Physical therapy management of pediatric and adolescent neck pain: a call to action

Abstract

Background: Neck pain is reported to be as high as 40% in adolescents and can be a precursor to developing adult persistent neck pain.

Objectives: To identify and review literature on physical therapy management of pediatric and adolescent neck pain.

Methods: A sensitive search strategy adhered to PRISMA guidelines. Our systematic review used the databases PubMed, CINAHL, and Embase including articles published from inception to May 2019. For the article to be included, it had to meet the following criteria: (a) age under 18?years old; (b) musculoskeletal neck pain; (c) any intervention or treatment provided by physical therapists; (d) English language; (e) any outcome measure that reported disability, function, or pain; (f) any and all published literature: randomized controlled trials (RCTs), systematic reviews, cohort studies, case reports, editorials, and commentaries.

Results: Our comprehensive search yielded 5,115 articles and two studies met eligibility. Both articles were written by the same author group. The articles investigated the effect of pain neuroscience education (PNE) plus deep neck muscle strengthening in twenty-one students ages 15-18?years old with chronic idiopathic neck pain. The results concluded there may be some benefit to PNE plus deep neck flexor and extensor strength.

Conclusions: The main finding of this systematic review is the paucity of published research on physical therapy management of pediatric and adolescent neck pain. Our systematic review serves as a call to action for physical therapists to perform further research in order to provide the best evidence-based care for this population.     

Ageing well with chronic musculoskeletal pain: protocol for a systematic review of non-pharmacological interventions aimed at reducing pain in an ageing population

Background: Chronic musculoskeletal pain in the elderly is highly prevalent, with osteoarthritis, low back pain, neck pain and other musculoskeletal disorders as the leading contributors to pain chronicity and disability. Previous reviews identifying effective components of non-pharmacological interventions for treating chronic pain have either few studies or the included studies examine outcome over a limited time span. This systematic review will investigate the effectiveness and components of interventions associated with management of chronic musculoskeletal pain in older adults (≥65 years).

Methods/Design: This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Randomised controlled trials of non-pharmacological interventions aimed at reducing pain in older adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, Web of Science and PEDro. Two review authors will independently screen articles retrieved from the search for eligibility, and extract relevant data on methodological issues. A narrative synthesis will be completed if there are insufficient data for a meta-analysis. The narrative synthesis will summarise the current state of knowledge, interventions, study designs and robustness of evidence.

Discussion: Findings of the study will inform support programs and interventions to assist people aging with pain, carers and other supporters and practitioners.

Systematic review registration: PROSPERO 2017:CRD42017074173.     

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention

Purpose: To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention.

Materials and methods: This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability.

Results: In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model.

Conclusions: Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach.

• Implications for rehabilitation

• Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain

• Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability

• Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner.

• Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

     

Outcomes of strengthening approaches in the treatment of low-grade spondylolisthesis

Abstract

Background: Historically, spondylolisthesis has been treated by a wide variety of techniques such as flexion exercises, bracing, abdominal stabilizing programs, general strengthening, stretching, and in some cases, motor control exercises. Although surgical treatment of spondylolisthesis has been outlined in current literature, strengthening programs have not been well defined for this population.

Objective: To describe the outcomes in randomized clinical or controlled trials (RCTs) in which either a global or local strengthening approach was assessed against another comparator in conservative treatment of patients with a low-grade spondylolisthesis.

Methods: A systematic review of the literature. This review was formatted using the PRISMA guidelines, a 27-item checklist and four-phase flow diagram. An electronic search strategy targeting randomized controlled and clinical trials that compared conservative treatments for low-grade (I and II) spondylolisthesis that used a local stabilization approach, motor control, and/or a general strengthening program versus a surgical intervention or a control group was used. Physiotherapy Evidence Database (PEDro) was used to critically appraise each study for quality. Outcome measures included changes in pain measured by the visual analog scale (VAS) along with secondary measures of functional disability, working status, and lumbar range of motion.

Results: Although 28 studies went through full text review, only three studies met inclusion criteria. Within the studies, global strengthening exercise programs significantly decreased subjects’ pain as measured using the VAS but did not significantly improve the level of disability. In contrast, local stabilization or motor control exercises demonstrated improvements in both pain and disability. No studies directly compared a global strengthening approach versus a stabilization approach.

Conclusion: Our findings indicate that both exercise training programs of local strengthening/stabilization interventions, as well as general strengthening programs may be beneficial as conservative strengthening management to patients with a low-grade spondylolisthesis. A direct comparison of these approaches is needed for the spondylolisthesis population.     

