Next Article in Journal
Is Negative Pressure Wound Therapy with Instillation Suitable for the Treatment of Acute Periprosthetic Hip Joint Infection?
Next Article in Special Issue
Insomnia Symptoms and Chronic Pain among Patients Participating in a Pain Rehabilitation Program—A Registry Study
Previous Article in Journal
Still’s Disease in the Constellation of Hyperinflammatory Syndromes: A Link with Kawasaki Disease?
Previous Article in Special Issue
Comorbid Conditions in Temporomandibular Disorders Myalgia and Myofascial Pain Compared to Fibromyalgia
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 10
Issue 15
10.3390/jcm10153245
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial

by
Belén Díaz-Pulido
1,
Yolanda Pérez-Martín
1,*,
Daniel Pecos-Martín
1,
Isabel Rodríguez-Costa
1,
Milagros Pérez-Muñoz
1,
Victoria Calvo-Fuente
1,
María Félix Ortiz-Jiménez
2 and
Ángel Asúnsolo-del Barco
3
1
Physiotherapy Department, University of Alcalá, 28871 Madrid, Spain
2
Puerta de Madrid Health Center, Public Health System of the Community of Madrid, 28802 Madrid, Spain
3
Surgery, Medical and Social Sciences Department, University of Alcalá, 28871 Madrid, Spain
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2021, 10(15), 3245; https://doi.org/10.3390/jcm10153245
Submission received: 17 June 2021 / Revised: 12 July 2021 / Accepted: 15 July 2021 / Published: 23 July 2021
(This article belongs to the Special Issue Improved Rehabilitation for Patients with Chronic Pain)
Browse Figures
Review Reports Versions Notes

Abstract

:
Neck pain is a frequent health problem. Manual therapy (MT) and transcutaneous electrical nerve stimulation (TENS) are recommended techniques for treatment of mechanical neck disorders (MND) in Spanish Public Primary Care Physiotherapy Services. The aim of this study was to compare the efficacy of MT versus TENS in active mobility and endurance in cervical subacute or chronic neck pain. Ninety patients with MND were randomly allocated to receive ten 30-min sessions of either MT or TENS, in a multi-centered study through 12 Primary Care Physiotherapy Units in the Madrid community. Active cervical range of motion (CD-ROM) and endurance (Palmer and Epler test) were evaluated pre- and post-intervention and at 6-month follow-up. A generalized linear model of repeated measures was constructed for the analysis of differences. Post-intervention MT yielded a significant improvement in active mobility and endurance in patients with subacute or chronic MND, and at 6-month follow-up the differences were only significant in endurance and in sagittal plane active mobility. In the TENS group, no significant improvement was detected. With regard to other variables, MT improved mobility and endurance more effectively than TENS at post-intervention and at 6-month follow-up in the sagittal plane. Only MT generated significant improvements in cervical mobility and endurance in the three movement planes.

1. Introduction

Nowadays neck pain is a frequent health problem associated with modern lifestyles [1], and is thought to affect between 21 and 71% of the population at some point in their lives [2]. Between 30% and 50% of the adult population reports having experienced neck pain in the previous year [3], and 50% to 85% of patients with neck pain will report neck pain 1 to 5 years later [4]. Musculoskeletal disorders, including chronic neck pain, produce increasing problems for patients and national economies [2,3,5,6,7,8,9,10,11,12,13,14]. The themes of disability deriving from chronic pain of the spine and appropriate approach to its treatment are current research topics in this field [15].
The annual prevalence of neck pain with disability, but without structural damage, varies between 1.7% and 11.5% in the general population [16]. It has been estimated that in Spain, chronic neck pain affects 9.6% of men and 21.9% of women [17] (D), and about 10% of the cases referred to physical therapists are due to neck pain [18].
Although treatments such as nonsteroidal anti-inflammatory drugs and dry needling are usually first-in-line in the field of referred pain, such as orofacial pain [19], the effects of conservative interventions in the treatment of neck pain, which include manual therapy (MT) and electrotherapy among others, have mainly been studied post-intervention with inconclusive results [6,20,21,22,23,24,25,26]. MT and transcutaneous electrical nerve stimulation (TENS) are recommended techniques for the treatment of mechanical neck disorders (MND) in Spanish Public Sector Primary Care Physical Therapy Services [27,28,29,30]. In this framework, both therapies are accepted as standard clinical practice, and the choice of one or the other depends on the physical therapist’s decision based on clinical patient manifestations, personal experience and formation, and time and available resources.
MT intervention, which includes manipulation, mobilization, massage, and neuromuscular techniques [31], has not been proven to be effective when used in an isolated way to improve mobility and muscular endurance in MND [6,8,20,21,26,31,32,33,34]. Whereas the Ottawa Panel was able to demonstrate that massage interventions are effective for relieving immediate post-treatment neck symptoms of pain, tenderness, and range of motion, data on the long-term effects are insufficient [2]. It has been proven that MT combined with pharmacological treatment, exercises, and medical advice is effective post-intervention [34]. Several studies [4,6,9,13,14,34,35,36,37] indicate that MT combined with exercise is more effective than other therapies or placebo to improve symptoms or to increase the patient’s satisfaction, although more estimates are necessary to understand the magnitude of the effect [4,9,20,24,33,34,37,38,39].
Regarding the use of electrotherapy, there have been studies of clinical trials with a small number of patients with MND that compared TENS with other treatments, without finding differences between groups post-intervention [6,8,9,31,33,40,41]. The results of studies on the effectiveness of TENS are scarce, limited, or contradictory [33,37]. Even the Royal Dutch Society for Physical Therapy indicates that it is not recommended that clinicians use electrotherapy for patients with neck pain grade I or II [4].
On the other hand, biomechanics and psychological factors have been identified in the transition from an acute to a chronic pain syndrome. In MND without an injury, it is considered that chronification is due to biomechanical overloading. If pain relief is the only aim of the treatment, then functional disorders (lack of strength, deficit of mobility, posture disorder, etc.) can persist and be precursors of future deficiency biomechanics and chronification of MND [42,43,44].
No study that compares the efficacy of both techniques on mobility and endurance has been found. The aim of the present study was to compare the effects of MT and TENS techniques on cervical active mobility and muscle endurance in patients with subacute and chronic mechanical neck disorders. A research of pain intensity relief has been previously published [45]. It was hypothesized that patients who received MT would have greater improvement in cervical mobility and endurance than those who received TENS.

2. Materials and Methods

2.1. Study Design

A multi-centered randomized clinical trial was performed in order to compare the effectiveness of MT versus TENS in patients diagnosed with subacute and chronic MND without neurologic signs according to the Quebec Task Strength Classification on Spinal Disorders [46] (grades I and II, according to 2000–2010 Neck Pain Task Force (NPTF) classification [16]) and neck pain with mobility deficits, neck pain with movement coordination impairments, and neck pain with headache (cervicogenic), according to the Neck Pain Revision [37]. The present study showed the effectiveness of MT and TENS in improving mobility and endurance.
The clinical trial was approved by the Ethics Committee of Hospital Clínico Universitario San Carlos. It was registered as NCT01153737 at www.ClinicalTrials.gov and funded by Instituto de Salud Carlos III, Fondo de Investigación Sanitaria/Fondos Europeos de Desarrollo Regional (PI/041320), (Spain).

