Is spinal manipulation therapy (SMT) effective in improving acute and subacute neck pain as compared to medication and home exercise with advice (HEA)?
Date of publication of randomized controlled trial: January 2012
Design
Randomized controlled trial (RCT).
Participants
272 persons aged 18 to 65 years (mean age: not reported, male %: 34%) having primary symptoms of mechanical, nonspecific neck pain for 2 to 12 weeks, with a score of 3 or greater on a 0 to 10-point neck pain scale.
Intervention
12-week spinal manipulation therapy (SMT) focusing on manipulation of areas of the spine with segmental hypomobility. Treatments were provided by chiropractors with a minimum of 5 years’ experience.
Comparator
Comparison 1: SMT versus conventional medication prescribed by licensed medical physicians, with a first line therapy of non-steroidal anti-inflammatory drugs and acetaminophen, and a secondary line therapy of narcotic medications and muscle relaxants.
Comparison 2: SMT versus home exercise with advice (HEA) focusing on self-mobilization exercise of the neck and shoulder joints. HEA were provided by therapists in two 1-hour sessions, 1 to 2 weeks apart, in which participants were instructed to do 5 to 10 repetitions of each exercise, up to 6 to 8 times per day.
Major Outcomes
Outcome 1: Reduction in participant-rated pain score measured with a 0-10-point pain scale from baseline to week 12;
Outcome 2: Reduction in participant-rated neck disability score measured with a 0-100-point Neck Disability Index from baseline to week 12;
Outcome 3: Improvement in flexion and extension degrees measured with a CA 6000 Spine Motion Analyzer (Orthopedic Systems, Union City, California) from baseline to week 12.
Settings
This trial was conducted in an outpatient setting.
Comparison    SMT versus conventional medication
Main Results
Compared to conventional medication, SMT showed significant superiority in reducing participant-rated pain score (mean difference (MD): 0.94, 95% CI: 0.37 to 1.51) and in improving flexion and extension degrees (MD: 3.11, 95% CI: 0.23 to 5.99). However, SMT did not show significantly stronger reduction in the participant-rated neck disability score (MD: 2.19, 95% CI: -0.31 to 4.69).
Comparison 1: SMT versus medication amongst subjects with acute and subacute neck pain
Outcomes (units) No. of studies (Total no. of participants) Mean (SD)/ No. of participants Heterogeneity test (I2) MD (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 1 (181) 3.75 (1.97)/ 91 2.81 (1.89)/ 90 Not applicable because there is only 1 trial 0.94 (0.37 to 1.51) Moderate
2 (NA) 1 (181) 14.96 (9.87)/ 91 12.77 (10.12)/ 90 Not applicable because there is only 1 trial 2.19 (-0.31 to 4.69) Low
3 (degrees) 1 (181) 5.87 (11.21)/ 91 2.75 (11.63)/ 90 Not applicable because there is only 1 trial 3.11 (0.23 to 5.99) Moderate
Keys: SD = standard deviation; MD = mean difference; CI = confidence interval.
Comparison    SMT versus HEA
Main Results
Compared to HEA, SMT did not show stronger effects in participant-rated pain score reduction (mean difference (MD): 0.44, 95% CI: -0.13 to 1.00), participant-rated neck disability score reduction (MD: 0.98, 95% CI: -1.51 to 3.47) and the flexion and extension degree improvement (MD: -0.40, 95% CI: -3.24 to 2.45).
Comparison 2: SMT versus HEA amongst subjects with acute and subacute neck pain
Outcomes (units) No. of studies (Total no. of participants) Mean (SD)/ No. of participants Heterogeneity test (I2) MD (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 1 (182) 3.75 (1.97)/ 91 3.31 (2.06)/ 91 Not applicable because there is only 1 trial 0.44 (-0.13 to 1.00) Low
2 (NA) 1 (182) 14.96 (9.87)/ 91 13.98 (10.66)/ 91 Not applicable because there is only 1 trial 0.98 (-1.51 to 3.47) Low
3 (degrees) 1 (182) 5.87 (11.21)/ 91 6.26 (11.50)/ 91 Not applicable because there is only 1 trial -0.40 (-3.24 to 2.45) Low
Keys: SD = standard deviation; MD = mean difference; CI = confidence interval.
Comparison    SMT versus conventional medication
Main Results
Compared to conventional medication, SMT showed significant superiority in reducing participant-rated pain score (mean difference (MD): 0.94, 95% CI: 0.37 to 1.51) and in improving flexion and extension degrees (MD: 3.11, 95% CI: 0.23 to 5.99). However, SMT did not show significantly stronger reduction in the participant-rated neck disability score (MD: 2.19, 95% CI: -0.31 to 4.69).
Comparison 1: SMT versus medication amongst subjects with acute and subacute neck pain
Outcomes (units) 1 (NA) 2 (NA) 3 (degrees)
No. of studies (Total no. of participants) 1 (181) 1 (181) 1 (181)
Mean (SD)/ No. of participants Intervention 3.75 (1.97)/ 91 14.96 (9.87)/ 91 5.87 (11.21)/ 91
Comparator 2.81 (1.89)/ 90 12.77 (10.12)/ 90 2.75 (11.63)/ 90
MD (95% CI) 0.94 (0.37 to 1.51) 2.19 (-0.31 to 4.69) 3.11 (0.23 to 5.99)
Overall quality of evidence* Moderate Low Moderate
Keys: SD = standard deviation; MD = mean difference; CI = confidence interval.
Comparison    SMT versus HEA
Main Results
Compared to HEA, SMT did not show stronger effects in participant-rated pain score reduction (mean difference (MD): 0.44, 95% CI: -0.13 to 1.00), participant-rated neck disability score reduction (MD: 0.98, 95% CI: -1.51 to 3.47) and the flexion and extension degree improvement (MD: -0.40, 95% CI: -3.24 to 2.45).
Comparison 2: SMT versus HEA amongst subjects with acute and subacute neck pain
Outcomes (units) 1 (NA) 2 (NA) 3 (degrees)
No. of studies (Total no. of participants) 1 (182) 1 (182) 1 (182)
Mean (SD)/ No. of participants Intervention 3.75 (1.97)/ 91 14.96 (9.87)/ 91 5.87 (11.21)/ 91
Comparator 3.31 (2.06)/ 91 13.98 (10.66)/ 91 6.26 (11.50)/ 91
MD (95% CI) 0.44 (-0.13 to 1.00) 0.98 (-1.51 to 3.47) -0.40 (-3.24 to 2.45)
Overall quality of evidence* Low Low Low
Keys: SD = standard deviation; MD = mean difference; CI = confidence interval.
Conclusion
Benefits
Compared to conventional medication, SMT was superior in reducing pain and in improving the flexion and extension. However, SMT did not provide stronger beneficial effect on disability reduction amongst subjects with acute and subacute neck pain. For outcomes 1 and 3, the overall quality of evidence is moderate. Further research is fairly likely to have an important impact on our confidence in this estimate of effect. For outcome 2, the overall quality of evidence is low. Further research is likely to have an important impact on our confidence in this estimate of effect. Compared to HEA, SMT did not provide stronger beneficial effects on pain and disability reduction, and flexion and extension improvement amongst subjects with acute and subacute neck pain. For all outcomes in this comparison, the overall quality of evidence is low. Further research is likely to have an important impact on our confidence in this estimate of effect.
Harms
No serious adverse events were reported in the trial. 40% of the SMT group and 46% of the HEA group participants reported mild adverse events, primarily musculoskeletal pain. Paresthesia, stiffness, headache, and crepitus were less frequent. 60% of the conventional medication group participants reported side effects, with the most common complaint being gastrointestinal symptoms and drowsiness. Dry mouth, cognitive disturbances, rash, congestion, and disturbed sleep were less commonly reported.
Link to Original Article
http://www.ncbi.nlm.nih.gov/pubmed/22213489
The synopsis is based on the following article:
Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine. 2012 Jan 3; 156(1 Pt 1):1-10.


* Interpretation of quality assessment results:
• Very low: Further research is most likely to have an important impact on our confidence in this estimate of effect.
• Low: Further research is likely to have an important impact on our confidence in this estimate of effect.
• Moderate: Further research is fairly likely to have an important impact on our confidence in this estimate of effect.
• High: Further research is unlikely to have an important impact on our confidence in this estimate of effect.
• Very high: Further research is most unlikely to have an important impact on our confidence in this estimate of effect.

Details of assessment method can be found at Chung VC, Wu XY, Ziea ET, Ng BF, Wong SY, Wu JC. Assessing internal validity of clinical evidence on effectiveness of CHinese and integrative medicine: Proposed framework for a CHinese and Integrative Medicine Evidence RAting System (CHIMERAS). European Journal of Integrative Medicine. 2015 Aug 31;7(4):332-41.