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Annals of Internal Medicine
Spinal Manipulation, Medication, or Home Exercise With Advice for
Acute and Subacute Neck Pain
A Randomized Trial

Gert Bronfort, DC, PhD; Roni Evans, DC, MS; Alfred V. Anderson, DC, MD; Kenneth H. Svendsen, MS; Yiscah Bracha, MS;
and Richard H. Grimm, MD, MPH, PhD

Background: Mechanical neck pain is a common condition that
adverse events. Blinded evaluation of neck motion was performed affects an estimated 70% of persons at some point in their lives.
Little research exists to guide the choice of therapy for acute andsubacute neck pain.
Results: For pain, SMT had a statistically significant advantage over
medication after 8, 12, 26, and 52 weeks (P Յ 0.010), and HEA
Objective: To determine the relative efficacy of spinal manipulation
was superior to medication at 26 weeks (P ϭ 0.02). No important therapy (SMT), medication, and home exercise with advice (HEA) differences in pain were found between SMT and HEA at any time for acute and subacute neck pain in both the short and long term.
point. Results for most of the secondary outcomes were similar tothose of the primary outcome.
Design: Randomized, controlled trial. (ClinicalTrials.gov registration
number: NCT00029770)
Limitations: Participants and providers could not be blinded. No
specific criteria for defining clinically important group differences
Setting: 1 university research center and 1 pain management clinic
were prespecified or available from the literature.
Conclusion: For participants with acute and subacute neck pain,
Participants: 272 persons aged 18 to 65 years who had nonspe-
SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in Intervention: 12 weeks of SMT, medication, or HEA.
similar outcomes at most time points.
Measurements: The primary outcome was participant-rated pain,
Primary Funding Source: National Center for Complementary and
measured at 2, 4, 8, 12, 26, and 52 weeks after randomization.
Alternative Medicine, National Institutes of Health.
Secondary measures were self-reported disability, global improve-ment, medication use, satisfaction, general health status (Short Ann Intern Med. 2012;156:1-10.
www.annals.org
Form-36 Health Survey physical and mental health scales), and For author affiliations, see end of text.
Neck pain is a prevalent condition that nearly three METHODS
quarters of persons experience at some point in their lives (1, 2). One of the most commonly reported The trial was conducted from 2001 to 2007 in Min- symptoms in primary care settings (3, 4), neck pain neapolis, Minnesota. Eligibility screening, randomization, results in millions of ambulatory health care visits each and short-term data collection occurred at a university- year and increasing health care costs (5– 8). Although it affiliated research center; long-term data collection took is not life-threatening, neck pain can have a negative place by mail. A university-affiliated outpatient clinic pro- effect on productivity and overall quality of life (1, vided SMT and instruction for home exercise. Medical treatment was provided at a pain management clinic. The Chiropractors, physical therapists, osteopaths, and institutional review boards of Northwestern Health Sci- other health care providers commonly apply spinal manip- ences University and Hennepin County Medical Center ulation, a manual therapy, for neck pain conditions (12),and home exercise programs and medications are alsowidely used (13). Recent Cochrane reviews (13, 14) report insufficient evidence to assess the effectiveness of com-monly used medications or home exercise programs for the treatment of acute neck pain. The evidence for spinal ma- Editors’ Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 nipulation is similarly limited, with only low-quality evi- Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . . 52 dence supporting its use for neck pain of short duration Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-30 Web-Only
Our goal was to test the hypothesis that spinal manip- ulation therapy (SMT) is more effective than medication or home exercise with advice (HEA) for acute and subacute 2012 American College of Physicians 1
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Original Research Conservative Interventions for Acute and Subacute Neck Pain off-site by the study statistician before enrollment and was concealed from the investigators, treatment providers, and Persons with acute or subacute neck pain often turn to research staff by using consecutively numbered, sealed, chiropractors and other practitioners of spinal manipulation opaque envelopes. As participants became eligible, enve- lopes were opened in consecutive order by a research staff Contribution
member in the presence of the participant.