2.2. Patients

Subjects included were patients between 18 and 60 years old, who were treated in 12 primary health care physiotherapy units that took part in the study in the Madrid region. Exclusion criteria were as follows: signs of neurological damage, pregnant women, previous neck rachis surgery, patients who received physical therapy or an alternative treatment of the neck or shoulder 6 months prior to the beginning of the study, or those with important psychiatric disorders or other health problems that would contraindicate the techniques to be used (i.e., pacemaker). Patients with neck pain caused by an inflammatory, neurological, or rheumatic disease, severe osteoporosis, fracture, luxation, or vertebrobasilar insufficiency were also excluded.
Consecutive patients with chronic neck pain referred by their primary care physicians and who met the inclusion criteria (revised by the primary care physical therapists) and signed the informed consent were recruited. Blinded allocation, concealed in closed envelopes, was on the basis of block randomization and was carried out also by the primary care physical therapists. Random sequences of 6 patients, assigned by external researchers, were obtained using the statistical program Epidat 3.1© (Xunta de Galicia, Santiago de Compostela, Spain), in order to create 2 equivalent groups.
Patients were evaluated pre-intervention, post-intervention, and at 6-month follow-up. The evaluations were assessed by a different group of physical therapists, so outcome variable evaluation was blinded. A detailed description of the trial’s protocol has been published previously by the investigation group [47].

2.3. Sample Size Determination

Ninety patients from the multicenter randomized clinical trial were included. The final potency of the study to detect clinically relevant changes (10/100 points) with the neck disability index (NDI) was 91.4%. Sample size determination was calculated according to the NDI, because data related to clinical significance of active mobility and cervical endurance were not found.
Based on the consulted bibliography, if the neck pain has a muscle-skeletal origin, a clinically relevant result appears when there is a change over 5/50 points in the NDI [48]. In this study, patients with neurological damage were excluded, and the clinical significant change considered was 10/100 points. Taking into account 12 SD points expected in the groups [26,49,50], and with an alfa signification of 0.05 and Beta error of 0.2, 46 patients were necessary, 23 in each group, to detect a clinically relevant difference between them. Ninety patients were required in order to investigate effectiveness in reducing pain intensity. Therefore, all patients from the multicenter randomized clinical trial were included.

2.4. Interventions

Therefore, TENS and MT interventions each consisted of 10 sessions, provided by primary care physical therapists for 30 min on alternate days. Applied MT techniques included those which in the Primary Care Physical Therapy Clinical Guidelines. These techniques were regularly used by most of the physical therapists in their daily clinical practice. Figure 1 shows the different components of both interventions.
In this way, the MT techniques consisted of the following: neuromuscular technique, post-isometric stretching, spray and stretching technique, and Jones technique [20,49,50]. These MT techniques are described in Table 1. An expert group, composed of 5 professionals with over 5 years’ experience each in MT physical therapy, decided to include the muscular groups that are regularly treated in this impaired group based on clinical experience, so the following muscles were assessed and selectively treated: superior trapezius, inferior trapezius, levatoranguliscapulaes, sternocleidomastoideus, suboccipital, anterior scalenus, multifidi, subclavie, pectoralis minor, and triceps braquii. In TENS group, a portable digital TENS model TENSMED911 (Enraf-Nonius, Vareseweg, Rotterdam, The Netherlands) was used, with a frequency of 80 Hz, with ≤150 µs pulse duration and adjusted amplitude. TENS electrode placements were located in the painful area, in the metamere, or in the nerve’s pathway [18]. All patients were taught how to perform isometric and neck mobility exercises in their homes and develop postural care skills. This information was explained individually in the first 2 sessions, and each patient also received written information.
During the planning of the study, the physical therapists received 1 session of training to assure homogeneity between the different interventions. The physical therapists that performed the interventions did not have knowledge of the patients’ evaluation data. Every unit received the necessary material (portable digital TENS, cervical range of motion (CROM) instrument, basic inclinometer).

2.5. Outcome Measures

Outcome measures of the study were the active range of motion (AROM) and the endurance of the neck muscles, which were registered at first in the 6 movements of the cervical spine, and after this were recorded in the 3 space planes, adding up the degrees of movements in each plane.
Neck mobility was measured with an inclinometer, the CROM Basic Cervical Range of Motion Instrument (Performance Attainment Associates, Sutton-in-Ashfield, UK) [53], which is recommended for active cervical mobility measures in patients with nonspecific neck pain, based on its best scores for clinimetric properties compared to other measurement systems, and also for its ease of use [38].
Endurance of the cervical muscles was measured using the Palmer and Epler test [54]; it is an ordinal categorical variable graduated as follows: “1” not functional, “2” poorly functional, “3” reasonably functional and “4” functional, using the average of the scores obtained in the 2 movements in each plane. It has been proven that, in patients with neck pain, cervical muscle endurance quantifications have excellent intra-observer reliability and moderate inter-observer reliability [55,56].
Other studied variables (descriptive, prognostic, or control) that could have an influence on active mobility and endurance were age, gender, physical disability (according to the Spanish translation of NDI [57], in which a 0 score indicates no disability and 50 the highest disability), pain intensity (measured in millimeters (mm) using the Visual Analogue Scale (VAS) [25]), duration of present neck pain (days), previous neck pain episodes (yes/no), previous accident incurring injury to the cervical spine (yes/no), and fulfillment of the recommended exercises and postural skills (yes/no).
Evaluations were carried out by physiotherapists from Department of University of Alcalá, who were blinded to the groups to which the patients were assigned. A training session was given to the physical therapists´ evaluation group.

2.6. Subject Follow up

Three evaluations (pre-, post-intervention, and at 6-months’ follow-up) were performed by physical therapists who disclaimed treatment of each patient. To minimize losses, patients who did not assist in the revision session were phoned at least twice.
Quality control was performed by the coordinating center (Primary Care Research Unit), with periodic supervision and feedback on the study process and data entry; progress reports were performed every 2 to 4 months and meetings with the research physical therapist, every 6 months.

2.7. Data Analysis

Statistical analysis was performed without revealing which treatment each patient had received. First, a descriptive analysis of the different studied variables in each intervention group was performed, in order to verify the homogeneity between both groups by using statistical tests.
Analysis of the intervention’s effectiveness was evaluated by protocol comparing the mean value of the answer variables in each of the space planes between both intervention groups pre-intervention, post-intervention, and at 6 months’ follow-up intervention. For this purpose, a general linear model of repeated measures was used, performing a simple contrast, where the reference value was the measurement at the beginning of the study (pre- intervention).
Finally, several models of multiple linear regression were carried out for the mobility and endurance: 1 model for each of the space planes, 1 and 6 months after the intervention.
Variables that were significant in the bivariate analysis and the variables that could cause a confounding phenomenon or interaction were added to the models. It was considered that adjustment was necessary to correct confounding bias if the change in the regression coefficient between the adjusted and unadjusted effect was over 10%. The interaction was studied with statistical significance tests for the parameters, and the interaction terms that were statistically significant (p < 0.05) were kept in the model.
Once the maximum model was defined, a gradual inclusion process by steps was performed and guided by the investigators, establishing as a criterion the square value of the adjusted multiple coefficient of determination (R2) and Mallow´s Cp. At all times the hierarchy principle was sustained. The statistical program SPSS© 17.0 (Chicago, IL, United States) was used to process and analyze the data.

