Are Manual Therapies, Passive Physical Modalities, Or Acupuncture Effective for the Management of...

7/25/2019 Are Manual Therapies, Passive Physical Modalities, Or Acupuncture Effective for the Management of Patients With Whiplash-Associated Disorders or Neck Pain and Associated D

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Accepted Manuscript

Title: Are manual therapies, passive physical modalities, or acupuncture

effective for the management of patients with whiplash-associated disorders or

neck pain and associated disorders? an update of the bone and joint decade task

force on neck pain and its associated disorders by the optima collaboration

Author: Jessica J. Wong, Heather M. Shearer, Silvano Mior, Craig Jacobs,

Pierre Ct, Kristi Randhawa, Hainan Yu, Danielle Southerst, Sharanya

Varatharajan, Deborah Sutton, Gabrielle van der Velde, Linda J. Carroll, Arthur Ameis, Carlo

Ammendolia, Robert Brison, Margareta Nordin, Maja Stupar, Anne Taylor-Vaisey

PII: S1529-9430(15)01234-6

DOI: http://dx.doi.org/doi: 10.1016/j.spinee.2015.08.024

Reference: SPINEE 56530

To appear in: The Spine Journal

Received date: 14-11-2014

Revised date: 5-6-2015Accepted date: 11-8-2015

Please cite this article as: Jessica J. Wong, Heather M. Shearer, Silvano Mior, Craig Jacobs,

Pierre Ct, Kristi Randhawa, Hainan Yu, Danielle Southerst, Sharanya Varatharajan, Deborah

Sutton, Gabrielle van der Velde, Linda J. Carroll, Arthur Ameis, Carlo Ammendolia, Robert

Brison, Margareta Nordin, Maja Stupar, Anne Taylor-Vaisey, Are manual therapies, passive

physical modalities, or acupuncture effective for the management of patients with whiplash-

associated disorders or neck pain and associated disorders? an update of the bone and jointdecade task force on neck pain and its associated disorders by the optima collaboration, The Spine

Journal(2015), http://dx.doi.org/doi: 10.1016/j.spinee.2015.08.024.

This is a PDF file of an unedited manuscript that has been accepted for publication As a service


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This is a PDF file of an unedited manuscript that has been accepted for publication As a service

Are manual therapies, passive physical modalities, or acupuncture effective for1

the management of patients with whiplash-associated disorders or neck pain and2

associated disorders? An update of the Bone and Joint Decade Task Force on3

Neck Pain and its Associated Disorders by the OPTIMa Collaboration4

5

Jessica J. Wong, BSc, DC, FCCS(C)1,2

; Heather M. Shearer, DC, MSc, FCCS(C)1,3

;6

Silvano Mior, DC, PhD3; Craig Jacobs, BFA, DC, MSc, FCCS(C)1,4; Pierre Ct, DC,7

PhD1,5,6

; Kristi Randhawa, BHSc, MPH1,4

; Hainan Yu, MBBS, MSc1,4

; Danielle8

Southerst, BScH, DC, FCCS(C)1,7

; Sharanya Varatharajan, BSc, MSc1,4

; Deborah9

Sutton, BScOT, MEd, MSc1,4

; Gabrielle van der Velde, DC, PhD8,9,10

; Linda J. Carroll,10

PhD11; Arthur Ameis, FRCPC, DESS, FAAPM&R12; Carlo Ammendolia, DC, PhD10,13;11

Robert Brison, MD, MPH14,15; Margareta Nordin, Dr. Med. Sci.16; Maja Stupar, DC,12

PhD1; Anne Taylor-Vaisey, MLS113

14


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4Division of Clinical Education, Canadian Memorial Chiropractic College, Canada1

5Canada Research Chair in Disability Prevention and Rehabilitation, University of2

Ontario Institute of Technology (UOIT)3

6Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT)4

7Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai5

Hospital6

8Toronto Health Economics and Technology Assessment (THETA) Collaborative7

9Leslie Dan Faculty of Pharmacy, University of Toronto8

10Institute for Work and Health9

11Alberta Centre for Injury Control and Research and School of Public Health, University10

of Alberta11

12Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of12


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Corresponding Author: Jessica Wong, UOIT-CMCC Centre for the Study of Disability1

Prevention and Rehabilitation, 6100 Leslie Street, Toronto, ON, M2H 3J1; Phone: +12

(416) 482-2340 x170; email:[email protected]

4

Keywords: systematic review, neck pain and associated disorders, whiplash-5

associated dis

orders, manual therapy, passive physical modalities, acupuncture6

7

Systematic Review Registration Numbers: CRD42013004372, CRD42013005167,8

CRD42013004301, CRD420130043959

10

11

12


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Background Context:In 2008, the Bone and Joint Decade 2000-2010 Task Force on1

Neck Pain and its Associated Disorders (Neck Pain Task Force) found limited evidence2

on the effectiveness of manual therapies, passive physical modalities, or acupuncture3

for the management of whiplash-associated disorders (WAD) or neck pain and4

associated disorders (NAD).5

Purpose:To update findings of the Neck Pain Task Force examining the effectiveness6

of manual therapies, passive physical modalities, and acupuncture for the management7

of WAD or NAD.8

Study Design/Setting: Systematic review and best evidence synthesis.9

Sample: Randomized controlled trials (RCTs), cohort studies, case-control studies10

comparing manual therapies, passive physical modalities, or acupuncture to other11

interventions, placebo/sham, or no intervention.12

Outcome measures: Self-rated or functional recovery, pain intensity, health-related13

li f lif h l i l d


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Results:We screened 8551 citations, 38 studies were relevant, and 22 had a low risk1

of bias. Evidence from seven exploratory studies suggests that: 1) for recent but not2

persistent NAD I-II: thoracic manipulation offers short-term benefits; 2) for persistent3

NAD I-II: technical parameters of cervical mobilization (e.g., direction or site of manual4

contact) do not impact outcomes, while one session of cervical manipulation is similar to5

Kinesiotaping; and 3) for NAD I-II: strain-counterstrain treatment is no better than6

placebo. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II:7

cervical and thoracic manipulation provides no additional benefit to high-dose8

supervised exercises; Swedish/clinical massage adds benefit to self-care advice; 2) for9

persistent NAD I-II: home-based cupping massage has similar outcomes to home-10

based muscle relaxation; low-level laser therapy (LLLT) does not offer benefits; Western11

acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture;12

needle acupuncture provides similar outcomes to sham-penetrating acupuncture; 3) for13

WAD I-II: needle electroacupuncture offers similar outcomes as simulated14

electroacupuncture; and 4) for recent NAD III: a semi-rigid cervical collar with rest and15


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INTRODUCTION1

Neck pain is a public health problem associated with disability, reduced health-related2

quality of life, and substantial health care system costs [1-3]. Numerous treatments,3

including manual therapies, passive physical modalities, and acupuncture, are4

commonly used to treat neck pain [4, 5]. However, few interventions have been5

demonstrated to be effective and most are associated with short-term benefits [5].6

7

Findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and8

Its Associated Disorders (Neck Pain Task Force)9

In 2008, the Neck Pain Task Force synthesized evidence on the effectiveness of10

manual therapies, passive physical modalities, and acupuncture for the management of11

whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD)12

(Table 1) [5, 6].13

14

For manual therapies the Neck Pain Task Force [5] found that:15


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For passive physical modalities, the Neck Pain Task Force [5] found that:1

LLLT was efficacious for short-term improvement of subacute or chronic neck2

pain;3

Pulsed electromagnetic therapy was more effective than placebo;4

Magnetic necklaces led to similar outcomes as placebo; and5

Collars, transcutaneous electrical nerve stimulation (TENS), ultrasound, heat,6

and electrical muscle stimulation were equally or less effective than other7

interventions.8

Finally, the Neck Pain Task Force reported that acupuncture may be effective for9

treating neck pain [5].10

11

The Neck Pain Task Force identified important gaps in the literature and outlined12

research priorities. These priorities included trials comparing cervical manipulation,13

thoracic manipulation, and traction for WAD and trials examining the effectiveness of14

conservative interventions for cervical radiculopathy [7].15


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effectiveness to a standard of care [8, 9]. Therefore, exploratory studies do not provide1

evidence of effectiveness and need to be considered separately when synthesizing2

evidence in a systematic review. Moreover, the findings of exploratory studies need to3

be validated in evaluation studies.4

5

The purpose of our systematic review was to update the findings of the Neck Pain Task6