The intervention protocol was tested in a pilot study This trial demonstrates that 12 weeks of spinal manipula- by our research team (19). Maximum treatment duration tion therapy (SMT) led to greater pain relief than medica-tion up to 1 year after treatment. However, trial partici- was 12 weeks. Treatment providers were trained in the pants had as much pain relief with home exercise with study intervention protocols and were required to docu- advice (HEA) as with SMT over the same period.
ment treatment activities in standardized clinical records,which were routinely monitored by research staff to ensure Participants were unblinded to interventions.
Implication
SMT Group
For relief of acute or subacute neck pain, SMT and HEA Six chiropractors with a minimum of 5 years’ experi- seemed to be similarly effective and both were more ence served as the primary providers of treatment. Visits lasted 15 to 20 minutes and included a brief history andexamination of the cervical and thoracic spine. The pri- mary focus of treatment was manipulation of areas of thespine with segmental hypomobility by using diversifiedtechniques, including low-amplitude spinal adjustments (a approved our study, and all participants gave written in- high-velocity type of joint thrust manipulation) and mobi- lization (a low-velocity type of joint oscillation) (20). The Participants
specific spinal level to be treated and the number of treat- Participants were recruited by using mailings targeted ment sessions over the 12 weeks was left to the discretion to persons with neck pain who were registered with Blue of the provider, based on manual palpation of the spine Cross/Blue Shield Minnesota and through newspaper and and associated musculature and the participant’s response radio advertisements. Interested persons were screened for to treatment (21). Adjunct therapy common to clinical eligibility at 2 baseline appointments by clinicians who practice included limited light soft-tissue massage, assisted were blinded to the randomization schedule. Inclusion cri- stretching, and hot and cold packs to facilitate the manip- teria were age 18 to 65 years; primary symptom of me- ulation treatment. Advice to stay active or modify activity chanical, nonspecific neck pain equivalent to grades I or II according to the Bone and Joint Decade 2000 –2010 TaskForce on Neck Pain and Its Associated Disorders classifi- Medication Group
cation (16, 17); current neck pain of 2 to 12 weeks’ dura- A licensed medical physician provided care to partici- tion; and a neck pain score of 3 or greater on a scale of 0 to pants, with the focus of treatment on prescription medica- 10. Participants were asked to refrain from seeking addi- tion. Visits lasted 15 to 20 minutes and included a brief tional treatment for neck pain from nonstudy health care history and examination. The first line of therapy was non- providers during the 12-week intervention.
steroidal anti-inflammatory drugs, acetaminophen, or both Exclusion criteria were cervical spine instability, frac- (22, 23). Participants who did not respond to or could not ture, neck pain referred from peripheral joints or viscera, tolerate first-line therapy received narcotic medications.
progressive neurologic deficits, existing cardiac disease re- Muscle relaxants were also used. Advice to stay active or quiring medical treatment, blood clotting disorders, diffuse modify activity was issued as needed. The choice of medi- idiopathic hyperostosis, inflammatory or destructive tissue cations and number of visits was made by the physician on changes of the cervical spine, infectious disease or other the basis of the participant’s history and response to severe disabling health problems, substance abuse, preg- nancy or breastfeeding, previous cervical spine surgery, andpending or current litigation. In addition, participants HEA Group
were excluded if they had received any of the study treat- Home exercise with advice was provided in two 1-hour sessions, 1 to 2 weeks apart, at the university- Randomization and Interventions
affiliated outpatient clinic. Six therapists provided instruc- Participants were randomly assigned at the second tion to participants. The primary focus was simple self- baseline appointment by using permutated blocks of dif- mobilization exercise (gentle controlled movement) of the ferent sizes (18). The randomization schedule was prepared neck and shoulder joints, including neck retraction, exten- 2 3 January 2012 Annals of Internal Medicine Volume 156 • Number 1 (Part 1)
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Conservative Interventions for Acute and Subacute Neck Pain Original Research Table 1. Baseline Demographic and Clinical Characteristics
Characteristic
SMT Group
Medication Group
HEA Group
Mean duration of neck pain (SD), wk Pain radiating to upper extremity, % Awake at night because of neck pain, % CES-D ϭ Center for Epidemiologic Studies Depression Scale; HEA ϭ home exercise with advice; SMT ϭ spinal manipulation therapy.
