What does “Treatment of Neck Pain: Noninvasive Interventions” tell us about chiropractic

 Those following our Spot the Mistake posts (here, and here) will notice someone has claimed we’ve gone “…on a chiropractic witch hunt”. As it happens, I disagree. Those who haven’t been following along, this post is an overview of the evidence for or against manipulative therapies (which includes chiropractic) in neck pain, as covered by this particular article from spine. It’s framed as a response to a specific commentors post here.

Let’s give Nick alot of credit for walking into potentially hostile territory though. Let’s give him even more credit for defending his ideas with a citation. He cited the article mentioned in the title, “Treatment of Neck Pain: Noninvasive Interventions, Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders.” Full citation at the bottom of the page.

Nick said:

Spinal manipulation (performed by osteopaths, physical therapists, and most often chiropractors) and /or NSAIDS are the evidence-recommended first lines of therapy in uncomplicated LBP and neck pain. A combination of exercise and manual therapy> is more effective with necck pain w/o radiculopathy than manipulation alone.
If you would like to educate yourself on neck pain and evidence based care, read the summary articles in Spine. You may be surprised(or not) of the efficacy and safety of spinal manipulation of the cervical spine and the lack of support for many other treatments.

Read summaries in Spine. 2008 Feb 15;33(4 Suppl):S123-52. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

(emphasis mine)

A few points.

  1. Spinal manipulation done by physical therapists, is not the same as that done by osteopaths, nor the same as that done by chiropractors. Conflating the three, is confusing the issue. Please note, that the paper conflates these as well, so it’s not Nick’s fault.
  2. “Manual therapies” are not the same thing as spinal manipulation. Mobilization, which is the most common treatment modality at my institution, is manual therapy, but NOT manipulation. Conflating the two is confusing the issue. 
  3. Are we reading the same paper? Looking up the paper you’ve cited in Spine, I don’t feel that it says at all what you just said.

Here’s some quotes from the discussion section of the paper:

Lack of scientifically acceptable evidence precludes summary statements on cervical and thoracic manipulation, traction, and NSAIDS and other medications in the treatment of WAD.

●Medications (orphenadrine/paracetamol, piroxi cam, indomethicin, benorylate/chlormezanone), per-cutaneous neuromuscular therapy, mobilization, and LLLT were found efficacious in the short-term when compared with placebo or sham interventions.


● Active exercise, combined with education emphasizing self management and return to normal function, was more beneficial than manual therapy, TENS, neck collar, or simple advice (singly or as part of a multimodal intervention) for patients with “nonspecific” neck pain. There were few if any differences between the effectiveness of endurance versus strength training, manipulation versus mobilization, manual therapies versus acupuncture, and various passive multimodal approaches without active exercise components.

(Emphasis all mine)

So what does that mean? The first quote says that with whiplash, there isn’t good scientific evidence on manipulation, traction, or medications.The second quote says that active exercise and education were more beneficial than manual therapy or anything else. Please note that active exercise is NOT chiropractic modality especially as researched by this paper, which calls chiropractic care manipulative.

Here’s what the same paper says about “manual therapies” in it’s conclusions and evidence statements.

Referring to whiplash:

There is consistent evidence from 4 RCTs that active therapies involving mobilization were associated with greater pain reduction in the short term among persons with acute WAD when compared with usual care, soft collars, passive modalities, or general advice.

There is evidence from one RCT that immobilization in a rigid collar for 2 weeks followed by active mobilization or active mobilization within 72
hours of injury was as effective as usual care (focused on reducing fear and staying active) for persons with acute WAD after 12 months of follow up.

(again, all emphasis mine)

So for whiplash, as mentioned in the discussion, mobilization within 72 hours, or mobilization after 2 weeks in a rigid collar works. Nothing at all about an evidence based role for manipulative therapies.

