Chronic Neck Pain and Chiropractic This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
Jump to: Reference Materials Chronic Pain Research Research Commentary
Who Are Candidates for Neck Pain?
Alternative Medicine Approaches Forward Head Posture
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Reference Materials
The Forward Head Posture Page
Persistent forward head posture (a.k.a “hyperkyphotic posture”) forces the suboccipital muscles to remain in constant contraction as they elevate the chin, and this puts pressure on the 3 suboccipital nerves. This nerve compression may cause headaches at the base of the skull, and can also mimic sinus (frontal) headaches.
Chiropractic Goes Head-to-Head With NSAIDs and Acupuncture
The following commentary involves reviewing a brilliant series of 3 consecutive studies, comparing popular forms of treatment for chronic spinal pain, including NSAID use, acupuncture, and spinal adjusting for relief. The author reports that this is the first study of long-term efficacy of 3 distinct and standardized treatment regimens for patients with chronic spinal pain syndromes.
Interpreting Research and the Case for Chiropractic
The Chiropractic Report ~ July 2011 ~ FULL TEXT
For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).
Rehabilitation Monograph Series ~ Chapter 15
By Richard C. Schafer, D.C., FICC and the ACAPress
The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury. The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.
Rehabilitation Monograph Series ~ Chapter 22
By Richard C. Schafer, D.C., FICC and the ACAPress
The cervical spine provides structural stability and support for the cranium, and a flexible and protective column for movement and balance adaptation, along with housing of the spinal cord and vertebral arteries. It also allows for directional orientation of the eyes and ears. Nowhere in the spine is the relationship between the osseous structures and the surrounding neurologic and vascular beds as intimate or subject to disturbance as it is in the cervical region. Whether induced by trauma or not, cervical subluxation syndromes may be reflected in total body habitus. IVF insults, and the effects of articular fixations can manifest throughout the motor, sensory, and autonomic nervous systems. Many peripheral nerve symptoms in the shoulder, arm, and hand will find their origin in the cervical spine, as may numerous brainstem disorders.
Rehabilitation Monograph Series ~ Chapter 8
By Richard C. Schafer, D.C., FICC and the ACAPress
The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur. The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.
Acute and Chronic Spine-Related Pain
Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ID: 3.4007
The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3]
North American Spine Society
It is usually not possible to know the exact cause of neck pain in the days or weeks after a car accident. We know the muscles and ligaments get strained and are probably inflamed, but they usually heal within six to ten weeks. Pain that lasts longer (than 6-10 weeks) is usually due to deeper problems such as injury to the disc or facet joint, or both. Read more here.
A Brief Review of Development and Current Status
Chiropractic & Osteopathy 2005 (Apr 27); 13 (1): 6 ~ FULL TEXT
The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.
For Neck Pain, Chiropractic and Exercise Are Better Than Drugs
The New York Times ~ January 3, 2012
This new study, published in the Annals of Internal Medicine, found that chiropractic care or simple exercises done at home were better at reducing pain than taking medications like aspirin, ibuprofen or narcotics.
Dynamic Chiropractic 2008 (Sep 23); 26 (20):
The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
Chronic Neck Pain Research
.
Undergoing Chiropractic Treatment: A Prospective Cohort Study
With 6 month Follow-up
Chiropractic & Manual Therapies 2013 (Jan 7); 21: 3 ~ FULL TEXT
Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement on the PGIC scale. At 6 months after start of chiropractic treatment there were no differences in any outcome measures between the two groups.
and Health Care Expenditures for Back and Neck Problems
Med Care. 2012 (Dec); 50 (12): 1029–1036
While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain – and research increasingly supports its utility from a clinical standpoint – this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000-plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.
Chiropractic Goes Head-to-Head With NSAIDs and Acupuncture
The following commentary involves reviewing a brilliant series of 3 consecutive studies, comparing popular forms of treatment for chronic spinal pain, including NSAID use, acupuncture, and spinal adjusting for relief. The author reports that this is the first study of long-term efficacy of 3 distinct and standardized treatment regimens for patients with chronic spinal pain syndromes.
