Manual Therapy, Physical Therapy, or
Continued Care by a General Practitioner
for Patients with Neck Pain.
A Randomized, Controlled TrialThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
Review a Point-by-Point Analysis of this Study
FROM: Annals of Internal Medicine 2002 (May 21); 136 (10): 713–722 ~ FULL TEXT
Jan Lucas Hoving, PT, PhD; Bart W. Koes, PhD; Henrica C.W. de Vet, PhD;
Danielle A.W.M. van der Windt, PhD; Willem J.J. Assendelft, MD, PhD;
Henk van Mameren, MD, PhD; Walter L.J.M. Devillé, MD, PhD; Jan J.M. Pool, PT;
Rob J.P.M Scholten, MD, PhD; and Lex M. Bouter, PhD
Department of Clinical Epidemiology,
Cabrini Hospital,
Victoria, Australia.
Jan.Hoving@med.monash.edu.au
In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.
BACKGROUND: Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared.
OBJECTIVE: To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner.
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.
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.
From the FULL TEXT Article:
Background
Neck pain is a common problem in the general population, with point prevalences between 10% and 15%. [1–3] It is most common at approximately 50 years of age and is more common in women than in men. [1, 2, 4–6] Neck pain can be severely disabling and costly, and little is known about its clinical course. [7–9] 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. [10, 11] 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.
Conservative treatment methods that are frequently used in general practice include analgesics, rest, or referral to a physical therapist or manual therapist. [12, 13] 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 “handson”) techniques, including mobilization or manipulation (high-velocity thrust techniques), also referred to as manual therapy. [14–19]
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” (unpublished data). 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. [20–23] 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. [20–23]
Koes and colleagues [24, 25] performed a randomized trial on back and neck pain and found promising results for manual therapy and physical therapy in subgroup analyses of patients with neck pain. In our randomized, controlled trial, we compared the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner in patients with nonspecific neck pain.
METHODS
Patients
Patients with nonspecific neck pain whose clinical presentation did not warrant referral for further diagnostic screening were referred to one of four research centers by 42 general practitioners for study selection. We excluded patients whose history, signs, and symptoms suggested a potential nonbenign cause (including previous surgery of the neck) or evidence of a specific pathologic condition, such as malignancy, neurologic disease, fracture, herniated disc, or systemic rheumatic disease. Two research assistants who were experienced physical therapists and were blinded to treatment allocation performed physical examinations at baseline and follow-up.
They used standardized inclusion and exclusion criteria and performed a short neurologic examination (Appendix Table 1, available at www.annals.org) and range-ofmotion assessment. The eligibility criteria were age between 18 and 70 years, pain or stiffness in the neck 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.
Random Assignment and Data Collection
All patient data were collected before randomization. Patients were assigned to a treatment group on the basis of block randomization after prestratification for symptom severity (severity scores <7 points or ≥7 points on a scale of 0 to 10); age (<40 years or ≥40 years); and, mainly for practical reasons, research center (four local centers). Randomized permuted blocks of six patients were generated for each stratum by using a computer-generated random-sequence table. A researcher who was not involved in the project prepared opaque, sequentially numbered sealed envelopes that contained folded cards indicating one of the three interventions.
Interventions
The intervention period lasted 6 weeks. Patients were allowed to perform exercises at home and to continue medication prescribed at baseline or use over-thecounter analgesics. Other co-interventions were discouraged but were registered if they occurred. Within the boundaries of the protocol, treatment could be reassessed and adapted to the patient’s condition. The specific treatment characteristics were registered at each visit. A maximum number of visits was set for each intervention group; however, the patients did not have to complete this maximum number if symptoms had resolved.Manual Therapy Our approach to manual therapy was eclectic and incorporated several techniques used in western Europe, North America, and Australia, including those described by Cyriax, Kaltenborn, Maitland, and Mennel (15, 16, 19). In our trial, manual therapy (defined as the use of passive movements to help restore normal spinal function) included “hands-on” muscular mobilization techniques (aimed at improving soft tissue function), specific articular mobilization techniques (to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine), and coordination or stabilization techniques (to improve postural control, coordination, and movement patterns by using the stabilizing cervical musculature) (26). Joint mobilization “is a form of manual therapy that involves low-velocity passive movements within or at the limit of joint range of motion”. [27]
Manual therapists must undergo extensive training to be able to skillfully perform mobilization techniques. [15, 19] Spinal manipulations (low-amplitude, high-velocity thrust techniques) were not included in this protocol. Fortyfive minute treatment sessions were scheduled once per week, for a maximum of six treatments. Six experienced manual therapists acknowledged by the Netherlands Manual Therapy Association performed the treatment.
