Arthritis Research UK National Primary Care Centre Winner of a Queen s Anniversary Prize For Higher and Further Education 2009

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1 Arthritis Research UK Winner of a Queen s Anniversary Prize For Higher and Further Education 2009 Musculoskeletal therapies for neck pain in primary care: from park bench to bedside Krysia Dziedzic Arthritis Research UK Professor of Musculoskeletal Therapies

2 Primary Care management of musculoskeletal conditions Common cause of chronic pain and disability in primary care From Park Bench. Arthritis Research UK

3 Annual incidence of consultations in primary care (per 10,000 population) Females Males RA OA LBP Regional pain Arthritis Research UK

4 Research activity Clinical trials High numbers of patients recruited Publications ++++ Arthritis Research UK

5 Evidence based clinical practice Community rheumatology General Practitioners & Community Pharmacists Physiotherapists Occupational Therapists..To Bedside Arthritis Research UK

6 Knowledge translation Research Question Develop protocol Implementation User Involvement Clinical Trial Dissemination Research Publication Research Findings Arthritis Research UK

7 Ask an important question Research Question User Involvement Arthritis Research UK

8 Workshops for physiotherapists 1998 Sim et al 1999 J Eval Clin Pract (4): Arthritis Research UK

9 Neck pain Neck pain is common and disabling Neck pain is frequently managed with physical approaches Arthritis Research UK

10 Treatment options include: Arthritis Research UK

11 Purpose To determine whether manual therapy (with advice and exercise) or Pulsed Shortwave Diathermy (with advice and exercise) are better than advice and exercise alone in the treatment of non-specific neck disorders Arthritis Research UK

12 Aim of the study Primary objective to compare at 6 months the effect of adding: 1. Manual Therapy 2. PSWD to Advice and Exercise alone Secondary objectives to compare clinical outcomes at 6 weeks to compare cost consequences at 6 months Arthritis Research UK

13 User Involvement Develop protocol Population Intervention Comparator Outcome Arthritis Research UK

14 A PRAGMATIC APPROACH: in primary care Protocol developers Arthritis Research UK

15 Population Inclusion 18 years and over Clinical diagnosis neck pain and/or stiffness (including unilateral arm pain) Referred from primary care to physiotherapy No treatment previous 6 months Exclusion Red flags Serious pathology, inflammatory arthritis, progressive neurological signs, contraindication to treatment, injury awaiting claim, pregnancy Arthritis Research UK

16 Intervention All patients received: home exercise sheet one to one advice on managing their neck problem an information leaflet to take home Arthritis Research UK

17 Interventions & Comparator + + Arthritis Research UK

18 Outcome Primary outcome measure Northwick Park Neck Pain Questionnaire pain disability measure (Leak et al, 1994) 9 Questions 100-point scale Arthritis Research UK

19 User Involvement Clinical Trial Is this treatment helpful on average for a wide range of patients? Arthritis Research UK

20 The effectiveness of manual therapy or pulsed short-wave diathermy in addition to exercise and advice for neck disorders; a pragmatic RCT in physiotherapy clinics Arthritis Research UK

21 Physiotherapy centres Arthritis Research UK

22 User Involvement Research Findings Arthritis Research UK

23 Results 735 patients were screened Target recruitment 350 in 22 months Mean age 51 years 63% Female Arthritis Research UK

24 40 38 Adjusted scores Adjusted mean Northwick Park score Treatment A&E MT 22 PSWD 20 Baseline 6 weeks 6 months Arthritis Research UK

25 Summary of results No differences in primary outcome at 6 m Patient satisfaction was in favour of MT Treatment course was shorter in the advice and exercise group 350 patients randomised, 15 centres, 70 physiotherapists 92% f/u at 6 months 98% received their allocated treatment Arthritis Research UK

26 Conclusion The addition of manual therapy or PSWD to exercise and advice alone does not provide any better clinical improvement in the physiotherapy treatment of nonspecific neck disorders Arthritis Research UK

