From: Work. 2012 Jan 1;41(0):2535-8

The aim was to analyze the relationship between periods with uninterrupted neck muscle activity for ≥4 min and neck and shoulder pain. The trapezius muscle activity was recorded bilaterally on 40 young workers and students during a full shift. Neck and shoulder pain, mechanical work load and decision control were reported at the same time as the muscle activity recording and 6 months later. A dose-response relationship was found between uninterrupted muscle activity and neck and shoulder pain, with a ten-fold higher risk for the group with more than half, compared to less than a third, of the shift with uninterrupted muscle activity. Self-reported mechanical work load showed a small but protective effect related to pain. Gender and decision control did not emerge as important risk factors in this model. In conclusion, this study indicates that work or other exposures that contains long periods with uninterrupted neck muscle activity of 4 min duration or longer should be minimized to reduce risk of neck and shoulder pain.

Long periods with uninterrupted muscle activity related to neck and shoulder pain

From: Work. 2012 Jan 1;41(0):2591-5

This study aimed to evaluate the posture, muscle activities, and self reported discomforts of neck pain notebook computer users on three monitor tilt conditions: 100°, 115°, and 130°. Six subjects were recruited in this study to completed typing tasks. Results showed subjects have a trend to show the forward head posture in the condition that monitor was set at 100°, and the significant less neck and shoulder discomfort were noted in the condition that monitor was set at 130°. These result suggested neck pain notebook user to set their monitor tilt angle at 130°.

Man Ther. 2012 Feb 4. [Epub ahead of print]

There is considerable evidence that neck pain is associated with alterations in spatial and temporal behaviors of the neck muscles and changes in muscle properties. Changes have been identified in various neck and axio-scapular muscles and the neck flexors have received particular attention. There is some functional specificity between superficial and deep flexors. Superficial muscles, sternocleidomastoid and anterior scalenes are major contributors to flexion torque while deep neck flexor muscles (longus capitis and colli) have an important role in supporting the normal neck curve and segments in posture and movement.

Of clinical and functional relevance, reduced activation of the deep neck flexor muscles has been identified in association with increased activation of the superficial flexor muscles in studies using the cranio cervical flexion test in patients with a variety of neck disorders. The evidence of reduced deep neck flexor activity comes from laboratory studies using a direct measure of electromyographic (EMG) amplitudes. A number of clinical studies have limited measurement to sternocleidomastoid activity using surface EMG electrodes and have indirectly inferred reduced deep neck flexor function on the evidence of an inverse relationship between sternocleidomastoid, anterior scalenes and deep neck flexor muscle activity from laboratory measures of neck pain patients.

Training the deep neck flexor muscles is regarded as an important component of neck rehabilitation programs because of the functional importance of the deep neck flexor and the evidence suggesting that the altered pattern of activation between the deep and superficial flexors (1) does not correct automatically with pain relief and (2) persists without specific training. Many factors influence the magnitude of neck pain. It is uncertain whether changes in muscle function are a cause or effect of pain, but a relationship has been shown between neck pain intensity and activity in the deep (lesser) and superficial (greater) neck flexor muscles. Concomitantly, the degree of pain reduction in patients with chronic neck pain has a relationship with the change in deep neck flexor activity following training. Clinical trials also support the effectiveness of training the deep neck flexor muscles and restoring their normal temporal relationship with the superficial flexors as a component of a multimodal program for the rehabilitation of neck pain disorders.

Appropriate training methods are required to address the observed impairment in neck flexor muscle behavior in the clinical setting. Cervical flexor strengthening exercises such as a head lift regime, while improving strength, do not successfully address the altered pattern of activation between the deep and superficial neck flexor muscles but a motor relearning approach using low load exercises to target the deep neck flexors can do so. A common form of deep neck flexor muscle training involves the patient learning the cranio cervical flexion action and training the endurance capacity of the deep neck flexor in the supine position. Training in this way effectively redresses the altered behavior in the flexor synergy identified in the cranio cervical flexion test by increasing the measurable activity in the deep neck flexors and reducing the activity of sternocleidomastoid and anterior scalene muscles. From a clinical viewpoint, training in supine alone limits the number of repetitions that a patient can practice in a day. Repetition is an important feature in the motor learning process. Training in supine also is not functional and there is mixed evidence for the transfer of improvement in cervical flexor muscle performance to function with such training alone.

