References: Neck Manipulation; Volume 3 Issue 6

1. AUTHOR	Hansen-D-T
TITLE	Chiropractic standards of practice and utilization guidelines in the care and treatment of injured workers.
SOURCE	Chiropractic Advisory Committee, Department of Labor and Industries, State of Washington, 1988

2. AUTHOR	Hurwitz-E-L, Aker-P-D, Adams-A-H, Meeker-W-C, Shekelle-P-G.
INSTITUTION	RAND, Santa Monica, CA, USA.
TITLE	Manipulation and mobilization of the cervical spine. A systematic review of the literature.
SOURCE	Spine 1996 Aug 1, VOL: 21 (15), P: 1746-59; discussion 1759-60, ISSN: 0362-2436 134 Refs.
ABSTRACT	STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. 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 manipulation 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. Author.

3. AUTHOR	Dabbs-V, Lauretti-W-J.
TITLE	A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain (see comments).
SOURCE	J-Manipulative-Physiol-Ther 1995 Oct, VOL: 18 (8), P: 530-6, ISSN: 0161-4754 43 Refs.
CM	Comment in: J-Manipulative-Physiol-Ther 1996 Mar-Apr; 19(3):220-1.
ABSTRACT	OBJECTIVE: We reviewed the literature to evaluate the risk of serious injury or death resulting from cervical manipulation and to assess the evidence that cervical manipulation is an effective treatment for mechanical neck pain. We also reviewed the literature to assess the risks and effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs), which are often used as the "conventional" first-line treatment for similar musculoskeletal conditions. 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 tha indicates NSAID use is any more effective than cervical manipulation for neck pain. Author.

4. AUTHOR	Powell-F-C, Hanigan-W-C, Olivero-W-C.
INSTITUTION	Department of Neuroscience, University of Illinois College of Medicine, Peoria.
TITLE	A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain (see comments).
SOURCE	Neurosurgery 1993 Jul, VOL: 33 (1), P: 73-8; discussion 78-9, ISSN: 0148-396X 39 Refs.
CM	Comment in: Neurosurgery 1994 Mar; 34(3):560-1.
ABSTRACT	Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self- referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles. Although these reviews agreed that most trials exhibited serious flaws, the data suggest that SMT demonstrates consistent effectiveness as an alternate treatment for adults with acute low back pain. SMT has not been shown to be superior to the other conservative methods, nor to offer long-term benefits. It is concluded that the risk/benefit ratio is acceptably low for SMT as therapy for adults with midline low back pain of less than 1 week in duration. The ratio was unacceptably high for patients with radicular symptoms or signs associated with prolapsed discs and neck pain. Potential complications and unknown benefits indicate that SMT should not be used in the pediatric population. Author.

5. AUTHOR	Assendelft-W-J, Bouter-L-M, Knipschild-P-G.
INSTITUTION	Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, The Netherlands.
TITLE	Complications of spinal manipulation: a comprehensive review of the literature (see comments).
SOURCE	J-Fam-Pract 1996 May, VOL: 42 (5), P: 475-80, ISSN: 0094-3509 41 Refs.
CM	Comment in: J-Fam-Pract 1996 Oct; 43(4):333; discussion 334-5; Comment in: J-Fam-Pract 1996 Oct; 43(4):333-4; discussion 334-5.
ABSTRACT	BACKGROUND: Spinal manipulative therapy (SMT) is a frequently applied therapy for back and neck pain. Serious complications of SMT are presented primarily in case reports. Many patients seen by physicians also seek care from therapists applying manipulative techniques. Therefore, background information on the risks of SMT is essential for physicians. METHODS: Relevant case reports, surveys, and review articles were identified using a comprehensive search of online and bibliographical databases. For every case, a record was made of first author, publication year, country, age and sex of the patient, background of the manipulator, preexisting conditions, type of complication, and course of the complication. Based on case reports and surveys, an estimation was made of the risk for the most frequently reported complications: vertebrobasilar accidents (VBAs) and cauda equina syndrome (CES). RESULTS: We derived 295 complications of spinal manipulations from the literature: 165 VBAs; 61 cases with disc herniation or progression to CES; 13 cerebral complications other than VBAs; and 56 other types of complications. The average age of patients with VBA was 38 years. Vertebrobasilar accidents occur mainly after a cervical manipulation with a rotatory component. Estimates of VBA range from 1 per 20,000 patients to 1 per 1 million cervical manipulations. The incidence of CES is estimated to be less that 1 per 1 million treatments. CONCLUSIONS: It is difficult to estimate the incidence of SMT complications, as they are probably underreported in the literature. Most non-VBA complications can be prevented by excluding patients with contraindications for SMT. Patients who develop complications such as CES should be treated as soon as possible. VBAs, however, are difficult to prevent and treat. Referral for SMT should not be made to practitioners applying rotatory cervical manipulation. Information about the risk of VBA should be included in an informed consent procedure for cervical manipulation with thrust techniques. Author.