'Spinal Manipulation, Exercise Trump Drugs for Neck Pain'

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FYI. s.fuchs dc

Spinal

Manipulation, Exercise Trump Drugs for Neck Pain

Fran

Lowry

January 5, 2012 — Spinal manipulation therapy (SMT) and exercises

that patients can learn to do at home are more effective than medication for

relieving neck pain, both in the short and long term, according to results from

a new study published in the January 2012 issue of the ls of Internal Medicine.

However,

the results of this trial are not going to be applicable to all patients, lead

author Gert Bronfort, DC,

PhD, from the Wolfe- Center for Clinical Studies, Northwestern

Health Sciences

University, Bloomington, Minnesota,

told Medscape Medical News.

" You

have to individualize the treatment, " he said. " It has a lot to do

with where the patients are in their history of neck pain, what they've

experienced in the past, and what their preferences are, but at least these

treatments represent some viable options that can be offered to patients. "

Dr.

Bronfort said that he and his team believed that spinal manipulation would be

better than medication for improving neck pain, at least in the short term,

based on their past experience. However, they were surprised to find that the home

exercise program turned out to be just as successful, he admitted.

" The

home program involved a couple hours of instruction in self care and specific

neck exercises, where patients were taught how to avoid certain postures, such

as sleeping and working postures, that would aggravate their neck pain, "

he explained.

Nonspecific Neck Pain

In the

study, 272 patients aged 18 to 65 years who had nonspecific neck pain for 2 to

12 weeks were randomly assigned to receive 12 weeks of spinal manipulation

therapy, medication, or home exercise with advice. The spinal manipulation

therapy was given by 5 chiropractors who were well-trained and experienced in

the procedure, Dr. Bronfort said.

Medication

was provided by licensed medical physicians, with a focus on prescription

drugs. First-line therapy was nonsteroidal anti-inflammatory drugs,

acetaminophen, or both, the authors note. Those patients who did not respond or

could not tolerate the first-line therapy received narcotic medications. Muscle

relaxants were also used, and advice to stay active or modify activity was

given as needed. " The choice of medications and number of visits was made

by the physician on the basis of the participant's history and response to

treatment, " the authors write.

Pain, as

reported by the study participants, was measured at 2, 4, 8, 12, 26, and 52

weeks.

Results

showed that spinal manipulation had a statistically significant advantage over

medication after 8, 12, 26, and 52 weeks (P

< .010), and that home exercise was superior to medication at 26 weeks (P = .02). No important differences in

pain were found between spinal manipulation therapy and home exercises at any

time.

Patients

who received spinal manipulation therapy or home exercises also reported

similar improvements in self-reported disability, medication use, general

health status, and adverse events. However, patients said they were more

satisfied with spinal manipulation than with home exercise.

With

regard to adverse effects, 40% of the spinal manipulation group and 46% of the

home exercise group reported adverse events. The most common was

musculoskeletal pain, and less frequently they experienced paresthesia,

stiffness, headache, and crepitus.

Among

patients randomly assigned to the medication group, 60% reported adverse effects.

The most common were gastrointestinal symptoms and drowsiness, followed by dry

mouth, cognitive disturbances, rash, congestion, and disturbed sleep.

Dr.

Bronfort pointed out that patients could not be blinded in this study, and that

this was an important limitation. He also suggested that participants who

received spinal manipulation may have been more likely to experience

improvement in their neck pain and be more satisfied with their care because

they had more frequent interactions with their care providers.

" When

we started the study there was really not very much scientific evidence to

support any treatment, really, " he said. " You would think that neck

pain would disappear by itself, and it does in a number of patients, but about

half will go on to have chronic or sporadic neck pain, even a year later. What

we don't know is to what extent spinal manipulation or home exercise can

prevent more chronic conditions, and this is something that we need to find

out. "

Pragmatic Trials

In an accompanying

editorial, Bruce F. , DC, MPH, DrPH, from Murdoch

University, Perth,

and Simon D. French, PhD, from the University

of Melbourne, both in Australia,

point out that the 3 therapies in this study were not compared with a placebo

or sham therapy. Such comparisons would have provided more convincing evidence

of effectiveness, they write.

A cost

analysis would also have been useful, they add, and they point out that neck

manipulation has the potential for a rare, but potentially catastrophic, risk

for vertebral artery stroke, and warn that patients should be advised of this

possibility.

" Pragmatic

trials, such as the one by Bronfort and colleagues, have their place in

answering important questions about current treatment approaches, but we need

innovative studies that explore which treatments benefit which of the many

people who experience disabling neck pain, " the editorialists conclude.

This

study was funded by the National

Center for Complementary

and Alternative Medicine, National Institutes of Health. Dr. Bronfort, Dr.

, and Dr. French have disclosed no relevant financial relationships.

Ann

Intern Med. 2012;156:1-10, 52-53. Article

abstract, Editorial extract