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MANIPULATION AND MOBILISATION FOR MECHANICAL NECK DISORDERS Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, This review should be cited as: Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, . Manipulation and mobilisation for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 2, 2007. Oxford: Update Software. A substantive amendment to this systematic review was last made on 30 October 2003. Cochrane reviews are regularly checked and updated if necessary.

A B S T R A C T Background Neck disorders are common, disabling, and costly. The effectiveness of manipulation and mobilisation remains unclear. Objective To assess whether manipulation and mobilisation, either alone or in combination with other treatments, relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND). Search strategy Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, were searched without language restrictions from their respective starting dates to March 2002. Selection criteria The studies had to be randomised (RCT) or quasi-randomised and investigate the use of manipulation or mobilisation as a treatment for mechanical neck disorders. Data collection and analysis Two independent authors conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardised mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated. Main results Of the 33 selected trials, 42% were high quality trials. Single sessions of manipulation or multiple sessions (3 to 11 weeks) of manipulation or mobilisation, or manipulation and mobilisation showed a nonsignificant benefit in pain relief when assessed against placebo, control groups or other treatments for acute/subacute/chronic MNDs with or without headache. There was strong evidence of benefit favouring multimodal care over a waiting list control for pain reduction [pooled SMD -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. There was moderate evidence of no difference in effect when multimodal care was compared to various other treatments. Reviewers' conclusions Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings.

S Y N O P S I S People with neck pain as well as people with neck pain plus related headache that lasted at least one month, who received multimodal care that included exercises plus mobilisation [movement imposed onto joints and muscles] or manipulation [adjustments] reported greater pain reduction, improved ability to perform everyday activities and an increase in their perceived effects of treatment than those who received no treatment.


This review of 33 trials did not favour manipulation or mobilisation done alone or in combination with various other physical medicine agents. It was unclear if manipulation and mobilisation performed in combination were beneficial, but when compared to one another, neither was superior.

B A C K G R O U N D Neck disorders are common, disabling to various degrees, and costly (Westerling 1980; Takala 1982; Makela 1991; Rajala 1995; C么t茅1998; Linton 1998; Borghouts 1999). A significant proportion of direct health care costs associated with neck disorders are attributable to visits to health care providers, to sick leave, and to the related loss of productive capacity (Borghouts 1998; Linton 1998; Skargren 1998). Manipulation and mobilisation are commonly used approaches to treatment in this situation. However, studies of their effectiveness have generally been short-term and inconclusive (Gross 1996; Kjellman 1999; Bogduk 2000; Hoving 2001; Peeters 2001; Gross 2002a).

O B J E C T I V E S This systematic review assessed the effect of manipulation and mobilisation either alone or in combination with other treatments on pain, function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders. Where appropriate, it also assessed the influence of treatment, methodological quality, symptom duration, and subtypes of neck disorder on the effect.

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Types of studies Any published or unpublished randomized controlled trial (RCT) or quasi-RCT, either in full text or abstract form, was included. A quasi-RCT uses methods of allocation that are subject to bias in assignment, such as, odd-even numbers, day of week, patient record, or social security number. As the total number of studies in this field is not large, we included quasi-RCTs. Types of participants The participants were adults (18 years or older) with the following neck disorders: Mechanical neck disorders, including whiplash associated disorders (WAD) category I and II (Spitzer 1987; Spitzer 1995), myofascial neck pain, and degenerative changes (Schumacher 1993); Neck disorder with headache (Olesen 1988; Sjaastad 1990; Olesen 1997); and Neck disorders with radicular findings, including WAD category III (Spitzer 1995; Spitzer 1987). For the purpose of this review, symptom duration was defined as acute (less than 30 days), subacute (30 days to 90 days) or chronic (greater than 90 days). Studies were excluded if they investigated neck disorders with definite or possible long tract signs (e.g. myelopathies); neck pain caused by other pathological entities (Schumacher 1993); headache associated with the neck, but not of cervical origin; co-existing headache, when either neck pain was not dominant or the headache was not provoked by neck movements or sustained neck postures; 'mixed' headache. Types of intervention Studies using manipulation or mobilisation techniques were all included in the review. In the studies, these techniques might be used individually, in tandem, or in combination with other treatment agents in what is called multimodal care. For example, manipulation plus mobilisation


can be used in combination with heat therapy and exercise. All studies used comparison groups which could be either a control group (placebo control, active control, or no treatment control) or various other treatment groups. Manipulation is a localised force of high velocity and low amplitude directed at cervical joint segments. Mobilisations use low-grade/velocity, small or large amplitude passive movement techniques or neuromuscular techniques within the patient's range of cervical motion and control. Types of outcome measures The outcomes of interest were pain relief, disability/function, patient satisfaction, and global perceived effect. We did not set any restriction on the type of tool used in the studies to measure these outcomes as there were no universally accepted tools available. Albeit, we found a number of studies did use validated tools.

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See: Cochrane Back Group search strategy See: methods used in reviews. A research librarian searched computerised bibliographic databases, without language restrictions, for medical, chiropractic, and allied health literature. The following databases were searched from their respective beginning to March 2002: CENTRAL (The Cochrane Library Issue 4, 2002), MEDLINE, EMBASE, Manual Alternative and Natural Therapy (MANTIS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Index to Chiropractic Literature (ICL). Screening of references, communication with the coordinator of the Cochrane Back Group, personal communication with identified content experts, and our own personal files were also used to identify potential references. Searches were staggered to allow 'horizon estimation' to guide our search strategy. Horizon estimation is a form of capture-mark-recapture that enable us to estimate the optimal point at which to conclude the search sequence. This sequence was set a priori. These methods are reported elsewhere (Goldsmith 1999). Subject headings (MeSH) and key words included anatomical terms, disorder or syndrome terms, treatment terms, and methodological terms consistent with those advised by the Cochrane Back Group. See for Search Strategy for MEDLINE.

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Four pairs of two independent authors each with expertise in medicine, physiotherapy, chiropractic, massage therapy, statistics, and clinical epidemiology conducted citation identification, study selection, data abstraction, and assessment of methodological quality. Agreement was assessed for study selection using the quadratic weighted Kappa statistic (Kw); Cicchetti weights (Cicchetti 1976). A third author was consulted in case of persisting disagreement. Assessment of Methodological Quality Methodological quality was judged using the three scales described below: the validated Jadad 1996 criteria (maximum score five, high score greater than 2; See); the abbreviated Cochrane collaboration back review group criteria (van Tulder 1997; van Tulder 2000) (maximum score 9, high score greater than 4; See); and the Cochrane grading system for quality of allocation concealment (A to D; See Characteristics Included Studies) and refers to how well the allocation to treatment group was concealed. Because they are validated, we used the Jadad criteria for the primary classification of methodological quality. We acknowledge that double blinding - one of the Jadad criteria - cannot be easily performed in manual therapy. As none of the currently available scales for measuring the validity or 'quality' of trials can be applied without reservation, we assessed the correlation between the Jadad and van Tulder scales [Spearman Rank Correlation (Rho)] as well as between high or low quality study classifications, as assessed by the two scoring systems [Cohen's Kappa (K)]. We noted explicit details on study design, number analysed and randomised, intention-totreat analysis, and power analysis in the methods column of the Table: Characteristics of Included Studies. The Jadad et al. 1996 Criteria and scores 1a. Was the study described as randomised? (Score 1 if yes)


1b and 1c. Was the method of randomisation described and appropriate to conceal allocation (Score 1 if appropriate and -1 if not appropriate); 2a. Was the study described as double-blinded? (Score 1 if yes); 2b and 2c. Was the method of double blinding described and appropriate to maintain double blinding (Score 1 if appropriate and -1 if not appropriate); 3. Was there a description of how withdrawals and dropouts were handled? (Score 1 if yes) The van Tulder et al. 2000 Criteria (Score: yes, no, don't know) A. Concealment of treatment allocation B. Withdrawal/dropout rate C. Co-intervention avoided or equal D. Blinding of patients E. Blinding of observer F. Intention-to-treat analysis G. Compliance H. Similarity of baseline characteristics I. Blinding of care provider The Cochrane Grading System for Quality of Allocation Concealment A. Adequate concealment of allocation B. Uncertainty about whether the allocation was adequately concealed C. The allocation was definitely not adequately concealed D. The score was not assigned Quantitative Analysis of Trial Results For continuous data, standardized mean differences (SMD) (95% confidence intervals (CI)) were calculated using a random effects model. In the absence of clear guidelines on the size of clinically important effect sizes, we used a commonly applied system by Cohen 1988: small (0.20), medium (0.50) or large (0.80). We assumed the minimum clinically important difference to be 10 on a 100-point pain intensity scale. Similarly, a minimum clinically important difference of five neck disability index units or 10% was considered relevant for the neck disability index (Stratford 1999). For continuous outcomes reported as medians, effect sizes were calculated (Kendal 1963 (p 237)). Relative risks (RR) were calculated for dichotomous outcomes.To facilitate analysis, data imputation rules were used when necessary (Gross 2002a). The number needed to treat (NNT) and treatment advantages were calculated for primary findings (Gross 2002a; See). Power analyses were conducted for each article reporting non-significant findings (Dupont 1990). Prior to calculation of a pooled effect measure, the reasonableness of pooling was assessed, based on clinical judgement. Statistical heterogeneity using Chi squared method between the studies was tested using a random effects model. In the absence of heterogeneity (p greater than 0.05), a pooled SMD or RR was calculated. Sensitivity analysis or meta-regression for the factors: symptom duration, methodological quality, and subtype of neck disorder were planned but were not carried out because we did not have enough data in any one category. Qualitative Analysis of Trial Results To reach final conclusions, qualitative analysis was carried out, using the levels of evidence listed below. 'Strong evidence' denoted consistent findings in multiple high quality RCTs. 'Moderate evidence' denoted findings in a single, high quality RCT or consistent findings in multiple low-quality trials. 'Limited evidence' indicated a single low-quality RCT. 'Conflicting evidence' denoted inconsistent results in multiple RCT. 'No evidence' meant no studies were identified. 'Evidence of adverse effect' was used for trials that showed lasting negative changes. The term 'evidence of benefit' was used for trials or meta-analyses large enough (for example: sample size greater than or equal to 70 per intervention arm) to be positive, with low risk of falsepositive conclusions. The sample size per intervention arm was based on the criteria for clinically important changes in outcomes seen in rheumatoid arthritis trials (Goldsmith 1993), since we were not aware of other criterion available for neck specific trials. The term 'evidence of no benefit' was used for trials or meta-analyses large enough (for example: power greater than or equal to 80%; sample size greater or equal to 70 per intervention arm) to be negative, with low risk of false-negative conclusions. Since we were unable to do the full meta-analysis we had planned because of the nature of the data, we considered a number of factors to place the results in a larger context. These factors were temporality, consistency, plausibility, strength of association, dose response, adverse events, and costs.


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Thirty-three trials were selected from 528 initially identified articles: 19 studied mechanical neck disorder: acute (Nordemar 1981; Mealy 1986; McKinney 1989); subacute (Wood 2001); chronic (Vasseljen 1995; Jordan 1998; Skargren 1998; Giles 1999; Bronfort 2001; Allison 2002); mixed (Sloop 1982; Vernon 1990; Cassidy 1992; Koes 1992; David 1998; Coppieters 2002; Hurwitz 2002); and symptom duration not reported (Parkin-Smith 1998, van Schalkwyk 2000) 12 studied headache of cervical origin: acute (Provinciali 1996; Giebel 1997); subacute (Karlberg 1996); chronic (Bitterli 1977; Jensen 1990; Nilsson 1997; Jull 2002); mixed (Howe 1983; Ammer 1990: 1 v 2; Hoving 2002; Hurwitz 2002); and symptom duration not reported (Reginiussen 2000) 6 studied neck disorder with some radicular signs and symptoms: chronic (Brodin 1985; Persson 2001); mixed (Howe 1983, Hoving 2002, Hurwitz 2002); and symptom duration not reported (Kogstad 1978) 6 studied whiplash associated disorders: acute (Mealy 1986; McKinney 1989; Provinciali 1996; Giebel 1997); chronic (Jensen 1990); and mixed (David 1998) 6 studied degenerative changes: chronic (Bitterli 1977; Brodin 1985; Giles 1999); and mixed (Sloop 1982; Cassidy 1992; David 1998). All included trials but one (n analysed = 317; Skargren 1998) were small, with less than 70 subjects per intervention arm. See Table: Characteristics of Included Studies for further details on treatments characteristics, co-interventions, baseline values, absolute benefits, reported results, SMD, RR, side effects and costs of care. Agreement between pairs of independent authors from diverse professional backgrounds for manual therapy was Kw 0.83, SD 0.15. We excluded 13 RCTs based on the type of participant (i.e. spasmodic torticollis, unable to split data from combined neck and low back trials, normal cervical spine), intervention (i.e. manual therapy was in both the treatment and control group) or design reasons (i.e. mechanistic trial design) (See Table: Characteristics of excluded studies). The remaining excluded studies were not RCTs.

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See and for methodological quality scores of each trial. We noted that 24% (vanTulder scale) to 42% (Jadad scale) of the included studies were rated as high quality. There was moderate correspondence between the scales' total scores (Rho = 0.65, 95% CI 0.43 to 0.86) and between high or low quality study classifications, as assessed by the two scoring systems (K 0.53; SD 0.17). Although conclusions of reviews can vary with the methodological quality criteria used, in our review, the main results related to multimodal care did not differ by quality scoring system. We found common methodological weaknesses of included studies to be: failure to describe or use appropriate concealment of allocation (58%) and lack of effective blinding procedures, including blinding of the outcome assessor (66%). Co-interventions were avoided in only a small number of studies (24%). We do not believe that methodological quality influenced the end results of our review, as both high and low quality studies had similar outcome directions. However, we were unable to formally test this notion using sensitivity analysis/meta-regression because we did not have enough data in any one disorder and treatment category.

