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1 May 2012, Vol 156, No. 9>
Letters | 1 May 2012

Acute and Subacute Neck Pain FREE

Gert Bronfort, DC, PhD; Roni Evans, DC, MS; and Richard Grimm, MD, MPH, PhD
[+] Article and Author Information

From Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN 55431, and 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.


Ann Intern Med. 2012;156(9):669. doi:10.7326/0003-4819-156-9-201205010-00019
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IN RESPONSE:

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.

References

1
Luce BR,  Kramer JM,  Goodman SN,  Connor JT,  Tunis S,  Whicher D,  et al..  Rethinking randomized clinical trials for comparative effectiveness research: the need for transformational change. Ann Intern Med. 2009;151:206-9. PubMed
 
2
Smith WS,  Johnston SC,  Skalabrin EJ,  Weaver M,  Azari P,  Albers GW,  et al..  Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60:1424-8. PubMed
 
3
Cassidy JD,  Boyle E,  Côté P,  He Y,  Hogg-Johnson S,  Silver FL,  et al..  Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33:S176-83. PubMed
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References

1
Luce BR,  Kramer JM,  Goodman SN,  Connor JT,  Tunis S,  Whicher D,  et al..  Rethinking randomized clinical trials for comparative effectiveness research: the need for transformational change. Ann Intern Med. 2009;151:206-9. PubMed
 
2
Smith WS,  Johnston SC,  Skalabrin EJ,  Weaver M,  Azari P,  Albers GW,  et al..  Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60:1424-8. PubMed
 
3
Cassidy JD,  Boyle E,  Côté P,  He Y,  Hogg-Johnson S,  Silver FL,  et al..  Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33:S176-83. PubMed
CrossRef
 

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