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World Health Organization Bone and Joint Decade Report (2008)

By far the most comprehensive recent evaluation of all neck pain therapies was performed by the Bone and Joint Decade 2000–2010  Task Force on Neck Pain and Its Associated Disorders.

1  In the panel’s report on noninvasive interventions, it concluded that,  “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy.”  Because chiropractors consistently include exercise advice and share relevant self-care educational materials with patients as part of overall care, 2 chiropractic management of neck pain substantially embodies the full range of noninvasive therapeutic approaches recommended by the Bone and Joint Decade Task Force.
1. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain:  noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15
2008;33(4 Suppl):S123-152.
2. Jamison JR. Health information and promotion in chiropractic clinics.  J Manipulative Physiol Ther. 2002;25:240-245
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Primary Care – Cost Effectiveness of Physiotherapy, Manual Therapy And GeneralPractitioner Care For Neck Pain

Patients who received care from general practitioners for neck pain were randomly allocated to receive manual therapy (spinal mobilization), physiotherapy (mainly exercise)or general practitioner care (counseling, education and drugs). Throughout this 52-week study, patients rated their perceived recovery, intensity of pain and functional disability.Manual therapy proved to be the most effective treatment for neck pain. The clinical outcome measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. While achieving this superior outcome, the   total costs of the manual therapy-treated patients were about one third of the costs of physiotherapy or general practitioner care.

Primary Care – Cost Effectiveness of Physiotherapy, Manual Therapy And GeneralPractitioner Care For Neck Pain: Economic Evaluation Alongside A RandomizedControlled Trial. Korthals-de Bos I, Hoving J, Van Tulder M, Van Molken R, Ader H, DeVet H, Koes B, et al. British Medical Journal 2003; 326: 911.

Joint policy statement regarding the cost effectiveness of chiropractic care presented by a united chiropractic profession American Chiropractic Association The Association of Chiropractic Colleges Congress of Chiropractic State Associations International Chiropractors Association  Copyright 2009

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Clinical Course in Patients Seeking Primary Care for Back Or Neck Pain:

n this study the results of a questionnaire mailed to patients who had sought primary care for nonspecific back or neck pain were reviewed.. The researchers attempted to examinethe long term clinical course of back and neck pain in the group of primary care patients.Researchers found that about 50% of the original patients continued to report pain and disability at both the one-year and five-year follow-up, however the outcome scores did not deteriorate overall. Researchers concluded that due to the frequency of recurring or                                                                                                                                                                                                                                                                                                    continual pain in patients, health policies and clinical decision models for long-term outcome must allow for these factors.

Clinical Course in Patients Seeking Primary Care for Back Or Neck Pain: A Prospective5-Year Follow-Up Of Outcome And Health Care Consumption. Enthoven P, Skargren E,Oberg B. Spine. 2004 Nov 1;29(21):2458-65

Joint policy statement regarding the cost effectiveness of chiropractic carepresented by a united chiropractic professionAmerican Chiropractic AssociationThe Association of Chiropractic CollegesCongress of Chiropractic State AssociationsInternational Chiropractors Association  Copyright 2009

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Duke University Headache Report, Cochrane Review

Duke University Headache Report, Cochrane Review In 2001, the Duke University Center for Health Policy Research and Education completed Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache, 1 based on a comprehensive review of all available headache research. Among its conclusions were that (1) in comparison to the use of the medication amitriptyline, chiropractic produces slightly less improvement during the treatment period, but markedly superior long-term results in the treatment of tension-type headache and (2) compared to various soft tissue procedures, a course of manipulation treatments produces sustained improvement in headache frequency and severity in the treatment of cervicogenic headache (pain originating in the neck and referred to the head). A 2004 systematic review of headache research for the Cochrane Collaboration, Noninvasive Physical Treatments for Chronic/Recurrent Headaches, 2 reached conclusions similar to the Duke report.

1. McCrory DC. Evidence report: Behavior and physical treatments for  tension-type and cervicogenic headaches. Des Moines, IA: Foundation for  Chiropractic Education and Research; 2001.
2. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments  for chronic/recurrent headache. Cochrane Database Syst Rev.
2004(3):CD001878.
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Chiropractic Manual Methods Plus Exercise Helpful for Chronic Neck Pain

Chiropractic Manual Methods Plus Exercise Helpful for Chronic Neck Pain (Sweden, 2006)  In a randomized clinical trial, Palmgren et al found that a group of chronic neck pain patients who received 15–25 chiropractic treatments over a 5-week period had significantly lower pain scores and greater head repositioning accuracy than another group with the same condition given a similar examination but no treatment.  1  Chiropractic care included  high- and low-velocity techniques, myofascial release, and spine-stabilizing  exercises. The researchers concluded that chiropractic care could be effective in reducing pain originating in the cervical spine—as well as enhancing proprioceptive sensibility (movement and position sense).

