title: Randomized controlled trial of exercise for chronic whiplash-associated disorders Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. The effectiveness of isometric exercises as compared to general exercises in the management of chronic non-specific neck pain. 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. Job stress management and ergonomic intervention for work-related upper extremity symptoms. Manual Therapy, Exercise, and Traction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial 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 Strength training and stretching versus stretching only in the treatment of patients with chronic neck pain: a randomized one-year follow-up study Effectiveness of Home-Based Cupping Massage Compared to Progressive Muscle Relaxation in Patients with Chronic Neck Pain—A Randomized Controlled Trial Upper trapezius relaxation induced by TENS and interferential current in computer users with chronic nonspecific neck discomfort: An electromyographic analysis. Does an Exercise Intervention Improving Aerobic Capacity Among Construction Workers Also Improve Musculoskeletal Pain, Work Ability, Productivity, Perceived Physical Exertion, and Sick Leave?: A Randomized Controlled Trial Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Development of motor system dysfunction following whiplash injury Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial. Developing and evaluating communication strategies to support informed decisions and practice based on evidence (DECIDE): protocol and preliminary results Primary care randomized clinical trial: manual therapy effectiveness in comparison with TENS in patients with neck pain. Randomized clinical trial assessing whether additional massage treatments for chronic neck pain improve 12- and 26-week outcomes. Comparative short-term effects of two thoracic spinal manipulation techniques in subjects with chronic mechanical neck pain: a randomized controlled trial. The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain: A Randomized Clinical Trial Effect of Training Supervision on Effectiveness of Strength Training for Reducing Neck/Shoulder Pain and Headache in Office Workers: Cluster Randomized Controlled Trial Lasting Effects of Workplace Strength Training for Neck/Shoulder/Arm Pain among Laboratory Technicians: Natural Experiment with 3-Year Follow-Up Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report The role of fear of movement in subacute whiplash-associated disorders grades I and II Short-Term Usual Chiropractic Care for Spinal Pain: A Randomized Controlled Trial High power laser therapy treatment compared to simple segmental physical rehabilitation in whiplash injuries (1° and 2° grade of the Quebec Task Force classification) involving muscles and ligaments. Self-management of persistent neck pain: a randomized controlled trial of a multi-component group intervention in primary health care. A Randomized Trial Comparing Acupuncture and Simulated Acupuncture for Subacute and Chronic Whiplash Are Work Disability Prevention Interventions Effective for the Management of Neck Pain or Upper Extremity Disorders? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration The Effect of Neck-specific Exercise With, or Without a Behavioral Approach, on Pain, Disability, and Self-Efficacy in Chronic Whiplash-associated Disorders Education of Patients After Whiplash Injury: Is Oral Advice Any Better Than a Pamphlet? Time-Wise Change in Neck Pain in Response to Rehabilitation with Specific Resistance Training: Implications for Exercise Prescription Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial α-Lipoic Acid and Superoxide Dismutase in the Management of Chronic Neck Pain: A Prospective Randomized Study Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. Effects of the Workplace Health Promotion Activities Soccer and Zumba on Muscle Pain, Work Ability and Perceived Physical Exertion among Female Hospital Employees Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial Randomized Controlled Trial of Workplace-based Rehabilitation for Work-related Rotator Cuff Disorder The effect of gallium arsenide aluminum laser therapy in the management of cervical myofascial pain syndrome: a double blind, placebo-controlled study Does training frequency and supervision affect compliance, performance and muscular health? A cluster randomized controlled trial. Spinal manipulative therapy and exercise for seniors with chronic neck pain. Influence of frequency and duration of strength training for effective management of neck and shoulder pain: a randomised controlled trial Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial No difference between postural exercises and strength and fitness exercises for early, non-specific, work-related upper limb disorders in visual display unit workers: a randomised trial. Randomized Trial of Therapeutic Massage for Chronic Neck Pain Implementation of specific strength training among industrial laboratory technicians: long-term effects on back, neck and upper extremity pain Implementation of neck/shoulder exercises for pain relief among industrial workers: A randomized controlled trial Effects of software programs stimulating regular breaks and exercises on work-related neck and upper-limb disorders. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study Influence of Self-Efficacy on Compliance to Workplace Exercise Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash? – A preliminary RCT The Treatment of Neck and Low Back Pain: Who Seeks Care? Who Goes Where? Qigong and exercise therapy for elderly patients with chronic neck pain (QIBANE): a randomized controlled study. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: Randomised controlled trial Effects of an exercise programme on preventing neck pain among office workers: a 12-month cluster-randomised controlled trial A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in northern Sweden. Microwave diathermy for treating nonspecific chronic neck pain: a randomized controlled trial. Effects of neck coordination exercise on sensorimotor function in chronic neck pain: a randomized controlled trial. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. Role of manual therapy with exercise regime versus exercise regime alone in the management of non-specific chronic neck pain. The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Coping and Recovery in Whiplash-associated Disorders: Early use of Passive Coping Strategies is Associated With Slower Recovery of Neck Pain and Pain-related Disability Effectiveness of participatory training for prevention of musculoskeletal disorders: a randomized controlled trial Supervised Exercise With and Without Spinal Manipulation Performs Similarly and Better Than Home Exercise for Chronic Neck Pain: A Randomized Controlled Trial Effects of Feldenkrais method on chronic neck/scapular pain in people with visual impairment: a randomized controlled trial with one-year follow-up. The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire Multimodal treatment program comparing 2 different traction approaches for patients with discogenic cervical radiculopathy: a randomized controlled trial. Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial Effect of strength training in addition to general exercise in the rehabilitation of patients with non-specific neck pain. A randomized clinical trial. Dose-Response of Strengthening Exercise for Treatment of Severe Neck Pain in Women Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain. Effectiveness of jyoti meditation for patients with chronic neck pain and psychological distress--a randomized controlled clinical trial. Simple educational intervention to improve the recovery from acute whiplash: results of a randomized, controlled trial. Effect of high-intensity laser therapy in the management of myofascial pain syndrome of the trapezius: a double-blind, placebo-controlled study Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments Dry-needling and exercise for chronic whiplash-associated disorders: a randomized single-blind placebo-controlled trial A randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial). Effectiveness of Specific Neck Stabilization Exercises or a General Neck Exercise Program for Chronic Neck Disorders: A Randomized Controlled Trial The efficacy of Sustained Natural Apophyseal Glides with and without Isometric Exercise Training in Non-specific Neck Pain Perceived value of spinal manipulative therapy and exercise among seniors with chronic neck pain: a mixed methods study. The efficacy of an integrated neuromuscular inhibition technique on upper trapezius trigger points in subjects with non-specific neck pain: a randomized controlled trial Five-Week Outcomes From a Dosing Trial of Therapeutic Massage for Chronic Neck Pain Strain-counterstrain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomized trial. The effectiveness of Long's manipulation on patients with chronic mechanical neck pain: a randomized controlled trial. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries. Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain Does work-site physical activity improve self-reported psychosocial workplace factors and job satisfaction? A randomized controlled intervention study Analysis on the effect of acupuncture in treating cervical spondylosis with different syndrome types Short-term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. Qigong Versus Exercise Versus No Therapy for Patients With Chronic Neck Pain: A Randomized Controlled Trial A new system for grading recommendations in evidence based guidelines Effects of long-term home-based exercise on health-related quality of life in patients with chronic neck pain: A randomized study with a 1-year follow-up A Tailored Workplace Exercise Program for Women at Risk for Neck and Upper Limb Musculoskeletal Disorders: A Randomized Controlled Trial Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: A cluster randomized controlled cross-over trial Immediate effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain The GRADE approach is reproducible in assessing the quality of evidence of quantitative evidence syntheses. A randomized controlled intervention trial to relieve and prevent neck/shoulder pain. Assessment of a traditional acupuncture therapy for chronic neck pain: a pilot randomised controlled study. Effect of yogic exercises on symptoms of musculoskeletal disorders of upper limbs among computer users: a randomised controlled trial. Yoga for chronic neck pain: a pilot randomized controlled clinical trial. Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical Range of Motion Exercise: Multi-Center Randomized Clinical Trial Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain
abstract: Abstract Whiplash‐associated disorders are common and incur considerable expense in social and economic terms . There are no known effective treatments for those people whose pain and disability persist beyond 3 months . We conducted a r and omized , assessor‐blinded , controlled trial at two centres in Australia . All participants received 3 advice sessions . In addition the experimental group participated in 12 exercise sessions over 6 weeks . Primary outcomes were pain intensity , pain bothersomeness and function measured at 6 weeks and 12 months . Exercise and advice was more effective than advice alone at 6 weeks for all primary outcomes but not at 12 months . The effect of exercise on the 0–10 pain intensity scale was −1.1 ( 95%CI −1.8 to −0.3 , p = 0.005 ) at 6 weeks and −0.2 ( 0.6 to −1.0 , p = 0.59 ) at 12 months ; on the bothersomeness scale the effect was −1.0 ( −1.9 to −0.2 , p = 0.003 ) at 6 weeks and 0.3 ( −0.6 to 1.3 , p = 0.48 ) at 12 months . The effect on function was 0.9 ( 0.3 to 1.6 , p = 0.006 ) at 6 weeks and 0.6 ( −0.1 to 1.4 , p = 0.10 ) at 12 months . High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months . In the short‐term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash . Exercise is more effective for subjects with higher baseline pain and disability STUDY DESIGN R and omized clinical trial . OBJECTIVES To examine the effectiveness of cervical traction in addition to exercise for specific subgroups of patients with neck pain . BACKGROUND Cervical traction is frequently used , but its effectiveness has not been adequately examined . Existing studies have failed to target patients most likely to respond . Traction is typically recommended for patients with cervical radiculopathy . A prediction rule has been described to identify a narrower subgroup of patients likely to respond to cervical traction . METHODS Patients with neck pain and signs of radiculopathy were r and omized to 4 weeks of treatment with exercise , exercise with mechanical traction , or exercise with over-door traction . Baseline assessment included subgrouping-rule status . The primary outcome measure ( Neck Disability Index , scored 0 - 100 ) and secondary outcome measure ( neck and arm pain intensity ) were assessed at 4 weeks , 6 months , and 12 months after enrollment . The primary analyses examined 2-way treatment-by-time interactions . Secondary analyses examined validity of the subgrouping rule by adding 3-way interactions . RESULTS Eighty-six patients ( 53.5 % female ; mean age , 46.9 years ) were enrolled in the study . Intention-to-treat analysis found lower Neck Disability Index scores at 6 months in the mechanical traction group compared to the exercise group ( mean difference between groups , 13.3 ; 95 % confidence interval : 5.6 , 21.0 ) and over-door traction group ( mean difference between groups , 8.1 ; 95 % confidence interval : 0.8 , 15.3 ) , and at 12 months in the mechanical traction group compared to the exercise group ( mean difference between groups , 9.8 ; 95 % confidence interval : 0.2 , 19.4 ) . Secondary outcomes favored mechanical traction at several time points . The validity of the subgrouping rule was supported on the Neck Disability Index at the 6-month time point only . CONCLUSION Adding mechanical traction to exercise for patients with cervical radiculopathy result ed in lower disability and pain , particularly at long-term follow-ups . The study protocol was registered at http:// clinical trials.gov ( NCT00979108 ) To evaluate the effectiveness of isometric exercises as compared to general exercises in  chronic non-specific neck pain .  For this r and omised controlled trial total 68 patients ( 34 each group ) with chronic non-specific neck pain were recruited from Alain Poly Clinic and Institute of Physical Medicine & Rehabilitation Dow University of Health Sciences , Karachi between May , 2012 and August , 2012 . Simple r and omisation method was used to assign participants into isometric exercise group and general exercise groups . The isometric exercise group performed exercises for neck muscle groups with a rubber b and and general exercises group performed active range of movement exercises for all neck movements . Patients in both groups received 3 supervised treatment sessions per week for 12 weeks . Visual Analogue Scale ( VAS ) , North wick Park Neck Pain Question naire and goniometer were used to assess pain , disability and neck range of movements at baseline and after 12 weeks . Both interventions showed statistically significant improvements in pain , function and range of movement p = 0.001f or isometric exercise group , p = 0.04 for general exercises group and p = 0.001 for range of movement . However , mean improvements in post intervention VAS score and North wick Park Neck Pain Question naire score was better in isometric exercises group as compared to general exercise group . In conclusion , both interventions are effective in the treatment of chronic non-specific neck pain however ; isometric exercises are clinical ly more effective than general exercises 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 In practice the secondary prevention of work-related upper extremity ( WRUE ) symptoms generally targets biomechanical risk factors . Psychosocial risk factors have also been shown to play an important role in the development of WRUE symptom severity and future disability . The addition of a stress management component to biomechanically focused interventions may result in greater improvements in WRUE symptoms and functional limitations than intervening in the biomechanical risk factors alone . Seventy office workers with WRUE symptoms were r and omly assigned to an ergonomics intervention group ( assessment and modification of work station and stretching exercises ) or a combined ergonomic and job stress intervention group ( ergonomic intervention plus two 1-h workshops on the identification and management of workplace stress ) . Baseline , 3- and 12-month follow-up measures of observed ergonomic risks and self-reported ergonomic risks , job stress , pain , symptoms , functional limitation , and general physical and mental health were obtained from all participants . While both groups experienced significant decreases in pain , symptoms , and functional limitation from baseline to three months with improvements continuing to 12 months post baseline , no significant differences between groups were observed for any outcome measures . Findings indicate that the additional two-session job stress management component did not significantly enhance the short- or long-term improvements brought about by the ergonomic intervention alone Background : To date , optimal strategies for the management of patients with cervical radiculopathy remain elusive . Preliminary evidence suggests that a multimodal treatment program consisting of manual therapy , exercise , and cervical traction may result in positive outcomes for patients with cervical radiculopathy . However , limited evidence exists to support the use of mechanical cervical traction in patients with cervical radiculopathy . Objective : The purpose of this study was to examine the effects of manual therapy and exercise , with or without the addition of cervical traction , on pain , function , and disability in patients with cervical radiculopathy . Design : This study was a multicenter r and omized clinical trial . Setting : The study was conducted in orthopedic physical therapy clinics . Patients : Patients diagnosed with cervical radiculopathy ( N=81 ) were r and omly assigned to 1 of 2 groups : a group that received manual therapy , exercise , and intermittent cervical traction ( MT EXTraction group ) and a group that received manual therapy , exercise , and sham intermittent cervical traction ( MTEX group ) . Intervention : Patients were treated , on average , 2 times per week for an average of 4.2 weeks . Measurements : Outcome measurements were collected at baseline and at 2 weeks and 4 weeks using the Numeric Pain Rating Scale ( NPRS ) , the Patient-Specific Functional Scale ( PSFS ) , and the Neck Disability Index ( NDI ) . Results : There were no significant differences between the groups for any of the primary or secondary outcome measures at 2 weeks or 4 weeks . The effect size between groups for each of the primary outcomes was small ( NDI=1.5 , 95 % confidence interval [CI]=−6.8 to 3.8 ; PSFS=0.29 , 95 % CI=−1.8 to 1.2 ; and NPRS=0.52 , 95 % CI=−1.8 to 1.2 ) . Limitations : The use of a nonvali date d clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study . Conclusions : The results suggest that the addition of mechanical cervical traction to a multimodal treatment program of manual therapy and exercise yields no significant additional benefit to pain , function , or disability in patients with cervical radiculopathy 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 Objective : To compare the effectiveness of a 12-month home-based combined strength training and stretching programme against stretching alone in the treatment of chronic neck pain .  Design : A r and omized follow-up study . Participants : One hundred and one patients with chronic non-specific neck pain were r and omized in two groups . Intervention : The strength training and stretching group was supported by 10 group training sessions and the stretching group was instructed to perform stretching exercises only as instructed in one group session . Main outcome measurements : Neck pain , disability , neck muscle strength and mobility of cervical spine were measured before and after the intervention . Results : No significant differences in improvement in neck pain and disability were found between the two training groups . Mean ( SD ) pain decreased from 64 ( 17 ) mm by 37 ( 95 % confidence interval ( CI ) 44 to 30 ) mm in the strength training and stretching group , and from 60 ( 17 ) mm by 32 ( 39 to 25 ) mm in the stretching group . The improvements in disability were significant in both groups ( P<0.001 ) , while the changes in neck strength and mobility were minor . Training adherence decreased over time from the targeted three sessions a week , ending up at 1.1 ( 0.7 ) times a week for strength training and stretching group and 1.4 ( 0.8 ) times a week for stretching group . Conclusions : No statistically significant differences in neck pain and disability were observed between the two home-based training regimens . Combined strength training and stretching or stretching only were probably as effective in achieving a long-term improvement although the training adherence was rather low most of the time Chronic neck pain is a major public health problem with very few evidence -based complementary treatment options . This study aim ed to test the efficacy of 12 weeks of a partner-delivered home-based cupping massage , compared to the same period of progressive muscle relaxation in patients with chronic non-specific neck pain . Patients were r and omly assigned to self-directed cupping massage or progressive muscle relaxation . They were trained and asked to undertake the assigned treatment twice weekly for 12 weeks . Primary outcome measure was the current neck pain intensity ( 0–100 mm visual analog scale ; VAS ) after 12 weeks . Secondary outcome measures included pain on motion , affective pain perception , functional disability , psychological distress , wellbeing , health-related quality of life , pressure pain thresholds and adverse events . Sixty one patients ( 54.1±12.7 years ; 73.8%female ) were r and omized to cupping massage ( n = 30 ) or progressive muscle relaxation ( n = 31 ) . After treatment , both groups showed significantly less pain compared to baseline however without significant group differences . Significant effects in favor of cupping massage were only found for wellbeing and pressure pain thresholds . In conclusion , cupping massage is no more effective than progressive muscle relaxation in reducing chronic non-specific neck pain . Both therapies can be easily used at home and can reduce pain to a minimal clinical ly relevant extent . Cupping massage may however be better than PMR in improving well-being and decreasing pressure pain sensitivity but more studies with larger sample s and longer follow-up periods are needed to confirm these results . Trial Registration Clinical Trials.gov BACKGROUND Recent studies have shown that a transcutaneous electrical nerve stimulation ( TENS ) and interferential current ( IFC ) application reduces pain in subjects with musculoskeletal disorders . However there are no clinical trials evaluating or comparing the muscle relaxation generated for these devices . PURPOSE To compare the muscle relaxation of the upper trapezius induced by the application of TENS and IFC in females with chronic nonspecific neck discomfort . METHODS Sixty-four females between 18 and 40 years of age and a history of nonspecific neck discomfort were r and omly assigned to a TENS or an IFC group . The women in the TENS ( N = 32 ; mean age 22 years ) and IFC ( N = 32 , mean age 23 years ) group were su bmi tted to current application during 3 consecutive days and were assessed by  electromyography ( EMG ) in different times aim ing to quantify the muscular tension of the upper trapezius . A visual analogue scale ( VAS ) was used as pain measure at baseline ( before TENS or IFC application ) and at the end of the study . RESULTS At baseline , demographic , pain , and EMG assessment data were similar between groups . Those in the IFC group had a significant trapezius relaxation after 3 IFC applications when compared to baseline and intermediate evaluations ( P < 0.05 ) . In contrast , the same analysis showed no significant difference between all assessment s in the TENS group ( P > 0.05 ) . In relation to pain relief , both groups showed an improvement at the end of the study when compared to baseline ( both , P < 0.05 ) . The between-group analysis showed no difference for the subjects who received such IFC as TENS application ( P < 0.05 ) . CONCLUSION IFC induced the upper trapezius relaxation after 3 sessions in females with neck discomfort , but the TENS application did not change the muscular tension . However , these results should be carefully interpreted due to the lack of differences between groups . A significant pain decrease was found in the subjects of both groups , however , only the IFC application presented a clinical ly important improvement Objective : To investigate whether an exercise intervention shown to increase aerobic capacity , would also lead to less musculoskeletal pain ; improved work ability , productivity , and perceived physical exertion ; and less sick leave . Methods : Sixty-seven construction workers were r and omized into an exercise group training 3 × 20 minutes per week and a control group . Question naires and text messages were completed before and after the 12-week intervention . Results : No significant changes were found in musculoskeletal pain , work ability , productivity , perceived physical exertion , and sick leave with the intervention . Question naires and text messages provided similar results of pain and work ability . Conclusions : Although the intervention improved aerobic capacity , it was not successful in improving musculoskeletal pain and other work-related factors . A detectable improvement presumably requires a more multifaceted intervention , larger sample size , or longer follow-up . Text messages may be a convenient data - collection method in future studies BACKGROUND Evidence suggests that brief physiotherapy programmes are as effective for acute whiplash-associated disorders as more comprehensive programmes ; however , whether this also holds true for chronic whiplash-associated disorders is unknown . We aim ed to estimate the effectiveness of a comprehensive exercise programme delivered by physiotherapists compared with advice in people with a chronic whiplash-associated disorder . METHODS PROMISE is a two group , pragmatic r and omised controlled trial in patients with chronic ( > 3 months and < 5 years ) grade 1 or 2 whiplash-associated disorder . Participants were r and omly assigned by a computer-generated r and omisation schedule to receive either the comprehensive exercise programme ( 20 sessions ) or advice ( one session and telephone support ) . Sealed opaque envelopes were used to conceal allocation . The primary outcome was pain intensity measured on a 0 - 10 scale . Outcomes were measured at baseline , 14 weeks , 6 months , and 12 months by a masked assessor . Analysis was by intention to treat , and treatment effects were calculated with linear mixed models . The trial is registered with the Australian New Zeal and Clinical Trials Registry , number ACTRN12609000825257 . FINDINGS 172 participants were allocated to either the comprehensive exercise programme  ( n=86 ) or advice group ( n=86 ) ; 157 ( 91 % ) were followed up at 14 weeks , 145 ( 84 % ) at 6 months , and 150 ( 87 % ) at 12 months . A comprehensive exercise programme was not more effective than advice alone for pain reduction in the participants . At 14 weeks the treatment effect on a 0 - 10 pain scale was 0·0 ( 95 % CI -0·7 to 0·7 ) , at 6 months 0·2 ( -0·5 to 1·0 ) , and at 12 months -0·1 ( -0·8 to 0·6 ) . CNS hyperexcitability and symptoms of post-traumatic stress did not modify the effect of treatment . We recorded no serious adverse events . INTERPRETATION We have shown that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme . The need to identify effective and affordable strategies to prevent and treat acute through to chronic whiplash associated disorders is an important health priority . Future avenues of research might include improving underst and ing of the mechanisms responsible for persistent pain and disability , investigating the effectiveness and timing of drugs , and study of content and delivery of education and advice . FUNDING The National Health and Medical Research Council of Australia , Motor Accidents Authority of New South Wales , and Motor Accident Insurance Commission of Queensl and BACKGROUND CONTEXT Evidence -based clinical practice guidelines ( CPGs ) for the management of patients with acute mechanical low back pain ( AM-LBP ) have been defined on an international scale . Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments . To date , the value of implementing full and exclusively CPG-based treatment remains unclear . PURPOSE To determine if full CPGs-based study care ( SC ) results in greater improvement in functional outcomes than family physician-directed usual care ( UC ) in the treatment of AM-LBP . STUDY DESIGN / SETTING A two-arm , parallel design , prospect i ve , r and omized controlled clinical trial using blinded outcome assessment . Treatment was administered in a hospital-based spine program outpatient clinic . PATIENT SAMPLE Inclusion criteria included patients aged 19 to 59 years with Quebec Task Force Categories 1 and 2 AM-LBP of 2 to 4 weeks ' duration . Exclusion criteria included " red flag " conditions and comorbidities contraindicating chiropractic spinal manipulative therapy ( CSMT ) . OUTCOME MEASURES PRIMARY OUTCOME improvement from baseline in Rol and -Morris Disability Question naire ( RDQ ) scores at 16 weeks . SECONDARY OUTCOMES improvements in RDQ scores at 8 and 24 weeks ; and in Short Form-36 ( SF-36 ) bodily pain ( BP ) and physical functioning ( PF ) scale scores at 8 , 16 , and 24 weeks . METHODS Patients were assessed by a spine physician , then r and omized to SC ( reassurance and avoidance of passive treatments , acetaminophen , 4 weeks of lumbar CSMT , and return to work within 8 weeks ) , or family physician-directed UC , the components of which were recorded . RESULTS Ninety-two patients were recruited , with 36 SC and 35 UC patients completing all follow-up visits . Baseline prognostic variables were evenly distributed between groups . The primary outcome , the unadjusted mean improvement in RDQ scores , was significantly greater in the SC group than in the UC group ( p=.003 ) . Regarding unadjusted mean changes in secondary outcomes , improvements in RDQ scores were also greater in the SC group at other time points , particularly at 24 weeks ( p=.004 ) . Similarly , improvements in SF-36 PF scores favored the SC group at all time points ; however , these differences were not statistically significant . Improvements in SF-36 BP scores were similar between groups . In repeated- measures analyses , global adjusted mean improvement was significantly greater in the SC group in terms of RDQ ( p=.0002 ) , nearly significantly greater in terms of SF-36 PF ( p=.08 ) , but similar between groups in terms of SF-36 BP ( p=.27 ) . CONCLUSIONS This is the first reported r and omized controlled trial comparing full CPG-based treatment , including spinal manipulative therapy administered by chiropractors , to family physician-directed UC in the treatment of patients with AM-LBP . Compared to family physician-directed UC , full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning Objective : To compare the effects of an isolated application of cervical spine thrust joint manipulation vs. the application of cervical , cervico-thoracic junction and thoracic manipulation on neck pain , disability and cervical range of motion in chronic neck pain . Design : R and omized clinical trial . Setting : Clinical practice . Participants : Eighty-two patients ( 41 females ) with chronic mechanical neck pain . Interventions : Patients were r and omly assigned to a cervical spine manipulation group or a full manipulative group who received mid-cervical , cervico-thoracic and thoracic joint manipulations . Measurements : Neck pain intensity ( 11-point numeric pain rating scale ) , self-reported disability ( Neck Disability Index ) and cervical range of motion were collected at baseline and one week after the intervention by an assessor blinded to the allocation of the patients . Results : A significant Group * Time interaction for Neck Disability Index ( P = 0.022 ) , but not for neck pain ( P = 0.612 ) , was found : patients in the full manipulative group exhibited greater reduction in disability than those who received the cervical spine manipulation alone , whereas both groups experienced similar decreases in neck pain . Patients in both groups experienced similar increases in cervical range of motion ( P > 0.4 ) . No effect of gender was observed ( P > 0.299 ) . Conclusions : In patients with chronic mechanical neck pain , manipulation of the cervical and thoracic spine leads to a greater reduction in disability at one week than after manipulation of the cervical spine alone , whereas changes in pain and range of motion are not affected differently 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 & NA ; Dysfunction in the motor system is a feature of persistent whiplash associated disorders . Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms . This study measured prospect ively , motor system function ( cervical range of movement ( ROM ) , joint position error ( JPE ) and activity of the superficial neck flexors ( EMG )  during a test of cranio‐cervical flexion ) as well as a measure of fear of re‐injury ( TAMPA ) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury . Subjects were classified at 3 months post injury using scores on the neck disability index : recovered ( < 8 ) , mild pain and disability ( 10–28 ) or moderate/severe pain and disability ( > 30 ) . Motor system function was also measured in 20 control subjects . All whiplash groups demonstrated decreased ROM and increased EMG ( compared to controls ) at 1 month post injury . This deficit persisted in the group with moderate/severe symptoms but returned to within normal limits in those who had recovered or reported persistent mild pain at 3 months . Increased EMG persisted for 3 months in all whiplash groups . Only the moderate/severe group showed greater JPE , within 1 month of injury , which remained unchanged at 3 months . TAMPA scores of the moderate/severe group were higher than those of the other two groups . The differences in TAMPA did not impact on ROM , EMG or JPE . This study identifies , for the first time , deficits in the motor system , as early as 1 month post whiplash injury , that persisted not only in those reporting moderate/severe symptoms at 3 months but also in subjects who recovered and those with persistent mild symptoms STUDY DESIGN R and omized clinical trial . OBJECTIVE To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation ( experimental group ) versus cervical spine nonthrust manipulation alone ( comparison group ) in individuals with mechanical neck pain . BACKGROUND Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain . Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone . METHODS Sixty-four participants with mechanical neck pain were r and omized into 1 of 2 groups , an experimental or comparison group . Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises , and the experimental group received additional thoracic spine thrust manipulations . Outcome measures were collected at baseline and at a 1-week follow-up , and included the numeric pain rating scale , the Neck Disability Index , and the global rating of change . RESULTS Participants in the experimental group demonstrated significantly greater improvements ( P<.001 ) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group . In addition , 31 of 33 ( 94 % ) participants in the experimental group , compared to 11 of 31 participants ( 35 % ) in the comparison group , indicated a global rating of change score of + 4 or higher at the 1-week follow-up , with an associated number needed to treat of 2 . CONCLUSION Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale , the Neck Disability Index , and the global rating of change Background Healthcare decision makers face challenges when using guidelines , including underst and ing the quality of the evidence or the values and preferences upon which recommendations are made , which are often not clear . Methods GRADE is a systematic approach towards assessing the quality of evidence and the strength of recommendations in healthcare . GRADE also gives advice on how to go from evidence to decisions . It has been developed to address the weaknesses of other grading systems and is now widely used internationally . The Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence ( DECIDE ) consortium ( http://www.decide-collaboration.eu/ ) , which includes members of the GRADE Working Group and other partners , will explore methods to ensure effective communication of evidence -based recommendations targeted at key stakeholders : healthcare professionals , policymakers , and managers , as well as patients and the general public . Surveys and interviews with guideline producers and other stakeholders will explore how presentation of the evidence could be improved to better meet their information needs . We will collect further stakeholder input from advisory groups , via consultations and user testing ; this will be done across a wide range of healthcare systems in Europe , North America , and other countries . Targeted communication strategies will be developed , evaluated in r and omized trials , refined , and assessed during the development of real guidelines . Discussion Results of the DECIDE project will improve the communication of evidence -based healthcare recommendations . Building on the work of the GRADE Working Group , DECIDE will develop and evaluate methods that address communication needs of guideline users . The project will produce strategies for communicating recommendations that have been rigorously evaluated in diverse setting s , and it will support the transfer of research into practice in healthcare systems globally 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 CONTEXT This is the first study to systematic ally evaluate the value of a longer treatment period for massage . We provide a framework of how to conceptualize an optimal dose in this challenging setting of nonpharmacologic treatments . PURPOSE The aim was to determine the optimal dose of massage for neck pain . STUDY DESIGN / SETTING Two-phase r and omized trial for persons with chronic nonspecific neck pain . Primary r and omization to one of five groups receiving 4 weeks of massage ( 30 minutes 2x/or 3x/wk or 60 minutes 1x , 2x , or 3x/wk ) . Booster r and omization of participants to receive an additional six massages , 60 minutes 1x/wk , or no additional massage . PATIENT SAMPLE A total of 179 participants from Group Health and the general population of Seattle , WA , USA recruited between June 2010 and August 2011 were included . OUTCOME MEASURES Primary outcomes self-reported neck-related dysfunction ( Neck Disability Index ) and pain ( 0 - 10 scale ) were assessed at baseline , 12 , and 26 weeks . Clinical ly meaningful improvement was defined as greater than or equal to 5-point decrease in dysfunction and greater than or equal to 30 % decrease in pain from baseline . METHODS Clinical ly meaningful improvement for each primary outcome with both follow-up times was analyzed using adjusted modified Poisson generalized estimating equations ( GEEs ) . Secondary analyses for the continuous outcomes used linear GEEs . RESULTS There were no observed differences by primary treatment group at 12 or 26 weeks . Those receiving booster dose had improvements in both dysfunction and pain at 12 weeks ( dysfunction : relative risk [RR]=1.56 [ 1.08 - 2.25 ] , p=.018 ; pain : RR=1.25 [ 0.98 - 1.61 ] , p=.077 ) , but those were nonsignificant at 26 weeks ( dysfunction : RR=1.22 [ 0.85 - 1.74 ] ; pain : RR=1.09 [ 0.82 - 1.43 ] ) . Subgroup analysis by primary and booster treatments found the booster dose only effective among those initially r and omized to one of the 60-minute massage groups . CONCLUSIONS " Booster " doses for those initially receiving 60 minutes of massage should be incorporated into future trials of massage for chronic neck pain Spinal Manipulation ( SM ) has been purported to decrease pain and improve function in subjects with non-specific neck pain . Previous research has investigated which individuals with non-specific neck pain will be more likely to benefit from SM . It has not yet been proven whether or not the effectiveness of thoracic SM depends on the specific technique being used . This double-blind r and omized trial has compared the short-term effects of two thoracic SM maneuvers in subjects with chronic non-specific neck pain . Sixty participants were distributed r and omly into two groups . One group received the Dog technique ( n = 30 ) , with the subject in supine position , and the other group underwent the Toggle-Recoil technique ( n = 30 ) , with the participant lying prone , T4 being the targeted area in both cases . Evaluations were made of self-reported neck pain ( Visual Analogue Scale ) ; neck mobility ( Cervical Range of Motion ) ; and pressure pain threshold at the cervical and thoracic levels ( C4 and T4 spinous process ) and over the site described for location of tense b and s of the upper trapezius muscle . Measurements were taken before intervention , immediately afterward , and 20 min later . Both maneuvers improved neck mobility and mechanosensitivity and reduced pain in the short term . No major or clinical differences were found between the groups . In the between-groups comparison slightly better results were observed in the Toggle-Recoil group only for cervical extension ( p = 0.009 ) , right lateral flexion ( p = 0.004 ) and left rotation ( p < 0.05 ) Study Design . R and omized clinical trial . Objective . To assess the effectiveness of manual physical therapy and exercise ( MTE ) for mechanical neck pain with or without unilateral upper extremity ( UE ) symptoms , as compared to a minimal intervention ( MIN ) approach . Summary of Background Data . Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain , but no studies have directly assessed its effectiveness for UE symptoms . Methods . A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain , with or without unilateral UE symptoms , were r and omized  to receive MTE or a MIN approach of advice , motion exercise , and subtherapeutic ultrasound . Primary outcomes were the neck disability index , cervical and UE pain visual analog scales ( VAS ) , and patient-perceived global rating of change assessed at 3- , 6- , and 52-weeks . Secondary measures included treatment success rates and post-treatment healthcare utilization . Results . The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores ( mean 1-year difference −5.1 , 95 % confidence intervals ( CI ) −8.1 to −2.1 ; P = 0.001 ) and short-term cervical VAS scores ( mean 6-week difference −14.2 , 95 % CI −22.7 to −5.6 ; P = 0.001 ) as compared to the MIN group . The MTE group also demonstrated significant within group reductions in short- and long-term UE VAS scores at all time periods ( mean 1-year difference −16.3 , 95 % CI −23.1 to −9.5 ; P = 0.000 ) . At 1-year , patient perceived treatment success was reported by 62 % ( 29 of 47 ) of the MTE group and 32 % ( 15 of 47 ) of the MIN group ( P = 0.004 ) . Conclusion . An impairment-based MTE program result ed in clinical ly and statistically significant short- and long-term improvements in pain , disability , and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice , a mobility exercise , and subtherapeutic ultrasound Objective . To investigate the effect of workplace neck/shoulder strength training with and without regular supervision on  neck/shoulder pain and headache among office workers . Method . A 20-week cluster r and omized controlled trial among 351 office workers was r and omized into three groups : two training groups with the same total amount of planned exercises three times per week ( 1 ) with supervision ( 3WS ) throughout the intervention period , ( 2 ) with minimal supervision ( 3MS ) only initially , and ( 3 ) a reference group ( REF ) . Main outcome is self-reported pain intensity in neck and shoulder ( scale 0–9 ) and headache ( scale 0–10 ) . Results . Intention-to-treat analyses showed a significant decrease in neck pain intensity the last 7 days in 3MS compared with REF : −0.5 ± 0.2 ( P < 0.02 ) and a tendency for 3WS versus REF : −0.4 ± 0.2 ( P < 0.07 ) . Intensity of headache the last month decreased in both training groups : 3WS versus REF : −1.1 ± 0.2 ( P < 0.001 ) and 3MS versus REF : −1.1 ± 0.2 ( P < 0.001 ) . Additionally , days of headache decreased 1.0 ± 0.5 in 3WS and 1.3 ± 0.5 in 3MS versus REF . There were no differences between the two training groups for any of the variables . Conclusion . Neck/shoulder training at the workplace reduced neck pain and headache among office workers independently of the extent of supervision . This finding has important practical implication s for future workplace interventions Objectives . This study investigated long-term effects and implementation processes of workplace strength training for musculoskeletal disorders . Methods . 333 and 140 laboratory technicians from private and public sector companies , respectively , replied to a 3-year follow-up question naire subsequent to a 1-year r and omized controlled trial ( RCT ) with high-intensity strength training for prevention and treatment of neck , shoulder , and arm pain . Being a natural experiment , the two participating companies implemented and modified the initial training program in different ways during the subsequent 2 years after the RCT . Results . At 3-year follow-up the pain reduction in neck , shoulder , elbow , and wrist achieved during the first year was largely maintained at both companies . However , the private sector company was rated significantly better than the public sector company in ( 1 ) training adherence , ( 2 ) training culture , that is , relatively more employees trained at the workplace and with colleagues , ( 3 ) self-reported health changes , and ( 4 ) prevention of neck and wrist pain development among initially pain-free employees . Conclusions . This natural experiment shows that strength training can be implemented successfully at different companies during working hours on a long-term basis with lasting effects on pain in neck , shoulder , and arm Background This systematic review up date d and extended the " UK evidence report " by Bronfort et al. ( Chiropr Osteopath 18:3 , 2010 ) with respect to conditions/ interventions that received an ' inconclusive ’ or ' negative ’ evidence rating or were not covered in the report . Methods A literature search of more than 10 general medical and specialised data bases was conducted in August 2011 and up date d in March 2013 . Systematic review s , primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included . Study quality was assessed using st and ardised instruments , studies were summarised , and the results were compared against the evidence ratings of Bronfort . These were either confirmed , up date d , or new categories not assessed by Bronfort were added . Results 25,539 records were found ; 178 new and additional studies were identified , of which 72 were systematic review s , 96 were r and omised controlled trials , and 10 were non-r and omised primary studies . Most ' inconclusive ’ or ' moderate ’ evidence ratings of the UK evidence report were confirmed . Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases ( manipulation/mobilisation [ with exercise ] for rotator cuff disorder ; spinal mobilisation for cervicogenic headache ; and mobilisation for miscellaneous headache ) . In addition , evidence was identified on a large number of non-musculoskeletal conditions not previously considered ; most of this evidence was rated as inconclusive . Conclusions Overall , there was limited high quality evidence for the effectiveness of manual therapy . Most review ed evidence was of low to moderate quality and inconsistent due to substantial method ological and clinical diversity . Areas requiring further research are highlighted Summary Fear of movement plays and important role in individuals with subacute whiplash‐associated disorders and it should be directly targeted in treatment . ABSTRACT Fear and avoidance of activity may play a role in fostering disability in  whiplash‐associated disorders ( WAD ) . This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear . People still symptomatic from WAD grade I‐II injuries approximately 3 months previously ( n = 191 ) completed question naires ( eg , Neck Disability Index [ NDI ] ) and were r and omized to 1 of the treatments : ( 1 ) informational booklet ( IB ) describing WAD and the importance of resuming activities , ( 2 ) IB + didactic discussion s ( DD ) with clinicians reinforcing the booklet , and ( 3 ) IB + imaginal and direct exposure desensitization ( ET ) to feared activities . DD and ET participants received three 2‐hour treatment sessions . Absolute improvements in NDI were in predicted direction ( ET = 14.7 , DD = 11.9 , IB = 9.9 ) . ETs reported significantly less posttreatment pain severity compared with the IB ( Mean = 1.5 vs 2.3 , P < .001 , d = 0.6 ) and DD ( M = 1.5 vs 2.0 , P = .039 , d = 0.6 ) groups . Reduction in fear was the most important predictor of improvement in NDI ( β = 0.30 , P < .001 ) , followed by reductions in pain ( β = 0.20 , P = .003 ) and depression ( β = 0.18 , P = .004 ) . The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome . Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and /or educational interventions to improve function Study Design . Parallel-group r and omized controlled trial . Objective . Establish the short-term effectiveness of chiropractic therapy for spinal pain compared with a sham intervention and explore the predictors of chiropractic treatment satisfaction . Summary of Background Data . Chiropractic treatment is widely used for spinal pain . However , a lack of sound evidence precludes conclusions about the effectiveness of chiropractic for spinal pain . Methods . Participants were adults experiencing spinal pain , r and omized to receive 2 treatments of chiropractic or sham therapy .  