Facilitating an upright posture activates the longus capitis/colli group. Thus a postural correction exercise which can be performed easily during the working day is advocated within a training program. It is unknown whether training the deep neck flexor with a postural exercise is effective and can change the aberrant pattern of neck flexor muscle activity demonstrated in the cranio cervical flexion test. The purpose of this initial study was to investigate the effect of a postural exercise in a controlled trial of a 2-week intervention in the first instance. It was hypothesized that the postural exercise alone was sufficient to improve deep neck flexor muscle performance, indicated by a measureable decrease in sternocleidomastoid activity over progressive stages of the cranio cervical flexion test.

The exercise intervention consisted of a 2-week program in this preliminary study as a change in muscle behavior can be expected from a motor learning program in this period. The intervention began immediately after the baseline assessment for subjects allocated to the exercise group. The postural exercise was performed in sitting and required the subject to assume firstly, an upright posture in a neutral lumbo-pelvic position. They were then taught to gently lift the base of the skull from the top of the neck as if to lengthen the cervical spine. This neck lengthening manoeuvre strongly activated the longus colli. A neutral scapular position was taught if the scapulae were judged clinically for example, to be in a position of downward rotation or protraction. Subjects received training until it was assessed that they could perform the postural exercise properly. They were asked to perform the exercise, holding the position for 10s ideally every 15–20 min throughout their waking day, akin to a work break and exercise routine for the two week duration of the trial. Subjects were provided with an exercise diary to record the number of times the exercise was performed each day. Subjects returned twice in the two week period before the follow up assessment to ensure correct performance of the exercise and for motivation and compliance purposes.

Training with a functional postural exercise improved performance in the cranio cervical flexion test, measured in this study as a decrease in sternocleidomastoid activity. No change was observed in the control group. The pre to post-intervention analysis within the exercise group revealed decreased sternocleidomastoid EMG amplitudes at the first and third stages of the test with non-significant lower amplitudes in the other stages. The exercise involved assuming an upright neutral postural position with the addition of a neck lengthening manoeuvre. Both elements have been shown to activate the deep neck flexor. It can only be inferred from this study that the decrease in sternocleidomastoid activity in the cranio cervical flexion test was accompanied by an improvement in the activation of the deep neck flexor. Nevertheless this relationship was shown training the deep neck flexor in supine where reduced sternocleidomastoid activity in the cranio cervical flexion test was associated with an increase in deep neck flexor activity. Thus the authors hypothesis that the postural exercise can improve deep neck flexor muscle performance can be provisionally supported. However it is premature to comment on whether this exercise alone would be would be sufficient to address the altered behaviour of the neck flexor synergy in neck pain patients. Importantly, the results provide a justification for a larger study with direct measures of both sternocleidomastoid and deep neck flexor muscles using more invasive direct measures of deep neck flexor muscle activity.

Training the deep neck flexor in supine and achieved an increase in deep neck flexor and a decrease in sternocleidomastoid EMG amplitude across all cranio cervical flexion test stages, with the exception of the lowest level (22 mmHg). This could imply that training the deep neck flexor in supine is more effective. However it may merely reflect the longer training period (6-weeks) as opposed to the 2-week period in the present study. The 2-week training period was chosen for this preliminary study as a change in muscle behaviour could be expected in this time but future trials of the two methods would necessarily test equivalent periods of training. Alternately the results could be a product of the relatively small sample size of the current study. Nevertheless, the present study demonstrating a decrease in activation of the sternocleidomastoid post-intervention suggests, albeit indirectly, that a functional method of training the deep neck flexor in an upright position does lead to improvements in deep neck flexor activation. From a clinical viewpoint, a greater benefit may be achieved by combining both formal and functional methods of training in the management of patients with neck pain disorders. Future research is warranted to explore longer periods of training with the postural exercise alone against formal training in the supine position as well as the possible combination of these training methods in a management regime for patients with neck pain disorders.