Chiropractic Care: Comparison of Acute and Chronic Patients
Chiropractic & Manual Therapies 2012 (Aug 24); 20 (1): 27 ~ FULL TEXT
The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.
for Acute and Subacute Neck Pain: A Randomized Trial
Annals of Internal Medicine 2012 (Jan 3); 156 (1 Pt 1): 1–10 ~ FULL TEXT
Bronfort’s paper, published in the influential Annals of Internal Medicine, began with the hypothesis that “spinal manipulation therapy (SMT) is more effective than medication or home exercise with advice (HEA) for acute and subacute neck pain.” And indeed, when the dust settled, the neck-pain patients receiving spinal manipulation had achieved significantly more pain relief than those receiving medication. However, a third group that received a few instructional sessions of home exercise advice achieved results that were, for all practical purposes, equal to the manipulation group. Despite the fact that a New York Times article about this study was published under the headline “For Neck Pain, Chiropractic and Exercise Are Better Than Drugs” a closer analysis leads to a far more guarded set of conclusions.
A Retrospective Study of Clinical Outcomes
J Manipulative Physiol Ther. 2011 (Oct); 34 (8): 533–538
This study provides a retrospective review of clinical outcomes for a sample of veterans with neck pain within a VHA chiropractic clinic. Despite the levels of service-connected disability and comorbidity among this sample of veteran patients seeking care for neck pain, mean clinical outcomes were considered to be both statistically significant and clinically meaningful. Although retrospective design-based limitations are identified, this study serves as a foundation for further research and provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain.
of a Diagnosis-Based Clinical Decision Guide in Patients
with Neck Pain
Chiropractic & Manual Therapies 2011 (Aug 27)
The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as interexaminer reliability, validity and efficacy of treatment based on the DBCDG.
Prevalence and Progression Over Time
Musculoskelet Disord. 2011 (May 16); 12: 98 ~ FULL TEXT
The following article appears to be the first study to track and review the progression of back pain in the same group of children, over a prolonged period, to see how (or if) it is a contributor to those same complains in adulthood. Of particular interest is Table 2, because it breaks down and tracks complaints of either neck, mid back, or low back pain in the same group of children at 3 different time periods: ages 9, 13 and 15 years old.
Who Are Likely to Achieve Short-Term Success With Manipulative
Interventions Directed at the Cervical and Thoracic Spine
J Manipulative Physiol Ther. 2011 (Mar); 34 (3): 144–152
The current study identified several prognostic clinical factors including pain intensity greater than 4.5 points, cervical extension less than 46°, hypomobility of T1 vertebra, a negative ULTT, and female sex that may potentially identify patients with mechanical neck pain who are likely to experience a rapid and positive response to the application of cervical and thoracic spine thrust manipulations. If 4 of 5 variables were present (LR+, 1.9), the likelihood of success increased from 61.7% to 86.3%
Military Medicine 2011 (Jan); 176 (1): 106–109
Eighty-two RAAF FJ aircrew responded to the survey. Ninety-five percent of the respondents experienced flight-related neck pain. The most commonly sought treatment modalities were on-base medical and physiotherapy services. Many respondents reported that currently provided on-base treatment and ancillary services such as chiropractic therapy are the most effective in alleviating symptoms.
and Comparison Between Chronic Neck Pain Patients and Controls
Spine (Phila Pa 1976). 2010 (Nov 15); 35 (24): 2103–2108
The cervical extensor muscles exhibit a consistent flexion-relaxation (FFR) phenomenon in healthy control subjects and the measurement is highly reproducible when measured 4 weeks apart in both controls and chronic neck pain patients. The FRR in neck pain patients is significantly higher than in control subjects suggesting that this measure may be a useful marker of altered neuromuscular function.
Associated With Unsteadiness: A Single Case Study
Chiropractic & Osteopathy 2008 (Nov 17); 16 (1): 15 ~ FULL TEXT
This case report indicates that an 8-week rehabilitation program combining therapeutic exercises with spinal manipulative therapy may have had an effect on improvement of postural control in a trauma Chronic Neck Pain patient with unsteadiness. These results warrant further studies to investigate the relationships between pain amelioration, sensorimotor control of the cervical spine, muscle fitness and postural steadiness.
Man Ther. 2010 (Aug); 15 (4): 315–333
Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control (pSMD -0.90 (95%CI: -1.78 to -0.02)). Low quality evidence also supported thoracic manipulation for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and immediate pain reduction in chronic neck pain (NNT 5; 29% treatment advantage). Optimal technique and dose need to be determined.
