A Population‐Based Study of Spinal Pain Among 35‐45‐Year‐Old Individuals: Prevalence, Sick Leave, and Health Care Use The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. A controlled trial on acupuncture for chronic neck pain. Neck Pain in Hong Kong: A Telephone Survey on Prevalence, Consequences, and Risk Groups Manual Therapy, Physical Therapy, or Continued Care by the General Practitioner for Patients With Neck Pain: Long-Term Results From a Pragmatic Randomized Clinical Trial Acupuncture for Chronic Pain in Japan: A Review Treatment of 482 cases of cervical spondylopathy by combining point-injection and needle-warming via moxibustion. Treatment of cervical spondylosis. Electroacupuncture versus physiotherapy. Diode Laser in Cervical Myofascial Pain: A Double‐Blind Study versus Placebo AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain syndrome. Repetitive magnetic stimulation
A novel therapeutic approach
for myofascial pain syndrome Primary care randomized clinical trial: manual therapy effectiveness in comparison with TENS in patients with neck pain. Using Guasha to treat musculoskeletal pain: A systematic review of controlled clinical trials GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). Acupuncture in the treatment of chronic cervical pain. A pilot study. The effect of 300mW, 830nm laser on chronic neck pain: A double-blind, randomized, placebo-controlled study Randomised trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain. Cervical Spine Disorders: A Comparison of Three Types of Traction Chronic myofascial pain: management by low-output helium-neon laser therapy. Acupuncture versus Placebo for the Treatment of Chronic Mechanical Neck Pain Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome Superficial Dry Needling and Active Stretching in the Treatment of Myofascial Pain – a Randomised Controlled Trial Efficacy of low level laser therapy in myofascial pain syndrome: an algometric and thermographic evaluation. Efficacy of 904 nm gallium arsenide low level laser therapy in the management of chronic myofascial pain in the neck: a double-blind and randomize-controlled trial. The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: a double blind, placebo-controlled study [Comparative study on effects of manipulation treatment and transcutaneous electrical nerve stimulation on patients with cervicogenic headache]. Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Controlled Trials of a Single Session Treatment of acute cervical pain — A comparative group study High-power pain threshold ultrasound technique in the treatment of active myofascial trigger points: a randomized, double-blind, case-control study. The Saskatchewan Health and Back Pain Survey: The Prevalence of Neck Pain and Related Disability in Saskatchewan Adults Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion. A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study. Evaluation of electromagnetic fields in the treatment of pain in patients with lumbar radiculopathy or the whiplash syndrome. Percutaneous Neuromodulation Therapy: Does the Location of Electrical Stimulation Effect the Acute Analgesic Response? Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. GRADE guidelines: 3. Rating the quality of evidence. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise – a randomised controlled trial Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management. Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries. A double blind randomized controlled study. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. Therapeutic effects of peripheral repetitive magnetic stimulation on myofascial pain syndrome Effectiveness of manual therapies: the UK evidence report Relief of chronic neck and shoulder pain by manual acupuncture to tender points--a sham-controlled randomized trial. The Clinical Efficacy of Low-Power Laser Therapy on Pain and Function in Cervical Osteoarthritis [Low energy laser treatment--effect in localized fibromyalgia in the neck and shoulder regions]. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points. [Controlled study on treatment of cervical spondylopathy of the nerve root type with acupuncture, moxibustion and massage as main]. PEDro. A database of randomized trials and systematic reviews in physiotherapy. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. A randomised trial to evaluate the effect of infra-red stimulation of local trigger points, versus placebo, on the pain caused by cervical osteoarthrosis. Chronic neck pain: a comparison of acupuncture treatment and physiotherapy. Adjuvant laser acupuncture in the treatment of whiplash injuries: a prospective, randomized placebo-controlled trial Manual therapy and exercise for neck pain: A systematic review. Low level laser therapy for myofascial pain in the neck and shoulder girdle. A double-blind, cross-over study. Pain in the neck and arm: a multicentre trial of the effects of physiotherapy, arranged by the British Association of Physical Medicine. The acupuncture treatment of neck pain: a randomized controlled study. A randomized clinical trial of TENS and exercise for patients with chronic neck pain A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials
Study Design . A question naire was mailed to 3000 r and omly selected 35‐45‐year‐old individuals in three communities in central Sweden . Objectives . To study the 1‐year prevalence of spinal pain and its ramifications in the form of pain , function , sick leave , and health care use . Summary of Background Data . Previous research ers have used a variety of definitions and population s , but primarily have investigated the occurrence of pain . Comprehensive data are needed concerning health care use , the degree of the pain problem , functional disturbances , and sick leave . Method . Participants in the study completed a question naire regarding spinal pain during the past year including the degree of their experienced pain , functional impairment , lost work days , and health care use . Results . A total of 2305 people ( 78.5 % ) responded to the question naire . Nonrespondents had similar characteristics but a slightly lower 1‐year prevalence rate than did respondents . For respondents , the prevalence of spinal pain during the past year was 66.3 % , with women having a slightly higher prevalence than men . Approximately 25 % of the respondents indicated that they had a substantial problem based on ratings of pain , functional impairment , and sick leave . Work absenteeism reported to the Public Social Insurance Office involved 19 % of those with pain , but an additional 15 % indicated unreported absenteeism . On average , those with pain visited health care providers three times during the past year , but a small number of those who experienced pain consumed large amounts of health care and illness benefits . An important gender difference was shown , such that when pain was at its worst , men took sick leave , whereas women sought health care . Conclusions . Taken together , these data indicate that spinal pain is common among 35‐45‐year‐old men and ‐ women , and that it is related to marked problems for approximately one fourth of those who experience pain . Gender differences exist in the pattern of sick leave and health care use , and a small proportion of those with pain consume very large amounts of the re sources . Consequently , there is a need for early , effective , preventive treatments STUDY DESIGN Systematic review and best evidence synthesis . OBJECTIVES To describe the prevalence and incidence of  neck pain and disability in workers ; to identify risk factors for neck pain in workers ; to propose an etiological diagram ; and to make recommendations for future research . SUMMARY OF BACKGROUND DATA Previous review s of the etiology of neck pain in workers relied on cross-sectional evidence . Recently published cohorts and r and omized trials warrant a re- analysis of this body of research . METHODS We systematic ally search ed Medline for literature published from 1980 - 2006 . Retrieved articles were review ed for relevance . Relevant articles were critically appraised . Articles judged to have adequate internal validity were included in our best evidence synthesis . RESULTS One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible . The annual prevalence of neck pain varied from 27.1 % in Norway to 47.8 % in Québec , Canada . Each year , between 11 % and 14.1 % of workers were limited in their activities because of neck pain . Risk factors associated with neck pain in workers include age , previous musculoskeletal pain , high quantitative job dem and s , low social support at work , job insecurity , low physical capacity , poor computer workstation design and work posture , sedentary work position , repetitive work and precision work . We found preliminary evidence that gender , occupation , headaches , emotional problems , smoking , poor job satisfaction , awkward work postures , poor physical work environment , and workers ' ethnicity may be associated with neck pain . There is evidence that interventions aim ed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers . CONCLUSION Neck disorders are a significant source of pain and activity limitations in workers . Most neck pain results from complex relationships between individual and workplace risk factors . No prevention strategies have been shown to reduce the incidence of neck pain in workers To evaluate the efficacy of Chinese medicine ( CM ) acupuncture for  chronic neck pain ( CNP ) , a single blind , controlled , crossover , clinical trial was undertaken . Twenty-nine volunteers with CNP were r and omly recruited into two groups . Both groups received two phases of treatment with a washout period between the two phases . Group A ( 14 volunteers ) received CM acupuncture in the first phase and sham acupuncture in the second , while Group B ( 15 volunteers ) received sham in the first and real in the second . CM acupuncture was individualized and consisted of nine sessions on both local and distal points . Manual twisting of the needle was applied on all points plus strong electrical stimulation of distal points in CM acupuncture . Sham acupoints ( lateral to the real ) and sham ( weak ) electrical stimulation was used in the control group . Comparison of subjective and objective measures between the two groups was made at different periods , including baseline , after each phase of treatment , after washout , and after the 16th week follow-up . The subjective measures included pain intensity , duration per day , analgesic medication count , visual analogue scales ( VAS ) and neck disability index ( NDI ) . The objective measures consisted of neck range of motion ( ROM ) and pain threshold ( PT ) . Both the real and sham treatments significantly reduced subjective pain , without significant differences between groups for most subjective measures . Objective measures showed no significant change for either group before and after each period or by inter-groups analysis . A minimum 16-week effect of both real and sham acupuncture was found for subjective measures in the follow-up periods . Further study is recommended with an increased sample size , a longer washout period , and a longer baseline period Study Design . A cross-sectional telephone survey was conducted using a two-stage r and omization process . Objectives . The objectives of this paper were to investigate the prevalence of neck pain and their consequences and risk groups in the Hong Kong population . Summary of Background Data . There has been a lack of recent information on the prevalence and consequences of neck pain in the population of Hong Kong . Methods . A total of 664 subjects were interviewed on the socio-demographic characteristics , occurrence , and consequences of neck pain . A r and om sample of the respondents was reinterviewed after 7 to 10 days later , by another interviewer for the reliability check . Results . The lifetime prevalence of neck pain was 65.4 % ( 95 % confidence interval , 61.8%–69.0 % ) . The 12-month prevalence was 53.6 % ( 41.0 % in male , 59.0 % in female ) ( 95 % confidence interval , 49.8%–57.4 % ) . About 15.0 % of these patients had moderate to severe pain . Moreover , 4.5 % of these subjects had to limit their social activities and 3.1 % had to limit their work . Multiple logistic regression analysis showed that females , managers , administrators , and professionals have a high risk  of neck pain in the population of Hong Kong . Conclusion .  