The functional, postural exercise to improve cervical muscle performance is a suitable option to cater for the increasing number of people working in office environments or other sedentary occupations. Evidence of altered working postures such as increased forward head posture, implying poor function of the deep neck flexor, has been shown in those with neck pain. Improvements in the maintenance of neck posture during sustained sitting postures have been achieved with training the deep neck flexor in the supine position. A practical, time efficient exercise performed easily throughout the day, such as the postural exercise evaluated in this study, may prove an essential aspect for effective training of the deep neck flexor in those sedentary workers with neck pain. Judging by the compliance rate recorded in this study, the exercise is convenient to perform. On average, the exercise was performed 15 times per day, equating to approximately once per waking hour, or twice per productive day-time hour.

It appears important that patients are taught the postural exercise with precision as undertaken in this currently study. Deep neck flexor muscles were activated when subjects were merely instructed to sit in a good posture. However higher levels of activity were recorded in the deep neck flexor (and lumbar multifidus) when subjects were facilitated into an upright neutral lumbo-pelvic and spinal posture. This highlights the need for care in teaching and training a postural exercise in the rehabilitation of neck pain patients. Incorporating a specific neck lengthening manoeuvre in the postural exercise is likely to enhance the deep neck flexor contraction.

Two weeks of training with the postural exercise alone did not change pain and disability measures, which is not surprising. Only one exercise intervention was used, focusing on a single muscle group, which is inadequate and unrealistic given the potential extent of changes in cervical and axio-scapular muscle function in neck pain disorders. There is ample evidence from systematic reviews that clearly indicates that multimodal management is superior to any single modality in reducing neck pain and disability.

This study determined that training with a postural exercise consisting of assumption of a neutral lumbo-pelvic and spinal posture with an added neck lengthening manoevre led to an improved pattern of cervical flexor muscle activity in the cranio cervical flexion test. The improvement manifested as a reduced level of sternocleidomastoid activity, infering an increase in deep neck flexor activation post-training. While further research is necessary to explore the benefits of this exercise, these observations suggest the worth of including such an exercise in the rehabilitation of patients with neck pain disorders.

From: Scand J Public Health. 2012 Feb 3. [Epub ahead of print]

To study whether having ever had local low back pain, sciatica, neck pain, or some combination of low back pain and neck pain, predicts sickness absence among municipal employees. The study sample (n=6911, 80% women, response rate 67%) included employees of the City of Helsinki who reached the age of 40, 45, 50, 55, or 60 years between 2000-02. Survey data on pain, working conditions, and health behaviours were linked to register data on sickness absence for three subsequent years. Sickness absence was categorised as self-certified (lasting for 1-3 days) and medically certified (lasting for 4 days or more) and the number of spells during the follow up was analysed using Poisson regression analysis.

In women, medically certified sickness absence was predicted by sciatica, neck pain and the combination of sciatica and neck pain, allowing for working conditions, body mass index, and smoking. Local low back pain did not predict medically certified sickness absence. Self-certified sickness absence was modestly predicted by all pain categories and by neck pain alone and with local low back pain or sciatica in men.

Medically certified sickness absence was predicted by sciatica and neck pain, but not by local low back pain. The association was accentuated in those with both sciatica and neck pain. Pain combinations may have a stronger effect on work ability than pain in one location.

From: BMC Musculoskelet Disord. 2012 Jan 31;13(1):10. [Epub ahead of print]

Cervical or neck pain is a general term used to designate any musculoskeletal disorder in the cervical region. Various pathologies encompass that generic definition and are most commonly related to degenerative changes or inflammation of cervical structures such as intervertebral discs, articular facets joints or nerve roots. Neck pain is a very common, disabling and costly condition. According to a review by the Neck Pain Task Force pertaining the prevalence of neck pain in industrialised countries, annual prevalence is situated within 30 to 50% in adult populations. In accordance with these results, in Canada, a bi-annual prevalence of 54% has been reported.

