Neck Pain & Radiculopathy
National and International Guidelines
No national or international guidelines available.
Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso PMJ. Cochrane Database of Systematic Reviews 2008, Issue 3.
The review included seven randomized controlled trials (RCT), with a total of 958 participants, that looked at the effects of continuous or intermittent mechanical traction for individuals with chronic neck pain (lasting for more than three months). Some had symptoms that radiated into the arms and head (radicular symptoms), others did not.
Only one RCT (100 participants) had a low risk of bias, which means we can have confidence in the findings. This trial found that on average, there was no statistically significant difference between continuous and placebo traction in reducing pain or improving function for individuals with chronic neck disorder with radicular symptoms.
In summary, our review found no evidence from RCTs with a low potential for bias that clearly supports or refutes the use of either continuous or intermittent traction for individuals with chronic neck disorders.
Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Cochrane Database of Systematic Reviews 2010, Issue 1.
This updated review included 27 trials (1522 participants) that compared manipulation or mobilization against no treatment, sham (pretend) treatments, other treatments (such as medication, acupuncture, heat, electrotherapy, soft tissue massage), or each other.
There is low quality evidence from three trials (130 participants) that neck manipulation can provide more pain relief for those with acute or chronic neck pain when compared to a control in the short-term following one to four treatment sessions. Low quality evidence from one small (25 participants) dosage trial suggests that nine or 12 sessions of manipulation are superior to three for pain relief at immediate post treatment follow-up and neck-related disability for chronic cervicogenic headache. There is moderate quality evidence from 2 trials (369 participants) that there is little to no difference between manipulation and mobilisation for pain relief, function and patient satisfaction for those with subacute or chronic neck pain at short and intermediate-term follow-up. Very low quality evidence suggests that there is little or no difference between manipulation and other manual therapy techniques, certain medication, and acupuncture for mostly short-term and on one occasion intermediate term follow-up for those with subacute and chronic neck pain (6 trials, 494 participants) and superior to TENS for chronic cervicogenic headache (1 trial, 65 participants).
There is very low to low quality evidence from two trial (133 participants) that thoracic (mid-back) manipulation may provide some immediate reduction in neck pain when provided alone or as an adjunct to electrothermal therapy or individualized physiotherapy for people with acute neck pain or whiplash. When thoracic manipulation was added to cervical manipulation alone, there was very low quality evidence suggesting no added benefit for participants with neck pain of undefined duration.
There is low quality evidence from two trials (71 participants) that a mobilisation is as effective as acupuncture for pain relief and improved function for subacute and chronic neck pain and neural dynamic techniques produce clinically important pain reduction for acute to chronic neck pain. Very low to low quality evidence from three trials (215 participants) suggests certain mobilisation techniques may be superior to others.
Adverse (side) effects were reported in 8 of the 27 studies. Three out of those eight studies reported no side effects. Five studies reported minor and temporary side effects including headache, pain, stiffness, minor discomfort, and dizziness. Rare but serious adverse events, such as stoke or serious neurological deficits, were not reported in any of the trials.
Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, Brønfort G, Santaguida PL. Cochrane Database of Systematic Reviews 2012, Issue 8
Twenty-one trials were used to assess if exercise could help reduce neck pain; improve function, patient satisfaction and/or quality of life. In these trials exercise was compared to either a placebo treatment, or no treatment (waiting list), or exercise combined with another intervention was compared with that same intervention (which could include manipulation, education/advice, acupuncture, massage, heat or medications). Results showed that exercise is safe, with temporary and benign side effects, although almost half of the trials did not report on adverse effects. An exercise classification system was used to ensure similarity between protocols when looking at the effects of different types of exercises. Exercise did show an advantage over the other comparison groups. There appears to be a role for exercises in the treatment of chronic neck pain and cervicogenic headache if stretching and strengthening exercises are focused on the neck and shoulder blade region. There appears to be no advantage to arm stretching and strengthening exercises or a general exercise program. There were a number of challenges with this review; for example, the number of participants in most trials was small and there was limited evidence on optimum doseage requirements.
Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PMJ. Cochrane Database of Systematic Reviews 2012, Issue 9.
15 trials were included in this review that assessed whether massage could help reduce neck pain and improve function. Results showed that massage is safe, and any side effects were temporary and benign. However, massage did not show a significant advantage over other comparison groups. Massage was compared with no treatment, hot packs, active range-of-movement exercises, acupuncture, exercises, sham laser, manual traction, mobilization, and education.
