Abandon cervical spine manipulation for mechanical neck pain?

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I always like following stories like this. Yesterdays BMJ had a Yes/No point/counterpoint on cervical spine manipulation for neck pain (subscription needed to access full text):

Should we abandon cervical spine manipulation for mechanical neck pain? Yes
BMJ 2012;344:e3679

Should we abandon cervical spine manipulation for mechanical neck pain? No
BMJ 2012;344:e3680

The British Chiropractic Association were quick to respond with a press release:
Should spinal manipulation for neck pain be abandoned?

The Stuff & Nonsense blog was quick to respond to the sentence I highlighed above in the press release. pointing out that the British Chiropractic Associations are the experts in cherry picking:
The British Chiropractic Association: experts in cherry-picking

Full post

As of posting this, there is only one comment on the articles at the BMJ from some physiotherapists:

At the time of posting this, the poll on the BMJ home page was running:
Yes 52.63% (60 votes)
No 47.37% (54 votes)

 

Browsing at Google news shows this story is getting a lot of traction.

 

Visiting a local Indian barber to get my hair cut (head shaved) for the princely sum of $USD3 I also enjoyed also a head massage followed- to my surprise- by a cervical neck manipulation!!!

Got to admit that afterward my neck felt great, and since then (almost 5 years ago) I have definitely has less neck trouble!!

Didn't see any qualifications on the wall to suggest he was also a Doctor of Chiropractic or a Physio...

 

The last cervical manipulation i had was in the 70's and haven't let any clinician or otherwise near my neck since, because of the vertebral artery!

 

The bold hegemony of medical political bodies is at times appalling. When you objectively consider the efficacy, history of safety and evidence supporting chiropractic spinal manipulation, it is not difficult to posit what they are up to at the BMJ. A very similar dog and pony show of misinformation was leveled at the chiropractic profession via the AMA in the US during the 50’s. The result was 11 years of legal wrangling in Wilk et. Al vs. the AMA in which began in 1976 and was concluded in 1987. The AMA and its officials were found guilty, as charged, of attempting to eliminate the chiropractic profession. During the proceedings it was shown that the AMA attempted to:
• Undermine Chiropractic schools
• Undercut insurance programs for Chiropractic patients
• Conceal evidence of the effectiveness of Chiropractic care
• Subvert government inquires into the effectiveness of Chiropractic
• Promote other activities that would control the monopoly that the AMA had on health care (This was upheld by the 7th United States Circuit Court of Appeals.)

The plain fact is that studies such as the Manga Report, RAND, AHCPR, New Zealand Commission of Inquiry and most recently the Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) all found spinal manipulation, as performed by chiropractic doctors superior to other interventions. This is high-quality evidence and cannot be ignored and keep in mind this research was performed by interdisciplinary teams.

Less research has been performed on neck pain and headache, but it is currently underway and what evidence is out there actually supports the unequivocally. I guarantee you the results will be similar, until then the profession must endure such heavy-handed attempts by the medical boards to contain the competition. The BMJ is cherry-picking the area where the least evidence exists and exploiting this, catastrophising and attempting to lay the foundation of mistrust of a valid healing art.

As for the issue of safety, we can waffle back and forth with the different studies but the plain fact is that conservatively 107,000 people are hospitalized for complications and adverse effects from NSAID’s yearly and at least 16,500 NSAIS related deaths occur among arthritis patients alone." (Singh Gurkirpal, MD, “Recent Considerations in Nonsteroidal Anti-Inflammatory Drug Gastropathy”, The American Journal of Medicine, July 27, 1998, p. 31S). This includes both rheumatoid and osteoarthritis, the latter, a condition commonly treated in the chiropractic office.

Given that this is fact and what the BMJ article proposes is based on opinion and speculation, patients should have choices based on the best evidence and the truth. I am fond of saying chiropractic is not for every one; you have a choice. Attempts to influence the public's choices based on fear mongering is anathema, pusillanimous and not in the public interest. The question should be how do we fund and structure better research to arrive at an unbiased truth? I know that the chiropractic profession is not afraid of the outcome; look at Medicare and Consumer Reports polls based on patient satisfaction of chiropractic care and decide if this is really about "safety"? Clearly, it is not.

Quality data on Vertebral Artery Dissection and stroke and reporting are both a concern to the chiropractic profession and the public obviously. What we need is to arrive at the truth and the opposition to cease misinforming and frightening the public unnecessarily. What we do know is that there is a risk of spinal manipulation causing these unfortunate events but that the risk does not appear to be any higher than visiting your family physician. This is fact. The BMJ conveniently left that part out.

I can tell you this. My malpractice rates are about double my auto insurance premiums and that if there were a statistical rationale for higher premiums due to payouts, insurers wouldn’t offer 1/3 million dollar policies for $1,300 per annum now would they?

Show us the money BMJ; where are all of these catastrophes attributed to cervical spinal manipulation as performed by chiropractic doctors? Show us the hard data, words and hyperbole are cheap and perhaps that is precisely why you don’t support your claims with facts?


