A study published in the Annals of Internal Medicine, by Gert Bronford (Wolfe-Harris, Center for Clinical Studies, Northwestern Health Sciences University, Minnesota, USA) and others, has found that spinal manipulation—both in the long- and short-term—is more effective than medication for managing acute and subacute neck pain. However, they also found that home exercise with advice results in similar outcomes to spinal manipulation.
Of the 272 patients, all of whom had mechanical non-specific neck pain for two to 12 weeks, in the study, 91 were assigned to spinal manipulation therapy for 12 weeks (specific spinal level to be treated and the number of treatments were at the discretion of the provider), 90 to the medication group (first-line therapy being non-steroidal anti-inflammatory drugs, acetaminophen or both, and narcotic medication if patients were unresponsive to or intolerant of first-line therapy), and 91 were assigned to home exercise with advice (advice on exercises provided in two one-hour sessions one to two weeks apart, with instructions to do five to 10 repetitions of each exercise up to six to eight times a day).
After 12 weeks, there was a significantly greater reduction in patient-rated pain in the spinal manipulation group compared with the medication group (0.94 greater reduction in pain; p=0.001). Also at 12 weeks, a significantly higher absolute proportion of patients in the spinal manipulation group experienced a reduction in pain of at least 50% than the medication group (82.2 vs. 69, respectively). At 26 and 52 weeks, patient-rated pain improvement scores still favoured spinal manipulation compared with medication. A higher absolute proportion of patients in the spinal manipulation group had a reduction in pain of at least 50% at 26 weeks than the medication group, but there was no difference between the groups in this outcome at 52 weeks.
However, compared with patients receiving home exercise with advice, the benefits of spinal manipulation were less apparent. At 12 weeks, the differences in patient-related pain improvement between the spinal manipulation and home exercise groups were smaller than between the spinal manipulation and medication groups and were not significant. In the long-term analysis (at 26 and 52 weeks), there were no significant differences between the spinal manipulation and home exercise groups. Additionally, there were no significant differences between these groups in the secondary outcomes apart from the fact that patients in the spinal manipulation group were more satisfied with their care than those in the home exercise group (in both the short- and long-term).
Bronfort et al reported that the findings for home exercise with advice (that its outcomes were not significantly different from spinal manipulation or medication) were “noteworthy” given the potential for cost savings using this type of treatment compared with spinal manipulation therapy or medication.
In an accompanying editorial, Bruce Walker and Simon French (Murdoch University, Australia, and the University of Melbourne, Australia) write that clinicians should consider patient preference when reviewing treatment options given the “marginal differences in effectiveness of the different treatments [spinal manipulation and home exercise with advice].” They added: “Patients with neck pain who are active may prefer home exercise, whereas others may want a more hands-on approach, such as manipulation or mobilisation. If the patient chooses manual therapy, its effectiveness and safety profile need to be discussed.” They explained that neck manipulation has a “rare but potentially catastrophic risk” of vertebral artery stroke, adding “Because similar outcomes are found with neck manipulation and mobilisation, a persuasive argument can be made for mobilisation as a first-line treatment for non-specific neck pain instead of the low-amplitude, high-velocity thrusts of manipulation.”
They concluded their editorial by saying that Bronfort et al’s study and similar studies have their place in “answering important questions about current treatment approaches” but added “we need innovative studies that explore which treatments benefit which of the many people who experience disabling neck pain.”
Speaking to Spinal News International, Bronfort said he would advise patients with acute or subacute neck pain to “keep active” and added that he would recommend that they seek advice from a specialist, who could provide “a short period of care that focuses on exercise and/or manual therapy” if their pain started to affect their quality of life (such as causing sleep disturbance or preventing them from working).
