MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Chiropractors and osteopaths have long tried to convince us that spinal manipulation and mobilisation are the best we can do when suffering from neck pain. But is this claim based on good evidence?

This recent update of a Cochrane review was aimed at assessing the effects of manipulation or mobilisation alone compared with those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up, and when appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). They also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies.

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain were included in this assessment.

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). The authors calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

Fifty-one trials with a total of 2920 participants could be included. The findings are diverse. Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

Confused? So am I!

In my view, these analyses show that the quality of most studies is wanting and the evidence is weak – much weaker than chiropractors and osteopaths try to make us believe. It seems to me that no truly effective treatments for neck pain have been discovered and that therefore manipulation/mobilisation techniques are as good or as bad as most other options.

In such a situation, it might be prudent to first investigate the causes of neck pain in greater detail  and subsequently determine the optimal therapies for each of them. Neck pain is a SYMPTOM, not a disease! And it is always best to treat the cause of a symptom rather than pretending we know the cause as chiropractors and osteopaths often do.

The authors of the Cochrane review seem to agree with this view at least to some extent. They conclude that although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

The call for further research is, of course, of no help for patients who are suffering from neck pain today. What would I recommend to them?

My advice is to be cautious:

  • Consult your doctor and try to get a detailed diagnosis.
  • See a physiotherapist and ask to be shown exercises aimed at reducing the pain and preventing future episodes.
  • Do these exercises regularly, even when you have no pain.
  • Make sure you do whatever else might be needed in terms of life-style changes (ergonomic work place, correct sleeping arrangements, etc.).
  • If you are keen on seeing an alternative practitioner for manual therapy, consult a osteopath rather than a chiropractor; the former tend to employ techniques which are less risky than the latter.
  • Avoid both chiropractors and long-term medication for neck pain.

12 Responses to Spinal manipulation/mobilisation for neck pain: caution is warranted

  • DD Palmer said “Chiropractic is founded on different principles from medicine.”
    Quite so.

    He asserted his techniques could relieve pressure and allow ‘innate intellegence’ to flow freely.
    Patients who believe there is such an entity as ‘innate intellegence’ and that it may be freed by adjustments of ‘subluxations’ and that such will allow relief of pain and symptoms – in other words, patients who want their ‘innate intellegence’ dealt with, might reasonably consult a chiropractitioner.

    Otherwise, what would be the point?

    As for osteopathy – same principles apply except that AT Still opined that spinal adjustment released vasoconstriction which otherwise inhibited neurological function. If that is what patients believe (having been given full information) – then they might reasonably consult an osteopath.
    Otherwise, what would be the point?

    First step: Make a diagnosis. Second step:Treat accordingly (most usually by awaiting natural resolution, but perhaps with the assistance of physiotherapy).

    But why complicate healthcare with meta-physical mumbo-jumbo?

  • Timing is everything – I am so pleased I didn’t read your cautious post on chiropractic bofore I fell off a chair, hit my head on a vacuum cleaner and hurt my lower back otherwise I may still be suffering pain. As it was I was fortunate that I had an appointment already scheduled the following day with my long standing and excellent chiropractor (she is extremely busy, so one has to book well ahead) and miraculously felt 100% better afterwards,

  • @ Edzard

    I would agree that caution is warranted.

    However, your advice that exercise is the most appropriate treatment for neck pain, is based on no more conclusive evidence than found in the mobilisation / manipulation Cochrane review.

    The most recent update of Cochrane review on exercise for neck pain has the following conclusion:

    “No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.”

    I would say that this conclusion is no worse but no better than the conclusion from the manipulation and mobilisation review. Therefore, you should also advise mobilisation / manipulation as well as exercise. However, on a risk/benefit view, manipulation can be excluded from recommended advice because of the known risks associated with it.

    People with neck pain should be made aware of what treatments are appropriate for neck pain and the risks that are associated with them, so they can make an informed decision. They should also be told that there is an option to do nothing and wait to see if the condition improves with time. They should be made aware that neck pain has many environmental and personal factors, which can influence the onset and course of neck pain. They should be encouraged to self manage their complaint via a variety of different techniques.

    • As I wrote in the post: one treatment seems to be as good or bad as the other. I nevertheless recommended exercise because it is cheap, risk-free, and involves the patient’s cooperation which may be good for ‘locus of control’ issues. This renders it, in my view, the preferred 1st choice.

      • @ Edzard

        In my view i would still say that mobilisation and exercise are on par with each other. Both can be cheap and help promote self efficacy (if used appropriately). Also the risks associated with each treatment are the same.
        Anyway thanks for the reply and we will agree to disagree.

        • no! manipulations of the neck have been associated with vertebral artery dissection, mobilisations are virtually risk-free.

          • @ Edzard

            I agree. I did write that manipulation can be excluded due to known risk associated with it. Mobilisations (which are different to manipulations) are fine but can still cause soreness after treatment, like exercises

          • it seems that we are in agreement

  • I agree with Edzard here; having suffered chronic pain from cervical spondylosis (arthritis in the neck) for about fifteen years I recently started doing various exercises recommended by a physiotherapist (head retraction, neck rotations and side bends) and my condition has improved tremendously – I now have a minimal amount of pain and stiffness after years of suffering. And he is quite right – it gives me a sense of me controlling my condition rather than it controlling me!

  • Good evening.
    would you be able to point me in the direction of evidence that shows that mobilisation is risk free as opposed to manipulation which has assoiciated risk including stroke …
    many thanks in advance

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