Neck pain affects a significant number of individuals. Recent studies have found more than 10% of Americans suffer from neck pain at any given time.

The reason is that the neck region contains many delicate, pain sensitive structures commonly exposed to abuse and abnormal stresses. Incomplete rehabilitation of past injuries, poor posture, prolonged sitting, and lack of periodic spinal alignments are some of the more common factors in the development of neck problems.

Fortunately, most individuals suffering from neck problems will find chiropractic care extremely beneficial. Unlike prescription drugs, most chiropractic procedures address the cause of the majority of neck problems, not simply the symptoms. Best of all, chiropractic care is safe, natural, and noninvasive… no side effects allowed!

Anatomy of the Neck

Within the neck lies the cervical spine, the upper most portion of the spinal column. The cervical spine is structurally and functionally unique from the other areas of the spinal column.

Structurally, the cervical spine is composed of 7 moderately small and unique vertebrae including associated muscles, ligaments, joints and nerves.

The cervical spine has many important functions which include providing support and mobility to the head and neck, providing essential information for the balance and coordination of the body, and protection for the upper spinal cord and associated spinal nerves.

Generous Amounts of Motion

The cervical spine is the most flexible region of the spine, providing the most generous amounts of flexion, extension, lateral flexion and rotation.

The 1st and 2nd cervical vertebrae, known as the atlas and axis respectively, have highly unique structures which allow them to form a pivot joint. This joint alone provides approximately 90 degrees of rotation in the cervical spine. These same vertebrae also contain special receptors within their joints which provide the brain with important information essential for the maintenance of balance and coordination. As you will see in “Causes”, injury or irritation to these mechanoreceptors results in balance disturbances and problems with coordination.

The remaining cervical vertebrae also provide large degrees of motion but mainly in flexion, extension and lateral flexion (side bending). Unfortunately, there’s an inverse relationship between mobility and stability. Thus, the cervical spine is more susceptible to injury compared with other areas of the spine.

Nervous System Protection
The cervical vertebrae immediately encase and protect the spinal cord as it descends from the skull.

The spinal cord travels through small holes in the rear of the cervical vertebrae, giving rise to spinal nerve roots at each vertebral level. These nerve roots exit through the small openings formed by adjacent vertebrae called the intervertebral foramina (IVF). The IVF is the “exit” out of the cervical spine as spinal nerves make their way to the head, face and arms. The IVF is a common location for nerve irritation and can give rise to a variety of head, neck and upper extremity symptoms in the cervical spine.

The Spinal Nerves
The nerves exiting the cervical spine are delicate and can become irritated or injured, giving rise to a number of different signs and symptoms.

The 1st through 3rd cervical nerves exiting from the cervical are responsible for providing sensations to the head and face. When these nerves are compressed, stretched or irritated they will cause pain and other altered sensations in regions of the head and face. Researchers have found irritation to the 2nd cervical nerve (the greater occipital nerve) to be a major source of head and face pain. The nerves from the mid and lower cervical spine combine to form the brachial plexus, a collection of nerves which innervate the arms. Compression, stretch or irritation to these nerves commonly cause pain, numbness, tingling and weakness in the arms.

Causes of Neck Pain

There are many causes for neck pain. Some causes result from acute injuries which cannot be avoided, such as an automobile accident resulting in a whiplash-type injury. Other causes can be avoided and result from the use of “bad” or improper habits and techniques, such as poor posture and improper lifting. These “other causes” make up the majority of neck pain causes and can be effectively treated once the cause(s) is/are identified and the appropriate measures to avoid these “bad” and improper habits and techniques are implemented.

Some of the more common causes of neck pain include:
incomplete rehabilitation of past injuries
lack of proper and periodic spinal alignments
presence of cervical spine subluxations
whiplash-type injuries
improper workstation setup
poor posture
prolonged sitting
prolonged use of non-ergonomically designed equipment
excessive repetitive neck motions
improper telephone techniques
excessive mental stress
physical inactivity
poor diet and nutritional practices

Treatments for Neck Pain

Doctors of chiropractic have long known that the most successful treatments involve the identification and correction of the underlying causes of the condition. That’s why chiropractic care has been so successful in the correction of back and neck conditions and the number one choice for back and neck care.

