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Conservative interventions provide short-term relief for non-specific neck pain: a systematic review.

Introduction

Neck pain affects up to two-thirds of people at some point during their life (Cote et al 1998). It remains one of the most common musculoskeletal complaints in primary care (Rekola et al 1993), yet many of those affected do not seek health care (Badcock et al 2003). Neck pain may be associated with specific conditions such as fracture, inflammatory disease, vascular disorders, or neurological compromise. However, for the majority of cases of neck pain, a specific cause cannot be identified and the classification non-specific neck pain is used (Hoving et al 2001).

The efficacy of interventions for non-specific neck pain has not been well established. Although many interventions have been investigated, previous systematic reviews (Binder 2005, Gross et al 2007, Hurwitz et al 2008) have investigated a diverse group of conditions additional to non-specific neck pain including radiculopathy, whiplash, and conditions that commonly, though not necessarily, have concomitant neck pain (eg headache, dizziness, brachialgia, back pain, and shoulder pain). These conditions are not homogeneous in that they have different clinical presentations and they are also believed to have different mechanisms. Better estimates of the effects of interventions for non-specific neck pain are likely to be found in trials in which all participants have non-specific neck pain.

Another factor that limits understanding of the effects of interventions for non-specific neck pain is that many of the available trials compare two or more active interventions without a no-intervention control. This type of trial is appropriate in circumstances where the efficacy of one of the interventions has been well established, or where the use of a no-intervention control might be unethical (Saunders 2003). However, in instances where the efficacy of the comparison intervention is simply presumed, there is no way of knowing whether either intervention is beneficial, ineffective, or even harmful. The use of a placebo or no intervention as a control provides a clearer answer about the efficacy of an intervention. Therefore, the research question for this review was:
   Which interventions for non-specific neck pain are more
   effective than placebo, sham, minimal intervention, or
   no intervention in reducing pain and disability?


Method

Identification and selection of studies

The databases MEDLINE, CINAHL, EMBASE, PEDro, and the Cochrane Register of Clinical Trials were searched from inception to February 2008 using a sensitive search strategy described by van Tulder et al (2003). (See Appendix 1 on the eAddenda for the full search strategy.) The bibliographies of all included trials and all systematic reviews located were searched for further relevant trials that had not been identified by the electronic search.

The inclusion criteria for trials are shown in Box 1. Two-arm trials that compared the relative effectiveness of two interventions, or different dosages or regimens of the same intervention, were excluded. Trials published in languages other than English were included if a suitable translation could be obtained. Trials that described participants having specific diagnoses (eg, cervical osteoarthritis or cervical myofascial pain) without confirmatory diagnostic tests as inclusion criteria were considered to be trials of non-specific neck pain. Trials that investigated mixed populations (eg, neck and back pain, neck/shoulder pain, neck/arm pain) or diffuse pain states (eg, chronic pain syndrome, fibromyalgia, cervicobrachialgia) were included only if outcomes were reported separately for the group of participants with neck pain. Trials were excluded if any of the participants had been given a specific diagnosis such as radiculopathy, myelopathy, fracture, infection, dystonia, tumour, inflammatory disease, or osteoporosis. Trials were excluded if some or all of the participants had whiplash-associated disorder or neck pain associated with trauma. Trials in which the participants' primary complaint was headache or upper limb pain were excluded unless the presence of neck pain was a specific inclusion criterion. Trials were excluded if prevention of neck pain in otherwise pain-free participants was the main aim of the intervention.
Box 1 Inclusion criteria.

Design

* Randomised controlled trial
Participants

* Adults, >18 years old

* Non-specific neck pain (in the area defined by
Merskey and Bogduk, 1994)

Intervention

* All interventions for neck pain

Outcome measures

* Pain

* Disability

Comparisons

* Intervention versus placebo / sham

* Intervention versus minimal intervention (eg, wait list)

* Intervention versus no intervention (eg, self-care
advice)


Retrieved citations were screened (AML) and titles unrelated to neck pain (eg, neck of femur, neck of bladder) were excluded. The remaining papers were independently screened by the lead author (AML) and by a second reviewer (KMR, CGM, or JHMc). Disagreement about inclusion or exclusion of studies was resolved by discussion. The reviewers were not blinded to information regarding the authors, journal of origin, or outcomes for each reviewed paper.

Assessment of characteristics of studies

Quality: Methodological quality was assessed using the PEDro scale (Maher et al 2003, de Morton 2009) by two independent trained assessors. Scores were extracted from the PEDro database where available. Trials were not excluded on the basis of quality.

Participants: The duration of the neck disorder was recorded to allow separate analysis of acute and chronic non-specific neck pain. Duration of up to 12 weeks was considered acute.

Interventions: Dosages of the interventions were recorded where available, as were descriptions of the intervention and the control intervention.

Outcome measures: The outcomes extracted were neck pain using a numerical scale and disability using a multi-item scale. Outcome data were extracted at the time closest to the conclusion of a course of treatment (short term), and at medium- and long-term follow-ups. We defined medium term as the time point between 3 and 9 months that was closest to 6 months. We defined long term as the time point after 9 months that was closest to 12 months (van Tulder et al 2003).

Data analysis

Data were extracted by the lead author (AML) and by a second reviewer working independently (KMR, CGM, JHMc). For trials with continuous outcomes the mean, standard deviation, and sample size of follow-up scores or change from baseline scores were extracted. If not reported, means and standard deviations were imputed from the reported measures of central tendency and variance (Higgins and Green 2006). For trials with dichotomous outcomes the number of subjects experiencing the outcome of interest and the total sample size were extracted.

Where continuous outcomes were reported in an individual study, the effects of the intervention were expressed as a mean difference with a 95% CI for each outcome. Where pooling of outcomes was deemed appropriate, a metaanalysis was conducted using a random effects model and the results were expressed as weighted mean differences.

Pain and disability scores were converted to a 0-100 point scale prior to calculation of effect size to enable comparison of outcomes between interventions and trials.

Where dichotomous outcomes were reported, the effects of the intervention were expressed as the relative risk of beneficial outcome with 95% CI.

Results

Flow of studies through the review

From 24 419 titles identified by the searches, 254 full-text publications were retrieved, of which 33 were included in the review. (Reasons for exclusion are presented in Figure 1.)

