Keywords
neck pain - spinal manipulation - physical therapy - exercise - mobilization therapy
Study Rationale and Context
Neck pain is a prevalent condition; more than 66% of the population will suffer from
neck pain in one's life span.[1] It is commonly caused by trauma, disk degeneration, disk herniation, or strains
of the neck muscles. Initial care for neck pain consists of rest, physical medicine
(heat/ice therapy), and pharmacotherapy. However, when conservative measures fail,
patients are referred for physical intervention to alleviate a patient's neck pain.
Alternative methods of treatment have become popular in mainstream medical practice,
leading to numerous types of treatment for neck pain. Spinal manipulation and mobilization
procedures are becoming an accepted therapy for cervical pain. In fact, in many countries,
patients are reimbursed for chiropractic care. There is data supporting and also discouraging
the use of such treatments; however, data on the effectiveness of these treatments
have not been summarized.
Objectives
To compare manipulation or mobilization of the cervical spine to physical therapy,
physiotherapy, or exercise for symptom improvement in patients with neck pain.
Materials and Methods
Study Design: Systematic review.
Search: PubMed and National Guideline Clearinghouse Databases; bibliographies of key articles.
Dates Searched: 1950 to August 2012.
Inclusion Criteria: Patients with neck pain. Studies explicitly designed to compare manipulation (chiropractic
therapy) or mobilization (manual therapy) of the cervical spine to physical therapy
or exercise for symptom improvement in patients with neck pain. Studies were considered
if comparison of manipulation or mobilization to physical therapy, physiotherapy,
or exercise in patients with neck pain was described in the title and/or abstract.
Exclusion Criteria: Cervical radiculopathy, spinal stenosis, myelopathic conditions, postsurgical pain,
disk herniation, history of cervical vertebral fractures or spinal tumor, headache
etiology of neck pain, spinal manipulation directed at the thoracic spine only (i.e.,
thoracic thrust manipulation), multimodal therapy, acupuncture, electrical stimulation,
injections, surgical correction, massage, behavioral therapy, no treatment, studies
with less than 10 subjects, and low quality studies (LoE III or lower).
Interventions: Cervical spinal manipulation (chiropractic therapy), cervical spinal mobilization
(manual therapy).
Comparators: Physical therapy, exercise, Feldenkrais method, home exercises/mobilization, counseling/education,
or pharmacotherapy if associated with physical therapy or exercise.
Outcomes: Pain reduction, decreased disability, symptom-free time, time/procedure length until
improvement, improved quality of life, complications of treatment, and cost of treatment.
Analysis: Descriptive statistics, statistics, and effect estimates as reported by authors.
Overall Strength of Evidence: Risk of bias for individual studies was based on using criteria set by The Journal of Bone and Joint Surgery,[2] modified to delineate criteria associated with methodological quality and risk of
bias based on recommendations from the Agency for Healthcare Research and Quality.[3]
[4] The overall strength evidence across studies was based on precepts outlined by the
Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group[5] and recommendations made by the Agency for Healthcare Research and Quality (AHRQ).[3]
[4]
Details about methods can be found in the online supplementary material.
Results
-
The search yielded 197 citations, 32 of which underwent full-text review. Only class
of evidence (CoE) I or II (low or moderately low risk of bias) studies were considered
for inclusion. Six studies met the inclusion criteria ([Fig. 1]).
-
A total of four unique studies of different populations comparing spinal manipulation
or mobilization therapy of the cervical spine to physical therapy or exercise in patients
with neck pain met the inclusion criteria. These studies were moderate-quality randomized
controlled trials (RCT; CoE II).[6]
[7]
[8]
[9]
[10]
[11]
[12] Three reports of the same study assessed different outcomes at different time points.[9]
[10]
[11] In addition, two other reports of a same study evaluated outcomes at two different
time points.[7]
[8] One CoE II RCT met very few methodological criteria for high-quality study design,
execution, and avoidance of bias.[12] Additional details regarding the critical appraisal and study exclusion criteria
are available in the online supplementary material.
-
[Table 1] describes the characteristics of included studies including subject and treatment
characteristics. [Table 2] summarizes outcomes evaluated and effect-size estimates if reported in the studies
of acute neck-pain patients, while [Table 3] summarizes outcomes evaluated and effect-size estimates if reported in the studies
of patients reporting chronic neck pain.
Fig. 1 Flowchart showing results of literature search.
