1. Spinal manipulation vs. Acetaminophen for chronic neck pain
2. Manual Mobilization for Neck Pain Patients Superior to Massage and Physical Therapies
3. Manipulation of the Cervical Spine - A Pilot Study
4. Pressure Pain Threshold Evaluation of the Effect of Spinal Manipulation in the Treatment of Chronic Neck Pain: A Pilot Study
5. The Immediate Effect of Manipulation vs. Mobilization on Pain and Range of Motion in the Cervical Spine: A Randomized Controlled Trial
6. Early Mobilization of Acute Whiplash Injuries
7. Three (3) Studies Evaluating the Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints
1. Spinal manipulation vs. Acetaminophen for chronic neck pain
- 12 chiropractic spinal adjustments over a 6 week period, or
- Acetaminophen 4X/day plus 12 visits with a nurse over a 6 week period.
Both groups were also instructed to exercise and use a heating pad. At the end of the 6 weeks, patients who received the chiropractic spinal manipulation reported a significant improvement in neck pain and function, showing increased range of motion and strength. Patients receiving medication and nurse care showed no significant changes or improvements. Researchers are currently performing a long-term follow-up.
- Baker B. Family Practice News 1996; June 1:14.
2. Manual Mobilization for Neck Pain Patients Superior to Massage and Physical Therapies
Cervical mobilization in comparison to other therapies has not been reported, but several researchers have found positive effects of mobilization. The purpose of this study is to address two problems:
- Do patients with restricted mobility and pain in cervical mobile segments benefit from mobilizing manual therapy?
- Is there any relationship between reduction of pain and increase of the total cervical spine mobility?
Subjects were patients with restricted movement in the pain-producing segment. The patients were examined and randomized into three groups:
- Group 1 - Patients were told that they should try a new type of drug known to reduce pain most efficiently; they received salicylate daily for 3 weeks.
- Group 2 - Patients had the same information as those in group 1, and in addition were told that they would have some special information to help ease their pain, and also treatment by a skilled physiotherapist; they received salicylate, and their manual (mock) therapy consisted of superficial massage, electrical stimulation, and slight relaxing traction given three times a week for three weeks.
- Group 3 - Patients had the same information as those in group 2; they received salicylate, and their specific therapy consisted of relaxation techniques such as superficial heat, soft tissue treatment and slight traction, and specific manual mobilization of the actual mobile segments in the cervical spine; three treatments were given each week for three weeks.
(The special information given to groups 2 and 3 included anatomy and pathophysiology of the cervical spine as well as biomechanical problems and practical problems such as lifting, carrying and relaxation).
Each patient estimated their pain and reported the actual level each week. Total cervical mobility in the coronal, sagittal and transverse planes was recorded before and after therapy each week and even one week after the therapy finished by a physiotherapist. In addition, social conditions were recorded by a social worker, and Eysenck personality inventory tests were used by assistants.
Results showed that the initial pain level was about the same in all three groups. Before the treatment, tender spots with increased consistency in the muscle were frequent in 80-90% of the patients in all three groups. Manual examination revealed the same distribution of hypo mobile segments, C7-T2, in the three groups. The effect on pain was evaluated by the pain level and the decrease of pain. Group 3 showed a significant difference in pain level after treatment from the other groups. Group 3 also showed a significant difference in decrease of pain one week after the treatment and at the conclusion of the treatment. Mobility increased significantly at the final treatment for group three compared to the other groups.
This study concludes that cervical pain patients can be improved by simple manual technique as a first step towards complete treatment.
- H. Brodin, Manuelle Medizin 1982; 20:90-94. From the Institution of Physical Medicine, Karolinska, Sjukhuset, Sweden.
A randomized controlled trial of manipulation of the cervical spine was carried out on 52 patients in general practice, and the results were assessed symptomatically and goniometrically for three weeks. Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder, and a nearly significant improvement in those with pain/paraesthesia in the arshared/stockpages/cp/conditions/neckpain/m/hand. Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained.