Participants and outcome assessors were blinded to group allocation . Primary outcomes at 2 weeks were pain intensity ( 0–10 scale ) and function ( 0–40 Functional Rating Index ) . Secondary outcomes were global change , minimum acceptable outcome , and treatment satisfaction . Treatment effects were estimated with linear mixed models for the primary outcomes . We used logistic regression to identify differences in the secondary outcomes and explore for predictors of treatment satisfaction . Results . One hundred eighty three participants ( chiropractic , n = 92 ; sham , n = 91 ) were recruited and included in the analyses . Participants receiving chiropractic therapy reported greater improvements in pain ( mean difference , 95 % confidence interval [ CI ] = 0.5 [ 0.1–0.9 ] ) , physical function ( mean difference [ 95 % CI ] = 2.1 [ 0.3–4.0 ] ) , and were more likely to experience global improvement ( 48 % vs. 24 % , P = 0.01 ) and treatment satisfaction ( 78 % vs. 56 % , P < 0.01 ) . There was no between-group difference in achieving a minimally acceptable outcome ( 34 % sham vs. 29 % chiropractic , P = 0.42 ) . Awareness of treatment assignment and achieving minimally important improvement in pain intensity were associated with chiropractic treatment satisfaction . Conclusion . Short-term chiropractic treatment was superior to sham ; however , treatment effects were not clinical ly important . Awareness of treatment assignment and clinical ly important reductions in pain were associated with chiropractic treatment satisfaction . Level of Evidence : INTRODUCTION whiplash is a frequent post traumatic pathology caused by muscle , tendon and capsular elements over stretching . The authors conducted a short term prospect i ve r and omised study to test the effectiveness of a multi wave High Power Laser Therapy ( HPLT ) versus conventional simple segmental physical rehabilitation ( PT ) included in Italian tariff nomenclature performance physiotherapy Study Design : prospect i ve r and omised study ( Level II ) . MATERIAL AND METHODS the authors identified 135 homogeneous patients with whiplash grade 1 - 2 of the Quebec Task Force classification ( QTFC ) . INAIL , the Italian National Workers Insurance , based in Milan , was reliable source for identifying patients . All patients with whiplash injuries grade 1 or 2 QTFC , were eligible for the study , starting from April 28 2010 to September 30 2010 . Patients referred to a Coordinator ( C.M. ) who applied the inclusion and exclusion criteria . Patients who agreed to participate were r and omly assigned to one of the two treatment groups . Date s for initial treatment session were arranged , including cervical spine X-ray , and assessment . Each patient gave informed consent for participation and agreed to adopt only the study treatment for 6 weeks . Group A ( 84 patients ) was treated with High Power Laser Therapy ( HPLT ) , Group B ( 51 patients ) received conventional simple segmental physical rehabilitation ( PT ) . During the treatment period , no other electro-medical therapy , analgesics or anti-inflammatory drugs were allowed . All patients were assessed at baseline ( T0 ) and at the end of the treatment period ( T1 ) using a Visual Analogical Scale ( VAS ) , ( T2 ) the date of return to work was registered afterwards . RESULTS there was a reduction in VAS pain scores at T1 . Group A ( VAS = 20 ) Group B ( VAS = 34,8 ) ( p = 0.0048 ) . Laser treatment allowed quick recovery and return to work ( T2 ) . Group A after 48 days against 66 days of Group B ( p=0.0005 ) . CONCLUSIONS results suggest that High Power Laser Therapy - is an effective treatment in patients with whiplash injury , compared to conventional simple segmental physical rehabilitation UNLABELLED Studies regarding self-management of persistent neck pain are infrequent . OBJECTIVE to compare treatment effects of ( a ) a multi-component pain and stress self-management group intervention ( PASS ) and ( b ) individually administered physical therapy ( IAPT ) for patients with persistent musculoskeletal tension-type neck pain . METHODS Persons seeking physical therapy treatment due to persistent tension-type neck pain at nine primary health care centers in Sweden were r and omly assigned to either PASS or IAPT . Before treatment ( baseline ) and at 10- and 20-weeks the participants completed a self- assessment question naire comprising : the Self-Efficacy Scale , the Neck Disability Index , the Coping Strategies Question naire , the Hospital Anxiety and Depression Scale , the Fear-Avoidance Beliefs Question naire and questions regarding neck pain , analgesics and utilization of health care . Intention-to-treat analyses were performed using repeated measures analysis of variance between baseline , 10-week and 20-week follow-up . RESULTS One hundred and fifty six participants were included ( PASS n=77 , IAPT n=79 ) . On average participants receiving PASS attended seven treatment sessions and participants receiving IAPT 11 sessions over the 20-week follow-up period . Repeated measures ANCOVA showed significant time x group interaction effects for ability to control pain ( p<0.001 ) , self-efficacy regarding pain-interfering activities ( p=0.005 ) , disability due to neck pain ( p=0.001 ) and levels of catastrophic thinking ( p<0.001 ) in favour of PASS . CONCLUSION PASS had a better effect than IAPT in the treatment of persistent musculoskeletal tension-type neck pain regarding coping with pain , in terms of patients ' self-reported pain control , self-efficacy , disability and catastrophizing , over the 20-week follow-up Study Design . A r and omized controlled trial with 3 and 6 months follow-up . Objective . To compare the effectiveness of acupuncture with simulated acupuncture in patients with subacute and chronic whiplash-associated disorders . Summary of Background Data . Acupuncture is widely used for the treatment of neck and other musculoskeletal pain , and there is some evidence supporting its effectiveness for short-term pain relief . The effectiveness of acupuncture in the treatment of whiplash-associated disorders is not clear . Methods . A total of 124 patients between 18 and 65 years with chronic ( 85 % ) or subacute whiplash-associated disorders ( Grade I or II ) were r and omly allocated to real or simulated electroacupuncture treatment for 12 sessions during a 6-week period . Both treatments involved skin penetration with acupuncture needles and were provided by a single university-trained acupuncturist in a University Clinic in Sydney , Australia . Primary outcome measures were pain intensity ( 10-cm visual analog scale ) , disability ( Neck Disability Index ) , and health-related quality of life ( SF-36 ) . Secondary outcomes were patient-specific activity scales , and the McGill Pain Rating Index . Results . Mean initial pain intensity for all participants was 5.6 cm . Participants receiving the real electroacupuncture treatment had significantly greater reduction in pain intensity at 3 and 6 months , 0.9 cm ( P = 0.05 ) and 1.3 cm ( P = 0.007 ) , respectively , in comparison to the sham electro-acupuncture group . After adjustment for baseline status , there was no significant reduction in disability , or improvement in health-related quality of life . There was an improvement in the activity scales of a similar size to the reduction in pain , but no difference in the McGill Index . Conclusion . Real electroacupuncture was associated with a significant reduction in pain intensity over at least 6 months . This reduction was probably not clinical ly significant . There was no improvement in disability or quality of life Abstract Purpose We conducted a systematic review to critically appraise and synthesize literature on the effectiveness of work disability prevention ( WDP ) interventions in workers with neck pain , whiplash-associated disorders ( WAD ) , or upper extremity disorders . Methods We search ed electronic data bases from 1990 to 2012 . R and om pairs of independent review ers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria . Scientifically admissible studies were summarized and synthesized following best- evidence synthesis methodology . Results Of the 6,359 articles retrieved , 16 r and omized controlled trials were eligible for critical appraisal and five were admissible . We found that a return-to-work coordination program ( including workplace-based work hardening ) was superior to clinic-based work hardening for persistent rotator cuff tendinitis . Workplace high-intensity strength training and workplace advice had similar outcomes for neck and shoulder pain . Mensendieck/Cesar postural exercises and strength and fitness exercises had similar outcomes for non-specific work-related upper limb complaints . Adding a brief job stress education program to a workplace ergonomic intervention was not beneficial for persistent upper extremity symptoms . Adding computer-prompted work breaks to ergonomic adjustments and workplace education benefited workers ’ recovery from recent work-related neck and upper extremity complaints . Conclusions At present , no firm conclusions can be drawn regarding the effectiveness of WDP interventions for managing neck pain , WAD , and upper extremity disorders . Our review suggests a return-to-work coordination program is more effective than clinic-based work hardening . Also , adding computer-prompted breaks to ergonomic and workplace interventions benefits workers ’ recovery . The current quality of evidence does not allow for a definitive evaluation of the effectiveness of ergonomic interventions Objectives : The aim of this study was to compare the effect on self-rated pain , disability , and self-efficacy of 3 interventions for the management of chronic whiplash-associated disorders :  physiotherapist-led neck-specific exercise ( NSE ) , physiotherapist-led NSE with the addition of a behavioral approach , or Prescription of Physical Activity ( PPA ) . Material s and Methods : A total of 216 volunteers with chronic whiplash-associated disorders participated in this r and omized , assessor blinded , clinical trial of 3 exercise interventions .  Self-rated pain/pain bothersomeness ( Visual Analogue Scale ) , disability ( Neck Disability Index ) , and self-efficacy ( Self-Efficacy Scale ) were evaluated at baseline and at 3 and 6 months . Results : The proportion of patients reaching substantial reduction in pain bothersomness ( at least 50 % reduction ) was more evident ( P<0.01 ) in the 2 NSE groups ( 29 % to 48 % ) compared with the PPA group ( 5 % ) at 3 months . At 6 months 39 % to 44 % of the patients in the 2 neck-specific groups and 28 % in the PPA group reported substantial pain reduction . Reduction of disability was also larger in the 2 neck-specific exercise groups at both 3 and 6 months ( P<0.02 ) . Self-efficacy was only improved in the NSE group without a behavioral approach ( P=0.02 ) . However , there were no significant differences in any outcomes between the 2 physiotherapist-led NSE groups . Discussion : NSE result ed in superior outcomes compared with PPA in this study , but the observed benefits of adding a behavioral approach to the implementation of exercise in this study were inconclusive Study Design . R and omized parallel-group trial with 1-year follow-up . Objective . To evaluate whether education of patients communicated orally by a specially trained nurse is superior to giving patients a pamphlet after a whiplash injury . Summary of Background Data . Long-lasting pain and physical disability after whiplash injuries are related to both serious personal suffering and huge socio-economic costs . Pure educational interventions after such injuries seem generally as effective as more costly interventions , but it is unknown if the way advice is communicated is of any importance . Methods . Participants with relatively mild complaints after car collisions were recruited from emergency departments and GPs . A total of 182 participants were r and omized to either : ( 1 ) a 1 hour-educational session with a specially trained nurse , or ( 2 ) an educational pamphlet . Outcome parameters were neck pain , headache , disability , and return to work . Recovery was defined as scoring pain 0 or 1 ( 0–10 point scale ) and not being off sick at the time of the follow-ups . Results . After 3 , 6 , and 12 months 60 % , 58 % , and 66 % , respectively of the participants had recovered . Group differences were nonsignificant on all outcome parameters , even though the outcome tended to be better for the group receiving personal advice . Conclusion . Prognosis did not differ between patients who received personal education and those who got a pamphlet . However , a systematic tendency toward better outcome with personal communicated information was observed and the question how patients should be educated to reduce the risk of chronicity after whiplash is worth further investigation , since no treatment have been proven to prevent long-lasting symptoms , and all forms of advice or educational therapy are so cheap that even a modest effect justifies its use Purpose To determine the time-wise effect of specific resistance training on  neck pain among industrial technicians with frequent neck pain symptoms . Methods Secondary analysis of a parallel-group cluster r and omized controlled trial of 20 weeks performed at two large industrial production units in Copenhagen , Denmark . Women with neck pain > 30 mm VAS ( N = 131 ) were included in the present analysis . The training group ( N = 77 ) performed specific resistance training for the neck/shoulder muscles three times a week , and the control group ( N = 54 ) received advice to stay active . Participants of both groups registered neck pain intensity ( 0–100 mm VAS ) once a week . Results Neck pain intensity was 55 mm ( SD 23 ) at baseline . There was a significant group by time interaction for neck pain ( F-value 2.61 , P<0.001 , DF = 19 ) . Between-group differences in neck pain reached significance after 4 weeks ( 11 mm , 95 % CI 2 to 20 ) . The time-wise change in pain showed three phases ; a rapid decrease in the training group compared with the control group during the initial 7 weeks , a slower decrease in pain during the following weeks ( week 8–15 ) , and a plateau during the last weeks ( week 16–20 ) . Adherence to training followed a two-phase pattern , i.e. weekly participation rate was between 70–86 % during the initial 7 weeks , dropping towards 55–63 % during the latter half of the training period . Conclusion Four weeks of specific resistance training  reduced neck pain significantly , but 15 weeks is required to achieve maximal pain reduction . The time-wise change in pain followed a three-phase pattern with a rapid effect during the initial 7 weeks followed by a slower but still positive effect , and finally a plateau from week 15 and onwards . Decreased participation rate may explain the decreased efficacy during the latter phase of the intervention Purpose Although there is growing evidence in favour of the bio-psychosocial approach to the treatment of  persistent neck pain  , it is question ed whether treating psychological factors can improve patient perceptions of disability , pain and quality of life . This r and omised , controlled study with 12 months ’ follow-up was conducted to evaluate the efficacy of adding cognitive-behavioural principles to exercises for chronic neck pain . Methods Eighty patients were r and omly assigned to the usual neck exercises plus cognitive-behavioural treatment ( PTcb group , 40 subjects ) or to treatment based on neck exercises alone ( PT group , 40 subjects ) . Before treatment ( T1 ) , at the end of treatment ( T2 ) and 12 months later ( T3 ) , all of the patients completed a booklet including the Neck Pain and Disability Scale , a numerical rating scale , and the Short-Form Health Survey Question naire ( SF-36 ) . Results The present trial failed to demonstrate its primary end point : the pre- and post-treatment difference in total NPDS scores was not statistically different between groups . Disability improved similarly in both groups over time , remaining stable until T3 in the PTcb group and slightly increasing at the same time in the PT group . Pain trends were comparable , with both groups showing an improvement between T1 and T2 , and a slight worsening between T2 and T3 . There were significant increases in all of the SF-36 domains except for health in general , and vitality in both groups by the end of treatment . SF-36 showed a between-group difference only for the physical activity domain ( 10.4 ; 95 % CI 2.4–18.5 ) . Conclusion Disability , pain and quality of life improved at the end of treatment in both groups , without differences between them Background and ObjectiveS ince oxidative stress plays a pathogenetic role in chronic neck pain ( CNP ) , we investigated whether a combination of α-lipoic acid ( ALA ) and superoxide dismutase ( SOD ) might improve pain control and the efficacy of physiotherapy ( “ multimodal therapy ” ) in patients with CNP . Setting This study was conducted in the Rehabilitation Unit of the Department of Surgical and Oncological Sciences at the University Policlinic in Palermo , Italy . Design and Patients This was a prospect i ve , r and omized , open study in out patients .Intervention Patients r and omly received either physiotherapy alone  ( group 2 ; n = 45 ) or a combination of ALA 600 mg and SOD 140 IU daily in addition to physiotherapy  ( group 1 ; n = 51 ) , for 60 days . Pain was assessed by a visual analogue scale ( VAS ) and a modified Neck Pain Question naire ( mNPQ ) . Treatment compliance and safety were also evaluated . Results Both groups experienced a significant reduction in the VAS and mNPQ scores after 1 month ; however , while no further improvement was observed in group 2 at 60 days , group 1 showed a further VAS reduction ( p < 0.001 ) . In addition , in the mNPQ at 60 days , more patients in group 1 than in group 2 reported that their neck pain was improved ( p < 0.01 ) , and they showed greater compliance with prescribed physiotherapy ( p = 0.048 ) . No drug reaction was observed . Conclusion Use of ALA/SOD in combination with physiotherapy may be a useful approach to CNP , being antioxidants that act on nerve inflammation and disease progression . Clinical Rehabilitation ImpactThese preliminary observations suggest that some interesting goals ( better pain control and physical wellbeing ) can be achieved by multimodal therapy in CNP patients Ketorolac tromethamine injected intramuscularly ( IM ) has been shown to be an effective analgesic in treating patients with acute musculoskeletal pain in the emergency department ( ED ) . The authors compare the efficacy of a single dose of IM ketorolac to osteopathic manipulative treatment ( OMT ) as delivered in the ED for the management of acute neck pain . A r and omized clinical trial was conducted in three EDs . A convenience sample of 58 patients with acute neck pain of less than three weeks ' duration were enrolled . Subjective measures of pain intensity on an 11-point numerical rating scale were gathered from patients immediately before treatment and one hour afterward . Subjects received either OMT or 30 mg , IM ketorolac . Subjects ' perceived pain relief was also recorded at one hour after treatment on a subjective 5-point pain relief scale . Twenty-nine patients received IM ketorolac , and 29 patients received OMT . Although both groups showed a significant reduction in pain intensity , 1.7+/-1.6 ( P < .001 [ 95 % CI , 1.1 - 2.3 ] ) and 2.8+/-1.7 ( P < .001 [ 95 % CI , 2.1 - 3.4 ] ) , respectively , patients receiving OMT reported a significantly greater decrease in pain intensity ( P=.02 [ 95 % CI , 0.2 - 1.9 ] ) . When comparing pain relief at one hour posttreatment , there was no significant difference between the OMT and ketorolac study groups ( P=.10 ) . The authors found that , at one hour posttreatment , OMT is as efficacious as IM ketorolac in providing pain relief and significantly better in reducing pain intensity . The authors conclude that OMT is a reasonable alternative to parenteral nonsteroidal anti-inflammatory medication for patients with acute neck pain in the ED setting Objectives This 40-week workplace physical training RCT investigated the effect of soccer and Zumba , respectively , on muscle pain intensity and duration , work ability , and rating of perceived exertion ( RPE ) during work among female hospital employees . Methods 107 hospital employees were cluster-r and omized into two training groups , and a control group . The training was conducted outside working hours as two-three 1-h sessions per week for the first 12 weeks , and continued as one-two 1-h sessions per week for the last 28 weeks . Muscle pain intensity and duration , work ability , and RPE during work were measured at baseline and after 12 and 40 weeks . Results After 12 weeks , both the soccer ( −1.9 , 95 % CI , −3.0 , −0.8 , P = 0.001 ) and the Zumba group ( −1.3 , 95 % CI , −2.3 , −0.3 , P = 0.01 ) reduced the pain intensity ( on a scale from 0 to 10 ) in the neck-shoulder region ( eta squared = 0.109 ) , whereas only the soccer group ( −1.9 , 95 % CI , −3.2 , −0.7 , P = 0.002 , eta squared = 0.092 ) showed a reduction after 40 weeks referencing the control group . After 40 weeks , both the soccer ( -16.4 days , 95 % CI , −29.6 , −3.2 , P<0.02 ) and the Zumba group ( -16.6 days , 95 % CI , −28.9 , −4.2 , P<0.01 ) reduced the pain duration during the past 3 months in the neck-shoulder region ( eta squared = 0.077 ) . No significant effects on intensity or duration of pain in the lower back , RPE during work or work ability were found . Conclusions The present study indicates that workplace initiated soccer and Zumba training improve neck-shoulder pain intensity as well as duration among female hospital employees . Trial Registration International St and ard R and omized Controlled Trial Number Register IS RCT N 61986892 Background Neck pain in adults is common and a leading cause of physical disability . Recently , a guideline was developed for the management of non-specific neck pain ( NSNP ) with an aim to improve the quality of the delivery of chiropractic care . One key guideline recommendation is to undertake multimodal care for patients with NSNP . The aim of this pilot study is to determine the feasibility of implementing a multifaceted knowledge translation intervention by promoting the use of multimodal care by chiropractors managing patients with NSNP . Methods / design The design is a cluster-r and omized controlled pilot and feasibility trial . Chiropractors in private practice in Canada will be approached to participate in the study . Thirty consenting chiropractors will be r and omized to receive either a theory-based educational intervention in the experimental group or simply a printed copy of the guideline in the control group .  Each chiropractor will recruit five neck pain patients ( a total of 150 patients ) into the study . Development of the multifaceted intervention was informed by the results of a related qualitative study based on the Theoretical Domains Framework and consists of a series of three webinars , two online case scenarios , a self-management video on Brief Action Planning , and a printed copy of the practice guideline . Primary feasibility outcomes for both chiropractors and patients include rates of ( 1 ) recruitment , ( 2 ) retention , and ( 3 ) adherence to the intervention . A checklist of proxy measures embedded within patient encounter forms will be used to assess chiropractors ’ compliance with guideline recommendations ( e.g. exercise and self-care prescriptions ) at study onset and at 3 months . Secondary outcomes include scores of behavioural constructs ( level of knowledge and self-efficacy ) for recommended multimodal care . Clinical outcomes include pain intensity and neck pain-specific disability . Analyses from this study will focus on generating point estimates and corresponding 95 % confidence intervals for parameters of a priori interest ( recruitment , retention , adherence , pain intensity , Neck Disability Index ) . Discussion Results of this study will inform the design of a larger cluster-r and omized controlled trial aim ed at evaluating the effectiveness of the theory-based tailored intervention and increasing the use of multimodal care by chiropractors managing patients with NSNP.Trial registration https:// clinical trials.gov/ , Introduction Return to work following an occupational injury is a multifactoral process although many traditional clinic-based rehabilitation programs do not appreciate the importance of workplace factors . A r and omized controlled trial was conducted to investigate the effect of workplace-based rehabilitation program on the return to work outcome of work-related rotator cuff disorder , which is based on the therapeutic use of actual work facilities and work environment . Methods A total of 103 workers were recruited and r and omly assigned into Clinic-based Work Hardening ( CWH ) or Workplace-based Work Hardening ( WWH ) groups . The CWH group were given traditional generic work hardening training while WWH group received workplace-based work hardening training with rehabilitative principles of athletic rotator cuff pathology , biomechanics and specific job activities . Results After four weeks , a higher return to work rate was obtained in WWH group compared to CWH group ( 71.4 % vs. 37 % , p < 0.01 ) . A statistically significant difference ( p < 0.05 ) was also noted in lowering of self-reported shoulder problems and functional work capabilities in the WWH group versus the CWH group . Conclusion Workplace-based rehabilitation program appeared to be more effective in facilitating the return to work process of the injured worker as assessed immediately following intervention . In particular this approached was associated with many of the psychosocial workplace factors related to separation from the work routine . The influence of peer group and /or employer could be minimized . This initial attempt with rotator cuff injuries appears promising however long-term outcome needs to be determined 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 ) The aim was to determine the effect of one weekly hour of specific strength training within working hours , performed with the same total training volume but with different training frequencies and duration s , or with different levels of supervision , on compliance , muscle health and performance , behavior and work performance . In total , 573 office workers were cluster-r and omized to : 1 WS : one 60-min supervised session/week , 3 WS : three 20-min supervised sessions/week , 9 WS : nine 7-min supervised sessions/week , 3 MS : three 20-min sessions/week with minimal supervision , or REF : a reference group without training . Outcomes were diary-based compliance , total training volume , muscle performance and question naire-based health , behavior and work performance . Comparisons were made among the WS training groups and between 3 WS and 3 MS . If no difference , training groups were collapsed ( TG ) and compared with REF . Results demonstrated similar degrees of compliance , mean(range ) of 39(33 - 44)% , and total training volume , 13.266(11.977 - 15.096)kg . Musculoskeletal pain in neck and shoulders were reduced with approx . 50 % in TG , which was significant compared with REF . Only the training groups improved significantly their muscle strength 8(4 - 13)% and endurance 27(12 - 37)% , both being significant compared with REF . No change in workability , productivity or self-rated health was demonstrated . Secondary analysis showed exercise self-efficacy to be a significant predictor of compliance . Regardless of training schedule and supervision , similar degrees of compliance were shown together with reduced musculoskeletal pain and improved muscle performance . These findings provide evidence that a great degree of flexibility is legitimate for companies in planning future implementation of physical exercise programs at the workplace . Clinical Trials.gov , number NCT01027390 BACKGROUND CONTEXT Neck pain , common among the elderly population , has considerable implication s on health and quality of life . Evidence supports the use of spinal manipulative therapy ( SMT ) and exercise to treat neck pain ; however , no studies to date have evaluated the effectiveness of these therapies specifically in seniors . PURPOSE To assess the relative effectiveness of SMT and supervised rehabilitative exercise , both in combination with and compared to home exercise ( HE ) alone for neck pain in individuals ages 65 years or older . STUDY DESIGN / SETTING R and omized clinical trial . PATIENT SAMPLE Individuals 65 years of age or older with a primary complaint of mechanical neck pain , rated ≥3 ( 0 - 10 ) for 12 weeks or longer in duration . OUTCOME MEASURES Patient self-report outcomes were collected at baseline and 4 , 12 , 26 , and 52 weeks after r and omization . The primary outcome was pain , measured by an 11-box numerical rating scale . Secondary outcomes included disability ( Neck Disability Index ) , general health status ( Medical Outcomes Study Short Form-36 ) , satisfaction ( 7-point scale ) , improvement ( 9-point scale ) , and medication use ( days per week ) . METHODS This study was funded by the US Department of Health and Human Services , Health Re sources and Services Administration . Linear mixed model analyses were used for comparisons at individual time points and for short- and long-term analyses . Blinded evaluations of objective outcomes were performed at baseline and 12 weeks . Adverse event data were collected at each treatment visit . RESULTS A total of 241 participants were r and omized , with 95 % reporting primary outcome data at all time points . After 12 weeks of treatment , the SMT with home exercise group demonstrated a 10 % greater decrease in pain compared with the HE-alone group , and 5 % change over supervised plus home exercise . A decrease in pain  favoring supervised plus HE over HE alone did not reach statistical significance . Compared with the HE group , both combination groups reported greater improvement at week 12 and more satisfaction at all time points . Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term . No serious adverse events were observed as a result of the study treatments . CONCLUSIONS SMT with HE result ed in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone . Supervised exercise sessions added little benefit to the HE-alone program Background Specific strength training can reduce neck and shoulder pain in office workers , but the optimal combination of exercise frequency and duration remains unknown . This study investigates how one weekly hour of strength training for the neck and shoulder muscles is most effectively distributed . Methods A total of 447 office workers with and without neck and /or shoulder pain were r and omly allocated at the cluster-level to one of four groups ; 1 × 60 ( 1WS ) , 3 × 20 ( 3WS ) or 9 × 7 ( 9WS ) min a week of supervised high-intensity strength training for 20 weeks , or to a reference group without training ( REF ) . Primary outcome was self-reported neck and shoulder pain ( scale 0–9 ) and secondary outcome work disability ( Disability in Arms , Shoulders and H and s ( DASH ) ) . Results The intention-to-treat analysis showed reduced neck and right shoulder pain in the training groups after 20 weeks compared with REF . Among those with pain ≥3 at baseline ( n=256 ) , all three training groups achieved significant reduction in neck pain compared with REF ( p<0.01 ) . From a baseline pain rating of 3.2 ( SD 2.3 ) in the neck among neck cases , 1WS experienced a reduction of 1.14 ( 95 % CI 0.17 to 2.10 ) , 3WS 1.88 ( 0.90 to 2.87 ) and 9WS 1.35 ( 0.24 to 2.46 ) which is considered clinical ly significant . DASH was reduced in 1WS and 3WS only . Conclusion One hour of specific strength training effectively reduced neck and shoulder pain in office workers . Although the three contrasting training groups showed no statistical differences in neck pain reduction , only 1WS and 3WS reduced DASH . This study suggests some flexibility regarding time-wise distribution when implementing specific strength training at the workplace Objective To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy . Design R and omised controlled trial . Setting Neurology outpatient clinics in three Dutch hospitals . Participants 205 patients with symptoms and signs of cervical radiculopathy of less than one month ’s duration Interventions Treatment with a semi-hard collar and taking rest for three to six weeks ; 12 twice weekly sessions of physiotherapy and home exercises for six weeks ; or continuation of daily activities as much as possible without specific treatment ( control group ) . Main outcome measures Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks . Results In the wait and see group , arm pain diminished by 3 mm/week on the visual analogue scale ( β=−3.1 mm , 95 % confidence interval −4.0 to −2.2 mm ) and by 19 mm in total over six weeks . Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction ( collar : β=−1.9 mm , −3.3 to −0.5 mm ; physiotherapy : β=−1.9 , −3.3 to −0.8 ) , result ing in an extra pain reduction compared with the control group of 12 mm after six weeks . In the wait and see group , neck pain did not decrease significantly in the first six weeks ( β=−0.9 mm , −2.0 to 0.3 ) . Treatment with the collar result ed in a weekly reduction on the visual analogue scale of 2.8 mm ( −4.2 to −1.3 ) , amounting to 17 mm in six weeks , whereas physiotherapy gave a weekly reduction of 2.4 mm ( −3.9 to −0.8 ) result ing in a decrease of 14 mm after six weeks . Compared with a wait and see policy , the neck disability index showed a significant change with the use of the collar and rest ( β=−0.9 mm , −1.6 to −0.1 ) and a non-significant effect with physiotherapy and home exercises . Conclusion A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy . Trial registration Clinical trials NCT00129714 QUESTION Are postural exercises delivered by Mensendieck/Cesar therapists more effective in decreasing pain , reducing disability and improving health-related quality of life in visual display unit workers with early non-specific work-related upper limb disorders than strength and fitness exercises delivered by physiotherapists ? DESIGN R and omised trial with concealed allocation and intention-to-treat analysis . PARTICIPANTS Eighty-eight ( 6 drop-outs ) visual display unit workers with early non-specific work-related upper limb disorders . INTERVENTION One group received 10 weeks of postural exercises while the other group received 10 weeks of strength and fitness exercises . OUTCOME MEASURES Pain was measured with a 10-cm visual analogue scale , disability was measured with the Disabilities of Arm , Shoulder and H and question naire , and health-related quality of life was measured with the Short Form-36 . Number of participants experiencing upper limb complaints was also collected . Outcome measures were collected at baseline and again at 3 , 6 , and 12 months . RESULTS There was no significant difference in decrease in pain between the groups at 3 months ( 0.6 cm , 95 % CI 0.0 to 1.2 ) , 6 months ( 0.2 , 95 % CI -0.3 to 0.7 ) , or at 12 months ( 0.1 , 95 % CI -0.6 to 0.8 ) . Differences between the groups in upper limb complaints , disability , and health related quality of life were also small and not significant at any measurement occasion . CONCLUSION Postural exercises did not result in a better outcome than strength and fitness exercises . However , 55 % of visual display unit workers with early non-specific work-related upper limb disorders reported being free of complaints one year after both interventions were commenced . TRIAL REGISTRATION IS RCT N15872455 Objectives Little is known about the effectiveness of therapeutic massage , one of the most popular complementary medical treatments for neck pain . A r and omized controlled trial was conducted to evaluate whether therapeutic massage is more beneficial than a self-care book for patients with chronic neck pain . Methods Sixty-four such patients were r and omized to receive up to 10 massages over 10 weeks or a self-care book .  Follow-up telephone interviews after 4 , 10 , and 26 weeks assessed outcomes including dysfunction and symptoms . Log-binomial regression was used to assess whether there were differences in the percentages of participants with clinical ly meaningful improvements in dysfunction and symptoms ( ie , > 5-point improvement on the Neck Disability Index ; > 30 % improvement from baseline on the symptom bothersomeness scale ) at each time point . Results At 10 weeks , more participants r and omized to massage experienced clinical ly significant improvement on the Neck Disability Index [ 39 % vs. 14 % of book group ; relative risk (RR)=2.7 ; 95 % confidence interval ( CI ) , 0.99 - 7.5 ] and on the symptom bothersomeness scale ( 55 % vs. 25 % of book group ; RR=2.2 ; 95 % CI , 1.04 - 4.2 ) . After 26 weeks , massage group members tended to be more likely to report improved function ( RR=1.8 ; 95 % CI , 0.97 - 3.5 ) , but not symptom bothersomeness ( RR=1.1 ; 95 % CI , 0.6 - 2.0 ) . Mean differences between groups were strongest at 4 weeks and not evident by 26 weeks . No serious adverse experiences were reported . Conclusions This study suggests that massage is safe and may have clinical benefits for treating chronic neck pain at least in the short term . A larger trial is warranted to confirm these results Background Previous studies have shown positive effects of physical exercise at the workplace on musculoskeletal disorders . However , long-term adherence remains a challenge . The present study evaluates long-term adherence and effects of a workplace strength training intervention on back , neck and upper extremity pain among laboratory technicians . Methods Cluster-r and omized controlled trial involving 537 industrial laboratory technicians . Subjects were r and omized at the cluster level to one of two groups : training group 1 ( TG1 , n = 282 ) performing supervised strength training from February to June 2009 ( round one ) or training group 2 ( TG2 , n = 255 ) performing supervised strength training from August to December 2009 ( round two ) . The outcome measures were changes in self-reported pain intensity ( 0–9 ) in the back , neck and upper extremity as well as Disability of the Arm , Shoulder and H and ( DASH , 0–100 ) . Results Regular adherence , defined as at least one training session per week , was achieved by around 85 % in both groups in the supervised training periods . In the intention-to-treat analyses there were significant group by time effects for pain in the neck , right shoulder , right h and and lower back and DASH - result ing in significant reductions in pain ( mean 0.3 to 0.5 ) and DASH ( mean 3.9 ) in the scheduled training group compared to the reference group . For TG1 there were no significant changes in pain in round two , i.e. they maintained the pain reduction achieved in round one . Subgroup analyses among those with severe pain ( > = 3 on a scale of 0–9 ) showed a significant group by time effect for pain in the neck , right shoulder , upper back and lower back . For these subgroups the pain reduction in response to training ranged from 1.1 to 1.8 . Conclusions Specific strength training at the workplace can lead to significant long-term reductions in spinal and upper extremity pain and DASH . The pain reductions achieved during the intensive training phase with supervision appears to be maintained a half year later Background Although leisure-time physical activity is important for health , adherence to regular exercise is challenging for many adults . The workplace may provide an optimal setting to reach a large proportion of the adult population needing regular physical exercise . This study evaluates the effect of implementing strength training at the workplace on non-specific neck and shoulder pain among industrial workers . Methods Cluster-r and omized controlled trial involving 537 adults from occupations with high prevalence of neck and shoulder pain ( industrial production units ) . Participants were r and omized to 20 weeks of high-intensity strength training for the neck and shoulders three times a week ( n = 282 ) or a control group receiving advice to stay physically active ( n = 255 ) . The strength training program followed principles of progressive overload and periodization . The primary outcome was changes in self-reported neck and shoulder pain intensity ( scale 0 - 9 ) . Results 85 % of the participants followed the strength training program on a weekly basis . In the training group compared with the control group , neck pain intensity decreased significantly ( -0.6 , 95 % CI -1.0 to -0.1 ) and shoulder pain intensity tended to decrease ( -0.2 , 95 % CI -0.5 to 0.1 , P = 0.07 ) . For pain-cases at baseline ( pain intensity > = 3 ) the odds ratio - in the training group compared with the control group - for being a non-case at follow-up ( pain intensity < 3 ) was 2.0 ( 95 % CI 1.0 to 4.2 ) for the neck and 3.9 ( 95 % CI 1.7 to 9.4 ) for the shoulders . Conclusion High-intensity strength training relying on principles of progressive overload can be successfully implemented at industrial workplaces , and results in significant reductions of neck and shoulder pain . Trial registration NCT01071980 OBJECTIVES This study evaluated the effects on work-related neck and upper-limb disorders  among computer workers stimulated ( by a software program ) to take regular breaks and perform physical exercises . Possible effects on sick leave and productivity were studied as well . A r and omized controlled design was used with cluster r and omization . Altogether 268 computer workers with complaints in the neck or an upper limb from 22 office locations were r and omized into a control group , one intervention group stimulated to take extra breaks and one intervention group stimulated to perform exercises during the extra breaks during an 8-weekperiod . Question naires were administered before and after the intervention , and questions were generated by the software during the intervention period . Computer usage was recorded online . RESULTS The data on self-reported recovery suggested a favorable effect ; more subjects in the intervention groups than in the control group reported recovery ( 55 % versus 34 % ) from their complaints and fewer reported deterioration ( 4 % versus 20 % ) . However , a comparison between the reported pre- and postintervention scores on the severity and frequency of the complaints showed no significant differences in the change among the three groups . No effects on sick leave were observed . The subjects in the intervention groups showed higher productivity . CONCLUSIONS The use of a software program stimulating workers to take regular breaks contributes to perceived recovery from neck or upper-limb complaints . There seems to be no additional effects from performing physical exercises during these breaks Background Evidence suggests that to facilitate physical activity sedentary people may adhere to one component of exercise prescriptions ( intensity , duration or frequency ) without adhering to other components . Some experts have provided evidence for determinants of adherence to different components among healthy people . However , our underst and ing remains scarce in this area for patients with neck or low back pain . The aims of this study are to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program , and to identify if adherence to both exercise components have distinct predictive factors . Methods A cohort of one hundred eighty-four patients with chronic neck or low back pain who attended physiotherapy in eight primary care centers were studied prospect ively one month after intervention . The study had three measurement periods : at baseline ( measuring characteristics of patients and pain ) , at the end of physiotherapy intervention ( measuring characteristics of the home exercise program ) and a month later ( measuring professional behaviors during clinical encounters , environmental factors and self-efficacy , and adherence behavior ) . Results Adherence to duration per session ( 70.9 % ± 7.1 ) was more probable than adherence to frequency per week ( 60.7 % ± 7.0 ) . Self-efficacy was a relevant factor for both exercise components ( p < 0.05 ) . The total number of exercises prescribed was predictive of frequency adherence ( p < 0.05 ) . Professional behaviors have a distinct influence on exercise components . Frequency adherence is more probable if patients received clarification of their doubts ( adjusted OR : 4.1 ; p < 0.05 ) , and duration adherence is more probable if they are supervised during the learning of exercises ( adjusted OR : 3.3 ; p < 0.05 ) . Conclusion We have shown in a clinic-based study that adherence to exercise prescription frequency and duration components have distinct levels and predictive factors . We recommend additional study , and advise that differential attention be given in clinical practice to each exercise component for improving adherence Background Continuous neck and shoulder pain is a common musculoskeletal complaint . Physical exercise can reduce pain symptoms , but compliance to exercise is a challenge . Exercise-specific self-efficacy has been found to be a predictor of participation in preplanned exercise . Little is known about the influence of exercise-specific self-efficacy on compliance to workplace physical exercise . Purpose To determine the influence of exercise-specific self-efficacy on compliance to specific strength exercises during working hours for laboratory technicians . Methods We performed a cluster-r and omized controlled trial , including laboratory technicians from two industrial production units in Copenhagen , Denmark . The participants were r and omized to supervised specific strength exercises for the neck and shoulder muscles  for 20 minutes three times a week ( n = 282 ) or to a reference group ( n = 255 ) . The participants answered baseline and follow-up questions regarding self-efficacy and registered all exercises in a diary . Results Overall compliance to exercises was 45 % . Compliance in company A ( private sector ) differed significantly between the three self-efficacy groups after 20 weeks . The odds ratio of compliance was 2.37 for moderate versus low self-efficacy , and 2.93 for high versus low self-efficacy . No significant difference was found in company B ( public sector ) or in the intervention group as a whole . Conclusion We did not find self-efficacy to be a general statistically significant predictor of compliance to exercises during 20 weeks , but found self-efficacy to be a predictor of compliance in a private sector setting . Workplace-specific differences might be present and should be taken into account STUDY DESIGN R and omized clinical trial . OBJECTIVE To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude ( HVLA ) thrust manipulation to nonthrust mobilization in patients with neck pain . BACKGROUND Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain , no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain . METHODS Patients completed the Neck Disability Index , the numeric pain rating scale , the flexion-rotation test for measurement of C1 - 2 passive rotation range of motion , and the craniocervical flexion test for measurement of deep cervical flexor motor performance . Following the baseline evaluation , patients were r and omized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical ( C1 - 2 ) and upper thoracic ( T1 - 2 ) spines . Patients were reexamined 48-hours after the initial examination and again completed the outcome measures . The effects of treatment on disability , pain , C1 - 2 passive rotation range of motion , and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance ( ANOVA ) . RESULTS One hundred seven patients satisfied the eligibility criteria , agreed to participate , and were r and omized into the HVLA thrust manipulation  ( n = 56 ) and  nonthrust mobilization  ( n = 51 ) groups . The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly ( P<.001 ) greater reductions in disability ( 50.5 % ) and pain ( 58.5 % ) than those of the nonthrust mobilization group ( 12.8 % and 12.6 % , respectively ) following treatment . In addition , the HVLA thrust manipulation group had significantly ( P<.001 ) greater improvement in both passive C1 - 2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization . The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up , using the global rating of change and Neck Disability Index cut scores , respectively . CONCLUSION The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain . LEVEL OF EVIDENCE Therapy , level 1b Abstract Patients with chronic whiplash associated disorders present with varied sensory , motor and psychological features . In this first instance it was question ed whether a multimodal program of physical therapies was an appropriate management to be broadly prescribed for these patients when it was known that some would have sensory features suggestive of a notable pain syndrome . A r and omised controlled trial was conducted with 71 participants with persistent neck pain following a motor vehicle crash to explore this question . Participants were r and omly allocated to receive either a multimodal physiotherapy program ( MPT ) or a self‐management program ( SMP ) ( advice and exercise ) . In the r and omisation process , participants were stratified according to the presence or not of widespread mechanical or cold hyperalgesia . The intervention period was 10 weeks and outcomes were assessed immediately following treatment . Even with the presence of sensory hypersensitivity in 72.5 % of subjects , both groups reported some relief of neck pain and disability ( Neck Disability Index ) and it was superior in the group receiving multimodal physiotherapy ( p = 0.04 ) . Post‐hoc observations however suggested that relief was marginal in the subgroup with both widespread mechanical and cold hyperalgesia . Further research is required to test the validity of this sub‐group observation and to test the effect of the intervention in the long term Background .Neck and low back pain are leading causes of morbidity and health care utilization . However , little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain . Objectives .The objectives of this study were to : 1 ) describe health care utilization for neck and back pain ; 2 ) determine the characteristics of individuals seeking health care for neck and back pain ; and 3 ) identify the characteristics of patients who consult medical doctors , chiropractors , or both .  Design . Population -based cross-sectional mailed survey . Subjects . Subjects were r and omly selected adults from the Saskatchewan Health Insurance and Registration File . Measures .Demographic , socio-economic , general health , comorbidity , health-related- quality -of-life , pain severity and health care utilization data were collected . The main outcome was whether subjects with prevalent neck or low back pain visited a  health care provider in the previous month . Results .Twenty-five percent of individuals with neck or low back pain visited a health care provider . Seeking health care was associated with disabling neck or back pain , digestive disorders , worse bodily pain and worse physical-role-functioning . Compared with medical patients , fewer chiropractic patients lived in rural areas or reported arthritis , but they reported better social and physical functioning . More patients consulting both providers reported disabling neck or back pain . Conclusions .Individuals seeking care for neck or back pain have worse health status than those who do not seek care . Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors UNLABELLED The aim of this study was to evaluate the effectiveness of qigong compared with exercise therapy and no treatment .  Elderly patients with chronic neck pain ( > 6 months ) were r and omly assigned to qigong or exercise therapy ( each 24 sessions over a period of 3 months ) or to a waiting list control . Patients completed st and ardized question naires at baseline and after 3 and 6 months . The main outcome measure was average neck pain on the visual analogue scale after 3 months . Secondary outcomes were neck pain and disability ( NPAD ) and quality of life ( SF-36 ) .  One hundred seventeen patients ( age , 76 + /- 8 years , 95 % women ) were included in the intention-to-treat analysis . The average duration of neck pain was 19.0 + /- 14.9 years . After 3 months , no significant differences were observed between the qigong group and the waiting list control group ( visual analogue scale mean difference , -11 mm [ CI , -24.0 ; 2.1 ] , P = .099 ) or between the qigong group and the exercise therapy group ( -2.5 mm [ - 15.4 ; 10.3 ] , P = .699 ) . Results for the NPAD were similar ( qigong vs waiting list -6.7 ( -15.4 ; 2.1 ) , P = .135 ; qigong vs exercise therapy 2.3 ( -6.2 ; 10.8 ) ; P = .600 ) . We found no significant effect after 3 months of qigong or exercise therapy compared with no treatment . Further studies should include outcomes more suitable to elderly patients , longer treatment , and patients with less chronic pain . PERSPECTIVE In a r and omized controlled study , we evaluated whether a treatment of 24 qigong sessions over a period of 3 months is ( 1 ) superior to no treatment and ( 2 ) superior to the same amount of exercise therapy in elderly patients ( age , 76 + /- 8 years , 95 % women ) with long-term chronic neck pain ( 19.0 + /- 14.9 years ) . After 3 and 6 months , we found no significant differences for pain , neck pain , disability , and quality of life among the 3 groups BACKGROUND Little is known about the effectiveness of treatments for acute whiplash injury . We aim ed to estimate whether training of staff in emergency departments to provide active management consultations was more effective than usual consultations ( Step 1 ) and to estimate whether a physiotherapy package was more effective than one additional physiotherapy advice session in patients with persisting symptoms ( Step 2 ) . METHODS Step 1 was a pragmatic , cluster r and omised trial of 12 NHS Trust hospitals including 15 emergency departments who treated patients with acute whiplash associated disorder of grade s I-III . The hospitals were r and omised by clusters to either active management or usual care consultations . In Step 2 , we used a nested individually r and omised trial . Patients were r and omly assigned to receive either a package of up to six physiotherapy sessions or a single advice session . R and omisation in Step 2 was stratified by centre . Investigator-masked outcomes were obtained at 4 , 8 , and 12 months . Masking of clinicians and patients was not possible in all steps of the trial . The primary outcome was the Neck Disability Index ( NDI ) . Analysis was intention to treat , and included an economic evaluation . The study is registered IS RCT N33302125 . FINDINGS Recruitment ran from Dec 5 , 2005 to Nov 30 , 2007 . Follow-up was completed on Dec 19 , 2008 . In Step 1 , 12 NHS Trusts were r and omised , and 3851 of 6952 eligible patients agreed to participate ( 1598 patients were assigned to usual care and 2253 patients were assigned to active management ) . 2704 ( 70 % ) of 3851 patients provided data at 12 months . NDI score did not differ between active management and usual care consultations ( difference at 12 months 0·5 , 95 % CI -1·5 to 2·5 ) . In Step 2 , 599 patients were r and omly assigned to receive either advice ( 299 patients ) or a physiotherapy package ( 300 patients ) . 479 ( 80 % ) patients provided data at 12 months . The physiotherapy package at 4 months showed a modest benefit compared to advice ( NDI difference -3·7 , -6·1 to -1·3 ) , but not at 8 or 12 months . Active management consultations and the physiotherapy package were more expensive than usual care and single advice session . No treatment-related serious adverse events or deaths were noted . INTERPRETATION Provision of active management consultation did not show additional benefit . A package of physiotherapy gave a modest acceleration to early recovery of persisting symptoms but was not cost effective from a UK NHS perspective . Usual consultations in emergency departments and a single physiotherapy advice session for persistent symptoms are recommended . FUNDING NIHR Health Technology Assessment programme & NA ; Regular physical exercise is a cornerstone in rehabilitation programs , but adherence to comprehensive exercise remains low . This study determined the effectiveness of small daily amounts of progressive resistance training for relieving neck/shoulder pain in healthy adults with frequent symptoms ; 174 women and 24 men working at least 30 h per week and with frequent neck/shoulder pain were r and omly assigned to resistance training with elastic tubing for 2 or 12 minutes per day 5 times per week , or weekly information on general health ( control group ) . Primary outcomes were changes in intensity of neck/shoulder pain ( scale 0 to 10 ) , examiner‐verified tenderness of the neck/shoulder muscles ( total tenderness score of 0 to 32 ) , and isometric muscle strength at 10 weeks . Compared with the control group , neck/shoulder pain and tenderness , respectively , decreased 1.4 points ( 95 % confidence interval −2.0 to −0.7 , p < 0.0001 ) and 4.2 points ( 95 % confidence interval −5.7 to −2.7 , p < 0.0001 ) in the 2‐minute group and 1.9 points ( 95 % confidence interval −2.5 to −1.2 , p < 0.0001 ) and 4.4 points ( 95 % confidence interval −5.9 to −2.9 , p < 0.0001 ) in the 12‐minute group . Compared with the control group , muscle strength increased 2.0 Nm ( 95 % confidence interval 0.5 to 3.5 Nm , p = 0.01 ) in the 2‐minute group and 1.7 Nm ( 95 % confidence interval 0.2 to 3.3 Nm , p = 0.02 ) in the 12‐minute group . In conclusion , as little as 2 minutes of daily progressive resistance training for 10 weeks results in clinical ly relevant reductions of pain and tenderness in healthy adults with frequent neck/shoulder symptoms . Trial registration : www.is rct n.org/IS RCT N60264809 . In generally healthy adults with frequent neck/shoulder muscle pain , as little as 2 minutes of daily progressive resistance training reduces pain and tenderness Objectives This study aim ed to evaluate the effects of an exercise programme focusing on muscle stretching and endurance training on the 12-month incidence of neck pain in office workers . Methods A 12-month prospect i ve cluster-r and omised controlled trial was conducted in healthy office workers with lower-than-normal neck flexion movement or neck flexor endurance . Participants were recruited from 12 large-scale enterprises . A total of 567 healthy office workers were r and omly assigned at the cluster level into either intervention ( n=285 ) or control ( n=282 ) groups . Participants in the intervention group received an exercise programme that included daily stretching exercise and twice-a-week muscle endurance training . Those in the control group received no intervention . The primary outcome measure was the 12-month incidence of neck pain , and the secondary outcome measures were pain intensity , disability level , and quality of life and health status . Analyses were performed using the Cox proportional hazard models . Results Over the 12-month follow-up , 12.1 % of participants in the intervention group and 26.7 % in the control group developed incident neck pain . Hazard rate ratios showed a protective effect of the exercise programme for neck pain ( HR=0.45 , 95 % CI 0.28 to 0.71 ) after adjusting for biopsychosocial factors . There was no significant difference in pain intensity , disability and quality of life and health status between those who reported incident neck pain in the intervention and control groups . Conclusions The exercise programme reduced incident neck pain and increased neck flexion movement for office workers with lower-than-normal neck flexion movement OBJECTIVE To examine the annual incidence of acute whiplash injuries after road traffic crashes in a geographic catchment area in Northern Sweden during the period 2000 - 2009 . DESIGN Descriptive epidemiology determined by prospect ively collected data from a defined population . SETTING The study was conducted at a public hospital in Sweden . PARTICIPANTS The population of the hospital 's catchment area ( 136,600 inhabitants in 1999 and 144,500 in 2009 ) . METHODS At the emergency department , all injured persons ( approximately 11,000 per year ) were asked to answer a question naire about the injury incident . Data from the medical records also were analyzed . From 2000 - 2009 , 15,506 persons were injured in vehicle crashes . Persons who were subject to an acute neck injury within whiplash-associated disorder grade s 1 - 3 were included . The overall and annual incidences were calculated as incidence . Age , gender , type of injury event , and direction of impact were described . The incidences were compared with national statistics on insurance cl aims from 2003 , 2007 , and 2008 to detect changes in the proportions of cl aims . MAIN OUTCOME MEASURES The annual incidence of acute whiplash injuries . Secondary outcome measures were types of injury events , age and gender distribution , changes in the proportion of rear-end crashes during 2000 - 2009 , and changes in the proportion of insurance cl aims during 2003 - 2008 . RESULTS During 2000 - 2009 , 3297 cases of acute whiplash injury were encountered . The overall incidence was 235/100,000/year . The average yearly increase in incidence was 1.0 % . Women comprised 51.9 % and men 48.1 % of the injured . Car occupants ( 86.4 % ) and bicycle riders ( 6.1 % ) were most frequently injured . The proportion of rear-end crashes decreased from 55 % to 45 % from 2000 - 2009 . The proportion of insurance cl aims significantly decreased between 2003 and 2008 ( P < .0001 , χ(2 ) test ) . CONCLUSION The incidence of emergency department visits attributable to acute whiplash injuries after road traffic crashes have been relatively stable during the past decade in our area , except in 2007 and 2008 , when a peak occurred BACKGROUND CONTEXT Although the use of deep heat therapy is widespread , there is scant literature available on its effectiveness in treating back or neck pain . PURPOSE The purpose of this study was to determine the efficacy of microwave diathermy to treat nonspecific chronic neck pain . DESIGN The study was design ed as a double-blind , r and omized controlled trial . PATIENT SAMPLE The patient sample consisted of 149 patients with nonspecific chronic neck pain in a hospital of the And alusian Public Health Care System , Spain OUTCOME MEASURES The study outcome measures are as follows : at baseline , pain intensity ( using a visual analogue scale ) , disability ( Neck Disability Index ) , and health-related quality of life ( 36-item short form health survey [ SF-36 ] ) ; at 3 weeks , baseline measures and patients ' perceived overall outcome and satisfaction with the treatment ; and at 6 months , 3-week measures , therapeutic co- interventions , and adherence to exercises . METHODS Patients were allocated r and omly to three groups . The first group received continuous microwave diathermy , the second group was administered pulsed microwaves , and the third group ( the control group ) received unplugged microwaves . All three groups received the same general treatment : range of motion , isometric exercises , and transcutaneous electrical nerve stimulation . RESULTS The three groups had reduced pain and disability , and improvement was seen in some dimensions of the SF-36 . However , there were no differences found in any of the parameters measured among the three therapeutic groups . CONCLUSIONS Microwave diathermy does not provide additional benefit to a treatment regimen of chronic neck pain that already involves other treatment approaches OBJECTIVE To evaluate the effect of neck coordination exercise on sensorimotor function in women with neck pain compared with best-available treatment and sham treatment . DESIGN Observer-blinded r and omized controlled trial with short-term and 6-month follow-ups . SUBJECTS Women with chronic non-specific neck pain were r and omized to 3 groups :  neck coordination exercise with a novel training device ; strength training for the neck and shoulders ; or massage .  Each group had 36 participants . METHODS The intervention period was 11 weeks with 22 individually supervised sessions . Primary outcomes were postural sway measures and precision of goal -directed arm movements . Secondary outcomes were range of motion for the neck , peak speed of axial rotation , and neck pain . A repeated measures multivariate analysis of variance ( MANOVA ) was conducted separately on the primary outcomes for the short-term and 6-month evaluations and on the sensorimotor secondary outcomes for the 6-month effect . The 6-month effect on pain was analysed with a repeated measures analysis of variance ( ANOVA ) . RESULTS No significant treatment effects in favour of neck coordination exercise were found for short-term or 6-month evaluations . CONCLUSION Neck coordination exercise is no better than strength training and massage in improving sensorimotor function . Further research should investigate the use of cut-offs for sensorimotor dysfunctions prior to proprioceptive or coordinative training STUDY DESIGN R and omized controlled trial . Objective To determine if force magnitude during posterior-to-anterior mobilization affects immediate and short-term outcomes in patients with chronic , nonspecific neck pain . BACKGROUND The optimal dose of mobilization to effectively treat patients with neck pain is not known . METHODS Patients with neck pain of at least 3 months in duration ( n = 64 ) were r and omized to receive a single treatment of posterior-to-anterior mobilization applied with 30 N or 90 N of mean peak force ( 3 sets of 30 seconds ) or a placebo ( detuned laser ) on the spinous process at the painful spinal level . Pressure pain threshold , pain measured with a visual analog scale ( range , 0 - 100 mm ) , cervical range of motion , and spinal stiffness at the painful spinal level ( measured with a custom device and normalized as a percentage of C7 stiffness ) were assessed before , immediately after , and at a mean ± SD follow-up of 4.0 ± 1.8 days following treatment . Repeated- measures analysis of covariance and Bonferroni-adjusted post hoc tests determined group differences for each outcome measure after treatment and at follow-up . RESULTS At follow-up , the 90-N group had less pain than the 30-N group ( mean difference , 11.3 mm ; 95 % confidence interval : 0.1 , 22.6 mm ; P = .048 ) and lower stiffness than the placebo group ( mean difference , 17.5 % ; 95 % confidence interval : 4.2 % , 30.9 % ; P = .006 ) . These differences were not present immediately after treatment . There were no significant between-group differences in pressure pain threshold or range of motion after treatment or at follow-up . CONCLUSION A specific dose of mobilization , in terms of applied force , appears necessary for reducing stiffness and potentially pain in patients with chronic neck pain . Changes were not observed immediately after mobilization , suggesting that its effects are not directly mechanical . TRIAL REGISTRATION Australian and New Zeal and Clinical Trials Registry ( http://www.anzctr.org.au/ ) : ACTRN12611000374965 . LEVEL OF EVIDENCE Therapy , level 1b- To evaluate the role of manual therapy with exercise regime versus exercise regime alone in the management of  non-specific chronic neck pain .  In this 62 subjects r and omized controlled trial 31 subjects in group A received manual therapy ( manipulation ) with supervised exercise regime whilst 31 subjects in group B performed only supervised exercise regime for the period of 3 weeks . Both groups had a home exercise program consisted of strengthening exercises for neck/scapuluar stability , stretching and general range of motion exercises for neck with advice regarding posture awareness and correction for 3 months . The results suggested significant reduction in pain intensity level in both groups ; over 3 weeks and 12 weeks ' time period in relation to baseline on visual analog scale ( p=0.001 ) . Similarly , statistically significant improvements noticed in Neck Disability Index ( NDI ) ( p=0.0001 ) in both groups while looking at baseline data with reference to 12 weeks ' time period . On closer inspection , the manual therapy ( manipulation ) with exercise regime appeared as a favorable treatment preference compared with exercise regime alone STUDY DESIGN Secondary analysis of a r and omized clinical trial ( RCT ) . OBJECTIVES To perform a secondary analysis on the treatment arm of a larger RCT to determine differences in treatment outcomes , adverse reactions , and effect sizes between patients who received cervical thrust manipulation  and those who received only nonthrust manipulation  as part of an impairment-based , multimodal treatment program of manual physical therapy ( MPT ) and exercise for patients with mechanical neck pain . BACKGROUND A treatment regimen of MPT and exercise has been effective in patients with mechanical neck pain . Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient population , and no studies have investigated the added benefit of cervical thrust manipulations as part of an overall MPT treatment plan . METHODS Treatment outcomes from 47 patients in the treatment arm of a larger RCT , with a primary complaint of mechanical neck pain , were analyzed . Twenty-three patients ( 49 % ) received cervical thrust manipulations as part of their MPT treatment , and 24 patients ( 51 % ) received only cervical nonthrust mobilizations . All patients received up to 6 clinic sessions , twice weekly for 3 weeks , and a home exercise program . Primary outcome measures were the Neck Disability Index ( NDI ) , 2 visual analog scales for cervical and upper extremity pain , and a 15-point global rating of change scale . Blinded outcome measurements were collected at baseline and at 3- , 6- and 52-week follow-ups . RESULTS Consistent with the larger RCT , both subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and disability scores . Low statistical power ( beta < or = .28 ) and the result ant small effect size indices ( -0.21 to 0.17 ) preclude the identification of any between-group differences . No serious adverse reactions were reported by patients in either subgroup . CONCLUSIONS Clinical ly meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation , as part of the MPT treatment plan , did not influence the results of the treatment arm of the larger RCT from which this study was drawn . Although no between-group differences can be identified , the small observed effect sizes in this study may benefit future studies with sample size estimation for larger RCTs and indicate the need to incorporate clinical prediction rule criteria as a means to improve statistical power . LEVEL OF EVIDENCE Therapy , level 4 UNLABELLED A r and omized controlled trial comparing manipulation with mobilization for recent onset neck pain .  OBJECTIVE To determine whether neck manipulation is more effective for neck pain than mobilization . DESIGN R and omized controlled trial with blind assessment of outcome . SETTING Primary care physiotherapy , chiropractic , and osteopathy clinics in Sydney , Australia . PARTICIPANTS Patients ( N=182 ) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner . INTERVENTIONS Participants were r and omly assigned to receive treatment with neck manipulation ( n=91 ) or mobilization ( n=91 ) . Patients in both groups received 4 treatments over 2 weeks . MAIN OUTCOME MEASURE The number of days taken to recover from the episode of neck pain . RESULTS The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group . Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization ( hazard ratio=.98 ; 95 % confidence interval , .66 - 1.46 ) . CONCLUSIONS Neck manipulation is not appreciably more effective than mobilization . The use of neck manipulation therefore can not be justified on the basis of superior effectiveness Objective : Coping is shown to affect outcomes in chronic pain patients ; however , few studies have examined the role of coping in the course of recovery in whiplash-associated disorders ( WAD ) . The purpose of this study was to determine the predictive value of coping style for 2 key aspects of WAD recovery , reductions in neck pain , and in disability . Methods : A population -based prospect i ve cohort study design was used to study 2986 adults with traffic-related WAD . Participants were assessed at baseline , 6 weeks , and 4 , 8 , and 12 months postinjury .  Coping  was measured at 6 weeks using the Pain Management Inventory  , and neck pain recovery was assessed at each subsequent follow-up , using a 100 mm  visual analogue scale ( VAS ) . Disability was assessed at each follow-up using the Pain Disability Index ( PDI ) . Pain recovery was defined as a VAS score of 0 to 10 ; disability recovery was defined as a PDI score of 0 to 4 . Data analysis used multivariable Cox proportional hazards models . Results : Those using high versus low levels of passive coping at 6 weeks postinjury experienced 28 % slower pain recovery and 43 % slower disability recovery . Adjusted hazard rate ratios for pain recovery and disability recovery were 0.72 ( 95 % CI , 0.59 - 0.88 ) and 0.57 ( 95 % CI , 0.41 - 0.78 ) , respectively . Active coping was not associated with recovery of neck pain or disability . Conclusions : Passive coping style predicts neck pain and self-assessed disability recovery . It may be beneficial to assess and improve coping style early in WAD Purpose Health and safety training program has been applied to prevent work-related  musculoskeletal disorders ( MSDs ) in workplace . We evaluated the effectiveness of participatory training and didactic training programs on MSD prevention among frontline workers in Shenzhen , China . Methods The authors r and omly assigned 918 workers from intervention factories to receive participatory training ( intervention group ) , and 907 workers from intervention factories and 1,654 workers from control factories to receive didactic training ( control_1 group , control_2 group , respectively ) from June 1 , 2008 to November 30 , 2009 . Participants were asked to report experience of ache , pain or discomfort in 10 body parts at baseline and 1 year after training . Data were analyzed to compare the MSD prevalence 1 year before and 1 year after training in different groups from 2009 to 2010 . Results The follow-up rate was 61 % ( 2,120/3,479 ) at 1 year after training . In the year after training , there were no statistically significant changes in the proportion of workers who reported MSD in any body part . MSD prevalence rates in the intervention group reduced from 16.8 to 9.9 % for lower extremities ( χ2 = 13.102 , p < 0.001 ) and from 12.9 to 8.3 % ( χ2 = 9.433 , p = 0.002 ) for wrist and finger at 1 year after training . However , the rates did not change significantly for upper back , lower back , neck , shoulder and elbow in the intervention group and for all 10 body parts in two control groups . Conclusions Overall , the training programs did not seem to prevent the occurrence of MSD among frontline workers . However , participatory training might be effective to reduce MSD in the lower extremities and wrist and finger Study Design . R and omized controlled trial using mixed methods . Objective . To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for  chronic neck pain .  Summary of Background Data . Neck pain is a common global health care complaint with considerable social and economic impact . Systematic review s have found exercise therapy ( ET ) to be effective for neck pain , either alone or in combination with spinal manipulation . However , it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise . Methods . Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic . Patients were r and omly assigned one of the following interventions : ( 1 ) high-dose supervised strengthening exercise with spinal manipulation ( exercise therapy combined with spinal manipulation therapy [ ET + SMT ] ) , ( 2 ) high-dose supervised strengthening exercise ( ET ) alone , or ( 3 ) low-dose home exercise and advice ( HEA ) . The primary outcome was patient-rated pain at baseline and at 4 , 12 , 26 , and 52 weeks . Secondary measures were disability , health status , global perceived effect , medication use , and satisfaction . Results . At 12 weeks , there was a significant difference in patient-rated pain between ET + SMT and HEA ( 1.3 points , P < 0.001 ) and ET and HEA ( 1.1 points , P = 0.001 ) . Although there were smaller group differences in patient-rated pain at 52 weeks ( ET + SMT vs. HEA , 0.2 points , P > 0.05 ; ET vs. HEA , 0.3 points , P > 0.05 ) , linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups ( ET + SMT vs. HEA , P = 0.03 ; ET vs. HEA , P = 0.02 ) . Similar results were observed for global perceived effect and satisfaction . Conclusion . Supervised strengthening exercise with and without spinal manipulation performed similarly , yielding better outcomes than home exercise particularly in the short term . Various stakeholders ' perspectives should be considered carefully when making recommendations regarding these therapies , taking into account side effects , preferences , and costs OBJECTIVE To determine whether the Feldenkrais method is an effective intervention for chronic neck/scapular pain in patients with visual impairment . DESIGN R and omized controlled trial with an untreated control group . SETTING Low vision center . PARTICIPANTS Patients ( N=61 ) with visual impairment ( mean , 53.3 y ) and nonspecific chronic ( mean , 23.8 y ) neck/scapular pain . INTERVENTIONS Participants were r and omly assigned to the Feldenkrais method group ( n=30 ) or untreated control group ( n=31 ) . Patients in the treatment group underwent one 2-hour Feldenkrais method session per week for 12 consecutive weeks . MAIN OUTCOME MEASURES Blind assessment of perceived pain ( visual analog scale [ VAS ] ) during physical therapist palpation of the left and right occipital , upper trapezius , and levator scapulae muscle areas ; self-assessed degree of pain on the Visual , Musculoskeletal , and Balance Complaints question naire ; and the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain scale . RESULTS Patients undergoing Feldenkrais method reported significantly less pain than the controls according to the VAS and Visual , Musculoskeletal , and Balance Complaints question naire ratings at posttreatment follow-up and 1-year follow-up . There were no significant differences regarding the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain scale ratings . CONCLUSIONS Feldenkrais method is an effective intervention for chronic neck/scapular pain in patients with visual impairment Prospect i ve single cohort study . To evaluate the NDI by comparison with the SF36 health Survey Question naire . The NDI is a simple ten-item question naire used to assess patients with neck pain . The SF36 measures functional ability , well being and the overall health of patients . It is used as a gold st and ard in health economics to assess the health utility , gain and economic impact of medical interventions . One hundred and sixty patients with neck pain attending the spinal clinic completed self- assessment question naires .  A second question naire was completed in 34 patients after a period of 1–2 weeks . The internal consistency of the NDI and SF36 was calculated using Cronbach ’s alpha . The test – retest reliability was assessed using the Bl and and Altman method . The concurrent validity of the NDI with respect to the SF-36 was assessed using Pearson correlations . Both question naires showed robust internal consistency : Cronbach ’s alpha for the NDI scale was acceptable ( 0.864 , 95 % confidence limits 0.825–0.894 ) though slightly smaller than that of the SF36 . The correlations between each item of the NDI scores and the total NDI score ranged from 0.447 to 0.659 , ( all with P < 0.001 ) . The test – retest reliability of the NDI was high ( intra-class correlation 0.93 , 95 % confidence limits 0.86–0.97 ) and comparable with the best values found for SF36 . The correlations between NDI and SF36 domains ranged from −0.45 to −0.74 ( all with P < 0.001 ) . We have shown that the NDI has good reliability and validity and that it compares well with the SF36 in the spinal surgery out patient setting OBJECTIVE The purpose of this study was to investigate the immediate and long-term effects of a 1-year multimodal program with the addition of 2 different traction approaches on the pain , function , disability , and nerve root function in patients with discogenic cervical radiculopathy ( CR ) . This study also attempted to identify the optimal traction angle based on the maximum recovery of the peak-to-peak amplitude of the flexor carpi radialis ( FCR ) H-reflex . METHODS This r and omized clinical trial with one-year follow-up included a total of 216 ( 101 female ) patients with unilateral lower discogenic CR were r and omly assigned to 1 of 3 groups . The st and ard care group ( C ) received the multimodal program ( pain relief methods , muscle strengthening , and thoracic spine manipulation ) . The ventroflexion traction group ( A ) received the same multimodal program as group C , with added traditional ventroflexion traction . The novel traction group ( B ) received the same multimodal program as group C in addition to a flexor carpi radialis ( FCR ) H-reflex-based traction method . Primary outcomes were the Neck Disability Index ( NDI ) and secondary outcomes included neck pain , arm pain , and the amplitude and latency of the H-reflex . Patients were assessed at 3 intervals ( pre-treatment , 4 weeks post-treatment , and the 1-year follow-up ) . RESULTS The mixed linear model with repeated measures indicated a significant group × time effect in favor of the novel cervical traction group ( B ) for measures of NDI ( F = 412.6 , P < .0005 ) , neck pain ( F = 108.9 , P < .0005 ) , arm pain ( F = 91.3 , P < .0005 ) , H- reflex amplitude ( F = 207.7 , P < .0005 ) , and H-reflex latency ( F = 58.9 P < .0005 ) . We found that the extension position of cervical spine ( 5 ° extension ) was the position that achieved the maximum improvement in the novel cervical traction method . CONCLUSIONS This preliminary study showed that a multimodal program with a novel cervical traction method added improved NDI , neck pain , arm pain , and the amplitude and latency of FCR H-reflex for a group of patients with chronic discogenic CR Abstract Thoracic spine manipulation has been shown to be effective for the management of neck pain . The purpose of this study was to investigate the immediate effect of a T3–T4 spinal thrust manipulation on autonomic nervous system activity in subjects with chronic cervical pain . An additional aim was to determine if the manipulation result ed in an immediate pain relief in patients with chronic neck pain when compared to a placebo intervention . One hundred subjects with chronic neck pain were r and omly assigned to receive either a thoracic thrust manipulation or a placebo intervention . The Friedman 's test was used to evaluate the change in pupil diameter within both groups . The Wilcoxen signed-ranks test was used to explore pupil changes over time and to make paired comparisons of the pupil change between the groups . The Mann – Whitney U test was used to compare the change in pain perception for the chronic cervical pain group subjects receiving either the thrust manipulation or the placebo intervention . The results demonstrated that manipulation did not result in a change in sympathetic activity . Additionally , there was no significant difference in the subject 's pain perception ( P=0.961 ) when comparing the effects of the thrust manipulation to the placebo intervention within this group of subjects with chronic neck pain . The clinical impression of this study is that manipulation of the thoracic spine may not be effective in immediately reducing pain in patients with chronic neck pain BACKGROUND The optimal type of exercise protocol in the physical rehabilitation of non-specific neck pain has not yet been established . Furthermore , the role of fear-avoidance belief in the maintenance of pain and disability has been highlighted . Research indicates that exercise may be a means to reduce fear-avoidance belief , but evidence is scarce . AIM To compare the effect of two different exercise programs on pain , strength and fear-avoidance belief . DESIGN R and omized clinical trial . SETTING A specialized outpatient hospital clinic in Denmark . POPULATION Twenty-three men and 60 women on sick leave due to non-specific neck pain . METHODS Participants were r and omized to either general physical activity ( GPA group ) or GPA and additional strength training of the neck and shoulder ( SST group ) . The primary outcome was pain intensity . Secondary outcomes were muscle strength of the neck and shoulder and fear-avoidance belief . RESULTS Pain was significantly reduced within groups with a median of -1 ( IQR : -3 to 0 , P<0.001 ) in the SST group and -1 ( IQR : -4 to 1 , P=0.046 ) in the GPA group . The difference between groups was not significant . Changes in strength did not differ between groups . Both groups experienced significant increases in neck flexion strength of 14.7 N ( IQR : -1 to 28.4 , P=0 . 001 ) in the SST group and 6.9 N ( IQR : -4.9 to18.6 , P=0.014 ) in the GPA group . Furthermore , the SST group achieved an increase of 18.6 N ( IQR : -2.6 to 69.7 , P=0.005 ) in neck extension . Fear-avoidance beliefs improved with 6 ( IQR : 3 to 12 , P<0.001 ) in the SST group , while the GPA group improved with 3 ( IQR : 0 to 8 , P=0.004 ) . This between-group difference was significant ( P=0.046 ) . CONCLUSION AND REHABILITATION IMPACT This study indicates that in rehabilitation of subjects severely disabled by non-specific neck pain , there is no additional improvement on pain or muscle strength when neck exercises are given as a home-based program with a minimum of supervision . However , strength training of the painful muscles seems to be effective in decreasing fear-avoidance beliefs Abstract And ersen , CH , And ersen , LL , Pedersen , MT , Mortensen , P , Karstad , K , Mortensen , OS , Zebis , MK , and Sjøgaard , G. Dose-response of strengthening exercise for treatment of severe neck pain in women . J Strength Cond Res 27(12 ) : 3322–3328 , 2013—Specific strength training is shown to relieve neck pain in office workers . The purpose of this study is to evaluate the effectiveness of specific strength training in women with severe neck pain and to analyze the dose – response relationship between training adherence and pain reduction . One hundred eighteen untrained women with severe neck pain ( > 30 mm VAS pain ) were included from a larger study , in which the subjects were r and omized to 20-week specific strength training for the neck/shoulders or to a control group . In the intention-to-treat analysis , the training group experienced greater pain relief than the control group ( p < 0.01 ) . Participants who adhered “ per protocol ” decreased pain by 35 mm VAS ( 95 % confidence interval : −26 to −44 ) from baseline to follow-up corresponding to a 70 % reduction . In the dose – response analyses , participants with medium and high training adherence showed better pain relief than the control group and those with low adherence ( p < 0.0001 ) . The decrease from baseline in the medium and high adherence groups was 37 mm VAS ( 28–46 mm ) and 33 mm VAS ( 24–43 mm ) , respectively . Specific strength training  reduces pain intensity in women with severe neck pain , and 1–2 training sessions per week for 20 weeks ( ∼30 training sessions ) seems sufficient for optimal pain relief Our purpose was to compare the effectiveness of three manual therapy techniques : high velocity , low amplitude ( HVLA ) , mobilization ( Mob ) and sustained natural apophyseal glide ( SNAG ) in patients with chronic neck pain ( CNP ) . The r and omized controlled trial included patients with mechanically reproducible CNP , who were r and omized to the treatment group . Outcome measures were the Visual Analogue scale ( VAS ) , Neck Disability Index ( NDI ) , Global Rating of Change ( GROC ) and Cervical Range of Motion ( CROM ) . Two-way repeated measures analysis of variance compared outcomes at baseline , at the end of treatment and 1 , 2 and 3 months after treatment . A total of 51 subjects completed the trial . No significant differences were found between HVLA , Mob and SNAG at the end of treatment and during the follow-up in any of the analysed outcomes . There were no differences in satisfaction for all techniques . The results lead to the conclusion that there is no long-term difference between the application of HVLA , Mob and SNAG in pain , disability and cervical range of motion for patients with CNP UNLABELLED Chronic neck pain is a common medical complaint partly mediated by psychosocial distress and having a high socioeconomic impact . There is preliminary evidence that stress reduction by meditation might be beneficial in chronic pain syndromes . We aim ed to evaluate the effectiveness of an 8-week meditation program ( jyoti meditation ) in patients with chronic neck pain by means of a r and omized clinical trial . Eighty-nine patients ( aged 49.7 ± 10.5 years , 73 female ) with chronic neck pain who scored > 40 mm on a 100-mm visual analog scale and had concomitant increased perceived stress were r and omized to an 8-week  meditation program ( jyoti meditation ) with weekly 90-minute classes ( n = 45 ) or to a home-based exercise program ( n = 44 ) with a wait list offer for meditation . Both groups were instructed to practice at home . Outcomes were assessed at baseline and after 8 weeks . Primary outcome measure was change of mean pain at rest ( visual analog scale score ) from baseline to week 8 . Secondary outcomes included pain at motion , functional disability , pain-related bothersomeness , perceived stress , quality of life , and psychological outcomes . Patients had neck pain for a mean of 11 years . Eighteen patients in the meditation group and 16 patients in the exercise group were lost to follow-up . Meditation training significantly reduced pain when compared to the exercise group after 8 weeks ( reduction of 45.5 ± 23.3 mm to 21.6 ± 17.2 mm in the meditation group , and 43.8 ± 22.0 mm to 37.7 ± 21.5 mm in the exercise group ; mean difference : 13.2 mm [ 95 % confidence interval : 2.1 , 24.4 ; P = .02 ] ) . Pain-related bothersomeness decreased more in the meditation group ( group difference 11.0 mm [ 95 % confidence interval : 1.0 , 21.0 ; P = .03 ] ) . No significant treatment effects were found for pain at motion , psychological scores , and quality of life , although the meditation group showed nonsignificant greater improvements compared to the exercise group . In conclusion , meditation may support chronic pain patients  in pain reduction and pain coping . Further well- design ed studies including more active control comparisons and longer-term follow-up are warranted . PERSPECTIVE This article presents the results of a r and omized controlled trial on the clinical effects of an 8-week meditation program or self-care exercise in patients with chronic neck pain . Meditation reduced pain at rest but not disability and might be a useful treatment option for pain management of chronic neck pain OBJECTIVES To determine if an educational intervention in the acute stage of whiplash injury may improve the recovery rate . METHODS Consecutive subjects were r and omized to one of two treatment groups : educational intervention or usual care . The intervention group received an educational pamphlet based on the current evidence . The control group did not receive these material s but received usual emergency department care and a st and ard nondirected discharge information sheet . Both groups underwent follow-up by telephone interview at two weeks and three months . The primary outcome measure of recovery was the patient 's response to the question , " How well do you feel you are recovering from your injuries ? " RESULTS A total of 112 subjects agreed to participate . Age , gender , precollision employment level and health , initial symptoms , collision parameters , and emergency treatments were similar between the groups . At two weeks postcollision , 7.3 % in the treatment group reported recovery compared with 8.8 % in the control group ( absolute risk difference , -1.5 % ; 95 % confidence interval = -12.6 % to 9.7 % ) . At three months postcollision , 21.8 % in the treatment group reported complete recovery compared with 21.0 % in the control group ( absolute risk difference , 0.8 % ; 95 % confidence interval = -14.4 % to 16.0 % ) . At three months , there were no clinical ly or statistically significant differences between groups in severity of remaining symptoms , limitations in daily activities , therapy use , medications used , lost time from work , or litigation . CONCLUSIONS An evidence -based educational pamphlet provided to patients at discharge from the emergency department is no more effective than usual care for patients with grade 1 or 2 whiplash-associated disorder Myofascial pain syndrome ( MPS ) of the trapezius muscle is one of the main causes of neck pain . In this r and omized , double-blind study , we evaluated the effects of high-intensity laser therapy ( HILT ) in female patients with chronic MPS of the trapezius muscle . The patients were assigned to two groups . The HILT group was treated with HILT and exercise , and the sham therapy group was treated with placebo HILT and exercise . The patients were assessed for pain , cervical active range of motion , disability , and quality of life . Evaluations were performed before treatment ( week 0 ) and after treatment ( weeks 4 and 12 ) . Both groups showed significant improvement in all parameters at weeks 4 and 12 . However , in a comparison of the percentage changes in the parameters at weeks 4 and 12 relative to pretreatment values , the HILT group showed greater improvement in pain scores , the neck disability index , and several subparts of the short-form 36 health survey ( SF-36 ) ( physical functioning , role limitations due to physical functioning , bodily pain , general health perceptions , social functioning , and role limitations due to emotional problems ) than did the sham therapy group . We conclude that HILT is an effective therapeutic method in the treatment of patients with chronic MPS of the trapezius muscle Summary This r and omised trial showed that multiprofessional stratified management had no effect beyond usual care in reducing transition rates to chronicity in patients with acute whiplash . ABSTRACT Acute whiplash is a heterogeneous disorder that becomes persistent in 40 % to 60 % of cases . Estimates of recovery have not changed in recent decades . This r and omized , single‐blind , controlled trial tested whether multidisciplinary individualized treatments for patients with acute whiplash ( < 4 weeks postinjury ) could reduce the incidence of chronicity at 6 mo by 50 % compared to usual care . Participants ( n = 101 ) were recruited from accident and emergency centres and the community . It was hypothesized that better recovery rates were achievable if the heterogeneity was recognised and patients received individualised interventions . Patients r and omized to pragmatic intervention ( n = 49 ) could receive pharmaceutical management ( ranging from simple medications to opioid analgesia ) , multimodal physiotherapy and psychology for post‐traumatic stress according to their presentations . The treatment period was 10 wks with follow‐up at 11 weeks and 6 and 12‐months . The primary outcome was neck pain and disability ( Neck Disability Index ( NDI ) ) . Analysis revealed no significant differences in frequency of recovery ( NDI ≤8 % ) between pragmatic and usual care groups at 6 months ( OR 95 % , CI = 0.55 , 0.23–1.29 ) , P = 0.163 ) or 12 mo ( OR 95 % , CI = 0.65 , 0.28–1.47 , P = 0.297 ) . There was no improvement in current nonrecovery rates at 6 mo ( 63.6 % , pragmatic care ; 48.8 % , usual care ) , indicating no advantage of the early multiprofessional intervention . Baseline levels of pain and disability had a significant bearing on recovery both at 6 and 12 mo in both groups , suggesting that future research focus on finding early effective pain management , particularly for the subgroup of patients with initial high levels of pain and  disability , towards improving recovery rates Abstract This r and omized controlled trial investigated the effectiveness and cost-effectiveness of dry-needling and exercise compared with sham dry-needling and exercise for chronic whiplash-associated disorders ( WAD ) . The setting was a single university centre and 4 physiotherapy practice s in Queensl and , Australia . Eighty patients with chronic WAD ( > 3 months ) were enrolled between June 2009 and August 2012 with 1-year follow-up completed in August 2013 . The interventions were 6 weeks of dry-needling to posterior neck muscles ( n = 40 ) and exercise or sham dry-needling and exercise ( n = 40 ) . The primary outcomes of the Neck Disability Index ( NDI ) and self-rated recovery were measured at baseline , 6 and 12 weeks , 6 and 12 months by a blinded assessor . Analysis was intention to treat . An economic evaluation was planned but missing data deemed further analysis unwarranted . Seventy-nine patients ( 99 % ) were followed up at 6 weeks , 78 ( 98 % ) at 12 weeks , 74 ( 93 % ) at 6 months , and 73 ( 91 % ) at 12 months . The dry-needling and exercise intervention was more effective than sham dry-needling and exercise  in reducing disability at 6 and 12 months but not at 6 and 12 weeks . The treatment effects were small and not clinical ly worthwhile . At 6 weeks , the treatment effect on the 0 - 100 NDI was −0.3 ( 95 % confidence interval −5.4 to 4.7 ) , 12 weeks −0.3 ( −5.2 to 4.9 ) , 6 months −4.4 ( −9.6 to −0.74 ) , and 12 months −3.8 ( −9.1 to −0.5 ) . There was no effect for self-rated recovery . In patients with chronic WAD  , dry-needling and exercise has no clinical ly worthwhile effects over sham dry-needling and exercise Evidence supports exercise-based interventions for the management of neck pain , however there is little evidence of its superiority over usual physiotherapy . This study investigated the effectiveness of a group neck and upper limb exercise programme ( GET ) compared with usual physiotherapy ( UP ) for patients with non-specific neck pain . A total of 151 adult patients were r and omised to either GET or UP . The primary measure was the Northwick Park Neck pain Question naire ( NPQ ) score at six weeks , six months and 12 months . Mixed modelling identified no difference in neck pain and function between patients receiving GET and those receiving UP at any follow-up time point . Both interventions result ed in modest significant and clinical ly important improvements on the NPQ score with a change score of around 9 % between baseline and 12 months . Both GET and UP are appropriate clinical interventions for patients with non-specific neck pain , however preferences for treatment and targeted strategies to address barriers to adherence may need to be considered in order to maximise the effectiveness of these approaches Objective . In a cohort of primary care patients with chronic neck pain , to determine whether specific neck stabilization exercises , in addition to general neck advice and exercise , provide better clinical outcome at 6 weeks than general neck advice and exercise alone . Methods . This was a multicenter r and omized controlled trial in 4 physical therapy departments . Seventy-four participants ( mean age 51.3 yrs ) were r and omized to specific neck stabilization exercises with a general neck advice and exercise program ( n = 37 ) or a  general neck advice and exercise program alone ( n = 37 ) . They attended a 1-hour clinical examination , followed by a maximum of 4 treatment sessions . Assessment s were undertaken at baseline , 6 weeks , and 6 months . The primary outcome was the Neck Pain and Disability Scale ( NPDS ) . Analysis was by intention to treat . Results . Seventy-one ( 96 % ) participants received their allocated intervention . There was 91 % followup at 6 weeks and 92 % followup at 6 months . The mean ( SD ) 6-week improvement ( reduction ) in NPDS score was 10.6 ( 20.2 ) for the specific exercise program and 9.3 ( 15.7 ) for the general exercise program . There were no significant between-group differences in the NPDS at either 6 weeks or 6 months . For secondary outcomes , participants in the specific exercise group were less likely to be taking pain medication at 6-week followup ( p = 0.02 ) . There were no other significant between-group differences . Conclusion . Adding specific neck stabilization exercises to a general neck advice and exercise program did not provide better clinical outcome overall in the physical therapy treatment of chronic neck pain Objective : To determine the efficacy of Sustained Natural Apophyseal Glides ( SNAGs ) with and without Isometric Exercise Training Program ( IETP ) in Non-specific Neck Pain ( NSNP ) Methods : This r and omized control trial of one year duration was conducted at out-patient department of Physiotherapy and Rehabilitation , Khyber Teaching Hospital ( KTH ) Peshawar , Pakistan from July 2012 to June 2013 . The sample of 102 patients of NSNP were r and omly selected through simple r and om sampling technique , and placed into two groups . The SNAGs manual physical therapy technique with IETP was applied on 51 patients in group A and SNAGs manual physical therapy techniques was applied alone on 51 patients in group B. The duration of intervention was 6 weeks , at 4 times per week . The Neck Disability Index ( NDI ) and Visual Analog Scale ( VAS ) for neck pain were assessment tools used for all patients before and after 6 weeks of physical therapy intervention . All the patients were assessed through NDI and VAS before intervention and at the completion of 6 weeks program . The data of all 102 was analyzed by SPSS-20 and statistical test was applied at 95 % level of significance determine the efficacy of both the treatments interventions and compare with each