Identifying The Cause

The first step in treating neck pain is to determine what has and is causing the neck pain. Once the causes and contributing factors are identified, a successful treatment plan can be structured to eliminate pain and achieve the goals of the patient.

The Treatment

The chiropractic treatments for neck pain incorporate the use of many therapies, all of which are gentle, safe, natural and noninvasive. However, the true power of chiropractic care is found in the chiropractic adjustment – the most effective and essential treatment employed by the chiropractor. The reason? Quite simply, the spinal adjustment corrects the major problems that the majority of neck pain sufferers have.

Most individuals experiencing neck pain have either: suffered an acute accident such as whiplash, where the structural integrity of the neck has been altered and tissue damage has occurred, or been exposed to long period of adverse neck and spinal stresses most commonly from bad or improper postural habits and techniques.

In both cases, the spinal components are almost always structurally misaligned and biomechanically faulty. In other words, the vertebrae and their supporting structures have lost their “optimal” positioning and their movements are occurring in an inappropriate and stressful manner. The only effective and long-term way to correct the structural malpositions and improper biomechanics is to realign the spinal segments and restore normalize motion. This is the job of the spinal adjustment. In addition to restoring positioning and motion, the spinal adjustment also produces a reflexive relief of pain and reduction in muscle spasm. This is due to the high number of mechanoreceptors in the joints of the vertebrae which are stimulated through the chiropractic adjustment.

Research has shown that stimulation of these mechanoreceptors sends signals to the brain which shutdown pain signals and result in muscle relaxation. Also, the adjustment helps to eliminate inflammation through the introduction of motion; inflammatory chemicals are known irritates to pain fibers.

Proper Habits and Techniques

Another key ingredient to a successful neck pain treatment plan includes the learning of proper postural habits and other techniques. Proper posture is a significant factor in the health of the neck and back and proper posture should always be practiced. Techniques common to daily living and work also play a major role in the development or lack of development of neck pain. This includes proper lifting techniques, telephone techniques, avoidance of repetitive motions, and much more. We can teach you correct habits and techniques which will protect your neck and back from discomfort and injury. Also, be sure to checkout our “Posture” and “Ergonomics” sections of our site for additional information.

Other Therapies

Other manual therapies such as massage, trigger point therapy, proprioceptive neuromuscular facilitation, and acupressure therapy may be utilized to assist in the relaxation of cervical muscles and increase cervical spine mobility.Therapeutic exercises and stretches which assist in the restoration of proper cervical motion and increase cervical muscle strength and coordination are commonly prescribed. Exercises and stretches are unique in that they can be performed outside the office without the assistance of the doctor.

Physical therapies commonly used by physical therapies may also be employed and include hot and cold applications, muscle stimulation, interferential therapy, therapeutic ultrasound, and diathermy.

Diet and nutrition also play a key role in the health of the cervical spine. Without the proper nutrients, the cervical spine and rest of the body are less able to remain healthy and heal once injured. If you diet and nutritional status is poor, we can help get you on track.

Healthy Living Tips For Neck and Upper Back Pain

Regular spinal checkups. Maintaining proper alignment and functioning of the neck and upper back through periodic spinal adjustments minimizes the stresses to structures of the cervical and thoracic spine. Also, keeping the nervous system free from interference ensures proper communication within the body, keeping you happy and healthy.

Practice proper posture, lifting and ergonomics. Practicing proper posture, lifting techniques and ergonomics are key in reducing neck and back injuries at work and play and minimizing future recurrences of past injuries. For more info, checkout the “Ergonomics” and “Posture” sections of our site.

