Research Review By Dr. Jeff Muir©


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Date Posted:

September 2019

Study Title:

Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis for an Appropriateness Panel


Coulter ID, Crawford C, Vernon H, Hurwitz EL, Khorsan R, Booth MS & Herman PM

Author's Affiliations:

RAND Corporation, Santa Monica, CA; University of California Los Angeles, School of Dentistry, Los Angeles, CA; Southern California University of Health Sciences, Whittier, CA; Canadian Memorial Chiropractic College, Division of Research, Toronto, ON, Canada; Office of Public Health Studies, University of Hawaii, Mānoa, Honolulu, HI; Yo San University of Traditional Chinese Medicine, Los Angeles, CA, USA.

Publication Information:

Pain Physician 2019; 22: E55-E70.

Background Information:

Neck pain is the second most common reason cited by patients for visits to complementary and integrative medicine (CIM) practitioners (1), with an estimated 66% of the population suffering from neck pain at some point during their lifetime (2). The vast majority of neck pain is not organic in its pathology and is therefore termed ‘nonspecific’ or ‘mechanical’ and is responsible for a significant portion of direct healthcare costs (3-5).

The range of interventions available to neck pain sufferers is broad and includes everything from analgesic medication to rehabilitation therapies to independent exercise (6-8). Manual therapies, including chiropractic spinal manipulation and mobilization, are among the adjunctive therapies available to patients and have been the subject of several systematic reviews (5, 6, 9, 10). While overall the evidence is somewhat equivocal, recent reviews have deemed spinal manipulation and mobilization as ‘viable’ options for treating neck pain and decreasing the associated disability (6). The long-term benefit of these manual therapies however, is not well-established in the literature, although some evidence indicates that such treatment is effective when compared with other therapies (11).

The purpose of this study was to conduct a systematic review of randomized, controlled trials published between January 2000 and September 2017 evaluating spinal manipulation and mobilization for chronic neck pain. Previous reviews included studies completed up to 2000. Therefore, the current review was designed to determine the current body of evidence on this topic.

Pertinent Results:

Included Studies:
Forty-seven unique randomized trials (53 publications) were deemed eligible for inclusion, of which 37 (42 publications) were unimodal and 10 (11 publications) were multimodal.

The SIGN 50 criteria were used to assess methodological quality. 18/37 unimodal studies were deemed to be of high quality, 16 of acceptable quality and 3 of low quality. The 10 studies evaluating multimodal approaches were all rated as being of acceptable quality.

Adverse Events:
Of the 37 unimodal studies, 12 reported no adverse events, 10 reported minor adverse events (e.g. transient pain increase at the site of treatment) and 15 studies did not report adverse events.

Of the 10 multimodal studies, 2 reported minor adverse events (e.g. muscle soreness), 1 reported no adverse events and 7 did not describe adverse events.

Multimodal Studies:
Heterogeneity among multimodal studies prevented meta-analysis of their collective results. Half (5/10) of these studies reported a positive outcome on pain, with studies of non-thrust interventions trending towards greater pain reductions than those with thrust interventions. Of studies measuring disability as an outcome, 7/8 reported improved function.

Unimodal Studies:
Heterogeneity among treatment approaches prevented substantial pooling of data for studies comparing thrust treatment to sham or no treatment, or comparing non-thrust treatment to sham or no treatment. Six studies comparing thrust interventions plus exercise with exercise alone were meta-analyzed for pain, disability and HRQoL. The pooled analysis indicated that at one month, a non-statistically significant reduction in pain in favour of thrust manipulation plus exercise existed (SMD = –0.37; 95% confidence interval [CI], –0.77 to 0.03; P = 0.07; I2 = 81%). A similar effect was noted at 3-months (SMD = –0.27; 95% CI, –0.60 to 0.06; P = 0.10; I2 = 64%), with a minimal effect noted at 6-months (SMD = –0.20; 95% CI, –0.54 to 0.14; P = 0.25; I2 = 70%).

Similar results were noted for disability. Non-statistically significant reductions in disability were noted at 1-month (SMD = –0.35; 95% CI, –0.76 to 0.06; P = 0.09; I2 = 81%), 3-months (SMD = –0.35; 95% CI, –0.70 to 0.00; P = 0.05; I2 = 68%) and 6-months (SMD = –0.12; 95% CI, –0.33 to 0.08; P = 0.23; I2 = 18%).

HRQoL was pooled across 3 studies, with non-significant changes noted at all timepoints (1-month: SMD = 0.19; 95% CI, –0.28 to 0.66; P = 0.43; I2 = 82%; 3-months: SMD = 0.25; 95% CI, –0.30 to 0.80; P = 0.38; I2 = 87%/ 6-months: SMD = 0.07; 95% CI, –0.46 to 0.59; P = 0.80; I2 = 86%).

