One of the numerous conditions chiropractors, osteopaths, and other manual therapists claim to treat effectively is tension-type headache (TTH). For this purpose, they (in particular, chiropractors) often use high-velocity, low-amplitude manipulations of the neck. They do so despite the fact that the evidence for these techniques is less than convincing.
This systematic review evaluated the evidence about the effectiveness of manual therapy (MT) on pain intensity, frequency, and impact of pain in individuals with tension-type headache (TTH).
Medline, Embase, Scopus, Web of Science, CENTRAL, and PEDro were searched in June 2020. Randomized clinical trials that applied MT not associated with other interventions for TTH were selected. The level of evidence was synthesized using GRADE, and Standardized Mean Differences (SMD) were calculated for meta-analysis.
Fifteen studies were included with a total sample of 1131 individuals. The analyses show that high-velocity, low-amplitude techniques were not superior to no treatment in reducing pain intensity (SMD = 0.01, low evidence) and frequency (SMD = -0.27, moderate evidence). Soft tissue interventions were superior to no treatment in reducing pain intensity (SMD = -0.86, low evidence) and frequency of pain (SMD = -1.45, low evidence). Dry needling was superior to no treatment in reducing pain intensity (SMD = -5.16, moderate evidence) and frequency (SMD = -2.14, moderate evidence). Soft tissue interventions were not superior to no treatment and other treatments on the impact of headache.
The authors concluded that manual therapy may have positive effects on pain intensity and frequency, but more studies are necessary to strengthen the evidence of the effects of manual therapy on subjects with tension-type headache. Implications for rehabilitation soft tissue interventions and dry needling can be used to improve pain intensity and frequency in patients with tension type headache. High velocity and low amplitude thrust manipulations were not effective for improving pain intensity and frequency in patients with tension type headache. Manual therapy was not effective for improving the impact of headache in patients with tension type headache.
So, this review shows that:
- soft tissue interventions are better than no treatment,
- dry needling is better than no treatment.
These two results fail to impress me. Due to a placebo effect, almost any treatment should be better than no therapy at all.
ALMOST, because high-velocity, low-amplitude techniques were not superior to no treatment in reducing the intensity and frequency of pain. This, I feel, is an important finding that needs an explanation.
As it is only logical that high-velocity, low-amplitude techniques must also produce a positive placebo effect, the finding can only mean that these manipulations also generate a negative effect that is strong enough to cancel the positive response to placebo. (In addition, they can also cause severe complications via arterial dissections, as discussed often on this blog.)
Too complicated?
Perhaps; let me, therefore, put it simply and use the blunt words of a neurologist who once was quoted saying this:
DON’T LET THE BUGGARS TOUCH YOUR NECK!
34 Responses to High velocity, low amplitude techniques are not superior to no treatment in the management of tension-type headache
Leave a Reply to Blue Wode Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Nothing new
“For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache.”
Evidence-based guidelines for the chiropractic treatment of adults with headache. Roland Bryans et al. J Manipulative Physiol Ther. 2011 Jun.
“The most frequent therapeutic approach by participants for tension headache management was advice on headache triggers (90.9%), stress management (90.1%) and soft tissue therapies (massage, myofascial, stretching or trigger point therapy) to the neck/shoulder area (88.1%).”
Moore, C., Leaver, A., Sibbritt, D. et al. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol 18, 171 (2018).
well, it should be BIG news for all those chiros who SMT for TTH regardless of the evidence.
I have been keeping up with your blog on a regular basis. Because of this, I’ve picked up a TON of useful information along the way, and the assortment of topics covered is not only excellent but also easily reading and applicable.
I simply wanted to compliment you on the excellent work that you are doing here. I Recommend You To Check This: short poems about friendship
thanks
And then, there are those, like my unfortunate wife, who seldom if ever suffered from headaches yet was convinced by her Chiropractor that upper neck manipulations where necessary for maintaining superior health! Achieving balance was the word this Chiropractor used, which is certainly ironic considering she now has little to no balance.
