spinal manipulation
A multi-disciplinary research team assessed the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes. For this purpose, they conducted a systematic review of the literature with network meta-analysis.
They included all 46 randomized clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Non-pharmacological treatments (eg, manual therapy) including acupuncture and dry needling or pharmacological treatments for improving pain and/or reducing disability considering any delivery parameters were included. The comparator had to be an inert treatment encompassing sham/placebo treatment or no treatment. The risk of bias was
- low in 9 trials (19.6%),
- unclear in 20 (43.5%),
- high in 17 (36.9%).
At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were:
- exercise (standardised mean difference (SMD) -1.40; 95% confidence interval (CI) -2.41 to -0.40),
- heat wrap (SMD -1.38; 95% CI -2.60 to -0.17),
- opioids (SMD -0.86; 95% CI -1.62 to -0.10),
- manual therapy (SMD -0.72; 95% CI -1.40 to -0.04).
- non-steroidal anti-inflammatory drugs (NSAIDs) (SMD -0.53; 95% CI -0.97 to -0.09).
Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%), and steroids (46.9%) trial arms.
The authors concluded that NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm-benefit balance.
The authors point out that previous published systematic reviews on spinal manipulation, exercise, and heat wrap did overlap with theirs: exercise (eg, motor control exercise, McKenzie exercise), heat wrap, and manual therapy (eg, spinal manipulation, mobilization, trigger points or any other technique) were found to reduce pain intensity and disability in adults with acute and subacute phases of NS-LBP.
I would add (as I have done so many times before) that the best approach must be the one that has the most favorable risk/benefit balance. Since spinal manipulation is burdened with considerable harm (as discussed so many times before), exercise and heat wraps seem to be preferable. Or, to put it bluntly:
if you suffer from NS-LBP, see a physio and not osteos or chiros!
Chronic low back pain (CLBP) is among the most common types of pain in adults. It is also the domain for many types of so-called alternative medicine (SCAM). However, their effectiveness remains questionable, and the optimal approach to CLBP remains elusive. Meditation-based therapies constitute a form of SCAM with high potential for widespread availability.
This systematic review and meta-analysis of randomized clinical trials evaluated the efficacy of meditation-based therapies for CLBP management. The primary outcomes were pain intensity, quality of life, and pain-related disability; the secondary outcomes were the experienced distress or anxiety and pain bothersomeness in the patients. The PubMed, Embase, and Cochrane databases were searched for studies published from their inception until July 2021, without language restrictions.
A total of 12 randomized clinical trials with 1153 patients were included. In 10 trials, meditation-based therapies significantly reduced the CLBP pain intensity compared with nonmeditation therapies (standardized mean difference [SMD] -0.27, 95% CI = -0.43 to – 0.12, P = 0.0006). In 7 trials, meditation-based therapies also significantly reduced CLBP bothersomeness compared with nonmeditation therapies (SMD -0.21, 95% CI = -0.34 to – 0.08, P = 0.002). In 3 trials, meditation-based therapies significantly improved patient quality of life compared with nonmeditation therapies (SMD 0.27, 95% CI = 0.17 to 0.37, P < 0.00001).
The authors concluded that meditation-based therapies constitute a safe and effective alternative approach for CLBP management.
The problem with this conclusion is that the primary studies are mostly of poor quality. For instance, they do not control for placebo effects (which is obviously not easy in this case). Thus, we need to take the conclusion with a pinch of salt.
However, since the same limitations apply to chiropractic and osteopathy, and since meditation has far fewer risks than these approaches, I would gladly recommend meditation over manipulative therapies. Or, to put it plainly: in terms of risk/benefit balance, meditation seems preferable to spinal manipulation.
Neurosurgeons from the Philippines recently presented the case of a 36-year-old woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and double vision. A cranial computed tomography scan showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief.
The headaches occurred 2 weeks after the patient had received a cervical chiropractic manipulation (CM). Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma. The patient improved with conservative management.
The authors found 12 articles of SIH and CM after a systematic review of the literature. Eleven patients (90.9%) initially presented with orthostatic headaches. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had a complete recovery. Recovery was achieved within 14 days from the start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch, and one required neurosurgical intervention.
The authors concluded that this report highlights that a thorough history is warranted in patients with new-onset headaches. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first-line treatment.
As the authors rightly state, their case report does not stand alone. There are many more. In 2014, an Australian chiropractor published this review:
Background: Intracranial hypotension (IH) is caused by a leakage of cerebrospinal fluid (often from a tear in the dura) which commonly produces an orthostatic headache. It has been reported to occur after trivial cervical spine trauma including spinal manipulation. Some authors have recommended specifically questioning patients regarding any chiropractic spinal manipulation therapy (CSMT). Therefore, it is important to review the literature regarding chiropractic and IH.
Objective: To identify key factors that may increase the possibility of IH after CSMT.
Method: A systematic search of the Medline, Embase, Mantis and PubMed databases (from 1991 to 2011) was conducted for studies using the keywords chiropractic and IH. Each paper was reviewed to examine any description of the key factors for IH, the relationship or characteristics of treatment, and the significance of CSMT to IH. In addition, other items that were assessed included the presence of any risk factors, neck pain and headache.
Results: The search of the databases identified 39 papers that fulfilled initial search criteria, from which only eight case reports were relevant for review (after removal of duplicate papers or papers excluded after the abstract was reviewed). The key factors for IH (identified from the existing literature) were recent trauma, connective tissue disorders, or otherwise cases were reported as spontaneous. A detailed critique of these cases demonstrated that five of eight cases (63%) had non-chiropractic SMT (i.e. SMT technique typically used by medical practitioners). In addition, most cases (88%) had minimal or no discussion of the onset of the presenting symptoms prior to SMT and whether the onset may have indicated any contraindications to SMT. No case reports included information on recent trauma, changes in headache patterns or connective tissue disorders.
Discussion: Even though type of SMT often indicates that a chiropractor was not the practitioner that delivered the treatment, chiropractic is specifically cited as either the cause of IH or an important factor. There are so much missing data in the case reports that one cannot determine whether the practitioner was negligent (in clinical history taking) or whether the SMT procedure itself was poorly administered.
The new case report can, of course, be criticized for being not conclusive and for not allowing to firmly establish the cause of the adverse event. This is to a large extent due to the nature of case reports. Essentially, they provide a ‘signal’, and once the signal is loud enough, we need to act. In this case, action would mean to prohibit the intervention that is under suspicion and initiate conclusive research to prove or disprove a causal relationship.
This is how it’s done in most areas of healthcare … except, of course in so-called alternative medicine(SCAM). Here we do not even have the most basic tool to get to the bottom of the problem, namely a transparent post-marketing surveillance system that monitors the frequency of adverse events.
And whose responsibility is it to put such a system in place?
I let you guess.
Guest post by Catherine de Jong
On the 22nd of February 2022, a criminal court in the Netherlands ruled in a case brought by a 33-year-old man who suffered a double-sided vascular dissection of his vertebral arteries during a chiropractic neck manipulation.
What happened?
On the 26th of January 2016, the man visited a chiropractor because he wanted treatment for his headache. The chiropractor treated him with manipulations of his neck. The first treatment was uneventful but apparently not effective. The man went back for a second time. Immediately after the second treatment, the patient felt a tingling sensation that started in his toes and spread all over his body. Then he lost consciousness. He was resuscitated by the chiropractor and transported to a hospital. Several days later he woke up in the ICU of the university hospital (Free University, now Amsterdam UMC). He was paralyzed and unable to speak. He stayed in the ICU for 5 weeks. After a long stay in a rehabilitation center, he is now at home. He is disabled and incapacitated for life.
Court battles
The professional liability insurance of the chiropractor recognized that the treatment of the chiropractor had caused the disability and paid for damages. The patient was thus able to buy a new wheelchair-adapted house.
Health Inspection investigated the case. They noticed that the chiropractor could not show that there was informed consent for the neck manipulation treatment, but otherwise saw no need for action.
Six days after the accident the man applied to the criminal court. The case was dropped because, according to the judge, proof of guilt beyond reasonable doubt was impossible.
In rare occasions, vertebral artery dissection (VAD) does occur spontaneously in people without trauma or a chiropractor manipulating their neck. The list of causes for VAD show, besides severe trauma to the head and neck (traffic accidents) also chiropractic treatment, and rare connective tissue diseases like Marfan syndrome. A spontaneous dissection is very rare.
It took several attempts to persuade the criminal court to start the case and the investigation into what had happened in the chiropractor’s office. Now the verdict has been given, and it was a disappointing one.
The chiropractor was acquitted. The defense of the chiropractor argued, as expected, that two pre-existent spontaneous dissections might have caused the headache and that, therefore, the manipulation of the neck would have played at most a secondary role.
It is this defense strategy, which is invariably followed in the numerous court cases in the US. Chiropractors in particular give credence to this argumentation.
The defense of the patient was a professor of neurology. He considered a causal link between manipulation to the neck and the double-sided VAD to be proven.
In the judgment, the judge refers 14 times to the ‘professional standard’ of the Dutch Chiropractors Association, apparently without realizing that this professional standard was devised by the chiropractors themselves and that it differs considerably from the guidelines of neurologists or orthopedics. In 2016, the Dutch Health Inspection disallowed neck manipulation, but chiropractors do not care.
The verdict of the judge can be found here: ECLI:EN:RBNHO:2022:1401
Chiropractic is a profession that is not recognized in the Netherlands. Enough has been written (also on this website) about the strange belief of chiropractors that a wrong position of the vertebrae (“subluxations”) is responsible for 95% of all health problems and that detecting and correcting them can relieve symptoms and improve overall health. There is no scientific evidence that chiropractic subluxations exist or that their alleged “detection” or “correction” provides any health benefit. In the Netherlands, there are about 300 practicing chiropractors. Most are educated in the UK or the USA. The training that those chiropractors receive is not recognized in the Netherlands.
Most chiropractic treatments do little harm, but that does not apply to neck manipulation. When manipulating the neck, the outstretched head is subjected to powerful stretches and rotations. This treatment can in rare cases cause damage to the arteries, which carry blood to the brain. In this case, a double-sided cervical arterial dissection can lead to strokes and cerebral infarctions. How often this occurs (where is the central complication registration of chiropractors?) is unknown, but given that the effectiveness of this treatment has never been demonstrated and that therefore its risk/benefit ratio is negative, any complication is unacceptable.
How big is the chance that a 33-year-old man walks into a chiropractor’s office with a headache and comes out with a SPONTANEOUS double-sided vertebral artery dissection that leaves him wheelchair-bound and invalid for the rest of his life? I hope some clever statisticians will tell me.
PS
Most newspaper reports of this case are in Dutch, but here is one in English
Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, the authors focused on the differential diagnosis, reviewing the available evidence.
A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section.
Right vertebral artery dissection with ischemia in the posterolateral medulla oblongata. In DWI (a) and ADC map (b) the arrow shows a punctate, shiny ischemic lesion, with typical reduction of ADC in the right posterolateral medulla oblongata. c and d CT angiography (axial and 3D reformat, c and d, respectively) showing a focal dissection of the V2 distal segment of the right vertebral artery, with the arrow in figure c pointing to the dissection. e MRI angiography (time of flight, TOF) showing the absence of visualization of right PICA.
The authors concluded that vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.
In the discussion section, the authors point out that the incidence of VAD in pregnancy is twice as common as in the rest of the female population. They also mention that a review of the literature regarding adverse effects of spinal manipulation in the pregnant and postpartum periods identified adverse events in five pregnant women and two postpartum women. The authors also include a table that summarizes all cases of VAD reported both prior and after delivery, with 24 cases distributed with a prevalence during the postpartum period (19 of the 24 cases). The clinical presentation of these cases is varied, with a higher frequency of headaches, vertigo, and diplopia, and the risk factors most represented are hypertension and migraines.
The authors finish with this advice: practitioners who do spinal manipulations should be aware of the possible complications of neck manipulation in pregnancy and the postpartum period, particularly in mothers with underlying medical disorders that may predispose to vessel fragility and VAD.
I would add advice of a different nature: consumers should always question whether the risks of any intervention outweigh its benefit. In the case of neck manipulations, the answer is not positive.
The purpose of this recent investigation was to evaluate the association between chiropractic utilization and use of prescription opioids among older adults with spinal pain … at least this is what the abstract says. The actual paper tells us something a little different: The objective of this investigation was to evaluate the impact of chiropractic utilization upon the use of prescription opioids among Medicare beneficiaries aged 65 plus. That sounds to me much more like trying to find a CAUSAL relationship than an association.
Anyway, the authors conducted a retrospective observational study in which they examined a nationally representative multi-year sample of Medicare claims data, 2012–2016. The study sample included 55,949 Medicare beneficiaries diagnosed with spinal pain, of whom 9,356 were recipients of chiropractic care and 46,593 were non-recipients. They measured the adjusted risk of filling a prescription for an opioid analgesic for up to 365 days following the diagnosis of spinal pain. Using Cox proportional hazards modeling and inverse weighted propensity scoring to account for selection bias, they compared recipients of both primary care and chiropractic to recipients of primary care alone regarding the risk of filling a prescription.
The adjusted risk of filling an opioid prescription within 365 days of initial visit was 56% lower among recipients of chiropractic care as compared to non-recipients (hazard ratio 0.44; 95% confidence interval 0.40–0.49).
