Table 1.
GRADE evaluation of interventions for neck pain
| Important outcomes | Symptom improvement, functional improvement, quality of life | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for people with non-specific neck pain without severe neurological deficit? | |||||||||
| 1 (60)[20] | Symptom improvement | Proprioceptive and strengthening exercises v usual care | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1, 3 papers (180)[29] [30] [31] | Symptom improvement | Endurance or strengthening (isometric) exercise v no specific exercise programme | 4 | –3 | 0 | -1 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and incomplete reporting of results. Directness point deducted for restricted population |
| 1 (180)[29] [30] [31] | Functional improvement | Endurance or strengthening (isometric) exercise v no specific exercise programme | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and unclear randomisation. Directness point deducted for restricted population |
| 1, 2 papers (103)[21] [22] | Symptom improvement | Exercise (strength training, endurance training, or coordination exercises) v stress management | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for restricted population |
| 1 (393)[32] | Symptom improvement | Exercise (dynamic muscle training) v relaxation training or advice to continue with ordinary activity | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for low uptake of interventions and for restricted population |
| 1 (393)[32] | Functional improvement | Exercise (dynamic muscle training) v relaxation training or advice to continue with ordinary activity | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for low uptake of interventions and for restricted population |
| 1 (218)[33] | Symptom improvement | Exercise plus infrared v TENS plus infrared v infrared alone | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for no consistent evidence of benefit across different symptoms |
| 1 (218)[33] | Functional improvement | Exercise plus infrared v TENS plus infrared v infrared alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for unclear outcome assessment |
| 1 (151)[34] | Symptom improvement | Exercise v sleeping neck support (pillow) v exercise plus pillow v placebo (hot or cold packs plus massage) | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and uncertainty about validity of control group as it included two active treatments. Directness point deducted for low overall baseline pain |
| 1 (100)[40] | Symptom improvement | Traction v sham traction | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results. |
| 1 (493)[41] | Symptom improvement | Traction v positioning v instruction in posture v neck collar v placebo tablets v untuned short-wave diathermy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results and inclusion of co-intervention (analgesics). Directness point deducted for unclear outcome assessment |
| 1 (81)[43] | Symptom improvement | PEMF treatment v sham PEMF treatment | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, sub-group analysis, and baseline differences between groups. Directness point deducted for unclear measurement of outcomes |
| 9 (at least 4470)[14] [15] [44] [45] [46] [47] [48] | Symptom improvement | Acupuncture v sham treatment, inactive treatment, or waiting list control | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for weak methods of RCTs and incomplete reporting. Directness points deducted for inclusion of people with whiplash or radicular pain, lack of clarity of diagnosis in 1 RCT, and use of a composite outcome measure |
| 1 (3766)[48] | Quality of life | Acupuncture v sham treatment, inactive treatment, or waiting list control | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for lack of blinding and incomplete reporting of results. Directness point deducted for lack of clarity of diagnosis |
| 1 (74)[14] | Symptom improvement | Spray and stretch v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for unclear outcome assessment |
| 1, 2 papers (183)[23] [24] [36] | Symptom improvement | Mobilisation v exercise or v usual care | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (77)[26] | Symptom improvement | McKenzie mobilisation v exercise or v control | 4 | -3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, poor methods, and incomplete reporting of results |
| 1 (315 people in total, only 96 of whom had neck pain)[59] | Symptom improvement | McKenzie mobilisation v CBT | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and no seperate reporting of people with neck pain. Directness points deducted for inclusion of co-intervention (advice booklets) |
| 3 (155)[49] | Symptom improvement | Manipulation v muscle relaxants, NSAIDs, or usual care | 4 | –1 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data. Directness points deducted for inclusion of people with back pain and control including different active treatments (including diazepam, anti-inflammatory drugs, and usual care) |
| 3 (506)[56] [57] [58] | Symptom improvement | Manipulation v mobilisation | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, lack of blinding, and short follow-up |
| 3 (506)[56] [57] [58] | Functional improvement | Manipulation v mobilisation | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, lack of blinding, and short follow-up |
| 1 (256)[55] | Symptom improvement | Manipulation or mobilisation v other physical treatments (exercises plus massage with or without heat, PEMF treatment, ultrasound, or short-wave diathermy) v usual care or placebo | 4 | –1 | 0 | –2 | 0 | Very low | Quality points deducted for incomplete reporting of results. Directness points deducted for combination of different treatments in comparison group and inclusion of people with back pain |
