Systematic review Manual therapy and exercise for neck pain: A systematic review Jordan Miller a , Anita Gross a, b, * , Jonathan D'Sylva a , Stephen J. Burnie c , Charles H. Goldsmith b , Nadine Graham a , Ted Haines b , Gert Brønfort d , Jan L. Hoving e a School of Rehabilitation Science, McMaster University, Hamilton, Canada b Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada c Chiropractic Clinician and Lecturer, Canadian Memorial Chiropractic College, Toronto, Canada d Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN, USA e Coronel Institute of Occupational Health and Research Centre for Insurance Medicine, Academic Medical Centre, Universiteit van Amsterdam, The Netherlands article info Article history: Received 24 November 2009 Received in revised form 26 January 2010 Accepted 8 February 2010 Keywords: Manual therapy Exercise Neck pain abstract Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI: 1.69,0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50 (95% CI:0.76,0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to tradi- tional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recom- mendations are made. Ó 2010 Elsevier Ltd. All rights reserved. 1. Background Neck pain is a frequent impairment associated with disability and substantive health care costs (Côté et al., 1998; Linton et al., 1998; Borghouts et al., 1999; Hogg-Johnson et al., 2008). Manipu- lation, mobilisation, or exercise applied as single-modal treatment approaches for neck pain have gained some support in Cochrane reviews (Gross et al., 2010 found earlier in this issue of Manual Therapy; Kay et al., 2009). Many practitioners believe that solo-care approaches do not accurately represent clinical practice or best- practice for individual patients. In our previous reviews (Gross et al., 1996, 2003, 2004, 2007), results supported the use of combined mobilisation, manipulation and exercise for short-term pain reduction, global perceived effect and patient satisfaction in acute and chronic neck pain with or without cervicogenic head- ache. Other quality reviews (Spitzer et al., 1995; Bogduk, 2001; Magee et al., 2000; Hoving et al., 2001; Peeters et al., 2001; Vernon et al., 2006, 2007; Hurwitz et al., 2008) agreed with these findings. Given that results were inconclusive for: 1) neck pain with radi- culopathy; 2) additional outcomes including function and quality of life; and 3) all outcomes at long-term follow-up, a systematic review update was warranted. The Cervical Overview Group update for other single- or multi-modal manual therapy approaches are reported elsewhere in this issue of Manual Therapy (Gross et al., 2010; D’Sylva et al., in this issue) (see Fig. 1). 2. Objectives Our systematic review update assesses the effectiveness of manual therapy and exercise for neck pain with or without radic- ular symptoms or cervicogenic headache on pain, function/ * Corresponding author. School of Rehabilitation Science, McMaster University, Hamilton, Canada. E-mail address: [email protected](A. Gross). Contents lists available at ScienceDirect Manual Therapy journal homepage: www.elsevier.com/math 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.02.007 Manual Therapy 15 (2010) 334e354
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lable at ScienceDirect
Manual Therapy 15 (2010) 334e354
Contents lists avai
Manual Therapy
journal homepage: www.elsevier .com/math
Systematic review
Manual therapy and exercise for neck pain: A systematic review
Jordan Miller a, Anita Gross a,b,*, Jonathan D'Sylva a, Stephen J. Burnie c, Charles H. Goldsmith b,Nadine Grahama, Ted Haines b, Gert Brønfort d, Jan L. Hoving e
a School of Rehabilitation Science, McMaster University, Hamilton, CanadabDepartment of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, CanadacChiropractic Clinician and Lecturer, Canadian Memorial Chiropractic College, Toronto, CanadadWolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN, USAeCoronel Institute of Occupational Health and Research Centre for Insurance Medicine, Academic Medical Centre, Universiteit van Amsterdam, The Netherlands
a r t i c l e i n f o
Article history:Received 24 November 2009Received in revised form26 January 2010Accepted 8 February 2010
Keywords:Manual therapyExerciseNeck pain
* Corresponding author. School of Rehabilitation SHamilton, Canada.
1356-689X/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.math.2010.02.007
a b s t r a c t
Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematicreview update assesses if manual therapy, including manipulation or mobilisation, combined withexercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfactionfor adults with neck pain with or without cervicogenic headache or radiculopathy. Computerizedsearches were performed to July 2009. Two or more authors independently selected studies, abstracteddata, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences(pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Lowquality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:�1.69,�0.06)), function/disability, and global perceived effect when manual therapy and exercise arecompared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:�0.76,�0.24)] than exercise alone, but no long-term differences across multiple outcomes for(sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidencesupports this treatment combination for pain reduction and improved quality of life over manual therapyalone for chronic neck pain; and suggests greater short-term pain reduction when compared to tradi-tional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recom-mendations are made.
� 2010 Elsevier Ltd. All rights reserved.
1. Background
Neck pain is a frequent impairment associated with disabilityand substantive health care costs (Côté et al., 1998; Linton et al.,1998; Borghouts et al., 1999; Hogg-Johnson et al., 2008). Manipu-lation, mobilisation, or exercise applied as single-modal treatmentapproaches for neck pain have gained some support in Cochranereviews (Gross et al., 2010 found earlier in this issue of ManualTherapy; Kay et al., 2009). Many practitioners believe that solo-careapproaches do not accurately represent clinical practice or best-practice for individual patients. In our previous reviews (Grosset al., 1996, 2003, 2004, 2007), results supported the use ofcombined mobilisation, manipulation and exercise for short-term
cience, McMaster University,
All rights reserved.
pain reduction, global perceived effect and patient satisfaction inacute and chronic neck pain with or without cervicogenic head-ache. Other quality reviews (Spitzer et al., 1995; Bogduk, 2001;Magee et al., 2000; Hoving et al., 2001; Peeters et al., 2001; Vernonet al., 2006, 2007; Hurwitz et al., 2008) agreed with these findings.Given that results were inconclusive for: 1) neck pain with radi-culopathy; 2) additional outcomes including function and quality oflife; and 3) all outcomes at long-term follow-up, a systematicreview updatewaswarranted. The Cervical OverviewGroup updatefor other single- or multi-modal manual therapy approaches arereported elsewhere in this issue of Manual Therapy (Gross et al.,2010; D’Sylva et al., in this issue) (see Fig. 1).
2. Objectives
Our systematic review update assesses the effectiveness ofmanual therapy and exercise for neck pain with or without radic-ular symptoms or cervicogenic headache on pain, function/
J. Miller et al. / Manual Therapy 15 (2010) 334e354 335
disability, quality of life, global perceived effect, and patientsatisfaction.
3. Methods
3.1. Study selection
Abbreviated inclusion criteria follow; see Gross et al., 2010earlier in this issue for detailed definitions.
3.1.1. Types of studiesRandomized controlled trial (RCT) or quasi-RCT.
3.1.2. Types of participantsAdults with acute (<1 month) to chronic (>3 months) neck pain
with or without radiculopathy or cervicogenic headache.
3.1.3. Types of interventionsManual therapy, including manipulation or mobilisation tech-
niques, combined with exercise compared to: a placebo; a wait list/no treatment control; an adjunct treatment (for example: mobi-lisation and exercise plus ultrasound versus ultrasound); or anothertreatment.
3.1.4. Type of outcomePain, function/disability, quality of life, global perceived effect,
and patient satisfaction for short-term (closest to 4 weeks) to long-term (closest to 12 months) follow-up.
3.2. Search methods
Computerized searches by a research librarian were updated toJuly 2009 and included bibliographic databases without languagerestrictions for medical, chiropractic, and allied health literature.The search strategies were detailed in our Cochrane review (Grosset al., 2010 found earlier in this issue).
3.3. Data collection and analysis
At least two reviewers independently conducted citation iden-tification, study selection, data abstraction, and risk of biasassessment according to Cochrane methodology detailed in Grosset al., (2010) earlier in this issue. Agreement was assessed forstudy selection using the quadratic weighted Kappa statistic (Kw);Cicchetti weights (Cicchetti, 1976). Characteristics of includedstudies can be found in Table 1.
Allison et al. (2002)Chronic neck pain (cervicalbrachial pain syndrome)n(A/R) 36/401 0 0 0 0 0 0Total Jadad score: 1/5Total van Tulder Score: 4/11Total risk of bias score: NC
Index treatmentNeural Treatment (NT): technique: neural tissue techniques,mobilisation, neuromuscular techniques, home mobilisationexercise techniques; frequency: NR; dose: 10 repetitions, 1e3times/dayComparison treatmentsArticular treatment (AT): thoracic and glenohumeral mobilisation,home exercise (stretches, theraband strengthening)Control group (CG): no treatment, allowed to seek treatment froma non-physiotherapy health care providerCo-intervention: NRDuration of treatment: 8 weeks, number of sessions NRDuration of follow-up: 0 days
Pain (VAS, 0 to 10)Baseline median: NT 4.6, AT 5.1, CG 3.3End of study median: NT 2.1, AT 3.4, CG 3.8Absolute Benefit: NT 2.5, AT 1.7, CG �0.4Reported Results: significant favoring NTSMD(NT v CG): �0.71 (95% CI:�1.52 to 0.09) [power 56%]SMD(NT v AT): �0.63 (95% CI:�1.46 to 0.20) [power 65%]Function (NPQ, 0 to 36)Baseline median: NT 12, AT 12.5, CG 12.5End of study median: NT 9.5, AT 11.0, CG 11.5Absolute benefit: NT 2.5, AT 1.5, CG 1.0Reported results: not significantSMD(NT v CG): �0.34 (95% CI:�1.12 to 0.45) [power 69%]SMD(NT v AT): �0.24 (95%CI:�1.56 to 0.57)[power 67%]QoL: NRGPE: NRPatient satisfaction: NRSide effect: NRCost of care: NR
Bonk et al. (2000)Acute WADN(A/R): 97/971 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder Score: 2/11Total risk of bias score: NC
Index treatmentActivity Therapy (AT): technique: a. mobilisation (passive),b. strengthening: isometric exercises, inter scapular musclestrengthening, c. postural exercise, d. advice; frequency:3 sessions week 1, 2 sessions week 2 and 3; dose: NR;route: cervical spineComparison treatmentsCollar Therapy (CT): collar worn during day for 3 weeks;no physiotherapy, activity, exercise or mobilisationCo-intervention: analgesic, anti-inflammatoryDuration of treatment: 3 weeks, 7 sessionsDuration of follow-up: 12 weeks
Pain (9 point linear scale):Baseline: NRReported results: significant difference favoring ATRR: 0.13 (95%CI: 0.02 to 1.02) [power 34%]Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effects: NRCost of care: NR
Brodin (1984, 1985)Chronic neck pain disorderwith some 25% havingradicular findings or lowercervical degenerativechangesn(A/R) 63/711 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder Score: 5/11Total risk of bias score: NC
