The new RAND study, "The Appropriateness of Manipulation and Mobilization of the Cervical Spine,"1 is likely be both hailed and criticized by the chiropractic profession. On the positive side, this report provides data that cervical spine manipulation may be effective (at least in the short term) for subacute or chronic neck pain, muscle tension headaches, and increased range of motion. On the negative side, the report highlights the lack of research on chiropractic efficacy, reporting that there is insufficient data to validate chiropractic's effectiveness for many conditions, an inadequacy which continues to impede the profession's acceptance within the health care arena.
The conclusions of the RAND study's nine-member panel came from evidence provided in the extensive literature review. The panel considered 1,436 indications for cervical manipulation and mobilization, and of that total only 122 (16%) were considered appropriate. The panel was uncertain regarding 586 (41%), and found 623 (43%) to be inappropriate.
The study's panel represents a diverse cross-section of the chiropractic profession, and includes three private practice chiropractors, one academic DC, one practitioner who has all three MD, PhD, DC degrees, an academic primary care physician, an academic neurologist, an academic orthopedic surgeon, and an academic neurosurgeon:
Arthur Croft, DC
Peter Curtis, MD
Thomas Ducker, MD
Ronald Evans, DC
Steve Garfin, MD
George McClelland, DC
David Sherman, MD
Rand Swenson, MD, PhD, DC
Howard Vernon, DC
The following summaries were presented in the report:
Acute Neck Pain "In summary, there are no RCTs (randomized, controlled trial) or case series presenting data about the efficacy of cervical spine manipulation specifically for patients with acute neck pain. The limited literature available on mobilization for acute neck pain indicates that it may be beneficial for some patients, as least compared to rest and cervical collar, although instruction on mobilization and exercises may be equally beneficial.The study may help to dispel or at least clarify the continual negative media coverage concerning the risk that chiropractic care, especially cervical adjustments, can pose to patients. The now-infamous "20/20" segment depicted cervical manipulation as having the potential to cause harm, but "20/20" did not bother to represent the appropriate risk factors (which are very low). This RAND Cervical Spine Study provides some long awaited figures that are consistent with the existing literature:Subacute and Chronic Neck Pain
"In summary, evidence from the literature supports the conclusion that cervical spine manipulation and/or mobilization may provide at least short-term pain relief and range of motion enhancement for persons with subacute or chronic neck pain. The published results are insufficient to make efficacy determinations separately for patients with subacute pain and patients with chronic neck pain.
Muscle Tension Headache
"In summary, the literature is sparse but suggests that cervical spine manipulation and/or mobilization may provide short-term relief for some patients with muscle tension (and other nonmigraine) headaches. The evidence for long-term benefit is much less conclusive.
Migraine Headache
"In summary, the literature is too limited to support or refute the use of cervical spine manipulation and/or mobilization for patients suffering from migraine headaches.
Shoulder/Arm/Hand Pain - Acute, Subacute, and Chronic Pain
"In summary, there is insufficient evidence to support or refute the use of cervical spine manipulation and/or mobilization for patients with thoracic outlet syndrome. The literature indicates that manipulation and mobilization may be more effective in patients with acute or subacute symptoms.
Carpal Tunnel Syndrome
"In summary, there is insufficient evidence to support or refute the use of cervical spine manipulation and/or mobilization for patients with carpal tunnel syndrome.
TMJ Disorders
"In summary, the current literature is insufficient to either support or refute the use of cervical spine manipulation and/or mobilization for patients with TMJ disorders.
Blood Pressure and Heart Rate
"In summary, the literature is too limited to make any determinations with respect to the effect of cervical spine manipulation on blood pressure and heart rate.
Cervical Spine/Intersegmental Motion
"In summary, the literature described above and in previous sections on Chronic Neck Pain and on Migraine Headache provides evidence that manipulation of the cervical spine increases range of motion and intersegmental mobility.
Cervical Spine Curvature
"In summary, evidence from the literature is insufficient to support or refute the use of cervical spine manipulation for influencing cervical curvatures."
"Chiropractors perform about 90 percent of manipulation in the United States. Using data from a community-based study of the use of chiropractic services (Shekelle and Brook, 1991) to provide a rough estimate of the number of cervical spine manipulations delivered in the United States, and assuming that published case reports represent one-tenth of the actual complication caseload, the rate of vertebrobasilar accidents (VBA) or other complications (e.g., cord compression, fracture, hematoma, etc.) as a result of cervical spine manipulation is estimated to be 1.46 per one million manipulations. Using the same methodology, the rates of serious complications and death from cervical spine manipulation are estimated to be 6.39 per 10,000,000 manipulations and 2.68 per 10,000,000 manipulations, respectively."RAND's estimate that vertebrobasilar accidents or other complications resulting from cervical spine manipulations are a mere 1.46 per one million manipulations is certainly a triumph for chiropractic. But that estimate is marred, obviously, by the overly conservative assumption that only 1 out of every 10 complications ever gets published in a case report. But this is probably the strength (and weakness) that most DCs will find with this report: it is very conservative in its review of the literature and subsequent recommendations.
It is evident from the RAND panel's findings that the chiropractic profession desperately needs to perform additional research. While much of what a chiropractor performs in practice has a basis in the literature, there is still a large portion that remains unstudied as well as misunderstood.
1. Coulter I, Hurwitz E, Adams A, Meeker W, Hansen D, Mootz R, Aker P, Genovese B, Shekelle P. The appropriateness of manipulation and mobilization of the cervical spine. RAND 1996.
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