A significant percentage of my recent clinical encounters have been patients with musculoskeletal, predominantly spinal, pain. I am always amazed by patients who admit that they will gladly pay a chiropractor hundreds of dollars while, in the same breath, they complain about a $4 co-pay for medications that I prescribe for the same problem. I have nothing against chiropractors. Quite the opposite, I think they might be onto something. They may have already known that our medications are not as good as touching the patient or engaging them in self-mobilization exercises. But some of us still need to be convinced.
A recently published randomized trial evaluating the comparative effectiveness of spinal manipulation therapy (SMT), medication, and home exercises with advice (HEA) may help persuade some of those skeptics (Ann Intern Med. 2012;156:1-10). Participants with mechanical, nonspecific current neck pain of 2-12 weeks duration were recruited through the community. Treatment took place over 12 weeks. SMT involved “a high-velocity type of joint thrust manipulation” and “a low-velocity type of joint oscillation” provided by chiropractors. Medications included NSAIDs, acetaminophen, or both and non-responders received narcotics or muscle relaxants by a licensed physician. HEA was provided in two 1-hour sessions focusing on “gentle controlled movement” of the neck and shoulder joints, neck retraction, extension, flexion, rotation, lateral bending, and scapular retraction. Participants were instructed to do 5 to 10 repetitions per day; laminated instruction cards were provided.
For pain, SMT was associated with a statistically significant advantage over medication after weeks 8, 12, 26, and 52 (P less than or equal to 0.010). HEA was superior to medication at 26 weeks (P = 0.02). No important differences in pain were found between SMT and HEA at any time point. HEA was associated with higher satisfaction with care.
In this study, medication performed the worst. Spinal manipulation was not demonstrably better than home exercises with advice. Primary care clinicians seeing patients with neck pain need to fight deeply-ingrained urges to “fix it with a pill” (or at least I do). Instead, we need office hand-outs of self-mobilization exercises for every potentially injured body part that can readily handed to and reviewed with patients. At the very least, this will decrease the number of daily complaints about medication co-pays.
Jon O. Ebbert, M.D., is professor of medicine at the Mayo Clinic in Rochester, Minn. He reported having no conflicts of interest.