There were a number of challenges with this review. Overall, the quality of the studies was poor and the number of participants in most trials was small. Most studies lacked a clear definition, description, or rationale for the massage technique used. Details on the credentials or experience of the person giving the massage were often missing. There was such a range of massage techniques and comparison treatments in the studies that we could not combine the results to get an overall picture of the effectiveness of massage. Therefore, no firm conclusions could be drawn and the effectiveness of massage for improving neck pain and function remains unclear.
Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A. Cochrane Database of Systematic Reviews 2009, Issue 4.
We cannot make any definitive statements about the efficacy of electrotherapy for neck pain because of the low or very low quality of the evidence for each outcome, which in most cases, was based on the results of only one trial.
For patients with acute neck pain, TENS possibly relieved pain better than electrical muscle stimulation, not as well as exercise and infrared and as well as manual therapy and ultrasound. There was no additional benefit when added to infrared, hot packs and exercise, physiotherapy or a combination of a neck collar, exercise and pain medication.
For patients with acute whiplash, iontophoresis was no more effective than no treatment, interferential current or a combination of traction, exercise and massage for relieving neck pain with headache; pulsed electro-magnetic field was more effective than ‘standard care’.
For patients with chronic neck pain, TENS possibly relieved pain better than placebo and electrical muscle stimulation, not as well as exercise and infrared and possibly as well as manual therapy and ultrasound; pulsed electro-magnetic field was possibly better than placebo, galvanic current, and electrical muscle stimulation. Magnetic necklaces were no more effective than placebo for relieving pain; there was no additional benefit when electrical muscle stimulation was added to either mobilisation or manipulation.
For patients with myofascial neck pain, TENS, FREMS (variation of TENS) and repetitive magnetic stimulation seemed to relieve pain better than placebo.
While over half of the trials were assessed as having a low risk of bias, seven of them did not describe how their participants were randomised, eight did not conceal the treatment assignment, and 12 did not control co-interventions. The trials were very small, with a range of 16 to 336 participants. Sparse and imprecise data mean the results cannot be generalized to the broader population and contributes to the reduction in the quality of the evidence, which was low or very low for all results. Therefore, further research is very likely to change the results and our confidence in them.
Gross A, Forget M, St George K, Fraser MMH, Graham N, Perry L, Burnie SJ, Goldsmith CH, Haines T, Brunarski D. Cochrane Database of Systematic Reviews 2012, Issue 3
Electronic bibliographic databases were searched up to 11 July 2010. Fifteen randomised controlled trials (1660 participants) looking at the effectiveness of patient education strategies for neck disorders were included. Of the 15 selected trials, only one trial depicting moderate quality evidence favoured the educational video for acute WAD. The remaining trials showed that patient education trials did not demonstrate evidence of benefit or favoured the comparison treatment being exercise for pain. Other outcomes were less frequently reported and did not yield results that diverged from those associated with pain. Participants who received advice to stay active reported little or no difference in pain compared with those who received no treatment, treatments focusing on rest, treatments focusing on exercise, physiotherapy and cognitive behavioural therapy. Additionally, stress-management therapies, when compared with no treatment, did not seem to have an effect on pain intensity in patients with mechanical neck disorders. Finally, self-care strategies (ergonomics, exercise, self-care, relaxation) do not seem to have an effect on pain when compared with no treatment.
No adverse events were reported in the trials.
In summary, the review authors concluded that there is no strong evidence for the effectiveness of educational interventions in various neck disorders.
Karjalainen KA, Malmivaara A, van Tulder MW, Roine R, Jauhiainen M, Hurri H, Koes BW. Cochrane Database of Systematic Reviews 2003, Issue 2.
There is not enough evidence to show whether or not multidisciplinary biopsychosocial rehabilitation programs are helpful for people with neck and shoulder pain. Prolonged neck and shoulder pain can lead to a combination of physical, psychological and social difficulties. For that reason, physical rehabilitation can also include psychological, behavioural and educational interventions. This kind of "multidisciplinary rehabilitation" is available in some pain clinics, and rehabilitation centres and clinics. The review of trials found there was not enough good evidence to show whether or not multidisciplinary biopsychosocial rehabilitation is beneficial to adults of working age with neck and shoulder pain.
Trinh K, Graham N, Gross A, Goldsmith CH, Wang E, Cameron ID, Kay TM, Cervical Overview Group. Cochrane Database of Systematic Reviews 2006, Issue 3.