Neck pain  is highly prevalent in Hong Kong , particularly among females , managers , administrators , and professionals Objectives The authors ' goals were to compare the effectiveness of manual therapy ( MT ; mainly spinal mobilization ) , physical therapy ( PT ; mainly exercise therapy ) , and continued care by the general practitioner ( GP ; analgesics , counseling and education ) over a period of 1 year . Methods One hundred eighty-three patients suffering for at least 2 weeks from nonspecific neck pain were r and omized to receive a 6-week treatment strategy of MT once a week , PT twice a week , or GP care once every 2 weeks . The primary outcome measures were perceived recovery , severity of physical dysfunctioning , pain intensity , and functional disability . Results The differences between groups considered over 1 year were statistically significant ( repeated measurements analyses P<0.001 to P=0.02 ) for all outcomes but borderline for the Neck Disability Index ( P=0.06 ) . Higher improvement scores were observed for MT for all outcomes , followed by PT and GP care . The success rate , based on perceived recovery after 13 weeks , was 72 % for MT , which was significantly higher than the success rate for continued GP care ( 42 % , P=0.001 ) but not significantly higher compared with PT treatment ( 59 % , P=0.16 ) . The difference between PT and GP approached statistical significance ( P=0.06 ) . After 1 year the success rates were 75 % , 63 % , and 56 % , respectively , and no longer significantly different . Conclusions Short-term results ( at 7 weeks ) have shown that MT speeded recovery compared with GP care and , to a lesser extent , also compared with PT . In the long-term , GP treatment and PT caught up with MT , and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up Many Japanese reports of acupuncture and moxibustion for chronic pain are not listed in medical data bases such as Medline . Therefore , they are not easily accessible to research ers outside of Japan . To complement existing review s of acupuncture and moxibustion for chronic pain and to provide more detailed discussion and analysis , we did a literature search using ‘ Igaku Chuo Zasshi We d ’ ( Japana Centra Revuo Medicina ) and ‘ Citation Information by National Institute of Information ’ covering the period 1978–2006 . Original articles and case reports of acupuncture and moxibustion treatment of chronic pain were included . Animal studies , surveys , and news articles were excluded . Two independent review ers extracted data from located articles in a pre-defined structured way , and assessed the likelihood of causality in each case . We located 57 papers written in Japanese ( 20 full papers , 37 case reports ) . Conditions examined were headache ( 12 trials ) , chronic low back pain ( 9 trials ) , rheumatoid arthritis ( 8 trials ) , temporom and ibular dysfunction ( 8 trials ) , katakori ( 8 trials ) and others ( 12 trials ) . While 23 were described as clinical control trials ( CCTs ) , 11 employed a quasi-r and om method . Applying the 5-point Jadad quality assessment scoring system , the mean score was 1.5 ± 1.3 ( SD ) . Eleven ( 52 % ) of the CCTs were conducted to determine a more effective procedure for acupuncture ; these compared a certain type of acupuncture with another type of acupuncture or specific additional points . In particular , the trigger point acupuncture was widely used to treat chronic low back pain in Japan . Many reports of chronic pain treatment by acupuncture and moxibustion are listed in Japanese data bases . From the data , we conclude that there is limited evidence that acupuncture is more effective than no treatment , and inconclusive evidence that trigger point acupuncture is more effective than placebo , sham acupuncture or st and ard care From January 1993 to December 1996 , we treated 482 cases of cervical spondylopathy with a combined method of point-injection and needle-warming via moxibustion . Except for the cases of sympathetic nerve type and spinal cord type , the combined method was superior to traction therapy in the control group and reported as follows . Clinical Data The Criteria of Diagnosis and Curative Effect in TCM issued by the State Administrative Bureau of TCM and Pharmacy in 1994 was adopted for the enrollment of patients of cervical spondylopathy and the pathological typing . Only the patients who had completed the treatment and with complete records were collected for analysis A prospect i ve , controlled clinical trial was undertaken to assess the relative efficacies of physiotherapy and electroacupuncture in the treatment of cervical spondylosis . The results suggested that , while both methods were effective , electroacupuncture produced an earlier symptomatic improvement with increased neck movement , especially in patients with mild degenerative changes of the cervical spine We present a double-blind trial in which a pulsed infrared beam was compared with a placebo in the treatment of myofascial pain in the cervical region . The patients were su bmi tted to 12 sessions on alternate days to a total energy dose of 5 J each . At each session , the four most painful muscular trigger points and five bilateral homometameric acupuncture points were irradiated . Those in the placebo group su bmi tted to the same number of sessions following an identical procedure , the only difference being that the laser apparatus was nonoperational . Pain was monitored using the Italian version of the McGill pain question naire and the Scott-Huskisson visual analogue scale . The results show a pain attenuation in the treated group and a statistically significant difference between the two groups of patients , both at the end of therapy and at the 3-month follow-up examination OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review OBJECTIVE The objective of the study was to investigate clinical effects of low-level laser therapy ( LLLT ) in patients with acute neck pain with radiculopathy . DESIGN Double-blind , r and omized , placebo-controlled study . SETTING The study was carried out between January 2005 and September 2007 at the Clinic for Rehabilitation at the Medical School , University of Bel grade , Serbia . PATIENTS AND INTERVENTION Sixty subjects received a course of 15 treatments over 3 weeks with active or an inactivated laser as a placebo procedure . LLLT was applied to the skin projection at the anatomical site of the spinal segment involved with the following parameters : wavelength 905 nm , frequency 5,000 Hz , power density of 12 mW/cm(2 ) , and dose of 2 J/cm(2 ) , treatment time 120 seconds , at whole doses 12 J/cm(2 ) . OUTCOME MEASURES The primary outcome measure was pain intensity as measured by a visual analog scale . Secondary outcome measures were neck movement , neck disability index , and quality of life . Measurements were taken before treatment and at the end of the 3-week treatment period . RESULTS Statistically significant differences between groups were found for intensity of arm pain ( P = 0.003 , with high effect size d = 0.92 ) and for neck extension ( P = 0.003 with high effect size d = 0.94 ) . CONCLUSION LLLT gave more effective short-term relief of arm pain and increased range of neck extension in patients with acute neck pain with radiculopathy in comparison to the placebo procedure OBJECTIVE This article examines the specific and nonspecific effects of Japanese  acupuncture on chronic myofascial neck pain in a r and omized single-blind trial . DESIGN Forty-six patients were r and omly assigned to receive relevant acupuncture , irrelevant acupuncture , or no-acupuncture control treatment consisting of nonsteroidal anti-inflammatory medication . The two acupuncture groups underwent comparable light shallow needling . The irrelevant acupuncture group received acupuncture at specific sites not relevant for cervical pain . OUTCOME MEASURES The study measures included the McGill Pain Question naire-Short Form ( SF-MPQ ) , the Short-Form Health Survey ( SF-36 ) , the Symptom Checklist 90-Revised ( SCL-90-R ) , medication diary , and physiologic measures . The factors examined as predictors of outcome pain ratings were experience with , beliefs about , and knowledge of acupuncture before treatment ; perceived efficacy , credibility , and logic of acupuncture ; perceived competence of the acupuncturist ; and painfulness of acupuncture . RESULTS No differences were found among the three groups at baseline , except that the relevant acupuncture group reported having had more previous acupuncture treatments . No significant differences in terms of perceived credibility or perceived effectiveness of treatment were found between the two acupuncture groups . The relevant acupuncture group had significantly greater pre-/posttreatment differences in pain than the irrelevant acupuncture and control groups ( p < .05 ) . The nonspecific effects of confidence in the acupuncturist , willingness to try any treatment , mood , and physiologic effect of needling were not predictive of treatment outcome , whereas confidence in the treatment and past experiences with acupuncture did correlate significantly with a decrease in pain . CONCLUSIONS Relevant acupuncture with heat contributes to modest pain reduction in persons with myofascial neck pain . Previous experience with and confidence in treatment help to predict benefit . Measurement of nonspecific effects of alternative therapy is recommended in future clinical trials OBJECTIVE We aim ed to evaluate the effectiveness of laser therapy in myofascial pain syndrome treatment . BACKGROUND DATA Myofascial pain syndrome is a disease that is characterized by hypersensitive points called trigger points found in one or more muscles and /or connective tissues . It can cause pain , muscle spasm , sensitivity , stiffness , weakness , limitation of range of motion and rarely autonomic dysfunction . Physical therapy modalities and exercise are used in the treatment of this frequently encountered disease . METHODS The placebo controlled , prospect i ve , long-term follow up study was planned with 60 patients who had trigger points in their upper trapezius muscles . The patients were divided into three groups r and omly . Stretching exercises were taught to each group and they were asked to exercise at home . Treatment duration was 4 weeks . Placebo laser was applied to group 1 , dry needling to group 2 and laser to group 3 . He-Ne laser was applied to three trigger points in the upper trapezius muscles on both sides with 632.8 nm . The patients were assessed at before , post-treatment , and 6 months after-treatment for pain , cervical range of motion and functional status . RESULTS We observed a significant decrease in pain at rest , at activity , and increase in pain threshold in the laser group compared to other groups . Improvement according to Nottingham Health Profile gave the superiority of the laser treatment . However , those differences among the groups were not observed at 6-month follow up . CONCLUSIONS Laser therapy could be useful as a treatment modality in myofascial pain syndrome because of its noninvasiveness , ease , and short-term application Abstract The aim of this study was to evaluate the short , medium and long – term effects of peripheral repetitive magnetic stimulation ( rMS ) on myofascial pain compared with transcutaneous electrical nerve stimulation (TENS).Fifty  – three subjects with myofascial trigger points ( TPs ) at the level of the superior trapezius muscle were allocated r and omly to three groups . The first group ( n = 17 ) was treated with rMS , the second ( n = 18 ) with TENS and the third ( n = 18 ) received a placebo treatment . Each treatment consisted of ten daily 20–minute sessions . Patients were evaluated before and immediately following treatment , and at one and three months after the end of treatment . Outcome measures were : the “ neck pain and disability visual analogue scale ” ( NPDVAS ) , an algometric evaluation of pain , an evaluation of the TP characteristics , and the range of cervical bending and rotation contralateral to the affected trapezius muscle . At the end of treatment , the rMS group showed a significant improvement in the NPDVAS , algometry , TP characteristics , and cervical contralateral rotation . This improvement also persisted at one and three months post – therapy . After treatment , the TENS group showed significant improvement in the same outcome measures except for algometry . At the one month follow – up visit , this improvement had returned to non significant levels in all outcome measures with the exception of NPDVAS.No significant effect of TENS was seen at the three – month follow – up visit . The placebo group showed no significant improvement in any measure . Our results strongly suggest that at medium and longer term intervals peripheral rMS may be more effective than TENS for the treatment of myofascial pain This study investigated effectiveness of manual therapy ( MT ) with transcutaneous electrical nerve stimulation ( TENS ) to reduce pain intensity in patients with mechanical neck disorder ( MND ) . A r and omized multi-centered controlled clinical trial was performed in 12 Primary Care Physiotherapy Units in Madrid Region . Ninety patients were included with diagnoses of subacute or chronic MND without neurological damage , 47 patients received MT and 43 TENS .  