Ottawa panel evidence-based clinical practice guidelines ...€¦ · Ottawa panel evidence-based clinical practice guidelines on therapeutic massage for neck pain Lucie Brosseau,

Journal of Bodywork & Movement Therapies (2012) 16, 300e325

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/jbmt

SYSTEMATIC REVIEW: MASSAGE & NECK

Ottawa panel evidence-based clinical practiceguidelines on therapeutic massage for neck pain

Lucie Brosseau, PhD c,i,*,1,2, George A. Wells, PhD a,b,1,2,Peter Tugwell, MD, MSc a,b,d,1,2, Lynn Casimiro, PhD c,i,1,2,Michael Novikov, MSc.S c,1,2, Laurianne Loew, MSc.S, PhD(c) c,1,2,Danijel Sredic, BSc f,1,2, Sarah Clement, BSc f,1,2,Amelie Gravelle, BSc f,1,2, Kevin Hua, BSc f,1,2,Daniel Kresic, BSc f,1,2, Ana Lakic, BSc f,1,2,Gabrielle Menard, BSc c,1,2, Pascale Cote, MSc.S c,1,2,Ghislain Leblanc, MSc.S c,1,2, Mathieu Sonier, MSc.S c,1,2,Alexandre Cloutier, MSc.S c,1,2, Jessica McEwan, MLIS e,1,2,Stephane Poitras, PhD c,1,3, Andrea Furlan, PhD, MD j,1,3,Anita Gross, MSc p,1,3, Trish Dryden, RMT k,1,3,Ron Muckenheim, RMT l,1,3, Raynald Cote, RMT m,1,3,Veronique Pare, RMT m,1,3, Alexandre Rouhani, RMT n,1,3,Guillaume Leonard, PhD o,1,3, Hillel M Finestone, MD g,1,3,Lucie Laferriere, MHA h,1,3, Simon Dagenais, DC q,1,3,Gino De Angelis, M.Sc c,4, Courtney Cohoon, M.A. c,4

aClinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, CanadabDepartment of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canadac School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, CanadadCentre for Global Health, Institute of Population Health, Ottawa, Ontario, CanadaeUniversity of Ottawa Health Sciences Library, Ottawa, Ontario, Canadaf School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canadag SCO Health Services, Elisabeth Bruyere Health Centre, Ottawa, Ontario, CanadahDirectorate Force Health Protection, Canadian Forces Health Services Group Headquarters, National Defense, Ottawa,Ontario, CanadaiMontfort Hospital Research Institute, Ottawa, Ontario, Canadaj Institute for Work and Health, Toronto, Ontario, CanadakResearch and Corporate Planning Centennial College, Toronto, Ontario, Canadal Everest College, St-Laurent, Ottawa, Ontario, CanadamAcademy of Massage and Orthotherapy, Gatineau, Quebec, Canada

1360-8592/$ - see front matter ª 2011 Published by Elsevier Ltd.doi:10.1016/j.jbmt.2012.04.001

http://dx.doi.org/10.1016/j.jbmt.2012.04.001

www.sciencedirect.com/science/journal/13608592

http://www.elsevier.com/jbmt



Therapeutic massage for neck pain 301

nCentre de Massotherapie et Soins Corporels l’Orchidee, Gatineau, Quebec, Canadao Sherbrooke University, Physiotherapy, Sherbrooke, Quebec, Canadap School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canadaq Palladian Health, West Seneca, New York, USA

Received 3 January 2012; received in revised form 30 March 2012; accepted 5 April 2012

KEYWORDSClinical practiceguidelines;Neck pain;Massage therapy;Randomizedcontrolled trial;Systematic review

1 Ottawa panel members.2 Ottawa methods group.3 External experts.4 Assistant manuscript writer.* Corresponding author. Roger Guind

5800x8015; fax: þ1 613 562 5428.E-mail address: Lucie.Brosseau@uo

Summary Objective: To update evidence-based clinical practice guideline (EBCPG) on theuse of massage compared to a control or other treatments for adults (>18 years) suffering fromsub-acute and chronic neck pain.Methods: A literature search was performed from January 1, 1948 to December 31, 2010 forrelevant articles. The Ottawa Panel created inclusion criteria focusing on high methodologicalquality and grading methods. Recommendations were assigned a grade (A, B, C, Cþ, D, Dþ,D�) based on strength of evidence.Results: A total of 45 recommendations from ten articles were developed including 8 positiverecommendations (6 grade A and 2 grade Cþ) and 23 neutral recommendations (12 grade Cand 11 grade D).Discussion: Therapeutic massage can decrease pain, tenderness, and improve range ofmotion for sub-acute and chronic neck pain.Conclusion: The Ottawa Panel was able to demonstrate that the massage interventions areeffective for relieving immediate post-treatment neck pain symptoms, but data is insuffi-cient for long-term effects.ª 2011 Published by Elsevier Ltd.

Introduction

Neck pain is common and thought to affect between 26 and71% of the population at some point in their lives (Brattberget al., 1989; Cote et al., 1998; Guez et al., 2002; Makelaet al., 1991; Rajala et al., 1995). Despite its high preva-lence, the aetiology of neck pain remains poorly under-stood and it is often difficult for the clinician to makea precise pathological diagnosis (Binder, 2007). Neck paincan be a source of disability and may require substantialhealth care resources and treatments (Bokarius andBokarius, 2010; Cote et al., 1998; Linton et al., 1998;Pleis and Coles, 2002).

Therapeutic massage e also known as soft tissuemanipulation e is a non-pharmacologic and non-invasivetreatment used for neck pain (Hoving et al., 2002).Different therapeutic massage techniques can be used, asdetermined by the therapist (Ernst, 2003). Systematicreviews from the past five years have generally concludedthat therapeutic massage is not effective for neck pain, andthat current randomized controlled trials (RCTs) are of low

on Hall, University of Ottawa, 451

ttawa.ca (L. Brosseau).

methodological quality (Bokarius and Bokarius, 2010; Ezzoet al., 2007; Gross et al., 2007; Haraldsson et al., 2006;Hurwitz et al., 2009). Other systematic reviews have sug-gested that the therapeutic massage may be more effectivewhen it is combined with exercise or other interventions(Bokarius and Bokarius, 2010; Bronfort et al., 2010).Previous guidelines from the Philadelphia Panel and theCanadian Chiropractic Association acknowledged the lackof evidence supporting therapeutic massage for neck pain(The Philadelphia Panel, 2001a, 2001b; CanadianChiropractic Association, 2005). Conclusions from thoseguidelines may now be outdated, and updated evidence isneeded to determine the current effectiveness of thetherapeutic massage for neck pain.

The objective of these updated Ottawa Panel clinicalpractice guidelines (CPG) was to systematically review theevidence from recent RCTs on the effectiveness oftherapeutic massage for neck pain, considering alloutcome measures. These utilize a detailed grading systemand an external expert panel to formulate finalrecommendations.

Smyth Road, Ottawa, Ontario, Canada, K1H 8M5. Tel.: þ1 613 568

mailto:[email protected]

302 L. Brosseau et al.

Methodology

Protocols and registration

The development process of the evidence-based clinicalpractice guidelines (EBCPGs) was similar to that of ThePhiladelphia Panel (2001a) and other EBCPGs created bythe Ottawa Panel (The Ottawa Panel, 2005, 2006, 2008).The methodology of this project followed the OttawaExpert Panel method, used a quantitative approachconsistent with the Cochrane Collaboration (www.cochrane.org) and applied a specific Grading System tothe evidence reviewed to develop recommendations (TheOttawa Panel, 2011).

Ottawa panel expert

The Ottawa Methods Group (OMG), consisting of a panel ofnine methodologists, approached professional associationswhose members treat patients with neck pain. The OMGthen chose nine specialists with clinical experience in:biostatistics, massage therapy, occupational therapy,chiropractic and physiotherapy. The OMG and selectedexperts then created the Ottawa Panel responsible for theEBCPGs in this report. A research team was assembled withexpertise in research methodology, and the development ofEBCPGs and their evaluation. Clinical experts were alsoincluded as Panel members such as massage therapists,physiotherapists, physiatrists and physicians.

Quantitative grading system

Working with the methodology of previous Ottawa Panelpublications (The Ottawa Panel, 2005; The Ottawa Panel,2006; The Ottawa Panel, 2008; The Ottawa Panel, 2011),the Appraisal of Guidelines Research and Evaluation(AGREE) criteria (www.agreecollaboration.org) was used

Table 1 Combined grading recommendations.

Grade Clinical importance

*Grade A (**Stronglyrecommended)

�20%

*Grade B �20%

*Grade Cþ (**Suggested use) �20%

*Grade C (**Neutral) <20%*Grade D (**Neutral) <20% (favors control)*Grade Dþ (**Suggested no use) <20% (favors control)

*Grade D� (**Strongly notrecommended)

�20% (favors control)

RCT, randomized controlled trial; CCT, clinical controlled trial (Taccording to *Ottawa Panel (The Ottawa Panel, 2008) for alphabetcochrane.org) for international nominal grading system. “Reprinted2008 American Physical Therapy Association.”

in the construction of EBCPGs. Recommendations fromthe Ottawa Panel are graded as Level I if there is evidencefrom at least one RCT and level II if evidence is from non-randomized studies. The strength of the evidence sup-porting recommendations is then graded: A, B, Cþ, C, D,Dþ, or D� corresponding to each level of the OttawaPanel grading system, which incorporates clinical impor-tance, statistical significance and study design. Refer toTable 1 for a description of the remaining Ottawa Panelgrades.

Type of participants (P)

To be eligible, studies had to be conducted in participantsover the age of 18 years, suffering from acute (less than 30days), sub-acute (30e90 days) or chronic (longer than 90days) neck disorders categorized as: mechanical neckdisorders (MND) and/or neck disorder with headache (NDH)and/or neck disorders with radicular findings (NDR) SeeTable 2.

Type of interventions (I)

Interventions considered included specific therapeuticmassage techniques (Swedish, fascial or connective tissuerelease techniques, cross fiber friction, and myofascialtrigger point techniques), either alone or combined withmanipulation, mobilization, other manual therapy inter-ventions, or other concurrent interventions (ice, heat,TENS, ultrasound, and combinations thereof).

Comparisons (C)

Studies considered compared massage to a control groupthat received no treatment, self-care, rest, heat and activerange of motion, sham laser acupuncture, sham ultrasoundor sham myofascial release and passive stretching. Head to

Statistical significance Study design

p < 0.05 RCT (single or meta-analysis)

p < 0.05 CCT or observational(single of meta-analysis)

Not significant RCT/CCT or observational(single or meta-analysis)

Not significant Any study designNot significant Any study designNot significant RC/CCT or observational

(single or meta-analysis)p < 0.05(favors control)

Well-designed RCTwith >100 patients (if <100patients becomes a Grade D)

he Ottawa Panel, 2008). Combined Grading Recommendationsical grading system and to the **Cochrane Collaboration (www.with permission Physical Therapy (2011;91:843e61). Copyright

http://www.cochrane.org


http://www.agreecollaboration.org



Table 2 Inclusion and exclusion criteria.

