Clinical features guiding manual therapy and exercise interventions in non-specific neck pain.

Background:

Non-specific neck pain (NSNP) is a prevalent and disabling condition characterised by neck pain with no specific underlying pathological cause identified. Although personalised management has been recommended, current clinical guidelines and prediction rules do not to provide specific guidance for identifying the patients who would benefit most from manual therapy or exercise, which are the most commonly recommended physiotherapy interventions.

Aims:

To ascertain, based on current evidence, whether matching patients with NSNP to specific interventions according to certain clinical features improves treatment outcomes and to identify those clinical features that might be associated with more favourable responses to manual therapy and exercise.

Methods:

A series of linked studies comprising: (1) a systematic review with meta analysis of trials comparing matched and unmatched interventions for NSNP; (2) a secondary meta-regression analysis of these trials to assess the impact of reporting completeness and fidelity of matched interventions on effect sizes; (3) a semi-structured interview study to explore Italian physiotherapists' clinical reasoning regarding the use of manual therapy and exercise; (4) an e-Delphi study of international experts to identify the clinical features they use for prioritising these treatments.

Results:

(1) Matched exercise therapy but not matched manual therapy demonstrated short-term benefits for pain and disability in NSNP over unmatched interventions. (2) Trials with inadequate intervention reporting appeared to overestimate the benefits of matched treatments. (3) Interviews with Italian physiotherapists indicated that clear mechanical symptoms and patient preference suggested manual therapy, while poor movement quality, weakness, or deconditioning suggested exercise therapy. (4) The Delphi study identified shared indicators for both interventions and highlighted distinct features: movement restrictions for manual therapy and impaired muscular and sensorimotor control for exercise.

Conclusions:

Trial evidence does not clearly support the superiority of matched over unmatched interventions for NSNP, and in fact poor reporting of interventions overinflates matched treatment effects. Despite this, experienced physiotherapists identified common and individual clinical indicators for the use of manual and exercise therapy. Future well-designed trials comparing matched and unmatched interventions using validated criteria for matching, clear reporting of intervention fidelity, and multidimensional outcomes are needed. Individual patient data meta-analyses and clinician-involved N-of-1 trials might contribute further useful evidence.