Manual Therapy 15 (2010) 303–304
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Editorial
Systematic reviews assessing multimodal treatments Systematic reviews can consider either single modality or multimodal treatments in evaluating treatment effects for musculoskeletal disorders, in this case, neck pain. The Cochrane Collaboration Back Group is currently expressing a preference for focussing systematic reviews to single treatment approaches rather than combined therapies, as in the latter, it is impossible to isolate the individual effects of, for example, mobilisation or manipulation from the effects of the total treatment. While this is true and has scientific merit, the risk is loosing comparisons of combined care (i.e., mobilisation, manipulation and soft tissue techniques; manipulation or mobilisation plus other physical medicine agents; mobilisation and manipulation plus exercise) from the Cochrane Review. The concern for clinicians is that in real life practice, patients with neck pain often present with several problems within the biopsychosocial spectrum. Furthermore and not surprisingly, there is evidence from physiological studies and clinical trials that each of the multiple dimensions of a patient’s presentation does not automatically respond to a single treatment approach and hence multimodal approaches are the real life clinical practice and are increasingly, the type of intervention tested in contemporary clinical trials. As editors of Manual Therapy, we have deemed it important to keep clinicians updated on best practice evidence, which we believe includes systematic reviews of not only single modality but also multimodal approaches. Over this and the next issue, Manual Therapy will publish four systematic reviews on the management of mechanical neck pain undertaken by the Cervical Overview Group which is part of the Cochrane Collaboration Back Group. These systematic reviews update the evidence of the effects of cervical mobilisation and manipulation but importantly they extend to review the evidence for multimodal treatments for neck pain. We have also invited Associate Professor Anita Gross to comment on the dilemma and introduce the series of reviews. 1. Associate Professor Anita Gross’ commentary 1.1. What is the value of doing systematic reviews assessing multimodal treatments? Since first publishing our overview in 1996 (Aker et al., 1996; Gross et al., 1996), the Cervical Overview Group (COG) has published three updates on neck pain that included manipulation and mobilisation as well as the effectiveness of exercise and other therapeutic modalities alone or as a component of multimodal approaches (Gross et al., 2002; Gross et al., 2004a,b; Gross et al., 2007). The following is our response to the ongoing debate of the value of conducting systematic reviews assessing multimodal treatments. 1356-689X/$ – see front matter Ó 2010 Published by Elsevier Ltd. doi:10.1016/j.math.2010.05.001
Clinician’s practice pattern may not be depicted by singlemodal or stand-alone treatment but rather utilization of a multimodal approach (Hurley et al., 2002). Additionally, recent best-evidence synthesis by the Bone and Joint Decade Task Force has recommended mobilisation or manipulation combined with exercise to be one of the current best practice approaches to treat neck pain (Huwitz et al., 2008). A frequent criticism of Cochrane and other systematic reviews is that in spite of their methodological rigor, they fail to provide clear clinical answers, or lack appropriate translation of the evidence into the realities of clinical practice. The solution to these debates will be resolved by using statistical and methodology experts to guide innovative study design for multimodal treatment as well as linking systematic review findings to clinical practice guidelines and practice ‘tool kits’ to aid knowledge translation into clinical practice (Gross et al., 2009). We present the following four systematic review updates in the next two issues of Manual Therapy, three relate to treatment and one to adverse events: (1) manipulation or mobilisations (Gross et al., 2010), (2) manipulation and mobilisation combined with exercise (Miller et al., 2010), (3) manipulation and mobilisation combined with other physical medicine agents (D’Sylva et al., this issue), and (4) adverse events associated with manipulation or mobilisations (Carlesso et al., this issue). The following clinical questions are the focus of our series of reviews: Do conservative management strategies that include mobilisation or manipulation have a positive effect on neck pain, function/disability, return to work, time lost from work, patient perceived effects, patient satisfaction or quality of life? Do trial factors, such as study quality, neck pain chronicity, neck pain subtype, or dose of intervention influence treatment effects? What are the costs and adverse effects associated with the treatments? Our review methods meet the guidelines for systematic reviews published by the Cochrane Collaboration Back Group. We include clinical trials if they meet the following criteria: Participants: acute, subacute, or chronic neck pain with or without cervicogenic headache or radicular findings. We have used the following terms to categorize neck pain: (1) neck pain to depict ‘non-specific’, mechanical or simple neck pain, (2) neck disorder with cervicogenic headache, (3) neck disorder with radicular signs and symptoms, (4) neck disorder associated with whiplash, (5) neck disorders associated with degenerative changes, and (6) neck disorders with associated myofascial pain.
304
Editorial / Manual Therapy 15 (2010) 303–304
Interventions: manual therapies include mobilisation using either passive or neuromuscular techniques or manipulation. These techniques could be a stand-alone therapy or used in a multimodal approach. Comparisons: (1) placebo [e.g., mobilisation versus mock/sham mobilisation; mobilisation versus another sham treatment (sham transcutaneous electrical nerve stimulation)], (2) other treatment (e.g., mobilisation and ultrasound versus ultrasound), and (3) wait list or no treatment. Outcomes: pain, function/disability, work related outcomes, patient satisfaction, patient global perceived effect or quality of life. References Aker P, Gross AR, Goldsmith C, Peloso P. Conservative management of mechanical neck disorders. a systematic overview and meta-analysis. British Medical Journal 1996;313:1291–6. Carlesso L, Gross A, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and for the treatment of neck pain in adults: a systematic review. Manual Therapy, in this issue, 10.1016/j.math. 2010.02.006. D’Sylva J, Gross A, Miller J, et al. Manual therapy with or without physical medicine modalities: a systematic review. Manual Therapy, in this issue, 10.1016/j.math. 2010.04.003. Gross AR, Aker P, Goldsmith C, Peloso P. Conservative management of mechanical neck disorders. a systematic overview and meta-analysis. The Online Journal of Current Clinical Trials 1996, July 30;5 (doc no 200). [accessed 15.07.97].
Gross AR, Bronfort G, Hoving J, et al. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004a;1(1): CD004249. Gross AR, Goldsmith C, Hoving J, et al. Conservative management of mechanical neck disorders: a systematic review. Journal Rheumatology 2007;34:1083– 102. Gross AR, Haines T, Goldsmith CH, Santaguida L, McLaughlin LM, Cervical Overview Group, et al. Knowledge to action: a challenge for neck pain treatment. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):351–63. Gross AR, Hoving JL, Haines TA, et al. A cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004b;29(14):1541–8. Gross AR, Kay T, Hondras M, et al. Manual therapy for neck pain: a systematic review. Manual Therapy 2002;7(3):131–49. Gross AR, Miller J, D’Sylva J, et al. Manipulation or mobilisation for neck pain. Cochrane Database of Systematic Reviews; 2010;. doi:10.1002/14651858. CD004249.pub3. Issue 1. Art. No.: CD004249 [accessed 6.04.10]. Hurley L, Yardley K, Gross AR, Hendry L, McLaughlin L. A survey to examine attitudes and patterns of practice of physiotherapists who perform cervical spine manipulation. Manual Therapy 2002;7(1):10–8. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions. Spine 2008;33(4 Suppl.):5123–52. Miller J, Gross A, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy and exercise for neck pain: a systematic review. Manual Therapy 2010;15(4): 334–54.
Gwendolen Jull*, Ann Moore The University of Queensland, Division of Physiotherapy, St Lucia, Queensland 4072, Australia * Corresponding author. Tel.: þ61 7 3365 1114. E-mail address:
[email protected] (G. Jull)
