Gert Bronfort, DC, PhD; Roni Evans, DC, MS; Richard Grimm, MD, MPH, PhD
Gert Bronfort, DC, PhD
Roni Evans, DC, MS
Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University
Bloomington, MN 55431
Richard Grimm, MD, MPH, PhD
Berman Center for Outcomes and Clinical Research
Minneapolis, MN 55404
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0299.
Bronfort G., Evans R., Grimm R.; Acute and Subacute Neck Pain. Ann Intern Med. 2012;156:669. doi: 10.7326/0003-4819-156-9-201205010-00019
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Published: Ann Intern Med. 2012;156(9):669.
In response to Dr. Ernst, our study was a pragmatic trial designed to assess the comparative effectiveness of 3 commonly used management options for neck pain. The design was chosen to represent as closely as possible what happens in the real-world clinical setting in which treatment is tailored to individual patients (1). Pragmatic trials are not meant to control for placebo and nonspecific effects (different environments, time spent with patients, and others). Control of such effects requires an explanatory or fastidious trial.
As described in the Discussion section of our article, both comparative effectiveness and fastidious trial designs are important but address very different research questions. We made no claim that any of the study treatments was superior to placebo or that the outcomes could not partially be explained by treatment-related, nonspecific effects.
We disagree with Mr. Chapman about the documented risk for significant adverse outcomes related to cervical spine manipulation. The best available evidence about the relationship between spinal manipulation and vertebral artery dissection comes from several large case–control studies (2, 3). These studies show that, although there is an association between visits to chiropractors and the subsequent development of vertebral vascular stroke, this type of stroke is extremely rare. Of importance, the risk is no greater than if patients seek care from their family medical physicians, who are very unlikely to apply spinal manipulation.
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