other . Results : The patients in group A , treated with SNAGs and followed by IETP for 6 weeks , demonstrated more improvement in pain and physical activity as assessed by VAS ( p=0.013 ) and NDI ( p=0.003 ) , as compared to the patients treated with SNAGS alone , as pain and function assessed by VAS ( p=0.047 ) and NDI ( p=0.164 ) . In group A the NDI score improved from 40 to 15 and VAS from 7 to 4 , while in group B the NDI score improved from 42 to 30 and VAS from 7 to 4 . Conclusion : Patients with non-specific neck pain treated with SNAGs manual physical therapy techniques and followed by IETP was more effective in reduction of pain and enhancement of function , as compared to those patients treated with SNAGs manual physical therapy techniques alone OBJECTIVE To explore perceptions of spinal manipulative therapy and exercise among adults aged 65 years and older with chronic neck pain . DESIGN Mixed methods study embedded within a r and omized clinical trial . SUBJECTS/ PATIENTS Interviews were conducted with 222 of 241 r and omized clinical trial participants . They had a mean age of 72.2 years and they had neck pain of moderate severity and of 6 years mean duration . METHODS Semi-structured interviews were conducted at the completion of the 12 week intervention phase , during which participants received spinal manipulative therapy and exercise interventions . Interviews explored determinants of satisfaction with care , whether or not therapy was worthwhile , and what was liked and disliked about treatment . Interviews were recorded and transcribed ; content analysis was used to identify themes within responses . RESULTS Participants placed high value on their relationships with health care team members , supervision , individualized care , and the exercises and information provided as treatment . Change in symptoms did not figure as prominently as social and process-related themes . Percpetions of age , activities , and co-morbities influenced some seniors ' expectations of treatment results , and comorbidities impacted perceptions of their ability to participate in active care . CONCLUSION Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care Abstract Currently , large levels of practice variability exist regarding the clinical deactivation of trigger points . Manual physical therapy has been identified as a potential means of resolving active trigger points ; however , to date the ideal treatment approach has yet to be eluci date d. The purpose of this clinical trial was to compare the effects of two manual treatment regimens on individuals with upper trapezius trigger points . Sixty patients , 19–38 years of age with non-specific neck pain and upper trapezius trigger points , were r and omized into one of two , 4 week physical therapy programs . One group received muscle energy techniques while the second group received an integrated neuromuscular inhibition technique ( INIT ) consisting of muscle energy techniques , ischemic compression , and strain – counterstrain ( SCS ) . Outcomes including a visual analog pain scale ( VAS ) , the neck disability index ( NDI ) , and lateral cervical flexion range of motion ( ROM ) were collected at baseline , 2 and 4 weeks after the initiation of therapy . Results revealed large pre – post-effect sizes within the INIT group ( Cohen 's d = 0.97 , 0.94 and 0.97 ) . Additionally , significantly greater improvements in pain and neck disability and lateral cervical flexion ROM were detected in favor of the INIT group ( 0.29–0.57 , 0.57–1.12 and 0.29–0.57 ) at a 95 % CI respectively . The findings of this study indicate the potential benefit of an integrated approach in deactivating upper trapezius trigger points . Further research should be performed to investigate the long-term benefits of the current treatment approach PURPOSE This trial was design ed to evaluate the optimal dose of massage for individuals with chronic neck pain . METHODS We recruited 228 individuals with chronic nonspecific neck pain from an integrated health care system and the general population , and r and omized them to 5 groups receiving various doses of massage ( a 4-week course consisting of 30-minute visits 2 or 3 times weekly or 60-minute visits 1 , 2 , or 3 times weekly ) or to a single control group ( a 4-week period on a wait list ) . We assessed neck-related dysfunction with the Neck Disability Index ( range , 0–50 points ) and pain intensity with a numerical rating scale ( range , 0–10 points ) at baseline and 5 weeks . We used log-linear regression to assess the likelihood of clinical ly meaningful improvement in neck-related dysfunction ( ≥5 points on Neck Disability Index ) or pain intensity ( ≥30 % improvement ) by treatment group . RESULTS After adjustment for baseline age , outcome measures , and imbalanced covariates , 30-minute treatments were not significantly better than the wait list control condition in terms of achieving a clinical ly meaningful improvement in neck dysfunction or pain , regardless of the frequency of treatments . In contrast , 60-minute treatments 2 and 3 times weekly significantly increased the likelihood of such improvement compared with the control condition in terms of both neck dysfunction ( relative risk = 3.41 and 4.98 , P = .04 and .005 , respectively ) and pain intensity ( relative risk = 2.30 and 2.73 ; P = .007 and .001 , respectively ) . CONCLUSIONS After 4 weeks of treatment , we found multiple 60-minute massages per week more effective than fewer or shorter sessions for individuals with chronic neck pain . Clinicians recommending massage and research ers study ing this therapy should ensure that patients receive a likely effective dose of treatment OBJECTIVE Strain-counterstrain is an osteopathic technique which is widely used for treating mobility restrictions in the neck . We aim ed to investigate whether a single strain-counterstrain intervention is more effective than a sham intervention in improving restricted cervical range of motion in patients with neck pain . METHODS 61 adult patients with neck pain and restricted cervical mobility were r and omly allocated to receive either a single strain-counterstrain intervention or a sham treatment . After outcome measurement all patients received full individualized osteopathic treatment .  Mobility of the cervical spine was measured by a blinded observer using the Cervical Range of Motion ( CROM ) tool . In addition , patients rated pain intensity and assessed the treatment effect . The main outcome measure was the sum of changes in mobility restriction ( in % ) after treatment compared to normal mobility . RESULTS All patients completed the study . Mobility restriction decreased by 2.0 % ( SD 6.9 % ) in the group receiving strain-counterstrain treatment and 0.6 % ( SD 5.7 % ) in the group receiving sham treatment ( mean difference 1.5 % , 95 % confidence interval -1.7 to 4.8 % ; p=0.35 ) . There were no significant differences between groups for secondary outcomes . After receiving the full osteopathic treatment the group initially receiving strain-counterstrain improved by another 4.2 % ( 7.0 % ; p=0.003 ) and the group initially receiving sham by another 5.6 % ( SD 6.8 % ; p<0.001 ) . CONCLUSIONS Strain-counterstrain as a single intervention did not have immediate effects on mobility and pain over a sham treatment . Future studies should probably focus on the investigation of full osteopathic treatment Long 's manipulation ( LM ) is a representative Chinese manipulation approach incorporating both spinal manipulation and traditional Chinese massage ( TCM ) techniques . This r and omized controlled trial ( RCT ) aim ed to compare the immediate and short-term relative effectiveness of LM to TCM on patients with chronic neck pain . Patients were r and omly assigned to either LM group or TCM group . LM group was treated with Long 's manipulation , while the TCM group received TCM therapy . Patients attended 8 sessions of treatment ( one session every three days ) . Outcome measures included neck disability ( Northwick Park Neck Pain Question naire ; NPQ ) , pain intensity ( Numeric Pain Rating Scale ; NPRS ) , patient perceived satisfaction of care ( PPS ) ( 11-point scale ) , craniovertebral angle ( CV angle ) and cervical range of motion ( ROM ) . A blinded assessor performed assessment at baseline , immediate after treatment and 3 months post treatment . LM group achieved significantly greater improvement than TCM group in pain intensity ( p < 0.001 ) , neck disability ( p = 0.049 ) and satisfaction ( p < 0.001 ) up to 3-month follow-up . There was no significant difference in improvements in CV angle and most of cervical ROM between groups ( p = 0.169 ∼ 0.888 ) with an exception of flexion at 3-month follow-up ( p = 0.005 ) . This study shows that LM could produce better effects than TCM in relieving pain and improving disability in the management of patients with chronic mechanical neck pain OBJECTIVE To determine the immediate effects on both pain and active range of motion ( ROM ) of the unilateral posteroanterior ( PA ) mobilization technique on the painful side in mechanical neck pain patients presenting with unilateral symptoms . DESIGN Triple-blind , r and omized controlled trial . SETTING Outpatient physical therapy , institutional clinic . PARTICIPANTS Patients ( N=60 ) , 2 physical therapists , and 1 assessor involved in this study . INTERVENTIONS The patients were r and omly allocated into either preferred or r and om mobilization group by using an opaque concealed envelope . The first therapist performed the screening , assessing , prescribing the spinal level(s ) , and the grade of mobilization . The second therapist performed the mobilization treatment according to their allocated group stated in an envelope . The assessor who was blind to the group allocation conducted the measurements of pain and active cervical ROM . MAIN OUTCOME MEASURES Pain intensity , active cervical ROM , and global perceived effect were measured at baseline and 5 minutes posttreatment . RESULTS After mobilization , there were no apparent differences in pain and active cervical ROM between groups . However , within-group changes showed significant decreases in neck pain at rest and pain on most painful movement ( P<0.001 ) with a significant increase in active cervical ROM after mobilization on most painful movement ( P=0.002 ) . CONCLUSIONS The results of this study did not provide support for the preference of the unilateral PA mobilization on the painful side to the r and om mobilization OBJECTIVES To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury ; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs ; and to gain participants ' perspective on experiencing whiplash injury , NHS treatment , and recovery within the context of the Managing Injuries of the Neck Trial ( MINT ) . DESIGN Two linked , pragmatic , r and omised controlled trials . In Step 1 , emergency departments ( EDs ) were cluster r and omised to usual care advice ( UCA ) or The Whiplash Book advice (WBA)/active management advice . In Step 2 , participants were individually r and omised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions . An economic evaluation and qualitative study were run in parallel with the trial . SETTING Twelve NHS trusts in Engl and comprising 15 EDs . PARTICIPANTS People who attended EDs with an acute whiplash injury of whiplash-associated disorder grade s I-III were eligible for Step 1 . People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2 . INTERVENTIONS In Step 1 , the control intervention was UCA and the experimental intervention was a psycho-educational intervention ( WBA/active management advice ) . In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments . MAIN OUTCOME The primary outcome was the Neck Disability Index ( NDI ) , which measures severity and frequency of pain and symptoms , and a range of activities including self-care , driving , reading , sleeping and recreation . Secondary outcomes included the mental and physical health-related quality -of-life ( HRQoL ) subscales of the Short Form question naire-12 items ( SF-12 ) and the number of work days lost . RESULTS A total of 3851 patients were recruited to Step 1 of the trial . 1598 patients attending EDs were r and omised to UCA , and 2253 were r and omised to WBA/active management . Outcome data were obtained at 12 months for 70 % and 80 % of participants at Step 1 and Step 2 , respectively . The majority of people recovered from the injury . Eighteen per cent of the Step 1 cohort had late whiplash syndrome . There was no statistically or clinical ly significant difference observed in any of the outcomes for participants attending EDs r and omised to UCA or active management advice [ difference in NDI 0.5 , 95 % confidence interval ( CI ) -1.8 to 2.8 ] . In Step 2 the physiotherapy package result ed in improvements in neck disability at 4 months compared with a single advice session , but these effects were small at the population level ( difference in NDI -3.2 , 95 % CI -5.8 to -0.7 ) . The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up ( difference -40.2 , 95 % CI -44.3 to -35.8 ) . CONCLUSIONS MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries . A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session . However , from a health-care perspective , the physiotherapy package was not cost-effective at current levels of willingness to pay . Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life . However , an important benefit of the physiotherapy package was a reduction in work days lost ; consequently , the intervention may prove cost-effective at the societal level . TRIAL REGISTRATION Current Controlled Trials IS RCT N33302125 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 16 , No. 49 . See the HTA programme website for further project information BACKGROUND Mechanical neck pain is a common condition that affects an estimated 70 % of persons at some point in their lives . Little research exists to guide the choice of therapy for acute and subacute neck pain . OBJECTIVE To determine the relative efficacy of spinal manipulation therapy ( SMT ) , medication , and home exercise with advice ( HEA ) for acute and subacute neck pain in both the short and long term . DESIGN R and omized , controlled trial . ( Clinical Trials.gov registration number : NCT00029770 ) SETTING 1 university research center and 1 pain management clinic in Minnesota . PARTICIPANTS 272 persons aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks . INTERVENTION 12 weeks of SMT , medication , or HEA . MEASUREMENTS The primary outcome was participant-rated pain , measured at 2 , 4 , 8 , 12 , 26 , and 52 weeks after r and omization . Secondary measures were self-reported disability , global improvement , medication use , satisfaction , general health status ( Short Form-36 Health Survey physical and mental health scales ) , and adverse events . Blinded evaluation of neck motion was performed at 4 and 12 weeks . RESULTS For pain  , SMT had a statistically significant advantage over medication after 8 , 12 , 26 , and 52 weeks ( P ≤ 0.010 ) , and HEA was superior to medication at 26 weeks ( P = 0.02 ) . No important differences in pain were found between SMT and HEA at any time point . Results for most of the secondary outcomes were similar to those of the primary outcome . LIMITATIONS Participants and providers could not be blinded . No specific criteria for defining clinical ly important group differences were prespecified or available from the literature . CONCLUSION For participants with acute and subacute neck pain  , SMT was more effective than medication in both the short and long term . However , a few instructional sessions of HEA result ed in similar outcomes at most time points . PRIMARY FUNDING SOURCE National Center for Complementary and Alternative Medicine , National Institutes of Health Purpose To investigate whether a work-site strength-training program has a positive effect on self-reported psychosocial workplace factors and job satisfaction . Methods We conducted a r and omized controlled trial among laboratory technicians implementing neck and shoulder exercises for pain relief , with 199 participants in the training group and 228 in the control group  . Influence at work , sense of community , time pressure , and job satisfaction were measured with the Copenhagen Psychosocial Question naire at baseline and post-intervention after 20 weeks . Results There was no statistically significant change in any of the four variables in the training group from baseline to follow-up ( all p ≥ 0.39 ) . When we used MANOVA to test for between-group effects over time , we did not find any statistically significant result ( all p > 0.14 ) . Conclusions This study does not provide evidence for an effect of a work-site strength-training program on self-reported psychosocial workplace factors and job satisfaction Objective To observe the clinical effect of acupuncture in treating cervical spondylosis with different syndrome types . Methods One hundred and seventeen patients were r and omized into the treated group : ( 59 cases ) , treated with normal acupuncture , and the control group ( 58 cases ) , treated with sham acupuncture , operated once every other day , 9 times in total ( in 18 days ) as one therapeutic course , and a succeeding 3-month follow-up study was carried out after terminating the therapy . The efficacy of treatment was evaluated with the Northwick Park Neck Pain Question naire ( NPQ ) and Visual Analogue Scale ( VAS ) , and the scores gained in patients with different syndrome types were analyzed with a general linear model . Results The NPQ and VAS : scores showed a linear decreasing tendency in both groups at the time of ending treatment and the 1st month of follow-up , but showed a secondary curve increasing tendency in the 3rd month of follow-up . Multivariate analysis showed the difference was of statistical significance ( P<0.05 ) . However , the analysis through lead-in of syndrome type as an individual influencing factor showed that syndrome type exerts a significant influence on VAS score ( P<0.05 ) , but has insignificant influence on the NPQ score ( P>0.05 ) . Conclusion Acupuncture shows : good immediate effect in treating cervical spondylosis , but its long-term effect is not satisfactory . The difference in syndrome type may have some impact on the effects of acupuncture in alleviating pain , but exerts no evident influence on the comprehensive effect STUDY DESIGN R and omized clinical trial . OBJECTIVE To compare the effectiveness of cervical spine thrust manipulation to that of Kinesio Taping applied to the neck in individuals with mechanical neck pain , using self-reported pain and disability and cervical range of motion as measures . BACKGROUND The effectiveness of cervical manipulation has received considerable attention in the literature . However , because some patients can not tolerate cervical thrust manipulation , alternative therapeutic options should be investigated . METHODS Eighty patients ( 36 women ) were r and omly assigned to 1 of 2 groups : the manipulation group , which received 2 cervical thrust manipulations , and the tape group , which received Kinesio Taping applied to the neck .  Neck pain ( 11-point numeric pain rating scale ) , disability ( Neck Disability Index ) , and cervical-range-of-motion data were collected at baseline and 1 week after the intervention by an assessor blinded to the treatment allocation of the patients . Mixed-model analyses of variance were used to examine the effects of the treatment on each outcome variable , with group as the between-subjects variable and time as the within-subjects variable . The primary analysis was the group-by-time interaction . RESULTS No significant group-by-time interactions were found for pain ( F = 1.892 , P = .447 ) or disability ( F = 0.115 , P = .736 ) . The group-by-time interaction was statistically significant for right ( F = 7.317 , P = .008 ) and left ( F = 9.525 , P = .003 ) cervical rotation range of motion , with the patients who received the cervical thrust manipulation having experienced greater improvement in cervical rotation than those treated with Kinesio Tape ( P<.01 ) . No significant group-by-time interactions were found for cervical spine range of motion for flexion ( F = 0.944 , P = .334 ) , extension ( F = 0.122 , P = .728 ) , and right ( F = 0.220 , P = .650 ) and left ( F = 0.389 , P = .535 ) lateral flexion . CONCLUSION Patients with mechanical neck pain who received cervical thrust manipulation or Kinesio Taping exhibited similar reductions in neck pain intensity and disability and similar changes in active cervical range of motion , except for rotation . Changes in neck pain surpassed the minimal clinical ly important difference , whereas changes in disability did not . Changes in cervical range of motion were small and not clinical ly meaningful . Because we did not include a control or placebo group in this study , we can not rule out a placebo effect or natural changes over time as potential reasons for the improvements measured in both groups . LEVEL OF EVIDENCE Therapy , level 1b Study Design . R and omized controlled trial . Objective . To evaluate whether qigong is more effective than no treatment and not inferior to exercise therapy . Summary of Background Data . Lifetime prevalence of chronic neck pain is close to 50 % . Qigong is often used by patients , although , the evidence is still unclear . Methods . Patients ( aged 20–60 years ) with chronic neck pain ( visual analog scale , VAS ≥40 mm ) were r and omized to 1 ) qigong or 2 ) exercise therapy ( 18 sessions over 6 months ) or 3 ) waiting list ( no treatment ) . At baseline and after 3 and 6 months , patients completed st and ardized question naires assessing neck pain ( VAS ) , neck pain and disability , and quality of life ( Short Form SF-36 question naire , SF-36 ) . The primary endpoint was average pain in the last 7 days on VAS at 6-month follow-up . Statistical analysis included generalized estimation equation models adjusted for baseline values and patient expectation . Results . A total of 123 patients ( aged 46 ± 11 years , 88 % women ) suffering from chronic neck pain for 3.2 ( SD ± 1.6 ) years were included . After 6 months , a significant difference was seen between the qigong and waiting list control groups ( VAS mean difference : −14 mm [ 95 % CI = −23.1 to −5.4 ] , P = 0.002 ) . Mean improvements in the exercise group were comparable to those in the qigong group ( difference between groups −0.7 mm [ CI = −9.1 to 7.7 ] ) but failed to show statistical significance ( P = 0.092 ) . Neck pain and disability , and SF-36 results also yielded superiority of qigong over no treatment and similar results in the qigong and exercise therapy groups . Conclusion . Qigong was more effective than no treatment in patients with chronic neck pain . Further studies could be design ed without waiting list control and should use a larger sample to clarify the value of qigong compared to exercise therapy The Scottish Intercollegiate Guidelines Network ( SIGN ) develops evidence based clinical guidelines for the NHS in Scotl and . The key elements of the methodology are ( a ) that guidelines are developed by multidisciplinary groups ; ( b ) they are based on a systematic review of the scientific evidence ; and ( c ) recommendations are explicitly linked to the supporting evidence and grade d according to the strength of that evidence . Until recently , the system for grading guideline recommendations was based on the work of the US Agency for Healthcare Research and Quality ( formerly the Agency for Health Care Policy and Research ) . 