Should we abandon cervical spine manipulation for mechanical neck pain? Yes
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3679 (Published 07 June 2012) Cite this as: BMJ 2012;344:e3679
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Debates on cervical manipulation almost always focus on safety concerns; Rarely, if ever, do we see views on biological plausibility.
In patients with neck pain, what exactly is supposed to be out of place that therapists are manipulating back? Or is it the spinal equivalent of 'cracking one's knuckles'.
As a surgeon I've treated cervical dislocations, and getting them to move back into place usually takes more force, and a more direct application of that force, than could be applied by the placing of fingers and thumbs over the posterior cervical musculature. I've also seen presentations at meetings demonstrating (in an open MRI scanner) that commonly used manipulative techniques do little more than indent the skin.
I accept that cervical manipulation is 'safe enough' and should not be abandoned on these grounds. For me it should be abandoned, at least from a government funding perspective, on the basis that it is likely to be as effective as homeopathy, and has the same level of biological plausibility, i.e. none.
Competing interests: I see private patients with spinal disorders and often get asked by health insurers to recommend long courses of chiropractic before they will fund them.
I’d like to comment on the call by Wand and associates for us to abandon cervical spine manipulation for mechanical neck pain. While I agree with the presented research concerning the relative risk of cervical artery dysfunction, I take issue with the other incorrect statements made regarding the “non-superiority of manipulation to alternative treatments”. Wand and associates base this on a recent Cochrane review [1] of randomized controlled trials (RCTs) of neck manipulation or mobilization. The major problem with those RCTs is that they were conducted on a heterogeneous group of patients with mechanical neck pain. Many practicing clinicians will agree that not all patients with neck pain are the same, so how can we expect a treatment approach (manipulation) to be effective for all of them. Recent clinical practice guidelines have suggested that subgrouping patients with mechanical neck pain and providing them with interventions that are more likely to benefit them is the way forward.[2]
In their response to the discussion, Wand and associates repeat their belief that “there is no compelling evidence that unique responders to cervical manipulation techniques either exist or, if they do, can be reliably identified.” As a clinician with over 30 years of experience, I have always “known” that there is a subgroup of patients with mechanical neck pain who will respond favorably to cervical spine manipulation. Now, as a researcher, I recently put that premise to the test by completing a derivation study for a clinical prediction rule for patients with mechanical neck pain who are more likely to benefit from manipulation.[3] The interesting thing was that the majority of patients in our study improved with manipulation, and there were no adverse events. Of course, this was likely due to the fact that patients were thoroughly screened for eligibility to participate in the trial, and there were strict exclusion criteria to ensure patient safety. Furthermore, the patients received a detailed history and physical examination, as well as the manipulation. In other words, care was taken to ensure that manipulation would be appropriate for each patient participating in the study, and due attention was paid to all ‘red flags’ and contraindications for manipulation. This has been suggested as an appropriate way to reduce the incidence of serious adverse events following cervical spine manipulation.
On the subject of bias, I find it interesting that authors who publish research suggesting that manipulation is unnecessary and inadvisable are more likely to have never learned manipulation and used it extensively in clinical practice. Equally, there are many authors like myself who will publish research suggesting that manipulation is no more risky than crossing a busy street (sensible persons would cross that street with caution) and that it can provide superior outcomes in SOME patients (not all) with mechanical neck pain. We may well be those who have studied and practiced cervical spine manipulation extensively (and safely) in our clinical practice.
[1] Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manipulation or mobilization for neck pain. Cochrane Database Syst Rev 2010; 1:CD00429
[2]Cleland JA, Childs JD, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, et al. Neck Pain. JOSPT 2008; 38(9):A1-A34
[3]Puentedura EJ, Cleland JA, Landers MR, Mintken PE, Low A, Fernandez-de-las-Penas C. Development of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thrust Joint Manipulation to the Cervical Spine. JOSPT 2012; 42(7):577-592
Competing interests: I have practiced cervical spine manipulation safely for over 30 years, and am currently conducting clinical research into its safety and effectiveness.
