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Three Part Question

[In adults presenting with chronic neck pain] is [manipulative therapy better than simple advice, NSAIDS and exercise] at [reducing pain and allowing a return to normal activities]

Clinical Scenario

A 24 year old male presents to his general practitioner following 6 months after a rear end RTA. There was little damage to the car at the time. He complains of chronic neck pain to a level that he feels unable to return to work as a labourer. Clinical examination shows some limitation of neck movements in all directions. Neurological examination is normal. You offer some NSAID drugs and an advice leaflet on how to mobilize the stiff neck. He asks if it would be possible to see an osteopath, chiropractor or physiotherapist as he has heard that they can work miracles for neck pain.

Search Strategy

Medline on OVID interface on the world wide web 2002-12/04
CINAHL on OVID interface on the world wide web 2002-12/04
EMBASE on OVID interface on the world wide web 2002-week 52 2004
AMED on OVID interface on the world wide web 2002-12/04
Cochrane Library via NELH Issue 4, 2004
MEDLINE, AMED, CINAHL, AMED
[exp NECK PAIN/ or exp NECK INJURIES/ or exp NECK/ or exp NECK MUSCLES/ or neck.mp.or WAD.mp. or exp WHIPLASH INJURIES/ or whiplash.mp.] AND [osteopathy.mp. or exp Osteopathic Medicine/ or exp Osteopathic Medicine/ or osteopa$.mp. or exp Chiropractic/ or chiropractor.mp. or exp Manipulation, Chiropractic/ or exp Physical Therapy Techniques/ or physiotherapy.mp. or exp Manipulation, Orthopedic/ or manual therapy.mp. or physiotherap$.mp.] limit to human, English and abstracts.
Cochrane
Neck and therapy and manual

Search Outcome

MEDLINE – Last systematic review published in 2004. Consequently MEDLINE search was restricted to the time after the last comprehensive systematic review (i.e. 2002) 244 papers found. 6 relevant to the question
EMBASE –.Last systematic review published in 2004. Consequently EMBASE search was restricted to the time after the last comprehensive systematic review (i.e. 2002) 244 papers found. 1 additional relevant papers found.
CINAHL – Last systematic review published in 2004. Consequently EMBASE search was restricted to the time after the last comprehensive systematic review (i.e. 2002) 108 papers found. No additional relevant paper found.
AMED - Last systematic review published in 2004. Consequently EMBASE search was restricted to the time after the last comprehensive systematic review (i.e. 2002) 82 papers found. No additional relevant paper found.
COCHRANE- 40 citations found of which 1 relevant review was found.
Papers combining neck and back pain patients were not included in this review unless separate data was presented. Papers relevant to the question are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gross AR 2004 Canada	Systematic review of papers examining the effect of any form of manipulation or mobilization for mechanical neck disorders. Inclusion criteria was wide, including neck pain with headache and whiplash disorders (grade 1-3).	Systematic Review of randomised and quasirandomised RCTs	No of papers included	528 papers were examined. 33 trials from 52 publications were included in the review.	High quality not adequately described in paper.Heterogenicity prevented statistical pooling of data.Blinding of participants impossible in this kind of trial, though blinding of assessors is.This review (and the studies on which it is based) cannot identify why multimodal care is apparently best.Insufficient evidence to draw conclusions for patients with radicular symptoms.
			Methodological quality	42% of included trials were considered high quality. Heterogeneity prevented meta-analysis of many trials.
			Effect of single session manipulation alone (4 RCTs, 2 analysed)	Moderate evidence that single session had no effect on short term pain relief (pooled standardised mean difference = -0.51 CI –1.10-0.07)
			Effect of multiple manipulation only sessions 5 trials, one analysed)	No consistent effect identified
			Mobilisation alone (4 trials)	Moderate evidence of no effect from four trials.
			Manipulation plus Mobilsation (6 trials)	When compared to no treatment results showed tendancy towards benefit.
			Manipulation or mobilsation plus other physical medicine agents.(6 trials)	Moderate evidence to suggest benefit
			Manipulation or mobilsation plus eercise.(15 trials)	Strong evidence of benefit. Pooled SMD -.85 (CI-1.2—0.5) for pain relief. Pooled SMD -.57 (CI-0.94 – -0.21) for function. Polled SMD –2.73 (CI-3.3 - -2.16) for perceived effect
Hurwitz 2002 USA	Neck pain patients with neck pain aged 18-70. Randomised to manipulation or mobilisation with and without heat or manipulation or mabilsation with and without electrical muscle stimulation.	RCT	Recruitment	336 of 960 eligible patients were enrolled. Over 80% of patients followed up to 6 months.	All patients had either manipulisation or mobilisation. Therefore no control group.Only HMO patients attending a chiropractor service.
			Manipulation vs. Mobilisation	No statistical or clinical difference at any measured time point in terms of neck disability index, average pain score or most severe pain score.
			Overall change in neck pain	Both groups had a reduction in their neck pain over the 6 months. E.g. average neck disability score reduced from approximately 13 to 7.
Evans 2002 Canada	191 patients with neck pain. Aged 10-65 years with neck pain for more than 12 weeks. Randomised to spinal manipulisation with exercise or high tech MedX rehabilitative exercise or spinal manipulation alone. All patients had 20 1 hour interventions.	RCT	High tech exercise vs low tech exercise regimens	No difference in disability, general health, improvement or additional meds. Patients preferred simple exercise regimen	Patients recruited through newspaper adverts.Differences found were (in the authors opinion) of questionable clinical significance. However, results showing trend to benefit from exercise were highly consistent suggesting effect though small is real.No control group of no intervention.
			Exercise regimens vs. spinal manipulisation alone	Exercise better for pain, though difference small. Overall trend for benefit from exercise regimens.
Korthals-de Bos 2002 Netherlands	183 patients with neck pain. Aged 18-70. Randomised to wither manual therapy, physiotherapy or GP care	PRCT & Economic evaluation	Perceived recovery rates at 7 weeks.	68% for manual 51% for physio, 36% for GP care.	Home exercise was recommended for all groups.Costs difficult to transfer to other healthcare systems.
			Perceived recovery rates at 52 weeks	72% for manual vs. 63% for physio vs. 56% for GP.
			Cost effectiveness	Manual therapy cheapest. e447 for manual vs e1297 for physio vs e1379 for GP care
Savolainen, 2004 Finland	75 employees with neck/shoulder pain aged 30-55 years. Randomised to 4 thoracic manipulations or instructions on physiotherapeutic exercise.	RCT	Muscle tenderness at 6 months	Poor data presentation. Authors state ;ess for both groups as compared to baseline.	34 (45%) dropped out. This is very high and makes the final results very questionable.Compared to other papers found this is of a low quality. Effect of multiple analyses not taken into account. Very difficult to see "true data" in published article.
			Muscle tenderness at 12 months	Poor data presentation. Authors state improvement for both groups as compared to baseline.
			Pain scores at 6 months	No significant differences
			Pain scores at 12 months	Small difference in "worst pain" score in favour of manipulation
Ernst 2003 UK	Systematic review of papers on chiropractic manipulation for neck pain. Only RCTs included.	Systematic review	Trials found	4 papers included. Jadad scores were 2,2,3,3.	Single review (two to assess trial quality only).
			Benefit of chiropractic manipulation	One trial showed short term transient benefit to manipulation. 2 trials comparing manipulation with exercise showed no difference at 12 month follow up.
Kjelllman 2002 Finland	77 patients with neck pain. Patients were randomised to exercise, McKenzie treatment or control.	RCT	active therapies vs. control	Suggests benefit to active treatment	THIS IS FROM THE ABSTRACT. FULL PAPER AWAITED AND WILL BE ADDED WHEN IT ARRIVES.

Comment(s)

Neck pain is a huge economic and clinical problem in many societies. There has been a great deal of controversy regarding the effectiveness of therapies such as chiropractics, osteopathy, physiotherapy and exercise for these patients. Despite this there is a large commercial market for the provision of such services which strongly suggests that patients perceive a need. Searching for evidence on the subject is difficult owing to the large number of trials published, yet the small number of high quality trials actually done. The Cochrane review by Gross published in 2004 suggests that multimodal treatments combing exercise, advice and manipulation or manipulation are most likely to be effective in the treatment of patients with neck pain. A combined approach appears to show benefit over simple advice and analgesics though we hope that future well conducted RCTs may be able to demonstrate this more clearly. The papers published since 2002 (the date of the last Cochrane search) do not significantly alter this finding.

Editor Comment

Kjellman paper still needs full appraisal See related BETs: Alternative therapies for neck pain. http://www.bestbets.org/cgi-bin/bets.pl?record=00195 Mobilisation of neck sprains http://www.bestbets.org/cgi-bin/bets.pl?record=00037 Acupuncture for neck pain http://www.bestbets.org/cgi-bin/bets.pl?record=00853 Prognosis in whiplash http://www.bestbets.org/cgi-bin/bets.pl?record=00855

Clinical Bottom Line

Mobilisation or manipulation combined with an exercise regimen is beneficial for patients with mechanical neck disorders.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P et al. A cochrane review of manipulation and mobilization for mechanical neck disorders. Spine Vol 29(14)()(pp 1541-1548), 2004
2. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: Clinical outcomes from the UCLA neck-pain study. American Journal of Public Health Vol 92(10)()(pp 1634-1641),
3. Evans R, Bronfort G, Nelson B, Goldsmith CH. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain Spine Vol 27(21)()(pp 2383-2389)
4. Korthals-de Bos IBC, Hoving JL, Van Tulder MW, Rutten-van Molken MPMH, Ader HJ, De Vet HCW et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: Economic evaluation alongside a randomised controlled trial British Medical Journal .Vol 326(7395)()(pp 911-914)
5. Savolainen A, Ahlberg J, Nummila H, Nissinen M Active or passive treatment for neck-shoulder pain in occupational health care? A randomized controlled trial Occupational Medicine Vol 54(6)()(pp 422-424)
6. Ernst E Chiropractic spinal manipulation for neck pain: a systematic review.[ Journal of Pain 4(8):417-21, 2003
7. Kjellman G, Oberg B A randomized clinical trial comparing general exercise, McKenzie treatment and a control group in patients with neck pain Journal of Rehabilitation Medicine 34(4):183-190