MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Some chiropractors claim that their main intervention, spinal manipulation, works for nonspecific neck pain by improving inter-vertebral range of motion (IV-RoM). But IV-RoM is difficult to measure, and whether it is related to clinical outcomes seems uncertain. Researchers from the Institute of Musculoskeletal Research & Clinical Implementation and the Anglo-European College of Chiropractic have just published a study that might throw some light on this issue. According to its authors, it was aimed at answering the following research questions:

  • Does cervical spine flexion and extension IV-RoM increase after a course of spinal manipulation?
  • Is there a relationships between any IV-RoM increases and clinical outcomes?
  • How does palpation compare with objective measurement in the detection of hypo-mobile segments?

Thirty patients with nonspecific neck pain and 30 healthy controls matched for age and gender received quantitative fluoroscopy (QF) screenings to measure flexion and extension IV-RoM (C1-C6) at baseline and 4-week follow-up. Patients received up to 12 neck manipulations and completed NRS, NDI and Euroqol 5D-5L at baseline, plus PGIC and satisfaction questionnaires at follow-up. IV-RoM accuracy, repeatability and hypo-mobility cut-offs were determined. Minimal detectable changes (MDC) over 4 weeks were calculated from controls. Patients and control IV-RoMs were compared at baseline as well as changes in patients over 4 weeks. Correlations between outcomes and the number of manipulations received and the agreement (Kappa) between palpated and QF-detected of hypo-mobile segments were calculated.

QF had high accuracy (worst RMS error 0.5σ) and repeatability (highest SEM 1.1σ, lowest ICC 0.9σ) for IV-RoM measurement. Hypo-mobility cut offs ranged from 0.8σ to 3.5σ. No outcome was significantly correlated with increased IV-RoM above MDC and there was no significant difference between the number of hypo-mobile segments in patients and controls at baseline or significant increases in IV-RoMs in patients. However, there was a modest and significant correlation between the number of manipulations received and the number of levels and directions whose IV-RoM increased beyond MDC (Rho=0.39, p=0.043). There was also no agreement between palpation and QF in identifying hypo-mobile segments (Kappa 0.04-0.06).

The authors concluded that this study found no differences in cervical sagittal IV-RoM between patients with non-specific neck pain and matched controls. There was a modest dose-response relationship between the number of manipulations given and number of levels increasing IV-RoM – providing evidence that neck manipulation has a mechanical effect at segmental levels. However, patient-reported outcomes were not related to this.

This conclusion seems a little odd to me. In my view the study suggests a clearly negative answer to all the three research questions formulated above. An interesting paragraph from the authors’ discussion section provides further insight: The lack of a relationship between symptomatic improvement and increased IV-RoM is also of interest. Clearly other mechanisms that improved the comfort and functional capacity of the patients in this study were in play, including spontaneous recovery. Other important biological factors may have included chemical factors in joint and muscle and activation patterns in the latter. However, this study seemed to rule out central pain hypersensitivity as a factor, as this was not detected at baseline in any of the patients. Psychological and social factors and their influence on functional behavior may also have had a role and may have been influenced by the interventions received.

So, spinal manipulation does not seem to work by improving IV-RoM. Could this be because spinal manipulation does not work at all?

37 Responses to More bad news for chiropractors

  • In my personal experience (anecdote alert!) a small amount of light manipulation can temporarily relieve certain types of very specific middle and lower back pain. The French health service thinks so too, after studying the subject. However, since it’s a weekend course for experienced doctors, it gives us a fairly good idea of how much of chiropractic they reckon is of any benefit at all!

    No references, sorry. It was covered by Magazine de la Santé; I think you’ve heard of them? 😀

  • Try Paracetamol?

    • good point!
      the news that paracetamol is ineffective for LBP is relevant: chiropractors across the world made a point out of claiming that their manipulations are as effective as paracetamol. as it turns out, it seems to be as ineffective [today came the news that paracetamol was shown to be no better than placebo for LBP]!

  • It is good to see chiropractors doing this type of research.
    Some other recent research investigating what is actually going on is relevant:

    Short-Term Effect of Spinal Manipulation on Pain Perception, Spinal Mobility, and Full Height Recovery in Male Subjects with Degenerative Disc Disease: A Randomized Controlled Trial.
    http://www.ncbi.nlm.nih.gov/pubmed/24862763
    Effect of spinal manipulation on the development of history-dependent responsiveness of lumbar paraspinal muscle spindles in the cat
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045034/?tool=pmcentrez&report=abstract
    The effect of application site of spinal manipulative therapy (SMT) on spinal stiffness.
    http://www.ncbi.nlm.nih.gov/pubmed/24139864
    Spinal Manipulative Therapy and Somatosensory Activation
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399029/?tool=pmcentrez&report=abstract
    Immediate Changes in Neck Pain Intensity and Widespread Pressure Pain Sensitivity in Patients With Bilateral Chronic Mechanical Neck Pain: A Randomized Controlled Trial of Thoracic Thrust Manipulation vs Non-Thrust Mobilization.
    http://www.ncbi.nlm.nih.gov/pubmed/24880778
    Instantaneous rate of loading during manual high-velocity, low-amplitude spinal manipulations.
    http://www.ncbi.nlm.nih.gov/pubmed/24928638
    The role of preload forces in spinal manipulation: experimental investigation of kinematic and electromyographic responses in healthy adults.
    http://www.ncbi.nlm.nih.gov/pubmed/24928637
    Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis
    http://www.sciencedirect.com/science/article/pii/S1050641112000065
    Outcomes of Acute and Chronic Patients With Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow-Up
    http://www.sciencedirect.com/science/article/pii/S0161475414000347
    Validation of a novel sham cervical manipulation procedure
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513586/?tool=pmcentrez&report=abstract
    Immediate effects of spinal manipulative therapy on regional antinociceptive effects in myofascial tissues in healthy young adults.
    http://www.ncbi.nlm.nih.gov/pubmed/23830709
    Immediate effects of spinal manipulation on nitric oxide, substance P and pain perception.
    http://www.ncbi.nlm.nih.gov/pubmed/24674816
    Using vertebral movement and intact paraspinal muscles to determine the distribution of intrafusal fiber innervation of muscle spindle afferents in the anesthetized cat
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578157/?tool=pmcentrez&report=abstract
    Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons.
    http://www.ncbi.nlm.nih.gov/pubmed/24928636
    The Role of Descending Inhibitory Pathways on Chronic Pain Modulation and Clinical Implications.
    http://www.ncbi.nlm.nih.gov/pubmed/24256177
    Descending pain modulation and chronification of pain.
    http://www.ncbi.nlm.nih.gov/pubmed/24752199

    I find this whole topic fascinating! What is actually going on when I manipulate a spine, prescribe exercises, advise on lifestyle changes/precipitating factors, educate patients on what is pain etc? It is a whole lot more than mechanical! The sample I have provided from my desktop library gives a good indication!

    P.S.
    “chiropractors across the world made a point out of claiming that their manipulations are as effective as paracetamol”
    Citations please!

    • Thinking_Chiro wrote: “Citations please!”

      Here’s an interesting one for you (lifted from the evidence page of the ‘Royal’ College of Chiropractors). It shows paracetamol to be the first choice medical treatment for non-specific aLBP, with spinal manipulation appearing further down the list:

      QUOTE

      3. European Commission Research Directorate General (2004) European Guidelines for the management of acute non-specific low back pain in primary care

      Summary of recommendations for treatment of acute non-specific low back pain:

      Give adequate information and reassure the patient
      Do not prescribe bed rest as a treatment
      Advise patients to stay active and continue normal daily activities including work if possible
      Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
      Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
      Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
      Multidisciplinary treatment programmes in occupational settings may be an option for workers with sub-acute low back pain and sick leave for more than 4 – 8 weeks

      Link: http://rcc-uk.org/index.php/evidence-for-chiropractic/

      That suggests that chiropractors are implying that if paracetamol doesn’t work, then spinal manipulation might. However, Cochrane reviews have been telling us for some time now that spinal manipulative therapy is no more effective in for acute low-back pain than inert interventions, sham SMT, or when added to another intervention:
      http://www.ebm-first.com/chiropractic/research-and-efficacy.html

      IOW, it looks like chiropractic spinal manipulative therapy is as ineffective as the first choice intervention of the European Guidelines – i.e. paracetamol.

  • From a lay point of view, Is it just me or does spinal manipulation just seem barmy? My daughter and granddaughter did/do ballet and great care is taken to stretch muscles and ligaments gradually with repeated training. No ballet teacher would wrench the spine as they do in any sort of manipulation. The”click” produced is easily explained by the over stretching of ligaments. It seems to me to be self evident that over extending any joint, let alone the spine is just a hit and miss bit of quackery. Yes, a sudden wrench may relieve muscle spasm, it may free up a nerve compressed by disc injury for arthritic bone, for a short time or it could make things a lot worse in the long run.

