Re: Should we abandon cervical spine manipulation for mechanical neck pain? Yes
Wand and colleagues make a case for the proposed abandonment of cervical manipulation based on uncertainty of its risk and benefits. We have been investigating and debating this clinical area for several years and agree that the data leaves us uncertain. However, we argue that the conclusions in this paper are erroneous, and potentially harmful for associated professions and their patients. Wand et al base their argument on misrepresentations of selected risk data which has previously been considered as unreliable and subject to bias1. Such data hold little informative content regarding scientific, clinical, or professional practice. Wand et al also fail to report on the complete lack of associated risk in the over 45s. All we have some certainty about is that, as Wand et al report, the risk of adverse events related to any form of manual therapy is extremely low and of little epidemiological relevance.
That said, reported cases do exist, and we ourselves have reported on such cases and are continually involved in medico-legal cases of these events, although more than half are related to non-manipulative procedures. There are key issues which emerge from the broad phenomena: The existing data studies attend poorly to both the nature and purpose of manipulation interventions. There are numerous types of cervical manipulation; some have mechanistic evidence to support potential injurious stress on vessels, e.g. the effect of movement on vessel strain and haemodynamics, and some do not 2. The same can be said for non-manipulative procedures, e.g assessment, and exercise prescription. Existing studies do not account or control for these confounders and variables.
Regarding benefits, pain is the sole outcome measure of existing studies, although manipulation is commonly used as part of a wide range of interventions as part of a package of care to influence movement dysfunction. The outcome data is therefore difficult to interpret for one component of the package of care to inform effectiveness. Some patients are at high risk of adverse events, and some are at low risk. Similarly, some patients will benefit greatly from manipulations, and some will not3. A recently undertaken national survey of UK osteopathic practice revealed no greater risk of cervical manipulation than any other intervention in any other area of the body4; a conclusion also supported by a recent systematic review of adverse events5. Wand et al suggest that there is no ‘satisfactory screening procedure that acceptably mitigates this risk’, yet there are huge scientifically-informed advances which allow clinicians to risk-manage as well as possible based on the totality of evidence6.
The issue here is not about whether a single intervention should be abandoned or not. It is about understanding the totality of epidemiological, mechanistic, and clinical evidence regarding our interventions, contextualised by better understanding of patient sub-populations, and a meaningful interpretation of effectiveness data. Focussing on the single intervention issues has the potential to avoid the real problems, and will serve to harm professions and patients. Some patients will still have strokes following therapy even if manipulation is abandoned. Better scientific reasoning and clinical judgement will lessen the already extremely low risk of adverse events. Emotive mis-use of data to support individual inter and intra-disciplinary rivalry serves little to benefit the greater good of patients, even when published alongside the counter arguments from Cassidy and colleagues (doi:10.1136/bmj.e3680).
1. Kerry R, Taylor AJ, Mitchell, JM, McCarthy C. Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice. Manual Therapy 2008;13: 278-288
2. Bowler N, Shamley D, Davies R. The effect of a simulated manipulation position on internal carotid and vertebral artery blood flow in healthy individuals. Manual Therapy 2011; 16: 87-93
3. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 2009; 39:378-387
4. Vogel S, Mars T, Keeping S et al 2012 Clinical Risk Osteopathy and Management (CROaM) project: national cross-sectional survey. BSO, London.
5. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: A systematic review. Manual Therapy 2010;15: 355-363
6. Taylor AJ, Kerry R. A systems based approach to risk assessment of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 2010;13:85-93
Competing interests: No competing interests