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Should spinal manipulation for treating neck pain be abandoned?

The British Medical Journal (BMJ) has on June 8, 2012 published a debate in which English and Canadian researchers disagree on the suitability of spinal manipulative therapy (SMT) for neck pain. The discussion centres on the the risk of a VBA stroke (VBA), which is a tear in the inner lining of the artery running up the neck and into the brain. It is summarised by the BBC here.

The English team believes that SMT can cause a VBA, that the risk of it happening outweighs the potential benefits, and that the procedure should be abandoned. However, their Canadian colleagues disagree saying that it is a valuable addition to patient care and that abandoning this type of treatment will harm the patients.

Chiropractic is the profession most well known for using SMT but it is also used by other professions, some more skilled than others. Looking objectively at all of the available evidence neck manipulation has been shown to be a safe and effective way of providing relief from neck pains and headaches. The latest larger review of recent research was published in 2010 and it is available here in PDF format.

This VBA debate has gone on for years and various scientific articles have pointed in opposite directions but it is particularly British researchers who appear determined to discredit SMT. The argument is whether the estimated 1 in 1,350,000 (yes, 1.35 million) risk of suffering a stroke from a vertebral artery dissection is worth it. For one practitioner manipulating 20 necks every weekday that is one occurrence every 260 years(!) and as you can read below some research suggests that SMT is unlikely cause the stroke.

In response to the debate the British Chiropractic Association published the following:

' A debate has been published in the British Medical Journal (8 June 2012), questioning the safety of neck manipulation.  Neck manipulation has been shown to be safe and effective and benefits thousands of people suffering from neck pain and headaches.  In fact, the risk of a stroke after treatment is the same whether you see a GP and get a prescription or see a chiropractor and get your neck adjusted.  Manipulation of the neck is at least as effective as other medical treatments and is safer than many of the drugs used to treat similar conditions.

The term chiropractic is often mis-used for treatment carried out by non-chiropractors.  This leads to over-reporting of incidents blamed on chiropractors,  including in the BMJ.

In one report of 24 cases attributed to chiropractors, not one was shown to be a chiropractor

Chiropractors are highly trained in spinal care.  In one UK study undertaken in 2007, of 50,000 neck treatments reviewed, not one single adverse event was reported.

The cherry-picking of poor quality research needlessly raises alarm in patients and does little to help the people suffering from neck pain and headaches to choose the most appropriate treatment.

If you have any concerns about your treatment, please discuss this with your chiropractor ' .

So - the fact that the stroke risk from going to your GP with a painful neck is the same as having your painful neck manipulated suggests that the pains are likely to be a sign that the dissection of artery has already got started with the stroke imminent. Hence neither treatment is to blame. Furthermore, in a January post I referred to a study showing that both SMT and exercise were more effective than commonly prescribed medication, which appear to carry a greater risk than receiving manipulative treatment. The risks associated with taking pain killing and anti-inflammatory drugs are not always appreciated by the patient.

The third study I think speaks for itself and one would hope that the researchers simply made a mistake.

I was involved in supplying data for the 2007 study, which was a large well-designed nationwide study. The sheer numbers of adverse reaction free neck adjustments help to prove the safety of spinal manipulation of the neck.

Current evidence suggests that spinal manipulation provided as a standalone therapy has no statistical benefit over standalone exercise therapy. However, at Park View Acupuncture and Chiropractic Clinic we do not use SMT as our only approach. We combine it with various muscle and soft tissue massage and stretching techniques, with mobilisation, exercises and home care advice. If we feel that SMT is inappropriate or if any of our patients prefer not to use SMT we simply choose other techniques more suitable to the patient in front of us, young or old.

We appreciate that it is difficult to sift through medical literature to choose a worthwhile therapy especially when, at times, even the researchers cannot make up their minds. Ask friends and family for recommendations, and share your personal experiences to benefit others. However, always make sure that the person you choose is qualified to do the job and is a member of a relevant professional body.

We aim to deliver evidence based, effective treatment - and should conclusive evidence suggest that we are better off doing things differently, then we will. For now, though, we will stick with what a balanced view of the current evidence suggests is best and provide a package of care tailored to each individual requesting our help.

As the BCA suggests feel free to call me on 01903 230066  or email me if you have any concerns or queries.

See also:: Chiropractic neck manipulation is safe

                  Neck Pain Task Force findings, Spine Journal 2008

Jan Olsen DC

Principal Chiropractor

Park View Acupuncture and Chiropractic Clinic



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