Chiropractic Spinal Manipulative Therapy for Acute Neck Pain

Chiropractic Spinal Manipulative Therapy for Acute Neck Pain: a 4- Arm Clinical Placebo Randomized Controlled Trial

Acute neck is very common in the general population and often causes disability over shorter or longer time periods. Unfortunately, the efficacy of chiropractic spinal manipulative therapy (CSMT) and the efficacy of Non-steroidal Anti-inflammatory Drugs (NSAIDs) on acute neck pain is unknown. This 4-arm randomized controlled trial (RCT) will likely provide evidence for the efficacy of CSMT as well as NSAIDs. The applied methodology of the study will aim towards the highest research standards possible for manual-therapy RCTs, thus avoiding typical methodological shortcomings from previous manual-therapy studies. Our aim is to establish evidence-based knowledge on the efficacy of CSMT and NSAIDs in the treatment of acute neck pain.

Study Overview

• Status: Recruiting
• Conditions: Acute Neck Pain
• Intervention / Treatment: Other: Chiropractic spinal manipulative therapy (CSMT); Other: CSMT sham manipulation; Drug: Ibuprofen; Drug: Placebo medication

Detailed Description

The Global Burden of Disease study ranks musculoskeletal neck pain as the most common disability worldwide. This study will highlight and validate CSMT for acute neck pain, compared to sham manipulation, ibuprofen and placebo medication. NSAIDs are the most frequently prescribed medications by GPs worldwide and are widely used for patients with back pain. However, evidence-based data are missing for acute neck pain patients treated with NSAIDs while existing evidence for CSMT for acute neck pain are limited by serious methodological shortcomings.

The 4-arm placebo-controlled RCT will assess the efficacy in the following four treatment groups:

1. Chiropractic spinal manipulative therapy (CSMT)
2. CSMT sham manipulation (placebo)
3. Ibuprofen (NSAID)
4. Placebo medication

We intend to invite 40 recruiting chiropractors from larger Norwegian cities, distributed by gender and geography. The study participants presenting to each chiropractor will be block-randomized equally into one of four study groups based on a computer-generated algorithm. Each chiropractor will include 16 participants, four into each arm. A total of 320 participants will be enrolled in the RCT, within 12 months. Participants randomized into the chiropractic treatment groups will receive 5 interventions over 12 days, i.e., CSMT or CSMT sham manipulation; while the pharmacological groups will receive 600mg ibuprofen or placebo administered 3 times daily for 12 days.

• Study Type: Interventional
• Enrollment (Estimated): 320
• Phase: Phase 4

Contacts and Locations

• Study Contact: Name: Anna J. Allen-Unhammer, PhD student; Phone Number: +4792870783; Email: a.j.allen-unhammer@medisin.uio.no
• Study Contact Backup: Name: Michael B. Russell, Professor; Phone Number: +4540171553; Email: m.b.russell@medisin.uio.no

Study Locations

• Norway
  • Oslo, Norway, 1478
    • Recruiting
    • Michael B. Russell
    • Contact: Michael B. Russell, Professor; Phone Number: +4540171553; Email: m.b.russell@medisin.uio.no
    • Principal Investigator: Aleksander Chaibi, PhD
    • Sub-Investigator: Anna J. Allen-Unhammer, PhD student

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 59 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion criteria

1. Eligible participants are between the age of 18 and 59 years old
2. Acute non-radicular neck pain, i.e., grade 1 or 2 according to the classification by the Bone and Joint Decade 2000-2010 Task Force on neck pain
3. Onset of the present episode ≤2 weeks prior to the 1st chiropractic visit
4. Moderate, severe or very severe pain intensity, i.e., ≥4, on a numeric rating scale (NRS) 0-10
5. Pain free for at least four consecutive weeks prior to the present pain episode
6. Not treated by a chiropractor during the past 3 months
7. Participants must accept not to seek other manual and/or pharmacological treatments for their acute neck pain during the intervention period
8. Non-pregnant women. Women in doubt shall have a negative fertility test before inclusion