* On a scale of 0 (none of the time) to 5 (all of the time).
† For example, repetitive motion, stress, or sleep position.
‡ On a scale of 0 to 100.
§ On a scale of 1 (much better) to 5 (much worse).
the SMT group experienced reductions of pain of at least
50% (Table 3). Differences in participant-rated pain im-
Table 2. Details of Interventions
provement between the SMT and HEA groups weresmaller and not statistically significant. Differences be- Group and Characteristic
tween the HEA and medication groups were also not sta-tistically significant, although a higher absolute proportion SMT group
of the HEA group experienced reductions in pain of at least 75% at 12 weeks compared with the medication Specific aspects of intervention, n (%) Longer-term analyses showed similar findings. At 26 and 52 weeks, participant-rated pain improvement favored SMT over medication, but not SMT over HEA or HEA over medication, compared with baseline. A higher abso- lute proportion in the SMT group than in the medicationgroup experienced reductions of pain of at least 50% at 26 Medication group
but not 52 weeks. Those proportions did not differ at any time in comparisons of SMT and HEA, and a higher ab- Specific aspects of intervention, n (%) solute proportion in the HEA group than in the medica- NSAID, opioid analgesic, and muscle relaxant tion group experienced reductions of pain of at least 75% Adjustment for baseline imbalances in sex, cause of pain, and depression did not change the group differences HEA group
Secondary Outcomes
Specific aspects of intervention, n (%) Group differences in most secondary outcomes were similar to those of the primary outcomes (Appendix Ta-
bles 1 to 4, available at www.annals.org). Spinal manipu-
lation therapy was superior to medication at the end of treatment and during follow-up in terms of global im- ADL ϭ activity of daily living; HEA ϭ home exercise with advice; NSAID ϭ provement, participant satisfaction, and SF-36 –assessed nonsteroidal anti-inflammatory drug; SMT ϭ spinal manipulation therapy.
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Original Research Conservative Interventions for Acute and Subacute Neck Pain Figure. Study flow diagram.
First baseline evaluation to
assess eligibility (n = 504)
Excluded (n = 165)
Did not meet inclusion criteria: 126
Declined to participate: 35
Other: 4

Second baseline evaluation to
assess eligibility (n = 339)
Excluded (n = 67)
Did not meet inclusion criteria: 10
Declined to participate: 32
Other: 25

Random assignment (n = 272)
Allocated to SMT group (n = 91)
Allocated to medication group (n = 90)
Allocated to HEA group (n = 91)
Received therapy: 91
Received therapy: 84
Received therapy: 91
Did not receive therapy: 6
Declined to participate: 5
Family issues and side effect

concerns: 1
Intervention phase
Intervention phase
Intervention phase
Lost to follow-up (n = 3)
Lost to follow-up (n = 21)
Lost to follow-up (n = 13)
Week 12: 1
Week 12: 6
Week 12: 4
Discontinued therapy (n = 2)
Discontinued therapy (n = 3)
Discontinued therapy (n = 3)
No improvement: 1
Pregnant: 1
Declined to participate: 3
Declined to participate: 1
Declined to participate: 2
Postintervention phase
Postintervention phase
Postintervention phase
Lost to follow-up (n = 22)
Lost to follow-up (n = 21)
Lost to follow-up (n = 31)
Week 26: 10
Week 26: 7
Week 26: 12
Week 52: 12
Week 52: 14
Week 52: 19
Analyzed (n = 91)
Analyzed (n = 90)
Analyzed (n = 91)
Participants were lost to follow-up if they did not provide data at each time point. Patients who discontinued treatment had the opportunity to providefollow-up data. HEA ϭ home exercise with advice; SMT ϭ spinal manipulation therapy.
expectation of change in neck pain. Table 2 provides de-
We evaluated 504 persons for eligibility, of whom 272 were randomly assigned: 90 to the medication Primary Outcomes
group, 91 to the SMT group, and 91 to the HEA group.
