BACKGROUND CONTEXT: In 2008, the lack of published evidence prevented the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force [NPTF]) from commenting on the effectiveness of psychological interventions for the management of neck pain.
PURPOSE: This study aimed to update findings of the NPTF and evaluate the effectiveness of psychological interventions for the management of neck pain and associated disorders (NAD) or whiplash-associated disorders (WAD).
STUDY DESIGN/SETTING: This study used systematic review and best-evidence synthesis.
SAMPLE: Randomized controlled trials, cohort studies, and case-control studies comparing psychological interventions to other non-invasive interventions or no intervention were the samples used in this study.
OUTCOME MEASURES: The outcome measures are (1) self-rated recovery; (2) functional recovery; (3) clinical outcomes; (4) administrative outcomes; and (5) adverse effects.
METHODS: We searched six databases from 1990 to 2015. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers used the Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. Studies with a low risk of bias were synthesized following best evidence synthesis principles. This study was funded by the Ontario Ministry of Finance.
RESULTS: We screened 1,919 articles, 19 were eligible for critical appraisal and 10 were judged to have low risk of bias. We found no clear evidence supporting relaxation training or cognitive behavioral therapy (CBT) for persistent grades I-III NAD for reducing pain intensity or disability. Similarly, we did not find evidence to support the effectiveness of biofeedback or relaxation training for persistent grade II WAD, and there is conflicting evidence for the use of CBT in this population. However, adding a progressive goal attainment program to functional restoration physiotherapy may benefit patients with persistent grades I-III WAD. Furthermore, Jyoti meditation may help reduce neck pain intensity and bothersomeness in patients with persistent NAD.
CONCLUSIONS: We did not find evidence for or against the use of psychological interventions in patients with recent onset NAD or WAD. We found evidence that a progressive goal attainment program may be helpful for the management of persistent WAD and that Jyoti meditation may benefit patients with persistent NAD. The limited evidence of effectiveness for psychological interventions may be due to several factors, such as interventions that are ineffective, poorly conceptualized, or poorly implemented. Further methodologically rigorous research is needed.
BACKGROUND: Although research on non-surgical treatments for neck pain (NP) is progressing, there remains uncertainty about the efficacy of cognitive-behavioural therapy (CBT) for this population. Addressing cognitive and behavioural factors might reduce the clinical burden and the costs of NP in society.
OBJECTIVES: To assess the effects of CBT among individuals with subacute and chronic NP. Specifically, the following comparisons were investigated: (1) cognitive-behavioural therapy versus placebo, no treatment, or waiting list controls; (2) cognitive-behavioural therapy versus other types of interventions; (3) cognitive-behavioural therapy in addition to another intervention (e.g. physiotherapy) versus the other intervention alone.
SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, and PubMed, as well as ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2014. Reference lists and citations of identified trials and relevant systematic reviews were screened.
SELECTION CRITERIA: We included randomised controlled trials that assessed the use of CBT in adults with subacute and chronic NP.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.
MAIN RESULTS: We included 10 randomised trials (836 participants) in this review. Four trials (40%) had low risk of bias, the remaining 60% of trials had a high risk of bias.The quality of the evidence for the effects of CBT on patients with chronic NP was from very low to moderate. There was low quality evidence that CBT was better than no treatment for improving pain (standard mean difference (SMD) -0.58, 95% confidence interval (CI) -1.01 to -0.16), disability (SMD -0.61, 95% CI -1.21 to -0.01), and quality of life (SMD -0.93, 95% CI -1.54 to -0.31) at short-term follow-up, while there was from very low to low quality evidence of no effect on various psychological indicators at short-term follow-up. Both at short- and intermediate-term follow-up, CBT did not affect pain (SMD -0.06, 95% CI -0.33 to 0.21, low quality, at short-term follow-up; MD -0.89, 95% CI -2.73 to 0.94, low quality, at intermediate-term follow-up) or disability (SMD -0.10, 95% CI -0.40 to 0.20, moderate quality, at short-term follow-up; SMD -0.24, 95% CI-0.54 to 0.07, moderate quality, at intermediate-term follow-up) compared to other types of interventions. There was moderate quality evidence that CBT was better than other interventions for improving kinesiophobia at intermediate-term follow-up (SMD -0.39, 95% CI -0.69 to -0.08, I(2) = 0%). Finally, there was very low quality evidence that CBT in addition to another intervention did not differ from the other intervention alone in terms of effect on pain (SMD -0.36, 95% CI -0.73 to 0.02) and disability (SMD -0.10, 95% CI -0.56 to 0.36) at short-term follow-up.For patients with subacute NP, there was low quality evidence that CBT was better than other interventions at reducing pain at short-term follow-up (SMD -0.24, 95% CI -0.48 to 0.00), while no difference was found in terms of effect on disability (SMD -0.12, 95% CI -0.36 to 0.12) and kinesiophobia.None of the included studies reported on adverse effects.
