Respiratory dysfunction in patients with chronic neck pain: systematic review and meta-analysis.

PURPOSE: To determine the differences in respiratory muscle strength and pulmonary function between patients with chronic neck pain (CNP) and asymptomatic individuals. METHODS: Databases were MEDLINE, CINAHL, Scopus, Web of Science and EMBASE up to the end of September 2021. Studies with cross-sectional and longitudinal design were selected, with adult patients with CNP and asymptomatic individuals with reports respiratory function. RESULTS: 11 studies met the inclusion criteria and 10 were included in the meta-analysis showing a statistically significant reduction in inspiratory/expiratory muscle strength (MIP/MEP) in the patients with CNP compared with the asymptomatic individuals (mean difference (MD) for MIP, -11.67 [-14.57 to -8.77]; MD for MEP, -11.80 [-14.99 to -8.60]) and pulmonary function: vital capacity (standardized mean difference (SMD), -0.31 [-0.56 to -0.06]); maximum voluntary ventilation (SMD, -0.36 [-0.59 to -0.14]); forced vital capacity (SMD, -0.53 [-0.99 to -0.06]); peak expiratory flow (SMD, -0.58 [-1.03 to -0.12]); and forced expiratory volume in the first second (SMD, -0.28 [-0.51 to -0.05]). CONCLUSIONS: Patients with CNP have reduced respiratory muscle strength and pulmonary function compared with asymptomatic individuals, and this difference could be clinically meaningful. However, more studies of high methodological quality and longitudinal studies are needed to strengthen the results of this meta-analysis. IMPLICATIONS FOR REHABILITATIONRespiratory dysfunction has been observed in patients with chronic neck pain.Patients with chronic neck pain present a decrease in respiratory muscle strength and pulmonary function compared with asymptomatic individuals.Respiratory pattern disorders should be considered in the clinical context of chronic neck pain.Interventions focused on respiratory muscle training could be helpful for this population.

Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: A systematic review and meta-analysis.

BACKGROUND: Previous reviews relating to the effects of respiratory muscle training (RMT) after stroke tend to focus on only one type of training (inspiratory or expiratory muscles) and most based the results on poor-quality studies (PEDro score ≤4). OBJECTIVES: With this systematic review and meta-analysis, we aimed to determine the effects of RMT (inspiratory or expiratory muscle training, or mixed) on exercise tolerance, respiratory muscle function and pulmonary function and also the effects depending on the type of training performed at short- and medium-term in post-stroke. METHODS: Databases searched were MEDLINE, PEDro, CINAHL, EMBASE and Web of Science up to the end of April 2020. The quality and risk of bias for each included study was examined by the PEDro scale (including only high-quality studies) and Cochrane Risk of Bias tool. RESULTS: Nine studies (463 patients) were included. The meta-analysis showed a significant increase in exercise tolerance [4 studies; n = 111; standardized mean difference [SMD] = 0.65 (95% confidence interval 0.27-1.04)]; inspiratory muscle strength [9 studies; n = 344; SMD = 0.65 (0.17-1.13)]; inspiratory muscle endurance [3 studies; n = 81; SMD = 1.19 (0.71-1.66)]; diaphragm thickness [3 studies; n = 79; SMD = 0.9 (0.43-1.37)]; and peak expiratory flow [3 studies; n = 84; SMD = 0.55 (0.03-1.08)] in the short-term. There were no benefits on expiratory muscle strength and pulmonary function variables (forced expiratory volume in 1 s) in the short-term. CONCLUSIONS: The meta-analysis provided moderate-quality evidence that RMT improves exercise tolerance, diaphragm thickness and pulmonary function (i.e., peak expiratory flow) and low-quality evidence for the effects on inspiratory muscle strength and endurance in stroke survivors in the short-term. None of these effects are retained in the medium-term. Combined inspiratory and expiratory muscle training seems to promote greater respiratory changes than inspiratory muscle training alone.