Regular exercise. Routine physical activity keeps the heart healthy and keeps the spine as well as the rest of the body strong and healthy. An effective exercise program should consist of a minimum of 3 sessions per week for 40 minutes. Involve friends and family, mix up the activities, keep it fun and stay consistent!

Proper diet and nutrition. Providing your body with the proper fuel increases performance, reduces the likelihood of injury and sickness, speeds recovery after injury, and keeps you feeling good. If, like the rest of us, you’re finding it difficult to get all the nutrients your body needs, it’s probably time to supplement. For information on nutritional supplements, checkout the ” Health Products ” section of our site.

Utilize stress management techniques. Stress is most often carried in the shoulders, upper back and yes, neck. While stress can’t be totally eliminated there are effective techniques to help bring it under control. Checkout the “Wellness Center” for more information on stress management or contact our office for an appointment.

Neck Pain Related Articles and Research

Spinal Manipulation vs. Acetaminophen for Chronic Neck Pain
In this University of Colorado study, researchers compared chiropractic spinal manipulation with Acetaminophen for the treatment of chronic neck pain. On average, patients had been suffering from neck pain on and off for approximately 10 years. Patients were split into 2 groups, receiving either:

12 chiropractic spinal adjustments over a 6 week period, or Acetaminophen 4X/day plus 12 visits with a nurse over a 6 week period. Both groups were also instructed to exercise and use a heating pad. At the end of the 6 weeks, patients who received the chiropractic spinal manipulation reported a significant improvement in neck pain and function, showing increased range of motion and strength. Patients receiving medication and nurse care showed no significant changes or improvements. Researchers are currently performing a long-term follow-up.

Manual Mobilization for Neck Pain Patients is Superior to Massage and Physical Therapies

Editors Summary
Cervical mobilization in comparison to other therapies has not been reported, but several researchers have found positive effects of mobilization. The purpose of this study is to address two problems:

Do patients with restricted mobility and pain in cervical mobile segments benefit from mobilizing manual therapy?
Is there any relationship between reduction of pain and increase of the total cervical spine mobility?
Subjects were patients with restricted movement in the pain-producing segment. The patients were examined and randomized into three groups:

Group 1 – Patients were told that they should try a new type of drug known to reduce pain most efficiently; they received salicylate daily for 3 weeks.

Group 2 – Patients had the same information as those in group 1, and in addition were told that they would have some special information to help ease their pain, and also treatment by a skilled physiotherapist; they received salicylate, and their manual (mock) therapy consisted of superficial massage, electrical stimulation, and slight relaxing traction given three times a week for three weeks.

Group 3 – Patients had the same information as those in group 2; they received salicylate, and their specific therapy consisted of relaxation techniques such as superficial heat, soft tissue treatment and slight traction, and specific manual mobilization of the actual mobile segments in the cervical spine; three treatments were given each week for three weeks.

(The special information given to groups 2 and 3 included anatomy and pathophysiology of the cervical spine as well as biomechanical problems and practical problems such as lifting, carrying and relaxation).

Each patient estimated their pain and reported the actual level each week. Total cervical mobility in the coronal, sagittal and transverse planes was recorded before and after therapy each week and even one week after the therapy finished by a physiotherapist. In addition, social conditions were recorded by a social worker, and Eysenck personality inventory tests were used by assistants.

Results showed that the initial pain level was about the same in all three groups. Before the treatment, tender spots with increased consistency in the muscle were frequent in 80-90% of the patients in all three groups. Manual examination revealed the same distribution of hypo mobile segments, C7-T2, in the three groups. The effect on pain was evaluated by the pain level and the decrease of pain. Group 3 showed a significant difference in pain level after treatment from the other groups. Group 3 also showed a significant difference in decrease of pain one week after the treatment and at the conclusion of the treatment. Mobility increased significantly at the final treatment for group three compared to the other groups.

This study concludes that cervical pain patients can be improved by simple manual technique as a first step towards complete treatment.