Improvement in participant-rated pain significantly The Figure summarizes recruitment, participation, and
differed with SMT compared with medication at 12 weeks (0.94 greater reduction in pain [95% CI, 0.37 to 1.51]; Table 1 summarizes the demographic and clinical
P ϭ 0.001) and in longitudinal analyses that incorporated characteristics of the randomly assigned participants. Po- pain ratings every 2 weeks from baseline to 12 weeks (0.55 tentially important between-group differences were noted greater reduction in pain [CI, 0.10 to 1.00]; P ϭ 0.017).
for sex, duration of neck pain, pain during the night, and At 12 weeks, a significantly higher absolute proportion of 4 3 January 2012 Annals of Internal Medicine Volume 156 • Number 1 (Part 1)
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Conservative Interventions for Acute and Subacute Neck Pain Original Research Table 1. Baseline Demographic and Clinical Characteristics
Characteristic
SMT Group
Medication Group
HEA Group
Mean duration of neck pain (SD), wk Pain radiating to upper extremity, % Awake at night because of neck pain, % CES-D ϭ Center for Epidemiologic Studies Depression Scale; HEA ϭ home exercise with advice; SMT ϭ spinal manipulation therapy.
* On a scale of 0 (none of the time) to 5 (all of the time).
† For example, repetitive motion, stress, or sleep position.
‡ On a scale of 0 to 100.
§ On a scale of 1 (much better) to 5 (much worse).
the SMT group experienced reductions of pain of at least
50% (Table 3). Differences in participant-rated pain im-
Table 2. Details of Interventions
provement between the SMT and HEA groups weresmaller and not statistically significant. Differences be- Group and Characteristic
tween the HEA and medication groups were also not sta-tistically significant, although a higher absolute proportion SMT group
of the HEA group experienced reductions in pain of at least 75% at 12 weeks compared with the medication Specific aspects of intervention, n (%) Longer-term analyses showed similar findings. At 26 and 52 weeks, participant-rated pain improvement favored SMT over medication, but not SMT over HEA or HEA over medication, compared with baseline. A higher abso- lute proportion in the SMT group than in the medicationgroup experienced reductions of pain of at least 50% at 26 Medication group
but not 52 weeks. Those proportions did not differ at any time in comparisons of SMT and HEA, and a higher ab- Specific aspects of intervention, n (%) solute proportion in the HEA group than in the medica- NSAID, opioid analgesic, and muscle relaxant tion group experienced reductions of pain of at least 75% Adjustment for baseline imbalances in sex, cause of pain, and depression did not change the group differences HEA group
Secondary Outcomes
Specific aspects of intervention, n (%) Group differences in most secondary outcomes were similar to those of the primary outcomes (Appendix Ta-
bles 1 to 4, available at www.annals.org). Spinal manipu-
lation therapy was superior to medication at the end of treatment and during follow-up in terms of global im- ADL ϭ activity of daily living; HEA ϭ home exercise with advice; NSAID ϭ provement, participant satisfaction, and SF-36 –assessed nonsteroidal anti-inflammatory drug; SMT ϭ spinal manipulation therapy.
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Original Research Conservative Interventions for Acute and Subacute Neck Pain Table 3. Between-Group Differences for Changes From Baseline in Participant-Rated Pain
Variable
SMT Group
Medication Group
HEA Group
Pain score*
Mean short-term change from week 0†Week 26 Proportion with absolute reduction in pain
HEA ϭ home exercise with advice; SMT ϭ spinal manipulation therapy.
