Prize-winning paper from the World Federation of Chiropractic 7th Biennial Congress
Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study

https://doi.org/10.1016/j.jmpt.2003.11.002Get rights and content

Abstract

Background

Minor side effects associated with chiropractic are common. However, little is known about their predictors or the effects of reactions on satisfaction and clinical outcomes.

Objective

The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain.

Methods

Neck pain patients were randomized to receive cervical spine manipulation or mobilization. At 2 weeks, subjects were queried about possible treatment-related adverse reactions and followed for 6 months with assessments for pain and disability at 2, 6, 13, and 26 weeks. Numerical rating scales and the Neck Disability Index were used to measure pain and disability. Perceived improvement and satisfaction with care were assessed at 4 weeks.

Results

Of 960 eligible patients, 336 enrolled and 280 responded to the adverse event questionnaire. Thirty percent of respondents reported at least 1 adverse symptom, most commonly increased pain and headache. Patients randomized to manipulation were more likely than those randomized to mobilization to report an adverse reaction (adjusted odds ratio = 1.44, 95% confidence interval = 0.85, 2.43). Subjects reporting adverse reactions were less satisfied with care and less likely to have clinically meaningful improvements in pain and disability.

Conclusions

Adverse reactions are more likely to be reported following cervical spine manipulation than mobilization. Chiropractors may reduce iatrogenesis and increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.

Introduction

Although major complications resulting from chiropractic care are very rare,1, 2, 3 transient discomfort and other minor side effects of chiropractic care are common. Recent prospective studies have shown 30% to 55% of patients receiving spinal manipulation experience minor side effects, such as local discomfort4, 5, 6 or additional pain7 shortly after treatment. Much less common are radiating pain or discomfort,4, 5, 7 stiffness,7 headache, and tiredness or fatigue.4, 5, 6, 7 Nausea and dizziness each comprise 5% or less of reported symptoms.4, 5, 6, 7 The majority of reactions have been reported to begin within 24 hours of the treatment visit and to resolve in less than 24 hours. However, little is known about (1) the frequency of adverse reactions specifically following chiropractic treatment of the cervical spine, (2) the effect of type of manual therapy on the incidence of adverse reactions, and (3) the effects of adverse reactions on patient satisfaction and clinical outcomes.

The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain.

Section snippets

Study design and source population

Neck pain patients were randomized in a balanced 2 × 2 × 2 factorial design to manipulation with and without heat and with and without electrical muscle stimulation (EMS) and mobilization with and without heat and with and without EMS. Subjects were followed for 6 months with assessments for pain and disability at 2 and 6 weeks and 3 and 6 months. The source population was approximately 90,000 to 110,000 members of a southern California health care network, which had chiropractors on staff at 4

Screening, enrollment, and follow-up

We screened a total of 1848 patients. Eight hundred eighty-eight (48%) patients were excluded for the following nonmedical reasons (frequency): pain not primarily in the neck (283), over 70 years old (169), third-party liability or workers' compensation (112), fee-for-service or non-HMO insurance (104), treatment in the past 1 month (100), less than 18 years old (24), inability to read English (24), plans to relocate (14), and not easily accessible by telephone (4). Patients were excluded for

Discussion

The results from this study of neck pain patients randomized to receive chiropractic manipulation or mobilization suggest that cervical spine manipulation is associated with relatively more adverse reactions than cervical spine mobilization and that experiencing an adverse reaction during the first 2 weeks of care results in relatively less satisfaction and perceived improvement 2 weeks later and less reductions in pain and disability after 6, 13, and 26 weeks of follow-up. Although these

Conclusion

Among neck pain patients treated by chiropractors, adverse reactions are more likely to be reported following cervical spine manipulation than cervical spine mobilization. Compared with subjects who did not report any adverse treatment effects, the findings suggest that subjects with adverse symptoms (1) were relatively less satisfied with care, (2) perceived less improvement in neck symptoms, and (3) had more pain and disability during subsequent follow-up. Larger prospective studies should be

Acknowledgements

This study was funded by grants from the Health Resources and Services Administration (R18 AH10008) and the National Chiropractic Mutual Insurance Company (NCMIC). Dr Hurwitz was also supported by a grant from the National Center for Complementary and Alternative Medicine (K23 AT00055). We wish to thank Dr Gary Pirnat and his staff of chiropractors for their active involvement and cooperation during the study. Special thanks also to the clinic management teams from La Habra, Brea, Buena Park,

References (24)

  • E.L. Hurwitz et al.

    Manipulation and mobilization of the cervical spinea systematic review of the literature

    Spine

    (1996)
  • W.J. Assendelft et al.

    Complications of spinal manipulationa comprehensive review of the literature

    J Fam Pract

    (1996)
  • S. Haldeman et al.

    Arterial dissections following cervical manipulationthe chiropractic experience

    Can Med Assoc J

    (2001)
  • O. Senstad et al.

    Side-effects of chiropractic spinal manipulationtypes, frequency, discomfort and course

    Scand J Prim Health Care

    (1996)
  • O. Senstad et al.

    Frequency and characteristics of side effects of spinal manipulative therapy

    Spine

    (1997)
  • C. Leboeuf-Yde et al.

    Side effects of chiropractic treatmenta prospective study

    J Manipulative Physiol Ther

    (1997)
  • A.J. Barrett et al.

    Adverse effects of spinal manipulation

    J R Soc Med

    (2000)
  • Cherkin DC, Mootz RD. Chiropractic in the United States: training, practice and research. Rockville (MD): Agency for...
  • M.G. Christensen et al.
  • Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters....
  • H.T. Vernon et al.

    The Neck Disability Indexa study of reliability and validity

    J Manipulative Physiol Ther

    (1991)
  • H. Vernon

    The Neck Disability Indexpatient assessment and outcome monitoring in whiplash

    J Musculoskelet Pain

    (1996)
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