Effectiveness of Manual Therapy (Manipulation), Physiotherapy and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints

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The following 3 studies come from the Netherlands and compare the effectiveness of manual therapy (manipulation), physiotherapy and treatment by general medical practitioners for nonspecific back and neck complaints.

• The Effectiveness of Manual Therapy, Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints
• Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up
• Randomized Clinical Trial of Manual Therapy and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures

The Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints

Authors Abstract

In a randomized trial, the effectiveness of manual therapy (manipulative techniques), physiotherapy, continued treatment by the general practitioner, and placebo therapy (detuned ultrasound and detuned short-wave diathermy) were compared for patients (n=256) with nonspecific back and neck complaints lasting for at least 6 weeks. The principle outcome measures were severity of the main complaint, global perceived effect, pain, and functional status. These are presented for 3, 6 and 12 weeks follow-up. Both physiotherapy and manual therapy (manipulation) decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner.

1. Spine 1992; 17:28-35. From the University of Limburg, Maastricht, the Netherlands.

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Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up

Editors Summary

The third trial of the series evaluating the effectiveness of manual therapy (manipulation) and physiotherapy utilized the same treatments and outcome measures as the prior studies, but chose changes in severity of the main complaint, limitation of physical functioning, and global perceived effect as the main outcome measures.

Results for this trial revealed an interesting factor: many patients in the GP (general medical practitioner treatment group) and placebo groups changed from their assigned treatment to another treatment during the one year follow-up. This clearly indicates the superiority of manual therapy (manipulation) and physiotherapy over the other two treatments, and the willingness of patients to turn to other treatments when their assigned treatment is not effective enough.

In terms of the change of the main complaint, the manual therapy (manipulation) group showed the largest improvement after 12 months follow up. Manual therapy also gave larger improvements in physical functioning than the physiotherapy group at all follow up measurements.

The global perceived effect after 6 and 12 months follow up was similar for both treatments. Thus, it can be concluded that manual therapy (manipulation) and physiotherapy are superior to GP and placebo treatment, and manual therapy (manipulation) is slightly better than physiotherapy after 12 months.

1. British Medical Journal 1992; 304:601-605. From the University of Limburg, Maastricht, the Netherlands.

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Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures

Editors Summary

This final trial utilized the same treatments as well as the same three outcome measures as the third study, but also assessed the relationship between the outcome measures via a subgroup analysis. The subgroup analysis was confined to manual therapy (manipulation) and physiotherapy only, focusing on specific subgroups that showed benefit, particularly from a certain therapy. The analysis was further confined to subgroups based on six predefined baseline characteristics only:

1. duration of the present episode (<1, >1 or =1 yr);
2. age (younger than 40 yr, 40 yr old and older than 40 yr);
3. localization of the complaints (back only, neck only, back and neck);
4. recruitment status (GP, advertisement);
5. severity of complaint (severity < 7 pts, severity 7 or >);
6. appropriateness of allocated treatment according to treating therapist (suitable/not suitable)

Results showed a greater improvement in the main complaint with manual therapy (manipulation) than with physiotherapy for patients with chronic conditions (duration complaint of 1 yr or more). Improvement in the main complaint was also larger with manual therapy (manipulation) than with physiotherapy for patients younger than 40 years (both were measured after 12 months follow up). Labeling of patients as "suitable" or "not suitable" for treatment with manual therapy (manipulation) did not predict differences in outcomes. There was a moderate to strong correlation between the three outcome measures, although a considerable number of patients gave a relatively low score for perceived effect while the research assistant gave a high improvement score for the main complaint and physical functioning. This finding indicates that the outcome measures represent different features of progress in back and neck patients, and that if research interest lies in the opinion of the patient and the observer, it will not suffice to measure just one of the outcome measures.

In conclusion, the subgroup analysis suggests better results of manual therapy (manipulation) compared to physiotherapy in chronic patients and in patients younger than 40 years. Future research must investigate the explorative findings of these subgroup analyses. Of particular interest may be the strong relationship between improvement of physical functioning and improvement of main complaint which can also indicate that the severity of the main complaint of a patient concurs with the patient's limitation in physical functioning.

1. Journal of Manipulative and Physiological Therapeutics 1993; 16:211-219. From the Institute for Research in Extra mural Medicine, Free University, Amsterdam, the Netherlands.

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