The primary outcome was pain intensity measured in millimeters using the Visual Analogue Scale ( VAS ) . Also disability , quality of life , adverse effects and sociodemographic and prognosis variables were measured . Three evaluations were performed ( before , when the procedure finished and six months after ) . Seventy-one patients ( 79 % ) completed the follow-up measurement at six months . In more than half of the treated patients the procedure had a clinical ly relevant " short term " result after having ended the intervention , when either MT or TENS was used . The success rate decreased to one-third of the patients 6 months after the intervention . No differences can be found in the reduction of pain , in the decrease of disability nor in the quality of life between both therapies . Both analyzed physiotherapy techniques produce a short-term pain reduction that is clinical ly relevant Background Guasha is a therapeutic method for pain management using tools to scrape or rub the surface of the body to relieve blood stagnation . This study aims to systematic ally review the controlled clinical trials on the effectiveness of using Guasha to treat musculoskeletal pain . Methods We search ed 11 data bases ( without language restrictions ) : MEDLINE , Allied and Complementary Medicine ( AMED ) , EMBASE , Cumulative Index to Nursing and Allied Health Literature ( CINAHL ) , Korean Studies Information ( KSI ) , DBPIA , Korea Institute of Science and Technology Information ( KISTI ) , KoreaMed , Research Information Service System ( RISS ) , China National Knowledge Infrastructure ( CNKI ) and the Cochrane Library . The search strategy was Guasha ( OR scraping ) AND pain . Risk of bias was assessed with the Cochrane criteria ( i.e. sequence generation , blinding , incomplete outcome measures and allocation concealment ) . Results Five r and omized controlled trials ( RCTs ) and two controlled clinical trials ( CCTs ) were included in the present study . Two RCTs compared Guasha with acupuncture in terms of effectiveness , while the other trials compared Guasha with no treatment ( 1 trial ) , acupuncture ( 4 trials ) , herbal injection ( 1 trial ) and massage or electric current therapy ( 1 trial ) . While two RCTs suggested favorable effects of Guasha on pain reduction and response rate , the quality of these RCTs was poor . One CCT reported beneficial effects of Guasha on musculoskeletal pain but had low method ological quality . Conclusion Current evidence is insufficient to show that Guasha is effective in pain management . Further RCTs are warranted and method ological quality should be improved In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias Thirteen patients with neck pain of at least two years ' duration participated in the study . Patients were r and omly assigned to either an acupuncture group or a placebo TNS ( transcutaneous nerve stimulation ) group . Initial pain scores revealed no significant difference between the groups with respect to pain severity . Patients were treated twice weekly for four weeks , at the end of which pain relief was measured using a simple descriptive scale . Even though an attempt was made to maximize the effect of placebo TNS using strong verbal suggestion , acupuncture still proved superior to placebo in the relief of cervical pain ( p less than 0.01 ) . The implication s of these findings are discussed Abstract A r and omized , double‐blind , placebo‐controlled study of low‐level laser therapy ( LLLT ) in 90 subjects with chronic neck pain was conducted with the aim of determining the efficacy of 300 mW , 830 nm laser in the management of chronic neck pain . Subjects were r and omized to receive a course of 14 treatments over 7 weeks with  either active or sham laser  to tender areas in the neck . The primary outcome measure was change in a 10 cm Visual Analogue Scale ( VAS ) for pain . Secondary outcome measures included Short‐Form 36 Quality ‐of‐Life question naire ( SF‐36 ) , Northwick Park Neck Pain Question naire ( NPNQ ) , Neck Pain and Disability Scale ( NPAD ) , the McGill Pain Question naire ( MPQ ) and Self‐Assessed Improvement ( SAI ) in pain measured by VAS . Measurements were taken at baseline , at the end of 7 weeks ' treatment and 12 weeks from baseline . The mean VAS pain scores improved by 2.7 in the treated group and worsened by 0.3 in the control group ( difference 3.0 , 95 % CI 3.8–2.1 ) . Significant improvements were seen in the active group compared to  placebo for SF‐36‐Physical Score ( SF36 PCS ) , NPNQ , NPAD , MPQVAS and SAI . The results of the SF‐36 – Mental Score ( SF36 MCS ) and other MPQ component scores ( afferent and sensory ) did not differ significantly between the two groups . Low‐level laser therapy ( LLLT ) , at the parameters used in this study , was efficacious in providing pain relief for patients with chronic neck pain over a period of 3 months Abstract Objectives : To compare the efficacy of acupuncture and conventional massage for the treatment of chronic neck pain . Design : Prospect i ve , r and omised , placebo controlled trial . Setting : Three outpatient departments in Germany . Participants : 177 patients aged 18–85 years with chronic neck pain . Interventions : Patients were r and omly allocated to five treatments over three weeks with acupuncture ( 56 ) , massage ( 60 ) , or “ sham ” laser acupuncture ( 61 ) . Main outcome measures : Primary outcome measure : maximum pain related to motion ( visual analogue scale ) irrespective of direction of movement one week after treatment . Secondary outcome measures : range of motion ( 3D ultrasound real time motion analyser ) , pain related to movement in six directions ( visual analogue scale ) , pressure pain threshold ( pressure algometer ) , changes of spontaneous pain , motion related pain , global complaints ( seven point scale ) , and quality of life ( SF-36 ) . Assessment s were performed before , during , and one week and three months after treatment . Patients ' beliefs in treatment were assessed . Results : One week after five treatments the acupuncture group showed a significantly greater improvement in motion related pain compared with massage ( difference 24.22 ( 95 % confidence interval 16.5 to 31.9 ) , P=0.0052 ) but not compared with sham laser ( 17.28 ( 10.0 to 24.6 ) , P=0.327 ) . Differences between acupuncture and massage or sham laser were greater in the subgroup who had had pain for longer than five years ( n=75 ) and in patients with myofascial pain syndrome ( n=129 ) . The acupuncture group had the best results in most secondary outcome measures . There were no differences in patients ' beliefs in treatment . Conclusions : Acupuncture is an effective short term treatment for patients with chronic neck pain , but there is only limited evidence for long term effects after five treatments . What is already known on this topic Acupuncture is a widespread complementary treatment Evidence from trials have given conflicting results on its use in the treatment of neck pain because of method ological shortcomings and because effects were compared either with alternative treatments or with different sham procedures imitating acupuncture , but not both What this study adds Compared with sham laser acupuncture and massage , needle acupuncture has beneficial effects on mobility and pain related to motion in patients with chronic neck pain Acupuncture was clearly more effective than massage , but differences were not always significant compared with sham laser acupuncture Acupuncture was the best treatment for patients with the myofascial syndrome and those who had had pain for longer than five A r and omized clinical trial was conducted to evaluate the efficacy of three commonly employed forms of traction in the treatment of cervical spine disorders . One hundred consenting men and women with disorders of the cervical spine were r and omly assigned to one of four treatment groups , static traction , intermittent traction , manual traction , or no traction . All patients , regardless of group assignment , were seen twice weekly . The four groups were shown to be similar with regard to age , sex , diagnosis , chronicity , and prescores on the seven outcome measures . Although the entire cohort of neck patients , regardless of group assignment , improved significantly on all the outcome variables over the 6-week period , patients receiving intermittent traction performed significantly better than those assigned to the no traction group in terms of pain ( P = 0.03 ) , forward flexion ( P = 0.01 ) , right rotation ( P = 0.004 ) and left rotation ( P = 0.05 ) Therapeutic benefits of low-output helium-neon laser therapy have not been established , but laser therapy has been suggested as an effective means of treating many acute and chronic musculoskeletal pain syndromes . Although not released for general clinical use by the FA , the helium-neon laser has been promoted to physical therapists and athletic trainers as potentially useful for the treatment of pain syndromes . In particular , it has been proposed that it may be more effective than conventional measures such as medication and conventional physical therapy in the treatment of myofascial pain syndromes ( fibrositis , fibromyalgia ) . The citations in the literature include only case reports . Sixty-two patients were treated by using acupuncture points .  Two sessions of five treatments were given six weeks apart . A crossover double-blind technique was used in the treatments . The clinical responses were assessed using portions of the McGill Pain Question naire . No statistical difference between the treatment and the placebo groups could be determined Context  Chronic neck pain  is a common , disabling condition and is difficult to treat . Because traditional therapies , such as physical therapy and nonsteroidal anti-inflammatory drugs , have limited effectiveness and can have adverse effects , many patients seek alternative therapies , such as acupuncture . Contribution This r and omized , controlled trial of acupuncture versus sham transcutaneous electrical stimulation for patients with chronic mechanical neck pain  identified no clinical ly significant benefit of acupuncture over placebo with respect to pain , function , or analgesic use . Implication s Acupuncture did not lead to clinical ly significant improvement in chronic mechanical neck pain when compared with placebo . The Editors Chronic mechanical neck pain can be caused by dysfunction of a variety of structures within the neck ( 1 - 3 ) but specifically excludes systemic problems such as rheumatoid arthritis . It is usually associated with unspecified degenerative changes ( cervical spondylosis ) that include osteoarthritis . Neck pain presents a substantial problem and may be responsible for as many days of work absenteeism as low back pain ( 4 ) . Osteoarthritis is the most common of the chronic diseases and affects most people older than 65 years of age ( 5 ) . It is degenerative and progressive in nature ( 1 - 3 , 6 ) . Because there is no cure for cervical spondylosis , treatment tends to center on symptom relief ( 7 , 8) . If the condition is symptomatic and symptoms are left untreated , this manifests as increasing episodic pain , stiffness , or both , and patients may then experience a spiral of increasing dysfunction ( 9 ) . Two systematic review s of conventional conservative physical therapy suggest that little evidence supports the efficacy of such intervention ( 8 , 10 ) . Nonsteroidal anti-inflammatory drugs , the mainstay of pharmacologic treatment , are associated with a wide spectrum of serious and well-documented adverse reactions ( 5 ) . There has been a huge increase in the use of complementary and alternative medicine in both the United States and the United Kingdom ( 11 , 12 ) . Acupuncture is the most frequently used type of complementary and alternative medicine therapy for the treatment of osteoarthritis ( 13 ) . Despite little sound evidence of efficacy ( 14 ) , approximately 1 million people seek complementary and alternative medicine treatment annually in the United States ( 15 ) . Two systematic review s of acupuncture in neck pain ( 4 , 16 ) suggest that there has been insufficient research in this area and that the published studies are of poor quality . Therefore , we conducted a rigorous evaluation to test whether western-style acupuncture performs better than placebo for treatment of chronic mechanical neck pain . We defined western acupuncture as a conventional diagnosis followed by individualized acupuncture treatment using a combination of prescriptive tender , local , and distal points . This is in contrast to a traditional Chinese approach , which would formulate an individualized diagnosis based on traditional Chinese theories of meridians and energy ( or qi ) . Methods Study Design and Patient Selection We design ed a r and omized , single-blind , placebo-controlled trial using a pragmatic treatment regimen . The study was conducted in the outpatient departments of Southampton General Hospital and Salisbury District Hospital in the United Kingdom . Between 1999 and 2001 , patients were referred by rheumatologists or family physicians or from physiotherapy waiting lists . Appropriate ethical approval was obtained from the Southampton and South West Hampshire Joint Research Ethics Committee . Patients were 18 to 80 years of age , had chronic ( > 2 months ) mechanical neck pain , and had a pain score of more than 30 mm on a visual analogue scale ( VAS ) for 5 of 7 pretreatment days ( possible score on this VAS ranges from 0 to 100 mm ) . We excluded pregnant patients ; those with a history of fracture or surgery to the neck , cervical congenital abnormality , uncontrolled low back pain , contraindication to acetaminophen , systemic illness ( for example , rheumatoid arthritis ) , or ongoing neck-related litigation or disability cl aims ; and those with current or recent manual neck treatment or steroid use ( oral or local injection ) . Sample Size Previous studies suggested a 50 % to 75 % improvement using  acupuncture  for patients with chronic pain  , compared with 30 % for placebo treatment ( 17 ) . We used these findings as the basis for our power calculation . At 5 % significance and 90 % power , 53 patients were required in each group to detect a 30 % difference in response between active and placebo treatments . Interventions Informed consent was obtained along with a full medical history , neurologic examination , cervical radiography , and laboratory investigations ( full blood count , erythrocyte sedimentation rate , and liver function tests ) . We told patients that we were comparing 2 types of intervention : 1 ) acupuncture with needles and 2 ) treatment with a machine design ed to stimulate acupuncture points through skin electrodes . The patients were informed that the treatment might or might not prove to be effective and that there was a 50 % chance that they would be assigned to a placebo but were not told what the placebo was . Blinding was not broken until 1 year after treatment . One practitioner performed all interventions . Acupuncture We used single-use , sterile , silver-h and le , prepacked needles without guide tubes . Sizes used were 13 mm 0.25 mm , 25 mm 0.25 mm , and 40 mm 0.25 mm . We based point selection on individualized western acupuncture techniques by using a list of points previously reported as being effective in neck pain ( 18 , 19 ) and by reaching a consensus according to our own clinical and teaching practice ( Appendix Table ) . The specific points for each individual were defined at each treatment session , depending on the patient 's pain distribution  and palpation of the neck and thorax to determine ah-shi points , or local tender points , for acupuncture . At least 1 distal point was used . Point location and depth of insertion were as described in traditional texts ( 19 ) . Six points on average , per side if pain was bilateral , were used on each patient , and deqi ( a term used to describe acupuncture needle sensation ) was obtained on each needle . Twenty-minute treatment sessions were given . The patient was checked every 6 or 7 minutes to ascertain whether deqi was still present , and needles were manipulated again if required . Placebo There is considerable debate about the ideal placebo for acupuncture studies ( 20 ) . To enhance the rigor of our study , we chose to use a previously well-vali date d placebo ( 17 , 21 - 23 ) that could not have a specific physiologic effect . The Noma FM-4 electroacupuncture stimulator ( Noma Ltd. , Southampton , United Kingdom ) was used . It has 4 channels , allowing pseudostimulation of up to 8 acupuncture points simultaneously , and emits visual and audio signals . Reusable electrodes ( Body Clock Health Care Ltd. , London , United Kingdom ) were fixed to the surface of the patient 's skin and were connected to the stimulator through decommissioned cables . The cables were severed inside the output plug , so that no current could reach the patient . Examination and point selection were the same as with real acupuncture for each treatment . Point location and treatment variables were changed during subsequent treatment sessions if patients felt they were not progressing . Patients were told that the machine could stimulate acupuncture points through high-frequency , low-intensity stimulation and therefore would not produce any sensation . If patients reported sensation , the therapist adjusted the unit for comfort ( although since this was a sham procedure , such adjustment made no real difference ) . Patients in both groups were instructed to use acetaminophen alone for pain relief and were not given or permitted any other form of treatment , including exercises or stretches , during the study and for 2 months after treatment ended . Patients were treated twice per week for 4 weeks . The therapist had taken an Acupuncture Association of Chartered Physiotherapists accredited course on western acupuncture techniques and had 7 years of experience practicing acupuncture . R and omization R and omization lists for Southampton General Hospital and Salisbury District Hospital were generated by using a computer program , R and omlogue , produced by Southampton University Department of Medical Statistics , Southampton , United Kingdom . Sealed envelopes containing the individual r and omization codes , numbered consecutively with sex and age strata , were then prepared ( sex strata were male and female , and age strata were 18 to 49 years and 50 to 80 years ) Patients were strictly allocated across 4 strata for either of the study hospitals according to the next available envelope number . Data Collection Before r and omization , patients were instructed to use a daily pain diary  ( on a VAS ) to record pain and  acetaminophen  use for 7 consecutive days . After a week , the pain diaries were examined , and if the inclusion criteria ( which were unknown to the patients ) were satisfied , r and omization occurred . Patients completed the various question naires before treatment and at 1 and 8 weeks after treatment . Pain continued to be recorded either weekly or daily throughout treatment and up to 8 weeks after treatment . Additional question naires and pain evaluation were also completed at 6 and 12 months after treatment . Figure 1 shows a flow chart of the trial . Figure 1 . Study flow with outcome assessment s. Outcomes The VAS score for pain 1 week after treatment , recorded daily for 7 consecutive days , was the primary outcome . Pain was recorded on a scale of 0 mm ( indicating no pain ) to 100 mm ( indicating worst pain imaginable ) . A significant outcome for acupuncture was considered to be a 30 % difference in VAS score between groups 5 weeks after r and omization ( 1 week after treatment ) , taking into account baseline pain . Secondary Low-energy laser therapy has been applied in several rheumatoid and soft tissue disorders with varying rates of success . The objective of our study was to investigate the effect of laser therapy on cervical myofascial pain syndrome with a placebo-controlled double-blind prospect i ve study model . It was performed with a total of 53 patients ( 35 females and 18 males ) with cervical myofascial pain syndrome . In group 1 ( n=23 ) , GaAs laser treatment was applied over three trigger points bilaterally and also one point in the taut b and s in trapezius muscle bilaterally with a frequency of 1000 Hz for 2 min over each point once a day for 10 days during a period of 2 weeks . In group 2 ( n=25 ) , the same treatment protocol was given , but the laser instrument was switched off during applications . All patients in both groups were instructed to perform daily isometric exercises and stretching just short of pain for 2 weeks at home . Evaluations were performed just before treatment ( week 0 ) , immediately after ( week 2 ) , and 12 weeks later ( week 14 ) . Evaluation parameters included pain , algometric measurements , and cervical lateral flexion . Statistical analysis was done on data collected from three evaluation stages . The results were evaluated in 48 patients ( 32 females , 16 males ) . Week 2 and week 14 results showed significant improvement in all parameters for both groups . However , comparison of the percentage changes both immediately and 12 weeks after treatment did not show a significant difference relative to pretreatment values . In conclusion , the results of our study have not shown the superiority of GaAs laser therapy over placebo in the treatment of cervical myofascial pain syndrome , but we suggest that further studies on this topic be done using different laser types and dosages in larger patient population A pragmatic , single blind , r and omised , controlled trial was conducted to test the hypothesis that superficial dry needling ( SDN ) together with active stretching is more effective than stretching alone , or no treatment , in deactivating trigger points ( TrPs ) and reducing myofascial pain . Forty patients with musculoskeletal pain , referred by GPs for physiotherapy , fulfilled inclusion / exclusion criteria for active TrPs . Subjects were r and omised into three groups : group 1 ( n=14 ) received  superficial dry needling ( SDN ) and active stretching exercises ( G1 ) ; group 2 ( n=13 ) received stretching exercises alone ( G2 ) ; and group 3 ( n=13 ) were no treatment controls ( G3 ) . During the three-week intervention period for G1 and G2 , the number of treatments varied according to the severity of the condition and subject/clinician availability . Assessment was carried out pre-intervention ( M1 ) , post-intervention ( M2 ) , and at a three-week follow up ( M3 ) . Outcome measures were the Short Form McGill Pain Question naire ( SFMPQ ) and Pressure Pain Threshold ( PPT ) of the primary TrP , using a Fischer algometer . Ninety-one per cent of assessment s were blind to grouping . At M2 there were no significant inter-group differences , but at M3 , G1 demonstrated significantly improved SFMPQ versus G3 ( p=0.043 ) and significantly improved PPT versus G2 ( p=0.011 ) . There were no differences between G2 and G3 . The mean PPT and SFMPQ scores correlated significantly in G1 only , though no significant inter-group differences were demonstrated . Numbers of patients requiring further treatment following the trial were : 6 ( G1 ) ; 12 ( G2 ) ; 9 ( G3 ) . Conclusion : SDN followed by active stretching is more effective than stretching alone in deactivating TrPs ( reducing their sensitivity to pressure ) , and more effective than no treatment in reducing subjective pain . Stretching without prior deactivation may increase TrP sensitivity BACKGROUND AND OBJECTIVES The efficacy of low level laser therapy ( LLLT ) in myofascial pain syndrome ( MPS ) seems controversial . Our aim was to clarify the effect of LLLT in MPS by using algometry and thermography . STUDY DESIGN / MATERIAL S AND METHODS Sixty-two patients with MPS having an active trigger point in the neck or upper back region were r and omly divided into two equal groups according to therapy applied ( group 1 : LLLT + stretching exercises , group 2 : stretching exercises alone ) . The outcome measures were pain measured with visual analogue scale ( VAS ) , algometry on the trigger point , algometric difference , thermographic difference , and thermal asymmetry . Comparison was made within and between the groups pre- and post-therapeutically and 3 weeks after therapy . RESULTS Mean pain values decreased more significantly in group 1 from baseline to 3 weeks follow up ( 7.54 - 3.06 ) while these values were 7.03 - 5.19 in group 2 ( P < 0.05 ) . Group comparisons revealed significant favorable differences in group 1 patients in terms of all other parameters at the first and the second evaluation post therapeutically ( P < 0.05 ) . CONCLUSIONS LLLT seemed to be beneficial for pain in MPS by using algometry and thermography BACKGROUND AND OBJECTIVES A prospect i ve , double-blind , r and omized , and controlled trial was conducted in patients with chronic myofascial pain syndrome ( MPS ) in the neck to evaluate the effects of infrared low level 904 nm Gallium-Arsenide ( Ga-As ) laser therapy ( LLLT ) on clinical and quality of life ( QoL ) . STUDY DESIGN / PATIENTS AND METHODS The study group consisted of 60 MPS patients . Patients were r and omly assigned to two treatment groups : Group I ( actual laser ; 30 patients ) and Group II ( placebo laser ; 30 patients ) . LLLT continued daily for 2 weeks except weekends . Follow-up measures were evaluated at baseline , 2 , 3 , and 12 weeks . All patients were evaluated with respect to pain at rest , pain at movement , number of trigger points ( TP ) , the Neck Pain and Disability Visual Analog Scale ( NPAD ) , Beck depression Inventory ( BDI ) , and the Nottingham Health Profile ( NHP ) . RESULTS In active laser group , statistically significant improvements were detected in all outcome measures compared with baseline ( P < 0.01 ) while in the placebo laser group , significant improvements were detected in only pain score at rest at the 1 week later of the end of treatment . The score for self-assessed improvement of pain was significantly different between the active and placebo laser groups ( 63 vs. 19 % ) ( P < 0.01 ) . CONCLUSION This study revealed that short-period application of LLLT is effective in pain relief and in the improvement of functional ability and QoL in patients with MPS The efficacy of low-level laser therapy ( LLLT ) in myofascial pain syndrome ( MPS ) seems controversial . A prospect i ve , double-blind , r and omized controlled trial was conducted in patients with chronic MPS in the neck to evaluate the effects of low-level 830-nm gallium arsenide aluminum ( Ga – As – Al ) laser therapy . The study group consisted of 64 MPS patients . The patients were r and omly assigned into two groups . In group 1 ( n = 32 ) , Ga – As – Al laser treatment was applied over three trigger points bilaterally for 2 min over each point once a day for 15 days during a period of 3 weeks . In group 2 ( n = 32 ) , the same treatment protocol was given , but the laser instrument was switched off during applications . All patients in both groups performed daily isometric exercise and stretching exercises for cervical region . Parameters were measured at baseline and after 4 weeks . All patients were evaluated with respect to pain ( at rest , movement , and night ) and assessed by visual analog scale , measurement of active range of motion using an inclinometer and a goniometer , and the neck disability index . In both groups , statistically significant improvements were