Characteristics of included studies

Quality: Trial quality was generally high with 60% of trials scoring at least 7 out of 10 on the PEDro scale (Table 1). The quality criteria related to blinding were commonly not met, with 17 trials not blinding participants and 26 trials not blinding therapists. Some of the interventions investigated, such as neck manipulation and exercise, are difficult to deliver with adequate blinding of participants or therapists. The other quality criteria that were most commonly not met were intention-to-treat analysis (22 trials) and concealment of treatment allocation (15 trials).

Participants: The majority of the eligible trials investigated participants with chronic neck pain (n = 19) or neck pain of mixed duration (n = 11). A single eligible trial (Pikula 1999) investigated acute neck pain. Two trials did not specify the duration of the episode of neck pain. (See Table 2.)

Interventions: The types of interventions investigated by the included trials were medications, relaxation, acupuncture, exercise, manual therapy, multi-modal intervention, and electrotherapy. (Specific interventions are presented in Table 2.) No eligible trials investigated the role of surgery, injections, or radiofrequency neurotomy for non-specific neck pain. The control intervention was a sham physical intervention in 20 trials, minimal intervention in 8 trials, no intervention in 3 trials, and placebo medication in 2 trials.

[FIGURE 1 OMITTED]

Outcome measures: Pain outcomes were reported by 31 of the 33 eligible trials. The most frequent pain outcome used was a numeric scale (n = 29). One trial reported pain outcomes using the von Korff scale (von Korff et al 1990), and one trial reported the number of participants who experienced improvement in neck pain. Disability outcomes were reported by 18 of the 33 eligible trials. The disability measures used included the Neck Disability Index (Vernon and Moir 1991, n = 8), Northwick Park Neck Pain Questionnaire (Leak et al 1994, n = 3), Million Scale (Million et al 1982, n = 2), Neck Pain and Disability Index (Wheeler et al 1999, n = 2), Modified Whiplash Disability Questionnaire (Skillgate et al 2007, n = 1), and single- and multiple-item numerical scales (n = 2) (Petrie and Hazleman 1986, Viljanen et al 2003).

Effect of interventions

For all interventions, pain outcomes at the conclusion of treatment are presented in Figure 2 and at medium-and long-term follow-up in Figure 3. For all interventions, disability outcomes at the conclusion of treatment are presented in Figure 4 and at medium-and long-term follow-up in Figure 5. (See also Tables 3 to 6 on the eAddenda for detailed data.)

Medication: Two trials were identified that compared the short-term analgesic effects of medications with placebo. One trial (Hoivik and Moe 1983) found more effective pain relief from an 8-day course of Norgesic (ie, combination orphenadrine 35mg and paracetamol 450mg) than placebo (MD -17, 95% CI -32 to -2). One trial (Thomas et al 1991) found no significant difference in immediate pain relief between single doses of diazepam (5mg) and placebo (MD -1, 95% CI -5 to 3). Neither trial reported medium- or long-term outcomes.

Relaxation: One trial investigated relaxation (Viljanen et al 2003). This three-arm trial compared intensive relaxation training with dynamic strengthening exercise and with minimal intervention in women with chronic neck pain. There was no significant difference in pain outcomes between relaxation training and minimal intervention at the conclusion of treatment (MD 2, 95% CI -4 to 8) or at medium- (MD 1, 95% CI -6 to 8), or long-term (MD 1, 95% CI -6 to 8) follow-up. In addition, there was no significant difference in disability outcomes between relaxation training and minimal intervention at the conclusion of treatment (MD 0, 95% CI -4 to 4), medium- (MD 1, 95% CI -3 to 6), or long-term (MD 3, 95% CI -2 to 7) follow-up.

Acupuncture: Five trials compared acupuncture with sham intervention. The shams used in these trials included needling procedures without skin penetration (Itoh et al 2007, Nabeta and Kawakita 2002) and deactivated electrotherapy devices (Petrie and Hazleman 1986, Vas et al 2006, White et al 2004). One trial compared acupuncture with minimal treatment (Witt et al 2006).

A variety of acupuncture approaches were investigated including traditional Chinese practice, western medical practice, and acupuncture applied to tender points identified by the practitioner. One four-arm trial (Itoh et al 2007) compared traditional Chinese acupuncture with acupuncture directed at 'trigger points', acupuncture directed to regions adjacent to 'trigger points', and sham acupuncture. The three acupuncture groups in this trial were combined to create a single pair-wise comparison.

Pooled outcomes from five trials (Itoh et al 2007, Nabeta and Kawakita 2002, Petrie and Hazleman 1986, Vas et al 2006, White et al 2004) showed no significant difference in pain outcomes between acupuncture and control at the conclusion of a course of treatment (WMD -12, 95% CI -23 to 0.1). Pooled results from the three trials (Petrie and Hazleman 1986, Vas et al 2006, White et al 2004) that reported medium-term pain outcomes showed acupuncture to be no more effective than control (WMD -4, 95% CI -15 to 7), consistent with the single trial (White et al 2004) that reported long-term pain outcomes (MD -4, 95% CI -13 to 7).

Pooled outcomes from five trials (Itoh et al 2007, Petrie and Hazleman 1986, Vas et al 2006, White et al 2004, Witt et al 2006) showed a significant but small difference in disability outcomes in favour of acupuncture at the conclusion of treatment (WMD -8, 95% CI -13 to -2). Pooled outcomes from the three trials (Petrie and Hazleman 1986, White et al 2004, Witt et al 2006) that reported medium-term disability outcomes demonstrated that acupuncture was not more effective than control (WMD -1, 95% CI -2 to 0.3), consistent with the single trial (White et al 2004) that reported long-term disability outcomes (MD -4, 95% CI -10 to 2).

[FIGURE 2 OMITTED]

Exercise: Five trials investigated exercise for non-specific neck pain. One three-arm trial (Kjellman and Oberg 2002) compared McKenzie exercise with general exercise and with sham ultrasound. Four trials compared various exercise approaches with minimal intervention. The exercise approaches included 'proprioceptive' exercises (Revel et al 1994), a combined program of neck stabilisation, relaxation, eye fixation, behavioural support, and posture training (Taimela et al 2000), group gymnastic exercises (Takala et al 1994), and muscle strengthening (Viljanen et al 2003).