Force [5] on the effectiveness of manual therapies, passive physical modalities, and7

acupuncture for the management of WAD and NAD.8

9

METHODS10

11

Registration12

We registered our protocol with the International Prospective Register of Systematic13


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major structural pathology (e.g., fractures, dislocations, spinal cord injury, infection,1

neoplasms, systemic disease).2

3

Interventions: We restricted our review to studies evaluating the specific effectiveness4

of manual therapies, passive physical modalities, or acupuncture (Table 3 in text;5

Table 4 - online). We defined manual therapy (i.e., manipulation, mobilization, traction,6

and soft tissue therapy) as the application of hands-on and/or mechanically-assisted7

treatments. We defined a passive physical modality as a physical treatment (physico-8

chemical or structural) involving a device that does not require active participation by9

the patient. Physico-chemical modalities have a common intention to treat using a10

thermal or electromagnetic effect. Structural modalities include non-functional assistive11

devices (to encourage a state of rest in anatomic positions) and functional assistive12

devices (to align, support, or indirectly facilitate function). We defined acupuncture as13

body needling, moxibustion, electroacupuncture, laser acupuncture, microsystem14


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Outcomes: Studies had to include one of the following outcomes to be elgigiSelf-rated1

or functional recovery, clinical outcomes (e.g., pain, disability), psychological symptoms,2

administrative outcomes, and/or adverse events.3

4

Study characteristics: Eligible studies met the following criteria: 1) English language;5

2) randomized controlled trials (RCTs), cohort studies, case-control studies; and 3) an6

inception cohort of a minimum of 30 participants per treatment arm for RCTs or 1007

subjects per exposed group for cohort studies or case-control studies. A sample size of8

30 is conventionally considered the minimum needed for non-normal distributions to9

approximate the normal distribution [13]. The assumption that data is normally10

distributed is required to ascertain a difference in sample means between treatment11

arms. We excluded the following: 1) guidelines, narrative reviews, letters, editorials,12

commentaries, unpublished manuscripts, dissertations, government reports, books and13

book chapters, conference proceedings, meeting abstracts, lectures and addresses,14

consensus development statements guideline statements; 2) cross sectional studies15


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We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central1

Register of Controlled Trials from January 1, 2000 to: 1) March 21, 2013 for2

manipulation, mobilization, and traction; 2) February 27, 2014 for soft tissue therapy; 3)3

April 9, 2013 for passive physical modalities, and 4) January 31, 2013 for acupuncture.4

We developed four distinct search strategies with a health sciences librarian (Appendix5

IA, IB, IC, ID), which were reviewed by a second librarian using the Peer Review of6

Electronic Search Strategies (PRESS) Checklist [14].7

8

The search strategy was first developed in MEDLINE and subsequently adapted to the9

other bibliographic databases. The search terms included subject headings (e.g., MeSH10

for MEDLINE) specific to each database and free text words relevant to WAD or NAD11

(grades I-III), manual therapies, passive physical modalities, and acupuncture. We used12

EndNote X6 reference management software to create a database containing the13

search results [15].14

15


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disagreements and reach consensus on the eligibility of studies. We involved a third1

reviewer if consensus could not be reached.2

3

4

Assessment of Risk of Bias5

Eligible studies were critically appraised by random pairs of independent, trained6

reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for7

RCTs, cohort studies, and case-control studies [16]. All reviewers were trained in the8

evaluation studies using the SIGN criteria. Consensus between paired reviewers was9

reached through discussion, with an independent third reviewer if necessary. Authors10

were contacted if additional information was needed. After critical appraisal, studies with11

a low risk of bias were included in our evidence synthesis.12

13


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allocation; 4) blinding of treatment and outcomes; 5) similarity of baseline characteristics1

between/among treatment arms; 6) co-intervention contamination; 7) validity and2

reliability of outcome measures; 8) follow-up rates; 9) analysis according to intention to3

treat principles; and 10) comparability of results across study sites (where applicable).4

After critical appraisal, studies judged to have adequate internal validity were deemed5

scientifically admissible (i.e. without high risk of bias) and were included in our data6

(results, evidence) synthesis.7

8

Data Extraction and Synthesis of Results9

The lead author extracted data from studies with a low risk of bias to build evidence10

tables and the data were independently checked by a second reviewer. Meta-analysis11

was not performed due to the heterogeneity of scientifically admissible studies with12

respect to patient populations, interventions, comparators, and outcomes. We13

performed a qualitative synthesis of findings from the studies with a low risk of bias to14


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1

Statistical Analyses2

We computed the inter-rater reliability for the screening of articles using the kappa3

coefficient () and 95% confidence intervals (CI) [19]. We calculated the percentage4

agreement for classifying studies into low or high risk of bias following independent5

critical appraisal. To quantify the effectiveness of interventions, we used data from6

studies with a low risk of bias by computing the relative risk or difference in mean7

change and its 95% CI where this information was available. The computation of the8

95% CI for the difference in mean change was based on the assumption that the pre-9

and post-intervention outcomes were highly correlated (r=0.8) [20, 21].10

11

We used standardized cut-off values to determine if clinically important changes were12

reached in each trial for common outcome measures. These include a between-group13

diff f 2/10 th N i R ti S l (NRS) [22] 10/100 th Vi l


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RESULTS1

Study Selection2

We screened 8551 citations (Figures IA, IB, IC, ID - online). Thirty-eight articles were3

critically appraised, of which 22 had a low risk of bias [27-49].4

5

The inter-rater agreement for screening of articles was: 1) k=0.94 (95% CI 0.90; 0.98)6

for manipulation, mobilization, and traction; 2) k=0.95 (95% CI 0.91, 0.99) for soft tissue7

therapy; 3) k=0.91 (95% CI 0.86, 0.97) for passive physical modalities; and 4) k=0.938

(95% CI 0.84, 1.00) for acupuncture. The percentage agreement for article admissibility9

during independent critical appraisal was 84.2% (32/38).10

11

Study Characteristics12

All 22 studies with a low risk of bias were RCTs (Table 5 - online) [27-49]. Of these, we13

t i d t di l t t di [27 37 41 50 53] d 15


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criteria: proper allocation concealment (20/22), proper blinding procedures where1

possible (20/22), and similarity at baseline across groups (17/22) [27-49]. The follow-up2

rate was above 75% in all but one study [31] (Table 5 - online).3

4

The main methodological limitations of studies with a high risk of bias included: poor or5

unknown randomization methods, poor or unknown allocation concealment, clinically6

important differences in baseline characteristics with no statistical adjustment in the7

analysis, likely attrition bias, and no report of intention to treat analysis [54-66]. We8

contacted the authors of five RCTs for additional information but none responded.9

10

Summary of the Evidence Published After the Neck Pain Task Force Report11

12

Exploratory Studies (Table 6 - online)13


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minimal-to-moderate muscle tension for 90 seconds. Sham strain-counterstrain involved1

digital pressure adjacent to the spinous process of C4 with 30 degrees of passive neck2

rotation for 90 seconds. There were no between-group differences in neck pain intensity3

(Neck Pain Disability Scale), intensity, cervical motion or self-perceived recovery [27].4

5

Recent-onset Grades I-II NAD6

Thoracic manipulation is efficacious for the management of recent NAD I-II [37, 38].7

Masaracchio et al. reported that patients who received two sessions of thoracic8

manipulation reported clinically important improvements in neck pain (NRS), disability9

(NDI), and self-rated recovery compared to those randomized to two sessions of10

cervical mobilization and home exercise [37]. Similarly, Cleland et al. found that11

individuals who received two thoracic manipulations had clinically important reductions12

in neck pain (NRS) and disability (NDI) compared to those treated with thoracic13

mobilization [38].14


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important reductions in pain (VAS) compared to those receiving randomly-directed1

mobilization [40]. Moreover, there were no post-intervention differences in cervical ROM2

or global perceived recovery [40].3

4

The efficacy of spinal manipulation for the management of persistent NAD I-II is unclear.5

There were no clinically or statistically significant differences in pain intensity (NRS),6

disability (NDI), and ROM outcomes between administration of one mid-cervical and7

one cervico-thoracic manipulation, and a 7-day application of KinesioTape over the8

cervical extensors [41]. Finally, one session of upper thoracic manipulation and placebo9

thoracic manipulation (applied manipulative force to an open hand contact at the upper10

thoracic spine) provide similar outcomes for pain (VAS) in patients with persistent NAD11

I-II [42].12

13

Evaluation Studies (Table 6 - online)14


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Recent-onset Grades I-II NAD1

In comparing a course of neck manipulation and neck mobilization (four treatments over2

two weeks) for recent NAD I-II, there were no differences in pain (NRS), disability (NDI),3

and health-related quality of life (SF-12) immediately and up to 12 weeks post-4

intervention for recent NAD I-II [44].5

6

A soft tissue therapy intervention combining ischemic compression, strain-counterstrain,7

and muscle energy technique is associated with statistically but not clinically significant8

differences in pain (VAS), disability (NDI), and lateral flexion compared to muscle9

energy technique alone [28]. One group received integrated neuromuscular inhibition10

technique (i.e., ischemic compression, strain-counterstrain, and muscle energy11

technique) to the upper trapezius while the other group received muscle energy12

technique alone to the upper trapezius.13

14


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(NRS), but not neck pain-related disability immediately post-intervention in patients with1

persistent NAD I-II [31].2

3

Compared to a self-care book, Swedish and/or clinical massage with self-care advice is4

superior for reducing neck disability (NDI) and symptom bothersomeness (NRS) in the5

short-term and for reducing symptom bothersomeness in the long-term for patients with6

persistent neck pain [29]. The massage group received various Swedish and clinical7

massage techniques at the discretion of the practitioner with verbal self-care advice,8

while the control group received information on neck pain causes, associated9

symptoms, exercises, posture, and treatment options.10

11

Cupping massage and progressive muscle relaxation lead to similar changes in pain12

(VAS), pain perception, disability (NDI), psychological outcomes and quality of life (SF-13

36) i ti t ith i t t NAD [30] P ti i t d i d t i


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syndrome [32]. Participants were randomized to receive LLLT to three trigger points1

bilaterally using either an active device (wavelength of 830-nm, frequency 1000 Hz,2

power output 58mW/cm2, dose 7J per point) or a device that was not activated.3

4

TENS and a multimodal soft tissue therapy program (neuromuscular technique, post-5

isometric stretching, spray and stretch, and strain-counterstrain) lead to similar changes6

in pain (VAS), disability (NDI), and health-related quality of life (SF-12) at one or six7

month follow-up for persistent NAD I-II [33]. Participants were randomized to: 1) TENS8

(80 Hz, 150s pulse duration); or 2) multimodal therapy that included a neuromuscular9

technique, post-isometric stretching, spray and stretch, Jones technique (i.e., strain-10

counterstrain). Both groups received a home program consisting of postural skills and11

exercises.12

13

The evidence does not support the use of needle acupuncture for the management of14

persistent NAD I-II. Two studies found that traditional Chinese medicine acupuncture15


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acupuncture involved needling of locally tender and traditional points, while the placebo1

group received inactivated electrodes to acupuncture points.2

3

Grade III NAD of Variable Duration4

Adding intermittent cervical traction to a multimodal program of care (postural5

education, manipulation or mobilization, exercise and home exercise) provides no6

additional benefits in pain (NRS) or disability (NDI) compared to sham cervical traction7

with the same multimodal care up to four weeks follow-up for the management of NAD8

grade III [45]. Patients were treated an average of seven visits over an average of 4.29

weeks.10

11

Recent-onset Grade III NAD12

Participating in a graded strengthening exercise program or wearing a semi-rigid13

cervical collar for six weeks provide similar improvements in arm pain (VAS), neck pain14


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to placebo LLLT (deactivated laser treatment) for the management of recent NAD III1

[34].2

3

Adverse Events4

Sixteen of the 22 studies with a low risk of bias addressed the occurrence of adverse5

events [27, 29-31, 33, 34, 36-41, 43, 44, 48, 67, 68]. Most adverse events were mild to6

moderate and transient (Table 6 and Table 7). No serious neurovascular adverse7

events were reported. Most studies had a rate of minor adverse events ranging from8

zero to about 30% [33, 35-37, 39, 40, 42-48, 50]. One study [43] reported mild and9

transient adverse events in 98.9% of patients who received high dose strengthening10

exercise therapy and spinal manipulation, and 96.6% who received the same exercise11

therapy alone. Two serious adverse events in patients allocated to cervical mobilization12

were reported in one study, but were reported as unrelated to treatment by the13

attending medical specialists (one participant had a cardiac event and one developed14


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LLLT, and traction for the management of NAD grade III. Key findings from our1

synthesis of the evidence are outlined in Table 8.2

3

New Findings since the Publication of the Neck Pain Task Force Report4

5

Exploratory studies:6

Based on exploratory evidence, we found that thoracic manipulation provides benefit to7

individuals with recent NAD grades I-II, but is no better than placebo for treating8

persistent NAD grades I-II. We found that the type of neck mobilization may not impact9

the outcomes of patients. We also found that one session of cervical and cervico-10

thoracic manipulation is as effective as one week of kinesiotape over the neck in the11

short-term for persistent NAD grades I-II. For soft tissue therapy, we found that strain-12

counterstrain is not efficacious for NAD.13

14

Evaluation studies:15


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relaxation performed by patients at home after they were instructed by a psychologist1

during a one hour session [30]. Finally, we found that LLLT was not effective for recent-2

onset NAD grade III and traction does not provide added benefit to a multimodal3

program for NAD III.4

5

Results that are Consistent with Findings of the Neck Pain Task Force6

7

Evaluation studies:8

We found that cervical manipulation and cervical mobilization lead to similar outcomes9

in individuals with recent NAD grades I-II. We also found that there were no serious10

adverse events reported in randomized clinical trials on manipulation. We did not find11

any studies that compared different techniques of cervical manipulation; therefore, it is12

unclear if specific cervical manipulation techniques are more effective than others.13

14

15


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possible that the clinical (not relaxation) massage provides benefit to patients with1

persistent neck pain.2

3

We found new evidence suggesting that LLLT is not effective for persistent NAD grades4

I-II. However, when combining the new evidence with Neck Pain Task Force findings5

from five studies [69-73], the preponderance of evidence suggests that clinic-based6

LLLT is effective for persistent NAD.7

8

We found that for NAD grade III, graded strengthening exercises and cervical collar with9

rest were equally effective.However, caution should be taken when considering the use10

of cervical collars because of the potential for iatrogenic disability [13, 74, 75].11

12

For acupuncture, we found that electroacupuncture is not effective for WAD I-II, while13

Western acupuncture and needle acupuncture is not effective for persistent NAD I-II.14

These new findings contradict the evidence available to the Neck Pain Task Force [75],15


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which may have a physiological effect; studies with non-penetrating sham/placebo1

interventions are needed.2

3

Findings of the Neck Pain Task Force that We Cannot Support or Clarify4

We did not find new evidence on the effectiveness of ultrasound, diathermy, heat5

therapy, electrical muscle stimulation, or magnetic necklaces. The Neck Pain Task6

Force found that TENS provides no clinically important benefit compared to placebo [75,7

76]. Our review found new evidence that TENS provides similar outcomes to a8

multimodal program of care focused on soft tissue therapy. However, as the9

effectiveness of this multimodal program of care is unknown, this new evidence cannot10

be used to support or refute the findings of the Neck Pain Task Force.Overall, there is a11

lack of evidence supporting the effectiveness of TENS in this population.12

13

U lik i t ti i t tifi d d i ibl t di i t l t


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standard of care. There should be caution in including results from exploratory studies1

into clinical guidelines or practice pending more robust evaluation studies. 2

3

Strengths and Limitations4

5

There are strengths to our review. We conducted a rigorous search of the literature and6

the search strategy was peer reviewed. We used clear case definitions, inclusion7

criteria, and exclusion criteria for the selection of studies and only considered studies8

with adequate sample sizes. We used the SIGN criteria to standardize the critical9

appraisal process [19]. Lastly, our conclusions were based on the best evidence10

synthesis method to minimize the risk of bias associated with using low quality studies11

