musculoskeletal therapies for neck pain in primary care ... · pulsed shortwave diathermy (with...
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Arthritis Research UKNational Primary Care Centre
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For Higher and Further Education 2009
Musculoskeletal therapies
Krysia DziedzicArthritis Research UK Professor of Musculoskeletal Therapies
for neck pain in primary care:from park bench to bedside
Primary Care management of
musculoskeletal conditions
l Common cause of
chronic pain and
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chronic pain and
disability in primary
care
From Park Bench……….
Annual incidence of
consultations in primary care (per 10,000 population)
250
300
350
400Females
Males
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0
50
100
150
200
RA OA LBP Regional pain
Research activity
l Clinical trials
− High numbers of
patients recruited
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patients recruited
− Publications ++++
Evidence based clinical
practice
l Community
rheumatology
General Practitioners
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l General Practitioners
& Community
Pharmacists
l Physiotherapists
l Occupational
Therapists ……….……….To Bedside
Research
Question
User
Involvement
Develop
protocol
Clinical
Trial
Implementation
Knowledge
translation
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Trial
Research
FindingsResearch
Publication
Dissemination
Research
Question
Ask an important question
User
Involvement
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l Workshops for physiotherapists
− 1998
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Sim et al 1999 J Eval Clin Pract. 1999 5(4):437-41.
Neck painl Neck pain is common
and disabling
l Neck pain is frequently managed
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frequently managed with physical approaches
Treatment options include:
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To determine whether manual therapy (with advice and exercise)
or
Purpose
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Pulsed Shortwave Diathermy (with advice and exercise)
are better than advice and exercise alone in the treatment of non-specific neck
disorders
Primary objectiveto compare at 6 months the effect of adding:
1. Manual Therapy
2. PSWD
Aim of the study
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to Advice and Exercise alone
Secondary objectives• to compare clinical outcomes at 6 weeks
• to compare cost consequences at 6 months
Develop
protocol Population
Intervention
Comparator
User
Involvement
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Comparator
Outcome
A PRAGMATIC APPROACH:
in primary care
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Protocol developers
Population
l Inclusion− 18 years and over
− Clinical diagnosis neck pain and/or stiffness (including unilateral arm pain)
− Referred from primary care to physiotherapy
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− Referred from primary care to physiotherapy
− No treatment previous 6 months
l Exclusion− ‘Red flags’
− Serious pathology, inflammatory arthritis, progressive neurological signs, contraindication to treatment, injury awaiting claim, pregnancy
Intervention
All patients received:• home exercise sheet
• one to one advice on managing
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• one to one advice on managing
their neck problem
• an information leaflet to take home
Interventions & Comparator
+ +
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+ +
Outcome
l Primary outcome measure• Northwick Park Neck Pain Questionnaire
• pain disability measure (Leak et al, 1994)
• 9 Questions 100-point scale
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Clinical
Trial
“Is this
treatment
helpful on
average
for a wide
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Trial
for a wide
range of
patients?”
The effectiveness of manual therapy or pulsed short-wave diathermy in addition to exercise and advice for neck disorders; a pragmatic RCT in physiotherapy clinics.
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pragmatic RCT in physiotherapy clinics.
1999-2002
Physiotherapy centres
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User
Involvement
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Research
Findings
Results
l 735 patients were screened
l Target recruitment 350 in 22 months
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l Mean age 51 years
l 63% Female
Ad
juste
d m
ea
n N
ort
hw
ick P
ark
sco
re
40
38
36
34
32
30
Adjusted scores
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6 months6 weeksBaseline
Ad
juste
d m
ea
n N
ort
hw
ick P
ark
sco
re
28
26
24
22
20
Treatment
MT
PSWD
A&E
Summary of results
l No differences in primary outcome at 6 m
l Patient satisfaction was in favour of MT
l Treatment course was shorter in the advice and exercise group
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advice and exercise group
l 350 patients randomised, 15 centres, 70 physiotherapists
− 92% f/u at 6 months
− 98% received their allocated treatment
Conclusion
The addition of manual therapy or PSWD to exercise and advice alone does not provide any better clinical improvement in
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provide any better clinical improvement in the physiotherapy treatment of non-specific neck disorders
User
Involvement
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Research
Publication
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Sensitivity to Change and Internal Consistency of the Northwick Park
Neck Pain Questionnaire and Derivation of a Minimal Clinically
Important Difference.