As the authors of the “Yes” position we are pleased that our paper has attracted wide attention and encouraged discussion. We would like to take the opportunity to address some of the key themes raised in these responses.
It is with regret that we read comments suggesting we have misrepresented the data and tried to stoke inter and intra-disciplinary rivalry. We have attempted from the start to provide a balanced and fair assessment of the available evidence, albeit one which in the end carries our own particular interpretation, just as all such reviews of the literature do. The article in question was never designed to be a systematic review of all the evidence. However, we do feel that our piece, unsystematic as it may be, is a fair reflection of the evidence and cannot be justly accused of extrapolation or misrepresentation.
While we acknowledge that there is uncertainty surrounding the causality of the association between manipulation and these events, we do not accept that the same uncertainty exists regarding the benefits. Indeed given the risk of bias of many of the trials included in the Cochrane review that we have cited, one might consider that the effect estimates for manipulation are likely to be overstated. We are not aware of any compelling evidence to the effect that manipulation confers unique benefit as part of a care package. Similarly there is no convincing evidence that unique responders to cervical manipulation techniques either exist or, if they do, can be reliably identified. The British Chiropractic Association has suggested that we have cherry picked low quality evidence. We believe that we have considered the key studies, but if the BCA are aware of important or more robust contradictory evidence then we would be very happy to consider it.
Dr Mann suggests that the UK BEAM trial provides evidence for the effectiveness of cervical manipulation, but since it was a trial of treatment for low back pain, this assertion is tenuous. However it is worth discussing this study as it highlights a number of important issues for manual therapists wishing to use high quality evidence rather than anecdote to inform their management of patients with neck pain. Firstly, the differences reported for the primary outcome measures were lower than the authors pre-set minimal clinically important difference. In addition, as is common to many trials of manual therapy for neck pain, the therapist, patients and the assessors were not blinded. It is likely that the already small effect sizes seen are exaggerated by the resulting biases. Most significantly in relation to the current discussion on high velocity manipulation techniques, it is important to recognise that clinicians were able to choose from a range of manual therapy techniques as well as mobilising and strengthening exercises. As is the case in many neck pain trials, effectiveness of a package of care provided by a manual therapist cannot be used to specifically endorse high velocity thrust manipulations, as they are often only part of a treatment package. It should also be noted that this package of care was designed and endorsed by the professional bodies representing osteopathy, chiropractic and physiotherapy in the UK and explicitly excluded the use of high velocity thrust techniques to the neck because of the chance of serious side effects.
We also do not accept that the existing data on risks, imperfect though it is, is uninformative. The fact that not all studies have shown an effect in the over 45's most likely reflects the other causes of these events in that population clouding the picture. Indeed finding the association in a group who would not normally be expected to experience such an event (i.e. <45 yrs) arguably makes the association more convincing. While attempts to develop screening procedures is commendable, given that the association between manipulation and VAD/stroke is found in this group who are less likely to present with key vascular risk factors, it seems unlikely that screening will achieve its goal satisfactorily. Reid and colleagues point out that in one survey [3] , 45% of these events may have been preventable, which still leaves a rather uncomfortable 55% that may not have been. Indeed acceptance of Cassidy and colleagues argument, that there are patients receiving cervical manipulation who present with a pre-existing dissection, only further illustrates that screening is far short of being effective.
We would suggest that comparisons with NSAIDs or surgical procedures are less useful. Beyond the issue of inadequate data for drawing fair comparisons and the likely underestimation of the true risks for manipulation, manual therapists might more simply ask how their own practice may be made safer. With a range of manual therapy approaches available to the practitioner, not performing one particular type of technique would impose little restriction on the therapist and would not be expected to seriously impact patient care. Indeed, the most meaningful comparison between manipulation and low velocity mobilisation for neck pain suggests that mobilisation may be associated with a lower recurrence rate [1].
