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by Max Kovler, PT Reg. (ON) for Mobile Physio

Most people will attest to the fact that neck (or cervical) pain is a common but self-limiting problem. However, many individuals experience neck pain as a series of exacerbations and remissions, and for some neck pain can be a chronic problem. Most frequently it’s labelled by the doctor as non-specific in the sense that accurately specifying the sore anatomical structure responsible is difficult, but the pain is ‘mechanical’ in that it is thought to arise from the joints and soft tissue that allow us to move our necks; correspondingly there may be a reduction in cervical range of motion and muscle strength. Most people intuitively seek out therapies such as massage for the soft tissues, mobilization or manipulation of the joints, or exercise to strengthen the muscles of the neck.Over the past 15 years there have been a number of studies that addressed the question of the relative efficacy of these treatment modalities in people with chronic neck pain.

Bronfort et al (2001) addressed the question of the relative efficacy of manual therapy and exercise in pain reduction in 191 chronic neck pain patients. Patients were randomly assigned to receive joint manipulation, exercise, or a combination of the two, 1-2 times per week for 12 weeks. It was found that joint manipulation did not add any significant reduction in reported pain (both groups reported an average of 58% reduction). The group that had joint manipulation alone also improved but only reported about a 45% reduction.

Hoving et al (2002) sought to examine the question of whether manual therapy, exercise therapy, or advice was most efficacious in reducing pain over six weeks in 183 patients who had neck pain for more than two weeks. Patients in each group had one appointment per week but appointment times varied, with the manual therapy group having the longest appointment times (45 minutes) and the advice group having the shortest appointment times (10 minutes). Another confounding factor was that the manual therapy group also had some exercises taught and the active exercise group also had some passive components (i.e. massage), while the education group were encouraged to do a home exercise program of stretches. Perhaps unsurprisingly all the groups had similar results in terms of pain reduction, with the group that had the most contact with the physiotherapist reporting the biggest reduction in pain (~60% improvement).

Dziedzic et al (2005) examined the relative efficacy of manual therapy and short wave diathermy (a type of passive pain relieving modality) when combined with exercise in 350 chronic neck pain patients over six weeks. It was found that neither manual therapy nor short wave diathermy added to the pain relief that was reported in the group that received exercise alone.

Hakkinen et al (2007) looked at the question of how a home exercise program of stretches taught to the patient to do daily compared with twice weekly therapy sessions with a physiotherapist who performed massage, manual therapy, and also passive stretching. After four weeks both groups said they improved in terms of their average pain but the physiotherapy group (~50%) improved somewhat more than the home stretching group (~40%). Unfortunately the investigators in this study didn’t include a control group so one can’t be certain that the improvements were the result of placebo or simply the passage of time.

Evans et al. (2012) addressed the question of whether manual therapy adds to the efficacy of exercise therapy and compared this with a home exercise program over 12 weeks of treatment for chronic neck pain patients. This study better controlled for the effect of attention by standardizing appointment times for each group. The study found that the manual therapy group did report less neck pain after 12 weeks although the difference was relatively small (59% vs 54% improvement). The patients who engaged in the home exercise program also reported about a 35% improvement; however they only had two sessions with the therapists and so the worse results could have been the result of less attention.

In conclusion, the available studies that examined the role of manual therapy and exercise in the treatment of chronic neck pain are inconclusive. Some reported that manual therapy yielded slightly superior pain relief in comparison to exercise alone, while others found no significant difference. None included a control group to compare the effect of the index treatment with that of the simple passage of time or placebo effects. Clearly more work in the area needs to be done to provide patients evidence-based guidance for their health care choices in the management of chronic neck pain.

Bronfort G, Nelson B, Aker PD, et al.
A randomized clinical trial of exercise and spinal manipulation for subjects with chronic neck pain.
Spine 2001;26: 788–7.

Hoving JL, Koes BW, de Vet HC, et al.
Manual therapy, physical therapy, or continued care by a general practitioner for patients
with neck pain. A randomized, controlled trial.
Ann Intern Med 2002;136(10):713–722

Dziedzic K, Hill J, Lewis M, et al.
Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics.
Arthritis Rheum 2005;53:214–22.

Hakkinen A, Salo P, Tarvainen U, Wiren K, Ylinen J.
Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain.
J Rehabil Med. Sep 2007;39(7):575-579.

Hakkinen A, Salo P, Tarvainen U, Wiren K, Ylinen J.
Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain.
J Rehabil Med. Sep 2007;39(7):575-579.

Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain: a randomized controlled trial.
Evans R, Bronfort G, Schulz C, Maiers M, Bracha Y, Svendsen K, Grimm R, Garvey T, Transfeldt E.
Spine (Phila Pa 1976). 2012 May 15;37(11):903-14.

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