Cervical radiculopathy forms an important subgroup of neck disorders and, although less prevalent than general neck pain, it has been shown to lead to more severe pain and disability. Cervical radiculopathy primarily results from an inflammation of a cervical nerve root induced by a lesion reducing the intervertebral foramen. This reduction is primarily induced by a herniated disc or a degenerative lesion of zygapophysial joints. Typical symptoms of cervical radiculopathy include pain in the cervical or periscapular region and in the upper limb, as well as neurological signs such as paresthesia, numbness, weakness and loss of reflexes in the affected nerve root distribution.

The diagnosis of cervical radiculopathy is commonly made through patient history and physical examination. A a positive response to the following four clinical tests results in a high predictive value for a diagnosis of cervical radiculopathy: 1 – cervical distraction test, 2 – upper limb tension test, 3 – Spurling test, and 4 – ipsilateral cervical rotation reduced by more than 60 degrees. If all four of these tests are positive, the positive likelihood ratio (LR+) of having a cervical radiculopathy is 30. If three out of these four tests are positive, the LR+ decreases to 6. A LR+ superior to 10 is considered large, and between 5 and 10 moderate; thus, it increases the possibility that the impairment in question is present. Hence, by combining these clinical tests, the possibility of obtaining a good clinical diagnostic accuracy in patients presenting signs and symptoms compatible with cervical radiculopathy is high.

While the clinical diagnostic process of cervical radiculopathy is relatively well documented, studies evaluating the effectiveness of rehabilitation interventions remain sparse. Published in 2010, a systematic review by Miller et al., pertaining to the effects of manual therapy and exercises on the treatment of neck pain, concluded that there is little evidence supporting the efficacy of these modalities in the treatment of cervical radiculopathies. Of the 17 randomised clinical trials (RCT) included in this systematic review, only three included subjects who presented radicular signs. Furthermore, in these three RCTs, subjects with or without radicular signs were combined for the statistical analysis used to evaluate the effects of the intervention. The authors of the systematic review concluded that, for neck pain, a combination of cervicothoracic mobilisations and exercises is the most effective rehabilitation approach to reduce pain and disability. No specific recommendation was, however, brought forth for cervical radiculopathies. Three RCTs published in 2009, but not included in the systematic review by Miller et al., also evaluated the effects of rehabilitation approaches for the treatment of cervical radiculopathy.

Kuijper etal. randomised 205 patients suffering from cervical radiculopathy within 3 groups: a cervical collar approach, an active physiotherapy approach, and a wait and see approach. The active physiotherapy approach involved mobilisations and stabilisation exercises; whereas the cervical collar approach included the use of a semi-hard cervical collar worn at all times for three weeks, then gradually weaned for three additional weeks. Three and six weeks into the intervention, a diminution of arm and neck pain was observed in the cervical collar and active physiotherapy groups. Functional improvement was also observed in both experimental groups at three weeks, but was only noted in the cervical collar group at six weeks. While this study’s conclusions seem to favour the cervical collar approach, it remains a controversial treatment option. According to the Quebec Task Force, cervical collar should be avoided due to its passive and decondition properties, and because it has been shown to hinder neck pain recuperation following motor vehicle accidents. These initial recommendations regarding the potential drawbacks of cervical collar use have recently been generalised to encompass all types of neck pain. Finally, two other studies have evaluated the effect of intermittent traction on patients suffering from cervical radiculopathy. They have, however, obtained contradictory results: one demonstrated that the addition of neck traction to a conventional intervention does not increase treatment efficacy, whereas the other claimed that traction supplementing a conventional intervention improves cervical and radicular pain, in comparison to a conventional intervention.

Numerous other approaches are commonly utilised in clinical settings, but a formal demonstration of their efficacy remains to be shown. Clinical approaches for cervical radiculopathies commonly include interventions targeting the opening of intervertebral foramen. It is well recognised that cervical movements causing the opening of intervertebral foramen, such as flexion, rotation and lateral flexion contralateral to the nerve root, increase the volume of the foramen, and consequently might decompress a swollen nerve root. Inversely, movements of extension, rotation and lateral flexion ipsilateral to the nerve root close the intervertebral foramen around the root. Thus, for acute and sub-acute radiculopathies, intervention programs should include treatment modalities that allow the opening of the intervertebral foramen. On the other hand, movements and positions that lead to intervertebral foramen closure should be avoided. However, no studies have evaluated the effects of a treatment approach that specifically take into consideration these biomechanical principles.