And later, referring to nonspecific neck pain and manual therapies, which is (from my read) where Nick says there is a role for chiropractic:

There is consistent evidence from 4 RCTs that cervical spine manipulation alone or with advice and home exercises was not associated with greater pain or disability reduction in the short or long-term in persons with subacute or chronic neck pain when compared with mobilization with or without traction, to strengthening exercises, or to instrumental manipulation.

There is consistent evidence from 4 RCTs that mobilization or exercise sessions alone or in combination with medication was positively associated with better pain and functional outcomes in the short-term (4–13 weeks) in people with subacute or chronic neck pain when compared to usual GP care, pain medications, or advice to stay active.

There is evidence from 2 RCTs that manipulation or mobilization was not associated with better pain or disability outcomes(3–12 months) in people with subacute or chronic neck pain when compared with exercises alone or to exercise combined with massage or passive modalities.

(emphasis mine)

 (UPDATED to reflect Tim’s correction noted below) Thats some weak kung-fu. The first paragraph says that manipulation with or without home exercises is no more effective than mobilization. The second paragraph says that mobilization, works better in the short term compared to usual care, pain meds, or just advice to be active. No mention of manipulation. The third paragraph explicitly says that neither manipulation nor mobilization are better in the long term (greater than three month) outcome, when compared to the alternatives.

So a valid criticism here could be that we don’t treat nonspecific neckpain well. You certainly couldn’t say that manipulation is the “evidence based treatment” of choice. 

 From the “Safety of interventions” section:

There is evidence from 2 population-based case control studies and a case-crossover study that chiropractic care was associated with a very smallincreased risk of posterior circulation stroke in people under age 45; however, because this increased risk is also seen in those seeking health care from their primary care physician, this association is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.

 There is evidence from one RCT that manipulation (vs. mobilization) was associated with an increased risk of minor adverse reactionsin patients with mostly subacute or chronic neckpain.

So is it safe? Well, as far as posterior circulation stroke is concerned (the subject that started all this!) chiropractic care was associated with a very small increased risk. But wait! Vindication! If you went to your PCP, you had the same increased risk.

The paper postulates that this could be due to people going to the doctor OR the chiropractor with a stroke in progress.  I feel that this is too speculative to take seriously. The reason I say this is that the data they covered does not say anything about the time course and history of pain the patients went to their PCP or DC for, which would be critical in knowing if a stroke was in progress, or caused by therapy.

 A stroke is an acute event. The patient would not necessarily have chronic neck pain already. Those who get referred to chiropractors usually are referred for chronic neck pain, rather than acute onset pain. Further research is necessary to make a point on the risk of stroke. Don’t worry, I’m searching, I just haven’t found a paper that actually covers this material well.

I’m biased on this particular point. I admit this for full disclosure, and I speak only from personal anecdote here. I’ve seen only 2 young patients (both  in their 20’s) with posterior circulation strokes associated with dissection. Both had just been to their chiropractor. Both said they were going for a “maintenance adjustment”, and neither had pain before going to their chiropractor. In both cases, the chiropractor said their pain after manipulation was normal, and both patients went to the ER only after another family member noticed gross neurologic signs.  Clearly these 2 patients can’t fit into the explanation offered by the paper, because they didn’t have pain when they went to the chiropractor.

And the last quote? More bad news for manipulation. Manipulation was associated with more minor adverse reactions (ironically, neck pain) than mobilization.

From the Cost effectiveness section:

There is evidence from one RCT that manual therapy (mobilization) was more cost effective in patients with subacute or chronic neck pain when compared with physical therapy (sessions of active exercises) and usual care by a general practitioner

Well, manual therapy can be more cost effective. Sadly, it’s mobilization, NOT manipulation that is found to be more cost effective.

From the “cervicogenic headache”

There is evidence from one RCT that therapeutic exercise with or without manipulation or mobilization was associated with fewer headaches and a
better global outcome after 1 year in patients with cervicogenic headache when compared with no treatment

 So it’s exercise that’s key, whether or not you add in manipulation OR mobilization, when we talk about cervicogenic headache. Still no positive manipulation recommendations.

