October 2010 Newsletter from Malik Slosberg, DC, MS

Leaver AM, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil 2010;91:1313-8

Gemmell H, Miller P. Relative effectiveness & adverse effects of cervical manipulation, mobilization & the activator instrument in patients with sub-acute non-specific neck pain. Chiropractic & Osteopathy 2010, 18:20.
It's mid-October and here are two new studies. Both of them are randomized controlled relative efficacy studies. One compares cervical manipulation and mobilization for neck pain of recent onset. The second compares cervical manipulation, mobilization and Activator in patients with subacute nonspecific neck pain. These studies are the most recent in a series of publications by numerous researchers which attempt to contrast and compare safety and effectiveness of various clinical interventions for neck pain. Of course, as with most recent studies, the focus is not simply on pain but, instead, uses other outcomes which include patient responses in terms of disability, recovery of activities of daily living (ADLs), as well as pain, and adverse events. Hope you find this update of interest.

Leaver AM, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil 2010;91:1313-8.
Randomized controlled trial (RCT) of 182 patients (Pts) with neck pain (NP) <3 months duration receiving 4 visits over 2 weeks of either high velocity low amplitude (HVLA) cervical spinal manipulation (CSM) or cervical mobilization (CMO) using slow oscillating movements at 12 physiotherapy, chiropractic, & osteopathy clinics in Sydney, Australia to determine if CSM provides more rapid and complete recovery from an episode of NP than CMO.
Primary Outcomes: Days to recover from the episode of NP. Secondary Outcomes: Time for recovery of ADLs, Numerical Rating Pain Scale, Neck Disability Index, Patient Specific Functional Scale, Global perceived effect, & Health-related quality of life at 4 & 12 weeks of follow-up (F-U). Adverse events were recorded in Pt diaries.
Results: Nearly half of the Pts in this study, in both CSM & CMO groups, did not fully recover from their NP. This is consistent with studies that report the persistent and often recurrent nature of nonspecific NP. However, there was a rapid and large improvement in pain scores in both groups. Recovery from NP for CSM and CMO groups were nearly identical. Median days to recovery of pain: 47 in CSM group and 43 in CMO group. The median days for recovery of normal activity was 22 in CSM group and 24 in CMO group. There were no significant differences between CSM and CMO groups in outcomes of pain, disability, function, global perceived effect, or health-related quality of life at any time point.
Relapses: In CSM grp, of 49 subjects who recovered by 12 weeks, 14 (28.6%) had a relapse or new episode of NP within 3 months. In CMO group, of 47 subjects who recovered by 12 weeks, 7 (14.9%) had a relapse. The difference in relapse rates favored CMO.
Adverse Events: There were no serious adverse events reported by patients in either group during treatment or at 3 months of follow-up.
Conclusions: Cervical SM is no more effective than MO. Use of cervical SM can not be justified on the basis of superior effectiveness.

Commentary: The findings of this randomized clinical trial echo the results of other recent studies which report that the outcomes from spinal manipulation and mobilization are, essentially, equivalent in terms of multiple outcomes and adverse events. What do we do with this information? The outcomes are quite positive, with statistically and clinically significant benefits with either type of intervention. From this perspective these findings suggest to me that our "bag of tricks" or arsenal with which we can help clients has markedly increased in size. Obviously, mobilization is within our scope of practice, not that most chiropractic colleges spend much time educating chiropractic students about these techniques. If we offer our patients evidenced-informed care, today, it may include HVLA adjustments, repetitive mobilization (has anyone heard of the Cox flexion-distraction technique?), and exercise prescription, which the chiropractic literature states can speed and improve recovery, as well as minimize episodic recurrences. Mobilization techniques may be particularly useful in acutely inflamed patients with involuntary muscle spasm which can create that rubbery wall of resistance that we might not want to forcefully break with an HVLA thrust.

Gemmell H, Miller P. Relative effectiveness & adverse effects of cervical manipulation, mobilization & the activator instrument in patients with sub-acute non-specific neck pain. Chiropractic & Osteopathy 2010, 18:20.
A pragmatic randomized controlled trial (RCT) of subacute nonspecific NP Pts(=/>4 wks & =/<12 wks) randomized into 3 groups. Treatment (Tx) Groups:
1. Specific HVLA SM (diversified);
2. Specific segmental MO;
3. Activator instrument using the Activator Methods protocols. All patients (Pts) received 2 Tx/week for 3 weeks or until becoming pain free if that occurred first. All Pts also received trigger point (TrP) therapy, exercise advice and ergonomic advice.
Primary outcome: Patient Global Impression of Change (PGIC);
Secondary outcome: Short form 36 questions (SF-36: a general health questionnaire), Neck Bournemouth Questionnaire, Numerical pain rating scale (NPRS). Pts also kept a diary of pain medication use and adverse effects of treatment at end of Tx, 3, 6, & 12 months of F-U.
Results: Subjects in each group: 16 SM Pts, 16 Activator Pts, 15 MO Pts . There were no significant differences on PGIC at any follow-up (F-U). All groups showed improvements at 12 months F-U. There were statistically and clinically significant improvements in all groups on the neck Bournemouth Questionnaire and NPRS. There were no moderate or severe adverse effects in any group.
Conclusions: All 3 treatment groups had long-term benefits for subacute NP. Any adverse effects were minor and resolved within 1-3 days. Unlike reports in previous studies, MO had a higher proportion of adverse effects than SM. Findings suggests that all 3 treatment groups exhibited long-term improvement without one being superior to the others. Due to the small sample size the result must be interpreted with caution.

Commentary: One of the most positive aspects of this study is the demonstration that all three interventions had long-term benefits. The vast majority of studies and systematic reviews have found that spinal manipulation and mobilization generally only have small to moderate short-term benefits. The findings of sustained benefits at 1 year follow-up after only 6 visits, regardless of whether the intervention was spinal manipulation, mobilization, or Activator suggests important long-term clinical effectiveness. Once again, this study like many recent randomized trials indicate that among spinal manipulation, mobilization, and Activator the choice of which intervention to use can be chosen according patient and clinician preferences, because they are all documented to achieve similar outcomes. As a 2009 paper comparing two biomechanically distinct techniques, diversified and Cox flexion-distraction, concluded that the choice of diversified (HVLA) or Cox (flexion-distraction) techniques made little difference in health benefits. From an evidence-based perspective, the authors conclude, that patient preference and clinical experience should drive how chiropractors and patients make decisions concerning what manipulative procedure to use because they all have similar outcomes.