Physical Therapy The physical therapists used a combination of several treatment options, but active exercise therapies were the cornerstone of their strategy. Active exercise therapy involves participation by the patient and includes active exercises (to improve strength or range of motion), postural exercises, stretching, relaxation exercises, and functional exercises.
Manual traction or stretching, massage, or physical therapy methods, such as interferential current or heat applications, could precede the exercise therapy. Specific manual mobilization techniques were not included in this protocol. Thirty-minute treatment sessions were scheduled twice per week for a maximum of 12 treatments. The treatment was performed by five experienced physical therapists. We prevented cross-contamination with manual therapy by choosing physical therapists who were not manual therapy specialists.
Continued Care by a General Practitioner Each patient in this group received standardized care from his or her general practitioner, including advice on prognosis, advice on psychosocial issues, advice on self-care (heat application, home exercises), advice on ergonomics (for example, size of pillow, work position), and encouragement to await further recovery. The treatment protocol was similar to the practice guidelines for low back pain issued by the Dutch College of General Practitioners. [28] Patients received an educational booklet containing ergonomic advice and exercises. [29] Medication, including paracetamol or nonsteroidal antiinflammatory drugs, was prescribed on a time-contingent basis if necessary. Ten-minute follow-up visits, scheduled every 2 weeks, were optional, and referral during the intervention period was discouraged.
Outcome Measures
Data were collected at the research center after 3 and 7 weeks. At 7 weeks, treatment results were expected to be maximal. The patients were repeatedly asked not to reveal any information about their treatment allocation to the research assistants. The success of blinding was evaluated at 7 weeks.
Primary outcome measures focused on perceived recovery, pain, and functional disability. Patients rated perceived recovery on a 6–point ordinal transition scale, ranging from “much worse” to “completely recovered.” Success was defined a priori as “completely recovered” or “much improved”. [30] In addition, on the basis of the systematic assessment of spinal mobility, palpation, and pain reported by the patient, the research assistant rated the severity of physical dysfunction on a numeric 11– point scale ranging from 0 (no physical dysfunction) to 10 (maximal dysfunction). Likewise, the patient measured pain severity in the previous week in three ways on a numeric 11–point scale (higher scores indicate more severe pain): “bothersomeness” of pain (affective pain), average pain, and most severe pain. [31, 32] Functional disability was measured according to the Neck Disability Index [33], which scores 10 activities of daily living on a scale of 0 to 5. Higher scores indicate more disability (maximum score, 50 points). Other studies have shown that the reliability and validity of the Neck Disability Index are acceptable. [34, 35]
Secondary outcome measures included the severity of the most important functional limitation, rated by the patient on a numeric 11–point scale. Range of motion of the cervical spine was measured by using the Cybex Electronic Digital Inclinometer 320 (Lumex, Inc., Ronkonkoma, New York). [36] General health was measured according to the self-rated health index (scale, 0 to 100) of the Euro Quality of Life scale. [37, 38] Patients recorded absences from work and analgesic use in a diary.
Statistical Analyses
We calculated sample sizes on the basis of the dichotomized score of the primary outcome measure “perceived recovery.” A difference of 25% or more in success rate was considered to be clinically significant. With a power of 0.8 and a significance level of 0.05, a minimum of 60 patients per treatment group was required. [39] Analyses were performed according to the intention to- treat principle, using SPSS statistical software (SPSS Inc., Chicago, Illinois). [40] We also performed an alternative analysis that excluded patients who had received any interventions other than the allocated treatments.
The differences in success rates for perceived recovery (risk differences) were analyzed by applying chisquare tests (univariate analysis). Likewise, differences in improvement rates for absence from work and use of analgesics were analyzed. For the continuous outcome measures, univariate analyses of variance were applied to the differences between the baseline measurement and each of the follow-up measurements (the mean improvement).