Side note: I know many (not all) chiropractors that discharge patients and don’t see them forever. Patients usually return to their care because they have a new injury or another episode of their symptoms.

 I’ll match your anecdote with one of my own. I’ve spoken to 12 chiropractors, and all said that everyone needs maintenance manipulations, for life, and that they never discharge patients. Awaiting nonanecdotal data, I don’t trust your anecdote anymore than I trust mine.

Thanks for your post. I will try and address a couple points for you just to put this aside to bed.

It does seem that there is a dearth of public knowledge on spinal manipulation and a strange stigma associated with it in the U.S. You see it accepted and utilized much more in Europe and Australia.

[Citation Needed]

There is a strange stigma associated with it in the US, by the way, because chiropractic here has consistently been associated with anti-science, and vitalistic schools of thought. The theorhetical basis of chiropractic stems from the believe that all disease is caused by obstruction in “innate intelligence,” which is counter to everything we’ve learned about physiology in the past 150 years. Since then some vague theories about nerve compression, or fascial compression has been discussed, but none of it validated.

1) In most cases, proper exercises and/or stretches will help neck pain. A patient should seek care if they are having severe symptoms or after a short duration (2-7 days) of unrelenting symptoms. Question: Where does the general public get those exercises?

Exercises are not primarily the domain of chiropractic care. Physical therapists are more equipped to do that. So are family practioners. The latter two also use evidence based modalities of exercise. Indeed, on my family medicine months, we spent alot of time teaching  exercises, and referring to physical therapists. 

2) If that patient does seek care, you would like them to utilize the most appropriate/evidence/value based therapy or practitioner. If you know or ask many practicing family MD/DO’s, you would find that not only is musculoskeletal care not their strongest area but they usually don’t enjoy seeing that patient type. My last post described the overwhelming evidence stating spinal manipulation/chiropractic manipulation be used used first in uncomplicated cervical pain.

Complete speculation, self-contradictory, and (I’m assuming) a complete misunderstanding of your own cited resource. Ask any DO, and they’ll tell you that their advantage over MD’s is more extensive training in the musculoskeletal system. You yourself mentioned DO’s on the list of practioners who provide spinal manipulation. Do you think that osteopaths don’t understand spinal manipulation as well as chiropractors but use it anyway?

As it happens, when you ask the practitioners who treat musculoskeletal pain, you get two groups. The first group is generalists – family practice, general internal medicine. In that case, no particular area is their “area of expertise”. The other group would be sports med doctors, and physical medicine doctors. They would tell you that yes, they know the musculoskeletal system inside and out. Your comment expresses a fundamental misunderstanding of the medical system, and differentiations among medical doctors.

As we have seen, your post did NOT describe overwhelming evidence stating spinal manipulation or chiropractic manipulation be used first in uncomplicated cervical pain. I assume that you misunderstood the text. It would be easy to mistake “manual” as meaning manipulation. Please note the article describes “manual” as both mobilization and manipulation. The article describes chiropractic care solely as manipulation, NOT mobilization.

As a side note, if you think you didn’t misunderstand the text, take the easy out and say you did anyway. Because the alternative is that you don’t know just how much you don’t know, or that you deliberately misrepresented the data.

3) I am not sure where you have received information on spinal manipulation being “expensive”. If you are eluding to the chiropractic profession being expensive, you will find that they are actually more cost effective when compared to medical care in spine pain. Increasing amounts of research shows this.

Well, see above, the paper YOU cited, doesn’t say that.

Sorry for this getting long. Some things need to be looked at without older, prejudiced glasses. Especially those that will be our future health care providers.

Our future health care providers need to look at things with evidence based eyes. Where the evidence is clear, there is no question. As far as this article is concerned, no good reason to use chiropractic for neck pain.

UPDATE: PalMD also has a post up dealing with chiropractic information being presented incorrectly.