Table 1
Characteristics of studies comparing spinal manipulation therapy to exercise or physical
therapy for neck pain
|
Author (Year)
|
Study design
|
Population
|
Subject and treatment characteristics
|
Intervention
|
Control
|
Follow-up (%)
|
Class of evidence
|
|
Bronfort[a] (2001)
Evans (2002)
|
Randomized clinical trial
1:1 randomization
|
N = 127[b]
Mean age: 44.3 ± 11.0 y (manipulation);
43.6 ± 10.5 y (exercise)
41% male
|
Age 20–65 y, primary complaint of mechanical neck pain (pain having no specific, identifiable
etiology that could be reproduced by neck movement or provocation tests) that had
persisted ≥ 12 wk. Median duration of pain: 5.0 (range 0.3–34) y.
Treatment duration was 11 wk, all subjects attended twenty 1-hour appointments
|
15-min treatment by 1 of 9 experienced chiropractors: short-lever, low-amplitude,
high-velocity spinal manipulation therapy to cervical and thoracic spine. Subjects
also received 45 min of detuned (sham) microcurrent therapy after manipulation therapy
(to minimize differences in potential attention bias). Instructed in use of home exercise
program (resistive extension, flexion, rotation exercises; n = 64)
|
Supervision by a physical therapist: stretching, upper body strengthening, 15–20 min
of aerobic exercise on stationary bike; dynamic progressive resistance exercises (∼20
repetitions) on MedX cervical extension and rotation machines. Instructed in use of
home exercise program (resistive extension, flexion, rotation exercises; n = 63)
|
Bronfort:
52 wk (88%)
Evans:
104 wk (74%)
|
II
|
|
Bronfort (2012)
|
Randomized clinical trial
1:1 randomization
|
N = 182[c]
Mean age: 48.3 ± 15.2 y (manipulation);
48.6 ± 12.5 y (exercise)
38% male
|
Age 18–65 y, primary complaint of grade I or II[d] mechanical, nonspecific neck pain of 2–12 wk duration; pain severity ≥ 3/10. Median
duration of pain: 6.9 ± 3.2 wk.
Treatment duration was 12 wk
|
15–20 min treatment by 1 of 6 experienced chiropractors: diversified spinal manipulation
therapy techniques, including low-amplitude, high-velocity, as well as low-velocity
adjustments to cervical and thoracic spine. Advice to stay active or modify activity
was recommended (n = 91)
|
Home exercise advice by 1 of 6 physical therapists: two 1-h sessions, 1–2 wk apart.
Provided advice about self-mobilization exercises of neck and shoulder joints and
neck musculature. Instructed to do 5–10 repetitions/exercise without resistance, 6–8
times/day. Information about cervical spine anatomy and postural instructions/demonstrations
were provided. Booklet and laminated cards of prescribed exercises were provided (n = 91)
|
52 wk
(76%)
|
II
|
|
Hoving[e] (2002)
Korthals-de-Bos (2003)
Hoving (2006)
|
Randomized clinical trial
1:1 randomization stratified by pain severity
|
N = 119[f]
Mean age: 44.6 ± 12.4 y (mobilization therapy);
45.9 ± 11.9 y (physical therapy)
37% male
|
Age 18–70 y, primary symptom of neck pain or stiffness for ≥ 2-wk duration, pain reproducible
during examination. Mean pain severity was 7.6/11; pain duration range: 2–13+ wk (pain
duration was ≤ 12 wk for 73% of subjects).
Treatment duration: 6 wk
|
Mobilization therapy, 45 min/session, 1 time/wk: passive movements, including “hands-on”
muscular mobilization techniques aimed at improving soft tissue function; articular
mobilization techniques to improve overall joint function and decrease restrictions
in movement at single or multiple cervical spine levels; muscle coordination or stabilization
techniques to improve postural control, coordination, and movement patterns; joint
mobilization, which involves low-velocity passive movements within or at the limit
of joint range of motion. Spinal manipulation therapy (low-amplitude, high-velocity
thrust techniques) was not included in this protocol (n = 60)
|
Physical therapy, 30 min/session, 2 times/wk: active exercise therapy to improve strength
and range of motion, postural exercises, stretching, relaxation exercises, and functional
exercises. Stretching, massage, and/or heat could precede physical therapy exercises;
manual mobilization techniques were not included in this protocol (n = 59)
|
Hoving (2002):
7 wk (99%)
Korthals-de Bos (2003), Hoving (2006):
52 wk (98%)
|
II
|
|
Moretti (2004)
|
Randomized clinical trial
1:1 randomization
|
N = 80
Mean age: 32 (26–43) y (manipulation);
34 (25–44) y (physical therapy)
30% male
|
Benign cervicobrachialgia of mechanical origin of >6 wk duration
|
Spinal manipulation therapy, 1 session/wk, 2–3 sessions: manipulation of cervical
vertebrae while spine is at maximum left/right rotation and is accompanied by clicking
noise; spine may be in neutral, flexion, or extension position (n = 40)
|
Physical therapy, 10 daily treatments/session, two sessions: functional rehabilitation
of the spine and massage therapy of muscular regions that were involved with defense
muscle contraction (n = 40)
|
12 wk posttreatment (100%)
|
II
|
a Two articles reported on the same study population: Bronfort (2001) reported on 11-
and 52-wk outcomes, while Evans (2002) presented 104-wk outcomes.