Confidence of Effect Estimates:
Overall risk of bias was not a serious concern among the included studies; however, heterogeneity among treatment protocols and/or comparators prevented meta-analysis and pooling of results in general. Only 6 studies demonstrated sufficient similarities to allow for pooling of data.

Clinical Application & Conclusions:

The authors conclude there is low to moderate quality evidence indicating that various types of manipulation and/or mobilization can reduce pain and improve function for chronic neck pain sufferers (of non-specific or mechanical origin). Importantly, it appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. Heterogeneity among studies limits the ability to draw broad conclusions regarding the effectiveness of treatment, although the interventions appear to be generally safe. The authors suggest that longitudinal studies are needed to firmly establish safety and effectiveness of these interventions. For now, manual therapies such as manipulation and mobilization are reasonable and likely effective treatment options for those with chronic neck pain.

Study Methods:

Several databases were searched for studies published between January 2000 and September 2017: PubMed/MEDLINE, Cochrane, Embase, Cinahl, PsycInfo, and Index to Chiropractic Literature (ICL). Searches were intentionally broad and did not specify interventions or include terms such as “chronic” or “nonspecific”.

An initial scoping review was performed to inform the definitions and categorization of studies for the systematic review. Results were discussed in committee and definitions and eligibility for the systematic review were determined.

Study Selection:

Six reviewers determined study eligibility, the criteria of which included:
  • A study population experiencing chronic and nonspecific neck pain
  • An intervention, with the involvement of a therapist, consisting of either: (i) manipulation (labeled as thrust), (ii) mobilization (labeled as non-thrust), or (iii) a multimodal integrative practice including manipulation and/or mobilization components as part of the approach
  • Comparison to sham, no treatment or any other active therapies, such as exercise, physiotherapy, or physical therapy
  • At least one outcome measuring a reduction in pain intensity/severity
  • An RCT with participants aged 18+
Quality Assessment and Data Extraction:

Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist for RCTs (12). External and internal validity were assessed using the External Validity Assessment Tool (EVAT) (13).

Data Synthesis and Analysis:

Studies were grouped based on the duration of chronic pain (3, 6 or 12 months) and whether treatment approaches were considered unimodal (thrust or non-thrust intervention arm compared to sham, no treatment or another active intervention), or multimodal (head-to-head comparison, combined or separate).

A minimum of 3 studies was required for meta-analysis. Where applicable, standard meta-analytic tests for heterogeneity (Q-value and I2 statistic) were used.

Study Strengths / Weaknesses:

  • Strong, comprehensive search criteria, including a scoping review to determine adequate definitions of intervention.
  • Broad eligibility criteria to maximize potential studies for inclusion review.
  • Clinically-relevant interventions and comparisons.
  • Low to moderate study methodological quality was noted in the available literature.
  • Heterogeneity among study interventions and timepoints limited meta-analysis of results, resulting in a low number of studies eligible for meta-analysis.

Additional References:

  1. Martin BI, Gerkovich MM, Deyo RA et al. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care 2012; 50:1029-1036.
  2. Côté P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998; 23:1689-1698.
  3. Borghouts JA, Koes BW, Vondeling H, Bouter LM. Cost-of-illness of neck pain in The Netherlands in 1996. Pain 1999; 80:629-636.
  4. Korthals-de Bos IB, Hoving JL, van Tulder MW et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: Economic evaluation alongside a randomised controlled trial. BMJ 2003; 326: 911.
  5. Gross A, Miller J, D’Sylva J et al. Manipulation or mobilisation for neck pain: A Cochrane Review. Man Ther 2010; 15: 315-333.
  6. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis. Spine J 2004; 4:335-356.
  7. Peloso P, Gross A, Haines T et al. Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev 2007; 3:CD000319.
  8. Carragee EJ, Hurwitz EL, Cheng I et al. Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: Injections and surgical interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S153-169.
  9. Schroeder J, Kaplan L, Fischer DJ, Skelly AC. The outcomes of manipulation or mobilization therapy compared with physical therapy or exercise for neck pain: A systematic review. Evid Based Spine Care J 2013; 4: 30-41.
  10. Gross A, Langevin P, Burnie SJ et al. Manipulation and mobilization for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev 2015; 9:CD004249.
  11. Furlan AD, Yazdi F, Tsertsvadze A et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012; 2012: 953139.
  12. Scottish Intercollegiate Guidelines Network. Sign 50: A Guideline Developer’s Handbook. 2010 [cited 2015 Jan 1]; Available from: Accessed March 10, 2019.
  13. Khorsan R, Crawford C. How to assess the external validity and model validity of therapeutic trials: A conceptual approach to systematic review methodology. Evid Based Complement Alternat Med 2014; 2014: 694804.