3. Results

In this study 47 and 43 patients were included in the MT and TENS group, respectively, between May 2005 and May 2007. Seventy-two of the enrolled patients finished all interventions (Figure 2).
The mean duration of the current episode of neck pain was 147 days, with a 95% confidence interval (CI) of 94–200 days. Overall, 71 patients (80%) completed the follow- up measurement at 6 months, and the number of losses was similar in both groups.
Sociodemographic characteristics and prognostic variables at baseline in each of the intervention groups, (no significant differences were found in these variables at the beginning of the treatment between both intervention groups, except for endurance in frontal plane (p = 0.03 U Mann-Whitney Test)), are shown in Table 2.
In the MT group, statistically significant differences were observed when studying the active cervical mobility and the endurance post-intervention in the three space planes. In this same intervention group, at 6-month follow-up significant differences were observed in the endurance; however, in active cervical mobility, differences were observed only in the sagittal plane. In the TENS group, no significant differences were found post-intervention or at 6-month follow-up. When comparing the mobility and endurance improvement between both intervention groups, no significant differences were found (Table 3). Evolution time is included in Figure 3 and Figure 4. Figure 3 shows little difference between groups in transversal and frontal plane active mobility. Improvement in sagittal plane mobility was maintained 6 months post-intervention in the TM group, but not in the TENS group. Figure 4 shows that the endurance improvement in the TM group was larger than in the TENS group post-treatment and 6 months later.
However, when MT and TENS effects were measured in the presence of other variables, it was found that MT provided more improvement than TENS in mobility and endurance at post-intervention and 6-month follow-up in the sagittal plane. The type of disability was the variable that influenced the results more, regardless of the type of intervention, so the higher the scores were on the NDI at baseline, the better the improvement, especially for mobility at 6-month follow-up. Post-intervention mobility improvements were observed in patients who developed the postural skills, while those patients with longer duration episodes and previous episodes obtained poorer results (Table 4).
Low numbers of adverse effects were observed among patients in the study (6.7% in the MT group and 2% in the TENS group post-intervention, and 2.7% in the MT group and 5.9% in TENS group at 6-month follow-up). Even though at 6-month follow-up adverse effects in the TENS group were double those in the MT group, statistically significant differences were not found at both time points in the study (post-intervention and at 6-month follow-up).

4. Discussion

Results of this study showed that post-intervention MT significantly improved active mobility and endurance in patients with subacute or chronic MND, but at 6-month follow-up the differences were only significant in endurance and in sagittal plane active mobility. In the TENS group, no significant improvement was detected either post-intervention or at 6-month follow-up. When measuring the effect of the interventions (MT or TENS) considering other variables, MT improved the mobility and endurance post-intervention and at 6-month follow-up in the sagittal plane to a greater extent than TENS.
It is important to point out that between the confounding and/or modifying variables of our study, it seemed that pain at baseline did not have as important an influence on the outcome measures as the physical disability measured with NDI, independently of the type of intervention, especially at 6-month follow-up. The higher score on the NDI, the larger the increase of mobility after the intervention, which meant that from a worst functional baseline, there seemed to be greater potential for recuperation and a larger range of movement obtained.
The latest and rigorous Neck Pain Clinical Practice Guidelines [4,14,37] propose, based on scientific evidence, offering multimodal care (based primarily on mobilization and/or manipulation in combination with exercise therapy) or stress self-management in patients with persistent or chronic neck pain: thoracic manipulation and cervical manipulation or mobilization; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises; mixed exercise for cervical/scapulothoracic regions (neuromuscular exercise, stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements).
In the same way, for subacute or normal recovery neck pain, they suggest offering multimodal care, manipulation or mobilization, range-of-motion home exercise, or multimodal manual therapy [14], as well as neck and shoulder girdle endurance exercises and thoracic and cervical manipulation and/or mobilization [37]. In case of a normal recovery, the Netherland Guidelines suggest that management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement “acting as usual” [4].
In no case did these Guidelines recommend the use of TENS based on scientific evidence with indications comparable to the findings of the present study. On the other hand, a recent meta-analysis of TENS for relief of spinal pain published by Resende et al. [58] concluded that the analysis of adequate stimulation parameters for this technique were not significantly different, and that there was no effect on disability; this review provides inconclusive evidence for TENS benefits because of the low quality of the studies and lack of uniformity in parameters and timing of assessment. In the same way, the recent umbrella Review of Systematic Reviews on the efficacy of TENS in cervical pain syndromes published by Paolucci et al. [59], indicates that it was not possible to provide precise recommendations in this regard, and that it is desirable to carry out further studies that support the effectiveness of using TENS in patients suffering from acute and chronic neck pain.
In this same sense, Häkkinen et al. [35] compared MT with neck stretching exercises at home in patients with chronic neck pain, finding a significant increase in active neck mobility in the three space planes 1 month after starting the intervention in both groups, with no significant differences between them; however, in passive mobility in the sagittal plane, the results in the MT group were better. Therefore, changes in mobility from baseline to 12 weeks were minor and non-significant in either group. These results coincide with the findings of our study, where the neck mobility improved in a significant way only with manual techniques and stretching and isometric exercises and fulfillment of postural skills at home, especially in the flexion and extension movements; however, in the present study, significant differences in the MT group were maintained at 6-month follow-up.
Zaproudina et al. [13] compared three treatments for chronic neck pain: manipulative therapy, physical therapy (stretching, massage, and exercises), and only massage. They observed a significant improvement in neck mobility in the three space planes after 1 month of treatment in all three groups, finding no significant differences between the groups. It was found that neck spine mobility in rotation movements tended to improve more statistically after manipulative techniques than after massage. The present study also found significant differences in cervical mobility in the three space planes in the MT group post-intervention and at 6-month follow-up in the sagittal plane. In this way, thorough, non-manipulative manual techniques, with less risk and adverse effects for the patients, could improve mobility in the transversal plane.
In the study of Tuttle et al. [60], specific posterior-anterior mobilization techniques in the symptomatic cervical location were compared with three other groups (control, placebo, and non-manipulative manual therapy groups), finding a larger improvement in neck mobility with the non-manipulative manual therapy group than in the other groups.
In a clinical trial, Heikki and Hemmilä et al. [61] compared a group that received manipulative therapies combined with soft massage to a control group without therapy, finding a significant improvement in the treatment group only in the mobility in the three space planes (29% in FP, 23% in SP, and 16% in TP) after 5 weeks of treatment. In this study, the improvement post-intervention in the MT group was 6%, 8%, and 6.2%, respectively; however, we must consider that in Heikki´s study the patients´ mobility situation was worse at baseline, and patients paid 22 euros for five sessions, which had larger implications for the solution of their affliction.
In the same way, Korthals de Bos [39] concluded that spinal mobilization is more effective, and less expensive, for treating neck pain than physical therapy or medical treatment. On the other hand, Guzman et al. [3] stated that manipulation can produce a transitory increase in pain and discomfort in up to 30% of patients; this risk appears less likely with mobilization.
As regards the effects of TENS in the mobility of patients with neck pain, Nordermar et al. [62] compared three groups: neck collar, neck collar combined with MT, and neck collar combined with TENS in patients with acute cervical pain, not finding any statistically significant differences between the TENS and MT groups. This coincided with the results of our study.
On the other hand, Dusunceli et al. [63] found that TENS is effective for improving neck mobility in cervical pain if combined with other active therapies such as neck stabilization exercises. In the present study, the combination of TENS, active exercises, and postural hygiene did not improve cervical mobility, so it would be interesting to research the effects of stabilization exercises because TENS did not seem to show improvement in the patients. Some previous studies have also demonstrated endurance increases in the cervical musculature even after passive treatment such as massage and stretching [35,64,65,66]. Rehabilitation medicine offers a range of pain management approaches. The rehabilitative approach may be particularly helpful for patients with refractory movement-associated pain who do not want, or cannot tolerate, pharmaco-analgesia [67]. The need to integrate multiple rehabilitation and pain management treatments to enhance the results of each treatment is a very topical issue.
An increase in neck muscle endurance seems to be associated with a decrease in neck pain. In earlier studies, muscle pain has been reported to affect motor control, possibly leading to functional deficit [36,68,69]. Jordan et al. [65] suggested that the gain in strength in the subjects of their study was probably a result of increased confidence. Additionally, Al-Obaidi et al. [70] suggested that an improvement in the cognitive perception of pain, and fear-avoidance beliefs regarding physical activities, might contribute to the improvement of isometric muscle strength in patients with chronic pain.
According to the studies of Häkkinen et al. [46,71,72], it seemed that endurance training was the most effective treatment for strength recovery in patients with neck pain. In this way, in the systematic reviews, only limited evidence was found for the benefit of active strengthening exercises for neck disorders [9,73].
Chiu et al. [64] studied the effect of TENS associated with infrared irradiation, finding that after 6 weeks, patients showed significant improvement in their isometric neck muscle strength. These results did not coincide with our study; this important difference might be due to the fact that in Chiu’s study, TENS was applied over the neck acupuncture points. Recently, Schabrun et al. found that interactive neurostimulation, a technique similar to TENS, did not obtain significant improvements in functionality compared to a placebo in patients with MNP [72]. Further investigations are required to determine the effects of these techniques.
According to the indications of the PRECIS tool [74], the design of the study was realistic. The patients all had chronic/subacute neck pain, and all were recruited at primary healthcare physical therapy units where all were treated. Both interventions were usually used and delivered by physical therapists in the usual practice for the care of such patients. Moreover, mobility and endurance outcomes both had meaning to the patients.
On the other hand, the difficulties encountered during our investigation were described in a previous publication [21]. In the present study, the Palmer and Epler test was used as a measuring instrument to assess the endurance variable; however, most studies that assessed muscle strength [35,71,75] used an isometric neck strength testing machine described previously in reliable studies; other studies evaluated cervical muscle endurance with one of the most used tests: the skull cervical flexion test. The lack of uniformity in this variable and measuring instruments placed a limitation on comparisons of the results. Another important issue in this study was the variety of techniques considered as MT. This point made comparisons of the results with general studies more difficult [23,76].
As a matter of practical applicability, in the present study, only MT was proven to be useful in increasing active cervical mobility and endurance in patients with neck pain. Adverse effects from the application of this therapy are almost nonexistent and of little clinical importance. Therefore, MT is recommended for treating these patients. According to a recent systematic literature review and meta-analysis [77], manipulation and mobilization appear safe for treating chronic nonspecific neck pain. However, studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for this affliction.
As future research, it would be interesting to investigate whether improvements in isometric strength or endurance are more effective in terms of functionality and decreasing relapses in these patients [24,41]. Biomechanical overload depends on external demands and internal response capacity of the tissues, which affect functional disorders (lack of strength, deficit of mobility, posture disorder, etc.). If these functional changes are maintained, they can be memorized as new motor patterns and persist after the injury that generated them. Abnormal movements induce a major overload and can perpetuate it [42,43,44].
It would be necessary to conduct more trials as well as pain education sessions to gain a better understanding of patient satisfaction and expectations [78] and perform a cost-benefit and 6-month follow-up analysis [79,80] to provide physical therapists with a stronger basis for their decision-making process. In this regard, Guzman J. et al. [3] suggested that patients should be informed about the risks and benefits of the different treatments, and physical therapists should take into consideration patients´ preferences regarding their treatment techniques. It is essential that future research on the effectiveness of different techniques, and of MT in particular, specify the localization, dose, and description of the selected therapy.