b Study population was 191 subjects; one group randomized to spine manipulation therapy
plus exercise did not meet inclusion criteria for, and was not included in, this systematic
review (n = 64).
c Study population was 272 subjects; one group randomized to medication only did not
meet inclusion criteria for, and was not included in, this systematic review (n = 90).
d Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders
classification.
e Three articles reported on the same study population; Hoving (2002) presented short-term
(7-wk) outcomes, while Korthals-de Bos (2002) and Hoving (2006) reported 52-wk outcomes.
f Study population was 183 subjects; one group randomized to continued care from general
practitioner did not meet inclusion criteria for, and was not included in, this systematic
review (n = 64).
Table 2
Summary of outcomes in CoE II studies comparing manipulative or mobilization therapy
to physical therapy, physiotherapy, or exercise in patients with acute neck pain
|
Comparison
|
Outcome
|
Time since start of treatment (weeks)
|
Author (year)
|
Manipulation therapy
N = 91
|
Home exercise
N = 91
|
Effect size[a]
(95% CI)
|
|
Spinal manipulation therapy vs. home exercise instructions by physical therapist,
12 wk treatment duration
|
Minor complications of treatment
|
12
|
|
40% (36/91)
|
46% (42/91)
|
0.86 (0.61–1.20)
|
|
|
Bronfort (2012)
|
Mean ± SD
|
Mean ± SD
|
p
-value
[a]
|
|
Neck pain (0–10 scale)
|
12
|
1.5 ± 1.7
|
1.7 ± 1.8
|
p = 0.13
|
|
52
|
1.6 ± 1.5
|
1.9 ± 2.3
|
p = 0.10
|
|
Neck disability (NDI)[b]
|
12
|
9.2 ± 8.7
|
11.1 ± 9.2
|
p = 0.95
|
|
52
|
10.0 ± 8.4
|
11.1 ± 11.3
|
p = 0.92
|
|
General health status, physical (SF-36)
|
12
|
52.5 ± 5.9
|
52.0 ± 6.4
|
p = 0.59
|
|
52
|
52.5 ± 6.7
|
52.5 ± 7.1
|
p = 0.75
|
|
General health status, mental (SF-36)
|
12
|
56.3 ± 7.6
|
55.9 ± 6.8
|
p = 0.83
|
|
52
|
56.3 ± 6.5
|
54.5 ± 9.3
|
p = 0.62
|
|
Over-the-counter analgesic use[c]
|
12
|
0.7 ± 1.6
|
1.2 ± 2.1
|
p = 0.77
|
|
52
|
0.5 ± 1.1
|
1.2 ± 2.1
|
p = 0.83
|
|
Flexion/extension range of motion (degrees)
|
12
|
104.1 ± 16.5
|
107.9 ± 18.4
|
p = 0.78
|
|
Rotation range of motion (degrees)
|
12
|
125.4 ± 18.3
|
127.6 ± 18.5
|
p = 0.72
|
|
Lateral bending range of motion (degrees)
|
12
|
69.9 ± 16.5
|
69.7 ± 16.7
|
p = 0.85
|
|
|
Mean change (95% CI)
|
Mean change (95% CI)
|
p
-value
[a]
|
|
Improvement[d]
|
12
|
2.0 (1.7–2.2)
|
2.2 (1.9–2.4)
|
p = 0.81
|
|
52
|
2.2 (2.0–2.5)
|
2.4 (2.1–2.8)
|
p = 0.66
|
|
Satisfaction with care
[e]
|
12
|
1.5 (1.4–1.7)
|
1.9 (1.7–2.1)
|
p
= 0.003
|
|
52
|
1.7 (1.5–1.8)
|
2.1 (1.8–2.3)
|
p
= 0.004
|
|
|
|
|
Mobilization therapy
N
= 60
|
Physical therapy
N
= 59
|
Effect size
(95% CI) or
p
-value
[a]
|
|
Mobilization therapy vs. physical therapy, 6-wk treatment duration
|
Complications:
increased neck pain for > 2 d
