Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain
A Randomized Trial
- Gert Bronfort, DC, PhD;
- Roni Evans, DC, MS;
- Alfred V. Anderson, DC, MD;
- Kenneth H. Svendsen, MS;
- Yiscah Bracha, MS; and
- Richard H. Grimm, MD, MPH, PhD
From Northwestern Health Sciences University, Pain Management and Rehabilitation Center, and Berman Center for Outcomes and Clinical Research at the Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
Background: Mechanical neck pain is a common condition that affects an estimated 70% of persons at some point in their lives. Little research exists to guide the choice of therapy for acute and subacute neck pain.
Objective: To determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term.
Design: Randomized, controlled trial. (ClinicalTrials.gov registration number:NCT00029770)
Setting: 1 university research center and 1 pain management clinic in Minnesota.
Participants: 272 persons aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks.
Intervention: 12 weeks of SMT, medication, or HEA.
Measurements: The primary outcome was participant-rated pain, measured at 2, 4, 8, 12, 26, and 52 weeks after randomization. Secondary measures were self-reported disability, global improvement, medication use, satisfaction, general health status (Short Form-36 Health Survey physical and mental health scales), and adverse events. Blinded evaluation of neck motion was performed at 4 and 12 weeks.
Results: For pain, SMT had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks (P ? 0.010), and HEA was superior to medication at 26 weeks (P = 0.02). No important differences in pain were found between SMT and HEA at any time point. Results for most of the secondary outcomes were similar to those of the primary outcome.
Limitations: Participants and providers could not be blinded. No specific criteria for defining clinically important group differences were prespecified or available from the literature.
Conclusion: For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points.
Primary Funding Source: National Center for Complementary and Alternative Medicine, National Institutes of Health.
Senna, Mohammed K. MD; Machaly, Shereen A. MD
Study Design. A prospective single blinded placebo controlled study was conducted.
Objective. To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic nonspecific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments.
Summary of Background Data. SMT is a common treatment option for LBP. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic nonspecific LBP has not been studied.
Methods. Sixty patients, with chronic, nonspecific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with “maintenance spinal manipulation” every 2 weeks for the following 9 months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-, 4-, 7-, and 10-month intervals.
Results. Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively). However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the nonmaintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.
Conclusion. SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
By Michael Smith, North American Correspondent, MedPage Today Published: March 21, 2011 Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
More than one in 10 people in a prospective cohort developed chronic widespread pain over a four-year period and most of them were involved in a traumatic event during that time, researchers reported.
Among those who reported new, widespread chronic pain, 43% said they had experienced a traffic accident, surgery, or broken bones over the same period, according to Gareth Jones, PhD, of the University of Aberdeen in Aberdeen, Scotland, and colleagues.
In contrast, only 36% of those who remained pain-free reported such an incident, Jones and colleagues reported online in Arthritis Care & Research.
Note that among those who reported new, widespread chronic pain, 76% said they had experienced a traffic accident, surgery, or broken bones over the same period.
Explain that traffic accidents alone was a significant predictor of new chronic widespread pain but lost significance after further adjustment for anxiety and sleep problems.
Much of the difference – which approached but did not reach statistical significance — was driven by traffic accidents, workplace injuries and fractures, Jones and colleagues reported.
Chronic widespread pain, according to the American College of Rheumatology, is pain above and below the waist, or on both the left and right sides of the body, for three months or longer.
Earlier research has suggested the prevalence of the condition a primary characteristic of fibromyalgia — is about 11% to 13%. People with chronic widespread pain often attribute it to a single precipitating condition, such as a car accident, but there is little evidence to support that, Jones and colleagues noted.
To help fill the gap, they turned to the EpiFunD Study (for Epidemiology of Functional Disorders), a large prospective cohort study in northwest England.
At the start of the study, 6,290 people were recruited from three general practices in Manchester, England and were asked to fill out a questionnaire, part of which asked about chronic pain.
For this study, the researchers asked the same questions four years later of those who had been chronic pain-free at baseline. All told, 4,444 were known to be available for follow-up and 2,069 completed a second questionnaire, Jones and colleagues reported.
Of those, 241 — or 11.6% — said they now had chronic widespread pain and 37.2% reported at least one traumatic event over the same period, including traffic accident, workplace injury, surgery, fracture, inpatient treatment for any other reason, and, in women, childbirth.
