Biochemicals Associated With Pain and Inflammation are Elevated in Sites Near to and Remote From Active Myofascial Trigger Points. Commentary

Background
Neck pain is common, disabling and costly Exercise is one treatment approach

Objectives
To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain

Search methods
We searched MEDLINE, MANTIS, ClinicalTrialsgov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors)

Selection criteria
We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy

Data collection and analysis
Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance The quality of the evidence was assessed using GRADE Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity

Main results
Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria

For acute neck pain only, no evidence was found

For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -071 (95% CI: -133 to -010)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -033 (95% CI: -055 to -010)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -045 (95%CI: -072 to -018)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -1490 (95% CI:-2240 to -739)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up

For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises

For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises

Authors' conclusions
No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function However, when only stretching exercises were used no beneficial effects may be expected Future research should explore optimal dosage

Exercises for mechanical neck disorders

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1–A83. doi:10.2519/jospt.2017.0302

Neck Pain: Revision 2017

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejp.1140

Assessment and manifestation of central sensitisation across different chronic pain conditions.

Senior Fitness Test Manual

https://onlinelibrary.wiley.com/doi/pdf/10.1002/j.1532-2149.2014.499.x

Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review.

The role of central sensitization in shoulder pain: A systematic literature review.

https://www.oarsijournal.com/article/S1063-4584(15)01314-X/pdf

Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review

https://fisioterapiajesusrubio.files.wordpress.com/2016/01/manual-therapy.pdf

Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review

Immediate Effects of Active Cranio-Cervical Flexion Exercise Versus Passive Mobilisation of the Upper Cervical Spine on Pain and Performance on the Cranio-Cervical Flexion Test

Enrique Lluch

Papers

Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review.

The role of central sensitization in shoulder pain: A systematic literature review.

Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review

Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review

Immediate Effects of Active Cranio-Cervical Flexion Exercise Versus Passive Mobilisation of the Upper Cervical Spine on Pain and Performance on the Cranio-Cervical Flexion Test