Motor effects of movement representation techniques and cross-education: a systematic review and meta-analysis.

INTRODUCTION: The objective was to assess the impact of movement representation techniques (MRT) through motor imagery (MI), action observation (AO) and visual mirror feedback (VMF) and cross-education training (CE) on strength, range of motion (ROM), speed, functional state and balance during experimental immobilization processes in healthy individuals, in patients with injuries that did not require surgery and in those with surgical processes that did or did not require immobilization. EVIDENCE ACQUISITION: MEDLINE, EMBASE, CINAHL and Google Scholar were searched. Thirteen meta-analyses were conducted. EVIDENCE SYNTHESIS: Regarding the immobilized participants, in the healthy individuals, MI showed significant results regarding maintenance of strength and ROM, with low-quality evidence. Regarding the process with no immobilization, VMF and MI techniques showed significant changes in maintaining ROM in patients with injury without surgery, with very low-quality evidence. Results had shown that MI demonstrated significantly higher maintenance of strength and speed in patients undergoing surgery, with low-quality evidence. No significant results were found in ROM. Low-quality evidence showed better results in AO plus usual care compared with usual treatment in isolation with respect to maintenance of functional state and balance. CE training demonstrated maintenance of strength in patients undergoing surgery, with moderate evidence; however, not in healthy experimentally immobilized individuals. VMF did not show significant results in maintaining ROM after surgery without immobilization, nor did MI in maintaining strength after surgery and immobilization. CONCLUSIONS: MRT and CE training have been shown to have a significant impact on the improvement of various motor variables and on physical maintenance in general.

Pain relief by movement representation strategies: An umbrella and mapping review with meta-meta-analysis of motor imagery, action observation and mirror therapy.

OBJECTIVE: To develop a mapping and umbrella review with a meta-meta-analysis (MMA) to critically evaluate the current evidence of motor imagery (MI), action observation and mirror therapy (MT) on pain intensity. METHODS: The study involved a systematic search of PubMed, PEDro, Scielo, EBSCO and Google Scholar. RESULTS: Ten systematic reviews were included in the qualitative synthesis, 70% of which showed high methodological quality. Three reviews found a significant reduction in chronic musculoskeletal pain as the result of applying movement representation methods (MRM) plus usual-care (UC), with a large clinical effect (standardized mean difference [SMD] of -1.47; 95% CI -2.05 to -0.88; heterogeneity Q = 1.66; p = 0.44; I2  = 0%). However, two reviews showed no statistically significant reduction in acute and postsurgical pain as a result of applying MI plus UC. Four reviews showed no significant reduction in phantom limb pain (PLP) as a result of applying MT plus UC interventions. In four reviews, the MMA showed a significant reduction in complex regional pain syndrome (CRPS) as a result of applying MT plus UC, with a large clinical effect (SMD -1.27; 95% CI -1.87 to -0.67; heterogeneity Q = 3.95; p = 0.27; I2  = 24%). In two reviews, the MMA showed no significant differences in poststroke pain as a result of applying MT plus UC. CONCLUSION: Results show that MRM could be effective for chronic musculoskeletal pain, with low to moderate-quality evidence. The results also show a reduction in pain intensity through MT interventions in patients with CRPS, although these results were not found in patients with PLP or poststroke pain. SIGNIFICANCE: This umbrella review analysed systematic reviews evaluating movement representation techniques, with the aim of synthesizing the available evidence regarding motor imagery, action observation and mirror therapy on pain. The results provide relevant information about the potential clinical use of movement representation techniques in different types of patients with painful conditions.

Effectiveness of motor imagery and action observation on functional variables: An umbrella and mapping review with meta-meta-analysis.

