WITHDRAWN: Physical medicine modalities for mechanical neck disorders.

BACKGROUND: Twenty-six to 71 percent of the adult population can recall experiencing an episode of neck pain or stiffness in their lifetime. The treatments that patients receive for neck pain are varied, as are the perceptions of the benefits of these treatments. In this age of increasing accountability, governmental agencies, third party payers and patients are demanding evidence-based practice performance. To track down the best estimate of efficacy of the various conservative management strategies for mechanical neck disorders, a four-part systematic review was prepared. Part two investigates and reports on the efficacy of physical medicine modalities. OBJECTIVES: Multiple physical medicine modalities are commonly included as part of therapeutic interventions for mechanical neck disorders (neck pain). The objective of this review was to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders. SEARCH STRATEGY: We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services and reference lists of the retrieved articles from 1985 to December 1993 and we contacted content experts. SELECTION CRITERIA: Randomised trials and controlled trials of physical medicine modalities in adults with mechanical neck disorder. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain information or data that could not be found in the published reports. MAIN RESULTS: Thirteen trials were included. The overall quality of the included trials was generally good. Two trials using electromagnetic therapy produced a significant reduction in pain (p <0.01) with three to four weeks of daily (eight hours per day) therapy sessions; and three using laser therapy did not differ significantly from a placebo (p=0.20) for six to 10 sessions of treatment. Not enough scientific testing exists to clearly determine the effectiveness of other therapies. This includes treatments such as exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic pain / cognitive behavioural rehabilitation strategies. AUTHORS' CONCLUSIONS: There is little information available from trials to support the use of physical medicine modalities for mechanical neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy with respect to pain reduction.

WITHDRAWN: Patient education for mechanical neck disorders.

BACKGROUND: To track down the best estimate of efficacy of the various conservative management strategies for mechanical neck disorders, a four-part systematic review was prepared. Part four investigates the efficacy of patient education strategies as the therapeutic intervention. OBJECTIVES: This review of patient education is one of four reviews of conservative management of mechanical neck disorders. The other reviews address manual, physical and drug therapies. The objective of this review was to assess the effects of patient education for pain in adults with mechanical neck disorders. SEARCH STRATEGY: We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services from 1985 to December 1993, reference lists of the retrieved articles and we contacted experts in the field. SELECTION CRITERIA: Randomised trials or controlled clinical trials of patient educational strategies for adults with mechanical neck disorders. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain data that could not be found in the published reports. MAIN RESULTS: Three trials were included. Their methodological quality varied from weak to strong. One trial did not find a significant reduction in pain using group instructional strategies (neck school) and exercise with or without psychological counselling compared to no treatment (standardised mean difference 0.07, 95% confidence interval -0.51 to 0.66, and -0.37, 95% confidence interval -0.95 to 0.22, respectively). Another trial did not find a significant reduction in pain using individualised patient education (advice), anti-inflammatories and analgesics compared with placebo (standardised mean difference 0.24, 95% confidence interval -0.58 to 1.07). The third trial found that advice which included demonstrated mobilization exercises, verbal and written instruction on posture correction, the use of a collar, heat sources, muscle relaxation and analgesics gave significant pain relief compared with general advice about mobilisation after a period of rest and use of analgesics at 4 weeks of treatment (standardised mean difference -0.62, 95% confidence interval -1.05 to -0.19) but at 6 weeks of treatment there was no longer any difference (s.m.d. -0.37, 95% confidence interval -0.8 to 0.05). The first two trials lacked statistical power and the third was methodologically weak. AUTHORS' CONCLUSIONS: Patient education utilising individualised or group instructional strategies has not been shown to be beneficial in reducing pain for mechanical neck disorders.

A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.

