Look Before You Speak

I was discussing the treatment patients with neck pain and associated headaches a while back with someone, when they posed a question about effectiveness of manual physical therapy for migraines. I knew there was evidence for the effectiveness of this intervention for cervicogenic and tension headaches, but was always under the confident impression there was no benefit for migraine headaches.

Nothing like having to speak on a topic to make you do a little digging. Although I am sure there are many criticisms that can be made regarding diagnostic criteria, methods, etc., this latest Cochrane Review on the topic by Bronfort and Colleagues (located initially in the Index of Cochrane abstracts…very helpful) provides evidence for the effectiveness of manual physical therapy for all 3 types of headaches. In some cases, more so than standard use medication (amitriptyline)…..does this sound familiar?. 

Anyway, this just reinforces to me the fact the saying that “The problem used to be there wasn’t much evidence, now it is more often the case that evidence is available that we just aren’t aware of”. Another reminder to look before we speak too emphatically about a subject we think we know about if we haven’t looked in a while.
 

Rob

Comments

[Britt Smith]

So true, so true. Gwen Jull was presenting evidence of her cervicogenic headache RCT, which demonstrated that nearly 50% of the subjects had 2 or more types of headache present, so sorting it all out is problematic.

With regard to not being aware of evidence...I have been approached by a Nikken person, you know magnets and all. I have absolutely no interest in this pyramid scheme, but I did run a search on magnets and pain management and found some intriguing evidence for effectiveness. I'll post a blog on the subject. Thanks Rob

[Jeff Hebert, DC]

Rob,
Good points all around. For the sake of clarification, as this is one of the few examples where the research is more chiropractic oriented, I wanted to point out that the authors are chiropractors and/or employees of a chiropractic college.

While there may be little to no difference in cervical spine manipulation performed by chiropractors and physical therapists, I'm not sure that the review is necessarily a reflection on manual physical therapy.

Thanks,

Jeff

[Britt Smith]

Jeff,
I think you make an interesting distinction, because the reviewers are chiropractors. I'm not sure if you are aluding to bias or to a unique nature of chiropractic practice.
With regard to bias, Assendelft et al in JAMA, 1995:
“…a review of spinal manipulation is more likely to have a positive outcome,
If the review deals with spinal manipulation only,
if a spinal manipulator was among the authors,
& if a comprehensive search was described.”
With regard to the 2nd point, they conclude the essay with...
“It can be equally true that reviewers who were not spinal manipulators were biased against the therapy.” [Last sentence in monograph,Assendelft WJJ, Koes BW, Knipschild PG, Bouter LM. JAMA.1995;274:1942-1948.].
Or, perhaps, chiropractic reviewers are trying to demonstrate effectiveness for a condition that is principally viewed as a medical condition, like asthma, dysmennorrhea and such. Any comments? Thanks,
Britt
PS. Jull noted that the migraine patients did respond to manipulation, also, but the 'pure' migraine patients could be distinguished by the combinations of impairments (compared to cervicogenic groups).

[Jeff Hebert, DC]

Hi Britt,

Excellent questions. I do not believe that spinal manipulation performed by a chiropractor is unique in comparison to an experienced manual physical therapist.

With that being said, I have never known a physical therapist who was comfortable with cervical spine manipulation- I believe that to a certain degree this is reasonable given the potential for injury and in light of some of the research on thoracic spine manipulation for neck pain (Childs, et al).

Chiropractors tend to be the ones manipulating cervical spines, and I believe that the majority of the literature cited in the review (the amitriptyline studies for sure) revolved around manipulation performed by chiro's.

Therefore, IMHO the conclusion that the referenced article supported manual physical therapy was a bit off (As I don't think you guys are out there manipulating many cervical spines).

Finally, as physical therapists have been vastly outperforming us DC's in the realm of manipulation research, I wanted to point out an instance where the chiropractors were contributing.

Thanks,

Jeff

[Britt]

Thanks, Jeff, indeed many of the chiropractic researchers are making wonderful contributions to the body of knowledge of manual therapy.
An interesting counter-point on the comment on PTs performing cervical manipulation is found in the article: Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77:145-154., which demonstrated that PTs selected and performed cervical manipulation much more frequently that lumbar manipulations. In
the editorial, Clinicians and Researchers Who Treat and Study Patients With Low Back Pain: Are You Listening? (Phys.Ther.1998)Delitto points out that this finding flys in the face of mounting evidence for the effectiveness of lumbar manipulation, particularly when compared to equivocal finding of manipulation of the neck (most like equivalent to mobilization). Any thoughts?
Britt

[Rob Wainner]

Jeff,

Thanks for the great insight and comments. In my post I admitted that while relaying the results of this Cochrane review, I had not read the original work on which the conclusions regarding manipulation and migraine HA were based. However, I am familiar with the original work by Jull et al. that was the basis of the recommendation for cervical HA. Her work included thrust as well as non-thrust manipulation. Her work also has a commonality with the Bronfort and Hoving neck pain/manipulation studies in that the manipulation PLUS exercise groups achieved better outcomes...thus the basis of my "manual physical therapy" comments. The superiority of a combined manip/ex approach has been observed in several lumbar manipulation trials as well (Childs JD et al., Delitto et al., Niemesto et al., and others). Inherent in my statement was an overgeneralization to be sure (based on the number of the other studies already mentioned), but one that is very plausible.

Thanks for calling my hand on it as well as the dialogue by you and Britt. I am looking forward to reading the original work the migraine/manipulation recommendation was based on. Have you read it yet? I seems you have.

Thanks again,

Rob

[Jeff Hebert]

Britt,

Regarding the Phys Ther. 1997;77:145-154 article, I'm not sure that I agree with your conclusion (although it is entirely possible that I am missing something). With the 3 criteria listed (initial third, middle third and final third stages of care) lumbar spine manipulation was utilized 3.7%, 0.7% and 0.6% respectively. On the other hand, cervical spine manipulation was performed 1.8%, 0.8% and 1.1% respectively.

With that being said, I would imagine the rates for lumbar spine manipulation would be quite a bit higher these days

Regarding the manipulation vs. mobilization question currently being debated, I was quite moved by the recent study gleaned from the UCLA neck pain study published by Hurwitz, et al. The recent study: Spinal manipulation and spinal mobilization influence different axial sensory beds. Med Hypotheses. 2005 Oct 19, seems to better fit my clinical experience (or maybe its bias) that the two approaches may have a unique mechanism and benefit.

Thank you for allowing me to participate in this dialogue.

Jeff

[Jeff Hebert]

Rob,
I have got to say that I am continually amazed at the level of professionalism and class displayed on this blog. I really appreciate the opportunity to participate here and interact with researchers such as yourself- thank you.

I too look forward to reading the full-text of the Cochrane review. I have read the amitriptyline vs cervical spine manipulation studies which were quite interesting IMHO.

Thanks,

Jeff

[Britt]

Jeff,
I'll look over the articles again, perhaps I missed a study when I cited the evidence.
I wasn't aware of the study from Med. Hypothesis. I look forward to reading it. I would be interested if different axial sensory beds makes any clinical difference in outcomes. Thanks, again for the citation and great discussion.
Britt