* On a scale of 0 (no neck pain) to 10 (worst neck pain possible).
† Group differences based on data from weeks 2, 4, 8, and 12.
‡ Group differences based on data from weeks 2, 4, 8, 12, 26, and 52.
physical but not mental function; SMT was also superior questionnaire collected by mail independent of study staff, to medication in measures of long-term medication use (1.26 fewer days per week of use at week 52 [CI, 0.53 to1.99 days]; P Ͻ 0.001).
Missing Data Analysis
The SMT and HEA groups performed similarly on Among the 272 participants, 219 (80.5%) provided most of the secondary outcomes, although SMT per- data on neck pain at every visit. We considered loss to formed better than HEA for satisfaction with care in both follow-up to be nonrandom for 12 participants, 6 of whom the short and long term. Home exercise with advice was never commenced treatment (all in the medication group) superior to medication in both the short and long term for and 6 of whom stopped participating in the study after satisfaction with care and for long-term medication use they received treatment (2 in the medication group, 1 in (1.00 fewer days per week of use at week 52 [CI, 0.27 to the SMT group, and 3 in the HEA group). We first im- puted values to the missing responses of these 12 partici- Appendix Table 4 shows changes in cervical spine mo-
pants by using the mean percentage reduction from base- tion after 4 and 12 weeks. Overall, the greatest changes in line at all time points specific to the group to which they cervical spine motion were observed in the HEA group.
belonged. Then, we imputed the rest of the missing data Results of the group differences in 3-dimensional cervical during treatment and the 2 posttreatment follow-up time spine motion patterns will be reported elsewhere.
points by using the SAS multiple imputation strategy, on One of the participants indicated that someone tried the assumption that the data were missing at random. The to influence his responses. Because this was a week-52 results of the analyses with imputed values changed the 6 3 January 2012 Annals of Internal Medicine Volume 156 • Number 1 (Part 1)
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Conservative Interventions for Acute and Subacute Neck Pain Original Research Table 3—Continued
Between-Group Difference (95% CI)
SMT Group Minus
SMT Group Minus
HEA Group Minus
Medication Group
HEA Group
Medication Group
estimates of group differences very little, and all statistically drowsiness. Dry mouth, cognitive disturbances, rash, con- significant differences remained the same.
gestion, and disturbed sleep were less commonly reported.
Nonstudy Treatments
During the 12-week intervention, 4 participants (3 in DISCUSSION
the medication group and 1 in the HEA group) reported In the absence of available criteria for what constitute visits to other health care providers for their neck pain. By clinically important group differences, several factors week 52, about equal numbers of persons in each treat- should be considered in aggregate. This includes the statis- ment group sought additional health care after completing tical significance of the results of our primary efficacy anal- the treatment phase (18 in the SMT group, 14 in the ysis, as well as those of the responder and secondary out- medication group, and 17 in the HEA group).
comes analyses. The durability of the treatment effect, the Adverse Events
safety and tolerability of the interventions, and the partic- No serious adverse events were reported in the study.
ipant’s ability and willingness to adhere to treatment Expected, nonserious adverse events that are typical to should also be taken into account (56).