Index treatmentGroup 3 (G3): technique: passive mobilisation as described byStoddard, massage, manual traction, superficial heat, analgesics,education (neck school including exercise); frequency:3 sessions/week; dose: NR; route: cervical spineComparison treatmentsGroup 1(G1): analgesicGroup 2 (G2): technique: mock therapy including superficialmassage, manual traction, electrical stimulation, analgesics,education (neck school including exercise); frequency:3 sessions/week; dose: NRCo-intervention: NRDuration of treatment: 3 weeks, 9 sessionsDuration of follow-up: 1 week
Pain (9 point linear scale):Baseline: NRReported results:RR(3 v o-cntl): 0.67 (95% CI: 0.43 to 1.04) [power 18%]RR(3 v 2): 0.59 (95% CI: 9.39 to 0.91)Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effects: 10 in o-cntl; G2 reported discomfort, usually smallcomplaints; RR: 9.22 (95% CI: 0.61 to 14.30); note one subjectdropped out due to acute cerebral disease (n ¼ 1), othersdropped out for the following reasons: acute abdominal pain(n ¼ 1); vacation and infection (n ¼ 1); acute pain in severaljoints (n ¼ 1); incapable of following planned treatment (n ¼ 4)Cost of care: NR
Bronfort et al. (2001);Evans et al. (2002)Chronic neck painn(A/R) 158e160/1911 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder score: 8/11Total risk of bias score: NC
Index treatmentsSpinal manipulation and low-technology exercises (SMT/Ex):teqhnique: a. chiropractic: manipulation, massage, described byFrymoyer, b. cardiovascular exercises: warm-up on stationary bike,c. stretching: light stretches as warm-up, upper body strengtheningexercises, d. progressive resisted exercises, strengthening of neckand shoulders described by Dyrssen et al: push-ups, dumbbellshoulder exercises; dynamic neck extension, flexion and rotationwith variable weight attachment pulley system; e. sham: shammicrocurrent therapy; frequency: 20 one hour sessions over 11weeks; dose: manipulation/massage 15 min, microcurrent 45 min;route: cervical spineComparison treatment:Spinal manipulation alone (SMT): teqhnique: a. chiropractic:manipulation, massage, described by Frymoyer, b. sham: shammicrocurrent therapy; frequency: 20 one hour sessions over 3months; dose: manipulation/massage 15min, microcurrent 45min;route: cervical spineHigh tech MedX and Rehabilitation Exercise (MedX): technique: a.cardiovascular exercises: warm-up on dual action stationary bike, b.stretching: light stretches as warm-up, c. strengthening of neck andshoulders: using variable resistance equipment; MedX equipmentresistance for neck extension and rotation to fatigue; frequency ¼20 one hour sessions over 11 weeks; dose: 20 repetition maxCo-intervention: home exercises including resisted rubber tubing for
Cumulative advantage (six patient-oriented outcomes)Reported results: favors SMT/Ex over SMT; MONOVA significant[Wilk's Lambda ¼ 0.85, (F(12, 302) ¼ 2.2, p < 0.01)]Pain (11-box scale, 0 to 10)Baseline mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0End of study mean: SMT 36.5, MedX 29.8, SMT/Ex 31.1Absolute benefit: SMT 20.1, MedX 27.3, SMT/Ex 24.9Reported results: group difference in patient-rated pain ANOVA[F(2,156) ¼ 4.2, p ¼ 0.02] favors the two exercise groupsSMD(SMT v MedX): 0.31 (95%CI:�0.08 to 0.70) [power 29%]SMD(SMT v SMT/Ex): 0.24 (95%CI:�0.14 to 0.61) [power 28%]SMD(SMT/Ex v MedX): 0.06 (95%CI:�0.33 to 0.44) [power 28%]Function (Neck Disability Index, 0 to 50)Baseline mean: SMT/Ex 27.2, SMT 27.6, MedX 28.1End of study mean: SMT/Ex 16.1, SMT 19.9, MedX 15.6Absolute benefit: SMT/Ex 11.1. SMT 7.7, MedX 12.5Reported results: no significant group differences were foundANOVA: F[2, 156] ¼ 2.04, p ¼ 0.13SMD(SMT v MedX): 0.33 (95% CI: �0.06 to 0.71) [power 23%]SMD(SMT v SMT/Ex): 0.31 (95% CI: �0.06 to 0.68) [power 28%]SMD(SMT/Ex vMedX): 0.31 (95% CI:�0.06 to 0.68) [power 25%]QoL (SF36 0 to 100)Baseline mean: SMT/Ex 71.7 MedX 69.0, SMT 69.1End of study mean: SMT/Ex 76.6, MedX 78.0, SMT 74.3Absolute benefit: SMT/Ex 4.5, MedX 5, SMT 5.2
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rotation and flexion; no concurrent treatment for neck pain by otherhealth care providersDuration of treatment: 11 weeks, 20 sessionsDuration of follow-up: 52 weeks
Reported results: SMT/Ex was superior to both MedX and SMTSMD (SMT/Ex v MedX): 0.10(95% CI:�0.28 to 0.48)SMD (SMT/Ex v SMT): �0.14(95% CI:�0.52 to 0.23)GPE improvement (1e9)End of Study Mean: SMT/Ex 78.6, MedX 78.2, SMT 91.9Reported Results:SMD (SMT/Ex v MedX): 0.01(95% CI:�0.39 to 0.41)SMD (SMT/Ex v SMT): �0.23(95% CI:�0.62 to 0.61)Patient satisfaction (1e7, satisfied to dissatisfied)Reported results: A clinically worthwhile cumulative advantagefavoring manipulation/exercise [low tech] group over exercise[hightech] & manipulation ANOVA: F[2, 158] ¼ 6.7, p ¼ 0.002SMD(SMT v MedX): 0.26 (95% CI:�0.13 to 0.65) [power 49%]SMD(SMT v SMT/Ex): 0.71 (95%CI: 0.33 to 1.10)SMD(SMT/Ex v MedX): �0.44 (95% CI:�0.83 to �0.05)Side effects: increase neck or headache pain 8 SMT/Ex, 9 MedX, 6SMT; increased radicular pain 1 SMT/Ex; severe thoracic pain 1SMT; all cases self-limiting and no permanent injuries;RR(SMT/Ex v MedX): 0.81 (95% CI: 0.23 to 1.55)RR(SMT v MedX): 0.61 (95% CI: 0.23 to 1.55)Cost of care: NR
Giebel et al. (1997)Acute neck pain withcervicogenic headache, WADn(A/R) 97/1031 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder Score: 5/11Total risk of bias score: NC
Index treatmentGroup 1 (G1): technique: mobilisation (passive, neuromuscular): forindividual segments active-assisted followed by passivemovements under light traction; PNF: active, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting;light traction with mobilisation; exercise; analgesic; anti-inflammatory; frequency: NR; dose: NR; route: cervical spineComparison treatmentGroup 2 (G2): collar: worn continuously, take off at night, advisedno exercise; analgesic; anti-inflammatoryCo-intervention: analgesics and antiinflammatories allowed in bothgroupsDuration of treatment: 3 weeks, sessions NRDuration of follow-up: 9 weeks
Pain (NRS101, 0 to 100)Baseline mean: G1 46.70, G2 49.20End of study mean: G1 0.64, G2 3.39Absolute benefit: G1 46.6, G2 45.81Reported results: significant favor G1SMD@2w treatment: �1.04 (95% CI:�1.46 to �0.61)SMD@3w treatment þ 9w follow-up: �4.88(95% CI:�5.68 to�4.07)NOTE that the large effect estimate for pain intensity in Giebel'strial is an artifact of both groups markedly improving frombaseline to almost no pain. Clinically this benefit translates toa 5.5% treatment advantage for the multimodal treatment.Function [household activity, physical activity, activity of dailyliving, social activity, neck mobility (11 point scale of MOPOFragenbogens)]Baseline: NRReported Results: significant favor G1SMD: 0.23 (95% CI:�0.17 to 0.63) (a positive sign denotesadvantage of the first group in the contrast) [power 100%]QoL: NRGPE: NRPatient satisfaction: NRSide effect: NRCost of care: G1 treatment economically favoredDirect care: G1 155DEM (78USD), G2 113DEM (57USD)Sick days [number patients � days off work]: G1 187, G2 330
Hoving et al. (2002);Hoving et al. (2006);Korthals -de Bos et al. (2001);Korthals-de Bos et al. (2003)Acute, subacute, chronicneck pain with and withoutradicular findings, orCervicogenic headachen(A/R) 178/1831 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder Score: 9/11Total risk of bias score: NC
Index treatmentManual Therapy (MT): technique: muscular and articularmobilisation techniques, coordination and stabilization techniques;low velocity passivemovements within or at the limit of joint range;excluded manipulation; frequency: one session/week; dose: 45 minsessions; route: cervical spineComparison treatmentsPhysical Therapy (PT): technique: active exercise therapies:strengthening, stretching (ROM), postural/relaxation/functionalexercise; optional modalities: manual traction, massage,interferential, heat; excluded specific mobilisations techniques;frequency: one session/week; route: cervical spineContinued Care by General Practitioner (GP): type: advice onprognosis, psychosocial issues, self care (heat, home exercise),ergonomics (pillow, work position), await further recovery; booklet(ergonomics, home exercise); medication: paracetamol, NSAID;frequency:follow-up every 2 weeks was optional; dose: 10 minsessions.Co-intervention: analgesics and antiinflammatories allowed in bothgroups, home exercise for all three groupsDuration of treatment: 6 weeks, median 6 sessions for MT, 9 sessionsPT, 2 sessions GP.Duration of follow-up: 52 weeks
Pain (NRS, 0 to 10)Baseline mean: MT 5.9, PT 5.7, GP 6.3End of study mean: MT 1.7, PT 2.6, GP 2.2Absolute benefit: MT 4.2, PT 3.1, GP 4.1Reported results: significant favoring MT over PTSMD (MT v PT): �0.41 (95% CI:�0.78 to �0.04)SMD (MT v GP): �0.04 (95% CI:�0.40 to �0.32)Function (Neck Disability Index, 0 to 50)Baseline: MT 13.6, PT 13.9, GP 15.9End of study mean: MT 6.4, PT 7.6, GP 7.4Absolute benefit: MT 7.2, PT 6.3, GP 8.5Reported results: significant favoring MT over PTSMD (MT v GP): 0.17 (95% CI:�0.19 to 0.58) [power 22%]SMD (MT v PT): 0.12 (95% CI:�0.48 to 0.25) [power 17%]QoL (EuroQ, 0 to 100):Baseline mean: MT 69.3, PT 75.3, GP 66.1End of study mean: MT 73.5, PT 78.4, GP 70.2Absolute benefit: MT 4.2, PT 3.1, GP 4.1Reported results:RR (MT v GP): 0.65 (95% CI: 0.40 to 1.06)RR (MT v PT): 0.76 (95% CI: 0.45 to 1.28)GPE (perceived recovery, 0e100%)Reported Results: significant favoring MT over PT and GPRR (MT v GP): 0.65 (95% CI: 0.40 to 1.06) [power 15%]RR (MT v PT): 0.76 (95% CI: 0.45 to 1.28) [power 9%]
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Patient satisfaction: NRSide effect: benign and transient (increased neck pain > 2 days,increased headache, arm pain/pins&needles, dizzinessCost of care: total costs: not significant; total direct costs:significant favors MT v PT; total indirect costs: significant favorMT v GP; duration off work: significant favor MT v GP
Jull et al. (2002)Chronic neck pain withcervicogenic headachen(A/R) 193/2001 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder score: 8/11Total risk of bias score: NC
Index treatmentManipulative Therapy (MT): technique: manipulation: highvelocity, low-amplitude manipulation described by Maitland;mobilisation (low velocity); frequency: 2 sessions/week; dose: 30min session duration; route: cervical spineCombined Therapy (MT/ExT): technique: manipulation,mobilisation, exercise; frequency: 2 sessions/week; dose: 30 minsession duration; route: cervical spineComparison treatmentExercise Therapy (ExT): technique: therapeutic low load exercise tocervical-scapular region: craniocervical flexor training withpressure biofeedback, scapular muscle training, postural correction,exercise performed throughout the day, isometric strengtheningwith co contraction of neck flexion and extension, stretching asneeded; frequency: 2 sessions/w; dose: 30 min session durationControl Group: no treatmentCo-intervention: NRDuration of treatment: 6 weeks, 8 to 12 sessionsDuration of follow-up: 52 weeks
Pain (headache intensity change score, VAS, 0 to 10)Baseline mean: MT 4.8, ExT 5.4, MT/ExT 5.1, Cntl 5.3Absolute benefit: MT 2.3, ExT 2.8, MT/ExT 2.7, Cntl 1.3Reported results: significant favoring MT and ExTSMD(MT v Cntl): �0.37 (95% CI:�0.78 to 0.04) [power 96%]SMD(MT v ExT): 0.21 (95% CI:�0.18 to 0.61) [power 96%]SMD(MT/ExT v ExT): 0.06 (95% CI:�0.35 to 0.46) [power 98%]SMD(MT/ExT v Cntl): �0.58 (95% CI: �1.00 to �0.17)Function (Northwick Park Neck Pain Questionnaire changescore, 0 to 36)Baseline mean: MT 27.5, ExT 29.6, MT/ExT 29.7, Control 30.7Absolute benefit: MT 11.2, ExT 15.7, MT/ExT 14.2, Control 6.4Reported results: significant favoring MT or MT/ExT overcontrol; no significant difference between MT, ExT and MT/ExTSMD(MT v Cntl): �0.39 (95% CI:�0.79 to 0.02) [power 100%]SMD(MT v ExT): 0.32 (95% CI:�0.08 to 0.72) [power 100%]SMD(MT/ExT v ExT): 0.11 (95% CI: �0.29 to 0.50) [power 59%]SMD(MT/ExT v Cntl): �0.64 (95% CI: �1.06 to �0.23)QoL: NRGPE (participant perceived effect, VAS, 0 to 100)Reported results: significant favoring MT and MT/ExT overcontrol, not significant for MT orMT/ExT when compared to ExTSMD(MT v Cntl): �2.36 (95% CI:�2.89 to �1.83)SMD(MT v ExT): 0.29 (95% CI:�0.10 to 0.69) [power 81%]SMD(MT/ExT v ExT): 0.01 (95% CI:�0.38 to 0.40) [power 59%]SMD(MT/ExT v Cntl): �2.73 (95% CI:�3.30 to �2.16)Patient satisfaction: NRSide effect: minor and temporary, 6.7% provoked by treatmentCost of care: NR