The behavior of pain in response to sit-stand workstations: a systematic review

Abstract

Background: Chronic neck and/or low back pain (LBP) is the most common musculoskeletal complaint among individuals employed in sedentary jobs. Literature is available on the behavior of chronic neck and LBP in response to sit-stand workstations (SSW) but lacks a clinically significant consensus.

Objective: The purpose of this systematic review is to report the clinical significance of the behavior of pain in response to SSW in comparison to traditional desks.

Methods: Articles were retrieved from electronic databases. Inclusion criteria were 1) employees in work environments that entail prolonged sitting time and with chronic neck and/or LBP, 2) intervention of SSW, and 3) the report on pain as an outcome. Exclusion criteria included 1) children or students, 2) intervention of mobility desks (i.e. treadmill, cycling), and 3) absence of pain prior to the study. Risk of bias was assessed using the PEDro scale.

Results: 3 studies were reported as Cohen’s d and revealed alleviation of neck and/or LBP with small to trivial clinical effect sizes. 1 study was calculated as odds ratio; its participants were more likely to report neck pain but less likely to report LBP with SSW compared to traditional desks. Another study reported results in p-values and were statistically significant for neck pain and insignificant for LBP.

Conclusion: Overall, findings suggest SSW may not absolutely relieve chronic neck or LBP but should not be excluded from pain management recommendations due to potential of positive impact.     

Mind-Body Exercise Performed by Physical Therapists for Reducing Pain and Disability in Low Back Pain: A Systematic Review With Meta-analysis

ObjectiveTo assess the effectiveness of mind-body (MB) exercise interventions provided by physical therapists for reducing pain and disability in people with low back pain (LBP).Data SourcesMEDLINE, Embase, CINAHL, and the Cochrane Library were searched for articles published in English between December 2010 and June 2020.Study SelectionRandomized controlled trials evaluating the effects of Pilates, yoga, and tai chi interventions performed by physical therapists on pain or disability outcomes in adults with musculoskeletal LBP were included.Data ExtractionData were extracted by 2 independent reviewers. Quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework and Cochrane risk of bias tools, respectively.Data Synthesis21,230 exercise trials were identified; 161 progressed to full-text review. Eight trials, 7 reporting on Pilates and 1 reporting on yoga, were included. Short-term outcomes for pain (SMD: -0.93; 95% confidence interval [CI]: -1.65 to -0.021) and disability (SMD: -0.74 95% CI: -1.36 to -0.012) indicated MB exercise was more effective than control intervention. Tests for subgroup differences between studies with exercise vs non-exercise control groups revealed a moderating effect on short-term outcomes where larger effects were observed in studies with non-exercise comparators. Long-term outcomes for pain (SMD: -0.60; 95% CI:-1.43 to 0.23) and disability (SMD: -1.05; 95% CI:-3.51 to 1.41) suggested that MB exercise is not more effective than control interventions for pain or disability. Quality of the evidence ranged from very low to low.ConclusionsPhysical therapist-delivered MB exercise interventions, which overwhelmingly consisted of Pilates, were more effective than control in the short and long-term for pain and in the short-term for disability, with differences in the short-term effects lessened when compared with an active intervention. Pilates interventions delivered by physical therapists represent a viable tool for the clinical management of chronic LBP.     

Reduction of cervical and respiratory muscle strength in patients with chronic nonspecific neck pain and having moderate to severe disability

Purpose: To investigate whether patients with chronic nonspecific neck pain and having moderate to severe disability have a greater cervical motor function impairment and respiratory disturbances compared with patients with chronic nonspecific neck pain having mild disability and asymptomatic subjects; and the association between these outcomes in patients with chronic nonspecific neck pain and healthy controls.

Methods: Cross-sectional study, 44 patients with chronic nonspecific neck pain and 31 healthy subjects participated. The neck disability index was used to divide the patients into 2 groups: 1) mild disability group (scores between 5 and 14 points); and 2) moderate to severe disability group (scores?>14 points). Cervical motor function was measured by cervical range of motion, forward head posture, neck flexor, and extensor muscle strength. Respiratory function and maximum respiratory pressures were also measured.