[FIGURE 3 OMITTED]

Pooled outcomes from three trials (Kjellman and Oberg 2002, Revel et al 1994, Taimela et al 2000) showed significant reduction in pain at the conclusion of a course of specific exercises (WMD -12, 95% CI -22 to -2). The single trial that reported medium- (MD -6, 95% CI -17 to 5) and long-term (MD 1, 95% CI -12 to 14) pain outcomes for specific exercise programs did not demonstrate similar benefit (Kjellman and Oberg 2002). One trial (Kjellman and Oberg 2002) showed no significant difference in disability at the conclusion of a course of specific exercises (MD -3, 95% CI -10 to 4) and medium- (MD -3, 95% CI -11 to 5) and long-term (MD 2, 95% CI -6 to 10) follow-up.

[FIGURE 4 OMITTED]

Pooled outcomes from the three trials that investigated general strength and conditioning exercise (Kjellman and Oberg 2002, Takala et al 1994, Viljanen et al 2003) showed no difference in pain outcomes (WMD 3, 95% CI -3 to 8) at the conclusion of treatment. This is consistent with the two trials (Kjellman and Oberg 2002, Viljanen et al 2003) that reported medium- (WMD -2, 95% CI -7 to 4) and long-term (WMD -0.1, 95% CI -6 to 6) pain outcomes. Pooled results from the two trials that reported disability outcomes (Kjellman and Oberg 2002, Viljanen et al 2003) from general strength and conditioning exercise showed no significant difference compared with minimal intervention at the conclusion of treatment (WMD 1, 95% CI -3 to 5) or medium- (WMD 1, 95% CI -3 to 5) or long-term (WMD -3, 95% CI -7 to 2) follow-up.

Manual therapy: In the three included trials of manipulation, there were four sham-controlled comparisons of the immediate analgesic effect of a single high-velocity manipulation. One trial (Cleland et al 2005) investigated the effect of thoracic spine manipulation on neck pain and two trials (Martinez-Segura et al 2006, Pikula 1999) investigated cervical spine manipulation. The three-arm trial by Pikula and colleagues (1999) compared two different manipulation techniques with sham. The two manipulation groups in this trial were combined to create a single pair-wise comparison. Three trials (Hemmila 2005, Hoving et al 2002, 2006, Skillgate et al 2007) were identified that compared manual therapy with minimal or no intervention.

[FIGURE 5 OMITTED]

Pooled outcomes from three trials (Cleland et al 2005, Martinez-Segura et al 2006, Pikula 1999) show a significant analgesic benefit from a single manipulation compared with control (WMD -22, 95% CI -32 to -11). Medium- and long-term outcomes were not reported in these trials. Disability was not assessed.

Pooled outcomes from two trials (Hoving et al 2002, Skillgate et al 2007) show that manual therapy provided better pain relief after a course of treatment than minimal treatment (WMD -12, 95% CI -16 to -7). A similar benefit was not reported in the single trial (Hoving et al 2006) that reported medium- (MD -7, 95% CI -16 to 2) and long-term (MD -1, 95% CI -11 to 9) pain outcomes. Pooled outcomes from three trials (Hemmila 2005, Hoving et al 2002, Skillgate et al 2007) show that manual therapy resulted in significantly better disability outcomes at the conclusion of treatment than control (WMD -6, 95% CI -11 to -2). A similar benefit was not demonstrated in the two trials (Hemmila 2005, Hoving et al 2006) that reported medium(WMD -8, 95% CI -24 to 7) and long-term (WMD -1, 95% CI -12 to 9) disability outcomes.

Multimodal physical therapies: Two trials compared multimodal physical therapies, which included exercises, massage, and various electrotherapies, with minimal treatment. One trial excluded manual therapies (Hoving et al 2002, 2006), and one trial included manual therapies (Palmgren et al 2006) in the range of treatments provided.

Multimodal physical therapy that did not include manual therapy did not provide better pain relief than control following a course of treatment (MD -2, 95% CI -10 to 6) or at medium- (MD -3, 95% CI -13 to 7) or long-term (MD 10, 95% CI -0.4 to 20) follow-up. It also did not provide better disability outcomes than control following a course of treatment (MD 0, 95% CI -5 to 5) or at medium- (MD 0.2, 95% CI -5 to 5) or long-term (MD 4, 95% CI -11 to 10) follow-up.

Multimodal physical therapy that included spinal manual therapy provided better pain relief than control following a course of treatment (MD -21, 95% CI -34 to -7). Medium-and long-term pain outcomes and disability outcomes were not reported in this trial.

Laser therapy: Eight trials were identified that compared laser therapy to sham. Pooled outcomes from the six trials (Altan et al 2005, Ceccherelli et al 1989, Dundar et al 2007, Gur et al 2004, Ozdemir et al 2001, Thorsen et al 1992) that reported pain outcomes at the completion of treatment showed no significant difference between laser and control (WMD -14, 95% CI -34 to 5). Pooled outcomes from the five trials (Altan et al 2005, Ceccherelli et al 1989, Chow et al 2004, Chow et al 2006, Gur et al 2004) that reported pain outcomes at medium-term showed a statistically significant difference in favour of laser therapy over control (WMD -20, 95% CI -33 to -7). No trials reported long-term outcomes.

Pooled outcomes from two trials (D undar et al 2007, Ozdemir et al 2001) that reported disability outcomes following a course of treatment showed no significant difference between laser and control (WMD -28, 95% CI -72 to 17). Pooled outcomes from two trials (Chow et al 2004, Chow et al 2006) that reported medium-term disability outcomes showed no significant difference between laser and placebo (WMD -6, 95% CI -14 to 2). No trials reported long term outcomes.

Pulsed electromagnetic therapy: Two trials (Sutbeyaz et al 2006, Trock et al 1994) compared pulsed electromagnetic therapy with sham. Pooled outcomes show no significant difference between pulsed electromagnetic therapy and control in pain (WMD -27, 95% CI -57 to 3) or disability (WMD -18, 95% CI -48 to 11) outcomes at the conclusion of a course of treatment. Neither trial reported medium- or long-term outcomes.

Electrotherapies: One three-arm trial (Vitiello et al 2007) compared two types of transcutaneous electrical nerve stimulation (TENS) with sham TENS. The active treatment arms were standard TENS and a commercially branded stimulator called 'ENAR'. There was no significant difference found between TENS or ENAR and control in terms of pain or disability at any of the time points reported, with the exception of better medium-term disability outcomes in favour of the nine participants in the ENAR group (MD -18, 95% CI -31 to -6). Long-term outcomes were not reported.

Infra-red therapy : A single trial (Lewith and Machin 1981) was identified that compared heat treatment using an infrared device with a sham TENS device. A larger proportion of participants treated with the infra-red device reported pain relief than in the control group (RR 7, 95% CI 1 to 39).

