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Neck manipulation study results - August 30, 2007 10:21:11 PM   
jlharris


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The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study.

Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW.Institute for Research in Extramural Medicine (EMGO-Institute), VU University Medical Center, Amsterdam, The Netherlands. sm.rubinstein@vumc.nl <sm.rubinstein@vumc.nl>


OBJECTIVE: This study describes both positive clinical outcomes and adverse events in patients treated for neck pain by a chiropractor. METHODS: This study was a prospective, multicenter, observational cohort study. Patients with neck pain of any duration who fulfilled the inclusion criteria were recruited in a practice-based study. Data were collected on the patients and from the chiropractors at baseline, the first 3 visits, and at 3 and 12 months. Clinical outcome measures included (1) neck pain in the 24 hours preceding the visit, (2) neck disability, (3) treatment satisfaction, (4) global assessment, and (5) adverse events. Recovery was defined as "completely improved" or "much better" using the global assessment scale. An adverse event was defined as either a new related complaint or a worsening of the presenting or existing complaint by >30% based upon an 11-point numerical rating scale. RESULTS: In all, 79 chiropractors participated, recruiting 529 subjects, representing 4891 treatment consultations. Follow-up was possible for 90% and 92%, respectively, at 3 and 12 months. Most patients had chronic, recurrent complaints; mild to moderate disability of the neck; and a mild amount of pain at baseline; and two thirds had sought previous care for the presenting complaint in the preceding 6 months. Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (<8%). Only 5 subjects (1%) reported to be much worse at 12 months. No serious adverse events were recorded during the study period. Of the patients who returned for a fourth visit, approximately half reported to be recovered, whereas approximately two thirds of the cohort were recovered at 3 and 12 months. CONCLUSION: Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.


______________________________________________________________________________________________________


Found this to be interesting.  Nice to see that it was being looked at.  Does it affect anyones belief (+ or -) regarding neck manipulation?  Especially considering the authors conclusions.  Thanks for the feedback.


< Message edited by jlharris -- August 30, 2007 10:24:47 PM >


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RE: Neck manipulation study results - August 31, 2007 6:21:38 AM   
bonez

 

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There is a rumor of some new information on this topic that is to be released by the Bone and Joint Decade Task Force on Neck Pain and It's associated Disorders. It is supposed to be released as a supplemental  to the fall addition of Spine.

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RE: Neck manipulation study results - August 31, 2007 10:35:19 PM   
3.5fig

 

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On Chiroweb they have an article about the study that will be coming out this fall.  I will attempt to link a post here...

http://www.chiroweb.com/archives/25/20/05.html

hope that works....it was quite a study and seems pretty definitive, but I have not read the study itself, just the review on Chiroweb which is not un-biased.


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RE: Neck manipulation study results - September 1, 2007 11:34:46 PM   
goodlooks58

 

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I have a patient right now who went to a chiro for 150 visits neck manipulation. End result: Wallenberg stroke with aterial dissection. What about that?! Needed 20 visits by a vestibular PT for balance control. 

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RE: Neck manipulation study results - September 4, 2007 6:01:31 AM   
3.5fig

 

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 Goodlooks58,

While the result of your patient is terrible, that does not negate the results of the soon to be published study.  If the article in Chiroweb is true, then we need to re-examine the causal relationship between cervical manipulation and stroke. As Dr. Haldeman stated "Current research suggests that dissections are probably multifactorail in origin". 

I understand that treating a patient who has suffered a stroke that appears to be caused by cervical manipulation can certainly cause a emotional reaction to the treatment itself,  I suggest that we take this research to heart and adapt the findings to our treatment approach and in our interactions with our patients.

To your question, "What about that?"  I would say, I feel terrible for your patient, but taking the findings of the new research into account, it would not change my view on the safety of manipulation.  One anecdote, however bad, does not negate the findings of this study.  I would have to ask you, what are your feelings regarding cervical manipulation in light of this new research?    

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RE: Neck manipulation study results - September 4, 2007 1:26:20 PM   
TMondale

 

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Pt's,

As I've said on this forum many times, and I hate to sound like a one trick pony, however we must get over this unsubstantiated fear of a full spectrum of manual therapy interventions.  It reflects poorly on our background, training and ability to critically analyze the evidence that's available. 

We all feel bad for those who there may have been connecting injuries with cervical manipulation iether thrust or non-thrust.  However to suggest that we should be selectively limiting this option for our patients based on the hysteria of the neurology and physiatry communities is regretable. 

Tim 

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RE: Neck manipulation study results - September 4, 2007 1:58:07 PM   
jlharris


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My personal opinion is that manipulation can provide dramatic results for a specific patient population.  The question I have is: 1.  Even if the possibility is remote (and manip seems to be a "piece" of that multifactorial cause), should we so freely manip C-spines as a common practice (ie neck pain being the only indicator of when to manip). 

