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Three Part Question

In [neck pain] is [manual therapy better than GP care] at [reducing pain and restoring function]?

Clinical Scenario

A 45 year old man presents with pain in the neck, wanting to know if he should be referred for Manual therapy (delivered by physiotherapists).

Search Strategy

Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (Broad Therapy Filter = ((clinical[Abstract] AND trial[Abstract]) OR clinical trials[neck pain, manual therapy, manipulative therapy] OR clinical trial[Journal] OR random*[Abstract] OR random allocation[Neck pain,] OR therapeutic use[manual therapy, manipulative therapy]). In addition the BestBETS database was searched using similar terms. Finally the PEDrO (Physiotherapy best evidence) database was searched, as above, with only papers already rated as 7/10 on the quality score being selected for inclusion.

Search Outcome

Altogether 352 abstracts were identified from the combined searches, after duplicates had been removed. Abstracts were screened in teams of two. Full papers were obtained for those papers that answered, or potentially answered the three part search question. This resulted in 12 papers being obtained. These papers were rated for quality and risk of bias using a standard proforma (See appendix 1) with papers scoring over 5/10 being summarised in Table 1. This process resulted in four papers being rated as good quality and directly answering the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hoving et al 2002 Netherlands	183 Primary Care patients with at least 2weeks of neck pain	3 groups GP care (medication) Manual therapy Physiotherapy exercises Pragmatic RCT 1b	Pain: 11 point NRS	Manual therapy group had greater reduction than the other two groups by 1.5 point greater than GP care	Short term follow up at 7 weeks (immediately after treatment. Dutch Healthcare system setting.
			Function: Neck Disability Index	Manual therapy group had greater reduction than the other two groups by 1.9 point greater than GP care
Hoving et al 2006 Netherlands	183 Primary Care patients with at least 2weeks of neck pain	3 groups GP care (medication) Manual therapy Physiotherapy exercises	Pain: 11 point NRS	Manual therapy group had greater reduction than the other two groups by 0.9 point greater than GP care	Follow up at 13 and 52 weeks
			Function: Neck Disability Index	Manual therapy group had greater reduction than the other two groups by 1.9 point greater than GP care
			Societal Costs	Patients receiving Manual therapy cost society less in the year following treatment (932 euro less than GP care alone)

Comment(s)

Manual therapy, provided by physiotherapists, offers beneficial improvement in neck pain in the short term however by 6 to 12 months there is no additional benefit of manual therapy over GP care. There is a suggestion that advice and exercise, provided by a physiotherapist, may be equally beneficial as manual therapy, in both the short and long term. However manual therapy is more cost effect for society than GP care alone or advice and exercise

Clinical Bottom Line

Manual therapy is more clinically effective than GP care in the short-term more cost effective than GP care or just advice and exercise in the long term.

References

1. Hoving JL, Koes BW, de Vet HC, van der Windt DA, Assendelft WJ, van Mameren H, Devillé WL, Pool JJ, Scholten RJ, Bouter LM. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial Ann Intern Med 2002; 136(10):713-22
2. Hoving JL, de Vet HC, Koes BW, Mameren H, Devillé WL, van der Windt DA, Assendelft WJ, Pool JJ, Scholten RJ, Korthals-de Bos IB, Bouter LM. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized clinical trial Clin J Pain 2006; 22(4):370-7
3. Hoving J.L, Van Tulder, M.W., Rutten-van-Molken, P.M.H. et al Cost effectiveness of physiotherapy, manual therapy and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial BMJ 2003; 911-914
4. Dziedzic K, Hill J, Lewis M, Sim J, Daniels J, Hay EM. Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics. Arthritis and Rheum 2005; 214-222
5. Lewis M, James M, Stokes E, Hill J, Sim J, Hay E, Dziedzic K.( An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial. Rheumatology (Oxford) 2007; 1701-1708