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Three Part Question

In [adults with neck sprain] does [osteopathy or chiropractic] improve [outcome]?

Clinical Scenario

A 25 year old female attends the emergency department having been in a rear end shunt. She complains of pain in her neck. On examination she has right sternomastoid tenderness and restricted movement. You diagnose a neck sprain and advise physiotherapy, exercise and anti-inflammatory drugs. She asks you whether she should go and see an osteopath or a chiropractor. You wonder whether there is any evidence for these alternative treatments.

Search Strategy

Medline using the OVID interface 1966-10/02, Cochrane Library 2002 Issue 3 and hand search of paper references.
[(exp Neck injuries OR exp Neck pain OR neck.mp OR whiplash.mp) AND (exp Osteopathic medicine OR osteopath$.mp OR chirop$.mp)] LIMIT to human AND English.

Search Outcome

206 papers were found, of which 13 were relevant. One literature review is not included in the table as all the papers are either represented in another review or described separately. 3 papers were excluded on the basis of having 10 or fewer patients. The remaining 9 papers are shown in the table. Many of the studies also include patients with lower back pain – only the neck pain patients are described in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Koes BW et al, Netherlands, 1991	5 RCTs all comparing cervical manipulation to a control Total number of patients combined 111	Review	Recovery	3 studies concluded manipulation better than collar and analgesics 2 Studies showed no significant difference between manipulation and diazepam, a collar and transcutaneous nerve stimulation	Studies rated poor-moderate on methodology scoring
Cassidy JD et al, 1992, Canada	100 patients with mechanical neck pain One manipulation vs mobilization	RCT	Mean improvement in pain as measured by visual analogue scale	17.3 (SD19.5) vs 10.5 (SD 14.8)	Only one treatment with pain score repeated immediately afterwards No long term follow-up Manipulation was not carried out by an osteopath or chiropractor
Koes BW et al, 1993, Netherlands,	29 patients with neck pain Physiotherapy (n=17) vs manual therapy n=12 (manipulation and mobilisation)	RCT	Subjective pain measurement and physical function over 12 months	Both groups improved without any statistical difference between groups	Patients were also assigned to receive treatment by their GP and placebo. These results were not reported Small numbers
Skargren EI et al, 1996, Sweden	70 patients with neck pain Physiotherapy (n=29) or chiropractic (n=41)	RCT	Subjective pain; Function,general health	Significant improvement in pain, function and general health in both groups	No breakdown of results between back and neck pain patients given for the last 2 outcomes
			Sick leave	No difference
			Fulfillment of patient expectation	41% of chiropractic group vs 24% physiotherapy group
			All measured until 6 months
Woodward MN et al, 1996, UK	28 patients with chronic “whiplash” syndrome All had chiropractic manipulation	Retrospective cohort	Disability at baseline and following treatment	26/28 patients had reduction in disability	Follow-up time period not specified Disability classified by either a chiropractor or by an orthopaedic doctor over the phone No control group
Verhoef MJ et al, 1997, Canada	106 patients with neck pain and 88 with neck and back pain All had chiropractic manipulation	Prospective cohort	Disability (Neck Disability Index)	Baseline mean score 23.5, mean score at 6 weeks 13.3 p<0.001	No control group
Jordan A et al, 1998, Denmark	119 patients with neck pain for more than 3 months Intensive training physiotherapy vs chiropractic treatment	RCT	Self reported pain and disability	All treatment modality groups had improved pain levels and disability scores	All groups underwent intervention No comparison with natural progression of injury
			Medication use	All groups progressively reduced analgesic intake
			All of above measured until 12 months
Giles LGF & Muller R, 1999, Australia	33 patients with neck pain for at least 13 weeks Chiropractor manipulation (n=18), acupuncture (n=7) or medication (n=7)	RCT	Disability (Neck Disability Index) Measured at 4 weeks	Manipulation group median index score reduced by 10 points p=0.001 No statistically significant reduction in acupunture or medication group	Very small numbers particularly in acupuncture and medication groups Numbers within table referring to number of patient with neck pain do not add up
			Pain as measured by visual analogue scale	Manipulation group median pain score reduced by 1.5 points p=0.002 No statistically significant reduction in acupuncture or medication groups
McMorland G & Suter E, 1999, Canada	61 patients presenting to a chiropractice with neck pain. All received chiropractic manipulation	Retrospective cohort	Neck Disability Index score	Reduction in score after 4 weeks of therapy	No statistics displayed 244 patients who did not complete therapy because they got better or worse were excluded No control group

Comment(s)

Virtually all of these studies are flawed and the numbers tiny. In particular there are no powerful studies comparing best conventional treatment with best alternative treatments. There were no papers relating directly to osteopathy.

Clinical Bottom Line

Chiropractic therapy is associated with improvement in neck symptoms but there is no evidence to show whether this improvement is greater or worse than that obtained with conventional treatment.

References

1. Koes BW, Assendlft WJJ, van der Heijden GJMG, et al. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991;303:1298-303.
2. Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilisation on pain and range of motion in the cervical spine: a randomised controlled trial. J Manipulative Physiol Ther 1992;15(9):570-575.
3. Koes BW, Bouter LM, van Mameren H, et al. A randomised clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: subgroup analysis and relationship between outcome measures. J Manipulative Physiol Ther 1993;16(4):211-219.
4. Skargren EI, Oberg BE, Carlsson PG, et al. Cost effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain. Spine 1996;22(18):2167-2177.
5. Woodward MN, Cook JCH, Gargan MF, et al. Chiropractic treatment of chronic whiplash injuries. Injury 1996;27(9):643-645.
6. Verhoef MJ, Page SA, Waddell SC. The chiropractic outcome study: Pain, functional ability and Satisfaction with care. J Manipulative Physiol Ther 1997;20(4):235-240.
7. Jordan A, Bendrix T, Nielsen H, et al. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. Spine 1998;23(3):311-319.
8. Giles LGF, Muller R. Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a non-steroidal anti-inflammatory drug and spinal manipulation. J Manipulative Physiol Ther 1999;22(6):376-381.
9. Mcmorland G, Suter E. Chiropractic management of mechanical neck and low-back pain: A retrospective, outcome-based analysis. J Manipulative Physiol Ther 1999;23(5):307-311.