Inclusion Exclusion

Study designsRandomized controlled trialQuasi Randomized controlled trialControlled clinical trialCohort studyCase-control study*English and French articles only

Study designsCase-series/case reportUncontrolled cohort studiesData (graphic) without a mean and SDSample size of less than 5 patientsper treatment groupStudies with more than 20% drop out rate

PopulationOut/InpatientsChronic versus acute conditions?Age groups >18 y oAdults who suffered from acute (less than 30 days),sub-acute (30 dayse90 days) or chronic(longer than 90 days) neck disorders categorized as:- Mechanical neck disorders (MND),- Neck disorder with headache (NDH)- Neck disorders with radicular findings (NDR)

PopulationCancer (and other Oncologic conditions)Cardiac conditionsDermatologic conditionsHealthy normalJuvenile ArthritisMixed population (other than OA and/or RA).Multiple conditionsNeurologic conditionsPaediatric conditions (no juvenile arthritis)Psychiatric conditionsPulmonary conditionsScoliosisDefinite or possible long tract signsNeck pain caused by other pathological entitiesHeadache not of cervical originCo-existing headacheMixed headache.

InterventionEligible control groups:- Placebo,- Untreated, sham,- Active physiotherapy treatments,-Active treatment control,- Inactive treatment uncontrolled.Chiropractic interventions (manipulation,mobilization, manual therapy)

Eligible interventions:- Massage techniques:- Swedish, fascial or connective tissue releasetechniques, cross fiber friction, andmyofascial trigger point techniques.

Multiple interventions (physiotherapy includingice, heat, massage, TENS, ultrasound, combinations)

InterventionBilateral interventions (if systemic effects)- Multidisciplinary, functional restoration programs.- Surgery of shoulder, knee, neck and low back(i.e. not the effect of the surgery, but theeffect of post-surgery physiotherapyintervention is eligible, e.g. CPM, exercises,thermotherapy, etc.)

- Medication (e.g. phonophoresis with meds)- Thermal biofeedback.- Subtle energy manipulations technique.

Outcomes- Absenteeism, sick leave, returnto work (if available)-Balance status-Cardio-pulmonary functions-Coordination status- Costs (economics)-Disease Activity- Disability- Oedema- EMG activity- Erythrocyte Sedimentation Rate (ESR)

Outcomes- Biochemical measures-Patient compliance to medication- Psychosocial measures (depression, homeand community activities, leisure, social roles,sexual functions)

- Serum markers (except ESR)

(continued on next page)


Table 2 (continued )

Inclusion Exclusion

- Flexibility- Functional status, activities ofdaily living *(self-care activities)

- Gait status- Girth, volume- Global perceived effect- Inflammation-Joint imaging- Medication intake (if reported)- Muscle strength, endurance and power- Pain- Patient satisfaction-Postural assessment- Quality of life- Range of motion, flexibility, mobility- Side effects (if reported)- Swelling- Weight loss


head comparisons were excluded except when two types ofdifferent massages were compared. See Table 3.

Outcomes (O)

Outcomes of interests in the primary studies includeddisability [neck disability index (NDI), whiplash disabilityquestionnaire (WDQ), Northwick Park Pain Questionnaire(NPPQ)], muscle stiffness visual analog scale (VAS),muscle strength (VAS), pain [neck pain scale, neck andshoulder pain and disability index, NPPQ, VAS, numericrating scale (NRS)], tenderness (pain pressure threshold(PPT)), self-rated quality of life (QOL), and range ofmotion.

Type of study designs

Only RCTs, controlled clinical trials (CCTs), cohort studies,and caseecontrol studies were selected, as they possesscomparison groups which allows an evaluation of efficacy.Studies were not included if they did not compare theintervention to a control group (e.g. uncontrolled cohorttrials), if the study design was a case-series or a casereport, if the data were reported without a mean anda standard deviation, if there were more than 20% ofwithdrawals by the participants, or a sample size ofless than 5 subjects per group. Only English and Frenchstudies were selected to avoid having them translated. SeeTable 4

Information sources

The library scientist (JME) performed a systematic search ofEnglish and French literature using a search strategyproposed by the Cochrane Collaboration. The main focus ofthe search was to identify the methodology (population andinterventions) and study the design determined by primarystudies, rather than specifying outcomes. Articles dating

from January 1, 1948 to December 31 were extracted fromthe following databases: Embase, Medline, HealthStar,Pubmed, Cinahl, Pedro psycinfo Rehabdata, SUMsearch,Dissertatino, Abstracts International databases, andCochrane Library.

Data collection process

Study selectionFollowing the systematic search of the literature, tworeviewers evaluated the studies and determined if theywere included or excluded based on the criteria outlined inTable 2. A reason was provided for all the excluded trials(see Table 5). The principal assessor (LB) was consultedwhenever uncertainty was present. This method was alsoendorsed by the Ottawa Panel experts (The Ottawa Panel,2011).

Data extraction and methodological qualityThe reviewers independently extracted the followinginformation using standardized data extraction forms:characteristics of participants, treatment, study design,allocation concealment, comparative results, and period ofdata collection.

The Jadad scale (Jadad et al., 1996) was used to assessthe methodological quality of each selected study. Eachstudy was awarded a maximum of five points: 2 points forthe randomization method, 2 points for double blinding,and 1 point for a description of dropouts.

A study assessed with a Jadad scale score of three ormore points (Jadad et al., 1996) was typically considered ashaving high methodological quality. Points for doubleblindness were rarely given due to the nature and difficul-ties of blinding therapists, subjects, and assessors (whowere subject for self-report scales) during physical therapytreatments. Consequently, more emphasis was placed onthe two other categories of the Jadad scale (Jadad et al.,1996) e randomization and withdrawals.

Table 3 Results of the relative difference of high methodological quality studies.

Study Treatmentgroup

Outcome No. ofpatients

Baselinemean

End ofstudymean

Absolutebenefit

Relativedifferencein Changefrom Baseline

Weightedmean difference(WMD) 95%Confidenceinterval (CI)

Cen et al.(2003)

TraditionalChineseTherapeuticMassage

Northwick ParkNeck PainquestionnaireLower betterEnd tx 6 weeks

9 32.46 13.24 �23.35 �73% WMD: �22.40CI Low: �33.13CI High: �11.67

Control(no treatment)

11 31.51 35.64

Cen et al.(2003)


ROM in neckextension, averageHigher betterEnd tx 6 weeks

9 40.38 49.38 8.70 20% WMD: �2.58CI Low: �14.61CI High: 9.45

Control(no treatment)

11 46.5 46.8

Cen et al.(2003)


ROM in lateralneck flexionHigher betterEnd tx 6 weeks

9 38.75 45.19 3.84 10% WMD: �4.24CI Low: �12.15CI High: 3.67

Control (notreatment)

11 38.35 40.95

Cen et al.(2003)


ROM in flexionHigher betterEnd tx 6 weeks

9 40.00 50 12.20 28% WMD: �5.90CI Low: �13.56CI High: 1.76

Control(notreatment)

11 46.3 44.1

Fryer andHodgson(2005)

Manual pressurerelease

Pressure painthresholdHigher betterEnd of treatment,one treatment

18 7.59 9.64 2.13 30% WDM: 3.03CI Low: 1.20CI High: 4.86

Control (Shammyofascialrelease)

17 6.69 6.61

Irnich et al.(2001)

Massage Pain Relatedto Motion(lower better)End tx 3 weeks

60 54.71 42.01 6.50 12% WMD: 4.06CI Low: �5.94CI High: 14.06

Control(Sham Laseracupuncturetreatment)

61 57.15 37.95

Irnich et al.(2001)

Massage Range of motion(higher better)End tx 3 weeks

60 287.8 294 �6.70 �2% WMD: �5.40CI Low: �14.38CI High: 3.58


61 286.5 299.4

Irnich et al.(2001)

Massage Pain Related toDirection(Lower better)End tx 3 weeks

60 34.88 29.28 4.60 13% WMD: 3.66CI Low: �2.38CI High: 9.70



Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit




61 35.82 25.62

Irnich et al.(2001)

Massage Pressure painthreshold(Higher better)End tx 3 weeks

60 1.07 1.11 0.07 7% WMD: 0.09CI Low: �0.09CI High: 0.27


61 1.05 1.02

Irnich et al.(2001)

Massage Range of motionHigher betterFollow up 1 week

60 287.8 292.9 �3.60 �1% WMD: �2.31CI Low: �12.31CI High: 7.71


61 286.5 295.2

Irnich et al.(2001)

Massage Pain related todirectionLower betterFollow up 1 week

60 34.88 31.78 8.30 23% WMD: 7.36CI Low: 1.32CI High: 13.40


61 35.82 24.42

Irnich et al.(2001)

Massage Pressure painthresholdHigher betterFollow up 1 week

60 1.07 0.98 �0.02 �2% WMD: 0.00CI Low: �0.20CI High: 0.20


61 1.05 0.98

Irnich et al.(2001)

Massage Quality of life:Role PhysicalHigher betterFollow up 1 week

60 41.82 54.19 12.37 31% WMD: 15.15CI Low: 4.62CI High: 25.68


61 39.04 39.04

Irnich et al.(2001)

Massage Quality of life:Pain IndexHigher betterFollow up 1 week

60 36.7 46.85 1.30 3% WMD: 1.21CI Low: �4.88CI High: 7.30


61 39.21 48.06

Irnich et al.(2001)

Massage Pain Relatedto Motion(lower better)Follow up3 months

60 54.71 40.31 3.00 5% WMD: 0.56CI Low: �9.88CI High: 11.00


Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit




61 57.15 39.75

Irnich et al.(2001)

Massage Range of motion(higher better)Follow up3 months

60 287.8 293.3 2.00 1% WMD: 3.30CI Low: �8.72CI High: 15.32


61 286.5 290

Irnich et al.(2001)

Massage Pain Related toDirection(Lower better)Follow up3 months

60 34.88 26.78 3.10 9% WMD: 2.16CI Low: �5.18CI High: 9.50


61 35.82 24.62

Irnich et al.(2001)

Massage Pressure painthreshold(Higher better)Follow up3 months

60 1.07 1.12 0.02 2% WMD: 0.04CI Low: �0.18CI High: 0.268


61 1.05 1.08

Irnich et al.(2001)

Massage Quality of life:Role Physical(Higher better)Follow up3 months

60 41.82 46.77 �0.88 �2% WMD: �1.90CI Low: �14.71CI High: 10.91


61 39.04 44.87

Irnich et al.(2001)

Massage Quality of life:Pain Index(Higher better)Follow up3 months

60 36.7 51.34 �1.03 �3% WMD: �3.54CI Low: �11.31CI High: 4.23


61 39.21 54.88

Shermanet al. (2009)