To assess the current evidence on motor imagery (MI) and action observation (AO) and their influence on functional variables. We conducted 3 meta-meta-analyses (MMA) to determine the effectiveness of MI and AO on arm functionality, performance on activities of daily living and gait mobility in stroke patients. For arm functionality, MMA revealed a statistically significant large effect size (standardised mean difference [SMD] = 1.05; 95 % CI 0.50-1.60; p<.001) but with evidence of heterogeneity (Q=55.67, p<.001, I2=93 %). For arm performance in activities of daily living, MMA revealed a significantly large effect size (SMD=1.76; 95 % CI 1.10-2.43; p<.001) but also with evidence of heterogeneity (Q=1.62, p=.44, I2=90 %). MMA showed no significant effects favouring intervention regarding gait mobility. The results of the systematic reviews showed that movement representation techniques combined with the usual treatment have a positive impact on improving function, with a very low to moderate quality of evidence for all variables except for range of motion in acute disorders and strength. MI and AO showed positive results for improving functional variables.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT. DESIGN: Systematic review and meta-analysis (MA). METHODS: A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies' objectives. The qualitative analysis was based on classifying the results into levels of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RESULTS: Regarding cervical MT, MA included three studies and showed statistically significant differences in pain intensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity reduction and pain-free maximal mouth opening, with a large clinical effect. CONCLUSIONS: Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain-free MMO over cervical intervention alone in TMD and headache, with low evidence.

Effectiveness of motor imagery and action observation training on musculoskeletal pain intensity: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Movement representation techniques such as motor imagery (MI) and action observation (AO) could play an important role in the field of rehabilitation of patients with musculoskeletal pain; however, the effects of these tools on clinical pain remain unclear. Our objective is therefore to develop a systematic review and meta-analysis of the effects of MI and AO regarding the pain intensity on patients with musculoskeletal pain. DATABASES AND DATA TREATMENT: MEDLINE, EMBASE, CINAHL and Google Scholar were searched. Last search was run on July 2019. Meta-analysis was conducted to determine the effectiveness on pain intensity in patients with post-surgical pain or chronic pain, and GRADE was used to rate the quality, certainty and applicability of the evidence. RESULTS: A total of 10 studies were included. AO or MI were compared versus usual rehabilitation care. The meta-analysis showed statistically significant differences in MI and AO interventions in patients with pain after surgery in six studies, with a large clinical effect (n = 124; SMD = -0.84; 95% CI: -1.47 to -0.21). In patients with chronic pain, results showed statistically significant differences in MI and AO interventions in three studies, with a large clinical effect (n = 83; SMD = -2.14; 95% CI: -3.81 to -0.47). Risk of bias, imprecision and inconsistency decreased the GRADE level of evidence. CONCLUSIONS: There was very low-quality evidence regarding the effects of movement representation techniques intervention (AO and MI) on pain intensity in patients with post-surgical pain. In addition, there was very low-quality evidence regarding the effects of MI and AO interventions on chronic pain. SIGNIFICANCE: Movement representation techniques in combination with usual care are capable of producing a decrease in pain intensity compared with conventional treatment, in both post-surgical and chronic pain. However, the very low-quality evidence found regarding these techniques showed that more research is needed for their application in a clinical context.

Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials.

BACKGROUND: Manual therapies are generally requested by patients with tension type headache. OBJECTIVE: To compare the efficacy of multimodal manual therapy vs. pharmacological care for the management of tension type headache pain by conducting a meta-analysis of randomized controlled trials. METHODS: PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro and SCOPUS were searched from their inception until June 2014. All randomized controlled trials comparing any manual therapy vs. medication care for treating tension type headache adults were included. Data were extracted and methodological quality assessed independently by two reviewers. We pooled headache frequency as the main outcome and also intensity and duration. The weighted mean difference between manual therapy and pharmacological care was used to determine effect sizes. RESULTS: Five randomized controlled trials met our inclusion criteria and were included in the meta-analysis. Pooled analyses found that manual therapies were more effective than pharmacological care in reducing frequency (weighted mean difference -0.8036, 95% confidence interval -1.66 to -0.44; three trials), intensity (weighted mean difference -0.5974, 95% confidence interval -0.8875 to -0.3073; five trials) and duration (weighted mean difference -0.5558, 95% confidence interval -0.9124 to -0.1992; three trials) of the headache immediately after treatment. No differences were found at longer follow-up for headache intensity (weighted mean difference -0.3498, 95% confidence interval -1.106 to 0.407; three trials). CONCLUSION: Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care. However, due to the heterogeneity of the interventions, these results should be considered with caution at this stage.