STUDY DESIGN: A randomized, parallel-group, single-blinded clinical trial was performed. After a 1-week baseline period, patients were randomized to 11 weeks of therapy, with posttreatment follow-up assessment 3, 6, and 12 months later. OBJECTIVES: To compare the relative efficacy of rehabilitative neck exercise and spinal manipulation for the management of patients with chronic neck pain. SUMMARY OF BACKGROUND DATA: Mechanical neck pain is a common condition associated with substantial morbidity and cost. Relatively little is known about the efficacy of spinal manipulation and exercise for chronic neck pain. Also, the combination of both therapies has yet to be explored. METHODS: Altogether, 191 patients with chronic mechanical neck pain were randomized to receive 20 sessions of spinal manipulation combined with rehabilitative neck exercise (spinal manipulation with exercise), MedX rehabilitative neck exercise, or spinal manipulation alone. The main outcome measures were patient-rated neck pain, neck disability, functional health status (as measured by Short Form-36 [SF-36]), global improvement, satisfaction with care, and medication use. Range of motion, muscle strength, and muscle endurance were assessed by examiners blinded to patients' treatment assignment. RESULTS: Clinical and demographic characteristics were similar among groups at baseline. A total of 93% of the patients completed the intervention phase. The response rate for the 12-month follow-up period was 84%. Except for patient satisfaction, where spinal manipulative therapy and exercise were superior to spinal manipulation with (P = 0.03), the group differences in patient-rated outcomes after 11 weeks of treatment were not statistically significant (P = 0.13). However, the spinal manipulative therapy and exercise group showed greater gains in all measures of strength, endurance, and range of motion than the spinal manipulation group (P < 0.05). The spinal manipulation with exercise group also demonstrated more improvement in flexion endurance and in flexion and rotation strength than the MedX group (P < 0.03). The MedX exercise group had larger gains in extension strength and flexion-extension range of motion than the spinal manipulation group (P < 0.05). During the follow-up year, a greater improvement in patient-rated outcomes were observed for spinal manipulation with exercise and for MedX exercise than for spinal manipulation alone (P = 0.01). Both exercise groups showed very similar levels of improvement in patient-rated outcomes, although the spinal manipulation and exercise group reported greater satisfaction with care (P < 0.01). CONCLUSIONS: For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.

Physical medicine modalities for mechanical neck disorders.

OBJECTIVES: Multiple physical medicine modalities are commonly included as part of therapeutic interventions for mechanical neck disorders (neck pain). The objective of this review was to assess the effects of physical medicine modalities for pain in adults with mechanical neck disorders. SEARCH STRATEGY: We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services and reference lists of the retrieved articles from 1985 to December 1993 and we contacted content experts. SELECTION CRITERIA: Randomised trials and controlled trials of physical medicine modalities in adults with mechanical neck disorder. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain information or data that could not be found in the published reports. MAIN RESULTS: Thirteen trials were included. The overall quality of the included trials was generally good. Two trials using electromagnetic therapy produced a significant reduction in pain (p <0.01) with three to four weeks of daily (eight hours per day) therapy sessions; and three using laser therapy did not differ significantly from a placebo (p=0.20) for six to 10 sessions of treatment. Not enough scientific testing exists to clearly determine the effectiveness of other therapies. This includes treatments such as exercise, traction, acupuncture, heat / cold applications, electrotherapies, cervical orthoses and chronic pain / cognitive behavioural rehabilitation strategies. REVIEWER'S CONCLUSIONS: There is little information available from trials to support the use of physical medicine modalities for mechanical neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy with respect to pain reduction.

Patient education for mechanical neck disorders.

BACKGROUND: To track down the best estimate of efficacy of the various conservative management strategies for mechanical neck disorders, a four-part systematic review was prepared. Part four investigates the efficacy of patient education strategies as the therapeutic intervention. OBJECTIVES: This review of patient education is one of four reviews of conservative management of mechanical neck disorders. The other reviews address manual, physical and drug therapies. The objective of this review was to assess the effects of patient education for pain in adults with mechanical neck disorders. SEARCH STRATEGY: We searched Medline, Embase, Chirolars, Index to Chiropractic Literature, Cinahl, Science Citation Index, Conference Proceedings Index, National Technical Information Services from 1985 to December 1993, reference lists of the retrieved articles and we contacted experts in the field. SELECTION CRITERIA: Randomised trials or controlled clinical trials of patient educational strategies for adults with mechanical neck disorders. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and two reviewers independently extracted data. Investigators were contacted to obtain data that could not be found in the published reports. MAIN RESULTS: Three trials were included. Their methodological quality varied from weak to strong. One trial did not find a significant reduction in pain using group instructional strategies (neck school) and exercise with or without psychological counselling compared to no treatment (standardised mean difference 0.07, 95% confidence interval -0.51 to 0.66, and -0.37, 95% confidence interval -0.95 to 0.22, respectively). Another trial did not find a significant reduction in pain using individualised patient education (advice), anti-inflammatories and analgesics compared with placebo (standardised mean difference 0.24, 95% confidence interval -0.58 to 1.07). The third trial found that advice which included demonstrated mobilization exercises, verbal and written instruction on posture correction, the use of a collar, heat sources, muscle relaxation and analgesics gave significant pain relief compared with general advice about mobilisation after a period of rest and use of analgesics at 4 weeks of treatment (standardised mean difference -0.62, 95% confidence interval -1.05 to -0.19) but at 6 weeks of treatment there was no longer any difference (s.m.d. -0.37, 95% confidence interval -0.8 to 0.05). The first two trials lacked statistical power and the third was methodologically weak. REVIEWER'S CONCLUSIONS: Patient education utilising individualised or group instructional strategies has not been shown to be beneficial in reducing pain for mechanical neck disorders.

