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Spinal manipulation for neck pain does not work

  • Nikolai Bogduk
    Correspondence
    Address reprint requests to Nikolai Bogduk, MD, Department of Clinical Research, Level 4, David Maddison Building, Royal Newcastle Hospital, Newcastle NSW 2300, Australia.
    Affiliations
    Department of Clinical Research, Royal Newcastle Hospital, Newcastle, NSW, Australia
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      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 previous
      • Aker P.D.
      • Gross A.R.
      • Goldsmith C.H.
      • Peloso P.
      Conservative management of mechanical neck pain Systematic overview and meta-analysis.
      or other recent reviews.
      • Gross A.R.
      • Kay T.
      • Hondras M.
      • Goldsmith C.
      • Haines T.
      • Peloso P.
      • Kennedy C.
      • Hoving J.
      Manual therapy for mechanical neck disorders A systematic review.
      • Harms-Ringdahl K.
      • Nachemson A.
      Acute and subacute neck pain: Nonsurgical treatment.
      • Peeters G.G.M.
      • Verhagen A.P.
      • de Bie R.A.
      • Oostendorp R.A.B.
      The efficacy of conservative treatment in patients with whiplash injury A systematic review of clinical trials.
      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,
      • Heller C.A.
      • Stanley P.
      • Lewis-Jones B.
      • Heller R.F.
      Value of x ray examinations of the cervical spine.
      • van der Donk J.
      • Schouten J.S.A.G.
      • Passchier J.
      • van Romunde L.K.J.
      • Valkenburg H.A.
      The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population.
      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.
      • van der Donk J.
      • Schouten J.S.A.G.
      • Passchier J.
      • van Romunde L.K.J.
      • Valkenburg H.A.
      The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population.
      In other studies the prevalence of disc degeneration was found not to differ in symptomatic and asymptomatic individuals.
      • Fridenberg Z.B.
      • Miller W.T.
      Degenerative disc disease of the cervical spine A comparative study of asymptomatic and symptomatic patients.
      Moreover, uncovertebral osteophytes and osteoarthrosis of the synovial joints of the neck were found to be less prevalent in symptomatic individuals.
      • Fridenberg Z.B.
      • Miller W.T.
      Degenerative disc disease of the cervical spine A comparative study of asymptomatic and symptomatic patients.
      Tender points or trigger points are neither reliable nor a valid sign of the cause of neck pain.
      • Bogduk N.
      The neck.
      • Bogduk N.
      • Simons D.G.
      Neck pain: Joint pain or trigger points.
      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 only
      • Cassidy J.D.
      • Lopes A.A.
      • Yong-Hing K.
      The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine A randomised controlled trial.
      • Vernon H.T.
      • Aker P.
      • Burns S.
      • Viljakaanen S.
      • Shjort L.
      Press pain threshold evaluation of the effect of spinal manipulation in the treatment of chronic neck pain A pilot study.
      and 2 long-term studies.
      • Bronfort G.
      • Evans R.
      • Nelson B.
      • Aker P.
      • Goldsmith C.H.
      • Vernon H.
      A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.
      • Jordan A.
      • Bendix T.
      • Nielsen H.
      • Hansen F.R.
      • Host D.
      • Winkel A.
      Intensive training, physiotherapy, or manipulation for patients with chronic neck pain A prospective, single-blind, randomised clinical trial.
      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.
      • Vernon H.T.
      • Aker P.
      • Burns S.
      • Viljakaanen S.
      • Shjort L.
      Press pain threshold evaluation of the effect of spinal manipulation in the treatment of chronic neck pain A pilot study.
      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,
      • Cassidy J.D.
      • Lopes A.A.
      • Yong-Hing K.
      The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine A randomised controlled trial.
      but Ernst did not point out that this difference disappears once the data are adjusted for baseline differences.
      • Hurwitz E.L.
      • Aker P.D.
      • Adams A.H.
      • Meeker W.C.
      • Shekelle P.G.
      Manipulation and mobilization of the cervical spine A systematic review of the literature.
      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 studies
      • Brodin H.
      Cervical pain and mobilization.
      • Brodin H.
      Cervical pain and mobilization.
      • Howe D.H.
      • Newcombe R.G.
      • Wade M.T.
      Manipulation of the cervical spine Pilot study.
      • Hoving J.L.
      • Koes B.W.
      • de Vet H.C.
      • van der Windt D.A.
      • Assendelft W.J.
      • van Mameren H.
      • Deville W.L.
      • Pool J.J.
      • Scholten R.J.
      • Bouter L.M.
      Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain A randomized, controlled trial.
      • McKinney L.A.
      • Dornan J.O.
      • Ryan M.
      The role of physiotherapy in the management of acute neck sprains following road-traffic accidents.
      • Mealy K.
      • Brennan H.
      • Fenelon G.C.C.
      Early mobilisation of acute whiplash injuries.
      used by systematic reviews
      • Gross A.R.
      • Kay T.
      • Hondras M.
      • Goldsmith C.
      • Haines T.
      • Peloso P.
      • Kennedy C.
      • Hoving J.
      Manual therapy for mechanical neck disorders A systematic review.
      • Harms-Ringdahl K.
      • Nachemson A.
      Acute and subacute neck pain: Nonsurgical treatment.
      to advance the efficacy of manual therapy did not all study manual therapy in isolation. Some combined manual therapy with exercises.
      • Hoving J.L.
      • Koes B.W.
      • de Vet H.C.
      • van der Windt D.A.
      • Assendelft W.J.
      • van Mameren H.
      • Deville W.L.
      • Pool J.J.
      • Scholten R.J.
      • Bouter L.M.
      Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain A randomized, controlled trial.
      • McKinney L.A.
      • Dornan J.O.
      • Ryan M.
      The role of physiotherapy in the management of acute neck sprains following road-traffic accidents.
      • Mealy K.
      • Brennan H.
      • Fenelon G.C.C.
      Early mobilisation of acute whiplash injuries.
      Thus, the effects of these 2 interventions cannot be disentangled in these studies, but other studies do provide data.
      McKinney et al
      • McKinney L.A.
      • Dornan J.O.
      • Ryan M.
      The role of physiotherapy in the management of acute neck sprains following road-traffic accidents.
      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 al
      • Hoving J.L.
      • Koes B.W.
      • de Vet H.C.
      • van der Windt D.A.
      • Assendelft W.J.
      • van Mameren H.
      • Deville W.L.
      • Pool J.J.
      • Scholten R.J.
      • Bouter L.M.
      Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain A randomized, controlled trial.
      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.

