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Spinal Manipulation, Exercise Trump Drugs for Neck Pain

January 5, 2012

From Medscape Medical News > Neurology

Spinal Manipulation, Exercise Trump Drugs for Neck Pain

January 5, 2012 — Spinal manipulation therapy (SMT) and exercises that patients can learn to do at home are more effective than medication for relieving neck pain, both in the short and long term, according to results from a new study published in the January 2012 issue of the Annals of Internal Medicine.

However, the results of this trial are not going to be applicable to all patients, lead author Gert Bronfort, DC, PhD, from the Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, Minnesota, told Medscape Medical News.

“You have to individualize the treatment,” he said. “It has a lot to do with where the patients are in their history of neck pain, what they’ve experienced in the past, and what their preferences are, but at least these treatments represent some viable options that can be offered to patients.”

Dr. Bronfort said that he and his team believed that spinal manipulation would be better than medication for improving neck pain, at least in the short term, based on their past experience. However, they were surprised to find that the home exercise program turned out to be just as successful, he admitted.

“The home program involved a couple hours of instruction in self care and specific neck exercises, where patients were taught how to avoid certain postures, such as sleeping and working postures, that would aggravate their neck pain,” he explained.

Nonspecific Neck Pain

In the study, 272 patients aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks were randomly assigned to receive 12 weeks of spinal manipulation therapy, medication, or home exercise with advice. The spinal manipulation therapy was given by 5 chiropractors who were well-trained and experienced in the procedure, Dr. Bronfort said.

Medication was provided by licensed medical physicians, with a focus on prescription drugs. First-line therapy was nonsteroidal anti-inflammatory drugs, acetaminophen, or both, the authors note. Those patients who did not respond or could not tolerate the first-line therapy received narcotic medications. Muscle relaxants were also used, and advice to stay active or modify activity was given as needed. “The choice of medications and number of visits was made by the physician on the basis of the participant’s history and response to treatment,” the authors write.

Pain, as reported by the study participants, was measured at 2, 4, 8, 12, 26, and 52 weeks.

Results showed that spinal manipulation had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks (P < .010), and that home exercise was superior to medication at 26 weeks (P = .02). No important differences in pain were found between spinal manipulation therapy and home exercises at any time.

Patients who received spinal manipulation therapy or home exercises also reported similar improvements in self-reported disability, medication use, general health status, and adverse events. However, patients said they were more satisfied with spinal manipulation than with home exercise.

With regard to adverse effects, 40% of the spinal manipulation group and 46% of the home exercise group reported adverse events. The most common was musculoskeletal pain, and less frequently they experienced paresthesia, stiffness, headache, and crepitus.

Among patients randomly assigned to the medication group, 60% reported adverse effects. The most common were gastrointestinal symptoms and drowsiness, followed by dry mouth, cognitive disturbances, rash, congestion, and disturbed sleep.

Dr. Bronfort pointed out that patients could not be blinded in this study, and that this was an important limitation. He also suggested that participants who received spinal manipulation may have been more likely to experience improvement in their neck pain and be more satisfied with their care because they had more frequent interactions with their care providers.

"When we started the study there was really not very much scientific evidence to support any treatment, really," he said. "You would think that neck pain would disappear by itself, and it does in a number of patients, but about half will go on to have chronic or sporadic neck pain, even a year later. What we don't know is to what extent spinal manipulation or home exercise can prevent more chronic conditions, and this is something that we need to find out."

Pragmatic Trials

In an accompanying editorial, Bruce F. Walker, DC, MPH, DrPH, from Murdoch University, Perth, and Simon D. French, PhD, from the University of Melbourne, both in Australia, point out that the 3 therapies in this study were not compared with a placebo or sham therapy. Such comparisons would have provided more convincing evidence of effectiveness, they write.

A cost analysis would also have been useful, they add, and they point out that neck manipulation has the potential for a rare, but potentially catastrophic, risk for vertebral artery stroke, and warn that patients should be advised of this possibility.

"Pragmatic trials, such as the one by Bronfort and colleagues, have their place in answering important questions about current treatment approaches, but we need innovative studies that explore which treatments benefit which of the many people who experience disabling neck pain," the editorialists conclude.

This study was funded by the National Center for Complementary and Alternative Medicine, National Institutes of Health. Dr. Bronfort, Dr. Walker, and Dr. French have disclosed no relevant financial relationships.

Ann Intern Med. 2012;156:1-10, 52-53. Article abstract, Editorial extract

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