The viewpoints posited in this head to head debate illustrate that the research evidence base does not convincingly support the unquestioned use of cervical spinal manipulation. However the pragmatic argument for the efficacy of spinal manipulation to the cervical spine goes beyond the merits of the quality of the research methodology in the determination of the potential risk of catastrophic outcomes for patients.

If cervical spinal manipulation does pose clinically significant risk to patients, then this should guide GPs and other health care professionals in their choice of recommendation or referral to chiropractors, osteopaths or physiotherapists, or to other health care providers who may use spinal manipulation for treating neck pain and dysfunction.

Thus research needs to identify which type of manual therapists may pose the biggest risk for producing catastrophic outcomes. Certainly fatalities following cervical manipulation are significantly biased towards chiropractic (1). With several hundred cases of severe complications following cervical manipulation apparently reported in the literature (2) it should possible to identify the professional designation of the manipulation provider in a large number of these reported instances.

There are over 2,600 chiropractors and more than 4,500 osteopaths in practice in the UK. Professor Eduard Ernst, one of complementary and alternative medicines most robust critics, frequently berates his colleagues in the medical profession for failing to make the distinction between osteopaths and chiropractors. Ernst’s basic premise is that because of the frequency with which spinal manipulation techniques are used in chiropractic practice, chiropractic care is inherently less safe than its osteopathy counterpart (3).

If the incidence of catastrophic adverse events is dose dependent, then any difference in the inter-professional frequency in the use of spinal manipulation is important and may indicate clinically very significant dissimilarity between the UK chiropractic and osteopathic professions.

Ernst suggests that in the UK, spinal manipulation is used regularly almost 100% of the time by chiropractors but only regularly 47% of the time by osteopaths (3). However it is worth noting that the study methodologies on which such comparisons are made are heterogeneous (4). It is interesting that at the same time that these epidemiological studies that Ernst cites were published, and with two to three times as many osteopaths as chiropractors in practice, the premium for professional indemnity insurance was 82% higher for UK chiropractors compared with the same level of cover for UK Osteopaths (5).

O’Connell et al claim that there are gentler equally efficacious approaches such as massage that could be used instead of spinal manipulation for the treatment of cervical problems. Previous studies have also shown that the regular use of massage type techniques at a frequency of 78% is nearly three times greater in UK osteopathic practice compared with UK chiropractic practice. (5). Thus indicating another clinically important difference between osteopaths and chiropractors.

More than twenty years ago I stated that most medical professionals erroneously equate osteopathy and spinal manipulation to being one and the same and fail to recognize the psychosocial concepts used by many osteopaths (6). Similarly as Ernst suggests medical practitioners do tend to group chiropractors and osteopaths under the same therapeutic umbrella (3). There is thus a compelling need for the medical profession, particularly those in primary care, to have a better appreciation of inter-professional differences in the potential usage of riskier versus safer, but relatively comparably efficacious manual therapy procedures for the treatment of neck problems.

Other clinically relevant differentiators include longer contact time spent with patients by osteopaths per therapeutic encounter (4), and less treatment sessions from osteopaths compared with chiropractors needed to achieve similar therapeutic improvements (7), For example Haas et al recommend 9-12 treatments of chiropractic care for the treatment of cervicogenic headache.(8).

With prolonged abnormal posture and psychosocial risk factors believed to be an important contributor to neck pain (9), the extra length of time per therapeutic encounter may give osteopaths more opportunity to identify and to provide psycho-educational management of any relevant biopsychosocial and ergonomic issues (10). There is some recent convincing research that providing pain and stress self-management as part of the package of care to the persistent tension-type neck pain patients may produce superior longer-term effects than for example individually administered physical therapy (11)

Medical practitioners may need to give additional and sufficient thought as to their most appropriate recommendations and be aware of risk-benefits when informing patients of the options for manual therapeutic neck pain management. Although spinal manipulation remains the most significantly useful short-term intervention for non-specific neck pain (12) and shows promise for tension type headaches (13) because of the potential risks of the technique it may be tempting for doctors to say “a plague on all your manual therapy houses” and to make an easy tactical retreat to behind the repeat prescription pad and provide patients with NSAIDs etc.

Whilst a wait and see approach may in some patient subgroups with certain psychological traits allow the chronification of pain (14,15 ). Particularly as many patients with neck pain fearing being labeled as neurotic, avoid discussion of psychosocial themes (16).

Maintenance based NSAID management for persistent pain within two months of starting NSAID use is in itself not without significant consequences, with a risk of fatal gastroduodenal complications as high as 1 in 1200 patients who would not have otherwise died had they not taken NSAIDs (17). Other less serious side effects and resulting morbidity from NSAIDS when used continually may result in an unacceptably high financial burden on the health services in dealing with such a high level of pharmaceutical iatrogenesis. This cost may ultimately be far greater perhaps than that resulting from the management of the iatrogenesis from cervical spinal manipulation.

References

1) Ernst E. Deaths after chiropractic: a review of published cases. International Journal of Clinical Practice 2010; 64(10): 1162-1165.
2) Jha A. Dangers of chiropractic treatments under reported, study finds The Guardian 14th May 2012. www.guardian.co.uk/lifeandstyle/2012/may/14/dangers-chiropractic-treatme...
3) Ernst E. Osteopathy how different is it to chiropractic? www.Pulsetoday.co.uk/comment-blogs/-/blogs/12958417/osteopathy-how-diffe...
4) Sanderson M. Should chiropractic and osteopathy be purchased for the treatment of back pain in Cambridge and Huntingdon? British Osteopathic Journal 1995; XVII: 9-29
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Competing interests: None declared