Improve the Value of Health Benefit Plans?
Mercer Health and Benefits LLC ~ October 12, 2009 ~ FULL TEXT
This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.
Dynamic Chiropractic 2008 (Sep 23); 26 (20):
The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
Manipulation of the Cervical Spine
J Manipulative Physiol Ther 2008 (Mar); 31 (3): 172–183
This study is the first attempt to identify variables that can predict immediate outcomes in terms of improvement and worsening of presenting symptoms, and global improvement, after cervical spine manipulation. From the findings, it was possible to identify some predictors of immediate improvement in presenting symptoms after cervical spine manipulation. Patients presenting with symptoms of “reduced neck, shoulder, arm movement, stiffness,” “neck pain,” “upper, mid back pain,” “headache,” “shoulder, arm pain,” and/or “none or one presenting symptom only” are likely to report immediate improvement in these symptoms after treatment. Patients presenting with any 4 of these symptoms were shown to have the highest probability of immediate improvement. This finding may enhance clinical decision making for selecting cervical manipulation in the treatment of patients with one or more of these complaints. Although it was possible to identify a number of predictor variables for immediate worsening in presenting symptoms and global improvement after cervical spine manipulation, these failed to provide a robust predictive model for clinical application.
Care for Neck Pain: A Prospective, Multicenter, Cohort Study
J Manipulative Physiol Ther 2007 (Jul); 30 (6): 408–418
In contrast to clinical trials of prescription medication, researchers in the area of conservative care for musculoskeletal complaints have focused their attention on treatment effectiveness and, to a much lesser degree, on adverse events. This study, consisting of patients treated in a wide variety of chiropractic practices and settings, describes both positive and negative, and short- and long-term clinical outcomes for a relatively large study population with neck pain. Although many of the subjects (in this study) had chronic, recurrent neck pain and had undergone prior care for this complaint, many patients experienced benefit from the treatment (based upon diminished pain and disability, the percentage of patients recovered and percentage satisfied with care). Furthermore, many responded relatively quickly to treatment (48% were recovered at the fourth visit).
A Systematic Review
J Rheumatol 2007 (May); 34 (5): 1083–1102
In a review of 88 unique RCTs, the authors found that “Exercise combined with mobilization/manipulation, exercise alone, and intramuscular lidocaine for chronic MND; intravenous glucocorticoid for acute whiplash associated disorders; and low-level laser therapy demonstrated either intermediate or longterm benefits. Optimal dosage of effective techniques and prognostic indicators for responders to care should be explored in future research.”
and Sedentary Activities in Adolescence
Spine 2007 (Apr 20); 32 (9): 1038–1044
Almost half of the girls and one third of the boys reported mild neck or occipital pain, or shoulder pain, and 3% of girls and 2% of boys reported severe neck or occipital pain, or shoulder pain during the past 6 months. High-level physical activity associated with an increased prevalence of both severe neck or occipital pain and severe shoulder pain in girls, but not in boys. Prolonged sitting was associated with a high prevalence of neck or occipital pain and shoulder pain in girls, and neck or occipital pain in boys. Of various sedentary activities, television watching and reading books associated with neck or occipital pain in girls, whereas playing or working with a computer associated with neck or occipital pain in boys. In girls, television watching also associated with mild shoulder pain.
A Systematic Review of Change Scores in Randomized Clinical Trials
J Manipulative Physiol Ther 2007 (Mar); 30 (3): 215–227
There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment. The current evidence does not support a similar level of benefit from massage.
Outcomes Among Primary Care Patients: Results from the UCLA Neck Pain Study
Disabil Rehabil 2006 (Nov 15); 28 (21): 1319–1329
Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.
a Single Cervical High-velocity Low-amplitude Manipulation in Subjects
Presenting with Mechanical Neck Pain: A Randomized Controlled Trial
J Manipulative Physiol Ther 2006 (Sep); 29 (7): 511–517
A group of 70 patients with neck pain (25 males and 45 females, ages 20-55 years) participated in this study. The lateral gliding test was used to establish an intervertebral joint dysfunction at the C3 through C4 or C4 through C5 levels. The subjects were randomly divided into either an experimental group, which received an HVLA thrust, or a control group, which received manual mobilization. Results suggest that a single cervical HVLA manipulation is more effective in reducing neck pain at rest, and in increasing active cervical range of motion, than a control mobilization procedure in subjects suffering from mechanical neck pain.
