_________________________________________________________________________ Neck Pain in Adults
Myofascial Release Therapy In myofascial release therapy, after myofascial tissue with pain- generating trigger points is identified, focused manual pressure and stretching is applied to loosen restricted muscle and joint movements and reduce pain. Pressure pain threshold is a validated measure of mechanical hyperalgesia and accurately discriminates chronic neck pain with neuropathic features from that without. Using an algometer (hand-held device), tissue pressure is increased until pain is evoked (the pressure pain threshold) [223]. Myofascial release therapy was compared with physical therapy for efficacy in reducing pressure pain threshold and neck pain in 41 patients randomized to myofascial release therapy (5 sessions) or multimodal physical therapy (10 sessions of ultrasound therapy, transcutaneous electrical nerve stimulation [TENS], and massage) over two weeks. At one-month follow-up, significant mean differences were found in pain scores and pressure pain threshold (trapezius, suboccipital) favoring myofascial release therapy. Better short- term improvement in neck pain with myofascial release therapy over physical therapy is suggested [223]. Joint-Directed Therapies Joint-directed therapies include manipulation and joint mobilization. Spinal manipulation and mobilization may restore normal range of motion and decrease pain. The therapeutic mechanisms remain unknown, but facet joint adjustment may normalize afferent signaling from mechanoreceptors to the CNS, which may improve muscle tone, decrease muscle guarding, promote effective local tissue metabolism, and lead to pain and range of motion improvements [51]. Manipulation Manipulative treatment applies manually guided force to reduce pain and improve physiologic function [103]. Manipulation is a broad term that includes high-velocity, low- amplitude thrusts to the cervical spine, and modalities such as myofascial release, counterstrain, and/or indirect or direct muscle energy techniques. Non-high-velocity, low-amplitude techniques may also be referred to as mobilization [16]. The most common chiropractic spinal manipulation is high- velocity, low-amplitude thrust to spinal segments, applied at or near the end of a joint’s passive range of motion to increase articular mobility or realign the spine. Manual manipulation is also performed by osteopathic physicians trained in manipulative medicine [224]. Some evidence supports chiropractic treatment of WAD [16]. A 2015 Cochrane review of multiple manipulation treatment sessions in neck pain concluded combining laser therapy with manipulation may be superior to manipulation or laser alone for acute and chronic neck pain [225]. For acute and subacute neck pain, manipulation was more effective than muscle relaxants, NSAIDs, and acetaminophen in improving pain
superior safety profile of cannabis versus opioids suggests that it can be a valuable addition to therapeutic options for chronic pain [217; 218; 219]. Limitations regarding dosage, length of treatment, adverse effects, long-term follow-up, and dependence require further investigation [220]. PHYSIOTHERAPIES Physiotherapies broadly encompass passive interventions (i.e., without patient exertion or effort), such as massage and manipulation, and active interventions (i.e., requires patient exertion and effort), such as physical and exercise therapy. They are delivered by trained and licensed allied healthcare professionals manually to affected soft tissue or joints, or through instruction and supervision with active interventions. Physiotherapies may also include mechanical devices that patients with positive results can purchase for continued use at home but must be prescribed by their physician [41].
Soft Tissue Therapies Massage
Massage therapy involves manual manipulation of soft tissue structures. Clinical (therapeutic) massage aims to accomplish specific goals, such as releasing muscle spasms. An example is myofascial trigger point therapy. Relaxation massage aims to relax muscles, move body fluids, and promote wellness [8]. Indications for massage include edema, muscle spasm, adhesions, and the need to improve peripheral circulation and range of motion or to increase muscle relaxation and flexibility prior to exercise. Massage can produce immediate pain reduction, and a frequency of one to two times per week for six to eight weeks is suggested [103]. Massage therapy (once- weekly for 10 weeks) can provide short-term relief for chronic cervical myofascial pain and reduce pain-related impairments [57]. A practice guideline concluded therapeutic massage can decrease pain and tenderness and improve range of motion in patients with subacute or chronic neck pain. Massage interventions are effective for relieving neck pain symptoms at post-treatment, but data on long-term effects are insufficient [221; 222]. Soft Tissue Mobilization Mobilization of soft tissue applies muscle energy, strain/ counter strain, myofascial release, manual trigger point release, and other manual therapy techniques to improve or normalize movement patterns by reducing soft tissue pain and restrictions [103]. Mobilization applies gentle pressure within or at the limits of normal motion with the goal of increasing cervical range of motion [65]. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression. Mobilization should be accompanied by active therapy. The usual course of treatment is up to three times per week for four to six weeks [103].
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