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"While we acknowledge that there is uncertainty surrounding the causality of the association between manipulation and these events, we do not accept that the same uncertainty exists regarding the benefits…
The British Chiropractic Association has suggested that we have cherry picked low quality evidence. We believe that we have considered the key studies, but if the BCA are aware of important or more robust contradictory evidence then we would be very happy to consider it…
Dr Mann suggests that the UK BEAM trial provides evidence for the effectiveness of cervical manipulation, but since it was a trial of treatment for low back pain, this assertion is tenuous. However it is worth discussing this study as it highlights a number of important issues for manual therapists wishing to use high quality evidence rather than anecdote to inform their management of patients with neck pain. Firstly, the differences reported for the primary outcome measures were lower than the authors pre-set minimal clinically important difference. In addition, as is common to many trials of manual therapy for neck pain, the therapist, patients and the assessors were not blinded. It is likely that the already small effect sizes seen are exaggerated by the resulting biases. Most significantly in relation to the current discussion on high velocity manipulation techniques, it is important to recognise that clinicians were able to choose from a range of manual therapy techniques as well as mobilising and strengthening exercises. As is the case in many neck pain trials, effectiveness of a package of care provided by a manual therapist cannot be used to specifically endorse high velocity thrust manipulations, as they are often only part of a treatment package. It should also be noted that this package of care was designed and endorsed by the professional bodies representing osteopathy, chiropractic and physiotherapy in the UK and explicitly excluded the use of high velocity thrust techniques to the neck because of the chance of serious side effects. We also do not accept that the existing data on risks, imperfect though it is, is uninformative. The fact that not all studies have shown an effect in the over 45's most likely reflects the other causes of these events in that population clouding the picture. Indeed finding the association in a group who would not normally be expected to experience such an event (i.e. <45 yrs) arguably makes the association more convincing. While attempts to develop screening procedures is commendable, given that the association between manipulation and VAD/stroke is found in this group who are less likely to present with key vascular risk factors, it seems unlikely that screening will achieve its goal satisfactorily.
Reid and colleagues point out that in one survey , 45% of these events may have been preventable, which still leaves a rather uncomfortable 55% that may not have been. Indeed acceptance of Cassidy and colleagues argument, that there are patients receiving cervical manipulation who present with a pre-existing dissection, only further illustrates that screening is far short of being effective. We would suggest that comparisons with NSAIDs or surgical procedures are less useful. Beyond the issue of inadequate data for drawing fair comparisons and the likely underestimation of the true risks for manipulation, manual therapists might more simply ask how their own practice may be made safer
…in possession of truly informed consent, why would one choose a technique that confers no unique benefit but poses a possible unique risk?
...In the end, it remains our opinion that cervical spinal manipulation is unnecessary and inadvisable given the other options available."
Neil O'Connell et al, British Medical Journal (27th June 2012)