    No sort of manipulation is going to treat any underlying pathology/mechanical problems and pure muscle spasm is going to get better on its own with symptomatic treatment whilst it does.

    • Providing immediate relief while making things worse in the long term fits perfectly with the business model of chiropractic, and with my experience of it.

      I think that if schools taught exercises to counter the effects of the predominant sedentary lifestyle then we could see a reduction in back pain in society; most passive treatments on the other hand seem to be useless.

  • In Reply to Blue:
    It actually tellling us that medicines front line treatment of chioce is a placebo with a high incidence of adverse events! So when a general practitioner tells a patient “go home rest and take a Paracetamol” its actually medical code for “Bugger if we know whats going on so take a placebo and lets see what happens”. I go through adverse event/informed consent with every patient, I wonder if the doctors do the same with Paracetamol, it is a common law requirement here?
    As for the patient advice above you ignored all the other advice that is bang on target and the right advice!

    • Thinking_Chiro – paracetamol might not be great for musculoskeletal pain due to its relatively weak anti-inflammatory effect, but it can’t be said that it has ”a high incidence of adverse events”. ON the contrary, for the astronomical numbers of doses of paracetamol taken every day around the world for mild pain or fever, the incidence of adverse events is miniscule.

      The real issue with manipulative treatment (be it physio or chiro) is whether the benefit is anything beyond relief of spasm and mobilisation – not any form of ”adjustment”.

    • Thinking_Chiro wrote: “It actually tellling us that medicines front line treatment of chioce is a placebo with a high incidence of adverse events!”

      Is there a prospective randomised trial that conclusively demonstrates that chiropractic management reduces the incidence of serious complications arising from paracetamol use?

      Thinking_Chiro wrote: “So when a general practitioner tells a patient “go home rest and take a Paracetamol” its actually medical code for “Bugger if we know whats going on so take a placebo and lets see what happens”.”

      I don’t know how many GPs advise patients to go home and rest (do you have any citations?), but the advice to take paracetamol would be following current guidelines.

      Thinking_Chiro wrote: “I go through adverse event/informed consent with every patient, I wonder if the doctors do the same with Paracetamol”

      They can rely on Patient Information Leaflets which are contained in every pack of paracetamol and detail its risks, benefits (NB. it continues to be a proven analgesic), contraindications, and safe dose. However, it’s evident that not all chiropractors warn patients about the risks associated with their manipulative treatments:

      http://www.ncbi.nlm.nih.gov/pubmed?cmd=Retrieve&list_uids=15726031&dopt=Abstract
      http://www.ncbi.nlm.nih.gov/pubmed?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17693332&ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

      It’s also worth remembering that adverse effects related to paracetamol are subject to post-marketing surveillance whereas spinal manipulation (which might also turn out to be a placebo for low back pain) is not. The few data that are available show spinal manipulation to have a consistent 50% incidence of mild adverse events – in addition to hundreds of case reports of catastrophic adverse events, including deaths.

      Thinking_Chiro wrote: “As for the patient advice above you ignored all the other advice that is bang on target and the right advice!”

      I was discussing the news about paracetamol for low back pain and the implications that it had for chiropractic. IOW, I was staying on topic.

      • Blue Wode – is this supposed to be a bad joke:

        “They can rely on Patient Information Leaflets which are contained in every pack of paracetamol and detail its risks, benefits ”

        …or is that how “informed consent” is practiced in the allopathic world?

        • JM wrote: “…is that how “informed consent” is practiced in the allopathic world?”

          Probably not, but it’s a reliable back-up. Is there an equivalent in the world of chiropractic?

          • Beats me – I’ve only seen a chiro once. I don’t remember what was on the intake form (probably 10 years ago or so), but I would guess it contained leaflet type info. Every massage, physio, & acu intake form that I’ve seen does. Wouldn’t think chiro would be much different.

  • @thinking chiro. You imply GPs palm people off with paracetamol whilst you inform/ explain adverse events and get consent. So how do you explain the manipulation you do to patients?

    Also do chiropractors change their practices with new evidence? You are still carrying out unevidenced treatments invented over 100 years ago. Medicine changes it’s treatments with new evjdence and if the evidence that paracetomol has little use stands up with more studies I have no doubt GPs will be advised to stop using it for LBP.

