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Am Fam Physician. 2012;86(1):80

Background: Neck pain is one of the most commonly reported symptoms in primary care settings. Treatment options include medication, home exercise programs, and spinal manipulation (versions of which are used by osteopaths, physical therapists, and chiropractors); however, the comparative effectiveness of these modalities remains unclear. Bronfort and colleagues conducted a randomized trial to compare spinal manipulation therapy with medication and home exercise for the treatment of acute and subacute neck pain.

The Study: The authors randomized a total of 272 adults with nonspecific neck pain to receive spinal manipulation therapy, medication, or home exercise with advice over a period of 12 weeks. Eligible participants had mechanical, nonspecific neck pain of two to 12 weeks’ duration and a neck pain score of 3 or greater on a scale of 0 to 10. Participants were excluded if they had progressive neurologic deficits or cervical spine problems, including instability, fracture, or inflammatory or destructive tissue changes.

Persons in the spinal manipulation group received low-amplitude spinal adjustments and mobilization at visits provided by chiropractors. Those in the medication group received nonsteroidal anti-inflammatory drugs, acetaminophen, or both, with muscle relaxants or narcotics as secondary therapy at the treating physician’s discretion. The home exercise group was instructed in self-mobilization exercises, including neck retraction, extension, flexion, rotation, lateral bending, and scapular retraction. Home exercise group participants were instructed to do five to 10 repetitions of each exercise up to six to eight times per day. The number of patient visits for the spinal manipulation and medication groups was determined by the treating physician, whereas the home exercise group received two one-hour training sessions, one to two weeks apart. The primary outcome for all groups was participant-rated pain on a scale of 0 (no pain) to 10 (worst pain possible), which was measured biweekly during the 12-week intervention, as well as at 26 and 52 weeks posttreatment.

Results: There was significantly less participant-reported pain in the spinal manipulation group than in the medication group over the first 12 weeks (0.94-point greater reduction in pain; P = .001), with similar findings at 26 weeks (0.78-point greater reduction; P = .009) and 52 weeks (0.87-point greater reduction; P = .005). The home exercise group had a significantly lower average pain score than the medication group at week 26 (0.69-point greater reduction; P = .021), but otherwise these interventions had statistically equivalent pain scores at all other points. There was no difference in participant pain between the spinal manipulation and home exercise groups at any point.

Conclusion: Spinal manipulation appears to be more effective than medication for treating acute and subacute neck pain. However, no apparent benefits of spinal manipulation therapy were demonstrated over several instructional sessions of home exercise with advice.

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