The following is a review of a study published in the BMC Musculoskeletal Disorders Journal. The full study can be viewed online at http://www.biomedcentral.com/1471-2474/12/219 or as a pdf here.
Adding to the growing body of evidence supporting the safety, efficacy, efficiency and patient satisfaction regarding upper cervical chiropractic techniques is the recent publication of "Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: A prospective, multicenter, cohort study". This latest research project, by the prolific Orthospinologists, Kirk Eriksen, D.C. and Roderic "Bo" Rochester D.C., uniquely validates and differentiates upper cervical chiropractic care from other chiropractic techniques and spinal manipulative therapy (SMT), while further documenting its remarkable effectiveness and efficiency.
Though chiropractic procedures have an enviable safety record, some studies have associated the risk of cerebral vascular incidents (stroke) when the neck is rotated and manipulated. This incidence has been estimated at 1 in 300,000 to 1 in 5.85 million manipulations with some studies showing no causal relationship. No study has examined the incidence of adverse reactions following upper cervical spinal adjustments and the associated clinical outcomes. The Eriksen study is the first to clearly document the safety of multiple upper cervical techniques with a population of 1,090 patients receiving 2,653 upper cervical adjustments over a 17 day period. Eighty three clinics in four countries participated in this exclusively upper cervical study with Orthospinology, Grostic Procedure, NUCCA, Atlas Orthogonal, Advanced Atlas Orthogonal, Blair, Knee Chest, Duff, Toggle and SONAR upper cervical techniques represented. Each doctor documented the response to care for 10 consecutive new patients for approximately two weeks with subjects ranging from 18 to 85 years of age with the mean age being 46.1 years. Females outnumbered males 699 (64.1%) to 391 (35.9%) and 95% of patients studied presented with headaches or musculoskeletal pain. No adjunct procedures such as full spine manipulation, mobilization, physical therapy or massage were utilized by the participating doctors, in order to maintain this study as purely upper cervical.
Adverse reactions (AEs) have been used to describe unfavorable outcomes with various health care interventions. In this study, the authors chose to document symptomatic reactions (SRs) instead to differentiate changes in the patient’s symptoms that in the clinical sense may represent the process of healing or shifts in posture that, while adverse to the patient, are not considered negative in the short term. A SR was defined as a new complaint or worsening of a presenting complaint by greater than 30% less than 24 hours after initiation of upper cervical care. The Neck Disability Index (NDI), Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) were used to assess the patient’s response to care and the impact of their pain on "activities of daily living". The intensity of the SR was graded on the 11 point NRS with "0" being no pain and "10" being the worst possible pain. An "intense" SR was defined as greater than 8 on the NRS. The initiation of the SR beginning in less than 30 minutes, .5 to 4 hours, 4 to 24 hours or more than 24 hours was recorded as was the duration of the SR as lasting less than 10 minutes,10 minutes to 1 hour, 1 hour to 24 hours or more than 24 hours.
Chief complaints distributed into 28 categories with 80.9% being spinal pain or dysfunction, and headaches. The majority (73.5%) of complaints were listed as chronic, associated with mild to moderate disability and moderate pain.
Some of the outstanding clinical outcomes of the study include noted improvement in headache pain at 62.8%, in cervical spine pain at 56.8%, in thoracic spine pain at 58.6% and in lumbar spine pain at 57.0% in approximately 17 days. Thirty-one per cent of patients required only one upper cervical adjustment, 28.6% required two UC adjustments, 19.4% required three UC adjustments, 11.6% required 4 UC adjustments and the remaining 9.3% had more than 4 UC adjustments. On average, patients were treated for 17 days, had 4.5 visits and received 2.4 adjustments. At follow-up, 62.2% of neck pain patients, 68.0% of headache patients, 67.9% of thoracic pain patients and 62.1% of low back pain patients returned to sub-clinical status in the approximate 2 week trial. Significantly improved outcomes using the NDI and OSW for those patients with disabilities relative to activities of daily living suggest clinical efficacy for patient function following upper cervical chiropractic care.
SRs were reported by 583 (53%) patients with 23% of those reactions rated at 0 or 1 and only 6.6% rated above or equal to 8 on the NRS. Fifty-four per cent occurred within 24 hours and 43.8% met the definition of SR (a new symptom not present at baseline or a worsening of a presenting complaint by greater than or equal to 30% occurring less than or equal to 24 hours). Nearly all SRs (95.9%) were nervous, circulatory or musculoskeletal system related with a mean intensity of roughly 3.5 on the NRS. The most frequent SRs meeting the accepted definition were: tiredness, radiating pain, neck pain, dizziness and headache in descending order of frequency. All SRs were primarily mild in intensity, with short duration of less than 24 hours and little effect on daily activities. There were no reports of serious SRs or AEs.
Patients reported a very high degree of satisfaction with UC chiropractic care scoring a mean of 9.1/10 on the NRS. Patients that experienced SRs were most likely to rate satisfaction lower, though the study points out the 9.1 score ranks highest among similar satisfaction rates of 7.1, and 5.4 for chiropractic and medical care respectively in the noted Hertzman-Miller study. The study also compares the fewer number of adjustments required and shorter follow-up period with other chiropractic studies while reporting similar or better outcome levels.
This study documents the major strengths of Upper Cervical chiropractic on safety, effectiveness, efficiency and satisfaction across a broad spectrum of patients distributed over a wide geographical region engaging in various UC techniques delivered by a relatively large group of doctors. It is yet another testament to the power of this unique approach to health.
Drs. Eriksen and Rochester with consulting and statistical help from Eric Hurwitz, D.C., PhD, and the contributions of 83 upper cervical chiropractors have produced a milestone study for the chiropractic profession. I know I speak for the authors and participating doctors in thanking the patients whom, without their trust, this study would not have been possible. The results of this study underscore the importance of UC chiropractic and the magnitude of the contributions to research available when chiropractors come together and work together.
Craig York, D.C.
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