Massage SymptombothersomenessLower betterFU 10 weeks

32 4.8 3.3 �1.1 �23% WMD: �1.20CI Low: �2.54CI High: 0.14



Table 3 (continued)



Baselinemean

End ofstudymean

Absolutebenefit



Control 32 4.9 4.5Shermanet al. (2009)

Massage Neck DisabilityLower betterFU 10 weeks

32 9.3 9.7 �1.3 �13% WMD: �2.30CI Low: �5.07CI High: 0.47

Control 32 10.3 12Shermanet al. (2009)

Massage SymptombothersomenessLower betterEnd of treatment26 weeks

32 4.8 4.0 0 0% WMD: �0.1CI Low: �1.43CI High: 1.23

Control 32 4.9 4.1Shermanet al. (2009)

Massage Neck disabilityLower betterEnd of treatment26 weeks

32 9.3 9.5 �0.9 �9% WMD: �1.90CI Low: �4.68CI High: 0.88

Control 32 10.3 11.4


Data analysis

Methods from the Cochrane Collaboration (www.cochrane.org) and The Philadelphia Panel (2001b) were used toperform statistical analysis. Weighed mean differences(WMDs), absolute benefit, and relative differences (RD)were calculated using continuous data. An improvement of20% relative to a control group was determined to indicateclinical improvement, based on the methods from ThePhiladelphia Panel (2001a) and recommendations from therheumatology and biostatistician experts of the OttawaPanel. This threshold was consistent with recommendationsfrom the American College of Rheumatology which statedthat 20% improvement is a clinically important differencefor patients (Felson et al., 1995) and it is within the meanminimum clinically important difference (MCID) offrequently used instruments to asses neck pain patients[NDI (MCID: 19%), NRS (MCID: 19%) (Cleland et al., 2008)NPPQ (MCID: 25%) (Sim et al., 2006), WDQ (MDC: 11%) (Williset al., 2004)]. For dichotomous variables, the clinicalimprovement was calculated as the difference between thepercent improved among the experimental and controlgroups (relative risks). For more details about the statisticalanalysis see the previous publications of The Ottawa Panel(2005, 2006, 2008, 2011).

Results

Literature search

The library scientist found 432 articles on the treatmentof neck pain with different types of massage in

December 2010, of which 61 articles were found to bepossibly relevant.

Of the 61 potential articles, 56 were excluded (see Table5). Some of the studies were excluded because they weresystematic reviews (Bokarius and Bokarius, 2010; Grahamet al., 2011; Gross et al., 2002, 2010; Haraldsson et al.,2006; Rickards, 2006; Verhagen et al., 2007; Vernonet al., 2007; Wang et al., 2009), they had a low methodo-logical quality score (Donoyama et al., 2010; Fernandez-de-las-Penas et al., 2006; Gemmell and Allen, 2008; Hou et al.,2002; Kostopoulos et al., 2008), they had a combination ofinterventions (Bronfort et al., 2001; Dziedzic et al., 2005;Ekici et al., 2009; Hoving et al., 2002; Skillgate et al.,2007), the massage was not isolated (Bronfort et al.,2001; Haas et al., 2010; Hoving et al., 2006; 2002; Koeset al., 1992; Skillgate et al., 2007; Zaproudina et al.,2007), the massage was performed on more than onebody part (Cambron et al., 2006), patients were healthy(Cambron et al., 2006; Fernandez-Perez et al., 2008;Henley et al., 2008), there was no control group(Cambron et al., 2007; Hakkinen et al., 2007; Karels et al.,2006; Moraska and Chandler, 2008; Yozbatiran et al., 2006),the drop out rate was higher than 20% (Evans et al., 2002),the results were ineligible because author did not sendadditional data when requested (Gam et al., 1998; Jordanet al., 1998; Pesco et al., 2005), there was no massage(Gonzalez-Iglesias et al., 2009; Hanten et al., 1997; Jameset al., 2009; Leaver et al., 2007; Perrin Rochester, 2009),the population was mixed (Hamre et al., 2007; Walachet al., 2003), it was a head to head study withoutcomparing two types of massage (Dziedzic et al., 2005;Gonzalez-Iglesias et al., 2009; Haas et al., 2010; Hakkinenet al., 2007; Hanten et al., 2000; Madson et al., 2010;



Table 4 Results of the relative difference of high methodological quality studies.

Study Treatment group Outcome Observedevents

Number ofpatients

Risk(% Occurace)

Riskdifference

Blikstad andGemmell (2008)

Activator triggerpoint therapy

Neck painHigher betterEnd tx 1 treatment

8 15 53.33 40%

Control (Shamultrasound)

2 15 13.33



Right lateralcervical flexionHigher betterEnd tx 1 treatment

6 15 40 0%


6 15 40



Left lateralcervical flexionHigher betterEnd tx 1 treatment

10 15 66.67 33.33%

Control(Sham ultrasound)

5 15 33.33



Pain pressure thresholdHigher betterEnd tx 1 treatment

7 15 46.67 26.67%

Control(Sham ultrasound)

3 15 20


Myofascialband therapy

Neck painHigher betterEnd tx 1 treatment

2 15 13.33 0%


2 15 13.33



Right lateralcervical flexionHigher betterEnd tx 1 treatment

5 15 33.33 �6.67%


6 15 40



Left lateralcervical flexionHigher betterEnd tx 1 treatment

6 15 40 6.67%


5 15 33.33



Pain pressure thresholdHigher betterEnd tx 1 treatment

5 15 33.33 13.33%


3 15 20


Ylinen et al., 2007; Zaproudina et al., 2007), the study wasnot in French or English (Jiang et al., 2009; Kang et al.,2008; Medvedeva, 2008; Olszewski et al., 2007; Wanget al., 2009), the intervention was not eligible (Karlberget al., 1996), they used psychosocial outcome measures(Moraska and Chandler, 2009), the study was a casereport study (Piovesan et al., 2007), the population wasasymptomatic (Sefton et al., 2010), and the populationhad a tension-type headache (Moraska and Chandler,2008; Toro-Velasco et al., 2009; von Stulpnagel et al.,2009).

Methodological quality

A total of 10 RCTs were deemed eligible (Blikstad andGemmell, 2008; Cen et al., 2003; Donoyama et al., 2010;Fernandez-de-las-Penas et al., 2006; Fryer and Hodgson,2005; Gemmell and Allen, 2008; Hou et al., 2002; Irnichet al., 2001; Kostopoulos et al., 2008; Sherman et al.,2009). In the Grading Recommendations (see Appendix A)and in the Table of included studies (see Appendix B), themethodological quality level is stated for each study andeach recommendation. Five RCTs had low methodological

Table 5 Table of excluded studies.

Studies Reason for exclusion

Bokarius and Bokarius (2010) Systematic reviewBronfort et al. (2001) Combination of intervention. Massage can’t be isolated.Cambron et al. (2006) Most of the patients have received a massage on more

than one body part. Patients are healthyCambron et al. (2007) No control group, only massageDziedzic et al. (2005) Head to head þ combined therapyEkici et al. (2009) Combination of interventions. In the CMT group, there is

not really a neck massage (massage of the region aroundthe neck). Neck pain due to fibromyalgia and not of a rheumatic cause

Evans et al. (2002) More than 20% drop out rateFernandez-Perez et al. (2008) Healthy patientsGam et al. (1998) Ineligible results e author did not send additional dataGonzalez-Iglesias et al. (2009) Head to head þ not massage involvedGraham et al. (2011) Systematic reviewGross et al. (2002) Systematic reviewGross et al. (2010) Systematic reviewHaas et al. (2010) Head to head þ do not isolate massageHakkinen et al. (2007) Head to head þ no control groupHamre et al. (2007) Mixed population (data grouped together) e not just neck injuriesHanten et al. (1997) No massageHanten et al. (2000) Head to headHaraldsson et al. (2006) Systematic reviewHenley et al. (2008) Healthy subjectsHoving et al. (2006) Massage not isolatedHoving et al. (2002) Combined therapy þ massage not isolated þ not specific effectJames et al. (2009) Mot massage but corporal alignmentJiang et al. (2009) Not French or EnglishJordan et al. (1998) No mean and SDKang et al. (2008) Not French or EnglishKarels et al. (2006) No comparison groupKarlberg et al. (1996) Physiotherapy not described: intervention not eligibleKoes et al. (1992) The treatment (massage) is not isolatedLeaver et al. (2007) No massage therapy mentioned (manipulation VS mobilisation)Madson et al. (2010) Head to headMedvedeva (2008) In RussianMedvedeva et al. (2008) In RussianMoraska and Chandler (2008) Population with tension-type headache (mixed source headache)

and not placebo controlledMoraska and Chandler (2009) Psychosocial measures (depression, stress, anxiety)Olszewski et al. (2007) In PolishPerrin Rochester (2009) Ineligible intervention e Chiropractic carePesco et al. (2005) Missing statistical dataPiovesan et al. (2007) Case report studyRickards (2006) Systematic reviewSefton et al. (2010) Asymptomatic populationSkillgate et al. (2007) Combination of intervention. Massage can’t be isolated.Toro-Velasco et al. (2009) Tension type headache populationVerhagen et al. (2007) Systematic reviewVernon et al. (2007) Systematic reviewvon Stulpnagel et al. (2009) Tension-type headache populationWalach et al. (2003) Mixed population (data grouped together) e not just neck injuriesWang et al. (2009) Chinese systematic reviewYlinen et al. (2007) Head to headYozbatiran et al. (2006) No control group, population with cervical disc herniaZaproudina et al. (2007) Massage not isolated þ head to head


Figure 2 Activator trigger point therapy versus control(Sham ultrasound): Pain pressure threshold.


quality (<3) (Donoyama et al., 2010; Fernandez-de-las-Penas et al., 2006; Gemmell and Allen, 2008; Hou et al.,2002; Kostopoulos et al., 2008); the latter due to doubleblinding not being possible with a physical intervention suchas therapeutic massage. Only the five RCTs with highmethodological quality (�3) according to the Jadad scale(Jadad et al., 1996) were selected (Blikstad and Gemmell,2008; Cen et al., 2003; Fryer and Hodgson, 2005; Irnichet al., 2001; Sherman et al., 2009).

Effectiveness of massage for neck pain

The following section focuses on the RCTs which demon-strated high methodological quality (Blikstad and Gemmell,2008; Cen et al., 2003; Fryer and Hodgson, 2005; Irnichet al., 2001; Sherman et al., 2009) (�3) according to theJadad scale (Jadad et al., 1996).

With regards to the Activator trigger point therapy (AAIinstrument) versus control (Sham Ultrasound), an RCT byBlikstad and Gemmell (2008) (n Z 30) (see Appendix A)demonstrated clinically important benefits for theimprovement in pain (NRS) at end of treatment (1 treatment)(relative difference Z 40%) (see Fig. 1), for left lateralcervical flexion (ROM) at end of treatment (1 treatment)(relative difference Z 33%) (see Fig. 3), and for tenderness(PPT) at end of treatment (1 treatment) (relativedifference Z 27%) (see Fig. 2). There was no benefit foundfor the improvement in the right lateral cervical flexion(ROM) at the end of treatment (1 treatment) (see Fig. 3).