Patients may wish to have their neck “clicked” but such demand is driven in part by the claims of the industry that promotes these therapies. After all, in possession of truly informed consent, why would one choose a technique that confers no unique benefit but poses a possible unique risk? We propose that rather than simply reacting to patient demand, manual therapists might use their skills to better persuade patients that lower risk alternatives are equally effective. We would also like to emphasise that the argument is not simply one of potential harm; as some responses have pointed out, many treatments carry risk. The issue is that although the risk is low, the potential consequences are severe, it is not possible to meaningfully mitigate this risk by screening and, as a standalone treatment, manipulation is not very effective and certainly no more effective than other treatments which are less likely to have such catastrophic consequences.
We also refute the allegation of bias towards any particular profession. Even a cursory read of the article would reveal that we have taken great pains to state that our comments are about a specific treatment technique only, one that is used by many different professions. At no point did we attack any particular professional group – on the contrary, we have made efforts to make this point clear and to correct some of the misquotes that have been attributed to us by various media outlets. It was not our decision to press release the paper, nor could we control the subsequent media coverage. We feel that we should be judged on what we published in the BMJ, not on how the media have chosen to interpret it. In the end, it remains our opinion that cervical spinal manipulation is unnecessary and inadvisable given the other options available.
1. Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010 Sep;91(9):1313-8.
Competing interests: No competing interests
It is important to make the distinction between standard chiropractic treatments and the gentler McTimoney chiropractic method (crudely described as "non-clunking" chiropractic). McTimoney chiropractic does not involve any spinal manipulation and the light, dexterous techniques can be used in all age groups safely.
Competing interests: No competing interests
Response to Wand et al Abandonment of Cervical Manipulation
The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) is the largest subgroup of the World Confederation of Physical Therapists (WCPT). IFOMPT has been promoting Excellence in Orthopaedic Manipulative Therapy (OMT) for over 38 years. It is one of the few professional bodies that have an internationally agreed standards document that guides the curricula in the teaching of manual and manipulative therapy (see www.ifompt.org).
The issue of both teaching and delivering high velocity thrust (HVT) techniques to the cervical spine is controversial particularly when the true risk of adverse events is unknown. Whilst the adverse events (stroke and vertebral artery dissection VAD) are significant, they are extremely rare events. The day to day issue for physical therapists who wish to use HVT in the management of cervical or any other musculoskeletal problems is based on a range of factors. IFOMPT has always promoted the philosophy that HVT is not a stand-alone treatment and is delivered within a continuum of care with ongoing monitoring and based on a sound clinical reasoning model. This point is clearly made in the reply by Kerry, et al (BMJ rapid response )1. A recent review of 134 case reports of adverse events from cervical manipulation has also indicated that approximately 45 % of these events could have been prevented had a more robust clinical reasoning process been applied during the patient assessment2. This would further support the idea that is patient selection that is important rather than the actual technique. Clinical reasoning is also strongly emphasised throughout IFOMPT standards document.
Another aspect of delivering this treatment is the ability to provide the recipient of this technique with an informed choice based on the risks, such that they can consent (or not) to the procedure. This is a legal requirement with any health procedure. This is a challenge where the true risk of the modality is not known, but this can be overcome, firstly, with an honest appraisal of what is currently known about the risk, and secondly, by giving the recipient an idea of the relative risk3. This may be in the form of a comparison with other commonly used modalities to treat the condition. For example, Dabbs et al2 in review of the literature and comparison to the use of NSAIDs for cervical pain, found a very low risk of injury with manipulation, compared to risk of adverse effects of taking NSAIDs. The likelihood of a serious gastrointestinal bleed from NSAIDs is 1 per 1000 and the death rate for NSAID associated GI problems is estimated at 0.04% per year among patients with osteoarthritis who receive NSAIDs, with 3200 deaths per year.4 The estimated death rate from cervical spine HVT manipulations per treatment is 0.00025% or 160 times less frequent than the NSAIDs death rate. The estimated injury rate of NSAIDs induced bleeding ulcers requiring hospitalization is 400 times greater than the estimated injury rate from manipulation. It is reasonable to ask which has greater risk, traditional medical therapy or judiciously applied spinal manipulation in appropriate selected patients?