5. Conclusions

Only MT had proven to be useful to increase active cervical mobility in the three planes and endurance in patients with neck pain. The adverse effects of the application of this therapy are almost nonexistent and have little clinical significance. Therefore, MT is recommended for treating patients with neck pain.

Author Contributions

Conceptualization, Y.P.-M. and Á.A.-d.B.; methodology, B.D.-P., Y.P.-M. and D.P.-M.; software, M.F.O.-J. and Á.A.-d.B.; validation, M.F.O.-J. and Á.A.-d.B.; formal analysis, M.F.O.-J. and Á.A.-d.B.; investigation, B.D.-P., Y.P.-M., D.P.-M. and M.P.-M.; resources, Y.P.-M. and Á.A.-d.B.; data curation, M.F.O.-J. and Á.A.-d.B.; writing—original draft preparation, B.D.-P., Y.P.-M. and I.R.-C.; writing—review and editing, B.D.-P., Y.P.-M., D.P.-M., I.R.-C., M.P.-M., V.C.-F. and Á.A.-d.B.; visualization, B.D.-P., Y.P.-M. and I.R.-C.; supervision, B.D.-P.; project administration, B.D.-P., Y.P.-M. and Á.A.-d.B.; funding acquisition, Y.P.-M. and Á.A.-d.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The clinical trial was approved by the Ethics Committee of the Hospital Clínico Universitario San Carlos. It was registered as NCT01153737 at www.ClinicalTrials.gov and funded by Instituto de Salud Carlos III, Fondo de Investigación Sanitaria/Fondos Europeos de Desarrollo Regional (PI/041320, Spain).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Acknowledgments

