PAIN+ CPN

BACKGROUND: Neck pain is a very common condition, ranked fourth in terms of years lived with disability worldwide. Telerehabilitation has been growing in popularity with advances in technologies and telecommunication. Despite the potential benefits and the increased number of trials, there is uncertainty about the effectiveness of telerehabilitation in people with non-specific neck pain.

OBJECTIVES: To evaluate the benefits and harms of telerehabilitation to improve pain and function compared to no treatment, waiting list, usual care, or any other active intervention in people with acute, subacute, and chronic non-specific neck pain.

SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, five other databases, and two trial registers to 11 April 2024 without language or publication status restrictions. We screened reference lists of relevant potential studies.

SELECTION CRITERIA: We included randomised controlled trials of telerehabilitation in adults with non-specific neck pain. We classified telerehabilitation interventions into three categories: 1. telehealth delivery of psychological or education interventions; 2. telehealth delivery of exercise or physical activity interventions; and 3. telehealth delivery of multicomponent interventions. We included trials comparing telerehabilitation with minimal intervention, matched non-telehealth treatment, and unmatched treatment controls. The primary outcomes were pain intensity, function, health-related quality of life, anxiety, depression, any adverse events, withdrawals due to adverse events, and short-term serious adverse events. The secondary outcomes were return to work, self-efficacy, fear avoidance, pain catastrophising, and adherence.

DATA COLLECTION AND ANALYSIS: Two review authors independently screened relevant records, extracted data, and assessed risk of bias in included studies. We extracted data using a standardised form. We pooled trial results using a random-effects model meta-analysis. We combined results in a meta-analysis using mean difference (MD with pain and disability outcomes expressed on a 0 to 100 scale) or standardised mean difference (SMD), and 95% confidence intervals (CI) for continuous outcomes at immediate-, short-, intermediate-, and long-term follow-up. Otherwise, we report the data with a narrative summary. We assessed heterogeneity using the I2 value and Chi2 test, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS: We included 13 randomised controlled trials (1042 participants). Most studies included women (71%), aged 21 to 60 years (mean 39 years, standard deviation 11 years). Studies used different modalities for telerehabilitation, such as telephone, smartphone applications, pre-recorded videos, videoconference, and websites. The studies were conducted in China, Denmark, Germany, Greece, Italy, the Netherlands, South Korea, Thailand, and Turkey. The telerehabilitation interventions lasted from one day to 48 weeks. Most studies had a low risk of selection bias, attrition bias, and reporting bias. All studies had a high risk of performance bias related to blinding of participants and therapists, and detection bias for outcome assessment. Chronic neck pain Telerehabilitation (psychological or education) versus minimal intervention We found very low-certainty evidence that there may be little to no difference between telerehabilitation (psychological or education) and minimal intervention in pain intensity at short-term follow-up, but the evidence is very uncertain (MD -8.4, 95% CI -23.9 to 7.1; 2 studies, 170 participants). We found moderate-certainty evidence that telerehabilitation (psychological or education) probably improves function when compared to minimal intervention at short-term follow-up (MD 6.0, 95% CI 0.9 to 11.1; 1 study, 53 participants). We found low-certainty evidence that telerehabilitation (psychological or education) may not improve health-related quality of life related to the Physical Component when compared to minimal intervention at short-term follow-up (mean: 47.4 with telerehabilitation versus 45.1 with minimal intervention; 1 study, 117 participants) and health-related quality of life related to Mental Component at short-term follow-up (mean: 45.4 with telerehabilitation versus 47.2 with minimal intervention; 1 study, 117 participants). We found moderate-certainty evidence that telerehabilitation (psychological or education) probably reduces anxiety slightly compared to minimal intervention at short-term follow-up (MD -4.5, 95% CI -8.9 to -0.1; 1 study, 53 participants). We found low-certainty evidence that there may be little to no difference between telerehabilitation (psychological or education) and minimal intervention for depression at short-term follow-up (MD -2.3, 95% CI -6.5 to 1.9; 1 study, 53 participants). No study in this comparison reported withdrawal due to adverse events or serious adverse events. Telerehabilitation (exercise and physical activity) versus minimal intervention We found low-certainty evidence that telerehabilitation (exercise and physical activity) may reduce pain intensity when compared to minimal intervention at short-term follow-up (MD -20.4, 95% CI -21.9 to -19.1; 3 studies, 146 participants). We found very low-certainty evidence that telerehabilitation may improve function compared to minimal intervention at short-term follow-up, but the evidence is very uncertain (MD 5.0, 95% CI 0.5 to 9.4; 3 studies, 146 participants). We found very low-certainty evidence that there may be little to no difference between telerehabilitation (exercise and physical activity) and minimal intervention in quality of life (Physical Component) at short-term follow-up (SMD -0.06, 95% CI -0.7 to 0.6; 2 studies, 64 participants) or quality of life (Mental Component) at short-term follow-up (SMD -0.3, 95% CI -0.8 to 0.2; 2 studies, 64 participants), but the evidence is very uncertain. No study in this comparison assessed anxiety, depression, withdrawal due to adverse events, or serious adverse events. Telerehabilitation (multicomponent interventions) versus minimal intervention We found low-certainty evidence that there may be little to no difference between telerehabilitation (multicomponent) and minimal intervention in pain intensity at short-term follow-up (MD -1.0, 95% CI -5.9 to 3.9; 1 study, 213 participants). No study in this comparison assessed function, health-related quality of life, anxiety, depression, withdrawals due to adverse events, and serious adverse events.

AUTHORS' CONCLUSIONS: The current available evidence is inconclusive due to its very low certainty, and thus the question of the effectiveness of telerehabilitation interventions for non-specific neck pain remains unanswered.

Rehab Clinician (OT/PT) rater

'Telerehabilitation for neck pain' (TH) refers to 'chronic non-specific neck pain'. Note: The upper limit of interventional effectiveness of any intervention is curtailed in the absence of diagnostic certainty. Given inherent diagnostic uncertainty, underlying functional, postural and patho-neuroanatomic mechanisms also appear equally uncertain. Thus, the significant heterogeneity with further heterogeneity is seen in biological sex and socioeconomic and cultural variables highlighting an absence of generalisability. The study included 13 RCTs with 1042 participants, 71% women, aged 21 to 60 yrs, conducted in China, Denmark, Germany, Greece, Italy, the Netherlands, South Korea, Thailand, and Turkey. The authors conclude that current available evidence supporting the utility of TH appears inconclusive due to pervasive very low certainty on a range of clinical indices (psychological / education / exercise/ physical activity / multicomponent interventions, versus minimal intervention.

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