There are many patients who seek the skills of a manual or manipulative physical therapist. These patients are looking for the most effective management of their musculoskeletal problem. Having a practitioner that has a range of skills on both thrust and non-thrust manipulative techniques provides the patient with greater choice. Delivery of manipulation in a clinically reasoned and informed way will always be the safe way forward rather than abandoning a single modality at a time where the evidence is still variable.
The IFOMPT Executive Committee welcomes this type of debate but feels that a balanced view of the the issues needs to be presented as we move forward.
Duncan Reid on behalf of the IFOMPT executive, Annalie Basson, Ken Olson, Erik Thoomes, Michael Ritche, and advice and comment from Tim Flynn.
References
1. Kerry, R, Taylor, A, Rushton, A, McCarthy, C and Mercer,C http://www.bmj.com/content/344/bmj.e3679/rr/588701
2. Puentedura, E., March, J.,Anders, J., Perez, A.,Landers, M., Wallman,H., and Cleland, J. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? Journal of Manual and Manipulative Therapy 2012, 20 (2) 66-74
3. Culy, R., Reid, D. A., & Diesfeld, K. Cervical spine manipulation, a procedure with a rare but potentially serious adverse reaction: Exploring the ethical dimensions in the New Zealand context. New Zealand Journal of Physiotherapy, (2011). 39(3), 114-121.
4. Dabbs, V and Lauretti, W. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics (1995), 18(8):530-6
Competing interests: No competing interests
Wand et al concede controversy and that the association between neck manipulation and outcome is ‘not fully resolved’ and ‘causality is not proved’; this is highlighted by the opposing views expressed in this debate and the published evidence. Consequently we question the motivation behind such a premature and provocative recommendation to abandon cervical manipulation.
Cervical manipulation is safer than most invasive medical procedures or prescribed medication.
If we were to adopt Wand et al’s rationale and propensity for risk elimination, and apply it equally, then many elective surgical procedures would be outlawed for the same reasons, as would many prescribed and over the counter medications.
As with all interventions in medicine, the qualified practitioner, having assessed the appropriateness of an intervention, must discuss the evidence base, treatment options and risks with the patient who can then make an informed choice. If these fundamentals of clinical practice are adhered to, then there is no need to legislate interventions out of practice.
Competing interests: No competing interests
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
5) Szmelskyj AO Readers comments Alan Szmelskyj, other healthcare professional, 01 Nov 2011 www.Pulsetoday.co.uk/comment-blogs/-/blogs/12958417/osteopathy-how-diffe...
6) Szmelskyj AO The difference between holistic osteopathic practice and manipulation. Holistic Medicine 1990: 5(3) 67-79
7) Bolton SP. Similarities and differences between chiropractic and osteopathy. Journal of the Australian Chiropractors Association 1987; 17(3): 90-93
8) Haas M, Groupp E, Alckin M et al. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. Journal of Manipulative and Physiological Therapeutics. 2004; 27(9): 547-553.
9) Walker-Bone K, Cooper C. Hard work never hurt anyone or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Annals of the rheumatic Disorders 2005: 64: 1391-1396
10) Szmelskyj AO.Psychosocial and hypnotic theories of osteopathy and therapeutic applications. Journal of Osteopathic Education and Clinical Practice 1997; 7(1): 32-40
11) Gustavsson c, Denison E, Von Koch L. Self management of persistent neck pain: two-year follow-up of a randomized controlled trial of a multicomponent group intervention in primary health care. Spine 2011; 36(25): 2105-2115.
12) Leaver AM, Refshauge KM, Maher CG et al. Conservative interventions provide short-term relief for non-specific neck pain: a systematic review. Journal of Physiotherapy 2010; 56(2): 73-85
13) Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: A systematic review of randomized controlled trials. Complementary Therapies in Medicine 2012; 20(4): 232-239.