Effectiveness of therapeutic patient education for adults with migraine. A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Our aim was to systematically review and meta-analyze the effectiveness of therapeutic patient education for migraine. METHODS: A literature search of multiple electronic databases (MEDLINE, EMBASE, PEDro, CINAHL, and PsychINFO) was conducted to identify randomized control trials (RCTs) published in the English and Spanish languages up to and including May 2013. Two reviewers independently selected the studies, conducted the quality assessment (Delphi list), and extracted the results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used throughout the systematic review and meta-analysis. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated for relevant outcome measures (headache frequency, headache disability, self-efficacy, depressive symptoms, and quality of life) and pooled in a meta-analysis using the random effects model. RESULTS: Fourteen RCTs were included in the systematic review. Only nine studies were included in the meta-analysis. The median quality score was 6.14 ± 1.29 (range: 5-9). There was strong-moderate evidence for intermediate-term effectiveness of therapeutic patient education on headache frequency (five studies: N = 940, SMD = -0.24, 95% CI of -0.48 to -0.01, P = 0.03), headache disability (four studies: N = 799, SMD = -1.02, 95% CI of -1.95 to -0.08, P = 0.03), and quality of life (three studies: N = 674, SMD = 0.36, 95% CI of 0.05-0.67, P = 0.02). There was no evidence for either short-term or intermediate-term effectiveness of therapeutic patient education on self-efficacy or depressive symptoms. CONCLUSION: This systematic review revealed strong-moderate evidence for intermediate-term effectiveness of therapeutic patient education for migraine. Further high-quality RCTs are required for conclusive determination of its effectiveness.

Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: A randomized-controlled trial.

OBJECTIVES: The aims were to investigate the effects of anterior-posterior upper cervical mobilization (APUCM) on pain modulation in craniofacial and cervical regions and its influence on the sympathetic nervous system. METHODS: Thirty-two patients with cervico-craniofacial pain of myofascial origin were randomly allocated into experimental or placebo groups. Each patient received 3 treatments. Outcome measures included bilateral pressure pain thresholds assessed at craniofacial and cervical points preintervention, after the second intervention and after the final treatment. Pain intensity and sympathetic nervous system variables (skin conductance, breathing rate, heart rate, and skin temperature) were assessed before and immediately after each intervention. RESULTS: The pressure pain thresholds in the craniofacial and cervical regions significantly increased (P<0.001) and pain intensity significantly decreased (P<0.001) in the treatment group compared with placebo. APUCM also produced a sympathoexcitatory response demonstrated by a significant increase in skin conductance, breathing rate, and heart rate (P<0.001), but not in skin temperature (P=0.071), after application of the technique compared with placebo. DISCUSSION: This study provided preliminary evidence of a short-term hypoalgesic effect of APUCM on craniofacial and cervical regions of patients with cervico-craniofacial pain of myofascial origin, suggesting that APUCM may cause an immediate nociceptive modulation in the trigeminocervical complex. We also observed a sympathoexcitatory response, which could be related to the hypoalgesic effect induced by the technique, but this aspect should be confirmed in future studies.

Influence of different upper cervical positions on electromyography activity of the masticatory muscles.

