What Works For Treating Neck Pain?
Study: Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain from of the Annals of Internal Medicine
The study involved 272 adults ages 18-65 with who had nonspecific neck pain for up to 12 weeks duration. The patients were essentially broken into thirds; 1/3 received chiropractic manipulation, 1/3 received instructions for self directed therapeutic to do at home, and 1/3 received medication from a medical provider. The chiropractic and therapeutic exercise group both significantly outperformed in pain reduction when compared to the medication group.
What I like about the study
Well first of all, I like anything that tries to measure and compare different treatments to see which is more effective:
- I like that there was a measurable difference showing that conservative and natural therapy was more effective than medication.
- I like that they tried to prevent overlap between treatment groups. This helps prevents the "muddling" of treatments and outcomes.
- I like that they looked at quality of life as well as pain scores. Both are subjective measuring tools but doing so tries to evaluate what I like to separate as the sensation of pain and he experience of hurt.
What I don't like about the study
The number of people in the study was relatively small. I don't get too beat up about this one because the nature of the study was in a clinical setting where people were getting actual treatment. It's hard to get a huge number of test subjects because of cost and time.
The authors tried to replicate a "real world" treatment setting but neglected to comment on the wide variety of patients and the treatments they received:
- There is more than one type of neck pain... For example, muscular neck pain will not respond well to treatments focused on a disc bulge.
- There was a big swing in age groups (18-65 year old's - obviously high schoolers are different than boomers...)
- There was a big swing in body mass index (can be an approximation of general fitness and metabolic health, e.g., diabetes or being out of shape).
- Treatment types were vague; What type of manipulation, volume of exercise, what medication, etc.
Also, while the article recommended cervical manipulation (adjustments by chiropractors) and exercise for acute neck pain, there wasn't a "wow" difference between the groups. Remember, this is a journal for medical providers... It begs the question to the reader (typically doctors, NP, and PAs), "which option will my patients be more compliant, taking medication or going to another appointment for therapy?" Or, given the similar outcome and no significant negative side effects "which would be easier?"
What all this means to me...
The types of people in the experiment groups are similar to what I see in practice. However, the treatment decisions or options were not.
Obviously, every patient's needs are different. What works for you may not work for someone else. This is especially true of treating neck and back pain. If we were studying which antibiotic is best for an infection, we're not too concerned about a patients stress level, physical fitness, or sleeping habits. The drug kills the bug or it doesn't...
Neck and back pain are different than other health problems. Even more complicated, there are different types of neck and back pain. Treatment outcomes can depend on a variety of factors:
A successful treatment plan will take all areas of health in to consideration. While it may seem useful to separate people into groups to test what works, treating individuals is not that clean and simple. Treatment and recovery will have ups and downs. What you need for pain management and therapy on week one, is not going to be the same on week 3 or 4. Not to mention that we don't live in a protective bubble and flare-ups will happen.
What about treatment?
It's definitely not 12 weeks of medication...
Seriously... Take just take medication (including pain killers) for up to 12 weeks? While it's my personal observation, I haven't come across many patients who rather take just take medication when given the option. I'd say most would say they'd rather fix their pain rather than manage it or cover it up. And, if you look at patient satisfaction reports and other studies, they really don't help that much with pain or outcome.
Now, if there is an inflammatory component to your neck pain, then anti-inflammatory medication can be helpful in the short term. The "big however" is, the inflammatory process doesn't go on for 3 months. It's a pretty organized process that has specific steps along the way. Too much or too little inflammation is a disease process and needs to be treated in a different way. Taking anti-inflammatory medication or a cortisone injection is not like using sunscreen... It doesn't exactly "wear-off." And, you can't take it in preparation as a "just in-case my neck hurts while playing tennis." It just doesn't work that way!
What type of neck pain is it?
Successful treatment requires understanding your pain. And in my opinion, there is no such thing as non-specific neck pain. When we ask the right questions and examine with a critical eye, uncovering what is causing your pain becomes knowable. To get started, I like to classify neck pain in to 3 groups; Mechanical, Inflammatory, and the sinister.
Let's get the sinister out of the way... This is the scary stuff! Cancer, infection, etc. I'm not going to spend much time here because it's rare. Neck pain as the first symptom is rare. I've been doing this for over 15 years in Charlotte, treated thousands of patients, and I've had only one case where neck pain was the primary symptom of cancer. Even then, the patient's history had red flags telling me something else was going on. It can happen, but it's just not common.
The inflammation problem... If you had an injury like whiplash, or sprained a ligament, or did something to cause a tendonitis, then most likely there's some inflammation going on. This is a well organized response to injury with specific and identifiable steps. This type of pain doesn't get better or worse depending on activity. It kind of hurst all the time and depending on the injury, cause muscle spasm. The good thing is that it is typically short lived and responds well to anti-inflammatory therapy and treatment.
Mechanical neck pain... Most neck pain falls into this category. This type of pain typically follows a pattern. It will have good days and bad days. The pain will increase or decrease depending on your activity or certain movements. It's that time you "just woke up with it..." and is very painful and stiff. We call it mechanical because it's associated with a movement, posture, or your environment. It's neck stiffness after a long day of tennis that won't go away with ibuprofen. It's neck and shoulder pain after sitting at your desk all day. Basically, you've done something to mechanically irritate the joints and tissues in your neck. Examples include; a disc bulge, osteoarthritis, a pinched nerve, or stiff joints.
So... what's causing my neck pain?
While the paper kind of indirectly said that any treatment option for neck pain will produce a similar outcome, It didn't state what kind of neck pain the patients were experiencing. If I had to take a wild guess, I'd predict that the majority of the cases in the study were the mechanical type.
The problem is that under the mechanical neck pain classification, there are many sub groups and differential diagnosis. Meaning, your neck pain is not the same as your neighbor's neck pain... If someone has a disc bulge, they most likely won't respond as well facet syndrome. It's a round hole and a square peg problem.
What is causing your neck pain and what is the best treatment for you is a smaller target to hit than what the study illustrates. It confirms my opinion that all patients need a proper mechanical evaluation to categorize the type of pain they are experiencing. This takes a little time, good listening, and a thorough exam. I think most pain is knowable and can be improved, if not resolved, when a diagnosis and treatment plan are lined up!
So with all that said, I still think I'm on the right path to how I evaluate and treat my patients. This isn't a bragging point or a pat on my back, it's a simple illustration of how messy things can when trying to sort out the signal from all the noise. Unfortunately, healthcare for neck and back pain is not right all the time and definitely not strait forward. Healthcare research in general is messy, nuanced, and complicated. But at the individual and personal level, powered with a good system, we can get some pretty clear answers.
M Schuster, DC