Results: Statistically differences were found between the patients with chronic nonspecific neck pain having a moderate to severe disability and the asymptomatic subjects for cervical and respiratory muscle strength. Comparisons between chronic nonspecific neck pain and the asymptomatic groups showed differences for all the variables, except for forward head posture. The regression model determined that strength of cervical flexion explained 36.4 and 45.6% of the variance of maximum inspiratory pressures and maximum expiratory pressures, respectively.

Conclusions: Only the chronic nonspecific neck pain group with moderate to severe disability showed differences compared with the healthy subjects. Neck muscle strength could be a good predictor of respiratory muscle function.

• Implications for rehabilitation

• Neck pain severity could be closely associated with decreased respiratory pressure in patients with chronic nonspecific neck pain.

• These findings suggest a new therapeutic approach for patients with moderate to severe disability, such as respiratory muscle training.

• The regression models show that a simple measurement of neck muscle strength could provide a reasonably accurate prediction for the respiratory function of these patients. Hence, this could provide an easy tool to assess respiratory function to physiotherapists without the need for sophisticated instrumentation.

     

The effectiveness of walking versus exercise on pain and function in chronic low back pain: a systematic review and meta-analysis of randomized trials

Objective: Walking is commonly recommended to relieve pain and improve function in chronic low back pain. The purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials concerning the effectiveness of walking interventions compared to other physical exercise on pain, disability, quality of life and fear-avoidance, in chronic low back pain.

Methods: Randomized controlled trials investigating the effects of walking alone compared to exercise and to exercise with added walking on adults with chronic low back pain were identified using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials (CENTRAL), PsychINFO, and SPORT Discus^TM databases. Two reviewers independently selected the studies and extracted the results. Study quality was assessed using the PEDro scale and the clinical relevance of each outcome measure was evaluated.

Results: Meta-analysis of five randomized controlled trials meeting inclusion criteria was performed. The effectiveness of walking and exercise at short-, mid-, and long-term follow-ups appeared statistically similar. Adding walking to exercise did not induce any further statistical improvement, at short-term.

Conclusions: Pain, disability, quality of life and fear-avoidance similarly improve by walking or exercise in chronic low back pain. Walking may be considered as an alternative to other physical activity. Further studies with larger samples, different walking dosages, and different walking types should be conducted.

• Implications for Rehabilitation

• Walking is commonly recommended as an activity in chronic low back pain.

• Pain, disability, and fear-avoidance similarly improve by walking or exercise.

• Adding walking to exercise does not induce greater improvement in the short-term.

• Walking may be a less-expensive alternative to physical exercise in chronic low back pain.

     

The role of physical status versus mental status in predicting the quality of life of patients with lumbar disk herniation

Purpose: To explore the role of physical status versus mental status in predicting the quality of life (QOL) of patients with lumbar disk herniation (LDH).

Method: In this correlative study 51 patients with LDH were recruited in their conservative stage of treatment. After profiling their physical status, all participants reported about pain level (according to VAS), pain perception using the Pain Catastrophizing Scale (PCS), and disability level (according to Oswestry Low Back Pain Disability Questionnaire). Their mental status was evaluated using the Spielberger’s State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI-II). Their QOL was evaluated by the World Health Organization Quality of Life Questionnaire, brief version (WHOQOL-BREF).

Results: Physical status/disability level correlated with anxiety and depression. While Physical status predicted physical QOL, mental status, and mainly anxiety and depression were the significant predictors of psychological, social, and environmental QOL.

Conclusions: Mental status may play a significant role in reducing most QOL domains among patients with LDH. The evaluation and intervention process should consider both physical and mental status and their relation to the person's QOL. Since QOL is a major parameter in determining intervention type and success this elaborated perspective may contribute to the intervention planning and outcomes.

• Implications for rehabilitaion

• A significant mental distress may accompany the physical disability of patients with LDH.

• The role of this mental distress in reducing the QOL of patients with LDH may be greater than that of their physical disability.

• The evaluation and intervention for patients with LDH should refer to both physical and mental status and explore their impacts on quality of life in order to elevate intervention success.