1.  Palmgren PJ, Sandstrom PJ, Lundqvist FJ, Heikkila H. Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. J Manipulative
Physiol Ther. Feb 2006;29(2):100-106
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Manual Therapy Superior to Comparison Treatments and Placebo (Netherlands, 1993)

A team of Dutch researchers led by Koes 1 studied patients with persistent back and neck complaints. In a randomized trial, they were treated with either manual therapy (spinal manipulation and mobilization), physiotherapy (exercises, massage, electrotherapy, ultrasound, shortwave diathermy), treatment by the general practitioner (analgesics, posture advice, home exercise and bedrest), or a placebo treatment consisting of  detuned shortwave diathermy and detuned ultrasound. For neck and back complaints together, improvements in severity of the main complaint were larger with manipulative therapy than physiotherapy; for neck complaints only, the mean improvement in the main complaint as shown by the visual analog scale was slightly better for manipulative rather than physical therapy. Both manual therapy and physiotherapy (both of which are part of the chiropractor’s scope of practice) were superior to medical care and  placebo. In this study, the placebo yielded results superior to medical care.
1 . Koes BW, Bouter LM, van Mameren H, et al. A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck  complaints: subgroup analysis and relationship between outcome measures.  J Manipulative Physiol Ther. 1993;16(4):211-219.

 

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RAND Appropriateness Study for Chronic Neck Pain (1995)

Neck pain is the second most common reason patients seek chiropractic care. While chiropractic care can be helpful to individuals with acute or chronic neck pain, at this time the research supporting spinal manipulation for chronic neck pain is stronger and more extensive than for acute cases. To put this into context, it should be understood that chiropractic is not unique in this respect; no other treatments for acute neck pain have strong research support.

The RAND Corporation conducted both a literature review and a multidisciplinary panel appropriateness study for neck pain.  1  This RAND report stated that spinal manipulation could deliver short-term pain relief and improved range of motion for subacute or chronic neck pain, while concluding that research on acute neck pain was too limited to reach any conclusion.

1. Coulter I, Hurwitz EL, Adams A, et al. The appropriateness of spinal manipulation and mobilization of the cervical spine: Literature review, indications and ratings by a multidisciplinary expert panel. Monograph
No. DRU-982-1-CCR. Santa Monica, CA: RAND; 1995.

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Randomized Controlled Trial Comparing Manual Therapy, Physical Therapy, or Continued Cared by General Practitioner

Background: Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared.

Objective: To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner.

Design: Randomized, controlled trial.

Setting: Outpatient care setting in the Netherland.

Patients: 183 patients, 18-70 years of age, who had had nonspecific neck pain for at least 2 weeks.

Intervention: 6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).

Measurements: Treatment was considered successful if the patient reported being “completely recovered” or “much improved” on an ordinary six-point scale. Physical dysfunction, pain intensity, and disability were also measured.

Results: At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0-10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.

Conclusion: In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.

Hoving et al. A Randomized Controlled Trial of Manual Therapy. Ann Intern Med. 2002;136:713-722.Manual Therapy, Physical Therapy, or Continue Care by a General Practitioner for Patients with Neck Pain, A Randomized, Controlled Trial., Pages 713-722

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Soft Tissue Injuries Often Hidden or Misdiagnosed in Car Accident Victims

Summary: Studied 22 cervical spines from traffic accident victims with fatal craniocerebral injuries (19 male victims and 3 female victims: mean age, 26 years). Two had parietal fractures, 20 had skull base fractures (seven ring fractures), and 16 had severe polytrauma. The spines with all soft tissues were frozen in situ and removed. Fine-focus specimen radiograms were taken in special views and evaluated by an expert orthopedic radiologist. The specimens were then cryosectioned, and all injuries were recorded at submillimeter intervals on high resolution film.

Ten radiological fracture diagnoses were incorrect; six were false positive, and four were false negative.

In the upper cervical spine, only one of 10 gross ligamentous disruptions was suspected on the radiograms.

In the lower cervical spine, 198 lesions were missed on the radiograms: 77 facet joint and ligamentum flavum injuries, 77 uncovertebral, and 22 disc lesions.

In two adolescents, eight cartilaginous end-plate avulsions of the discs were found.

At second look evaluation, only 4 of the 245 unrecognized bone and discoligamentous lesions were detected on the radiograms.

All spines were injured.

Multiple soft-tissue injuries were common.

Jonsson et al. Hidden Cervical Spine Injuries in Traffic Accident Victims with Skull Fractures.Journal of Spinal Disorders. Vol. 4 No. 3. pp 251-263. 1991.

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Systematic Review of Randomized Trials Show SMT has Better Effect than Massage and Comparable Effect to First-Line Prophylactic Prescription Meds

Background: Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increaseingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these.

Objective: To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials.

Study Selection: Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.

Data Extraction: Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials.

Data Synthesis: Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups, and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the pre-specified assumptions/rules regarding the evidence determination were applied.

Conclusions: SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality.

Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed and analyzed trials with follow up periods of sufficient length.

Bronfort et al. Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review. Journal of Manipulative and Physiological Therapeutics, Volume 24, Number 7, September 2001.

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