Sadly, she listened to his advice and regularly went for Chiropractic neck “treatments”.
Either way, I’d opt for a headache any day over the risk of ripped vertebral arteries and a life confined to the wheelchair. Experiencing the worst outcome Locked In Syndrome is not for the faint of heart.
There is no evidence that a properly performed manipulation causes a VAD in a healthy individual.
oh really?
you are surpassing yourself!
Show me.
Timing of the VAD is crucial to determine causality.
Best I’ve seen to time a VAD is using multiple MRI sequences: T2-F, DWI, ADC with thin sliced MRI angiography with black blood protocols along with patient reported history. And even then it requires a committee of neuro-radiologists and vascular neurology to ascertain probable etiology and timing.
Got one of those?
you are not very good at defending the indefensible, I find.
Show me your best evidence.
My statement again:
There is no evidence that a properly performed manipulation causes a VAD in a healthy individual.
‘DC’ wrote “Show me your best evidence. My statement again: There is no evidence that a properly performed manipulation causes a VAD in a healthy individual.”
QUOTE
Argument from ignorance (from Latin: argumentum ad ignorantiam), also known as appeal to ignorance (in which ignorance represents “a lack of contrary evidence”), is a fallacy in informal logic. It asserts that a proposition is true because it has not yet been proven false or a proposition is false because it has not yet been proven true. This represents a type of false dichotomy in that it excludes the possibility that there may have been an insufficient investigation to prove that the proposition is either true or false. It also does not allow for the possibility that the answer is unknowable, only knowable in the future, or neither completely true nor completely false. In debates, appealing to ignorance is sometimes an attempt to shift the burden of proof.
— Wikipedia
END OF QUOTE
QUOTE
The argument to ignorance is a logical fallacy of irrelevance occurring when one claims that something is true only because it hasn’t been proved false, or that something is false only because it has not been proved true. A claim’s truth or falsity depends on supporting or refuting evidence to the claim, not the lack of support for a contrary or contradictory claim.
The argument to ignorance seems to be more seductive when it can prey on wishful thinking. People who want to believe in immortality, for example, may be more prone to think that the lack of proof to the contrary of their desired belief is somehow relevant to supporting it.
— The Skeptic’s Dictionary
END OF QUOTE
If you have a health problem, the last person you should consult is a chiropractor
DON’T LET THE BUGGERS TOUCH YOUR NECK!
If you don’t have a health problem, the last person you should consult is a chiropractor
So you can’t provide any evidence that refutes my statement.
“Craniocervical arterial dissection is a major cause of ischaemic stroke in young adults. The pathogenesis is not fully understood but is thought to be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. Intrinsic susceptibility is thought to be a generalised arteriopathy, vascular anomaly or genetic predisposition.”
BMC Musculoskelet Disord. 2012; 13: 164
“Patients with a spontaneous dissection of the vertebral artery are thought to have an underlying structural defect of the arterial wall, although the exact type of arteriopathy remains elusive in most cases…”
J Korean Neurosurg Soc. 2008 Sep; 44(3): 109–115
“The etiology of CAD is multifactorial and appears to be linked to both environmental and genetic factors.”
Schmidek and Sweet Operative Neurosurgical Techniques (Sixth Edition), 2012
Chicken or egg?
“Vertebral artery dissection (VAD) is frequently misdiagnosed because presenting symptoms are often nonspecific…
Thus, it is common for the condition to be initially mistaken for migraine or a musculoskeletal disorder.”
Cummings Otolaryngology: Head and Neck Surgery, 2021
So again, show me a case where they used multiple MRI sequences: T2-F, DWI, ADC with thin sliced MRI angiography with black blood protocols along with patient reported history. And even then it requires a committee of neuro-radiologists and vascular neurology to ascertain probable etiology and timing.