In memory of and thanks to Escortell-Mayor Esperanza, an inspiring and indispensable researcher in the development of the project that supported the present study. The authors want to thank all the volunteers for their participation in this study.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Aker, P.D.; Gross, A.R.; Goldsmith, C.H.; Peloso, P. Conservative management of mechanical neck pain: Systematic overview and meta-analysis. BMJ 1996, 313, 1291–1296. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  2. Brosseau, L.; Wells, G.A.; Tugwell, P.; Casimiro, L.; Novikov, M.; Loew, L.; Sredic, D.; Clément, S.; Gravelle, A.; Hua, K.; et al. Ottawa panel evidence-based clinical practice guidelines on therapeutic massage for neck pain. J. Bodyw. Mov. Ther. 2012, 16, 300–325. [Google Scholar] [CrossRef] [PubMed]
  3. Guzman, J.; Haldeman, S.; Carroll, L.J.; Carragee, E.J.; Hurwitz, E.L.; Peloso, P.; Nordin, M.; Cassidy, J.D.; Holm, L.W.; Côté, P.; et al. Clinical practice implications of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Eur. Spine J. 2008, 17, 199–213,. [Google Scholar] [CrossRef] [Green Version]
  4. Bier, J.D.; Scholten-Peeters, W.G.M.; Staal, J.B.; Pool, J.; van Tulder, M.W.; Beekman, E.; Knoop, J.; Meerhoff, G.; Verhagen, A.P. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Phys. Ther. 2018, 98, 162–171. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  5. Borghouts, J.A.; Koes, B.A.; Vondeling, H.; Bouter, L.M. Cost-of-illness of neck pain in The Netherlands in 1996. Pain 1999, 80, 629–636. [Google Scholar] [CrossRef]
  6. Gross, A.R.; Kay, T.; Hondras, M.; Goldsmith, C.; Haines, T.; Peloso, P.; Kennedy, C.; Hoving, J. Manual therapy for mechanical neck disorders: A systematic review. Man. Ther. 2002, 7, 131–149. [Google Scholar] [CrossRef]
  7. Viljanen, M.; Malmivaara, A.; Uitti, J.; Rinne, M.; Palmroos, P.; Laippala, P. Effectiveness of dynamic muscle training, relaxation training, or ordinary activity for chronic neck pain: Randomised controlled trial. BMJ 2003, 327, 475–479. [Google Scholar] [CrossRef] [Green Version]
  8. Gross, A.R.; Hoving, J.L.; Haines, T.A.; Goldsmith, C.H.; Kay, T.; Aker, P.; Bronfort, G.; Cervical Overview Group. Movilización Activa y Pasiva Para Trastornos Mecánicos de Cuello. In Cochrane Library Plus En Español Oxford: Update Software; Wiley: New York, NY, USA, 2003. [Google Scholar]
  9. Gross, A.R.; Aker, P.D.; Goldsmith, C.H.; Peloso, P. Physical Medicine Modalities for Mechanical Neck Disorders. Cochrane Database Syst. Rev. 2000, CD000961. [Google Scholar] [CrossRef]
  10. Ezzo, J.; Haraldsson, B.G.; Gross, A.R.; Myers, C.D.; Morien, A.; Goldsmith, C.H.; Bronfort, G.; Peloso, P.M. Massage for mechanical neck disorders: A systematic review. Spine 2007, 32, 353–362. [Google Scholar] [CrossRef] [Green Version]
  11. Hogg-Johnson, S.; van der Velde, G.; Carroll, L.J.; Holm, L.W.; Cassidy, J.D.; Guzmán, J.; Côté, P.; Haldeman, S.; Ammendolia, C.; Carragee, E.; et al. The Burden and Determinants of Neck Pain in the General Population. Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008, 33, 39–51. [Google Scholar] [CrossRef]
  12. Vernon, H.; Humphreys, B.K. Chronic mechanical neck pain in adults treated by manual therapy: A systematic review of change scores in randomized controlled trials of a single session. J. Manip. Physiol. Ther. 2008, 16, E42–E52. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  13. Zaproudina, N.; Hänninen, O.O.; Airaksinen, O. Effectiveness of traditional bone setting in chronic neck pain: Randomized clinical trial. J. Manip. Physiol. Ther. 2007, 30, 432–437. [Google Scholar] [CrossRef] [PubMed]
  14. Bussières, A.E.; Stewart, G.; Al-Zoubi, F.; Decina, P.; Descarreaux, M.; Hayden, J.; Hendrickson, B.; Hincapié, C.; Pagé, I.; Passmore, S.; et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J. Manip. Physiol. Ther. 2016, 39, 523–564. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  15. Farì, G.; Santagati, D.; Pignatelli, G.; Scacco, V.; Renna, D.; Cascarano, G.; Vendola, F.; Bianchi, F.P.; Fiore, P.; Ranieri, M.; et al. Collagen Peptides, in Association with Vitamin C, Sodium Hyaluronate, Manganese and Copper, as Part of the Rehabilitation Project in the Treatment of Chronic Low Back Pain. Endocr. Metab. Immune Disord Drug Targets 2021, 21. [Google Scholar] [CrossRef]
  16. Haldeman, S.; Carroll, L.; Cassidy, J.D.; Schubert, J.; Nygren, A. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive summary. Spine 2008, 33, S5–S7. [Google Scholar] [CrossRef] [Green Version]
  17. Nestares, T.; Salinas, M.; de-Teresa, C.; Diaz-Castro, J.; Moreno-Fernandez, J.; Lopez-Frias, M. Factores de riesgo relacionados con los hábitos de vida en pacientes con patología osteomuscular. Nutr. Hosp. 2017, 34, 444–453. [Google Scholar] [CrossRef] [Green Version]
  18. Meseguer Henarejos, B.; Medina i Mirapeix, F.; Canovas Gascón, J.J.; Esteban Argente, I.; Torres Vaquero, A.I.; Alcántara, F. Prevalencia, consecuencias y factores de riesgo de la cervicalgia. Fisioterapia 2000, 22, 13–32. [Google Scholar]
  19. Dalewski, B.; Kaminska, A.; Szydlowski, M.; Kozak, M.; Sobolewska, E. Comparison of Early Effectiveness of Three Different Intervention Methods in Patients with Chronic Orofacial Pain: A Randomized Controlled Clinical Trial. Pain Res. Manag. 2019, 11, 7954291. [Google Scholar] [CrossRef] [Green Version]
  20. Adel, R.V.; Luykx, R.H.J. Electroterapia de Frecuencia Baja y Media; Enraf Nonius: Madrid, España, 1996. [Google Scholar]
  21. Escortell-Mayor, E.; Lebrijo-Pérez, G.; Asúnsolo-del-Barco, A.; Sánchez-Sánchez, B. Difficulties in carrying out public projects of investigation in primary care. Atención Primaria 2008, 40, 536–537. [Google Scholar] [CrossRef] [Green Version]
  22. Girardin, M. Terapia Manual de La Disfunción Neuromuscular y Articular; Paidotribo: Barcelona, Spain, 2004; ISBN 9788480193702. [Google Scholar]
  23. Gross, A.R.; Aker, P.D.; Quartly, C. Manual therapy in the treatment of neck pain. Rheum. Dis. Clin. 1996, 22, 579–598. [Google Scholar] [CrossRef]
  24. Hurwitz, E.L.; Aker, P.D.; Adams, A.H.; Meeker, W.C.; Shekelle, P.G. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996, 21, 1746–1758. [Google Scholar] [CrossRef] [PubMed]
  25. Jensen, M.P.; Turner, J.A.; Romano, J.M.; Fisher, L.D. Comparative reliability and validity of chronic pain intensity measures. Pain 1999, 83, 157–162. [Google Scholar] [CrossRef]
  26. Ylinen, J.; Takala, E.P.; Nykanen, M.J.; Kautlainen, H.J.; Häkkinen, A.; Airaksinen, O.V.P. Effects of twelve-month strength training subsequent to twelve-month stretching exercise in treatment of chronic neck pain. J. Strength Cond. Res. 2006, 20, 304–308. [Google Scholar] [CrossRef]