My OPINION being that neck manip isn't worth the benefit (in fact, the study above demonstrates a 56% adverse reaction rate to it), the above question is a little rhetorical.  Unfortunately, the evidence so far doesn't seem to swing significantly or consistantly in either direction to make a solid evidence based decision at this point for me.

Thanks for your feedback 3.5fig.

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RE: Neck manipulation study results - September 4, 2007 6:20:15 PM   
JCOY

 

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"(in fact, the study above demonstrates a 56% adverse reaction rate to it),"
 
Have you read the study?----or only the abstract---or only "what others have told you about"  the study?  The "adverse reactions" referred to were mostly  muscle stiffness, lasting less than 24 hrs.  
 
Much akin to PT treatments,  wouldn't you say? 
 
 
 

< Message edited by JCOY -- September 4, 2007 6:24:59 PM >

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RE: Neck manipulation study results - September 4, 2007 7:04:04 PM   
jlharris


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I don't know.  The tough aspect is what specifically is an "adverse" reaction.  Increased pain, decreased mobility, more swelling?  The abstract says the most common was pain related.  So, yes, much akin to non-manip (I purposefully didn't say PT as manip is part of PT too).  The problem is, I've never done a study, or read a study, in which "adverse" reactions were measured.  Although I've never had a pt complain of "dizziness, nausea, or ringing in the ears" after a treatment.  Not even with an upper thoracic manipulation (which gave great C-spine pain relief, whole other subject though).  That doesn't mean it doesn't occur, I suppose.

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RE: Neck manipulation study results - September 4, 2007 9:09:29 PM   
JCOY

 

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You can find the complete study here:

http://www.jmptonline.org/article/PIIS0161475407001789/fulltext#section5


"My OPINION being that neck manip isn't worth the benefit....."
It is NOT a neck "manipulation" study(therefore the title you gave this thread is misnamed/misleading).  It is a "neck pain" study.

And while you, personally, have never been aware of any patients of yours experiencing "nausea, dizziness, or ringing in the ears"...............I feel confident saying that other PTs have.

< Message edited by JCOY -- September 4, 2007 10:09:19 PM >

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RE: Neck manipulation study results - September 4, 2007 11:33:44 PM   
jlharris


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Jcoy,

Thank you for the link to the full text.  Your absolutely right.  I guess my experience with DC's dogmatically clinging to and objecting to the use of manip by other practitioners, erroneously allowed me to assume the intervention used was cervical manip. 

However, from the article:
quote:


Intervention

The treatment was left to the discretion of the chiropractor. The type of manipulative and/or mobilization technique used was recorded on standardized forms immediately following the first and third treatment, as well as the use of any adjunct therapy, the number of adjustments given, the area that was treated, whether the chiropractor considered that rotation was used, and whether multiple manipulative attempts were directed at a single segment.

So, the question is (and I don't expect you to know the answer) what is "Chiropractic care for neck pain" if not _adjustments_ or manipulations?  The quote from the article would lend one to believe that manip = chiropractic care.

Again, I think manipulation is a must treatment for a certain population, and that I have concerns about cervical manip and it's safety vs. benefit.  Reading the full text (again, thank you) I haven't been swayed.  I will be very interested in the article listed on Chiroweb that 3.5fig mentioned though.

Thanks again for helping me discuss the article.

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RE: Neck manipulation study results - September 5, 2007 3:40:56 AM   
rwillcott

 

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Regardless of the study, cervical manipulations are not the be all end all neck treatment.  I get by fine with Mulligan SNAGs, mobilizations and thoracic manipulations.  Jull et. al. performed a study comparing mobilizations to manipulations when treating neck pain and found no difference.  Also, this study : Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study by Hurwitz et al Spine , 2005 is worth a read.

Here's the link:

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15990659&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

Also, the majority of patients I treat don't want to have their necks manipulated.

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RE: Neck manipulation study results - September 5, 2007 3:47:41 AM   
rwillcott

 

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Here's another one worth reading:

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15247576&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

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RE: Neck manipulation study results - September 5, 2007 3:49:26 AM   
rwillcott

 

