Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain
From: Ann Intern Med. 2002;136:713-722.
Background: Neck pain is a common problem in the general population, with point prevalences between 10% and 15%. It is most common at approximately 50 years of age and is more common in women than in men. Neck pain can be severely disabling and costly, and little is known about its clinical course. Limited range of motion and a subjective feeling of stiffness may accompany neck pain, which is often precipitated or aggravated by neck movements or sustained neck postures. Headache, brachialgia, dizziness, and other signs and symptoms may also be present in combination with neck pain. Although history taking and diagnostic examination can suggest a potential cause, in most cases the pathologic basis for neck pain is unclear and the pain is labeled nonspecific.
Objective: To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner. Conservative treatment methods that are frequently used in general practice include analgesics, rest, or referral to a physical therapist or manual therapist. Physical therapy may include passive treatment, such as massage, interferential current, or heat applications, and active treatment, such as exercise therapies. Physical therapists can specialize in passive manual or hands on techniques, including mobilization or manipulation (high-velocity thrust techniques), also referred to as manual therapy. According to the International Federation of Orthopedic Manipulative Therapies, “Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities”.
Today, many different manual therapy approaches are applied by various health professionals, including medical doctors, physical therapists, massage therapists, manual therapists, chiropractors, and osteopathic doctors. Reviews of trials involving manual therapy or physical therapy show that most interventions in these categories are characterized by a combination of passive and active components. Although a combination of manual therapy or physical therapy that includes exercises appears to be effective for neck pain, these therapies have not been studied in sufficient detail to draw firm conclusions, and the methodologic quality of most trials on neck pain is rather low.
Design: Randomized, controlled trial.
Setting: Outpatient care setting in the Netherlands.
Patients: 183 patients, 18 to 70 years of age, who had had nonspecific neck pain for at least 2 weeks, neck symptoms reproducible during physical examination, willingness to adhere to treatment and measurement regimens, no physical therapy or manual therapy for neck pain during the previous 6 months, no involvement in litigation, and written informed consent. Patients with concurrent headaches, nonradicular pain in the upper extremities, and low back pain were not excluded, but neck pain had to be the main symptom for all patients.
Intervention: 6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).
Measurements: Treatment was considered successful if the patient reported being “completely recovered” or “much improved” on an ordinal six-point scale. Physical dysfunction, pain intensity, and disability were also measured.
Results: At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.
Conclusion: In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
Discussion: We compared the effectiveness of frequently used treatments for nonspecific neck pain in general practice. We found that manual therapy was more effective than continued care, and our results consistently favored manual therapy on almost all outcome measures. Although physical therapy scored slightly better than continued care, most of the differences were not statistically significant. In addition, although manual therapy seemed to be more effective than physical therapy, differences were small for all outcome measures except perceived recovery and were not always statistically significant. The magnitude of the differences between manual therapy and physical therapy, but also between manual therapy and continued care, were most pronounced for perceived recovery. Because perceived recovery combines other outcomes, such as pain, disability, and patient satisfaction, it may be the most responsive outcome measure. For pain intensity, statistically significant differences among the treatment groups ranged from 0.9 to 1.5 on a scale of 0 to 10. Although smaller differences could have been detected with larger sample sizes, they would not have been clinically relevant.
It is of interest that the postulated objective of manual therapy, that is, the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine. The differences among groups in scores on the Neck Disability Index were small (.2 points) and are not considered clinically important. The low disability scores on the Neck Disability Index at baseline may have left only a small margin for improvement. Other studies using the Neck Disability Index have also found that function may not be severely limited in patients with nonspecific neck pain. Our study confirms that manual therapy seems to be a favorable treatment option for patients with neck pain.
Comment: As the most specially trained and educated health care practitioners in the field of manipulation, it would have been interesting comparing the results of manipulations performed by chiropractors. The study places bias and emphasis on physical therapists performing manipulation as consistant attempts by the medical profession to reposition this form treatment.