     

Effects of the craniocervical flexion and isometric neck exercise compared in patients with chronic neck pain: A randomized controlled trial

ABSTRACT

Introduction: The present study compared the effects of neck isometric exercise (NIE) and craniocervical flexion exercise (CFE) on cervical lordosis, muscle endurance of cervical flexion, neck disability index (NDI), and active cervical range of motion (ACROM) in all three planes in patients with non-specific, chronic neck pain (CNP). Materials and Methods: Forty-one patients from a university hospital-based rehabilitation center were randomly assigned to an experimental (22 patients performing CFE) or control (19 patients performing NIE) group. All patients performed three 30-second repetitions of stretching exercises for the neck flexor, extensor, lateral flexor, and rotator as warm-up and cool-down exercises. The patients in the experimental group then underwent CFE 30 minutes/day, 3 times a week, for 8 weeks, while the control group underwent NIE. The main outcome measures were pain on visual analogue scale (VAS) and perceived disability based on the neck disability index (NDI). The secondary outcomes were cervical lordosis measured by an absolute rotation angle (ARA), muscle endurance of cervical flexion, and ACROM. Results: Both groups showed improved pain, NDI, endurance of the cervical flexor muscles, and ACROM in all three planes after 8 weeks (p < 0.001 for all). All these outcomes, except for the NDI, showed significantly greater improvements following CFE than following NIE (p < 0.05 for all). In particular, a significantly improved ARA of cervical lordosis was found following CFE but not following NIE (p < 0.05). Conclusions: CFE targeted at retraining the craniocervical flexor muscles was useful for improving or restoring the pain, cervical lordosis, and neck-related function disorders among patients with non-specific CNP.     

Sex-based differences in pain distribution in a cohort of patients with persistent post-traumatic neck pain

Objectives: To analyze a cohort of 745 consecutive patients referred to a regional specialist clinic for evaluation of post-traumatic neck pain during a five-year period.

Methods: A cross-sectional observational study of baseline assessments performed by multi-professional rehabilitation teams according to a standardized checklist.

Results: The cohort contained nearly twice as many females as males (64% versus 36%). The type of injury did not differ between sexes. Of the entire cohort, 38% were diagnosed with widespread pain, 50% with regional pain, and 12% with local pain. The pain distribution among the females was 43% widespread, 48% regional, and 9% local, and corresponding figures among males were 29%, 53%, and 18%. Longer time between trauma and assessment did not affect pain distribution among the men, but a tendency towards more widespread pain was observed among the women.

Discussion: The importance of "female sex" as risk factor for the development of persistent pain after neck trauma needs to be discussed further. The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls for both multidisciplinary assessments and treatment strategies. The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.

• Implications for rehabilitation

• Patients suffering from pain and disability after neck trauma constitute a significant proportion of patients with persistent pain.

• The importance of the risk factor “female sex" should be further discussed in the development of persistent pain after neck trauma.

• The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls both for multidisciplinary assessments and treatment strategies.

• The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.

     

Are neck pain scales and questionnaires compatible with the international classification of functioning,disability and health? A systematic review

Purpose.?To identify neck-pain-specific questionnaires and scales that measure functioning and disability and assess whether their contents are comparable to the international classification of functioning, disability and health (ICF).

Methods.?A systematic search was conducted in LILACS, MEDLINE, CINAHL, and SPORTSDISCUS databases, identifying questionnaires and scales used to assess neck-related functioning and disability from 1966 to November 2007. Each item of each scale or questionnaire was extracted and classified according to the ICF categories.

Results.?The databases yielded a total of 888 articles, of which seven questionnaires were identified and included in the review. A total of 74 items were analyzed, 27 linked to body function, 46 to activities and participation, 1 to environmental factors, and 5 to non-classified items. While the pain disability index tends to focus on limitations to body functions, the functional rating index and the Copenhagen neck functional disability scale appear to be limited to measuring activity. Three questionnaires (the neck Bournemouth Questionnaire, the neck disability index, and the neck pain and disability scale) have demonstrated a well-balanced distribution of items across the ICF components.

Conclusion.?Most identified questionnaires reflect limitations or restrictions in one component only. These results provide valuable information on the content quality of these questionnaires for health-care providers and researchers.     

Limited scientific evidence supports the use of conservative treatment interventions for pain and function in patients with subacromial impingement syndrome: randomized control trials

Abstract

Background: Different conservative treatment interventions are often used to decrease pain and improve function in patients with subacromial impingement syndrome (SAIS). However, the current evidence to support the use of these interventions has not been established.

Objectives: To determine the evidence for conservative treatment interventions regarding pain and function compared to any intervention for SAIS patients.

Methods: A systematic review of randomized controlled trials, published in English between 1 January 1999 and 31 May 2010, was performed using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and manual searching. The methodological quality (PEDro scale) and evidence grade (SBU) were rated. Eight studies were of high quality, four were medium quality, and eight were low quality. Various conservative treatment interventions were evaluated: acupuncture, electrotherapy modalities, exercises, mixed modalities, changing posture, and use of a functional brace.