Pain and/or stiffness in the neck or pain referred to the head, shoulder, arm or hand are presentations of common neck disorders. The pathology of these conditions is uncertain and some probable causes are: minor subluxations of intervertebral facet joints, derangements of intervertebral discs with secondary osteoarthritis of the interarticular joints, or meniscoid entrapment in the upper cervical apophyseal joints straining the joint capsule. Manipulation for these conditions is controversial, and this study tries to assess its effectiveness.
Subjects were selected, were assessed by doctors A and B, and were divided into either the treatment or control group. The treatment group was treated by manipulation and/or injection (if the neck was too painful) and was asked to return for further treatment at Dr. A's discretion. Both groups were treated with axapropazone. They were all instructed not to tell Dr. B whether they had been manipulated or not. Patients then returned to Dr. B who again recorded their symptoms and measured their neck movements via a goniometer.
Results showed that among patients initially affected with a symptom, the proportion showing immediate improvement after manipulation was greater than the corresponding proportion in controls; the difference reached significance for neck pain and neck stiffness and shoulder pain/paraesthesia. Manipulation also produced a highly significant immediate improvement in rotation and lateral flexion. The improved rotation was maintained at one and three weeks, but the lateral flexion improvement did not last. However, more than half the control group experienced improved symptoms despite no measured improvement in movement, confirming clinical impression.
- Journal of the Royal College of General Practitioners 1983; 33:574-579.
4. Pressure Pain Threshold Evaluation of the Effect of Spinal Manipulation in the Treatment of Chronic Neck Pain
Nine subjects with chronic mechanical neck pain syndromes were evaluated for pressure pain threshold (PPT) over standardized tender points in the paraspinal area surrounding a manipulable spinal lesion. The subjects were then allocated randomly to an intervention consisting of either an oscillatory mobilization of the cervical spine (n=4), which was designated as the control procedure, or a rotational manipulation of the cervical spine (n=5). An assessor-blinded re-evaluation of the pressure pain threshold levels was conducted after 5 minutes. In the group receiving a manipulation the mean increases in pressure pain threshold ranged from 40-56% with an average of 45%. In the control group no change in any of the pressure pain thresholds was found. These results were analyzed using ANOVA and were found to be statistically significant (p < 0.0001). This study confirms that manipulation can increase local paraspinal pain threshold levels. The use of the pressure pain threshold meter allows for the determination of such a beneficial effect in the deeper tissues.
Very few clinical trials have been produced to provide evidence that manipulative treatment by chiropractors is beneficial to patients with neck pain. The senior author of this study, Howard T. Vernon, conducted clinical analog studies in which the results of a single manipulation were compared to control procedures.
In the first study, a single thoracic manipulation produced a significantly higher rise in cutaneous pain tolerance levels than the manipulation group. In the second study, a single manipulation of the cervical spine produced a modest increase in plasma beta-endorphin levels while control and sham procedures dropped. These studies support the idea that pain relief occurs subsequent to manipulation, and to the theory that this pain relief is a result of reflex mechanisms activated by the thrust. The reflex mechanisms can be described as afferent bombardment from the articular and myofascial receptors which produces pre-synaptic inhibition of segmental pain pathways and possibly activation of the endogenous opiate system. The purpose of this study is to extend this earlier work to prove that a single manipulation would produce a significantly higher rise in pressure pain threshold levels in the paraspinal area surrounding a spinal fixation as compared to a control procedure. In this study, a more accurate device is used, the pressure threshold meter. The advantages are that this device can objectively measure pressure pain threshold over tender points in muscles as well as measure functional changes in the deeper tissues around a joint. Subjects were chiropractic patients diagnosed with chronic mechanical neck pain for an average duration of less than 3 months. The research treating physician assessed for joint dysfunction of the cervical spine, and marked the "fixated" or hypo mobile segment. The treater left the room and the assessor entered to conduct a PPT assessment of four tender points above and below, and on each side of the fixated level. The points were consistently measured as:
- ipsilateral to the clinically painful side, slightly below the fixation;
- ipsilateral, above;
- contralateral, above;
- contralateral, below.