  27. Medina i Mirapeix, F.; Meseguer Henarejos, A.B.; Montilla Herrador, J. Clinical Practice Guideline for the mechanical neck pain physiotherapy treatment [Guía de práctica clínica para el tratamiento y seguimiento fisioterápico de la cervicalgia mecánica]. Fisioterapia 2000, 22, 33–46. [Google Scholar]
  28. Escortell Mayor, E.; Pérez Muñoz, M.; Martín Castro, B. Guía de Actuación: Procedimientos de Intervención de Fisioterapia en Atención Primaria Área 3; Gerencia de Atención Primaria Área 3 Servicio Madrileño de Salud: Madrid, Spain, 2010. [Google Scholar]
  29. Fernández Moreno, R. coordinador. Indicadores de actividad. In Procesos Susceptibles de Atención y Técnicas de Tratamiento En Las Unidades de Fisioterapia de Atención Primaria; Servicio Madrileño de Salud: Comunidad de Madrid, Spain, 2014. [Google Scholar]
  30. Gerencia Asistencial de Atención Primaria, Consejería de Sanidad. Cartera de Servicios Estandarizados de Atención Primaria de Madrid; Gerencia Asistencial de Atención Primaria: Madrid, Spain, 2018. [Google Scholar]
  31. Binder, A. Neck pain. BMJ 2006, 11, 1103–1124. [Google Scholar]
  32. Hoving, J.L.; Gross, A.R.; Gasner, D.; Kay, T.; Kennedy, C.; Hondras, M.A.; Haines, T.; Bouter, L.M. A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain. Spine 2001, 26, 196–205. [Google Scholar] [CrossRef]
  33. Kroeling, P.; Gross, A.R.; Goldsmith, C.H. A Cochrane review of electrotherapy for mechanical neck disorders. Spine 2005, 30, E641–E648. [Google Scholar] [CrossRef] [PubMed]
  34. Guzman, J.; Haldeman, S.; Carroll, L.J.; Carragee, E.J.; Hurwitz, E.L.; Peloso, P.; Nordin, M.; Cassidy, J.D.; Holm, L.W.; Côté, P.; et al. Clinical practice implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its associated disorders: From concepts and findings to recommendations. Spine 2008, 33, S199–S213. [Google Scholar] [CrossRef] [PubMed]
  35. Häkkinen, A.; Salo, P.; Tarvainen, U.; Wirén, K.; Ylinen, J. Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain. J. Rehabil. Med. 2007, 39, 575–579. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  36. Ylinen, J.; Kautiainen, H.; Wirén, K.; Häkkinen, A. Stretching exercises vs manual therapy in treatment of chronic neck pain: A randomized, controlled cross-over trial. J. Rehabil Med. 2007, 39, 126–132. [Google Scholar] [CrossRef] [Green Version]
  37. Blanpied, P.R.; Gross, A.R.; Elliott, J.M.; Devaney, L.L.; Clewley, D.; Walton, D.M.; Sparks, C.; Robertson, E.K. Neck Pain: Revision 2017. J. Orthop Sports Phys. Ther. 2017, 47, A1–A83. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  38. De Koning, C.H.; van den Heuvel, S.P.; Staal, J.B.; Smits-Engelsman, B.C.; Hendriks, E.J. Clinimetric evaluation or active range of motion measures in patients with non-specific pain: A systematic review. Eur. Spine J. 2008, 7, 905–921. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  39. Korthals-de, B.I.; Hoving, J.L.; van Tulder, M.W.; Rutten-van Mölken, M.P.; Ader, H.J.; de Vet, H.C.W.; Koes, B.W.; Vondeling, H.; Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: Economic evaluation alongside a randomised controlled trial. BMJ 2003, 326, 911–916. [Google Scholar] [CrossRef] [Green Version]
  40. Kjellman, G.V.; Skargren, E.I.; Oberg, B.E. A critical analysis of randomised clinical trials on neck pain and treatment efficacy. A review of the literature. Scand. J. Rehabil. Med. 1999, 31, 139–152. [Google Scholar] [CrossRef]
  41. Hurwitz, E.L.; Carragee, E.J.; van der Velde, G.; Carroll, L.J.; Nordin, M.; Guzman, J.; Peloso, P.M.; Holm, L.W.; Côté, P.; Hogg-Johnson, S.; et al. Treatment of neck pain: Noninvasive interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008, 33, S123–S152. [Google Scholar] [CrossRef] [Green Version]
  42. Valera-Garrido, F.; Martínez-Rodríguez, A.; Medina-i-Mirapeix, F.; Meseguer –Henarejos, A.; Millan-Robles, F.; Campillo-Pomata, E. El modelo biopsicosocial en los síndromes de dolor vertebral: Implicaciones para la protocolización. Rev. Iberoam Fisioter Kinesiol. 2001, 4, 81–87. [Google Scholar]
  43. Jull, G.; Moore, A.; Falla, D.; Lewis, J.; McCarthy, C.; Sterling, M. Grieve’s Modern Musculoskeletal Physiotherapy, 4th ed.; Elsevier: London, UK, 2015; ISBN 9780702051524. [Google Scholar]
  44. Jull, G.; Falla, D.; Treleaven, J.; O’Leary, S. Management of Neck Pain Disorders E-Book: A Research Informed Approach, 1st ed.; Elsevier Health Sciences: London, UK, 2018; ISBN 9780702074769. [Google Scholar]
  45. Escortell-Mayor, E.; Riesgo-Fuertes, R.; Garrido-Elustondo, S.; Asúnsolo-del Barco, A.; Díaz-Pulido, B.; Blanco-Díaz, M.; Bejerano-Álvarez, E.; TEMA-TENS Group. Primary care randomized clinical trial: Manual Therapy effectivenes in comparison with TENS in patiens with neck pain. Man. Ther. 2011, 16, 66–73. [Google Scholar] [CrossRef]
  46. Spitzer, W.O.; Leblanc, F.E.; Dupuis, M. Scientific approach to the assessment and management of activity related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987, 7, 1–59. [Google Scholar]
  47. Escortell-Mayor, E.; Lebrijo-Pérez, G.; Pérez-Martín, Y.; Asúnsolo-del-Barco, A.; Riesgo-Fuertes, R.; Saa-Requejo, C. Randomized clinical trial for primary care patients with neck pain: Manual therapy versus electrical stimulation. Atención Primaria. 2008, 40, 337–343. [Google Scholar] [CrossRef] [Green Version]
  48. Stratford, P.W.; Riddle, D.L.; Binkley, J.M.; Spadoni, G.; Westaway, M.D.; Padfield, B. Using the Neck Disability index to make decisions concerning individual patients. Physiother Can. 1999, 51, 107–112. [Google Scholar]
  49. Ylinen, J.; Savolainen, S.; Airaksinen, O.; Kautiainen, H.; Salo, P.; Häkkinen, A. Decreased strength and mobility in patients after anterior cervical diskectomy compared with healthy subjects. Arch. Phys. Med. Rehabil. 2003, 84, 1043–1047. [Google Scholar] [CrossRef]
  50. Cleland, J.A.; Childs, J.D.; Whitman, J.M. Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Arch. Phys. Med. Rehabil. 2008, 89, 69–74. [Google Scholar] [CrossRef]
  51. Chaitow, L. Técnica Neuromuscular: Tratamiento de Los Tejidos Blandos: Método Diagnóstico y Terapéutico de La Disfunción Tisular; Bellaterra: Barcelona, Spain, 1999; ISBN 84-7290-027-4. [Google Scholar]
  52. Travell, J.G.; Simons, G.D. Miofascial Pain and Dysfunction. The Trigger Point Manual [Dolor y Disfunción Miofascial. El Manual de Los Puntos Gatillo], 2nd ed.; Medica Panamericana: Madrid, Spain, 2001; ISBN 0683083635. [Google Scholar]
  53. Lantz, C.A.; Chen, J.; Buch, D. Clinical validity and stability of active and passive cervical range of motion with regard to total and unilateral uniplanar motion. Spine 1999, 24, 1082–1089. [Google Scholar] [CrossRef] [PubMed]