R E S U L T S We were unable to carry out sensitivity analyses for symptom duration and subtype of neck disorder because we did not have enough data in any one category. Primary studies within a given treatment category frequently examined various disorder types of mixed symptom duration. Manipulation alone: Four RCTs assessed the effect of a single session of manipulation (Sloop 1982; Howe 1983; Vernon 1990; Cassidy 1992). When compared to a control (other treatments deemed to be ineffective), there was moderate evidence that single sessions did not result in short-term pain relief [pooled SMD -0.51 (95% CI: -1.10 to 0.07)] (Sloop 1982; Vernon 1990) for acute, subacute, or chronic mechanical neck disorders. We judged these two trials to be clinically comparable and they were not statistically heterogenous. Recent research suggests that muscle relaxants show no evidence of benefit and so would not have an interactive effect (Gross 2003; Peloso 2003). It is our clinical belief, substantiated by evidence from the section below on


mobilisation, that a sham mobilisation would have minimal to no clinical effect. Two further trials showed a similar negative effect but were not included in the meta-analysis due to the type of outcomes and disorder subtype: Howe 1983 compared manipulation plus azapropazone with azapropazone in subjects with chronic radicular findings or headache, while Cassidy 1992 compared manipulation to a muscle energy technique for acute, subacute, and chronic mechanical neck disorder. Five trials assessed the effect of six to 20 sessions of manipulation, conducted over three to11 weeks, against various comparisons. The comparisons were wait list control (Bitterli 1977: B v C); soft tissue treatments (Nilsson 1997); high-technology exercise (Bronfort:SMTv MedX 2001); manipulation with low-technology exercise (Bronfort:SMTvSMT/Ex 2001); tenoxicam with ranitidine (Giles 1999:ManipvMed); low voltage electrical acupuncture (Giles 1999: ManipvAcup); and physiotherapy (Skargren: Chiro v PT 1998). In every case, the results were negative. No group showed more benefit than another for the outcomes pain, function, patient satisfaction or global perceived effect in short-term follow-up assessments for chronic mechanical neck disorders. Three trials found no difference in short and intermediate-term pain relief when manipulation was compared to mobilisations for acute, subacute and chronic mechanical neck disorders (Vernon 1990; Cassidy 1992; Hurwitz 2002) or subacute/chronic neck disorder with headache or radicular findings (Hurwitz 2002). Three further trials compared one manipulation technique to another. There was limited evidence of no difference in pain relief and functional improvement at short-term follow-up when: thoracic manipulation was added to cervical manipulation (Parkin-Smith 1998) for mechanical neck disorder with symptom duration not defined; a rotatory manipulation was compared to a lateral break manipulation (van Schalkwyk 2000) for mechanical neck disorder with symptom duration not defined; and instrumental manipulation was compared against manual manipulation (Wood 2001) for subacute mechanical neck disorder. Mobilisation alone Four trials compared mobilisation against cold pack (Jensen 1990), collar (Nordemar 1981:MTvCol), transcutaneous electrical nerve stimulation (Nordemar 1981:MTvTNS), acupuncture (David 1998), and ultrasound (Coppieters 2002). There was moderate evidence of no difference in pain and function outcomes from one high quality trial with long-term follow-up (David 1998: MT v Acup) for subacute/chronic mechanical neck disorder including whiplast associated disorder (WAD), and three smaller trials with short-term follow-up for acute (Jensen 1990, Nordemar 1981:MTvCol, Nordemar 1981:MTvTNS) or subacute/chronic (Coppieters 2002: NT v US) mechanical neck disorder including WAD. Multimodal Care: Manipulation and Mobilisation Six trials assessed manipulation and mobilisation. When mobilisation and manipulation were compared to a placebo, there was no evidence of difference in pain and function noted in one very small but high quality RCT for subacute and chronic mechanical neck disorder (Koes 1992: MT v pl). When compared to no treatment, results showed a tendency toward short and long-term benefit for chronic neck disorder with headache across three outcomes: pain relief [pooled SMD -0.34 (95% CI: -0.71 to 0.03)] (Bitterli 1977: A v C; Jull 2002: MT v Cntl); function improvement [SMD -0.39 (95% CI:- 0.79 to 0.02)] (Jull 2002: MT v Cntl); and global perceived effect [SMD -2.36 (95% CI: -2.89 to -1.83)] (Jull 2002: MT v Cntl). When trials studied the effects of mobilisation against physiotherapy care (Koes 1992: MT v PT; Skargren: Chiro v PT 1998; Reginiussen 2000), general practitioner care (Koes 1992: MT v GP), and exercise (Jull 2002: MT v ExT; Jull 2002: MTv MTExT), conflicting results were shown for the outcomes of pain and function. This may have occurred in part from the use of different exercise regimes and of course from the use of differing comparison groups. There was limited evidence that mobilisation and manipulation gave results similar to manipulation alone for chronic mechanical neck disorders (Bitterli 1977: A v B). In addition, there was moderate evidence from one high quality trial with long term follow-up, of no difference in pain, function or satisfaction for chronic mechanical neck disorder, when one combination of mobilisation, manipulation, and other soft tissue techniques was compared to another (Jordan 1998). Multimodal Care: Manipulation or Mobilisation plus other Physical Medicine Agents Six trials compared manipulation and/or mobilisation in combination with various physical medicine agents against no treatment controls (Brodin 1985: 3 v 2) for chronic neck disorder with radicular findings and degenerative changes;


placebo tablets (Kogstad 1978:MT v Pl) for neck disorder with radicular findings of unclear symptom duration; exercise (Jordan 1998:PT v Int) for chronic mechanical neck disorder; combined exercise/traction/massage (Kogstad 1978:MT v CT) for neck disorder with radicular findings of unclear symptom duration; various combinations of manipulation (Jordan 1998: PT v CH) for chronic mechanical neck disorder; intermittent collar use (McKinney 1989: 2 v 3) for acute whiplash associated disorder; direct galvanic current, ultrasound, and ultraviolet light (Ammer 1990: 1 v 2) for acute, subacute and chronic neck disorder with headache; massage/munaripack (Ammer 1990: 1 v 3) for acute, subacute and chronic neck disorder with headache; mobilisation or manipulation plus heat or electric muscle stimulation (Hurwitz 2002) for subacute and chronic mechanical neck disorder with or without radicular findings or headache; and a combination of massage, manual traction, electrical stimulation, analgesics and education (Brodin 1985: 3 v 2) for chronic neck disorder with radicular findings. In summary, there is moderate evidence showing no difference in benefit for pain relief, improvement in function, and global perceived effect for various disorder subtypes and for various symptom durations. This finding was from both low and higher quality trials with both short and long-term follow-up periods. Multimodal Care: Mobilisation and Manipulation plus Exercise Focus Fifteen trials with both short and long-term follow-up met the inclusion criteria for chronic mechanical neck disorder (Bronfort:SMT/ExvMedX 2001; Allison 2002:NT v CG), subacute or chronic mechanical neck disorder with headache (Karlberg 1996; Jull 2002), as well as acute, subacute and chronic mechanical neck disorder with or without radicular findings or headache (Brodin 1985, Hoving 2002). When compared to a wait list control, there was strong evidence of maintained long-term benefit favouring multimodal care for: pain relief [pooled SMD -0.85 (95% CI: -1.20 to -0.50)] for chronic mechanical neck disorder (Allison 2002:NT v CG), for chronic mechanical neck disorder with or without radicular findings (Brodin 1985: 3 v 1), and for subacute and chronic neck disorder with headache (Karlberg 1996; Jull 2002:MTExTvCntl). This translates into an absolute benefit of 23 to 27 mm VAS units and treatment advantage as high as 41%. The NNT to achieve this advantage was from two to five (See). improved function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] for chronic mechanical neck disorder (Allison 2002:NT v CG) and for subacute/chronic neck disorder with headache (Jull 2002:MTExTvCntl). global perceived effect [SMD -2.73 (95% CI: -3.30 to -2.16)] for subacute and chronic neck disorder with headache (Jull 2002:MTExTvCntl). The common elements in this care strategy in all the studies were mobilisation or manipulation plus exercise. Other elements that may have been included were medication, thermal agents (heat or cold) and education.These results were also noted when compared against non-exercise based treatments. Is exercise the "active ingredient"? We don't know. On the one hand, patients were more satisfied with manipulation plus exercise over manipulation or exercise alone. On the other hand, when mobilisation and manipulation plus exercise was compared against exercise, there was moderate evidence of no difference for pain relief or improvement in function (Bronfort:SMT/ExvMedX 2001; Hoving 2002: MT v PT; Jull 2002:MTExTv ExT). Persson 2001 evaluated chronic neck disorders with radicular findings. At short-term follow-up, there was evidence of benefit favouring surgery over physiotherapy care and collar use. At longterm follow-up, no difference was found between physiotherapy care, collar use, and surgery. Other Considerations Adverse Events Side effects were reported in 31% of the trials. They were benign, transient, and included headache, radicular pain, thoracic pain, increased neck pain, distal paraesthesia, dizziness, and ear symptoms. The rate of serious adverse events could not be determined in this review. Cost of Care


There was moderate evidence favouring reduced costs for manual therapy care for acute, subacute, and chronic mechanical neck disorder with or without headache or radicular findings (Provinciali 1996; Giebel 1997; Skargren 1998; Hoving 2002).

D I S C U S S I O N Methodological Quality We have observed four positive advances in more recently published reports of trials. Trials were larger, were of higher methodological quality, had longer-term follow-up, and used self-reported ratings (e.g. pain, disability self-report questionnaires, global perceived effect) as primary outcomes on a more consistent basis. We attach great value to the patient's opinion, as do recent guidelines in the low back literature (Bombardier 2000; van Tulder 2000), and believe its subjectivity is insufficient argument against its use. Balancing self-report outcomes with 'observerbased performance measures' would be ideal; unfortunately, the latter measures do not yet exist in the neck care literature. Certain methodological issues are inherent to the design of trials on manual therapy for neck pain. Manual therapy cannot easily be studied in a double-blinded manner (blinding therapists and patients) in clinical practice. Therefore, it is essential to blind the outcome assessor and the investigator doing the analyses. Expectation bias could be minimized by selecting patients without prior knowledge/experience or without strong expectations for either treatment. This could be achieved through administration of a brief questionnaire prior to inclusion into the trial (e.g. How do you expect your neck pain to change as a result of the following treatments you may receive in the study?). Even though some would suggest modifying the quality assessment instrument for studies in which the nature of intervention precludes blinding of participants and therapist, using a common validated tool to assess RCTs keeps the methodological quality and resulting strength of the evidence in perspective. Another issue is that co-interventions, contamination, and compliance are not commonly monitored during the trial or dealt with through study design. Co-interventions may bias results in favour of a treatment while contamination of the control arm of a study may serve to undermine the treatment effect. Is the benefit of manual therapy more or less influenced by patient satisfaction compared to, for example, exercise? As shown in this review, placebo trials were scarce and credible placebo treatments that mimic manual therapy were absent. It is difficult to assess to what degree 'handson effect', attention, assessment techniques, other forms of feedback, or interaction and communication between manual therapist and the patient are 'unique' traits of those who provide manual therapy. We acknowledge that these effects may play some role in manual therapy treatment methods. Comparison against findings of other reviews In our previous systematic review, which included studies to 1997, results remained inconclusive and were available only for the short-term. Since then, 13 RCTs have been published and included in our current review. Recent trials have added further support to the role of multimodal care in achieving clinically important pain reduction, global perceived effect and patient satisfaction in acute and chronic neck disorder with or without headache. The most common care elements included mobilisation or manipulation plus exercise. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Given that we continue to not find evidence in support of manipulation or mobilisation as solo treatments, some reviews (Spitzer 1995; Bronfort 1997; Magee 1997; Bogduk 2000) agreed with these findings. Our findings are in disagreement with other reviews (Florian 1991; Vernon 1995; Hurwitz 1996; Bronfort 1997; Pollman 1997; Kjellman 1999). We agree with Peeters 2001 that it is difficult to identify the effective components of a multimodal active treatment approach without using factorial design. In addition, there are differences between reviews in the definition or clustering of different treatments, disorder subgroups reviewed, the technique definition, and outcome measures reported (Hoving 2001). Adverse events and cost of care Adverse events reported from RCTs in this review were benign, transient side effects. Clearly, smaller randomised trials are unlikely to detect rare adverse events. From surveys and review articles, the risk of a serious irreversible complication for cervical manipulations has been reported to vary from one adverse event in 3,020 to one in 1,000,000 manipulations (Assendelft 1996; Gross 2002b). Better reporting of adverse events is required. In addition, there was moderate evidence of an economic advantage in using multimodal care, defined as mobilisation or manipulation plus exercise, for mechanical neck disorders. As more trials become available, details of direct and indirect costs can be better summarised.


Methodological issues of our review Selection of all relevant studies is essential to ensure validity of a systematic review. 'Selection bias' was not likely to be present in our review. We took a structured criterion-based approach to the identification of citation postings and selection of trials. Agreement between pairs of independent authors from diverse professional backgrounds was substantial (Kw 0.83, SD 0.15). 'Language bias' may be present in our review, as we did not search non-English computerized databases. 'Publication bias' was not guarded against in this update. Additional outcomes that we should be noting in our future reviews are cervicogenic dizziness and vertigo. It is perhaps most relevant to traumatic neck injuries; some 40 to 80% of whiplash sufferers experience vertigo and may get therapeutic benefit from manual therapy (Oostendrop 1999).

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Implications for practice Multimodal care, including mobilisation and/or manipulation plus exercise, is beneficial for pain relief, functional improvement and global perceived effect for subacute/chronic mechanical neck disorder with or without headache. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other types of treatments for pain, function, and global perceived effect. It was not possible to determine which technique or dosage was more beneficial, or if certain subgroups benefited more from one form of care than another. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Implications for research Meta-analysis of data across trials and sensitivity analysis were hampered by the wide spectrum of comparisons, treatment characteristics and dosages. Factorial design would help determine the active treatment agent(s) within a treatment mix. Phase II trials would help identify the most effective treatment characteristics and dosages. Greater attention to methodological quality is needed.

A C K N O W L E D G E M E N T S We are indebted to the many authors of primary studies for their support in retrieving original research. We thank our volunteers, translators, the Back Group editors, and our editor Susan James.

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T A B L E S Characteristics of included studies Study

Allison 2002

Methods

Type of Trial: RCT crossover designNumber Analysed/Randomised: 36/40Intension-totreat Analysis: conductedPower Analysis: not reported (NR)

Participants

Chronic mechanical neck disorder (cervical brachial pain syndrome)

Interventions

INDEX TREATMENTNeural Treatment (NT): neural tissue techniques, mobilisation, neuromuscular techniques, home mobilisation exercise techniques (10 repetitions, 1 to 3 times/day)COMPARISON TREATMENTSArticular treatment (AT): thoracic and glenohumeral mobilisation, home exercise (stretches, theraband strengthening)Control


group (CG): no treatment, allowed to seek treatment from a non-physiotherapy health care providerCO-INTERVENTION: NRTreatment Schedule: 8 weeks / ?sessionDuration of follow-up: 0 days

Outcomes

PAIN (VAS, 0 to10)Baseline Median: NT 4.6, AT 5.1, CG 3.3End of Study Median: NT 2.1, AT 3.4, CG 3.8Absolute Benefit: NT 2.5, AT 1.7, CG -0.4Reported Results: significant favouring NTSMD(NT v CG): -0.71(95%CI:-1.52 to 0.09) [power 56%]SMD(NT v AT): -0.63(95%CI:-1.46 to 0.20) [power 65%]FUNCTION (Northwick Park Questionnaire, 0 to 36)Baseline Median: NT 12, AT 12.5, CG 12.5End of Study Median: NT 9.5, AT 11.0, CG 11.5Absolute Benefit: NT 2.5, AT 1.5, CG 1.0Reported Results: not significantSMD(NT v CG): -0.34(95%CI:-1.12 to 0.45)SMD(NT v AT): -0.24(95%CI:-1.56 to 0.57)PATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Allison 2002:NT v AT

Methods

[Refer to Allison 2002 for details; author described neural treatment v articular treatment]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Allison 2002:NT v CG

Methods

[Refer to Allison 2002 for details; author described neural treatment v control group]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Ammer 1990

Methods

Type of Trial: RCTNumber Analyzed/Randomized: 45/45Intension-to-treat Analysis: NRPower Analysis: NR

Participants

Acute, subacute, chronic neck disorder with headache

Interventions

INDEX TREATMENTGroup 1(G1): Manipulation given at 1st and 6th treatment day, Galvanic Current (pulsed)COMPARISON TREATMENTSGroup 2 (G2): Galvanic Current (direct), Ultrasound, Ultraviolet LightGroup 3 (G3): Massage, Munaripack-mustard paste (cayenne pepper and kaolinerde combined in water)CO-INTERVENTION: noneTreatment Schedule: 2 weeks, 10 sessionsDuration Follow-up: 0 days

Outcomes

PAIN (0-5)Baseline Median: G1 3, G2 3, G3 3Reported Results: not significantFUNCTION: NRPATIENT PERCEIVED EFFECT (1-5)Reported Results: not significantSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear


Study

Ammer 1990: 1 v 2

Methods

[Refer to Ammer 1990 for details; author described group 1 v 2]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Ammer 1990: 1 v 3

Methods

[Refer to Ammer 1990 for details; author described group 1 v 3]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Bitterli 1977

Methods

Type of Trial: quasi-RCTNumber Analysed/Randomised: 24/30Intension-to-treat Analysis: conductedPower Analysis: NR

Participants

Chronic neck disorder with headache or degenerative changes (spondylogenic)

Interventions

INDEX TREATMENTGroup A (A): manipulation (mean 6.2 manipulations over 3.2 sessions) and mobilisation (3 session), technique described by MaigneGroup B (B): manipulation (mean 7.2 manipulations over 3.8 sessions)COMPARISON TREATMENTGroup C (C): wait list controlCO-INTERVENTION: noneTreatment Schedule: 3 weeks, 3 to 4 sessionsDuration Follow-up: 12 weeks