Exclusion criteria

1. Contraindication to ibuprofen

   1. active peptic ulcer
   2. gastrointestinal bleeding
   3. previous repeated episode (≥2 detected events) with peptic ulcer or gastrointestinal bleeding
   4. previous gastrointestinal bleeding or ulcer using NSAIDs
   5. hypersensitivity to ibuprofen
   6. asthma induced by acetylsalicylic acid or other NSAIDs
   7. urticarial
   8. rhinitis
   9. severe heart failure (NYHA class IV)
   10. renal failure (glomerulus infusion <30 ml/min)
2. Taken pain- and/or anti-inflammatory medicine during the past 24 hours? (Patients that have taken acute pain- and/or anti-inflammatory medicine, including ibuprofen, can be included if they come back after 24 hours without having taken the medicine where they then fill out questionnaires and are randomized at the clinic)
3. On prescribed antidepressant
4. Major psychiatric disorder
5. Pregnancy or intention to be pregnant
6. Contraindication to SMT
7. Signs of spinal radiculopathy including progressive neurological deficit
8. Upper cervical spine instability (positive Sharp-Purser test)
9. Previous fracture in the cervical and/or thoracic spine
10. Previous cervical spine surgery
11. Recent (<6 months) severe physical trauma to the head, neck or thoracic spine within the previous 6 months
12. Concomitant low back pain with moderate, severe or very severe pain intensity (≥4 on a NRS)
13. Current chronic pain (defined as ≥3 months duration)
14. Rheumatoid arthritis
15. Recent (<2 weeks) acute respiratory infection with fever
16. Any presence of ischemic symptoms upon examination
17. Horner's syndrome
18. Medical history of arterial anomalies
19. History of connective tissue disorder
20. Familial history of cervical artery dissection
21. Other vascular disorders
22. Inability to understand instructions given in the Norwegian language
23. Inability to fill out digital questionnaires
24. Other reasons to exclude the patient as deemed necessary by the chiropractor

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Chiropractic Spinal Manipulative Therapy (CSMT); A specific contact, high-velocity, low-amplitude, spinal thrust manipulation directed to spinal biomechanical dysfunction in the cervical and/or thoracic spinal column, as diagnosed by standard chiropractic tests, in accordance with their clinical judgment.	Other: Chiropractic spinal manipulative therapy (CSMT); See study arm.
Sham Comparator: CSMT sham manipulation; A broad non-specific contact, low-velocity, low-amplitude sham push manoeuvre in a non-therapeutic directional line.	Other: CSMT sham manipulation; See study arm.
Active Comparator: Ibuprofen; Ibuprofen 600mg, 3 times daily for 12 days.	Drug: Ibuprofen; See study arm.; Other Names: Orifarm
Sham Comparator: Placebo medication; Placebo medication, x 3 times daily for 12 days.	Drug: Placebo medication; See study arm.; Other Names: Placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean pain intensity change	Numerical Rating Scale (NRS) 0-10	From Day-0 to Day-14 between CSMT and sham CSMT, CSMT and ibuprofen, and CSMT and placebo medicine.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean pain intensity change	Numerical Rating Scale (NRS) 0-10	From Day-0 to Day-14. Comparison between ibuprofen and placebo medicine.
Mean pain intensity change	Numerical Rating Scale (NRS) 0-10	From Day-0 to Day 2-13 in the treatment period, and from Day-0 to Day 7, 28, 56, 84 and 168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Mean duration (hours) of neck pain change	Hours (0-24)	From Day-0 to Day 2-13 and 14; From Day-0 to Day 7, 28, 56, 84 and 168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Mean number of days with neck pain per week	Weekly number of days	From the treatment period (14 days) to the periods; day 1-7, 22-28, 50-56, 78-84 and 162-168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Proportions of participants with mean daily pain intensity reduction of ≥50%, ≥75% and 100%	Numerical Rating Scale (NRS) 0-10	From Day-0 to Day 2-13 and 14, and from Day-0 to Day 7, 28, 56, 84 and 168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Proportions of participants with mean duration (hours) reduction of ≥50%, ≥75% and 100%	Hours 0-24	From Day-0 to Day 2-13 and 14, and from Day-0 to Day 7, 28, 56, 84 and 168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Proportions of participants with mean reduction of number of days with neck pain per week of ≥50%, ≥75% and 100%	Weekly number of days	From the treatment period (14 days), to the periods: Day 1-7, 22-28, 50-56, 78-84 and 162-168 post-treatment, respectively, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine
Improvement in Research and development 12 (RAND-12) score (12 questions each with 5 possible answers)	RAND-12 Term Short Form Health Survey (0 to 100, with higher scores indicating better physical and mental health functioning)	From Day-0 to Day-14, Day-84 and 168 post-treatment, respectively, comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Improvement in Neck Disability Index score (10 questions each with 6 possible answers)	Neck Disability Index (0-100, where 0 = no disability and 100 = complete disability)	From Day-0 to Day-14, Day-84 and 168 post-treatment, respectively, comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Adverse event (AE) analysis	Within and between group adverse events analysis	Daily during intervention period (day 2-13). AE analysis of CSMT, sham CSMT, ibuprofen, and placebo medicine, and comparison between CSMT and sham CSMT, CSMT and ibuprofen, CSMT and placebo medicine, ibuprofen and placebo medicine.
Analysis of patients' blinding (Manual therapy)	Numerical rating scale (NRS) 0-10 in relation to receiving real CSMT (0 absolutely unsure and 10 absolutely sure that real CSMT was received), irrespective of whether the patient received sham or real CSMT	Daily during intervention period (Day-0, Day 2-13). Analysis of CSMT and sham CSMT, and comparison between CSMT and sham CSMT.
Analysis of patients' blinding (Medicine)	Numerical rating scale (NRS) 0-10 in relation to receiving ibuprofen (0 absolutely unsure and 10 absolutely sure that ibuprofen was received), irrespective of whether the patient received ibuprofen or placebo medicine	Daily during intervention period (Day-0, Day 2-13). Analysis of ibuprofen and placebo medicine, and comparison between ibuprofen and placebo medicine.
Patients' and chiropractors' expectations to treatment efficacy	Numerical rating scale (NRS) 0-10 (0 no expectation at all and 10 the highest possible expectation to treatment efficacy)	Day-0
Analysis of patients' satisfaction to treatment efficacy	Numerical rating scale (NRS) 0-10 (0 no satisfaction at all, and 10 the highest possible satisfaction)	Day-14 of the intervention period

