Wednesday, May 15, 2013

Studies Examine Nondrug Therapies for Neck Pain

Neck PainUp to half of all persons can expect to experience at least some neck pain in their lifetime. Pharmacotherapy for neck pain is generally only palliative in nature and evidence for the effectiveness of nondrug therapies has been limited. Therefore, neck pain has become a major health burden in most societies worldwide. Three recent studies report on the efficacy of nondrug approaches for managing several types of neck pain, finding favorable outcomes of yoga and fear-avoidance training, while disparaging spinal manipulative therapy.

Study 1: Reducing Fear To Help Improve Whiplash Pain

Writing in the journal PAIN®, researchers at the University of Washington, Seattle, note that between 10% and 42% of people who experience a whiplash-associated disorder (WAD) develop chronic neck pain and may experience other symptoms, such as depression and anxiety [Robinson et al. 2013]. Yet, the majority of patients with WAD initially have neck injuries of lesser severity; namely, grade I (neck symptoms, but no physical signs) or grade II (neck symptoms plus some musculoskeletal signs, such as decreased range of motion or point tenderness).

Studies have reported that patients with WAD tend to avoid activities they fear will worsen their pain or produce further injury, or both. In many cases this fear of pain/injury leads to activity avoidance, resulting in physical deconditioning, loss of confidence, and delayed recovery.

The study by Robinson et al. examined the role of fear after WAD and assessed the effectiveness of 3 different nondrug approaches targeting fear. Persons still symptomatic from WAD grade I-II injuries approximately 3 months previously completed several assessment questionnaires (eg, Neck Disability Index, or NDI) and were then randomized to 1 of 3 groups (there were 173 subjects available for final analysis):

  • Group 1: subjects were provided an informational booklet describing WAD and the importance of resuming activities (control condition, n=54).
  • Group 2: informational booklet + didactic sessions (lecture/discussion) with clinicians reinforcing the booklet (n=60).
  • Group 3: informational booklet + imaginal and direct exposure desensitization to feared activities (n=59).

Didactic sessions and exposure desensitization sessions were delivered during three biweekly treatment sessions. Exposure desensitization involved therapist-guided imagining and actually engaging in head/neck movements judged by participants to be fear invoking, until the fear response was lessened over time.

Results indicated that absolute improvements in Neck Disability Index scores were significant (p<0.017) and in the expected direction, with group 3 (booklet + exposure desensitization) faring better than group 2 (booklet + didactic sessions) or group 3 (booklet alone). Subjects receiving exposure desensitization (group 3) also reported significantly less posttreatment pain severity compared with group 1 (effect size Cohen’s d = 0.60; p<0.001) or group 2 (d = 0.60; p=0.039).

Reduction in fear was the most important predictor of improvement in Neck Disability Index scores, followed by reductions in pain and in depression. The researchers conclude that their results highlight the importance of fear in individuals with subacute whiplash-associated disorder (WAD), and that addressing such fear via exposure therapy and/or educational interventions to improve function may be important for recovery.

Study 2: Yoga Benefits Neck Pain

Holger Cramer, PhD — from the University of Duisburg-Essen, Essen, Germany — and colleagues observe that neck pain is the second most common condition for which complementary therapies are used [Cramer et al. 2013]. In the United States, more than half of patients suffering from neck pain use complementary therapies, and yoga is among the most widespread. An estimated 15 million American adults report having practiced yoga at least once in their lifetime, with 20% of those using yoga explicitly for spinal-pain relief.

The study by Cramer et al. enrolled 51 patients with chronic nonspecific neck pain (mean age 48 years; 82% female) in a 9-week Iyengar yoga intervention and assessed outcomes at 12 months after completion. The program was specifically designed for patients with chronic neck pain without previous experience in yoga, and consisted of weekly 90-minute classes during the 9-week period. Outcome measures included neck pain intensity on a 100mm visual analog scale, functional disability (Neck Disability Index), health-related quality of life (Short-Form 36 questionnaire, SF-36), and global improvement.

Writing in Pain Medicine, the researchers report that from baseline to the 12-month followup, at which time there were 36 patients assessed, there were significant moderate-to-large effects favoring yoga; ie, demonstrating pain intensity improvement (Cohen’s d=0.86 [calculated from study data]; p< 0.001), decreases in neck-related disability (d=0.56; p = 0.001), and improvement in bodily pain on the SF-36 (d=0.65; p = 0.005).