| 1 (119)[54] | Symptom improvement | Manipulation or mobilisation v exercise | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (191)[60] [65] | Symptom improvement | Manipulation plus strengthening exercises v either treatment alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (191)[60] [65] | Functional improvement | Manipulation plus strengthening exercises v either treatment alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (350)[35] | Symptom improvement | Manual therapy (manipulation, mobilisation) plus advice plus exercise v pulsed short-wave diathermy plus advice plus exercise v advice plus exercise alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting and combined intervention group of manual therapy |
| 1 (66)[28] | Symptom improvement | Exercise plus behavioural modification v exercise plus CBT | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of people with shoulder pain |
| 1 (185)[69] | Symptom improvement | CBT plus physiotherapy v CBT v minimal treatment | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness points deducted for inclusion of people with back pain and unclear clinical relevance of reported outcome |
| 2 (525)[70] [71] | Symptom improvement | Patient education or patient education plus exercise v no treatment, CBT or stress management | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting and inclusion of co-intervention (exercise). Directness point deducted for inclusion of people with back and shoulder pain |
| 3 (316)[75] [76] [74] | Symptom improvement | Muscle relaxants v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting of results, and short follow-up. Directness point deducted for inclusion of people with range of musculoskeletal disorders |
| Waht are the effects of treatments for acute whiplash injury? | |||||||||
| 5 (970)[80] [81] [82] [83] [84] | Symptom improvement | Early mobilisation (including exercises) v immobilisation or less active treatment | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for poor follow-up, and incomplete reporting of results. Directness points deducted for no direct statistical comparison between groups, and inclusion of co-interventions (other neck interventions) |
| 2 (519)[84] [80] | Functional improvement | Early mobilisation (including exercises) v immobilisation or less active treatment | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for no direct statistical comparison between groups and inclusion of co-interventions (other neck interventions) |
| 2 (659)[84] [86] | Symptom improvement | Early return to normal activity v immobilisation or v early mobilisation | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for no direct statistical comparison between groups, and inclusion of co-interventions (other neck interventions) |
| 2 (659)[84] [86] | Functional improvement | Early return to normal activity v immobilisation v early mobilisation | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for inclusion of co-interventions (other neck interventions) |
| 2 (280)[87] [88] | Symptom improvement | Exercise v soft collar or v usual care | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for high rate of withdrawals, baseline differences between groups, and use of co-intervention |
| 2 (280)[87] [88] | Functional improvement | Exercise v soft collar or v usual care | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for high rate of dropouts baseline differences between groups, and use of co-intervention |
| 1 (59) [89] | Symptom improvement | Different exercise regimens v each other | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results. |
| 1 (59) [89] | Functional improvement | Different exercise regimens v each other | 4 | –2 | 0 | 0 | 0 | Low | |
| 1 (40)[90] | Symptom improvement | PEMF treatment v sham PEMF treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of co-intervention |
| 1 (60)[91] | Symptom improvement | Multimodal treatment v physical treatments | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of different comparators in control group |
| 1 (60)[91] | Functional improvement | Multimodal treatment v physical treatments | 4 | –1 | 0 | –2 | 0 | Low | Quality point deducted for sparse data. Directness points deducted for inclusion of different comparators in control group |
| What are the effects of treatments for chronic whiplash injury? | |||||||||
| 1 (24)[96] | Symptom improvement | Percutaneous radiofrequency neurotomy v sham treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (33)[97] | Symptom improvement | Multimodal treatment v physical treatments | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and difference in time spent by therapist with the two groups |
| 1 (33)[97] | Functional improvement | Multimodal treatment v physical treatments | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and difference in time spent by therapist in the two groups |
| 1 (134)[98] | Symptom improvement | Exercise plus advice v advice alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for use of additional treatment |
| 1 (134)[98] | Functional improvement | Exercise plus advice v advice alone | 4 | –1 | 0 | –1 | 0 | Low | Quality points deducted for sparse data. Directness point deducted for use of additional treatment |
| What are the effects of treatments for neck pain with radiculopathy? | |||||||||
| 1 (81)[100] | Symptom improvement | Surgery v physical treatments or v immobilisation in a neck collar | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and lack of blinding of outcome assessors |
| 1 (24)[104] | Symptom improvement | Epidural corticosteroid plus epidural local anaesthetic plus morphine v epidural interlaminar corticosteroid plus lidocaine | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and no direct statistical comparison between groups |
Type of evidence: 4 = RCT; 2 = Observational. Consistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio