Spinal Manipulation for Tension-type Headache
Vol. 282 No. 3,
July 21, 1999

JAMA
Letters
© 1999 American Medical Association. All rights reserved.
 

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Spinal Manipulation for Tension-type Headache  
 

To the Editor: As an osteopathic family physician who incorporates osteopathic manipulation therapy (OMT) into my daily practice, I was concerned by the design and conclusions of the article by Drs Bove and Nilsson.1 The article should lead one to conclude only that the particular method of manipulation used was not helpful.

Before dismissing the role of manipulation from the therapeutic armamentarium for headaches, it is important to look more closely at other relevant factors. First, OMT is consistently more comprehensive than the treatment described in this study (techniques were confined to the cervical spine and musculature surrounding the cervical and upper thoracic spine). Holistic therapy mandates that one treats the whole body, not just the affected part. By so doing, OMT is often successful in reducing symptoms, improving outcomes, decreasing direct and indirect costs (such as physician office visits), as well as decreasing the frequency of treatments.2

Finally, the outcomes measured involved symptom assessment over 19 weeks. I would suggest that treatments for episodic tension-type headaches (ETTHs) (which, in my experience, are usually of a chronic and long-standing nature) cannot be assessed accurately after only 19 weeks, especially when limited techniques had been applied 11 weeks earlier. It would be enormously helpful if future research were to compare different types of manipulation as well as examine additional (or perhaps more) relevant outcomes. My patients and I still believe that manipulation has tremendous value in treating ETTH. Let's not give up.


 
Michael Felder, DO, MA
Rhode Island Hospital Medical Foundation
Cranston
 
 

1. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579. ABSTRACT

2. American Osteopathic Association. Protocols for Osteopathic Manipulative Treatment. American Osteopathic Association; Chicago, Ill; 1998:5.
 

To the Editor: Several concerns are apparent after review of the study of spinal manipulation in the treatment of ETTH by Bove and Nilsson.1

First, in our viewpoint, the "toggle recoil technique" is not an appropriate manipulative intervention in spinal manipulation of the upper elements of the cervical spine. Rotary manipulation based on asymmetry of the atlas and palpable tenderness of the facet joints would be preferable in the treatment phase of this study. Toggle recoil technique certainly is not a technique advanced in our curriculum and may provoke pain if excessive force is applied. A more judicious application of rotary manipulation of the atlas and axis may have produced a greater therapeutic effect if it was used exclusively in the study. Furthermore, the low statistical power of this study raises the possibility of a type II error. The authors assume that a larger study2 demonstrated positive effects of spinal manipulation due to "personal contact" of the subject and physician. This is opinion and conjecture on the part of the authors, and such speculation does not invalidate the results of the larger study. The overall trend in the effects of spinal manipulation generally is positive in larger, controlled studies.

The authors also mention the possibility that a type II error occurred due to the small number of participants in the study and that a larger number of subjects might have identified a treatment effect. Their final statement that their data suggest that such an effect, if statistically significant, would be of little clinical significance is a puzzling one.

A 1995 study by Nilsson3 of manipulation as treatment for cervicogenic headache showed no significant effect of manipulation. In a 1997 study, Nilsson and colleagues4 observed that the 1995 result could have been due to a type II error (eg, too few participants). Their 1997 study was then conducted with a larger sample size, for the express purpose of avoiding a type II error, and a statistically significant effect of manipulation for cervicogenic headache was demonstrated.


 
Rod L. Kaufman, DC
Paul Delaney, DC, PhD
Glendale Chiropractic Clinic
Glendale, Calif
 
 

1. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579. ABSTRACT

2. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995;18:148-154. MEDLINE

3. Nilsson NA. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1995;18:435-440. MEDLINE

4. Nilsson NA, Christenson HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1997;20:326-330. MEDLINE
 

To the Editor: The conclusion drawn by Drs Bove and Nilsson1 did not seem to accurately reflect the results of their study. Spinal manipulation was not assessed "as an isolated intervention," but was tested in combination with deep friction massage. The conclusion regarding its efficacy for ETTHs is therefore incorrect and misleading. This study also regards spinal manipulation as a whole to reflect the 2 techniques that were administered in this study. There are thousands of spinal manipulative techniques. Only 2 were used in this study (toggle recoil and diversified). To imply that these techniques are reflective of spinal manipulation as a whole, as the authors did, would be akin to generalizing the efficacy for all analgesics based on a limited study involving aspirin.

What, if any, were the criteria used to assess spinal joint dysfunction? Was interobserver reliability assessed? Did the level of altered spinal biomechanical integrity correlate with the patients' symptomatic complaints? Was a reflexogenic pathway established between the level of the spinal lesion and the examination findings?

In my experience, spinal manipulation is an effective form of treatment for patients who have ETTHs resulting from cervical joint dysfunction. Unfortunately, this study failed to identify these patients and failed to correlate the patients' symptoms with their history or examination findings.


 
Adrian M. Marcus, DC
Fairfield County Chiropractic Center
Greenwich, Conn
 
 

1. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576-1579. ABSTRACT
 

In Reply: We thank the authors of these letters, since as practitioners they represent the people our findings affect. However, the letters indicate overinterpretation and misinterpretation of our results, something we avoided. Perhaps more important, the authors collectively fail to acknowledge that we have years of experience treating headaches using various manual therapies. In our practices, our results and discussions with others indicated ambiguity regarding the response of headaches to manual therapy, and we both became scientists to look for answers. As chiropractors, we would have preferred a positive outcome, of course. As scientists, we just looked for the truth.

Space does not permit us to answer all the concerns raised in these 3 letters. Any discussion of reflexogenic pathways and altered biomechanical integrity should be saved for the appropriate theoretical venue. However, some issues warrant attention because they indicate prevalent misunderstandings.

The manipulative techniques used in this study reflected the majority of practices and teaching methods. Our practitioner used a variety of techniques, indicated by the "gold standard" of palpation and applied using years of accumulated experience. It is unlikely that the choice matters, however, since most therapists use strikingly similar techniques, especially in the cervical spine. Moreover, there is no indication that one technique that gaps the joint is superior to another, although most chiropractors would agree that gapping the joint is important. We remind readers that any adjustment, applied injudiciously, can provoke pain and other symptoms.

The possibility of a type II error always exists; we minimized ours using a statistical power of 90% to detect a 1-hour difference in daily headache hours. But our point here, really, is that even if a statistically significant treatment effect is found in a randomized controlled trial, that treatment effect may not be large enough to be of practical clinical interest (ie, "of clinical significance"). For example, in our research, a larger sample size may have shown a statistically significantly reduced analgesic intake. However, even at the extremes of our confidence intervals, this would not have amounted to more than a half dose of the analgesics.

Headache diagnosis is fraught with pitfalls, and tension and cervicogenic headache presentations often overlap. In our experience, many field practitioners are not aware of the distinctions between these specific diagnostic categories, yielding statements like " . . . ETTHs resulting from cervical joint dysfunction." Headaches resulting from cervical joint dysfunction are cervicogenic headaches. This is important because this group of patients responds remarkably well to manipulation. Our combined clinical and scientific experience suggests that if a manipulation treatment helped a tension-type headache, it probably was a misdiagnosed cervicogenic headache.1

We suggest that practitioners learn to differentiate cervicogenic and tension-type headaches, since they clearly demand different treatments, and the 2 types together amount to about 80% of all headache cases.2, 3 We also suggest that practitioners apply the information contained in research articles judiciously and without emotion, and consider, when possible, the intent of the authors.


 
Geoffrey Bove, DC, PhD
Beth Israel Deaconess Medical Center
Boston, Mass

Niels Nilsson, DC, MD, PhD
Odense University
Odense, Denmark
 
 

1. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1997;20:326-330. MEDLINE

2. Nilsson N. The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine. 1995;20:1884-1888. MEDLINE

3. Rasmussen BK. Epidemiology of headache. Cephalalgia. 1995;15:45-68. MEDLINE
 
 
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Edited by Margaret A. Winker, MD, Deputy Editor, and Phil B. Fontanarosa, MD, Interim Coeditor.