Between Acute Whiplash Injuries and Chronic Neck Pain
Pain Res Manag. 2006 (Summer); 11 (2): 79–83
Patients were defined as individuals with chronic neck pain, and controls as those with chronic back pain. The two groups were surveyed for cause of chronic pain as well as demographic information. The two groups were compared using an exposure-odds ratio. Forty-five per cent of the patients attributed their pain to a motor vehicle accident. An OR of 4.0 and 2.1 was calculated for men and women, respectively. Based on the results of the present study, it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.
Patients with a Primary Diagnosis Involving Acute Neck Pain
J Manipulative Physiol Ther 2006 (May); 29 (4): 288–296
A total of 115 patients were contacted, of whom 94 became study participants, resulting in 60 women (64%) and 34 men. The mean age was 39.6 years (SD, 15.7). The mean number of visits was 24.5 (SD, 21.2). Pain levels improved significantly from a mean of 7.6 (median, 8.0) before treatment to 1.9 (median, 2.0) after treatment (P < .0001). The overall patient satisfaction rate was 94%.
J Occup Rehabil 2006 (Jun 3): 16 (2): 247–254
This paper describes the conservative management of a patient who was disabled from work for 2 years, using an integrated approach including chiropractic manipulation, pain education, restricted duty and clear communications among all parties involved. After 15 weeks, the patient returned to her previous occupation as a nurse, first part time, and subsequently full time. There are more articles like this in the CASE STUDIES Section.
Sensibility and Subjective Pain Intensity in Patients with Nontraumatic
Chronic Neck Pain
J Manipulative Physiol Ther 2006 (Feb); 29 (2): 100–106
There was no difference between the treatment patients and the control subjects at the beginning with regard to age, sex, subjective pain intensity, range of motion, and HRA. At the 5-week follow-up, the treatment patients showed significant reductions in pain and improvement of all HRA aspects measured whereas the control subjects did not show any reduction in pain and improvement in only one HRA aspect. The results of this study suggest that chiropractic care can be effective in influencing the complex process of proprioceptive sensibility and pain of cervical origin. Short, specific chiropractic treatment programs with proper patient information may alter the course of chronic cervical pain.
- A Brilliant Series of 3 Research Studies
The Pilot Study (1999)
Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing
Acupuncture, A Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation
J Manipulative Physiol Ther 1999 (Jul); 22 (6): 376-381
Randomization was successful. After a median intervention period of 30 days, spinal manipulation was the only intervention that achieved statistically significant improvements (all expressed as percentages of the original scores) with (1) a reduction of 30.7% on the Oswestry scale, (2) an improvement of 25% on the neck disability index, and (3) reductions on the visual analogue scale of 50% for low back pain, 46% for upper back pain, and 33% for neck pain (all P<.001). Neither of the other interventions showed any significant improvement on any of the outcome measures.
The Trial (2003)
Acupuncture, and Spinal Manipulation
Spine (Phila Pa 1976) 2003 (Jul 15); 28 (14): 1490-1502
Randomization proved to be successful. The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 25% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension. However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50% vs 42%).
The Long-term Follow-up (2005)
the Efficacy of Medication, Acupuncture, and Spinal Manipulation
for Chronic Mechanical Spinal Pain Syndromes
J Manipulative Physiol Ther 2005 (Jan); 28 (1): 3-11
The results of this “fastidious” approach were able to add some information regarding the efficacy of treatment regimens in patients with chronic spinal pain syndromes. Overall, patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes. For patients receiving acupuncture, consistent improvements were also observed, although without reaching statistical significance (with a single exception). For patients receiving medication, the findings were less favorable. Larger studies are now clearly justified.
End of the Trial Series .
Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564–569
For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a significant reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.
Cochrane Database Syst Rev 2005 (Jul 20); 3: CD004250
The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic MND, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term.