Manipulation of the Cervical Spine

Authors Abstract
A randomized controlled trial of manipulation of the cervical spine was carried out on 52 patients in general practice, and the results were assessed symptomatically and goniometrically for three weeks. Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paraesthesia in the shoulder, and a nearly significant improvement in those with pain/paraesthesia in the arm/hand. Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained.

Editors Summary

Pain and/or stiffness in the neck or pain referred to the head, shoulder, arm or hand are presentations of common neck disorders. The pathology of these conditions is uncertain and some probable causes are: minor subluxations of intervertebral facet joints, derangements of intervertebral discs with secondary osteoarthritis of the interarticular joints, or meniscoid entrapment in the upper cervical apophyseal joints straining the joint capsule. Manipulation for these conditions is controversial, and this study tries to assess its effectiveness.

Subjects were selected, were assessed by doctors A and B, and were divided into either the treatment or control group. The treatment group was treated by manipulation and/or injection (if the neck was too painful) and was asked to return for further treatment at Dr. A’s discretion. Both groups were treated with axapropazone. They were all instructed not to tell Dr. B whether they had been manipulated or not. Patients then returned to Dr. B who again recorded their symptoms and measured their neck movements via a goniometer.

Results showed that among patients initially affected with a symptom, the proportion showing immediate improvement after manipulation was greater than the corresponding proportion in controls; the difference reached significance for neck pain and neck stiffness and shoulder pain/paraesthesia. Manipulation also produced a highly significant immediate improvement in rotation and lateral flexion. The improved rotation was maintained at one and three weeks, but the lateral flexion improvement did not last. However, more than half the control group experienced improved symptoms despite no measured improvement in movement, confirming clinical impression.

Pressure Pain Threshold Evaluation of the Effect of Spinal Manipulation in the Treatment of Chronic Neck Pain

Authors Abstract

Nine subjects with chronic mechanical neck pain syndromes were evaluated for pressure pain threshold (PPT) over standardized tender points in the paraspinal area surrounding a manipulable spinal lesion. The subjects were then allocated randomly to an intervention consisting of either an oscillatory mobilization of the cervical spine (n=4), which was designated as the control procedure, or a rotational manipulation of the cervical spine (n=5). An assessor-blinded re-evaluation of the pressure pain threshold levels was conducted after 5 minutes. In the group receiving a manipulation the mean increases in pressure pain threshold ranged from 40-56% with an average of 45%. In the control group no change in any of the pressure pain thresholds was found. These results were analyzed using ANOVA and were found to be statistically significant (p < 0.0001). This study confirms that manipulation can increase local paraspinal pain threshold levels. The use of the pressure pain threshold meter allows for the determination of such a beneficial effect in the deeper tissues.

Editors Summary

Very few clinical trials have been produced to provide evidence that manipulative treatment by chiropractors is beneficial to patients with neck pain. The senior author of this study, Howard T. Vernon, conducted clinical analog studies in which the results of a single manipulation were compared to control procedures. In the first study, a single thoracic manipulation produced a significantly higher rise in cutaneous pain tolerance levels than the shashared/stockpages/cp/conditions/neckpain/m/manipulation group. In the second study, a single manipulation of the cervical spine produced a modest increase in plasma beta-endorphin levels while control and sham procedures dropped. These studies support the idea that pain relief occurs subsequent to manipulation, and to the theory that this pain relief is a result of reflex mechanisms activated by the thrust. The reflex mechanisms can be described as afferent bombardment from the articular and myofascial receptors which produces pre synaptic inhibition of segmental pain pathways and possibly activation of the endogenous opiate system. The purpose of this study is to extend this earlier work to prove that a single manipulation would produce a significantly higher rise in pressure pain threshold levels in the paraspinal area surrounding a spinal fixation as compared to a control procedure. In this study, a more accurate device is used, the pressure threshold meter. The advantages are that this device can objectively measure pressure pain threshold over tender points in muscles as well as measure functional changes in the deeper tissues around a joint. Subjects were chiropractic patients diagnosed with chronic mechanical neck pain for an average duration of less than 3 months. The research treating physician assessed for joint dysfunction of the cervical spine, and marked the “fixated” or hypo mobile segment. The treater left the room and the assessor entered to conduct a PPT assessment of four tender points above and below, and on each side of the fixated level.