Outcomes

PAIN (VAS, 0 to 100)Baseline Mean: A 60.50, B 64.40,C 57.60End of Study Mean: A 38.50, B 27.80, C 43.50Absolute Benefit: A 22.0, B 36.6, C 14.1Reported Results: not significantSMD(A v C): -0.18(95%CI:-1.12 to 0.75) [power 10%]SMD(A v B): 0.36(95%CI:-0.58 to 1.30) [power 7%]SMD(B v C): -0.54(95%CI:-1.43 to 0.36) [power 10%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: manipulation and mobilisation were well tolerated with the customary reaction of minimal benign reaction lasting less than 24 hours;RR: 1.34(95%CI: 0.77 to 2.34)COST OF CARE: NR

Notes Allocation concealment

C - Inadequate

Study

Bitterli 1977: A v B

Methods

[Refer to Bitterli 1977 for details; author described group A versus group B]

Participants Interventions Outcomes Notes Allocation concealment

C - Inadequate

Study

Bitterli 1977: A v C


Methods

[Refer to Bitterli 1977 for details; author described group A v C]

Participants Interventions Outcomes Notes Allocation concealment

C - Inadequate

Study

Bitterli 1977: B v C

Methods

[Refer to Bitterli 1977 for details; author described group B v C]

Participants Interventions Outcomes Notes Allocation concealment

C - Inadequate

Study

Brodin 1985

Methods

Type of Trial: RCTNumber Analysed/Randomised: 63/71Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Chronic mechanical neck disorder with some 25% of n had neck disorder having radicular findings or lower cervical degenerative changes

Interventions

INDEX TREATMENTGroup 3 (G3): mobilisation (passive) described by Stoddard, massage, manual traction, superficial heat, analgesics, education (neck school including exercise, 3 hours), 3 sessions/weekCOMPARISON TREATMENTSGroup 1(G1): analgesicGroup 2 (G2): Mock Therapy included superficial massage, manual traction, electrical stimulation, analgesics, education (neck school including exercise, 3 hours), 3 sessions/weekCO-INTERVENTION: NRDuration of Therapy Period: 3 weeks, 9 sessionsDuration of Follow-up: 1 week

Outcomes

PAIN (9 point linear scale):Baseline: NRReported Results:RR(3v1): 0.67(95%CI: 0.43 to 1.04) [power 18%]RR(3v2): 0.59(95%CI: 9.39 to 0.91)FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: 10 in G1; G2 reported discomfort, usually small complaints; RR: 9.22(95%CI:0.61 to 14.30); note one subject dropped out due to acute cerebral disease (n = 1), others dropped out for the following reasons: acute abdominal pain (n = 1); vacation and infection (n = 1); acute pain in several joints (n = 1); incapable of following planned treatment (n = 4)COST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Brodin 1985: 2 v 1

Methods

[Refer to Brodin 1985 for details; author described group 2 v 1]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear


Study

Brodin 1985: 3 v 1

Methods

[Refer to Brodin 1985 for details; author described group 3 v 1 ]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Brodin 1985: 3 v 2

Methods

[Refer to Brodin 1985 for details; author described group 3 v 2]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Bronfort 2001

Methods

Type of Trial: RCTNumber Analysed/Randomised: 158-160/191Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Chronic mechanical neck disorder

Interventions

INDEX TREATMENTSSpinal manipulation (SMT): manipulation described by Frymoyer, 20 sessions/3 monthsSpinal manipulation and low-technology exercises (SMT/Ex): manipulation, low-technology exercises: supervised rehabilitative exercise including aerobic warm up, stretching, progressive resisted exercises, upper body strengthening exercises described by Dyrssen et al, one hour duration/20 sessions/11 weeksCOMPARISON TREATMENTMedX exercises (MedX): high-technology exercises: medically supervised rehabilitative exercise using MedX equipment including stretching, aerobic exercise (bike), upper body strengthening, progressive resisted exercises using MedX machines, one hour duration/20 sessions/11 weeksCO-INTERVENTION: home exercises including resisted rubber tubing for rotation and flexionDuration of Therapy Period: 11 weeks, 20 sessionsDuration of Follow-up: 3, 6, 12 months

Outcomes

CUMULATIVE ADVANTAGE for six patient-oriented outcomesReported Results: favours SMT/Ex over SMT; MONOVA value yielded a significant group difference [Wilk's Lambda = 0.85, (F(12, 302) = 2.2, p < 0.01)]PAIN (11-box scale, 0 to 10)Baseline Mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0End of Study Mean: SMT 36.5, MedX 29.8, SMT/Ex 31.1Absolute Benefit: SMT 20.1, MedX 27.3, SMT/Ex 24.9Reported Results: group difference in patient-rated pain ANOVA [F(2,156) = 4.2, p = 0.02] favours the two exercise groupsSMD(SMT v MedX): 0.31(95%CI:-0.08 to 0.70) [power 29%]SMD(SMT v SMT/Ex): 0.24(95%CI:-0.14 to 0.61) [power 28%]SMD(SMT/Ex v MedX): 0.06(95%CI:-0.33 to 0.44) [power 28%]FUNCTION (Neck Disability Index, 0 to 50)Reported Results: no significant group differences were found ANOVA: F[2, 156] = 2.04, p = 0.13SMD(SMT v MedX): 0.33(95%CI:-0.06 to 0.71) [power 23%]SMD(SMT v SMT/Ex): 0.31(95%CI:-0.06 to 0.68) [power 28%]SMD(SMT/Ex v MedX): 0.31(95%CI:-0.06 to 0.68) [power 25%]PATIENT SATISFACTION (1 to 7, completely satisfied - completely dissatisfied)Reported Results: A clinically worthwhile cumulative advantage was reported favouring manipulation/exercise [low tech] group over exercise [high tech] and manipulation alone ANOVA: F[2, 158] = 6.7, p = 0.002SMD(SMT v MedX): 0.26(95%CI:-0.13 to 0.65) [power 49%]SMD(SMT v SMT/Ex): 0.71(95%CI: 0.33 to 1.10)SMD(SMT/Ex v MedX): -0.44(95%CI:-0.83 to -0.05)PATIENT RATED IMPROVEMENT (1 to 9)Reported Results: substantial improvement over time, ANOVA: F[2, 174] = 1.7, p = 0.18 SMD(SMT v MedX): 0.29(95%CI:-0.10 to 0.67) [power 38%]SMD(SMT v SMT/Ex): 0.29(95%CI:-0.08 to 0.67) [power 44%]SMD(SMT/Ex v MedX): 0.01(95%CI:-0.37 to 0.39) [power 38%]SIDE EFFECTS: increase neck or headache pain 8 SMT/Ex, 9 MedX, 6 SMT;


increased radicular pain 1 SMT/Ex; severe thoracic pain 1 SMT; all cases self-limiting and no permanent injuries;RR(SMT/ExvMedX): 0.81(95%CI: 0.23 to 1.55)RR(SMTvMedX): 0.61(95%CI: 0.23 to 1.55)COST OF CARE: NR Notes Allocation concealment

A - Adequate

Study

Bronfort:SMT/ExvMedX

Methods

[Refer to Bronfort 2001 for details; author described SMT and exercise v MedX]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Bronfort:SMT/ExvSMT

Methods

[Refer to Bronfort 2001 for details; author described SMT and exercise v SMT]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Bronfort:SMTv MedX

Methods

[Refer to Bronfort 2001 for details; author described SMT v MedX]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Bronfort:SMTvSMT/Ex

Methods

[Refer to Bronfort 2001 for details; author described SMT v SMT and exercise]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Cassidy 1992

Methods

Type of Trial: RCTNumber Analysed/Randomised: 100/100Intention-to-treat Analysis: conductedPower Analysis: conducted


Participants

Acute, subacute, chronic mechanical neck disorder without radicular signs and symptoms and with varied degenerative changes [spondylosis]

Interventions

INDEX TREATMENTManipulation (Manip): rotation manipulation away from the direction of pain, one manipulation, one sessionCOMPARISON TREATMENTMobilisation (Mob): muscle energy technique described by Bourdillon, an isometric contraction localised to the involved level, held for 5 seconds, repeated 4 times with increasing rotation or lateral flexion of the localised levels, one sessionCO-INTERVENTION: noneDuration of Therapy Period: one sessionDuration of Follow-up: none

Outcomes

PAIN (NRS101)Baseline Mean: manip 37.7, mob 31.0End of Study Mean: manip 20.4, mob 20.5Absolute Benefit: manip 17.3, mob 10.5Reported Results: not significantSMD: 0.00(95%CI:-0.40 to 0.39) [power 16%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: no complications; 3 subjects in each group reported more pain after intervention;RR: 0.97(95%CI: 0.47 to 2.03)COST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Coppieters 2002

Methods

Type of Trial: RCTNumber Analysed/Randomised: 20/20Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Subacute, chronic mechanical neck disorder without radicular signs and symptoms

Interventions

INDEX TREATMENTExperimental Group: mobilisations included lateral glide techniques described by Elvey 1986 and Vicenzino et al 1999, the arm is progressively positioned from a unloaded to a preloaded position, mean 4.5 minute treatment duration, session one grade two technique, session 2 to 3, grade 3 technique, C5 and C6 most frequently treatedCOMPARISON TREATMENTControl Group: pulsed ultrasoundCOINTERVENTION: NRDuration of Therapy Period: one sessionDuration of Follow-up: none

Outcomes

PAIN (NRS101)Baseline Mean: experimental 7.3, control 7.7End of Study Mean: experimental 5.8, control 7.4Absolute Benefit: experimental 1.5, control 0.3Reported Results: positive immediate effect favouring mobilisationsSMD: -0.78(95%CI:-1.70 to 0.13) [power 58%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

David 1998

Methods

Type of Trial: RCTNumber Analysed/Randomised: 51/70Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Subacute, chronic mechanical cervical disorder with degenerative changes [i.e. cervical spondylosis], whiplash associated disorder

Interventions

INDEX TREATMENTPhysiotherapy Goup (PT): mobilisation (passive): standard localised mobilisation described by Maitland, rotation, posterior anterior oscillations, longitudinal traction, a maximum of 6 sessions, one session/week for 6 weeksCOMPARISON TREATMENT:Acupuncture Group (A): local needling of trigger point, regional needling (GB21-supraspinatus tender area), distal needling (LI4-web space between thumb and first finger); needle left in situ for 15 minutes, one session / week for 6 weeksCOINTERVENTION: NRDuration of Therapy Period: 6 weeks, 6 sessionsDuration of Followup: 24 weeks

Outcomes

PAIN (VAS, 0 to 100)Baseline Mean: PT 51, A 51End of Study Mean: PT 22, A 28Absolute Benefit: PT 29, A 23Reported Results: not significantSMD: -0.33(95%CI:0.88 to 0.23) [power 24%]FUNCTION (Northwick Park neck pain questionnaire, 0 to 36)Baseline Mean: PT 36, A 36End of Study Mean: PT 22, A 25Absolute Benefit: PT 14, A 11Reported Results: not significantSMD: -0.16(95%CI:-0.72 to 0.39) [power 15%]PATIENT SATISFACTION: NRSIDE EFFECTS: no side effects occurred for acupunctureCOST OF CARE: NR


Notes

Publication Type: journalPeer Reviewed: don't knowFunding agency has a Peer Review Mechanism: not reportedCountry: UK

Allocation concealment

B - Unclear

Study

Giebel 1997

Methods

Type of Trial: RCTNumberAnalysed/Randomised: 97/103Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Acute neck disorder with headache, whiplash associated disorder

Interventions

INDEX TREATMENTGroup 1 (G1): mobilisation (passive, neuromuscular): for individual segments active-assisted followed by passive movements under light traction; PNF: active, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting; light traction with mobilisation; exercise; analgesic; antiinflammatoryCOMPARISON TREATMENTGroup 2 (G2): collar: worn continuously, take off at night, advised no exercise; analgesic; antiinflammatoryCO-INTERVENTION: analgesics and antiinflammatories allowed in both groupsDuration of Treatment: 3 weeksDuration of Follow-up: 9 weeks

Outcomes

PAIN (NRS101)Baseline Mean: G1 46.70, G2 49.20End of Study Mean: G1 0.64, G2 3.39Absolute Benefit: G1 46.6, G2 45.81Reported Results: Physiotherapy has a clear advantage over collarsSMD@2w treatment: -1.04(95%CI:-1.46 to -0.61)SMD@3w treatment + 9w follow-up: -4.88(95%CI:-5.68 to -4.07)NOTE that the large effect estimate for pain intensity in Giebel's trial is an artifact of both groups markedly improving from baseline to almost no pain. Clinically this benefit translates to a 5.5% treatment advantage for the multimodal treatment.FUNCTION [household activity, physical activity, activity of daily living, social activity, neck mobility (11 point scale of MOPO Fragenbogens)]Baseline: NRReported Results: significant favour G1SMD: 0.23(95%CI:-0.17 to 0.63) (a positive sign denotes advantage of the first group in the contrast) [power 100%]SIDE EFFECT: NRCOST OF CARE:cost of direct care: G1 155DEM (78USD), G2 113DEM (57USD)sick days [number patients x days off work]: G1 187, G2 330Reported Results: G1 treatment economically favoured

Notes Allocation concealment

B - Unclear

Study

Giles 1999

Methods

Type of Trial: RCTNumberAnalysed/Randomised: 98/157 for all spinal patients; 62/? for neck subgroupIntention-to-treat Analysis: NRPower Analysis: NR

Participants

Chronic mechanical neck disorder with degenerative changes

Interventions

INDEX TREATMENTManipulation (manip): high velocity, low amplitude manipulation, 15 to 20 minute appointments, 6 sessions/median 19 daysCOMPARISON TREATMENTAcupuncture (acup): 8 to10 needles with low-volt electrical stimulation to tender points, 6 sessions/median 40 daysMedication (med): tenoxicam (NSAID) with ranitidine, median 15 daysCO-INTERVENTION: NRDuration of Treatment: 3 to 4 weeksDuration of Follow-up: none

Outcomes

PAIN (neck pain change scores, VAS 0 to10)Baseline Median: manip 4.5, acup 2.0, med 4.0Absolute Benefit: manip 1.5, acup 1.0, med 0.5Reported Results: not clearSMD(Manip v Med): -0.35(95%CI:-1.05 to 0.35) [power 5%]SMD(Manip v Acup): -0.23(95%CI:-1.04 to 0.50) [power 7%]FUNCTION (neck disability index, 0 to 50)Baseline Median: manip 32, acup 40, med 28Absolute Benefit: manip 10.0, acup 6.0, med 0.0Reported Results: not clearSMD(Manip v Med): -0.92(95%CI:-1.74 to -0.10)SMD(Manip v Acup): -0.33(95%CI:-1.12 to 0.46) [power 7%]SIDE EFFECT: no side effects occurred for acupuncture or manipulationCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Giles 1999:ManipvMed

Methods

[Refer to Giles 1999 for details; author described manipulation v medication]


Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Giles1999:ManipvAcup

Methods

[Refer to Giles 1999 for details; author described manipulation v acupuncture]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Hoving 2002

Methods

Type of Trial: RCTNumberAnalysed/Randomised: 178/183Intention-to-treat Analysis: conductedPower Analysis: conducted

Participants

Acute, subacute, chronic mechanical neck disorder with and without radicular findings, neck disorder with headache