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma.

BACKGROUND: Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma. METHODS: We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study. RESULTS: Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness. CONCLUSIONS: In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

Conservative management of mechanical neck pain: systematic overview and meta-analysis.

OBJECTIVE: To review the efficacy of conservative management of mechanical neck disorders. METHODS: Published and unpublished reports were identified through computerised and manual searches of bibliographical databases, reference lists from primary articles, and letters to authors, agencies, foundations, and content experts. Selection criteria were applied to blinded articles, and selected articles were scored for methodological quality. Effect sizes were calculated from raw pain scores and combined by using meta-analytic techniques when appropriate. RESULTS: Twenty four randomised clinical trials met the selection criteria and were categorised by type of intervention: nine used manual treatments; 12 physical medicine methods; four drug treatment; and three education of patients (four trials investigated more than one form of intervention). The intervention strategies were summarised separately. Pooling of studies was considered only within each category. Five of the nine trials that used manual treatment in combination with other treatments were combined. One to four weeks after treatment the pooled effect size was -0.6 (95% confidence interval -0.9 to -0.4), equivalent to an improvement of 16 (6.9 to 23.1) points on a 100 point scale. Sensitivity analyses on study quality, chronicity, and data imputation did not alter this estimate. For other interventions, studies could not be combined to arrive at pooled estimates of effect. CONCLUSIONS: There is little information available from clinical trials to support many of the treatments for mechanical neck pain. In general, conservative interventions have not been studied in enough detail to assess efficacy or effectiveness adequately.

Searching chiropractic literature: a comparison of three computerized databases.

PURPOSE: To determine the efficiency of three computerized bibliographic databases in retrieving literature relevant to the chiropractor. METHODS: A cross-sectional design was used. English-language citations from 1990-92, on the topics of scoliosis, sciatica and neck pain, were searched in CHIROLARS, Index to Chiropractic Literature (ICL) and MEDLINE. Citations were assessed for relevance criteria by two assessors; a third assessor was used when both were unsure of relevance. Inter- and intraexaminer reliability of the relevance assessments was determined using the weighted Kappa statistic. The outcomes assessed were search time, search costs, number of citations, relevance, number of unique citations and the number of citations from refereed journals. Relative recall and cost per citation were used as primary measures of database efficiency. RESULTS: A total of 846 citations were retrieved. After exclusions, 786 citations were assessed for relevance. Interexaminer reliability of the relevance assessments was moderate [K(w) (standard error) = 0.46 (0.03)]. Intra-examiner reliability was fair for each of the assessors [K(w) (SE) = .36 (.10) and .35 (.10), respectively]. Of the 385 relevant citations, CHIROLARS retrieved 88 (relative recall = 23%) at a cost of CAN$1.01 per relevant citation, ICL retrieved 37 (relative recall = 10%) at CAN$.65 per relevant citation, and MEDLINE retrieved 260 (relative recall = 68%) at CAN$.52 per relevant citation. CONCLUSIONS: MEDLINE was found to be the most efficient database to search for literature relevant to the chiropractor; it retrieved the highest proportion of relevant citations and was the least expensive. CHIROLARS was the second most efficient of the three databases. No single database can function as a stand-alone source of information. For comprehensive searching, having an experienced reference librarian search MEDLINE in combination with at least one other database is recommended.

Manual therapy in the treatment of neck pain.

In general, manual therapies have been demonstrated to be effective for mechanical neck pain in the short term when used in combination with other treatments. No one treatment protocol has been shown to be optimal as specific types of manual therapies have not been investigated in detail. Safety is a prime consideration when applying these treatments. The risk of increased symptoms resulting from manual therapy is low (in the range of 1%-2%), with the most common symptom aggravation being vertigo or dizziness. The risk of serious complication or death from neck manipulation is extremely low (in the range of 0.0001%). Optimal levels of education, training, and competency are integral to the safe performance of manual therapy.

Manipulation and mobilization of the cervical spine. A systematic review of the literature.

STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status. RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.

Conservative management of mechanical neck disorders. A systematic overview and meta-analysis.

