| IntroductionNeck pain is common. Most of the people experienced neck pain in their life, mainly with neck and shoulder pain, upper extremity pain, numbness, as the main symptoms. With the high prevalence rate and growing incidence rate, as we I I as the high recurrence rate, neck pa in adversely affect the socio-economic system, family and the health care system. In American, the medical expenses on spinal care, including neck pain, is about19.39billion US dollars, which is the second most costly musculoskeletal health care expenses.There is normally no indication for surgery in case of neck pain. Most patients seek for conservative treatment. There are different conservative treatments based on the diversity and complexity of the causes of neck pain. Current research did not find a conservative treatment which is better than the other treatments, and yet to find the gold standard of conservative treatment of neck pain. Conservative treatment options are personalized, in response to different clinical conditions require, such as acute or chronic neck, pain level, neck activity and whether the pain was accompanied by neurological symptoms. Also, conservative treatment programs change with the patient's condition. For patients with neck pain treatment strategies developed primarily from clinical experience. The current use of a wider range of practices include manual therapy, acupuncture, traction, cervical exercise therapy, i n which manua I therapy i s the most common use of pract ices, and shows the most treatment effect satisfaction in patients.Spinal manipulation and mobilization techniques are the two commonly used approached. Their main difference lies in the use of high-speed thrust in spinal manipulation in the spine. The purposes of treatments are to relieve mechanical compression of the nerve, to improve the local microcirculation, restore spinal balance and relieve muscle spasm. However, some may argue that there is lack of evidence on the efficacy of the techniques. Some studies suggest that practices therapeutic effect is limited to only short-term effects. There are studies that some practices, especial ly the cervical spine movement joints practices may cause cervical basilar artery blockage that induced risk of stroke, and is not recommended. In this way, the scientific nature of the manual therapy, efficacy and safety was questioned. The aims of this systematic review are to assess relative evidence about neck pain treatment by manipulation, to identify the problems of the present study, provide the basis for the formulation of future research strategies, address the likely problems of clinical trial design and provide the basis for the formulation of future research strategy.MethodsThis research applied the review method of the Cochrane Collaboration, evaluated the neck pain research a I I over the world. A detailed inclusion and exclusion criteria was developed (including research methods, participants, interventions, and outcome measurement). A systematic and comprehensive search strategy was prepared according to the criteria. All sel ected research articles were randomized controlled trials (RCT) researches. Computerized bibliographic databases, from Cochrane library, MEDLINE, EMBASE, EBSCO (ASP+BSP), EBSCOhost, NSTL, CNKI, Wanfang databases, CBM, CQVIP, clinical trial registration platform (ICTRP) of the World Health Organization (WHO), China clinical trial registration, were searched up to December2011. Literature references were used to improve the supplementary search through Google, Ba idu and other search engi nes. Two i ndependent rev iews conducted study selection, data abstraction and methodological quality assessment. The data obtained were recorded using the designed data collection form. Outcome were evaluated independently by the2researchers in accordance with the relevant standards of the Cochrane systematic evaluation manual "(Higgins,2008), judge of bias include adequate sequence generation, allocation concealment, adequate blinding measures, incomplete data assessment, selective reporting bias, similar groups at baseline, and other types of bias. Articles quality assessment based on the modified Jadad scale (1-3points as low quality,4-7regarded as high quality). Statistical analysis was done with the software Revman5.0and GRADEpro from the Cochrane collaboration. For the treatment effects measurement, the relative risk (RR) and95%confidence interval were used for dichotomous variables and comprehensive representation. For continuous data comparison, mean difference (MD) and standard mean deviation (SMD) between the two groups were used. The clinical heterogeneity among articles, which might undergo data combination, was analyzed before any data combination. When there was no statistical heterogeneity between studies (P≥0.1,12≤50%), A fixed effect model (Mantel-Haenszel method) was used. When there was significant heterogeneity (P<0.1,12>50%), but the data could be merged from the clinical point of view, then a random effects model analysis (DerSimonian-Laird Method) would be applied.Results811related research articles were retrieved,28trials were selected. There are10Chinese literatures and18English literatures posted in1990-2011, the study sites involving eight countries and regions including China, USA and United Kingdom.17different intervention comparisons were noted.10researches showed low risk of bias. In terms of al location concealment, patient blinding, outcome assessor blinding, and incomplete outcome data addressed, relatively higher risk of bias appeared in the trials printed in Chinese than those printed in English. One meta-analysis of2trials,171patients, showed an instant alleviation of neck pain after a manipulative treatment. Manipulation showed a better treatment effect than mobilization [SMD1.81(95%CI-1.01,4.64)]. Another meta-analysis of the same2trials focused on the range of movement improvement, no statistical difference was shown between two treatments. Neck flexion [SMD0.45(95%CI0.14,0.76)], Neck extension [SMD0.71(95%CI0.07,1.34)]。One study, with36neck pain patients comparing the treatment effect between manipulation and placebo, showed an obvious advantage in instant pain alleviation in the study group[SMD1.72(95%CI0.94,2.50)]. Another study of32neck pain patients showed a distinct improvement in terms of range of movement with manipulation, left [SMD1.4295%CI0.59,2.26], right [SMD1.28(95%CI0.46,2.10)]. These evidence suggested the short term effect of manipulation in neck painrelieve and cervical range of movement improvement. One meta-analysis of2trials,120patients studied the different treatment effect of mobilization. The meta-analysis showed no significant different between two groups, VAS at rest [SMD0.10(95%CI-0.26,0.46)] VAS at the most painful moment [SMD0.25(95%CI-0.27,0.78)]. Another meta-analysis of the same2trials showed no significant different in the change of movement improvement between two mobilization treatments. Neck flex ion [SMD0.43(95%CI0.07,0.79)], Neck extension [SMD0.28(95%CI-0.08,0.64)] In regard to the long term treatment effect of manipulation, one study,82patients, compared Chinese manipulation and traction. Compared with the control group (Traction), manipulation gave a significant superiority in terms of sign scores, short term effectsign score improvement [SMD-0.62(95%CI-1.05,-0.20)], four weeks follow-up sign score improvement [SMD-1.02(95%CI-1.49,-0.55)]. The result suggested the long term effect of the manipulation. However, the study could only provide low quality evidence on the issue. More specific, large sampling and low risk of bias RCT researches are in need to provide reliable evidence on the long term effect of manipulation. In terms of cervical curvature improvement in neck pain patient treatment, one study,80patients, showed a significant improvement compared with traction treatment [SMD0.12(95%CI-0.32,0.56)]. A total of five studies report adverse events in the course of treatment. Cass idy research reported increase in pain level after treatment,3cases in treatment group and3cases in control group. The other four studies reported no adverse reactions.ConelusionManipulation isasafe and effective form of neck pain treatment. Manipulation and mobilization shows apparent effect on neck pain relieve and neck range of movement improvement. Manipulation showed a dominant effect. Systematic review is a breakthrough in the study of manipulation in spinal diseases. It helps to establish clinical path, treatment ideas and improve the clinical triage system and use the medical resources effectively. We are looking forward for more specific, low risk of bias and large sampling study to give evidence on manipulation effectiveness and safety. |
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