Discussion

For people with non-specific neck pain, our findings suggest that there are several interventions that provide clinically worthwhile improvements in pain and disability, at least in the short term. The long-term benefits of these interventions have not been demonstrated; however, few studies have examined long-term outcomes. Importantly, we identified only one eligible trial that investigated patients with acute neck pain, greatly limiting evidence-based decision making about management of this group.

Consistent with previous reviews (Gross et al 2007, Hurwitz et al 2008), our results support the use of physical therapies that involve combinations of manual therapy and exercise. Our results add to the evidence supporting manual therapy by demonstrating short-term analgesic benefit from neck manipulation, thoracic manipulation, and neck mobilisation applied as single modality interventions. Our results also support the use of exercise for neck pain. Exercise programs that targeted specific impairments, such as head repositioning accuracy (Revel et al 1994) or combinations of neck stabilisation, relaxation, eye fixation, and posture training (Taimela et al 2000), were effective interventions. In contrast, it would appear that general strength and conditioning programs (Kjellman and Oberg 2002, Takala et al 1994, Viljanen et al 2003), which are commonly used for treatment of chronic pain and disability, were not effective for neck pain.

Australian guidelines advocate primary care for neck pain that includes reassurance, advice, and prescription of simple analgesic medication (NHMRC 2004). The appeal of this approach is that the interventions are simple, inexpensive, accessible, and presumed to be safe and effective. Some of the recommendations in the guidelines (eg, reassurance and advice) have not been tested, and others (eg, prescription of simple analgesics) have not been tested adequately for nonspecific neck pain. A trial investigating the efficacy of these primary care measures is therefore a research priority.

The scarcity of studies of simple analgesics is part of a broader pattern of lack of evidence for commonly used pharmacological interventions for neck pain. We found no trials that investigated the efficacy of non-steroidal anti-inflammatory, opioid, muscle relaxant, antidepressant, or antineuritic medication. Similarly, we found no trials that investigated local anaesthetic, nerve block, or Botulinum toxin injection for non-specific neck pain. The widespread use of analgesic and other medications for neck pain underpins the need for better knowledge about the efficacy and safety of these interventions.

The therapeutic benefits of interventions such as acupuncture and laser are supported, although not convincingly, by this review. Although the pooled results of the acupuncture trials demonstrated a statistically significant improvement in disability outcomes, the point estimate of the effect size (7.5 points on a 100-point index) is small. This result is also disproportionately influenced by the single large (n = 3441), lower quality trial (Witt el at 2006) that used a minimal-intervention comparison rather than sham acupuncture. Separate analysis of disability outcomes from the sham-controlled trials of acupuncture (WMD -6, 95% CI -15 to 3) suggest that the small difference seen between acupuncture and minimal medical care relate to the non-specific effects of provision of care. Similarly, while the results for laser therapy were promising, the results from the eight included trials varied from exceptionally effective to slightly harmful. This conflict in the findings is difficult to explain. Pooled results demonstrated no between-group difference at the conclusion of treatment, whereas a significant reduction in pain was found at medium-term follow-up. A delayed analgesic effect does not seem plausible. Furthermore, this pattern of delayed onset of benefit did not consistently appear within trials that measured at both time points, and appears to be partly an artefact of the different studies included at the two time points. The included trials of laser therapy investigated similar treatment and dosage protocols, although there was considerable diversity in trial quality and outcomes measured. The lack of consistency between trials in the timing of follow-up assessments resulted in different trials being pooled at post-treatment and medium-term time points, so the clinical course of symptoms should not be inferred from these data. A more focused review of laser therapy might provide further explanation about the reasons for the inconsistent trial outcomes.

Few trials examined other electrophysical agents and those that did were inconclusive. Two trials of pulsed electromagnetic therapy suggest that this intervention is not effective. There was sparse evidence concerning the various forms of TENS therapy with only one small study reporting no significant results. There were no eligible trials that investigated any of the other electrophysical agents commonly used for neck pain.

There is increasing evidence for an association between psychological factors and musculoskeletal pain and disability (Linton 2000), and therefore a strong rationale supports psychological interventions. However, the role of psychological interventions for neck pain has not been well investigated despite the increasing popularity of these therapies. Some of the psychological therapies, such as those that address coping, adjustment, and problem solving, involve generic pain-management principles and have been investigated in broader spinal pain, or chronic musculoskeletal pain populations (Morley et al 1999). The one trial identified in this review that investigated intensive training in relaxation, a therapy often provided with other psychological interventions, showed that this treatment was not effective for decreasing neck pain.

The role of surgery in the management of non-specific neck pain was not well supported by this review. Surgical trials excluded from this review were almost exclusively conducted on patients with specific pathology, usually a demonstrated neurological compromise. We found no controlled trials that investigated the use of procedures such as fusion or disc replacement for non-specific neck complaints. Given the high potential for serious adverse events and the high costs associated with surgery there is a need to establish better knowledge about the outcome of these procedures.

Despite the extensive evidence identified and summarised by this review, several questions have not been answered comprehensively. Although we identified 221 studies that investigated interventions for neck pain, only 33 trials met our criteria of having participants with clearly defined nonspecific neck pain, and using a placebo, sham, or minimal or no intervention as a control. There is a need for greater consistency in classification of neck pain and conditions associated with neck pain. We excluded a large number of trials in which two active interventions were compared, ie, without comparison to a placebo, sham, or minimal or no intervention. This type of comparative trial should be a lower research priority in making determinations about efficacy.

This review has identified evidence supporting some interventions for non-specific neck pain. However, none of these interventions was shown to have lasting benefit. There is a need to establish whether simple and inexpensive measures such as reassurance, self-care advice, and simple analgesics provided by trained practitioners are effective for neck pain. Future research might focus on the question of whether the addition of commonly provided or novel interventions confers additional benefits to quality baseline care. This is particularly pertinent for interventions that involve exposure to additional risks or incur additional costs.

eAddenda: Appendix 1, Tables 3 to 6 available at jop. physiotherapy.asn.au

Support: AL was funded by a University of Sydney scholarship. CM is funded by a NHMRC fellowship.

Competing interests: None declared.

Correspondence: Dr Andrew Leaver, Faculty of Health Sciences, The University of Sydney, NSW, Australia. Email: andrew. leaver @ sydney.edu.au

References

Altan L, Bingol U, Aykac M, Yurtkuran M (2005) Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome. Rheumatology International 25: 23-27.