[20]. A best evidence synthesis is considered an appropriate alternative to a meta-12

analysis when heterogeneity exists across patient populations, interventions,13

comparisons, and outcomes [20].14

15


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Since 2008, there is new scientific evidence on the effectiveness of manual therapies,1

passive physical modalities, and acupuncture informing their use for the management of2

neck pain. Our update of the Neck Pain Task Force suggests that mobilization,3

manipulation, and clinical massage are effective interventions for the management of4

neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation5

massage, and other passive physical modalities (heat, cold, diathermy, hydrotherapy,6

ultrasound) are not effective and should not be used to manage neck pain.7

8

Acknowledgement9

10

This study was funded by the Ontario Ministry of Finance and the Financial Services11

Commission of Ontario (RFP No.: OSS_00267175). This research was undertaken, in12

part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Ct,13

Canada Research Chair in Disability Prevention and Rehabilitation at the University of14


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1

2

References3

1. Miller J, Gross A, D'Sylva J, et al. Manual therapy and exercise for neck pain: a4

systematic review. Man Ther 2010;15:334-54.5

2. Cote P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey.6

The prevalence of neck pain and related disability in Saskatchewan adults. Spine (Phila7

Pa 1976) 1998;23:1689-98.8

3. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world9

population: a systematic critical review of the literature. Eur Spine J 2006;15:834-48.10

4. Gross AR, Kay T, Hondras M, et al. Manual therapy for mechanical neck11

disorders: a systematic review. Man Ther 2002;7:131-49.12

5. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain:13

noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force14

on Neck Pain and Its Associated Disorders Spine (Phila Pa 1976) 2008;33:S123 5215


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8. Ergina PL, Barkun JS, McCulloch P, Cook JA, Altman DG. IDEAL framework for1

surgical innovation 2: observational studies in the exploration and assessment stages.2

BMJ 2013;346:f3011.3

9. McCulloch P, Cook JA, Altman DG, Heneghan C, Diener MK. IDEAL framework4

for surgical innovation 1: the idea and development stages. BMJ 2013;346:f3012.5

10. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec6

Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its7

management. Spine (Phila Pa 1976) 1995;20:1S-73S.8

11. Guzman J, Hurwitz EL, Carroll LJ, et al. A new conceptual model of neck pain:9

linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on10

Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33:S14-23.11

12. World Health Organization. Acupuncture: review and analysis of reports on12

controlled clinical trials. Geneva: World Health Organization; 2002.13

13. Norman GR, Streiner DL. Biostatistics: The Bare Essentials, 3rd Edition.14

Hamilton: BC Decker; 2008.15


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17. van der Velde G, van Tulder M, Cote P, et al. The sensitivity of review results to1

methods used to appraise and incorporate trial quality into data synthesis. Spine (Phila2

Pa 1976) 2007; 32: 796-806.3

18. Slavin RE. Best evidence synthesis: an intelligent alternative to meta-analysis. J4

Clin Epidemiol 1995;48:9-18.5

19. Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa6

statistic. Fam Med 2005;37:360-3.7

20. Abrams KR, Gillies CL, Lambert PC. Meta-analysis of heterogeneously reported8

trials assessing change from baseline. Stat Med 2005; 24:3823-44.9

21. Follmann D, Elliott P, Suh I, Cutler J. Variance imputation for overviews of clinical10

trials with continuous response. J Clin Epidemiol 1992;45:769-73.11

22. Carroll LJ, Jones DC, Ozegovic D, Cassidy JD. How well are you recovering?12

The association between a simple question about recovery and patient reports of pain13

intensity and pain disability in whiplash-associated disorders. Disabil Rehabil14

2012;34:45-52.15


34/90

25. McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G. The reliability of the Vernon and1

Mior neck disability index, and its validity compared with the short form-36 health survey2

questionnaire. Eur Spine J 2007;16:2111-7.3

26. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for4

systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535.5

27. Klein R, Bareis A, Schneider A, Linde K. Strain-counterstrain to treat restrictions6

of the mobility of the cervical spine in patients with neck pain: a sham-controlled7

randomized trial. Complement Ther Med 2013;21:1-7.8

28. Nagrale AV, Glynn P, Joshi A, Ramteke G. The efficacy of an integrated9

neuromuscular inhibition technique on upper trapezius trigger points in subjects with10

non-specific neck pain: a randomized controlled trial. J Man Manip Ther 2010;18:37-43.11

29. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial12

of therapeutic massage for chronic neck pain. Clin J Pain 2009;25:233-8.13

30. Lauche R, Materdey S, Cramer H, et al. Effectiveness of home-based cupping14

massage compared to progressive muscle relaxation in patients with chronic neck pain-15


35/90

33. Escortell-Mayor E, Riesgo-Fuertes R, Garrido-Elustondo S, et al. Primary care1

randomized clinical trial: manual therapy effectiveness in comparison with TENS in2

patients with neck pain. Manual Therapy 2011;16:66-73.3

34. Konstantinovic LM, Cutovic MR, Milovanovic AN, et al. Low-level laser therapy4

for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized5

study. Pain Medicine 2010;11:1169-78.6

35. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or7

physiotherapy versus wait and see policy for recent onset cervical radiculopathy:8

randomised trial. BMJ 2009;339:b3883.9

36. Saavedra-Hernandez M, Castro-Sanchez AM, Arroyo-Morales M, et al. Short-10

term effects of kinesio taping versus cervical thrust manipulation in patients with11

mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther12

2012;42:724-30.13

37. Masaracchio MC, Hellman M, Hagins M, et al. Short-term combined effects of14

thoracic spine thrust manipulation and cervical spine nonthrust manipulation in15


36/90

randomized controlled trial. Archives of physical medicine and rehabilitation [serial on1

the Internet]. 2009; 90(2).2

40. Kanlayanaphotporn RC, Vachalathiti R. Immediate effects of the central3

posteroanterior mobilization technique on pain and range of motion in patients with4

mechanical neck pain. Dis Rehab 2010;32:622-8.5

41. Saavedra-Hernandez M, Castro-Sanchez AM, Arroyo-Morales M, et al. Short-6

term effects of kinesio taping versus cervical thrust manipulation in patients with7

mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther8

2012;42:724-30.9

42. Sillevis RC, Hellman M, Beekhuizen K. Immediate effects of a thoracic spine10

thrust manipulation on the autonomic nervous system: a randomized clinical trial. J11

Manual Manipulat Ther 2010;18:181-90.12

43. Evans R, Bronfort G, Schulz C, et al. Supervised exercise with and without spinal13

manipulation performs similarly and better than home exercise for chronic neck pain: a14

randomized controlled trial. Spine (Phila Pa 1976) 2012;37:903-14.15


37/90

46. Cameron ID, Wang E, Sindhusake D. A randomized trial comparing acupuncture1

and simulated acupuncture for subacute and chronic whiplash. Spine 2011;36:E1659-2

65.3

47. Fu WL, Zhu X, Yu P, Zhang J. Analysis on the effect of acupuncture in treating4

cervical spondylosis with different syndrome types. Chinese J Integrative Med5

2009;15:426-30.6

48. Liang ZZ, Yang X, Fu W, Lu A. Assessment of a traditional acupuncture therapy7

for chronic neck pain: a pilot randomised controlled study. Complement Ther Med8

2011;19 Suppl 1:S26-32.9

49. White PL, Prescott P, Conway J. Acupuncture versus placebo for the treatment10

of chronic mechanical neck pain: a randomized, controlled trial. Annals Intern Med11

2004;141:911-9.12

50. Cleland JA, Glynn PE, Whitman JM, et al. Short-term response of thoracic spine13

thrust versus non-thrust manipulation in patients with mechanical neck pain: preliminary14

analysis of a randomized clinical trial. J Manual Manipulat Ther 2007;14:172.15


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53. Sillevis R, Cleland J, Hellman M, Beekhuizen K. Immediate effects of a thoracic1

spine thrust manipulation on the autonomic nervous system: a randomized clinical trial.2

J Manual Manipulat Ther 2010;18:181-90.3

54. Andersen LLM, Hansen J, Burr H. A prospective cohort study on severe pain as4

a risk factor for long-term sickness absence in blue- and white-collar workers. Occup5

Environ Med 2011;68:590-2.6

55. Biemans JM. Efficacy and effectiveness of percutaneous tibial nerve stimulation7

in the treatment of pelvic organ disorders: a systematic review. Neuromodulation8

2013;16:25-33.9

56. Lin MNL, Liu JH, Zhang AP, et al. Needle scalpel combined with massage10

therapy and simple massage therapy for nerve-root type cervical spondylopathy: a11

randomized controlled analysis on 100 patients. Zhongguo Linchuang Kangfu 2004;12

