I came across a post via NY Times Health Blog about a new study on effectiveness of Chiropractic care, simple exercise/advice and medications for neck pain.  As you can expect, I jumped right in to read.  You can check it out here yourself before you read this.  I will not summarize it per say but do want to give my two (actually 3 or more) cents on how this affects our profession.

#1.  Chiropractic Care…manipulation…works!

For those who practice Spinal Manipulation Therapy (SMT), you probably disagree with most higher level evidence, Cochrane reviews (example here), that there is no more benefit of manipulation over mobilizations for neck pain.  This individual study did not compare the two in particular but is a great win simply to show improvement with manipulation.  Now the study looked at chiropractic care (not to get into very much detail on their manipulation styles, techniques, etc.) so I will just refer to the result as manipulation.  Should we as a profession do more SMT? 

#2.  Medication doesn’t work comparable to SMT and exercise/advice.

Nothing more needs to be said.  If you just get this from this article, please share it with your patients.  Some of those skulls are just thick though…

#3.  Home Exercise with Advice (HEA) works!..but…

The article has a supplemental sheet so the reader can know what exercises were performed (find here). This is great and made it easy for the patients to follow. Don’t get me wrong, research has to be fairly general and cover all bases when it comes to exercise (as you know we have millions of exercises out there…) but wow, I really do not the ones in this study!  Some are good, such as retraction and rotation, but who really lies off the edge of plinth and does cervical extension. And maybe I’m biased, but I do not like side-bend or flexion; particularly the way it is shown.  Or better yet, lets just move our necks in any direction possible.  No-brainer. 

To sum, I like this study but am disappointed for our profession for many reasons.  

–Annals of Internal Medicine is a highly reputable journal for physicians and guides their choices for patient care.  They can now either refer to DC care, print off these exercises for their patients, do not recommend medication and boom, we are not needed.  I do not know the numbers (someone out there probably does), but we need to get more physical therapy research into big time journals for other healthcare providers to recognize us.  

–NY Times Health Blog is big time.  I don’t know how many people go to this site for information, but I know for sure its much more than any physical therapist’s blog.  I am sure millions of people read that blog! The consumer can find information out more and more on his/her own and honestly, this site is a great start (I check it out regularly).  With Chiropractic and Neck Pain in the title, this shuts us down even more.  We are making significant gains in terms of being musculoskeletal specialists, but still not first to go to when pain arises. With neck pain affecting an American ~70% sometime in their life, don’t you think they will continue to undergo DC care?

–Exercises  = blah. To be honest, if I wasn’t a physical therapist, I would think “our part” in this study is lame, unchallenging (I mean just move your neck in any direction right?), and simply undermines our profession.  We do not need a doctorate as everyone knows to sit up straight, correct?  The exercise and advice is what we do!  And again, wow, not exciting.  What I get from this article is DC care is awesome, stay away from medication, and oh yeh, keep your head moving.  

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8 comments

  1. Good to see more posts from you Harrison! Not sure how the exercises were presented, but some of them were based on McKenzie’s Treat Your Own Neck. Only a DC study would have SMT for 12 weeks! That’s beating a dead horse for the acute/subacute patients. The fact is whether it’s SMT or repetitive movements (hopefully a directional preference was chosen at the PT visit), most people with simple, uncomplicated cervical and lumbar dysfunction just needs to move. You know my bias, but I am MDT trained as well, and can see why it worked. Hey, at least the SMT group was more satisfied in the long run.

    1. E.,
      Thanks for the comment! Marriage, new state, first home has taken up some time from blogging! I guess I was more troubled that with a study that has been exposed to millions (even saw this same study on ABC News the night after I blogged it), then I would like to see more specific, directional-preferenced approach by the PT vs just simple ROM. But, we know that ROM is important and just proves we can be of assistance. I am not MDT trained but do agree with the principles. If you get a chance to look at the pdf attachment, seems like some of the exercises would be quite painful and even difficult to get into position. Good study though.

  2. Interesting take on the article. I’m just confused by what exactly you’re saying. Are you stating that as physiotherapists we are “too educated” to prescribe simple ROM exercises? The article just said that csp manips and exercise are better than meds for neck pain. We as PT’s do that with clients every day! Thus we are getting clients better by doing this, wouldn’t you agree?

    Is it because the chiropractic in the title makes it seem like only chiros can perform the therapy listed in the study?

    1. Jesse,
      Good to hear from you! I have been reading your blog and meant to comment. Good stuff man! I’m glad it has taken off for you.

      As for the post, the 2nd part of your question is my take (chiropractic in title). They are still by far most common provider of spinal pain using SMT but as you know, PTs are getting on the bandwagon. If I read this (or even saw it on national news…in USA), I would first think stop taking medication and see chiropractic if neck pain arose. Maybe I just see that most of my clients do not want to move on their own! (especially if it is painful, which would be our time to jump in and evaluate)

      As for the simple ROM exercises, yes, I we do prescribe these everyday and its the main part of our treatment approach but I just wished it wasn’t so…cookie-cutter. Meaning, they gave them every direction of movement and to go back to Dr. E’s post below, no directional preference was addressed (may not have needed this though…). Maybe looking too much into this.
      Hv

      1. Great point Harrison. Here in Toronto, many chiropractors and physios practice in very similar ways. Yes, chiro’s still do the vast majority of SMT but like you said, this is changing slowly. Maybe the point to take away is that movement of key, regardless of directional preference. I also agree with your original argument that we as physiotherapists need to do a MUCH better job of advertising our worth and what we can do. Glad to see you blogging again! I enjoy you’re stuff. And thanks for reading mine!
        All the best to you and your new wife! Congrats

  3. Regarding the Cochrane review, it’s important to note that in using meta-analyses we’re really just looking at things “on average” and not subgrouping/dx’ing patients the way we’d do in practice. So as long as the message stays “no benefit to routine mobilising/manipulating patients” we’re good… if the take away message is “yeah, no difference” then that’s bad…

    1. @vyapada — good point on the Cochrane review. I agree. Good to be ‘evidenced-informed’ on the top notch evidence but definitely putting it into perspective on a daily basis. CPRs are continuing to be on the verge of helping subgroups.
      Hv

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