Interventions

INDEX TREATMENTManual Therapy (MT): muscular and articular mobilisation techniques, coordination and stabilization techniques; low velocity passive movements within or at the limit of joint range; excluded manipulation; 45 minute sessions, one session per week for a maximum of 6 sessions [median 6 (IQR 5 to 6)]COMPARISON TREATMENTSPhysical Therapy (PT): active exercise therapies: strengthening, stretching (ROM), postural/ relaxation/ functional exercise; optional modalities: manual traction, massage, interferential, heat; excluded specific mobilisations techniques, median 9 (IQR 7 to 12) sessionsContinued Care by General Practitioner (GP): advice on prognosis, psychosocial issues, self care (heat, home exercise), ergonomics (pillow, work position), await further recovery; booklet (ergonomics, home exercise); medication: paracetamol, NSAID; 10 minute follow-up every 2 weeks was optional; excluded referral for other treatment, median 2 (IQR 1 to 4) treatmentsCOINTERVENTION: analgesics and antiinflammatories allowed in both groups, home exercise for all three groupsDuration of Treatment: 6 weeks, 6 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (NRS, 0 to 10)Baseline Mean: MT 5.9, PT 5.7, GP 6.3End of Study Mean: MT 1.7, PT 2.6, GP 2.2Absolute Benefit: MT 4.2, PT 3.1 , GP 4.1Reported Results: significant favouring MT over PTSMD (MT v PT): -0.41(95%CI:-0.78 to -0.04)SMD (MT v GP): -0.04(95%CI:-0.40 to -0.32)FUNCTION (Neck Disability Index, 0 to 50)Baseline: MT 13.6, PT 13.9, GP 15.9End of Study Mean: MT 6.4, PT 7.6, GP 7.4Absolute Benefit: MT 7.2, PT 6.3 , GP 8.5Reported Results: significant favouring MT over PTSMD (MT v GP): 0.17(95%CI:-0.19 to 0.58) [power 22%]SMD (MT v PT): 0.12(95%CI:-0.48 to 0.25) [power 17%]GLOBAL PERCEIVED EFFECT (perceived recovery, %)Reported Results: significant favouring MT over PT and GPRR (MT v GP): 0.65(95%CI: 0.40 to 1.06) [power 15%]RR (MT v PT): 0.76(95%CI: 0.45 to 1.28) [power 9%]SIDE EFFECT: benign and transientincreased neck pain > 2 daysRR(MT v GP): 3.91(95%CI: 1.15 to 13.34)RR(MT v PT): 2.70(95%CI: 0.91 to 8.01)RR(PT v GP): 1.45(95%CI: 0.34 to 6.19)increased headacheRR(MT v GP): 1.65(95%CI: 0.84 to 3.23)RR(MT v PT): 0.88(95%CI: 0.51 to 1.52)RR(PT v GP): 1.87(95%CI: 0.98 to 3.60)arm pain / pins&needlesRR(MT v GP): 2.13(95%CI: 0.68 to 6.72)RR(MT v PT): 0.87(95%CI: 0.36 to 2.11)RR(PT v GP): 2.44(95%CI: 0.79 to 7.51)dizzinessRR(MT v GP): 1.60(95%CI: 0.47 to 5.39)RR(MT v PT): 0.84(95%CI: 0.30 to 2.36)RR(PT v GP): 1.90(95%CI: 0.59 to 6.16)COST OF CARE: favours MTtotal costsResults: not significantSMD(MT v GP): -0.41(95%CI:-0.77 to -0.05)SMD(MT v PT): -0.34(95%CI:-0.70 to 0.02)SMD(PT v GP): -0.02(95%CI:-0.38 to 0.33)total direct costsResults: significant favours MT v PTSMD(MT v GP): -0.28(95%CI:-0.64 to 0.07)SMD(MT v PT): -0.49(95%CI:-0.85 to -0.17)SMD(PT v GP): 0.21(95%CI:-0.15 to 0.56)total indirect costsResults: significant


favour MT v GPSMD(MT v GP): -0.40(95%CI:-0.75 to -0.04)SMD(MT v PT): -0.28(95%CI:-0.64 to 0.08)SMD(PT v GP): -0.07(95%CI:-0.43 to 0.28)duration off workResults: significant favour MT v GPSMD(MT v GP): -0.43(95%CI:-0.85 to -0.01)SMD(MT v PT): -0.29(95%CI:-0.71 to 0.12)SMD(PT v GP): -0.10(95%CI:-0.51 to 0.32) Notes Allocation concealment

A - Adequate

Study

Hoving 2002: MT v GP

Methods

[Refer to Hoving 2002 for details; author described manual therapy v continued care by general practitioner]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Hoving 2002: MT v PT

Methods

[Refer to Hoving 2002 for details; author described manual therapy v physical therapy]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Hoving 2002: PT v GP

Methods

[Refer to Hoving 2002 for details; author described physical therapy v continued care by general practitioner]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Hoving 2002: PT v MT

Methods

[Refer to Hoving 2002 for details; author described physical therapy v manual therapy]

Participants Interventions Outcomes Notes Allocation

A - Adequate


concealment Study

Howe 1983

Methods

Type of Trial: RCTNumberAnalysed/Randomised: 44/52Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Subacute, chronic mechanical neck disorder with radicular findings and headache

Interventions

INDEX TREATMENTManipulation Group: up to 3 manipulation in 1 session, azapropazoneCOMPARISON TREATMENTSControl Group: azapropazone; dose unknownCO-INTERVENTION: 2 subjects had lignocaine-hydrocortisone injections in manipulation groupDuration of Treatment: 1 sessionDuration of Follow-up: 3 weeks

Outcomes

PAIN (count, neck/shoulder/arm/hand pain and headache present)Baseline Mean: NRReported Results: significant favouring manipulationRR: 0.56(95%CI: 0.19 to 1.68) [power 18%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Hurwitz 2002

Methods

Type of Trial: RCT (2x2x2 factorial design)Number Analysed/Randomised: 269/336Intention-to-treat Analysis: done by designPower Analysis: NR

Participants

Subacute and chronic mechanical neck disorder with or without radicular symptoms and headache

Interventions

INDEX TREATMENTSManipulation (Manip): at least 1 controlled, dynamic thrust applied with high velocity low amplitude force with minimal extension and rotation, directed at 1 or more restricted upper thoracic or cervical spine joint segmentsManipulation with heat (Manip/Heat): 10-minute moist heat application before manipulationManipulation with electrical muscle stimulation (Manip/EMS): 10-minute application of this modality before manipulation; parameters NRMobilisation (Mob): 1 or more low velocity, variable amplitude movements applied within the patient's passive range of motion directed to 1 or more restricted upper thoracic or cervical spine joint segmentsMobilisation with heat (Mob/Heat): 10-minute moist heat application before mobilisationMobilisation with EMS (Mob/EMS): 10-minute application of this modality before mobilisation; parameters NRCOMPARISON TREATMENTSAny of the above noted treatment combinationsCO-INTERVENTION: All participants received information on posture and body mechanics and one or more of the following: stretching, flexibility, or strengthening exercises and advice about ergonomic and workplace modificationsDuration of Therapy Period: NR (?6 weeks)Duration of Follow-up: 6 months

Outcomes

PAIN INTENSITY (average pain during previous week, most severe pain, NRS 0 to10)Baseline Mean: NR for each subgroupEnd of Study Mean: NR for each subgroupReported Results: no significant difference, heat therapies condition improved slightly more; the differences were clinically negligibleSMD(manip v mob): 0.15(95%CI:-0.32 to 0.61)SMD(manip+heat+EMS v mob):-0.28(95%CI:-0.77 to 0.21)SMD(mod+heat+EMS v manip): 0.24(95%CI:-0.24 to 0.71)RR(heat v no heat): 1.14(95%CI Mixed: 0.95 to 1.37)RR(EMS v no EMS): 0.90(95%CI Mixed: 0.73 to 1.13)FUNCTION (Neck Disability Index, 0 to 50)Baseline Mean: NR for each subgroupEnd of Study Mean: NR for each subgroupReported Results: no significant differenceSMD(manip v mob): 0.07(95%CI:-0.40 to 0.54)SMD(manip+heat+EMS v mob):-0.08(95%CI:-0.56 to 0.41)SMD(mod+heat+EMS v manip): 0.14(95%CI:-0.33 to 0.62)RR(heat v no heat) 1.14 (95%CI Mixed: 0.94 to 1.38)RR(EMS v no EMS) 0.87 (95%CI Mixed: 0.69 to 1.10)SATISFACTION (10-50 scale; at 4w of care)SMD(manip v mob): 0.11(95%CI:-0.35 to 0.58)SMD(manip+heat+EMS v mob): 0.14(95%CI:-0.35 to 0.62)SMD(mod+heat+EMS v manip): -0.12(95%CI:-0.59 to 0.36)SIDE EFFECTS: interviewed at 4 weeks of care, no known study related adverse events; manipulation group had statistically significant more transient minor discomfort (16%) v mobilisation group (8.7%)COST OF CARE: number of disability days were not significantly different between groups

Notes


Allocation concealment

A - Adequate

Study

Jensen 1990

Methods

Type of Trial: RCT (crossover at week 3 for those not improved)Number Analysed/Randomised: 19/23Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Chronic neck disorder with headache [post traumatic]

Interventions

INDEX TREATMENTManual Therapy Group (MT): mobilisation (passive, neuromuscular): soft passive movements of the joint at the outer range of motion described by Stoddard; muscle energy technique an isometric muscle contraction performed by the patient in the opposite direction to the manual treatment described by Bourdillon; the cervical and upper six segments of the thoracic spine were mobilised; at each session 2 to 3 segments were treated, one session/week; analgesicsCOMPARISON TREATMENTCold Pack Group (cold): cold pack 15 to 20 minutes for one session/week; analgesicsCO-INTERVENTION: NRDuration of Therapy Period: 2 week, 2 sessionsDuration of Follow-up: 7 weeks (range: 49 to 69 days)

Outcomes

PAIN (headache intensity, VAS 0 to 100, recorded 4x per day; total markings in mm per week)Baseline Mean: MT 534, Cold 779.9SMD: -1.06 (95%CI:-2.03 to -0.08) [power 9%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECT: recorded as outcome measure, frequency of dizziness, visual disturbances, and ear symptoms (a plugged sensation or tinnitus)COST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Jordan 1998

Methods

Type of Trial: RCTNumber Analysed/Randomised: 102/119Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Chronic mechanical neck disorder without radicular findings

Interventions

INDEX TREATMENTChiropractic Group (CH): manipulation: high velocity, low-amplitude thrust to cervical, traction (manual), manual treatment: given to tender muscles and trigger points, neck school, 2 sessions/weekPhysiotherapy Group (PT): mobilisation (passive), massage, traction (manual), hot pack, ultrasound, proprioceptive neuromuscular facilitation, neck school, 2 sessions/weekCOMPARISON TREATMENTIntensive Training Group (Int ): exercise: group sessions, stationary bicycle, stretching, strength training for neck (Neck Exercise Unit ), shoulder, scapular and chest muscles; massage; traction [manual]; hot pack, ultrasound, proprioceptive neuromuscular facilitation, neck school, 2 sessions/weekCO-INTERVENTION: NRDuration of Therapy Period: 6 weeks, 12 sessionsDuration of Follow-up: 46 weeks

Outcomes

PAIN [headache intensity, three 11 point box scale (max. score 30)]Baseline: NRSMD(PTv Int): 0.00(95%CI:-0.47 to 0.47) [power 11%]SMD(CHvPT and CHvInt): 0.00(95%CI:-0.48 to 0.48) [power 11%]FUNCTION [self-report disability index (max. score 30)]SMD(PTv Int): -0.25(95%CI: -0.73 to 0.22) [power 18%]SMD(CHvPT): 0.00(95%CI:-0.48 to 0.48) [power 11%]SMD(CHvInt): -0.36(95%CI:-0.84 to 0.12) [power 11%]GLOBAL PERCEIVED EFFECT (patient perceived effect, 6 point scale)SMD(CHvPT and CHvInt): 0.00(95%CI:-0.48 to 0.48) [power 11%]SIDE EFFECT: CH: persistent acute pain (n = 1)COST OF CARE: NR

Notes Allocation concealment

A - Adequate

Study

Jordan 1998: PT v CH

Methods Participants Interventions Outcomes


Notes Allocation concealment

A - Adequate

Study

Jordan 1998:CH v Int

Methods

[Refer to Jordan 1998 for details; author described CH v Int]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jordan 1998:PT v CH

Methods Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jordan 1998:PT v Int

Methods

[Refer to Jordan 1998 for details; author described PT v Int]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jordan1998: CH v PT

Methods

[Refer to Jordan 1998 for details; author described CH v PT]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jull 2002

Methods

Type of Trial: RCTNumber Analysed/Randomised: 193/200Intention-to-treat Analysis: calculatedPower Analysis: NR

Participants

Chronic neck disorder with headache

Interventions

INDEX TREATMENTManipulative Therapy (MT): manipulation: high velocity, low-


amplitude manipulation described by Maitland; mobilisation (low velocity), 30 minute session duration, 2 sessions/w, 8 to 12 sessions totalCombined Therapy (MT/ExT): manipulation, mobilisation, exercise, 30 minute session duration, 2 sessions/w, 8 to 12 sessions totalCOMPARISON TREATMENTExercise Therapy (ExT): therapeutic low load exercise to cervical-scapular region: craniocervical flexor training with pressure biofeedback, scapular muscle training, postural correction, exercise performed throughout the day, isometric strengthening with co contraction of neck flexion and extension, stretching as needed, 30 minute session duration, 2 sessions/w, 8 to 12 sessions totalControl Group: no treatmentCO-INTERVENTION: NRDuration of Therapy Period: 6 weeks, 8 to 12 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (headache intensity change score, VAS, 0 to 10)Baseline Mean: MT 4.8, ExT 5.4, MT/ExT 5.1, Control 5.3Absolute Benefit: MT 2.3, ExT 2.8, MT/ExT 2.7, Control 1.3Reported Results: significant favouring MT and ExTSMD(MTv Cntl): -0.37(95%CI:0.78 to 0.04) [power 96%]SMD(MTvExT): 0.21(95%CI:-0.18 to 0.61) [power 96%]SMD(MT/ExTvExT): 0.06(95%CI:-0.35 to 0.46) [power 98%]SMD(MT/ExTvCntl): -0.58(95%CI:-1.00 to -0.17)FUNCTION (Northwick Park neck pain questionnaire change score, 0 to 36)Baseline Mean: MT 27.5, ExT 29.6, MT/ExT 29.7, Control 30.7Absolute Benefit: MT 11.2, ExT 15.7, MT/ExT 14.2, Control 6.4Reported Results: significant favouring MT or MT/ExT over control; no significant difference between MT, ExT and MT/ExT comparisonsSMD(MTv Cntl): -0.39(95%CI:-0.79 to 0.02) [power 100%]SMD(MTvExT): 0.32(95%CI:-0.08 to 0.72) [power 100%]SMD(MT/ExTvExT): 0.11(95%CI:-0.29 to 0.50) [power 59%]SMD(MT/ExTvCntl): -0.64(95%CI:-1.06 to -0.23)GLOBAL PERCEIVED EFFECT (participant perceived effect, VAS 0 to 100)Reported Results: significant favouring MT and MT/ExT over control, not significant for MT or MT/ExT when compared to ExTSMD(MTv Cntl): -2.36(95%CI:-2.89 to -1.83)SMD(MTvExT): 0.29(95%CI:-0.10 to 0.69) [power 81%]SMD(MT/ExTvExT): 0.01(95%CI:-0.38 to 0.40) [power 59%]SMD(MT/ExTvCntl): -2.73(95%CI:-3.30 to -2.16)SIDE EFFECT: minor and temporary, 6.7% of headaches were provoked by treatmentCOST OF CARE: NR

Notes Allocation concealment

A - Adequate

Study

Jull 2002: MT v Cntl

Methods

[Refer to Jull 2002 for details; author described manual therapy group v control group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jull 2002: MT v ExT

Methods

[Refer to Jull 2002 for details; author described manual therapy group v exercise treatment]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jull 2002: MTv MTExT

Methods

[Refer to Jull 2002 for details; author described manual therapy group v manual therapy and exercise treatment]


Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jull 2002:MTExTv ExT

Methods

[Refer to Jull 2002 for details; author described manual therapy and exercise treatment v exercise treatment]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Jull 2002:MTExTvCntl

Methods

[Refer to Jull 2002 for details; author described manual therapy and exercise treatment v control group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Karlberg 1996

Methods

Type of Trial: RCTNumber Analysed/Randomised: 17/17Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Subacute mechanical neck disorder with headache

Interventions

INDEX TREATMENTPhysiotherapy Group (PT): mobilisation (passive, neuromuscular): technique described by Kaltenborn and Lewit, soft tissue treatment, physiotherapy treatment = exercise: stabilization exercise described by Feldenkrais, relaxation techniques described by Jacobson, NSAID, education; median 13 sessions (range: 5 to 23)/9 weeksCOMPARISON TREATMENTDelayed Treatment Group (D): wait period: 8 weeks without treatmentCO-INTERVENTION: NRDuration of Treatment: median 8 to 9 weeks, 13 sessionsDuration of Follow-up: 0 days

Outcomes

PAIN (headache intensity, VAS 0 to 100)Baseline Mean: PT 54, D 56End of Study Mean: PT 31, D 55Absolute Benefit: PT 23, D 1Reported Results: significant favouring PTSMD: -1.47(95%CI:-2.58 to -0.36)FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Koes 1992

Methods

Type of Trial: RCTNumber Randomised: 64Number Analysed: 58/64, not specified for 6 month and 1 year follow-up for neck only groupIntention-to-treat Analysis: calculated


[see chapter 5, table 6]Power Analysis: calculated, 50 subjects per group Participants

Subacute, chronic mechanical neck disorder

Interventions

ND EX TREATMENTManual Therapy Group (MT): manipulation and mobilisation: described by Dutch Society of Manual Therapy, [Note: all therapists except for placebo therapists were free to choose from their usual therapeutic domain within explicitly formulated limits, e.g. no manipulative techniques were performed by the physio]; mean 5.4 (SD: 6) sessions/8.9 weeksCOMPARISON TREATMENTPhysical Therapy Group (PT): massage, exercise, heat, electrotherapy (10% received exercise/massage; 44% heat/ exercise/massage; 12% electrotherapy/exercise/massage; 9% electrotherapy/ heat/ exercise/ massage; 3% exercise only; 9% exercise/heat; 5% electrotherapy/exercise; 5% massage only; 3% massage/heat), exercise, heat, electrotherapy; mean 14.7 (SD: 14) sessions/7.8 weeksGeneral Practitioner Group (GP): analgesics, NSAID, education: posture, home exercises, participation in sports, bed rest and other treatment modalities; 1 sessionPlacebo Treatment (Pl): de-tuned SWD & US; 2 times/week, mean 11.1 (SD: 12) sessions/5.8 weeksCO-INTERVENTION: detailed in chapter 6, table 5Duration of Therapy Period: varied from 1 to 9 weeksDuration of Follow-up: 9 weeks of treatment plus 3 weeks follow-up Note: 6 and 12 months data not reported due to extensive cross over of care

Outcomes

PAIN (WHYMPI: 10 point scale)Baseline: NRReported Results: better results favouring MT@ 9w treatment + 3w follow-upSMD(MTvpl): 0.10(95%CI; -0.68 to 0.89) [power 8%]SMD(MTvGP): -0.50(95%CI:-1.28 to 0.28) [power 11%]SMD(MTvPT): -0.64(95%CI:-1.35 to 0.08) [power 14%]FUNCTION (physical functioning,10 point scale)Baseline Mean: MT 6.11, PT 5.6, GP 5.29, Pl 5.71End of Study Mean: MT 1.20, PT 2.52, GP 3.86, Pl 1.26Absolute Benefit: MT 4.91, PT 3.08, GP 1.43, Pl 4.45Reported Results: significant favouring MT@ 9w treatment +3w follow-up:SMD(MTvpl): 0.06(95%CI:-0.86 to 0.74) [power 10%]SMD(MTvGP): -0.91(95%CI:-1.74 to 0.08) [power 12%]SMD(MTvPT): -0.75(95%CI:-1.50 to 0.00) [power 17%]GLOBAL PERCEIVED EFFECT:Reported Results: not significant between groupsPATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

A - Adequate

Study

Koes 1992: MT v GP

Methods

[Refer to Koes 1992 for details; author described manual therapy (MT) group v general practitioner (GP) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Koes 1992: MT v PT

Methods

[Refer to Koes 1992 for details; author described manual therapy (MT) group v physical therapy (PT) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Koes 1992: MT v pl


Methods

[Refer to Koes 1992 for details; author described manual therapy (MT) group v placebo (pl) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Koes 1992: PT v GP

Methods

[Refer to Koes 1992 for details; author described physical therapy (PT) group v general practitioner (GP) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Koes 1992: PT v MT

Methods

[Refer to Koes 1992 for details; author described physical therapy (PT) group versus manual therapy (MT) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Koes 1992: PT v pl

Methods

[Refer to Koes 1992 for details; author described physical therapy (PT) group v placebo (pl) group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Kogstad 1978

Methods

Type of Trial: quasi-RCTNumber Analysed/Randomised: 50/50Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Mechanical neck disorder with radicular symptoms, duration NR

Interventions

INDEX TREATMENTManual Therapy Group (MT): manipulation (described by Brodin), heat, soft tissue massage; 40-minute sessions, 2 sessions/week for 4 weeksCOMPARISON TREATMENTConventional Therapy Group (CT): heat, soft tissue massage, isometric exercises, home exercises and 15 minutes intermittent mechanical


traction 60-minute sessions, 3 sessions/week for 5 weeksPlacebo Group (Pl): placebo tablets 3 times/day for 5 weeksCO-INTERVENTION: 3 patients in placebo group received conventional treatment or manual therapy during 18 month follow-up periodDuration of Therapy Period: 5 weeks, 8 sessions for MT; 12 sessions for CTDuration of Follow-up: 18 months Outcomes

GLOBAL PERCEIVED EFFECT (objective and subjective findings)Reported Results: not significantRR(MT v CT): 0.77(95%CI: 0.16 to 3.61) [power 6%]RR(MT v Pl): 0.33(95%CI: 0.08 to 1.32) [power 8%]SIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

C - Inadequate

Study

Kogstad 1978:MT v CT

Methods

[Refer to Kogstad 1978 for details; author describes Manual Therapy Group versus Conventional Therapy Group]

Participants Interventions Outcomes Notes Allocation concealment

C - Inadequate

Study

Kogstad 1978:MT v Pl

Methods

[Refer to Kogstad 1978 for details; author describes Manual Therapy versus Placebo Group]

Participants Interventions Outcomes Notes Allocation concealment

C - Inadequate

Study

McKinney 1989

Methods

Type of Trial: RCTNumber Analysed/Randomised: 170/247Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Acute mechanical neck disorder, whiplash associated disorder

Interventions

INDEX TREATMENTGroup 2 (G2): mobilisation (passive, active): described as active and passive repetitive movements using principles of Maitland and McKenzie; heat/cold application, short wave diathermy, hydrotherapy, traction; "the full gamut of physiotherapeutic aids was available as deemed appropriate"; education: posture and exercise to perform at home; standard analgesic; collar: fitted with soft collar (intermittent use); three 40-minute sessions/weeks for 6 weeksCOMPARISON TREATMENTGroup 1 (G1): education: mobilization after an initial 10 to 14 day rest period, general advice; analgesics; collar: fitted with soft collar (continuous use)Group 3 (G3): education: posture correction, use of analgesics, use of collar (restricted to very short periods in situations where their neck was vulnerable to sudden jolting, if collar worn exercise should be performed immediately after), use of heat sources, muscle relaxation, encouraged to perform demonstrated mobilisation exercises; analgesicsCO-INTERVENTION: NRDuration of Therapy Period: 6 weeks, 24 sessionsDuration of Follow-up: 2 weeks

Outcomes

PAIN (VAS 0 to 10)Baseline Median: G1 5.6, G2 5.3, G3 5.3End of Study Median: G1 3.0, G2 1.9, G3 1.8Absolute Benefit: G1 2.6, G2 3.4, G3 3.5Reported Results: significantly better than rest (G1)SMD(2v1): -0.48 (95%CI:-0.90 to -0.06)SMD(2v3):


0.50 (95%CI:-0.28 to 0.39) [power 16%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR Notes Allocation concealment

B - Unclear

Study

McKinney 1989: 2 v 1

Methods

[Refer to McKinney 1989 for details; author described group 1 v 2]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

McKinney 1989: 2 v 3

Methods

[Refer to McKinney 1989 for details; author described group 2 v 3]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Mealy 1986

Methods

Type of Trial: RCTNumber Analysed/Randomised: 51/61Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Acute mechanical neck disorder, whiplash associated disorder

Interventions

INDEX TREATMENTActive Group (A): mobilisation (passive): technique described by Maitland; exercise: within the limits of pain, daily, every hour at home; heat; ice; analgesicsCOMPARISON TREATMENT:Standard Group (S): soft cervical collar, worn for two weeks; rest for two weeks before beginning gradual mobilisation; analgesicsCOINTERVENTION: NRDuration of Therapy Period: 8 weeksDuration of Follow-up: 0 days

Outcomes

PAIN (pain intensity, linear analogue scale 0 to 10)Baseline Mean: A 5.71, S 6.44End of Study Mean: A 1.69, S 3.94Absolute Benefit: A 4.02, S 2.50Reported Results: significant favouring active groupSMD: -0.86(95%CI:-1.44 to -0.29)FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECT: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Nilsson 1997

Methods

Type of Trial: RCTNumber Analysed/Randomised: 53/54Intention-to-treat Analysis: NRPower Analysis: yes

Participants

Chronic neck disorder with headache

Interventions

INDEX TREATMENTManipulation Group (manip): manipulation: toggle recoil (mean 12) for upper cervical spine, diversified (mean 10) technique for mid- and lower cervical spine; high velocity, low amplitude thrust at the end point of passive range of motion, 6 sessions/3 weeksCOMPARISON TREATMENTSoft Tissue Group (ST): massage: deep


frictions and trigger point treatment of posterior muscles of shoulder girdle, upper thoracic and lower cervical, 6 session/3 weeks; laser: laser light in the upper cervical region ("no effect apart from placebo can be expected from such low power laser"), 6 sessions/3 weeksCO-INTERVENTION: NRDuration of Therapy Period: 3 weeks/6 sessionsDuration of Follow-up: 1 week

Outcomes

PAIN (headache intensity per episode, VAS 0 to 100)Baseline Median: manip 48, ST 37End of Study Median: manip 15, ST 6Absolute Benefit: manip 33, ST 31Reported Results: significant favouring manipulationSMD: -0.45(95%CI:-0.99 to 0.10) [power 16%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Nordemar 1981

Methods

Type of Trial: RCTNumber Analysed/Randomised: 30/30Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Acute mechanical neck disorder without radicular findings

Interventions

INDEX TREATMENTManual Therapy Group (MT): mobilisation (neuromuscular, passive): static muscle work against resistance in a painless direction for 5-6 seconds followed by postcontractory passive rotation in the painless direction, postcontractory or reciprocal inhibition was used to stretch muscle; soft tissue treatment: parameters not specified; gentle traction [manual]; collar: semi-soft material modified to patients pain position; education: rest, use of medication, encouraged use of soft collar intermittently and when not wearing collar to move neck to the point of pain in every direction, patient encouraged to use neck collar at night if this provided additional relief; analgesics: salicylic acid, paracetamol, dextropropoxiphen; 30 minutes, 3 times/weekCOMPARISON TREATMENTTranscutaneous Electrical Nerve Stimulation Group (TENS): duration treatment 15 minutes, 3 times/week; collar, education, medication: same as manual therapy groupCollar Group: collar, education, medication: same as manual therapy groupCO-INTERVENTION: NRDuration of Therapy Period: 2 weeks, 6 sessionsDuration of Follow-up: 10 weeks

Outcomes

PAIN [neck pain intensity, VAS (at rest + pain in motion) 0 to 100]Baseline Mean: MT 97, TENS 83, Collar 90End of Study Mean: MT 18, TENS 17, Collar 35Absolute Benefit: MT 79, TENS 66, Collar 55Reported Results: not significantSMD(MTvCol): -0.45(95%CI:-1.34 to 0.44) [power 7%]SMD(MTvTENS): 0.04(95%CI:-0.83 to 0.92) [power 5%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Nordemar 1981:MTvCol

Methods

[Refer to Nordemar 1981 for details; author described manual therapy group v collar group]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Nordemar 1981:MTvTNS

Methods

[Refer to Nordemar 1981 for details; author described manual therapy group v transcutaneous electrical nerve stimulation group]


Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Parkin-Smith 1998

Methods

Type of Trial: RCTNumber Analysed/Randomised: 30/30Intention-to-treat Analysis: not calculatedPower Analysis: calculated

Participants

Mechanical neck disorder without radicular signs and symptoms, duration disorder NR

Interventions

INDEX TREATMENT:Group A: manipulation (cervical)COMPARISON TREATMENT:Group B: manipulation (cervical, thoracic)CO-INTERVENTION: not specifiedDuration of Therapy Period: 3 weeks/6 sessionsDuration of Follow-up: none

Outcomes

PAIN INTENSITY (NRS101)Baseline Mean: A 33.89, B 33.00End of Study Mean: A 17.17, B 13.18Absolute Benefit: A 16.72, B 19.82Reported Results: not significantSMD: 0.29(95%CI:-0.43 to 1.01) [power 94%]FUNCTION (Neck Disability Index 0 to 50)Baseline Mean: A 18.24, B 17.64End of Study Mean: A 6.89, B 4.71Absolute Benefit: A 11.35, B 12.93Reported Results: not significantSMD: 0.30(95%CI:-0.42 to 1.02) [power 100%]SIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Persson 2001

Methods

Type of Trial: RCTNumber Analysed/Randomised: 79/81Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Chronic neck disorder with radicular findings

Interventions

INDEX TREATMENTPT Group: physiotherapy decided by the physiotherapist according to patient's symptoms and individual preferences [manual therapies (massage, manual traction, gentle mobilisation); modalities for pain relief like TENS, application of heat or cold (moist, ultrasound); exercise (relaxation exercises; active stretching, strengthening, endurance exercises, postural correction); ergonomic instruction]; 15 sessions of 30 to 45 minutesCOMPARISON TREATMENTS:Surgery Group: surgery [anterior cervical discectomy technique described by Cloward (1958); mobilisation on the 1st postoperative day; cervical collar use for 1 to 2 days post-operatively ]Collar Group: cervical collar (rigid collars during day; soft collar at night)COINTERVENTION:Surgery group: 8 patients had 2nd operation, 11 patients received physiotherapyPT group: 1 patient had surgeryCollar group: 5 patients had surgery, 12 patients received physiotherapyDuration of Therapy Period: 12 weeks, 15 sessionsDuration of Follow-up: 56 weeks

Outcomes

PAIN INTENSITY (VAS 0 to 100)Baseline Mean: surgery 47, PT 50, collar 49End of Study Mean: surgery 30, PT 39, collar 35Absolute Benefit: surgery 17, PT 11, collar 14Reported Results: not significantSMD(PT v collar): 0.16(95%CI:-0.38 to 0.70) [power 82%]SMD(PT v surgery): 0.33(95%CI:-0.21 to 0.87) [power 76%]WORST PAIN (VAS 0 to 100)Baseline Mean: surgery 72, PT 70, collar 68End of Study Mean: surgery 42, PT 53, collar 52Absolute Benefit: surgery 20, PT 17, collar 16Reported Results: not significantSMD(PT v collar): 0.04(95%CI:-0.50 to 0.57)SMD(PT v surgery): 0.28(95%CI:-0.27 to 0.82)SIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

A - Adequate

Study

Persson 2001:PTv col

Methods

[Refer to Persson 2001 for details; author described physical therapy group v collar


group] Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Persson 2001:PTvsurg

Methods

[Refer to Persson 2001 for details; author described physical therapy group v surgery group]