8(23).13

57. Schomacher J. The effect of an analgesic mobilization technique when applied at14

symptomatic or asymptomatic levels of the cervical spine in subjects with neck pain: a15


39/90

60. Dehner CH, Strobel P, Scheich M, et al. Comparison of the relative benefits of 21

versus 10 days of soft collar cervical immobilization after acute whiplash injury. Arch2

Phys Med Rehab 2006;87:1423-7.3

61. Rigato MB, Fortunato M, Giordano N. Comparison between the analgesic and4

therapeutic effects of a musically modulated electromagnetic field (TAMMEF) and those5

of a 100 Hz electromagnetic field: blind experiment on patients suffering from cervical6

spondylosis or shoulder periarthritis. J Med Engineer Tech 2002;26:253-8.7

62. Vassiliou T, Kaluza G, Putzke C, Wulf H, Schnabel M. Physical therapy and8

active exercises - An adequate treatment for prevention of late whiplash syndrome?.9

Randomized controlled trial in 200 patients. Pain 2006;124:69-76.10

63. Bonk AD, Ferrari R, Giebel GD, Edelmann M, Huser R. Prospective, randomized,11

controlled study of activity versus collar, and the natural history for whiplash injury, in12

Germany. J Musculoskeletal Pain 2000;8:123-32.13

64. Majlesi JU. High-power pain threshold ultrasound technique in the treatment of14

active myofascial trigger points: a randomized, double-blind, case-control study. Arch15


40/90

67. Cameron I, Sindhusake D. A randomized trial comparing acupuncture and1

simulated acupuncture for subacute and chronic whiplash. Spine 2011;36:E1659-65.2

68. Witt CM, Brinkhaus B, Liecker B, et al. Acupuncture for patients with chronic3

neck pain. Pain 2006;125:98-106.4

69. Thorsen H, Gam AN, Svensson BH, et al. Low level laser therapy for myofascial5

pain in the neck and shoulder girdle. A double-blind, cross-over study. Scand J6

Rheumatol 1992;21:139-41.7

70. Ceccherelli F, Altafini L, Lo Castro G, et al. Diode laser in cervical myofascial8

pain: a double-blind study versus placebo. Clin J Pain 1989;5:301-4.9

71. Chow RT, Heller GZ, Barnsley L. The effect of 300 mW, 830 nm laser on chronic10

neck pain: a double-blind, randomized, placebo-controlled study. Pain 2006;124:201-10.11

72. Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S. Efficacy of 904 nm gallium12

arsenide low level laser therapy in the management of chronic myofascial pain in the13

neck: a double-blind and randomize-controlled trial. Lasers Surg Med 2004;35:229-35.14

73. Ozdemir F, Birtane M, Kokino S. The clinical efficacy of low-power laser therapy15


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76. Smania N, Corato E, Fiaschi A, et al. Repetitive magnetic stimulation: a novel1

therapeutic approach for myofascial pain syndrome. J Neurol 2005;252:307-14.2

77. Juni P, Holenstein F, Sterne J, Bartlett C, Egger M. Direction and impact of3

language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol4

2002;31:115-23.5

78. Moher D, Fortin P, Jadad AR, et al. Completeness of reporting of trials published6

in languages other than English: implications for conduct and reporting of systematic7

reviews. Lancet 1996;347:363-6.8

79. Moher D, Pham B, Lawson ML, Klassen TP. The inclusion of reports of9

randomised trials published in languages other than English in systematic reviews.10

Health Technol Assess 2003;7:1-90.11

80. Sutton AJ, Duval SJ, Tweedie RL, Abrams KR, Jones DR. Empirical assessment12

of effect of publication bias on meta-analyses. BMJ 2000;320:1574-7.13

81. Morrison A, Polisena J, Husereau D, et al. The effect of English-language14

restriction on systematic review-based meta-analyses: a systematic review of empirical15


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85. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck1

disorders: a systematic review. J Rehabil Med 2006;38:145-52.2

86. Australian Acute Musculoskeletal Pain Group. Evidence-based management of3

acute musculoskeletal pain. 2003.4

87. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic5

management of back pain. Report of the International Paris Task Force on Back Pain.6

Spine (Phila Pa 1976) 2000;25:1S-33S.7

88. Sherman KJ, Dixon MW, Thompson D, Cherkin DC. Development of a taxonomy8

to describe massage treatments for musculoskeletal pain. BMC Complement Altern9

Med 2006;6:24.10

11

12

Appendix IA: MEDLINE search strategy for neck pain and associated disorders,13

whiplash-associated disorders, and manual therapy14


43/90

10. "neck injur*".ab,ti.1

11. "neck pain*".ab,ti.2

12. "cervical pain*".ab,ti.3

13. "neck ache*".ab,ti.4

14. "neckache*".ab,ti.5

15. "cervicalgia*".ab,ti.6

16. "cervicodynia*".ab,ti.7

17. "radiculopath*".ab,ti.8

18. "brachial plexus neuropath*".ab,ti.9

19. torticollis.ab,ti.10

20. ("headache*" adj4 (whiplash or WAD or neck pain)).ab,ti.11

21. Randomized Controlled Trials as Topic/12

22. exp Controlled Clinical Trials as Topic/13

23. exp consensus development conferences as topic/14

24. meta-analysis.pt.15

25. exp case-control studies/16


44/90

35. (case adj control*).ab,ti.1

36. ((double or single) adj3 blind*).ab,ti.2

37. "placebo*".ab,ti.3

38. or/1-204

39. or/21-375

40. Musculoskeletal Manipulations/6

41. Manipulation, Spinal/7

42. Manipulation, Chiropractic/8

43. Manipulation, Orthopedic/9

44. Manipulation, Osteopathic/10

45. Motion Therapy, Continuous Passive/11

46. Muscle Stretching Exercises/12

47. (manipulat* adj4 (spinal or lumbar or thoracic or cervical)).ab,ti.13

48. (mobili?ation adj4 (spinal or lumbar or thoracic or cervical)).ab,ti.14

49. (manipulat* adj4 (chiropract* or osteopath* or orthopedic* or orthopaedic*)).ab,ti.15

50. (mobli?ation adj4 (chiropract* or osteopath* or orthopedic* or orthopaedic*)).ab,ti.16


45/90

59. (musculoskeletal and (physiotherap* or physical therap*)).ab,ti.1

60. or/40-592

61. 38 and 39 and 603

62. limit 61 to (english language and yr="2000 -Current")4

5

6

Appendix IB: MEDLINE search strategy for neck pain and associated disorders,7

whiplash-associated disorders, and soft tissue therapy8

1. Acupressure/9

2. Complementary Therapies/10

3. Manipulation, Chiropractic/11

4. Manipulation, Orthopedic/12

5. Manipulation, Osteopathic/13

6. Massage/14

7. Muscle Stretching Exercises/15

8. Musculoskeletal Manipulations/16


46/90

18. Aston patterning.ab,ti.1

19. "Ayurvedic massage*".ab,ti.2

20. bodywork.ab,ti.3

21. Chih Ya.ab,ti.4

22. cranial release.ab,ti.5

23. (cranio-sacral and (massage or therap*)).ab,ti.6

24. (craniosacral and (massage or therap*)).ab,ti.7

25. Cyriax friction.ab,ti.8

26. "deep tissue therap*".ab,ti.9

27. Feldenkrais method.ab,ti.10

28. "friction massage*".ab,ti.11

29. Graston.ab,ti.12

30. Gua Sha.ab,ti.13

31. Guasha.ab,ti.14

32. Hakomi method.ab,ti.15

33. "Hot stone massage*".ab,ti.16


47/90

43. "Pfrimmer therap*".ab,ti.1

44. "polarity therap*".ab,ti.2

45. ((post isometric or post-isometric) and relaxation).ab,ti.3

46. "pressure point* therap*".ab,ti.4

47. proprioceptive neuromuscular facilitation.ab,ti.5

48. reflexology.ab,ti.6

49. "reflexotherap*".ab,ti.7

50. Reiki.ab,ti.8

51. Rolfing.ab,ti.9

52. Shiat?u.ab,ti.10

53. (soft tissue and (mobili?ation or therap*)).ab,ti.11

54. (soft-tissue and (mobili?ation or therap*)).ab,ti.12

55. "sports massage*".ab,ti.13

56. "Swedish massage*".ab,ti.14

57. TCM.ab,ti.15

58. "Thai massage*".ab,ti.16


48/90

68. VMTX.ab,ti.1

69. Zhi Ya.ab,ti.2

70. "Zone therap*".ab,ti.3

71. or/1-704

72. exp Back/5

73. exp Back Injuries/6

74. Back Pain/7

75. Low Back Pain/8

76. Coccyx/in [Injuries]9

77. Intervertebral Disc Degeneration/10

78. Intervertebral Disc Displacement/11

79. Lumbar Vertebrae/in [Injuries]12

80. exp Lumbosacral Plexus/13

81. Lumbosacral Region/in [Injuries]14

82. Osteoarthritis, Spine/15

83. Piriformis Muscle Syndrome/16


49/90

93. (back and (ache* or injur* or pain*)).ab,ti.1

94. (backache* and (injur* or pain*)).ab,ti.2

95. (back pain or back-pain).ab,ti.3

96. coccydynia.ab,ti.4

97. coccyx.ab,ti.5

98. dorsalgia.ab,ti.6

99. (lumbar disc* and (extruded or degenerat* or herniat* or prolapse* or sequestered or7

