Faculty Bibliography

BACKGROUND CONTEXT: In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). PURPOSE: To update findings of the Neck Pain Task Force examining the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best evidence synthesis. SAMPLE: Randomized controlled trials (RCTs), cohort studies, case-control studies comparing manual therapies, passive physical modalities, or acupuncture to other interventions, placebo/sham, or no intervention. OUTCOME MEASURES: Self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events. METHODS: We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory versus evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We screened 8551 citations, 38 studies were relevant, and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that: 1) for recent but not persistent NAD I-II: thoracic manipulation offers short-term benefits; 2) for persistent NAD I-II: technical parameters of cervical mobilization (e.g., direction or site of manual contact) do not impact outcomes, while one session of cervical manipulation is similar to Kinesiotaping; and 3) for NAD I-II: strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II: cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises; Swedish/clinical massage adds benefit to self-care advice; 2) for persistent NAD I-II: home-based cupping massage has similar outcomes to home-based muscle relaxation; low-level laser therapy (LLLT) does not offer benefits; Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture; needle acupuncture provides similar outcomes to sham-penetrating acupuncture; 3) for WAD I-II: needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and 4) for recent NAD III: a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes; LLLT does not offer benefits. CONCLUSIONS: Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, ultrasound) are not effective and should not be used to manage neck pain.

BACKGROUND CONTEXT: In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises. PURPOSE: To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III. Study Design/setting: Systematic review and best evidence synthesis. SAMPLE: Studies comparing the effectiveness of exercise to other conservative interventions or no intervention. OUTCOME MEASURES: Outcomes of interest included: 1) self-rated recovery; 2) functional recovery; 3) pain intensity; 4) health-related quality of life; 5) psychological outcomes; and/or 6) adverse events. METHODS: We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the SIGN criteria. The results of scientifically admissible studies were synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We retrieved 4761 articles and 21 RCTs were critically appraised. Ten RCT's were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain grades I/II, unsupervised range of motion exercises, non-steroidal anti-inflammatories (NSAIDs) and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD grades I/II, supervised qigong and combined strengthening, range of motion and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally supervised high dose strengthening is not superior to home exercises or advice. CONCLUSIONS: We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone. Systematic Review Registration Number: CRD42013003717.

BACKGROUND CONTEXT: Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). PURPOSE: To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best-evidence synthesis. PATIENT SAMPLE: We included randomized controlled trials (RCTs), cohort studies, and case-control studies. OUTCOME MEASURES: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. METHODS: We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. RESULTS: We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. CONCLUSIONS: Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II 3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III 3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

Study Design Systematic review. Background Acupuncture is a commonly used treatment for musculoskeletal disorders (MSDs); however, little is known about the effectiveness of acupuncture therapies for the management of MSDs. Objective To summarize and evaluate the available research on the effectiveness and safety of acupuncture therapies for MSDs of the extremities. Methods We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials for the period January 1990 to January 2015 for randomized controlled trials (RCTs), cohort and case-control studies. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. A best-evidence synthesis was performed to synthesize results from included studies. Results from low risk of bias studies were synthesised in a sensitivity analysis to determine the impact of excluding high risk of bias studies. Results The search strategy revealed 5180 articles, of which 15 finally met the inclusion criteria: 10 RCTs had low risk of bias and 5 RCTs had high risk of bias. The studies with low risk of bias suggest that traditional needle acupuncture: for carpal tunnel syndrome (CTS) is superior to oral steroids (one RCT; 77 participants) and may be superior to vitamin B1 and B6 supplements (one RCT; 64 participants); and is superior to exercise for Achilles tendinopathy (one RCT; 64 participants). Traditional needle acupuncture does not provide important benefit compared with placebo for upper extremity pain (one RCT; 128 participants), or compared with no intervention for patellofemoral pain (one RCT; 75 participants). The evidence is inconclusive suggesting no important effectiveness of traditional needle acupuncture for shoulder pain (2 RCTs; 849 participants). Studies with low risk of bias suggest that electroacupuncture: may be superior to placebo for shoulder injuries (one RCT; 130 participants); and may not be importantly superior to night splinting for persistent CTS (one RCT; 78 participants). Finally, studies with low risk of bias suggest that dry needling may be superior to placebo for plantar fasciitis (one RCT, 84 participants). Studies with high risk of bias consistently suggest that acupuncture interventions are superior to other treatments. Our sensitivity analysis suggest that including high risk of bias studies would have impacted our evidence synthesis. Specifically, it would have provided support for the management of shoulder pain. Moreover, including high risk of bias studies would suggest that traditional needle acupuncture interventions may be effective for the management of lateral epicondilitis and piriformis syndrome. Conclusion Our qualitative syntheses suggest that the effectiveness of acupuncture interventions is inconsistent for the management of MSDs of the extremities. Traditional needle acupuncture may be beneficial for CTS and Achilles tendinopathy but not beneficial for non-specific upper extremity pain and patellofemoral syndrome. Electroacupuncture may be effective for shoulder injuries and similar to night wrist splint for CTS. The effectiveness of dry needling for plantar fasciitis is equivocal. Level of Evidence Therapy, 1a. J Orthop Sports Phys Ther, Epub 26 Apr 2016. doi:10.2519/jospt.2016.6270.