Participants Interventions Outcomes Notes Allocation concealment

A - Adequate

Study

Provinciali 1996

Methods

Type of Trial: RCTNumber Analysed/Randomised: 60/60Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Acute, subacute neck disorder with headache (cervico-encephalic syndrome = fatigue, dizziness, poor concentration, disturbed accommodation and impaired adaptation to light intensity), whiplash associated disorder

Interventions

INDEX TREATMENTGroup A: mobilisation (passive): technique described by Mealy;massage: technique described by Mealy; exercise (eye fixation): described by Shutty to alter dizziness; neck school described by Sweeney, relaxation training based on diaphragmatic breathing in supine position according to Shutty, active reduction of cervical and lumbar lordosis based on suggestion provided by Neck School according to Sweeney, psychological support to reduce anxiety and limit emotional influence described by Radanov; 10 one-hour sessions/2 weekCOMPARISON TREATMENTGroup B: TENS, PEMF, US, 10 one-hour sessions/2 weekCO-INTERVENTION: NRDuration of Therapy Period: 2 weeks/10 sessionsDuration of Follow-up: 24 weeks

Outcomes

PAIN (neck pain intensity, VAS 0 to 10)Baseline Median: A 6.8, B 7.4End of Study Median: A 4.8 B 2.0Absolute Benefit: A 2.0, B 5.4Reported Results: significant favouring group ASMD: -0.79(95%CI:-1.32 to -0.26)FUNCTION (Return to Work)Baseline: NRReported Results: significant favouring group ASMD: -1.05(95%CI:1.59 to -0.26)GLOBAL PERCEIVED EFFECT (self assessment of outcome, ordinal scale -3 to +3)Reported Result: significant favouring group A, p < 0.001SIDE EFFECTS: NRCOST OF CARE:return to workResults: significant difference favours Group A, a treatment advantage of 16 daysSMD: -1.05(95%CI:-1.59 to -0.51)sick days savedResults: 143 days saved favouring Group A

Notes Allocation concealment

B - Unclear

Study

Reginiussen 2000

Methods

Type of Trial: RCTNumber Analysed/Randomised: ?/63Intention-to-treat Analysis: NRPower Analysis: NR

Participants

Neck disorder with headache, duration disorder NR

Interventions

INDEX TREATMENTManual Therapy (MT): mobilisation, manipulation, soft tissue techniques, massage/stretch, 6 sessions over 3 weeksCOMPARISON


TREATMENTPhysiotherapy (PT): exercise: stretches, shortwave diathermy, 6 sessions over 3 weeksCO-INTERVENTION: NRDuration of Therapy Period: 3 weeks/6 sessionsDuration of Follow-up: 12 weeks Outcomes

PAIN (headache and neck pain intensity)Baseline: NRReported Results: significant favouring MTFUNCTION (Neck Disability Index, 0 to 50)Baseline: NRReported Results: not significantSIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Skargren 1998

Methods

Type of Trial: RCTNumber Analysed/Randomised: 317/323Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Chronic mechanical neck disorder without radicular findings

Interventions

INDEX TREATMENTChiropractic (chiro): 97% manipulation,11% mobilisation, 2% traction, 2% soft tissue treatment, 1% individual training, mean 5.6 sessions over mean 4.9 weeksCOMPARISON TREATMENTPhysiotherapy (PT): 1% manipulation, 25% mobilisation, 15% traction, 25% soft tissue treatment, 33% McKenzie treatment, 21% individual training, 15% TENS/ ultrasound/ cold, 15% individual program, 6% relaxation training, 4% acupuncture, 1% instruction on individual training, mean 7.5 sessions over mean 6.4 weeksCO-INTERVENTION: 0 to 6 months of both chiropractic and physiotherapy treatment: chiro 5.2%, PT 6.7%Duration of Therapy Period: 5 to 6 weeks, 6 to 8 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (neck pain intensity change scores, VAS 0 to 100)Baseline Mean: Chiro 52, PT 61Absolute Benefit: Chiro 16, PT 33Results: significant favouring PTSMD(Chiro v PT): 0.66(95%CI: 0.16 to 1.16)FUNCTION (Oswestry Questionnaire, 0 to 100%)Baseline Mean: Chiro 25, PT 27Absolute Benefit: Chiro 8, PT 12Results: not significantSMD(Chiro v PT): 0.32(95%CI:-0.17 to 0.8) [power 100%]PATIENT SATISFACTION: NRSIDE EFFECTS: NRCOST OF CARE:direct costs (for both neck and lumbar)Results: significant favours PTSMD(PT v Chiro): -0.28(95%CI:-0.50 to -0.05)indirect costs (for both neck and lumbar; of employed subjects)a) median costResults: not significantSMD(PT v Chiro): -0.02(95%CI:-0.25 to 0.22)b) sick leaveResults: not significantRR(PT v Chiro): 1.08(95%CI: 0.75 to 1.54)c) number of days off workResults: not significantSMD(PT v Chiro): 0.06(95%CI:-0.18 to 0.30)

Notes Allocation concealment

B - Unclear

Study

Skargren: Chiro v PT

Methods

[Refer to Skargren 1998 for details; author described chiropractic v physiotherapy]

Participants Interventions Outcomes Notes Allocation concealment

B - Unclear

Study

Skargren: PT v Chiro

Methods

[Refer to Skargren 1998 for details; author described physiotherapy v chiropractic]

Participants Interventions Outcomes


Notes Allocation concealment

B - Unclear

Study

Sloop 1982

Methods

Type of Trial: RCT crossover designNumber Analysed/Randomised: 39/39Intention-totreat Analysis: conductedPower Analysis: NR

Participants

Subacute, chronic mechanical neck disorder with variable degenerative changes [cervical spondylosis]

Interventions

INDEX TREATMENTManipulation Group (manip): manipulation: technique described by Cyriax, Maigne, Maitland, Matthews; muscle relaxantCOMPARISON TREATMENT:Control Treatment: muscle relaxantCO-INTERVENTION: "other medical management was not restricted during the study"Duration of Therapy Period: one sessionDuration of Followup: 3 weeks (then crossover occurs)

Outcomes

PAIN (neck pain intensity, VAS 0 to 100)Baseline: NRAbsolute Benefit: MT 18, Control 5Reported Results: not significantSMD: 0.40(95%CI:-0.23 to 1.04) [power 5%]FUNCTION (selected daily activities, VAS 0 to 100)Baseline: NRReported Results: not significantGLOBAL PERCEIVED EFFECT [patient perceived effect, 0 (completely well) to 8 (worst possible) collapsed to dichotomous response (improved/not improved)]Reported Results: not significantRR: 0.59(95%CI: 0.34 to 1.05)SIDE EFFECTS: 2 people had superficial phlebitis following diazepam injection and recovered uneventfully; 2 people in manipulation group reported a new discomfort in their necks followed by improvement in their chronic neck painRR: 1.0(95%CI: 0.4 to 2.4)COST OF CARE: NR

Notes Allocation concealment

A - Adequate

Study

Vasseljen 1995

Methods

Type of Trial: RCT [Group 3 not randomised]Number Analysed/Randomised: 24/24Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Chronic mechanical neck disorder

Interventions

INDEX TREATMENTGroup 1 (G1): mobilisation (passive): provided when indicated; massage: 5 to10 minutes; exercise: strength on weight training apparatus, 5 to 10 minutes, and stretching 3 to 4 minutes, total 20 to 30 minutes; education: ergonomic principles, home exercise on postural control, strength and flexibility training of the shoulder/neck region; two one hour sessions/week for 10 sessionsCOMPARISON TREATMENTGroup 2 (G2): exercise: adopted from Dyrssen, 1.1kg dumbbells in both hands, 4 arm exercises each performed 10 times, cycle repeated 3 times; load adjusted for 10 repetitions, abdominal and back exercises; breathing techniques; 5 minutes stretching exercise to shoulder/neck; education: same as Group 1; three 30 minute session/week for 6 weeksCO-INTERVENTION: NRDuration of Therapy Period: 5 to 6 weeks, 10 to 18 sessionsDuration of Follow-up: 24 weeks; mailed questionnaire

Outcomes

PAIN (neck pain intensity, VAS 0 to10)Baseline Mean: G14.2, G2 4.2End of Study Mean: G1 2.2, G2 2.1Absolute Benefit: G1 2.0, G2 2.1Reported Result: not significantSMD: 0.09(95%CI:-0.71 to 0.89) [power 9%]RR: 0.29(95% CI: 0.07 to 1.10)FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS NRCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Vernon 1990

Methods

Type of Trial: RCTNumber Analysed/Randomised: 9/9Intention-to-treat Analysis: conductedPower Analysis: NR

Participants

Acute, subacute, chronic mechanical neck disorder

Interventions

INDEX TREATMENTManipulation (M): rotational, high velocity, low-amplitude


thrustCOMPARISON TREATMENT:Sham/Mobilisation (S): rotational mobilisation with gentle oscillations into elastic barrier; technique described by Sandoz,COINTERVENTION: NRDuration of Treatment: one sessionDuration of Follow-Up: none

Outcomes

PAIN [pain pressure threshold, algometer (kg/cm)]Baseline Mean: M 3.4, S 2.3End of Study Mean: M 4.8, S 2.3Absolute Benefit: M 1.4. S 0.0Reported Results: significant favouring manipulation when assessed by ANOVASMD(point 2): -1.15(95%CI:-2.65 to 0.34) [power 5%]FUNCTION: NRPATIENT SATISFACTION: NRSIDE EFFECTS: no complicationsCOST OF CARE: NR

Notes Allocation concealment

B - Unclear

Study

Wood 2001

Methods

Type of Trial: Quasi-RCTNumber Analysed/Randomised: 30/30Intention-to-treat Analysis: calculatedPower Analysis: reported

Participants

Subacute mechanical neck disorder

Interventions

INDEX TREATMENTGroup A: manipulation using Activator II Adjusting Instrument, mechanical force, manually assisted, 2 to 3 sessions/weekCOMPARISON:Group B: manual manipulation, high velocity, low amplitude manual adjustment, 2 to 3 sessions/weekCO-INTERVENTION: no medication for at least one month, no other treatment modalities, exercises, or education was prescribedDuration of Therapy Period: 8 sessions, 4 weeksDuration of Follow-up: 4 weeks

Outcomes

PAIN INTENSITY (NRS101)Baseline Mean: Group A 52.5, Group B 48.0End of Study Mean: Group A 23.5, Group B 18.7Absolute Benefit: Group A 29.0, Group B 29.3Reported Results: no significant differenceSMD: 0.29(95%CI:-0.43 to 1.01) [power 99%]FUNCTION (Neck Disability Index 0 to 50)Baseline Mean: Group A 31.8, Group B26.8End of Study Mean: Group A 13.5, Group B 11.0Absolute Benefit: Group A 18.3, Group B 15.8SMD: 0.23(95% CI:-0.48 to 0.95) [power 96%]SIDE EFFECTS: NRCOST OF CARE: NR

Notes Allocation concealment

C - Inadequate

Study

van Schalkwyk 2000

Methods

Type of Trial: quasi-RCTNumber Analysed/Randomised: 30/30Intention-to-treat Analysis: NRPower Analysis: calculated

Participants

Mechanical neck disorder, duration NR

Interventions

INDEX TREATMENTGroup A: cervical rotary break manipulation with contact taken on the ipsilateral side, described by Szaraz, 10 sessions non consecutiveCOMPARISON TREATMENTGroup B: lateral break manipulation with contact taken on the contralateral side, described by Szaraz, 10 sessions non consecutiveCO-INTERVENTION: NRDuration of Therapy Period: 4 weeksDuration of Follow-up: 4 weeks

Outcomes

PAIN INTENSITY (NRS101)Baseline Mean: Group A 38.28, Group B 33.25End of Study Mean: Group A 9.40, Group B 17.54Absolute Benefit: Group A 28.88, Group B 15.71Reported Results: not significant; however our calculations show the difference to favour Group ASMD -0.82(95%CI:-1.57 to -0.07) [power 96%]FUNCTION (NDI, 0 to 50)Baseline Mean: Group A 22.53, Group B 16.4End of Study Mean: Group A 6.00, Group B 6.13Absolute Benefit: Group A 16.53, Group B 10.27Reported Results: not significant [power 34%]SMD -0.01(95%CI:-0.72 to 0.71)

Notes Allocation concealment

C - Inadequate

Characteristics of excluded studies


Study

Reason for exclusion

Donkin 2002

1. Population: Tension-type headache

Dostal 1997

1. Intervention: manipulation was used in combination with ibuprofen as a control

Durianova 1977

1. Outcome: the outcome measure used was not clearly stated

Fitz-Ritson 1994

1. Population: unsure, sample not adequately described [query whiplash associated neck disorder].

Goldie 1970

1. Intervention: Manual therapy in active and control group.

Jahanshahi 1991

1. Population: no sample with neck disorder meeting inclusion criteria [torticollis]

Jensen 1995

1. Intervention: no manual therapy intervention

Leboeuf 1987

1. Population: no sample with neck disorder meeting inclusion criteria [repetitive strain injury of upper limb]

Levoska 1993

1. Intervention: Manual therapy in treatment and control group.

Linton 2001

1. Population: unable to split data into neck pain only group

Mezaki 1995

1. Design: unsure RCT 2. Population: no subjects with neck disorder meeting inclusion criteria [spasmodic torticollis]

Schenk 1994

1. Population: no sample with neck disorder meeting inclusion criteria [normal cervical spine]

Sterling 2001

1. Design: a mechanistic trial

Characteristics of ongoing studies

Study

Bronfort 2000

Guerriero 1997

Trial name or title

Conservative Treatment for Neck Pain: A Pilot Study

Comparative effects of manipulation and physical therapy on motion in the cervical spine

Participants

Interventions

Outcomes

acute and subacute neck pain

medical care v chiropractic care v self care

pain, disability, general health status, overall improvement, satisfaction, bothersomeness and frequency of symptoms, OTC medication use, health care utilization, cervical ROM

chronic neck pain

cervical spine manipulation v sham treatment v cervical spine manipulation, ischemic compression of

cervical ROM

Starting date

Contact information

Wolf-Harris Center for Clinical Studies, 2501 West 84th St. Bloomington, MN 55431, USA gbronfort@nwhealth.edu

Palmer Institute of Graduate Studies and Research, Davenport, Iowa.

Notes


myofascial trigger points , PNF, interferential therapy

not specified

Department of Neuroscience and Locomotion, Physiotherapy, Faculty of Health Sciences, Linkopings Universitet, Sweden

cervicobrachial pain syndrome

manipulative therapy versus placebo physiotherapy versus control

EMG muscle onset, pain, functional disability

B Nagy, The Centre for Musculoskeletal Studies, University Department of Surgery, The University of Western Australia, Australia. email: gta@cms.uwa,edu.au

ScottDawkins 1997

The comparative effectiveness of adjustments versus mobilisation in chronic mechanical neck pain

chronic mechanical neck pain

adjustments (diversified) v mobilisation (muscle energy technique)

cervical ROM, NRS, short form McGill Pain questionnaire, NDI

Technikon Natal College of Chiropractic, Durban, South Africa

Stokke 1995

A randomised comparison of chiropractic and physiotherapy treatment for neck pain of functional (mechanical) origins. A controlled clinical trial

neck pain, neck and head pain, neck and shoulder pain

chiropractic spinal manipulation v physiotherapy v medication

NDI, pain intensity VAS

Institute of Community Medicine, School of Medicine, University of Tramso, 9037 Tromso, Norway.