  54. Magee, D. Ortopedia, 2nd ed.; Interamericana Mc Graw-Hill: Mexico City, Mexico, 1994; ISBN 968252055X. [Google Scholar]
  55. Boyles, R.E.; Walker, M.J.; Young, B.A.; Strunce, J.B.; Wainner, R.S. The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: A secondary analysis. J. Orthop. Sports Phys. Ther. 2010, 40, 133–140. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  56. Edmondston, S.J.; Wallumrod, M.E.; MacLéid, F.; Kvamme, L.S.; Joebges, S.; Brabham, G.C. Reliability or isometric muscle endurance test in subjects with postural neck pain. J. Manipul. Physiol. Ther. 2008, 31, 348–352. [Google Scholar] [CrossRef]
  57. Medina, F.; Messeguer, A.B.; Montilla, J. Clinical Practice Guideline for the mechanical neck pain physiotherapy diagnosis [Guía de práctica clínica para el diagnóstico fisioterápico de la cervicalgia mecánica]. Fisioterapia 2000, 22, 13–32. [Google Scholar]
  58. Resende, L.; Merriwether, E.; Rampazo, É.; Dailey, D.; Embree, J.; Deberg, J.; Liebano, R.E.; Sluka, K.A. Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain. Eur. J. Pain 2018, 22, 663–678. [Google Scholar] [CrossRef]
  59. Paolucci, T.; Agostini, F.; Paoloni, M.; de Sire, A.; Verna, S.; Pesce, M.; Ribecco, L.; Mangone, M.; Bernetti, A.; Saggini, R. Efficacy of TENS in Cervical Pain Syndromes: An Umbrella Review of Systematic Reviews. Appl. Sci. 2021, 11, 3423. [Google Scholar] [CrossRef]
  60. Tuttle, N.; Barrett, R.; Laakso, L. Relation between changes in posteroanterior stiffness and active range of movement of the cervical spine following manual therapy treatment. Spine 2008, 33, E673–E679. [Google Scholar] [CrossRef] [Green Version]
  61. Heikki, M.; Hemmilä, M.D. Bone setting for prolongad neck pain: A randomized clinical trial. J. Manip. Physiol. Ther. 2005, 28, 507–515. [Google Scholar] [CrossRef]
  62. Nordemar, R.; Thörner, C. Treatment of acute cervical pain-a comparative group study. Pain 1981, 10, 93–101. [Google Scholar] [CrossRef]
  63. Dusunceli, Y.; Ozturk, C.; Atamaz, F.; Hepguler, S.; Durmaz, B. Efficacy of neck stabilization exercises for neck pain: A randomized controlled study. J. Rehabil. Med. 2009, 41, 626–631. [Google Scholar] [CrossRef] [Green Version]
  64. Chiu, T.T.; Hui-Chan, C.W.; Cheing, G. A randomized clinical trial of TENS and exercise for patients with chronic neck pain. Clin. Rehabil. 2005, 19, 850–860. [Google Scholar] [CrossRef]
  65. Jordan, A.; Bendix, T.; Nielsen, H.; Hansen, F.R.; Host, D.; Winkel, A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial. Spine 1998, 23, 311–318. [Google Scholar] [CrossRef]
  66. Levoska, S.; Keinanen-Kiukaannieni, S. Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow- up. Arch. Phys. Med. Rehabil. 1993, 74, 425–430. [Google Scholar] [PubMed]
  67. Cheville, A.L.; Smith, S.R.; Basford, J.R. Rehabilitation Medicine Approaches to Pain Management. Hematol/Oncol Clin. N. Am. 2018, 32, 469–482. [Google Scholar] [CrossRef]
  68. Hodges, P.W.; Moseley, G.L. Pain and motor control of the lumbopelvic region: Effect and possible mechanisms. J. Electromyogr. Kinesiol. 2003, 13, 361–370. [Google Scholar] [CrossRef]
  69. Falla, D.; Bilenkij, G.; Jull, G. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine 2004, 29, 1436–1440. [Google Scholar] [CrossRef]
  70. Al-Obaidi, S.M.; Nelson, R.M.; Al-Awadhi, S.; Al-Shuwaie, N. The role of anticipation and fear of pain in the persistence of avoidance behaviour in patients with chronic low back pain. Spine 2000, 25, 1126–1131. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  71. Häkkinen, A.; Kautiainen, H.; Hannonen, P.; Ylinen, J. Strentght training and stretching versus stretching only in the treatment of patients with chronic neck pain: A randomized one-year follow-up study. Clin. Rehabil. 2008, 22, 592–600. [Google Scholar] [CrossRef]
  72. Schabrun, S.M.; Cannan, A.; Mullens, R.; Dunphy, M.; Pearson, T.; Lau, C.; Chipchase, L.S. The effect of interactive neurostimulation therapy on myofascial trigger point associated with mechanical neck pain: A preliminary randomized, sham-controlled trial. J. Altern. Complement. Med. 2012, 18, 946–952. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  73. Kay, T.M.; Gross, A.; Goldsmith, C.H.; Santaguida, P.L.; Hoving, J.; Bronfort, G.; Santaguida, P.L. Exercise for Mechanical Neck Disorders (Cochrane Review). Cochrane Database Syst. Rev. 2012, 15, CD004250. [Google Scholar] [CrossRef] [Green Version]
  74. Loudon, K.; Treweek, S.; Sullivan, F.; Donnan, P.; Thorpe, K.E.; Zwarenstein, M. The PRECIS-2 tool: Designing trials that are fit for purpose. BMJ 2015, 8, 350. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  75. Ylinen, J.; Häkkinen, A.; NyKänen, M.; Kautiainen, H.; Takala, E.P. Neck muscle training in the treatment of chronic neck pain: A three-year follow-up study. Eur. Med. 2007, 43, 161. [Google Scholar]
  76. Kelly, M.; Cardy, N.; Melvin, E.; Reddin, C.; Ward, C.; Wilson, F. The craniocervical flexion test: An investigation or performance in young asymptomatic subjects. Man. Ther. 2013, 18, 83–86. [Google Scholar] [CrossRef] [PubMed]
  77. Coulter, I.D.; Crawford, C.; Vernon, H.; Hurwitz, E.L.; Khorsan, R.; Booth, M.S.; Herman, P.M. Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis for an Appropriateness Panel. Pain Phy-Sician 2019, 22, E55–E70. [Google Scholar] [CrossRef]
  78. Rondon-Ramos, A.; Martinez-Calderon, J.; Diaz-Cerrillo, J.; Rivas-Ruiz, F.; Ariza-Hurtado, G.; Clavero-Cano, S.; Luque-Suarez, A. Pain Neuroscience Education Plus Usual Care Is More Effective than Usual Care Alone to Improve Self-Efficacy Beliefs in People with Chronic Musculoskeletal Pain: A Non-Randomized Controlled Trial. J. Clin. Med. 2020, 9, 2195. [Google Scholar] [CrossRef]
  79. Pérez-Martín, Y.; Díaz-Pulido, B.; Lebrijo-Pérez, G. Efectividad del tratamiento fisioterápico en pacientes con cervicalgia mecánica. Fisioterapia 2002, 24, 165–174. [Google Scholar] [CrossRef]
  80. Garrido- Elustondo, S.; Riesgo-Fuertes, R.; Escortell-Mayor, E.; Asúnsolo-del-Barco, A.; Pérez-Martín, Y.; Martín-Castro, B. Satisfaction of patients with mechanical neck disorders attended by Primary Care Physical Therapists. J. Eval. Clin. Pract. 2010, 16, 445–450. [Google Scholar] [CrossRef]
Jcm 10 03245 g001 550
Figure 1. Graphical depiction of MT and TENS interventions. MT: Manual therapy; TENS: transcutaneous electrical nerve stimulation.
Figure 1. Graphical depiction of MT and TENS interventions. MT: Manual therapy; TENS: transcutaneous electrical nerve stimulation.
Jcm 10 03245 g001
Jcm 10 03245 g002 550
Figure 2. Flow chart: Progress of patients through trial.
Figure 2. Flow chart: Progress of patients through trial.
Jcm 10 03245 g002
Jcm 10 03245 g003 550
