“Hands-off” therapies are more effective than “hands-on” approaches in the treatment of chronic cervical pain

This paper aimed to systematically review the current literature comparing hands-off approaches with hands-on approaches from a biopsychosocial perspective of pain processing in people suffering from chronic primary neck pain (CPNP).

An electronic search was conducted on PubMed, Web of Science, Scopus, and Cochrane Library. Initial searches were carried out in November 2022, with electronic database searches repeated on November 25, 2024. Eligibility criteria which were randomized controlled trials comparing hands-off approaches alone or in combination with hands-on approaches and hands-on approaches alone in people with CPNP were checked by two independent authors. The risk of bias was assessed using the revised Cochrane Risk of Bias Tool (RoB). The strength of conclusion was determined using the evidence-based guideline development approach.

Fifteen studies with a total of 1029 participants were included in this review. The RoB was rated as low RoB for two studies, some concerns for two studies and high RoB for 11 studies. Pain processing was assessed by pain intensity (100 % of the studies), pain sensitivity (53 % of the studies), pain-related participation in social roles (46 % of the studies), pain-related emotions (26 % of the studies), and pain-related beliefs (6 % of the studies).

Limited quality of evidence was found for the hands-off approaches alone being more effective on pain intensity than hands-on approaches alone in the long term. Limited- to moderate-quality of evidence was found for hands-off approaches combined with hands-on approaches, being more effective than hands-on approaches alone in improving pain intensity, pain sensitivity, pain-related participation in social roles, pain-related emotions, and pain-related beliefs in the short-, mid- or long-term.

The authors concluded that the current findings suggest that hands-off approaches alone are superior to hands-on approaches in the long term, at least for pain intensity. Hands-off approaches in combination with hands-on approaches were also more effective than hands-on approaches for pain processing. However, substantial heterogeneity warrants a cautious interpretation of these results. More high-quality, randomized, controlled trials with homogenous data collection and larger sample sizes are needed.

We probably all know what “hands-on” therapies are; they comprise, for instance, manipulation, mobilisation or massage. But what precisely are “hands-off” approaches for treating neck pain? “Hands-off” approaches for treating neck pain generally refer to methods that don’t involve direct manual manipulation of the spine or aggressive interventions. There are many different options; here are some examples:

• rest,
• exercise,
• heat or cold therapies,
• medications,
• life-style modifications’
• ergonomics,
• stress management,
• mind-body therapies.

This review suggests that an ill-defined bunch of “hands -off” treatments are preferable to those that involve manual manipulations. The review is not focussed on safety issues which would even more clearly favour the former over the latter.

As we are not told which “hands-off” approaches are better than others, we cannot draw many meaningful conclusions from this finding – except, of course, for the one I have mentioned more often than I care to remember:

Don’t ever let a chiropractor (or osteopath) touch your neck!