    • I agree with Dorothy Paterson. If you’re a “thinking Chiro”, why are you a chiropracter at all? The name implies adherence to a daft medical pseudoscience — you yourself have repeatedly picked up on the daftnesses. So why don’t you just call yourself a physiotherapist or something similar? Could it be that including “chiropracter” in your title means you’re better placed to pull in cash from the gullible wealthy with lower back pain?

  • In rely to Blue:
    Those leaflets are there to protect the drug company, and paracetamol is an over the counter (OTC) drug, so its use is not monitored by prescribing doctors as it should be!
    http://en.wikipedia.org/wiki/Paracetamol
    http://en.wikipedia.org/wiki/Paracetamol_toxicity
    It should not be available OTC!
    “Is there a prospective randomised trial that conclusively demonstrates that chiropractic management reduces the incidence of serious complications arising from paracetamol use?”
    I do not prescribe or recommend it or any other OTC meds, no connection to chiropractic! Chiropractors are not permitted to here!

    In reply to Sue:
    First line of Paracetamol Toxicity link above.
    “paracetamol toxicity is one of the most common causes of poisoning worldwide. In the United States and the United Kingdom it is the most common cause of acute liver failure”
    http://www.news.com.au/lifestyle/health/supermarkets-banned-from-selling-large-packs-of-paracetamol/story-fneuz9ev-1226705313346

    In reply to Dorothy Paterson:
    “So how do you explain the manipulation you do to patients?”
    Good question Dorothy, informed consent is a mandatory common law requirement here for all professions. The key elements are:
    1. Diagnosis
    2. Proposed treatment
    3. Risk/Benefit analysis
    4. Adverse Events
    5. Prognosis with time frames
    6. Alternative treatments
    7. Option of doing nothing
    8. Do you understand
    9. Sign
    This came into effect here around 2000, though I have been doing it since 1995. My form has gone through 6 revisions over that time as advised by COCA and medico legal advice at conferences.

    “Also do chiropractors change their practices with new evidence?”
    Another very good question, I am constantly revising how I practice and the majority of chiropractors do. There is a minority of subluxation based chiropractors who are buried in the past and resistant to change. One of the greatest frustrations practicing as an evidence based chiropractor is that the critics lump us all into the same boat. Chiropractic has a poor record of critical self examination. I strongly support reform and change as best practice presents itself, so this criticism (external and internal) is very important to this process. I agree with much of what the critics say, I would just appreciate that they make the distinction between subluxation and evidence based chiropractors, as carpet bombing the profession damages the reformers within the profession and this is unacceptable collateral damage. This doesn’t help the reform process!

    In Reply to FrankO:
    “Carpet Bombing!”
    Having said that:
    “you yourself have repeatedly picked up on the daftnesses.”
    Every profession has its daftness and every profession has its reformers!
    “So why don’t you just call yourself a physiotherapist or something similar?”
    Physio’s are not immune to daftness and unfortunately they are acquiring some of out daft practices without being held to account. Some of their manipulative physio’s are as evangelical as the worst in chiropractic, just Google “Osteopractor” as one example.

    • @ Thinking_Chiro

      I’m not interested in whether or not you personally prescribe or recommend paracetamol or any other OTC meds, I asked “Is there a prospective randomised trial that conclusively demonstrates that chiropractic management reduces the incidence of serious complications arising from paracetamol use?”

      Is there?

      Re “…paracetamol is an over the counter (OTC) drug, so its use is not monitored by prescribing doctors as it should be!” What about the Yellow Card system? https://yellowcard.mhra.gov.uk/ Anyone can report to it. However, I understand that chiropractic patients cannot report to the Chiropratic Patient Incident Report and Learning System (CPiRLS) which is, as far as I know, the only chiropractic adverse reporting system in the world. Further, it is, apparently, greatly underutilised by chiropractors for reasons that include “fear of retribution, being too busy and insufficient clarity on what to report”. See here:
      http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html

      It’s also worth noting that the CPiRLS has been on the go for around nine years http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154058/ whereas the Yellow Card System was introduced 50 years ago. I think readers will be able to draw the obvious conclusion from that.

      Re paracetamol toxicity: Surely that’s not the case if paracetamol is taken at the recommended dose (i.e. responsibly)?

