SMT, Meds and Exercise for Neck Pain

Study Title: Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial
Authors: G. Bronfort, R. Evans, A. Anderson, K. Svendson, Y. Bracha, R. Grimm
Journal: Annals of Internal Medicine
Date: 2012
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My thoughts

• First of all, seeing this study capture the attention of many manual and rehabilitation therapists through the power of the internet reminded me of the old "Start the Car" ikea commercial.
• As a chiropractor that highly values exercise and rehabilitation, most would assume that I too would take this paper, "start the car", and run away with it. Unfortunately, I wanted to read the actual paper and see what all the hype was about beyond the good publicity from the New York Times.
• There's no question that I strongly believe manipulation and exercise may be better alternatives to medication in some if not many "pain" presentations, however, overtime I have learned to become more attached to patient-specific care more than anything else. Patient-specific care may indeed call for meds, manipulation and exercise - but patient-specific care may also call for reassurance, education, and / or soft tissue therapy.
• Now having read the actual study, the authors did do a relatively good job to prescribe individually based exercises but I do think they could have been more thorough. Gentle stretching and scapular retraction exercises, as well as neck and possibly (although not convincing in this paper) thoracic manipulations don't cut it when it comes to sending a message that SMT and exercise are better than meds. I understand that this is a research paper so I will accept some limitations in the study.
• While there was significant difference in follow up at 6 months, no significant differences were found at the 1 year mark of follow up when compared to baseline. To me, this likely indicates symptomatic relief or treating the DP (which I think is ok)...but what about the root cause? And what about integrated care? Because how often do you just manipulate or just rehab? I know quite well many of you who read this blog also combine the two. But you probably combine other therapeutic approaches as well. What I don't want to see is manipulating people's necks for the simple reason that this paper said it was more beneficial. If it is indicated, and the patient consents, then by all means. But if not, don't "start the car". We need to be more precise and we need to be accountable.
• Again, it is a research study and I get that we can't control for everything in research but I do think we can be a little more responsible when drinking the kool-aid. And responsibility means taking an objective, rather than emotional opinion...especially on social media. So please feel free to advocate that SMT and Exercise may sometimes be better a alternative than medication for neck pain (and that meds are often unnecessary), but please also recognize that generalizing the study's results to all of your patients is an act that is no different than advocating for meds alone.

Bronfort, G et al. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine, vol 156; 1-10....