Tanaka 1995

Chiropractic therapy compared to medical therapy for chronic cervical pain

chronic cervical spine pain

chiropractic care: (lateral flexion) manipulation, exercise plus heat v medical care: heat, exercise, acetaminophen

McGill Pain questionnaire, NDI, cervical ROM, cervical muscle strength (Cybex), SF-36

Kjellman 1997

Comparison of treatment of neck pain

Nagy 2000

Randomised placebo controlled trial for cervico brachial pain syndrome using manual therapy

Whittingham 1995

The efficacy of cervical manipulation (toggle recoil) for chronic headache with upper cervical joint

neck pain

chronic headache

not specified

cervical manipulation (toggle recoil) v placebo

Sickness impact profile, NDI, Pain drawings, Pain threshold [PPT, algometer], cervical ROM,

start: Nov 1994 complete: June 1995

end date April/May 1995

Colorado Prevention Centre, Denver, Colorado, USA

Phillip Chiropractic and Osteopathic Research Centre, Out-patient Clinic Bundoora Campus, R.M.I.T., Melbourne, Australia


dysfunction

A D D I T I O N A L

T A B L E S

Methodological Quality: Jadad Scale

Author (Year)

1aRandomized

1bAppropriate

1cInadequate

2aDouble Blind

2bAppropriate

2cInadequate

3Withdrawals

Allison 2002

1

0

0

0

0

0

0

1/5

Ammer 1990

1

0

0

0

0

0

1

2/5

Bitterli 1977

1

0

-1

0

0

0

0

0/5

Brodin 1984 Brodin 1985

1 1

0 1

0 0

0 0

0 0

0 0

1 1

2/5 3/5

Bronfort 2001

1

1

0

0

0

0

1

3/5

Cassidy 1992

1

0

0

0

0

0

1

2/5

Coppieters 2002a Coppieters 2002b

1

1

0

0

0

0

1

3/5

David 1998

1

1

0

0

0

0

1

3/5

Giebel 1997

1

0

0

0

0

0

1

2/5

Giles 1999

1

0

0

0

0

0

1

2/5

Hoving 2002 Hoving 2001 Korthals-de Bos 2002

1 1 1

1 1 1

0 0 0

0 0 0

0 0 0

0 0 0

1 1 1

3/5 3/5 3/5

Howe 1983

1

1

0

0

0

0

0

2/5

Hurwitz 2002

1

1

0

0

0

0

1

3/5

Jensen 1990

1

1

0

0

0

0

1

3/5

Jordan 1998

1

1

0

0

0

0

1

3/5

Jull 2002

1

1

0

0

0

0

1

3/5

Karlberg 1996

1

0

0

0

0

0

1

2/5

Koes 1991Koes 1992aKoes 1992bKoes 1992cKoes 1992dKoes 1992eKoes 1993

1111111

1111111

0000000

0101000

0000000

0000000

0111111

2/54/53/54/53/53/53/5

Total Score


Kogstad 1978

1

0

-1

0

0

0

0

0/5

McKinney 1989aMcKinney 1989b

11

11

00

00

00

00

10

3/52/5

Mealy 1986

1

1

0

1

0

0

1

4/5

Nilsson 1995Nilsson 1996Nilsson 1997

111

000

000

000

000

000

111

2/52/52/5

Nordemar 1981

1

0

0

0

0

0

1

2/5

Parkin-Smith 1998

1

0

0

0

0

0

0

1/5

Persson 19962001

1

1

0

0

0

0

1

3/5

Provinciali 1996

1

0

0

0

0

0

1

2/5

Reginiussen 2000

1

0

0

0

0

0

0

1/5

Skargren 1997Skargren 1998

1

0

0

0

0

0

1

2/5

Sloop 1982

1

1

0

1

1

0

1

5/5

van Schalkwyk 2000

1

0

0

0

0

0

1

2/5

Vasseljen 1995

1

0

0

0

0

0

1

2/5

Vernon 1990

1

0

0

0

0

0

1

2/5

Wood 2001

1

0

0

0

0

0

1

2/5

Methodological Score: van Tulder Scale Author

A

B

C

D

E

F

G

H

I

Allison 2002

0

1

0

0

1

1

0

0

0

Ammer 1990

0

1

0

0

0

1

0

1

0

Bitterli 1977

0

1

0

0

0

0

0

1

0

Brodin 1984 Brodin 1985

0 1

1 1

0 0

0 0

0 0

0 0

0 0

0 1

0 0

Bronfort 2001

1

1

1

0

1

1

0

1

0

Cassidy 1992

0

1

1

0

0

1

1

1

0


Coppieters 2002a Coppieters 2002b

1

1

1

0

1

0

1

1

0

David 1998

1

1

0

0

0

0

0

1

0

Giebel 1997

0

1

1

0

1

0

0

1

0

Giles 1999

1

0

0

0

0

0

1

1

0

Hoving 2002 Hoving 2001 Korthals-de Bos 2002

1 1 1

1 1 1

1 0 0

0 0 0

1 1 1

1 1 1

1 0 0

1 0 0

0 0 0

Howe 1983

1

0

0

0

1

0

0

0

0

Hurwitz 2002

1

1

1

0

0

1

0

1

0

Jensen 1990

1

1

0

0

0

0

0

1

0

Jordan 1998

1

1

1

0

0

0

1

1

0

Jull 2002

1

1

0

0

1

1

1

1

0

Karlberg 1996

0

1

0

0

0

1

0

1

0

Koes Koes Koes Koes Koes Koes Koes

1 1 1 1 1 1 1

1 1 1 1 0 1 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

1 1 1 1 1 1 1

1 1 1 1 1 1 0

0 0 0 0 0 0 0

0 1 1 1 1 1 1

0 0 0 0 0 0 0

Kogstad 1978

0

0

0

0

0

0

0

0

0

McKinney 1989a McKinney 1989b

1 1

0 0

0 0

0 0

1 1

0 0

0 0

1 1

0 0

Mealy 1986

1

1

0

0

1

0

0

1

0

Nilsson 1995 Nilsson 1996 Nilsson 1997

0 0 0

1 1 1

0 0 0

0 0 0

1 1 1

0 0 1

0 0 0

1 1 1

0 0 0

Nordemar 1981

0

1

0

0

0

1

1

0

0

Parkin-Smith 1998

0

0

0

0

0

0

0

1

0

Persson 2001

1

1

0

0

0

1

0

1

0

Provinciali 1996

0

1

0

0

1

1

0

1

0

Reginiussen 2000

0

0

0

0

1

0

0

1

0

Skargren 1997 Skargren 1998

0

0

0

0

0

0

1

1

0

Sloop 1982

1

1

0

1

1

1

1

1

0

1991 1992a 1992b 1992c 1992d 1992e 1993


van Schalkwyk 2000

0

1

0

0

0

1

0

1

0

Vasseljen 1995

0

1

0

0

0

1

1

1

0

Vernon 1990

0

1

1

0

1

1

1

0

0

Wood 2001

0

1

1

0

0

1

0

1

0

NNT & Treatment Advantage: Pain Relief with Multimodal Care Author/Comparison

NNT

Advantage (%)

Brodin 1985: 3v1

4 [complete neck pain reduction]

N/A

Bronfort 2001: SMT/Ex v SMT

10 [clinically important pain reduction]

12.5%

Geibel 1997: 1 v 2

8 [complete neck pain reduction]9 [complete H/A reduction]

5.5%

Hoving 2002: MT v GP

20 [clinically important pain reduction]

5.0%

Jull 2002: MT/ExT v Cntl

5 [clinically important pain reduction]

27.1%

Karlberg 1996: treatment v delayed treatment

2 [clinically important pain reduction]

40.8%

McKinney 1989: 2 v 1

11 [clinically important pain reduction]

17.1%

Mealy 1986

6 [clinically important pain reduction]

40.8%

Provinciali 1996: A v B

6 [clinically important pain reduction] 31 [complete pain reduction]

36.9%

Skargren 1998: PT v Chiro

4 [clinically important pain reduction]

26.1%

Vasseljen 1995

11 [clinically important pain reduction]4 [substantive pain reduction]

11.9%

Search Strategy for MEDLINE

1. neck/ or neck muscles/ or exp cervical plexus/ or exp cervical vertebrae/ or Atlanto-Axial Joint/ or atlanto-occipital joint/ or axis/ or atlas/ or spinal nerve roots/ or exp brachial plexus/ 2. (odontoid or cervical or occip: or atlant:).tw. 3. 1 or 2 4. exp arthritis/ or exp myofascial pain syndromes/ or fibromyalgia/ or spondylitis/ or exp spinal osteophytosis/ or spondylolisthesis/ 5. exp headache/ and cervic:.tw. 6. whiplash injuries/ or cervical rib syndrome/ or torticollis/ or cervico-brachial neuralgia.ti,ab,sh. or exp radiculitis/ or polyradiculitis/ or polyradiculoneuritis/ or thoracic outlet syndrome/ 7. (monoradicul: or monoradicl:).tw. 8. 4 or 5 or 6 or 7 9. random:.ti,ab,sh. 10. randomised controlled trial.pt. 11. double-blind method/ 12. single blind method/ 13. placebos/ 14. clinical trial.pt. 15. exp clinical trials/ 16. controlled clinical trial.pt. 17. (clin$ adj25 trial$).ti,ab. 18. ((singl$ or doubl$ or trebl$) adj25 (blind$ or mask$)).ti,ab.


19. placebo$.ti,ab. 20. or/9-19 21. exp arthritis/rh,th or exp myofascial pain syndromes/rh,th or fibromyalgia/rh,th or spondylitis/rh,th or exp spinal osteophytosis/rh,th or spondylosis/rh,th or spondylolisthesis/rh,th 22. exp headache/rh,th and cervic:.tw. 23. whiplash injuries/rh,th or cervical rib syndrome/rh,th or thoracic outlet syndrome/rh,th or torticollis/rh,th or cervico-brachial neuralgia/rh,th or exp radiculitis/rh,th or polyradiculitis/rh,th or polyradiculoneuritis/rh,th 24. or/21-23 25. exp alternative medicine/ or chiropractic/ 26. (acupuncture or biofeedback or chiropract: or electric stimulation therapy or kinesiology or massage or traditional medicine or relaxation or therapeutic touch).tw. 27. or/25-26 28. 3 and 24 29. 3 and 8 and 27 30. 28 or 29 31. 20 and 30

R E F E R E N C E S References to studies included in this review Allison 2002 {published data only} Allison GT, Nagy BM, Hall T. A randomized clinical trial of manual therapy for cervico-brachial pain syndrome - a pilot study. Manual Therapy 2002;7:95-102. Allison 2002:NT v AT {published data only} refer to Allison 2002. . :-. Allison 2002:NT v CG {published data only} refer to Allison 2002. . :-. Ammer 1990 {published data only} Ammer K, rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, Rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, Rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-68. Ammer K, Rathkolb O. Physical therapy in occipital headaches. Manual Medizin 1990;28:65-8. Ammer 1990: 1 v 2 {published data only} refer to Ammer 1990. . :-. Ammer 1990: 1 v 3 {published data only} refer to Ammer 1990. . :-. Bitterli 1977 {published data only} Bitterli J, Graf R, Robert F, Adler R, Mumenthaler M. Zur objectivierung der manualtherapeutischen beeinflussbarkeit des spondylogenen kopfschmerzes. Nervenarzt 1977:259-262. Bitterli 1977: A v B {published data only} refer to Bitterli 1977. . :-. Bitterli 1977: A v C {published data only} refer to Bitterli 1977. . :-. Bitterli 1977: B v C {published data only} refer to Bitterli 1977. . :-. Brodin 1985 {published data only}


Brodin H. Cervical pain and mobilization. Internation Journal of Rehabilitation Research 1984;7:190-1. Brodin H. Cervical pain and mobilization. Manual Medicine 1985:18-22. Brodin 1985: 2 v 1 {published data only} refer to Brodin 1985. . :-. Brodin 1985: 3 v 1 {published data only} refer to Brodin 1985. . :-. Brodin 1985: 3 v 2 {published data only} refer to Brodin 1985. . :-. Bronfort 2001 {published data only} Bronfort G, Evan R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001;26:788-99. Bronfort:SMT/ExvMedX {published data only} refer to Bronfort 2001. . :-. Bronfort:SMT/ExvSMT {published data only} refer to Bronfort 2001. . :-. Bronfort:SMTv MedX {published data only} refer to Bronfort 2001. . :-. Bronfort:SMTvSMT/Ex {published data only} refer to Bronfort 2001. . :-. Cassidy 1992 {published data only} Cassidy J. The immediate effect on manipulation vs mobilisation pain and range of motion in the cervical spine: A randomized controlled trial [Letter]. Journal of Manipulative and Physiological Therapeutics 1993;16:279-80. Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: A randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 1992;15:570-75. Coppieters 2002 {published data only} Coppieters MW, Stappaerts KH. The immediate effects of manual therapy in patients with cervicobrachial pain on neural origin: A pilot study. IFOMT 2000: International Federation of Orthopaedic Manipulative Therapists in conjunction with the 11th biennial conference of the manipulative physiotherapists association of Australia. Perth: The University of Western Australia, 2000:Poster 7. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K. Aberrant protective force generation during neural provocation testing and the effect of treatment in patients with neurogenic cervicogenic pain. :-. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K. Immediate effect of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. :-. David 1998 {published data only} David J, Modi S, Aluko AA, Robertshaw C, Farebrother J. Chronic neck pain: A comparison of acupuncture treatment and physiotherapy. British Journal of Rheumatology 1998:118-22. Giebel 1997 {published data only} Giebel GD, Edelmann M, Huser R. Die distorsion der halswirbelsaule: Fruhfunktionalle vs. ruhigstellende behandlung. Zentralbl Chir 1997;122:517-21. Giles 1999 {published data only} Giles LGF, Muller R. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. Journal of Manipulative and Physiological Therapeutics 1999;22:376-81. Giles 1999:ManipvMed {published data only}


refer to Giles 1999. . :-. Giles1999:ManipvAcup {published data only} refer to Giles 1999. . :-. Hoving 2002 {published data only} Hoving JL, Vet HCW, Koes BW, Mameren H, Deville WJLM, Windt DAWM. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized trial. In: Hoving JL, editor(s). Wageningen: Pons & Looijen bv, 2001:59-73. Hoving JL, Koes BW, Vet HCW, Windt DAWM, Assendelft WJJ, Mameren H. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine 2002;136:713-59. Korthals-de Bos IBC, Hoving JL, Tulder MW, Rutten-van Molken MPMH, Ader HJ. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. British Medical Journal 2003;326:1-6. Korthals-de Bos IBC, Hoving JL, Tulder MW, Rutten-van Molken MPMH, Ader HJ. Manual therapy is more cost-effective than physical therapy and GP care for patients with neck pain. In: Wageningen: Pons & Looijen bv, 2001:75-89. Hoving 2002: MT v GP {published data only} see Hoving 2002. . :-. Hoving 2002: MT v PT {published data only} see Hoving 2002. . :-. Hoving 2002: PT v GP {published data only} see Hoving 2002. . :-. Hoving 2002: PT v MT {published data only} see Hoving 2002. . :-. Howe 1983 {published data only} Howe DH, Newcombe RG, Wade MT. Manipulation of the cervical spine - a pilot study. Journal of the Royal College of General Practitioners 1983;33:574-9. Hurwitz 2002 {published data only} Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: Clinical outcomes from the UCLA Neck-Pain Study. Research and Practice 2002;92:1634-41. Jensen 1990 {published data only} Jensen OK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache. Cephalalgia 1990:241-50. Jordan 1998 {published data only} Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain: A prospective single-blind randomized clinical trial. Spine 1998;23:311-19. Jordan 1998: PT v CH {published data only} refer to Jordan 1998. . :-. Jordan 1998:CH v Int {published data only} refer to Jordan 1998. . :-. Jordan 1998:PT v CH {published data only} refer to Jordan 1998. . :-. Jordan 1998:PT v Int {published data only} refer to Jordan 1998. . :-. Jordan1998: CH v PT {published data only}


refer to Jordan 1998. . :-. Jull 2002 {unpublished data only} Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;in press:-. Jull 2002: MT v Cntl {published data only} refer to Jull 2002. . :-. Jull 2002: MT v ExT {published data only} refer to Jull 2002. . :-. Jull 2002: MTv MTExT {published data only} refer to Jull 2002. . :-. Jull 2002:MTExTv ExT {published data only} refer to Jull 2002. . :-. Jull 2002:MTExTvCntl {published data only} refer to Jull 2002. . :-. Karlberg 1996 {published data only} Karlberg M, Magnusson M, Eva-Maj M, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Archives of Physical Medicine and Rehabilitation 1996;77:874-82. Koes 1992 {published data only} Koes B. A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Subgroup analysis and relationship between outcomes measure. Journal of Manipulative and Physiological Therapeutics 1993;16:211-19. Koes B, Boutter LM, Knipshild PG. The effectiveness of manual therapy, physiotherapy and continued treatment by general practitioner for chronic nonspecific back and neck complaints. Journal of Manipulative and Physiological Therapeutics 1991:498-502. Koes BW. Efficacy of manual therapy and physiotherapy for back and neck complaints. :-. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GH, Hofhuizen DM, Houben JP. Randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Manual Therapy in the Netherlands ;1:7-12. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GM, Hofhuizen DM. Randomized clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ :601-5. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GM, Hofhuizen DM. A blind randomized clinical trial of manual therapy and physiotherapy for chronic back and neck complaints: Physical outcome measures. Journal of Manipulative Physiological Therpeutics ;15:16-23. Koes BW, Bouter LM, Mameren H, Essers AH, Verstegen GM, Hofhuizen DM. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. Spine ;17:28-35. Koes 1992: MT v GP {published data only} refer to Koes 1992. . :-. Koes 1992: MT v pl {published data only} refer to Koes 1992. . :-. Koes 1992: MT v PT {published data only} refer to Koes 1992. . :-. Koes 1992: PT v GP {published data only} refer to Koes 1992. . :-. Koes 1992: PT v MT {published data only} refer to Koes 1992. . :-.


Koes 1992: PT v pl {published data only} refer to Koes 1992. . :-. Kogstad 1978 {published data only} Kogstad , OA , Karterud S, Gudmundsen J. Cervicobrachialgia. A controlled trial with conventional treatment and manipulation. Tidiskr Nor Loegeforen 1978;98:845-48. Kogstad 1978:MT v CT {published data only} refer to Kogstad 1978. . :-. Kogstad 1978:MT v Pl {published data only} refer to Kogstad 1978. . :-. McKinney 1989 {published data only} McKinney LA. Early mobilisation and outcome in acute sprains of the neck. British Medical Journal ; 299:1006-8. McKinney LA, Dornan JO, Ryan M. The role of physiotherapy in the management of acute neck sprains following road-traffic accidents. Archives of Emergency Medicine ;6:27-33. McKinney 1989: 2 v 1 {published data only} refer to McKinney 1989. . :-. McKinney 1989: 2 v 3 {published data only} refer to McKinney 1989. . :-. Mealy 1986 {published data only} Mealy K, Brennan H, Fenelon GC. Early mobilisation of acute whiplash injuries. British Medical Journal 1986:656-57. Nilsson 1997 {published data only} Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1995;18:435-40. Nilsson N, Christensen HW, Hartvigsen J. Lasting changes in passive range of motion after spinal manipulation: A randomized, blind, controlled trial. Journal of Manipulative and Physiological Therapeutics 1996;19:165-68. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicaogenic headache. Journal of Manipulative and Physiological Therapeutics 1997;20:326-330. Nordemar 1981 {published data only} Nordemar R, Thorner C. Treatment of acute cervical pain - a comparative group study. Pain 1981;10:93-101. Nordemar 1981:MTvCol {published data only} refer to Nordemar 1981. . :-. Nordemar 1981:MTvTNS {published data only} refer to Nordemar 1981. . :-. Parkin-Smith 1998 {published data only} Parkin-Smith GF, Penter CS. A clinical trial investigating the effect of two manipulative approaches in the treatment of mechanical neck pain: A pilot study. Journal of the Neuromusculoskeletal System 1998;6:6-16. Persson 2001 {published data only} Persson L, Karlberg M, Magnusson M. Effects of different treatments on postural performance in patients with cervical root compression. A randomized prospective study assessing the importance of the neck in poastural control. Journal of Vestibular Research 1996;6:439-53. Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine 1997;22:751-58. Persson LCG, Lilja A. Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar - a blinded, prospective randomized study. Disability and Rehabilitation 2001;23:325-35.


Persson LCG, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. European Spine Journal 1994;6:256-66. Persson 2001:PTv col {published data only} refer to Persson 2001. . :-. Persson 2001:PTvsurg {published data only} refer to Persson 2001. . :-. Provinciali 1996 {published data only} Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodal treatment to prevent the late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine 1996;28:105-11. Reginiussen 2000 {published data only} Reginiussen T, Johnsen R, Torstensen TA. Efficiency of manual therapy on patients with cervicogenic headache: A randomized single blinded controlled trial. Internation Federation of Manipulation Therapy, 7th Scientific Conference. Perth: University of Western Australia, November 2000:Abstract 105. Skargren 1998 {published data only} Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Spine 1998;23:1875-84. Skargren EI, Oberg BE. Predictive factors for 1-year outcome of low-back and neck pain in patients treated in primary care: comparison between the treatment strategies chiropractic and physiotherapy. Pain 1998;77:201-7. Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain, Six-month follow-up. Spine 1997;22:216771. Skargren: Chiro v PT {published data only} refer to Skargren 1998. . :-. Skargren: PT v Chiro {published data only} refer to Skargren 1998. . :-. Sloop 1982 {published data only} Sloop PR, Smith DS, Goldenberg E, Dore C. Manipulation for chronic neck pain: A double-blind controlled study. Spine 1982;7:532-35. van Schalkwyk 2000 {published data only} Schalkwyk R, Parkin-Smith GF. A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: A pilot study. Journal of Manipulative and Physiological Therapeutics 2000;23:324-31. Vasseljen 1995 {published data only} Vasseljen O, Johansen BM, Westgaard RH. The effect of pain reduction on perceived tension and EMG-recoded trapezius muscle activity in workers with shoulder and neck pain. Scandinavian Journal of Rehabilitation Medicine 1995:243-52. Vernon 1990 {published data only} Vernon HT, Aker P, Burns S, Viljakaanen S, Short L. Pressure pain threshold evaluation of the effect of spinal manipulation in the treatment of chronic neck pain: A pilot study. Journal of Manipulative and Physiological Therapeutics 1990;13:13-6. Wood 2001 {published data only} Wood TG, Colloca CJ, Matthews R. A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction. Journal of Manipulative and Physiological Therapeutics 2001;24:260-71. * indicates the major publication for the study References to studies excluded from this review


Donkin 2002 Donkin RD, Parkin-Smith GF, Gomes AN. Possible effect of chiropractic manipulation and combined manual traction and manipulation on tension-type headache: A pilot study. Journal of the Neuromusculoskeletal System 2002;10:89-97. Dostal 1997 Dostal C, Pavelka K, Lewit K. Ibuprofen in the treatment of the cervicaocranial syndrome in combination with manipulative therapy. Fysiatrickay a Reumatologickay Vestniak [Czech] :258-63. Durianova 1977 Durianova J. Functional muscle changes and their influence by physiatric means. Fysiat Revmatol Vestn {Slovak} 1977:16-21. Fitz-Ritson 1994 Fitz-Ritson D. Efficacy of low energy laser therapy for extensor neck muscles and sleep pattern improvement after "whiplash"injury. Journal of Manipulative and Physiological Therapeutics 1994;May 17:277-78. Goldie 1970 Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scandanavian Journal of Rehabilatation Medicine 1970;2:117-21. Jahanshahi 1991 Jahanshahi M, Sartory G, Marsden CD. EMG biofeedback treatment of torticollis: A controlled outcome study. Biofeedback and Self Regulation 1991;16:413-48. Jensen 1995 Jensen I, Nygren A, Goldie I, Westerholm P, Jonsson E. The role of the psychologist in multidisciplinary treatments for chronic neck and shoulder pain: a controlled cost-effectiveness study. Scandanavian Journal of Rehabilatation Medicine 1995;27:19-26. Leboeuf 1987 Leboeuf C, Grant BR, Maginnes GS. Chiropractic treatment of repetitive stress injuries: A preliminary prospective outcome study of SMT versus SMT combined with massage. Journal of the Australian Chiropractors' Association ;17:11-4. Levoska 1993 Levoska S, Keinanen-Kiukaanneimi S. Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up. Archives of Physical Medicine and Rehabilitation 1993;74:425-30. Linton 2001 Linton SL, Ryberg M. A cognative-behavioural group intervention as prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial. Pain 2001;90:83-90. Mezaki 1995 Mezaki T, Kaji R, Kimura J, Mannen T. Dose-response relationship in the treatment of cervicaldystonia with botulinum toxin type A (AGN 191622): A phase II study. Brain and Nerve 1995:857-62. Mezaki T, Kaji R, Kimura J, Osame M, Mizuno Y, Hirayama K. The clinical usefulness of botulinum toxin type A for spasmodic torticollis and facial spasm. Brain and Nerve 1995;47:749-54. Schenk 1994 Schenk R, Adelman K, Rousselle J. The effects of muscle energy technique on cervical range of motion. The Journal of Manual & Manipulative Therapy 1994;2:149-55. Sterling 2001 Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001;6:72-81. Ongoing studies Bronfort 2000


Bronfort G, Garvey T, Transfeldt E, Anderson A, Bittell S. Conservative treatment for neck pain: A pilot study A. Proceedings of the 2000 International Conference on Spinal Manipulation. DesMoines, IA, USA: Foundation for Chiropratic Education and Research, 2000:53. Guerriero 1997 Guerriero D. Comparative effects of manipulation and physical therapy on motion in the cervical spine. Proceedings of the International Conference on Spinal Manipulation [Abstract]. Arlington, Virginia; U.S.A.: April 12-13, 1991. Kjellman 1997 Kjellman G, Oberg B, Skargren E. Comparison of treatment in neck pain. The Second International Forum for Primary Care Research on Low Back Pain [Abstract]. The Hague, The Netherlands: May 30-31, 1997. Nagy 2000 Nagy B, Allison GT, Hall T. Randomised placebo controlled trail for cervicobrachial pain syndrome using manual therapy. International Federation of Manipulative Therapy, 7th Scientific Conference. Perth: The University of Western Australia, November 2000:Abstract 72. Scott-Dawkins 1997 Scott-Dawkins C. The comparative effectiveness of adjustments versus mobilisation in chronic mechanical neck pain. Proceedings of the Scientific Symposium. Tokyo, Japan: June 2-8, 1997. Stokke 1995 Stokke O. A randomized comparison of chiropractic and physiotherapy treatment for neck pain of functional (mechanical) origins: A controlled clinical trial. Conference Proceedings of the Chiropractic Centennial Foundation [Abstract]. July, 1995:372-373. Tanaka 1995 Tanaka, D. Pilot study of chiropractic therapy compared to medical therapy for chronic cervical pain. Conference Proceedings of the Chiropractic Centennial Foundation [Abstract]. 1995:374-375. Whittingham 1995 Whittingham W, English R. The efficacy of cervical manipulation (Toggle Recoil) for chronic headaches with upper cervical dysfunction. Conference Proceedings of the Chiropractic Centennial Foundation [Abstract]. 1995:297-298. Additional references Assendelft 1996 Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. Journal of Family Practice 1996;42:475-80. Bogduk 2000 Bodgduk N. . Journal of Musculoskeletal Pain 2001;8:29-53. Bombardier 2000 Bombardier C. Outcome assessment in the evaluation of treatment of spinal disorders: Summary and general recommendations. Spine 2000;25:3100-3. Borghouts 1998 Bourghouts JAJ, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: A systematic review. Pain. 1998; Vol. 77:1-13. Borghouts 1999 Borghouts JAJ, Koes BW, Bouter LM. Cost-of-illness in neck pain in the Netherlands in 1996. Pain 1999;80:629-36. Bronfort 1997 Bronfort , G . In: Efficacy of spinal manipulation and mobilisation for low back and neck pain: A systematic review and best evidence synthesis Amsterdam: Thesis Publishers Amsterdam, 1997:-. Cicchetti 1976 Cicchetti DV. Assessing inter-rater reliability for rating scales: resolving some basic issues. Brit J Psychiat 1976;129:452-6.


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G R A P H S Graphs and Tables To view a graph or table, click on the outcome title of the summary table below. MANIPULATION AND MOBILISATION: Meta-analyses Outcome title

No. of studies

No. of participants

Statistical method

Effect size

01 Pain Intensity

Standardised Mean Difference (Random) 95% CI

Subtotals only

02 Function

Standardised Mean Difference (Random) 95% CI

Subtotals only

03 Global Perceived Effect

Standardised Mean Difference (Random) 95% CI

Totals not selected

MULTIMODAL CARE - Manipulation or Mobilisation plus Exercise: Qualitative Assessment Outcome title

No. of studies

No. of participants

Statistical method

Effect size

01 Pain Intensity: multimodal [theme: mobilisation and/or manipulation + exercise] v control/comparison

Standardised Mean Totals not Difference selected (Random) 95% CI

02 Pain Intensity: multimodal [theme: mobilisation and/or manipulation + exercise v control/comparisons]

Relative Risk (Random) 95% CI

03 Pain Intensity: multimodal [theme: mobilisation and/or manipulation + exercise v

Standardised Mean Totals not Difference selected (Random) 95% CI

Totals not selected


control/comparison

C O V E R

S H E E T

Manipulation and mobilisation for mechanical neck disorders Reviewer(s) Contribution of Reviewer(s)

Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, This is one review of a series conducted by the Cervical Overview Group: Aker P, Bronfort G, Eddy A, Goldsmith C, Graham N, Gross A, Haines T, Haraldsson B, Houghton P, Kay T, Kroeling P, Peloso P, Radylovick Z, Santaguida P, Trinh K A Gross, J Hoving, T Haines - reviewers CH Goldsmith - statistician CH Goldsmith, P Aker, K Trinh, T Haines, G Bronfort, P Peloso methodological quality assessment N Graham, A Gross, B Haraldsson, C Kennedy, T Haines, P Houghton study selection J Hoving, A Gross, G Bronfort, T Kay - data abstraction J Hoving, A Gross, T Haines - synthesis, recommendations A Eady - research librarian

Issue protocol first published Issue review first published Date of last minor amendment Date of last substantive amendment Most recent changes Date new studies sought but none found Date new studies found but not yet included/excluded Date new studies found and included/excluded Date reviewers' conclusions section amended Contact address

Cochrane Library number Editorial group Editorial group code

2003 issue 1 2004 issue 1 10 March 2003 30 October 2003

Information not supplied by reviewer Information not supplied by reviewer Information not supplied by reviewer Information not supplied by reviewer Ms Anita Gross IAHS, rm 441 1400 Main Street West, 4th Fl Hamilton Ontario CANADA L8S 1C7 Telephone: 905-525-1256 Facsimile: 905-521-6135 E-mail: grossa@mcmaster.ca CD004249 Cochrane Back Group HM-BACK

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External sources of support

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Consortial Center for Chiropractic Research - National Institutes of Health, Bethesda, MD USA Hamilton Hospital Association CANADA University of Saskatchewan, Clinical Teaching and Research Award CANADA Hamilton Health Sciences Corporation, Chedoke-McMaster Foundation CANADA

Internal sources of support


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St Joseph's Healthcare, Centre for Acute Injury Rehabilitation CANADA McMaster University, Department of Clinical Epidemiology and Biostatistics; School of Rehabilitation Sciences; Occupational Health Program CANADA Cabrini Hospital, Department of Clinical Epidemiology AUSTRALIA Monash University, Department of Epidemiology and Preventive Medicine AUSTRALIA LAMP Occupational Health Program CANADA Hamilton Health Science Corporation, Rehabilitation Program CANADA


Manipulation and mobilisation for mechanical neck disorders