OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache.
SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache.
METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal anipulation on patients' pain status.
RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.
CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.
Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 21 (15): 1746-1759 (Aug 1 1996)
OBJECTIVE: To discuss the case of a patient suffering from severe headache complaints who was previously unresponsive to regional cervical spine care.
CLINICAL FEATURES: A prodrome was described. In addition to headache itself, associated symptoms included light sensitivity, blurred vision and nausea. A visit to a hospital emergency room was often necessary to reduce pain intensity.
INTERVENTION AND OUTCOMES: Manual chiropractic spinal adjustment were performed as the only treatment intervention. After a course of treatment, the patient reported no visits to the emergency room, even after a 1-yr follow-up, and the average visual analogue pain scores decreased.
CONCLUSION: This patient seemed to respond favorably to conservative care that included regions of spine not traditionally associated with headache pain. This suggests that some individuals may require a more comprehensive evaluation if regional care fails to promote a positive response within a few weeks. Controlled, randomized trials will assist in comparing effectiveness of various treatment interventions.
Stude DE, Sweere JJ. A holistic approach to severe headache symptoms in a patient unresponsive to regional manual therapy. J Manipulative Physiol Ther 19 (3): 202-207 (Mar 1996)
DATA SOURCES: A series of Medicine literature searches were performed, and materials were reviewed from 1966-1994. Key words included: Chiropractic or Orthopedic Manipulation; Non-Steroidal Anti-Inflammatory Agents; Neck or Back Pain; Randomized Controlled Trials; Adverse Effects.
STUDY SELECTION: Studies and literature reviews that provided
a numerical estimate of the risk of serious adverse effects or
death from cervical manipulation or NSAID use were selected. Also,
randomized, controlled studies that evaluated the effectiveness
of manipulation or NSAID use for neck pain were included.
DATA SYNTHESIS: Although there are a small number of well-performed trials of cervical manipulation for neck pain, we were unable to locate even a single randomized, controlled trial examining NSAID use specifically for neck pain. As for comparative safety, the best available evidence indicates that NSAID use poses a significantly greater risk of serious complications and death than the use of cervical manipulation for comparable conditions.
CONCLUSION: 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. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.
Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther 1996; 18 (8) 530-6.
DESIGN: Qualitative literature review.
RESULTS: Of nine studies of manipulation for tension-type headaches that reported quantitative outcomes, four were randomized clinical trials and five were case series designs. These studies reported on 729 subjects, 613 of whom received manipulation. Outcomes ranged from good to excellent. Manipulation seems to be better than no treatment, some types of mobilization and ice, and it seems to be equivalent to amitriptyline but with greater durability of effect than this medication. Of three studies on migraine, only one was a randomized clinical trial. These studies reported on 202 subjects, 156 of whom received manipulation. The outcomes ranged from fair to very good.
CONCLUSION: A modest body of clinical studies exists dealing with the effect of manipulation and headache. The overall results are encouraging, even if not quite supportive in the case of tension-type headache. Further studies in this area are definitely warranted, particularly well-controlled studies in migraine.
Vernon HT. The effectiveness of chiropractic manipulation in the treatment of headache: an exploration in the literature. J Manipulative Physiol Ther 18 (9): 611-617 (Nov 1995)