Study Suggests Potential Value of Manipulation Plus Exercise for Neck Pain

In today's health care arena, published research is a key element of successful clinical care. Research enables practitioners to provide accurate, effective treatment options supported by the literature, reinforcing public and professional acceptance of the benefits of chiropractic while expanding opportunities for insurance coverage and reimbursement.

What's the latest research say about managing neck pain? A study in the November 1, 2002, issue of the international journal Spine suggests that spinal manipulation and rehabilitative exercises together are more advantageous than manipulation alone or machine-based exercise for treating neck pain. In the study, lead researchers Roni Evans, DC, Gert Bronfort, DC, et al., also found that low-tech rehabilitative exercise plus manipulation resulted in greater patient satisfaction than high-tech, rehabilitative machine exercise (utilizing a MedX cervical rotation/extension machine) or manipulation alone.

This randomized clinical trial involved only 20- to 65-year-olds with mechanical neck pain of at least 12 weeks duration. Mechanical neck pain was considered "having no specific, identifiable etiology (i.e., infection, inflammatory disease), but could be reproduced by neck movement or provocation tests." Pain had to be localized dorsally and between the occipital and thoracic regions. Also excluded were cases of: pain referred from peripheral joints or viscera; progressive neurological deficits; severe osteopenia; previous spine surgery; severe infection or disability; inability to work because of pain; or previous or current similar treatment.

At the Physician's Neck and Back Clinic in Roseville, Minn., and the Wolfe-Harris Center for Clinical Studies at Northwestern Health Sciences University in Bloomington, 191 patients were randomized into three groups for treatment and evaluation:

• Spinal Manipulation Therapy (SMT) Alone: This group received 15 minutes of evaluation and "manual spinal manipulation with light soft-tissue massage ... to facilitate the spinal manipulative therapy" from experienced chiropractic clinicians. These patients were also given 45 minutes of sham microcurrent therapy after treatment to minimize potential bias due to differences in attention given.


• Manipulation Plus Rehabilitative Exercise: Patients received the spinal manipulation described above, but instead of sham treatment, they received rehabilitative exercise from trained exercise therapists. Sessions included stationary-bike warm-up and stretching; upper-body strengthening exercises; and dynamic neck exercises consisting of extension, flexion and rotation movements on a therapy table while wearing headgear with 1.25- to 10-pound weight attachments on a pulley system. Weights were gradually increased over treatments based on ability and improvement.


• Mechanized Rehabilitative Exercise: This intervention involved warm-up stretching and stationary biking; strengthening exercises of the upper back and shoulders; and neck exercises using a variable-resistance, cervical extension and rotation machine designed by the MedX Corporation of Ocala, Fla. When using the MedX machine, patients' torsos were immobilized to focus movements on neck musculature, and patients were encouraged to exercise to fatigue (up to 20 repetitions), despite possible pain, with periodically increased resistance levels.

All patients completed 20 one-hour appointments over an 11-week period. Twice at baseline, and five and 11 weeks after beginning treatment, subjects completed self-report questionnaires and were assessed for neck strength, motion and endurance in blinded fashion. Three, six, 12 and 24 months following treatment, patients were mailed questionnaires with a primary focus on self-rated pain (pain from 0-10, with 10 being "worst neck pain possible"). Disability was determined using the Neck Disability Index (NDI), and the Medical Outcomes Study Short Form 36-Item Health Survey was used to evaluate general health. Satisfaction with care was determined on a seven-point scale, ranging from "completely satisfied" to "completely dissatisfied." Additionally, global change was measured on a nine-point ordinal scale, and over-the-counter (OTC) medication usage was recorded.

Results

Of the 191 randomized patients, 178 completed the 11-week treatment and 145 offered self-reports at all followup points over the next 24 months. SMT plus exercise was found to be clinically significant over both other treatments in terms of patient satisfaction. This advantage persisted over the two-year follow-up period.

The authors lamented the lack of clinical significance when comparing other outcome measures (pain, disability, improvement and health status). Additionally, they noted that no significant differences were observed between groups when comparing neck disability, OTC medication use and general health.

Despite these limitations, the authors concluded: "The fact that there are consistent group differences in most outcome measures across time indicates the robustness of the results, and suggests that although the differences may be small, they are likely real ... These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers."

Reference

• Evans R, Bronfort G, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine 2002:27(21), pp. 2383-2389.