Clinical Journal of Pain. 22(9):820-826, November/December 2006.
Sim, Julius PhD; Jordan, Kelvin PhD; Lewis, Martyn PhD; Hill, Jonathan
MSc; Hay, Elaine M. MD; Dziedzic, Krysia PhD
Predictors of Poor Outcome in Patients With Neck Pain Treated by
Physical Therapy.
Clinical Journal of Pain. 23(8):683-690, October 2007.
Hill, Jonathan C. MSc; Lewis, Martyn PhD; Sim, Julius PhD; Hay, Elaine M.
MD; Dziedzic, Krysia PhD
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Rheumatology (Oxford). 2007
Nov;46(11):1701-8.
An economic evaluation of three
physiotherapy treatments for non-specific
neck disorders alongside a randomized trial.
Lewis M, James M, Stokes E, Hill J, Sim J,
Hay E, Dziedzic K.
Lewis M, Morley S, van der Windt DA, Hay E, Jellema P, Dziedzic K, Main
CJ. Measuring practitioner/therapist effects in randomised trials of low back
pain and neck pain interventions in primary care settings. Eur J Pain. 2010
Nov;14(10):1033-9. Epub 2010 May 4. PubMed PMID: 20444631.
Schellingerhout JM, Heymans MW, Verhagen AP, Lewis M, de Vet HC, Koes
BW. Prognosis of patients with nonspecific neck pain: development and
external validation of a prediction rule for persistence of complaints. Spine
(Phila Pa 1976). 2010 Aug 1;35(17):E827-35. PubMed PMID: 20628331.
Verhagen AP, Lewis M, Schellingerhout JM, Heymans MW, Dziedzic K, de
Vet HC, Koes BW. Do whiplash patients differ from other patients with non-
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Vet HC, Koes BW. Do whiplash patients differ from other patients with non-
specific neck pain regarding pain, function or prognosis? Man Ther. 2011 Mar
13. [Epub ahead of print] PubMed PMID: 21406332.
Whitehurst DG, Bryan S. Another Study Showing that Two Preference-Based
Measures of Health-Related Quality of Life (EQ-5D and SF-6D) are not
Interchangeable. But why Should we Expect Them to be? Value Health. 2011
Feb 9. [Epub ahead of print]
Verhagen et al, 2011 Man Therapy
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Average function (0-100)
And another trial…..
Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck
stabilization exercises or a general neck exercise program for chronic neck
disorders: a randomized controlled trial. J Rheumatol. 2009;36(2):390-7.
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PRF
User
Involvement
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Dissemination
Physiotherapy arc
neck trial, hands on
or electrotherapy
research
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We found that:
· on average there was no additional benefit of adding manual therapy or pulsed shortwave
diathermy to the package of advice and exercise.
· at 6 weeks the group receiving manual
What works for neck problems?
PANTHER study results
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· at 6 weeks the group receiving manual therapy with advice and exercise were more
satisfied with their physiotherapy compared with
those who had advice and exercise on its own.
· on average patients receiving advice and
exercise with no further addition to treatment
tended to have fewer treatment sessions than the
other two approaches.
“In an attempt to find out what really works, British physiotherapists conducted a rigorous clinical trial……. These findings
are important. They show that the best options for neck pain are fairly simple and
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inexpensive.”