detected in all outcome measures compared with baseline ( p < 0.05 ) . However , no significant differences were obtained between the two groups ( p > 0.05 ) . In conclusion , although the laser therapy has no superiority over placebo groups in this study , we can not exclude the possibility of effectivity with another treatment regimen including different laser wavelengths and dosages ( different intensity and density and /or treatment interval ) OBJECTIVE To compare the effects of manipulation treatment and transcutaneous electrical nerve stimulation ( TENS ) on patients with cervicogenic headache . METHODS Seventy patients with cervicogenic headache were r and omly allocated to receive manipulation treatment and TENS treatment , which were given every other day respectively for total 40 days . The headache degree ( numeric rating scale , NRS ) , frequency , lasting time and the range of motion ( ROM ) of the cervical spine 2 weeks before treatment and 4 weeks after treatment , were compared . RESULTS Before treatment , there were no significant differences in the headache NRS scores , frequency , lasting time and the ROM scores between the two groups ( P>0.05 ) . After treatment , the headache NRS score , frequency , lasting time in the manipulation group decreased significantly ( P<0.01 ) , while in the TENS group just the headache NRS score decreased significantly ( P<0.05 ) . The ROM scores in both groups showed no significant changes ( P>0.05 ) . The response rate of manipulation treatment is 94.5 % , significantly higher than 64.5 % of TENS treatment ( P<0.05 ) . CONCLUSION The manipulation treatment is an effective method for patients with cervicogenic headache OBJECTIVE To assess the long-term benefits of medication , needle acupuncture , and spinal manipulation as exclusive and st and ardized treatment regimens in patients with chronic ( > 13 weeks ) spinal pain syndromes . STUDY DESIGN Extended follow-up ( > 1 year ) of a r and omized clinical trial was conducted at the multidisciplinary spinal pain unit of Townsville 's General Hospital between February 1999 and October 2001 . PATIENTS AND METHODS Of the 115 patients originally r and omized , 69 had exclusively been treated with the r and omly allocated treatment during the 9-week treatment period ( results at 9 weeks were reported earlier ) . These patients were followed up and assessed again 1 year after inception into the study reapplying the same instruments ( ie , Oswestry Back Pain Index , Neck Disability Index , Short-Form-36 , and Visual Analogue Scales ) . Question naires were obtained from 62 patients reflecting a retention proportion of 90 % . The main analysis was restricted to 40 patients who had received exclusively the r and omly allocated treatment for the whole observation period since r and omization . RESULTS Comparisons of initial and extended follow-up question naires to assess absolute efficacy showed that only the application of spinal manipulation revealed broad-based long-term benefit : 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups . CONCLUSIONS In patients with chronic spinal pain syndromes , spinal manipulation , if not contraindicated , may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit The purpose of this study was to evaluate the effect of electromagnetic field therapy ( PEMF ) on pain , range of motion ( ROM ) and functional status in patients with cervical osteoarthritis ( COA ) . Thirty-four patients with COA were included in a r and omized , double-blind study . PEMF was administrated to the whole body using a mat 1.8 × 0.6 m in size . During the treatment , the patients lay on the mat for 30 min per session , twice a day for 3 weeks . Pain levels in the PEMF group decreased significantly after therapy ( p<0.001 ) , but no change was observed in the placebo group . The active ROM , paravertebral muscle spasm and neck pain and disability scale ( NPDS ) scores improved significantly after PEMF therapy ( p<0.001 ) but no change was observed in the sham group . The results of this study are promising , in that PEMF treatment may offer a potential therapeutic adjunct to current COA therapies in the future Abstract We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain , in r and omized clinical trials of a single session of manual therapy . A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted . Trials that scored above 60 % on the PEDro Scale were included . Change scores that scored above 60 % on the PEDro Scale were included . Change scores were analyzed for absolute , percentage change and e ect size ( ES ) whenever possible . Nine trials were identi ed : 6 for spinal manipulation , 4 for spinal mobilization or non-manipulative manual therapy ( 2 overlapping trials ) , and 1 trial using ischemic compression . No trials were identi ed for massage therapy or manual traction . Four manipulation trials ( Five groups ) reported mean immediate changes in 100-mm VAS of –18.94 ( 9.28 ) mm . ES for these changes ranged from .33 to 2.3 . Two mobilization trials reported immediate VAS changes of –11.5 and –4 mm ( ES of .36 and .22 , respectively ) ; one trial reported no difference in immediate pain scores versus sham mobilization . e ischemic compression study showed statistically signi ca nt immediate decreases in 100-mm pain VAS ( average = –14.6 mm ) . There is moderate-to-high quality evidence that immediate clinical ly important improvements are obtained from a single session of spinal manipulation . e evidence for mobilization is less substantial , with fewer studies reporting smaller immediate changes . ere is insu cient evidence for ischemic compression to draw conclusions . There is no evidence for a single session of massage or manual traction for chronic neck pain Thirty patients with acute cervical pain were r and omized into 3 groups and treated with neck collar , transcutaneous nerve stimulation , or manual therapy . The improvement was rapid in all groups , but the restoration of the cervical mobility was significantly more rapid in the transcutaneous nerve stimulation group . Some of the patients with manual therapy treatment had remarkably quick symptom reduction , although this was not significantly better than the collar alone . It is concluded that transcutaneous nerve stimulation is a valuable pain reducer and gives a more rapid restoration of cervical mobility in acute cervical pain OBJECTIVE To study what effects a high-power , pain-threshold , static ultrasound technique applied to acute myofascial trigger points of the upper trapezius has on pain and on active cervical lateral bending . DESIGN Double-blind r and omized trial . SETTING Physical therapy unit of a private general hospital . PARTICIPANTS Seventy-two adults with acute pain on 1 side of the neck , admitted to the outpatient unit during 1999 and 2000 . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Visual analog scale and goniometric measurement of active lateral bending of the neck performed daily after treatment sessions and length of treatment ( number of therapy sessions ) . RESULTS High-power ultrasound applied to the trigger points before stretching the muscle was more effective ( P<.05 ) than conventional ultrasound , and it also significantly ( P<.001 ) decreased the length of therapy . CONCLUSIONS High-power , pain-threshold , static ultrasound technique may be considered in the treatment of patients with acute myofascial pain syndrome , with the underst and ing that this technique dem and s more concentration and communication between the patient and the therapist Study Design . Population ‐based , cross‐sectional mailed survey . Objective . To determine the lifetime , period , and point prevalence of neck pain and its related disability among Saskatchewan adults and investigate the presence and strength of nonresponse bias . Summary of Background Data . In Europe , the life‐time and point prevalence of neck pain is almost as high as the prevalence of low back pain . Similarly , chronic neck pain is highly prevalent and a common source of disability in the working‐age population . However , no studies specifically have documented the prevalence of neck pain and its related disability in North America . Methods . The Saskatchewan Health and Back Pain Survey was mailed to 2184 r and omly selected Saskatchewan adults aged 20‐69 years . Fifty‐five percent of the study population participated . The presence of nonresponse bias was investigated through logistic regression and wave analysis . The Chronic Pain Question naire was used to classify the severity of chronic neck pain . Results . The age‐st and ardized lifetime prevalence of neck pain is 66.7 % ( 95 % confidence interval , 63.8‐69.5 ) , and the point prevalence is 22.2 % ( 95 % confidence interval , 19.7‐24.7 ) . The age‐st and ardized 6‐month prevalence of low‐intensity and low‐disability neck pain is 39.7 % ( 95 % confidence interval , 36.7‐42.7 ) , whereas it is 10.1 % ( 95 % confidence interval , 8.2‐11.9 ) for high‐intensity and low‐disability neck pain and 4.6 % ( 95 % confidence interval , 3.3‐5.8 ) for significantly disabling neck pain . The prevalence of low‐intensity and low‐disability neck pain decreases with age . More women experience high‐disability neck pain than men . Wave analysis suggests that the point prevalence and 6‐month prevalence of high‐intensity and low‐disability neck pain are overestimated in this survey . Conclusion . This cross‐sectional study shows that neck pain is highly prevalent in Saskatchewan and that it significantly disables 4.6 % ( 95 % confidence interval , 3.3‐5.8 ) of the adult population BACKGROUND CONTEXT Multilevel fusions , the use of allograft bone , and smoking have been associated with an increased risk of nonunion after anterior cervical discectomy and fusion ( ACDF ) procedures .  Pulsed electromagnetic field ( PEMF ) stimulation has been shown to increase arthrodesis rates after lumbar spine fusion surgery , but there are minimal data concerning the effect of PEMF stimulation on cervical spine fusion . PURPOSE To determine the efficacy and safety of PEMF stimulation as an adjunct to arthrodesis after ACDF in patients with potential risk factors for nonunion . STUDY DESIGN A r and omized , controlled , prospect i ve multicenter clinical trial . PATIENT SAMPLE Three hundred and twenty-three patients with radiographic evidence ( computed tomography-myelogram [ CT-myelo ] or magnetic resonance imaging [ MRI ] ) of a compressed cervical nerve root and symptomatic radiculopathy appropriate to the compressed root that had failed to respond to nonoperative management were enrolled in the study . The patients were either smokers ( more than one pack per day ) and /or were undergoing multilevel fusions . All patients underwent ACDF using the Smith-Robinson technique .  Allograft bone and an anterior cervical plate were used in all cases . OUTCOME MEASURES Measurements were obtained preoperatively and at each postoperative interval and included neurologic assessment , visual analog scale ( VAS ) scores for shoulder/arm pain at rest and with activity , SF-12 scores , the neck disability index ( NDI ) , and radiographs ( anteroposterior , lateral , and flexion-extension views ) . Two orthopedic surgeons not otherwise affiliated with the study and blinded to treatment group evaluated the radiographs , as did a blinded radiologist . Adverse events were reported by all patients throughout the study to determine device safety . METHODS Patients were r and omly assigned to one of two groups : those receiving PEMF stimulation after surgery ( PEMF group , 163 patients ) and those not receiving PEMF stimulation ( control group , 160 patients ) . Postoperative care was otherwise identical . Follow-up was carried out at 1 , 2 , 3 , 6 , and 12 months postoperatively . RESULTS The PEMF and control groups were comparable with regard to age , gender , race , past medical history , smoking status , and litigation status . Both groups were also comparable in terms of baseline diagnosis ( herniated disc , spondylosis , or both ) and number of levels operated ( one , two , three , or four ) . At 6 months postoperatively , the PEMF group had a significantly higher fusion rate than the control group ( 83.6 % vs. 68.6 % , p=.0065 ) . At 12 months after surgery , the stimulated group had a fusion rate of 92.8 % compared with 86.7 % for the control group ( p=.1129 ) . There were no significant differences between the PEMF and control groups with regard to VAS pain scores , NDI , or SF-12 scores at 6 or 12 months . No significant differences were found in the incidence of adverse events in the groups . CONCLUSIONS This is the first r and omized , controlled trial that analyzes the effects of PEMF stimulation on cervical spine fusion . PEMF stimulation significantly improved the fusion rate at 6 months postoperatively in patients undergoing ACDF with an allograft and an anterior cervical plate , the eligibility criteria being patients who were smokers or had undergone multilevel cervical fusion . At 12 months postoperatively , however , the fusion rate for PEMF patients was not significantly different from that of the control group . There were no differences in the incidence of adverse events in the two groups , indicating that the use of PEMF stimulation is safe in this clinical setting Forty-four patients with chronic cervical osteoarthritis took part in this study . Patients were treated with acupuncture , sham-acupuncture , diazepam or placebo-diazepam in r and omized order . Pain was rated on visual analogue scales before , during , and after treatment . Two scales were separately used to rate the intensity ( sensory component ) and the unpleasantness ( affective component ) of pain . The results analyzed from these trials show that diazepam , placebo-diazepam , acupuncture and sham-acupuncture have a more pronounced effect on the affective than on the sensory component of pain .  