More people with chronic widespread pain reported a traumatic event — 88 of 203 versus 596 of 1,638 — and the crude odds ratio was 1.34 with a 95% confidence interval from 0.996 to 1.80. While that approached significance, the researchers noted, adjustment for age, sex, baseline pain status, and the general practice from which participants were recruited attenuated the odds ratio even further.
In an analysis adjusted for age, sex, general practice and baseline pain status, traffic accidents alone remained a significant predictor of new chronic widespread pain.
The odds ratio was 1.84, with a 95% confidence interval from 1.10 to 3.11, Jones and colleagues reported, but it lost significance after further adjustment for anxiety and sleep problems.
Nonetheless, they argued, there is “some evidence to suggest that involvement in a road traffic accident, specifically, may confer an increase in the risk” of the condition.
Future research should try to determine what specific aspects of traffic accidents might be responsible, they concluded.
The researchers cautioned that the loss of more than half of the cohort to follow-up reduced the study’s statistical power. And, they added that it was not possible to tell which came first chronic pain or a traumatic event.
BACKGROUND CONTEXT: Evidence-based clinical practice guidelines (CPGs) for the management of patients with acute mechanical low back pain (AM-LBP) have been defined on an international scale. Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments. To date, the value of implementing full and exclusively CPG-based treatment remains unclear.
PURPOSE: To determine if full CPGs-based study care (SC) results in greater improvement in functional outcomes than family physician-directed usual care (UC) in the treatment of AM-LBP.
STUDY DESIGN/SETTING: A two-arm, parallel design, prospective, randomized controlled clinical trial using blinded outcome assessment. Treatment was administered in a hospital-based spine program outpatient clinic.
PATIENT SAMPLE: Inclusion criteria included patients aged 19 to 59 years with Quebec Task Force Categories 1 and 2 AM-LBP of 2 to 4 weeks’ duration. Exclusion criteria included “red flag” conditions and comorbidities contraindicating chiropractic spinal manipulative therapy (CSMT).
OUTCOME MEASURES: Primary outcome: improvement from baseline in Roland-Morris Disability Questionnaire (RDQ) scores at 16 weeks. Secondary outcomes: improvements in RDQ scores at 8 and 24 weeks; and in Short Form-36 (SF-36) bodily pain (BP) and physical functioning (PF) scale scores at 8, 16, and 24 weeks.
METHODS: Patients were assessed by a spine physician, then randomized to SC (reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar CSMT, and return to work within 8 weeks), or family physician-directed UC, the components of which were recorded.
RESULTS: Ninety-two patients were recruited, with 36 SC and 35 UC patients completing all follow-up visits. Baseline prognostic variables were evenly distributed between groups. The primary outcome, the unadjusted mean improvement in RDQ scores, was significantly greater in the SC group than in the UC group (p=.003). Regarding unadjusted mean changes in secondary outcomes, improvements in RDQ scores were also greater in the SC group at other time points, particularly at 24 weeks (p=.004). Similarly, improvements in SF-36 PF scores favored the SC group at all time points; however, these differences were not statistically significant. Improvements in SF-36 BP scores were similar between groups. In repeated-measures analyses, global adjusted mean improvement was significantly greater in the SC group in terms of RDQ (p=.0002), nearly significantly greater in terms of SF-36 PF (p=.08), but similar between groups in terms of SF-36 BP (p=.27).
CONCLUSIONS: This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.
Objectives: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).
Method: A total of 894 cases followed 1 year using workers’ compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.
Results: Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).
Conclusions: In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.
Journal of Occupational & Environmental Medicine:
April 2011 – Volume 53 – Issue 4 – p 396–404
On Februrary 8th, 2010 a survey was published in the Archives of Internal Medicine regarding the management of acute low back pain in general practice to see if low back pain guidelines were being followed. In summary, the care being provided did not match evidence based care. Primarily, too much imaging and incorrect pharmaceuticals used for acute low back pain. The study categorized spinal manipulation under a general therapy catagory, so it is unclear how often GP’s refer for spinal manipulation. The following is the abstract, and full text of the article can be found here.
Low Back Pain and Best Practice Care
A Survey of General Practice Physicians
Christopher M. Williams, MAppSc; Christopher G. Maher, PhD; Mark J. Hancock, PhD; James H. McAuley, PhD; Andrew J. McLachlan, PhD; Helena Britt, PhD; Salma Fahridin, MHSc; Christopher Harrison, MSocHlth; Jane Latimer, PhD
Archives of Internal Medicine 2010;170(3):271-277.
