RCC Research Bulletins

Comparative effectiveness of spinal manipulation for sciatica

In 2006, Santilli et al reported that, compared with sham manipulation, active spinal manipulation is more effective at six months at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion. A recent network meta-analysis of the many different treatment strategies (Lewis et al, 2015) has now concluded that spinal manipulation is one of a number of interventions that provides significant improvement for sciatica compared to inactive control or conservative therapy. The other effective interventions include acupuncture, non-opioid analgesia, epidural injections and surgery. Note that an earlier cohort study demonstrated similar clinical effectiveness and a cost benefit of employing spinal manipulation as opposed to nerve root injections for patients with symptomatic MRI-confirmed lumbar disc herniation (Peterson et al, 2013).

References:

Lewis RA et al (2015) Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 15, 1461–1477.

Peterson C et al (2013) Symptomatic magnetic resonance imaging-confirmed lumbar disc herniation patients: A comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections. Journal of Manipulative and Physiological Therapeutics219, 36(4), 218-225.

Santilli V et al (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal 6, 131–137.

Cost effectiveness of manual therapy

A systematic review of the cost-effectiveness of manual therapy for musculoskeletal pain, funded by the Royal College of Chiropractors, was recently published in the Journal of Manipulative and Physiological Therapeutics. The conclusions of the review were positive for the cost-effectiveness of manual therapy approaches to management of low back and shoulder pain, but found inconsistent results for management of neck pain. The full article can be read here.

Cost-effectiveness studies evaluate only the direct costs of provision of the care received and the review highlights some limitations in the available evidence, including the fact that more extensive economic evaluations (that would include the longer term costs and/or savings in healthcare) have not been conducted. Consequently the RCC recognises economic evaluation studies as one of the research priorities for chiropractic.

This study was part of the wide-ranging independent evaluation of manual therapy that the RCC commissioned to be conducted by Warwick Evidence, a research group that have been involved in clinical guideline development for NICE. An earlier publication in Chiropractic and Manual Therapies (Clar et al, 2014) reported some of the findings of their review of the clinical effectiveness of manual therapy approaches for different conditions. The full report produced by Warwick Evidence can be found here (Sutcliffe et al, 2012).

Cervical Artery Dissection and Cervical Spinal Manipulation

The RCC’s Research Committee has highlighted a recent review article from the American Heart Association Stroke Council (Biller et al, 2014) that provides a scientific statement for healthcare professionals of the current state of evidence on the diagnosis and management of vertebral and carotid artery dissections and of their statistical association with cervical manipulative therapy.

The article, published in Stroke, was produced by a multidisciplinary writing group that included a chiropractor. The article, which can be accessed in full here makes important reading for any chiropractor as it provides the most up to date evidence summary for cervical artery dissections, that includes:

  • The incidence, aetiology and pathology of cervical artery dissections
  • A comprehensive list of risk factors that should be considered during pre-treatment screening
  • Characterisations of the signs and symptoms that may be present in a patient in whom either a vertebral or a carotid artery dissection is underway
  • Information on diagnosis and investigations
  • Information on medical management, clinical outcomes and prognosis

In relation to the association between cervical manipulative therapy and cervical artery dissection, it is acknowledged that this may be performed by chiropractors, osteopaths, physical therapists or allopathic medical professionals. Evidence relating to the biomechanics of cervical manipulation and possible mechanisms of cervical artery dissections is reviewed. The article critically reviews the findings of case-control studies, concluding that:

  • A few studies suggest an association between cervical manipulative therapy and cervical artery dissection, but did not distinguish whether thrust techniques were involved.
  • The best available evidence suggests cervical artery dissection, particularly vertebral artery dissection, may be of a low incidence but could be a serious complication of cervical manipulative therapy
  • A single study reported a similar association of vertebral artery dissection with chiropractic visits as with primary care physician visits, thus the association may not be causal
  • Increased education of providers of cervical manipulative therapy may be warranted to improve diagnosis of cervical artery dissection
  • Patients with neck pain should be informed of the potential risks and benefits of receiving cervical manipulative therapy and practitioners should carefully consider cervical artery dissection prior to performing cervical manipulation