Pharmacological, psychological, and patient education interventions for patients with neck pain: results of an international survey.

BACKGROUND: Examination of practice patterns compared to existing evidence identifies knowledge to practice gaps. OBJECTIVES: To describe the utilization of pharmacological, patient education, primary psychological interventions and relaxation therapies in patients with neck pain by clinicians. METHODS: An international cross-sectional survey was conducted to determine the use of these interventions amongst 326 clinicians treating patients with neck pain. RESULTS: Nineteen countries participated. Results were analyzed by usage amongst physical therapists (39%) and chiropractors (35%), as they were the predominant respondents. Patient education (95%) and relaxation therapies (59%) were the most utilized interventions. Tests of subgroup differences determined that physical therapists used patient education significantly more than chiropractors. Use of medications and primary psychological interventions were reported by most to be outside of scope of practice. The high rate of patient education is consistent with supporting evidence. However, usage of relaxation therapies is contrary to evidence suggesting no benefit for improved pain or function for chronic neck pain. CONCLUSION: This survey indicates that patient education and relaxation therapies are common treatments provided by chiropractors and physical therapists for patients with neck pain. Future research should address gaps associated with variable practice patterns and knowledge translation to reduce usage of interventions shown to be ineffective.

Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey.

BACKGROUND: Clinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens. AIM: To describe the utilization of interventions in patients with neck pain by clinicians. METHODS: A cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain. RESULTS: The survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41-66%) working in private practice (69-95%). Exercise and manual therapies were consistently (98-99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and 'other' interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics). CONCLUSIONS: This survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.

Results of an International Survey of Practice Patterns for Establishing Prognosis in Neck Pain: The ICON Project.

Results of an international survey of health care providers for neck pain are reported. The survey specifically collected self-reported practice patterns for establishing a prognosis in neck pain. Over 440 responses from 27 countries were collected. Descriptive results indicate that respondents assigned large prognostic impact to factors including mechanism of injury and psychological or behavioral constructs. Range of motion, age and sex were routinely collected despite relatively moderate impact on prognosis. A comparison between chiropractic and manual/physical therapy groups showed differences in practice patterns that were unlikely to affect prognostic accuracy. The results suggest a gap exists between current best-evidence and actual practice when the goal is to establish a prognosis in neck pain.

An ICON Overview on Physical Modalities for Neck Pain and Associated Disorders.

INTRODUCTION: Neck pain is common, can be disabling and is costly to society. Physical modalities are often included in neck rehabilitation programs. Interventions may include thermal, electrotherapy, ultrasound, mechanical traction, laser and acupuncture. Definitive knowledge regarding optimal modalities and dosage for neck pain management is limited. PURPOSE: To systematically review existing literature to establish the evidence-base for recommendations on physical modalities for acute to chronic neck pain. METHODS: A comprehensive computerized and manual search strategy from January 2000 to July 2012, systematic review methodological quality assessment using AMSTAR, qualitative assessment using a GRADE approach and recommendation presentation was included. Systematic or meta-analyses of studies evaluating physical modalities were eligible. Independent assessment by at least two review team members was conducted. Data extraction was performed by one reviewer and checked by a second. Disagreements were resolved by consensus. RESULTS: Of 103 reviews eligible, 20 were included and 83 were excluded. Short term pain relief - Moderate evidence of benefit: acupuncture, intermittent traction and laser were shown to be better than placebo for chronic neck pain. Moderate evidence of no benefit: pulsed ultrasound, infrared light or continuous traction was no better than placebo for acute whiplash associated disorder, chronic myofascial neck pain or subacute to chronic neck pain. There was no added benefit when hot packs were combined with mobilization, manipulation or electrical muscle stimulation for chronic neck pain, function or patient satisfaction at six month follow-up. CONCLUSIONS: The current state of the evidence favours acupuncture, laser and intermittent traction for chronic neck pain. Some electrotherapies show little benefit for chronic neck pain. Consistent dosage, improved design and long term follow-up continue to be the recommendations for future research.

A survey of patient's perceptions of what is "adverse" in manual physiotherapy and predicting who is likely to say so.

OBJECTIVES: The primary objective was to describe the patient perspective regarding the identification and occurrence of adverse responses related to manual therapy. A secondary objective evaluated predictors of the incidence rate of adverse responses identified by patients receiving manual physiotherapy. STUDY DESIGN AND SETTING: A cross-sectional survey of patients receiving manual physiotherapy recruited by physiotherapists in Canada was conducted. The survey included questions about the symptoms patients identified as adverse, causal associations with treatment, and the impact of contextual factors. Descriptive statistics are reported, and Poisson modeling predicted factors associated with identification of adverse responses. RESULTS: A response rate of 76.2% (324 of 425) was obtained. Having lumbar spine dysfunction was a significant predictor of all adverse responses (incidence rate ratio [IRR] 95% confidence interval [CI] = 1.513 [1.025, 2.235], P = 0.037) and was associated with 51% greater identification of adverse responses compared with those with an extremity disorder. Expectation of soreness was "protective" against identifying major adverse responses (IRR [95% CI] = 0.915 [0.838, 0.999], P = 0.047); they had an 8.5% lower rate of identifying major adverse responses relative to those without this expectation. CONCLUSIONS: The patient perspective is important to consider if a comprehensive framework for defining adverse responses in manual therapies is to be developed.

Complementary and alternative medicine in back pain utilization report.

OBJECTIVES: This systematic review was undertaken to evaluate which complementary and alternative medicine (CAM) therapies are being used for persons with back pain in the United States. DATA SOURCES: MEDLINE, CINHAHL, EMBASE, and Cochrane Central, and a variety of CAM specific databases were searched from 1990 to November 2007. A grey literature search was also undertaken, particularly for clinical practice guidelines (CPG) related to CAM. REVIEW METHODS: Standard systematic review methodology was employed. Eligibility criteria included English studies of adults with back pain, and a predefined list of CAM therapies. RESULTS: A total of 103 publications were evaluated; of these 29 did not present CAM therapy use stratified for back pain. There were a total of 65 utilization studies, 43 of which were American. Four publications evaluated the concurrent use of four or more CAM therapies and these suggest that chiropractic/manipulation is the most frequently used modality followed by massage and acupuncture. A limited number of publications evaluated utilization rates within multiple regions of the back and show that CAM was used least for treating the thoracic spine and most for the low back. However, rates of the use of massage were similar for neck and lower back regions. Concurrent use of different CAM or conventional therapies was not well reported. From 11 eligible CPG, only one (for electro-acupuncture) provided recommendations for frequency of use for low back pain of all acuity levels. Eighteen cost publications were reviewed and all but one publication (cost-effectiveness) were cost identification studies. There is limited information on the impact of insurance coverage on costs and utilization specific to back pain. CONCLUSIONS: There are a few studies evaluating the relative utilization of various CAM therapies for back pain. For those studies evaluating utilization of individual CAM therapies, the specific characteristics of the therapy, the providers, and the clinical presentation of the back pain patients were not adequately detailed; nor was the overlap with other CAM or conventional treatments.