For the evaluation of myofascial band therapy versuscontrol (Sham Ultrasound), an RCT by Blikstad and Gemmell(2008) (n Z 30) (see Appendix A) showed no benefit for theimprovement in pain (NRS) at end of treatment (1 treatment)(see Fig. 4), for left lateral cervical flexion (ROM) at end of

Figure 1 Activator trigger point therapy versus control(Sham ultrasound): Neck pain.

treatment (1 treatment) (see Fig. 6), and for tenderness(PPT) at endof treatment (1 treatment) (see Fig. 5). The rightlateral cervical flexion (ROM) at end of treatment (1 treat-ment) (see Fig. 6) showed no benefit but favored the control.

Figure 3 Activator trigger point therapy versus control(Sham ultrasound): Cervical flexion.

Figure 4 Myofascial band therapy versus control (Shamultrasound): Neck pain.

Figure 6 Myofascial band therapy versus control (Shamultrasound): Cervical flexion.


Concerning Traditional Chinese Therapeutic Massageversus control (no treatment), an RCT by Cen et al. (2003)(n Z 20) (see Appendix A) demonstrated clinically impor-tant benefits for the improvement in pain (NPPQ) at end oftreatment (6 weeks) (relative differenceZ 73%) (see Fig. 8).Clinical significance without statistical significance wasfound for the improvement in neck flexion (ROM) at endof treatment (18 treatments over 6 weeks) (relative

Figure 5 Myofascial band therapy versus control (Shamultrasound): Pain pressure threshold.

differenceZ 20%) (see Fig. 7), and for neck extension (ROM)at end of treatment (6 weeks) (relative difference Z 28%)(see Fig. 7). There was no benefit found for the improvementin neck lateral flexion (range of motion) at end of treatment(6 weeks) (see Fig. 7).

Figure 7 Traditional Chinese therapeutic massage versuscontrol (no treatment): Range of motion.

Figure 8 Traditional Chinese therapeutic massage versuscontrol (no treatment): Neck pain.

Figure 9 Manual pressure release versus control (shammyofascial release): Pressure pain threshold.

Figure 10 Massage versus placebo (sham laser acupuncture):Pain related to motion.


For the intervention of manual pressure release versuscontrol (Sham myofascial release), an RCT by Fryer andHodgson (2005) (n Z 35) (see Appendix A) showed clini-cally important benefits for the improvement in PPT (digitalAlgometer) at the end of treatment (1 treatment) (relativedifference Z 30%) (see Fig. 9).

A study by Irnich et al. (2001) (nZ 121) (see Appendix A),which looked at the effects of conventional western massageversus placebo (Sham laser acupuncture), presented clini-cally important benefits for the improvement in QOL: rolephysical (SF-36) at follow up (1 week) (relativedifference Z 31%) (see Fig. 14). There was no benefit foundfor the improvement in PPT (pressure Algometer) at end oftreatment (3 weeks) and follow up (3 months) (see Fig. 13),QOL: pain index (SF-36) at follow up (1 week) (see Fig. 14),and active ROM (3D ultrasound real time motion analyser) atfollow up (3 months) (see Fig. 11). There was no benefitdemonstrated, however the control group was favored forimprovement in pain related to motion (VAS) at end oftreatment (3 weeks) (see Fig. 10), active ROM (3D ultrasoundreal timemotion analyser) at end of treatment (3weeks) (seeFig. 11), pain related to direction (VAS) at endof treatment (3weeks) (see Fig. 12), active ROM (3D ultrasound real timemotion analyser) at follow up (1 week) (see Fig. 11), painrelated to direction (VAS) at follow up (1 week) (see Fig. 12),PPT (pressure Algometer) at follow up (1 week) (see Fig. 13),pain related to motion (VAS) at follow up (3 months) (seeFig. 10), pain related to direction (VAS) at follow up (3months) (see Fig. 12), QOL: role physical (SF-36) at follow up(3months) (see Fig. 14), andQOL: pain index (SF-36) at followup (3 months) (see Fig. 14).

In regards to the Swedish and clinical massage tech-niques versus control (self-care), an RCT by Sherman et al.(2009) (n Z 64) (see Appendix A) demonstrated clinicallyimportant benefits without statistical significance for theimprovement in symptom bothersomeness at end of

Figure 11 Massage versus placebo (sham laser acupuncture):Range of motion.

Figure 12 Massage versus placebo (sham laser acupuncture):Pain related to direction.

Figure 13 Massage versus placebo (sham laser acupuncture):Pressure pain threshold.

Figure 14 Massage versus placebo (sham laser acupuncture):Quality of life.


Figure 15 Massage versus control (self-care): Symptombothersomeness.

Figure 16 Massage versus control (self-care): Disability.


treatment (up to 10 treatments over 10 weeks) (relativedifferenceZ 23%) (see Fig. 15). There was no benefit foundfor the improvement in disability (NDI) at end of treatment(up to 10 treatments over 10 weeks) and follow up (16weeks) (see Fig. 16), and symptoms bothersomeness atfollow up (16 weeks) (see Fig. 15).

Discussion

When comparing various massage technique interventionswith control interventions, the Ottawa Panel was able todemonstrate that different types of therapeutic massage asstandalone interventions may provide effective immediatepost-treatment relieve for neck pain. However, due to thelimitations of the evidence reviewed, further research isrequired. From a total of 31 recommendations, 6 were gradeA, 2 were grade Cþ, 12 had grade C, and 11 had grade D.

Previous reviews and guidelines about neck pain did findthat therapeutic massage was an effective treatment due toinsufficient evidence in the RCTs they considered (Phila-delphia The Philadelphia Panel, 2001a; D’Sylva et al., 2010;Hurwitz et al., 2009; Haraldsson et al., 2006; Gross et al.,2007; Ezzo et al., 2007). That evidence generally includedoutdated RCTs and only a small number of high quality RCTsin which it was impossible to isolate the effects of thera-peutic massage (Bronfort et al., 2010; The PhiladelphiaPanel, 2001a). Bronfort et al. (2010) is the only systematicreview in which therapeutic massage was considered aneffective treatment for chronic neck pain (i.e. neck pain thatlasts for more than 3 months). This review reveals that

therapeutic massage could potentially be an effectivetreatment for neck pain, but further research is required toreinforce the efficacy of neck massage. The results are lessconclusive for other outcomes such as ROM and tenderness.As such, the Ottawa Panel guidelines are not fully in linewithBronfort’s result, because selection criteria were differentfor the evidence considered.

Physiological effects

The physiological effects that make therapeutic massageand myofascial release effective are still not fully under-stood. The interaction is very complex due to the simulta-neous physiological and psychological aspects involved. TheGate theory is commonly used to explain the effect ofmassage on pain (Melzack and Wall, 1965). This theoryproposed that massage and other manual therapiesgenerate a pressure stimulus via touch, which reaches thespinal cord faster by traveling through the myelinated andlarge nerve fibers (Ab fibers) than the pain stimulus trav-eling through less insulated, and therefore slower, nervefibers (Ad and C fibers). By reaching the spinal cord faster,the pressure stimulus closes the gate and inhibits noci-ceptive signals before they reach the supra-spinal struc-tures implicated in pain processing (Field et al., 2007).

Manual therapy has also been demonstrated to causechanges in blood levels for a few hormones, includingendorphins (Bialosky et al., 2009). Ischemic compressiontherapy has a similar theory to explain the pain reductiondue to myofascial release. It is hypothesized that a strongperipheral stimulus, such as high pressure massage, wouldmodify the trigger point circuit (Hong, 2002) reducing its


sensitivity and blocking the pain stimulus before they canreach higher centers (cerebral cortex) (Hong, 2004). Highpressure massage can release tension in the myofascialtrigger point (MTrP), which can improve the local circula-tion and subsequently facilitate the healing of the under-lying etiological lesion (Hong, 2006). According to Hong,healing the underlying etiological lesion should always bethe main focus of the treatment and is the main method toprevent the reoccurrence of the MTrP and pain (Hong, 2004,2006). Recently, Minasny (2009) has published a theory thatintegrates neurobiologic, ideomotor action and conscious-ness theories to explain the mechanical unwinding (indirectmyofascial release used by massage therapists and osteo-pathic practitioners) (AACOM, 2009). According to hisproposed theoretical framework, touching, stretching andmanual therapy will induce relaxation in the para-sympathetic nervous system and activate the centralnervous system, therefore reducing muscle tone. Thisinduces a sensation of reduced pain and relaxation, therebyintroducing the ideomotor action (Minasny, 2009). Furtherresearch is needed to have a better understanding of thephysiological and psychological mechanisms of massage.

Finally, it is likely that the analgesia induced by painfulmassage techniques such as trigger points be attributed tothe activation of the diffuse noxious inhibitory control. Theneurophysiological basis of this phenomenon, also known ascounter-irritation analgesia (Willer et al., 1999) has beendescribed in 1979 by Le Bars et al. (1979). Briefly, theapplication of a local nociceptive stimulus activates Ad andC fibers. Once in the central nervous system, the nocicep-tive signal travel up the spinal cord and make synapses withbrainstem structures implicated in the modulation of pain.The activation of these structures then produces analgesiavia the recruitment of descending inhibition systems pro-jecting back to the spinal cord via the dorsolateral funic-ulus (Villanueva et al., 1986).

Limitations

One limitation of the included RCTs is the lack of stan-dardization in the massage interventions reviewed. Massagetherapies commonly combines different techniques, andevery therapist may use them in a different manner withdifferent dosages and parameters. Another limitation in theevidence reviewed was the control groups, as some studies(Fernandez-de-las-Penas et al., 2006; Gemmell and Allen,2008; Hong, 2002) compared massage to another treat-ment, rather than to an inert treatment. However, if bothtreatments were effective, the lack of a control wouldmean that massage wouldn’t show a significant improve-ment. Given the fact that the purpose of the study was todemonstrate the efficacy of therapeutic massage, this wasa major limitation. The lack of follow up assessments wasanother major limitation. Out of the 10 included RCTs,eight did not have any follow up data, and six only assessedimmediate outcomes (Blikstad and Gemmell, 2008;Donoyama et al., 2010; Fernandez-de-las-Penas et al.,2006; Fryer and Hodgson, 2005; Gemmell and Allen, 2008;Hong, 2002). Also, the challenge with therapeuticmassage is that it involves therapeutic touching, which mayalso have non-specific effects on pain and anxiety (Smith

and Broida, 2007). In addition, it is difficult to performdouble-blind massage studies because of the physicalnature of the intervention for both the subject and thetherapist (Menard, 2002).