headache
pain or paresthesia of the arms
dizziness
|
7
|
Hoving (2002), Korthals-de Bos (2003), Hoving (2006)[f]
|
18.3% (11/60)
28.3% (17/60)
13.3% (8/60)
10.0% (6/60)
|
6.8% (4/60)
32.3% (19/60)
15.3% (9/60)
11.9% (7/60)
|
2.75 (0.93–8.15)
0.89 (0.52–1.55)
0.89 (0.37–2.12)
0.86 (0.31–2.37)
|
|
Analgesic use
|
7
|
50.8% (30/59)
|
52.5% (31/59)
|
0.97 (0.68–1.37)
|
|
52
|
36.7% (22/60)
|
39.0% (23/59)
|
0.94 (0.59–1.49)
|
|
Work absence (% subjects)
|
7
|
12.8% (6/47)[g]
|
28.6% (12/42)[g]
|
0.45 (0.18–1.09)
|
|
Perceived recovery (%)
[h]
|
7
|
68.3%
|
50.8%
|
p
< 0.05
|
|
|
Mean ± SD
|
Mean ± SD
|
p
-value
|
|
Work absence (days, mean ± SD)
|
52
|
1.3 ± 4.1
|
7.5 ± 31.4
|
p = NS
|
|
Perceived recovery (mean ± SD)
|
52
|
71.7 ± 43
|
62.7 ± 37
|
p = NS
|
|
Average neck pain improvement from baseline (0–10 scale)
|
7
|
3.5 ± 2.3
|
2.8 ± 2.3
|
p = NS
|
|
52
|
4.2 ± 2.4
|
3.1 ± 2.9
|
p
< 0.05
|
|
Most severe pain improvement from baseline (0–10 scale)
|
7
|
4.5 ± 3.1
|
3.3 ± 3.1
|
p = NS
|
|
Neck pain “bothersomeness” improvement from baseline (0–10 scale)
|
7
|
4.8 ± 3.1
|
3.7 ± 3.1
|
p = NS
|
|
Neck disability improvement from baseline (NDI)[i]
|
7
|
7.8 ± 7.0
|
6.0 ± 7.0
|
p = NS
|
|
52
|
7.2 ± 7.5
|
6.3 ± 8.0
|
p = NS
|
|
Patient-rated severity improvement from baseline of most important functional limitation
(0–10 scale)
|
7
|
4.4 ± 3.8
|
3.4 ± 3.1
|
p = NS
|
|
52
|
5.3 ± 3.1
|
3.9 ± 3.1
|
p = NS
|
|
General health improvement (health index of Euro Quality of Life, 0–100 scale)
|
7
|
15.0 ± 15.5
|
8.8 ± 15.5
|
p
< 0.05
|
|
52
|
11.8 ± 17.1
|
4.0 ± 19.9
|
p = NS
|
|
Utility improvement from baseline (Euro Quality of Life scale)
|
52
|
0.82 ± 0.13
|
0.79 ± 0.14
|
p = NS
|
|
Physical dysfunction improvement from baseline, researcher-rated (0–10 scale)
|
7
|
3.4 ± 2.3
|
2.9 ± 2.3
|
p = NS
|
|
52
|
3.7 ± 2.1
|
3.3 ± 2.6
|
p = NS
|
|
Flexion–extension range of motion improvement
|
7
|
15.3 ± 20.2
|
11.0 ± 20.9
|
p = NS
|
|
52
|
16.8 ± 20.1
|
9.3 ± 24.2
|
p = NS
|
|
Rotation range of motion improvement
|
7
|
21.8 ± 21.7
|
13.1 ± 22.5
|
p = NS
|
|
Lateral flexion range of motion improvement
|
7
|
13.4 ± 16.3
|
8.8 ± 16.3
|
p = NS
|
|
Total treatment costs
|
52
|
€447 ± 525
|
€1297 ± 3475
|
p
< 0.05
|
|
|
Time since completion of treatment
|
|
Mobilization therapy
N
= 80
|
Physical therapy
N
= 80
|
|
|
Mobilization therapy vs. physical therapy, 2–3-wk treatment duration
|
|
|
Moretti (2004)
|
Mean
[j]
|
Mean
[j]
|
p
-value
[a]
|
|
Pain (VAS, 0–10 scale)
|
4
|
1.2
|
6.6
|
p
< 0.01
|
|
12
|
1.3
|
7.1
|
p
< 0.01
|
|
Flexion–extension range of motion (degrees)
|
12
|
NR
|
NR
|
p = NS
|
|
Rotation range of motion (degrees)
|
12
|
NR
|
NR
|
p = NS
|
|
Lateral flexion range of motion (degrees)
|
12
|
NR
|
NR
|
p = NS
|
Entries in bold represent significant outcome difference.
Abbreviations: CI, confidence interval; NDI, Neck Disability Index; NR, not reported;
NS, not significant; SD, standard deviation; SF-36, Short Form 36 (health status survey,
physical and mental components); ROM, range of motion; VAS, visual analogue scale.
a Effect size or p-value as reported by the authors.
b NDI scale for this study ranged from 0 (no dysfunction) to 100 (maximal dysfunction).
c Over-the-counter medication use was reported by patients as number of days during
a week when individuals take over-the-counter medication for neck pain (range 0–7
d).
d Patient-rated improvement was assessed using a 9-point ordinal scale, with choices
ranging from 1 (100% improved) to 5 (0% improvement) to 9 (100% worse).
e Patient-rated satisfaction with care was assessed using a 7-point scale, with choices
ranging from 1 (completely satisfied, couldn't be better) to 4 (neither satisfied
nor dissatisfied) to 7 (completely dissatisfied, couldn't be worse).
f Three articles reported on the same study population; Hoving (2002) presented short-term
(7-wk) outcomes, while Korthals-de Bos (2002) and Hoving (2006) reported 52-wk outcomes.
g Outcomes reported on patients who were employed.
h Patient-rated perceived recovery was assessed using a 6-point scale, ranging from
“much worse” to “completely recovered.”
i NDI scale for this study scored 10 activities of daily living on a scale of 0–5 (maximum
score = 50 points).
j Standard deviations were not reported.
Table 3
Summary of outcomes in CoE II studies comparing manipulative or mobilization therapy
to physical therapy or physiotherapy or exercise in patients with chronic neck pain
|
Comparison
|
Outcome
|
Time since start of treatment (weeks)
|
Author (year)
|
Manipulation therapy
N = 64
|
Exercise
N = 63
|
Effect size[a]
(95% CI)
|
|
Manipulation therapy vs. exercise with physical therapist, 11 week treatment duration
|
Complications/side effects
|
11
|
|
9.4% (6/64)
|
14.3% (9/63)
|
0.66 (0.25–1.74)
|
|
Bronfort (2001), Evans (2002)
[b]
|
Mean ± SD
|
Mean ± SD
|
p
-value
[a]
|
|
Neck pain (0–10 scale)
|
11
|
2.9 ± 2.1
|
2.3 ± 1.8
|
p = NS
|
|
52
|
3.5 ± 2.3
|
2.9 ± 2.0
|
p
= 0.02
|
|
104
|
3.9 ± 2.3
|
3.4 ± 2.4
|
p = 0.02
|
|
Neck disability (NDI)[c]
|
11
|
15.8 ± 12.3
|
12.4 ± 9.9
|
p = NS
|
|
52
|
19.9 ± 13.1
|
15.6 ± 13.1
|
p = NS
|
|
104
|
20.5 ± 13.5
|
16.6 ± 12.4
|
p = NS
|
|
General health status (SF-36)
|
11
|
78.7 ± 16.0
|
81.0 ± 11.8
|
p = NS
|
|
52
|
74.3 ± 17.8
|
78.0 ± 13.7
|
p = NS
|
|
104
|
70.8 ± 20.4
|
76.3 ± 14.1
|
p = NS
|
|
Over-the-counter analgesic use[d]
[e]
|
11
|
88.3 ± 47.6
|
92.1 ± 47.6
|
p = NS
|
|
52
|
93.1 ± 47.6
|
79.0 ± 43.3
|
p = NS
|
|
104
|
76.2 ± 42.9
|
70.2 ± 38.1
|
p = NS
|
|
Improvement[f]
[e]
|
11
|
98.9 ± 47.9
|
85.8 ± 50.0
|
p = NS
|
|
52
|
91.9 ± 45.0
|
78.2 ± 50.5
|
p = NS
|
|
104
|
83.1 ± 41.7
|
75.0 ± 43.2
|
p = NS
|
|
Satisfaction with care[g]
[e]
|
11
|
96.9 ± 48.6
|
88.6 ± 42.9
|
p = NS
|
|
52
|
98.9 ± 44.7
|
87.1 ± 45.6
|
p = NS
|
|
104
|
88.3 ± 37.4
|
82.5 ± 41.7
|
p = NS
|
|
Mean change (95% CI)
|
Mean change (95% CI)
|
Effect size
|
|
Flexion static endurance increase (weight × seconds)
|
11
|
73.7 (28.6–119.1)
|
66.2 (16.0–116.3)
|
p = NS
|
|
Extension static endurance increase (weight × seconds)
|
11
|
145.6 (50.5–240.6)
|
159.6 (54.5–264.8)
|
p = NS
|
|
Flexion dynamic endurance increase (weight × seconds)
|
11
|
20.7 (5.3–6.0)
|
29.4 (13.1–45.7)
|
p = NS
|
|
Extension dynamic endurance increase (weight × seconds)
|
11
|
47.3 (28.0–66.6)
|
70.2 (50.1–90.4)
|
p = NS
|
|
Flexion strength increase (pounds)
|
11
|
4.0 (2.6–5.5)
|
6.0 (4.8–7.6)
|
p = NS
|
|
Extension strength increase (pounds)
|
11
|
2.4 (0.5–4.3)
|
7.6 (5.6–9.6)
|
p < 0.05
|
|
Rotation strength increase (pounds)
|
11
|
1.2 (−0.5–2.6)
|
1.8 (0.5–3.1)
|
P = NS
|
|
Flexion/extension ROM (degrees)
|
11
|
1.6 (−1.2–4.4)
|
6.8 (3.9–9.8)
|
p < 0.05
|
|
Rotation ROM (degrees)
|
11
|
5.7 (3.0–8.4)
|
8.1 (5.3–11.0)
|
p = NS
|
|
Side bending ROM (degrees)
|
11
|
2.2 (−0.4–4.7)
|
5.1 (2.4–7.8)
|
p = NS
|
Abbreviations: CI, confidence interval; NS, not significant; NDI, Neck Disability
Index; SF-36, Short Form 36 (functional health status); ROM, range of motion; SD,
standard deviation.
a Effect size or p-value as reported by the authors.
b Two articles reported on the same study population; Bronfort (2001) reported on 11-
and 52-wk outcomes, while Evans (2002) presented 104-week outcomes.
c NDI scale ranged from 0 (no dysfunction) to 100 (maximal dysfunction).
d OTC medication use was reported by patients using a 5-point scale, with choices ranging
from “none” to “every day.”
e Results converted to rank transformed score.
f Patient-rated improvement was assessed using a 9-point ordinal scale, with choices
ranging from “no symptoms” to “twice as bad.”
g Patient-rated satisfaction with care was assessed using a 7-point scale, with choices
ranging from “completely satisfied (couldn't be better)” to “completely dissatisfied
(couldn't be worse).”
Acute Neck Pain ([Table 2])
Patient-Reported Outcomes
-
Pain: Pain improvement was assessed in all studies involving subjects with acute neck
pain.
-
○ One study comparing spinal manipulation therapy to home exercise instructions by
a physical therapist found no differences in pain severity (0 to 10 scale, with 0
representing no pain and 10 representing pain “as bad as it could be”) between groups
at 12 and 52 weeks.[6]
-
○ Another study assessed average and most severe neck pain and pain “bothersomeness”
(0 to 10 scales) in subjects who underwent mobilization therapy or physical therapy.
There were no significant differences between groups at 7 weeks. However, at 52 weeks,
the physical therapy group reported a significantly greater improvement in average
neck pain from baseline levels compared with subjects who were treated with mobilization
therapy (p < 0.05).[9]
[10]
[11]
-
○ A third study compared subjects who underwent mobilization therapy or physical therapy
and found significantly lower levels of pain, rated with a 0 to 10 visual analogue
scale (VAS), at 4 and 12 weeks after treatment in subjects who underwent mobilization
therapy (p < 0.01).[12]
-
Disability: There were no significant differences in disability reported in manipulation
therapy versus home exercise groups or in mobilization compared with physical therapy
treatment groups at any time point in subjects with acute neck pain.[6]
[9]
[10]
[11]
-
Patient-reported treatment improvement:
-
○ There were no significant differences in self-reported treatment improvement (assessed
using a 9-point scale, ranging from 1 [100%improvement] to 5 [0% improvement] to 9
[100% worse], see [Table 3]) in subjects who underwent spinal manipulation therapy vs. home exercise instructions
at 12 or 52 weeks.[6]
-
○ Subjects who underwent mobilization therapy reported a greater perceived recovery
(assessed using a 6-point scale, ranging from “much worse” to “completely recovered”)
than those who received physical therapy at 7 weeks therapy (p < 0.05), though this improvement was no longer apparent at 52 weeks (P = NS).[9]
[10]
[11]
-
Treatment satisfaction:
-
○ Subjects who received manipulation therapy reported a greater satisfaction with
care (assessed using a 7-point scale, ranging from 1 [completely satisfied, could
not be better] to 4 [neither satisfied nor dissatisfied] to 7 [completely dissatisfied,
could not be worse]) at 12 weeks (p = 0.003) and 52 weeks (p = 0.004) compared with those who underwent home exercise instructions.[6]
-
Health status:
-
○ No differences in physical or mental health status, measured with the SF-36, were
found between spinal manipulation and home exercise instruction treatment groups at
12 or 52 weeks.[6]
-
○ Subjects who underwent mobilization therapy compared with physical therapy reported
a greater improvement in general health at 7 weeks, measured with the health index
of the Euro Quality of Life scale, though this improvement was no longer apparent
at 52 weeks.[9]
[10]
[11] No significant treatment differences between mobilization therapy and physical therapy
treatment groups were found with utility improvement at 52 weeks, measured with the
Euro Quality of Life scale.[9]
[10]
[11]
Functional Outcomes
-
Range of motion (ROM): There were no significant differences in flexion–extension
ROM, rotation ROM, or lateral extension ROM between groups (manipulation therapy vs.
