musculoskeletal therapies for neck pain in primary care ... · pulsed shortwave diathermy (with...

Arthritis Research UKNational Primary Care Centre

Winner of a Queen’s Anniversary Prize

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

Arthritis Research Campaign

National Primary Care Centre

Keele University

Arthritis Research UK National Primary Care Centre

Winner of a Queen’s Anniversary Prize 2009

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



Keele University



Trial

Research

FindingsResearch

Publication

Dissemination

Research

Question

Ask an important question

User

Involvement



Keele University



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

User

Involvement



Keele University



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

User

Involvement



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MANAGEMENT OF NECK PAIN IN

PRIMARY CARE

Hands on (Series 6) No 8: Spring 2011

Arthritis Research UK Primary Care Centre

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

musculoskeletal therapies for neck pain in primary care ... · pulsed shortwave diathermy (with...

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