Exercise Shown Effective for Management of Neck Pain—Who Needs OMT?
King HH. Exercise Shown Effective for Management of Neck Pain—Who Needs OMT?. J Am Osteopath Assoc 2013;113(1):94–96. doi: 10.7556/jaoa.2013.113.1.94.
Evans R, Bronfort G, Schulz C, et al. Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain. Spine. 2012;37(11):903-914.
How many of us have told patients to “use it or lose it” as we prescribed exercises for general health enhancement, as well as for remediation or prevention of low back and neck pain? Patient compliance in my experience is quite modest at best. So when asked, I always say, “The best exercises are the ones that you do!” Exercise has almost no downside; it has been shown to be beneficial in so many different health conditions encountered in human experience, especially in the management of chronic pain.1 Elkiss and Jerome,1 for example, provide an outstanding discussion on this topic that is worth review by every osteopathic physician and medical student, not only because of their discussion of the benefits of exercise but also because of the chapter's excellent embodiment and explication of osteopathic principles in the treatment of patients with pain.
Researchers at Northwestern Health Sciences University, Wolfe Harris Center for Clinical Studies in Bloomington, Minnesota, found that high-dosed supervised exercise therapy with spinal manipulation therapy (ET+SMT) did not produce significantly better outcomes than the high-dosed supervised exercise therapy (ET) alone, and that both ET+SMT and ET produced significantly better outcomes than low-dose home exercise and advice (HEA).
This well-powered randomized controlled trial used a patient-rated pain scale (0-10 scale) as the primary outcome measure; secondary outcome measures included Neck Disability Index, Medical Outcomes Study 36-Item Short Form, and intensive individual interviews to assess patient satisfaction. Objective biomechanical assessments of cervical spine motion, isometric strength, and dynamic endurance were performed at baseline and at 12 weeks by blinded examiners.
Patients were recruited by advertisement. Inclusion requirements were age 18 to 65 years; primary complaint of biomechanical, nonspecific neck pain duration of 12 weeks or more; and a neck pain score of 3 or greater. Exclusion criteria were previous cervical spine operation, neck pain referred from peripheral joints, progressive neurologic deficits, cardiac disease, inflammatory changes of the cervical spine, substance abuse, and pregnancy.
Patients (N=270) were randomly assigned among the 3 groups (ie, ET+SMT, ET, and HEA) at baseline for the 12-week trial. Data were collected at 2 baseline appointments (at 4 and 12 weeks) and after group assignment (at 24 and 52 weeks). The key to this study was the nature of the ET, which focused on neck and upper body strengthening individualized for each patient. The protocol called for 20 one-on-one supervised sessions of 1-hour duration with an emphasis on high numbers of repetitions and increasing loads with patient wearing headgear with variable weight attachments. Upper body strengthening included push-ups and dumb-bell shoulder and chest exercises. The strengthening program also included light warm-up and stretching before and after strengthening.
In the ET+SMT group, the ET was preceded by a 15- to 20-minute session of SMT administered by a licensed chiropractor. The SMT was applied to the cervical and thoracic spine, as determined by the chiropractor, using high-velocity, low-amplitude thrust to the areas of interest. Light soft-tissue massage was used as needed.
The HEA group received two 1-hour sessions with therapists who taught simple self-mobilization of the neck and shoulder joints; exercises were individualized to each patient. Patients in this group were instructed to do 5 to 10 repetitions of each exercise in the series up to 6 to 8 times per day. Each patient received a booklet with exercises illustrated. Patients were followed up in person 1 to 2 weeks later and were instructed to continue the exercises for the remainder of the trial.
There were no differences in the demographics between the 3 groups. At 4 weeks, all 3 groups reported decreased pain levels. At 12 weeks, there was a statistically significant reduction in pain reported by the ET+SMT and the ET groups compared with the HEA group. There was no difference between the ET+SMT and the ET groups at 12 weeks. At 26- and 52-week follow-up, there was no difference in self-reported pain. However, at 52 weeks, the ET+SMT and the ET groups reported significantly higher patient satisfaction scores. The authors suggested that SMT conferred little additional benefit when added to supervised exercise for chronic neck pain.
The authors noted that the study was not designed to differentiate between the specific effects of the exercise and SMT and the contextual or nonspecific effects including patient-provider interactions. However, it was impressive to see how a highly structured, intensive strengthening regimen and even a low-dose exercise regimen (HEA) reduced neck pain over 52 weeks from 5.5 to 5.7 for all 3 groups to a range of 3.1 to 3.6—findings that were considered clinically meaningful.
The question of whether or not osteopathic manipulative treatment is as beneficial as exercise in the treatment of patients with neck pain is not really addressed in this study. Most exercise programs implemented in osteopathic medical practice are not of the intensive nature as that used in this study. Indeed, it is questionable that third-party payers would cover such an exercise program even if the patients are highly satisfied, as suggested in this study. However, it is worthy to note that exercise is beneficial in the management of neck pain and deserves greater attention in osteopathic medical education in my opinion. This study was selected for review because of the long-term study of the patients and the opportunity to examine the effects of exercise in health care services.
“The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of The Journal of the American Osteopathic Association (JAOA) strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (mseffinger@westernu.edu), or JAOA Editorial Advisory Board Member Hollis H. King, DO, PhD (hollis.king@fammed.wisc.edu).
Elkiss ML, Jerome JA. Chronic pain management. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011:253-275.
Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G, Cervical Overview Group. Exercise for mechanical neck disorders. Cochrane Database Syst Rev. 2005;(3):CD004250.