Acupuncture was significantly more effective than placebo-diazepam ( p less than 0.05 ) , but not significantly more effective than diazepam or sham-acupuncture Back pain and the whiplash syndrome are very common diseases involving tremendous costs and extensive medical effort . A quick and effective reduction of symptoms , especially pain , is required . In two prospect i ve r and omized studies , patients with either lumbar radiculopathy in the segments L5/S1 or the whiplash syndrome were investigated . Inclusion criteria were as follows : either clinical ly verified painful lumbar radiculopathy in the segments L5/S1 and a Laségue 's sign of 30 degrees ( or more ) , or typical signs of the whiplash syndrome such as painful restriction of rotation and flexion/extension . Exclusion criteria were prolapsed intervertebral discs , systemic neurological diseases , epilepsy , and pregnancy . A total of 100 patients with lumbar radiculopathy and 92 with the whiplash syndrome were selected and entered in the study following a 1:1 ratio . Both groups ( magnetic field treatment and controls ) received st and ard medication consisting of diclofenac and tizanidine , while the magnetic field was only applied in group 1 , twice a day , for a period of two weeks . In patients suffering from radiculopathy , the average time until pain relief and painless walking was 8.2 + /- 0.5 days in the magnetic field group , and 11.7 + /- 0.5 days in controls p < 0.04 ) . In patients with the whiplash syndrome , pain was measured on a ten-point scale . Pain in the head was on average 4.6 before and 2.1 after treatment in those receiving magnetic field treatment , and 4.2/3.5 in controls . Neck pain was on average 6.3/1.9 as opposed to 5.3/4.6 , and pain in the shoulder/arm was 2.4/0.8 as opposed to 2.8/2.2 ( p < 0.03 for all regions ) . Hence , magnetic fields appear to have a considerable and statistically significant potential for reducing pain in cases of lumbar radiculopathy and the whiplash syndrome We studied the effect of the location of electrical stimulation on the acute analgesic response to percutaneous neuromodulation therapy in patients with nonradiating neck pain . Sixty-eight patients received three different nonpharmacologic modalities , namely “ needles only ” ( neck ) , local ( neck ) dermatomal stimulation , and remote ( lower back ) dermatomal stimulation in a r and om sequence over the course of an 11-wk study period . All treatments were given for 30 min , 3 times per week for 3 wk , with 1 wk “ off ” between each modality . The assessment tools included the health status survey short form ( SF-36 ) question naire , as well as 10-cm visual analog scales for assessing pain , physical activity , and quality of sleep . The pain visual analog scale was repeated 5–10 min after each treatment session . The daily oral nonopioid analgesic requirements were recorded in the patient diary during the entire study period . At the end of each 3-wk treatment block , the SF-36 question naire was repeated . Compared with needles only and remote dermatomal stimulation , local dermatomal stimulation produced a significantly greater decrease in pain ( 38 % ± 17 % vs 9 % ± 16 % and 13 % ± 18 % ) , increase in physical activity ( 41 % ± 21 % vs 11 % ± 17 % and 16 % ± 15 % ) , and improvement in the quality of sleep ( 34 % ± 18 % vs 7 % ± 17 % and 10 % ± 18 % ) compared with baseline values ( P < 0.05 ) . The need for oral analgesic medications was decreased by an average of 6 % ± 15 % , 37 % ± 18 % , and 9 % ± 13 % during the 3-wk treatment period with the needle only , local dermatomal , and remote dermatomal stimulation , respectively . The posttreatment SF-36 test results revealed that all three modalities produced improvements compared with the pre study scores for both the physical component summary and mental component summary . However , the magnitude of the changes in the physical component summary and mental component summary with local dermatomal stimulation was significantly greater ( + 7.9 and + 3.6 , respectively ) than needle only ( + 3.4 and + 1.7 , respectively ) or remote dermatomal stimulation ( + 3.7 and + 1.9 , respectively ) . No side effects were reported at the needle insertion sites . We conclude that electrical stimulation at the specific dermatomal levels corresponding to the local pathology produces greater short-term improvements in pain control , physical activity , and quality of sleep in patients with chronic neck pain . Implication s The location of peripheral electrical stimulation influences the acute analgesic response to percutaneous modulation therapy in patients with long-term neck pain . This study demonstrates that electrical stimulation at the involved dermatomal levels produced a greater hypoalgesic effect than remote dermatomal stimulation . These data suggest that percutaneous modulation therapy-induced analgesia results from neuromodulatory changes & NA ; To evaluate immediate effects of two different modes of acupuncture on motion‐related pain and cervical spine mobility in chronic neck pain patients compared to a sham procedure . Thirty‐six patients with chronic neck pain and limited cervical spine mobility participated in a prospect i ve , r and omized , double‐blind , sham‐controlled crossover trial . Every patient was treated once with needle acupuncture at distant points , dry needling ( DN ) of local myofascial trigger points and sham laser acupuncture ( Sham ) . Outcome measures were motion‐related pain intensity ( visual analogue scale , 0–100 mm ) and range of motion ( ROM ) . In addition , patients scored changes of general complaints using an 11‐point verbal rating scale . Patients were assessed immediately before and after each treatment by an independent ( blinded ) investigator . Multivariate analysis was used to assess the effects of true acupuncture and needle site independently . For motion‐related pain , use of acupuncture at non‐local points reduced pain scores by about a third ( 11.2 mm ; 95 % CI 5.7 , 16.7 ; P=0.00006 ) compared to DN and sham . DN led to an estimated reduction in pain of 1.0 mm ( 95 % CI −4.5 , 6.5 ; P=0.7 ) . Use of DN  slightly improved ROM by 1.7 ° ( 95 % CI 0.2 , 3.2 ; P=0.032 ) with use of non‐local points improving ROM by an additional 1.9 ° ( 95 % CI 0.3 , 3.4 ; P=0.016 ) . For patient assessment of change , non‐local acupuncture was significantly superior both to Sham ( 1.7 points ; 95 % CI 1.0 , 2.5 ; P=0.0001 ) and DN ( 1.5 points ; 95 % CI 0.4 , 2.6 ; P=0.008 ) but there was no difference between DN and Sham ( 0.1 point ; 95 % CI −1.0 , 1.2 ; P=0.8 ) . Acupuncture is superior to Sham in improving motion‐related pain and ROM following a single session of treatment in chronic neck pain patients . Acupuncture at distant points improves ROM more than DN ; DN was ineffective for motion‐related pain STUDY DESIGN R and omized clinical trial . OBJECTIVES To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain . BACKGROUND Different treatment modalities have been described for patients with neurogenic cervicobrachial pain . Although it has been suggested that a more specific approach , like cervical mobilization , would be more effective , effect studies are scarce . METHODS AND MEASURES Twenty patients with subacute peripheral neurogenic cervicobrachial pain were assessed . Besides other criteria , patients were included if a cervical segmental motion restriction was present which could be regarded as a possible cause of the neurogenic disorder . Patients were r and omly assigned to a mobilization or ultrasound group . Mobilization consisted of a contralateral lateral glide technique . The range of elbow extension , symptom distribution , and pain intensity during the neural tissue provocation test for the median nerve were used as outcome measures . Results were analyzed using a 2-way mixed- design ANOVA . RESULTS Significant differences in treatment effects between the 2 groups could be observed for all outcome measures ( P < or = .0306 ) . For the mobilization group , the increase in elbow extension from 137.3 degrees to 156.7 degrees , the 43.4 % decrease in area of symptom distribution , and the decreased pain intensity from 7.3 to 5.8 were significant ( P < or = .0003 ) . For the ultrasound group , there were no significant improvements ( P > or = .0521 ) . CONCLUSIONS When a cervical dysfunction can be regarded as a cause of the neurogenic disorder or as a contributing factor that impedes natural recovery , a cervical lateral glide mobilization has positive immediate effects in patients with subacute peripheral neurogenic cervicobrachial pain . This movement-based approach seems preferable to ultrasound This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence OBJECTIVES This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain . METHODS Neck-pain patients were r and omized to the following conditions : manipulation with or without heat , manipulation with or without electrical muscle stimulation , mobilization with or without heat , and mobilization with or without electrical muscle stimulation . RESULTS Of 960 eligible patients , 336 enrolled in the study .  Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months . CONCLUSIONS Cervical spine manipulation and mobilization yield comparable clinical outcomes & NA ; The effect of treatment with ultrasound , massage and exercises on myofascial trigger‐points ( MTrP ) in the neck and shoulder was assessed in a r and omised controlled trial . The outcome measures were pain at rest and on daily function ( Visual Analogue Scale , VAS ) , analgesic usage , global preference and index of MTrP. Long‐term effect for treatment and control groups was assessed after 6 months using a question naire . The patients were r and omised to three groups . The first group was treated with ultrasound , massage and exercise ( A ) , the second group with sham‐ultrasound , massage and exercise ( B ) , while the third group was a control group ( C ) . The duration of the study was 6 weeks . Treatment was given twice a week from the second to the fifth week . The number and index of MTrPs were recorded at each treatment session in groups A and B but only at entry as well as end of study in group C. VAS and analgesic usage was recorded in all three groups throughout the study period . Six months after the last treatment session a question naire was send to the patients . A total of 67 patients were included . Nine patients dropped‐out during the study , which left 58 patients that could be included in the final analysis . Twenty patients were r and omised to group A , 18 to group B and 18 to group C. A significant reduction in index were found between treatment groups ( A and B ) and control group ( C ) , but no difference between group A and B. VAS scores , analgesic usage or global preference showed no difference between group A , B or C. The patients in the group C were offered treatment ( ultrasound , massage , exercise ) after the 6 weeks treatment period . At the question naire after 6 month 44 ( 87 % ) of the 52 patients from all three groups who had treatment responded . Sixty‐four percent answered that they had had good or some effects , 68 percent were still doing the exercise programme and 17 percent had received other forms of therapy after they had completed the study . No difference between groups given ultrasound or sham ultrasound were found . It is concluded that US give no pain reduction , but apparently massage and exercise reduces the number and intensity of MTrP. The impact of this reduction on neck and shoulder pain is weak OBJECTIVES Interventions that take psychosocial factors into account are recommended for patients with persistent back or neck pain . We compared the effectiveness of a brief physiotherapy pain management approach using cognitive-behavioural principles ( Solution-Finding Approach-SFA ) with a commonly used method of physical therapy ( McKenzie Approach-McK ) . METHODS Eligible patients referred by GPs to physiotherapy departments with neck or back pain lasting at least 2 weeks were r and omized to McK ( n= 161 ) or to SFA ( n= 154 ) . They were further r and omized to receive an educational booklet or not . The primary outcome was the Tampa Scale of Kinesiophobia ( TSK ) ( Activity-Avoidance scale used as a proxy for coping ) at 6 weeks , and 6 and 12 months . RESULTS Of 649 patients assessed for eligibility , 315 were recruited ( 219 with back pain , 96 with neck pain ) . There were no statistically significant differences in outcomes between the groups , except that at any time point SFA patients supported by a booklet reported less reliance on health professionals ( Multidimensional Health Locus of Control Powerful Others Scale ) , while at 6 months McK patients showed slightly more improvement on activity-avoidance ( TSK ) . At 6 weeks , patient satisfaction was greater