Badcock LJ, Lewis M, Hay EM, Croft PR (2003) Consultation and the outcome of shoulder-neck pain: a cohort study in the population. Journal of Rheumatology 30: 2694-2699.

Binder A (2005) Neck pain. Clinical Evidence 13: 1501-1524.

Ceccherelli F, Altafini L, Lo Castro G, Avila A, Ambrosio F, Giron GP (1989) Diode laser in cervical myofascial pain: a double-blind study versus placebo. Clinical Journal of Pain 5: 301-304.

Chow RT, Barnsley L, Heller GZ, Siddall PJ (2004) A pilot study of low-power laser therapy in the management of chronic neck pain. Journal of Musculoskeletal Pain 12: 71-81.

Chow RT, Heller GZ, Barnsley L (2006) The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain 124: 201-210.

Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T (2005) Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy 10: 127-135.

Cote P, Cassidy JD, Carroll L (1998) The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 23: 1689-1698.

de Morton N (2009) The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Australian Journal of Physiotherapy 55: 129-133.

Dundar U, Evcik D, Samli F, Pusak H, Kavuncu V (2007) The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: a double blind, placebo-controlled study. Clinical Rheumatology 26: 930-934.

Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, et al (2007) Conservative management of mechanical neck disorders: a systematic review. Journal of Rheumatology 34: 1083-1102.

Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S (2004) Efficacy of 904 nm gallium arsenide low level laser therapy in the management of chronic myofascial pain in the neck: a double-blind and randomize-controlled trial. Lasers in Surgery & Medicine 35: 229-235.

Hemmila HM (2005) Bone setting for prolonged neck pain: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 28: 508-525.

Higgins J, Green S (2006) Extraction of study results. In Higgins JPT, Green S (Eds) Cochrane Handbook for Systematic Reviews of Interventions 4.2.6, Issue 4. Chichester: Wiley,

Hoivik HO, Moe N (1983) Effect of a combination of orphenadrine/paracetamol tablets ('Norgesic') on myalgia: a double-blind comparison with placebo in general practice. Current Medical Research & Opinion 8: 531-535.

Hoving JL, de Vet HCW, Koes BW, van Mameren H, Deville WLJ, van der Windt DAW, et al (2006) Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized clinical trial. Clinical Journal of Pain 22: 370-377.

Hoving JL, Koes BW, de Vet HC, van der Windt DA, Assendelft WJ, van Mameren H, et al (2002) Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Annals of Internal Medicine 136: 713-722.

Hoving JL, Gross AR, Gasner DM, Kay TB, Kennedy CB, Hondras MA, et al (2001) A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain. Spine 26: 196-205.

Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al (2008) Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 20002010 Task Force on Neck Pain and Its Associated Disorders. Spine 33: S123-152.

Itoh K, Katsumi Y, Hirota S, Kitakoji H (2007) Randomised trial of trigger point acupuncture compared with other acupuncture for treatment of chronic neck pain. Complementary Therapies in Medicine 15: 172-179.

Kjellman G, Oberg B (2002) A randomized clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain. Journal of Rehabilitation Medicine 34: 183-190.

Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank AO (1994) The Northwick Park neck pain questionnaire, devised to measure neck pain and disability. Rheumatology 33: 469-474

Lewith GT, Machin D (1981) A randomised trial to evaluate the effect of infra-red stimulation of local trigger points, versus placebo, on the pain caused by cervical osteoarthrosis. Acupuncture & Electro-Therapeutics Research 6: 277-284.

Linton SJ (2000) A review of psychological risk factors in back and neck pain. Spine. 25: 1148-1156

Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M (2003) Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy 83: 713-721.

Martinez-Segura R, Fernandez-de-las-Penas C, Ruiz-Saez M, Lopez-Jimenez C, Rodriguez-Blanco C (2006) Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 29: 511-517.

Merskey H, Bogduk N (1994) Classification of chronic pain. Description of pain terms and definitions of pain terms (2nd edn). Seattle: IASP Press.

Million R, Hall W, Nilsen KH, Baker RD, Jayson MIV (1982) Assessment of the progress of the back-pain patient. Spine 7: 204-212

Morley S, Eccleston C, Williams A (1999) Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain.80: 1-13.

Nabeta T, Kawakita K (2002) Relief of chronic neck and shoulder pain by manual acupuncture to tender points: a sham-controlled randomized trial. Complementary Therapies in Medicine 10: 217-222.

NHMRC (2004) Australian Acute Musculoskeletal Pain Guidelines Group Evidence-based management of acute musculoskeletal pain: a guide for clinicians. Bowen Hills: Australian Academic Press.

Ozdemir F, Birtane M, Kokino S (2001) The clinical efficacy of low-power laser therapy on pain and function in cervical osteoarthritis. Clinical Rheumatology 20: 181-184.

Palmgren PJ, Sandstrom PJ, Lundqvist FJ, Heikkila H (2006) Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. Journal of Manipulative and Physiological Therapeutics 29: 100-106.

Petrie JP, Hazleman BL (1986) A controlled study of acupuncture in neck pain. British Journal of Rheumatology 25: 271-275.

Pikula JR (1999) The effect of spinal manipulative therapy (SMT) on pain reduction and range of motion in patients with acute unilateral neck pain: a pilot study. Journal of the Canadian Chiropractic Association 43: 111-119.

Rekola KE, Keinanen-Kiukaanniemi S, Takala J (1993) Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician. Journal of Epidemiology & Community Health 47: 153-157.

Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL (1994) Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Archives of Physical Medicine and Rehabilitation 75: 895-899.

Saunders J (2003) Risk, Helsinki 2000 and the use of placebo in medical research. Clinical Medicine 3: 435-439.

Skillgate E, Vingard E, Alfredsson L (2007) Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial. Clinical Journal of Pain 23: 431-439.

Sutbeyaz ST, Sezer N, Koseoglu BF (2006) The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatology International26: 320-324.

Taimela S, Takala E, Asklof T, Seppala K, Parviainen S (2000) Active treatment of chronic neck pain: a prospective randomized intervention. Spine 25: 1021-1027.

Takala EP, Viikari-Juntura E, Tynkkynen EM (1994) Does group gymnastics at the workplace help in neck pain? A controlled study. Scandinavian Journal of Rehabilitation Medicine 26: 17-20.

Thomas M, Eriksson SV, Lundeberg T (1991) A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study. American Journal of Chinese Medicine 19: 95-100.

