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Supervised Exercise With and Without Spinal Manipulation Performs Similarly and Better Than Home Exercise for Chronic Neck Pain: A Randomized Controlled Trial

Evans, Roni, DC, MS*; Bronfort, Gert, DC, PhD*; Schulz, Craig, DC, MS*; Maiers, Michele, DC, MPH*; Bracha, Yiscah, MS; Svendsen, Kenneth, MS; Grimm, Richard, MD, MPH, PhD; Garvey, Timothy, MD§; Transfeldt, Ensor, MD§

doi: 10.1097/BRS.0b013e31823b3bdf
Randomized Trial

Study Design. Randomized controlled trial using mixed methods.

Objective. To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for chronic neck pain.

Summary of Background Data. Neck pain is a common global health care complaint with considerable social and economic impact. Systematic reviews have found exercise therapy (ET) to be effective for neck pain, either alone or in combination with spinal manipulation. However, it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise.

Methods. Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic. Patients were randomly assigned one of the following interventions: (1) high-dose supervised strengthening exercise with spinal manipulation (exercise therapy combined with spinal manipulation therapy [ET + SMT]), (2) high-dose supervised strengthening exercise (ET) alone, or (3) low-dose home exercise and advice (HEA). The primary outcome was patient-rated pain at baseline and at 4, 12, 26, and 52 weeks. Secondary measures were disability, health status, global perceived effect, medication use, and satisfaction.

Results. At 12 weeks, there was a significant difference in patient-rated pain between ET + SMT and HEA (1.3 points, P < 0.001) and ET and HEA (1.1 points, P = 0.001). Although there were smaller group differences in patient-rated pain at 52 weeks (ET + SMT vs. HEA, 0.2 points, P > 0.05; ET vs. HEA, 0.3 points, P > 0.05), linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups (ET + SMT vs. HEA, P = 0.03; ET vs. HEA, P = 0.02). Similar results were observed for global perceived effect and satisfaction.

Conclusion. Supervised strengthening exercise with and without spinal manipulation performed similarly, yielding better outcomes than home exercise particularly in the short term. Various stakeholders' perspectives should be considered carefully when making recommendations regarding these therapies, taking into account side effects, preferences, and costs.

This is a randomized clinical trial of 270 patients with mechanical neck pain. Interventions were high-dose supervised strengthening exercise combined with spinal manipulation, high-dose supervised strengthening exercise alone, and low-dose mobilization exercise and advice. The primary outcome measure was patient-rated pain at 4, 12, 26, and 52 weeks.

*Northwestern Health Sciences University, Wolfe Harris Center for Clinical Studies, Bloomington, MN;

Cincinnati Children's Hospital, Division of Health Policy and Clinical Effectiveness, Cincinnati, OH;

Berman Center for Outcomes & Clinical Research, Minneapolis, MN; and

§Twin Cities Spine Center, Piper Building, Minneapolis, MN. Dr Svendsen is an independent consultant.

Address correspondence and reprint requests to Roni Evans, DC, MS, Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN 55431; E-mail:

Acknowledgment date: March 8, 2011. First revision date: July 30, 2011. Acceptance date: September 19, 2011.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received to support this work.

No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

© 2012 Lippincott Williams & Wilkins, Inc.