Chiropractic and Exercise for Seniors with Chronic Neck Pain
Summary provided by Dean L. Smith, D.C., Ph.D.
The last On Target article I wrote outlined the current chiropractic guidelines for neck pain (NP). Neck pain prevalence estimates in adults range from 30% to 50%. In those individuals aged 70 years or more, 20% experience NP at least once a month. In the elderly population, NP is associated with other health complaints and poorer self-rated health. Because of the quick growth of this segment of the population, the socioeconomic and public health consequences of NP are significant. It has been recommended that commonly used pain medications should be lessened in elderly patients because of the risk of drug interaction and associated comorbidities. So, there is a need for safe and cost-effective approaches to managing NP conditions without drugs, while also improving the general health and quality of life amongst the elderly.
Treatment modalities typically used by doctors of chiropractic (DCs) to care for patients with neck pain include spinal manipulation, mobilization, device-assisted spinal manipulation, education about modifiable lifestyle factors, physical therapy modalities, heat/ice, massage, soft tissue therapies such as trigger point therapy, and strengthening and stretching exercises.
Current chiropractic guidelines for treatment of neck pain indicate that cervical manipulation, mobilization, manual therapy, exercise, and massage can be recommended for the chiropractic treatment of nonspecific, mechanical neck pain. The strongest recommendations are usually made for spinal manipulation in combination with another intervention (usually exercise and/or patient education). However, most of the studies that have investigated chiropractic treatment of neck pain have focused on younger adults rather than seniors. So, the authors of this study sought to determine the relative short- and long-term effectiveness of spinal manipulative therapy with home exercise (SMT with home exercise) for seniors with neck pain. They did so by comparing SMT plus exercise against supervised rehabilitative exercise and home exercise (supervised plus home exercise), and home exercise alone for patients 65 years and older with NP by the use of change in average pain during the past week as the primary outcome.
Individuals 65 years of age or older with a primary complaint of mechanical neck pain, rated ≥ 3 (0–10) for 12 weeks or longer in duration. Patients were randomly allocated to each group. All participants in the study received 12 weeks of care. A total of 80 people were in the SMT and home exercise group, 82 in the SRE and home exercise group (supervised rehabilitative exercise), and 79 in the home exercise (HE) only group. Home exercise consisted of four, 45-60 minute sessions provided by chiropractors or exercise therapists. Exercises were prescribed to improve flexibility, balance, coordination and strength/endurance. SMT (with home exercise) was provided by chiropractors. SMT using diversified technique was aimed at inducing joint motion. The number and frequency of treatments was determined by the individual chiropractor with a maximum of 20 visits allowed per patient. SRE plus home exercise consisted of 20, one-hour exercise sessions supervised by exercise therapists. Supervised session expanded on the home program with supplementary exercises and progressions to challenge neck and upper-torso strength and endurance, as well as balance, to participant tolerance.
Self-reported outcomes were collected at baseline, 4, 12, 26 and 52 weeks after randomization. The primary outcome measure was average level of NP over the previous week using a numerical rating scale (0-10). Self-reported secondary measures included neck disability, general health, satisfaction, medication use. In addition, biomechanical outcomes, including cervical motion, strength and endurance, as well as hand-grip strength and ‘‘Timed Up-and-Go’’ tests were collected at baseline and week 12.
• After 12 weeks of treatment, the SMT with home exercise group demonstrated a 10% greater decrease in pain compared with the HE-alone group, and 5% change over supervised plus home exercise
• Compared with the HE group, both combination groups reported greater improvement at week 12 and more satisfaction at all time points
• Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term
• No serious adverse events were observed as a result of the study treatments
• The average number of chiropractic visits was 15.1
• The average number of supervised exercise sessions was 16.6
• Nonserious, expected adverse events were frequently reported in all three treatment groups (56% in the SMT with home exercise group; 90% in the supervised plus home exercise group; 58% in the home exercise–alone group)
• There were no significant between-group differences in pain during post-treatment follow-up at weeks 26 and 52
• There were no significant between-group differences in biomechanical outcomes
• SMT with home exercise resulted in greater decreases in pain after 12 weeks of treatment compared with both the supervised plus home exercise and the home exercise–alone groups
• Supervised exercise sessions appear to add little to home exercise alone
• There were no long-term differences in pain between groups
Reference: Maiers M, Bronfort G, Evans R, Hartvigsen J, Svendsen K, Bracha Y, Schulz C, Schulz K, Grimm R. Spinal manipulative therapy and exercise for seniors with chronic neck pain. Spine J. 2013 Nov 10.