Research Review By Dr. Kent Stuber©


Download MP3

Date Posted:

November 2012

Study Title:

Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain


Evans R, Bronfort G, Schulz C et al.

Author's Affiliations:

Northwestern Health Sciences University, Wolfe Harris Center for Clinical Studies, Minnesota, USA.

Publication Information:

Spine 2012; 37(11): 903-914.

Background Information:

Chronic neck pain is common and can have a substantial impact on those who endure it. Up to 75% of people will experience neck pain at some point in their lives, and many deal with it on an ongoing basis! Both manual therapy and exercise have been found to be effective for neck pain through high-quality systematic reviews – both are recommended interventions for chronic neck pain. However, it is unclear whether it is better for exercise therapy for chronic neck pain patients to be home-based or supervised, and to what extent spinal manipulation may add to the benefits of exercise. Therefore, the objective of this mixed-methods study was to “evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for chronic neck pain.”

Pertinent Results:

  • 270 patients (72% female) were randomized into treatment 3 groups, with over 92% of participants completing at least 80% of their treatment visits
  • Between group differences were noted in patient age and symptom frequency and duration, but the groups were otherwise similar
  • Average symptom duration was just over 9 years and average pain levels were around 5.6/10
  • All three groups showed improvement in all outcome measures over the course of the treatment period (12 weeks)
  • At 12 weeks, the Exercise Training and SMT group (ET+SMT) and Exercise Training Alone (ETA) group showed statistically significant improvement compared with the Home Exercise and Advice (HEA) group for pain, global perceived effect, and patient satisfaction
  • Further, the ET+SMT group showed a significantly greater reduction in disability than the HEA group
  • The ET+SMT group did produce a greater reduction in patient rated pain when compared with the ETA group across all time points, but not to a statistically significant degree
  • Significant differences favoring ET+SMT and ETA groups over the HEA group were noted in static flexion, dynamic extension, and bilateral isometric strength
  • At 52 weeks, there were no significant between-group differences in any of the outcome measures except for patient satisfaction, with the ET+SMT and ETA groups being more satisfied than the HEA group (although the linear mixed model analysis showed significant differences favoring the ET+SMT and ETA groups in pain, global perceived effect, and satisfaction)
  • Side effects were mild and transient (at expected levels and generally meaning that no treatment was required) with more side effects reported in the ETA and ET+SMT groups. No major side effects resulting from SMT were reported.
  • The qualitative interviews indicated that pain severity was the most important outcome to the study subjects, and satisfaction with care was mostly determined by interaction with study personnel which happened most frequently with ETA and ET+SMT interventions

Clinical Application & Conclusions:

The main results of this study are that an intense supervised strengthening program, with or without spinal manipulation, outperformed a low dose home exercise and advice program for patients with chronic neck pain with respect to most of the outcome measures evaluated (pain intensity, perceived benefit, and satisfaction), including functional measures such as neck endurance and strength. These results would seemingly only stand to reason, however the results appeared mainly in the short-term (first 12 weeks). In addition, large proportions of the HEA group did experience clinically meaningful improvements in pain, both short term and long term. As such, the authors opined that it may be most reasonable to recommend low dose home exercise and advice to patients with chronic neck pain initially. If that does not produce appreciable clinical gains, then move on to a high dose supervised exercise program (+/- SMT). Clinicians need to consider factors such as side effects, likelihood of patient compliance with exercise programs, time commitment and physical effort.

Overall, SMT was beneficial, but its addition to the supervised exercises did not produce a substantial advantage compared to the group that received supervised exercise without SMT. (EDITOR’S NOTE: As always, clinical experience and individual patient preference for treatment must be considered, and we should remember that SMT is still a recommended intervention for neck pain, especially when combined with exercise [2]).

Another important finding emerged from the qualitative patient interviews, which indicated that personal attention from health professionals was important to patients. This is something most manual therapists don’t think of often, but we should remember that how we interact and communicate with our patients can have profound impacts on our clinical results.

Study Methods:

This study was a single-centre, three-armed RCT of patients with chronic mechanical non-specific neck pain (> 12 weeks), along with a qualitative study of the involved patients, making it a mixed-methods study. Outcome measures consisted of numerical pain rating scales along with the Neck Disability Index (NDI), Short Form (SF)-36, global perceived effect, medication use, and treatment satisfaction. Outcomes were measured at baseline, 4 and 12 weeks, with follow up at 26 and 52 weeks. Biomechanical assessments included range of motion, isometric strength, and endurance – these were assessed at baseline and 12 weeks.

Patients also underwent face-to-face interviews at 12 weeks regarding which outcomes were most important to them and which factors they considered when determining satisfaction with care.

The treatments in the three groups lasted for 12 weeks with at least 80% treatment attendance and consisted of one of the following:
  1. High dose supervised strengthening exercise alone (ETA): The exercises consisted of a 5 minute aerobic warm-up, stretching before and after, neck strengthening (using headgear with added weights attached to a single pulley system) and upper body strengthening (push-ups, dumbbell shoulder and chest exercises). Intensity varied according to patient ability. Sessions were delivered one-on-one and consisted of 20x1 hour sessions with higher repetitions (15-25) emphasized.
  2. High dose supervised strengthening exercise with spinal manipulation (ET+SMT): Exercise was conducted as above, but included a 15-20 minute session with a chiropractor who determined sites of manipulation via palpation and employed high-velocity, low-amplitude spinal manipulation (with up to 5 minutes of light soft tissue massage).
  3. Low-dose home exercise and advice (HEA): Patients in this group attended 2x1 hour sessions with exercises consisting of simple self-mobilization of the neck and shoulder joints (retraction, extension, flexion, rotation, lateral bending, scapular retraction) without resistance. Patients were instructed to do 6-8 daily sessions of 5-10 repetitions. Patients were provided with visual materials illustrating the exercises, along with general educational information on cervical spinal anatomy, postural advice, advice for conducting different activities, and basic ergonomic advice.

Study Strengths / Weaknesses:

This study had several strengths, including strong adherence to protocol and no large between group differences in co-intervention use. One of the other design strengths was the use of a qualitative component to determine what is most important to patients in terms of outcomes and their clinical interactions. This is a unique feature of this study and one that this research group is known for.

Study weaknesses include the absence of a home exercise and advice with spinal manipulation group, or a spinal manipulation alone group. The addition of these two treatment arms would have added to the value of this study. In addition, there were issues with subject blinding to group allocation – this is virtually unavoidable in this type of study. Finally, between group differences were noted after randomization in patient age, and symptom duration and frequency, although this was accounted for during data analysis.

Additional References:

  1. Hurwitz EL, Carragee EJ, van der Velde, et al. Treatment of neck pain: noninvasive interventions: results of the Bond and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S123-S152.
  2. Miller J et al. Manual therapy and exercise for neck pain: A systematic review. Man Ther 2010; 1-21.