Two measurements were taken at each point and the assessor left the room. The treater entered and applied the appropriate treatment of either a rotational mobilization with gentle oscillations into the elastic barrier, or a rotational manipulation (high velocity, low amplitude thrust). All subjects were asked if they felt pain and if they believed that they had received a "real" treatment. Finally, the blinded assessor re measured the tender points twice after 5 minutes.
Results revealed a statistically significant rise in pressure pain threshold ranging from 40-55% in all four points around the fixation level in the manipulation group compared to virtually no change in the mobilization group. All subjects that were manipulated reported no pain and regarded the manipulation as a "real" treatment. Of the four mobilized subjects, three reported no pain and none regarded the mobilization as "real". These findings are behavioral as related to the subjects perception of pain, but the underlying mechanism of spinal reflexes causing pain threshold changes is still supported especially since no subject felt pain from the manipulation.
In conclusion, the pressure pain threshold meter has proven to be useful in objectifying the effect of manipulation versus mobilization in the cervical spine of subjects suffering from chronic mechanical neck pain, and these findings support the theoretical mechanisms proposed to explain the effects of spinal manipulation on spinal pain.
1. Journal of Manipulative and Physiological Therapeutics 1990; 13:13-16. From the Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.
5. The Immediate Effect of Manipulation vs. Mobilization on Pain and Range of Motion in the Cervical Spine
- Objective - The main objective of this study is to compare the immediate results of manipulation to mobilization in neck pain patients.
- Design - The patients were compared in a randomized controlled trial without long-term follow-up.
- Setting - The study was conducted at an outpatient teaching clinic on primary and referred patients.
- Patients - One hundred consecutive outpatients suffering from unilateral neck pain with referral into the trapezius muscle were studied. Fifty-two subjects were manipulated and 48 subjects were mobilized. The mean (SD) age was 34.5 (13.0) yr for the manipulated group and 37.7 (12.5) for the mobilized group. Sixteen subjects had neck pain for less than 1 week, 34 subjects had pain for between 1 wk and 6 mo and 50 subjects had pain for more than 6 mo. Seventy-eight subjects had a past history of neck pain. Thirty-one subjects had been involved in an injurious motor vehicle accident and 28 subjects had other types of minor trauma to the neck. There were no significant differences between the two treatment groups with respect to history of neck pain or level of disability as measured by the Pain Disability Index.
- Intervention - The patients received either a single rotational manipulation (high-velocity, low-amplitude thrust) or mobilization in the form of muscle energy technique.
- Main Outcome Measures - Prior to and immediately after the treatments, cervical spine range of motion was recorded in three planes, and pain intensity was rated on the 101-point numerical rating scale (NRS-101). Both pre- and post-test measurements were conducted in a blinded fashion.
Results - The results show that both treatments increase range of motion, but manipulation has a significantly greater effect on pain intensity. 85% of the manipulated patients and 69% of the mobilized patients reported pain improvement immediately after treatment. However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (p=.05).
Conclusion - This study demonstrates that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree. Further studies are required to determine any long-term benefits of manipulation for mechanical neck pain.
Neck pain with decreased mobility is a common condition that improves, for most cases, with time , but may persist in others as moderate or severe pain for several years after the initial onset. Many different treatments have been used to handle mechanical neck pain, but few clinical trials have been performed to establish their effectiveness.
The purpose of this study is to compare the immediate results of manipulation and mobilization on pain and ROM in patients with unilateral mechanical neck pain. Subjects were patients suffering from unilateral, mechanical neck pain with radiation into the trapezius, and local cervical paraspinal tenderness. After the initial exam and before the treatment, patients rated their pain intensity on the NRS-101. Cervical ROM was measured next by a goniometer after which patients were randomized into two groups:
- Group 1- Cervical Manipulation - involved contacting the pillar on the painful side of the neck at the level of tenderness, passively rotating the neck away from the painful side as far as possible, and applying a high-velocity, low-amplitude thrust in the same direction.