Jull et al. (2007)Chronic neck pain WAD IIn(A/R) 69/711 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder Score: 6/11Total risk of bias score: NC
Index treatmentMultimodal physical therapy (MPT): exercise, mobilisations,education and assuranceExercise: technique: low load exercise to re-educate flexors,extensors, and scapular stabilizers, exercises to retrain kinestheticsense; frequency: 10e15 sessions in 10 weeks; dose: low loadexercises; route: exercise advice and use of exercise diaryMobilisations: technique: low velocity mobilisations; frequency:10e15 sessions in 10 weeks; dose: low velocity mobilisations; routecervical spineEducation and assurance: type: education and assurance providedregarding ergonomics of activity of daily living and work practices;frequency: recommended 2 times/day; dose: NR; route: educationand adviceComparison treatmentSelf management program (SMP): technique: education regardingexercise, staying active and recovery process following a WAD,ergonomic advice same in both arms; frequency: exercisesrecommended 2 times/day; dose: NR; route: advice and educationCo-intervention: NRDuration of treatment: 10 weeks, 10e15 sessionsDuration of follow-up: none
Pain: NRFunction (Northwick Park Neck Pain Index, 0 to 36)Baseline mean: MPT 37.7, SMP 38.4End of treatment change score: MPT �10.4, SMP�4.6Reported Results: significantSMD(MPT v SMP): �0.49 (95% CI: �0.97 to �0.01)QoL: NRGPE perceived benefit (VAS, 0e10)Mean perceived benefit: MPT 7.3, SMP-4.2Reported results: significantSMD(MPT v SMP) 1.32: (95% CI: 0.80 to 1.85)GPE perceived symptom relief (VAS, 0e10)Mean perceived symptom relief: MPT 6.9, SMP-4.2Reported results: significantSMD(MPT v SMP): 1.15 (95% CI: 0.64 to 1.66)Patient satisfaction: NRSide effect: NRCost of care: NR
Karlberg et al. (1996)Subacute neck pain withcervicogenic headachen(A/R) 17/171 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder Score: 5/11Total risk of bias score: NC
Index treatmentPhysiotherapy Group (PT): technique: mobilisation (passive,neuromuscular) as described by Kaltenborn and Lewit, soft tissuetreatment, physiotherapy treatment included exercise: stabilizationexercise described by Feldenkrais, relaxation techniques describedby Jacobson, non-steroidal anti-inflammatory, education;frequency: median 13 sessions/9 weeks; dose: NR; route: cervicalspineComparison treatmentDelayed Treatment Group (D): wait period: 8 weeks withouttreatmentCo-intervention: NRDuration of treatment: median 8e9 weeks, 13 sessionsDuration of follow-up: none
Pain (headache intensity, VAS, 0 to 100)Baseline mean: PT 54, D 56End of study mean: PT 31, D 55Absolute benefit: PT 23, D 1Reported results: significant favoring PTSMD: �1.47(95% CI:�2.58 to �0.36)Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effect: NRCost of care: NR
McKinney et al. (1989);McKinney et al. (1994)
Index treatmentGroup 2 (G2): technique: mobilisation (passive, active) e active and
passive repetitive movements using principles of Maitland andMcKenzie, heat/cold application, short wave diathermy,hydrotherapy, traction, “the full gamut of physiotherapeutic aidswas available as deemed appropriate”, education e posture andexercise to perform at home, standard analgesic, collar e fitted withsoft collar (intermittent use), frequency: 3 sessions/week; dose: 40-min sessions; route: cervical spineComparison treatmentGroup 1 (G1): education: mobilisation after an initial 10e14 day restperiod, general advice; analgesics; collar: fitted with soft collar(continuous use)Group 3 (G3): education: posture correction, use of analgesics, useof collar (restricted to very short periods in situations where theirneckwas vulnerable to sudden jolting, if collar worn exercise shouldbe performed immediately after), use of heat sources, musclerelaxation, encouraged to perform demonstrated mobilisationexercises; analgesicsCo-intervention: NRDuration of treatment: 6 weeks, 24 sessionsDuration of follow-up: 2 weeks
End of study median: G1 3.0, G2 1.9, G3 1.8Absolute benefit: G1 2.6, G2 3.4, G3 3.5Reported results: significantly better than rest (G1)SMD(2 v 1): �0.48 (95% CI:�0.90 to �0.06)SMD(2 v 3): 0.50 (95% CI:�0.28 to 0.39) [power 16%]Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effect: NRCost of care: NR
Mealy et al. (1986)Acute WADn(A/R) 51/611 1 0 1 0 0 1Total Jadad score: 4/5Total van Tulder Score: 6/11Total risk of bias score: NC
Index treatmentActive Group (A): technique: mobilisation (passive) as described byMaitland, exercise within the limits of pain, heat, ice, analgesics;frequency: daily, every hour at home; dose: NR; route: cervicalspineComparison treatment:Standard Group (S): soft cervical collar, worn for two weeks; rest fortwo weeks before beginning gradual mobilisation, analgesicsCo-intervention: NRDuration of treatment: 8 weeksDuration of follow-up: none
Pain (pain intensity, linear analogue scale, 0 to 10)Baseline mean: A 5.71, S 6.44End of study mean: A 1.69, S 3.94Absolute benefit: A 4.02, S 2.50Reported results: significant favoring active groupSMD: �0.86 (95% CI: �1.44 to �0.29)Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effect: NRCost of care: NR
Palmgren et al. (2006)Chronic neck pain; radicularsigns and symptoms: NRn(A/R): 36/411 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder score: 3/11Total risk of bias score: NC
Index treatment: (pragmatic, tailored to patient)Chiropractic care (chiro): technique: education, manipulation,myofascial technique, exercise (spine stabilizing for cervical regionand cervicothoracic junction); frequency: 3 to 5 sessions/week;dose: NR; route: cervical spineComparison treatment:Advice: advice given on simple regular exercise, done at ownvolition over 5 weeksCo-intervention: information on anatomy, physiology of spine,ergonomic principles, instruction on exercise and coping with pain,explanation of future outlookDuration of treatment: 5 weeks, 15 to 25 sessionsDuration of follow-up: none
Pain intensity (VAS, 0e100 mm)Baseline mean: chiro 47.9, advice 42.2End of study mean: chiro 18.9, advice 45.3Absolute benefit: chiro 29.0, advice -3.1Reported results: significant favoring chiropractic careSMD: �1.56 (95% CI: �2.31 to �0.82)Function: NRGPE: NRQoL: NRPatient satisfaction: NRSide effects: NRCost of care: NR
Persson et al. (2001);Persson et al. (1994);Persson et al. (1996);Persson et al. (1997)Chronic neck pain withradicular findingsn(A/R) 79/811 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder score: 6/11Total risk of bias score: NC
Index treatmentPT Group: technique: physiotherapy decided by the physiotherapistaccording to patient's symptoms and individual preferences[manual therapies (massage, manual traction, gentle mobilisation);modalities for pain relief like transcuatneous electrical nervestimulation, application of heat or cold (moist, ultrasound); exercise(relaxation exercises; active stretching, strengthening, enduranceexercises, postural correction); ergonomic instruction]; frequency:15 sessions/12 weeks; dose: 30e45 min sessionsComparison treatments:Surgery Group: surgery [anterior cervical discectomy techniquedescribed by Cloward (1958); mobilisation on the 1st postoperativeday; cervical collar use for 1e2 days post-operatively ]Collar Group: cervical collar (rigid collars during day; soft collar atnight)Co-intervention:Surgery group: 8 patients had 2nd operation, 11 patients receivedphysiotherapyPT group: 1 patient had surgeryCollar group: 5 patients had surgery, 12 patients receivedphysiotherapyDuration of treatment: 12 weeks, 15 sessionsDuration of follow-up: 56 weeks
Pain intensity (VAS, 0 to 100)Baseline mean: surgery 47, PT 50, collar 49End of study mean: surgery 30, PT 39, collar 35Absolute benefit: surgery 17, PT 11, collar 14Reported results: not significantSMD(PT v collar): 0.16 (95% CI:�0.38 to 0.70) [power 82%]SMD(PT v surgery): 0.33 (95% CI:�0.21 to 0.87) [power 76%]Worst pain (VAS, 0 to 100)Baseline mean: surgery 72, PT 70, collar 68End of study mean: surgery 42, PT 53, collar 52Absolute benefit: surgery 20, PT 17, collar 16Reported results: not significantSMD(PT v collar): 0.04 (95% CI: �0.50 to 0.57)SMD(PT v surgery): 0.28 (95% CI: �0.27 to 0.82)Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effects: NRCost of care: NR
Index treatmentGroup A: technique: mobilisation (passive) as described by Mealy,massage as described by Mealy, exercise (eye fixation) as describedby Shutty to alter dizziness, neck school described by Sweeney,
Pain intensity (neck pain intensity, VAS, 0 to 10)Baseline median: A 6.8, B 7.4End of study median: A 4.8 B 2.0Absolute benefit: A 2.0, B 5.4
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fatigue, dizziness, poorconcentration,accommodation andadaptation to light intensity),WADn(A/R) 60/601 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder score: 5/11Total risk of bias score: NC
relaxation training based on diaphragmatic breathing in supineposition according to Shutty, active reduction of cervical and lumbarlordosis based on suggestion provided by Neck School according toSweeney, psychological support to reduce anxiety and limitemotional influence described by Radanov; frequency: 5 sessions/week; dose: 1-h sessionsComparison treatment:Group B: transcutaneous electrical nerve stimulation, pulsedelectromagnetic field, ultrasoundS, 10 1-h sessions/2 weekCo-intervention: NRDuration of treatment: 2 weeks, 10 sessionsDuration of follow-up: 24 weeks
Reported results: significant favoring group ASMD: �0.79 (95% CI: �1.32 to �0.26)Function (Return to Work)Baseline: NRReported Results: significant favoring group ASMD: �1.05 (95% CI: �1.59 to �0.26)QoL: NRGPE (self assessment of outcome, ordinal scale �3 to þ3)Reported result: significant favoring group A, p < 0.001Patient satisfaction: NRSide effects: NRCost of care:Return to work: significant difference favors Group A,a treatment advantage of 16 days; SMD: �1.05(95% CI:�1.59to �0.51);Sick days saved: 143 days saved favoring Group A
Skargren et al. (1998);Skargren et al. (1997)Chronic neck pain withoutradicular findingsn(A/R) 317/3231 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder score: 3/11Total risk of bias score: NC
Index treatmentPhysiotherapy (PT): technique: 1% manipulation, 25% mobilisation,15% traction, 25% soft tissue treatment, 33% McKenzie treatment,21% individual training, 15% transcutaneous electrical nervestimulation/ultrasound/cold, 15% individual program, 6% relaxationtraining, 4% acupuncture, 1% instruction on individual training;frequency: mean 7.5 sessions over mean 6.4 weeksComparison treatmentChiropractic (chiro): technique: 97% manipulation, 11%mobilisation, 2% traction, 2% soft tissue treatment, 1% individualtraining, frequency: mean 5.6 sessions over mean 4.9 weeks; dose:NR; route: cervical spineCo-intervention: 0e6 months of both chiropractic andphysiotherapy treatment: Chiro 5.2%, PT 6.7%Duration of treatment: 5e6 weeks, 6 to 8 sessionsDuration of follow-up: 52 weeks