Due to the important incapacities related to cervical radiculopathy, and to the few studies pertaining to the efficacy of rehabilitation in this population, the authors believe in the importance of better understanding the potential of cervical mobilisations and exercises that lead to the opening of the intervertebral foramen. The primary objective of this RCT is to compare, in terms of pain and disability, a rehabilitation program targeting the opening of intervertebral foramen to a conventional rehabilitation program, in patients presenting acute or subacute cervical radiculopathy. Based on biomechanical principles, the hypothesis is that the rehabilitation program targeting the opening of intervertebral foramen will be significantly more effective in reducing pain and disability than the conventional rehabilitation program, mainly at the 4-week evaluation. In considering the passage of time, the differences between the two interventions should be less important at 8-week.

This double-blind randomised clinical trial will allow the comparison, in terms of pain and disability, of patients presenting a cervical radiculopathy which will have been randomly assigned to one of the two intervention groups: the first group (n = 18) will receive a 4-week rehabilitation program targeting the opening of intervertebral foramen, the second group (n = 18) will receive a 4-week conventional rehabilitation program. Participants will be evaluated on three separate occasions: at baseline (week 0), at the end of the 4-week program (week 4), and four weeks following the end of the program (week 8).

Rehabilitation program targeting the opening of intervertebral foramen: The same program as for the conventional rehabilitation program will be applied, with two exceptions:

• Of the four mobilisation techniques, there will be two mandatory techniques targeting the opening of the intervertebral foramen on the same side and at the same level as the radiculopathy: global contralateral rotation mobilisation and ipsilateral lateral glide in a flexion position (10 repetitions * 30 seconds for each technique). The physiotherapist, according to the biomechanical evaluation results, will choose the two other mobilisation techniques including rotations, lateral glides, postero-anterior glides, infero-medial glides or supero-anterior glides mobilisations.

• The third exercise of the home program will be an opening technique: contralateral rotation exercise (contralateral to the affected segment; 10 repetitions * 3 seconds, 10 times /day). Therefore, the number of mobilisation techniques and home exercises will be the same for the two intervention groups.

Based on the important incapacities related to cervical radiculopathy, control trials are urgently needed to define ideal intervention approaches in rehabilitation for this population. Recent systematic reviews have highlighted the lack of such trials, and thus, the need to establish the effectiveness of rehabilitation approaches. The rational for the need to determine the effectiveness of a rehabilitation program targeting the opening of intervertebral foramen of the affected segment was presented. This RCT will be the first study that directly compares a rehabilitation program targeting the opening of intervertebral foramen to a conventional rehabilitation program for patients with cervical radiculopathy. The results of this study may help to establish best clinical practice guidelines for this patient population.

For participant recruitment, please visit Effect of Mobilizations and Exercises Targeting the Opening of Intervertebral Foramens Following Cervical Radiculopathy

From: Work. 2012 Jan 1;41(1):99-108

This study examined the effects of various backpack loads on elementary schoolchildren’s posture and postural compensations as demonstrated by a change in forward head position. A convenience sample of 11 schoolchildren, aged 8-11 years participated. Sagittal digital photographs were taken of each subject standing without a backpack, and then with the loaded backpack before and after walking 6 minutes (6MWT) at free walking speed. This was repeated over three consecutive weeks using backpacks containing randomly assigned weights of 10%, 15%, or 20% body weight of each respective subject. The craniovertebral angle was measured using digitizing software, recorded and analyzed.

Subjects demonstrated immediate and statistically significant changes in craniovertebral angle, indicating increased forward head positions upon donning the backpacks containing 15% and 20% body weight. Following the 6MWT, the craniovertebral angle demonstrated further statistically significant changes for all backpack loads indicating increased forward head postures. For the 15 & 20% body weight conditions, more than 50% of the subjects reported discomfort after walking, with the neck as the primary location of reported pain. Backpack loads carried by schoolchildren should be limited to 10% body weight due to increased forward head positions and subjective complaints, primarily neck pain, at 15% and 20% body weight loads.

