July 2010 Newsletter from Malik Slosberg, DC, MS

Article # 1: Gross A, et al. Manipulation or mobilization for neck pain: A Cochrane Review.  Manual Therapy 2010; 15(4): 315-333.
Article #2: Miller J, et al. Manual Therapy and Exercise for Neck Pain: A Systematic Review. Manual Therapy 2010, online ahead of print. doi:10.1016 / j.math.2010.02.007.
It's mid-July and here are two very important 2010 review articles which summarize the most recent evidence on the management of neck pain with spinal manipulation (SM) or mobilization (MO) as single interventions or SM or MO in conjunction with exercise prescription as a multidisciplinary approach to managing neck pain. The research makes it clear that the combination provides both short and long-term benefits which are not found when SM, MO, or exercise are the sole intervention. Look at the findings of the following two studies thoroughly and you will see what the most effective and evidence-based clinical approach is today. Think about integrating this approach into your clinical practice in order to improve patient satisfaction, benefits of care, great word-of-mouth about your practice and new patient referrals. I hope you find the information valuable. Please let your chiro friends know about this free research update.

Article # 1: Gross A, et al. Manipulation or mobilization for neck pain: A Cochrane Review.  Manual Therapy 2010; 15(4): 315-333.

A review of the research literature through July 2009 to assess if manipulation (SM) or mobilization (MO) as single-modal treatments improve pain, function/disability, patient (Pt) satisfaction, quality of life, & global perceived effect in adults with neck pain (NP) with or without cervicogenic headache (CGH) or radicular findings; the review excludes combined therapies. Of 68 randomized controlled trials (RCTs) & 114 publications, 27 RCTs including 1805 subjects (Ss) were selected, representing 32 publications for SM or MO performed as a single-modal application for NP. 33% of 27 trials had a low risk of bias. All included trials were small, with < 70 Ss per intervention arm. For acute neck disorder (not WAD) the authors noted a striking lack of high quality evidence. For chronic non-specific NP, trials were sparse & inconclusive. There is a dearth of evidence for MO or SM for WAD.
Results: Manipulation alone of the cervical region: 16 trials found:
1. There is moderate quality evidence (2 trials, 369 Ss) that SM produces similar changes in pain, function & Pt satisfaction compared to MO for subacute or chronic NP at short & intermediate-term follow-up (F-U), but benefits are not maintained over the long-term. 
2. There is low quality evidence (3 trials, 130 Ss) that SM alone vs a control may provide immediate & short-term pain relief after 1 to 4 treatments (Txs) in Ss w acute or chronic NP.
3. Low quality evidence (1 trial, 25 Ss) suggests that 9 or 12 sessions of SM are superior to 3 sessions for pain relief & neck-related disability for chronic cervicogenic headach at immediate post-Tx F-U.  Larger dose-finding trials are needed to establish the optimal dose. 
4. Very low quality evidence at short-term follow-up: one SM technique is not superior to another for pain reduction for subacute NP.
5. SM is equivalent to certain medication (2 trials, 69 Ss), acupuncture (2 trials, 81 Ss), certain soft-tissue treatments (1 trial, 53 Ss) or certain combined Txs for subacute & chronic NP & to some extent improved function.
6. SM may be superior to TENS (1 trial, 64 Ss) for individuals with chronic cervicogenic headache.
7. Adverse events reported from RCTs were benign, transient side effects. The risk of a serious irreversible complication (e. g., stroke) for cervical manipulations has been reported to vary from one adverse event in 3020 to one in 1,000,000 manipulations. 
Commentary: This is a Cochrane review, the “gold standard” for literature reviews. The volume of literature related to NP evaluation and management makes it difficult for individual clinicians to identify, read, and compare all of the research. Clinical practice guidelines (CPGs) locate, evaluate, & summarize the scientific evidence & are valuable tools in the implementation of evidence-based medicine. Health care providers involved in managing NP should be guided by the best available scientific evidence to minimize the use of ineffective, excessively costly, or even harmful procedures. In addition, adhering to recommendations from CPGs on the management of NP is associated with improved clinical outcomes & decreased costs. This, unfortunately, doesn’t mean that all published CPGs or reviews of CPGs are completely objective or unbiased. There is the process of selection of which studies are included in the review and who are the reviewers (MDs, PhDs, DCs, PTs, etc). Nevertheless, they are the best attempt to include all relevant, well-designed published research.
What this Cochrane Review concludes is this: SM & MO produce similar results as a single modal Tx for NP and that their beneficial results are relatively short-term & are not maintained over the long-term. Low quality evidence suggests that more visits is better than less visits, that one SM technique gets similar results to other SM technique, that adverse events are generally benign & transient. As you will see from the next study, SM or MO with exercise achieves better and longer lasting beneficial effects. Multidisciplinary care, including SM or MO and exercise is more effective than either SM or MO or exercise alone. This is an extremely important clinical finding and should shape the methods of care DCs provide to their neck pain patients.

Article #2: Miller J, et al. Manual Therapy and Exercise for Neck Pain: A Systematic Review. Manual Therapy 2010, online ahead of print. doi:10.1016 / j.math.2010.02.007.
This Cervical Overview Group systematic review update assesses if manual therapy, including manipulation (SM) or mobilization (MO), combined with exercise improves pain, function/disability, quality of life, global perceived effect, & patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. 17 RCTs met the criteria for this review.
Major Findings:
1. Manipulation or mobilization and exercise produce a greater long-term improvement in pain & global perceived effect when compared to no Tx for chronic NP, subacute/chronic NP w cervicogenic headache, & chronic neck pain w or w/o radicular findings. 
2. Manual therapy (SM or MO) + exercise produce greater short-term pain relief than exercise alone but produce no long-term difference across multiple outcomes for NP of chronic & mixed duration with or without cervicogenic headache. 
3. The combination of manual therapy + exercise produces greater improvements in pain, function, quality of life & Pt satisfaction when compared to SM or MO alone for chronic neck pain. 
4. SM or MO + exercise are favored over traditional care for reducing pain at short-term follow-up for acute whiplash associated disorders (WAD), but may be no different at long-term follow-up for NP of chronic or mixed duration. 
5. The combination of manual therapy & exercise seems to produce greater short-term pain reduction than exercise alone & longer-term changes across multiple outcomes in comparison to manual therapy alone. 
6. There was insufficient evidence available to draw any conclusions for neck disorder with radicular findings. 
7. Adverse events: Side effects were reported in 18% (3/17) of trials. All side effects were benign & transient & included cervical pain, thoracic pain, headache, radicular Sx, & dizziness.
8. The rate of rare but serious adverse events (strokes or serious neurological deficits) couldn’t be established from this review.
Commentary: This review reinforces the new emerging and increasingly dominant paradigm for management of neck pain (NP). The accumulation of evidence over the past decade makes it very clear that multidisciplinary care is more effective than single-modal approaches, including SM, for the management of both LBP and NP. This review concludes that SM or MO + exercise produce greater improvement in pain & global perceived effect than no Tx for many kinds of NP, that SM or MO results in greater short-term pain relief than exercise alone, that SM or MO + exercise improve long-term changes across multiple outcomes versus SM or MO alone. In addition, side effects are benign & transient. In none of the studies reviewed did any serious adverse advent occur so risks of strokes or serious neurological deficits couldn’t be established.

In conclusion, these two reviews demonstrate that SM or MO as a single intervention is not as effective as SM or MO in combination with exercise prescription. These findings should influence how DCs approach and managed NP as well as LBP. If we can integrate this information into clinical practice we will improve our patients’ outcomes, satisfaction, and improve referrals of new patients.