Pain intensity (neck pain intensity change scores, VAS, 0 to 100)Baseline mean: Chiro 52, PT 61Absolute benefit: Chiro 16, PT 33Results: significant favoring PTSMD (PT v Chiro): �0.66 (95% CI: �1.16 to �0.16)Function (Oswestry Questionnaire, 0 to 100)Baseline mean: Chiro 25, PT 27Absolute benefit: Chiro 8, PT 12Results: not significantSMD(PT v Chiro): �0.32 (95% CI: �0.81 to 0.17)[power 100%]QoL (VAS 0 to 100):Baseline mean: Chiro 38, PT 37End of study mean: Chiro 43.0, PT 46.1Absolute benefit: Chiro 5.0, PT 9.1Reported results:SMD (PT v Chiro): �0.22 (95% CI: �0.71 to 0.27)GPE: NRPatient satisfaction: NRSide effects: NRCost of care:Direct costs (for both neck and lumbar): significant favors PT,SMD(PT v Chiro): �0.28 (95% CI: �0.50 to �0.05);Indirect costs (for both neck and lumbar; of employed subjects);a) median cost: not significant; SMD(PT v Chiro): �0.02(95%CI:�0.25 to 0.22);b) sick leave: not significant, RR(PT v Chiro): 1.08 (95% CI: 0.75to 1.54);c) number of days off work: not significant; SMD(PT v Chiro):0.06 (95% CI: �0.18 to 0.30)
Vasseljen et al. (1995)Chronic neck painn(A/R) 24/241 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder score: 4/11Total risk of bias score: NC
Index treatmentGroup 1 (G1): technique: mobilisation (passive) e provided whenindicated, massage, exercise e strength on weight trainingapparatus, education e ergonomic principles, postural control,strength and flexibility training of shoulder and neck region;frequency: 2 sessions/week; dose: 1 h sessions, 5e10 min ofmassage, 5e10 min of exercise, and 3e4 min of stretchingComparison treatmentGroup 2 (G2): type: exercise e adopted from Dyrssen, 1.1 kgdumbbells in both hands, 4 arm exercises each performed 10 times,cycle repeated 3 times; load adjusted for 10 repetitions, abdominaland back exercises; breathing techniques; 5 min stretching exerciseto shoulder/neck; education: same as Group 1; frequency: 3sessions/week; dose: 30 min sessions;Co-intervention: NRDuration of treatment: 5e6 weeks, 10 to 18 sessionsDuration of follow-up: 24 weeks; mailed questionnaire
Pain intensity (neck pain intensity, VAS, 0 to10)Baseline mean: G14.2, G2 4.2End of study mean: G1 2.2, G2 2.1Absolute benefit: G1 2.0, G2 2.1Reported result: not significantSMD: 0.09 (95% CI: �0.71 to 0.89) [power 9%]RR: 0.29 (95% CI: 0.07 to 1.10)Function: NRQoL: NRGPE: NRPatient satisfaction: NRSide effects: NRCost of care: NR
Walker et al. (2008)Chronic non-specific neckpainn(A/R) 94/981 1 0 0 0 0 1Total Jadad score: 3/5Total van Tulder score: 4/11Total risk of bias score: 5/12
Index treatmentManual therapy and home exercise (MTE): technique: one to threemanual therapy techniques including thrust and non-thrustmobilisations, muscle energy and stretching techniques, homeexercise including cervical retraction, deep neck flexorsstrengthening, cervical rotation exercises; frequency: 2 sessions/week; dose: NR; duration: 3 weeks; route: cervical spineComparison treatmentMinimal Intervention (MIN): technique: GP advice on posture,maintaining activity, range of motion exercises and medication use,and sub-therapeutic ultrasound; frequency: 2 sessions/week; dose:
Pain intensity (cervical, VAS, 0 to 100)Baseline mean: MTE 53.7, MIN 51.1End of study mean: MTE 17.7, MIN 24.5Absolute benefit: MTE 36.0, MIN 46.6Reported results: significant at 3 week and 6 week follow-upsbut not at 52 weeks49 week follow-up SMD (MTE v MIN): �0.29 (95% CI: �0.71 to0.13)Function (NDI 0 to 50)Baseline mean: MTE 15.5, MIN 17.0End of study mean: MTE 5.5, MIN 10.6
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10% duty cycle, 0.1 W/cm2, 10 min; duration: 3 weeksCo-intervention: comparable between groupsDuration of treatment: 3 weeks, 6 sessionDuration of follow-up: 49 weeks
Absolute benefit: MTE 10, MIN 6.4Reported results: significant at all three time points49 week follow-up SMD (MTE v MIN): �0.68 (95% CI: �1.11 to�0.25)QoL: NRGPE (Global Rating of Change scale, �7 to 7)49week follow-up mean: MTE 4.5, MIN 2.6Reported results: significant at all three time points49week follow-up SMD (MTE v MIN): 0.46 (95% CI: 0.03 to 0.88)Patient satisfaction: NRSide effects: NRCost of care: NR
Ylinen et al. (2003)Chronic neck painn(A/R) 179/1801 0 0 0 0 0 1Total Jadad score: 2/5Total van Tulder score: 6/11Total risk of bias score: NC
Index treatmentEndurance (E) Group:a. 12 day institutional rehabilitation program b. exercises [neckflexor muscles by lifting the head up from the supine position in 3series of 20 repetitions; 5 sessions per week; 45 min for 12 daysb. dynamic exercises for the shoulders and upper extremities bydoing dumbbell shrugs, presses, curls, bent-over rows, flyes, andpullovers performing 3 sets of 20 repetitions for each exercise witha pair of dumbbells each weighing 2 kg.c. exercises for the trunk and leg muscles against their individualbody weights by doing a single series of squats, sit-ups, and backextension exercisesd. each training session concluded with stretching exercises for theneck, shoulder, and upper limb muscles for 20 mine. also advised to perform aerobic exercise 3 times/week for 30 minf. received written information about the exercises to be practiced athome 3 times/weekg. multimodal rehabilitation program, including aspects commonlyassociated with traditional treatment: relaxation training, aerobictraining, behavioral support to reduce fear of pain and improveexercise motivation, and lectures and practical exercises inergonomicsh. during the rehabilitation course, each patient received 4 sessionsof physical therapy, which consisted mainly of massage andmobilisation to alleviate neck pain and to enable those with severeneck pain to perform active physical exercisesStrength (S) Group:a. 12 day institutional rehabilitation programb. exercise used elastic rubber band to train the neck flexor musclesin each session performed in sitting, a single series of 15 repetitionsdirectly forward, obliquely toward right and left, and directlybackwardc. aim to maintain the level of resistance at 80% of the participant'smaximum isometric strength re coded at the baseline and at follow-up visitsd. load was checked with a handheld isometric strength testingdevice during the training sessionse. dynamic exercises for the shoulders and upper extremities bydoing dumbbell shrugs, presses, curls, bent-over rows, flyes, andpullovers with individually adjusted single dumbbell, 1 set for eachexercise with the highest load possible to perform 15 repetitions f.dynamic exercises for the shoulders and upper extremities by doingdumbbell shrugs, presses, curls, bent-over rows, flyes, and pulloversperforming 3 sets of 20 repetitions for each exercise with a pair ofdumbbells each weighing 2 kg.g. exercises for the trunk and leg muscles against their individualbody weights by doing a single series of squats, sit-ups, and backextension exercisesh. each training session concluded with stretching exercises for theneck, shoulder, and upper limb muscles for 20 mini. also advised to perform aerobic exercise 3 times/week for 30 minj. received written information about the exercises to be practiced athome 3 times/weekk. multimodal rehabilitation program, including aspects commonlyassociated with traditional treatment: relaxation training, aerobictraining, behavioral support to reduce fear of pain and improveexercise motivation, lectures and practical exercises in ergonomicsl. during the rehabilitation course, each patient received 4 sessionsof physical therapy, which consisted mainly of massage andmobilisation to alleviate neck pain and to enable those with severeneck pain to perform active physical exercises
Pain intensity (neck, VAS, 0 to 100)Baseline median: E 57, S 58, C 58End of study median: E 14, S 12, C 19Absolute benefit: E 8, S 9, C 3Reported results: pain was at the same level in the 3 groupsSMD(E v C): �0.74 (95% CI: �1.12 to �0.37)SMD(S v C): �0.85 (95% CI: �1.23 to �0.48)Function (NDI, 0 to 50)Baseline median: E 22, S 21, C 22Reported results: disability index was the same level in the 3groupsSMD(E v C): �0.50 (95% CI: �0.87 to �0.13)SMD(S v C): �0.60 (95% CI: �0.96 to �0.23)QoL: NRGPE: NRPatient satisfaction: NRSide effects: NRCost of care: NR
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Comparison treatment3. Control (C) Group:a. 3 days at rehabilitation centre for tests and recreational activitiesb. advised to perform aerobic exercise 3 times/week, 30 minc. written information about stretching exercises to practice athome 3 times/week for 20 min per dayCo-intervention: analgesics; 80% of Control group, 49% of Endurancegroup, and 57% of the Strength group used additional therapists asfollows: massage and stretching about 65%; hot and ice packs,electrotherapy, acupuncture, traction, and zone therapy frombetween 5 and 7%Duration of treatment: 12 session, 3 weeksDuration of follow-up: 12 months
KEY: Methodological Quality Rating using the Jadad et al., 1996 Criteria and scores: 1a. Was the study described as randomized? (Score 1 if yes); 1b and c. Was the method ofrandomization described and appropriate to conceal allocation (Score 1 if appropriate and �1 if not appropriate); 2a. Was the study described as double-blinded? (Score 1 ifyes); 2b and c. Was the method of double blinding described and appropriate to maintain double blinding (Score 1 if appropriate and �1 if not appropriate); 3 Was therea description of how withdrawals and dropouts were handled? (Score 1 if yes).n (A/R) e sample number analyzed/randomized; WAD e whiplash associated disorder; I e Index treatment; C e Comparison or Control treatment; v e versus; NC e notcalculated; NR e not reported; VAS e visual analogue scale; NRS e numeric rating scale; SMD e standard mean difference, RR e relative risk; CI e confidence interval;p e probability value; MONOVA e multiple analysis of variance.
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We calculated standardized mean differences with 95% confi-dence intervals (SMD; 95% CI) and relative risk (RR) with associatednumber-needed-to-treat (NNT) and treatment advantage (%) (seeTable 2 and Table 3 for definitions). To facilitate analysis, we useddata imputation rules (see Appendix 1). Power analyses wereconducted for articles reporting non-significant findings (Dupontand Plummer, 1990).
Prior to calculation of a pooled effect measure (pSMD or pRR),we assessed the reasonableness of pooling on clinical grounds (SeeGross et al. Part 1 for details). We reported the statistical hetero-geneity (I2 > 40%, p < 0.05) between studies when pooled resultswere found to be heterogeneous.
3.4. Quality assessment
Methodological quality was judged using:
� the Jadad et al., 1996 criteria (maximum score five, high scoregreater than two);
� the Cochrane Back Review Group criteria (van Tulder et al.,2003) (maximum score 11, high score greater than five); and
Table 2Calculations for treatment advantage and number-needed-to-treat.
Term Definiton
Percent treatment advantage (%) Calculation of the clinically important diffeKarlberg et al., 1996 data are used in this eThe assumption made was that a positive mTreatment controlMean/Median Mean/Median Mean/MedianBaseline [SD] Final [SD] Baseline [SD] Final54[23] 31[10] 56[15] 55[20]% Improvement [treatment] equals the diffebaseline [54] which equals 42.6%.% Improvement [control] equals the differebaseline [56] which equals 1.8%.The treatment advantage equals 42.6% min
Number-Needed-to-Treat (NNT) The number of patients a clinician needs tothe minimal clinically important differenceon a 100 point scale equals 44 and for the cFor experimental group: 44 minus 31 dividFor control group: 46 minus 55 divided byThen 0.9032 minus 0.3085 equals 0.5947.NNT equals 1 divided by 0.5947 which equ
� the adapted Cochrane ‘Risk of Bias’ method (maximum score12, high score greater than five) (Furlon et al., 2009); Specificcriteria for each of the items within these methodologicalassessment tools are described in our Cochrane review (Grosset al., 2010 earlier in this issue). The Cervical Overview Groupuses a calibrated team of interdisciplinary assessors of seniorand junior methodologists making it not feasible to upgradeall former trials in the our series to the new Cochrane “Risk ofBias” system in this update.
