Author Names

Fredin, K., & Lorås, H

Reviewer Name

Meera V. Bucklin, SPT

Reviewer Affiliation(s)

Duke DPT

 

Paper Abstract

This study looks at the musculoskeletal condition of neck pain and its two main therapies- manual therapy, exercise therapy, and a combination of the two. The study assesses whether or not the combined treatment of manual therapy (MT) and exercise therapy (ET) are more effective than either in isolation in relieving pain and improving function in adults with neck pain graded I-II through a systematic review and meta-analysis. The studies included were found on EMBASE, MEDLINE, AMED, CENTRAL, and PEDro through the dates of July 2017 and if they rated pain intensity or disability on a numeric scale. A secondary outcome assessed was quality of life. The studies were assessed using the PEDro scale, and the quality of evidence was assessed as being low, citing the lack of blinding of patients and therapists for 4 of the studies. The meta-analysis found 1169 articles and was narrowed down to 7 studies that were used that investigated the addition of ET to MT. Small and non-significant differences were found in pain at rest, neck disability, and QOL at immediate post-treatment, 6 months, and 12-month follow-ups. The quality of evidence was moderate for pain-at-rest outcomes and moderate to low for neck disability and QOL outcomes. The combined treatment of MT and ET for neck pain does not seem to be more effective in reducing neck pain at rest or neck disability or improving QOL in adult patients with grade I-II neck pain than ET alone.

 

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

  1. Is the review based on a focused question that is adequately formulated and described?
  • Yes
  1. Were eligibility criteria for included and excluded studies predefined and specified?
  • Yes
  1. Did the literature search strategy use a comprehensive, systematic approach?
  • Yes
  1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
  • Yes
  1. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
  1. Were the included studies listed along with important characteristics and results of each study?
  • Yes
  1. Was publication bias assessed?
  • No
  1. Was heterogeneity assessed? (This question applies only to meta-analyses.)
  • Yes

 

Key Finding #1

There were non-significant differences in pain at rest, neck disability, and QOL for patients with just ET alone and MT with ET.

Key Finding #2

Long-term outcomes of combined therapy were considered to be low-quality evidence as there was a loss of follow-up and presented with little to insignificant differences in outcomes.

Key Finding #3

The study finds a gap in research for the effects of solely MT compared to ET as opposed to the combined therapy comparisons.

Key Finding #4

The study results indicated that if manual therapy has effects it ad little to the overall treatment outcomes when in supplement to exercise therapy for patients with neck pain.

 

Please provide your summary of the paper

This study found that there were no significant short or long-term effects of the addition of manual therapy to exercise therapy in the outcomes of patients with grade I-II neck pain but listed several limitations to their study. They had less than 1000 total participants over 7 included studies and noted only including studies written in English listed as limitations to their study. As a strength of this study, the inclusion criteria were strict in its inclusion of what manual therapy was. # articles were not included as their intervention of manual therapy was hot pack and heat therapy as well so it can be determined this meta-analysis looked at true manual therapy interventions. Secondly, it acknowledges the heterogeneity of neck pain and the benefits of a multi-mechanism approach to treatment.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study’s overall rating of finding moderate to low-quality evidence to support the treatment of neck pain with MT and ET was used to support the need for further research on the sole and combined effects of both treatments at varying points in time. Although this study does not point towards or away from manual therapy it does offer insight into the level of research available to justify it as an intervention.