Journal of Manipulative and Physiological Therapeutics
Volume 29, Issue 7 , Pages 598-599, September 2006

Foundation for Chiropractic Education and Research, Brookline, MA

Article Outline

 

In Reply:

Several points need to be brought to the reader's attention regarding this highly detailed yet vexingly elusive study, in response to the preceding Letter to the Editor from the authors. With regard to odds ratios, the authors correctly state that this matter was previously discussed elsewhere, and that it was incorrect to dichotomize treatment effects into categories in which P values are more or less than .05.1 The fact remains, however, that the confidence intervals that fall substantially above and below the value 1 in the article's Table 3 hardly instill confidence in the validity of the inferences drawn from these data. Furthermore, of the total 85 patients, Table 3 suggests that (1) 70 (82%) displayed a higher odds ratio pertaining to electromagnetic stimulation (EMS) or no EMS vs manipulation or mobilization (1.50 vs 1.38) with reference to neck pain, stiffness, or soreness; (2) 44 (52%) revealed a higher odds ratio of EMS vs no EMS vs manipulation or mobilization (1.22 vs 1.00) with reference to headache; and (3) 17 (20%) indicated a higher odds ratio pertaining to EMS vs no EMS vs manipulation (1.61 vs 1.39) as well as a higher odds ratio relating to heat vs no heat vs manipulation vs mobilization (1.49 vs 1.39). These data are hard to reconcile with the authors' contention that most of 75% and 83% show that manipulation vs mobilization is stronger than the other estimates involving heat or EMS. It would also challenge the authors' contention that I “cherry picked” a single estimate to support my contention that adverse reactions were not the sole domain of cervical spine manipulations.

Despite the factorial design and the regression models cited by the authors in their study, it would have been far more straightforward to present the actual demographics in the comparison groups specifically pertaining to such preceding conditions as moderate or severe headache or elevated neck disability scores. Given the copious demographics shown in Table 1 comparing responders vs nonresponders, one wonders why the same presentation was not afforded to patients undergoing manipulation vs mobilization, the heart of this study.

Regarding the author's assertion that my references to nonsteroidal antiinflammatory drugs involved patients with chronic pain who took large doses for long durations as opposed to shorter-term treatments for chiropractic patients, at least one study can be cited in which patients who took medication for the same length of time as the chiropractic treatment experienced significant side effects and were forced to drop out of a randomized controlled trial.2 Overall, the facts that the complication rates of nonsteroidal antiinflammatory drugs are several orders of magnitude higher than the complication rates reported for manipulation and that a significant proportion of these are life-threatening for commonly prescribed courses of treatment cannot be dismissed as the authors have appeared to have done.

Although the authors describe the chiropractic adjustments administered as “movements of low velocity and variable amplitude directed to one or more restricted upper thoracic and/or cervical spine joint segments,”3 the argument remains that, despite the fact that nearly 200 chiropractic techniques have been described,4 very few of these have been specified in the research literature and none in the article of Hurwitz et al.3 This would appear to make the entire issue of replication all but impossible.

The authors suggest that the validity of my citations is undercut by the fact that 29 are at least 5 years old. Yet, the systematic reviews and meta-analysis cited by the authors, some of which are positive,5, 6 have incorporated many of these very same studies. One simply cannot have it both ways. The “one most recent and relevant study” that the authors suggest that I have misinterpreted does in fact support the effectiveness of manipulation and/or mobilization plus exercise.7 Because I had only referred in my text to “the benefits of such procedures,” it is difficult to discern precisely where the misinterpretation might have taken place.

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References 

  1. Hurwitz EL, Morgensten H. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA Neck Pain Study. Letter Spine. 2006;31:252–254
  2. Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. J Manipulative Physiol Ther. 1998;21:317–326
  3. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang L-M. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA Neck Pain Study. Spine. 2005;30:1477–1484
  4. Bergmann TF. Various forms of chiropractic technique. Editorial Chiropr Tech. 1993;5:53–55
  5. Vernon H, McDemaid CS, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complement Ther Med. 1999;7:142–155
  6. Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24:457–466
  7. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004;29:1541–1548

PII: S0161-4754(06)00184-9

doi:10.1016/j.jmpt.2006.07.003

Journal of Manipulative and Physiological Therapeutics
Volume 29, Issue 7 , Pages 598-599, September 2006

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