AUTHORS' CONCLUSIONS: With regard to chronic neck pain, CBT was found to be statistically significantly more effective for short-term pain reduction only when compared to no treatment, but these effects could not be considered clinically meaningful. When comparing both CBT to other types of interventions and CBT in addition to another intervention to the other intervention alone, no differences were found. For patients with subacute NP, CBT was significantly better than other types of interventions at reducing pain at short-term follow-up, while no difference was found for disability and kinesiophobia. Further research is recommended to investigate the long-term benefits and risks of CBT including for the different subgroups of subjects with NP.
BACKGROUND: Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.
OBJECTIVES: To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache.
SEARCH METHODS: We searched computerised bibliographic databases (inception to 11 July 2010).
SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain.
DATA COLLECTION AND ANALYSIS: Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled.
MAIN RESULTS: Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.
Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. 
Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.
Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up.
AUTHORS' CONCLUSIONS: With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.
BACKGROUND: Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness. OBJECTIVES: To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain. SEARCH STRATEGY: We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials. SELECTION CRITERIA: Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints. DATA COLLECTION AND ANALYSIS: Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information. MAIN RESULTS: We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting. AUTHORS' CONCLUSIONS: Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.
BACKGROUND: Many treatments are available for whiplash patients but there is little scientific evidence for their accepted use. Patients with whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms from Grade 0 (no complaints or physical signs) to Grade 4 (fracture or dislocation).
OBJECTIVES: To assess the effectiveness of conservative treatment for patients with whiplash injuries rated as Grades 1 or 2 (neck and musculoskeletal complaints).
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2006, Issue 3), MEDLINE, CINAHL, PsycINFO, and PEDro to November 2006 and screened references of identified randomised trials and relevant systematic reviews.
SELECTION CRITERIA: We selected randomised controlled trials published in English, French, German or Dutch, that included patients with a whiplash-injury, conservative interventions, outcomes of pain, global perceived effect or participation in daily activities.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed the methodological quality using the Delphi criteria and extracted the data onto standardised data-extraction forms. We did not pool the results because of the heterogeneity of the population, intervention and outcomes and lack of data. A pre-planned stratified analysis was performed for three different comparisons.
MAIN RESULTS: Twenty-three studies (2344 participants) were included in this update, including nine new studies. A broad variety of conservative interventions were evaluated. Two studies included patients with chronic symptoms (longer than three months), two included subacute (four to six weeks) symptoms, two had undefined duration of symptoms, and 17 studied patients with acute (less than three weeks) symptoms. Only eight studies (33.3%) satisfied one of our criteria of high quality, indicating overall, a poor methodological quality. Interventions were divided into passive (such as rest, immobilisation, ultrasound, etc) and active interventions (such as exercises, act as usual approach, etc.) and were compared with no treatment, a placebo or each other.
Clinical and statistical heterogeneity and lack of data precluded pooling. Individual studies demonstrated effectiveness of one treatment over another, but the comparisons were varied and results inconsistent. Therefore, the evidence neither supports nor refutes the effectiveness of either passive or active treatments to relieve the symptoms of WAD, Grades 1 or 2.
AUTHORS' CONCLUSIONS: The current literature is of poor methodological quality and is insufficiently homogeneous to allow the pooling of results. Therefore, clearly effective treatments are not supported at this time for the treatment of acute, subacute or chronic symptoms of whiplash-associated disorders.
In 2008, the lack of published evidence prevented the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force [NPTF]) from commenting on the effectiveness of psychological interventions for the management of neck pain.
PURPOSE:
This study aimed to update findings of the NPTF and evaluate the effectiveness of psychological interventions for the management of neck pain and associated disorders (NAD) or whiplash-associated disorders (WAD).
STUDY DESIGN/SETTING:
This study used systematic review and best-evidence synthesis.
SAMPLE:
Randomized controlled trials, cohort studies, and case-control studies comparing psychological interventions to other non-invasive interventions or no intervention were the samples used in this study.
OUTCOME MEASURES:
The outcome measures are (1) self-rated recovery; (2) functional recovery; (3) clinical outcomes; (4) administrative outcomes; and (5) adverse effects.
METHODS:
We searched six databases from 1990 to 2015. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers used the Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. Studies with a low risk of bias were synthesized following best evidence synthesis principles. This study was funded by the Ontario Ministry of Finance.
RESULTS:
We screened 1,919 articles, 19 were eligible for critical appraisal and 10 were judged to have low risk of bias. We found no clear evidence supporting relaxation training or cognitive behavioral therapy (CBT) for persistent grades I-III NAD for reducing pain intensity or disability. Similarly, we did not find evidence to support the effectiveness of biofeedback or relaxation training for persistent grade II WAD, and there is conflicting evidence for the use of CBT in this population. However, adding a progressive goal attainment program to functional restoration physiotherapy may benefit patients with persistent grades I-III WAD. Furthermore, Jyoti meditation may help reduce neck pain intensity and bothersomeness in patients with persistent NAD.
CONCLUSIONS:
We did not find evidence for or against the use of psychological interventions in patients with recent onset NAD or WAD. We found evidence that a progressive goal attainment program may be helpful for the management of persistent WAD and that Jyoti meditation may benefit patients with persistent NAD. The limited evidence of effectiveness for psychological interventions may be due to several factors, such as interventions that are ineffective, poorly conceptualized, or poorly implemented. Further methodologically rigorous research is needed.
