help clinicians to better understand the experiences of individuals with persistent nonspecific neck pain when using immersive VR, as well as its use at home. This understanding can improve patient care and optimize the effectiveness of immersive VR as a treatment method.

Effectiveness of Manual Joint Mobilization Techniques in the Treatment of Nonspecific Neck Pain: Systematic Review With Meta-Analysis and Meta-Regression of Randomized Controlled Trials

OBJECTIVE: The purpose of this study was to investigate the effects of cervical joint mobilization techniques (JMTs) on pain and disability in adults with nonspecific neck pain. DESIGN: This study is an intervention systematic review with meta-analysis and meta-regression of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched MEDLINE, Cochrane CENTRAL, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Web of Science databases, including references from other reviews or clinical practice guidelines up to October 16, 2024. STUDY SELECTION CRITERIA: Eligible RCTs evaluated JMTs compared to routine physiotherapy, minimally active interventions, or no treatment. The primary outcome was pain; secondary outcomes were disability, Global Perceived Effect (GPE), quality of life, psychosocial status, and adverse events. DATA SYNTHESIS: Meta-analyses and meta-regression were conducted for pain, disability, and GPE. The risk of bias was assessed with Cochrane RoB 2.0 Tool; the certainty of the evidence was assessed with the Grading of Recommendations, Assessment, Development, and Evaluations approach. We used The Template for the Intervention Description and Replication checklist to evaluate the quality of reporting of interventions delivered. RESULTS: Results from 16 RCTs were pooled (n = 1,157 participants), reporting nonclinically positive results on pain reduction (mean difference [MD] = -0.86 (95% confidence interval [-1.35, -0.36])), disability (MD=-2.11 [-3.31, -0.91]), and GPE (standardized mean difference = 0.11 ([-0.15, 0.37]) and high heterogeneity. The meta-regressions did not identify any covariates associated with the treatment effects. Minor side effects (increased neck pain and headache) were reported. CONCLUSION: There was very low certainty evidence supporting the efficacy of JTMs for reducing pain and improving disability in people with NSNP. J Orthop Sports Phys Ther 2025;55(3):1-20. Epub 12 February 2025. doi:10.2519/jospt.2025.12836.

Investigation of the effectiveness of interactive telerehabilitation and transcutaneous electrical nerve stimulation on pain, functionality, disability and quality of life in patients with nonspecific chronic neck pain: a randomised controlled trial

OBJECTIVES

Despite the widespread use of TENS in the treatment of chronic nonspecific neck pain (CNNP), there are few studies on Telerehabilitation (TR), and no studies comparing their effectiveness compared to each other in this field. It was planned to investigate and compare the effectiveness of TENS and TR, which is an online rehabilitation tool.

METHODS

Forty-eight (female 45, male 3) patients with CNNP, aged 36.31 + 12.54 years, were randomized into TENS, TR or control groups. Pain severity was determined by Visual Analog Scale (VAS), Bournemouth Neck Questionnaire (NBQ), Neck Disability Index (NDI), Copenhagen Neck Functional Disability Scale (CNFDS), and World Health Organization Quality of Life Module (WHOQOL-BREF).

RESULTS

VAS, NBQ, NBI, CNFDS Time*Group interaction showed a significant positive change after treatment (p = 0.013, p = 0.007, p = 0.022, p = 0.005, respectively). The effect size of this difference over time was large (pη2 = 0.177, pη2 = 0.198, pη2 = 0.156, pη2 = 0.208, respectively). Post-treatment, the highest mean difference was found in VAS and NDI values in the TENS (MD:2.656, MD:7.000, p < 0.001), NBQ, CNFDS, WHOQOL-Bref in the TR (MD:13.187, MD:5.312, MD:-9.660, p < 0.001, respectively).

CONCLUSION

VAS and NBQ in the TENS and NDI, CNFS, WHOQOL-Bref in the TR group were more effective after treatment than before treatment in patients with CNNP.

TRIAL REGISTRATION

The clinical trial registration number for this study was: NCT06206343 (ClinicalTrials.gov).