If it reveals that the VAD occurred when the cSMT was performed (or relatively close) and the person had no intrinsic factors and the procedure is one that is taught in colleges and was performed appropriately then I will reject my statement:
There is no evidence that a properly performed manipulation causes a VAD in a healthy individual.
as I stated before: you are no good at defending the indefensible!
“There is no evidence that a properly performed manipulation causes a VAD in a healthy individual.”
A healthy individual does not require a properly performed manipulation. This ought to be sufficient to explain the paucity of evidence.
Healthy refers to not having any contraindications to the procedure.
“Healthy refers to not having any contraindications to the procedure.”
No, it doesn’t.
In this context it does. But if you want to use the broader definition go ahead, it just makes it harder to show my statement is false.
‘DC’ wrote “In this context it does. But if you want to use the broader definition go ahead, it just makes it harder to show my statement is false.”
Functional illiteracy is rearing its ugly head again: nobody claimed your statement is false. On the contrary, I explained why your statement ought to be true.
As Edzard said: you are no good at defending the indefensible!
Good. Then it questions if David’s wife was truly healthy, which is what my comment was directed towards. Do try and follow the thread.
‘DC’ wrote “Good. Then it questions if David’s wife was truly healthy, which is what my comment was directed towards. Do try and follow the thread.”
Are you trying to be an idiot, because you’re doing a great job of appearing to be far beyond plain stupid. Contemptible behaviour.
Yes, there is a paucity of evidence, as ought to be the case. But, (within the context of the article on which we are commenting) this does not, and cannot, lead to the illogical conclusion: Absence of evidence means evidence of absence.
Good grief!
As usual Pete can’t follow a thread.
If a client visits a chiropractor, and this client is “truly healthy”, “a healthy individual” [the terms used by ‘DC’] then the only “properly performed manipulation” would be no manipulation, because all manipulations carry a risk, and they carry no benefit to an already “truly healthy” person. I.e. all risk, no benefit.
But, this person was told by her chiropractor that upper neck manipulations where necessary for maintaining superior health!
That is chiroquacking BS; an prime example of bogus treatment. It is hideously offensive of ‘DC’ to state:
As Edzard said: you are no good at defending the indefensible!
I truly appreciate your command of the English language and the clarity you bring to this topic Pete!
My beautiful young healthy wife Sandra Nette was at her prime and wonderfully fit. As a non-smoker, perfect weight and someone who always placed her health of the outmost importance, it would seem she would defy your logic.
In fact, following her horrendous injury at the hands of a Chiropractor on September 13th, 2007, it was to her credit that her excellent lifestyle habits and overall fitness, that she survived this needless neck injury.
Interestingly, during her one-year hospital stay, it was noted on medical records and throughout repeated exhaustive testing, that she had the internal organs of someone twenty years her junior. This obviously attributed to her overall “recovery” and the reason she is still alive today.
In most cases there is an intrinsic weakness in the artery.
This is one reason why it is thought that those who have had a spontaneous VAD are at greater risk of later having an aortic aneurysm.
Some of the more subtle symptoms of a VAD are the same reasons people seek chiropractic care. Neck pain and headache.
Research indicates that the largest strain on the VA occurs within normal range of motion, not during the manipulation.
Hence it’s difficult to determine causation.
Regardless I’m glad your wife is doing good.
David Nette wrote “my unfortunate wife, who seldom if ever suffered from headaches yet was convinced by her chiropractor that upper neck manipulations where necessary for maintaining superior health”
Readers might be interested to know that ultimately the chiropractor in question “…admitted to committing fraud and perjury. Initially, he had claimed that Sandy had signed a form to undergo the manoeuvre that caused her cascade of strokes. But two years after the incident, he finally admitted, under oath, to faking her signature on medical records.”
Ref. https://tinyurl.com/58drx7fd
Appallingly, rather than being struck off, he was handed a mere three-month suspension.
yes, appalling!
Thank you very much Blue Wode for your accurate account of the well documented legal misconduct and fraud by the actions of the Chiropractor. The criminal actions and his unfortunate poor decisions only added to our grief but were ultimately overshadowed by the emergent medical needs of the day.