slipped)).ab,ti.8

100. (lumbar disk* and (extruded or degenerat* or herniat* or prolapse* or sequestered9

or slipped)).ab,ti.10

101. "low* back pain".ab,ti.11

102. "low*-back-pain*".ab,ti.12

103. (lumbar and (pain or facet or nerve root* or osteoarthritis or radicul* or spinal13

stenosis or spondylo* or zygapophys*)).ab,ti.14

104. "lumbarsacr*".ab,ti.15

105. lumboischialgia.ab,ti.16

106. "lumbosacr*".ab,ti.17


50/90

116. "tailbone pain*".ab,ti.1

117. "vertebrogenic pain*".ab,ti.2

118. or/72-1173

119. Whiplash Injuries/4

120. Neck Injuries/5

121. Neck Pain/6

122. Neck Muscles/in [Injuries]7

123. exp Cervical Vertebrae/in [Injuries]8

124. Radiculopathy/9

125. exp Brachial Plexus Neuropathies/10

126. Torticollis/11

127. whiplash.ab,ti.12

128. "neck injur*".ab,ti.13

129. "neck pain*".ab,ti.14

130. "cervical pain*".ab,ti.15

131. "neck ache*".ab,ti.16


51/90


142. Controlled Clinical Trials as Topic/2

143. Clinical Trials as Topic/3

144. exp Case-Control Studies/4

145. exp Cohort Studies/5

146. Double-Blind Method/6

147. Single-Blind Method/7

148. Placebos/8

149. randomized controlled trial.pt.9

150. controlled clinical trial.pt.10

151. comparative study.pt.11

152. (meta analys* or meta-analys* or metaanalys*).ab,ti.12

153. (cohort and (study or studies or analys*)).ab,ti.13

154. (random* and (control* or clinical or allocat*)).ab,ti.14


156. ((double or single) and blind*).ab,ti.16


52/90

1

Appendix IC: MEDLINE search strategy for neck pain and associated disorders,2

whiplash-associated disorders, and passive physical modalities3

1. exp Hydrotherapy/4

2. Laser Therapy, Low-Level/5

3. Cryotherapy/6

4. Magnetic Field Therapy/7

5. exp Electric Stimulation Therapy/8

6. exp Orthotic Devices/9

7. exp Diathermy/10

8. Hot Temperature/tu [Therapeutic Use]11

9. Casts, Surgical/12

10. Fluid Therapy/13

11. Magnetics/tu [Therapeutic Use]14

12. "Bedding and Linens"/15

13. High-Energy Shock Waves/tu [Therapeutic Use]16


53/90

22. (hot and (therap* or pack* or compress or massage or lamp or pad or bath or soak1

or tub or bottle or superficial or therapeutic)).ab,ti.2

23. ((shockwave* or shock wave* or shock-wave*) and (ultrasonic or therap* or3

radiation)).ab,ti.4

24. "assistive device*".ab,ti.5

25. (athletic and (tape or taping)).ab,ti.6

26. "back belt*".ab,ti.7

27. (braces or brace or bracing).ab,ti.8

28. (cast or casts).ab,ti.9

29. (collar or collars).ab,ti.10

30. (corset or corsets).ab,ti.11

31. "cryotherap*".ab,ti.12

32. diathermy.ab,ti.13

33. (electric* and (stimulation or EMS or heating pad*)).ab,ti.14

34. electroanalgesia.ab,ti.15

35. (electrogalvanic stimulation or EGS).ab,ti.16

36 (electromagnet* and (radiation or therap*)) ab ti17


54/90

46. infrared.ab,ti.1

47. (interferential current* or ICS or IFC).ab,ti.2

48. iontophoresis.ab,ti.3

49. "kinesiotap*".ab,ti.4

50. (laser* and (phototherapy or irradiation or biostimulation or light or therap*)).ab,ti.5

51. "low level laser*".ab,ti.6

52. "lumbar support*".ab,ti.7

53. (magnetic and (necklace* or therap* or bracelet*)).ab,ti.8

54. Microcurrent Electrical Neuromuscular Stimulation.ab,ti.9

55. "microwave*".ab,ti.10

56. "moist air bath*".ab,ti.11

57. muscle activation.ab,ti.12

58. myofascial release.ab,ti.13

59. (Neuromuscular Electrical Stimulation or NMES).ab,ti.14

60. "orthotic*".ab,ti.15

61. (paraffin and (treatment* or therap*)).ab,ti.16


55/90

71. (splint or splinting or splints).ab,ti.1

72. "spray and stretch".ab,ti.2

73. (tape or taping).ab,ti.3

74. (transcutaneous electrical stimulation or TENS).ab,ti.4

75. ultrasound.ab,ti.5

76. vapocoolant spray.ab,ti.6

77. "vibration therap*".ab,ti.7

78. "warm compress*".ab,ti.8

79. "wax treatment*".ab,ti.9

80. whirlpool.ab,ti.10

81. or/19-8011

82. 18 or 8112

83. Whiplash Injuries/13

84. Neck Injuries/14

85. Neck pain/15



56/90

96. "neckache*".ab,ti.1

97. "cervicalgia*".ab,ti.2

98. "cervicodynia*".ab,ti.3

99. "radiculopath*".ab,ti.4



102. (headache* adj4 (whiplash or WAD or neck pain)).ab,ti.7

103. or/83-1028

9


105. Controlled Clinical Trials as Topic/11


107. exp cohort studies/13

108. double-blind method/14

109. single-blind method/15

110. Placebos/16


57/90

120. "placebo*".ab,ti.1

121. or/104-1202

122. 82 and 103 and 1213

123. limit 122 to (english language and yr="2000 -Current")4

5

6

Appendix ID:MEDLINE search strategy for neck pain and associated disorders,7

whiplash-associated disorders, and acupuncture8

1. exp Whiplash Injuries/9

2. exp Neck Injuries/10

3. exp Neck pain/11


5. exp Cervical Vertebrae/in [Injuries]13

6. exp Radiculopathy/14

7. exp Brachial Plexus Neuropathies/15

8. exp Torticollis/16


58/90




21. exp Controlled Clinical Trials as Topic/4

22. meta-analysis.pt.5


24. exp Cohort Studies/7

25. Double-Blind Method/8

26. single-blind method/9

27. Placebos/10

28. randomized controlled trial.pt.11

29. controlled clinical trial.pt.12

30. (meta analys* or meta-analys* or metaanalys*).ab,ti.13

31. (cohort adj4 (study or studies or analys*)).ab,ti.14

32. (random* adj4 (control* or clinical or allocat*)).ab,ti.15



59/90

43. "acupuncture*".ab,ti.1

44. (needling and (dry or body or "trigger point*")).ab,ti.2

45. acupressure.ab,ti.3

46. auriculotherapy.ab,ti.4

47. (Shiatsu or Shiatzu or Zhi Ya or Chih Ya).ab,ti.5

48. moxibustion.ab,ti.6

49. electrical stimulation.ab,ti.7

50. (Ching Lo or Jing Luo or Jingluo).ab,ti.8

51. artemisia vulgaris.ab,ti.9

52. Japanese Meridian Therapy.ab,ti.10

53. French Energetic.ab,ti.11

54. Korean Constitutional.ab,ti.12

55. Lemington Five Elements.ab,ti.13

56. intramuscular stimulation.ab,ti.14

57. or/1-1915

58. or/20-3516


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Figure 1B: Selection and Critical Appraisal of Studies on the Effectiveness of Soft1