Figure 3. Active mobility evolution by planes in both intervention groups. Abbreviations: SP, sagittal plane; FP, frontal plane; TP, transverse plane; MT, manual Therapy; TENS, transcutaneous electric nerve stimulation.
Figure 3. Active mobility evolution by planes in both intervention groups. Abbreviations: SP, sagittal plane; FP, frontal plane; TP, transverse plane; MT, manual Therapy; TENS, transcutaneous electric nerve stimulation.
Jcm 10 03245 g003
Jcm 10 03245 g004 550
Figure 4. Endurance evolution by planes in both intervention groups. Abbreviations: SP, sagittal plane; FP, frontal plane; TP, transverse plane; MT, manual therapy; TENS, transcutaneous electric nerve stimulation.
Figure 4. Endurance evolution by planes in both intervention groups. Abbreviations: SP, sagittal plane; FP, frontal plane; TP, transverse plane; MT, manual therapy; TENS, transcutaneous electric nerve stimulation.
Jcm 10 03245 g004
Table
Table 1. Description of Manual Therapy Technics [22,51,52].
Table 1. Description of Manual Therapy Technics [22,51,52].
MT TechnicDescription
Neuromuscular techniqueLongitudinal strokes were performed along the fibers of each muscle to stretch locally the areas of most tension that were previously located. The technique was applied with the physical therapist’s first finger, and using the last four fingers as support.
Post-isometric stretchingThe patient was placed in a stretching position that was comfortable for the affected muscles, and he/she was asked to do an isometric contraction for 5 to 7 s. After that, a new barrier was searched for, and the sequence was repeated up to three times.
Spray and stretching techniqueFrom a comfortable position for the patient, the first cold spray was applied to the target muscle’s MTrPs, in order to start immediately afterward with muscle stretching up to the position the patient allowed. After this, the area was sprayed again, but this time the whole area with pain was covered, in order to perform another stretch. On each area the spray could only be applied three times.
Jones techniquePressure was applied to the painful points and/or the MtrPs, which had previously been located, until pain was generated. Then a position where pain disappeared was searched (maximum comfort position), and it was maintained for 90 s before passively returning to the original position.
Abbreviations: MT, manual therapy.
Table
Table 2. Sociodemographic characteristics and the prognostic variables at baseline.
Table 2. Sociodemographic characteristics and the prognostic variables at baseline.
Manual Therapy (n = 47)TENS (n = 43)
Gender: women (n (%))42 (89.4)38 (88.4)
Age (decimal ages) (X (SD))40.8 (11.6)39.3 (9.7)
Previous neck pain episodes (n (%))38 (84.4)37 (86.0)
History of accident with cervical impaired (n (%))12 (26.1)6 (14.3)
Disability: NDI (X (SD))31.6 (11.3)34.4 (13.9)
Pain: VAS (X (SD))54.9 (18.8)56.4 (20.2)
Cervical current episode duration (days) (X (SD))141 (280.8)154.3 (216.2)
Abbreviations: n (%), number (percentage); X (SD), mean (standard deviation); NDI, neck disability index; VAS, visual analogue scale.
Table
Table 3. Cervical active mobility and endurance differences before and after treatment in the different planes.
Table 3. Cervical active mobility and endurance differences before and after treatment in the different planes.
BaselineBasal and Post-InterventionBasal and 6-Months Follow-Up
MT Group (CI 95%) (n = 47)TENS Group x (CI 95%) (n = 43)MT Group Difference (CI 95%) (n = 45)TENS Group Difference (CI 95%) (n = 42)Between Groups p-ValueMT Group Difference (CI 95%) (n = 36)TENS Group Difference (CI 95%) (n = 35)Between Groups p-Value
MOBILITY (planes)
SAGITAL111.62 (105.9–117.3)112.86 (106.6–119.2)8.93 (4.37–13.50)3.44 (−1.54–8.42)0.372 (*)5.68 (0.37–11.0)−2.38 (−11.37–6.60)0.114 (*)
FRONTAL83.34 (77.5–89.2)82.95 (76.8–89.1)4.98 (1.28–8.67)1.62 (−3.70– 6.93)0.583 (*)−0.46 (−6.66–5.73)3.09 (−4.45–10.62)0.459 (*)
TRANSVERSAL122.85 (115.2–130.5)124.72 (116.2–133.3)7.64 (1.24–14.05)4.05 (-2.57– 10.67)0.902 (*)4.89 (−2.23–12.02)8.79 (−0.39–17.97)0.494 (*)
ENDURANCE (planes)
SAGITAL3.44 (3.2–3.6)3.67 (3.5–3.8)0.33 (0.15–0.49)0.12 (−0.01–0.25)0.140 (†)0.3 (0.11–0.49)0.11 (−0.04–0.28)0.505 (†)
FRONTAL3.11 (2.9–3.3)3.42 (3.2–3.6)0.43 (0.24–0.62)0.08 (−0.13– 0.29)0.114 (†)0.3 (0.10–0.50)0.07 (−0.19–0.34)0.234 (†)
TRANSVERSAL2.57 (2.3–2.7)2.59 (2.3–2.7)0.33 (0.12–0.55)0.11 (−0.13–0.35)0.117 (†)0.32 (0.07–0.57)0.04 (−0.24–0.33)0.114 (†)
Abbreviations: X, mean; CI, confidence interval; MT, manual therapy; TENS, transcutaneous electrical nerve stimulation. p < 0.05. * General linear model of repeated means, simple contrast; † U de Mann–Whitney.
Table
Table 4. Influence of study variables on cervical active mobility and endurance.
Table 4. Influence of study variables on cervical active mobility and endurance.
ModelsInterventionDisability (NDI)Episode DurationPostural CompliancePrevious Episode
Rcpβpβpβpβpβp
Post-intervention
MOBILITY (planes)SAGITAL0.160.00−6.580.03 −0.020.026.750.03−9.630.04
FRONTAL0.040.07−3.180.32 6.540.04
TRANSVERSAL0.060.03−5.260.240.460.01
ENDURANCE (planes)SAGITAL0.090.020.840.01−0.030.04
FRONTAL0.150.000.290.07
TRANSVERSAL0.060.020.250.11
Six months after intervention
MOBILITY (planes)SAGITAL0.100.01−10.080.040.560.01
FRONTAL0.080.043.580.440.420.04−0.020.07
TRANSVERSAL0.170.000.730.890.880.00
ENDURANCE (planes)SAGITAL0.170.010.560.00 −0.810.040.310.10
FRONTAL0.260.000.060.730.020.00
TRANSVERSAL0.160.000.200.26 0.000.00
Abbreviations: Rc, coefficient of determination; p, p-value; β, standardized coefficient; NDI, neck disability index. p < 0.05.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Díaz-Pulido, B.; Pérez-Martín, Y.; Pecos-Martín, D.; Rodríguez-Costa, I.; Pérez-Muñoz, M.; Calvo-Fuente, V.; Ortiz-Jiménez, M.F.; Asúnsolo-del Barco, Á. Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial. J. Clin. Med. 2021, 10, 3245. https://doi.org/10.3390/jcm10153245

AMA Style

Díaz-Pulido B, Pérez-Martín Y, Pecos-Martín D, Rodríguez-Costa I, Pérez-Muñoz M, Calvo-Fuente V, Ortiz-Jiménez MF, Asúnsolo-del Barco Á. Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial. Journal of Clinical Medicine. 2021; 10(15):3245. https://doi.org/10.3390/jcm10153245

Chicago/Turabian Style

Díaz-Pulido, Belén, Yolanda Pérez-Martín, Daniel Pecos-Martín, Isabel Rodríguez-Costa, Milagros Pérez-Muñoz, Victoria Calvo-Fuente, María Félix Ortiz-Jiménez, and Ángel Asúnsolo-del Barco. 2021. "Efficacy of Manual Therapy and Transcutaneous Electrical Nerve Stimulation in Cervical Mobility and Endurance in Subacute and Chronic Neck Pain: A Randomized Clinical Trial" Journal of Clinical Medicine 10, no. 15: 3245. https://doi.org/10.3390/jcm10153245

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop