Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Manual therapy in combination with other treatments may provide short-term relief in mechanical neck pain

ACP J Club. 1997 May-Jun;126:70. doi:10.7326/ACPJC-1997-126-3-070


Source Citation

Aker PD, Gross AR, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ. 1996 Nov 23;313:1291-6.


Abstract

Objective

To evaluate the effectiveness of conservative treatment in reducing pain in adults with mechanical neck disorders.

Data sources

Studies were identified by searching MEDLARS, EMBASE, CINAHL, and CHIROLARS and by searching indexes of conference proceedings from 1985 to December 1993. Bibliographies of relevant papers were also scanned, and experts were contacted.

Study selection

Studies were selected if they were randomized controlled trials that evaluated conservative treatments for mechanical neck disorders in adults. Conservative treatments were defined as any noninvasive and nonsurgical form of treatment, including drugs, manual treatments, education of patients, and physical medicine methods. Mechanical neck disorders included conditions that caused neck pain with or without referral into the shoulder and upper arm.

Data extraction

Data were extracted on sample size, treatments studied, and pain scores.

Main results

24 studies met the selection criteria. Interventions assessed were manual treatments (9 studies), physical medicine methods (12 studies), drug treatment (4 studies), and education of the patients (3 studies). Data from 5 of the 9 studies that evaluated manual treatments in combination with other treatments were pooled. 1 to 4 weeks after treatment, the pooled effect size was -0.6 (95% CI -0.9 to -0.4), which equates to an improvement of 16.2 (CI 6.9 to 23.1) points on a 100-point pain scale. 4 of the 12 studies that evaluated physical medicine methods were combined. 2 studies that evaluated electromagnetic therapy documented a reduction in pain (P < 0.01), and 2 studies that evaluated laser therapy found a nonsignificant difference when pain scores were compared with the placebo groups (P = 0.63). Not enough evidence existed for other therapies to determine benefit or harm, including exercise, medication, and education. Adverse effects were not well documented but no serious complications or deaths were reported.

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. Some support for the use of electromagnetic therapy and against the use of laser therapy exists. In general, other interventions have not been studied in adequate detail to assess their effectiveness or efficacy.

Source of funding: In part, McGregor Clinic Fund, Hamilton Foundation.

For article reprint: Dr. C.H. Goldsmith, Centre for Evaluation of Medicines, St. Joseph's Hospital, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada. FAX 905-521-6129.


Commentary

Radio-frequency neurotomy provided lasting relief for chronic cervical joint pain

Neck pain is one of the most common symptoms for which patients seek treatment from primary care physicians. The socioeconomic burden of this disorder is enormous, and many conservative treatments have been proposed and used for it. As discussed in the review by Aker and colleagues, all of the better studies on conservative measures for the treatment of mechanical neck pain contained insufficient numbers of patients to scientifically show a benefit to those who were treated. To date, studies have failed to show that these conservative treatments do more good than harm.

It is important to note that the review by Aker and colleagues applies to patients with neck disorders that are not associated with neurologic deficit, headache, fractures, inflammatory disease, or neoplasm. The type of pain that is studied in this review is often referred to as muscle strain or muscle spasm. The results of this review do not pertain to patients who have radicular pain (i.e., radiating down the upper arm) and is often associated with cervical disc protrusion.

Such conservative measures as drugs, traction, ultrasonography, transcutaneous stimulation, and electromagnetic therapy have been used by clinicians for several years. Thus, the clinician is faced with a dilemma when dealing with a patient with mechanical neck pain because of the lack of clear evidence to indicate which treatment should be used. Until studies with larger patient populations are completed, the clinician should use treatments that are not likely to cause harm, such as rest and physical therapy, rather than treat patients with drugs that may have side effects or cause addiction.

The treatment for chronic neck pain after whiplash injury has also been disappointing. Such treatments as pain medications, physical therapy, intra-articular injections, or corticosteroids have not been found to have dramatic clinical benefit. The study by Lord and colleagues evaluates the effectiveness of radio-frequency neurotomy for patients with chronic neck pain lasting > 3 months after whiplash injury. This study showed a clear clinical and statistical benefit for radio-frequency neurotomy. Complications from the procedure were minimal and included dysesthesias that were not troublesome to patients.

It is important for the clinician to realize which patients are likely to benefit from radio-frequency neurotomy. The pain should be nonradicular, and patients should have been treated with conservative therapy (including analgesics, nonsteroidal anti-inflammatory drugs, opioids, physical therapy, traction, acupuncture, chiropracty, transcutaneous electrical nerve stimulation, heat, and exercise) for ≥ 3 months before considering this invasive treatment. Radio-frequency neurotomy should not be used in patients with C2-3 zygapophyseal-joint pain. Patients who are being considered for radio-frequency neurotomy should first have the cervical zygapophyseal joints blocked with local anesthetic to confirm that the pain is localized to these joints.

When faced with a patient who has chronic neck pain after whiplash injury and who has not responded to ≥ 3 months of conservative therapy, the clinician should strongly consider referring the patient to a specialist skilled in diagnostic cervical zygapophyseal-joint blocks and radio-frequency neurotomy.

Barbara Scherokman, MD
Kaiser PermanenteSpringfield, Virginia, USA


Author's Response

No clear evidence exists that directs clinicians to recommend rest and physical therapy care in general or not to recommend the use of medication for adults with acute or chronic mechanical neck disorders. Some early evidence based on randomized controlled trials (within methodologic limits) can assist with the clinical decision-making when attempting to manage pain for adults with acute or chronic mechanical neck disorders. The following treatments provide benefit: manual therapy combined with other therapies (commonly analgesics, patient education, heat or cold application, and exercise), electromagnetic field therapy, muscle relaxants, acupuncture, and topical anti-inflammatory agents. No benefit was shown from laser therapy, spray-and-stretch procedures, individualized or group educational strategies alone, traction, and transcutaneous electrical nerve stimulation; exercise alone was of unclear benefit.

Anita R. Gross, MSc