The points were consistently measured as:

ipsilateral to the clinically painful side, slightly below the fixation;
ipsilateral, above;
contra lateral, above;
contra lateral, below.
Two measurements were taken at each point and the assessor left the room. The treater entered and applied the appropriate treatment of either a rotational mobilization with gentle oscillations into the elastic barrier, or a rotational manipulation (high velocity, low amplitude thrust). All subjects were asked if they felt pain and if they believed that they had received a “real” treatment. Finally, the blinded assessor re measured the tender points twice after 5 minutes.

Results revealed a statistically significant rise in pressure pain threshold ranging from 40-55% in all four points around the fixation level in the manipulation group compared to virtually no change in the mobilization group. All subjects that were manipulated reported no pain and regarded the manipulation as a “real” treatment. Of the four mobilized subjects, three reported no pain and none regarded the mobilization as “real”. These findings are behavioral as related to the subjects perception of pain, but the underlying mechanism of spinal reflexes causing pain threshold changes is still supported especially since no subject felt pain from the manipulation.

In conclusion, the pressure pain threshold meter has proven to be useful in objectifying the effect of manipulation versus mobilization in the cervical spine of subjects suffering from chronic mechanical neck pain, and these findings support the theoretical mechanisms proposed to explain the effects of spinal manipulation on spinal pain.

The Immediate Effect of Manipulation vs. Mobilization on Pain and Range of Motion in the Cervical Spine

Authors Abstract
Objective – The main objective of this study is to compare the immediate results of manipulation to mobilization in neck pain patients.
Design – The patients were compared in a randomized controlled trial without long-term follow-up.

Setting – The study was conducted at an outpatient teaching clinic on primary and referred patients.

Patients – One hundred consecutive outpatients suffering from unilateral neck pain with referral into the trapezius muscle were studied. Fifty-two subjects were manipulated and 48 subjects were mobilized. The mean (SD) age was 34.5 (13.0) yr for the manipulated group and 37.7 (12.5) for the mobilized group. Sixteen subjects had neck pain for less than 1 week, 34 subjects had pain for between 1 wk and 6 mo and 50 subjects had pain for more than 6 mo. Seventy-eight subjects had a past history of neck pain. Thirty-one subjects had been involved in an injurious motor vehicle accident and 28 subjects had other types of minor trauma to the neck. There were no significant differences between the two treatment groups with respect to history of neck pain or level of disability as measured by the Pain Disability Index.

Intervention – The patients received either a single rotational manipulation (high-velocity, low-amplitude thrust) or mobilization in the form of muscle energy technique.

Main Outcome Measures – Prior to and immediately after the treatments, cervical spine range of motion was recorded in three planes, and pain intensity was rated on the 101-point numerical rating scale (NRS-101). Both pre- and post-test measurements were conducted in a blinded fashion.

Results – The results show that both treatments increase range of motion, but manipulation has a significantly greater effect on pain intensity. 85% of the manipulated patients and 69% of the mobilized patients reported pain improvement immediately after treatment. However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (p=.05).

Conclusion – This study demonstrates that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree. Further studies are required to determine any long-term benefits of manipulation for mechanical neck pain.