10 trials (661 participants) were included in this review that examined the effects of acupuncture on neck pain for individuals with chronic neck pain (lasting for at least three months). One study also included individuals with neck pain that lasted for at least six weeks, but they considered it to be chronic. Acupuncture was compared to sham acupuncture, waiting list, other sham treatments (sham laser, sham TENS) or other treatments (mobilization, massage, traction). Acupuncture treatments appear to be safe and only minor, transient and benign adverse effects were reported in the trials.
The trials were of moderate methodological quality, but the number of participants in each trial was relatively low. There was a range of individuals studied, acupuncture techniques used and outcomes measured, so we could not combine the results of the trials to get an overall picture of the effectiveness of acupuncture. Therefore, we could only draw limited conclusions.
Individuals with chronic neck pain who received acupuncture reported, on average, better pain relief immediately after treatment and in the short-term than those who received sham treatments. Individuals with chronic neck pain with symptoms radiating to the arms who received acupuncture reported, on average, better pain relief in the short-term than those who were on a waiting list.
Langevin P, Peloso PMJ, Lowcock J, Nolan M, Weber J, Gross A, Roberts J, Goldsmith CH, Graham N, Burnie SJ, Haines T. Cochrane Database of Systematic Reviews 2011, Issue 7.
This review included nine trials (503 participants) that examined the effects of Botulinum toxin Type-A (BoNT-A) for patients with neck pain that had lasted for at least four to six weeks. In some instances, they also had pain that extended into the head, called a 'cervicogenic headache'.
High quality evidence was available from five trials (252 participants) that found no significant difference in pain at four weeks, between those who received BoNT-A for subacute and chronic neck pain and those who received placebo injections. Low quality evidence showed that BoNT-A injections were no better than placebo for neck pain at six months (one trial; 24 participants) or for disability (one trial; 45 participants). Very low quality evidence from one study (31 participants) suggested that BoNT-A was better than placebo for patients with chronic neck pain when patients reported on their overall sense of benefit at four weeks.
Evidence from a single small study in patients with neck pain and accompanying headache (32 participants) showed that BoNT-A was no better than placebo at four weeks and six months after treatment.
There was very low quality evidence (two trials, 95 participants) showing that BoNT-A combined with exercise for chronic neck pain patients, was no better at four weeks or six months, than a variety of other treatments (exercise, or exercise combined with dry needling, or lidocaine, or ultrasound), for several different types of outcomes, including pain, disability and quality of life.
Side effects were reported to be mild and transient, with about 27% of subjects reporting side effects after receiving BoNT-A treatment. They included injection site soreness, shoulder or arm weakness, fatigue, heaviness, numbness, flu-like symptoms, systemic fever, shivering, generalized muscle soreness, vertigo (dizziness) and headache. Rare, but serious side effects, such as the relaxing of respiratory muscles or allergic reactions have been reported.
At this time, there is no evidence to support the use of BoNT-A for treating individuals with chronic neck pain or associated headache. These conclusions are limited by the overall quality and quantity of the available data.
Peloso PMJ, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie SJ, Cervical Overview Group. Cochrane Database of Systematic Reviews 2007, Issue 3.
Medication (drugs), given by mouth or injections are commonly used to treat neck pain. In this review, we included 36 trials that studied the effects of drugs on neck pain. Most of the trials used strong research methods, which reduced the potential for bias in the results. However, there were not many drugs that were studied in multiple trials, which made it difficult to pool results from different trials. For this reason, we were only able to draw conclusions on a few medications.
The main drugs studied were:
- oral (non-steroidal) anti-inflammatories (NSAIDs) and analgesics;
- psychotropics (drugs that act by their effects on the brain and spinal cord);
- corticosteroid injections (anti-inflammatory drugs);
- local anaesthetics (local freezing); and
- Botulinum toxin A injection (Botox A, a drug that acts on muscle spasm).
Corticosteroid injections given within eight hours of the injury appear to reduce the pain of acute whiplash. Local anaesthetics appear to reduce chronic neck pain. An epidural injection of a corticosteroid plus local anaesthetic seems to reduce pain and improve function for patients with chronic neck pain with associated arm symptoms. However, there are not enough studies on any one drug to allow a high degree of confidence in these results. Muscle relaxants, analgesics and NSAIDs have unclear benefits. There is moderate evidence showing that, on average, Botulinum toxin A is no better than saline injections at lessening pain and disability.
There was no information given in the trials about possible side effects of the different drugs, but some individuals may experience stomach problems from NSAIDs and drowsiness, dizziness and other side effects from some of the others. Therefore, individuals with neck pain should discuss the pros and cons with their physicians before using them.