Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial.

Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Ann Intern Med. 2012 Jan 3;156(1 Pt 1):1-10.

Neck pain is a common complaint that is seen by many types of medical providers – physicians, chiropractors, physical therapists, etc.  It is a condition that nearly 75% of people experience at some point in their lives and can have a detrimental effect on a patient’s productivity and overall quality of life. Recent Cochrane reviews have found insufficient or limited evidence to assess the effectiveness of common treatment strategies.  In this study, Bronfort et al tested the effectiveness of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and sub-acute neck pain.  They studied 272 patients (aged 18 to 65 years old) that had grade I or II neck pain (Bone and Joint Task Force; no major structural causes of pain) for 2 to 12 weeks’ duration and a neck pain score of 3 or greater (scale 0 to10).  Patients were randomly assigned to a 12-week intervention group consisting of SMT, medication, or HEA.  The SMT was conducted by one of 6 chiropractors using multiple techniques that included low-amplitude spinal adjustments and mobilizations (frequency of visits was individualized at the discretion of the chiropractor).  The medication group saw a physician whose first line treatment was NSAIDs, acetaminophen, or both.  Second line treatment was narcotics and/or muscle relaxants.  The HEA was provided by one of 6 physical therapists and focused on individualized simple self-mobilization exercise programs (gentle controlled movements) 6 to 8 times/day.  The primary outcome was participant-rated pain and was measured throughout the 12-week intervention, as well as at weeks 26 and 52.  Secondary outcomes included cervical spinal motion and Neck Disability Index.  Bronfort et al found that there was a significant improvement in pain with SMT compared with medication at 12 weeks, but not when compared to HEA.  There was not a significant difference between HEA and medication at 12 weeks, but a higher absolute proportion of the HEA group experienced pain relief of at least 75% compared with the medication group.  Similar findings were found at 26 and 52 weeks.

This is an important study since patients are seeking treatment from different medical providers while, collectively, the nation and patients are trying to lower health care costs.  The researchers conclude that SMT and HEA appear to be viable treatment options for treating neck pain.  Furthermore, with results of the HEA group, this has the potential for cost savings over both SMT and medications.  Home exercise therapy can be effective with motivated patients and should include close follow-up to ensure patients are improving.  This study also supports the effectiveness of treatment provided by chiropractors for neck pain.  Patient care needs to be individualized, which makes it beneficial to have multiple types of evidence-based treatment modalities available.  Further studies can be done to assess if there are strategies to determine which treatment options would be optimal as a first line treatment.  What have been your experiences with patients that have tried multiple modalities of treatment for neck pain?

Written by:  Kris Fayock, MD and Peter Vitanzo, MD
Reviewed by: Jeffrey Driban

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Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, & Grimm RH (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine, 156 (1 Pt 1), 1-10 PMID: 22213489