OBJECTIVE: The aim of this study was to determine the activity of the masseter and anterior temporalis muscles in relation to different positions of the upper cervical spine during maximal voluntary isometric clenching by surface electromyography (EMG). METHODS: This was a cross-sectional study with a repeated-measures design performed using 25 asymptomatic subjects (13 female and 12 male; mean age, 31 years; SD, 8.51). The EMG activity of the masseter and anterior temporalis muscles was recorded bilaterally during maximal clenching at neutral position and during extension, flexion, ipsilateral lateral flexion, contralateral lateral flexion, and ipsilateral and contralateral rotations in maximal flexion. In addition, the upper cervical range of motion and mandibular excursions were assessed. The EMG activity data were analyzed using a 3-way analysis of variance in which the factors considered were upper cervical position, sex (male and female), and side (right and left), and the hypothesis of importance was the interaction side x position. RESULTS: The 3-way analysis of variance detected statistically significant differences between the several upper cervical positions (F = 13.724; P < .001) but found no significant differences for sex (F = 0.202; P = .658) or side (F = 0.86; P = .53) regarding EMG activity of the masseter muscle. Significant differences were likewise observed for interaction side x position for the masseter muscle (F = 12.726; P < .001). The analysis of the EMG activity of anterior temporalis muscle did not produce statistically significant differences (P > .05). CONCLUSION: This preliminary study suggests that the upper cervical movements influence the surface EMG activity of the masseter muscle. These findings support a model in which there are interaction between the craniocervical and the craniomandibular system.

Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: The aim of this study is to perform a qualitative and quantitative analysis of the scientific literature regarding the use of acupuncture in the treatment of pain associated with temporomandibular disorders (TMDs). METHODS: By using electronic databases, the goal was to search and evaluate all the randomized controlled trials (RCTs) in which acupuncture was used in the management of pain attributed to these clinical entities. For the meta-analysis, an adequate description of the results' statistical data was required along with a comparison of the treatment with a control group using a placebo or sham. Two independent reviewers evaluated the quality of the studies using the Jadad scale. RESULTS: A total of 8 RCTs were selected, and the quality of only 4 was considered acceptable. These 4 studies showed positive results such as reducing pain, improving masticatory function, and increasing maximum interincisal opening. By combining the studies (n=96) and analyzing the results, it was concluded that acupuncture is more effective than placebo in reducing pain intensity in TMD (standardized mean difference 0.83; 95% confidence interval, 0.41-1.25; P=0.00012). DISCUSSION: The results of this meta-analysis suggest that acupuncture is a reasonable adjunctive treatment for producing a short-term analgesic effect in patients with painful TMD symptoms. Although the results described are positive, the relevance of these results was limited by the fact that substantial bias was present. These findings must be confirmed by future RCTs that improve the methodologic deficiencies of the studies evaluated in this meta-analysis.

Effectiveness of acupuncture in the treatment of temporomandibular disorders of muscular origin: a systematic review of the last decade.

OBJECTIVE: The purpose of this review is to evaluate the effectiveness of using acupuncture treatment for temporomandibular disorders (TMD) of muscular origin according to research published in the last decade. METHODS: The information was gathered using the MEDLINE, EMBASE, CINAHL, and CISCOM databases. The inclusion criteria for selecting the studies were the following: (1) only randomized controlled trials (RCTs) were selected; (2) studies had to be carried out on patients with TMD of muscular origin; (3) studies had to use acupuncture treatment; and (4) studies had to be published in scientific journals between 1997 and 2008. Two (2) independent reviewers analyzed the methodological quality of the studies using the Delphi list. A total of four RCTs were chosen once the methodological quality was judged as being acceptable. All of the studies included in the review compared the acupuncture treatment with a placebo treatment. All of them described results that were statistically significant in relation to short-term improvement of TMD signs and symptoms of a muscular origin, except one of the analyzed studies that found no significant difference between acupuncture and sham acupuncture. CONCLUSIONS: In the authors' opinion, research into the long-term effects of acupuncture in the treatment of TMD is needed. We also recommend larger samples sizes for future studies, so the results will be more reliable.