Physiotherapy Management of Cervical Pain – Research Evidence

In a follow-up to the last post I thought it might be useful to provide some up to date research evidence in relation to Physiotherapy management of Cervical Pain.

Obviously there are numerous research articles out there and it is impossible to know them all. I have limited what I present here mainly to systematic reviews (generally thought of as the best level of evidence).See the following link regarding Levels of Evidence.

Cervical Pain, Whiplash and Headaches

Bertozzi et al (2013)

  • Systematic Review of RCTs concerning the effect of Therapeutic Exercise (TE) on pain and disability among people with CNSNP.
  • Seven studies met inclusion criteria.
  • TE proved to have:
    • Medium significant short and intermediate term effects on pain.
    • Medium but not significant short and intermediate term effects on disability.
  • Consistent with other reviews, the results support the use of TE in the management of CNSNP.
  • In particular, a significant overall effect size was found supporting TE for its effect on pain in both the short and intermediate terms.

Kay et al (2012)

  • Systematic Review investigating effects of exercise on mechanical neck pain.
  • Six of the 21 selected trials had low risk of bias.
  • Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term.
  • Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.

Vincent et al (2012)

  • Systematic Review
  • Of 27 identified trials, 18 were of high quality.
  • In acute neck pain, effective treatments were:
    • Thoracic manipulation combined with electrothermal therapy in the short term and cervical manipulation in the long term.
  • In chronic neck pain and neck pain of variable duration, both pain and function improved consistently at all follow-up time points.
  • None of the manual therapies used alone or in combination was superior over the others.
  • In the long term, exercises alone or combined with manual therapies were superior over manual therapies used alone.
  • Manual therapies contribute usefully to the management of nonspecific neck pain. The level of evidence is moderate for short-term effects of upper thoracic manipulation in acute neck pain, limited for long-term effects of neck manipulation, and limited for all techniques and follow-up durations in chronic neck pain.

d’Sylva et al (2010)

  • Systematic Review
  • Assessed the effect of:
    • (1) manipulation and mobilisation
    • (2) manipulation, mobilisation and soft tissue work
    • (3) manual therapy with physical medicine modalities
  • These treatments were assessed in regards to their effect on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain.
  • Moderate quality evidence suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction. This treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain.
  • Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief, improved function and GPE for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities.

Miller et al (2010)

  • Systematic Review assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy.
  • Of 17 randomized controlled trials included, 29% had a low risk of bias.
  • Low quality evidence suggests clinically important long-term improvements in pain, function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment.
  • High quality evidence suggests greater short-term pain relief than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache.
  • Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash.
  • Evidence regarding radiculopathy was sparse.

Gross et al (2010)

  • Cochrane Systematic Review.
  • 33% of 27 trials had a low risk of bias.
  • Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up.
  • Low quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control.
  • Low quality evidence also supported thoracic manipulation for pain reduction and increased function in acute pain and immediate pain reduction in chronic neck pain.
  • Optimal technique and dose need to be determined.

Hurwitz et al (2009)

  • Systematic Review
  • Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety).
  • For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities.
  • For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term.
  • For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.
  • Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy.

Cervical Radiculopathy

Thoomes et al (2013)

  • Systematic Review
  • Fifteen articles were included that corresponded to 11 studies. Two studies scored low risk of bias.
  • There is low-level evidence that a collar is no more effective than physiotherapy at short-term follow-up and very low-level evidence that a collar is no more effective than traction.
  • There is low-level evidence that traction is no more effective than placebo traction and very low level-evidence that intermittent traction is no more effective than continuous traction.
  • On the basis of low-level to very low-level evidence, no 1 intervention seems to be superior or consistently more effective than other interventions.
  • Regardless of the intervention assignment, patients seem to improve over time, indicating a favorable natural course. Use of a collar and physiotherapy show promising results at short-term follow-up.

Boyles et al (2011)

  • Systematic Review
  • Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability.
  • High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.

Cervical Joint Position Sense and Dizziness

Lystad et al (2011)

  • Systematic Review investigating Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness.
  • A total of fifteen articles reporting findings from thirteen unique investigations, including five randomised controlled trials and eight prospective, non-controlled cohort studies were included in this review. The methodological quality of the included studies was generally poor to moderate.
  • All but one study reported improvement in dizziness following either unimodal or multimodal manual therapy interventions. Some studies reported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain and vertebrobasilar artery blood flow velocity.
  • There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking.
  • Further research to elucidate potential synergistic effects of manual therapyand vestibular rehabilitation is strongly recommended.

