Edzard Ernst
MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

Are cervical manipulations for neck pain truly ‘much safer than the use of NSAIDs’?

Published Monday 21 January 2019

In 1995, Dabbs and Lauretti reviewed the risks of cervical manipulation and compared them to those of non-steroidal, anti-inflammatory drugs (NSAIDs). They concluded that the best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. This article must be amongst the most-quoted paper by chiropractors, and its conclusion has become somewhat of a chiropractic mantra which is being repeated ad nauseam. For instance, the American Chiropractic Association states that the risks associated with some of the most common treatments for musculoskeletal pain—over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDS) and prescription painkillers—are significantly greater than those of chiropractic manipulation.

As far as I can see, no further comparative safety-analyses between cervical manipulation and NSAIDs have become available since this 1995 article. It would therefore be time, I think, to conduct new comparative safety and risk/benefit analyses aimed at updating our knowledge in this important area.

Meanwhile, I will attempt a quick assessment of the much-quoted paper by Dabbs and Lauretti with a view of checking how reliable its conclusions truly are.

The most obvious criticism of this article has already been mentioned: it is now 23 years old, and today we know much more about the risks and benefits of these two therapeutic approaches. This point alone should make responsible healthcare professionals think twice before promoting its conclusions.

Equally important is the fact that we still have no surveillance system to monitor the adverse events of spinal manipulation. Consequently, our data on this issue are woefully incomplete, and we have to rely mostly on case reports. Yet, most adverse events remain unpublished and under-reporting is therefore huge. We have shown that, in our UK survey, it amounted to exactly 100%.

To make matters worse, case reports were excluded from the analysis of Dabbs and Lauretti. In fact, they included only articles providing numerical estimates of risk (even reports that reported no adverse effects at all), the opinion of exerts, and a 1993 statistic from a malpractice insurer. None of these sources would lead to reliable incidence figures; they are thus no adequate basis for a comparative analysis.

In contrast, NSAIDs have long been subject to proper post-marketing surveillance systems generating realistic incidence figures of adverse effects which Dabbs and Lauretti were able to use. It is, however, important to note that the figures they did employ were not from patients using NSAIDs for neck pain. Instead they were from patients using NSAIDs for arthritis. Equally important is the fact that they refer to long-term use of NSAIDs, while cervical manipulation is rarely applied long-term. Therefore, the comparison of risks of these two approaches seems not valid.

Moreover, when comparing the risks between cervical manipulation and NSAIDs, Dabbs and Lauretti seemed to have used incidence per manipulation, while for NSAIDs the incidence figures were bases on events per patient using these drugs (the paper is not well-constructed and does not have a methods section; thus, it is often unclear what exactly the authors did investigate and how). Similarly, it remains unclear whether the NSAID-risk refers only to patients who had used the prescribed dose, or whether over-dosing (a phenomenon that surely is not uncommon with patients suffering from chronic arthritis pain) was included in the incidence figures.

It is worth mentioning that the article by Dabbs and Lauretti refers to neck pain only. Many chiropractors have in the past broadened its conclusions to mean that spinal manipulations or chiropractic care are safer than drugs. This is clearly not permissible without sound data to support such claims. As far as I can see, such data do not exist (if anyone knows of such evidence, I would be most thankful to let me see it).

To obtain a fair picture of the risks in a real life situation, one should perhaps also mention that chiropractors often fail to warn patients of the possibility of adverse effects. With NSAIDs, by contrast, patients have, at the very minimum, the drug information leaflets that do warn them of potential harm in full detail.

Finally, one could argue that the effectiveness and costs of the two therapies need careful consideration. The costs for most NSAIDs per day are certainly much lower than those for repeated sessions of manipulations. As to the effectiveness of the treatments, it is clear that NSAIDs do effectively alleviate pain, while the evidence seems far from being conclusively positive in the case of cervical manipulation.

In conclusion, the much-cited paper by Dabbs and Lauretti is out-dated, poor quality, and heavily biased. It provides no sound basis for an evidence-based judgement on the relative risks of cervical manipulation and NSAIDs. The notion that cervical manipulations are safer than NSAIDs is therefore not based on reliable data. Thus, it is misleading and irresponsible to repeat this claim.

 

Posted in alternative medicine, bias, bogus claims, case report, causation, chiropractic, commercial interests, cost-effectiveness, critical thinking, death, economic evaluation, informed consent, medical ethics, methodology, neck-pain, osteopathy, pain, pseudo-science, risk, risk/benefit, spinal manipulation, symptom-relief

25 Responses to Are cervical manipulations for neck pain truly ‘much safer than the use of NSAIDs’?

  • Dr Julian Money-Kyrle on Monday 21 January 2019 at 14:19

    Edzard,

    I agree with your conclusion, that we don’t have evidence to show that chiropractic manipulation is safer than NSAID’s for neck pain, and for that matter we don’t have evidence that it is less safe.

    Leaving chiropractic aside, NSAID’s have very real dangers, and our understanding of these have changed in the past 23 years. The most well-known side-effect is irritation of the stomach and an increase in stomach acidity, which is unpleasant in itself but can lead to severe bleeding and ulceration. It is now fairly common practice to prescribe proton pump inhibitors with NSAID’s to mitigate this risk. On the other hand, more and more NSAID’s are being found to increase the risk of coronary heart disease, and as a result some of them (such as diclofenac) are only prescribed when there is no good alternative; personally I suspect that the coronary risk will eventually be shown with all NSAID’s but we don’t have the evidence yet.

    Apart from that, NSAID’s are well known to be toxic to the kidneys and are a relatively common contributor to acute renal failure. They cause sodium retention which can precipitate acute left ventricular failure. These are all problems which I have seen many times over the course of my career, and any of them can be fatal.

    As well as oral and injectable forms, many NSAID’s are also available “topically” as gels. I have put the word in inverted commas as the instructions are to rub the gel over the affected part of the body, the implication, perhaps, being that it is absorbed directly into the underlying joints. While it is certainly true that rubbing over a painful area gives relief (and we know why from the work of Melzac and Wall), the drug is absorbed through the skin into the blood, where it can have the same effects on the kidneys and gastrointestinal system as though it had been swallowed, except that the dosage is less certain.

    As an aside, I have often wondered why patients using transdermal patches tend to stick them over the target organ (i.e. on the chest for GTN, over the ovaries for HRT…) when the effect is blood-borne.

    So given that NSAID’s really can be quite hazardous, and that the dangers of cervical manipulation seem to be rare, it may well be that the latter is safer. The problem is, we can only be sure of that if there are systems in place for identifying and reporting adverse incidents, and for chiropractic there are not. At least the risks of NSAID’s are known and quanitified, so that they can be weighed against the benefits in each case, and they are also amenable to monitoring.

    Reply
  • Alec Cockle on Monday 21 January 2019 at 15:27

    I am still amazed how the medical ‘fraternity’ and experts still get confused between symptom reduction and cure of causation. I have experience of neck pain for nearly 6 years. Visits to doctors and Chiropractor was to prescribe paracetamol or ibuprofen, use a low, firm pillow and neck exercises. Any neck exercise was like I had broken a bone in the neck…Further suggestion was try to improve posture. Well I have always felt that a good rest and relaxation gave me better results as I felt the pain was due to physical strain sometime in the past, weakening some upper back area.
    Finally, my recent visit to a sports masseur actually found the cause and provided relief within the deep muscle in the back and shoulders, such that I feel 10 years younger and can bend and stretch and even turn my head left and right without straining. At age 80 I am now convinced a lot of age mobility problems are due to weak , and tight muscle and regular sports massage and the correct exercise will enhance life more than any NSAIDS or Chiropractor moves.

    Reply
  • alec on Monday 21 January 2019 at 19:11

    Six years, three physicians, two Chiropractices… One hour with Sports massage therapist. Solved.

    Reply
  • Ron Jette on Tuesday 22 January 2019 at 00:55

    “chiropractic manipulation”

    Pretty much sums it up, don’t you think?

    Reply
  • Richard Rawlins on Tuesday 22 January 2019 at 05:33

    Mr Cockle,
    Your symptoms may have improved, but what was their cause?

    What was the problem you claim to have been solved?

    Your post of yesterday said your sports masseur had “actually found the cause.”
    What was it?
    (Please don’t reply “muscle spasm” – what was the cause?)

    Reply
  • DC on Wednesday 23 January 2019 at 19:35

    NSAIDs and opioid analgesics (especially for acute pain) were generally found to be effective but beneficial effects were evident mostly in the short-term [7, 14, 16, 29, 38, 94, 104, 105]. Cyclooxygenase (Cox)-2 selective inhibitors (e.g. celecoxib), were found to be effective for musculoskeletal pain relief. However, these were more likely to be associated with higher risks of adverse cardiovascular and gastrointestinal events (hazard ratio 2.18, 95% CI 1.82, 2.61), compared to non-selective NSAIDs [48, 49]. In the long-term and for more chronic pain presentations, stepwise analgesia according to the WHO analgesic ladder (mostly based on expert opinion) may be recommended [20, 29, 106–109]. Medium effect sizes were commonly reported S4 Table. For instance, topical NSAIDs were found to be more beneficial compared to placebo with summary RR of 1.9 (95% CI, 1.7 to 2.2) and a NNT of 4.6 (95% CI, 3.8 to 5.9) in the short-term [98, 99, 110, 111]. Furthermore, duloxetine, commonly used for multi-site pain may be carefully considered where there has been inadequate clinical response to initial pharmacologic treatments [48]. The effects of analgesics for improving function were less often reported in included reviews and guidelines.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5480856/

    Reply
  • DC on Wednesday 23 January 2019 at 19:37

    EE: “As to the effectiveness of the treatments, it is clear that NSAIDs do effectively alleviate pain,…”

    From the paper he referenced….