Improvements in pain intensity were predicted by weekly minutes of yoga practice at home during the 4 weeks prior to final assessment, and improved neck-related disability and overall bodily pain were predicted by regular yoga practice during the past 12 months. Nearly 7 out of 10 patients (68.6%) rated their overall health as at least somewhat improved as a result of yoga practice.

In conclusion, a 9-week yoga intervention appears to be effective in relieving pain and functional disability in patients with chronic nonspecific neck pain for at least 12 months; however, sustained yoga practice seems to be the most important predictor of long-term effectiveness. Still, the researchers advise, more rigorous studies are needed that compare yoga with active control groups before the long-term effectiveness of yoga for chronic neck pain can be conclusively judged.

Study 3: Spinal Manipulation for Neck Pain Doubted

Writing in the April 2013 edition of Pain Medicine, Josephine Smith and Philip S. Bolton — from the University of Newcastle, Callaghan, New South Wales, Australia — observe that cervical-spine manipulation is one of several treatments available for conservative care of neck pain [Smith and Bolton 2013]. Manipulative therapy is often considered as an option when invasive treatments are not indicated or prove ineffective.

However, the researchers note, there is only low-to-moderate-quality evidence that manipulation may be of benefit in the treatment of neck pain, and cervical spine manipulation is not without risks. Up to half of patients undergoing manipulation experience at least one adverse reaction, usually involving local discomfort and typically lasting 24 hours, and vertebrobasilar stroke is a possible but rare catastrophic complication. While this complication may be due to an undiagnosed ischemic event presenting as neck pain, rather than manipulation being the cause, it highlights the importance of having a clear diagnostic rationale for considering a patient for cervical spine manipulation.

Smith and Bolton write, “Pain physicians might trust that cervical spine manipulation is a specific treatment for a specific diagnosable entity, and that those who provide manipulation take steps to make specific diagnosis before undertaking this therapy. However, although this might be a respectful image of manipulative therapy, it is not necessarily the case. There are over 290 synonyms used to describe the entity or lesion that chiropractors and others manipulate, but formal evidence of their ability to detect and treat these entities is lacking.”

The researchers conducted a systematic review of the literature to determine what clinical criteria or characteristics are used to diagnose the need for cervical spine manipulation. A secondary aim was to assess the reliability and validity of these features. They note: “A clear understanding of these determinants is necessary if prudent referral and case management is to be achieved by pain physicians and others who might consider manipulation as a treatment for neck pain.”

A thorough literature search for randomized controlled trials (RCT) involving mobilization or manipulation for neck pain uncovered 30 studies meeting inclusion criteria. Results of a descriptive analysis determined that acute and chronic “mechanical” neck pain was the most common (43%) diagnosis at recruitment to the RCTs, but some (10%) included patients with cervicogenic headache.

All RCTs lacked detail more descriptions of diagnostic criteria or interventions used. Clinical examinations were used to determine the need for neck manipulation in over half (63%) of the RCTs. These usually involved exclusion of serious conditions, manual examination for tenderness on palpation, and/or altered vertebral motion in the neck or upper thoracic region, all of which are known to lack validity, according to Smith and Bolton. The remaining 37% of the RCTs did not report a diagnostic strategy.

Only 1 study reported that examination was conducted after treatment to determine if the treatment had actually resolved the “manipulable lesion” and this was limited to assessment of localized pain. Although 87% of trial reports did not declare how success in treating a manipulable lesion was measured, 4 of them indicated that success was supported by detection of an audible sound during treatment. In 1 article, success was noted as when “a release was produced.” Two other articles referred in their discussion sections to the occurrence of a “crack” when treating the manipulable lesion.

Smith and Bolton stress that their review highlights the absence of reliable and valid diagnostic protocols to determine the need for spinal manipulation in persons presenting with nonserious, idiopathic, or whiplash-associated (grade II) neck pain. The use of manipulation for neck pain is at best empirical, the researchers assert, with manipulation being performed simply on the basis of a neck pain complaint.

The researchers rather strongly conclude the following:

“There is no available evidence, based on this review, that manipulative therapists diagnose and successfully treat lesions that pain physicians cannot detect or treat. It may be that there are specific entities for which manipulation might be indicated, but this still has to be shown.”

“Future studies of treatment should use inclusion criteria that have been shown to be reliable and valid; and they should show that relief of pain is associated with normalization of the clinical signs used to detect the manipulable lesion. However, until that is done, referring patients for manipulative therapy does not serve to address an elusive cause of pain, but rather is simply transferring the care of a person with neck pain.”


The review by Smith and Bolton, in Study 3, eschewing spinal manipulative therapy, or SMT, for neck pain is rather surprising in that one of the researchers is a chiropractor (Bolton) and the other is a physiotherapist (Smith); so, it might be expected that they would have biases much more favorable toward SMT. The researchers did not assess therapeutic outcome results of the 30 RCTs that they reviewed, apparently because the studies were so heterogeneous and it was so unclear as to exactly what specific conditions were being treated, or why.

Essentially, Smith and Bolton appear to be condemning all past research on manipulative therapy for neck pain as being unreliable and invalid. It is unknown, however, whether the protocols used in those research trials reflected diagnostic criteria and procedures actually used by spinal manipulative therapists (eg, chiropractors, osteopaths) in everyday practice — presumably they did and, if so, this would be of concern.

A prior Pain-Topics UPDATE [here] discussing SMT for neck pain found an advantage of this therapy over medication or home exercise regimens; albeit, effect sizes were small and there were numerous limitations of the research design that focused on how therapies are delivered in everyday practice (ie, a pragmatic trial). Other research literature reviews (see [UPDATE here]) have noted unfavorable results of SMT for treating a variety of musculoskeletal pain conditions.

YogaYoga has consistently demonstrated favorable outcomes for helping to ameliorate diverse musculoskeletal pain conditions, as demonstrated in Study 2, by Cramer et al. However, this study was hampered by its small size, with a significant dropout rate, and lack of a control group. Yet, it demonstrated that important long-term (12-month) benefits can be realized in patients who continue practicing yoga on their own.

A previous Pain-Topics UPDATE [here] discussed a well-designed study finding large effect sizes favoring yoga as helpful for chronic neck pain. Two important points are worth noting: 1) the studies have excluded patients with specific pathology that would contraindicate moderate exercise, and 2) most studies have used Iyengar yoga routines that were specially adapted to the needs of patients with neck pain (more general yoga programs administered by inexperienced instructors might be unhelpful or even harmful).

Study 1, by Robinson et al., examining the role of fear and its amelioration for aiding recovery from acute neck pain, provides an interesting perspective on factors that might hinder therapeutic success. As noted in a recent UPDATE article [here], patients with neck pain may also suffer substantially from depression and anxiety.

Robinson et al. found that 87% of their subjects had significant fear of cervical movement, and removing that as an impediment was helpful in promoting pain relief and functionality. However, these results are limited to persons with mild whiplash-related pain conditions (grade I and II), and it is unknown from the research whether effects persisted over time. It also is possible that some of the improvement may have reflected a degree of spontaneous recovery over time and/or due to the added personal attention from therapists in the fear-desensitization group, rather than by effects only of the study interventions.

Most certainly, fear, anxiety, and depression may be factors that inhibit responses to pain management interventions, so these negative influences need to be taken into account. Whether the approaches studied by Robinson et al. — ie, exposure desensitization or didactic instruction — are most effective and cost justifiable remain to be determined. At the same time, however, the economic costs and toll in suffering associated with ineffectively-treated acute neck pain conditions that become chronic and debilitating should be considered.

> Cramer H, Lauche R, Hohmann C, et al. Yoga for Chronic Neck Pain: A 12-Month Follow-Up. Pain Medicine. 2013;14(4):541-548 [
> Robinson JP, Theodore BR, Dansie EJ, et al. The role of fear of movement in subacute whiplash-associated disorders grades I and II. Pain. 2013;154(3):393-401 [
abstract here].
> Smith J, Bolton PS. What Are the Clinical Criteria Justifying Spinal Manipulative Therapy for Neck Pain? — A Systematic Review of Randomized Controlled Trials. Pain Medicine. 2013;14(4):460-468 [

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