these treatments did occur and were all transient in nature, In this trial of SMT versus medication or HEA for the requiring little or no change to activity levels. Forty percent treatment of acute and subacute neck pain, SMT seemed of the SMT group and 46% of the HEA group reported more effective than medication according to various mea- adverse events, primarily musculoskeletal pain. Paresthesia, sures of neck pain and function. However, SMT demon- stiffness, headache, and crepitus were less frequent (Appen-
strated no apparent benefits over HEA. Spinal manipula- dix Table 5, available at www.annals.org). Sixty percent of
tion therapy and HEA led to similar short- and long-term participants in the medication group reported side effects, outcomes, but participants who received medication seemed the most common being gastrointestinal symptoms and to fare worse, with a consistently higher use of pain med- www.annals.org
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Original Research Conservative Interventions for Acute and Subacute Neck Pain ication for neck pain throughout the trial’s observation sessors, and long-term postrandomization follow-up (6 and period. The performance of the HEA group, which has the 12 months.) It also has limitations. First, participants and potential for cost savings over both SMT and medication providers could not be blinded because of the nature of the treatments received and delivered. Second, no criteria are Participants and clinicians consider the potential for available to define clinically important group differences side effects when making treatment decisions. Although for the different outcomes. Finally, our study does not the frequency of reported side effects was similar among differentiate between the specific effects of treatment and the 3 groups (41% to 58%), the nature of the side effects the contextual (nonspecific) effects, including participant– differed, with participants in the SMT and HEA groups provider interactions and expectations. This study was in- reporting predominantly musculoskeletal events and those tended to be pragmatic in nature and to answer clinical in the medication group reporting side effects that were questions regarding commonly used treatment approaches more systemic in nature. Of note, participants in the med- by approximating how they are delivered in practice.
ication group reported higher levels of medication use after For participants with acute and subacute neck pain, SMT was more effective than management with medica- Most participants had subacute neck pain that lasted tion in both the short and long term; however, a few ses- more than 4 weeks, beyond the time when pain will prob- sions of supervised instruction in HEA resulted in similar ably resolve spontaneously, and evidence suggests that one half of persons with nonspecific neck pain continue to haveneck pain 1 year after the original report (57). Although From Northwestern Health Sciences University, Pain Management and our trial did not have a placebo group, the observed results Rehabilitation Center, and Berman Center for Outcomes and Clinical are unlikely to be due to natural history alone.
Research at the Minneapolis Medical Research Foundation, Minneapo-lis, Minnesota.
To date, few clinical trials have assessed the effective- ness of noninvasive interventions for acute and subacute Acknowledgment: The authors thank the study staff for dedicating sub-
neck pain not associated with whiplash; therefore, no stantial time and energy to ensure successful completion of the trial, as evidence-informed first-line therapy for this type of neck well as Brent Leininger, DC, and Jennifer Hart, MS, for their technical assistance in preparing this manuscript.
the Cochrane Library, using the terms spinal manipulation Grant Support: By the National Institutes of Health’s National Center
for Complementary and Alternative Medicine (grant R01 AT000707).
and neck pain, to identify all randomized trials publishedfrom 1960 to 2011 that evaluated SMT for acute or sub- Potential Conflicts of Interest: Disclosures can be viewed at www.acponline
acute neck pain. We found 3 trials (58 – 61). Our trial is .org/authors/icmje/ConflictOfInterestForms.do?msNumϭM11-0299.
most similar to that of Hoving and colleagues (58, 59), inwhich 75% of patients had neck pain of less than 12 weeks’ Reproducible Research Statement: Study protocol and statistical code:
duration. Six weeks of manual therapy (mainly spinal mo- Available from Dr. Bronfort (e-mail, [email protected]). Data set: bilization) was compared with usual medical care (advice, home exercise, and medication). The investigators found Requests for Single Reprints:
manual therapy to be superior to medical care, with reduc- Center for Clinical Studies, Northwestern Health Sciences Univer- tions in pain and disability similar to what we observed at sity, 2501 West 84th Street, Bloomington, MN 55431; e-mail, 8 weeks but less than what we observed at 12 weeks. Pool and colleagues (60) compared 6 weeks of manual therapy(up to 6 sessions) with 6 weeks of a behavioral-graded Current author addresses and author contributions are available at activity program (maximum of 18 sessions of 30 minutes each). At 3 months, the behavioral-graded activity programdemonstrated slightly larger reductions in pain and disabil-ity than manual therapy; however, the magnitude of im- References
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Phys Ther. 2007;87:431-40. [PMID: 17341509] Register to receive the table of contents via e-mail at www.annals.org/site/misc/alerts.xhtml. You may choose to receive any or all of thefollowing: Notification that a new issue of Annals of Internal Medicine is onlineComplete table of contents for new issuesSpecial announcements from ACP and AnnalsCME coursesEarly-release articles 10 3 January 2012 Annals of Internal Medicine Volume 156 • Number 1 (Part 1)
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Annals of Internal Medicine
Current Author Addresses: Drs. Bronfort and Evans: Wolfe-Harris
Author Contributions: Conception and design: G. Bronfort, R. Evans,
Center for Clinical Studies, Northwestern Health Sciences University, 2501 West 84th Street, Bloomington, MN 55431.