Editors Summary

Neck pain with decreased mobility is a common condition that improves, for most cases, with time , but may persist in others as moderate or severe pain for several years after the initial onset. Many different treatments have been used to handle mechanical neck pain, but few clinical trials have been performed to establish their effectiveness. The purpose of this study is to compare the immediate results of manipulation and mobilization on pain and ROM in patients with unilateral mechanical neck pain. Subjects were patients suffering from unilateral, mechanical neck pain with radiation into the trapezius, and local cervical paraspinal tenderness. After the initial exam and before the treatment, patients rated their pain intensity on the NRS-101. Cervical ROM was measured next by a goniometer after which patients were randomized into two groups: Group 1- Cervical Manipulation- involved contacting the pillar on the painful side of the neck at the level of tenderness, passively rotating the neck away from the painful side as far as possible, and applying a high-velocity, low-amplitude thrust in the same direction. Group 2- Cervical Mobilization- involved application of muscle energy technique (active resisted isometric contraction held for 5 seconds and repeated four times with increasing rotation or lateral flexion of the neck; aims to improve mobility and pain via post-isometric relaxation) to hypertonic muscles responsible for restricting joint movement. All treatments were given once and were applied to the symptomatic side. Patients rated their pain intensity again within five minutes after the treatment, and the ROM exam was also repeated.

Results show that both manipulation and mobilization have the immediate effect of decreasing pain and increasing cervical ROM. Improvements were slightly higher in the manipulation group, and the overall pain improvement on the NRS-101 was 1.5 times greater than the mobilized group. The question is which treatment would give better results when considering long-term follow up and risk/benefit (manipulation may cause a cerebrovascular accident whereas mobilization will not, but mobilization may be of little therapeutic value).

In conclusion, this study proves that manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain, but both treatments increase cervical ROM to the same degree. Further studies should examine the long-term benefits of manipulation for mechanical neck pain.

Early Mobilization of Acute Whiplash Injuries

Authors Abstract
Acute whiplash injuries are a common cause of soft tissue trauma for which the standard treatment is rest and initial immobilization with a soft cervical collar. Because the efficacy of this treatment is unknown a randomized study in 61 patients was carried out comparing the standard treatment with an alternative regimen of early active mobilization. Results showed that eight weeks after the accident the degree of improvement seen in the actively treated group compared with the group given standard treatment was significantly greater for both cervical movement (p<0.05) and intensity of pain (p<0.0125).

The results of this study indicate that early mobility of the neck following whiplash accident compared with a cervical collar and instructions to rest results in significantly less pain and stiffness.

Editors Summary

Whiplash injuries are due to sudden flexion and hyperextension of the spine with hyperextension as the main cause of damage. Standard treatment consists of a period of immobility using a soft cervical collar and simple analgesia before gradual mobilization. The purpose of this study is to evaluate the efficacy of this standard treatment compared with an alternative treatment of daily neck exercises and mobilization using the Maitland technique.

Subjects were patients with acute whiplash injuries who had not suffered a cervical fracture. Intensity of pain was assessed and cervical mobility was measured via a goniometer from which the total cervical movement was calculated. Patients were then randomized into two groups:

Group 1 – Standard treatment- soft cervical collar and instruction to rest for two weeks before beginning gradual mobilization; analgesia was given as required.

Group 2 – Active treatment- application of ice in the first 24 hours and then neck mobilization using the Maitland technique (repetitive and passive movements within the patients’ tolerance with tiny movements and movements with a restricted amplitude for pain and spasm, and movements with larger amplitude for stiffness) and daily exercises of the cervical spine within pain limits every hour at home; application of local heat after each treatment; no analgesia was required.

Both groups were assessed for residual pain and cervical movement at four and eight weeks after the accident.

Results proved that patients who are treated actively show significantly greater improvement in both cervical movement and intensity of pain compared with patients treated the standard way. At four weeks, a significant increase in cervical movement occurred in the patients given active treatment but not in those given standard treatment. At eight weeks, the same findings were yielded indicating that the increase in cervical mobility occurred earlier and to a significantly greater degree with active treatment. In terms of pain, the improvement was greater at both four and eight weeks in the group given active treatment compared with those given standard treatment.