HNO 2005 (May 11)
It is discussed controversially whether cervicogenic pain in the head and/or neck is a pathogenic entity. The good results obtained with manual therapy in patients with head and neck pain contradict the refusal of the majority of the neurologists to accept the diagnosis "cervicogenic headache." Complaints about headache are frequently encountered in the general ENT clinic. The versatile picture of the cervicogenic headache is caused by the complex neural connections in the region of the upper cervical spine. The differential diagnosis of the cervicogenic headache is described.
and Neck Complaints
J Manipulative Physiol Ther 2005 (Mar); 28 (3): 187-193
In a study of 277 lateral cervical x-rays, patients with lordosis of 20° or less were more likely to have cervicogenic symptoms (P < .001). The association between cervical pain and lordosis of 0° or less was significant (P < .0001). The odds that a patient with cervical pain had a lordosis of 0° or less was 18 times greater than for a patient with a noncervical complaint. Patients with cervical pain had less lordosis and this was consistent over all age ranges. There are more articles like this in the Spinal Allignment and Function Page.
the Efficacy of Medication, Acupuncture, and Spinal Manipulation
for Chronic Mechanical Spinal Pain Syndromes
J Manipulative Physiol Ther 2005 (Jan); 28 (1): 3-11
The results of this “fastidious” approach were able to add some information regarding the efficacy of treatment regimens in patients with chronic spinal pain syndromes. Overall, patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes. For patients receiving acupuncture, consistent improvements were also observed, although without reaching statistical significance (with a single exception). For patients receiving medication, the findings were less favorable. Larger studies are now clearly justified.
Clin J Pain 2005 (Jan); 21 (1): 18–26
In this paper, researchers in a medical school rehabilitation department were interested in finding out what treatments were most effective at reducing pain for neuromuscular diseases (like amyotrophic lateral sclerosis and myotonic muscular dystrophies). Interestingly, chiropractic scored the highest relief rating (7.33 out of 10), scoring higher than the relief provided by these medical treatments: nerve blocks (6.75) or Opioid analgesics (6.37). WOW!!!
and Associated Neck Pain: A Randomized Pilot Study
J Manipulative Physiol Ther 2004 (Nov); 27 (9): 547—553
Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.
and Neck Pain: A Systematic Review and Best Evidence Synthesis
Spine Journal (of the North American Spine Society) 2004 (May); 4 (3): 335–356
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
and Insidious Onset Neck Pain Patients
Manual Therapy 2004 (May); 9 (2): 89–94
The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude (normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all P<0.05) and had significantly greater shortfalls from the pressure targets in the test stages (P<0.05). No significant differences were evident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy is common to neck pain of both whiplash and insidious origin.
Clinical Chiropractic 2004 (Mar): 7 (1): 16—23
The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow-up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain.
Acupuncture, and Spinal Manipulation
Spine (Phila Pa 1976) 2003 (Jul 15); 28 (14): 1490–1502
The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (3%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 23% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension.
Practitioner Care for Neck Pain: Economic Evaluation Alongside
a Randomised Controlled Trial
British Medical Journal 2003 (Apr 26); 326 (7395): 911 ~ FULL TEXT
A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study. After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group. You may also enjoy this WebMD review (Thursday, April 24, 2003) titled: Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective, and More Cost-Effective, than Traditional Treatments
Chiropractic Care That Helped to Improve Quality of Life
Chiropractic Journal of Australia 2002 (Dec); 32 (4): 119-130 ~ FULL TEXT
Observation over an extended period assists in understanding the progression of chronic disorders. This patient experienced substantially reduced symptoms with chiropractic care during the 7-year observation period. Of note is the repeated exacerbation of neck pain that often precedes exacerbation in ear symptoms, along with the relief of both following adjustment and an association between improved hearing and improved cervical alignment.
and Two Types of Exercise for Patients with Chronic Neck Pain
Spine 2002 (Nov 1); 27 (21): 2383–2389
The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.