      Also, let’s not forget that spinal manipulation can frequently cause an exacerbation of pain which might cause some patients to increase or initiate OTC pain relief therapy such as paracetamol or NSAIDs. [Ref: Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management, 21(3): 238-242, March 2001]

    • more evidence that you might more aptly be called NONTHINKING CHIRO

    • Paracetamol is not nearly as harmful as you try to portray it. it is used a lot for suicide attempts in huge doses but at normal levels, it is quite innocent. in the trial that recently showed it to be ineffective for LBP it was as well tolerated as placebo: ” number of participants reporting adverse events (99 [18·5%] in the regular group, 99 [18·7%] in the as-needed group, and 98 [18·5%] in the placebo group) were similar between groups” [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/fulltext]

  • In reply to Blue:
    CPiRLS was the right idea wrong organization. That is the registration boards job for every profession. Here the chiropractic board investigares every reported incidence.
    “Is there a prospective randomised trial that conclusively demonstrates that chiropractic management reduces the incidence of serious complications arising from paracetamol use?”
    I fail to see the connection!
    As for Paracetamol toxicity, if it was released onto the market today it would be by prescription only and monitored by doctors as it should, instead of being available on the supermarket shelf.

    • how do you know?

      • @ Thinking_Chiro

        Re “I fail to see the connection!”

        In your post on Friday 25 July 2014 at 23:40 you said that medicine’s “front line treatment of choice is a placebo with a high incidence of adverse events!”.

        In response to that I asked if there was a prospective randomised trial that conclusively demonstrated that chiropractic management reduced the incidence of serious complications arising from paracetamol use in back pain patients.

        IOW, bearing in mind that the evidence for chiropractic spinal manipulation for back pain is extremely slim (i.e. likely to be a placebo), and that many chiropractic back pain patients also have their necks manipulated, can you demonstrate, convincingly, that chiropractic is a better intervention for back pain patients than paracetamol because chiropractic’s risk/benefit profile shows it to be a superior alternative? Can you show, conclusively, that back pain patients experience as good results, or better, from chiropractic treatment which causes them to decrease or stop their use of paracetamol, thus reducing the “high incidence of adverse events” which you claim arise paracetamol’s use?

        • Paracetamol is just a pain killer, yes? If all it does is mask pain and possibly allow the patient to aggravate the underlying issue…could you post a link to studies showing the long term risk/benefit ratio of treating acute LPB symtoms?

  • In reply to Edzard:
    “how do you know?”
    After the recent Paracetamol paper I talked to a surgeon who is on state and federal commissions. Two other surgeons at the table concured. I know its anecdote, but extremely well connected and knowledgable anecdote/doctors!

    In reply to Blue:
    Its not that chiropractic reduces Paracetamol use, its the relative associated risk:
    http://en.wikipedia.org/wiki/Non-steroidal_anti-inflammatory_drug#Adverse_effects
    This article on Paracetamol is sobering:
    http://qjmed.oxfordjournals.org/content/95/9/609.long
    Doctors should be the gatekeepers for these drugs, not the supermarkets!

    • Thinking_Chiro wrote: “Doctors should be the gatekeepers for these drugs, not the supermarkets!”

      By that logic, medical doctors should also be gatekeepers for referrals to chiropractors (i.e. chiropractors’ main intervention, spinal manipulation, cannot be generally recommended due to an unfavourable risk/benefit profile).

      • Blue Wode said:

        By that logic, medical doctors should also be gatekeepers for referrals to chiropractors (i.e. chiropractors’ main intervention, spinal manipulation, cannot be generally recommended due to an unfavourable risk/benefit profile).

        Now that sounds like an excellent idea!

  • Vertebral artery injuries in cervical spine surgery

    http://www.thespinejournalonline.com/article/S1529-9430(13)01556-8/abstract?elsca1=etoc&elsca2=email&elsca3=1529-9430_20140801_14_8_&elsca4=Orthopaedics

    5 people died in approx 165000 surgeries… so approx 1 in 35000 risk of dying by VAI in cervical spine surgery.

    • …and your point is?
      mine is that surgery has proven benefit, while cervical manipulation has not.

      • “mine is that surgery has proven benefit,” EE, that is an unverified opinion, not referenced nor based upon fact. You can do better than that!!!! Please reference that all surgeries are beneficial, that the surgeon does it for the best reason, and that they are all based upon sound scientific rationale. Please do not hide behind semantics, just provide the peer review reference to your statement.

  • In reply to Edzard:
    “…and your point is?
    mine is that surgery has proven benefit, while cervical manipulation has not.”
    The Royal Australasian College of Surgeons puts the percentage of surgical procedures backed by research and trials at optimistically 20%, thats 80% anecdote/its how we have always done it and it works! With the accountants breathing down their necks it has them very concerned!

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