    “NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo.”

    Reply
  • DC on Wednesday 23 January 2019 at 19:42

    a few more comments from the paper Ernst referenced…

    “Our review of 35 randomised placebo-controlled trials demonstrates that NSAIDs are effective in reducing pain and disability in patients with spinal pain, although treatment effects above those of placebo are small and arguably not clinically important. For every six patients treated with NSAIDs, rather than placebo, only one additional patient would benefit considering a between-group difference of 10 points for clinical importance in the short-term. Furthermore, when looking at different spinal pain, outcomes or time points in only 3 of the 14 analyses were the pooled effects
    only marginally above our 10-point threshold for clinical relevance. NSAIDs were associated with higher number of patients reporting gastrointestinal adverse effects in the short-term follow-up (ie, <14 days). No data on safety at medium-term or long-term follow-ups were provided by included trials."

    Reply
  • DC on Friday 25 January 2019 at 14:13

    “So the question remains, why is the use of NSAIDs so persistently popular, despite the defects described above. The answer seems to be their popularity enhanced by advertising, their undoubted analgesic efficacy (without the scary symptoms accompanying the use of opioids) and partial lack of translation of the reported results into the occurrence of symptoms over a period which could be associated with NSAID use.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016595/

    Reply
    • Edzard on Friday 25 January 2019 at 14:39

      full abstract of the article [on bone healing – aren’t you scraping the barrel a bit?]:
      Tissue damage following injury triggers the processes of coagulation, inflammation and healing. In tissues surrounding the bone, the result of the healing process is a scar, while bone tissue has a unique ability to achieve shape, strength and pre-injury function. Bone healing is a process of regeneration rather than classic recovery. The result of this process is the formation of new, healthy bone tissue instead of a scar. Many factors can inhibit or impair the bone healing process, and their influence is critical during the stages of inflammation and angiogenesis and finally on the clinical outcome. Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential role associated with their analgesic potency and anti-inflammatory effects. NSAIDs are also the most often used drugs in patients who require pain control and inflammation reduction due to musculoskeletal diseases or injures. Although their analgesic effect is well documented, NSAIDs also interfere with bone healing; therefore, the relative benefits and disadvantages connected with their administration should be taken into consideration. Despite the negative effect, NSAIDs have beneficial properties, but their clinical benefits in relation to dose and time of use are still unclear. Therefore, in this review, we focus on bone healing with relation to the impact of NSAIDs.

      Reply
  • DC on Saturday 26 January 2019 at 06:51

    something else for ypur blog

    “NSAIDs exhibited a rapid onset of risk for myocardial infarction in the first week of use. Use for 8-30 days at a high dose was particularly harmful for ibuprofen (>1200 mg/day), naproxen (>750 mg/day), and rofecoxib (>25 mg/day) (table 3⇑ and red line in fig 2⇑). The depletion of susceptibles effect50 is a possible explanation for the spikes in risk observed with all NSAIDs. For celecoxib and diclofenac, a single wave of acute myocardial infarction cases occurred within one week (table 3⇑, fig 2⇑).”

    https://www.bmj.com/content/357/bmj.j1909

    Reply
  • DC on Saturday 26 January 2019 at 13:29

    A little more info perhaps?

    N onsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2 inhibitors (COXIBs) are perhaps some of the most extensively used medications in the world.1 In a recent survey of selected prescription and nonprescription drugs recorded during physician office and hospital visits, the U.S. Department of Health and Human Services determined that NSAIDs were the fifth most utilized medication in all age groups.2 The prevalence of at least once-weekly NSAID use in individuals aged 65 and older has been reported to be as high as 70%, with one-half of this group taking at least seven doses per week.3 Finally, preventable NSAID-related hospital admissions have been reported to range from 7% to 11%.4-6 NSAIDs and COXIBs are used for the treatment of fever, inflammation, and pain; in addition to these indications, aspirin also is used for the prevention of vascular events.

    Gastrointestinal (GI) side effects are common and potentially serious, with as many as 60% of people who use traditional NSAIDs experiencing some type of adverse effect.10-12 Per year, upper-GI complications will develop in 1% to 2% of people using these NSAIDs.13-15 This rate is three to five times higher than in people who do not use these NSAIDs.13-15 The risk of severe complications is even higher in individuals with established risk factors, with a potential case-fatality rate of 5%.16

    https://www.uspharmacist.com/article/adverse-events-associated-with-nsaids

    Reply

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