ACA's statement on the JAMA study

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

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Date: Wednesday, November 11, 1998 12:26 PM
From: AmerChiro@aol.com
To: Frankp@chiro.org
Subject: Re: November 11, 1998 JAMA article, "Spinal Manipulation in the Treatment of Episodic Tension-Type Headache: A Randomized Controlled Trial"


Hello.

Below is ACA's statement on the JAMA study. We sent this out to the national media the day before the study was published, and we also distributed it to ACA and chiropractic leaders across the country. The list of chiropractic studies on headache that are mentioned is only in hard copy, so we cannot e-mail it to you. However, if you would like, we can certainly fax it if you provide us with your fax number. Thanks for your help.

American Chiropractic Association Response to November 11, 1998 JAMA article,
"Spinal Manipulation in the Treatment of Episodic Tension-Type Headache: A Randomized Controlled Trial"

The study, "Spinal Manipulation in the Treatment of Episodic Tension-Type Headache: A Randomized Controlled Trial," published in the November 11 issue of the Journal of the American Medical Association (JAMA) is an interesting addition to the scientific literature on this subject. The American Chiropractic Association believes the study showed positive results for chiropractic. Spinal manipulation was just as effective as the massage treatment, and both treatments brought about significant pain relief and resulted in a reduction in the number of analgesics used by the ETTH patients.

Specifically, the study focuses on two separate types of treatment — manipulative therapy and soft tissue massage — performed by one chiropractor on two different groups of patients. The study actually demonstrates that both types of treatment produced a positive effect when used separately. During a typical course of treatment, most doctors of chiropractic employ a combination of both types of therapy when treating patients with ETTH.

The study's authors acknowledge that this new study is in "stark contrast" to a similar previous study they conducted on spinal manipulation and cervicogenic headache — a type of headache that is characterized by pain on one side of the head, with associated neck pain on the same side. The earlier study found that the same manipulative techniques that were used in the current JAMA study produced clinically significant improvements in cervicogenic headache duration, intensity and use of analgesics in comparison to a massage therapy group. This is an important finding, and points to the need for more research to determine which types of treatment are the most effective for different types of headache. In addition, this conclusion also underscores the importance of accurately diagnosing each headache patient to determine which type of headache he or she is suffering from emdash a skill that is well within the training and practice of doctors of chiropractic.

In addition, the JAMA study supports the chiropractic profession's current classification of ETTH as being of muscular origin, and cervicogenic headache as being of structural/skeletal origin. It makes sense that soft tissue massage would be an effective treatment for ETTH, while spinal manipulation would be especially effective for cervicogenic headache. This new study contributes greatly to our understanding of the origin of various types of headache, and consequently, the most appropriate treatments for them.

This study also further supports a previous study by Boline et. al. That study gave chiropractic manipulative therapy (CMT) higher marks for outcomes versus amitriptyline in the management of chronic tension type headaches. Chiropractic care (including CMT) gave better results by way of reduced headache frequency, intensity, and over-the-counter medication use with improved functional health status at the final evaluation point four weeks post care. One may surmise that, although massage and CMT may be equal in the treatment of episodic tension type headaches, they both have more lasting effect on these types of headaches than some medications like amitriptyline.

A small concern with the study, however, is that measurements on patients were not taken until seven weeks following the initiation of treatment. Since both spinal manipulation and soft tissue massage are acknowledged to release muscle tension, it is not surprising that they both elicited positive effects in the long term. It would have been more useful if the authors had measured relief immediately following each treatment, to determine which therapy worked faster. After all, from the patient's perspective, short-term relief is also of extreme importance in the treatment of headaches.

Readers should also keep in mind that a growing body of scientific evidence has demonstrated that chiropractic care is an effective treatment for headaches. For more information on these studies, contact the American Chiropractic Association at (800) 986-4636, ext. 240.

The new JAMA study is an interesting addition to this body of evidence. We applaud the authors and await future studies on this topic.

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