From: J Orthop Sports Phys Ther. 2012;42(1):21.

Neck pain is very common and fortunately resolves quickly in most individuals. However, in certain cases neck pain can last longer and result in chronic pain, limited neck motion, and disability. In fact, chronic neck pain is the second leading cause of workers’ compensation claims in the United States. Treatments that can quickly reduce pain, increase motion, and improve the ability of the muscles to protect the neck may help decrease long-term disability associated with neck pain. A variety of manual therapy treatments are currently used to manage neck pain. These treatments include mobilization, which slowly and repeatedly moves the neck joints and muscles, and manipulation, which delivers a single, small, quick movement to the joints and muscles.

Researchers treated 107 patients. About half of these patients received a manipulation of the neck, on the part closest to the head, and of the upper back. The other patients received manual therapy that mobilized the spine without using manipulation. After 48 hours, the patients who received the manipulation treatment experienced a 58% decrease in pain and a 50% decrease in disability. By contrast, patients who received the mobilization treatment only had a 13% decrease in pain and actually showed a 13% increase in disability. In addition, the patients who received the manipulation had increased motion and improved control of their neck muscles compared to the patients in the mobilization group. The researchers concluded that the combination of upper neck and back manipulation was more effective in the first 48 hours of treatment than the mobilization treatment. Potential benefits include less pain, better neck motion, and improved ability to perform daily activities.

Chiropractors have known this for decades! Unfortunately, assimilation by the medical profession is a priority and ultimately relates to greed through political means.

Source: Neck pain: manipulation of your neck and upper back leads to quicker recovery

From: Eur Spine J. 2012 Jan 8. [Epub ahead of print]

Clinical guidelines provide similar recommendations for the management of new neck pain and low back pain but it is unclear if general practitioner’s (GP) care is similar. While GP’s management of low back pain is well documented, little is known about GP’s management of neck pain. We aimed to describe GP’s management of new neck pain and compare this to GP’s management of new low back pain in Australia between April 2000 and March 2010. All GP-patient encounters for a new (i.e. first visit to any medical practitioner) neck pain or low back pain problem were compared in terms of treatment delivered, referral patterns and requests for laboratory and imaging investigations.

General practitioners in Australia have managed new neck pain and low back pain problems at a rate of 3.1 and 5.8 per 1,000 GP-patient encounters, respectively. GP’s primarily utilised medications, in particular non-steroidal anti-inflammatory drugs, to manage new neck and low back pain problems and referred approximately 25% of all patients for imaging. Patients with new neck pain are more frequently managed using physical treatments and were referred more often to allied health professionals and specialists. In comparison, patients with new low back pain were managed more frequently with medication, advice, provision of a sickness certificate and ordering of pathology tests.

This is the first time GP management of a new episode of neck pain has been documented using a nationally representative sample and it is also the first time that the management of back and neck pain has been compared. Despite guidelines endorsing a similar approach for the management of new neck pain and low back pain, in actual clinical practice Australian GPs manage these two conditions differently.

From: Coll Antropol. 2011 Sep;35 Suppl 2:187-90

The predominance in performing surgery of major spine injuries by neurosurgeons usually has the consequence of treating all types of spine injuries by neurosurgeons – neurotraumatologists. In the neurosurgical wards of Clinical Hospital Rijeka, the authors take care of the majority of these patients, following both the major, as well as minor whiplash injuries of the neck. The article overviews patients admitted in the one year period (October 1st 2009-October 1st 2010) where 1077 cases of neck injuries were analyzed. Vast majority of these injuries were due to traffic accidents (over 94%), and only a small proportion were serious injuries that needed a surgical approach decompression and stabilization (c1%). The authors analyzed minor neck injuries thoroughly both because of the increasing number of whiplash neck injuries and because more complicated diagnostic and therapeutic protocols occupy too much time in the ambulatory practice of neurotraumatologists each year thus representing a growing financial burden to the health organizations and to the society as a whole.