Results: Limited scientific evidence (LSE) indicates positive effects of exercise and mixed modalities regarding pain and function and high-intensity laser therapy (HILT) regarding pain in SAIS patients. LSE also indicate no effect of electrotherapy modalities, apart from HILT, as treatment for SAIS.

Conclusions: The lack of high quality interventions limits the ability to draw conclusions regarding efficacy from several of the included studies. However, exercise may be as efficient as surgery, manual therapy in combination with exercise seems to be more effective than exercise alone and high-dose exercises seem to be more effective than low-dose exercises. Furthermore, there is contradictory evidence to support the use of acupuncture.     

Effectiveness of manual therapy in the treatment of non-specific neck pain: a review

Abstract

The aim of the current review was to assess the evidence for the effectiveness of cervical spine manipulation and mobilisation in the treatment of non-specific neck pain. A review of the literature was performed in a systematic format, based upon a structured search of six computerised bibliographic databases, together with manual searching of selected journals and reference lists to identify randomised clinical trials (RCTs) researching the effectiveness of manual therapy in the treatment of non-specific neck pain. The methodological quality of the studies was assessed using a set of pre-defined criteria adapted from Koes et al. (Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303 :1298–303) and updated in the light of recent literature.

A total of 12 RCTs met the selection criteria. The scores achieved for methodological quality of the studies ranged from 25 points to 67 points out of a possible 100 points. Only four RCTs scored above 50 points: two of these reached a positive conclusion about the effectiveness of spinal manual therapy in the treatment of non-specific neck pain, and two a negative conclusion. Eight RCTs scored below 50 points; six of these reached a positive conclusion and two a negative conclusion.

RCTs researching the effectiveness of manual therapy for non-specific neck pain demonstrate methodological shortcomings in both design and reporting. The effectiveness of spinal manual therapy on non-specific neck pain remains inconclusive. The available evidence favoured spinal manual therapy when it was used in conjunction with exercise, particularly in the treatment of patients with chronic non-specific neck pain. Further, well-designed RCTs are needed to draw valid conclusions about the effectiveness of spinal manual therapy on nonspecific neck pain. In such future RCTs, placebo treatments should be designed to be indistinguishable (as far as possible) from manual therapy, and without the specific effects of active therapy. Furthermore, psychosocial factors should be considered prior to randomisation of patients by using appropriate measures.     

Yoga for Chronic Neck Pain: A Pilot Randomized Controlled Clinical Trial

Yoga has been found effective in the treatment of chronic low back pain. We aimed to evaluate the effectiveness of Iyengar yoga in chronic neck pain by means of a randomized clinical trial. Seventy-seven patients (aged 47.9 ± 7.9, 67 female) with chronic neck pain who scored >40 mm on a 100-mm visual analog scale (VAS) were randomized to a 9-week Iyengar yoga program with weekly 90-minute classes (n = 38) or to a self-care/exercise program (n = 38). Patients were examined at baseline and after 4 and 10 weeks. The primary outcome measure was change of mean pain at rest (VAS) from baseline to week 10. Secondary outcomes included pain at motion, functional disability, quality of life (QOL), and psychological outcomes. Twelve patients in the yoga group and 11 patients in the self-care/exercise group were lost to follow-up, with higher study nonadherence in the self-care group (5 versus 10 patients). Mean pain at rest was reduced from 44.3 ± 20.1 to 13.0 ± 11.6 at week 10 by yoga and from 41.9 ± 21.9 to 34.4 ± 21.1 by self-care/exercise (group difference: −20.1, 95% confidence interval: −30.0, −10.1; P < .001). Pain at motion was reduced from 53.4 ± 18.5 to 22.4 ± 18.7 at week 10 by yoga and from 49.4 ± 22.8 to 39.9 ± 21.5 by self-care/exercise (group difference: −18.7, 95% confidence interval: −29.3, −8.1; P < .001). Significant treatment effects of yoga were also found for pain-related apprehension, disability, QOL, and psychological outcomes. Sensitivity analyses suggested minimal influence of dropout rates. Both programs were well tolerated. In this preliminary trial, yoga appears to be an effective treatment in chronic neck pain with possible additional effects on psychological well-being and QOL. The effectiveness of yoga in chronic neck pain should be further tested by comparative effectiveness studies with longer observation periods.