14) Lee KC Chui TT, Lam TH. The role of fear avoidance beliefs in patients with neck pain: relationship with current and future disability and work capacity. Clinical Rehabilitation 2007; 21(9): 812-821.
15) Pool JJ Ostelo RW, Knol D et al. Are psychological factors prognostic indicators of outcome in patients with sub-acute neck pain? Manual Therapy 2010; 15(1): 111-116.
16) Scherer M, Schaefer H, Blozik E et al. The experience and management of neck pain in general practice: the patients’ perspective. European spine Journal 2010; 19(6): 963-971.
17) Tramer MR, Moore RA, Reynolds DJM et al. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 2000; 85: 169-182.
Competing interests: No competing interests
If there was a concern about the safety of manipulation of the cervical spine, surely it would make sense to do a prospective study on patients who undergo manipulation and see whether there are significant side effects of this procedure?
This was done on 19,722 patients by Thiel and colleagues (1).
Wand and colleagues, appear to have overlooked this study that was designed to address the very issue that they are concerned about. The conclusion of the study was that ‘the risk of a serious adverse event, immediately, or up to 7 days after treatment, was low to very low’.
1. Thiel HW, Bolton, JE, Docherty S, Portlock JC, Safety of chiropractic manipulation of the cervical spine:a prospective national survey. Spine 2007; 32(21):2375-8
Competing interests: chiropractor
As a doctor (now also an osteopath) with longstanding interest and personal experience of back pain and its treatment, I have followed this debate for three decades, over which time no clear causality has been established. However, a narrative does appear to be emerging: that although there may be a minuscule risk of manipulation actually causing dissection in younger patients, any residual causal risk would seem to depend on who does the manipulation.
Vertebral artery dissection is an extremely rare event, with an even smaller number having had cervical manipulation beforehand. This possible risk of severe complications approaches the levels of risk seen for commonly accepted procedures such as childhood immunisations, and is less than 1/20th of the risk of being hospitalised for severe GI bleeding due to Ibuprofen.
Cassidy et al rightly argue that informed choice is important, otherwise we should also summarily ban horse-riding, trampolining and surfing on similar (or worse) risk criteria.
In the Ontario study, of those people consulting a chiropractor before suffering dissection, a similar number had consulted a GP, suggesting simply that, particularly for the younger population, people may feel that a chiropractor/osteopath is an appropriate first port of call when suffering neck pain. Neither GPs nor chiropractors may be good at spotting dissection presenting as neck pain or headache, and this may be an area for further education.
Physiologically, - excluding those patients with collagen diseases - it is counter-intuitive that dissection associated with manipulation does not occur in >45yo age group, where atheroma and calcification would make arteries more, not less, vulnerable to injury by distortion. Practitioners do not limit manipulation to <45yo age group.
Wand et al state that there is no added benefit from manipulation as a treatment. The very high quality UK-BEAM trial and subsequent cost-effectiveness analysis both provide recent and robust evidence to the contrary, as do the 2009 NICE Guidelines. Anecdotally, having suddenly, completely and enduringly obviated hundreds of patients' neck pains and headaches (some of whom had been suffering these symptoms for several or many years), I have no doubt that manipulation, correctly applied, can directly address and remedy the cause of some headaches, neck and back pain. When informed of the possibility of a very low risk of stroke as a result of upper cervical manipulation, virtually all patients have been content to proceed, which perhaps attests to the severity of their symptoms and their ability to put risk into perspective.
The association of dissection with manipulation by chiropractors, but not osteopaths, was attributed by Wand to osteopaths using less manipulation in treatment. If this were true one would still expect to see osteopaths figure in the statistics, but they don't. There may be fundamental differences between physiotherapists, osteopaths and chiropractors in the way that manipulation of the upper cervical spine is taught, but Wand does not consider this.