for McK ( median 90 % compared with 70 % for SFA ) . Both interventions result ed in modest but clinical ly important improvements over time on the Rol and Disability Question naire Scores and Northwick Park Neck Pain Scores . CONCLUSIONS The McK approach result ed in higher patient satisfaction overall but the SFA could be more cost-effective , as fewer ( three vs four ) sessions were needed The st and ard treatment of acute whiplash injuries ( soft collar and analgesia ) is frequently unsuccessful . Pulsed electromagnetic therapy PEMT ( as pulsed 27 MHz ) has been shown to have pro-healing and anti-inflammatory effects . This study examines the effect of PEMT on the acute whiplash syndrome . One half of the 40 patients entering the study received active PEMT collars : the other half facsimile ( placebo ) . All patients were given instructions to wear the collar for eight hours a day at home and advised to mobilise their necks . At 2 and 4 weeks the actively treated group had significantly improved ( p less than 0.05 ) in terms of pain ( visual analogue scale ) . By chance movement scores for the PEMT group were significantly worse at entry to the study than the control group ( p less than 0.05 ) . At 12 weeks they had become significantly better ( p less than 0.05 ) . PEMT as described is safe for domiciliary use and this study suggests that PEMT has a beneficial effect in the management of the acute whiplash injury OBJECTIVE To compare needle acupuncture , medication ( tenoxicam with ranitidine ) , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain syndromes . DESIGN Prospect i ve , r and omized , independently assessed preintervention and postintervention clinical pilot trial . SETTING Specialized spinal pain syndrome out-patient unit at Townsville General Hospital , Queensl and , Australia . SUBJECTS Seventy-seven patients ( without contraindication to manipulation or medication ) were recruited . INTERVENTIONS One of three separate , clearly defined intervention protocol s : needle acupuncture , nonsteroidal anti-inflammatory medication , or chiropractic spinal manipulation . MAIN OUTCOME MEASURES Main outcome measures were changes ( 4 weeks vs. initial visit ) in the scores of the ( 1 ) Oswestry Back Pain Disability Index , ( 2 ) Neck Disability Index , and ( 3 ) three visual analogue scales of local pain intensity . RESULTS R and omization was successful . After a median intervention period of 30 days , spinal manipulation was the only intervention that achieved statistically significant improvements ( all expressed as percentages of the original scores ) with ( 1 ) a reduction of 30.7 % on the Oswestry scale , ( 2 ) an improvement of 25 % on the neck disability index , and ( 3 ) reductions on the visual analogue scale of 50 % for low back pain , 46 % for upper back pain , and 33 % for neck pain ( all P<.001 ) . Neither of the other interventions showed any significant improvement on any of the outcome measures . CONCLUSIONS The consistency of the results provides , in spite of several discussed shortcomings of this pilot study , evidence that in patients with chronic spinal pain syndromes  spinal manipulation , if not contraindicated , results in greater improvement than acupuncture and medicine OBJECTIVE To evaluate short- and medium-term effects of peripheral repetitive magnetic stimulation ( rMS ) on myofascial pain . METHODS Eighteen patients who presented with myofascial trigger points ( TPs ) at the level of the superior trapezius were separated into two groups according to a restricted r and omization scheme . Group 1 ( n=9 ) underwent treatment with rMS that consisted of a total of 10 sessions , each lasting 20min , in which 4000 magnetic stimuli were administered in 5s trains at 20Hz at the TP . Group 2 ( n=9 ) received a placebo treatment that consisted of the application of a non-functioning ultrasound therapy device to the TP . Patients were evaluated before treatment , at the end of treatment , and again 1 week and 1 month after the conclusion of the treatment . Clinical evaluation included parameters for measuring pain levels ( VAS , NPDVAS and algometry ) , the myofascial TP characteristics and the range of cervical movement ( ROM ) . RESULTS The rMS group showed a significant improvement in VAS , NPDVAS , algometry , as well as in the characteristics of the TP after conclusion of treatment . Improvements in the ROM were also present in rotation and controlateral bending . This improvement persisted after 1 month . On the other h and , the placebo group did not show any significant improvement in the tests considered . CONCLUSIONS The results of this study show that peripheral rMS may have positive short- and medium-term therapeutic effects on myofascial pain Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic OBJECTIVES To compare the effects of real acupuncture to tender points for neck and shoulder pain and stiffness ( Japanese : katakori ) with those of sham acupuncture . DESIGN R and omized-controlled trial . METHODS Thirty-four volunteers from an acupuncture school with complaints of chronic pain and stiffness , who had no arm symptoms and gave informed consent , were r and omly allocated to acupuncture or sham groups . Acupuncture or sham acupuncture was applied to the tender points once a week for 3 weeks . In the acupuncture group the acupuncture needle was inserted to the muscle , then the sparrow pecking technique was applied five times . Sham acupuncture was done without insertion of the needle . Dull pain and stiffness were evaluated by visual analog scale ( VAS ) before , and every 2 days after the first needling for 1 month . Pressure pain threshold on the tender points was measured before and after each treatment . RESULTS There was no statistical difference of VAS scores between acupuncture and sham groups 9 days after the last treatment . However , the acupuncture group showed significant reduction of VAS scores immediately after and /or 1 day after the real acupuncture treatments ( P<0.01 ) . The effect tended to be prolonged after repeated treatment . Pressure pain thresholds tended to increase after real acupuncture treatment but not after sham acupuncture . CONCLUSIONS Acupuncture applied to tender points appears to have short-term effects on neck and shoulder pain and stiffness , but this study was unable to demonstrate any long-term superiority over sham acupuncture Abstract : Pain is a major symptom in cervical osteoarthritis ( COA ) .  Low-power laser ( LPL ) therapy has been cl aim ed to reduce pain in musculoskeletal pathologies , but there have been concerns about this point . The aim of this study was to evaluate the analgesic efficacy of LPL therapy and related functional changes in COA . Sixty patients between 20 and 65 years of age with clinical ly and radiologically diagnosed COA were included in the study . They were r and omised into two equal groups according to the therapies applied , either with LPL or placebo laser . Patients in each group were investigated blindly in terms of pain and pain-related physical findings , such as increased paravertebral muscle spasm , loss of lordosis and range of neck motion restriction before and after therapy . Functional improvements were also evaluated . Pain , paravertebral muscle spasm , lordosis angle , the range of neck motion and function were observed to improve significantly in the LPL group , but no improvement was found in the placebo group . LPL seems to be successful in relieving pain and improving function in osteoarthritic diseases The effect of low-level laser therapy ( GaAlAs , 830 nm , continuous ) for chronic myofascial pain in the neck and shoulder girdle was assessed in a double-blind r and omized study with 36 female participants . Treatments were given six times during two weeks with a total effect of 4.5 - 22.5 J per treatment depending on the number of tender points . No significant effect was found , neither in pain relief nor in tablet intake between the laser and the placebo group . None of the participants reported any side-effects This study is design ed to investigate the immediate effectiveness of electrotherapy on myofascial trigger points of upper trapezius muscle . Sixty patients ( 25 males and 35 females ) who had myofascial trigger points in one side of the upper trapezius muscles were studied . The involved upper trapezius muscles were treated with three different methods according to a r and om assignment : group A muscles ( n = 18 ) were given placebo treatment ( control group ) ; group B muscles ( n = 20 ) were treated with electrical nerve stimulation ( ENS ) therapy ; and group C muscles ( n = 22 ) were given electrical muscle stimulation ( EMS ) therapy . The effectiveness of treatment was assessed by conducting three measurements on each muscle before and immediately after treatment : subjective pain intensity [ ( PI ) with a visual analog scale ] , pressure pain threshold [ ( PT ) with algometry ] , and range of motion [ ( ROM ) with a goniometer ] of upper trapezius muscle ( lateral bending of cervical spine to the opposite side ) . When the effectiveness of treatment was compared with that of the placebo group ( group A ) , there was significant improvement in PI and PT in group B ( P < 0.01 ) but not in group C ( P > 0.05 ) . The improvement of ROM was significantly more in group C ( P < 0.01 ) as compared with that in group A or group B. When each group was divided into two additional subgroups based on the initial PI , it was found that ENS could reduce PI and increase PT significantly ( P < 0.05 ) , but did not significantly ( P > 0.05 ) improve ROM , as compared with the placebo group for both subgroups . EMS could significantly ( P < 0.05 ) improve ROM , but not PT , better than the placebo groups , for either subgroup . It could reduce PI significantly more ( P < 0.05 ) than placebo controls only for the subgroup with mild to moderate pain , but not with severe pain . For pain relief , ENS was significantly better ( P < 0.05 ) than EMS ; but for the improvement of ROM , EMS was significantly better ( P < 0.05 ) than ENS . It is concluded that ENS is more effective for immediate relief of myofascial trigger point pain than EMS , and EMS has a better effect on immediate release of muscle tightness than ENS OBJECTIVE To probe into clinical value of comprehensive program of acupuncture , moxibustion and massage as main for treatment of cervical spondylopathy of the nerve root type . METHODS Five centers , single blind , r and omized controlled method were used , 660 cases were divided into a treatment group of 317 cases and a control group of 311 cases . They were treated respectively with comprehensive program of acupuncture , moxibustion and massage as main , and comprehensive program of physical therapy as main . Establish syndrome detection scale and multiply dimensional effect assessment indexes , and evaluate the therapeutic effects and safety . RESULTS The cured rate , the cured-markedly effective rate were 42.9 % , 64.4 % in the treatment group , respectively , better than 16.7 % , 36.3 % in the control group ( P<0.01 ) ; after treatment of 2 weeks , clinical symptoms improved in the both groups , but the treatment group was better than the control group in the improvement degrees of neck-shoulder-limb pain , neck rigidity , abnormality of cervical anteflexion , etc . ( P<0.01 or P<0.05 ) ; the treatment group was shorter than the control group in the time of producing the effect and therapeutic course ( P<0.01 ) . CONCLUSION Comprehensive program of acupuncture , moxibustion and massage as main is safe and effective for treatment of cervical spondylopathy , with a better therapeutic effect compared with the comprehensive program of physical therapy This paper describes PEDro , the Physiotherapy Evidence Data base . PEDro is a web-based data base of r and omized controlled trials and systematic review s in physiotherapy . It can be accessed free of charge at http://ptwww.cchs.usyd.edu.au/pedro . The data base contains bibliographic details and abstract s of most English- language r and omized trials and systematic review s in physiotherapy , and of many trials and review s in other language s. Trials on the data base are rated on the basis of their method ological quality so that users of the data base can quickly identify trials of high quality . Trials and systematic review s are extensively indexed to facilitate search ing . PEDro provides an important information re source to support evidence -based clinical practice OBJECTIVE To investigate the immediate effect of physical therapeutic modalities on myofascial pain in the upper trapezius muscle . DESIGN R and omized controlled trial . SETTING Institutional practice . PATIENTS One hundred nineteen subjects with palpably active myofascial trigger points ( MTrPs ) . INTERVENTION Stage 1 evaluated the immediate effect of ischemic compression , including 2 treatment pressures ( P1 , pain threshold ; P2 , averaged pain threshold and tolerance ) and 3 duration s ( T1 , 30s ; T2 , 60s ; T3 , 90s ) . Stage 2 evaluated 6 therapeutics combinations , including groups B1 ( hot pack plus active range of motion [ ROM ] ) , B2 ( B1 plus ischemic compression ) , B3 ( B2 plus transcutaneous electric nerve stimulation [ TENS ] ) , B4 ( B1 plus stretch with spray ) , B5 ( B4 plus TENS ) , and B6 ( B1 plus interferential current and myofascial release ) . MAIN OUTCOME MEASURES The indexes of changes in pain threshold ( IThC ) , pain tolerance ( IToC ) , visual analog scale ( IVC ) , and ROM ( IRC ) were evaluated for treatment effect . RESULTS In stage 1 , the IThC , IToC , IVC , and IRC were significantly improved in the groups P1T3 , P2T2 , and P2T3 compared with the P1T1 and P1T2 treatments ( P<.05 ) . In stage 2 , groups B3 , B5 , and B6 showed significant improvement in IThC , ItoC , and IVC compared with the B1 group ; groups B4 , B5 , and B6 showed significant improvement in IRC compared with group B1 ( P<.05 ) . CONCLUSIONS Ischemic compression therapy provides alternative treatments using either low pressure ( pain threshold ) and a long duration ( 90s ) or high pressure ( the average of pain threshold and pain tolerance ) and short duration ( 30s ) for immediate pain relief and MTrP sensitivity suppression . Results suggest that therapeutic combinations such as hot pack plus active ROM and stretch with spray , hot pack plus active ROM and stretch with spray as well as TENS , and hot pack plus active ROM and interferential current as well as myofascial release technique , are most effective for easing MTrP pain and increasing cervical ROM Cl aims have been made that local heat is particularly useful in treating  osteoarthritis pain .  