From: Arch Phys Med Rehabil. 2010 Sep;91(9):1313-1318

To determine whether neck manipulation is more effective for neck pain than mobilization, a randomized controlled trial with blind assessment of outcome was undertaken by the authors. The setting was Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.

Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks, from which the number of days taken to recover from the episode of neck pain.

The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization. The authors concluded that neck manipulation is not appreciably more effective than mobilization. The authors further noted that the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

It would be interesting to note a similar number of patients without any neck manipulation or mobilization and the number of median days to recover from nonspecific neck pain of less than 3 months duration. Additionally, the conclusion that “the use of neck manipulation therefore cannot be justified on the basis of superior effectiveness” should include – for nonspecific neck pain less than 3 months in duration with 4 treatments over a 2 week period. Without the entire article, one can only speculate why 4 treatments over 2 weeks would be deemed reasonable treatment for a nonspecific entity with either modality.

I presume the full article would delineate the criteria for being deemed suitable for treatment with manipulation or mobilization by the treating practitioner and if the evaluation methods were uniform between practitioners. Furthermore, the article should indicate specific analysis to reach a broad conclusion that manipulation cannot be justified on the basis of superior effectiveness – in fact, the abstract should have indicated that mobilization was more effective than manipulation for nonspecific neck pain of less than 3 months duration in a heterogeneous group of treating practitioners performing 4 treatments over a 2 week period.

From: Work. 2010;35(3):369-94

The literature relevant to the treatment of Whiplash Associated Disorders is extensive and heterogeneous. A Participatory Action Research approach was used to engage a chiropractic community of practice and stakeholders in a systematic review to address a general question: ‘Does chiropractic management of whiplash associated disorders clients have an effect on improving health status?’ A systematic review of the empirical studies relevant to whiplash associated disorders interventions was conducted followed by a review of the evidence.

The initial search identified 1,155 articles. Ninety-two of the articles were retrieved, and 27 articles consistent with specific criteria of whiplash associated disorders intervention were analyzed in-depth. The best evidence supporting the chiropractic management of clients with whiplash associated disorders is reported. Further review identified ways to overcome gaps needed to inform clinical practice and culminated in the development of a proposed care model: the whiplash associated disorders-plus model.

There is a baseline of evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash associated disorders. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The whiplash associated disorders-plus model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, subacute and chronic pain due to whiplash associated disorders. Furthermore, the whiplash associated disorders-plus model can be used in the future study of interventions and outcomes to advance evidence-based care in the management of whiplash associated disorders.

From: N Z Med J. 2010 Apr 9;123(1312):36-44

Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache, migraine, infant colic, colic, ear infection, earache, otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence).

A review of 200 chiropractor websites and 9 chiropractic associations’ World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment.

The authors found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache, migraine. Unsubstantiated claims were made about asthma, ear infection, earache, otitis media, neck pain.

The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. The authors suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

It is unclear from the abstract of this article what “sound evidence” and “some evidence” is considered or based on. To make a statement that website claims by some chiropractors constitute an ethical and public health issue is a bold and biased opinion. The fact that medical professionals and their associates are absorbing chiropractic methods would indicate these claims are not an ethical and public health issue. Additionally, chiropractors have been practicing for more than 100 years without using medications or surgery. To state that there is no evidence to support the use of chiropractic methods for neck pain or whiplash is an ethical and public health issue. Current evidence supports the use of chiropractic methods for cervicogenic headache. Perhaps the entire article would prove more efficacious in defining “sound evidence” and “some evidence”, along with relating these claims as an ethical and public health issue, however, the conclusions reached by the authors based on 209 website claims (ubiquitous?) in 5 countries are certainly biased and their motivations should be questioned.

Based on the authors conclusions, I recommend that all chiropractic and association websites state, “We might help some lower back pain, but that’s it!” or “If your looking for sound evidence, try drugs and surgery”.

From: Work. 2010;35(3):369-94

The literature relevant to the treatment of Whiplash Associated Disorders is extensive and heterogeneous. A Participatory Action Research (PAR) approach was used to engage a chiropractic community of practice and stakeholders in a systematic review to address a general question: ‘Does chiropractic management of Whiplash Associated Disorder clients have an effect on improving health status?’ A systematic review of the empirical studies relevant to Whiplash Associated Disorders interventions was conducted followed by a review of the evidence.

The initial search identified 1,155 articles. Ninety-two of the articles were retrieved, and 27 articles consistent with specific criteria of Whiplash Associated Disorder intervention were analyzed in-depth. The best evidence supporting the chiropractic management of clients with Whiplash Associated Disorders is reported. Further review identified ways to overcome gaps needed to inform clinical practice and culminated in the development of a proposed care model: the Whiplash Associated Disorders-Plus Model.

There is a baseline of evidence that suggests chiropractic care improves cervical range of motion (cROM) and pain in the management of Whiplash Associated Disorders. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The Whiplash Associated Disorders-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, subacute and chronic pain due to Whiplash Associated Disorders. Furthermore, the Whiplash Associated Disorders-Plus Model can be used in the future study of interventions and outcomes to advance evidence-based care in the management of Whiplash Associated Disorders.

From: J Manipulative Physiol Ther. 2010 March – April;33(3):168-177.

Chronic neck pain is a common problem in modern, industrialized countries. It has been estimated that 67% of people will experience neck pain at some point in their lives. A proportion of these individuals with neck pain do not experience complete resolution of their pain and disability, which can turn into a more complex chronic pain syndrome. What is not well understood is what causes neck pain to become chronic. An emerging school of thought in the mechanism of chronicity in nonspecific neck pain is that it is related to abnormal muscle recruitment patterns, which may put the spine at greater risk of further injury. Impaired neuromuscular function in patients with chronic neck pain is becoming increasingly recognized, most notably, an impaired ability to activate the neck flexor muscles during rapid limb movements and an impaired ability to relax the neck extensor muscles.

The solution proposed in previous research has been based on the idea of using specific exercise strategies to improve these impaired neuromuscular patterns. Recent research indicates that both exercise and chiropractic care involving spinal manipulation may also be able to improve these impaired neuromuscular patterns. Chiropractic techniques appear to be able to help normalize altered patterns of muscle recruitment and sequencing observed in the presence of musculoskeletal impairments and pain.

Contemporary research into the pathogenesis of nonspecific neck pain relates to the manifestation of abnormal muscle recruitment patterns. Impaired neuromuscular function in patients with chronic neck pain is becoming increasingly recognized, most notably the impaired activation of the neck flexor muscles during rapid upper limb movement. An additional measure that may be used for impaired neuromuscular function is the cervical flexion-relaxation response, a measure of the ability to relax the cervical extensors at full forward flexion. There is a lack of evidence for how commonly used interventions for chronic neck pain, such as spinal manipulation or exercise, may change these measures of impaired neuromuscular function in the neck.

The flexion-relaxation response, commonly measured in the posterior kinetic chain muscles (such as the erector spinae, hamstrings), is the electrical silence that is observed during full forward flexion of the trunk or neck as the passive structures of the spine maintain stability. Individuals with either chronic neck or back pain have been shown to exhibit heightened muscle activity at full flexion of the neck and trunk, respectively. Recent results suggest that for the lumbar spine, the flexion-relaxation response may be an important marker of neuromuscular impairment, which can show improvement with an appropriate intervention. After an exercise intervention for individuals with chronic low back pain, it was shown that changes in the flexion-relaxation response explained 38% of the improvement in self-reported disability. This change seems to be predominantly manifested as improved relaxation at full trunk flexion. Although the cervical flexion-relaxation response is a reliable measure able to discriminate between patients with and without chronic neck pain, it is not known if this response will change after treatment interventions.

Similar to the deep abdominal muscles, the cervical flexor muscles have a pattern of activating within 50 milliseconds before the onset of activity in the deltoid muscles during rapid upper limb movements in healthy subjects. Falla et al (2004) showed impaired feed-forward activation in people with chronic neck pain. When subjects with a history of neck pain performed arm flexion, the activation onsets of deep cervical flexors ipsilateral to the sight of arm movement as well as the contralateral (right) sternocleidomastoid and anterior scalene muscles were significantly delayed compared with the relative latencies for the control group.

A recent review by Vernon et al found moderate to high quality evidence that manipulation at 6, 12, and up to 104 weeks was an effective treatment for neck pain not due to whiplash with effect sizes from 0.56 to 3.2, most of which would be considered large. These effect sizes were maintained up to 12 weeks posttreatment. Only 2 studies had long-term data but still showed large effect sizes for up to 104 weeks. A Cochrane review found a strong benefit of manipulation and/or mobilization combined with exercise vs waiting list controls for pain reduction, improvement in function and global perceived effort. What has not been assessed in most neck pain intervention studies is whether the treatment is able to affect neuromuscular function. It may be that manipulation is able to affect one type of neuromuscular impairment and another specific exercise, and that the combined treatment effect may be synergistic. It may also be that improved neuromuscular function may be a marker of an effective treatment.

The purpose of this study was to evaluate manipulation-based chiropractic care combined with strengthening exercises as compared with strengthening exercises only for the treatment of chronic neck pain, with the inclusion of the cervical flexion-relaxation response and cervical feed-forward activation latencies as measures of neuromuscular activation.

The main hypotheses of this study were (1) that improvements in functional capacity would be greatest for patients who received the combination of chiropractic care and exercise compared with exercise only and (2) that these improvements would be reflected by changes in neuromuscular deficits.

The major finding in this study was that chiropractic care combined with 8 weeks of exercise and exercise alone are both effective at reducing perceived levels of functional neck disability and pain. The null hypothesis was proven in this study because there were no significant differences between the 2 groups. The effective size calculations for the differences between the 2 groups was .293, which is a small effect,28 and the sample size calculations indicated that 145 subjects per group would be needed to show a difference between the 2 groups based on the NDI. Population scores suggest that both groups had mild disability at baseline, and although a decrease in score was observed in both groups, the classification did not change after the intervention. It may be because both groups were in the “mild category,” and it was a pilot study that the study lacked sufficient power to show a difference between treatments. There was also a lot of variability in the degree of change between individual subjects as shown by the large SDs, which had the effect of decreasing the effective size and increasing the estimated sample size required to show a difference between the 2 groups. Another important consideration is whether the small difference between the 2 groups has enough clinical relevance to justify the costs of an RCT involving 290 participants.

There was a decrease for both groups in current pain scores and “worst pain,” which was significant overall, but again, because of the large degree of variability between the groups, the effect sizes were small for both, and sample size estimates indicated that 88 subjects per group would be needed to show a difference between treatments for “pain now” and 82 per group for “worst pain.”

Improvements in the flexion-relaxation results would be indicated by an increased flexion-relaxation response, indicating improved relaxation (decreased myoelectric activity at full flexion). Both groups would be considered initially impaired based on previous work in the lumbar spine. The flexion-relaxation response actually worsened slightly for the exercise group and improved minimally for the manipulation group. This result contrasts with previous work, which showed that an 8-week exercise intervention was able to improve the flexion-relaxation response in the lumbar spine. The fact that the manipulation group group that had manipulation before exercise improved slightly is in keeping with previous work in the lumbar spine. This trend toward improvement in the manipulation group group as compared with the exercise group group is in keeping with the authors initial hypothesis and suggests spinal manipulation before exercise may help to normalize neuromuscular function and enable people to better cope with the demands of exercise. Given the reasonably low number of participants required to determine whether the 2 forms of treatment have differential effects on this outcome measure, the authors could recommend a future RCT with 40 participants per group to allow for dropouts.

Improvements in feed-forward responses would be indicated by faster onset times in the cervical flexor muscles in relation to deltoid onset times (within 50 milliseconds). Previous work by Falla et al indicated that chronic neck pain patients exhibit delayed activation of the cervical flexor muscles. The baseline results for feed-forward activation were not impaired in the chronic neck pain patients who participated in this trial when compared with Falla’s results. This could explain the lack of finding for the anterior scalene muscles in the manipulation group group compared with Marshall and Murphy’s study where only subjects who showed evidence of delayed feed-forward activation received spinal manipulation therapy. The authors do not think the feed-forward changes reported in this study should be used for sample size calculations, because the participants did not actually show delayed activation before the treatments.

An important consideration in interpreting our results is that 8 weeks may not be enough time to show the full range of improvement in neuromuscular measures. A more recent article by Marshall and Murphy for the low back has indicated that at a 9-month follow-up feed-forward activation had improved in a group of chronic low back pain patients even though these changes were not present after 12 weeks of exercise.

This pilot study showed that both exercise and exercise combined with manipulation can improve pain and disability in people with long-term neck pain. The study indicates that the flexion-relaxation response changes had an effective size of .636, and 32 subjects per group would be needed to show a difference between the 2 treatments with an a of .05 and a power of 0.8.

From: J Manipulative Physiol Ther. 2010 Feb;33(2):96-101

The purpose of this study was to examine the effect of manipulative therapy on the shoulder girdle, in addition to usual care provided by the general practitioner, on the outcomes of physical examination tests for the treatment of shoulder complaints.

In clinical practice, a dysfunction of the shoulder girdle can be treated by manipulative therapy, which aim is to restore normal functioning of the shoulder girdle. To date, with only 1 randomized trial favoring manipulative therapy for the shoulder girdle, the evidence for the effectiveness of manipulative treatment in the treatment of shoulder complaints is scarce. Therefore, the authors conducted a randomized trial to study the effect of manipulative therapy for the shoulder girdle in addition to usual care by the general practitioner in the treatment of shoulder complaints. The design of this study and the main patient-experienced results are already published. The results indicate that additional manual therapy for the structures of the shoulder girdle accelerates recovery of patient-experienced shoulder symptoms and reduces their severity. In the present article, the results for the physical examination outcome measures are presented.

In the clinical research of musculoskeletal complaints, physical testing of pain and mobility by the physician are important outcomes. However, this concerns mostly multiple physical examination tests and multiple outcome measures. This requires multiple statistical testing. Together with small study sizes (more outcomes than patients), this may lead to spurious significant results from randomized trials affecting the interpretability of the outcome of the trial.

The challenge is to reduce the number of variables in such a way that they are clinically sensible and statistically manageable. To overcome the aforementioned problems with pain and mobility as outcome measures of our randomized trial, we tried to reduce the individual physical examination tests for pain and mobility to relevant components. In this study, we used a physical assessment of pain and mobility of the shoulder and shoulder girdle as outcome measures. They consist primarily of the assessment of active and passive limitations in shoulder movement and pain experienced during these movements and a physical examination of the cervicothoracic spine, consisting of passive movements of the neck and pain experienced in these movements. The authors used factor analysis to identify relevant components from these variables thereby reducing the number of outcome measures in a clinically meaningful sense and to increase statistical power. The purpose of this study was to examine the effect of manipulative therapy on the shoulder girdle, in addition to usual care provided by the general practitioner, on the outcomes of physical examination tests for the treatment of shoulder complaints.

This was a randomized controlled trial in a primary care setting in the Netherlands. A total of 150 participants were recruited from December 2000 until December 2002. All patients received usual care by the general practitioner. Usual care included one or more of the following depending on the needs of the patient: information/advice, oral analgesics or nonsteroidal antiinflammatory drugs, corticosteroid injections, exercises, and massage. In addition to usual care, the intervention group received manipulative therapy, up to 6 treatment sessions in a 12-week period. Twenty-four physical examination tests were done at baseline and after 6, 12, and 26 weeks. Factor analysis was done to reduce the number of outcome measures.

The factor analysis resulted in 4 factors: “shoulder pain,” “neck pain,” “shoulder mobility,” and “neck mobility.” At 6 weeks, no significant differences between groups were found. At 12 weeks, the mean changes of all 4 factors favored the intervention group; the factors “shoulder pain” and “neck pain” reached statistical significance. At 26 weeks, differences in the factors “shoulder pain”, “shoulder mobility”, and “mobility neck” statistically favored the intervention group.

In clinical trials concerning treatment of shoulder complaints, factor analysis is useful for the reduction of multiple outcomes of physical examination data and therefore increases statistical power. On the basis of the factors derived from physical examination tests of the shoulder and the cervicothoracic spine, the authors conclude that manipulative therapy, in addition to usual care by the general practitioner, diminishes the severity of the pain in the shoulder and neck and improves the mobility of the shoulder and the cervicothoracic spine. Results were most prominent at 26 weeks after initiation of treatment.

From: Physiother Res Int. 2010 Feb 9. [Epub ahead of print]

The deep neck flexor muscles stabilize the cervical spine and cervicogenic pain appears to adversely affect their endurance capacity. They are inaccessible to direct palpation, thereby making assessment difficult. However, the cranio-cervical flexion test provides an indirect method of assessing the endurance capacity of the deep neck flexor muscles. The purpose of the present study was to evaluate the intratester reliability of the cranio-cervical flexion test in asymptomatic subjects.

The clinical protocol of the cranio-cervical flexion test was measured on two occasions with 7 days between measurements. Prior to testing, participants were trained and compensation strategies were corrected. Nineteen asymptomatic participants (mean age 24.9 years; range 22-36) were recruited.

The test had excellent intratester reliability (intraclass correlation coefficient = 0.983; standard error of the mean = 8.94; smallest real difference = 24.7). A Bland and Altman’s limits of agreement analysis confirmed the high reliability of the test.

The cranio-cervical flexion test results demonstrated excellent intra-tester reliability in asymptomatic subjects, thus contributing to the normative data regarding the test.

Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004249

Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain.

To assess if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life, and global perceived effect in adults with acute, subacute and chronic neck pain with or without cervicogenic headache or radicular findings.

(The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, Manual Alternative and Natural Therapy, CINAHL, and Index to Chiropractic Literature were updated to July 2009. Randomised controlled trials on manipulation or mobilisation. Two review authors independently selected studies, abstracted data, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.

The authors included 27 trials (1522 participants). Cervical Manipulation for subacute and chronic neck pain : Moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate term follow-up. Low quality evidence showed manipulation alone compared to a control may provide short term relief following one to four sessions and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache.

Optimal technique and dose need to be determined. Thoracic Manipulation for acute/chronic neck pain : Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured a single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5, 29% treatment advantage).

Mobilisation for subacute/chronic neck pain: In addition to the evidence noted above, low quality evidence for subacute and chronic neck pain indicated that 1) a combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) there was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; and 3) neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisation techniques were superior.

Cervical manipulation and mobilisation produced similar changes. Either may provide immediate or short term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

From: J Man Manip Ther. 2009;17(2):101-8

The purpose of this single-blinded, randomized controlled trial was to compare the effects of a manual treatment technique on neck pain and movement sensation when applied in different segments of the cervical spine. Consecutive patients with neck pain (n=126) were recruited and randomly allocated to two groups (A or B). Group A received a single 4-minute pain alleviating traction at the most symptomatic zygopophyseal joint of the cervical segment, where movement was correlated with pain. Group B received the same treatment 3 segments away from the concordant segment. Pain intensity and sensation of movement were assessed with a numeric rating scale. Statistical analysis included a t-test for paired and unpaired samples. Pre- and post-test findings demonstrated significant improvements in both types of mobilization although there was no significant difference between the two groups. Similar results have been reported in the literature for cervical manipulation. The findings of this study question the necessity of precise symptom localization tests for a pain treatment. However, limitations of the study prevent generalization of these results.

From: J Chiropr Med. 2009 Dec;8(4):143-55.

The purpose of this study was to determine the feasibility of a chiropractic practice-based research network to investigate the treatment of acute neck pain and to report resulting findings. Participating chiropractors recruited sequentially presenting acute neck pain patients on their initial visit to the office. Patients were treated by the chiropractors using their usual methods. Data were prospectively collected by having patients complete the Neck Disability Index, Characteristic Pain Intensity score, and a patient satisfaction questionnaire. Questionnaires were completed during routine office visits at baseline and then at weeks 1, 2, 4, 8, and 26, either in the office or by mail.

Ten chiropractors supplied data on 99 patients. The number of cases contributed by each of the participating chiropractors ranged from 1 to 54, with a mean (SD) of 9.2 (10.5). Mean (SD) Neck Disability Index scores were 36 (17.9) at baseline and 9.8 (12.2) at the final evaluation; the Characteristic Pain Intensity scores were initially 55.3 (20.4) and were 24.5 (21.5) at the final evaluation. Transient minimal adverse effects were reported by chiropractors for only 7 (7.8%) patients. No serious adverse reactions were reported.

The practice-based research methodology used in this study appears to be a feasible way to investigate chiropractic care for acute neck pain, and its methodologies could be used to plan future research.

Tags: acute, neck, pain, , chiropractic, , chiropractors