A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain

doi:10.1155/2012/953139

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Evid Based Complement Alternat Med. 2012; 2012: 953139.

Published online 2011 Nov 24. doi: 10.1155/2012/953139

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Table 5

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

Duration and cause of pain	Outcomes	GRADE*	Findings
Manipulation versus no treatment

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

Unknown specific	NA	Insufficient No trial	NA

Unknown nonspecific	Pain 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 specific	NA	Insufficient No trial	NA

Acute/subacute nonspecific	Pain 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 specific	NA	Insufficient No trial	NA

Chronic nonspecific	Pain 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).
Chronic nonspecific	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 specific	NA	Insufficient No trial	NA

Unknown nonspecific	Pain 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 specific	NA	Insufficient No trial	NA

Chronic nonspecific	Pain 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).
Chronic nonspecific	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, 30–33, 35, 36, 41, 45, 47–49, 52–66, 66, 68–72, 75, 77–83, 85, 208–210] versus 42 [26, 27, 30, 33, 36, 41, 47, 49, 66–72, 75, 77–83, 85–91, 208–210], 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 specific	NA	Insufficient No trial	NA

Acute/subacute nonspecific	Pain 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, specific	NA	Insufficient No trial	NA

Mixed, nonspecific	Pain 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.