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Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study.
Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM.Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA 90095-1772, USA. ehurwitz@ucla.edu
STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To document the types and frequencies of adverse reactions associated with the most common chiropractic treatments for neck pain, and to identify possible clinical predictors of adverse reactions to chiropractic treatment. SUMMARY OF BACKGROUND DATA: Chiropractic care is frequently sought by patients for relief from neck pain; however, adverse reactions related to its primary modes of treatment have not been well examined. METHODS: A total of 336 patients with neck pain presenting to 4 southern California health care clinics were randomized in a balanced 2 x 2 x 2 factorial design to manipulation with or without heat, and with or without electrical muscle stimulation (EMS); and mobilization with or without heat and with or without EMS. Discomfort or unpleasant reactions from chiropractic care were self-assessed at 2 weeks after the randomization/baseline visit. RESULTS: Of the 280 participants (83%) who responded, 85 (30.4%) had 212 adverse symptoms as a result of chiropractic care. Increased neck pain or stiffness was the most common symptom, reported by 25% of the participants. Less common were headache and radiating pain. Patients randomized to manipulation were more likely than those randomized to mobilization to have an adverse symptom occurring within 24 hours of treatment (adjusted odds ratio [OR] = 1.44, 95% confidence interval [CI] = 0.83, 2.49). Heat and EMS were only weakly associated with adverse symptoms (heat: OR = 0.94, 95% CI = 0.54, 1.62; EMS: OR = 1.09, 95% CI = 0.63, 1.89). Moderate-to-severe neck disability at baseline was strongly associated with adverse neurologic symptoms (OR = 5.70, 95% CI = 1.49, 21.80). CONCLUSIONS: Our results suggest that adverse reactions to chiropractic care for neck pain are common and that despite somewhat imprecise estimation, adverse reactions appear more likely to follow cervical spine manipulation than mobilization. Given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.
PMID: 15990659 [PubMed - indexed for MEDLINE]

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RE: Neck manipulation study results - September 5, 2007 6:00:56 AM   
jlharris


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Great links thank you.  I, too, like to use mobs, SNAGS and thoracic manip for my neck pain pt's (alond with DNF, Low trap, and serratus ant strengthening when appropriate).

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RE: Neck manipulation study results - September 5, 2007 11:53:47 AM   
JCOY

 

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jlharris posts:

quote:

So, the question is (and I don't expect you to know the answer) what is "Chiropractic care for neck pain" if not _adjustments_ or manipulations?  The quote from the article would lend one to believe that manip = chiropractic care.



There appears to be a misperception that DC treatment of neck pain utilizes ONLY manipulation to the cervicals,..........and that manipulation is ONLY HVLA?    Both are inaccurate.

As pointed out in the first study:

"The treatment was left to the discretion of the chiropractor. The type of manipulative and/or mobilization technique used was recorded on standardized forms immediately following the first and third treatment, as well as the use of any adjunct therapy, the number of adjustments given, the area that was treated, whether the chiropractor considered that rotation was used, and whether multiple manipulative attempts were directed at a single segment."

An example of a widely used DC *non-HVLA*  manipulation (which is taught in the core curriculum in DC schools):
http://www.coxtechnic.org/thetreatment.asp
http://www.coxtechnic.com/homepage.asp

Hope this helps to provide more accuracy and dispel some of the myths relative to both of these (mis)perceptions.

< Message edited by JCOY -- September 5, 2007 9:27:31 PM >

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RE: Neck manipulation study results - September 6, 2007 3:19:29 AM   
jlharris


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JCOY,

Thanks for trying to help dispell some of my misconceptions about chiropractic care.  Unfortunately, in the area of the country I live (which I call Palmerville), the face of DC's presented entail manip and a fistfull of woo (such as craniosacral - obviously not limited to DC's -, applied keniesiology, surface EMG, and use of the "activator"). 

Nice to see how a competent DC gives care to their pt's.

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Jason L. Harris, PT, DPT
My PT Blog

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RE: Neck manipulation study results - September 7, 2007 4:26:32 PM   
JCOY

 

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Thank-you Jason for the vote of confidence----However----- I am in the majority of the profession.  It is unfortunate that you have only knowledge of a minority that practice per your description.  It's always the loose cannons that get the "press" huh?

On the Cox site I provided...........you can find DCs in your area(that you are most likely unaware of) that practice per my post above.   http://www.coxtechnic.com/Nebraska.html     AND-  there are more on the "inactive" list.  AND- there are many more DCs that use Cox but are neither "active" or "inactive".......of which I would be one.

I try to keep in mind that both professions see the results of the chuckleheads and failures of the other!   I know that can be hard at times(like when my patients have been charged $300 to be given a standard/generic sheet of exercises by a PT).  Hopefully, the dialogue here will positively benefit, and dispel (mis)perceptions we both may have of the other.

< Message edited by JCOY -- September 7, 2007 4:34:58 PM >

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RE: Neck manipulation study results - September 8, 2007 2:40:26 AM   
bonez

 

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As an evidence based D.C. I too am familiar with snags, mobs, myofascial release, scap stabilization, and most important the wait and see approach for natural hx neck pain. These are all part of my day to day world. But unless I have mis read much of the data there is a significant sub group in the cad group that present to practitioners ( and I say practitoners as we have had a mob/manip pt in our area have an adverse reaction) as dissections in progress. These are not always caught in exam/hx and neck pain is one of the biggest symptoms.
Better hx exam skills and possibly the wait and see approach before beginning therapy on acute necks may prove to be the best process.

< Message edited by bonez -- September 8, 2007 2:43:36 AM >

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