Sadly, when injury or death occurs as a direct result of a Chiropractic manipulation, the Canadian Chiropractic Protection Association is in my opinion a clear example of the Fox guarding the Henhouse.
By Sandys Chiropractors actions and admitting to forging her signature and medical records, lying under oath and committing perjury …one would think these deliberate actions would indeed warrant more than a three-month suspension and them dropping their in-house insurance coverage. What a joke.
Had this blatant corruption been committed by a licensed Medical Doctor in our Province of Alberta the College of Phyicians and Surgeons would have provided at least an avenue for some form of accountability that would not resemble a carnival circus.
My personal views are if they, the Chiropractors, are going to continue with this rapid upper neck manipulation technique and continue taking needless chances with people’s health regardless of the odds, then they best have appropriate insurance coverage to cover long term disability. Of course that is IF you are “lucky” enough to survive.
Big news indeed Doc lol (Thank you for this well researched post!)
The problem is there is NO standard Uniform Care amongst this group.
When it comes to deciding on whether to perform this rapid upper neck manipulation “technique” it’s a free for all out there.
It all comes down to risk versus benefit in my opinion….and for me a headache is not worth losing a life.
agreed
Despite all the Rabbit trails and attempts on these blogs by the Chiropractic community to deflect from the truth, the unfortunate and devasting, effects from rapid neck manipulations continue to this day. Sad really, considering all the needless carnage.
To promote and continually attempt to divert from the very real and documented adverse effects caused from serious injury to one’s vertebral arteries is a disservice to humanity.
So, what are the risks of twisting one’s neck on a repeated basis? Let me name just a few…Locked In Syndrome, loss of eyesight, various degrees of limb movement impairment, the inability to swallow or speak, scores of various stroke related issues continue to pile up. And these are just the documented that can be attributed immediately following a Chiropractic Neck Manipulation. One can’t truly even account for the many who have perished while driving home from one of these procedures, having experienced a sudden stroke, and die in a vehicle accident. But I digress.
With even the slightest risk, of any one of these listed negative outcomes presenting as a real possibility, why are the Chiros continuing to encourage patients to allow this rapid upper neck twisting procedure? It’s simple really…without “performing” this specialty technique, what by definition would we call what defines a Chiropractor? For the public at large, this very “rapid neck twisting” act is what sets them apart from the mainstream Therapists and Medical Doctors. It defines who they are.
Risk versus Benefit must set the standard. I can assure you that to those who comment my wife is doing “good” after fifteen years of multiple surgeries and her quality-of-life fleeting at best…would rephrase after spending just one day in our household. We are living this nightmare.
We look forward to the day when common sense prevails, and the needless catastrophic injuries caused from Chiropractors end once and for all. And dialogue like these Forums just might very well be the tipping point of that much needed change we so desire.
My apologies if I misread your comments. I thought you wrote that she was doing good.
Of course. Apology accepted.
Forgive me if I come across as bitter or angered but this crippling injury was not what we pictured for our lives.
We have just past the fifteen-year mark since that terrible day when our lives as we knew it changed forever.
Many specialists gave Sandy a slim mere two to four percent margin of surviving and most said even if she does, we could expect permanent institutional care required for the rest of her life. She has defied all the odds.
Kudos to the surgeon and team who recently replaced both her TMJ joints. Sandy can now open her mouth much wider, and this helps tremendously with her ability to chew and swallow.
We are also indebted to the talented surgeons, who following years of no limb movement, were able to reconstruct both limbs and straightened much of the long-term limb curvatures. Although most of the time Sandy is confined to a wheelchair, she can now take a few steps with a walker and do most transfers on her own!
Chiropractic “treatments” were a part of her life. She understood and was encouraged to visit her Chiropractor for maintaining optimal health. It didn’t end well for Sandy but at least she survived.
I’m sure it’s been a challenging course for you and your wife.
I regularly try to educate my peers on such matters as it relates to VAD.
Take care.