- Group 2- Cervical Mobilization - involved application of muscle energy technique (active resisted isometric contraction held for 5 seconds and repeated four times with increasing rotation or lateral flexion of the neck; aims to improve mobility and pain via post-isometric relaxation) to hypertonic muscles responsible for restricting joint movement. All treatments were given once and were applied to the symptomatic side. Patients rated their pain intensity again within five minutes after the treatment, and the ROM exam was also repeated.
Results show that both manipulation and mobilization have the immediate effect of decreasing pain and increasing cervical ROM. Improvements were slightly higher in the manipulation group, and the overall pain improvement on the NRS-101 was 1.5 times greater than the mobilized group. The question is which treatment would give better results when considering long-term follow up and risk/benefit (manipulation may cause a cerebrovascular accident whereas mobilization will not, but mobilization may be of little therapeutic value).
In conclusion, this study proves that manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain, but both treatments increase cervical ROM to the same degree. Further studies should examine the long-term benefits of manipulation for mechanical neck pain.
1. Journal of Manipulative and Physiological Therapeutics 1992; 15:570-575. From the Department of Orthopedic Surgery, Royal University Hospital, Saskatoon, Saskatchewan.
6. Early Mobilization of Acute Whiplash Injuries
Acute whiplash injuries are a common cause of soft tissue trauma for which the standard treatment is rest and initial immobilization with a soft cervical collar. Because the efficacy of this treatment is unknown a randomized study in 61 patients was carried out comparing the standard treatment with an alternative regimen of early active mobilization. Results showed that eight weeks after the accident the degree of improvement seen in the actively treated group compared with the group given standard treatment was significantly greater for both cervical movement (p<0.05) and intensity of pain (p<0.0125).
The results of this study indicate that early mobility of the neck following whiplash accident compared with a cervical collar and instructions to rest results in significantly less pain and stiffness.
Whiplash injuries are due to sudden flexion and hyperextension of the spine with hyperextension as the main cause of damage. Standard treatment consists of a period of immobility using a soft cervical collar and simple analgesia before gradual mobilization. The purpose of this study is to evaluate the efficacy of this standard treatment compared with an alternative treatment of daily neck exercises and mobilization using the Maitland technique.
Subjects were patients with acute whiplash injuries who had not suffered a cervical fracture. Intensity of pain was assessed and cervical mobility was measured via a goniometer from which the total cervical movement was calculated. Patients were then randomized into two groups:
- Group 1 - Standard treatment - soft cervical collar and instruction to rest for two weeks before beginning gradual mobilization; analgesia was given as required.
- Group 2 - Active treatment - application of ice in the first 24 hours and then neck mobilization using the Maitland technique (repetitive and passive movements within the patients' tolerance with tiny movements and movements with a restricted amplitude for pain and spasm, and movements with larger amplitude for stiffness) and daily exercises of the cervical spine within pain limits every hour at home; application of local heat after each treatment; no analgesia was required.
Both groups were assessed for residual pain and cervical movement at four and eight weeks after the accident.
Results proved that patients who are treated actively show significantly greater improvement in both cervical movement and intensity of pain compared with patients treated the standard way. At four weeks, a significant increase in cervical movement occurred in the patients given active treatment but not in those given standard treatment. At eight weeks, the same findings were yielded indicating that the increase in cervical mobility occurred earlier and to a significantly greater degree with active treatment. In terms of pain, the improvement was greater at both four and eight weeks in the group given active treatment compared with those given standard treatment.
These results confirm the expectations that initial immobility (lack of movement) after whiplash injuries gives rise to persistent pain and stiffness whereas a more rapid improvement can occur by early active management without any consequent increase in discomfort.
1. British Medical Journal 1986; 292:656-657. From the Department of Orthopedics, St. James's Hospital, Dublin 8, Ireland.
7. Three (3) Studies Evaluating the Effectiveness of Manual Therapy (Manipulation), Physiotherapy and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints
The following 3 studies come from the Netherlands and compare the effectiveness of manual therapy (manipulation), physiotherapy and treatment by general medical practitioners for nonspecific back and neck complaints.
