Spinal Manipulation for Back and Neck Pain: Does It Work?

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Spinal Manipulation for Back and Neck Pain: Does It Work?


In her office at McMaster University in Toronto, Anita Gross, MSc, has logged paper after paper showing that spinal manipulation can help control neck pain. “The evidence keeps growing and growing,” she says.
Gross, a physiotherapist and associate professor of rehabilitation science, helped write a 2015 Cochrane review of the literature and is already at work on updating that paper
Mounting evidence also supports spinal manipulation for low back pain, says Roger Chou, MD, professor of medicine at Oregon Health & Science University in Portland, Oregon, who led a similar review for the Agency for Healthcare Research and Quality last year

Evidence for Cervical Manipulation

Gross and her colleagues reached similar conclusions about improving pain, function, and quality of life related to neck complaints. “There is some immediate pain relief—not necessarily long-term,” she says. And most of the evidence was for chronic rather than acute symptoms.
Results for mobilization and manipulation were similar, and both might work best in combination with exercise. “Across our different Cochrane reviews, we can say that probably the combination of manual therapy and exercise seems to be a dominant piece that’s coming out as being a wise choice,” Gross says.
In acute and subacute neck pain, cervical manipulation was more effective than various combinations of analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs for improving pain and function in the short and intermediate term. The evidence for treating neck pain with cervical spinal manipulation was not as strong as the evidence for treating it with thoracic spinal manipulation, Gross and her colleagues found.[1]
But the research left many gaps. Spinal manipulation is difficult to study because patients and practitioners can’t be effectively blinded to the treatment. Most effects are subjective. And it’s hard to standardize treatments from one practitioner to another. “This is more complicated than looking at whether acetaminophen works, for example,” says Dr Chou.
In part for this reason, the researchers couldn’t find much evidence for the superiority of any particular spinal manipulation technique or any category of practitioner. Nor could they determine the optimum frequency or duration. “In the trials that have been done, it’s hard to see clear differences, whether it’s chiropractic or osteopathy, or whether somebody is doing it once vs five times a week,” Dr Chou says.
When he does refer patients for spinal manipulation, Dr Chou tries to make sure the practitioner is not going to apply additional therapies that are unproven. “There are some chiropractors who do manipulation, and they are also doing things that may be counterproductive, such as getting radiography that isn’t necessary and telling people there is something wrong with their alignment that makes people worry about things they shouldn’t be worried about,” says Dr Chou. “Those are folks I try to avoid if I can.”
He advises patients to try spinal manipulation for 3-4 weeks, then move on to something else if it isn’t helping. But he acknowledges that he has no research to support that recommendation.
Gross, who practices manual therapy, refers practitioners to an online “neck pain toolkit” developed by a collaboration of physiotherapists.[7] For low back pain, she recommends “Low Back Pain Strategy,” a similar resource developed by the Ontario Ministry of Health and Long-Term Care.[8] But she adds that no literature review or evidence-based algorithm can provide all of the guidance a practitioner needs to treat a patient’s back or neck pain.
The decision to use spinal manipulation “always has to be based on more than just research evidence,” Gross insists. “It has to be based on good sound clinical reasoning, biology, the psychosocial elements around you, and the individual you are helping.”

References

  1. Manipulation and mobilisation for neck disorders. Cochrane. September 23, 2015. http://bit.ly/2l7M2dP Accessed January 26, 2016.
  2. Noninvasive treatments for low back pain. Agency for Healthcare Research and Quality. February 29, 2016. http://bit.ly/2lACICR Accessed January 26, 2016.
  3. Homola S. Bonesetting, chiropractic, and cultism. Chirobase. 1963. http://bit.ly/2l7y1gA Accessed January 26, 2016.
  4. Wieting MJ. Massage, traction, and manipulation. Medscape. November 2, 2015. http://bit.ly/2lAFVCE Accessed January 26, 2016.
  5. Keating JC Jr. D.D. Palmer’s religion of chiropractic. Chiro.org. March 1995. http://bit.ly/2lAI2q0’s_Religion-of-Chiro.pdf Accessed January 26, 2016.
  6. Cugalj AP, McManus K. Manual treatments. PM&R Knowledge Now. September 20, 2013. http://bit.ly/2l7ILve Accessed January 26, 2016.
  7. Neck pain tool-kit: step 1. Physiopedia. http://bit.ly/2lAyFXo Accessed January 26, 2016.
  8. Low back pain strategy. Ontario Ministry of Health and Long-Term Care. September 16, 2016. http://bit.ly/2l7Umu9 Accessed January 26, 2016.

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