Multivariate analyses (multiple logistic regression and analyses of covariance) were performed to examine the influence of the following covariates: baseline value of an outcome measure, therapist, age, severity, research center, sex, duration of the current episode, previous episodes of neck pain, headache of cervical origin, radiating pain below the elbow, and patient preference for treatment. For all comparisons, a two-tailed P value of 0.05 was considered statistically significant. A statistician who had no knowledge of the randomization code performed all analyses.
The Scientific Committee and Medical Ethical Committee of the Vrije Universiteit Medical Center in Amsterdam, the Netherlands, approved the protocol.
Role of the Funding Sources
The two grant agencies approved the design of the trial but had no influence on the conduct and reporting of the study.
RESULTS
Patient Selection and Follow-up
During a period of 21 months (February 1997 to October 1998), 223 patients were referred by their general practitioners. Of these, 40 did not meet the selection criteria (Figure 1). A total of 183 patients were randomly assigned: 60 to manual therapy, 59 to physical therapy, and 64 to continued care. One patient withdrew from the manual therapy group because of lack of time and also missed the baseline pain measurements. Values were occasionally missing for some variables in a few other patients.
Patient Characteristics and Baseline Similarity
All patients had multiple symptoms and signs (Table 1). Mean patient age was 45 years, and approximately 60% were women. Most patients had had neck pain for 12 weeks or fewer, and many had had previous episodes of neck pain. Patients rated the “bothersomeness” of their pain, on average, as 7.6 on a numeric 11–point scale. The mean score for the Neck Disability Index was 14.5 points (“minimally disabled,” according to Vernon and Mior [33]). Only minor baseline differences were found among the three groups (Table 1).
Interventions
The study design allowed the manual therapists, physical therapists, and general practitioners to vary the number of treatments up to a maximum, to perform their own evaluations, and to treat individual patients according to their own findings. However, the specific treatment options were limited to those listed in the protocol and the specific treatment characteristics were recorded (Appendix Table 2, available at www.annals .org). The median number of visits was 6 (interquartile range, 5 to 6) in the manual therapy group, 9 (interquartile range, 7 to 12) in the physical therapy group, and 2 (interquartile range, 1 to 4) in the continued care group. Figure 1 shows the protocol deviations and additional treatments in each group.
Adverse Reactions
Minor, benign, short-term adverse reactions were reported (Table 2). Headache, pain and tingling in the upper extremities, and dizziness occurred more frequently in patients who received manual and physical therapy than in those who received continued care. Patients in the manual therapy group were more likely to report a temporary increase in neck pain that lasted more than 2 days after receiving therapy.
Evaluation of Blinding
Research assistants remained unaware of the allocated treatment for 93.4% of patients (n = 170). At 7 weeks, blinding was not successful in 12 patients (2 in the manual therapy group, 3 in the physical therapy group, and 7 in the continued care group). In most of these 12 cases, the patient accidentally mentioned the treatment.
Intention-to-Treat Analysis
In general, the outcome measures showed distinct differences both within groups (compared with baseline) and among groups. These differences usually favored manual therapy more than physical therapy and physical therapy more than continued care (Figure 2). Adjustment for covariates (research center, severity, age, sex, headache, duration of neck pain, previous episodes, and baseline outcomes of the outcome measure) did not greatly influence the results. Because only small differences in outcome were seen among the manual therapists and among the physical therapists, multilevel analysis was not necessary. For the continuous outcomes, we present the adjusted means and confidence intervals. We did not adjust the percentages of binary outcomes (Table 3) because we preferred to present risk differences instead of odds ratios.
The success rate at 7 weeks was twice as high for the manual therapy group (68.3%) as for the continued care group (35.9%) (difference, 32.4 percentage points [95% CI, 15.8 to 49.0 percentage points]). Physical dysfunction, pain, and functional disability were less severe in the manual therapy group than in the continued care and physical therapy groups. Some differences in outcome measures were already statistically significant at 3 weeks.
At 7 weeks, the success rate was higher for physical therapy (50.8%) than for continued care (35.9%), but this difference was not statistically significant. For the other outcome measures, small but mostly nonsignificant differences were found in favor of physical therapy compared with continued care by a general practitioner. At 3 weeks, more patients worsened with continued care (n = 9) than with physical therapy (n = 3) or manual therapy (n = 0). The success rates for manual therapy were statistically significantly higher than those for physical therapy. Manual therapy scored better than physical therapy on all outcome measures, although not all differences were significant.