27 User Involvement Research Publication Arthritis Research UK

28 Arthritis Research UK

29 Sensitivity to Change and Internal Consistency of the Northwick Park Neck Pain Questionnaire and Derivation of a Minimal Clinically Important Difference. Clinical Journal of Pain. 22(9): , November/December Sim, Julius PhD; Jordan, Kelvin PhD; Lewis, Martyn PhD; Hill, Jonathan MSc; Hay, Elaine M. MD; Dziedzic, Krysia PhD Predictors of Poor Outcome in Patients With Neck Pain Treated by Physical Therapy. Clinical Journal of Pain. 23(8): , October Hill, Jonathan C. MSc; Lewis, Martyn PhD; Sim, Julius PhD; Hay, Elaine M. MD; Dziedzic, Krysia PhD Rheumatology (Oxford) Nov;46(11): An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial. Lewis M, James M, Stokes E, Hill J, Sim J, Hay E, Dziedzic K. Arthritis Research UK

30 Lewis M, Morley S, van der Windt DA, Hay E, Jellema P, Dziedzic K, Main CJ. Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings. Eur J Pain Nov;14(10): Epub 2010 May 4. PubMed PMID: Schellingerhout JM, Heymans MW, Verhagen AP, Lewis M, de Vet HC, Koes BW. Prognosis of patients with nonspecific neck pain: development and external validation of a prediction rule for persistence of complaints. Spine (Phila Pa 1976) Aug 1;35(17):E PubMed PMID: Verhagen AP, Lewis M, Schellingerhout JM, Heymans MW, Dziedzic K, de Vet HC, Koes BW. Do whiplash patients differ from other patients with nonspecific neck pain regarding pain, function or prognosis? Man Ther Mar 13. [Epub ahead of print] PubMed PMID: Whitehurst DG, Bryan S. Another Study Showing that Two Preference-Based Measures of Health-Related Quality of Life (EQ-5D and SF-6D) are not Interchangeable. But why Should we Expect Them to be? Value Health Feb 9. [Epub ahead of print] Arthritis Research UK

31 Verhagen et al, 2011 Man Therapy Average function (0-100) Arthritis Research UK

32 And another trial.. Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. 2009;36(2): PRF Arthritis Research UK

33 User Involvement Dissemination Arthritis Research UK

34 Physiotherapy arc neck trial, hands on or electrotherapy research Arthritis Research UK

35 We found that: What works for neck problems? PANTHER study results on average there was no additional benefit of adding manual therapy or pulsed shortwave diathermy to the package of advice and exercise. at 6 weeks the group receiving manual therapy with advice and exercise were more satisfied with their physiotherapy compared with those who had advice and exercise on its own. on average patients receiving advice and exercise with no further addition to treatment tended to have fewer treatment sessions than the other two approaches. Arthritis Research UK

36 In an attempt to find out what really works, British physiotherapists conducted a rigorous clinical trial. These findings are important. They show that the best options for neck pain are fairly simple and inexpensive. Professor Ernst The Guardian 9 th August 2005 Arthritis Research UK

37 Implementation User Involvement Arthritis Research UK

38 Manual therapy (manipulation, mobilisation) plus advice plus exercise versus pulsed short wave diathermy plus advice plus exercise versus advice plus exercise alone: One subsequent pragmatic multicentre RCT (350 people with chronic neck pain) assessed whether the addition of manual therapy (hands on, passive or active assisted movements, mobilisations, or manipulations; 63% had mobilisation physiotherapy) or pulsed short wave diathermy over 6 weeks to advice plus exercise was more effective than advice plus exercise alone. [26] The primary outcome measure was pain as measured by the Northwick Park Neck Pain Questionnaire. The RCT found no significant difference in pain between adding manual therapy to advice plus exercise and advice plus exercise alone at 6 weeks or 6 months (6 months, difference in mean Northwick Park change scores: + 1.4, 95% CI 2.8 to + 5.5). [26] It also found no significant difference in pain between adding pulsed short wave diathermy to advice plus exercise and advice plus exercise alone at 6 weeks or 6 months (6 months, difference in mean Northwick Park change scores: + 1.3, 95% 2.9 to + 5.5). [26] Binder N. Neck Pain. BMJ Clinical Evidence 2006;11:1103 Arthritis Research UK