Thorsen H, Gam AN, Svensson BH, Jess M, Jensen MK, Piculell I, et al (1992) Low level laser therapy for myofascial pain in the neck and shoulder girdle. A double-blind, crossover study. Scandinavian Journal of Rheumatology 21: 139-141.

Trock DH, Bollet AJ, Markoll R (1994) The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. Journal of Rheumatology 21: 1903-1911.

van Tulder M, Furlan A, Bombardier C, Bouter L, Editorial Board of the Cochrane Collaboration Back Review G (2003) Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review group. Spine 28: 1290-1299.

Vas J, Perea-Milla E, Mendez C, Sanchez Navarro C, Leon Rubio JM, Brioso M, et al (2006) Efficacy and safety of acupuncture for chronic uncomplicated neck pain: a randomised controlled study. Pain 126: 245-255.

Vernon H, Mior S (1991) The neck disability index: A study of reliability and validity. Journal of Manipulative Physiological Therapeutics 14:409-415.

Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P (2003) Effectiveness of dynamic muscle training, relaxation training, or ordinary activity for chronic neck pain: randomised controlled trial. BMJ 327: 475-477.

Vitiello AL, Bonello R, Pollard H (2007) The effectiveness of ENAR for the treatment of chronic neck pain in Australian adults: a preliminary single-blind, randomised controlled trial. Chiropractic & Osteopathy 15: 1-11.

Von Korff M, Dworkin SF, Le Resche L (1990) Graded chronic pain status: an epidemiologic evaluation. Pain 40: 279-291.

Wheeler AH, Goolkasian P, Baird AC, Darden BV (1999) Development of the neck pain and disability scale: item analysis, face, and criterion-related validity. Spine 24: 1290.

White P, Lewith G, Prescott P, Conway J (2004) Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Annals of Internal Medicine 141: 911-919.

Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN (2006) Acupuncture for patients with chronic neck pain. Pain 125: 98-106.

Andrew M Leaver (1), Kathryn M Refshauge (1), Christopher G Maher (2) and James H McAuley (3)

(1) The University of Sydney, (2) The George Institute for International Health, (3) Prince of Wales Medical Research Institute Australia
Table 1. Quality of included studies (PEDro scores).

Study                    Random       Concealed      Groups
                       allocation    allocation    similar at
                                                    baseline

Altan 2005                  Y             N             Y
Checcherelli 1989           Y             N             N
Chow 2004                   Y             Y             Y
Chow 2006                   Y             Y             Y
Cleland 2005                Y             Y             Y
Dundar 2007                 Y             Y             Y
Gur2004                     Y             N             Y
Hemmila 2005                Y             Y             Y
Hoivik 1983                 Y             N             Y
Hoving 2002                 Y             Y             Y
Hoving 2006                 Y             Y             Y
Itoh 2007                   Y             N             Y
Martinez-Segura 2006        Y             N             Y
Nabeta 2002                 Y             N             Y
Kjellman 2002               Y             Y             Y
Lewith 1982                 Y             Y             N
Ozdemir 2001                Y             N             Y
Palmgren 2006               Y             Y             Y
Petrie 1986                 Y             N             N
Pikula 1999                 Y             Y             Y
Revel 1994                  Y             N             Y
Skillgate 2007              Y             Y             Y
Sutbeyaz 2006               Y             Y             Y
Taimela 2000                Y             N             Y
Takala 1994                 Y             N             Y
Thomas 1991                 Y             N             Y
Thorsen 1992                Y             N             Y
Trock 1994                  Y             Y             N
Vas 2006                    Y             Y             Y
Viljanen 2003               Y             Y             Y
Vitiello 2007               Y             Y             N
White 2004                  Y             Y             Y
Witt 2006                   Y             N             Y

Study                  Participant    Therapist     Assessor
                        blinding      blinding      blinding

Altan 2005                  Y             N             Y
Checcherelli 1989           Y             Y             Y
Chow 2004                   Y             Y             Y
Chow 2006                   Y             Y             Y
Cleland 2005                Y             N             Y
Dundar 2007                 Y             N             Y
Gur2004                     Y             N             Y
Hemmila 2005                N             N             Y
Hoivik 1983                 Y             Y             N
Hoving 2002                 N             N             Y
Hoving 2006                 N             N             Y
Itoh 2007                   Y             N             Y
Martinez-Segura 2006        N             N             N
Nabeta 2002                 Y             N             Y
Kjellman 2002               N             N             N
Lewith 1982                 N             N             N
Ozdemir 2001                Y             N             Y
Palmgren 2006               N             N             N
Petrie 1986                 N             N             Y
Pikula 1999                 N             N             N
Revel 1994                  N             N             N
Skillgate 2007              N             N             N
Sutbeyaz 2006               Y             Y             Y
Taimela 2000                Y             N             N
Takala 1994                 N             N             Y
Thomas 1991                 Y             N             N
Thorsen 1992                Y             Y             Y
Trock 1994                  Y             N             Y
Vas 2006                    N             N             Y
Viljanen 2003               N             N             Y
Vitiello 2007               N             N             Y
White 2004                  N             Y             N
Witt 2006                   N             N             N

Study                     < 15%      Intention-     Between-
                        dropouts      to-treat        group
                                      analysis     difference
                                                    reported

Altan 2005                  Y             N             Y
Checcherelli 1989           Y             N             Y
Chow 2004                   Y             N             Y
Chow 2006                   Y             Y             Y
Cleland 2005                Y             N             Y
Dundar 2007                 Y             N             Y
Gur2004                     Y             N             Y
Hemmila 2005                Y             Y             Y
Hoivik 1983                 Y             N             Y
Hoving 2002                 Y             Y             Y
Hoving 2006                 Y             Y             Y
Itoh 2007                   N             N             Y
Martinez-Segura 2006        Y             N             Y
Nabeta 2002                 N             Y             Y
Kjellman 2002               Y             N             Y
Lewith 1982                 Y             N             Y
Ozdemir 2001                N             N             N
Palmgren 2006               Y             N             Y
Petrie 1986                 Y             N             Y
Pikula 1999                 Y             N             Y
Revel 1994                  N             N             Y
Skillgate 2007              Y             Y             Y
Sutbeyaz 2006               Y             N             N
Taimela 2000                Y             Y             Y
Takala 1994                 Y             N             Y
Thomas 1991                 Y             N             Y
Thorsen 1992                Y             N             N
Trock 1994                  Y             N             Y
Vas 2006                    N             Y             Y
Viljanen 2003               Y             Y             Y
Vitiello 2007               N             N             Y
White 2004                  N             Y             Y
Witt 2006                   N             Y             Y