Jull et al (2007)

  • Randomised (no control group) trial.
  • This study compared the effects of conventional proprioceptive training and craniocervical flexion (C-CF) training on cervical joint position error (JPE) in people with persistent neck pain. The aim was to evaluate whether proprioceptive training was superior in improving proprioceptive acuity compared to another form of exercise, which has been shown to be effective in reducing neck pain.
  • Sixty-four female subjects with persistent neck pain and deficits in JPE were randomized into two exercise groups: proprioceptive training or C-CF training.
  • Exercise regimes were conducted over a 6-week period, and all patients received personal instruction by an experienced physiotherapist once per week.
  • A significant pre- to postintervention decrease in JPE, neck pain intensity, and perceived disability was identified for both the proprioceptive training group and the C-CF training group.
  • Patients who participated in the proprioceptive training demonstrated a greater reduction in JPE from right rotation compared to the C-CF training group.
  • No other significant differences were observed between the two groups.
  • The results demonstrated that both proprioceptive training and C-CF training have a demonstrable benefit on impaired cervical JPE in people with neck pain, with marginally more benefit gained from proprioceptive training.
  • The results suggest that improved proprioceptive acuity following intervention with either exercise protocol may occur through an improved quality of cervical afferent input or by addressing input through direct training of relocation sense.

Conservative Treatment versus Surgery

van Middlekoop et al (2013)

  • Systematic Review
  • Patients included had neck pain with or without radiculopathy or myelopathy.
  • In total, three RCTs and six CCTs were identified comparing different surgical interventions with conservative care, of which one had a low risk of bias.
  • Overall there is very low quality of evidence available on the effectiveness of surgery compared to conservative care in neck pain patients showing overall no differences.
  • Most studies on surgical techniques comparing these to conservative care showed a high risk of bias. The benefit of surgery over conservative care is not clearly demonstrated.

Persistent Inflammation in Whiplash

Linnman et al (2011)
  •  Twenty-two patients with enduring pain after a rear impact car accident (Whiplash Associated Disorder grade II) and 14 healthy controls were investigated.
  • Patients displayed significantly elevated tracer uptake in the neck.
  • This suggests that whiplash patients have signs of local persistent peripheral tissue inflammation, which may potentially serve as a diagnostic biomarker.


Bertozzi L, Gardenghi I, Turoni F, Villafañe JH, Capra F, Guccione AA, Pillastrini P. Effect of Therapeutic Exercise on Pain and Disability in the Management of Chronic NonspecificNeck Pain: Systematic Review and Meta-Analysis of Randomized Trials. Phys Ther. 2013 Apr 11. [Epub ahead of print]

Boyles R, Toy P, Mellon J, Hayes M, Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011 August; 19(3): 135–142.

d’Sylva J, Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, Haines T, Bronfort G, Hoving JL, Cervical Overview Group. Manual therapy with or without physical medicine modalities for neck pain: a systematic review Manual Therapy 2010 Oct;15(5):415-433.

Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL; COG. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther. 2010 Aug;15(4):315-33.

Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Cote P, Hogg-Johnson S, Cassidy JD, Haldeman S. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders [with consumer summary]. Journal of Manipulative and Physiological Therapeutics 2009 Feb;32(2 Suppl):S141-S175.

Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res. 2007 Mar;25(3):404-12.

Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, Brønfort G, Santaguida PL. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Aug 15;8:CD004250.

Linnman C, Appel L, Fredrikson M, Gordh T, Söderlund A, Långström B, Engler H. Elevated [11C]-D-deprenyl uptake in chronic Whiplash Associated Disorder suggests persistent musculoskeletal inflammation. PLoS One. 2011 Apr 19;6(4):e19182.

Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV. Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap. 2011 Sep 18;19(1):21.

Miller J, Gross A, d’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Bronfort G, Hoving JL. Manual therapy and exercise for neck pain: a systematic review. Manual Therapy 2010 Aug;15(4):334-354.

Thoomes EJ, Scholten-Peeters W, Koes B, Falla D, Verhagen AP. The Effectiveness of Conservative Treatment for Patients With Cervical Radiculopathy: ASystematic Review. Clin J Pain. 2013 Feb 26. [Epub ahead of print]

van Middelkoop M, Rubinstein SM, Ostelo R, van Tulder MW, Peul W, Koes BW, Verhagen AP. Surgery versus conservative care for neck pain: a systematic review. Eur Spine J. 2013 Jan;22(1):87-95.

Vincent K, Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Systematic review of manual therapies for nonspecific neck pain. Joint Bone Spine. 2012 Nov 16. pii: S1297-319X(12)00257-6. doi: 10.1016/j.jbspin.2012.10.006. [Epub ahead of print]

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

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