PT Crab 🦀 Issue 163 - Best of Neck

As we roll into the New Year I’m continuing the run of “Best Ofs” from the last three years of PT Crab coverage. There’s more than 500 article summaries to choose from and we’ve covered necks quite a bit, I had a lot to choose from in this edition. You’d think with all this knowledge, I wouldn’t have chronic neck pain. But you’d think wrong. Still, it’s improving. And I’m going to start PT for it myself soon too.

Like I said last week, I’m currently building out content schedules for the next few months, so if you have a topic you like, do send me an email and let me know. You can always reach me at Luke@PTCrab.org with ideas or interests. I’m also attaching a survey to each of these issues so I can learn more about my audience. Please do fill it out if you can! It would be exceedingly helpful for me.

If you want to help with the survey (please do! It's really short) you can find it here.

With that, necks.

Add Education to Neck PT. Please.

The Gist - Before we dive into this one, I just want to let you know that the first author was named L. López-López, which is an awesome name. Now, we talk paper.

This was an RCT designed to figure out if adding a self-management program to standard chronic neck pain PT was helpful across a variety of outcome measures. Patients in both groups “underwent a physical therapy program aimed at improving soft tissue and joint function, postural control, coordination and movement patterns, and decreasing any restrictions in movement at single or multiple segmental levels in the cervical spine. The sessions included muscular mobilization techniques, specific stretching, articular mobilization, and coordination and stabilization techniques.” But only the experimental group also received an educational program that emphasized self-management via lots of information (details below in Tell Me More).

At baseline and immediately after four weeks of PT, there were no significant differences between the two groups. They moved apart at 3 months, where the self-managed patients improved on every outcome measure including pain, NDI, fear avoidance, and catastrophizing. Quite impressive.

Tell Me More - They don’t share the full details of the self-management program, but they do give details on the contents of what patients were given. Here it is in brief:

The self-management intervention was aimed to give more control to patients that should be responsible for the daily self-management of their chronic neck pain.
The program contents were educational information, symptom management, problem- solving, dealing with the emotions of chronic illness (e.g., stress and depression), relaxation exercise, use of medication, healthy lifestyles, and communication skills (with friends, family, and health care providers). Educational information included the application of local heat/cold, sleeping face down, using a correct sitting posture, alternating body position, and using a correct lifting technique, which were complemented by a problem-based session.

Basically, a lot of information about how to control their neck pain. And if you, as a PT or student are like “well that’s obvious, I always tell my patients those things,” stop. That may be true, but this study specifically discusses telling them in an organized way and helping the patients use them. As someone who has been treated by multiple PTs for a lot of neck pain, I’ve never been offered information like that. Maybe consider adding more education to your process, especially in a standardized way.

Paper? Right here y’all.

Craniocervical Flexion vs. Other Exercises. It’s a draw.

The Gist - This systematic review and meta-analysis looked into two methods to go after non-specific neck pain, craniocervical flexion exercise (AKA deep neck flexor exercise) and other, non-specific exercise. The point was to compare both types to no treatment and to each other to determine which is a better way to take out neck pain. And if you read the headline here, you won’t be surprised to learn that it was a draw. They found 16 articles for a qualitative synthesis and 9 for a quantitative one. 11 of the 16 used the same low-load craniocervical flexion protocol from a Jull study from 2004that is unfortunately from a book chapter so it’s hard to access online. But from reading through the other studies that used the protocol, it seems that people were taught to do craniocervical flexion and than taken through a 6 week process where they progressed it through different ranges of pressure and neck flexion using one of those Chattanooga stabilization air bladder thingies(tm).

To go back to our study, “regardless of the type of active exercise adopted to treat neck pain, it seems that the CCF protocol offers results comparable with other exercise protocols. These protocols involve high- load exercises (head lift exercise in the supine position) and generic progressive resistance exercise programs for the neck muscles performed on a daily or weekly basis for a duration of 4 to 12 consecutive weeks.”

The researchers say that this is good because it allows for a shared decision-making process with patients to find what types of exercises they believe will work best.

Tell Me More - Let’s dig into the exercise protocol a bit more. Using a description from this Gallego Izquierdo paper from the Journal of Rehabilitation Medicine in 2016, we can get the details of what they did. It was a low load training protocol that taught the CCF movement in supine with the head and neck in neutral via a gentle nod while ensuring SCM and anterior scalenes were turned off. Once they figured out the motion, patients held progressively increasing pressures against the neck Stabilizer over the course of six weeks. They didn’t use the stabilizer at home, but attempted to replicate the pressure they were using there instead, then got checked on twice per week at a PT clinic.

Since the results in this paper were a bit muddled, the authors went on to discuss further research in this area to help elucidate things further. One of those papers showed that motor control exercises for the neck are helpful, but not more helpful than other active exercises, like general strengthening, yoga, and Pilates. Overall, we don’t yet have evidence to show that anything is especially helpful for non-specific neck pain, we just know that pretty much everything helps, but it doesn’t help a ton. So, yay? I guess? We need more work on this.

Paper? Yupp.

The big ultrasound review.

The Gist - Researchers publishing in the Archives of PM&R (Impact Factor 3.996 if you believe in that stuff) recently popped out a big review of ultrasound’s effects on neck pain and would you believe that we’re still not sure? Ultrasound wasn’t in the most recent (2017) CPGs for treating neck pain, likely because we don’t have a lot of systematic reviews about its effect. Well here’s one more and this one was mostly positive actually.

They included 12 studies with 705 participants that looked at patients with active trigger points in the neck, shoulder, trapezius muscle, and upper trapezius muscle (which, I know, are all in the neck and shoulder, but that’s what the paper says, okay?). 10 studies used continuous ultrasound, three used pulsed, meaning that one study used both (if you already figured that out, yay algebra!). They used intensities from 0.5W/cm to 3W/cm and multiple megahertz. Yay for heterogeneity. 7 of the studies compared ultrasound to something else while 5 compared it to sham ultrasound or no treatment.

Quick results here, more further on

Versus “other treatments”:

• Pain at rest: No effect due to inconsistency.
• Pain during movement: -0.49 difference on 0-10 scale
• Disability: Significant in one study, not another
• Quality of Life: Unknown due to heterogeneity

Versus sham or no treatment:

• Pain at rest: -1.6 to -1.9 on a 0-10 scale
• Pain during movement: -2.53 on 0-10 scale

Tell Me More - I’ve already run pretty long on this, so I don’t have too much more to say. Overall, like many systematic reviews, this one says that even though they had 12 RCTs to work with, the testing was too heterogenous and low quality to put a lot of power behind the results. Everything above was a result from just two or three of the twelve studies, not great on each metric. And if you’ve read other reviews and said “wait, this seems inconsistent with those.” First, good for you for noticing, and second, you’re right. The authors address that and say that it is likely down to the exclusion criteria they worked with. But read the whole paper for details.

Whole paper? Whole paper.

Is it migraine? Is it neck pain? Is it both?

The Gist - How can you tell if neck pain is a symptom of migraine or just independent neck pain? The study at the top of this edition told us that we should be treating migraine-associated neck pain anyway, but it can be useful to figure out if the migraine is coming from the neck pain or not. Some people, like the British Association for the Study of Headaches, think we should only be treating neck pain if it’s independent of migraine, so there is some controversy out there. These researchers put together a large systematic review and meta analysis to find out if we can find out whether neck pain is independent of migraine attacks or if it’s associated.

They looked into 20 different cervical/cervicocranial muscle tests to figure out which could say whether pain is associated with migraine. In total, they looked at 35 studies in the qualitative synthesis and 18 in the quantitative one with a total of 1,371 participants. After that, they describe each test and how sensitive it was, but I’m just going to go through the winners.

7 tests were able to detect musculoskeletal impairments in people with migraine. These were: cervical ROM, cervical extension weakness, flexion-rotation test, and pain pressure thresholds at the temporalis, SCM, and UT muscles. Forward head position was significant in standing, but not sitting. There wasn’t sufficient evidence to demonstrate that joint position error, manual joint palpation, deep neck flexor endurance, or the craniocervical flexion test could differentiate between people with migraine and controls.

Tell Me More - The overall point of this paper is to give us a good bundle of cervical tests that could be positive in people with migraine, demonstrating that they have cervical problems in addition to migraine attacks. People who don’t have these deficits “might benefit from general exercises or relaxation as nonpharmacological strategies to compliment pharmacological management,” but not necessarily cervical exercises, according to the paper.

What we still don’t know, or at least largely don’t know, is if treating these cervical impairments will decrease the number of migraine attacks. They’ll probably improve cervical pain and irritation, but outside of a few specific types of migraine (like the one that responded to dry needling, above) we don’t really know what the connection between specific exercise and migraine attack is. We do know that general exercise is very good for migraine and that vestibular therapy is often helpful as well, at least to treat the symptoms thereof, but we don’t yet have a lot of data about what exactly to do for migraine. This paper concludes that “assumptions to a specific musculoskeletal therapy in patients with migraine should be part of future research,” and I agree.

Paper? Right here.

That’s the week! Thanks for coming along to learn more about necks and I hope your New Year is progressing well.

Bye!