      Hoving JL. Neck Pain in Primary Care (PhD thesis). Amsterdam, the Netherlands, Vrie Universitet, 2001

      Brodin,
      • Brodin H.
      Cervical pain and mobilization.
      • Brodin H.
      Cervical pain and mobilization.
      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 al
      • Howe D.H.
      • Newcombe R.G.
      • Wade M.T.
      Manipulation of the cervical spine Pilot study.
      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.
      • McKinney L.A.
      • Dornan J.O.
      • Ryan M.
      The role of physiotherapy in the management of acute neck sprains following road-traffic accidents.
      • Mealy K.
      • Brennan H.
      • Fenelon G.C.C.
      Early mobilisation of acute whiplash injuries.
      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.
      • McKinney L.A.
      Early mobilisation and outcomes in acute sprains of the neck.
      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.
      • Brodin H.
      Cervical pain and mobilization.
      • Brodin H.
      Cervical pain and mobilization.
      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 study
      • Jordan A.
      • Bendix T.
      • Nielsen H.
      • Hansen F.R.
      • Host D.
      • Winkel A.
      Intensive training, physiotherapy, or manipulation for patients with chronic neck pain A prospective, single-blind, randomised clinical trial.
      and 57 of 100 to 37 of 100 in the other.
      • Bronfort G.
      • Evans R.
      • Nelson B.
      • Aker P.
      • Goldsmith C.H.
      • Vernon H.
      A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.
      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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