MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Neck pain affects a vast number of people and leads to reduced quality of life and high costs. Clinically, it is a difficult condition to manage, and the effect sizes of the currently available treatments are moderate at best. Activity and manual therapy are first-line treatment options in several guidelines. But how effective are they really?

This study investigated the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in a multidiscipline range of primary care clinics.

The treatment modalities utilized were spinal manipulative therapy combined with home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS – 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively.

One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both groups and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used.

Sixty-six subjects were randomized to the intervention group, and 65 to the control group. For NRS – 11, a B-coefficient of – 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures.

Four intense adverse events were reported in the study, three in the intervention group, and one in the control group. More adverse incidents were reported in the intervention group, with a mean pain intensity (NRS-11) of 2,75 compared to 1,22 in the control group. There were no statistically significant differences between the two groups.

The authors concluded that there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain.

This is a rigorous and well-reported study. It suggests that adjuvant manipulations are not just ineffective for neck pain, but also cause some adverse effects. This seems to confirm many previously discussed investigations concluding that chiropractors do not generate more good than harm for patients suffering from neck pain.

9 Responses to No effect from adding chiropractic manipulations to exercises for neck pain

  • “All subjects were scheduled for four treatments over the course of 2 weeks. The intervention dose and period were chosen as previous research had shown this would be sufficient to see a change in pain levels in a similar patient group [29, 30].”

    Really? One paper had to do with LBP with various levels of persistent pain and the other one was on acute neck pain in which they only did thoracic manipulation.

    Sigh.

  • One obvious question that regularly presents itself is why those alternative practitioners keep on doing what they do, in spite of the huge amount of of evidence that their activities are quite useless.

    There is of course not one single reason, and different practitioners will have varying reasons, but it might be an interesting exercise to try and put together a list of motivations. Here are some things that I can come up with:

    They really believe that their modality of choice works.
    This, however, raises several more questions: What do they base their belief on? Because by now, they all must be aware that real doctors and real medical science have quite a different opinion. Do they rely on the evidence of their own eyes (“We See It Work”)? They must by now know about the placebo effect and the fact that the vast majority of ailments eventually resolves naturally – and therefore that they may be fooling themselves. Or do they use the same trick as religious people and those dealing with cognitive dissonance? I.e. only be receptive to signs, signals and evidence that confirms their belief, and shut out / drown out any contrary information. (Also see Morton’s Demon.)
    Talking about religion: many people become alternative practitioners as a result of what is called a Revelation Event: someone close (or the person themselves) is apparently miraculously cured of a serious or chronic condition by using chiropractic/homeopathy/reiki/naturopathy/herbalism/therapeutic touch/… (choose any of the 200+ alternative modalities). These people probably are the True Believers, and hardest to convince that they are wrong nevertheless.

    They are addicted to their customers’ respect and adoration
    Enjoying people’s respect and often even admiration as a knowledgeable healer can be very addictive, and it also helps to instil the notion that they’re Doing Good Things, even if they themselves doubt the very nature of their activities. Of course it also requires ignoring and/or forgetting all those times that someone was less satisfied with the services they paid for.

    They know that they’re selling nonsense, but it’s hard to turn down easy money.
    One important motivation is of course Easy Money: alternative practitioners can easily charge €100 per hour without any real education, skills or knowledge – far more than the average GP makes. It is in fact legitimized fraud, because customers never receive what they are promised and pay for: effective healthcare. However, I think that there are only very few practitioners out there who are honest enough to admit this even to themselves – so most legitimize their activities by pointing to one of the other reasons mentioned.
    One notable exception here are the people who design and build devices for quackery, e.g. ‘bioresonance computers(*)’ and the likes. These people absolutely know that those products they build are completely bogus from A to Z, because they need to deliberately design and program these machine to produce a semblance of functionality. A normal practitioner such as a homeopath may convince himself that his ‘remedies’ work because they ‘see it work every day’, but these technicians never see things work at all, because all the mumbo-jumbo involving bioresonance is 100% made up – so they absolutely know that they are defrauding their customers.

    *: And many bioresonance devices don’t even bother to measure anything at all. They just have a display and some blinking lights to make it look like it’s doing something useful, and a simple piece of software that more or less randomly selects a diagnosis and a treatment, with some restraints built in to prevent all too obviously nonsensical output (e.g. prostate problems diagnosed for females).

    No doubt, there are even more reasons why alternative practitioners stick to their guns. Maybe other readers can come up with more suggestions?

    And I’m also genuinely interested in the motivations of the actual practitioners themselves – some of whom I know read this blog as well. Feel free to respond if think you can give your honest opinion. I promise I will not use it against you!

  • how about we just stick to the paper at hand? Is it really evidence for or against anything for which most manual therapist actually do on a daily basis?

    The original project was on chronic neck and shoulder pain and was a pilot study looking at HRV.

    Is there any evidence that two weeks of care will have a significant change on chronic neck pain?

    I suppose one could tease thru the papers below but it’s unlikely one will see a significant difference within two weeks regardless of the approach.

    “Vernon et al (87,88) published 2 systematic reviews on neck pain. They indicated moderate to high quality evidence in support of spinal manipulation or mobilization for chronic nonspecific neck pain (8,15,19,20,87).” Pain Physician. 2019 Mar; 22(2): E55–E70.

    Of course a pilot study on CGH and cSMT, they found that “Our pilot study adds to an emerging picture of SMT dose for the treatment of headache. It showed that a plateau in intervention effect might be found in the range of 8 to 16 treatment sessions, although a dose effect at these treatment levels cannot be ruled out.” Spine J. 2010 Feb; 10(2): 117.

    Similar dose responses are seen for cLBP.

    So 4 treatments over 2 weeks for “persistent” neck and shoulder pain? Yes, the results don’t surprise me.

    Sigh.

  • “ Adverse events in this study were few and mainly mild, in line with previous studies [54, 56] confirming that both interventions are safe.”

    • EE: This seems to confirm many previously discussed investigations concluding that chiropractors do not generate more good than harm for patients suffering from neck pain.

      Acute and subacute LBP….“Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.”

      “With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term.”

      Gianola S, Bargeri S, Del Castillo G, et al Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis British Journal of Sports Medicine Published Online First: 13 April 2021.

      Of course sharing a MA and SR on neck pain and manual therapy won’t tickle some folks confirmation bias.

      “ Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions. It appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. The studies comparing to no treatment or sham were mostly testing the effect of a single dose, which may or may not be helpful to inform practice. According to the published trials reviewed, manipulation and mobilization appear safe. However, given the low rate of serious adverse events, other types of studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for nonspecific chronic neck pain.” Pain Physician 2019; 22:E55-E70 • ISSN 2150-1149

      • your efforts to white-wash chiropractic are well-established, albeit pathetic.

        • EE: your efforts to white-wash chiropractic are well-established, albeit pathetic.

          interesting response. I point out some issues with the paper (issues which you failed to mention), a paper which you called a “…rigorous and well-reported study.”, and you accuse me of whitewashing?

          Psst…the paper was on spinal manipulation and exercise, not chiropractic.

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