Tissue Therapy for the Management of Neck Pain2

Figure 1C: Selection and Critical Appraisal of Studies on the Effectiveness of Passive3

Physical Modalities for the Management of Neck Pain4

Figure 1D: Selection and Critical Appraisal of Studies on the Effectiveness of5

Acupuncture for the Management of Neck Pain6

7

8

9

10

11

12


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Table 1: Summary of the Findings from the Neck Pain Task Force on the1

Effectiveness of Manual Therapies, Passive Physical Modalities, and2

Acupuncture for the Management of Neck Pain and Associated Disorders3

and Whiplash-associated Disorders [6]14

Origin/Grade Duration Intervention and Comparison Outcome/Follow-up

WAD Grade

I-II

Recent Pulsed electromagnetic therapy >

sham

Pain/short term

Collars, heat, cold other interventions Pain/short term

NAD or WAD

Grade I-II

Recent/persistent/variable Manipulation = mobilization Pain or disability/ short

term

Recent and persistent Manipulation/mobilization = other

conservative interventions

Pain or disability/ short

term

NAD Grade I-

II

Persistent Low level laser therapy > sham Pain/short term

Western massage < acupuncture Pain/short term

Western massage = sham acupuncture Pain/short term

Recent/persistent/variable Cervical collar, TENS, ultrasound, heat

therapy electrical muscle stimulation

Pain/short term


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Table 2: Classification of Grades for Whiplash-associated Disorders [10] and1

Neck Pain and Associated Disorders [11]2

Grade Definition

Qubec Task Force Classification of Grades of Whiplash-associated Disorders[13]

I Subjects with neck pain and associated symptoms in the absence of objective physical signs

IISubjects with neck pain and associated symptoms in the presence of objective physical signs

and without evidence of neurological involvement

III

Subjects with neck pain and associated symptoms with evidence of neurological involvement

including decreased or absent reflexes, decreased or limited sensation, or muscular

weakness

IV Subjects with neck pain and associated symptoms with evidence of fracture or dislocation

The Neck Pain Task Force Classification of Grades of Neck Pain and Associated Disorders [5]

INo signs or symptoms suggestive of major structural pathology and no or minor interference

with activities of daily living

IINo signs or symptoms of major structural pathology, but major interference with activities of

daily living

IIINo signs or symptoms of major structural pathology, but presence of neurologic signs such


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Table 3. Definition and Categories of Manual Therapies, Passive Physical1

Modalities, and Acupuncture2

Intervention

Category

Definition

Manual Therapies

Manipulation Manipulation includes techniques incorporating a high velocity, low amplitude

impulse or thrust applied at or near the end of a joints passive range of motion

[82]

Mobilization Mobilization includes techniques incorporating a low velocity and small or large

amplitude oscillatory movement, within a joints passive range of motion [82, 83]

Traction Traction is defined as a manual or mechanically assisted application of an

intermittent or continuous distractive force [84, 85]

Soft Tissue Therapy Soft tissue therapy is defined as a mechanical form of therapy where soft tissue

structures are passively pressed and kneaded, using physical contact with the

hand or mechanical device [86]. Soft tissue techniques using acupuncture points

and exercise (such as active stretches) were not considered soft tissue therapy.

Exercise is defined as any series of active movements aiming to train or develop


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(cold packs, ice massage, vapocoolant spray). Examples of passive applications

affecting structures beneath the skin surface include but are not limited to LLLT,

electrotherapy (transcutaneous electrical stimulation (TENS), electrogalvanic

stimulation, electrical muscle stimulation, microcurrent, pulsed electromagnetic

therapy, ultrasound, microwave, and ultrasonic shockwave therapy.

Structural Structural modalities include non-functional assistive devices that may either

encourage a state of rest in anatomic positions (e.g., pillows, seat cushions) or

actively inhibit or prevent movement (e.g., collars, corsets, casts, slings, and

rest splints). Functional assistive devices (e.g., shoe orthotics, tenodesis splints,

taping, and assistive braces) may align, support, or otherwise indirectly facilitate

function in the affected region.

Acupuncture

Acupuncture (all forms

of acupuncture)

In accordance with the World Health Organization [12], we defined acupuncture

8 interventions as body needling (traditional, medical, modern, dry needling,

trigger point needling, etc.), moxibustion (burning of herbs), electroacupuncture,

laser acupuncture, microsystem acupuncture (such as ear acupuncture), and

acupressure (application of pressure at acupuncture points).

1


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Table 4: Taxonomy of Soft Tissue Therapies [88]1

Principal

Goals of

Treatment

Relaxation

Massage

Clinical Massage Movement Re-

education

Energy Work

Intention Relax muscles,

move body fluids,

promote wellness

Accomplish specific

goals such as

releasing muscle

spasms

Induce sense of

freedom, ease and

lightness in body

Free energy

blockages

Additional

Goals of

Treatment1

Nourish cells,

remove wastes

from cells,

diminish pain,

relax body

Focus on muscle or

fascia, relieve pain

and restricted

motion, use

focused therapeutic

goals

Use movement to

enhance posture,

body awareness,

movement, or

function

Assist the flow of

energy in the body

Commonly - Swedish - Myofascial

t i i t

- Proprioceptive

l

- Acupressure

R iki


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(examples3) - Percussion

- Vibration

- Passive

stretching

- Cross-fiber

friction

stretching

- Rocking

pressure

- Holding

- Rocking

- Traction

1Additional goals of treatment were retrieved from the body of the paper by Sherman et al. [88]1

2While some styles of massage are commonly used in addressing one of the four principal treatment2

goals, some may be used to address several distinct treatment goals.3

3By varying the intent (or purpose) for a technique, many of them can be used in massages with different4

principal treatment goals.5

4Acupressure was considered an acupuncture technique in our review (not a soft tissue therapy)6

7

8

9

10

11


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Table 5: Risk of Bias for Accepted Randomized Controlled Trials on Neck Pain1

based on Scottish Intercollegiate Guidelines Network (SIGN) Criteria [16]2

Author,

Year

Research

Question

Randomiz-

ation

Concealment Blinding Similarity

at

baseline

Similarity

between

arms

Outcome

measures

Percent drop-out Intention

to treat

Comparable

results

between

sites

Cameron et al.,

2011 [46]Y Y Y Y N CS Y

6 months:

Electroacupuncture:

0%

Simulated

acupuncture: 8%

Y NA

Cleland et al., 2007

[50]Y Y Y CS N CS Y

2 to 4 days post-

intervention: noneY CS

Dundar et al., 2007

[32]

Y Y CS Y Y Y Y 4 weeks:

0% for both groups

NA NA

Escortell-

M t l 2011

Y Y Y Y N CS Y Intervention

completion:

Y CS


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7.9%; HEA: 5.6%

26 weeks:

ET + SMT:13.2%;

ET: 12.4%; HEA:

15.6%

52 weeks:

ET + SMT- 15.4%;

ET: 16.9%; HEA:

14.4%

Fu et al., 2009 [47] Y Y Y Y Y Y Y

Treatment group:

2/59= 3.39%

Control group:

3/58=5.17%

N2 NA

Kanlayanaphotporn

et al., 2009 [51]Y Y Y Y Y CS Y

Immediately post-

intervention: noneNA NA

KanlayanaphotpornY Y Y Y Y Y Y

Immediately post-NA NA


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2.9%; Control: 1.5%

6 months:

Collar: 8.7%; PT:

2.9%; Control: 7.6%

Lauche et al., 2013

[43]

Y Y Y Y Y Y Y

Post-intervention:

CM: 13.3%

PMR: 9.7%

Y NA

Leaver et al., 2010

[44]Y Y Y Y Y Y Y

12 weeks:

Manipulation: 2.2%;

Mobilization: 3.3%

Y CS

Liang et al.,

2011[48]Y Y Y Y CS Y Y

At 3 months:

Acupuncture group:

5/93 = 5.4%

Placebo group:

7/97 = 7.2%

N2 NA

Post-intervention:


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MET0%

Saavedra-

Hernandez et al.,

2012 [41]