Things are generally other than they seem, and ignorance that never looks beneath the rind becomes disabused when you show the kernel. Lies always come first, dragging fools along by their irreparable vulgarity. Truth always lags last, limping along on the arm of Time. The wise therefore reserve for it the other half of that power which the common mother has wisely given in duplicate. Deceit is very superficial, and the superficial therefore easily fall into it. Prudence lives retired within its recesses, visited only by sages and wise men.

Balthasar Gracian

 

David - thanks for that!

I don't really have an opinion one way or another.

My interest in the story, like a lot of others I follow are the issues of cherry picking (by both sides!) and confirmation biases and the use, misue, undertsanding, misunderstanding etc of science and how the popular media interpets it (hence why I started the thread) - to me its more about those sorts of issues...

I see parallels to this in the barefoot issues, the MMR and autism issues, the 9/11 consiprary theories, the holocaust deniers, why smart people fall for pseudoscience, how the n=1 outweighs the science, etc

 

Craig,

Thank you for that. I know you well enough to know better than to assume that your interest was anything other than an objective interest in science Craig. You allude parallels of the barefoot issues, the MMR and autism issues, the 9/11 consiprary theories, the holocaust deniers...not lost on me either, completely agree!

Those of you who know me also know that there isn't anything that Craig wrote that isn't acceptable to me either. As a practicing DC, I admit a bias based on my own clinical experience, devotion to my patients and to my profession.

That said, where we're discussing the efficacy of chiropractic spinal manipulation for low back and neck pain (and often a variety of headaches), it is no longer "alternative" but "mainstream" and the public deserves the truth about both its efficacy AND its safety. These sordid scare tactics aren't anything new but they are tiresome. Good on the physio who responded so appropriately.

To Craig T: I'm sure you're aware of the symbolism of the Barber's Pole of lore? They performed surgery, tooth extractions and bloodletting....and apparently spinal manipulation!

To Mark: The evidence of a link between SMT VAS and stroke is not conclusive, that is what we do know despite all of the rhetoric. A good clinician screens patients very carefully and rules out potential red flags prior to attempting SMT of the cervical spine. There are of course other much more common risks that are routinely ruled out as well, just as there are with medications, surgery, physical therapy and OTC interventions. Informed consent finally became law in my state this year and I for one support it.

 

Craig, how do you place the so-called 9/11 conspiracy theories in with those other mentioned. You'll be spouting the Popular Mechanics articles as proof of disproof soon. Try some in-depth reading, don't believe the conspiracy theories, beware of the straw-man arguments, and David I would be a 'red flag' for SMT of the cervical spine, mark

 

David, I'd assume dissection isn't necessary for an emboli to form from vertebral artery plaques? Is the data just as insignificant for this process? thanks, mark

 

Mark,

I am not aware of any literature showing an increased risk of emboli from cervical manipulation loosing a thrombus in those with vertebral plaques. It is plausible, but then it is also plausible to visit the hair salon and extend and rotate your neck in the sink and have this occur and such cases have been documented.

I would hope that any provider performing manipulation would inquire as to the complete health of the patient and rule out comorbidities, anticoagulant medication etc.

 

The folks who truly know the risks for just about everything are insurance companies.

If you ask a local chiro in my area what their cost for malpractice insurance is....it is about $1000.00.

If you ask the local orthopedic surgeon....it is about 25-50-100 times that amount.

I guess that really sheds light on what is risky in medicine and what is not!


Howard

 

Mark that should have read vertebral artery plaques.

Statistically, the top four reasons for chiropractic malpractice claims are and remain:

1. Failure to diagnose
2. Failure to refer
3. Disc herniation
4. Other miscellaneous complaints, such as burns

Statistics on this are very difficult to find, some place chiropractic claims for VAD at 9% of all claims, most are dramatically lower. Honest statistics would be welcome.

The only stroke found to be associated with cervical spinal manipulation is vertebral artery dissection (VAD). The problem is that in many of the cases studied, the only presenting complaint was “neck pain” a non-specific symptom commonly treated in the chiropractic office. We just do not have conclusive proof one way or the other that these patients would have suffered a dissection had they not had SMT. I agree that reporting needs to be improved and documented in the literature, as well as inadequate and misreporting.

I had a call today from a local neurologist, who happens to be a friend, to discuss another matter. I took the opportunity ask him if in his 8 years of medical training, residency, decades of private practice and affiliation with the local hospital, if he had ever encountered a case of VAD post chiropractic SMT. His answer was no, but he had seen Wallenberg cases due to rollercoaster rides at popular local theme parks. This is in an area populated with a higher than average number of DC’s FYI.

The frank disparity of malpractice insurance premiums was not lost on Howard. I wonder how the BMJ would spin those niggling statistics? Perhaps the NHS should conduct a patient satisfaction poll as Medicare did in the US, it is difficult to arrive at the truth relying on competing professions' turf schisms. I think based on the outcome of such a poll, cost-effectiveness, benefit to risk etc we could "put this baby to bed".

It is safe, you just don't like it because its not "med"icine. No surprise here. On our end if some of my colleagues would simply abandon some long-held beliefs that aren't scientific and embrace better research and science, perhaps the media bloody noses would be less frequent.