Head to Head
Should we abandon cervical spine manipulation for mechanical neck pain? No
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BMJ
2012;344:e3680
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I read the arguments for and against the cervical spine manipulation for mechanical neck pain with great interest, of particular interest was the rather large number of competing interests of the authors arguing 'No'. The patient group in question is invariably poorly defined with the diagnosis of 'mechanical neck pain' being extremely subjective and woolly; this results in numerous problems when interpreting the evidence regarding treatment effects, after all what is being treated? I am not sure it is consistent or well defined in the literature. Therefore the plausibility of manipulation in treating mechanical neck pain appears highly dubious in my opinion (1), and it appears highly likely that manipulation is merely a dangerous placebo which should be avoided. 1. Austin Bradford Hill, “The Environment and Disease: Association or Causation?,” Proceedings of the Royal Society of Medicine, 58 (1965): 295-300.
Competing interests: None declared
Oxford University, Nuffield Orthopaedic Centre
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We think that an important issue scarcely considered is the importance of medical evaluation before chiropractic or other integrative treatments. In our opinion the expert physician (could be also an expert medical practitioner) after a complete evaluation of the patient can advise the patient about the best treatment for his/her neck pain: chiropractic but also acupuncture, massage, an orthopedic, rheumatological, neurological consultation, simple counseling, paracetamol or adding a radiological exam.
I have seen patients treated 10-15 times in a month without improvement just because a wrong diagnosis was given by a non-physician health-caregiver; or patients who interrupted the chiropractic or osteopath treatment because of abrupt worsening; this type of problem is little discussed in the medical literature, but we think that it is nevertheless an important subject.
We think that in medically selected patients cervical spine manipulation for mechanical neck pain can be very effective because in a minute this approach can dramatically improve pain symptoms and the patient can return to his/her normal duties. About safety, we think that it is still concerning to make a high velocity, thrust manoeuvre thinking to move or adjust vertebrae, this is conceptually wrong and potentially dangerous, especially if not carried out without careful anamnestic and clinical/radiological evaluation.
Competing interests: None declared
Center for Integrative Medicine, Careggi, Universitary Hospital of Florence, Department of Preclinical and Clinical Pharmacology “M. Aiazzi Mancini”, University of Florence, Viale G. Pieraccini 6, 50139 Florence, Italy
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Primum Non Nocere
Recently I was asked to care for a 31 year old woman. At 25 weeks gestation she had left sided neck pain, and saw a chiropractor for neck manipulation. At the time of the manipulation she noted severe right sided neck pain, and over the next few hour developed a right sided Horner's syndrome. Magnetic resonance imaging demonstrated right internal carotid artery dissection extending to the level of the petrous temporal bone.
Cassidy et al correctly state that stroke due to craniocervical dissection may result from activities as diverse as conducting an orchestra to weight-lifting. A review of the literature reveals almost 500 cases of cerebral artery dissection within hours-days of neck manipulation. Cassidy et al chose not to acknowledge a recent study comparing individuals less than 55 years who had confirmed or suspected craniocervical dissection compared with matched controls with stroke from another cause.1 The study found that mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection with an odds ratio of 23.53 .
Cassidy et al acknowledge there is no evidence that cervical manipulation is a superior modality of treatment for headache or neck pain. Stroke is a devastating event, especially in young people. No matter how uncommon, if there is any possibility that stroke may be a complication of cervical manipulation, the principle of Primum Non Nocere should mandate the abandonment of this procedure.
1. Thomas LJ, Rivett DA, Attia JR, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Man Ther 2011:16;351-6.
The patient has given signed informed consent for her case history to be published.
Competing interests: None declared
Mater Hospital, Raymond Tce South Brisbane
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Performing a short lever cervical manipulation has been proven to be safe and effective at reducing pain and increasing mobility to a hypomobile joint. In fact, when you compare cervical manipulation to the hospitalizations (76,000)and deaths in the US (7,600) from NSAIDs, cervical manipulation is almost non-existent. Long lever manipulation of C1 on C2 is the manipulation indicated for possible harm or death. So, don't do a torsional (long lever) manipulation to this one area of the cervical spine. Keep it safe, keep it short lever, and know your level of skill, precautions, and contraindications to manipulation. So, NO, we should not abandon manipulation to the cervical spine.
Competing interests: None declared
Spectrum Physical Therapy, New York
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Sir,
As a veterinary ophthalmologist, I was intrigued when I developed acute onset unilateral Horner's Syndrome a few years ago - a condition which I had, until that time, only encountered in my canine and feline patients.
An MRI scan revealed the cause to be a dissection of the ipsilateral internal carotid artery.
The condition had developed within 24 hours of chiropractic manipulation of my neck for ongoing chronic neck pain.
Whilst n=1 and I have lived to tell the tale, I would most certainly not subject myself to neck manipulation again, and I suspect that the authors of this paper might be a little more circumspect regarding the cost/benefit ratio of this procedure should they, or their family or friends, have experienced the same temporal relationship between near-catastrophic cranial vascular injury and cervical spine manipulation.
Sincerely
Peter Renwick MA VetMB DVOphthal MRCVS
RCVS Specialist in Veterinary Ophthalmology
Competing interests: None declared
Willows Referral Service, Highlands Road, Solihull B90 4NH
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Professor Cassidy's article to support the continuance of chiropractic neck manipulation can be condensed into the following core facts:
1. Manipulation is no better or no worse than several other non-invasive methods of tackling neck pain.
2. These methods appear to be superior to placebo.
3. Manipulation is popular.
None of these reasons make manipulation inherently preferable to the other choices of therapy, so the decision boils down to a risk-benefit assesment of the interventions. It is here that Cassidy tries to muddy the considerable evidence base that exists demonstrating manipulation causes harm through vertebral artery dissection ("stroke").
My view would be that if there is any suggestion that dissection may occur with manipulation then it should not be considered to be "first line", but studiously avoided until a clearer evidence base for its use and safety is available.
Another thing concerns me. That is the assertion that the association between manipulation and stroke is purely due to a temporal artefact, because patients who are experiencing an evolving arterial dissection would get headaches and might consult a chiropractor for treatment. This claim is not backed up by any evidence, and this clinical scenario sounds like a highly implausible excuse to explain away a causal association.
My concern arises because if this were actually to be true, then it would suggest that chiropractors are hopeless clinicians, who are subjecting unsuspecting patients with an evolving stroke to needless neck manipulation when what they should really be doing is dialling 999. This hardly inspires confidence in the chiropractic profession.
Competing interests: None declared
Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, FY3 8NR
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