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Table 5

Summary of findings of manipulation for neck pain (only pain and functional outcomes).

Duration and cause of painOutcomesGRADE*Findings
Manipulation versus no treatment

Acute/subacute, chronic, and mixed, (specific, nonspecific)NA Insufficient
No trial
NA

Unknown specificNA Insufficient
No trial
NA

Unknown nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [112], there was no significant difference between manipulation and “no treatment” groups in immediate-term posttreatment pain intensity.

Manipulation versus placebo

Acute/subacute specificNA Insufficient
No trial
NA

Acute/subacute nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: High
Consistency: yes
Directness: yes
In two trials [113, 114], manipulation was significantly more effective than placebo immediately after treatment. In the first trial [113] ipsilateral manipulation (but not contralateral; P = 0.93) was significantly better than placebo ultrasound (mean VAS score: 23.6 ± 18.6 versus 46.5 ± 21.8, P = 0.001). In the other trial [114], manipulation was significantly better than placebo (light hand placement on the side of neck without application of any side-different pressure or tension) (numerical data not reported; P = 0.01).

Chronic specificNA Insufficient
No trial
NA

Chronic nonspecificPain intensity score (VAS)Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
In two studies [115, 116], manipulation techniques were significantly better than placebo immediately after treatment.
In the first trial [115] cervical osteopathy was better than placebo (sham ultrasound). In the second trial [116] a single thoracic manipulation was significantly better than placebo (hand manoeuvre without high velocity thrust).
Disability score (NDI) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [116] a single thoracic manipulation was significantly better than placebo (hand manoeuvre without high velocity thrust).

Mixed (specific, nonspecific)NA Insufficient
No trial
NA

Unknown specificNA Insufficient
No trial
NA

Unknown nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: High
Consistency: NA (only 1 trial)
Directness: yes
In one trial [117], manipulation was significantly better than placebo immediately after treatment (P < 0.001).
The mean VAS reductions in manipulation and placebo groups were 15.5 (95% CI: 11.8, 19.2) and 4.2 (95% CI: 1.9, 6.6), respectively.

Manipulation versus pain medication

Acute/subacute, mixed, or unknown (specific, nonspecific)NA Insufficient
No trial
NA

Chronic specificNA Insufficient
No trial
NA

Chronic nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: High
Consistency: no
Directness: yes
In one trial [118] although both manipulation and medication (Diazepam) groups improved, there was no between-group significant difference at short-term followup after treatment (5.0 ± 3.2 versus 1.8 ± 3.1, P = 0.20).
In two other trials [69, 70], manipulation was significantly better than medication (e.g., NSAIDs, Celebrex, Vioxx, Paracetamol) at immediate/short-term followup after treatment. In one of these trials [69] the proportion of pain-free patients after the treatment was significantly greater in the manipulation group compared to the medication group (27.3% versus 5.0%, P = 0.05).
Disability score (NDI) Low
Design: RCT
ROB: High
Consistency: yes
Directness: yes
In two other trials [69, 70], manipulation was significantly better than medication (e.g., NSAIDs, Celebrex, Vioxx, Paracetamol) at immediate/short-term followup after treatment. In one trial, [69] the median (IQR) values for manipulation and medication groups were 22 [26, 3033, 35, 36, 41, 45, 4749, 5266, 66, 6872, 75, 7783, 85, 208210] versus 42 [26, 27, 30, 33, 36, 41, 47, 49, 6672, 75, 7783, 8591, 208210], respectively. No between-group P value was reported. In the other trial [70] the median (95% CI) changes (from baseline) in manipulation and medication groups were −10.00 (95% CI: −14.0, −4.0) versus 0.0 (95% CI: −14.0, 2.7), respectively (P < 0.001).

Manipulation versus physiotherapy

Acute/subacute, chronic, mixed, or unknown (specific, nonspecific)NA Insufficient
No trial
NA

Manipulation versus mobilization

Acute/subacute specificNA Insufficient
No trial
NA

Acute/subacute nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [114], there was no statistically significant difference between manipulation and mobilization immediately after treatment (P = 0.16; no other numerical data were reported).

Mixed, specificNA Insufficient
No trial
NA

Mixed, nonspecificPain intensity score (VAS)—immediately after treatment Low
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
Two trials reported comparison of pain intensity between manipulation and mobilization at immediate followup [119, 120].
In the first trial [120] spinal manipulation was significantly better than mobilization (P < 0.001). The mean VAS reductions in manipulation and mobilization groups were 3.5 (95% CI: 3.1, 3.9) and 0.4 (95% CI: 0.2, 0.5), respectively.
In the second trial [119], manipulation was significantly better (but at borderline due probably to low study power) than mobilization (mean reduction on NRS-101: −17.3 ± 19.5 versus −10.5 ± 14.8, P = 0.05).
Pain intensity score (VAS)—intermediate-term after treatment Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [121] the intermediate-term posttreatment differences between the manipulation and mobilization groups were clinically negligible and statistically nonsignificant (NRS-11: −0.02, 95% CI: −0.69, 0.65) and disability (NDI: 0.46, 95% CI: −0.89, 1.82).
Disability (NDI score) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [121] the intermediate-term posttreatment differences between the manipulation and mobilization groups were clinically negligible and statistically nonsignificant (mean difference in NDI score: 0.46, 95% CI: −0.89, 1.82).

Chronic or unknown (specific, nonspecific)NA Insufficient
No trial
NA

Manipulation versus usual care

Acute/subacute, chronic, mixed, or unknown (specific, nonspecific)NA Insufficient
No trial
NA

Manipulation versus acupuncture (see Table 3 for acupuncture for neck pain)

Manipulation versus massage

Acute/subacute, chronic, mixed, or unknown (specific, nonspecific)NA Insufficient
No trial
NA

Manipulation versus exercise

Acute/subacute, chronic, mixed, or unknown (specific, nonspecific)NA Insufficient
No trial
NA

*Precision in formal grading was applied only to pooled results.

VAS: visual analog scale; RMDQ: Roland-Morris disability scale; NHP: Nottingham health profile; MPQ: McGill pain questionnaire; PDI: pain disability index; SF: short form; NPQ: neck pain questionnaire; SF-PQ: short form pain questionnaire; PRI: pain rating index; PPI: present pain intensity; NA: not applicable; NDI: neck disability index; IQR: interquartile range.

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