Y Y Y Y Y CS Y

1 week:

Manipulation: 10%;

Kinesio Taping: 0%

Y NA

Sherman et al.,

2009 [42]

Y Y Y Y Y CS Y

4 weeks:

M+SCA3%

SCB9%

10 weeks:

M+SCA3%

SCB12%

26 weeks:

M+SCA6%

SCB12%

Y CS

Sillevis et al., 2010Y Y Y Y Y Y Y

Immediately post-

intervention:NA NA


71/90

6 months:

Acupuncture: 13/70

= 18.6%

Placebo: 11/65 =

16.9%

12 months:

Acupuncture: 16/70

= 23.1%

Placebo: 12/65 =

18.5%

Young et al., 2009

[45]

Y Y Y Y N CS Y

4 weeks:

Traction: 13.3%;

Sham: 16.7%

Y CS

1Includes participant withdrawal and loss to follow-up; Yyes; Nno; CScant say; NA not1

applicable; CMcupping massage; ETexercise therapy; HEAhome exercise and advice; INIT 2

integrated neuromuscular inhibition technique; LLLT: low-level laser therapy; LM Longs manipulation;3

Mmassage; METmuscle energy technique; MMT: multimodal therapy; PMRprogressive muscle4

relaxation; SCA self-care advice; SCB self-care book; SCS strain-counterstrain; SMT: spinal5


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71

Table 6. Evidence Table for Accepted Randomized Controlled Trials on Manual Therapies, Passive Physical Modalities, and1

Acupuncture for Neck Pain and Associated Disorders and Whiplash-associated Disorders2

Author(s),

Year

Setting and

Subjects, Number

(n) Enrolled

Interventions, Number

(n) of Subjects

Comparisons,

Number (n) of

Subjects

Follow-up Outcomes Key Findings2

Exploratory Studies

Cleland et

al., 2007 [50]

Patients (18-60

y.o.) from primary

care physicians to 1

of 5 outpatient

orthopedic physical

therapy clinics in

the U.S.A. (NH, MA,

CO, MN, CA)

between June 2005

and July 2006.

Case definition:

neck pain (NDI

score > 10%) with

or without

unilateral upper-

extremity

symptoms. (n=60);

=56 days

Thrust mobilization/

manipulation by

physical therapists:

thrust to upper

thoracic (T1-T4) & mid

thoracic spine (T5-T8)

spine; general cervical

mobility exercise; usual

activities; current

medication. (n=30)

Non-thrust

mobilization/

manipulation

provided by trained

physical therapists:

30 second grade III or

IV central posterior-

anterior non-thrust

(T1-T6); general

cervical mobilityexercise; usual

activities; current

medication. (n=30)

2-4 days after

one

intervention

Primary outcome:

Disability (NDI-0-

100%)

Secondary

outcomes:

Pain (NPRS)

0-10); Self-

perceived

Global rating of

change (GROC) -7

to 7

Adverse events

Statistically significant mean difference

(thrust mobilization/manipulationnon-

thrust mobilization/manipulation:

Disability: 10.03% (95% CI 5.3;14.7)

Pain: 2.03 (95% CI 1.4; 2.7)

GROC: 1.5 (95% CI 0.48; 2.5)

(50% in manipulation group reported

moderate change in status vs 10% in

mobilization group

No serious side effects. About, 30% patients

in both groups experienced mild moderate

side effects lasting 20 on

100mm VAS.

(n=60);

=804 days

Preferred mobilization

by physical therapist (1

session): unilateral PA

pressure, ipsilateral to

pain. (n=30)

Random mobilization

by physical therapist

(1 session):

mobilizations

randomly directed

pressure (i.e. central

PA, ipsilateral

unilateral PA, or

contralateral

unilateral PA) to the

cervical spine. (n=30)

5 minutes

after

treatment

Primary outcome:

Pain (VAS 0-100);

Active CROM;

Global perceived

effect

1-7

Adverse events

No significant difference in pain, active

CROM, with the exception of flexion, and

global perceived effect between groups.

Mean difference (preferred -random

mobilization)

Active CROM in Flexion: 2.6 (95% CI 0.38;

4.83)

No reported adverse events

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72

Author(s),

Year

Setting and

Subjects, Number

(n) Enrolled


(n) of Subjects

Comparisons,

Number (n) of

Subjects


Kanlayanaph

otporn et al.,

2010 [52]

Patients (20-70

y.o.).

Case definition:nonspecific pain,

exacerbated by

neck movements or

by sustained neck

postures. Neck pain

at rest >20 on

100mm VAS.

(n=60); =1575

days

Central PA mobilization

by physical therapists

(1 session): PA

pressure over thespinous process of the

cervical vertebra.

(n=30)

Random mobilization

by trained physical

therapist (1 session):

mobilizationsrandomly directed

pressure (i.e. central

PA, right unilateral

PA, or left unilateral

PA. (n=30)

5 minutes

after

treatment

Primary outcome:

Pain (VAS 0-100);

Active CROM

(assessed withCROM device);

Global perceived

effect

Adverse events

No significant differences between groups in

neck pain at rest or CROM, except for pain

intensity on most painful movement:

Mean difference (central PA mobilization

random mobilization): Pain intensity on the

most painful movement: 9.2 (95% CI 0.3;

18.0)

No difference between groups in patients

rating of global perceived effect.

No adverse events reported.

Klein et al.,

2013 [32]

Adults (18-65 y.o.)

with acutenonspecific neck

pain referred from

private general

practice in Bavaria,

Germany between

February and

August 2011.

(n=61)

Case definition:

Acute episode of

nonspecific neck

pain and cervical

joint restrictions

Strain-counterstrain by

GP (1 session): Neckpositioned by therapist

away from restricted

cervical segment for 90

seconds then slowly

repositioned to

neutral. (n=30)

Sham strain-

counterstrain by GP(1 session): Neck

passively rotated 30

to the left and held

for 90 seconds as

therapist placed

finger slightly right of

the C4 spinous

process. Neck then

slowly repositioned

to neutral. (n=31)

Immediately

afterintervention

Primary outcome:

Cervical motion(goniometer)

Secondary

outcomes:

Neck pain

intensity (from

NPDS), self-

perceived global

assessment

(much worse,

slightly worse,

unchanged,

slightly better,

much better)

Adverse events

No statistically significant difference between

groups for neck pain intensity or cervicalmotion.

Self-perceived recovery (strain-counterstrain

versus sham):

Slightly worse: 3% versus 3%

Unchanged: 37% versus 55%

Slightly better: 53% versus 36%

Much better: 7% versus 7%

Mild transient adverse events reported (i.e.

pain and/or dizziness):

Strain-counterstrain: 13.3%

Sham: 3.2%

Masaracchio

et al., 2013

[37]

Patients (18-60

y.o.) who

presented to

physical therapy or

Thoracic thrust

manipulation + cervical

nonthrust

manipulations and

Cervical nonthrust

manipulation and

home exercises by

physical therapist (2

2-3 days after

intervention

Neck pain (NPRS

0-10);

Disability (NDI 0-

50); Global rating

Statistically significant mean differences

between groups (experimental minus

comparison)*

Neck pain: 1.5 (95% CI 1.06; 1.94)

Page 72 of 89


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73

Author(s),

Year

Setting and

Subjects, Number

(n) Enrolled


(n) of Subjects

Comparisons,

Number (n) of

Subjects


volunteered from

2009-2011.

Case definition:

neck pain (


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74

Author(s),

Year

Setting and

Subjects, Number

(n) Enrolled


(n) of Subjects

Comparisons,

Number (n) of

Subjects


clinics in the USA in

2008.

Case definition:non-specific pain

(3 months) in

cervical and

cervicothoracic

region down to T4,

provoked with neck

movements.

(n=108)

session): applied

manipulative force to a

closed hand contact at

the upper thoracicspine (T3-T4). (n=50)

manipulative force to

an open hand

contact at the upper

thoracic spine (T3-4).(n=51)

outcome:

puplliometric

measure

(Friedman Test)

diameter in manipulation group; however,

statistically significant change in placebo

group over time.

Evaluation Studies

Cameron et

al., 2011 [46]

Participants (18-65

y.o.) recruited

through newspaper

in Australia.

(n=124)

Case Definition:

WAD I-II (>1 month

duration)

Real

Electroacupuncture

(RE) by acu

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