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15-01-2012 | Physical rehabilitation | Article

Spinal manipulation, exercise ‘marginally’ better than medication for neck pain


Free abstract

MedWire News: Spinal manipulation and home exercise with advice seem more effective than medication for treating neck pain, report researchers in the Annals of Internal Medicine.

However, authors of an accompanying editorial say that these differences are only "marginal."

The research compares the efficacy of three treatment options for acute and subacute neck pain - spinal manipulation therapy (SMT), medication, and home exercise with advice - using a randomized controlled trial.

Gert Bronfort (Northwestern Health Sciences University, Minneapolis, Minnesota, USA) and fellow study authors assigned 272 patients, aged 18 to 65 years, who had experienced nonspecific neck pain for 2 to 12 weeks to receive a 12-week course of one of the three treatment interventions.

The SMT intervention involved low-amplitude spinal adjustments and mobilization during sessions with a chiropractor lasting 15-20 minutes. The medication group received nonsteroidal anti-inflammatory drugs, acetaminophen, or both, as the first line of therapy, and if the patients did not respond then narcotics were prescribed. The home exercise patients were given two 1-hour instruction sessions and were told to do 5-10 repetitions of each exercise six to eight times a day.

The researchers measured participant-rated pain at baseline and at 2, 4, 8, 12, 26, and 52 weeks on an 11-point scale ranging from 0 (no pain symptoms) to 10 (highest severity of pain).

The study found that reported pain improved by a significantly greater degree in the SMT group than the medication group from 8 week onwards, whereas exercise was superior to medication at 26 weeks only. However, the analysis failed to find any statistically significant differences between SMT and exercise at any time-point.

"The authors acknowledge the strengths and weaknesses of the study, which overall is sound and has a low risk for bias," comment Bruce Walker (Murdoch University, Australia) and Simon French (The University of Melbourne, Australia) in their editorial.

However, the therapy interventions were not compared with a placebo, which "would provide more convincing evidence of effectiveness," they say. Furthermore, the researchers did not record patient adherence to the treatment regimens, and there was no cost-effectiveness element to the analysis.

Walker and French suggest that the "marginal" heterogeneity in beneficial treatments may reflect the fact neck pain could actually be a "heterogeneous collection" of conditions, rather than singular diagnosis.

"Given the marginal differences in effectiveness of the different treatments, clinicians should consider (among other things) patient preference," they say.

However, they stress that patients need to be well-informed as to the safety profile of each option: "For example, neck manipulation has a rare but potentially catastrophic risk for vertebral artery stroke."

They conclude: "Research to identify diagnostic subsets of people with nonspecific neck pain may enable us to better direct therapies, such as medication, manipulation, mobilization, and home exercises to the patients who are most likely to benefit from them."

By Chloe McIvor

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