These results confirm the expectations that initial immobility (lack of movement) after whiplash injuries gives rise to persistent pain and stiffness whereas a more rapid improvement can occur by early active management without any consequent increase in discomfort.

Effectiveness of Manual Therapy (Manipulation), Physiotherapy and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints

The following 3 studies come from the Netherlands and compare the effectiveness of manual therapy (manipulation), physiotherapy and treatment by general medical practitioners for nonspecific back and neck complaints.

The Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints
Authors Abstract

In a randomized trial, the effectiveness of manual therapy (manipulative techniques), physiotherapy, continued treatment by the general practitioner, and placebo therapy (detuned ultrasound and detuned short-wave diathermy) were compared for patients (n=256) with nonspecific back and neck complaints lasting for at least 6 weeks. The principle outcome measures were severity of the main complaint, global perceived effect, pain, and functional status. These are presented for 3, 6 and 12 weeks follow-up. Both physiotherapy and manual therapy (manipulation) decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner.

Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up

Editors Summary

The third trial of the series evaluating the effectiveness of manual therapy (manipulation) and physiotherapy utilized the same treatments and outcome measures as the prior studies, but chose changes in severity of the main complaint, limitation of physical functioning, and global perceived effect as the main outcome measures.

Results for this trial revealed an interesting factor: many patients in the GP (general medical practitioner treatment group) and placebo groups changed from their assigned treatment to another treatment during the one year follow-up. This clearly indicates the superiority of manual therapy (manipulation) and physiotherapy over the other two treatments, and the willingness of patients to turn to other treatments when their assigned treatment is not effective enough.

In terms of the change of the main complaint, the manual therapy (manipulation) group showed the largest improvement after 12 months follow up. Manual therapy also gave larger improvements in physical functioning than the physiotherapy group at all follow up measurements.

The global perceived effect after 6 and 12 months follow up was similar for both treatments. Thus, it can be concluded that manual therapy (manipulation) and physiotherapy are superior to GP and placebo treatment, and manual therapy (manipulation) is slightly better than physiotherapy after 12 months.

Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures

Editors Summary

This final trial utilized the same treatments as well as the same three outcome measures as the third study, but also assessed the relationship between the outcome measures via a subgroup analysis. The subgroup analysis was confined to manual therapy (manipulation) and physiotherapy only, focusing on specific subgroups that showed benefit, particularly from a certain therapy. The analysis was further confined to subgroups based on six predefined baseline characteristics only:

duration of the present episode (<1, >1 or =1 yr);
age (younger than 40 yr, 40 yr old and older than 40 yr);
localization of the complaints (back only, neck only, back and neck);
recruitment status (GP, advertisement);
severity of complaint (severity < 7 pts, severity 7 or >);
appropriateness of allocated treatment according to treating therapist (suitable/not suitable)
Results showed a greater improvement in the main complaint with manual therapy (manipulation) than with physiotherapy for patients with chronic conditions (duration complaint of 1 yr or more). Improvement in the main complaint was also larger with manual therapy (manipulation) than with physiotherapy for patients younger than 40 years (both were measured after 12 months follow up). Labeling of patients as “suitable” or “not suitable” for treatment with manual therapy (manipulation) did not predict differences in outcomes. There was a moderate to strong correlation between the three outcome measures, although a considerable number of patients gave a relatively low score for perceived effect while the research assistant gave a high improvement score for the main complaint and physical functioning. This finding indicates that the outcome measures represent different features of progress in back and neck patients, and that if research interest lies in the opinion of the patient and the observer, it will not suffice to measure just one of the outcome measures.

In conclusion, the subgroup analysis suggests better results of manual therapy (manipulation) compared to physiotherapy in chronic patients and in patients younger than 40 years. Future research must investigate the explorative findings of these subgroup analyses. Of particular interest may be the strong relationship between improvement of physical functioning and improvement of main complaint which can also indicate that the severity of the main complaint of a patient concurs with the patient’s limitation in physical functioning.

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