The Somatic Connection  |   July 2016
HVLA or Stretch May Not Be Necessary for Nonspecific Back or Neck Pain Relief
Author Notes
  • Professor, Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California 
Article Information
The Somatic Connection   |   July 2016
HVLA or Stretch May Not Be Necessary for Nonspecific Back or Neck Pain Relief
The Journal of the American Osteopathic Association, July 2016, Vol. 116, 488-489. doi:
The Journal of the American Osteopathic Association, July 2016, Vol. 116, 488-489. doi:
Paanalahti K, Holm LW, Nordin M, et al. Three combinations of manual therapy techniques within naprapathy in the treatment of neck and/or back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2016;17:176. doi:10.1186/s12891-016-1030-y. 
Because of controversy regarding the safety of the use of high-velocity, low-amplitude (HVLA) spinal manipulation for patients with neck or back pain, researchers in Sweden designed an innovative randomized clinical trial (RCT) at an educational clinic in which students being trained in naprapathic manual therapy (NMT) used a variety of manual procedures to determine efficacy and safety. Naprapathy is a registered health profession and the largest manual therapy profession in Sweden. Originated in Chicago, Illinois, in 1907 by Oakley Smith, DC, DN, naprapathy is a drugless, manual diagnostic and treatment system that entails using a “combination of manual techniques such as spinal manipulation/mobilization, stretching and massage used to treat shortened or pathologic soft and connective tissue” thought to be common causes of musculoskeletal pain conditions. 
A convenience sample of participants aged 18 to 65 years (mean [SD], 35 [11.8] years) were recruited among patients seeking care at the student clinic at the naprapathic school in Sweden. Patients who met the inclusion criteria of nonspecific neck and/or back pain (N=1057; 70% women; 54% had neck pain; 36% had chronic pain; mean [SD] baseline pain, 5.5 [1.8] of 10) were randomly assigned to NMT, NMT excluding spinal manipulation, or NMT excluding stretching. The primary outcomes were “minimal clinically important improvement” in pain intensity (decrease by at least 2 points on a 10-point pain scale) and pain-related disability (decrease by at least 1 point on a modified standard scale) compared with baseline. Naprapathy students in the seventh semester of 8 total semesters provided treatments for about 45 minutes as needed according to patient response and need (mean [SD] number of treatments per patient, 3.6 [1.5]). Power analysis was used to determine sample size, and intention-to-treat approach was used to analyze data from dropouts. Generalized estimating equations and logistic regression were used to examine the association between the treatments and outcomes. 
Patients were excluded if any of the following were present or true: pregnant; not fluent in Swedish; had less than 2 on the pain scale or less than 1 on the disability scale; cancer; manual therapy by a licensed professional in the recent month for the same condition; duration of the current complaint less than 1 week; contraindication for, or refusal to be treated by, spinal (HVLA) manipulation; lack of evidence of hypomobility in the joints of the spine in the area of the complaint; red flags or significant underlying pathologic disease; or on “sick leave due to planned/completed surgery for neck and/or back pain.” 
At the 12-week follow-up, “64% had a minimal clinically important improvement in pain intensity and 42% in pain-related disability. The corresponding chances to be improved at 52-week follow-up were 58% and 40% respectively.” There were no systematic differences in effect based on sex or whether spinal manipulation or stretching were excluded from the treatment at 1-year follow-up in terms of minimal clinically important improvement for pain intensity (P=.41), pain-related disability (P=.85), and perceived recovery (P=.98). The proportion of participants who had not sought additional care for their neck or back pain during the preceding 3 months at the 52-week follow-up was 61% among all 3 treatment arms. 
These findings lend support to the use of soft tissue massage and gentle mobilizations of the spine in managing musculoskeletal dysfunction related to low back and neck pain. It is likely that participants who receive manipulative care from more experienced professionals would have even greater pain relief; however, the fact that students in training were able to provide considerable benefit to patients using manual therapy is encouraging.