Every so often a study comes along that you know is going to garner loads of attention and be cited by many for years to come. This month’s issue of Spine includes just such a study. Walker et al. published their work entitled, "The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain." This well designed study compared a group of patients receiving impairment-based manual physical therapy and exercise (MTE) to a group receiving a minimal intervention consisting of sub-therapeutic ultrasound,advice and range of motion exercise (MIN).
The researchers included some important key design features in the study that help make it very generalizable to practice. First, the allowed for subjects to present with or without upper extremity symptoms while still falling under the umbrella of "mechanical neck pain." This was controlled by excluding those subjects with more than 2 neurological signs on the same nerve root level. Secondly, the authors limited their intervention period to 6 sessions in an attempt to replicate "realistic reimbursable practice patterns."
The intervention delivered to the MTE group consisted of an impairment-based evaluation and treatment, a framework where the clinician carefully examines the patient and employs manual therapy techniques alongside continual reassessment to address a prioritized list of patient impairments. Both thrust and non-thrust mobilization techniques were employed followed by a standardized home exercise program. Therapists were not limited in terms of technique selection or body region to treat, and could also prescribe additional exercises to reinforce the manual techniques performed.
In short, the MTE group achieved superior outcomes across the entire study. Here are the key points as summarized in the paper:
● "Manual physical therapy and exercise consisted of impairment-based
manual interventions and reinforcing exercises directed to the
cervico-thoracic spine and ribs. Subtherapeutic ultrasound provided by physical therapists was added to a minimal intervention approach of education, motion exercise, and medications to maintain patient expectations for physical therapy care and symptom improvement.
● Manual physical therapy and exercise was significantly more effective
in reducing neck pain and disability, and increasing patient-perceived
improvements during short- and long-term follow-ups.
● Statistical and clinical improvement in upper extremity pain scores was demonstrated at all follow- up periods for patients receiving manual physical therapy and exercise.
● Treatment success rates, as determined by those patients achieving a
large improvement in symptoms,were significantly greater in the manual
physical therapy and exercise group at all follow-up periods.
● Manual physical therapy and exercise is a safe and effective treatment approach for patients with mechanical neck pain, with or without unilateral upper extremity symptoms."
This study joins others showing similar results to provide broad support for manual physical therapy for patients with mechanical neck pain. The decreased healthcare utilization rate for the MTE group compared to the MIN group was promising in that the MIN group sought additional care twice as often as the MTE group. In fact, those versed in evidence-based lingo will take note of the number needed to treat reported in this study: to achieve a benefit in 1 patient, 4 will need to be treated. A very strong number!
Congratulations to all the authors for a nice study that will provide support for the physical therapy profession, at a time when it is desperately needed.
ERIC
Michael J. Walker, Robert E. Boyles, Brian A. Young, Joseph B. Strunce, Matthew B. Garber, Julie M. Whitman, Gail Deyle, Robert S. Wainner (2008). The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain Spine, 33 (22), 2371-2378 DOI: 10.1097/BRS.0b013e318183391e