Study                     Point         Total
                        estimate      (0 to 10)
                           and
                       variability
                        reported

Altan 2005                  Y             7
Checcherelli 1989           Y             7
Chow 2004                   Y             9
Chow 2006                   Y            10
Cleland 2005                Y             8
Dundar 2007                 Y             8
Gur2004                     Y             7
Hemmila 2005                Y             8
Hoivik 1983                 Y             7
Hoving 2002                 Y             8
Hoving 2006                 Y             8
Itoh 2007                   Y             6
Martinez-Segura 2006        Y             5
Nabeta 2002                 Y             7
Kjellman 2002               Y             6
Lewith 1982                 Y             5
Ozdemir 2001                Y             5
Palmgren 2006               Y             6
Petrie 1986                 Y             5
Pikula 1999                 Y             6
Revel 1994                  Y             4
Skillgate 2007              Y             7
Sutbeyaz 2006               Y             8
Taimela 2000                Y             7
Takala 1994                 Y             6
Thomas 1991                 Y             6
Thorsen 1992                Y             7
Trock 1994                  Y             7
Vas 2006                    Y             7
Viljanen 2003               Y             8
Vitiello 2007               Y             5
White 2004                  Y             7
Witt 2006                   Y             5

Table 2. Table of description of main aspects of studies.

Study             Participants   Intervention

Altan et al       n = 53         Exp = Laser: GaAs, 1000 Hz, 904 nm,
(2005)            Chronic        50 W
                                 Con = Sham laser
                                 Both groups: 2 min per point,
                                 10 treatments over 10 days

Checcherelli      n = 27         Exp = Laser: GaAlAs, 1000 Hz,
et al             Chronic        904 nm, 25 W
(1989)                           Con = Sham laser
                                 Both groups: 12 treatments over
                                 4 wk

Chow et al        n = 27         Exp = Laser: DioLase, 830 nm,
(2004)            Chronic        300 mW
                                 Con = Sham laser
                                 Both groups: 30 min x 14
                                 treatments over 7 wk

Chow et al        n = 27         Exp = Laser: DioLase, 830 nm,
(2006)            Chronic        300 mW
                                 Con = Sham laser
                                 Both groups: 30 min x
                                 14 treatments over 7 wk

Cleland et al     n = 36         Exp = Thoracic spine manipulation
(2005)            Mixed          Con = Sham manipulation: placed
                                 in pre-manipulative position
                                 Both groups: single treatment

Dundar et al      n = 27         Exp = Laser: GaAsAl, 1000 Hz,
(2007)            Unspecified    9830 nm, power 450 mW
                                 Con = Sham laser
                                 Both groups: 15 treatments over
                                 15 days

Gur et al         n = 60         Exp = Laser: GaAlAs, 2800 Hz,
(2004)            Chronic        904 nm, 11.2 mW
                                 Con = Sham laser
                                 Both groups: 10 treatments over
                                 2 wk

Hemmila et al     n = 42         Exp = Bone setting: traditional
(2005)            Sub-acute or   non-manipulative manual therapy
                  chronic        5 treatments over 5 wk
                                 Con = No intervention

Hoivik et al      n = 44         Exp = Norgesic: orphenadrine 35 mg,
(1983)            Unspecified    paracetamol 450 mg 3 tablets/day x
                                 8 days
                                 Con = Placebo medication

Hoving et al      n = 183        Exp 1 = Manual therapy: spinal
(2002)            Mixed          mobilisation techniques
                                 6 treatments over 6 wk
                                 Exp 2 = Multimodal intervention:
                                 exercise and passive techniques
                                 excluding manual therapy
                                 12 treatments over 6 wk
                                 Con = Minimal intervention:
                                 medical primary practitioner visit
                                 up to 3 visits

Hoving et al      n = 183        Exp 1 = Manual therapy: spinal
(2006)            Mixed          mobilisation techniques 6
                                 treatments over 6 wk
                                 Exp 2 = Multimodal intervention:
                                 exercise and passive techniques
                                 excluding manual therapy
                                 12 treatments over 6 wk
                                 Con = Minimal intervention:
                                 medical primary practitioner visit
                                 up to 3 visits

Study             Participants   Intervention
Itoh et al        n = 40         Exp 1 = Standard acupuncture
(2007)            Chronic        Exp 2 = Trigger-point acupuncture
                                 Exp 3 = Non-trigger-point
                                 acupuncture
                                 Con = Sham acupuncture: blinded
                                 simulated needling without skin
                                 penetration
                                 All groups 30 min x 6 treatments
                                 over 10 wk

Kjellman et al    n = 77         Exp 1 = General exercises: ROM,
(2002)            Mixed          endurance and strength 16
                                 sessions over 8 wk
                                 Exp 2 = McKenzie exercises
                                 sessions at discretion of
                                 therapist over 8 wk
                                 Con = Sham ultrasound
                                 regimen unspecified

Lewith et al      n = 26         Exp = Infra-red: applied to
(1982)            Sub-acute or   tender points for 5 to 10 s
                  chronic        Con = Sham TENS
                                 Both groups: 4 treatments over 2 wk

Martinez-         n = 70         Exp = Neck manipulation
Segura et al      Sub-acute or   Con = Sham manipulation: manual
(2006)            chronic        positioning of the neck
                                 Both groups: single treatment

Nabeta et al      n = 27         Exp = Acupuncture: 'sparrow
(2002)            Chronic        pecking technique' directed at
                  Acupuncture    tender points
                  students       Con = Sham acupuncture: blinded
                                 simulated acupuncture with blunt
                                 needles no penetration, simulated
                                 removal of needles
                                 Both groups: 5 min x 3 treatments
                                 over 3 wk

Ozdemir et al     n = 60         Exp = Laser: Ga-As Al, 830 nm,
(2001)            Mixed          50 mW
                                 Con = Sham laser: not well
                                 described
                                 Both groups: 12 points x
                                 15 s/point x 10 treatments over
                                 10 days

Palmgren et al    n = 37         Exp = Multimodal intervention:
(2006)            Chronic        chiropractic mobilisation/
                                 manipulation, massage, exercises
                                 3 to 5 treatments over 5 wk
                                 Con = Minimal intervention: advice

Petrie et al      n = 27         Exp = Acupuncture: 5 needles
(1986)            Chronic        Con = Sham TENS
                                 Both groups: 20 min x 8 treatments
                                 over 4 wk

Pikula et al      n = 36         Exp 1 = Manipulation in direction
(1999)            Acute          of the painful side
                                 Exp 2 = Manipulation in direction
                                 of the non-painful side
                                 Con = Sham ultrasound

Revel et al       n = 60         Exp = Eye coordination exercises
(1994)            Chronic        15 sessions over 8 wk
                                 Con = Minimal intervention: not
                                 fully described

Skillgate et al   n = 263        Exp = Multimodal intervention:
(2007)            Mixed          Naprapathic therapy (spinal manual
                                 therapy, massage, stretches, and
                                 advice re prevention,
                                 rehabilitation activities and
                                 ergonomics)
                                 45 min x 6 treatments over 6 wk
                                 Con = Minimal intervention:
                                 medical primary practitioner visit
                                 up to 2 visits

Sutbeyaz et al    n =34          Exp = PEMT: 0.1 to 64 Hz
(2006)            Chronic        Con = Sham PEMT: not well described
                                 Both groups: 30 min x 2
                                 treatments/day over 3 wk

Taimela et al     n = 76         Exp 1 = Active multimodal
(2000)            Chronic        intervention: stabilisation
                                 exercises, relaxation training,
                                 behavioural support, eye fixation
                                 exercises, posture training
                                 24 sessions over 12 wk
                                 Exp 2 = A neck lecture and 2
                                 training sessions in home
                                 exercises, progress diary
                                 Con = Minimal intervention: A
                                 neck lecture with written
                                 information about home exercises

Takela et al      n = 44         Exp = Group gymnastics
(1994)            Chronic        45 min x 10 sessions over 10 wk

                                 Con = No intervention
Thomas et al      n = 44         Exp = Diazepam: 5mg
(1991)            Chronic        single dose
                                 Con = Placebo medication

Thorsen et al     n = 60         Exp = Laser: GaALAs, 830 nm,
(1992)            Mixed          30 mW, max 9J per treatment
                  Laboratory     Con = Sham laser
                  technicians    Both groups: 6 treatments over 2 wk

Trock et al       n = 81         Exp = PEMT
(1994)            Chronic        Con = Sham PEMT: not well described
                                 Both groups: 30 min x 18
                                 treatments over 4 to 6 wk

Vas et al         n = 123        Exp = Acupuncture
(2006)            Chronic        Con = Sham TENS
                                 Both groups: 30 min x 5 treatments
                                 over 3 wk

Viljanen et al    n = 393        Exp 1 = Dynamic muscle training:
(2003)            Chronic        stretching and strengthening of
                                 muscles of neck and upper
                                 arm using dumbbells
                                 36 sessions over 12 wk
                                 Exp 2 = Relaxation training
                                 techniques: progressive muscle
                                 relaxation, autogenic training,
                                 functional relaxation, systematic
                                 desensitisation
                                 36 sessions over 12 wk
                                 Con = No intervention

Vitiello et al    n = 30         Exp 1 = ENAR
(2007)            Sub-acute or   Exp 2 = TENS
                  chronic        Con = Sham ENAR
                                 All groups: 15 min x 12 treatments
                                 over 6 wk

White et al       n = 135        Exp = Acupuncture
(2004)            Chronic        Con = Sham TENS
                                 Both groups: 20 min x 8 treatments
                                 over 4 wk

Witt et al        n = 3766       Exp = Acupuncture
(2006)            Chronic        Up to 15 treatments
                                 Con = Minimal intervention

Study             Outcome measures

Altan et al       Pain: VAS
(2005)

Checcherelli      Pain: VAS
et al
(1989)

Chow et al        Pain: VAS
(2004)            Disability: Northwick Park Neck Pain
                  Questionnaire

Chow et al        Pain: VAS
(2006)            Disability: Northwick Park Neck Pain
                  Questionnaire

Cleland et al     Pain: VAS
(2005)

Dundar et al      Pain: VAS
(2007)            Disability: Vernon Moir Neck Disability Index

Gur et al         Pain: VAS
(2004)            Disability: Vernon Moir Neck Disability Index

Hemmila et al     Disability: Million scale
(2005)

Hoivik et al      Pain: VAS
(1983)

Hoving et al      Pain: VAS
(2002)            Disability: Vernon Moir Neck Disability Index

Hoving et al      Pain: VAS
(2006)            Disability: Vernon Moir Neck Disability Index

Study             Outcome measures
Itoh et al        Pain: VAS
(2007)            Disability: Vernon Moir Neck Disability Index

Kjellman et al    Pain: VAS
(2002)            Disability: Vernon Moir Neck Disability Index

Lewith et al      Pain: Number improved
(1982)

Martinez-         Pain: VAS
Segura et al
(2006)

Nabeta et al      Pain: VAS
(2002)

Ozdemir et al     Pain: VAS
(2001)            Disability: Neck Pain and Disability Index

Palmgren et al    Pain VAS
(2006)

Petrie et al      Pain: VAS
(1986)            Disability: Single item scale

Pikula et al      Pain: VAS
(1999)

Revel et al       Pain: VAS
(1994)

Skillgate et al   Pain: von Korff scale
(2007)            Disability: Modified Whiplash Disability
                  Questionnaire

Sutbeyaz et al    Pain: VAS
(2006)            Disability: Million scale

Taimela et al     Pain: VAS
(2000)

Takela et al      Pain: VAS
(1994)

Thomas et al      Pain: VAS
(1991)

Thorsen et al     Pain: VAS
(1992)

Trock et al       Pain: VAS
(1994)

Vas et al         Pain: VAS
(2006)            Disability: Northwick Park Neck Pain
                  Questionnaire

Viljanen et al    Pain: VAS
(2003)            Disability: 8 item scale

Vitiello et al    Pain: VAS
(2007)            Disability: Vernon Moir Neck Disability Index

White et al       Pain: VAS
(2004)            Disability: Vernon Moir Neck Disability Index

Witt et al        Disability: Neck Pain and Disability Index
(2006)

Exp = experimental group, Con = control group, ENAR = electro
neuro adaptive regulator (proprietary branded TENS), PEMT =
pulsed electromagnetic therapy, TENS = transcutaneous electrical
nerve stimulation, VAS = visual analogue scale
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Title Annotation:Research
Author:Leaver, Andrew M.; Refshauge, Kathryn M.; Maher, Christopher G.; McAuley, James H.
Publication:Australian Journal of Physiotherapy
Article Type:Report
Date:Jun 1, 2010
Words:8200
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