Confessions of a Quackbuster

This blog deals with healthcare consumer protection, and is therefore about quackery, healthfraud, chiropractic, and other forms of so-Called "Alternative" Medicine (sCAM).

Saturday, July 09, 2005

Chiropractic Therapy for Neck Pain May Have High Rate of Adverse Reactions

Medscape Medical News
Release Date: July 8, 2005

Chiropractic Therapy for Neck Pain May Have High Rate of Adverse Reactions

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd


To earn CME credit, read the news brief along with the CME information that follows and answer the test questions.

Release Date: July 8, 2005; Valid for credit through July 8, 2006

Credits Available

Physicians - up to 0.25 AMA PRA Category 1 continuing physician education credits

July 8, 2005 — Chiropractic therapy for neck pain has a high rate of adverse reactions, according to the results of a randomized study published in the July 1 issue of Spine. The investigators suggest that if chiropractic treatment is needed, mobilization is better than manipulation.

"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," write Eric L. Hurwitz, DC, PhD, from the UCLA School of Public Health in Los Angeles, California, and colleagues. "Recent observational studies have shown that within hours after treatment, nearly a third to a half of chiropractic patients have transient unpleasant reactions such as discomfort, increased pain or stiffness, radiating symptoms, headache, and tiredness, and minor adverse reactions have been noted in recent clinical trials assessing the effectiveness of manual therapies and methods commonly used by chiropractors."

At four southern California health care clinics, 336 patients with neck pain were randomized in a balanced 2×2×2 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. Two weeks after the randomization and baseline visit, patients assessed their own discomfort or unpleasant reactions from chiropractic care.

Of 280 participants (83%) who responded, 85 (30.4%) reported 212 adverse symptoms after chiropractic care. The most common symptom was increased neck pain or stiffness, reported by 25% of the participants; headache and radiating pain were less common. Compared with patients randomized to mobilization, those randomized to manipulation were more likely to report an adverse symptom occurring within 24 hours of treatment (adjusted odds ratio [OR], 1.44, 95% confidence interval [CI], 0.83 - 2.49).

Although heat (OR, 0.94; 95% CI, 0.54 - 1.62, and EMS (OR, 1.09; 95% CI, 0.63 - 1.89) were only weakly associated with adverse symptoms, moderate-to-severe neck disability at baseline was strongly associated with adverse neurologic symptoms (OR, 5.70; 95% CI, 1.49 - 21.80).

Study limitations include potential outcome misclassification, confounding, lack of generalizability, and the imprecision of estimates.

"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," the authors write. "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."

The Health Resources and Services Administration and the National Chiropractic Mutual Insurance Company supported this study (NCMIC), and Dr. Hurwitz was supported by a grant from the National Center for Complementary and Alternative Medicine. No benefits in any form have been or will be received from a commercial party related directly or indirectly to this study.

Spine. 2005;30:1477-1484

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

* Describe adverse effects after chiropractic treatment for neck pain.

* Identify predictors of adverse effects after chiropractic treatment for neck pain.

Clinical Context

Neck pain affects approximately 10% of North American and Western European populations for up to 45% of each year, and 50% to 70% of individuals have neck or shoulder pain at least once in their lives. Chiropractic care accounts for one third of all alternative medicine visits in the United States, and neck pain is second only to back pain in accounting for patients seeking manipulative therapy. Studies of manual vs physical therapy have found a higher rate of increased neck pain, headache, upper extremity pain, or paresthesia after treatment. Surgical or pharmacologic treatments are also associated with adverse effects. According to the authors, little is known about the types and frequencies of less severe but potentially consequential adverse reactions to chiropractic treatments for neck pain.

This is a 2×2×2 factorial design study of 336 patients from a health maintenance organization (HMO) randomized to receive either manipulation or mobilization, with and without heat and/or EMS for 10 minutes, in the treatment of neck pain to ascertain adverse effects within 24 hours and 2 weeks of treatment.

Study Highlights

* Inclusion criteria were being a member of an HMO, being age 18 to 70 years, having neck pain, and not receiving treatment in the preceding 1 month. Exclusion criteria were injury, tumor, infection or other nonmechanical cause of neck pain, progressive neurologic deficit, severe coexisting disease, use of electrical devices, blood coagulation disorder, and pending litigation.

* Baseline evaluation included medical history and physical examination. All patients received general education about posture, body mechanics, and workplace ergonomics and were given exercise recommendations.

* The spinal manipulation group received at least 1 controlled dynamic thrust, with minimal extension and rotation within pain tolerance. The spinal mobilization group received 1 or more movements of low velocity and variable amplitude. Treatments followed practice guidelines of the Mercy Center Consensus Conference for chiropractic care.

* Patients assigned to heat received 10 minutes of moist heat, whereas those assigned to EMS received 10 minutes of this modality before manual therapy. Those assigned to both received them simultaneously.

* Structured questionnaires were administered at baseline and 2 weeks. Pain was rated on a 10-point scale (0 = no pain; 10 = worst pain). Disability was rated by the 10-item (50-point) Neck Disability Index (NDI; 0 = no disability; 50 = greatest disability). Expectation of treatment was rated on a 10-point scale (0 = not confident that treatment will be successful; 10 = confident). Health status was assessed using the Short Form-36 Health Survey (SF-36).

* Adverse reaction was determined at 2 weeks by asking patients about unpleasant sensations or discomfort using an 10-point numeric scale. Categories of adverse effects included increased neck pain, stiffness or soreness, radiating pain or discomfort, tiredness or fatigue, headache, and neurologic symptoms.

* Half of the participants were between ages 30 and 50 years. Most perceived their health as good to excellent. More than two thirds were female, married, and employed full time. Duration of neck pain was > 1 year in one third and <>/= 2 were more likely to occur in the manipulation group (OR, 1.44; 95% CI, 0.83 - 2.49).

* Heat and EMS were only weakly associated with adverse symptoms (heat OR, 0.94; EMS OR, 1.09).

* Predictors of any adverse effects within 2 weeks included neck trauma, pain for <> 8, NDI scores > 16, moderate or severe headache (OR, 5.18), nausea in the past month, and lack of confidence in treatment.

* The OR for serious neurologic adverse effects for those with neck disability was 3.15.

Pearls for Practice

* Potential adverse effects of chiropractic manipulation or mobilization include increased neck pain, stiffness or soreness, radiating pain or discomfort, tiredness or fatigue, headache, and neurologic symptoms.

* Predictors of adverse effects include neck trauma history, pain for less than one year, worsening of neck pain since onset, pain ratings higher than 8, NDI scores higher than 16, moderate or severe headache (highest OR, 5.18), nausea in the preceding month, and lack of confidence in treatment.


This blog has more information on this matter:

MUST SEE!: Dangers of chiropractic therapy (lots of info!)

Risks Related to Manipulation of the Cervical Spine:Consequences for Evidence Based Practice