Although disability on the Neck Disability Index improved in all three groups by at least 5.9 points (continued care group), the differences among groups were not statistically significant. Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care. General health perception on the self-rated health index of the Euro Quality of Life scale showed a statistically significant difference in favor of manual therapy compared with continued care and physical therapy.
Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. Respectively, 13% (6 of 47), 29% (12 of 42), and 26% (12 of 46) of patients were absent due to neck pain; differences among groups were not statistically significant. A similar trend was seen for patients who used analgesics (51% [30 of 59] in the manual therapy group, 53% [31 of 59] in the physical therapy group, and 80% [51 of 64] in the continued care group). Manual therapy and physical therapy each resulted in statistically significantly less analgesic use than continued care.
Alternative Analysis
We performed an alternative analysis that excluded 14 patients who received treatment other than that allocated. Results were similar to those of the intentionto- treat analyses. For example, at 7 weeks, the success rates were 70.7% for manual therapy, 50.8% for physical therapy, and 34.6% for continued care.
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 (35). 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 (8, 41). We recommend further investigation of disease-specific outcome measures for neck pain. Only Koes and colleagues (24, 25) have compared the effectiveness of manual therapy (manipulation and mobilization) and physical therapy (exercise, traction, and other methods) with that of continued care and a placebo treatment. Our study confirms their findings that manual therapy and physical therapy are superior to continued care.
The general practitioners performed a routine examination, which is common in general practice. Although we tried to enroll all eligible patients who consulted their general practitioner with a new episode of neck pain during the recruitment period, the numbers of patients recruited by each general practitioner suggest that potential participants were lost at this point. However, we feel that our study sample reflects patients with nonspecific neck pain who were seen in everyday practice. The natural course of neck pain in everyday practice might best be reflected by the progress in the continued care group. Borghouts and colleagues (9), in a systematic summary of the available evidence, found that patients with chronic neck pain who received a variety of common interventions experienced between 37% and 95% improvement when assessed from 3 weeks to 1 year.
In the physical therapy and manual therapy groups, the “hands-on approach,” frequent visits, and opportunities for intensive patient–therapist interaction may have contributed to the observed effects. The differences in effect between the physical therapy and manual therapy groups, however, suggest that the superiority of manual therapy cannot be explained by nonspecific effects alone. In this trial, manual therapy was performed by physical therapists with formal training. We believe that manual therapy has added value because therapists are knowledgeable about spinal problems, are skilled in performing specific manual techniques, and are educated about the potential risks. (42). Active treatment components, such as those used in the physical therapy strategy, tend to become more dominant over time as the patient improves (41, 43). In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy or continued care and was considered to be the most effective component.
Our results suggest that in everyday practice, for every 3 patients referred to manual therapy and every 7 patients referred to physical therapy, 1 additional patient will completely recover within 7 weeks than would have recovered after continued care by a general practitioner (number needed to treat on the basis of perceived recovery). Although differences were not particularly large for all outcome measures, manual therapy seems to be a favorable treatment option for patients with neck pain.
Acknowledgments:
The authors thank Anita Gross for critical review of the manuscript; Eva Stokx, Luite van Assen, Vera Veldman, and Ingeborg Korthals-de Bos for data collection and data entry; Frans Krapels for advice on usual care; and Brigitte Kapteijn and Raymond Swinkels for advice on physical and manual therapy. They also thank the participating physical therapists, manual therapists, general practitioners, and patients.
Grant Support:
By Netherlands Organization for Scientific Research (904–66–068) and the Fund for Investigative Medicine of the Health Insurance Council (OG95–008).
References:
Makela M, Heliovaara M, Sievers K, Impivaara O, Knekt P, Aromaa A.
Prevalence, determinants, and consequences of chronic neck pain in Finland.
Am J Epidemiol. 1991;134:1356–67Andersson HI, Ejlertsson G, Leden I, Rosenberg C.
Chronic pain in a geographically defined general population: studies of
differences in age, gender, social class, and pain localization.
Clin J Pain. 1993;9:174–82Brattberg G, Thorslund M, Wikman A.
The prevalence of pain in a general population. The results of a postal survey in a county of Sweden.
Pain. 1989;37: 215–22Takala EP, Viikari–Juntura E, Tynkkynen EM.
Does group gymnastics at the workplace help in neck pain? A controlled study.
Scand J Rehabil Med. 1994; 26:17–20Bovim G, Schrader H, Sand T.
Neck pain in the general population.