Clinical implication

Massage and myofascial release therapies are able tosomewhat attenuate neck pain, but seem to be used moreas a complementary treatment due to the immediate post-treatment relief of symptoms. Although the pathologicalprocesses responsible for neck pain can often be difficult toidentify, identifying and addressing these processes shouldremain the primary focus of the health care professional(Hong, 2006). Nevertheless, therapeutic massage can bea valuable tool to temporarily minimize the pain associatedwith acute neck pain episodes.

Conclusion

The Ottawa Panel CPGs recommends therapeutic massageas an effective intervention that may provide an immediatepost-treatment reduction in symptoms related to sub-acuteand chronic mechanical neck disorders. However, the long-term effects of therapeutic massage are still unclear due tocontradicting data, lack of follow up data and a limitednumber of high quality studies. Future research is neededto examine the role of therapeutic massage as part ofa comprehensive, multidisciplinary approach and it’s long-term effects.

Acknowledgment

The authors are indebted to Lucie Poulin MA3 for her valuablecomments. This systematic review was financially supportedby Holistic Health Research Funds, The University of OttawaResearch University Chair Award and the Ministry of HumanResources, Summer Students Program (Canada).

Appendix AGrading recommendations

Activator trigger point therapy (AAI instrument) (Activatortrigger point therapy involved placing the activatorperpendicular over the trigger point using a force setting of3 (170N).) versus Control (Sham Ultrasound) Level 1 (1 RCT,N Z 30, high quality) (Blikstad and Gemmell, 2008). GradeA for pain (Numerical Rating Scale), left lateral cervicalflexion (ROM) and pain pressure threshold (Pain PressureAlgometer) at end of treatment (1 treatment) (clinicallyimportant benefit demonstrated). Grade C for the rightlateral cervical flexion (ROM) at end of treatment (1treatment) (no benefit demonstrated). Patients with sub-acute unilateral or bilateral neck pain that could expandto shoulder and upper arm (4e12 weeks).

Myofascial band therapy (firm thumb pressure in a slowstroking motion) versus Control (Sham Ultrasound) Level 1(1 RCT, N Z 30, high quality) (Blikstad and Gemmell, 2008).Grade C for pain (Numerical Rating Scale), left lateralcervical flexion (ROM) and pain pressure threshold (Pain


Pressure Algometer) at end of treatment (1 treatment) (nobenefit demonstrated). Grade D for the right lateralcervical flexion (ROM) at end of treatment (1 treatment)(no benefit demonstrated but favoring control). Patientswith sub-acute unilateral or bilateral neck pain that couldexpand to shoulder and upper arm (4e12 weeks).

Traditional Chinese Therapeutic Massage (one fingermeditation massage and rolling massage) versus Control (notreatment), Level 1 (1 RCT, N Z 20, high quality) (Cenet al., 2003). Grade A for pain (Northwick Park neck painquestionnaire) at end of treatment (6 weeks) (clinicallyimportant benefit demonstrated). Grade Cþ for neckflexion and extension (range of motion) at end of treatment(6 weeks) (clinically important benefit demonstratedwithout statistical significance). Grade C for neck lateralflexion (range of motion) at end of treatment (6 weeks) (nobenefit demonstrated). Patients with chronic mechanicalneck pain and neck tightness (�1 year).

Anma therapy (mainly kneading and lesser amounts ofstroking and pressing) versus Control (rest intervention)(lying down for 40 min), Level 1 (1 RCT, NZ 15, low quality)(Donoyama et al., 2010). Grade A for muscle stiffness (VAS)at end of treatment (1 treatment) (clinically importantbenefit demonstrated). Patients with chronic neck andshoulder stiffness.

Ischemic compression (gradually increasing pressureapplied to the myofascial trigger point and maintained untilthe discomfort and/or pain eased by around 50% perceivedby the own patient, at witch time pressure was increaseduntil discomfort appeared again) versus Transverse frictionmassage (applied with the forefinger and reinforced withthe middle finger at the pressure pain threshold level ofeach patient.) Level 1 (1 RCT, N Z 40, low quality)(Fernandez-de-las-Penas et al., 2006). Grade C for pain(VAS) and pressure pain threshold (pressure thresholdmeter) at end of treatment (1 treatment) (no benefitdemonstrated). Patients with acute to chronic mechanicalneck pain (�2 weeks).

Manual pressure release (slowly applied pressure to themyofascial trigger point until the subject reporteda moderate but easily tolerable pain value of 7/10) versusControl (sham myofascial release) (Extremely light pressurewas applied to the myofascial trigger point). Level 1 (1 RCT,N Z 35, high quality) (Fryer and Hodgson, 2005). Grade Afor pain pressure threshold (digital Algometer) at end oftreatment (1 treatment) (clinically important benefitdemonstrated). Patients with myofacial trigger points intrapezius muscle.

Ischemic compression (Continuous, perpendicular deepthumb pressure to trigger point for 30e60 s) versus Acti-vator group 10 thrusts with a force of 170 N were deliveredon the trigger point (1 thrust/second). Level 1 (1 RCT,N Z 52, low quality) (Gemmell and Allen, 2008). Grade Afor pressure pain threshold (pressure pain Algometer) atend of treatment (1 treatment) (clinically importantbenefit demonstrated). Grade C for global impression ofchange (patient global impression of change) and pain(numerical rating scale) at end of treatment (1 treatment)(no benefit demonstrated). Patients with acute to sub-acute upper trapezius trigger point (�12 weeks).

Ischemic compression therapy (pressure applied on themyofascial trigger point at different durations (30, 60 or 90 s)and at different pain levels (pain threshold and pain toler-ance), heat (hot pack placed for 20 min) and active range ofmotion (active range of motion for the cervical spine) versusHot pack therapy (hot pack placed for 20 min) and activerange of motion (active range of motion for the cervicalspine), Level 1 (1 RCT, N Z 34, low quality) (Hong (2002)).Grade C for pain intensity (VAS), pain tolerance (pressuretolerance Algometer) and pain threshold (pain thresholdmeter) at end of treatment (1 treatment) (no benefitdemonstrated).). Patients with upper trapezius triggerpoints.

Massage (Conventional Western massage: effleurage,petrissage, friction, tapotement and vibration) vs. Placebo(Sham laser acupuncture) (inactivated laser on acupuncturepoints), Level 1 (1 RCT, N Z 121, high quality) (Irnich et al.(2001)). Grade A for role physical (SF-36) at follow up (1week) (clinically important benefit demonstrated). Grade Cfor pressure pain threshold (pressure Algometer) at end oftreatment (3 weeks) and follow up (3 months), pain index(SF-36) at follow up (1 week) and active range of motion (3Dultrasound real time motion analyser) at follow up (3months) (no benefit demonstrated). Grade D for painrelated to motion (VAS), active range of motion (3D ultra-sound real time motion analyser) and pain related todirection (VAS) at end of treatment (3 weeks), active rangeof motion (3D ultrasound real time motion analyser), painrelated to direction (VAS), pressure pain threshold (pres-sure Algometer) at follow up (1 week), pain related tomotion (VAS), pain related to direction (VAS), role physical(SF-36), and pain index (SF-36) at follow up (3 months) (nobenefit demonstrated but favoring control). Patients withsub-acute to chronic unspecific neck pain (�1 month).

Ischemic compression and passive stretching (Ischemictrigger points compression therapeutic manipulative tech-nique, three applications of 60 s each, followed by a 30-srest period) vs. Passive stretching (muscle placed undertension at the end of the range of motion for 45 s, 3 timeswith 30 s rest intervals), Level 1 (1 RCT, N Z 60, lowquality) (Kostopoulos et al. (2008)). Grade A for sponta-neous electrical activity (EMG), pain intensity (VAS) andpain pressure threshold (pressure Algometer) at end oftreatment (2 weeks) (clinically important benefit demon-strated). Grade C for pressure tolerance (pressure Algo-meter) at end of treatment (2 weeks) (no benefitdemonstrated but favoring control). Patients with trapeziustrigger point.

Massage (variety of Swedish and clinical massage tech-niques) vs. Control (self-care) (read; “What to do for a painin the neck” book), Level 1 (1 RCT, N Z 64, high quality)(Sherman et al. (2009). Grade Cþ for symptom bohersom-ness (11 point numerical rating scale) at end of treatment(10 weeks) (clinically important benefit demonstratedwithout statistical significance). Grade C for disability(neck disability index) at end of treatment (10 weeks) andfollow up (16 weeks) and symptoms bothersomness (11point numeriacal rating scale) at follow up (16 weeks) (nobenefit demonstrated). Patients with chronic unspecificneck pain (�12 weeks).

Appendix B. Table of included studies

Author/year Sample

size

Population details Symptom

duration

Age (mean,

SD for control)

Treatment Comparison

group

Concurrent

therapy

Session/week

no. of weeks

Follow

up

Quality R,

B, W

Blikstad and

Gemmell(2008)

RCT

Total: 45Gr1: 15

Gr2: 15Gr3: 15

Inclusion criteria:(1) Between ages

of 18 and 55(2) Unilateral or

bilateral neck pain

that had lasted forat least 4 weeks but

no longer than 12(3) Neck pain could

extend to theshoulder region

and upper arm,(4) Neck pain at 4

on an 11 pointnumerical rating

scale (NRS)(5) Presence of an

active triggerpoint in the

trapezius muscle(an active upper

trapezius TrP wasdefined as a tender

nodule in a taut bandthat referred pain in a

pattern specific forupper trapezius

TrP1 or TrP2)(6) Decreased

cervical lateralflexion (LF) to

the oppositeside of the active

upper trapezius TrP.

Exclusion criteria:(1) Specific neck pain

(radiculopathy,

systematic disease, etc.)(2) Blood coagulation disorder

(3) Currently takinganticoagulants

(eg. Warfarin)(4)Long-term steroid use.

N/A Age:

Gr1: X Z 23.9;SD Z 3.925.

Gr2: X Z 22.6SD Z 2.384

Gr3: X Z 24.9SD Z 5.44

Gr1: Myofascial

band therapy: bandtherapy consisted of

firm thumbpressure

in a slow strokingmotion from the

lateral shoulder tothe mastoid process

along the uppertrapezius muscle

and through theactive TrP for 1 min.

Gr2: Activator AAIis a hand held device

that deliverscontrolled

and reproducibleforces. The

design ofthe activator allows

the force to bedelivered on to a

very specific point.

The Activator IVfeatures force

setting rangingfrom 1 to 4. Activator

trigger pointtherapy involved

placing theActivator IV

perpendicularover the trigger

point using a forcesetting of 3 (170 N).

The trigger pointwas treated with the

Activator IV using 10thrusts at a rate of

one thrustper second.

Gr3: Sham Ultrasound

(contro): a detunedMedi-Link Systems

ultrasound machinefrom Electro-Medical

Supplies (Greenham)Ltd. Was used as a

sham control. Thesubject was informed

that pulsed ultrasoundwas going to be used

and they should notfeel any sensation

of heat or pain, andif they felt anything

to let the clinicianknow and the machine

would be turned down.Since this was a

sham treatmentsuch adjustments

made no difference.Ultrasound lotion

was applied over

the TrP andultrasound head

was moved slowlyover the upper

trapezius musclein the region of

the TrP for 2 min.The machine’s

integrated timerwas used to alert

the clinician whenthe 2 min have

elapsed.

N/A 1 treatment

session

2,2,0

318L.

Brosse

auetal.

Cen et al.

(2003)

RCT

Total: 28Gr1: 9

Gr2: 8

Inclusion criteria:(1) Episodes of neck

pain and loss in

ROM for aperiod exceeding

one year(2) Noticeable daily

neck pain andtightness

(3) Neck muscle painand tightness

associated with amechanical

disorder of thecervical spine

(whiplash, trauma,etc); no regular

therapeutic treatment

(more than 1x week)in the previous

3 months

N/A Gr1: X Z 47,

SD Z 11Gr2: X Z 51,

SD Z 7

Gr1: Traditional

ChineseTherapeutic

Massage (TCTM);

-One fingermeditation

massage: usetip and(or) the

whorled surfaceof the thumb to

rub soft tissue,swing thumb

forwards,backwards,

in one pass,12 passes/minute

-Rolling massageMassage program:

combination ofthe one finger

massage androlling massage,

30 min,3 times a week,

for 6 weeks

Gr2: Control

group: Notreatment

N/A 3x weekly

for 6 weeks

N/A 2,0,1

Fryer and

Hodgson(2005)

RCT

Total:35Gr1: 18

Gr2: 17

Inclusion criteria:(1) Presence of MTrPs

in the trapezius muscle

(2) Between 20 and 33years of age.

Exclusion criteria:(1) Generalized primary

fibromyalgia syndrome(2)Taken analgesic

medication in thepast 24 h

(3) Had no identifiablemyofascial MTrPs in

the upper trapeziusmuscle.

N/A N/A Gr1: Manual

pressure release:Encouraged to

relax as muchas possible before

pressure wasapplied.

Examiner 1applied slow

pressure to theMTRP until the

subject reported

a ’moderate buteasily tolerable’

pain value of 7/10(0 Z no pain)

Examiner 2recorded the value.

MPR pressure wassustained for 60 s

Gr2: Control:

Sham myofascialrelease: Extremely

light pressure of nogreater than 2 N/cm2

was applied to theMTrP. Subjects were

informed that theywere being treated

with an indirectosteopathic

myofascial

release technique,that the technique

involved subtlemovement of the

skin andunderlying tissues,

and that theyshould feel no

N/A One

treatment

N/A 2,1,0


Therapeutic

massa

geforneck

pain

319

(continued )

Author/year Samplesize

Population details Symptomduration

Age (mean,SD for control)

Treatment Comparisongroup

Concurrenttherapy

Session/weekno. of weeks

Followup

Quality R,B, W

while examiner 2

monitored thepressure reading

and promptedexaminer 1 to

maintain constantpressure

pain. The light

pressure washeld for 60 s.

Examiner 1 madeno attempt to

palpate orengage any

perceived tissuebarriers in order

to make the shamtreatment inert.

Irnich et al.(2001)

Total: 177Gr1: 60

Gr2: 61

Inclusion criteria:(1) Painful restriction

of cervical spinemobility for longer

than 1 month(2)No treatment

at least 2 weeksbefore entering

the study

Exclusion criteria:(1) Undergone surgery(2) Dislocations

(5) Fractures(4) Neurological

deficits(5) Systematic

disorders(6) Contradictions

to treatment.

Painfulrestriction of

cervical spinemobility for

longerthan 1 month

Gr1: X Z 52.7,SD Z 11.5

Gr2: X Z 52.2,SD Z 13.2

Gr1: Massage:Conventional

western massage,Techniques

included:effleurage,

petrissage,

friction,tapotement

and vibration,no spine

manipulationor non

conventionaltechniques

Gr2: Sham lasertreatment:

Performed withlaser pen which

was inactivated bymanufacturer,

only red light was

emitting, patientswere not aware of

inactivation, samepoints were treated

as in acupuncturefor 2 min at a

distance of 0.5e1cm from the skin

N/A Patientswere treated

5x over 3weeks, each

session was30 min

N/A 2,0,1

320L.

Brosse

auetal.

Sherman et al.

(2009)

RCT

Total: 62Gr1: 32

Gr2: 32

Inclusion criteria:(1) Between 20 and

64 years of age

(2) Neck painpersistence

of >12 weeks(3) Received primary care

for neck pain at least3 months prior.

Exclusion criteria:(1) Neck pain due

to non-mechanicalcauses

(2) Complex neckpain (inappropriate

for massage)(3) Unstable serious

medical or psychiatricconditions/dementia

(4) Minimal neck pain(5) Use of massage

for neck pain inthe past year

(6) Language barrier

N/A Gr1: X Z 47.4,

SD Z 12.3Gr2: X Z 46.4,

SD Z 11.3

Gr1: Massage.

Up to 10 massagetreatments over

10 weeks (varietyof Swedish and

clinical massagetechniques)

Gr2: Control.

Self-care; read"what to do for

a pain in theneck" book by

Jerome Schofferman.Includes information

on potential causesof neck pain,

neck-relatedheadache, whiplash,

recommendedstrengthening

exercise, body

mechanics andposture,

conventionaltreatment,

complementarytherapies for neck

pain and first aidfor intermittent

flare-ups. Noadditional

informationabout using

the bookwas provided

N/A 10 massage

treatmentsover 10

weeks

N/A 2,0,1

Therapeutic

massa

geforneck

pain

321


References

American Association of Colleges of Osteopathic Medicine(AACOM), 2009. Educational Council on Osteopathic Principles.Glossary of Osteopathic Terminology Usage Guide. AACOM,Chevy Chase, Maryland. http://www.aacom.org/resources/bookstore/Documents/GOT2009ed.pdf (accessed 25.8.11.).

Bialosky, J.E., Bishop, M.D., Price, D.D., Robinson, M.E.,George, S.Z., 2009. The mechanisms of Manual Therapy in thetreatment of musculoskeletal pain: a comprehensive model.Manual Therapy 14, 531e538.

Binder, A., 2007. The diagnosis and treatment of nonspecific neckpain and whiplash. Eura Medicophys 43 (1), 79e89.

Blikstad, A., Gemmell, H., 2008. Immediate effect of activatortrigger point therapy and myofascial band therapy on non-specific neck pain in patients with upper trapezius triggerpoints compared to sham ultrasound: a randomized controlledtrial. Clinical Chiropractic 11, 23e29.

Bokarius, A.V., Bokarius, V., 2010. Evidence-based review ofmanual therapy efficacy in treatment of chronic musculoskel-etal pain. World Institute of Pain 10 (5), 451e458.

Brattberg, G., Thorslund, M., Wikman, A., 1989. The prevalence ofpain in a general population. The result of a postal survey in thecountry of Sweden. Pain 37, 215e222.

Bronfort, G., Evans, R., Nelson, B., Aker, P.D., Goldsmith, C.H.,Vernon, H., 2001. A randomized clinical trial of exercise andspinal manipulation for patients with chronic neck pain. Spine26 (7), 788e799.

Bronfort, G., Haas, M., Evans, R., Leininger, B., Triano, J., 2010.Effectiveness of manual therapies: the UK evidence report.Chiropractic and Osteopathy 18 (3), 1e33.

Canadian Chiropractic Association and the Canadian Federation ofChiropractic Regulatory Boards, 2005. Chiropractic clinicalpractice guideline: evidence-based treatment of adult neckpain not due to whiplash. Journal of the Canadian ChiropracticAssociation 49 (3), 158e209.

Cambron, J.A., Dexheimer, J., Coe, P., 2006. Changes in bloodpressure after various forms of therapeutic massage: a prelimi-nary study. The Journal of Alternative and ComplementaryMedicine 12 (1), 65e70.

Cambron, J.A., Dexheimer, J., Coe, P., Swenson, R., 2007. Side-effects of massage therapy: a cross-sectional study of 100clients. The Journal of Alternative and Complementary Medi-cine 13 (8), 793e796.

Cen, S.Y., Loy, S.F., Sletten, E.G., Mclaine, A., 2003. The effect oftraditional Chinese Therapeutic Massage on individuals withneck pain. Clinical Acupuncture and Oriental Medicine 4,88e93.

Cote, P., Cassidy, D., Corroll, L., 1998. The Saskatchewan healthand back pain survey. The prevalence of neck pain andrelated disability in Saskatchewan adults. Spine 23 (15),1689e1698.

Cleland, J.A., Childs, J.D., Whitman, J.M., 2008. PsychometricProperties of the neck disability index and numeric pain ratingscale in patients with mechanical neck pain. Archives of Phys-ical Medicine and Rehabilitation 89, 69e74.

Donoyama, N., Munakata, T., Shibasaki, M., 2010. Effects of Anmatherapy (traditional Japanese massage) on body and mind.Journal of Bodywork and Movement Therapies 14, 55e64.

D’Sylva, J., Miller, J., Gross, A., Burnie, S.J., Goldsmith, C.H.,Graham, N., Haines, T., Brønfort, G., Hoving, J.L., 2010.Cervical Overview Group Manual Therapy with or withoutphysical medicine modalities for neck pain: a systematicreview. Manual Therapy 15, 415e433.

Dziedzic, K., Hill, J., Lewis, M., Sim, J., Daniels, J., Hay, E.M.,2005. Effectiveness of manual therapy or pulsed short wavediathermy in addition to advice and exercise for neck disorders:

a pragmatic randomized controlled trial in physical therapyclinics. Arthritis and Rheumatism 53 (2), 214e222.

Ekici, G., Bakar, Y., Akbayrak, T., Yuksel, I., 2009. Comparison ofmanual lymph drainage therapy and connective tissue massagein women with fibromyalgia: a randomized controlled trial.Journal of Manipulative and Physiological Therapeutics 32 (2),127e133.

Ernst, E., 2003. The safety of massage therapy. Rheumatology 42,1101e1106.

Evans, R., Bronfort, G., Nelson, B., Goldsmith, C.H., 2002. Two-Year follow-up of a randomized clinical trial of spinal manipu-lation and two types of exercise for patients with chronic neckpain. Spine 27 (21), 2383e2389.

Ezzo, J., Haraldsson, B.G., Gross, A.R., Myers, C.D., Morien, A.,Goldsmith, C.H., Bronfort, G., Peloso, P.M., 2007. Cervicaloverview group massage for mechanical neck disorders:a systematic review. Spine 32 (3), 353e362.

Felson, D.T., Anderson, J.J., Boers, M., et al., 1995. Preleminarydefinition of improvement in rheumatoid arthritis (AmericanCollege of Rheumatolgy). Arthritis Rheumatism 38, 727e735.

Fernandez-de-las-Penas, C., Alonso-Blanco, C., Fernandez-Carnero, J., Miangolarra- Page, J.C., 2006. The immediateeffect of ischemic compression technique and transverse fric-tion massage on tenderness of active and latent myofascialtrigger points: a pilot study. Journal of Bodywork and MovementTherapies 10, 3e9.

Fernandez-Perez, A.M., Peralta-Ramırez, M.I., Pilat, A.,Villaverde, C., 2008. Effects of myofascial Induction techniqueson Physiologic and Psychologic parameters: a randomizedcontrolled trial. The Journal of Alternative and ComplementaryMedicine 14 (7), 807e811.

Field, T., Diego, M., Hernandez-Reif, M., 2007. Massage therapyresearch. Developmental Review 27 (1), 75e89.

Fryer, G., Hodgson, L., 2005. The effect of manual pressure releaseon myofascial trigger points in the upper trapezius muscle.Journal of Bodywork and Movement Therapies 9, 248e255.

Gam, A.N., Warming, S., Hordum Larsen, L., Jensen, B.,Hoydalsmo, O., Allon, I., Andersen, B., Gotzsche, N.E.,Petersen, M., Mathiesen, B., 1998. Treatment of myofascialtrigger-points with ultrasound combined with massage andexercise e a randomised controlled trial. Pain 77, 73e79.

Gemmell, H., Allen, A., 2008. Relative immediate effect ofischemic compression and activator trigger point therapy onactive upper trapezius trigger points: a randomized trial. Clin-ical Chiropractic 11, 175e181.

Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J.A.,Alburquerque-Sendın, F., Palomeque-del-Cerro, L., Mendez-Sanchez, R., 2009. Inclusion of thoracic spine thrust manipula-tion into an electro-therapy/thermal program for the manage-ment of patients with acute mechanical neck pain:a randomized clinical trial. Manual Therapy 14, 306e313.

Graham, N., Gross, A., Goldsmith, C.H., Klaber Moffett, J.,Haines, T., Burnie, S.J., Peloso, P.M.J., 2011. Mechanical trac-tion for neck pain with or without radiculopathy (Review). TheCochrane Library Issue 2, 1e42.

Gross, A.R., Goldsmith, C., Hoving, J.L., Haines, T., Peloso, P.,Aker, P., Santaguida, P., Myers, C., 2007. Cervical overviewGroup Conservative management of mechanical neck disorders:a systematic review. The Journal of Rheumatology 34 (5),1083e1102.

Gross, A.R., Kay, T., Hondras, M., Goldsmith, C., Haines, T.,Peloso, P., Kennedy, C., Hoving, J., 2002. Manual therapy formechanical neck disorders: a systematic review. ManualTherapy 7 (3), 131e149.

Gross, A., Miller, J., D’Sylva, J., Burnie, S.J., Goldsmith, C.H.,Graham, N., Haines, T., Brønfort, G., Hoving, J.L., 2010.Manipulation or Mobilisation for neck pain: a cochrane review.Manual Therapy 5, 315e333.

http://www.aacom.org/resources/bookstore/Documents/GOT2009ed.pdf

http://www.aacom.org/resources/bookstore/Documents/GOT2009ed.pdf


Guez, M., Hildingsson, C., Nilsson, M., Toolanen, G., 2002. Theprevalence of neck pain: a population-based study fromnorthern Sweden. Acta Orthop Scand 73 (4), 455e459.

Haas, M., Schneider, M., Vavrek, D., 2010. Illustrating risk differ-ence and number needed to treat from a randomized controlledtrial of spinal manipulation for cervicogenic headache. Chiro-practic & Osteopathy 18 (9), 1e8.

Hakkinen, A., Salo, P., Tarvainen, U., Wiren, K., Ylinen, J., 2007.Effect of manual therapy and stretching on neck musclestrength and mobility in chronic neck pain. Journal of Reha-bilitation Medicine 39, 575e579.

Hamre, H.J., Witt, C.M., Glockmann, A., Ziegler, R., Willich, S.N.,Kiene, H., 2007. Rhythmical massage therapy in chronicdisease: a 4-year prospective cohort study. The Journal ofAlternative and Complementary Medicine 13 (6), 635e642.

Hanten, W.P., Barrett, M., Gillespie-Plesko, M., Jump, K.A.,Olsen, S.L., 1997. Effects of active head retraction withretraction/extension and occipital release on the pressure painthreshold of cervical and scapular trigger points. PhysiotherapyTheory and Practice 13, 285e291.

Hanten, W.P., Olson, S.L., Butts, N.L., Nowicki, A.L., 2000. Effec-tiveness of a home program of ischemic pressure followed bysustained stretch for treatment of myofascial trigger points.Physical Therapy 80 (10), 997e1003.

Haraldsson, B., Gross, A., Myers, C.D., Ezzo, J., Morien, A.,Goldsmith, C.H., Peloso, P.M.J., Brønfort, G., 2006. Cervicaloverview group massage for mechanical neck disorders(Review). The Cochrane Library Issue 3, 1e77.

Henley, C.E., Ivins, D., Mills, M., Wen, F.K., Benjamin, B.A., 2008.Osteopathic manipulative treatment and its relationship toautonomic nervous system activity as demonstrated by heartrate variability: a repeated measures study. Osteopathic Medi-cine and Primary Care 2, 7.

Hong, C.Z., 2004. Myofascial pain therapy. Journal of Muscu-loskelatal Pain 12 (3e4), 37e43.

Hong, C.Z., 2006. Treatment of myofascial pain syndrome. CurrentPain and Headache Reports 10 (5), 345e349.

Hong, C.Z., 2002. New trends in myofascial pain syndrome. ChineseMedical Journal (Tai Pei) 65 (11), 501e512.

Hou, C.-R., Tsai, L.-C., Cheng, K.-F., Chung, K.-C., Hong, C.-Z.,2002. Immediate effects of various physical therapeuticmodalities on cervical myofascial pain and trigger-point sensi-tivity. Archives of Physical Medicine and Rehabilitation 83,1406e1414.

Hoving, J.L., de Vet, H.C.W., Koes, B.W., van Mameren, H.,Deville, W.L.J.M., van der Windt, D.A.W.M.,Assendelft, W.J.J., Pool, J.J.M., Scholten, R.J.P.M., Korthals-de Bos, I.B.C., Bouter, L.M., 2006. Manual therapy, physicaltherapy, or continued care by the general practitioner forpatients with neck pain: long-term results from a pragmaticrandomized clinical trial. The Clinical Journal of Pain 22 (4),370e377.

Hoving, J.L., Koes, B.W., de Vet, H.C.W., van der Windt, D.A.W.M.,Assendelft, W.J.J., van Mameren, H., Deville, W.L.J.M.,Pool, J.J.M., Scholten, R.J.P.M., Bouter, L.M., 2002. Manualtherapy, physical therapy, or continued care by a generalpracticioner for patients with neck pain: a randomized,controlled trial. Annals of Internal Medicine 136 (10), 713e722.

Hurwitz, E.L., Carragee, E.J., van der Velde, G., Carroll, L.J.,Nordin, M., Guzman, J., Peloso, P.M., Holm, L.W., Cote, P.,Hogg-Johnson, S., Cassidy, J.D., Haldeman, S., 2009. Treatmentof neck pain: noninvasive interventions e Results of the boneand Joint Decade 2000e2010 Task force on neck pain and itsassociated disorders. Journal of Manipulative and PhysiologicalTherapeutics 32 (2S), S141eS175.

Irnich, D., Behrens, N., Molzen, H., Konig, A., Gleditsch, J.,Krauss, M., Natalis, M., Senn, E., Beyer, A., Schops, P., 2001.Randomised trial of acupuncture compared with conventional

massage and "sham" laser acupuncture for treatment of chronicneck pain. British Journal of Medicine 322, 1306e1311.

Jadad, A.R., Moore, R.A., Carroll, D., Jenkinson, C.,Reynolds, J.M., Gavaghan, D.J., McQuay, H.J., 1996. Assessingthe quality of reports of randomized clinical trials: is blindingnecessary? Controlled Clinical Trials 17, 1e12.

James, H., Castaneda, L., Miller, M.E., Findley, T., 2009. Rolfingstructural integration treatment of cervical spine dysfunction.Journal of Bodywork and Movement Therapies 13, 229e238.

Jiang, S.Y., Yan, J.T., Fang, M., Zuo, Y.Z., Gong, L., Sun, W.Q.,2009. Biomechanical changes associated with vertebral body inthe process of cervical spondylosis treatment. Journal of Clin-ical Rehabilitative Tissue Engineering Research 13 (11),2029e2032.

Jordan, A., Bendix, T., Nielsen, H., Hansen, F.R., Host, D.,Winkel, A., 1998. Intensive training, physiotherapy, ormanipulation for patients with chronic neck pain: a prospec-tive, single-blinded, randomized clinical trial. Spine 23 (3),311e318.

Kang, F., Wang, Q.C., Ye, Y.G., 2008. A randomized controlled trialof rotatory reduction manipulation and acupoint massage in thetreatment of younger cervical vertigo. Zhongguo Gu Shang.China Journal of Orthopaedics and Traumatology 21 (4),270e272.

Karels, C.H., Polling, W., Bierma-Zeinstra, S.M.A., Burdorf, A.,Verhagen, A.P., Koes, B.W., 2006. Treatment of arm, neck,and/or shoulder complaints in physical therapy practice. Spine31 (17), E584eE589.

Karlberg, M., Magnusson, M., Malmstrom, E.-M., Melander, A.,Moritz, U., 1996. Postural and symptomatic improvement afterphysiotherapy in patients with dizziness of suspected cervicalorigin. Archives of Physical Medicine and Rehabilitation 77,874e882.

Koes, B.W., Bouter, L.M., van Mameren, H., Essers, A.H.M.,Verstegen, G.M.J.R., Hofhuizen, D.M., Houben, J.P.,Knipschild, P.G., 1992. Randomised clinical trial of manipulativetherapy and physiotherapy for persistent back and neckcomplaints: results of one year follow up. British MedicalJournal 304, 601e605.

Kostopoulos, D., Nelson, A.J., Ingber, R.S., Larkin, R.W., 2008.Reduction of spontaneous electrical activity and pain percep-tion of trigger points in the upper trapezius muscle troughtrigger point compression and passive stretching. Journal ofMusculoskeletal Pain 16 (4), 266e278.

Linton, S.J., Hellsing, A.L., Hallden, K., 1998. population-basedstudy of spinal pain among 35e45 year old individuals. Preva-lence, sick leave and health care use. Spine 23, 1457e1463.

Leaver, A.M., Refshauge, K.M., Maher, C.G., Latimer, J.,Herbert, R.D., Jull, G., McAuley, J.H., 2007. Efficacy ofmanipulation for non-specific neck pain of recent onset: designof a randomised controlled trial. BMC Musculoskeletal Disorders8 (18).

Le Bars, D., Dickenson, A.H., Besson, J.M., 1979. Diffuse noxiousinhibitory controls (DNIC). I. Effects on dorsal horn convergentneurones in the rat. Pain 6 (3), 283e304.

Madson, T.J., Cieslak, K.R., Gay, R.E., 2010. Joint Mobilization vsMassage for Chronic Mechanical Neck Pain: a pilot study toassess recruitment strategies and estimate outcome measurevariability. Journal of Manipulative and Physiological Thera-peutics 33 (9), 644e651.

Makela, M., Heliovaara, M., Sievers, K., Impivaara, O., Knekt, P.,Aromaa, A., 1991. Prevalence determinants and consequencesof chronic neck pain in Finland. American Journal of Epidemi-ology 134, 1356e1367.

Medvedeva, L.A., 2008. Cervicogenic headaches: aspects of diag-nosis and analgesia. Anesteziologiia I Reanimatologiia 5, 96e99.

Medvedeva, L.A., Zagorul’ko, O.I., Gnezdilov, A.V.,Syrovegin, A.V., 2008. Use of anesthesiological technologies in


the complex treatment of cervicocranial pain syndromes.Anesteziologiia I Reanimatologiia 5, 92e96.

Melzack, R., Wall, P.D., 1965. Pain mechanisms: a new theory.Science 150 (699), 971e979.

Menard, M.B., 2002. Methodological issues in the design andconduct of massage therapy research. Massage Therapy: TheEvidence for Practice, 27e41.

Minasny, B., 2009. Understanding the process of fascial unwinding.International Journal of Therapeutic Massage and Bodywork 2(3), 10e17.

Moraska, A., Chandler, C., 2008. Changes in clinical parameters inpatients with tension-type headache following massagetherapy: a pilot study. The Journal of Manual and ManipulativeTherapy 16 (2), 106e112.

Moraska, A., Chandler, C., 2009. Changes in psychological param-eters in patients with tension-type headache following massagetherapy: a pilot study. The Journal of Manual and ManipulativeTherapy 17 (2), 86e94.

Olszewski, J., Repetowski, M., Kusmierczyk, K., 2007. Porow-nawcza ocena wynikow leczenia zawrotow glowy pochodzeniaszyjnego za pomoca farmakoterapii lub fizjoterapii (Compara-tive assessment of results in cervical vertigo pharmacotherapyvs physiotherapy treatment). Otolaryngologia Polska 61 (5),827e830.

Perrin Rochester, R., 2009. Neck pain and disability outcomesfollowing chiropractic upper cervical care: a retrospective caseseries. Journal of the Canadian Chiropractic Association 53 (3),173e185.

Pesco, M.S., Chosa, E., Tajima, N., 2005. Comparative study ofHands-on therapy with active exercises vs Education with activeexercises for the management of upper back pain. Journal ofManipulative and Physiological Therapeutics 29 (3), 228e235.

Piovesan, E.J., Di Stani, F., Kowacs, P.A., Mulinari, R.A.,Radunz, V.H., Utiumi, M., Muranka, E.B., Giublin, M.L.,Werneck, L.C., 2007. Massaging over the greater occipital nervereduces the intensity of migraine attacks: evidence for inhibi-tory trigemino-cervical convergence mechanisms. Arquivos DeNeuro-Psiquiatria 65 (3 A), 599e604.

Pleis, J.R., Coles, R., 2002. Summary health statistics for U.S.adults: national health Interview survey, 1998. National centerfor health statistics. Vital Health Stat 10, 1e113.

Rajala, U., Keinanen-Kiukanniemi, S., Uusimaki, A., Kivela, S.L.,1995. Muscoloskeletal pains and depression in a middle-agedFinnish population. Pain 61, 451e457.

Rickards, L.D., 2006. The effectiveness of non-invasive treatmentsfor active myofascial trigger point pain: a systematic review ofthe literature. International Journal of Osteopathic Medicine 9,120e136.

Sefton, J.M., Yarar, C., Berry, J.W., Pascoe, D.D., 2010. Thera-peutic massage of the neck and shoulders produces changes inperipheral blood flow when assessed with dynamic infraredthermography. The Journal of Alternative and ComplementaryMedicine 16 (7), 723e732.

Sherman, K.J., Cherkin, D.C., Hawkes, R.J., Miglioretti, D.L.,Deyo, R.A., 2009. Randomized trial of therapeutic massage forchronic neck pain. Clinical Journal of Pain 25 (3), 233e238.

Sim, J., Jordan, K., Lewis, M., Hill, J., Hay, E.M., Dziedzic, K.,2006. Sensitivity to change and internal consistency of theNorthwick Park neck pain questionnaire and derivation ofa minimal clinically important difference. Clinical Journal ofPain 22 (9), 820e826.

Skillgate, E., Vingard, E., Alfredsson, L., 2007. Naprapathic manualtherapy or evidence-based care for back and neck pain:a randomized, controlled trial. The Clinical Journal of Pain 23(5), 431e439.

Smith, D.W., Broida, J.P., 2007. Pandimensional field patternchanges in healers and healees. Journal of Holistic Nursing 25(4), 217e225.

The Ottawa Panel, Brosseau, L., Wells, G., Tugwell, P., Egan, M.,Dubouloz, C.J., Casimiro, L., Robinson, V., Pelland, L.,McGowan, K., Lamb, B., 2005. Ottawa Panel evidence-basedclinical practice guidelines for therapeutic exercises andmanual therapy in the treatment of osteoarthritis. PhysicalTherapy 85, 907e971.

The Ottawa Panel, Brosseau, L., Wells, G.A., Finestone, H.M.,Egan, M., Dubouloz, C.J., Graham, I., Bilodeau, M.,Casimiro, L., Robinson, V., McGowan, J., 2006. Ottawa Panelevidence-based clinical practice guidelines for Post-Strokerehabilitation. Topics in Stroke Rehabilitation 13 (2), 1e269.

The Ottawa Panel, Brosseau, L., Wells, G.A., Tugwell, P., Egan, M.,Wilson, K.G., Dubouloz, C.J., Casimiro, L., Robinson, V.A.,McGowan, J., Busch, A., Poitras, S., Moldofsky, H., Harth, M.,Finestone, H.M., Nielson, W., Haines-Wangda, A., Russell-Doreleyers, M., Lambert, K., Marshall, A.D., Veilleux, L., 2008.Ottawa Panel evidence-based clinical practice guidelines forstrengthening exercises in the management of fibromyalgia.Part 2. Physical Therapy 88 (7), 873e886.

The Ottawa Panel, Brosseau, L., Wells, G.A., Tugwell, P., Egan, M.,Dubouloz, C.J., Casimiro, L., Welch, V., McEwan, J., et al.,2011. Ottawa Panel evidence-based clinical practice guidelinesfor the management of osteoarthritis in adults who are obeseand overweight. Physical Therapy 91 (6), 843e861.

The Philadelphia Panel, Ottawa Methods Group, . Brosseau, L.,et al., 2001a. Philadelphia Panel evidence-based clinical prac-tice guidelines on selected rehabilitation interventions for neckpain. Physical Therapy 81 (10), 1701e1717.

The Philadelphia Panel, Ottawa Methods Group, Wells, G.,Tugwell, P., Brosseau (Co-PI), L., et al., 2001b. PhiladelphiaPanel evidence-based clinical practice guidelines on selectedrehabilitation interventions: overview and methodology. Phys-ical Therapy 81, 1629e1640.

Toro-Velasco, C., Arroyo-Morales, M., Fernandez-de-Las-Penas, C.,Cleland, J.A., Barrero-Hernandez, F.J., 2009. Short-termeffects of manual therapy on heart rate variability, mood state,and pressure pain sensitivity in patients with chronic tension-type headache: a pilot study. Journal of Manipulative andPhysiological Therapeutics 32 (7), 527e535.

Verhagen, A.P., Karels, C., Bierma-Zeinstra, S.M.A., Feleus, A.,Dahaghin, S., Burdorf, A., de Vet, H.C.W., Koes, B.W., 2007.Ergonomic and physiotherapeutic interventions for treatingwork-related complaints of the arm, neck or shoulder in adults:a cochrane systematic review. Eura Medicophys 43 (3),391e405.

Vernon, H., Humphreys, K., Hagino, C., 2007. Chronic mechanicalneck pain in adults treated by manual therapy: a systematicreview of change scores in randomized clinical trials. Journalof Manipulative and Physiological Therapeutics 30 (3),215e227.

Villanueva, L., Chitour, D., Le Bars, D., 1986. Involvement of thedorsolateral funiculus in the descending spinal projectionsresponsible for diffuse noxious inhibitory controls in the rat.Journal of Neurophysiology 56 (4), 1185e1195.

von Stulpnagel, C., Reilich, P., Straube, A., Schafer, J.,Blaschek, A., Lee, S.-H., Muller-Felber, W., Henschel, V.,Mansmann, U., Heinen, F., 2009. Myofascial trigger points inchildren with tension-type headache: a new diagnostic andtherapeutic option. Journal of Child Neurology 24 (4), 406e409.

Walach, H., Guthlin, C., Konig, M., 2003. Efficacy of massagetherapy in chronic pain: a pragmatic randomized trial. TheJournal of Alternative and Complementary Medicine 9 (6),837e846.

Wang, S.-Z., Lin, H.-L., Song, H.-M., Zhong, W.-H., Wo, T.-X.,Liu, G.-J., Chen, S.-Q., 2009. Conservative in the treatment ofprotrusion of cervical vertebra intervertebral disc: a systematicreview. Chinese Journal of Evidence-Based Medicine 9 (3),331e336.


Willer, J.C., Bouhassira, D., Le Bars, D., 1999. Neurophysiolog-ical bases of the counterirritation phenomenon: diffusecontrol inhibitors induced by nociceptive stimulation. Neu-rophysiologie Clinique/Clinical Neurophysiology 29 (5),379e400.

Willis, C., Niere, K.R., Hoving, J.L., Green, S., O’Leary, E.F.,Buchbinder, R., 2004. Reproducibility and responsiveness of thewhiplash disability questionnaire. Pain 110, 681e688.

Ylinen, J., Kautiainen, H., Wiren, K., Hakkinen, A., 2007.Stretching exercises vs manual therapy in treatment of chronic

neck pain: a randomized, controlled cross-over trial. Journal ofRehabilitation Medicine 39, 126e132.

Yozbatiran, N., Gelecek, N., Karadibak, D., 2006. Influence ofphysiotherapy programme on peak expiratory flow rate (PEFR)and chest expansion in patients with neck and low back pain.Journal of Back and Musculoskeletal Rehabilitation 19, 35e40.

Zaproudina, N., Hanninen, O.O.P., Airaksinen, O., 2007. Effec-tiveness of traditional bone setting in chronic neck pain:randomized clinical trial. Journal of Manipulative and Physio-logical Therapeutics 30 (6), 432e437.