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Spinal manipulation and exercise 'best for neck pain'

Spinal manipulation and home exercises are more effective than medication in relieving neck pain, a US trial reports.

The findings will reignite the debate over the effectiveness of spinal manipulation, after a Cochrane review found only low-quality evidence supporting its use for neck pain of short duration and concerns over potential adverse events.

A 12-week course of spinal manipulation had a statistically significant advantage over medication in reducing self-reported pain after eight, 12, 26 and 52 weeks, according to the study, published in the Annals of Internal Medicine. Home exercise with advice gave similar results to spinal manipulation.

The trial – conducted from 2001 to 2007 - included 272 people aged between 18 and 65 with non-specific neck pain lasting two to 12 weeks.

First-line therapy in the medication group was NSAIDs, paracetamol or both. Patients who did not respond or could not tolerate first-line therapies were given opioid analgesics or muscle relaxants. Participants in the home exercise group received two one-hour sessions one to two weeks apart where they were instructed in simple self-mobilisation exercises with advice on prescribed exercises and daily activities such as lifting, pushing and pulling. Techniques used for participants in the spinal manipulation group included low-amplitude spinal adjustments and mobilisation.

Participants rated neck pain on a scale of zero (no pain) to 10 (worst possible) over 52 weeks. Pain scores improved from a mean of 5.27 in week zero to 1.50 in week 12 in the spinal manipulation group, compared with from 4.93 to 2.08 in the medication group and 5.05 to 1.74 in the home exercise group. At 52 weeks mean pain scores were 1.60, 2.14 and 1.92 for the spinal manipulation, medication and home exercise groups respectively. No serious adverse events were reported.

Study leader Dr Gert Bronfort, vice president of research at Northwestern Health Sciences University, Minnesota, said: ‘Spinal manipulation was more effective than medication in both the short and long term, although a few sessions of supervised instruction in home exercises resulted in simular outcomes at most time points.'

But Dr Louise Warburton, a GPSI in musculoskeletal medicine in Shrewsbury and president of the Primary Care Rheumatology Society, criticised the lack of a placebo group: ‘I would never refer patients for spinal manipulation for neck pain as a first resort because of the potential adverse effects, which are rare but significant, such as carotid artery dissection. More conservative methods are preferable.'

Ann Intern Med 2012, online 2 January

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