Spine. 1994;19:1307–9Jacobsson L, Lindga¨rde F, Manthorpe R.
The commonest rheumatic complaints of over six weeks’ duration in a twelve–month period
in a defined Swedish population. Prevalences and relationships.
Scand J Rheumatol. 1989;18:353–60Cote P, Cassidy JD, Carroll L.
The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain
and related disability in Saskatchewan adults.
Spine. 1998;23:1689–98Borghouts JA, Koes BW, Vondeling H, Bouter LM.
Cost–of–illness of neck pain in The Netherlands in 1996.
Pain. 1999;80:629–36Borghouts JA, Koes BW, Bouter LM.
The clinical course and prognostic factors of non–specific neck pain: a systematic review.
Pain. 1998;77:1–13Cote P, Cassidy JD, Carroll L.
The factors associated with neck pain and its related disability in the Saskatchewan population.
Spine. 2000;25:1109–17Picavet HS, Van Gils HW, Schouten JS.
Klachten aan het bewegingsapparaat in de Nederlandse bevolking prevalenties, consequenties en risicogroepen
[Musculoskeletal complaints in the Dutch population].
Bilthoven, The Netherlands: RIVM (National Institute of Public Health and the Environment); 2000.Borghouts J, Janssen H, Koes B, Muris J, Metsemakers J, Bouter L.
The management of chronic neck pain in general practice. A retrospective study.
Scand J Prim Health Care. 1999;17:215–20. Kroese ME, De Vet HC, Scholten RJ.
Een inventarisatie van (de behoefte aan) onderzoek naar de effectiviteit van behandelingen voor een aantal chronische benigne pijnsyndromen. Deel 1: Inventarisatie van regelmatig toegepaste behandelingen
[An inventory of research on the effectiveness (and need for) treatments for several
chronic benign pain syndromes. Part 1: a summary of frequently used treatments].
Maastricht, the Netherlands: Universiteit Maastricht; 1999.Baumgarten K, Hoppenbrouwers GC, Van der Wurf P, Oostendorp RA, Heerkens YF.
Functieprofiel manueel therapeut
[Profile manual therapist: version 1.0].
Amersfoort, the Netherlands:
Report Nederlands Paramedisch Instituut; 1996.Basmajian JV, Nyberg R, eds.
Rational Manual Therapies.
Baltimore: Williams & Wilkins; 1993.Cookson JC.
Orthopedic manual therapy—an overview. Part II: the spine.
Phys Ther. 1979;59:259–67Farrell JP, Jensen GM.
Manual therapy: a critical assessment of role in the profession of physical therapy.
Phys Ther. 1992;72:843–52Fitzgerald GK, McClure PW, Beattie P, Riddle DL.
Issues in determining treatment effectiveness of manual therapy.
Phys Ther. 1994;74:227–33Gross AR, Aker PD, Quartly C.
Manual therapy in the treatment of neck pain.
Rheum Dis Clin North Am. 1996;22:579–98Gross AR, Aker PD, Goldsmith CH, Peloso P.
Physical medicine modalities for mechanical neck disorders.
Cochrane Database Syst Rev. 2000;CD000961Hoving JL, Gross AR, Gasner D, Kay T, Kennedy C, Hondras MA, et al.
A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain.
Spine. 2001;26:196–205Van Tulder MW, Goossens M, Hoving JL.
Nonsurgical treatment of chronic neck pain.
In: Nachemson AL, Jonsson E, eds. Neck and Back Pain:
The Scientific Evidence of Causes, Diagnosis, and Treatment.
Philadelphia: Lippincott Williams & Wilkins; 2000.Gross AR, Aker PD, Goldsmith CH, Peloso P.
Conservative management of mechanical neck disorders.
A systematic overview and meta–analysis.
Online J Curr Clin Trials. 1996;Doc No 200–201Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, et al.
The effectiveness of manual therapy, physiotherapy, and treatment by
the general practitioner for nonspecific back and neck complaints.
A randomized clinical trial.
Spine. 1992;17:28–35Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GJ, Hofhuizen DM, et al.
A randomized clinical trial of manual therapy and physiotherapy for persistent back
and neck complaints: subgroup analysis and relationship between outcome measures.
J Manipulative Physiol Ther. 1993;16:211–9Van der EL, Lunacek PB, Wagemaker AJ.
Manuele Therapie: wervelkolom behandeling
[Manual Therapy: Treatment of the Spine].
2nd ed. Rotterdam: Manuwel; 1993.Di Fabio RP.
Manipulation of the cervical spine: risks and benefits.
Phys Ther. 1999;79:50–65Faas A, Chavannes AW, Koes BW, Van den Hoogen JM, Mens JM, Smeele LJ.
NHG–Standaard–Lage–Rugpijn
[NHG–Practice Guidelines for Low Back Pain].
Huisarts en Wetenschap. 1996;39:18-31.Lanser K.
De nekschool: nekklachten voorkomen, wat doe ik er zelf aan?
[The Neck School: Prevention of Neck Pain, What Can I Do about It Myself?].
3rd ed. Hardinxveld-Giessendam, the Netherlands: Lanser; 1994.Feinstein AR.
Clinimetrics.
New Haven, CT: Yale Univ Pr; 1987:91-103.Carlsson AM.
Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale.
Pain. 1983;16:87-101Jaeschke R, Singer J, Guyatt GH.
A comparison of seven-point and visual analogue scales. Data from a randomized trial.
Control Clin Trials. 1990;11:43-51Vernon H, Mior S.
The Neck Disability Index: a study of reliability and validity.
J Manipulative Physiol Ther. 1991;14:409-15Hains F, Waalen J, Mior S.
Psychometric properties of the neck disability index.
J Manipulative Physiol Ther. 1998;21:75-80Stratford PW, Riddle DL, Binkley JM, Spadoni G, Westaway MD, Padfield B.
Using the Neck Disability Index to make decisions concerning individual patients.
Physiotherapy Canada. 1999;51:107-12.Koes BW, Van Mameren H, Bouter LM, Essers A, Elzinga W, Verstegen GM, et al.
Reproduceerbaarheid van metingen aan de wervelkolom met de hoekmeter EDI 320
[Reproducibility of measurements on the spine with the Cybex Electronic Goniometer].
Nederlands Tijdschrift voor Fysiotherapie. 1990;100: 31-5.EuroQol—a new facility for the measurement of health-related quality of life.
The EuroQol Group. Health Policy. 1990;16:199-208Essink-Bot ML, Krabbe PF, Bonsel GJ, Aaronson NK.
An empirical comparison of four generic health status measures.
The Nottingham Health Profile, the Medical Outcomes Study 36-item Short-Form Health Survey,
the COOP/ WONCA charts, and the EuroQol instrument.
Med Care. 1997;35:522-37.Pocock SJ.
Clinical Trials: A Practical Approach.
New York: J Wiley; 1989: 125-9.Norusis MJ.
SPSS 9.0. Guide to Data Analysis.
Chicago: SPSS; 1999.Jette DU, Jette AM.
Physical therapy and health outcomes in patients with spinal impairments.
Phys Ther. 1996;76:930-41; discussion 942-5.Assendelft WJ, Bouter LM, Knipschild PG.
Complications of spinal manipulation: a comprehensive review of the literature.
J Fam Pract. 1996;42:475-80.Jette AM, Delitto A.
Physical therapy treatment choices for musculoskeletal impairments.
Phys Ther. 1997;77:145-54
Point by Point Review
Thanks to Dan Murphy, D.C. for contributing this summation:
1. “Manual therapy was more effective than continued physician care, and our results consistantly favored manual therapy on almost all outcome measures.”
2. “Although physical therapy scored slightly better than continued physician care, most of the differences were NOT statistically significant.”
3. “The postulated objective of manual therapy for the restoration of normal joint motion was achieved, as indicated by the relatively large increase in range of motion of the cervical spine.”
4. This study confirms Koes study (1992) that “manual therapy and physical therapy are superior to continued physician care.”
5. “In the physical therapy and manual therapy groups, the hands-on approach, frequent visits, and opportunities for intensive patient-therapist interaction may have contributed to the observed [superior] effects.”
6. “The differences in effect between the physical therapy and manual therapy groups, however, suggest that the superiority of manual therapy cannot be explained by nonspecific effects alone.” WOW!
7. “In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy OR continued physician care, and was considered to be the most effective component.” WOW! This is very important, because since the 1993 Mercy Document, passive care has been criticised as leading to “physician dependence”, while this study showed the superiority of passive treatment over the active treatment components!
8. “The physical therapy patients achieved significantly worse success rates while using twice the number of patient visits as the manual therapy group!” If you tend to question this conclusion, please note that the principal author of this study is a physical therapist!
9. “The physical therapy provided was primarily active exercise, while the manual therapy was primarily passive joint mobilization (the first component of spinal adjusting/manipulation).”
10. “The manual therapy group had no patients worse after 3 weeks of treatment, whereas the physician care group scored 9/64 worse, or 14% worse.”
11. Finally, “Primary care physicians should consider [referral for] manual therapy when treating patients with neck pain .”
A Summary of the Study from the Annals of Internal Medicine
SUMMARIES FOR PATIENTS
Manual Therapy, Physical Therapy, or Care by Primary Care Doctors for Patients with Neck Pain
21 May 2002 | Volume 136 Issue 10 | Page I36
Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians–American Society of Internal Medicine.
The summary below is from the full report titled "Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial." It is in the 21 May 2002 issue of Annals of Internal Medicine (volume 136, pages 713-722). The authors are JL Hoving, BW Koes, HCW de Vet, DAWM van der Windt, WJJ Assendelft, H van Mameren, WLJM Devillé, JJM Pool, RJPM Scholten, and LM Bouter.
What is the problem and what is known about it so far?
Neck pain is common and can interfere with daily activities. Neck pain usually goes away without treatment, but patients often seek treatment to speed recovery. Treatments include pain medications, rest, manual therapy, and physical therapy. In manual therapy, a trained therapist moves a patient's neck in specific ways to help improve neck mobility. In physical therapy, a trained therapist assists patients with exercises to improve neck mobility. The main difference between manual therapy and physical therapy is that the therapist moves the patient in manual therapy, while physical therapy requires the patient to do exercises. The best treatment for neck pain is not known.
Why did the researchers do this particular study?
To compare the effectiveness of three treatments for neck pain: routine care by a doctor (rest and medication), manual therapy, or physical therapy.
Who was studied?
183 adults who had had nonspecific neck pain for at least 2 weeks. Nonspecific means that the neck pain was due to strain of muscles and joints rather than to some serious problem such as a broken bone. Forty-two primary care doctors in the Netherlands referred patients to the study.
How was the study done?
The researchers used a computerized coin flip to assign patients to treatment with manual therapy, physical therapy, or continued care by their doctor. One of 6 manual therapists performed the manual therapy for 45 minutes, once per week, for up to 6 weeks. One of 5 physical therapists performed the physical therapy for 30 minutes, twice per week, for up to 6 weeks. The doctors used medications to treat pain and inflammation and gave advice about rest, hot compresses, and home exercises. All patients were allowed to use home exercises, nonprescription medicines, or medicines their doctors had prescribed before referring them to the study. Seven weeks after beginning treatment, patients rated their neck pain on a scale from "much worse" to "completely recovered." The researchers compared the number of patients in each group who reported feeling "much improved" or "completely recovered."
What did the researchers find?
In the manual therapy group, 68.3% of patients felt "much improved" or "completely recovered" compared with 50.8% of patients in the physical therapy group and 35.9% of doctor-treated patients. The differences between manual therapy and either physical therapy or treatment by a doctor were large enough to prove that there were true differences between the groups. The results suggested that physical therapy might also be better than treatment by a doctor, but the study was too small to prove this.
What were the limitations of the study?
The results could be different with different therapists or doctors.
What are the implications of the study?
Doctors should consider referring patients with neck pain to manual therapy.
Related articles in Annals:
- Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain: A Randomized, Controlled Trial
- Jan Lucas Hoving, Bart W. Koes, Henrica C.W. de Vet, Danielle A.W.M. van der Windt, Willem J.J. Assendelft, Henk van Mameren, Walter L.J.M. Devillé, Jan J.M. Pool, Rob J.P.M Scholten, and Lex M. Bouter
Annals 2002 136: 713-722. (in )[Abstract] [Summary] [Full Text]
Return to ChiroZINE ARTICLES
Return to CHRONIC NECK PAIN
Return to COST-EFFECTIVENESS
Return to CHIROPRACTIC RESEARCH Articles
Return to INITIAL PROVIDER/FIRST CONTACT
Return to COST EFFECTIVENESS JOINT STATEMENT
Since 9-05-2002
| Home Page | Visit Our Sponsors | Become a Sponsor |
Please read our DISCLAIMER |