This r and omised trial evaluates the short term efficacy of local heat , on the pain caused by cervical osteoarthrosis . Two treatment groups were compared , one receiving mock TNS and the other heat from an infra-red gun ( the IRS Medtec 100 ) . Both the placebo and treatment groups received treatment on local tender trigger points . Each patient received four treatments . Pain was assessed before entry into the trial and after the completion of treatment ; the parameters used for assessing pain were , analgesic intake , sleep disturbance due to pain and subjective pain score .  Twenty-six patients were entered into the trial , twenty-five completed treatment . In the group receiving treatment from the infra-red gun ( IRS Medtec 100 ) 75 % obtained significant pain relief . In the group receiving mock TNS 31 % obtained significant pain relief . A chi-squared test comparing these two groups give a P value of 0.07 OBJECTIVE To evaluate the effectiveness of acupuncture , as compared with physiotherapy , in the management of  chronic neck pain .  DESIGN Seventy adult patients with non-inflammatory neck pain of > 6 weeks duration and with no abnormal neurology were r and omly assigned to receive either of the treatments . Thirty-five patients were included in each group . OUTCOME MEASURES Pain by visual analogue scale and neck pain question naire , improvement in range of movement of neck relative to baseline , and well-being ( general health question naire ) . Measurements were recorded at the start of treatment , at 6 weeks and at 6 months . RESULTS Both treatment groups improved in all criteria . Acupuncture was slightly more effective in patients who had higher baseline pain scores . CONCLUSIONS Both acupuncture and physiotherapy are effective forms of treatment . Since an untreated control group was not part of the study design , the magnitude of this improvement can not be quantified ZusammenfassungDie Peitschenschlagverletzung der Halswirbelsäule ist i m klinischen Alltag ein häufiges Verletzungsbild . Die verschiedenen zur Anwendung gebrachten Therapiekonzepte bringen in den meisten Fällen die Beschwerden in kurzer Zeit zum Abklingen , können jedoch nicht verhindern , dass es bei einigen Prozent der Verletzten zu chronischen Krankheiten führt . In dieser prospektiv r and omisierten placebokontrollierten Einfachblindstudie wurde die Wirkung einer adjuvanten Laserakupunkturbeh and lung auf die akuten Beschwerden sowie das Ergebnis 1 Jahr nach der Verletzung untersucht . Die Patienten der Gruppe 1 ( Laserakupunkturgruppe , n = 23 ) wurden mit Laserakupunktur ( 5 mW HeNe Laser auf 22 Akupunkturpunkte für je 15s ) sowie Schanzkrawatten und einer Kombination aus Paracetamol und dem Myotonolytikum Chlormezanon beh and elt , während in der Gruppe 2 ( n = 22 ) bei gleichem Beh and lungsschema ein Placebo-Laser zur Anwendung kam . Die Beh and lung wurde 3-mal pro Woche bis zur Beschwerdefreiheit durchgeführt . Es zeigte sich weder in der Akutphase i m Hinblick auf die Beweglichkeit in allen 3 Ebenen , die Dauer der Schmerzen und die Tragedauer der Schanzkrawatte sowie die Medikamenteneinnahme noch in der Inzidenz von chronisch rezidivierenden Beschwerden wie myofasciale Schmerzen , Cephalea , Vertigo und Tinnitus Vorteile der Laserakupunkturbeh and lung . CONCLUSION : Bei der Peitschenschlagverletzung erscheint eine adjuvante Laserakupunkturtherapie mit einem 5 mW HeNe Laser und einer Bestrahlungszeit von 15s wirkungslos . Summary Following introduction of the compulsory use of seat belts in cars , whiplash injuries of the cervical spine have become common in everyday practice . Current treatment approaches lead to resolution of the symptoms within a short time in most cases but can not prevent a small proportion of patients developing persistent health problems . The effects of adjuvant treatment with laser acupuncture on the acute symptoms and the results one year after the injury were studied in this prospect i ve , r and omized , placebo-controlled single-blind study . One group of patients ( n = 23 ) were treated with laser acupuncture ( 5 mW HeNe laser on 22 acupuncture points for 15 s each ) plus cervical collar and a combination of paracetamol and chlormezanone ; a second group ( n = 22 ) received the same treatments but with the use of a placebo laser . The treatment was given three times per week until the patient was asymptomatic . No statistically significant advantage of the laser acupuncture treatment was found in the acute phase ( mobility in all three planes , duration of pain and duration of use of a cervical collar ) or the chronic phase ( drug use and the incidences of chronic recurrent problems such as myofascial pain , headaches , vertigo and tinnitus ) . CONCLUSION : Adjuvant laser acupuncture with a 5 mW HeNe laser and an irradiation time of 15 s appears to be ineffective in the management of whiplash injuries Manual therapy is often used with exercise to treat neck pain . This cervical overview group systematic review up date 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 search es were performed to July 2009 . Two or more authors independently selected studies , abstract ed data , and assessed method ological quality . Pooled relative risk ( pRR ) and st and ardized mean differences ( pSMD ) were calculated . Of 17 r and omized controlled trials included , 29 % had a low risk of bias . Low quality evidence suggests clinical ly 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 traditional care for acute whiplash . Evidence regarding radiculopathy was sparse . Specific research recommendations are made In a controlled , cross-over study the effect of low level laser therapy ( LLLT ) was evaluated . During a five weeks period forty-seven female laboratory technicians received six laser and six placebo treatments to tender points in the neck and shoulder girdle . Subjects rated the placebo treatment significantly more beneficial than LLLT ( p = .04 ) . There was no reduction in consumption of analgesics associated with either laser or placebo treatment . The results indicate no beneficial effect of LLLT for myofascial pain The British Association of Physical Medicine is planning to Though fulfilling these criteria the follo carry out a series of multicentre trials of physical treatments . excluded from the trial : The present paper is a report of the first trial , which was devoted 1 . Patients in whom the symptoms were to the conservative management of pain in tle upper limb to local lesions such as cervicalrib , rotate believed to arise within the neck . This syndrome was chosen shoulder , tennis-elbow  , or a  carpal-tunnel sy ] because it is very common and often treated by physical 2 . Patients who had definitive disorders methods , though with little evidence of their value . Furthersuch asrheumatoid arthritis or Paget 's di , more , it has been the subject of a preliminary -studf ( Steinberg bony injury to the cervical spine in the prec and Mason , 1959 ) . 3 . Patients with abnormal neurological s An advisory committee1 was set up to plan the trial , and nine compression . London hospitals ' agreed to take part . 4 . Patients currently being treated phenylbutazone Thirty patients with cervical spine pain syndromes persisting a mean of 8 years were assigned r and omly into equal treatment and control groups . After 12 weeks , 12 of 15 ( 80 % ) of the treated group felt improved , some dramatically , with a mean 40 % reduction of pain score , 54 % reduction of pain pills , 68 % reduction of pain hours per day and 32 % less limitation of activity . Two of 15 ( 13 % ) of the control group reported slight improvement after 12.8 weeks . The control group had a mean 2 % worsening of the pain score , 10 % reduction in pain pills , no lessening of pain hours and 12 % less limitation of activity Objective : To investigate the effect of transcutaneous electrical nerve stimulation ( TENS ) on acupuncture points and neck exercise in chronic neck pain patients . Design : A r and omized clinical trial . Setting : Hospital-based practice . Subjects : Two hundred and eighteen patients with chronic neck pain . Interventions : Subjects were r and omized into three groups , receiving either ( 1 ) TENS over the acupuncture points plus infrared irradiation ( TENS group ) ; ( 2 ) exercise training plus infrared irradiation ( exercise group ) ; or ( 3 ) infrared irradiation alone ( control ) ; twice a week for six weeks . Outcome measures : The values of verbal numeric pain scale , Northwick Park Neck Pain Question naire , and isometric neck muscle strength were assessed before , at the end of the six-week treatment , and at the six-month follow-up . Results : Results demonstrated that after the six-week treatment , significant improvement in the verbal numerical pain scale was found only in the TENS group ( 0.60±2.54 , p=0.027 ) and the exercise group ( 1.57±2.67 , p<0.001 ) . Though significant reduction in Northwick Park Neck Pain Question naire score was found in all three groups , post-hoc tests showed that both the TENS and the exercise group produced better improvement ( 0.38±0.60 % and 0.39±0.62 % respectively ) than the control group ( 0.23±0.63 % ) . Significant improvement ( p = < 0.001 to 0.03 ) in neck muscle strength was observed in all three groups , however , the improvement in the control group was not clinical ly significant and it could not be maintained at the six-month follow-up . Conclusions : After the six-week treatment , patients in the TENS and exercise group had a better and clinical ly relevant improvement in disability , isometric neck muscle strength , and pain . All the improvements in the intervention groups were maintained at the six-month follow-up PURPOSE To determine whether the isolated intervention of high-velocity , low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache . DESIGN R and omized controlled trial with a blind observer . SETTING Ambulatory outpatient facility in an independent NHS-funded chiropractic research institution . PARTICIPANTS Thirty-nine subjects suffering from frequent headaches who fulfilled the IHS criteria for cervicogenic headache ( excluding radiological criteria ) . These subjects were recruited from among some 400 headache sufferers who responded to newspaper advertisements . INTERVENTION Half of the group received high-velocity , low-amplitude cervical manipulation twice/wk for 3 wk . The other half received low-level laser in the upper cervical region and deep friction massage ( including trigger points ) in the lower cervical/upper thoracic region , also twice/wk for 3 wk . MAIN OUTCOME MEASURE The change from week 2 to week 6 in analgesics use per day , headache intensity per episode and number of headache hr per day . RESULTS Despite a significant reduction in the manipulation group on all three outcome measures , differences between the two treatment groups failed to reach statistical significance . CONCLUSION The results suggest a possible effect of manipulation on cervicogenic headache , but because of method ological problems , such an effect could not be unequivocally demonstrated The CONSORT statement is used worldwide to improve the reporting of r and omised controlled trials . Kenneth Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . To encourage dissemination of the CONSORT 2010 Statement , this article is freely accessible on bmj.com and will also be published in the Lancet , Obstetrics and Gynecology , PLoS Medicine , Annals of Internal Medicine , Open Medicine , Journal of Clinical Epidemiology , BMC Medicine , and Trials
INTRODUCTION Neck pain is common , can be disabling and is costly to society .
Physical modalities are often included in neck rehabilitation programs .
Interventions may include thermal , electrotherapy , ultrasound , mechanical traction , laser and acupuncture .
Definitive knowledge regarding optimal modalities and dosage for neck pain management is limited .
PURPOSE To systematic ally review existing literature to establish the evidence -base for recommendations on physical modalities for acute to chronic neck pain .