39 Systematic review Manual therapy with or without physical medicine modalities for neck pain: a systematic review Jonathan D Sylva, Jordan Miller, Anita Gross, et al and for the Cervical Overview Group. Best Evidence on Assessment and Intervention for Neck Pain Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Eric L. Hurwitz, 1 Eugene J. Carragee, 2,3 Gabrielle van der Velde, 4,5,6,7 Linda J. Carroll, 8 Margareta Nordin, 9,10 Jaime Guzman, 11,12 Paul M. Peloso, 13 Lena W. Holm, 14 Pierre Côté, 5,6,7,15 Sheilah Hogg-Johnson, 5,16 J. David Cassidy, 6,7,15 and Scott Haldeman 17,18 Arthritis Research UK

40 Neck Pain Task Force Grade I: Grade II: Grade III: Grade IV: Arthritis Research UK

41 Grade I Neck pain with no signs or symptoms of major structural pathology and no or little interference with daily activities; will likely respond to minimal intervention such as reassurance and pain control; does not require investigations or ongoing treatment Arthritis Research UK

42 Grade II Grade II: Neck pain with no signs or symptoms of major structural pathology but interference with usual daily activities; requires pain relief and early intervention aimed at preventing longterm disability Arthritis Research UK

43 Grade III Neck pain with no signs or symptoms of major abnormality structural pathology, but presence of neurological signs such as decreased reflexes, weakness or sensory deficit; might require investigation and, occasionally more invasive treatments Arthritis Research UK

44 Grade IV Neck pain with signs or symptoms of major structural pathology, such as fracture, myelopathy, neoplasm, or systemic disease; requires prompt investigation and treatment Arthritis Research UK

45 Knowledge translation User Involvement Arthritis Research UK

46 MANAGEMENT OF NECK PAIN IN PRIMARY CARE Hands on (Series 6) No 8: Spring 2011 Arthritis Research UK Primary Care Centre Krysia Dziedzic, Carol Doyle, Lucy Huckfield, Treena Larkin, Kay Stevenson, Panos Sargiovannis, Nadia Corp, Nadine Foster Core treatment recommendations for non-specific neck pain Exercises, manual therapy, analgesics, acupuncture, and low-level laser therapy have been shown to provide some degree of short-term relief of neck pain without trauma. Manual therapy is often used with exercise to treat neck pain for pain reduction and improved quality of life. Exercises and mobilization have been shown to provide some degree of short-term relief after a motor vehicle collision. Arthritis Research UK

47 Referral to Secondary care Injection therapy Manual therapy and exercise General exercises Laser Assess for red flags First line pain relief Advice to remain active Posture and seating Address psychosocial factors Patient information and Acupuncture exercise sheet Ergonomics Local Agencies e.g. exercise in the community Surgery Pain management and cognitive behavioural therapy Arthritis Research UK

48 From Park Bench to Bedside 1997 Knowledge translation Research Question Develop protocol Implementation User Involvement Clinical Trial Dissemination Research Publication Research Findings 2011 Arthritis Research UK

49 Comparison with OA & LBP OA NICE OA guidelines support for self management access to information, exercise, weight loss first line analgesia LBP NICE LBP guidelines advice, exercise acupuncture, manual therapy, exercises Arthritis Research UK

50 Acknowledgements Primary Care Musculoskeletal Research Centre Study participants Physiotherapists Therapy managers General practices User Group Forum General practitioners Arthritis Research UK