Prevalence and relative frequency of cervicogenic headache in population- and clinic-based studies: A systematic review and meta-analysis

BackgroundCervicogenic headache is a rare headache disorder which is garnering increasing clinical and research interest, but whose prevalence and clinical phenotype is surrounded by uncertainty. We found it timely to systematically appraise the current literature on prevalence, relative frequency, and clinical features of cervicogenic headache in population- and clinic-based settings.MethodsPubMed and Embase were searched for observational, population- and clinic-based studies published between 1 January 1942 and 3 September 2024 that reported on the prevalence and relative frequency of cervicogenic headache, diagnosed according to the International Classification of Headache Disorders. The titles, abstracts, and full text-articles were screened by two independent investigators. To estimate prevalence and pooled relative frequency of cervicogenic headache across clinic- and population-based studies, random-effects meta-analyses were conducted. The study was pre-registered on PROSPERO (identifier: CRD42024498128) and reported in accordance with the Guidelines for Meta-Analyses of Observational Studies in Epidemiology.ResultsThree studies met the inclusion criteria from the International Classification of Headache Disorders for diagnosing cervicogenic headache. One was population-based reporting on the prevalence and two were clinic-based reporting on the relative frequency of cervicogenic headache among adult patients who were evaluated for headache in a tertiary care unit. The one population study reported a prevalence of 3.9% with females representing 77.8% of those affected. In the two clinic-based studies, the relative frequency was found to be 3.1% (95%, CI, 2.6-3.8) amongst the adult outpatient population of 3165 patients evaluated for headache, with women representing 80.8% (95%, CI, 71.9-87.4).ConclusionsBased on this meta-analysis, data on the prevalence and relative frequency of cervicogenic headache are limited. The scarcity of data stresses the need for further research into cervicogenic headache, the diagnostic criteria, and its current position in the International Classification of Headache Disorders.

Development and Implementation of MyPainHub, a Web-Based Resource for People With Musculoskeletal Conditions and Their Health Care Professionals: Mixed Methods Study

BACKGROUND

Musculoskeletal conditions, including low back pain (LBP), neck pain, and knee osteoarthritis, are the greatest contributors to years lived with disability worldwide. Resources aiming to aid both patients and health care professionals (HCPs) exist but are poorly implemented and adopted.

OBJECTIVE

We aimed to develop and implement MyPainHub, an evidence-based web-based resource designed to provide comprehensive, credible and accessible information for people with, and HCPs who manage, common musculoskeletal conditions.

METHODS

This mixed methods study adhered to the New South Wales Translational Research Framework and was evaluated against the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Consultation with key stakeholders (patients, HCPs, researchers, industry, consumer groups, and website developers) informed content, design, features, and functionality. Development then aimed to meet the identified need for a "one-stop shop"-a central location for information about common musculoskeletal conditions tailored to a person's condition and risk of poor outcomes. MyPainHub was then developed through an iterative process and implementation strategies were tailored to different health care settings. Quantitative and qualitative evaluation occurred with patients and HCPs.

RESULTS

In total, 127 stakeholders participated in the development phase; initial consultation with them led to embedding 2 validated screening tools (the Short Form Örebro Musculoskeletal Pain Screening Questionnaire and the Keele STarT MSK tool) in MyPainHub to guide information tailoring for patients based on risk of poor outcomes. Development occurred in parallel and feedback from stakeholders informed design and content including structure, functionality, and phrasing and images to use to emphasize key points. Consultation resulted in information for patients being categorized using key guideline-based messages (general information, your pathway, exercise, and imaging) while information for clinicians was categorized into assessment, management, and prognosis. Implementation occurred in different health care settings with the most effective strategies being interactive education via webinars and workshops. The evaluation phase involved web-based questionnaires (patients: n=44; HCPs: n=29) and focus groups (patients: n=6; HCPs: n=6). Patients and HCPs found MyPainHub user-friendly, acceptable, credible, and potentially able to support self-management. Patient participants identified areas for improvement such as including more specific information on preventative measures and pain relief options. Despite positive feedback, only 35% (10/29) of HCPs used MyPainHub with their patients. HCP participants identified challenges including insufficient training and lack of familiarity with using web-based resources in existing clinical workflows. Following implementation, the information contained on MyPainHub changed knowledge and practice for some patients and HCPs.

CONCLUSIONS

Following extensive and iterative stakeholder engagement, MyPainHub was developed as an evidence-based web-based resource and perceived by patients and HCPs as user-friendly, credible, and acceptable. Active implementation strategies are required for adoption and implementation and greater training focusing on strategies to implement MyPainHub into clinical practice may be necessary.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619000871145; https://tinyurl.com/438kkyt3.

Dry needling for mechanical neck pain: A systematic review and meta-analysis of randomized controlled trials

Background

Dry needling (DN) has emerged as a potential treatment for mechanical neck pain, but the evidence remains inconclusive. This study aimed to assess the efficacy of DN in improving pain and functionality in patients with chronic mechanical neck pain.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Databases, including PubMed, Cochrane Library, Scopus, and Google Scholar, were searched from December 2013 to January 2024. Studies involving adult participants with chronic mechanical neck pain treated with DN were included in the study. The primary outcomes were pain pressure threshold (PPT), Neck Disability Index (NDI), and cervical range of motion. Statistical analysis used a random-effect model.

Results

Nine RCTs with a total of 540 participants were included in the study. DN significantly improved the PPT with an MD of 0.52 (95% confidence interval [CI], 0.39-0.65; P < 0.001). NDI also showed a significant improvement, with an MD of -0.68 (95% CI, -1.32--0.05; P = 0.04). In terms of cervical range of motion, DN improved flexion (MD 4.07, 95% CI, 0.39-7.75; P = 0.03) and right rotation (MD 8.20, 95% CI, 3.05-13.35; P = 0.002), but no significant differences were observed in extension, left rotation, or lateral flexions (P > 0.05).

Conclusion

DN appears effective in short-term pain relief and functional outcomes for patients with mechanical neck pain but shows limited impact on the cervical range of motion.

The effect of mechanical traction on cervical radiculopathy: protocol for the TracCerv2 single-blind, randomised controlled trial

OBJECTIVES

To evaluate the effect at 3 months of an intensive cervical traction protocol on disability in people with cervical radiculopathy and compare with placebo traction.

DESIGN

The trial is national, multi-centre, randomised, placebo-controlled and single-blinded. It began in March 2024 and will end in September 2027. Participants are allocated to receive mechanical cervical traction or placebo mechanical cervical traction.

SETTING

Seven hospitals in France.

PARTICIPANTS

We will include 206 individuals with cervical radiculopathy diagnosed 3 to 12 months previously, hospitalised to undergo mechanical traction. Main inclusion criteria: age ≥ 18 years, Neck Disability Index ≥ 15/50 points and presence of ≥ 3 of 4 diagnostic signs of cervical radiculopathy.

INTERVENTIONS

All participants undergo 2 × 30 min of traction per day for 5 consecutive days. For mechanical cervical traction, the maximum weight is ≤ 12 kg and for placebo traction ≤ 600g.

MAIN OUTCOME MEASURES

The primary outcome is disability (Neck Disability Index), secondary outcomes include pain related outcomes, medication consumption, surgery and days off work.

RESULTS

This study will provide a robust evaluation of the mid-term effectiveness of mechanical traction on disability in chronic cervical radiculopathy. The results will demonstrate whether a simple technique involving a short, intensive protocol reduces the duration of disability and pain.

CONCLUSIONS

The availability of robust evidence supporting or refuting the use of cervical traction as part of the management of cervical radiculopathy will enable optimisation of treatment. The results could lead to the drafting of evidence-based recommendations regarding the use of mechanical traction to treat cervical radiculopathy.

CLINIAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05952167).

The impact of neck pain and movement performance on the interarticular compressive force of the cervical spine: a cross-sectional study based on OpenSim

BACKGROUND

Excessive interarticular compressive force (CF) caused by poor posture increases the risk of neck pain. However, existing research on cervical CF is based on healthy individuals, and studies on those with neck pain are lacking. This study aims to address this gap by simultaneously collecting data from individuals with neck pain and asymptomatic individuals, simulating the CF during physiological movements such as flexion-extension, lateral bending, and rotation, to explore the impact of neck pain and movement performance on the interarticular CF.

METHODS

A 3D motion capture system and a multicervical unit were utilized to collect kinematic data and maximum voluntary isometric contraction (MVIC), respectively. The kinematic data were processed in OpenSim, using individually scaled cervical spine models. Time and peak angles were obtained via inverse kinematics, and the CF was calculated via joint reaction analysis. Regression analysis was conducted to assess the correlations between neck pain status, movement performance characteristics (time, peak angle, MVIC) and CF normalized by body mass. Variables with p < 0.1 in the univariate regression were included in the multivariate regression model for further adjustment.

RESULTS

Sixty participants were enrolled in the study, comprising 30 individuals in the neck pain group and 30 in the asymptomatic group. The mean peak CF in the neck pain group exceeded that in the asymptomatic group during cervical flexion-extension (13.0 -13.4%), lateral bending (10.4 -15.6%), and rotation (7.0 -8.3%) movements. Multivariate regression analysis revealed that the presence of neck pain was correlated with a significant increase in peak CF during the phases of flexion (p = 0.02), right lateral bending (p = 0.04 except for C6-C7), and left rotation (p = 0.02). The peak CF was positively correlated with peak angles in flexion (p < 0.001), extension (p = 0.001), left lateral bending at C3/4 (p = 0.009), C4/5 (p = 0.008), C5/6 and C6/7 (p = 0.007), right lateral bending at C3/4 and C4/5 (p = 0.002), C5/6 and C6/7 (p = 0.001), left rotation (p < 0.001), and right rotation (p = 0.02) movements. Conversely, peak CF was negatively correlated with MVIC in flexion (p = 0.02), extension at C4/5 (p = 0.008) and C5/6 (p = 0.007), left lateral bending (p = 0.001), right lateral bending at C3/4 (p = 0.02), C4/5 and C5/6 (p = 0.01), and C6/7 (p = 0.009) movements. No significant correlation was found between peak CF and the time taken for movement.

CONCLUSIONS

This study reveals the differences in CF between individuals with neck pain and asymptomatic individuals during identical movements. The peak CF appears to correlate with the presence of neck pain, MVIC, and peak angle. These findings highlight the importance of muscle strength training. Early identification of reduced neck muscle strength could be crucial for preventing and relieving neck pain.

Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review

OBJECTIVE

This systematic review aimed to determine the methodological quality of international clinical practice guidelines (CPGs) and the clinical credibility and implementability of recommendations regarding manipulation or mobilization treatment recommendations proposed in CPGs for the management of people with neck pain. A secondary aim of this review was to provide an overview of recommendations for manipulation or mobilization in patients with neck pain. Manipulation or mobilization treatment of patients with neck pain is under debate for its potential risk of serious adverse events. Serious adverse events are rare, but it is the clinicians' responsibility to thoroughly screen patients at risk of vascular complications. A third aim of this review was to describe the extent to which the included guidelines inform clinical practice about screening for the risk of complications due to vascular pathology in the cervical spine.

METHODS

A systematic review of 13 electronic databases and 4 repositories was performed for potentially relevant guidelines published between January 1, 2000 and September 22, 2022. Two reviewers independently appraised eligible guidelines using Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Appraisal of Guidelines for Research and Evaluation: Recommendation EXcellence (AGREE-REX) criteria. A best evidence synthesis was performed, and screening of risk factors was assessed.

RESULTS

A total of 19 CPGs were included, of which 5 were of high quality. All high-quality guidelines recommend the use of manipulation or mobilization, with or without exercise. Eight (42%) guidelines described the screening of risk factors for adverse events. Two (11%) guidelines met the a priori defined criteria for screening and scored present and complete.

CONCLUSION

International CPGs consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding the identification of patients at risk for vascular complications.

IMPACT

The findings of this study allow guideline developers to improve the quality of future neck pain guidelines and consider including vascular screening tools. Furthermore, it proposes recommendations to physical therapists interested in applying manipulations and mobilizations in the treatment of patients with neck pain.

LAY SUMMARY

International clinical practice guidelines consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding identifying patients at risk for vascular complications.

Investigating Brain Structure and Functional Alterations in the Transition from Acute to Chronic Neck Pain: A Resting-State fMRI Study

Purpose

The objective of this research is to delve into the central pathological mechanisms involved in the transformation from acute to chronic pain.

Patients and Methods

This study enrolled 86 individuals with acute neck pain and 89 with chronic neck pain. Utilizing a 3.0T MR scanner, we obtained three-dimensional T1-weighted imaging (3D-T1WI) images and analyzed structural differences between the two groups with Freesurfer software to evaluate alterations in cortical thickness. Additionally, Blood Oxygen Level-Dependent functional Magnetic Resonance Imaging (BOLD-fMRI) images were acquired to assess intergroup differences in low-frequency amplitude using DPARSF software.

Results

Chronic neck pain patients exhibited increased cortical thickness in the left rostral middle frontal, left isthmus cingulate, left superior frontal, and right precuneus regions compared to those with acute neck pain. Low-frequency amplitude measures revealed decreased activity in the left dorsolateral superior frontal gyrus and left postcentral gyrus, among other areas, and increased activity in the right middle frontal gyrus and the opercular part of the right inferior frontal gyrus.

Conclusion

Our findings indicate that dysfunction and structural changes in the limbic system and prefrontal cortex may play a pivotal role in the progression from acute to chronic neck pain. These insights provide a significant new direction for understanding the central mechanisms underlying pain chronicity.

Manual physical therapy for neck disorders: an umbrella review

INTRODUCTION

Neck pain is a common musculoskeletal disorder, with a prevalence rate (age-standardized) of 27.0 per 1000 in 2019. Approximately 50-85% of individuals with acute neck pain do not experience complete resolution of symptoms, experiencing chronic pain. Manual therapy is a widely employed treatment approach for nonspecific neck pain (NSNP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). This umbrella review synthesized systematic reviews examining manual physical therapy for individuals with cervical disorders.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed with Prospero registration (CRD42022327434). Four databases were searched from January 2016 to May 2023 for systematic reviews with or without meta-analysis examining manual therapy for individuals with neck pain of any stage. Interventions included any manual physical therapy of the cervical or thoracic spine as well as neuromobilization of the upper quarter. Primary outcomes included pain and disability. Two reviewers screened for eligibility and completed data extraction. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool.

RESULTS

A total of 35 SRs were included: 15 NSNP, 7 cervical radiculopathy, 9 CGH and 4 samples with combined diagnoses. AMSTAR 2 ratings of the SRs support high confidence in results for 10 reviews, moderate confidence in 12 reviews and low to critically low confidence in 13 reviews. For NSNP, there was high confidence in the results showing manual therapy combined with exercise was superior to either treatment in isolation. In cervical radiculopathy, neural mobilization, distraction, soft tissue treatment and mobilization/manipulation to cervical and thoracic spine were supported with moderate confidence in results. For CGH, there was high confidence in the results supporting the use of cervical spine mobilization/manipulation, soft tissue mobilization, and manual therapy combined with exercise. Original authors of SRs reported varying quality of primary studies with lack of consistent high quality/low risk of bias designs.

CONCLUSION

Manual therapy plus exercise, cervical or thoracic mobilization and manipulation, neuromobilization, and other types of manual therapy were supported as effective interventions in the management of pain and disability for individuals with NSNP, CGH, or CR in the short-term.

Neck range of motion prognostic factors in association with shoulder and elbow injuries in professional baseball pitchers

BACKGROUND

The authors observed an association between cervical spine mobility and arm injury risk in baseball players; however, there is a need to assess the generalizability of cervical measurement data. Assessing the downstream associations of cervical dysfunction on shoulder and elbow injuries can inform clinical interventions to help reduce future arm injuries. The purpose of this study was to assess the generalizability of neck range of motion measures as arm injury prognostic factors in professional baseball pitchers.

METHODS

A prospective cohort of professional baseball pitchers in one Major League Baseball Organization was studied. Pitchers underwent preseason neck range of motion including cervical flexion, extension, rotation, lateral flexion, and the flexion-rotation test, and were followed for the season. The outcome was the occurrence of a shoulder or elbow injury. A Cox proportional hazards analysis was performed and reported as hazard ratios with 95% confidence intervals (95% CIs).

RESULTS

A total of 88 pitchers were included (age: 24.2 [2.4] years; left-handed: 21 [23%]; fastball velocity: 92.3 [1.8]), with 15,942 athlete exposure days collected over the season. Pitcher neck range of motion was assessed (flexion: 64° [10°]; extension: 69° [11°]; difference in lateral flexion: -1° [7°]; difference in neck rotation: -2° [9°]; difference in cervical flexion-rotation test: -1° [7°]). A total of 20 arm injuries (shoulder: 9 [10%]; elbow: 11 [13%]; combined rate: 1.3 [95% CI: 0.7, 1.7] per 1000 exposure days) were suffered by pitchers during the season. For every degree increase in the difference in dominant (rotating to dominant shoulder) vs. nondominant (rotating to nondominant shoulder) neck rotation, there was a 4-fold increase in arm injury hazard (hazard ratio: 4.0 [95% CI: 1.1, 13.9], P = .031). No other neck measurements demonstrated prognostic value.

CONCLUSIONS

A deficit in dominant vs. nondominant neck rotation was prognostic for a pitching arm injury. However, the cervical rotation test did not have prognostic value in this sample. Further research is required to assess the generalizability and scalability of neck range of motion assessment in relation to baseball shoulder and elbow injuries across different competition levels.

Comparative effectiveness of manual therapy, pharmacological treatment, exercise therapy, and education for neck pain (COMPETE study): protocol of a systematic review with network meta-analysis

BACKGROUND AND CONTEXT OF THE STUDY: Neck pain is a prevalent and globally burdensome problem. Clinical practice guidelines have recommended conservative treatments such as education, exercise therapy (ET), manual therapy (MT), and pharmacological therapy (i.e., medication) to manage all types of neck pain based on the chronicity of the disease (acute, subacute, and chronic pain). However, there is scarce evidence to determine which interventions constitute the most effective strategy for this condition. RESEARCH QUESTION: What are the best conservative treatment options (i.e., ET, MT, education, and/or medication) to relieve pain and disability-related outcomes in patients with neck pain? THE OVERALL PURPOSE OF THE STUDY: (1) To identify which type of conservative treatment (education, ET, MT, and/or medication) and their combinations have the greatest probability of being most effective for neck pain using a network meta-analysis (NMA) approach. (2) To rank these conservative treatments in terms of safety (when possible) and effectiveness for managing neck pain. METHODOLOGY: Systematic review (SR) with NMA of randomized controlled trials (RCTs). Studies should include adults (aged > 18) with neck pain who received any of the interventions of interest (education, ET, MT, and medication). The main outcome will be pain intensity. Searches will be conducted in Ovid Medline All®, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and Cochrane Library Trials database. No language or publication date restrictions will be applied. The revised Cochrane Risk-of-Bias (RoB) tool for RCTs (RoB-2) will be used to evaluate RoB, and the certainty of evidence will be evaluated by Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). NMAs will be conducted to rank interventions according to their effectiveness and safety (when possible), allowing a comprehensive analysis of all available evidence, with different nodes specified for all conservative interventions of interest, placebo, sham therapy, and non-intervention control. This NMA will help clinicians and the scientific community choose the most effective strategy or combinations of strategies for treating neck pain. The information gathered in this project will inform decision-making and guide personalized care of individual patients in the future.

Physical measures of physical functioning as prognostic factors in predicting outcomes for neck and thoracic pain: Protocol for a systematic review

BACKGROUND

Spinal pain is prevalent and burdensome worldwide. A large proportion of patients with neck and thoracic pain experience chronic symptoms, which can significantly impact their physical functioning. Therefore, it is important to understand factors predicting outcome to inform effective examination and treatment. Knowledge of physical measures of physical functioning as prognostic factors can enhance patient-centered care and aid decision-making. The evidence regarding physical outcome measures as prognostic factors for neck and thoracic pain is unclear. The objective of this study is to summarize the evidence for physical outcome measures of physical functioning as prognostic factors in predicting outcomes in people with neck and thoracic pain.

METHODS AND ANALYSIS

This systematic review follows Cochrane guidelines and aligns with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Included studies will be prospective longitudinal cohort studies in which physical measures of physical functioning are explored as prognostic factors for adults with neck and thoracic pain. A comprehensive search will be performed in key databases (MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science) and the grey literature, with hand searches of key journals, and the reference lists of included studies. Two reviewers will independently perform study selection, data extraction, risk of bias assessment (QUIPS, Quality in Prognostic Studies tool), and quality assessment (Grading of Recommendations Assessment, Development, and Evaluation).

IMPLICATIONS

This systematic review will identify physical measures of physical functioning prognostic factors for neck and thoracic pain populations. Findings will inform researchers about gaps in existing evidence, and clinicians about factors to aid their clinical decisions and to enhance the overall quality of care for individuals with neck and thoracic pain.

Evaluation of the Application of Clinical Practice Guideline Recommendations on the Classification of Patients With Neck Pain

Background: Clinical practice guidelines (CPGs) are developed to synthesize evidence into recommendations for clinical practice. Minimal evidence exists on the evaluation practice of physical therapists in the treatment of patients with neck pain. Purpose: We sought to describe (1) the extent to which clinicians perform the Neck Pain CPG-recommended examination measures and (2) the percentage of patients properly classified. Methods: We retrospectively analyzed the electronic health records of 397 patients with neck pain at an ambulatory care setting in an academic medical center. The frequency of physical therapists' evaluation measures, subjective findings, positive examination results, and the percentage of patients properly classified into impairment-based categories (IBCs) were recorded. Descriptive statistics and χ2 tests were used to assess patient demographics and compare classification accuracy across IBCs. Results: Of the 397 patients, 56% were classified into an IBC. The most common IBC was neck pain with mobility deficits (24%), followed by neck pain with radiating pain (17%), neck pain with movement coordination impairments (NPMCIs) (8%), and neck pain with headache (6%). Neck pain with movement coordination impairment had the lowest percentage of proper classifications. Classification accuracy was highest when subjective and objective findings were combined and varied between IBCs. Conclusion: Our findings suggest that physical therapists evaluating patients with neck pain may have increased classification accuracy when subjective and objective findings are considered. Decreased classification accuracy was demonstrated in the NPMCI category, highlighting opportunities for further education and research.

Provider kinematic strategies during the delivery of spinal manipulation and mobilization: a scoping review of the literature

BACKGROUND

Spinal manipulation (MAN) and mobilization (MOB) are biomechanically different yet both elicit pain reduction and increased range of motion. Previous investigations have focused on quantifying kinetics (e.g., applied forces) or, recipient kinematics (i.e., movements) during MAN and MOB. While these studies provide valuable information, they do not report on the strategies adopted by providers when performing the complex motor tasks of MAN and MOB. This review sought to synthesise the literature reporting on provider kinematics during the delivery of MAN and MOB.

METHODS

This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. MEDLINE (Ovid), PsychINFO, Cochrane Library, Web of Science, Embase, Scopus, PEDro, ICL and CINAHL databases were searched from inception to September 2023 for terms relating to provider kinematics during the delivery of MAN and MOB. Data were extracted and reported descriptively, including: general study characteristics, number and characteristics of individuals who delivered/received MAN and/or MOB, region treated, equipment used and kinematic parameters of the individual delivering the procedure.

RESULTS

Of 4,844 records identified, five (0.1%) fulfilled the eligibility criteria and were included in the analysis. Of these, provider kinematics were reported for the delivery of MAN in four (80%) and for the delivery of MOB in one (20%) article. Practitioners applied the procedure in all (100%) and students in one (20%) study. Spinal regions treated were: lumbar (n = 4), thoracic (n = 2) and cervical (n = 1). Data were reported heterogeneously but were most commonly captured using either video or motion capture equipment (n = 4, 80%). The direction of applied force was fully reported in one (20%) and only partially reported (one spinal region) in another study.

CONCLUSIONS

There are a small number of studies reporting heterogeneously on provider kinematics during the delivery of MAN and MOB. Clear reporting of the procedure from a biomechanical perspective and of the measurement equipment used could enable future meta-analysis of provider kinematic data, the use of provider kinematic data in the development of technique skills curricula and could feasibly be used to mitigate risk of injury for providers.