Background Acute low back pain (LBP) is primarily managed in general practice. We aimed to describe the usual care provided by general practitioners (GPs) and to compare this with recommendations of best practice in international evidence-based guidelines for the management of acute LBP.
Methods Care provided in 3533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines. The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004).
Results Although guidelines discourage the use of imaging, over one-quarter of patients were referred for imaging. Guidelines recommend that initial care should focus on advice and simple analgesics, yet only 20.5% and 17.7% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37.4%) and opioids (19.6%). This pattern of care was the same in the periods before and after the release of the local guideline.
Conclusions The usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time. The unendorsed care may contribute to the high costs of managing LBP, and some aspects of the care provided carry a higher risk of adverse effects.
A new study came out in the New England Journal of Medicine regarding Vertebroplasty and its ineffectiveness. The randomized controlled trial found no beneficial effect to the popular procedure compared to a sham procedure.
If your doctor is suggesting Vertebroplasty, you might want a second opinion, or talk to your doctor about these studies. This procedure is not free of risk as there has been reported deaths with the procedure as well as lung and heart damage.
Here are the conclusions from each study:
A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures
New England Journal of Medicine – Volume 361:557-568 August 6, 2009 Number 6
Conclusions We found no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures, at 1 week or at 1, 3, or 6 months after treatment.
A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures
New England Journal of Medicine – Volume 361:569-579 August 6, 2009 Number 6
Conclusions Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group.
To Your Health,
Dr. Trent Artichoker MS, DC
Denver Chiropractic, LLC
3890 Federal Blvd Unit 1
Denver, CO 80211
Treating chronic low back pain can be difficult, to say the least. A recent article by the American Family Physician explored various nonpharmacologic treatment options for chronic low back pain. Among the options, spinal manipulation therapy is mentioned, “Spinal manipulation provides modest short- and long-term relief of back pain, improves psychological well-being, and increases functioning.”
American Family Physician
Volume 79 Number 12 • June 15, 2009
Chronic Low Back Pain: Evaluation and Management
ALLEN R. LAST, MD, MPH, and KAREN HULBERT, MD
What are the options for treating or managing chronic back pain?
1. Acupuncture – short term relief, improve function
2. Exercise therapy focused on the core – small improvement in pain and function
3. Behavior and progressive relaxation therapy – as effective as exercise for short term pain relief
4. Biofeedback therapy – mixed results
5. Multidisciplinary rehab program with psychological, social, or vocational intervention – alleviate subjecive disability, reduce pain, return person to work five weeks earler, reduce sick time by 7 days, benefit persists up to five years
6. Acupuncture massage and pressure point massage – mildly helpful in reducing pain, benefits up to one year
7. Massage – most effective when combined with exercise, stretching, and education
8. Spinal Manipulation – modest short and long tern relief of back pain, improves psychological well-being, and increases function
9. Viniyoga – six weeks of yoga decreased need for meds
10. Other forms of yoga – mixed results
11. Back schools – conflicting evidence
12. Low-level laser therapy – conflicting evidence
13. lumbar supports – conflicting evidence
14. Prolotherapy – conflicting evidence
15. Short wave diathermy – conflicting evidence
16. Transcutaneous electrical nerve stiulation – conflicting evidence
17. Ultrasound – conflicting evidence
After reading through article, i’m reminded of the difficulties and limitations of researching back pain and evaluation strategies. Ever since words have been written, we still do not know the best strategies in treating chronic back pain. There are to many variables to isolate and test, and we may never know the best treatments, especially since patients respond differently to the same treatments. So, we have seen chiropractic patients respond wonderfully who had chronic low back pain.
This is the big question, and I believe our health care system needs to change its modus operandi. That is more focus on preventive care. Diet, exercise, and lifestyle should be rewarded. What if your health insurance paid for a gym membership, a personal trainer, a dietician, or a life coach.
I’m happy, that as a Denver chiropractor and overall health advocate, that I have been trained in a variety of treatment techniques for people of suffer with back pain.
To Your Health,
Dr. Trent Artichoker MS, DC
Denver Chiropractic, LLC
3890 Federal Blvd Unit 1
Denver, CO 80211