OBJECTIVE: This overview reports the efficacy of conservative treatments (drug therapy, manual therapy, patient education, physical medicine modalities) in reducing pain in adults with mechanical neck disorders. METHODS: Computerized bibliographic database searches from 1985 to December 1993, information requests from authors, and bibliography screenings were used to identify published and unpublished research. Applying strict criteria, two investigators independently reviewed the blinded articles. Each selected trial was evaluated independently for methodologic quality. RESULTS: Twenty-four randomized controlled trials (RCTs) and eight before-after studies met our selection criteria. Twenty RCTs rated moderately strong or better in terms of methodologic quality. Five trials using manual therapy in combination with other treatments were clinically similar, were statistically not heterogeneous (p = 0.98), and were combined to yield an effect size of -0.6 (95% CI: -0.9, -0.4), equivalent to a 16 point improvement on a 100 point pain scale. Four RCTs using physical medicine modalities were combined using the inverse chi-square method: two using electromagnetic therapy produced a significant reduction in pain (p < 0.01); and two using laser therapy did not differ significantly from a placebo (p = 0.63). Little or no scientific evidence exists for other therapies, including such commonly used treatments as medication, rest and exercise. CONCLUSIONS: Within the limits of methodologic quality, the best available evidence supports the use of manual therapies in combination with other treatments for short-term relief of neck pain. There is some support for the use of electromagnetic therapy and against the use of laser therapy. In general, other interventions have not been studied in enough detail adequately to assess efficacy or effectiveness. This overview provides the foundation for an evidence-based approach to practice. More robust design and methodology should be used in future research, in particular, the use of valid and reliable outcomes measures.

Nocturnal enuresis: treatment implications for the chiropractor.

OBJECTIVE: A comprehensive review of the literature concerning the etiology, diagnosis, and the natural history of primary nocturnal enuresis is presented. Contemporary treatment options are discussed in light of the documented annual remission rate of this disorder. DATA SOURCE: Articles reviewed were obtained by conducting a computer-aided search of papers indexed in Medline and the Index to Chiropractic Literature from 1989 to 1993. In addition, the Chiropractic Research Abstracts Collection and bibliographies from pertinent articles were manually searched. DATA SYNTHESIS: Primary nocturnal enuresis affects some 200,000 children and their families throughout Canada. Twenty percent of children wet the bed at age 5, 10% at age 10, and only about 1% at age 15. The documented natural history of the disorder reveals that for those affected, 10% to 20% exhibit spontaneous resolution per year. Contemporary treatment options center on three factors that play primary roles in the etiology of this condition: functional bladder capacity, patient conditioning and the circadian rhythm of nocturnal ADH secretion. CONCLUSIONS: The success of each therapeutic option must, in part, be attributed to the natural history of enuresis, as well as any educational or placebo aspects of treatment. Conditioning therapy utilizing the urine pad alarm may be the most reasonable initial mode of intervention. Spinal manipulative therapy has been shown to possess an efficacy comparable to the natural history.

Elastic Supports and Body SuitsEffective Energy-Storing Garments.

The principles behind the use of lumbar supports have changed drastically in recent years. Once used for immobilization, lumbar supports and body suits are now being used to encourage mobility and return to function in low back pain patients. Modern concepts regarding the stored/strain energy of elastic garments are introduced, followed by a discussion of how body suits and elastic supports utilize these properties to assist the low back pain patient. A number of different types of elastic garments are illustrated.The use of rigid corsets for low back pain began around the turn of the century with the use of plaster jackets. More recently, heavy nylon, steel stays, and complex plastics have been used for the same purpose. The rationale for this type of immobilization includes assistance for weakened muscles, protection from injury, correction of deformity, control of pain, restriction of spinal movements, and increased temperature.1-4Some of these proposed physiologic mechanisms have been investigated, including intraabdominal and intradiscal pressure changes, paraspinal electro myographic (EMG) activity, and intersegmental as well as gross spinal motions.4-9 The results ofthese studies have been equivocal, as have the findings of clinical trials investigating the efficacy of rigid orthoses.10-15 Further, certain disadvantages to the use of rigid orthoses have been described, including possible muscle atrophy and dependency. Also, because of the discomfi)rt of the devices and the resultant interference with activities of daily living, patient compliance can be poor.16Corsets and other similar rigid supports are not commonly used now, except for a few special cases. Elastic body suits or supports are replacing the rigid-backed brace, and the emphasis is shifting from immobilization to assisted mobility and increased function. These new garments are comfortable, and the patient is almost unaware of their presence.In this article the principles of stored or strain (elastic) energy will be reviewed, followed by a discussion of the merits of its use in the back pain patient. We will also illustrate some types of elastic garments available today.