National Cross Sectional Surveys
British Medical Journal 2002 (Oct 5); 325 (7367): 743–745 ~ FULL TEXT
To study changes in the prevalence of pain in the back or neck in adolescents between the years 1985 and 2001, the authors compared biennial nationwide postal surveys, between 1985-2001, and annual classroom surveys, from 1996-2001. They found that pain in the neck, shoulder, and lower back is becoming more common in Finnish adolescents. This pain suggests a new disease burden of degenerative musculoskeletal disorders for future adults. Prevalence of pain in the back and neck was greater in the 1990s than in the 1980s and increased steadily from 1993 to 1997. Pain of the neck and shoulder and pain of the lower back was much more common in 1999 than in 1991 and in 2001 than in 1999. Pain was more common among girls and older groups: pain of the neck and shoulder affected 24% of girls and 12% of boys in 14 year olds, 38% of girls and 16% of boys in 16 year olds, and 43% of girls and 19% of boys in 18 year olds; pain in the lower back affected 8% of girls and 7% of boys in 14 year olds, 14% of girls and 11% of boys in 16 year olds, and 17% of boys and 13% of girls in 18 year olds.
Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial
Ann Intern Med 2002 (May 21); 136 (10): 713-722
Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared. In this study, manual therapy was a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
Instrumental (MFMA) Versus Manual (HVLA) Manipulation in the Treatment
of Cervical Spine Dysfunction
J Manipulative Physiol Ther 2001 (May); 24 (4): 260–271
The results of this clinical trial indicate that both instrumental (MFMA) manipulation and manual (HVLA) manipulation have beneficial effects associated with reducing pain and disability and improving cervical range of motion in this patient population. A randomized, controlled clinical trial in a similar patient base with a larger sample size is necessary to verify the clinical relevance of these findings.
of the Atlantoaxial Joint
J Tradit Chin Med 1999 (Dec); 19 (4): 273–278
The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis.
Nociceptive, Neuropathic, and Psychologic Mechanisms
J Manipulative Physiol Ther 1999 (Sep); 22 (7): 458–472
Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.
Acupuncture, A Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation
J Manipulative Physiol Ther 1999 (Jul); 22 (6): 376–381
The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.
Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms
of Symptom Generation
J Manipulative Physiol Ther 1998 (May); 21 (4): 267–280 ~ FULL TEXT
Joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease. You may also enjoy this response from another chiropractic researcher.
Pain, Functional Ability and Satisfaction With Care
J Manipulative Physiol Ther 1997 (May); 20 (4): 235–240
Based on these results, it seems that patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments, thus reinforcing previous results showing the benefits of chiropractic treatment for back and neck pain.
Chronic Neck Pain: A Pilot Study
J Manipulative Physiol Ther 1997 (Feb); 20 (2): 80–85
Subjects receiving manipulation demonstrated a mean reduction in visual analogue scores of 44%, along with a 41% improvement in mean scores for the head repositioning skill. In comparison, a 9% mean reduction in visual analogue scores and a 12% improvement in head repositioning scores was observed for the stretching group. The difference in the outcomes of the head repositioning skill scores was significant (p < or = .05).
A Placebo–Controlled Prevalence Study
SPINE 1996 (Aug 1); 21 (15): 1737–1744
The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks. The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition. In this study, sixty-eight consecutive patients referred for chronic neck pain after whiplash were studied. Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo-controlled local anesthetic blocks. Two different local anesthetics and a placebo injection of normal saline were administered in random order and under double-blindfolded conditions. A positive diagnosis was made if the patient's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection. Overall, the prevalence of cervical zygapophysial joint pain (C2-C3 or below) was 60% (93% confidence interval, 46%, 73%).
for the Treatment of Neck Pain
J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536
As for comparative safety, the best available evidence indicates that NSAID use poses a significantly greater risk of serious complications and death than the use of cervical manipulation for comparable conditions. In conclusion, the best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.
Scand J Rehabil Med 1995 (Sep); 27 (3): 131–136
This study revealed that palpation for pain was the most reproducable and accurate assessment of reported neck pain. They state: "Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self–reported questionnaires on dysfunctions of the neck."
After Whiplash
Spine Journal 1995 (Jan 1); 20 (1): 20–26
In a significant proportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggest many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic block. In this study, fifty consecutive, referred patients with chronic neck pain after whiplash injury were studied using double-blind, controlled, diagnostic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. A positive diagnosis was made only if both blocks relieved the patient's pain and bupivacaine provided longer relief. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.
Review of Clinical and Experimental Evidence
Pain 1993 (Mar); 52 (3): 259–285
Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also play a significant role.
Who Are Candidates for Neck Pain?
