The Somatic Connection  |   April 2012
Spinal Manipulation and Home Exercise Improve Neck Pain
Article Information
The Somatic Connection   |   April 2012
Spinal Manipulation and Home Exercise Improve Neck Pain
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 157-158. doi:10.7556/jaoa.2012.112.4.157
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 157-158. doi:10.7556/jaoa.2012.112.4.157
Bonfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012;156(1 pt 1):1-10.  
Neck pain is a common complaint of patients seen by osteopathic physicians. Osteopathic manipulative treatment is often provided to manage the somatic dysfunction related to the complaint. This study on spinal manipulation therapy (SMT), medication, and home exercise for patients with neck pain was funded by the National Institutes of Health's National Center for Complementary and Alternative Medicine and was designed as a pragmatic randomized clinical trial to try to replicate conditions typically seen in clinical practice. 
Researchers and clinicians at a university clinic in Minnesota recruited 272 patients aged 18 to 65 years (mean age range, 46.8-48.8 years per group; women, 58% to 72% per group) who had a complaint of mechanical, nonspecific neck pain for 2 to 12 weeks duration and severity of at least 3 on a 10-point pain scale. Patients were randomly assigned to 1 of 3 intervention groups: (1) SMT with or without mobilization or soft-tissue procedures as performed by 1 of 6 chiropractors, (2) medication provided by a medical physician at a university pain management clinic using conventional care standards for musculoskeletal pain (ie, nonsteroidal anti-inflammatory drugs, acetaminophen, muscle relaxants, and/or narcotics, as indicated by history and physical examinations), or (3) home exercise with advice (HEA) provided by 1 of 6 therapists (ie, individualized instruction in anatomy, stretching, range of motion, and ergonomics and an informational booklet with exercise instruction). Outcomes were measured using standard validated surveys, which assessed subjective pain improvement (primary outcome); disability; global improvement; medication use; satisfaction; general health status at 2, 4, 6, 8, 12, 26, and 52 weeks; and blinded objective evaluation of neck motion at 4 and 12 weeks. 
Both the SMT group (after 8, 12, 26, and 52 weeks; P<.010) and HEA group (at 26 weeks; P<.02) had more relief than the medication group as measured during at least 1 time point in the study but not at all time points. Responses for the SMT and HEA groups were equivocal at all time points, although patients in the SMT group were more satisfied than those in the HEA group and those in the HEA group were more satisfied than those in the medication group. Results for most of the secondary outcomes were similar to those of the primary outcome. Interestingly, the HEA group had better range of motion than the SMT and medication groups. No cost analysis was reported, although the fact that a couple of educational sessions by therapists was as effective as SMT and more effective than medication leads to the supposition that this intervention will decrease health care industry and patient expenditures. Further analysis along these lines is warranted before recommendations for clinical practice should be made. 
Of note is that no serious adverse events were reported. Transient self-limited musculoskeletal pain was reported after both SMT (40%) and HEA (46%) interventions, with less frequent complaints such as paresthesias, headache, and crepitus. On the other hand, systemic adverse effects were reported in 60% of patients in the medication group, most commonly gastrointestinal symptoms and drowsiness but also dry mouth, cognitive disturbances, rash, congestion, and disturbed sleep. 
This study has several limitations to consider. Neither a placebo nor a control group was used. Neither patients nor providers could be blinded to treatment group allocation. No standard intervention protocol was used by the intervention providers; each session was individualized to the patient's complaints, the provider's assessment, and patient's response to intervention. Timing and number of interventions with the provider by group was also not standardized (SMT group, 2-23 visits; medication group, 1-8 visits; HEA group, 1-2 visits). Therefore, although the results cannot prove efficacy, cause, or effect, they can demonstrate relative effectiveness of 1 intervention vs another as each is practiced in the real world without artificial modification by the research designers. It is recommended that placebo, sham, and control groups be added to the next phase; then, a study in which patients are given combinations of interventions should be conducted to determine if any combination is better than single therapies.—M.A.S.