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Sick leave	Number of days and grade of sick leave	Mean number of days at Day-0 compared to Week-12 and Week-24 post-treatment.
Validation of user ID-number	Number and proportions of incorrect typing of ID-numbers during digital questionnaire completion.	All digital questionnaires from Day-0 to study completion, that is to 24-weeks follow-up.
Facilitatory/inhibitory factors/dilemmas affecting recruitment Qualitative focus group interviews to explore facilitatory/inhibitory factors and possible dilemmas experienced by chiropractor investigators.	Qualitative focus group interviews with all chiropractor investigators.	Up to 6 months

Collaborators and Investigators

• Sponsor: University Hospital, Akershus
• Collaborators: University of Oslo; The Dam Foundation
• Investigators: Study Director: Michael B. Russell, Professor, Division for Research and Innovation, Akershus University Hospital, Norway; Principal Investigator: Aleksander Chaibi, PhD, Institute for Health and Society, Faculty of Medicine, University of Oslo, Norway

Publications and helpful links

General Publications

• Chaibi A, Stavem K, Russell MB. Spinal Manipulative Therapy for Acute Neck Pain: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. J Clin Med. 2021 Oct 28;10(21):5011. doi: 10.3390/jcm10215011.
• Chaibi A, Saltyte Benth J, Bjorn Russell M. Validation of Placebo in a Manual Therapy Randomized Controlled Trial. Sci Rep. 2015 Jul 6;5:11774. doi: 10.1038/srep11774.

Helpful Links

• Background and rationale for the RCT
• CSMT Sham manipulation procedure

Study record dates

Study Major Dates

• Study Start (Actual): May 23, 2022
• Primary Completion (Estimated): December 31, 2023
• Study Completion (Estimated): August 1, 2024

Study Registration Dates

• First Submitted: May 5, 2022
• First Submitted That Met QC Criteria: May 11, 2022
• First Posted (Actual): May 13, 2022

Study Record Updates

• Last Update Posted (Actual): August 8, 2023
• Last Update Submitted That Met QC Criteria: August 4, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Keywords: Clinical trial; Randomized controlled trial (RCT); Acute neck pain
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Neck Pain; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Anti-Inflammatory Agents; Antirheumatic Agents; Cyclooxygenase Inhibitors; Ibuprofen
• Other Study ID Numbers: 28498; 2021-005483-21 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No