3.5. Qualitative analysis of trial results
We assessed the quality of the body of the evidence using theadopted GRADE approach (see Fig. 2 and Gross et al., 2010eAppendix 4 earlier in this issue for GRADE domains) (TheCochrane Collaboration, 2008; Furlan et al., 2007);
� High quality of evidence: Further research is unlikely to changeour confidence in the estimate of effect. There are consistentfindings among 75% of RCTs with low risk of bias that can be
rence or change on a percent scale was estimated as follows.xample:ean/median value is improvement and a negative is deterioration.
Mean/Median[SD]
rence between the change in the treatment group [23] divided by the treatment
nce between the change in the control group [1] divided by the control
us 1.8% which equals 40.8%.treat in order to achieve a clinically important improvement in one. Assumingto be 10%, the baseline of the experimental mean of 54 minus 10 units changeontrol 56 minus 10 units change equals 46.ed by 10 equals z ¼ 1.3 which gives an area under the normal curve of 0.9032.20 equals z ¼ �0.5 which gives an area under the normal curve of 0.3085.
als 1.66 or 2 when rounded.
Table 3NNT & treatment advantage.
Author/Comparison NNT Advantage (%)
Allison et al. (2002) outcome: pain 3 [clinically important pain reduction] 69.4%Brodin (1985) outcome: pain 4 [complete neck pain reduction] N/ABronfort et al. (2001) outcome: pain 10 [clinically important pain reduction] 12.5%Giebel et al. (1997) outcome: pain 8 [complete neck pain reduction]9 [complete H/A reduction] 5.5%Hoving et al. (2002) outcome: pain 20 [clinically important pain reduction] 5.0%Jull et al. (2002) outcome: pain 5 [clinically important pain reduction] 27.1%McKinney et al. (1989) outcome: pain 11 [clinically important pain reduction] 17.1%Mealy et al. (1986) outcome: pain 6 [clinically important pain reduction] 40.8%Palmgren et al. (2006) outcome: pain 3 [clinically important pain reduction] 67.9%Provinciali et al. (1996) outcome: pain 6 [clinically important pain reduction] 36.9%
31 [complete pain reduction]Skargren et al. (1998) outcome: pain 4 [clinically important pain reduction] 26.1%Vasseljen et al. (1995) outcome: pain 11 [clinically important pain reduction]4 [substantive pain reduction] 11.9%
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generalized to the population in question. There are sufficientdata, with narrow confidence intervals. There are no knownor suspected reporting biases. (All of the domains are met.)
� Moderate quality of evidence: Further research is likely to havean important impact on our confidence in the estimate ofeffect and may change the estimate. (One of the domains isnot met.)
� Low quality of evidence: Further research is very likely to havean important impact on our confidence in the estimate ofeffect and is likely to change the estimate. (Two of thedomains are not met.)
� Very low quality of evidence: We are very uncertain about theestimate. (Three of the domains are not met.)
4. Results
4.1. Description of studies
We selected 17 trials representing 31 publications from 1820citation postings (See Fig. 1):
� 17 studied neck pain: acute (Mealy et al., 1986; McKinneyet al., 1989; Giebel et al., 1997; Bonk et al., 2000); subacute(Karlberg et al., 1996); chronic (Brodin, 1985; Vasseljen et al.,1995; Skargren and Oberg, 1998; Bronfort et al., 2001;Persson and Lilja, 2001; Allison et al., 2002; Jull et al., 2002;Ylinen et al., 2003; Palmgren et al., 2006; Walker et al.,2008); and mixed duration (Provinciali et al., 1996; Hovinget al., 2002)
Fig. 2. Depiction of GRADE domains and scoring. Six domains may result in (�1)subtraction while three domains may result in (þ1) addition.
� 5 studied whiplash associated disorders (WAD I and II): acute(Mealy et al., 1986; McKinney et al., 1989; Giebel et al., 1997;Bonk et al., 2000); andmixed duration (Provinciali et al.,1996);
subacute (Karlberg et al., 1996); chronic (Jull et al., 2002); andmixedduration (Provinciali et al.,1996;Hovingetal., 2002); and
� 3 studied neck disorders with some radicular signs andsymptoms including WAD III: chronic (Brodin, 1985; Perssonet al., 2001); mixed (Hoving et al., 2002).
Agreement between pairs of independent authors from diverseprofessional backgrounds for manual therapy was Kw 0.83, SD 0.15.We excluded 77 RCTs based on the type of participant, intervention,outcome, or design. One Spanish RCT is awaiting additional dataand 17 RCTs were ongoing studies.
4.2. Quality assessment for included studies
Five trials (29%) had a low risk of bias (Mealy et al., 1986;Bronfort et al., 2001; Persson et al., 2001; Hoving et al., 2002; Jullet al., 2002) and 12 trials had high risk of bias (Brodin, 1985;McKinney et al., 1989; Vasseljen et al., 1995; Karlberg et al., 1996;Provinciali et al., 1996; Giebel et al., 1997; Skargren et al., 1998;Bonk et al., 2000; Allison et al., 2002; Ylinen et al., 2003;Palmgren et al., 2006; Walker et al., 2008). See Fig. 3 forsummary table of risk of bias findings. Methodological weaknessthat we found in multiple trials included: failure to describe or useappropriate concealment of allocation (53%, 9/17) and lack ofeffective blinding procedures [observer 59% (10/17); patient 100%(17/17); care provider 100% (17/17)]. We note two limitations inapplying the methodological criteria to our trials: 1) it is difficult toblind the patient and impossible to blind the care provider inmanual treatments; and 2) when self-report measures are used, thetrials do not fulfill the observer blinding criteria. Only a few trialsavoided co-intervention (24%; 4/17) and acceptable compliancewas found in 24% (4/17) of trials.
4.3. Main results
Various combinations of manual therapy and exercise emergedfor neck pain. Our findings are first reported by outcome and thenlisted by type of comparison. The quality of evidence is an integralpart of our summary of findings reported in Table 4.
4.3.1. Pain
� versus a mock therapy or no treatment control: We foundevidence of long-term pain relief from four trials comparing
Fig. 3. Methodological quality summary: review of authors judgements about each methodological quality item for included studies.
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manual therapy and exercise to a control for chronic neckdisorder (Allison et al., 2002); subacute and chronic neckdisorder with headache (pSMD �0.87; 95% CI: �1.69 to�0.06; Karlberg et al., 1996; Jull et al., 2002); and chronic neckpain with or without radicular findings (Brodin, 1985). Thistranslates into an absolute benefit of 23e27 mm VAS units,a treatment advantage as high as 69%, and an NNT varyingfrom three to five. See Fig. 4 for forest plots of all paincomparisons.
� versus primarily exercise with or without modalities: Bronfortet al. (2001), Hoving et al. (2002), Jull et al. (2002), andVasseljen et al. (1995) compared manipulation, mobilisationand exercise to exercise in participants with neck pain ofmixed duration, with or without cervicogenic headache.Since the interaction effect of manipulation, mobilisation andexercise is unclear, we elected to present these data withinthis review. Results from the study by Vasseljen et al. (1995)could not be combined due to a dissimilar outcome
Table 4Summary of findings across all outcomes and comparisons.
rct-ST Low na (�1) (�1) 35 41 RR 0.67(0.43, 1 4) AB nc; TA nc; NNT 4 low
Function/DisabilityJull et al. (2002) subacute to
chronic neck pain withcervicogenic headache
rct-LT Low na (�1) (�1) 48 46 SMD �0.64(�1.06,�0.23)
AB 14 NPQ; TA 31%, NNT 6 low
Allison et al. (2002) chroniccervicobrachial pain
rct-post High (�1) na (�1) (�1) 17 10 SMD �0.34(�1.12, 0.45)
AB 25 NPQ; TA 13%; NNT 11 very low
Global perceived effectJull et al. (2002) subacute and
chronic neck pain withcervicogenic headache
rct-LT Low na (�1) (�1) 48 46 SMD �2.73(�3.03, �2.16)
AB 69%; TA nc; NNT nc very low
2. Manipulation, mobilisation þ exercise versus traditional care or general practitioner carePainGiebel et al. (1997) acute WAD rct-ST High (�1) 47 50 pSMD �0.97
(�1.32,�0.63)AB 47 mm; TA 5%, NNT 8 moderate
Mealy et al. (1986) acute WAD rct-I Low 26 25 AB 40 mm; TA 41%, NNT 6McKinney et al. (1989) acute WAD rct-ST High (�1) na (�1) (�1) 54 26 RR 0.96(0.58, 1 1) AB 34 mm; TA 17%, NNT 11 very lowHoving et al. (2002) acute to
Walker et al., 2008 chronic neck pain rct-LT High (�1) 46 42 AB 36 mm; TA nc; NNT nc46FunctionGiebel et al. (1997) acute WAD rct-ST High (�1) na (�1) (�1) 47 50 SMD 0.23
ST: AB 34 mm; TA 40%; NNT 6 highLT: AB 27 mm; TA 0.3%; NNT 38
Bronfort et al. (2001) chronic neck pain rct-LT Low 55 49 ST: AB 33 mm;TA 14%; NNT 9LT: AB 25 mm;TA 3%, NNT 11
Hoving et al. (2002) acute to chronicneck pain þ/� radiculopathy orcervicogenic headache
rct-LT Low 58 59 ST: AB 35 mm;TA 10%; NNT 16LT: AB 42 mm;TA 29%, NNT 7
Vasseljen et al. (1995) chronic neck pain rct-ST High (�1) na (�1) (�1) 12 12 RR 0.67(0.35, 1.28)
AB 20 mm;TA 12%, NNT 11
Very low
FunctionJull et al. (2002) subacute to chronic
neck pain with cervicogenic headacherct-LT Low na 48 51 pSMD-0.00
(�0.22, 0.22)AB 14 NPQ; TA 5%favors exercise;NNT na
high
Bronfort et al. (2001) chronic neck pain rct-LT Low na 55 49 AB 11 NDI; TA -4%favors exercise; NNT na
Hoving et al. (2002) acute to chronic neckpain þ/� radiculopathy or cervicogenic headache
rct-LT Low na 58 59 AB 7.2 NDI;TA 7%; NNT na
Global perceived effectJull et al. (2002) subacute to chronic
neck pain with cervicogenic headacherct-LT Low na (�1) (�1) 48 51 pSMD-0.14
(�0.44, 0.15)nc low
Bronfort (200) chronic neck pain rct-LT Low na (�1) (�1) 51 45 ncHoving et al. (2002) acute to chronic neck
pain þ/� radiculopathy or cervicogenic headacherct-LT Low na (�1) (�1) 58 59 RR 0.76
(0.45, 1.28)nc low
Patient satisfactionBronfort et al. (2001) chronic neck pain rct-LT Low na (�1) (�1) 51 45 SMD 0.06
(�0.33, 0.44)nc low
Quality of lifeBronfort et al. (2001) chronic neck pain rct-IT Low I2 67% (�1) 55 49 pSMD-0.18
(�0.64, 0.28)AB 5 SF36(0e100), TA -6%favore exercise;NNT na
moderate
Hoving et al. (2002) acute to chronic neckpain þ/� radiculopathy or cervicogenic headache
rct-IT Low 58 59 AB 12 EuroQ(0e100), TA 12%; NNT na
Key: Ne number; rcte randomized controlled trial; nae not applicable; nce not calculated data not available;WADewhiplash; STe short term; LTe long term; I2e Iganen value; pSMDe pooled standardmean difference; RRe Relative Risk; AB e absolute benefit; TA e treatment advantage; NNT e number needed to treat; Quality e Cochrane GRADE of high, moderate, low, or very low; NPQ e Northwick Park Neck Pain Questionnaire; NDI e NeckDisability Index.
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Fig. 4. Forest plot of pain comparison: Manipulation or mobilisation and exercise versus comparison group.
J. Miller et al. / Manual Therapy 15 (2010) 334e354348
measure for pain. When the remaining data were pooled,results favored manipulation, mobilisation and exercise overexercise alone in the short-term [SMD pooled �0.50 (95% CI:�0.76 to �0.24); heterogeneity: p ¼ 0.25, I2 ¼ 27%], whileresults were similar in the long-term [pSMD �0.10 (95% CI:
�0.42 to 0.21); heterogeneity: p ¼ 0.13, I2 ¼ 50%]. Differencesin exercise treatment and study groups may explain some ofthe heterogeneity in results.
� versus primarily mobilisation and manipulation: Two trials(Skargren et al., 1998; Bronfort et al., 2001) compared
J. Miller et al. / Manual Therapy 15 (2010) 334e354 349
manipulation, mobilisation and exercise to manipulation andmobilisation alone for chronic neck pain. Since the interactioneffect of manipulation, mobilisation and exercise is unclear,we again elected to present these data within this review.Pooled data favored combining exercise with mobilisationand manipulations for intermediate to long-term pain relief[pSMD �0.48 (95% CI: �0.78 to �0.18)] with a 9e25% treat-ment advantage and NNT from 4 to 14.
� versus traditional care: Five trials (Mealy et al.,1986;McKinneyet al., 1989; Giebel et al., 1997; Hoving et al., 2002; Walkeret al., 2008) compared manipulation or mobilisation andexercise to traditional care (at least two of three interventionsincluded: collar, medication and advice). McKinney et al.(1989) used an outcome that we were not able to pool.Giebel et al. (1997) and Mealy et al. (1986) found greater painrelief in participants with acute WAD at short-term follow-up[pSMD �0.97 (95% CI: �1.32 to �0.63]. Hoving et al. (2002)and Walker et al. (2008) found no long-term difference inpain between groups for subjects with neck pain of chronic ormixed duration [pSMD �0.14 (95% CI: �0.42 to 0.13)].
� versus advice (including exercise advice): Palmgren et al.(2006) and Ylinen et al. (2003) compared manual therapyand exercise to exercise advice in participants with chronicneck pain. Ylinen et al. (2003) reported that mobilisation,massage and exercise produced greater pain relief thanexercise advice one year after treatment [endurance focusedexercise SMD �0.74 (95% CI: �1.12 to �0.37); strengthfocused exercise SMD �0.85 (95% CI: �1.23 to �0.48)].Palmgren et al. (2006) reported greater pain reduction withthe combined treatment approach immediately following thetreatment period [SMD �1.56 (95% CI: �2.31 to �0.82)]. Theabsolute benefit across these treatments varied from 29 to 40mm on a pain scale 0e100 mm and translates into a treat-ment advantage of 68% and NNT 3.
� versus other treatment: Four trials (Brodin, 1985; Provincialiet al., 1996; Bonk et al., 2000; Persson et al., 2001) comparedmanipulation,mobilisation andexercise to other interventions:
1. modalities: transcutaneous electrical nerve stimulation,pulsed electromagnetic field therapy and ultrasound(Provinciali et al., 1996);
2. surgery (Persson et al., 2001);3. collar (Bonk et al., 2000; Persson et al., 2000); and4. medication as an adjunct to both trial arms (Brodin, 1985).
Provinciali et al. (1996) and Bonk et al. (2000) reported signifi-cant results favoring mobilisation and exercise over other inter-ventions for acute or subacute WAD with or without headache.Brodin (1985) and Persson et al. (2001) reported no significantdifference between the groups for chronic neck pain with orwithout radicular findings.
4.3.2. Function and disability
� versus a mock therapy or no treatment control: Whencompared to a control, there was evidence of functionalimprovements immediately post treatment and after long-term follow-up with this combined care approach for chronicneck pain (Allison et al., 2002) and for subacute/chronic neckpain with cervicogenic headache (Jull et al., 2002). Long-termtreatment advantage of 31% could be achieved for one in sixpatients or a 14 point absolute benefit on the Northwick ParkNeck Pain Questionnaire (0e36 scale) (see Fig. 5 for forestplots of all function comparisons).
� versus primarily exercise with or without modalities: Bronfortet al. (2001), Hoving et al. (2002) and Jull et al. (2002)
compared manipulation, mobilisation and exercise to exercisealone. When the data were pooled, we found no statisticaldifferencebetweengroups at short-termand long-termfollow-up for mixed duration or chronic neck pain with or withoutcervicogenic headache [pSMD 0.00 (95% CI: �0.22 to 0.22)].
� versus primarily manipulation or mobilisation: Bronfort et al.(2001) and Skargren et al. (1998) compared manipulation,mobilisation and exercise to manipulation or mobilisationalone. Pooled data favored manual therapy and exercise[pSMD �0.31 (95% CI: �0.61 to �0.02); heterogeneity: p ¼0.04, I2 ¼ 0%]. This reflects and absolute benefit from 11 NeckDisability Index units to 12 Oswestery units with a treatmentadvantage of 13e20% and NNT of 8e9.
� versus traditional care: We found three trials (Giebel et al.,1997; Hoving et al., 2002, and Walker et al., 2008) comparingmanipulation or mobilisation and exercise to traditional care.Giebel et al. reported no significant difference in short-termfunctional improvements for acute WAD. At long-term follow-up, pooled data suggests no significant difference betweengroups for participants with neck pain of chronic or mixedduration [pSMD �0.28 (95% CI: �1.05 to 0.49); heterogeneity:p¼ 0.006, I2 ¼ 87%]. The differences in results between groupsmay be explained by the differences in exercise protocol.
� versus advice including exercise advice: Ylinen et al. (2003)reported that mobilisation, massage and exercise producedgreater improvements in function than exercise advice forchronic neck pain at long-term follow-up [endurance focusSMD �0.50 (95% CI: �0.87 to �0.13); strength focus SMD�0.60 (95% CI: �0.96 to �0.23)].
4.3.3. Quality of life
� versus primarily exercise with or without modalities: Two trials(Bronfort et al., 2001; Hoving et al., 2002) showed no statis-tically significant difference whenwe pooled data to comparemanipulation ormobilisation and exercise to exercise alone atlong-term follow-up for chronic or mixed duration neck pain[pSMD�0.16 (95% CI: �0.67 to 0.35); heterogeneity: I2 ¼ 73%,p ¼ 0.06]. Statistical differences in the results may beexplained by some differences in exercise treatments orpatient groups
� versus primarily manipulation or mobilisation: We identifiedtwo trials investigating the effects of manipulation or mobi-lisation and exercise tomanipulation ormobilisation alone onquality of life for chronic neck pain (Bronfort et al., 2001;Skargren et al., 1998). Pooled data suggested manipulationor mobilisation and exercise had a similar effect at both shortand long-term follow-up [pSMD �0.17 (95% CI: �0.47 to0.12); heterogeneity I2 0%, p ¼ 0.08].
� versus general practitioner care: One trial showed no signifi-cant difference when manual therapy and exercise werecompared to general practitioner care (Hoving et al., 2002).
4.3.4. Global perceived effect
� versus a mock therapy or no treatment control: There wasevidence of a long-term benefit favoring manual therapy andexercise when compared to a wait-list control (for subacuteand chronic neck disorder with cervicogenic headache SMD�2.73; 95% CI: �3.30 to �2.16) (Jull et al., 2002). The treat-ment advantage was 69%.
� versus primarily exercise with or without modalities: Bronfortet al. (2001), Hoving et al. (2002) and Jull et al. (2002)
Fig. 5. Forest plot of function comparison: Manipulation or mobilisation and exercise versus comparison group.
J. Miller et al. / Manual Therapy 15 (2010) 334e354350
reported no statistically significant difference in globalperceived effect between groups receiving manipulation,mobilisation and exercise and groups receiving exercise alonefor chronic neck pain with or without cervicogenic headacheand neck pain of mixed duration at long-term follow-up.The combination of manipulation and exercise also producedsimilar results to manipulation alone [pSMD �0.14 (95%CI:�0.44, 0.15); I2 10%, p ¼ 0.29; Bronfort, 2001; Jull, 2001].
� versus traditional care: We found equal or greater benefitswhen this care approach was compared to traditional care forglobal perceived effect at long-term follow-up for neck painof chronic or mixed duration (Hoving et al., 2002; Walkeret al., 2008).
4.3.5. Patient satisfaction
� versus primarily exercise with or without modalities: There wasno difference in patient satisfaction when manipulation andexercisewas compared to exercise alone (Bronfort et al., 2001).
� versus primarily manipulation and mobilisation: Whencompared to manipulation alone, manipulation and exerciseresulted in greater patient satisfaction at long-term follow-upfor chronic neck pain (Bronfort et al., 2001).
4.3.6. Adverse eventsSide effects were reported in 18% (3/17) of trials. All side effects
were benign and transient and included cervical pain, thoracic pain,headache, radicular symptoms, and dizziness. The rate of rare butserious adverse events such as stokes or serious neurological deficitscould not be established from our review. Adverse events are dis-cussed further in another review in this series (Carlesso, in this issue).
4.3.7. Cost of careThere was moderate evidence favoring reduced costs for care
consisting of manual therapy and exercise for acute, subacute, andchronic mechanical neck disorder with or without headache orradicular findings (Giebel et al., 1997; Hoving et al., 2002;Provinciali et al., 1996; Skargren et al., 1998).
J. Miller et al. / Manual Therapy 15 (2010) 334e354 351
4.4. Summary of findings
The summary of findings table (Table 4) details the relative andabsolute treatment effect with related quality assessment.
We note low quality evidence (2 pooled trials, 111 participants)suggesting manipulation, mobilisation and exercise producegreater long-term pain reduction (absolute benefit 23e37mm, NNT5, treatment advantage 27%) when compared to no treatment forchronic neck pain and subacute/chronic neck pain with cervico-genic headache. Additionally, low quality evidence suggests animprovement in function (absolute benefit 14 to 25 Northwick ParkNeck Pain Questionnaire; NNT 6, treatment advantage 31%), andglobal perceived effect (treatment advantage 69%) for subacute/chronic neck pain with cervicogenic headache. The evidence is lessclear for chronic cervicobrachial pain.
High quality evidence (3 pooled trials, 320 participants)suggests that manipulation or mobilisation and exercise producegreater short-term pain relief than exercise alone and similareffects in long-term pain, function, global perceived effect, patientsatisfaction and quality of life to various forms of exercise alone forsubacute/chronic neck pain with or without cervicogenic headacheand neck pain of mixed duration.
We found moderate quality evidence (2 pooled trials, 178participants) showing that the combination of manipulation ormobilisation and exercise produces greater pain reduction andquality of life than manipulation or mobilisation alone for chronicneck pain. Additionally, low quality evidence (2 pooled trials, 178participants) supports evidence of benefit for improved functionand patient satisfaction.
We determined moderate quality evidence supports the use ofmanipulations, mobilisations and exercise over traditional care forreduction in pain at short-term follow-up for acute WAD (2 pooledtrials, 141 participants), but there is low quality evidence that this isnot achieved in the long-term for neck pain of chronic or mixedduration (2 pooled trials, 208 participants). There is low qualityevidence showing no difference in function at short-term follow-upfor acuteWAD and no difference in function, global perceived effector quality of life at long-term follow-up for neck pain of chronic ormixed duration.
Very low quality evidence suggests that manipulation, mobi-lisation and exercise may be superior to treatments with primarilyadvice on exercise.
There was sparse low or very low quality evidence of nodifference for chronic neck pain with radiculopathy when manip-ulation, mobilisation and exercise are compared to collar use,surgery and analgesic medication.
5. Discussion
In our previous systematic review:
� up to 1996 (Gross et al., 1996): results remained inconclusivefor mobilisation or manipulation as a single intervention andsuggested support for combined mobilisation, manipulationand exercise for short-term pain reduction.
� up to 2003 (Gross et al., 2003): results showed no evidence insupport of manipulation or mobilisation alone but showedfurther support to the use of combined mobilisation, manipu-lationand exercise in achieving clinically important butmodestpain reduction, global perceived effect and patient satisfactioninacute andchronicneckdisorderwithorwithout cervicogenicheadache. There was insufficient evidence available to drawconclusions for neck disorder with radicular findings. Otherhigh quality reviews (Spitzer et al.,1995; Bronfort,1997;Mageeet al., 2000; Bogduk, 2001) agreed with these findings.
� up to 2009: The benefits of combined mobilisation ormanipulation plus exercise, were reinforced with additionaltrials, across multiple outcomes, and in the long-term. Aclinically important change across multiple outcomes wasnoted in subacute/chronic neck pain with or without cervi-cogenic headache. Manipulation or mobilisation added toexercises alone provides some added short-term pain relief.
We are in concordance with other findings showing a dearth ofquality evidence for manual therapy and exercise for WAD(Verhagen et al., 2007).We are in agreement with the best evidencesynthesis by Hurwitz et al., (2008) who supported the use ofmanual therapy and exercises for neck pain in comparison toalternative treatments and suggested a lack of research in patientsexperiencing neck pain with radicular symptoms.
Why combine manual therapy and exercise? The use of manipu-lation and mobilisation alone provides short-term pain relief.Exercise appears to improve pain and function over the long-term(Kay et al., 2008). The combination of manual therapy and exercise,however, seems to produce greater short-term pain reduction thanexercise alone and longer-term changes across multiple outcomesin comparison to manual therapy alone.
What is the best manipulation or mobilisation to utilize incombination with exercise? The answer to this question remainsunclear. Evidence from our Cochrane Review suggests that mobi-lisation and manipulation produce similar changes in pain andfunction and that one mobilisation technique may be favored overanother. Additional head to head comparisons of different manualtherapy techniques alone and in combination with exercise areneeded to determine the most effective approach.
What is the best exercise to use in combination with manualtherapy? Since the strength of evidence supporting the combina-tion of manipulation, mobilisation, and exercise continues to grow,future investigations should look at which exercise techniques areoptimally combined with manual therapy. A Cochrane review (Kayet al., 2008) has demonstrated the positive effect of specific cervi-coscapular resisted exercises, C1/2 self-SNAG exercises, craniocer-vical endurance exercise and low load endurance exercise, andupper extremity stretching and strengthening exercises, but theoptimal exercises to combine with manual therapy remainunknown.
5.1. Implications for practice
� Manipulation or mobilisation and exercise producesa greater long-term improvement in pain and globalperceived effect when compared to no treatment for chronicneck pain, subacute/chronic neck pain with cervicogenicheadache, and chronic neck pain with or without radicularfindings.
� Manual therapy and exercise produce greater short-term painrelief than exercise alone but produces no long-term differ-ence across multiple outcomes for neck pain of chronic andmixed duration with or without cervicogenic headache.
� The combination of manual therapy and exercise producesgreater improvements in pain, function, quality of life andpatient satisfaction when compared to manipulation ormobilisation alone for chronic neck pain.
� Manipulations, mobilisations and exercise are favored overtraditional care for reducing pain at short-term follow-up foracute WAD, but may be no different at long-term follow-upfor neck pain of chronic or mixed duration.
There was insufficient evidence available to draw any conclu-sions for neck disorder with radicular findings.
J. Miller et al. / Manual Therapy 15 (2010) 334e354352
5.2. Implications for research
Meta-analysis of data across trials and sensitivity analysis werehampered by the wide spectrum of comparisons, treatment char-acteristics and dosages. Factorial design would help determine theactive treatment agent(s) within a treatment mix. Phase II trialswould help identify the most effective treatment characteristicsand dosages for both exercise and manual therapy. The use ofsimilar validated outcome measures that are sensitive to changeand use of more homogenous diagnostic subgroups would increasemeasurement precision. Vigilance to recommended CONSORTstandards would enhance methodological quality.
Acknowledgements
We thank our volunteers, students, and translators. This is onereview of a series conducted by the Cervical Overview Group:Bronfort G, Burnie SJ, Cameron ID, Eddy A, Ezzo J, Goldsmith CH,Graham N, Gross A, Haines T, Haraldsson B, Kay T, Kroeling P,Morien A, Peloso P, Radylovick Z, Santaguida P, Trinh K, Wang E.
Declarations of interest
Two of our authors are authors in included studies. AlthoughGert Bronfort and Jan Hoving were authors, they were not involvedin decisions around the inclusion, quality assessment or dataextraction of their studies.
Sources of support
External sources of support (from 1992 to 2009) have included
� Problem-based Research Award; Sunnybrook and Women'sCollege Health Sciences Foundation, Canada
� Consortial Center for Chiropractic Research e National Insti-tutes of Health, Bethesda, MD, USA
� Hamilton Hospital Association, Canada� University of Saskatchewan, Clinical Teaching and Research
Award, Canada� Hamilton Health Sciences Corporation, ChedokeeMcMaster
Foundation, Canada
Appendix 1. Data imputation rules
The preliminary assumption made for imputation of missingvalues was that data were missing completely at random (Littleand Rubin, 1987). In other words, it was assumed that data werenot missing due to some factors confounded with the treatmenteffect.
McKinney et al. (1989) and Provinciali et al. (1996)
The standard deviation was estimated for the outcome painintensity using the reported p value boundary to establish the zvalue. Since z equals the experimental mean minus the controlmean divided by the variation measure, the standard deviationcould be calculated. It was assumed that the variance in both thecontrol and experimental group were the same. The SMD was thencalculated using the reported median and estimated SD values.
Vasseljen et al. (1995)
Estimating Standard Deviations from 90% Confidence Intervalson Medians (Gardner and Altman, 1989): The basic idea is to
estimate the order number for the lower bound (r) and the upperbound (s) for a 90% Confidence Interval (CI) on the median where 1less than or equal to r less than or equal to s less than or equal to n,where n is the sample size.
Once r and s are known, the expected value of the r-th [roundeddown] and s-th (rounded up) order statistic can be used to estimatethe standard deviation from an assumed normal distribution,where Z subscript 0.95 ¼ 1.645 is the 0.95 percentile from a stan-dard normal distribution. (Similarly for 95% CI).
Examples used here.
From r and s, an estimate of the empirical distribution functioncan be obtained and from these an expectation for a normaldistribution function with unknown standard deviation.
Using Minitab (version 9.2) and the inverse cumulative distri-bution function one can estimate the number of standard devia-tions associated with that particular r and s for the specific samplesize.
One may then estimate the standard deviation by dividing thedifference in the confidence interval bounds by the constant K2.
Eg; 90% CI is 3e8 for n ¼ 35 the length is 8 e 3 ¼ 5 so thestandard deviation is 5/0.7255 ¼ 6.89
References
Allison GT, Nagy BM, Hall T. A randomized clinical trial of manual therapy forcervico-brachial pain syndrome e a pilot study. Manual Therapy 2002;7(2):95e102.
Bonk AD, Ferrari R, Giebel GD, Edelmann M, Huser R. Prospective, randomized,controlled study of activity versus collar, and the natural history for whiplashinjury, in Germany. Journal of Musculoskeletal Pain 2000;8(1/2):123e32.
Brodin H. Cervical pain and mobilisation. International Journal of RehabilitationResearch 1984;7(2):190e1.
Brodin H. Cervical pain and mobilisation. Manual Medicine 1985;2:18e22.Bronfort G, Evan R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized
clinical trial of exercise and spinal manipulation for patients with chronic neckpain. Spine 2001;26(7):788e99.
D’Sylva J, Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, et al. Manualtherapy with or without physical medicine modalities for neck pain:a systematic review. Manual Therapy, in this issue.
Evans R, Bronfort G, Nelson B, Goldsmith C. Two-year follow-up of a randomizedclinical trial of spinal manipulation and two types of exercise for patients withchronic neck pain. Spine 2002;27:2383e9.
Giebel GD, Edelmann M, Huser R. Die distorsion der halswirbelsaule: Fruhfunk-tionalle vs. ruhigstellende behandlung. Zentralbibliotak Chiropractic1997;122:517e21.
Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, vanMameren H, et al. Manual therapy, physical therapy, or continued care bya general practitioner for patients with neck pain. A randomized controlledtrial. Annals of Internal Medicine 2002;136:713e22.
Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, vanMameren H, et al. Manual therapy, physical therapy, or continued care bya general practitioner for patients with neck pain: long-term results froma pragmatic randomized clinical trial. Clinical Journal of Pain 2006;22(4):370e7.
Hoving JL, de Vet HCW, Koes BW, van Mameren H, Deville WJLM, van derWindt DAWM, et al. In: Hoving JL, editor. Manual therapy, physical therapy, orcontinued care by the general practitioner for patients with neck pain: long--term results from a pragmatic randomized trial. 1st ed. Wageningen: Pons &Looijen BV; 2001. p. 59e73.
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trialof exercise and manipulative therapy for cervicogenic headache. Spine 2001;27(17):1835e43.
J. Miller et al. / Manual Therapy 15 (2010) 334e354 353
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trialof exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1845e943.
Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivityinfluence outcomes of physical rehabilitation for chronic whiplash? e Apreliminary RCT. Pain 2007;129:28e34.
Karlberg M, Magnusson M, Eva-Maj M, Melander A, Moritz U. Postural and symp-tomatic improvement after physiotherapy in patients with dizziness of sus-pected cervical origin. Archives of Physical Medicine and Rehabilitation1996;77:874e82.
Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, deVet HC, et al. Cost effectiveness of physiotherapy, manual therapy, and generalpractitioner care for neck pain: economic evaluation alongside a randomizedcontrolled trial. British Medical Journal 2003;326(7395):911.
Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, deVet HC, et al. Manual therapy is more cost-effective than physical therapy andGP care for patients with neck pain. 1st ed. Wageningen: Pons & Looijen BV;2001. pp. 75e89.
McKinney LA, Dornan JO, Ryan M. The role of physiotherapy in the management ofacute neck sprains following road-traffic accidents. Archives of EmergencyMedicine 1989;6(1):27e33.
McKinney MB. Behandlung der HWS-Distorsionen bei sog. Schleuderverletzungen.Orthopade 1994;23:287e90.
Mealy K, Brennan H, Fenelon GC. Early mobilisation of acute whiplash injuries.British Medical Journal 1986;92:656e7.
Palmgren PJ, Sandstrom PJ, Lundqvist FJ, Heikkila H. Improvement after chiropracticcare in cervicocephalic kinesthetic sensibility and subjective pain intensity inpatients with nontraumatic chronic neck pain. Journal of Manipulative andPhysiological Therapeutics 2006;29:100e6.
Persson L, Karlberg M, Magnusson M. Effects of different treatments on posturalperformance in patients with cervical root compression. A randomizedprospective study assessing the importance of the neck in postural control.Journal of Vestibular Research 1996;6(6):439e53.
Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managedwith surgery, physiotherapy, or a cervical collar. A prospective, randomizedstudy. Spine 1997;22(7):751e8.
Persson LCG, Lilja A. Pain, coping, emotional state and physical function in patientswith chronic radicular neck pain. A comparison between patients treated withsurgery, physiotherapy or neck collar e a blinded, prospective randomizedstudy. Disability and Rehabilitation 2001;23(8):325e35.
Persson LCG, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscleweakness and sensory loss in patients with cervical radiculopathy treated withsurgery, physiotherapy or cervical collar. A prospective, controlled study.European Spine Journal 1994;6(4):256e66.
Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodal treatment to preventthe late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine1996;28:105e11.
Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost andeffectiveness of chiropractic and physiotherapy as primary management forback pain. Spine 1998;23(17):1875e84.
Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis ofchiropractic and physiotherapy treatment for low back and neck pain, Six-month follow-up. Spine 1997;22(18):2167e71.
Skargren EI, Oberg BE. Predictive factors for 1-year outcome of low-back and neckpain in patients treated in primary care: comparison between the treatmentstrategies chiropractic and physiotherapy. Pain 1998;77:201e7.
Vasseljen O, Johansen BM, Westgaard RH. The effect of pain reduction on perceivedtension and EMG-recoded trapezius muscle activity in workers with shoulderandneck pain. Scandinavian Journal of RehabilitationMedicine 1995;27:243e52.
Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, et al. Theeffectiveness of manual physical therapy and exercise for mechanical neck pain.Spine 2008;33(22):2371e8.
Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T, et al. Activeneck muscle training in the treatment of chronic neck pain in women. JAMA2003;289(19):2509e16.
Additional references
Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, et al, ConsortGroup (Consolidated Standards of Reporting Trials). The revised CONSORTstatement for reporting randomized trials: explanation and elaboration. Annalsof Internal Medicine 2001;134(8):663e94.
Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation:a comprehensive review of the literature. Journal of Family Practice 1996;42(5):475e80.
Beattie P. Measurement of health outcomes in the clinical setting: applications tophysiotherapy. Physiotherapy Theory and Practice 2001;17:173e85.
Bogduk N. Whiplash: why pay for what does not work? Journal of MusculoskeletalPain 2001;8(1/2):29e53.
Bombardier C. Outcome assessment in the evaluation of treatment of spinal disorders:summary and general recommendations. Spine 2000;25(24):3100e3.
Borghouts JAJ, Koes BW, Bouter LM. The clinical course and prognostic factors ofnon-specific neck pain: a systematic review. Pain 1998;77:1e13.
Borghouts JAJ, Koes BW, Bouter LM. Cost-of-illness in neck pain in the Netherlandsin 1996. Pain 1999;80:629e36.
Bronfort G. Efficacy of spinal manipulation and mobilisation for low back and neckpain: a systematic review and best evidence synthesis. Amsterdam: ThesisPublishers; 1997.
Bronfort G, Haas M, Evans RL, Boutar LM. Efficacy of manipulation and mobilisationfor low back pain and neck pain: a systematic review and best evidencesynthesis. The Spine Journal 2004;4(3):335e56.
Carlesso L. Adverse events associated with cervical manipulation or mobilizationfor neck pain. Manual Therapy, in this issue.
Childs JD, Cleland JA, Elliott JM, Flynn TW, Teyhen DS, Wainner RS, et al. Neck pain:a clinical practice guideline linked to the international classification of function,disability, and health from the orthopaedic section of the American PhysicalTherapy Association. Journal of Orthopaedic and Sports Physical Therapy2008;38(9):A1e34.
Cicchetti DV. Assessing inter-rater reliability for rating scales: resolving some basicissues. British Journal of Psychiatry 1976;129:452e6.
Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinicalprediction rule for guiding treatment of a subgroup of patients with neck pain:use of thoracic spine manipulation, exercise, and patient education. PhysicalTherapy 2007;87(1):9e23.
Cohen J. Statistical power analysis for the behavioural sciences. 2nd ed. Hillsdale,NJ: Lawrence Erlbaum Associates; 1988.
Côté P, Cassidy D, Corroll L. The Saskatchewan health and back pain survey. Theprevalence of neck pain and related disability in Saskatchewan adults. Spine1998;23(15):1689e98.
Côté P, Kristman V, Vidmar M, Van Eerd D, Hogg-Johnson S, Beaton D, et al. Theprevalence and incidence of work absenteeism involving neck pain: a cohort ofOntario lost-time claimants. Spine 2008;33(4S):S192e8.
Dixon WJ, Massey Jr FJ. Introduction to statistical analysis. 3rd ed. Toronto:McGraw-Hill Book Co.; 1969.
Dupont WD, Plummer WD. Power and sample size calculations: a review andcomputer program. Controlled Clinical Trials 1990;11:116e8.
Farrar JT, Young Jr JP, LaMoureaux L, Worth JL, Poole RM. Clinical importance ofchanges in chronic pain intensity measured on an 11-point numerical ratingscale. Pain 2001;94:149e58.
Felson DT, Anderson JJ, Boers M, Bombardier C, Furst D, Goldsmith C, et al. Americancollege of rheumatology: preliminary definition of improvement in rheumatoidarthritis. Arthritis and Rheumatism 1995;38(6):727e35.
Finch E, Brooks D, Stratford P, Mayo N. Physical rehabilitation outcome measures:a guide to enhanced clinical decision making. 2nd ed. Lippincott Williams andWilkins; 2002.
Furlan AD, Pennick V, van Tulder MW, Shekelle P, Bombardier C, Bouter L. Updatedmethod guidelines for systematic reviews in the cochrane back review group.Cochrane Back Review Group Editorial Board; 2007.
Gardner MJ, Altman DG. Statistics with confidence: confidence intervals andstatistical guidelines. British Medical Journal 1989;72(4):119e21.
Gemmell H, Miller P. Comparative effectiveness of manipulation, mobilisation andthe Activator instrument in the treatment of non-specific neck pain: a system-atic review. Chiropractic and Osteopathy 2006;14(7).
Goldsmith CH, Boers M, Bombardier C, Tugwell P. Criteria for clinically importantchanges in outcomes. Development, scoring and evaluation of rheumatoidarthritis patients and trial profiles. Journal of Rheumatology 1993;20(3):561e5.
Gross AR, Aker PD, Quartly C. Manual therapy in the treatment of neck pain.Rheumatic Diseases Clinics of North America 1996;22(3):579e98.
Gross A, Goldsmith C, Kay T. Cervical overview group. conservative management ofmechanical neck disorders: a series of systematic reviews. In: Association ofchiropractic colleges and research agenda conference (ACC-RAC) 2003.Davenport, IA: Consortial Center for Chiropractic Research; 2003. p. 29.
Gross AR, Kay TM, Kennedy C, Gasner D, Hurley L, Yardley K, et al. Clinical practiceguideline on the use of manipulation or mobilisation in the treatment of adultswith mechanical neck disorder. Manual Therapy 2002;7(4):193e205.
Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. Cervical overviewgroup. Manipulation and mobilisation for mechanical neck disorders. CochraneDatabase of Systematic Reviews 2004;(1). CD004249.
Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, et al. Cervical OverviewGroup. Conservative management of mechanical neck disorders: a systematicreview. Journal of Rheumatology 2007;34(5):1083e102.
Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manipulation ormobilisation for neck pain: a cochrane review.Manual Therapy 2010;15(4):315e33.earlier article in this issue.
Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Cote P, Carragee EJ, et al. A newconceptual model of neck pain: linking onset, course, and care: the bone andjoint decade 2000e2010 task force on neck pain and its associated disorders.Spine 2008;33(4S):S14e23.
Hogg-Johnson S, van der Velde G, Carroll LJ, Holm LW, Cassidy JD, Guzman J, et al.Bone and joint decade 2000e2010 task force on neck pain and its associateddisorders. the burdon and determinants of neck pain in the general population:results of the bone and joint decade 2000e2010 task force on neck pain and itsassociated disorders. Spine 2008;33(4S):S39e51.
Hoving JL, Gross AR, Gasner D, Kay T, Kennedy C, Hondras MA, et al. A criticalappraisal of review articles on the effectiveness of conservative treatment ofneck pain. Spine 2001;26(2):196e205.
J. Miller et al. / Manual Therapy 15 (2010) 334e354354
Hurwitz EL, Carragee JEJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al.Treatment of neck pain: noninvasive interventions: results of the bone and jointdecade 2000e2010 task force on neck pain and its associated disorders. Spine2008;33(4S):S123e52.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al.Assessing the quality of reports of randomized clinical trials: is blindingnecessary? Controlled Clinical Trials 1996;17:1e12.
Jovey RD. General principles of pain management. In: Jovey RD, editor. Managingpain. 1st ed. Toronto: Healthcare and Financial Publishing, Rogers Media; 2002.p. 15e20.
Kay TM, Gross A, Goldsmith CH, Hoving JL, Brønfort G. Exercises for mechanicalneck disorders. Cochrane Database of Systematic Reviews 2009;(Issue 4). Art.No.: CD004250.
Kay T, Rutherford S, McCall R, Voth S, Gross AR, Santaguida L, et al. Exercises formechanical neck disorders: a cochrane review update. Orthopaedic Sympo-sium; 2008.
Kendal MG, Stuart A. The advanced theory of statistics. 2nd ed., vol. 1. New York:Hafner Publishing Co.; 1963.
Kjellman GV, Skargren EI, Oberg BE. A critical analysis of randomised clinical trialson neck pain and treatment efficacy. A review of the literature. ScandinavianJournal of Rehabilitation Medicine 1999;31:139e52.
Lee CE, Simmonds MJ, Novy DM, Jones S. Self-reports and clinician-measuredphysical function among patients with low back pain: a comparison. Archives ofPhysical Medicine and Rehabilitation 2001;82:227e31.
Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among35e45 year old individuals. Prevalence, sick leave and health care use. Spine1998;23(13):1457e63.
Little RJA, Rubin DB. Statistical analysis with missing data. Toronto: J Wiley & SonsInc.; 1987.
MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, McAlpine C, et al.Measurement properties of the neck disability index: a systematic review.Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):400e17.
MacPherson H, White A, Cummings M, Jobst KA, Rose K, Niemtzow RC, STRICTAGroup. Standards for reporting interventions in controlled trials of Acupunc-ture: the STRICTA recommendations. Journal of Alternative and ComplementaryMedicine 2002;8(1):85e9.
Magee DJ, Oborn-Barret E, Turner S, Fenning N. A systematic overview of thecurrent research evidence on the selected treatment interventions on softtissue neck injury following trauma. Physiotherapy Canada 2000;52(2):111e30.
Makela M, Heliovaara M, Sievers K, Impivaara O, Knekt P, Aromaa A. Prevalence,determinants and consequences of chronic neck pain in Finland. AmericanJournal of Epidemiology 1991;134:1356e67.
Olesen J. Classification and diagnostic criteria for headache disorders, cranialneuralgias and facial pain. Cephalgia 1988;8(7):61e2.
Olesen J, Gobel H. ICD-10 Guide for Headaches. Guide to the classification, diagnosisand assessment of headaches in accordance with the tenth revision of theInternational classification of diseases and related health problems and itsapplication to neurology. Cephalalgia 1997;17(Suppl. 19):29e30.
Peeters GGM, Verhagen AP, deBie RA, Oostendorp RAB. The efficacy of conservativetreatment in patients with whiplash injury. Spine 2001;26(4):E64e73.
Rajala U, Keinanen-Kiukanniemi S, Uusimaki A, Kivela S-L. Muscoloskeletal painsand depression in a middle-aged Finnish population. Pain 1995;61:451e7.
Rubinstein SM, Pool JJM, van Tulder MW, Riphagen II , de Vet HCW. A systematicreview of the diagnostic accuracy of provocative tests of the neck for diagnosingcervical radiculopathy. European Spine Journal 2007;16:307e19.
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-basedmedicine: how to practice and teach EBM. 2nd ed. Edinburgh: Churchill Liv-ingstone; 2000.
Schumacher HR, Klippel JH, Koopman WJ, editors. Primer on the rheumaticdiseases. 10th ed. Atlanta: Arthritis Foundation; 1993.
Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria.Headache 1990;30:725e6.
Spitzer WO, Leblanc FE, Dupuis M. Scientific approach to the assessment andmanagement of activity related spinal disorders. Spine 1987;7:S1e59.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientificmonograph of the Quebec task force on whiplash-associated disorders: rede-fining “whiplash” and its management. Spine 1995;20:S1e73.
Stratford PW, Riddle DL, Binkley JM, Spadoni G, Westaway MD, Padfield B. Using theneck disability index to make decisions concerning individual patients. Phys-iotherapy Canada; 1999:107e19. Spring.
Takala J, Sievers K, Klaukka T. Rheumatic symptoms in the middle-aged population insouthwestern Finland. Scandinavian Journal of Rheumatology 1982;47:15e29.
The Cochrane Collaboration. Cochrane handbook for systematic reviews of inter-ventions. Version 5.0.1 edition. Cochrane Library; 2008.
van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM, the Editorial Board of theCochrane Collaboration Back Review Group. Method guidelines for systematicreviews in the Cochrane Collaboration Back Review Group for spinal disorders.Spine 1997;22(20):2323e30.
van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain. Asystematic review within the framework of the Cochrane Collaboration BackReview Group. Spine 2000;25(21):2784e96.
van Tulder M, Furlan A, Bombardier C, Bouter L. Editorial board of the cochranecollaboration back review group. Updated method guidelines for systematicreviews in the cochrane collaboration back review group. Spine 2003;28(12):1290e9.
Verhagen AP, Scholten-Peeters GG, vanWijngaarden S, de Bie RA, Bierma-Zeinstra SM.Conservative treatment for whiplash. Cochrane Database of Systematic Reviews;2007;. doi:10.1002/14651858.CD003338.pub3. Issue 2. Art. No.: CD003338.
Vernon HT, Humphreys BK, Hagino CA. A systematic review of conservative treat-ments for acute neck pain not due to whiplash. Journal of Manipulative andPhysiological Therapeutics 2005;28:443e8.
Vernon H, Humphreys BK, Hagino C. The outcome of control groups in clinical trialsof conservative treatments for chronic mechanical neck pain: a systematicreview. BMC Musculoskeletal Disorders 2006;7(58):1e10.
Vernon H, Humphreys K, Hagino C. Chronic mechanical neck disorders in adultstreated by manual therapy: a systematic review of change scores in randomizedclinical trials. Journal of Manipulative and Physiological Therapeutics2007;30:215e27.
Westerling D, Jonsson BG. Pain from the neck-shoulder region and sick leave.Scandinavian Journal of Social Medicine; 1980:8131e6.