Professor Ernst The Guardian 9th August 2005
Implementation User
Involvement
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Manual therapy (manipulation, mobilisation) plus advice plus
exercise versus pulsed short wave diathermy plus advice plus
exercise versus advice plus exercise alone:
One subsequent pragmatic multicentre RCT (350 people with chronic neck pain)
assessed whether the addition of manual therapy (hands on, passive or active
assisted movements, mobilisations, or manipulations; 63% had mobilisation
physiotherapy) or pulsed short wave diathermy over 6 weeks to advice plus
exercise was more effective than advice plus exercise alone. [26] The primary
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exercise was more effective than advice plus exercise alone. [26] The primary
outcome measure was pain as measured by the Northwick Park Neck Pain
Questionnaire. The RCT found no significant difference in pain between adding
manual therapy to advice plus exercise and advice plus exercise alone at 6 weeks
or 6 months (6 months, difference in mean Northwick Park change scores: + 1.4,
95% CI –2.8 to + 5.5). [26] It also found no significant difference in pain between
adding pulsed short wave diathermy to advice plus exercise and advice plus
exercise alone at 6 weeks or 6 months (6 months, difference in mean Northwick
Park change scores: + 1.3, 95% –2.9 to + 5.5). [26]
Binder N. Neck Pain. BMJ Clinical Evidence 2006;11:1103
Systematic review
Manual therapy with or without physical medicine
modalities for neck pain: a systematic review
Jonathan D’Sylva, Jordan Miller, Anita Gross, et al and
for the Cervical Overview Group.
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Best Evidence on Assessment and Intervention for Neck Pain
Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint
Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders
Eric L. Hurwitz, 1 Eugene J. Carragee,2,3 Gabrielle van der Velde,4,5,6,7 Linda J. Carroll,8
Margareta Nordin,9,10 Jaime Guzman,11,12 Paul M. Peloso,13 Lena W. Holm,14 Pierre
Côté,5,6,7,15 Sheilah Hogg-Johnson,5,16 J. David Cassidy,6,7,15 and Scott Haldeman17,18
Neck Pain Task Force
l Grade I:
l Grade II:
Grade III:
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l Grade III:
l Grade IV:
Grade I
l Neck pain with no signs or symptoms of major structural pathology and no or little interference with daily activities; will
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little interference with daily activities; will likely respond to minimal intervention such as reassurance and pain control; does not require investigations or ongoing treatment
Grade II
l Grade II: Neck pain with no signs or symptoms of major structural pathology but interference with usual daily
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but interference with usual daily activities; requires pain relief and early intervention aimed at preventing long-term disability
Grade III
l Neck pain with no signs or symptoms of major abnormality structural pathology, but presence of neurological signs such
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but presence of neurological signs such as decreased reflexes, weakness or sensory deficit; might require investigation and, occasionally more invasive treatments
Grade IV
l Neck pain with signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or
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fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment
Knowledge
translation
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MANAGEMENT OF NECK PAIN IN
PRIMARY CARE
Hands on (Series 6) No 8: Spring 2011
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Krysia Dziedzic, Carol Doyle, Lucy Huckfield,
Treena Larkin, Kay Stevenson, Panos Sargiovannis,
Nadia Corp, Nadine Foster
Core treatment recommendations for non-specific neck pain
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Core treatment recommendations for non-specific neck pain
Exercises, manual therapy, analgesics, acupuncture, and low-level laser
therapy have been shown to provide some degree of short-term relief of
neck pain without trauma.
Manual therapy is often used with exercise to treat neck pain for pain
reduction and improved quality of life.
Exercises and mobilization have been shown to provide some degree of
short-term relief after a motor vehicle collision.
Injection
Assess for red flags
First line pain relief
Manual
therapy and exercise
Referral to
Secondary care
General
exercisesLaser
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Injection
therapy
First line pain relief
Advice to remain active
Posture and seating
Address psychosocial factors
Patient information and
exercise sheet
Surgery
Pain management and
cognitive behavioural therapy
Acupuncture
Local Agencies
e.g. exercise in the community
Ergonomics
Research
Question
User
Involvement
Develop
protocol
Clinical
Trial
Implementation
Knowledge
translation
1997
From Park Bench to Bedside
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Trial
Research
FindingsResearch
Publication
Dissemination
2011
Comparison with OA & LBP
l OA− NICE OA guidelines
− support for self management
− access to information, exercise, weight loss
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− access to information, exercise, weight loss
− first line analgesia
l LBP− NICE LBP guidelines
− advice, exercise
− acupuncture, manual therapy, exercises
Acknowledgements
l Primary Care Musculoskeletal Research Centre
l Study participants
General practices
Physiotherapists
Therapy managers
User Group Forum
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l General practices User Group Forum
General practitioners
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