home exercise, as well as mobilization vs. physical therapy) in studies involving
acute neck pain subjects.[6]
[9]
[10]
[11]
[12]
Other Outcomes
-
Complications: Reported complications were minor and were similar between manipulation
therapy compared with home exercise and mobilization therapy compared with physical
therapy treatment groups.[6]
[9]
[10]
[11]
-
Costs: One study assessed costs associated with care and found lower total medical
utilization costs at 52 weeks after treatment associated with manipulation therapy
compared with physical therapy (p < 0.05).[11]
-
Other: In acute pain subjects, no significant differences in short- or long-term analgesic
use were found between manipulation therapy versus home exercise, as well as mobilization
therapy versus physical therapy treatment groups.[6]
[9]
[10]
[11] Further, there were no significant differences in work absence, researcher-rated
physical dysfunction, or patient-rated severity of the most important functional limitation
in subjects who underwent mobilization therapy or physical therapy.[9]
[10]
[11]
Chronic Neck Pain ([Table 3])
Patient-Reported Outcomes
-
Pain: In chronic pain subjects who received spinal manipulation therapy or intensive
exercise with a physical therapist, no difference in pain intensity was found between
the two groups at 11 weeks after treatment initiation, using a 0 to 10 rating scale
with 0 representing no pain and 10 representing pain “as bad as it could be.” However,
at 52 and 104 weeks, significantly lower pain levels were reported in the exercise
group (p = 0.02).[7]
[8]
-
Disability: There were no significant differences in neck disability in subjects who
underwent manipulation therapy or exercise treatment.[7]
[8]
-
Patient-reported treatment improvement: No significant differences between manipulation
therapy or exercise treatment groups were reported for self-rated improvement (rated
with a 9-point scale ranging from 1 [“no symptoms”] to 9 [“twice as bad”]) at 11,
52, or 104 weeks.[7]
[8]
-
Patient-reported treatment satisfaction: In subjects who underwent spinal manipulation
therapy or intensive exercise, no significant differences between treatment groups
were reported for satisfaction with care (rated with a 7-point scale ranging from
1 [“completely satisfied”] to 7 [“completely dissatisfied”]; see [Table 4]) at 11, 52, or 104 weeks.[7]
[8]
-
Health status: Health status was assessed with the SF-36, and no significant differences
between manipulation therapies compared with exercise treatment groups were reported.[7]
[8]
Table 4
Strength of evidence summary
|
Outcome
|
Strength of evidence
|
Conclusions and comments
|
Baseline
|
Downgrade
|
Upgrade
|
|
Spinal manipulation therapy vs. exercise
|
|
Pain
|
Acute: LOW
Chronic: LOW
|
• Acute: No short- or long-term pain improvement differences in manipulation therapy
compared with home exercise treatment groups were reported in one study
• Chronic: No short-term pain improvement differences were found in manipulation therapy
vs. intense exercise treatment groups, though a long-term pain improvement was associated
with exercise in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown, imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Disability
|
Acute: LOW
Chronic: LOW
|
• Acute: No disability improvement was reported in manipulation therapy compared with
home exercise in one study
• Chronic: No disability improvement was reported in manipulation therapy compared
with home exercise in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown,
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Treatment improvement
|
Acute: LOW
Chronic: LOW
|
• Acute: No short- or long-term treatment improvement between mobilization therapy
and home exercise groups were found in one study
• Chronic: No short- or long-term treatment improvement differences between mobilization
therapy and home exercise groups were found in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown,
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Health status
|
Acute: LOW
Chronic: LOW
|
• Acute: No physical or mental health status change between manipulation therapy and
exercise groups was found in one study
• Chronic: No health status improvement was reported in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown,
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Treatment satisfaction
|
Acute: LOW
Chronic: LOW
|
• Acute: Short- and long-term treatment satisfaction was associated with manipulation
therapy compared with home exercise in one study
• Chronic: No differences in treatment satisfaction were found between mobilization
therapy and home exercise groups in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown,
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Functional improvement
|
Acute: LOW
Chronic: LOW
|
• Acute: No short-term functional improvement differences in flexion/extension, rotation,
or lateral flexion range of motion were found in manipulation therapy vs. home exercise
groups in one study
• Chronic: Short-term improvement in extension strength, but not flexion or rotation
strength, and an improvement in flexion/extension range of motion, but not rotation
or lateral flexion range of motion, were found in subjects who underwent exercise
compared with mobilization therapy in one study