1 2 However , experience over more than five years of guideline development led to a growing awareness of this system 's weaknesses . Firstly , the grading system was design ed largely for application to questions of effectiveness , where r and omised controlled trials are accepted as the most robust study design with the least risk of bias in the results . However , in many areas of medical practice r and omised trials may not be practical or ethical to undertake ; and for many questions other types of study design may provide the best evidence . Secondly , guideline development groups often fail to take adequate account of the method ological quality of individual studies and the overall picture presented by a body of evidence rather than individual studies or they fail to apply sufficient judgment to the overall strength of the evidence base and its applicability to the target population of the guideline . Thirdly , guideline users are often not clear about the implication s of the grading system . They misinterpret the grade of recommendation as relating to its importance , rather than to the strength of the supporting evidence , and may therefore fail to give due weight to low grade recommendations . # # # # Summary points A revised system of determining levels of evidence and grade s Purpose : To evaluate whether long-term neck and upper body exercises conducted in economical community-based outpatient clinic and home-based setting s could improve health-related quality of life (HRQoL)for  individuals affected by chronic neck pain . The effect of baseline HRQoL and neck pain values on training adherence was also studied . Methods : Subjects ( n = 101 , 91 women/10 men , mean age 41.0 ± 9.5 years ) with chronic non-specific neck pain were r and omized to a combined strength-training and stretching-exercise group ( CSSG , n = 49 ) or to a stretching exercise group ( SG , n = 52 ) . HRQoL was assessed at baseline and after 12 months using the R AND -36 question naire . Comparisons between groups were performed using bootstrap-type analysis of covariance . The impact of HRQoL and neck pain values on training adherence , determined using participants ’ exercise logs , was studied using generalized estimating equations . Results : CSSG showed significant improvements in five and SG in four of eight of the HRQoL dimensions . There were no significant differences between the groups . Adherence to long-term training was only slightly affected by baseline-assessed HRQoL and neck pain values . Conclusions : The two training protocol s were feasible and equally effective in improving HRQoL. Baseline HRQoL and pain values had only a minor effect on training adherence . Implication s for Rehabilitation Long-term strength training and stretching are effective in improving HRQoL in people with chronic neck pain . Baseline HRQoL and neck pain values have little effect on training adherence Objective : The aim of this study was to evaluate a tailored physical activity protocol performed in a work environment with a group of female workers employed in manual precision tasks to reduce upper limb pain . Methods : Sixty female subjects were r and omly assigned to an intervention group or a control group . The IG was administered of a 6-month , twice-a-week , tailored exercise program , whereas the CG received no intervention . Results : The IG showed a reduction on shoulder pain accompanied by increases on the range of motion measures . In addition , reductions in upper limb pain and neck disability were detected with concomitant increases in grip strength . Conclusions : This study indicated positive effects of a tailored workplace exercise protocol in female workers exposed to moderate risk for work-related musculoskeletal disorders , showing clinical ly meaningful reductions of pain symptoms and disability on upper limb and neck regions & NA ; The purpose of the study was to examine the effects of a workplace physical exercise intervention on the perceived intensity of headache and the intensity of symptoms in the neck and shoulders , as well as on the extension and flexion strength of the upper extremities . The study was a cluster r and omized controlled trial . The cross‐over design consisted of physical exercise intervention ( 15 weeks ) and no‐intervention ( 15 weeks ) . The subjects ( n=53 ) were office workers ( mean age 46.6 ( SD 8.4 ) ) who reported headache ( n=41 ) symptoms in the neck ( n=37 ) or shoulders ( n=41 ) , which had restricted their daily activities during the last 12 months . Pain symptoms were measured using the Borg CR10 scale and muscular strength with a 5RM test . Statistical analyses were based on linear mixed models . Physical exercise intervention result ed in a slight , but statistically significant , decrease in the intensity of headache and neck symptoms , as well as an increase in the extension strength of the upper extremities . The mean decrease in headache during the 5‐week period was 0.64 CR10 ( 95 % CI 0.28–1.00 ) ( P=0.001 ) or 49 % ( 95 % CI 22–77 ) , and 0.42 CR10 ( 95 % CI 0.11–0.72 ) ( P=0.002 ) or 49 % ( 95 % CI 13–85 ) in the intensity of neck symptoms . The mean increase in the extension strength of the upper extremities was 1.3 kg ( 95 % CI 0.5–2.1 ) ( P=0.001 ) or 4 % ( 95 % CI 1–6 ) . The intervention had no effect on the intensity of shoulder symptoms or the flexion strength of the upper extremities . Specific exercise may be clinical ly important to alleviate headache and neck symptoms Purpose . To determine the immediate effects of the central posteroanterior ( PA ) mobilization technique on both pain and active cervical range of motion in patients with mechanical neck pain presenting with central or bilateral symptoms . Methods . A r and omized controlled trial was conducted in 60 patients who were r and omly allocated into either ‘ central PA ’ or ‘ r and om ’ mobilization group .  Two physical therapists and one assessor participated . Outcome measures included neck pain at rest , pain on the most painful movement , and active cervical range of motion taken before and immediately 5 min after the mobilization treatment . Results . Significant reductions in pain at rest and on the most painful movement were noted within-group comparisons ( p < 0.001 ) . However , the ‘ central PA ’ mobilization group obtained a significantly greater reduction in pain on the most painful movement than the ‘ r and om ’ mobilization group ( p < 0.05 ) . Both mobilization techniques had no effects on the active cervical range of motion . However , the differences in the means of pain reduction between both mobilization techniques were modest ( < 10 mm ) . Conclusion . The clinical recommendation regarding the selection of the central PA mobilization technique for treating patients with central or bilateral mechanical neck pain is therefore arguably OBJECTIVE We evaluated the inter-rater reliability ( IRR ) of assessing the quality of evidence ( QoE ) using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) approach . STUDY DESIGN AND SETTING On completing two training exercises , participants worked independently as individual raters to assess the QoE of 16 outcomes . After recording their initial impression using a global rating , raters grade d the QoE following the GRADE approach . Subsequently , r and omly paired raters su bmi tted a consensus rating . RESULTS The IRR without using the GRADE approach for two individual raters was 0.31 ( 95 % confidence interval [ 95 % CI ] = 0.21 - 0.42 ) among Health Research Methodology students ( n = 10 ) and 0.27 ( 95 % CI = 0.19 - 0.37 ) among the GRADE working group members ( n = 15 ) . The corresponding IRR of the GRADE approach  in assessing the QoE was significantly higher , that is , 0.66 ( 95 % CI = 0.56 - 0.75 ) and 0.72 ( 95 % CI = 0.61 - 0.79 ) , respectively . The IRR further increased for three ( 0.80 [ 95 % CI = 0.73 - 0.86 ] and 0.74 [ 95 % CI = 0.65 - 0.81 ] ) or four raters ( 0.84 [ 95 % CI = 0.78 - 0.89 ] and 0.79 [ 95 % CI = 0.71 - 0.85 ] ) . The IRR did not improve when QoE was assessed through a consensus rating . CONCLUSION Our findings suggest that trained individuals using the GRADE approach improves reliability in comparison to intuitive judgments about the QoE and that two individual raters can reliably assess the QoE using the GRADE system PURPOSE The objective of this study is to investigate the effect of three different workplace interventions on long-term compliance , muscle strength gains , and neck/shoulder pain in office workers . METHODS A 1-yr r and omized controlled intervention trial was done with three groups :  specific resistance training ( SRT , n = 180 ) , all-round physical exercise ( APE , n = 187 ) , and reference intervention ( REF , n = 182 ) with general health counseling . Physical tests were performed and question naires answered at pre- , mid- , and postintervention . The main outcome measures were compliance , changes in maximal muscle strength , and changes in intensity of neck/shoulder pain ( scale 0 - 9 ) in those with and without pain at baseline . RESULTS Regular participation was achieved by 54 % , 31 % , and 16 % of those of the participants who answered the question naire in SRT ( 78 % ) , APE ( 81 % ) , and REF ( 80 % ) , respectively , during the first half of the intervention period , and decreased to 35 % , 28 % and 9 % , respectively , during the second half . Shoulder elevation strength increased 9 - 11 % in SRT and APE ( P < 0.0001 ) . Participants with neck pain at baseline decreased the intensity of neck pain through SRT , from 5.0 + /- 0.2 to 3.4 + /- 0.2 ( P < 0.0001 ) , and through APE , from 5.0 + /- 0.2 to 3.6 + /- 0.2 ( P < 0.001 ) , whereas REF caused no change . For participants without shoulder pain at baseline , there was a significantly greater increase in pain over the 1-yr period in REF compared with SRT and APE ( P < 0.01 ) . CONCLUSION Compliance was highest in SRT but generally decreased over time . SRT and APE caused increased shoulder elevation strength , were more effective than REF to decrease neck pain among those with symptoms at baseline , and prevent development of shoulder pain in those without symptoms at baseline OBJECTIVE This study is aim ed to assess the efficacy of traditional acupuncture for chronic neck pain in patients by comparing the differences in symptoms , dysfunctions and quality of life . METHODS The study used a two-arm , single-blinded , r and omised controlled design . The patients were r and omised to the study group and control group , who respectively received traditional acupuncture and placebo treatment . The Northwick Park Neck Pain Question naire ( NPQ ) , visual analogue scale ( VAS ) , Short Form ( 36 ) Health Survey ( SF-36 ) and doctor 's judgement were applied for measuring effectiveness . The patients ' effectiveness outcome was assessed , respectively , before the intervention , immediately after the intervention , at the end of the first month of follow-up and at the end of the third month of follow-up . The statistical analysis was done on Statistical Package for Social Sciences ( SPSS ) v13 , which included comparison of demographic and clinical homogeneity , the repeated measures approach based on the general linear model ( GLM ) for effectiveness assessment and the sum rank test for doctors ' subjective efficacy judgement . RESULTS Totally , 190 patients were recruited and 178 patients ( 88 in the study group and 90 in the control group ) completed the intervention and follow-up assessment . The scores of NPQ , VAS and SF-36 were improved after the intervention and during follow-up ( P<0.01 vs. before the intervention ) . The patients in the study group had better effectiveness outcome in NPQ , VAS and in the VT , SF and MH domains of SF-36 ( P<0.05 ) . CONCLUSION Traditional acupuncture can relieve pain intensity and improve the quality of daily life with a relative long-term clinical efficacy in patients with chronic neck pain BACKGROUND AND OBJECTIVES Upper extremity musculoskeletal disorders ( MSD ) are very common in regular computer users and leading cause of work related illness . The objective of the present study is to evaluate effectiveness of yogic exercises in the improvement of symptoms of MSDs of upper limbs . MATERIAL S AND METHODS 60 study participants were r and omly divided into two groups that is yoga with counselling and only counselling group for 12 weeks . Symptom severity and functional status were assessed using the self administered Boston Carpal Tunnel Question naire and pre design ed symptom question naire before and after intervention . RESULTS There was significant reduction in symptom severity score ( P = 0.002 ) and improvement in functional status score in yoga with counselling group when compared to only counselling group . There is also a significant decrease in self reported symptoms like CT myalgia symptom ( P = 0.019 ) and improvement in weakness . CONCLUSION The present study showed a yoga based regimen is more effective than counselling alone in relieving symptoms of computer related musculoskeletal disorders UNLABELLED Yoga has been found effective in the treatment of  chronic low back pain . We aim ed to evaluate the effectiveness of Iyengar yoga in chronic neck pain by means of a r and omized clinical trial . Seventy-seven patients ( aged 47.9 ± 7.9 , 67 female ) with chronic neck pain who scored > 40 mm on a 100-mm visual analog scale ( VAS ) were r and omized to a 9-week Iyengar yoga program  with weekly 90-minute classes ( n = 38 ) or to a self-care/exercise program ( n = 38 ) . Patients were examined at baseline and after 4 and 10 weeks . The primary outcome measure was change of mean pain at rest ( VAS ) from baseline to week 10 . Secondary outcomes included pain at motion , functional disability , quality of life ( QOL ) , and psychological outcomes . Twelve patients in the yoga group and 11 patients in the self-care/exercise group were lost to follow-up , with higher study nonadherence in the self-care group ( 5 versus 10 patients ) . Mean pain at rest was reduced from 44.3 ± 20.1 to 13.0 ± 11.6 at week 10 by yoga and from 41.9 ± 21.9 to 34.4 ± 21.1 by self-care/exercise ( group difference : -20.1 , 95 % confidence interval : -30.0 , -10.1 ; P < .001 ) . Pain at motion was reduced from 53.4 ± 18.5 to 22.4 ± 18.7 at week 10 by yoga and from 49.4 ± 22.8 to 39.9 ± 21.5 by self-care/exercise ( group difference : -18.7 , 95 % confidence interval : -29.3 , -8.1 ; P < .001 ) . Significant treatment effects of yoga were also found for pain-related apprehension , disability , QOL , and psychological outcomes . Sensitivity analyses suggested minimal influence of dropout rates . Both programs were well tolerated . In this preliminary trial , yoga appears to be an effective treatment in chronic neck pain with possible additional effects on psychological well-being and QOL . The effectiveness of yoga in chronic neck pain should be further tested by comparative effectiveness studies with longer observation periods . PERSPECTIVE This article presents the results of a r and omized controlled trial on the clinical effects of a 9-week yoga program or self-care exercise in patients with chronic neck pain . Yoga led to superior pain relief and functional improvements and might be a useful treatment option for chronic neck pain Background A clinical prediction rule ( CPR ) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed , but has yet to be vali date d. Objective The purpose of this study was to examine the validity of this CPR . Design This was a multi-center r and omized clinical trial . Methods One hundred forty patients with a primary report of neck pain were r and omly assigned to receive either 5 sessions of stretching and strengthening exercise ( exercise-only group ) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise ( manipulation + exercise group ) . Data on disability and pain were collected at baseline , 1 week , 4 weeks , and 6 months . The primary aim ( treatment group × time × status on the prediction rule ) was examined using a linear mixed model with repeated measures . Time , treatment group , and status on the rule , as well as all possible 2-way and 3-way interactions , were modeled as fixed effects , with disability ( and pain ) as the dependent variable . Effect sizes were calculated for both pain and disability at each follow-up period . Results There was no 3-way interaction for either disability or pain . A 2-way ( group × time ) interaction existed for both disability and pain . Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group . The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period . The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up . Limitations Different exercise approaches may have result ed in a different outcome . Conclusions The results of the current study did not support the validity of the previously developed CPR . However , the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long-term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only Context  Neck pain is common among primary care patients . Evidence on the effectiveness of therapies for neck pain is limited . A previous r and omized , controlled trial suggested benefits from manual therapy and physical therapy . Contribution This r and omized , controlled trial of manual therapy , physical therapy , and continued care by a doctor confirms the superiority of manual therapy and physical therapy over continued care . At 7 weeks , 68.3 % of patients in the manual therapy group reported resolved or much improved pain , compared with 50.8 % of patients in the physical therapy group and 35.9 % of patients in the continued care group . Clinical Implication s Primary care physicians should consider manual therapy when treating patients with neck pain .  The Editors Neck pain is a common problem in the general population , with point prevalences between 10 % and 15 % ( 1 - 3 ) . It is most common at approximately 50 years of age and is more common in women than in men ( 1 , 2 , 4 - 6 ) . Neck pain can be severely disabling and costly , and little is known about its clinical course ( 7 - 9 ) . Limited range of motion and a subjective feeling of stiffness may accompany neck pain , which is often precipitated or aggravated by neck movements or sustained neck postures . Headache , brachialgia , dizziness , and other signs and symptoms may also be present in combination with neck pain ( 10 , 11 ) . Although history taking and diagnostic examination can suggest a potential cause , in most cases the pathologic basis for neck pain is unclear and the pain is labeled nonspecific . Conservative treatment methods that are frequently used in general practice include analgesics , rest , or referral to a physical therapist or manual therapist ( 12 , 13 ) . Physical therapy may include passive treatment , such as massage , interferential current , or heat applications , and active treatment , such as exercise therapies . Physical therapists can specialize in passive manual ( or h and s-on ) techniques , including mobilization or manipulation ( high-velocity thrust techniques ) , also referred to as manual therapy ( 14 - 19 ) . According to the International Federation of Orthopedic Manipulative Therapies , Orthopedic manipulative ( manual ) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities ( unpublished data ) . Today , many different manual therapy approaches are applied by various health professionals , including medical doctors , physical therapists , massage therapists , manual therapists , chiropractors , and osteopathic doctors . Review s of trials involving manual therapy or physical therapy show that most interventions in these categories are characterized by a combination of passive and active components ( 20 - 23 ) . Although a combination of manual therapy or physical therapy that includes exercises appears to be effective for neck pain , these therapies have not been studied in sufficient detail to draw firm conclusions , and the method ologic quality of most trials on neck pain is rather low ( 20 - 23 ) . Koes and colleagues ( 24 , 25 ) performed a r and omized trial on back and neck pain and found promising results for manual therapy and physical therapy in subgroup analyses of patients with neck pain . In our r and omized , controlled trial , we compared the effectiveness of manual therapy , physical therapy , and continued care by a general practitioner in patients with nonspecific neck pain . Methods Patients Patients with nonspecific neck pain whose clinical presentation did not warrant referral for further diagnostic screening were referred to one of four research centers by 42 general practitioners for study selection . We excluded patients whose history , signs , and symptoms suggested a potential nonbenign cause ( including previous surgery of the neck ) or evidence of a specific pathologic condition , such as malignancy , neurologic disease , fracture , herniated disc , or systemic rheumatic disease . Two research assistants who were experienced physical therapists and were blinded to treatment allocation performed physical examinations at baseline and follow-up . They used st and ardized inclusion and exclusion criteria and performed a short neurologic examination ( Appendix Table 1 ) and range-of-motion assessment . The eligibility criteria were age between 18 and 70 years , pain or stiffness in the neck for at least 2 weeks , neck symptoms reproducible during physical examination , willingness to adhere to treatment and measurement regimens , no physical therapy or manual therapy for neck pain during the previous 6 months , no involvement in litigation , and written informed consent . Patients with concurrent headaches , nonradicular pain in the upper extremities , and low back pain were not excluded , but neck pain had to be the main symptom for all patients . R and om Assignment and Data Collection All patient data were collected before r and omization . Patients were assigned to a treatment group on the basis of block r and omization after prestratification for symptom severity ( severity scores < 7 points or 7 points on a scale of 0 to 10 ) ; age ( < 40 years or 40 years ) ; and , mainly for practical reasons , research center ( four local centers ) . R and omized permuted blocks of six patients were generated for each stratum by using a computer-generated r and om-sequence table . A research er who was not involved in the project prepared opaque , sequentially numbered sealed envelopes that contained folded cards indicating one of the three interventions . Interventions The intervention period lasted 6 weeks . Patients were allowed to perform exercises at home and to continue medication prescribed at baseline or use over-the-counter analgesics . Other co- interventions were discouraged but were registered if they occurred . Within the boundaries of the protocol , treatment could be reassessed and adapted to the patient 's condition . The specific treatment characteristics were registered at each visit . A maximum number of visits was set for each intervention group ; however , the patients did not have to complete this maximum number if symptoms had resolved . Manual Therapy Our approach to manual therapy was eclectic and incorporated several techniques used in western Europe , North America , and Australia , including those described by Cyriax , Kaltenborn , Maitl and , and Mennel ( 15 , 16 , 19 ) . In our trial , manual therapy ( defined as the use of passive movements to help restore normal spinal function ) included h and s-on muscular mobilization techniques ( aim ed at improving soft tissue function ) , specific articular mobilization techniques ( to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine ) , and coordination or stabilization techniques ( to improve postural control , coordination , and movement patterns by using the stabilizing cervical musculature ) ( 26 ) . Joint mobilization is a form of manual therapy that involves low-velocity passive movements within or at the limit of joint range of motion ( 27 ) . Manual therapists must undergo extensive training to be able to skillfully perform mobilization techniques ( 15 , 19 ) . Spinal manipulations ( low-amplitude , high-velocity thrust techniques ) were not included in this protocol . Forty-five minute treatment sessions were scheduled once per week , for a maximum of six treatments . Six experienced manual therapists acknowledged by the Netherl and s Manual Therapy Association performed the treatment . Physical Therapy The physical therapists used a combination of several treatment options , but active exercise therapies were the cornerstone of their strategy . Active exercise therapy involves participation by the patient and includes active exercises ( to improve strength or range of motion ) ,  postural exercises , stretching , relaxation exercises  , and functional exercises . Manual traction or stretching , massage , or physical therapy methods , such as interferential current or heat applications , could precede the exercise therapy . Specific manual mobilization techniques were not included in this protocol . Thirty-minute treatment sessions were scheduled twice per week for a maximum of 12 treatments . The treatment was performed by five experienced physical therapists . We prevented cross-contamination with manual therapy by choosing physical therapists who were not manual therapy specialists . Continued Care by a General Practitioner Each patient in this group received st and ardized care from his or her general practitioner , including advice on prognosis , advice on psychosocial issues , advice on self-care ( heat application , home exercises ) , advice on ergonomics ( for example , size of pillow , work position ) , and encouragement to await further recovery . The treatment protocol was similar to the practice guidelines for low back pain issued by the Dutch College of General Practitioners ( 28 ) . Patients received an educational booklet containing ergonomic advice and exercises ( 29 ) . Medication , including paracetamol or nonsteroidal anti-inflammatory drugs , was prescribed on a time-contingent basis if necessary . Ten-minute follow-up visits , scheduled every 2 weeks , were optional , and referral during the intervention period was discouraged . Outcome Measures Data were collected at the research center after 3 and 7 weeks . At 7 weeks , treatment results were expected to be maximal . The patients were repeatedly asked not to reveal any information about their treatment allocation to the research assistants . The success of blinding was evaluated at 7 weeks . Primary outcome measures focused on perceived recovery , pain , and functional disability . Patients rated perceived recovery on a 6-point ordinal transition scale , ranging from much worse to completely recovered . Success was defined a priori as completely recovered or much improved ( 30 ) . In addition , on the basis of the systematic assessment of spinal mobility , palpation , and pain reported by
target: For workers with persistent neck and shoulder pain , evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone ( grade s I-III NAD ) .
  A multimodal approach including manual therapy , self-management advice , and exercise is an effective treatment strategy for both recent-onset and persistent neck pain
background: OBJECTIVE The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders ( NADs ) and whiplash-associated disorders ( WADs ) .
  This guideline replaces 2 prior chiropractic guidelines on NADs and WADs .