A Case-control Study
J Rheumatol 2005 (Aug); 32 (8): 1576—1583
In total, 26% of drivers reported post-accident neck pain. Women, younger individuals, and those with a history of neck pain were more likely to report neck pain following their accident. In addition, a number of accident related and psychosocial factors were independently associated with reporting post-accident neck pain: collision from behind; vehicle stationary at impact; collision severity; not being at fault; and monotonous work. Based on these 8 factors, the likelihood of having neck pain increased from 7% with < 2 risk factors to 62% with > 5.
A Longitudinal Study in Young Adults
Spine 2004 (Aug 1); 29 (15): 1662-1669
A random sample of 826 high school students was investigated when they were 15 to 18 years old and again at 22 to 25 years of age. In 7 years, the prevalence of weekly neck and shoulder pain increased from 17% to 28%. Among those who were asymptomatic at baseline, 6-month incidence of occasional or weekly neck and shoulder pain was 59% 7 years later. In an adjusted model, psychosomatic symptoms remained an associated factor for prevalent neck and shoulder pain 7 years later for both females and males. In females, neck and shoulder pain in adolescence was associated with prevalent neck and shoulder pain in adulthood, and sports loading dynamically in the upper extremities was an associated factor for a low prevalence of neck and shoulder pain 7 years later. In separate analyses of incident neck and shoulder pain, psychosomatic stress symptoms predicted neck and shoulder pain in adulthood.
University Academic Staff in Hong Kong
J Occup Rehabil 2002 (Jun); 12 (2): 77–91
Among those with neck pain during computer processing, 60.3% had a forward head posture. However, a low correlation between psychosocial factors and neck pain was demonstrated (r = 0.343). Academic staff in tertiary institutions could be considered as a high-risk group of job-related neck pain.
Surgery of the Cervical Spine
J Manipulative Physiol Ther 2001 (Sep); 24 (7): 477-482
The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.
J Contemp Dent Pract 2001 (Aug 15); 2 (3): 17-30
In the practice of dentistry, stress, tension, and postural practices can contribute to back and neck problems. Two hundred and four dentists and dental auxiliary (87 males and 117 females) in Riyadh city, Saudi Arabia were surveyed to determine the prevalence of postural problems. The candidates were interviewed and observed during practice. The data obtained showed that 111 (54.4%) of the subjects complained of neck pain and 150 (73.3%) complained of back pain.
for Patients with Chronic Neck Pain
Spine (Phila Pa 1976) 2001 (Apr 1); 26 (7): 788–797
For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.
Medicine (Baltimore) 1995 (Sep); 74 (5): 281–297
Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. With regard to baseline findings the following significant differences were found (on this cohort): Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray.
New England Journal of Medicine 1994 (Apr 14): 330 (15): 1083—1084
Whiplash injuries occur in more than 1 million people in the United States every year (1). Although the majority become asymptomatic in a matter of weeks to a few months, 20 to 40 percent have symptoms that are sometimes debilitating and persist for years. This so–called late whiplash syndrome has become one of the most controversial conditions in medicine. Some attribute the persistent symptoms to unresolved injury, whereas others attribute them to underlying psychological factors or the possibility of financial gain.
Phys Ther 1992 (Jun); 72 (6): 425–431
Subjects with kyphosis and rounded shoulders had an increased incidence of interscapular pain, and those with a forward-head posture had an increased incidence of cervical, interscapular, and headache pain.
Chronic Neck Pain Commentary
Editorial Commentary:
A recent balanced article in the Feb 13, 2008 issue of JAMA (Journal of the American Medical Association) revealed that between 1997 and 2005, the costs for “standard medical management” of spinal pain syndromes (both neck and back) increased by an inflation-adjusted 63%, while measured outcomes for physical functioning, work or school limitations, and social limitations among adults actually declined. During this same period, there was also an overall increase in the number of individuals who experienced neck or back pain (from 20.7% to 24.7%).
During this same time period, the inclusion of a chiropractic benefit within a large managed care program (observed over a 4-year period) resulted in significant savings, as well as a reduction in the rates of surgery, and unnecessary use of advanced imaging, inpatient care, and plain-film radiographs.
These 2 studies, along with many similar findings, make it apparent that chiropractic should be the FIRST choice of management for those with musculoskeletal complaints. You may want to refer to the Cost-Effectiveness Page or the Patient Satisfaction Page for more supportive information on this topic.
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