BACKGROUND: Manual therapy as spinal manipulation, spinal mobilization, stretching and massage are common treatment methods for neck and back pain. The objective was to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy (spinal manipulation, spinal mobilization, stretching and massage) to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain. METHOD: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathogskolan - the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes. RESULTS: At 12 weeks follow-up, 64 % had a minimal clinically important improvement in pain intensity and 42 % in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58 % and 40 % respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately. CONCLUSION: The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92249294.

PURPOSE: The estimated prevalence of poor sleep in patients with non-specific chronic low back pain is estimated to 64 % in the adult population. The annual cost for musculoskeletal pain and reported poor sleep is estimated to be billions of dollars annually in the US. The aim of this cohort study with one-year follow-up was to explore the role of impaired sleep with daytime consequence on the prognosis of non-specific neck and/or back pain. METHODS: Secondary analysis of a randomized controlled trial, including 409 patients. RESULTS: Patients with good sleep at baseline were more likely to experience a minimal clinically important difference in pain [OR 2.03 (95 % CI 1.22-3.38)] and disability [OR 1.85 (95 % CI 1.04-3.30)] compared to patients with impaired sleep at one-year follow-up. CONCLUSION: Patients with non-specific neck and/or back pain and self-reported good sleep are more likely to experience a minimal clinically important difference in pain and disability compared to patients with impaired sleep with daytime consequence.

BACKGROUND: Soft-tissue therapy is commonly used to manage musculoskeletal injuries. OBJECTIVE: To determine the effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities. DESIGN: Systematic Review. METHODS: We searched six databases from 1990 to 2015 and critically appraised eligible articles using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Evidence from studies with low risk of bias was synthesized using best-evidence synthesis methodology. RESULTS: We screened 9869 articles and critically appraised seven; six had low risk of bias. Localized relaxation massage provides added benefits to multimodal care immediately post-intervention for carpal tunnel syndrome. Movement re-education (contraction/passive stretching) provides better long-term benefit than one corticosteroid injection for lateral epicondylitis. Myofascial release improves outcomes compared to sham ultrasound for lateral epicondylitis. Diacutaneous fibrolysis (DF) or sham DF leads to similar outcomes in pain intensity for subacromial impingement syndrome. Trigger point therapy may provide limited or no additional benefit when combined with self-stretching for plantar fasciitis; however, myofascial release to the gastrocnemius, soleus and plantar fascia is effective. CONCLUSION: Our review clarifies the role of soft-tissue therapy for the management of upper and lower extremity musculoskeletal disorders and injuries. Myofascial release therapy was effective for treating lateral epicondylitis and plantar fasciitis. Movement re-education was also effective for managing lateral epicondylitis. Localized relaxation massage combined with multimodal care may provide short-term benefit for treating carpal tunnel syndrome. More high quality research is needed to study the appropriateness and comparative effectiveness of this widely utilized form of treatment.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. CONCLUSION: A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.