The results proved that the majority of the injured are male (over 60%), young and active (almost two thirds 21-40 years of age), had commonly sustained a Quebec Task Force (QTF) injury of grades 2 and 3 (almost 90%), and, if properly treated, recovered completely after a mean therapy period of ten weeks. Only a minority complained of prolonged residual symptoms, some of them connected with medico-legal issues (less than 20%). The results shown are in contrast with the general opinion that malingerers in search of financial compensation prevail in these cases, and leads to the conclusion that minor neck injuries (including whiplash) as well as Whiplash Associated Disorder are real traumatological entities, that have to be seriously dealt with.

From: Ann Intern Med. 2012 Jan 3;156

Neck pain is a prevalent condition that nearly three quarters of persons experience at some point in their lives. One of the most commonly reported symptoms in primary care settings, neck pain results in millions of ambulatory health care visits each year and increasing neck health care costs. Although it is not life-threatening, neck pain can have a negative effect on productivity and overall quality of life.

Chiropractors, physical therapists, osteopaths, and other neck health care providers commonly apply spinal manipulation, a manual therapy, for neck pain conditions, and home exercise programs and medications are also widely used. Recent Cochrane reviews report insufficient evidence to assess the effectiveness of commonly used medications or home exercise programs for the treatment of acute neck pain. The evidence for spinal manipulation is similarly limited, with only low-quality evidence supporting its use for neck pain of short duration.

The goal was to test the hypothesis that spinal manipulation therapy is more effective than medication or home exercise with advice (neck exercises) for acute and subacute neck pain.

Neck exercises with advice was provided in two 1-hour sessions, 1 to 2 weeks apart, at the universityaffiliated outpatient clinic. Six therapists provided instruction to participants. The primary focus was simple selfmobilization exercise (gentle controlled movement) of the neck and shoulder joints, including neck retraction, extension, flexion, rotation, lateral bending motions, and scapular retraction, with no resistance. The delivery method was 1-on-1, and the program was individualized to each participant’s abilities, tolerance, and activities of daily living.

Participants were instructed to do 5 to 10 repetitions of each exercise up to 6 to 8 times per day. A booklet (24) and laminated cards of prescribed exercises were provided. Sessions were supplemented with information about the basic anatomy of the cervical spine and advice, including postural instructions and practical demonstrations of lifting, pushing, pulling, and other daily actions.

In the absence of available criteria for what constitute clinically important group differences, several factors should be considered in aggregate. This includes the statistical significance of the results of the primary efficacy analysis, as well as those of the responder and secondary outcomes analyses. The durability of the treatment effect, the safety and tolerability of the interventions, and the participant’s ability and willingness to adhere to treatment should also be taken into account.

In this trial of spinal manipulation therapy versus medication or neck exercises for the treatment of acute and subacute neck pain, spinal manipulation therapy seemed more effective than medication according to various measures of neck pain and function. However, spinal manipulation therapy demonstrated no apparent benefits over neck exercises. Spinal manipulation therapy and neck exercises led to similar short and long term outcomes, but participants who received medication seemed to fare worse, with a consistently higher use of pain medication for neck pain throughout the trial’s observation period. The performance of the neck exercises group, which has the potential for cost savings over both spinal manipulation therapy and medication interventions, is noteworthy.

Participants and clinicians consider the potential for side effects when making treatment decisions. Although the frequency of reported side effects was similar among the 3 groups (41% to 58%), the nature of the side effects differed, with participants in the spinal manipulation therapy and neck exercises groups reporting predominantly musculoskeletal events and those in the medication group reporting side effects that were more systemic in nature. Of note, participants in the medication group reported higher levels of medication use after the intervention.

Most participants had subacute neck pain that lasted more than 4 weeks, beyond the time when pain will probably resolve spontaneously, and evidence suggests that one half of persons with nonspecific neck pain continue to have neck pain 1 year after the original report. Although our trial did not have a placebo group, the observed results are unlikely to be due to natural history alone.

To date, few clinical trials have assessed the effectiveness of noninvasive interventions for acute and subacute neck pain not associated with whiplash; therefore, no evidence-informed first-line therapy for this type of neck pain has been established.

For participants with acute and subacute neck pain, spinal manipulation therapy was more effective than management with medication in both the short and long term; however, a few sessions of supervised instruction in neck exercises resulted in similar outcomes at most time points.

Reference: Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain