Acute neck pain (ANP) is a common condition that has been shown in some studies to affect over 40% of the population. Accordingly, many Chiropractors treat patients with this condition, even though there is little research evidence to support it. It should be noted, however, that no form of treatment has been shown to be clearly effective for this condition and, in general, the condition has not been studied very well. In fact, a systematic review by Vernon et al concluded that there were very few high-quality clinical trials for any conservative treatments that are commonly used to treat ANP.
There are a variety of reasons why so little research has been carried out on ANP, but mainly it is because acute patients are often in the subacute or chronic stage by the time they are included in a clinical study. Because of this methodology problem, the current study used a practice-based research (PBR) model in order to shorten the delay between patient recruitment and the beginning of chiropractic care. Hence, ANP patients would be much more likely to be in the acute stage when they entered the study.
The purpose of this study was primarily to establish a chiropractic PBR network and to determine the feasibility of using it to investigate chiropractic care for patients with ANP. The current paper mainly reports the study's treatment outcomes, including pain, disability, and patient satisfaction with the care they received.
Pertinent Results:
? A total of 99 ANP patients were included in the study; 34 (37.8%) were men and 56 (62.2%) were women; the mean age of the group was 41.6 years.
? Ten chiropractors actually contributed data, despite the fact that 28 chiropractors agreed to participate. The mean number of cases contributed by the chiropractors was 9.2, but the range was from 1 to 54, which was rather wide. Four of the chiropractors were very active at recruiting subjects, contributing 89% of the total data on the patients.
? Progressive improvement of all outcome measures was reported at each of the data collection points, except for a slight worsening of the Characteristic Pain Intensity (CPI) score at week 8.
? Sixty-two (68.9%) of the patients completed the chiropractic care that was initially recommended to them.
? Only 30% of the ANP episodes were caused by trauma, which were primarily (70% of the cases) related to injuries sustained in automobile collisions.
? A prior history of neck pain was reported by 54% of the patients and secondary conditions were reported by 62% of them, mainly involving back pain, headache, and/or an upper extremity problem.
? Very few of the patients were referred to other healthcare providers: 4 to medical doctors and 2 to massage therapists.
? Patients were overall highly satisfied with their chiropractic care, with 47 out of 49 (96%) of them indicating that they were either "Very satisfied" or "Satisfied" and 98% of them indicating that they "Definitely would" or were "Very likely" to choose chiropractic care again if they ever noticed a similar problem again. Patient satisfaction responses were provided by 49 of the patients.
The chiropractors reported that 7 patients had transient minor adverse effects to chiropractic care; 7.8% of the patients where data was available. Symptoms included:
? increased neck pain in 5 patients (2 were very mild, 2 mild, and 1 moderate)
? dizziness in 1 (moderate)
? the "Other" category was selected in 1 case (mild)
Most of the patients (63) received physical therapy modalities in addition to manipulation, including ultrasound, massage (most commonly used), heat, electrical stimulation, and cryotherapy. Soft tissue techniques (e.g., trigger point therapy) were also commonly used. Further, advice about activities of daily living was given to the majority of patients, especially exercise recommendations.
1,235 distinct cervical spine manipulations were performed, which were mostly carried out with the patient in a supine position. 74% of the manipulations were applied below the level of C4, most commonly at the level of C6.
Clinical Application & Conclusions:
Patient improvements were observed when comparing sequential evaluations on all outcomes and nearly all of the patients who responded to the satisfaction questionnaire were very satisfied or satisfied with their chiropractic care. These results compare favorably with the small number of other studies that have looked at chiropractic care for ANP.
This study's main conclusion was that the practice-based methodology that was utilized is a feasible way to investigate the management of ANP by chiropractors. That being said, it should be noted that it was very difficult to obtain follow-through from many of the doctors. Recruiting the chiropractors was fairly easy; a number of them expressed interest in participating, enrolled in the practice-based network, and promised to recruit patients. However, most did not even begin to fulfill their obligation. Only 10 out of 28 chiropractors who initially agreed to participate actually collected and supplied data and most of the data came from just 4 of the chiropractors. As the primary investigator of this study, I urge readers who have the occasion to participate in PBR to do everything in their power to cooperate with the investigators. Many investigators shy away from PBR because of its known difficulties, even though we as a profession could feasibly and economically multiply our research efforts if more PBR studies were carried out.
It is interesting that the rate of adverse effects in this study was only 7.8% in patients where data was available. In contrast, other studies have reported rates up to 6 times higher (2-4). Perhaps some of this difference was due to the way the data were collected. In the current study, the chiropractors reported adverse effects that they observed in their patients, whereas the patients completed questionnaires in the other studies. There are problems with both methods. For instance, the patients may check off a number of selections in a questionnaire when presented with a laundry list of symptoms. The power of suggestion (response bias) may prompt them to list adverse effects that they wouldn't otherwise think of. An example is fatigue following manipulation, which is a question asked in some of the above mentioned studies. I have through the years had a number of patients tell me that they felt very relaxed and were able to sleep soundly for the first time in years after their first adjustment. These patients considered these "adverse effects" to be very positive, but they would appear to be negative effects in one of the studies because the patient would have selected the "fatigued" response.
The chiropractor conveying the patient's adverse effects as was done in the current study may also lead to problems; for instance, the patient may not tell the doctor about minor symptoms, the patient may leave care (possibly related to a severe reaction to treatment), the chiropractor may think that the adverse effect was not related to treatment, etc. The best way to query patients about adverse effects to chiropractic care has not, in my opinion, been devised yet and more studies are certainly needed.
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