|
Acute: HIGH
Chronic: HIGH
|
YES (2)
consistency unknown,
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
|
Mobilization therapy vs. physical therapy
|
|
Pain
|
Acute: LOW
Acute: LOW
|
• Acute: Short-term pain improvement was associated with mobilization therapy, compared
with physical therapy, in one study, and there were no differences between groups
in another study
• Acute: long-term pain improvement was associated with physical therapy, compared
with mobilization therapy, in one study and was not reported in another study
|
Acute: HIGH
Acute: HIGH
|
YES (2)
inconsistent, imprecise
YES (2)
consistency unknown,
imprecise
|
NO
|
|
Disability
|
Acute: LOW
|
• Acute: No disability improvement was reported in mobilization therapy compared with
physical therapy in one study
|
Acute: HIGH
|
YES (2)
consistency unknown,
imprecise
|
NO
|
|
Treatment improvement
|
Acute: LOW
|
• Acute: Short-term perceived treatment recovery was associated with mobilization
therapy, compared with physical therapy, in one study
|
Acute: HIGH
|
YES (2)
consistency unknown,
imprecise
|
NO
|
|
Health status
|
Acute: LOW
|
• Acute: Short-term health status improvement was associated with mobilization therapy,
compared with physical therapy, in one study. No long-term utility (quality of life)
improvement between groups was found in another study
|
Acute: HIGH
|
YES (2)
consistency unknown,
imprecise
|
NO
|
|
Functional improvement
|
Acute: MODERATE
Acute: LOW
|
• Acute: No short-term functional improvement differences in flexion/extension, rotation,
or lateral flexion range of motion were found in manipulation therapy vs. home exercise
groups in two studies
• Acute: No long-term functional improvement differences in flexion/extension, rotation,
or lateral flexion range of motion were found in manipulation therapy vs. home exercise
groups in one study
|
Acute: HIGH
Acute: HIGH
|
YES (1)
imprecise
YES (2)
consistency unknown,
imprecise
|
NO
NO
|
Functional Outcomes
-
Functional outcomes in chronic pain subjects were assessed at 11 weeks after initiation
of treatment. There were no significant differences in flexion or extension endurance
in subjects who received spinal manipulation therapy compared with exercise with a
physical therapist. The exercise group experienced a greater improvement in extension
strength, but not flexion or rotation strength, compared with the manipulation therapy
group (p < 0.05). Further, the exercise group experienced a greater increase in flexion or extension
range of motion, but not rotation or lateral flexion range of motion, compared with
the manipulation therapy group (p < 0.05).[7]
Other Outcomes
-
Complications: There were no significant differences in treatment complications reported
when comparing subjects who underwent spine manipulation therapy to those who received
exercise.[7]
-
Other: No significant differences between treatment groups were reported for analgesic
use at 11, 52, or 104 weeks.[7]
[8]
Clinical Guidelines
Only one potentially relevant clinical guideline was identified.
The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders
(Neck Pain Task Force) provided recommendations for assessment and treatment of patients
with neck pain.[13]
-
The Neck Pain Task Force recommends that people seeking primary care for neck pain
should be triaged into four groups:
-
○ Grade I: No signs of major pathology and no or little interference with daily activities
-
○ Grade II: No signs of major pathology, but interference with daily activities
-
○ Grade III: Neurologic signs of nerve compression
-
○ Grade IV: Signs of major pathology
-
Diagnostic testing is not indicated in the initial assessment of grade I or II neck
pain. People with suspected grade III neck pain might require elective investigation.
People with suspected grade IV neck pain require immediate investigation.
-
Exercises and mobilization have been shown to provide some degree of short-term relief
of grade I or II neck pain after a motor vehicle collision.
-
Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser
have been shown to provide some degree of short-term relief of grade I or II neck
pain without trauma.
-
Those with confirmed grade III and severe persistent radicular symptoms might benefit
from corticosteroid injections or surgery. Those with confirmed grade IV neck pain
require management specific to the diagnosed pathology.
Evidence Summary
In patients who underwent manipulation therapy compared with exercise, the overall
strength of evidence was low for treatment of both acute and chronic pain; that is,
we have low confidence that the evidence reflects the true effect of differences in
outcomes between treatments, and future research is likely to change the confidence
in the estimate of effect and is likely to change the estimate ([Table 4]). For comparisons of mobilization therapy versus physical therapy, the overall strength
of evidence is low for all outcomes with the exception of short-term functional improvement,
which was considered moderate, meaning that we have moderate confidence that the evidence
reflects the true effect, and further research may change our confidence in the estimate
of effect and may change the estimate ([Table 4]). No studies were performed in patients with chronic pain comparing these treatments.
