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Study DesignSystematic review.
Study RationaleNeck pain is a prevalent condition. Spinal manipulation and mobilization procedures are becoming an accepted treatment for neck pain. However, data on the effectiveness of these treatments have not been summarized.
ObjectiveTo compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain.
MethodsA systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database, and bibliographies of key articles, which compared spinal manipulation or mobilization therapy with physical therapy or exercise in patients with neck pain. Articles were included based on predetermined criteria and were appraised using a predefined quality rating scheme.
ResultsFrom 197 citations, 7 articles met all inclusion and exclusion criteria. There were no differences in pain improvement when comparing spinal manipulation to exercise, and there were inconsistent reports of pain improvement in subjects who underwent mobilization therapy versus physical therapy. No disability improvement was reported between treatment groups in studies of acute or chronic neck pain patients. No functional improvement was found with manipulation therapy compared with exercise treatment or mobilization therapy compared with physical therapy groups in patients with acute pain. In chronic neck pain subjects who underwent spinal manipulation therapy compared to exercise treatment, results for short-term functional improvement were inconsistent.
ConclusionThe data available suggest that there are minimal short- and long-term treatment differences in pain, disability, patient-rated treatment improvement, treatment satisfaction, health status, or functional improvement when comparing manipulation or mobilization therapy to physical therapy or exercise in patients with neck pain. This systematic review is limited by the variability of treatment interventions and lack of standardized outcomes to assess treatment benefit.
Neck pain is a prevalent condition; more than 66% of the population will suffer from neck pain in one's life span.1 It is commonly caused by trauma, disk degeneration, disk herniation, or strains of the neck muscles. Initial care for neck pain consists of rest, physical medicine (heat/ice therapy), and pharmacotherapy. However, when conservative measures fail, patients are referred for physical intervention to alleviate a patient's neck pain.
Alternative methods of treatment have become popular in mainstream medical practice, leading to numerous types of treatment for neck pain. Spinal manipulation and mobilization procedures are becoming an accepted therapy for cervical pain. In fact, in many countries, patients are reimbursed for chiropractic care. There is data supporting and also discouraging the use of such treatments; however, data on the effectiveness of these treatments have not been summarized.
To compare manipulation or mobilization of the cervical spine to physical therapy, physiotherapy, or exercise for symptom improvement in patients with neck pain.
Study Design: Systematic review.
Search: PubMed and National Guideline Clearinghouse Databases; bibliographies of key articles.
Dates Searched: 1950 to August 2012.
Inclusion Criteria: Patients with neck pain. Studies explicitly designed to compare manipulation (chiropractic therapy) or mobilization (manual therapy) of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain. Studies were considered if comparison of manipulation or mobilization to physical therapy, physiotherapy, or exercise in patients with neck pain was described in the title and/or abstract.
Exclusion Criteria: Cervical radiculopathy, spinal stenosis, myelopathic conditions, postsurgical pain, disk herniation, history of cervical vertebral fractures or spinal tumor, headache etiology of neck pain, spinal manipulation directed at the thoracic spine only (i.e., thoracic thrust manipulation), multimodal therapy, acupuncture, electrical stimulation, injections, surgical correction, massage, behavioral therapy, no treatment, studies with less than 10 subjects, and low quality studies (LoE III or lower).
Interventions: Cervical spinal manipulation (chiropractic therapy), cervical spinal mobilization (manual therapy).
Comparators: Physical therapy, exercise, Feldenkrais method, home exercises/mobilization, counseling/education, or pharmacotherapy if associated with physical therapy or exercise.
Outcomes: Pain reduction, decreased disability, symptom-free time, time/procedure length until improvement, improved quality of life, complications of treatment, and cost of treatment.
Analysis: Descriptive statistics, statistics, and effect estimates as reported by authors.
Overall Strength of Evidence: Risk of bias for individual studies was based on using criteria set by The Journal of Bone and Joint Surgery,2 modified to delineate criteria associated with methodological quality and risk of bias based on recommendations from the Agency for Healthcare Research and Quality.3,4 The overall strength evidence across studies was based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group5 and recommendations made by the Agency for Healthcare Research and Quality (AHRQ).3,4
Details about methods can be found in the online supplementary material.
Only one potentially relevant clinical guideline was identified.
The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) provided recommendations for assessment and treatment of patients with neck pain.13
In patients who underwent manipulation therapy compared with exercise, the overall strength of evidence was low for treatment of both acute and chronic pain; that is, we have low confidence that the evidence reflects the true effect of differences in outcomes between treatments, and future research is likely to change the confidence in the estimate of effect and is likely to change the estimate (Table 4). For comparisons of mobilization therapy versus physical therapy, the overall strength of evidence is low for all outcomes with the exception of short-term functional improvement, which was considered moderate, meaning that we have moderate confidence that the evidence reflects the true effect, and further research may change our confidence in the estimate of effect and may change the estimate (Table 4). No studies were performed in patients with chronic pain comparing these treatments.
Analytic support for this work was provided by Spectrum Research, Inc. with funding from AOSpine.
Conflict of Interest None
Understandably, nonoperative care of spine-related pain remains the preferred primary treatment approach for all but the most serious spinal conditions. When back symptoms persist beyond an acute phase of several days, several nonoperative options are used, including activity modifications, pharmacologic, educational, physical, exercise, and manipulative (“hands-on”) modalities. Sadly, attempts at scientific assessment of the outcomes and efficacies of nonoperative treatment of refractory back-related pain—be it in the neck or the low back—remain one of the most frustrating but also expensive aspects of spine care. In a systematic review of exercise, acupuncture, and spinal manipulation, Standaert et al found no advantage of one modality over another with a low level of evidence.1 There was insufficient evidence to allow for the determination of cost-effectiveness and general lack of validation for any such therapy to be performed beyond 8 weeks without thorough reevaluation. In a systematic review of pharmacologic management of chronic low back pain, opioids were found to be not recommended over nonsteroidal anti-inflammatory drugs due to a significant rate of side effects.2 For surgical practices, there are emerging methods to assess the impact of procedures on patient well-being and cost-effectiveness as expressed in Quality Adjusted Life Years (QUALYS), but so far these methodologies have not been applied to nonoperative care.3,4
Our reviewers universally welcomed the initiative of the authors of this systematic review. They expressed worries about the influence and variability of patient education provided. The authors complied with this concern by adjustment of inclusion and exclusion criteria and excluding pharmacotherapy. Patient education is felt to be an essential adjuvant to all care options, yet its effect on patient outcomes remains unclear.5 The other concerns are much harder to address: the variability of manual and physical therapies applied, the inconsistent practitioner and patient interactive responsiveness (including a placebo effect), and the difficulty in establishing a differentiation of relatively harmless self-limiting discomfort to a more chronic pain state. Overall, the findings of this review by Schroeder et al were consistent with the findings of other systematic reviews, such as the Standaert et al study on low back pain. There is no discernible advantage of one modality over another, and the overall effectiveness of these interventions remains elusive. While most patients seem to get better over time, there remains a troubling group of patients who fail to respond and develop chronic pain. This valuable review hopefully strengthens the impetus for a more formal study on the role of nonoperative care, its preferred implementation strategies, and early recognition of patients who fail to respond to usual nonoperative care.