In fact, the call for all cervical manipulation to be banned shows some detachment from the subject matter. It is only upper cervical manipulations that are in question, and of those, only those techniques involving rotation would anatomically predispose to vertebral artery compromise. There are a number of manipulation techniques I have learned for the upper cervical spine, some of which involve minimal or no rotation at all.
We all wish to minimise risk to patients, and to that end it may be useful for chiropractors, physiotherapists and osteopaths to liaise regarding upper cervical manipulation techniques. It is however, far from the reach of the existing evidence to call for a blanket ban. Cervical manipulation is a useful and effective mechanical treatment for a mechanical problem.
Competing interests: No competing interests
Re: Should we abandon cervical spine manipulation for mechanical neck pain? Yes
Dear Editor,
Various methods of manual therapy, kinesiatrics and combined programs are used in joint diseases. There have been numerous reports on benefits from exercises and manual therapy in osteoarthritis (OA) but the role of placebo effect and conflicts of interest is difficult to assess. The aim of this rapid response is to express caution concerning manual therapy of conditions with degenerative changes and insufficient regeneration: OA, spine lesions especially in the cervical area e.g. after professional activities such as bearing of heavy weights, those with vertebrobasilar insufficiency [1], symptoms of “severe compressive vascular vertebral syndromes” [2], “vertebral artery syndrome” [3] and chronic pain [4]. Some more examples from Russia: manual therapy of osteochondrosis (the term is used within the meaning of OA) by the pressure with therapist’s thumbs “up to a strong feeling of pain” in the C1-C7 area, forceful back- and sidewards (up to 60° from vertical) movements and turning (up to 90°) of the patient’s head [5]; manual therapy of “cervical spondyloarthritis aggravated by vertigo” by hitting with the therapist’s knuckles (10-12 kg/cm², multiple courses) [6]. Adverse events following manual treatments to the spine are common, although serious complications are rare [7-9]. In particular, cervical spine manipulations may carry a risk for neurovascular complications [10]. There is a well-founded opinion that the non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulations inadvisable [10].
Certainly, maintaining an optimal level of the physical fitness is important but the exercise/rest ratio should be moderate especially in degenerative lesions, wear and tear in aged people as well as certain posttraumatic conditions. For example, it is often stated that hand exercises in OA should be of low intensity, performed in periods with little pain and inflammation. In this connection it is logical that splints i.e. immobilization reduced hand pain in OA more consistently than exercises [11]. A meta-analysis demonstrated that splints significantly reduced hand pain [11]. In conditions of insufficient regeneration, cartilaginous structures should be protected from further damage by overstrain and manual treatments.
References
1. Tjan VN, Gojdenko VS. Method of treating chronic vertebrobasilar insufficiency. Patent RU2447876C2 (2012).
2. Khoroshukhin VJ, Khoroshukhina OK, Tsvetkova IV. Manual techniques applied for vertebra-neurologic syndromes. Patent RU2325892C2 (2008).
3. Gritsenko AG, Pavlov AB, Naziev AI, Lychkova AE. Method for treating the cases of cervical osteochondrosis with concomitant vertebral artery syndrome. Patent RU2150929C1 (2000).
4. Evseev VI. Method for treating osteochondrosis of the cervical spine. Patent RU2654574C1 (2018).
5. Shishonin AJu. Method for treating cervical osteochondrosis. Patent RU2243758C2 (2005).
6. Gritsenko AG, Gritsenko KA. Method for treating cervical spondyloarthritis aggravated by vertigo. RU2114595C1 (1998).
7. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. J Orthop Sports Phys Ther 2009;39:378-87.
8. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap 2017;25:37.
9. Ivanenko TA. X-ray signs of ligamentous cervical injuries from joint manual therapy. Vestn Rentgenol Radiol 2008;(2-3):56-8.
10. Wand BM, Heine PJ, O'Connell NE. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ 2012;344:e3679.
11. Kjeken I, Smedslund G, Moe RH, et al. A systematic review of design and effects of splints and exercise programs in hand osteoarthritis. Arthritis Care Res 2011;63:834-48.
Competing interests: No competing interests