Analysis and interpretation of the data: G. Bronfort, R. Evans, K.H.
Dr. Anderson: Medical Pain Management, 5775 Wayzata Boulevard, Suite 110, St. Louis Park, MN 55416.
Drafting of the article: G. Bronfort, R. Evans, Y. Bracha, R.H. Grimm.
Mr. Svendsen: 900 Forest Avenue, Birmingham, MI 48009.
Critical revision of the article for important intellectual content: Mr. Bracha: Division of Health Policy and Clinical Effectiveness, Cin- G. Bronfort, R. Evans, Y. Bracha, R.H. Grimm.
cinnati Children’s Hospital, 3333 Burnet Avenue, MLC 5040, Cincin- Final approval of the article: G. Bronfort, R. Evans, A.V. Anderson, Y. Bracha, R.H. Grimm.
Provision of study materials or patients: A.V. Anderson.
Dr. Grimm: Berman Center for Outcomes and Clinical Research, 825 Statistical expertise: G. Bronfort, K.H. Svendsen, Y. Bracha, South 8th Street, Suite 440, Minneapolis, MN 55404.
R.H. Grimm.
Obtaining of funding: G. Bronfort, R. Evans, R.H. Grimm.
Administrative, technical, or logistic support: G. Bronfort, R. Evans.
Collection and assembly of data: R. Evans, A.V. Anderson.
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Medication
Difference
Medication
Between-Group
Disability
Medication
Participant-Rated
Baseline
Medication
Differences
Between-Group
1.
Table
medication
disability
Appendix
Variable
Duration
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Medication
Difference
Between-Group
Satisfaction
Medication
Improvement
Participant-Rated
Medication
Differences
Between-Group
2.
improvement
Table
satisfaction
Appendix
Variable
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Medication
Difference
Between-Group
Component
Medication
Physical
Baseline
Medication
Differences
Between-Group
3.
Table
component
component
Appendix
Physical
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Medication
Difference
Between-Group
Medication
Cervical
Baseline
Medication
Differences
Between-Group
4.
Table
extension†
bending§
Appendix
Rotation‡
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Appendix Table 5. Adverse Events During the 12-Week Treatment Period*
SMT Group
Medication Group
HEA Group
Absolute Difference (95% CI), percentage points
(n ؍ 84)†
SMT Group Minus
SMT Group Minus
HEA Group Minus
Medication Group
HEA Group
Medication Group
HEA ϭ home exercise with advice; SMT ϭ spinal manipulation therapy.
* Data are the numbers (percentages) of adverse events. Participants who reported an event at least once over the course of treatment; participants could report Ն1 type of event.
† We excluded 6 participants in this group from analysis because they received no treatment.
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Source: http://www.eastbournechiropractic.co.uk/Bronfort%202012.pdf

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Kangweon-Kyungki Math. Jour. 14 (2006), No. 2, pp. 241–248Abstract. We define a G-fuzzy congruence, which is a generalizedfuzzy congruence, and characterize the G-fuzzy congruence gener-ated by a left and right compatible fuzzy relation on a semigroup. The concept of a fuzzy relation was first proposed by Zadeh [9]. Sub-sequently, Goguen [2] and Sanchez [7] studied fuzzy relations in vari-ous

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