The Journal of Pain
Volume 4, Issue 8 , Pages 427-428, October 2003

Spinal manipulation for neck pain does not work

  • Nikolai Bogduk

      Affiliations

    • Department of Clinical Research, Royal Newcastle Hospital, Newcastle, NSW, Australia
    • Corresponding Author InformationAddress reprint requests to Nikolai Bogduk, MD, Department of Clinical Research, Level 4, David Maddison Building, Royal Newcastle Hospital, Newcastle NSW 2300, Australia.

Article Outline

 

In his review, Ernst raises concerns about his methodology. He offers that the review might be criticized for failing to detect all the literature and for not using MANTIS (Chirolars). In this respect he can be reassured. Experts in the field know of no literature that Ernst has not covered, and none has been reported in previous1 or other recent reviews.9, 10, 20 One can also afford the cynicism that if a study has not appeared in journals indexed by MEDLINE, CISCOM, Amed, and the Cochrane Library, it is surely unlikely to provide convincing evidence that would overturn conclusions based on studies in high quality, peer-reviewed journals.

Ernst is also concerned that neck pain is an ill-defined disorder and that manipulation might differentially affect pain associated with osteoarthritis, spondylosis, increased muscular tone, trigger points, or myofascial pain. These are spurious concerns. In the first instance, no one in clinical practice makes the distinction. No one has ever claimed that manipulation is differentially effective according to whether the patient has osteoarthritis or myofascial pain. Patients are treated with manipulation for neck pain, irrespective of other features. In the second instance, none of the entities listed by Ernst are valid. According to some studies, spondylosis is only slightly more prevalent in symptomatic subjects than in asymptomatic ones,11, 21 but the odds ratios for disc degeneration or osteoarthrosis as predictors of neck pain are only 1.1 and 0.97, respectively, for women and 1.7 and 1.8, respectively, for men.21 In other studies the prevalence of disc degeneration was found not to differ in symptomatic and asymptomatic individuals.8 Moreover, uncovertebral osteophytes and osteoarthrosis of the synovial joints of the neck were found to be less prevalent in symptomatic individuals.8 Tender points or trigger points are neither reliable nor a valid sign of the cause of neck pain.2, 3

The conclusions that Ernst draws, therefore, are not constrained by methodologic flaws. They are, however, constrained by the paucity of literature. The review found only 4 studies, 2 pertaining to the immediate effects of manipulation only7, 22 and 2 long-term studies.6, 16

Ernst was somewhat generous in his assessment of the 2 short-term studies. One did not assess pain but measured only changes in pressure pain threshold.22 This cannot be taken as evidence that manipulation works for neck pain, even in the short term. The study is essentially immaterial. The other study reported that the decrease in pain after manipulation was significantly greater than that after muscle energy therapy,7 but Ernst did not point out that this difference disappears once the data are adjusted for baseline differences.15 Therefore, the result of this second study is not inconclusive, as Ernst finds, but negative.

On the basis of the 2 long-term studies, Ernst correctly finds that manipulation is not more effective than exercises. Security in this conclusion is provided in the form of concurrent and convergent validity. Other studies not involving chiropractors led to the same conclusion. Ernst excluded these from his review, for he sought expressly to focus on chiropractic therapy. However, it is not as if there is another literature that establishes that manual therapy performed not by chiropractors happens to be effective.

The seminal studies4, 5, 12, 14, 18, 19 used by systematic reviews9, 10 to advance the efficacy of manual therapy did not all study manual therapy in isolation. Some combined manual therapy with exercises.14, 18, 19 Thus, the effects of these 2 interventions cannot be disentangled in these studies, but other studies do provide data.

McKinney et al18 found that home exercises were no less effective than manual therapy in the short term but were significantly more effective in providing complete relief of pain in the long term. Hoving et al14 found that manual therapy combined with exercises was more effective than usual care by a general practitioner at 7 weeks after treatment; but it was not significantly better than physiotherapy based on exercises, with respect to relief of pain, disability, and quality of life measures. On longer-term follow-up, differences between all groups attenuated and extinguished.13

Brodin,4, 5 who used manual therapy alone, found it to be superior to physiotherapy but also found that manual therapy was not more effective than treatment simply with salicylates. Likewise, Howe et al12 found manipulation to be no more effective than treatment with a non-steroidal anti-inflammatory drug.

In essence, the literature provides an incomplete but unflattering profile of the efficacy of manipulation for neck pain. For acute neck pain, we have no data from any study on what proportion of patients are rendered pain free immediately after treatment or in the short term. The studies only attested to some degree of reduction of pain.18, 19 At 2 years after treatment, the only study that provided data indicated that manual therapy is as effective as analgesics, but that home exercises are more effective.17 For chronic neck pain, only one study provided short-term data on the efficacy of manipulation, namely that 48% of patients were rendered pain free at 1 and 4 weeks.4, 5 No long-term data are available on the proportion of patients achieving complete relief of pain. The studies reviewed by Ernst reported only mean improvements. These amounted to changes in visual analog scores for pain of only 12 of 30 to 6 of 30 in one study16 and 57 of 100 to 37 of 100 in the other.6

Regardless of whether manipulation is more effective when compared to other treatment for neck pain, its absolute effects are limited and modest. Reduce pain it might, but eradicate pain it does not. Moreover, it is not more effective than other interventions, which do not require the same degree of allegedly necessary training and skill, which do not carry the same risks of morbidity, and which the patients can do for themselves, if and once properly instructed.

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References 

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PII: S1526-5900(03)00733-8

doi:10.1067/S1526-5900(03)00733-8

The Journal of Pain
Volume 4, Issue 8 , Pages 427-428, October 2003

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