- The Effectiveness of Manual Therapy, Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints
- Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up
- Randomized Clinical Trial of Manual Therapy and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures
1. The Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints
In a randomized trial, the effectiveness of manual therapy (manipulative techniques), physiotherapy, continued treatment by the general practitioner, and placebo therapy (detuned ultrasound and detuned short-wave diathermy) were compared for patients (n=256) with nonspecific back and neck complaints lasting for at least 6 weeks. The principle outcome measures were severity of the main complaint, global perceived effect, pain, and functional status. These are presented for 3, 6 and 12 weeks follow-up. Both physiotherapy and manual therapy (manipulation) decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner.
1. Spine 1992; 17:28-35. From the University of Limburg, Maastricht, the Netherlands.
2. Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up
The third trial of the series evaluating the effectiveness of manual therapy (manipulation) and physiotherapy utilized the same treatments and outcome measures as the prior studies, but chose changes in severity of the main complaint, limitation of physical functioning, and global perceived effect as the main outcome measures.
Results for this trial revealed an interesting factor: many patients in the GP (general medical practitioner treatment group) and placebo groups changed from their assigned treatment to another treatment during the one year follow-up. This clearly indicates the superiority of manual therapy (manipulation) and physiotherapy over the other two treatments, and the willingness of patients to turn to other treatments when their assigned treatment is not effective enough.
In terms of the change of the main complaint, the manual therapy (manipulation) group showed the largest improvement after 12 months follow up. Manual therapy also gave larger improvements in physical functioning than the physiotherapy group at all follow up measurements.
The global perceived effect after 6 and 12 months follow up was similar for both treatments. Thus, it can be concluded that manual therapy (manipulation) and physiotherapy are superior to GP and placebo treatment, and manual therapy (manipulation) is slightly better than physiotherapy after 12 months.
1. British Medical Journal 1992; 304:601-605. From the University of Limburg, Maastricht, the Netherlands.
3. Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures
This final trial utilized the same treatments as well as the same three outcome measures as the third study, but also assessed the relationship between the outcome measures via a subgroup analysis. The subgroup analysis was confined to manual therapy (manipulation) and physiotherapy only, focusing on specific subgroups that showed benefit, particularly from a certain therapy. The analysis was further confined to subgroups based on six predefined baseline characteristics only:
- duration of the present episode (<1, >1 or =1 yr);
- age (younger than 40 yr, 40 yr old and older than 40 yr);
- localization of the complaints (back only, neck only, back and neck);
- recruitment status (GP, advertisement);
- severity of complaint (severity < 7 pts, severity 7 or >);
- appropriateness of allocated treatment according to treating therapist (suitable/not suitable)
Results showed a greater improvement in the main complaint with manual therapy (manipulation) than with physiotherapy for patients with chronic conditions (duration complaint of 1 yr or more). Improvement in the main complaint was also larger with manual therapy (manipulation) than with physiotherapy for patients younger than 40 years (both were measured after 12 months follow up). Labeling of patients as "suitable" or "not suitable" for treatment with manual therapy (manipulation) did not predict differences in outcomes. There was a moderate to strong correlation between the three outcome measures, although a considerable number of patients gave a relatively low score for perceived effect while the research assistant gave a high improvement score for the main complaint and physical functioning. This finding indicates that the outcome measures represent different features of progress in back and neck patients, and that if research interest lies in the opinion of the patient and the observer, it will not suffice to measure just one of the outcome measures.
In conclusion, the subgroup analysis suggests better results of manual therapy (manipulation) compared to physiotherapy in chronic patients and in patients younger than 40 years. Future research must investigate the explorative findings of these subgroup analyses. Of particular interest may be the strong relationship between improvement of physical functioning and improvement of main complaint which can also indicate that the severity of the main complaint of a patient concurs with the patient's limitation in physical functioning.
1. Journal of Manipulative and Physiological Therapeutics 1993; 16:211-219. From the Institute for Research in Extra mural Medicine, Free University, Amsterdam, the Netherlands.