The authors concluded that, among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.
The way this conclusion is formulated is well in accordance with the data. However, throughout the paper, the authors imply that chiropractic care is the cause of fewer opioid prescriptions. For instance: The observed advantage of early chiropractic care mirrors the results of a prior study on a population of adults aged 18–84. The suggestion is that chiropractic saves patients from taking opioids.
It does not need a lot of fantasy to guess why some people might want to create this impression. I am sure that chiropractors would be delighted if the US public felt that their manipulations were the solution to the opioid crisis. For many months, they have been trying hard enough to pretend this is true. Yet, I know of no convincing data to demonstrate it.
The new investigation thus turns out to be a lamentable piece of pseudo research. Retrospective case-control studies can obviously not establish cause and effect, particularly if they do not even account for the severity of the symptoms or the outcomes of the treatment.
In so-called alternative medicine (SCAM) we have an amazing number of ‘discoveries’ which – IF TRUE – should have changed the world. Here I list of 10 of my favorites:
- Diluting and shaking a substance makes it not weaker but stronger.
Homeopaths call this process ‘potentisation’. They use it to produce highly ‘potent’ remedies that contain not a single molecule of the original substance. The assumption is that potentisation transfers energy or information. Therefore, they claim, molecules are no longer required for achieving a clinical effect.
2. A substance that causes a certain symptom in a healthy person can be used to cure that symptom when it occurs in a patient.
The ‘like cures like’ principle of homeopathy is based on the notion that the similimum provokes an artificial disease which in turn defeats the condition the patient is suffering from.
3. Subluxations of the spine are the cause of most diseases that affect us humans.
DD Palmer, the inventor of chiropractic, insisted that almost all diseases are due to subluxations. These misplaced vertebrae, he claimed, are the root cause of any disease by inhibiting the flow of the ‘innate’ which in turn caused ill health.
4. Adjusting such subluxations is the best way to restore health.
Palmer, therefore, was sure that only adjustments of these subluxations were able to restore health. All other medical interventions were useless or even dangerous, in his view. Thus Palmer opposed medicines or vaccinations.
5. An imbalance of two life forces is the cause of all illnesses.
Practitioners of TCM believe that all illnesses originate from an energetic imbalance. Harmony between the two life forces ‘yin and yang’ means health.
6. Balance can be restored by puncturing the skin at specific points.
Acupuncturists are convinced that their needling is nothing less than attacking the root cause of his or her problem. Therefore, they are convinced that acupuncture is a cure-all.
7. Our organs are represented in specific areas on the sole of our feet.
Reflexologists have maps of the sole of a foot where specific organs of the body are located. They palpate the foot and when they feel a gritty area, they conclude that the corresponding organ is in trouble.
8. Massaging these areas will positively influence the function of specific organs.
Once the diseased or endangered organ is identified, the area in question needs to be massaged until the grittiness disappears. This intervention, in turn, will have a positive influence on the organ in question.
9. Healing energy can be sent into our body where it stimulates the self-healing process and restores health.
Various types of energy healers are convinced that they can transmit energy that comes from a divine or other source into a patient’s body. The energy enables the body to heal itself. Thus, energy healing is a panacea and does not even require a proper diagnosis to be effective.
10. Toxins accumulate in our bodies and must be eliminated through a wide range of SCAMs.
The toxins in question can originate from within the body and/or from the outside. They accumulate and make us sick. Therefore, we need to eliminate them, and the best way to achieve this is to use this or that SCAM
I could, of course, list many more such ‘discoveries’ – SCAM is full of them. They are all quite diverse but have one important thing in common: they are false (i.e. there is no good evidence for them and they fly in the face of science).
If they were true, they would have changed the world by revolutionizing science, physics, physiology, anatomy, pathology, therapeutics, etc.
ALL THESE UGLY FACTS DESTROYING SUCH BEAUTIFUL THEORIES!
WHAT A SHAME!!!
Compelling evidence has long shown that diagnostic imaging for low back pain does not improve care in the absence of suspicion of serious pathology. However, the effect of imaging use on clinical outcomes has not been investigated in patients presenting to chiropractors. The aim of this study was to determine if diagnostic imaging affects clinical outcomes in patients with low back pain presenting for chiropractic care.
A matched observational study using prospective longitudinal observational data with a one-year follow-up was performed in primary care chiropractic clinics in Denmark. Data were collected from November 2016 to December 2019. Participants included low back pain patients presenting for chiropractic care, who were either referred or not referred for diagnostic imaging at their initial visit. Patients were excluded if they were younger than 18 years, had a diagnosis of underlying pathology, or had previously had imaging relevant to their current clinical presentation. Coarsened exact matching was used to match participants referred for diagnostic imaging with participants not referred for diagnostic imaging on baseline variables including participant demographics, pain characteristics, and clinical history. Mixed linear and logistic regression models were used to assess the effect of imaging on back pain intensity and disability at two weeks, three months, and one year, and on global perceived effect and satisfaction with care at two weeks.
A total of 2162 patients were included, and 24.1% of them were referred for imaging. Near perfect balance between matched groups was achieved for baseline variables except for age and leg pain. Participants referred for imaging had slightly higher back pain intensity at two weeks (0.4, 95%CI: 0.1, 0.8) and one year (0.4, 95%CI: 0.0, 0.7), and disability at two weeks (5.7, 95%CI: 1.4, 10.0), but these differences are unlikely to be clinically meaningful. No difference between groups was found for the other outcome measures. Similar results were found when a sensitivity analysis, adjusted for age and leg pain intensity, was performed.
The authors concluded that diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. These results support that current guideline recommendations against routine imaging apply equally to chiropractic practice.
This study confirms what most experts suspected all along and what many chiropractors vehemently denied for years. One could still argue that the outcomes do not differ much and therefore imaging does not cause any harm. This argument would, however, be wrong. The harm it causes does not affect the immediate clinical outcomes. Needless imaging is costly and increases the cancer risk.
Neck pain affects a vast number of people and leads to reduced quality of life and high costs. Clinically, it is a difficult condition to manage, and the effect sizes of the currently available treatments are moderate at best. Activity and manual therapy are first-line treatment options in several guidelines. But how effective are they really?
This study investigated the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in a multidiscipline range of primary care clinics.
The treatment modalities utilized were spinal manipulative therapy combined with home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS – 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively.
One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both groups and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used.
Sixty-six subjects were randomized to the intervention group, and 65 to the control group. For NRS – 11, a B-coefficient of – 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures.
Four intense adverse events were reported in the study, three in the intervention group, and one in the control group. More adverse incidents were reported in the intervention group, with a mean pain intensity (NRS-11) of 2,75 compared to 1,22 in the control group. There were no statistically significant differences between the two groups.
The authors concluded that there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain.
This is a rigorous and well-reported study. It suggests that adjuvant manipulations are not just ineffective for neck pain, but also cause some adverse effects. This seems to confirm many previously discussed investigations concluding that chiropractors do not generate more good than harm for patients suffering from neck pain.
The effectiveness of manipulation versus mobilization for the management of spinal conditions, including cervicogenic headache, is conflicting, and a pragmatic approach comparing manipulation to mobilization has not been examined in a patient population with cervicogenic headache.
This study evaluated the effectiveness of manipulation compared to mobilization applied in a pragmatic fashion for patients with cervicogenic headache.
Forty-five (26 females) patients with cervicogenic headache were randomly assigned to receive either pragmatically selected manipulation or mobilization. Outcomes were measured at baseline, the second visit, discharge, and 1-month follow-up. The endpoints of the study included the Neck Disability Index (NDI), Numeric Pain Rating Scale (NPRS), the Headache Impact Test (HIT-6), the Global Rating of Change (GRC), the Patient Acceptable Symptoms Scale (PASS). The primary outcome measures were the effects of treatment on disability and pain. They were examined with a mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization) as the between-subjects variable and time (baseline, 48 hours, discharge, and follow-up) as the within-subjects variable.
The interaction for the mixed model ANOVA was not statistically significant for NDI (p = 0.91), NPRS (p = 0.81), or HIT (p = 0.89). There was no significant difference between groups for the GRC or PASS.
The authors concluded that manipulation has similar effects on disability, pain, GRC, and cervical range of motion as mobilization when applied in a pragmatic fashion for patients with cervicogenic headaches.
Essentially, this study is an equivalence trial comparing one treatment to another. As such it would need a much larger sample size than the 45 patients enrolled by the investigators. If, however, we ignored this major flaw and assumed the results are valid, they would be consistent with both manipulation and mobilization being pure placebos.
I can imagine that many chiropractors find this conclusion unacceptable. Therefore, let me offer an alternative: both approaches were equally effective. Therefore, mobilization, which is associated with far fewer risks, is preferable. This means that patients suffering from cervicogenic headache should see an osteopath who is less likely to use manipulation than a chiropractor.
And again, I can imagine that many chiropractors find this conclusion unacceptable.