Hurwitz, E., Carragee, E., van der Velde, G., Carroll, L., Nordin, M., Guzman, J., Peloso, P., Holm, L., Côté, P., Hogg-Johnson, S., Cassidy, J., & Haldeman, S. (2008). Treatment of Neck Pain: Noninvasive Interventions Spine, 33 (Neck Pain Suppl) DOI: 10.1097/BRS.0b013e3181644b1d

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13 Comments on “What does “Treatment of Neck Pain: Noninvasive Interventions” tell us about chiropractic”

  1. Incidentally Nick, is there anything you want to disclose about your profession at this time?
    Are you a neutral player here? A mere chiropractic enthusiast? Or do you have a dog in this race?

  2. catgirl Says:

    Thank you for the excellent post. I have experienced both chiropractic and osteopathic adjustments in the past, and they are certainly not the same. I haven’t had physical therapy, so I can’t really compare it to the others. But I am surprised to see those three very different things lumped together. I’m curious, do you have any data on osteopathy for neck and back pain? What about just getting massages for occasional back pain? Also, what’s the difference between manipulation and mobilization? (It’s possible that I just didn’t read clearly enough.)

    • Manipulation is adjustments as done by an osteopath/chiropractor/physiotherapist.
      Theorhetically they are moving you in ways unlike the normal movement of the joint. Either off axis from the normal movement, or further than normal movement.

      Mobilization exercises are movements within the normal range of motion for the joint.

  3. MXH Says:

    Nice post! A lot of people skew findings from research articles to serve their needs (and make it look like they’ve won an argument). Since few people actually bother to read the papers they cite, it usually works. This is an important lesson to many of us, just because someone says an article backs up their claims, doesn’t mean that it actually does.

  4. Tim Kreider Says:

    Tales, it looks to me like you misinterpreted a sentence in your fourth quote box. I read it as: manipulation was not associated with “greater pain reduction” than was mobilization; i.e., it was “no more effective”, rather than “not worse” as your bold font suggests. But I didn’t go to the original source, so maybe your reading is correct given the full context.

    Minor point. Great post!

  5. JLK Says:

    WhiteCoat – I have no idea what kind of doctor you intend to become, but if you become a primary care or a GYN or any other doctor that I would be likely to use frequently…..will you be MY doctor? 😉

    • I’d love to! You probably wouldn’t want to be seeing me on a regular basis though! I’m going into Emergency Medicine.

      If that seems weird since my posts have been pretty PCP/OBGYN oriented, it’s because I’ve been writing about where I’ve been rotating.

      Oh, and the fact that most of the pseudoscientists don’t mess with emergency medicine.

  6. D. C. Sessions Says:

    WcT, I’m delighted to read that you’re heading into Emergency. Awesome field, even to a peripheral first responder (ski patrol) like me. Hope your adrenal system is up to it.

    If you want a tip on retiring that killer debt: Indian Health Service. Last I looked, we have a shortage in the West, and they more than make up for the unimpressive pay with loan forgiveness.

    Either downside or upside, your choice: it ain’t urban. That’s either hell on earth or about as sweet as it gets, only you can tell.

    • I’ve looked into it, but not in the west – I’m a solidly midwestern boy, and theres some spots up here as well.

      My fiance’ and I are both in professional school, we felt like the only way to manage a family is to end up somewhere we have family nearby to help out. So most of our destinations are midwestern as well.

      The local programs are all great though, and I’m well networked with the programs out here.

      Honestly, I’ve spent time in the inner city, and some in the rural county hospitals. Both settings interest me. It’s more the underserved aspect of it that appeals to me. Where the population is underserved, I get to do a little more primary care, and a little more speciality care all at the same time. And the patients are so much more grateful.

      In some of those inner city areas, I feel like we can still practice medicine like it’s meant to be practiced, not looking over our shoulders for a lawyer, not kicking our patients out the door.

      The question will be end career goals. Right now, I’m really feeling academia, which (mostly) places me in the inner city.

  7. I used to be suggested this website by way of my cousin. I am no longer positive whether or not this post is written by means of him as nobody else recognize such specific about my difficulty. You are wonderful! Thank you!chiropractic

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