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Combination of Chiropractic and Exercise as an Alternative to Non-Steroidal Anti-Inflammatory Drugs for the Treatment of Neck Pain: Should a Combination of Chiropractic and Exercise be the First Line of Therapy for Neck Pain? A Commentary on the Available Research.

This commentary will evaluate the current evidence to determine if it would be favorable to make chiropractic the first line of therapy for patients with neck pain.

The two major issues with the use of NSAIDs regarding neck and spinal pain in general is associated with the conflicting evidence regarding efficacy as well as the negative adverse effects.

NSAID EFFICACY FOR NECK PAIN: In 2017, Machado, et al, performed a systematic review and meta-analysis of 35 randomized controlled trials which revealed that the magnitude of the difference in outcomes between NSAIDs and placebo groups is not clinically important for spinal pain. The study concluded that at present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. (1)

NSAID SAFETY: Regarding NSAID safety, the Arthritis, Rheumatism, and Aging Medical Information System estimates that adverse effects due to NSAIDs are associated with more than 100,000 hospitalizations and more than 16,000 deaths in the U.S. each year. Both non-selective and selective COX-2 inhibitors have now been shown to be associated with an increased risk for cardiovascular events. These studies, together with the outcomes of the recent US Food and Drug administration decision to require 'black box' warnings regarding potential cardiovascular risks associated with NSAIDs, suggest that the use of COX-2 inhibitors as the sole strategy for gastroprotection in patients with arthritis and other pain syndromes must be reconsidered, particularly among those at risk for cardiovascular events. (2)

A few studies have evaluated the risk of cardiovascular complications following the intake of NSAID's. In 2011, Trelle, et al, conducted a meta-analysis of 31 trials and 116,429 patients and found that compared to placebo Rofecoxib was associated with the highest risk of myocardial infarction, followed by lumiracoxib. Ibuprofen was associated with the highest risk of stroke followed by diclofenac. Etoricoxib and diclofenac were associated with the highest risk of cardiovascular death. (3) These findings were confirmed by a systematic review conducted by Mcgettigan, et al in 2011. (4) Finally, in 2013, Bhala, et al, conducted a meta-analysis of 280 trials of NSAIDs versus placebo (124,513 participants, 68,342 person-years) and 474 trials of one NSAID versus another NSAID (229,296 participants, 165,456 person-years). This study found that major vascular events were increased by about a third by a COX-2 inhibitor or diclofenac, mainly due to an increase in major coronary events.

Ibuprofen also significantly increased major coronary events, but not major vascular events. Compared with placebo, of 1000 patients allocated to a COX-2 inhibitor or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events. Vascular death was increased significantly by COX-2 inhibitors and diclofenac, non-significantly by ibuprofen, but not by naproxen. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (COX-2 inhibitors, diclofenac, ibuprofen, and naproxen. (5)

These studies lead to a recent official publication of the College of Family Physicians of Canada, Cyclooxygenase-2 (COX-2) inhibitors and traditional NSAIDs except naproxen increase the risk of serious cardiovascular events and death. When prescribing NSAIDs, patients' gastrointestinal (GI) and CV risks should be assessed, with naproxen or low-dose ibuprofen preferentially chosen for patients at risk of CV disease. (6) All NSAIDs increase the risk of gastrointestinal reactions by 2.5 times. (1)

SPINAL MANIPULATION SAFETY: Studies on spinal manipulation safety have concentrated mainly on debunking its causal association with cerebrovascular accidents. Three studies are worth discussing in terms of spinal manipulation safety.

In 1995, Dabbs, et al, performed a literature review from 1966 to 1994 and found that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. The study also concluded that there is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain. (7) In 2012, Haynes, et al, conducted a systematic review of the literature which revealed that conclusive evidence is lacking for a strong association between neck manipulation and stroke. (8) Finally, in 2016, Church, et al, performed a systematic review and meta-analysis of 253 articles which showed that there is no convincing evidence to support a causal link between chiropractic manipulation and coronary artery dissection. (9)

SPINAL MANIPULATION EFFICACY FOR NECK PAIN: Regarding spinal manipulation efficacy for neck pain, four studies should be referenced. In 2002, Gross, et al, published a systematic review of randomized trials which revealed that multi-modal manual therapy care including exercise were superior to a control, to certain physical medicine methods and to rest for pain (10) In 2008, Hurwitz, et al, conducted a review of the literature between 1980 and 2006 which revealed that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain. (11) In 2010, Miller, et al, performed a systematic review of 17 randomized controlled trials and found moderate quality evidence supporting the treatment combination of manual therapy and exercise for pain reduction over manual therapy alone for chronic neck pain and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. (12)

Finally, in 2016, Zhu, et al, conducted a systematic review and meta-analysis of three randomized controlled trials with 502 participants which showed moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy. (13)

NSAIDs VS SPINAL MANIPULATION: In 2012, Furlan, et al, conducted a systematic review and metaanalysis and found that in two trials manipulation was significantly better than medication (e.g., NSAIDs, Celebrex, Vioxx, Paracetamol) in reducing pain intensity for neck pain at immediate/short-term follow up. (14) In 2016, Wong, et al, conducted a systematic review of systematic reviews which showed that in one study for the management of neck pain and associated disorders, intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy. (15)


NSAIDs VS ACUPUNCTURE: The systematic review and meta-analysis by Furlan, et al, also revealed that in one trial for subjects with chronic non-specific pain, acupuncture was significantly better in reducing pain than NSAIDs immediately after treatment. In 2015, Yuan, et al, performed a systematic review and meta-analysis of 75 randomized controlled trials and found significant superiority favoring acupuncture over medications for pain relief at immediate term. (16) A recent study in 2017 found that the combination between chiropractic and Acupuncture reduced back pain as much as NSAIDs. (17)

SPINAL MANIPULATION VS ACUPUNCTURE: The systematic review and meta-analysis by Yuan, et al, revealed that acupuncture was inferior to manipulation in reducing neck pain. (15)

In conclusion, there seems to be good evidence to suggest a combination of chiropractic and exercises as the first line of therapy for neck pain as an alternative to NSAIDs. Perhaps acupuncture could be used as adjunct therapy to chiropractic for the treatment of neck associated disorders since there is research supporting its efficacy. (18),(19) Due to the high risk of cardiovascular and gastrointestinal events, NSAIDs should be avoided for the treatment of neck associated disorders.


(1.) Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal antiinflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017;76(7):1269-1278.

(2.) Abramson SB, Weaver AL. Current state of therapy for pain and inflammation. Arthritis Res Ther. 2005;7 Suppl4:S1-6.

(3.) Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal antiinflammatory drugs: network meta-analysis. BMJ. 2011;342:c7086.

(4.) Mcgettigan P, Henry D. Cardiovascular risk with nonsteroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Med. 2011;8(9):el001098.

(5.) Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal antiinflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013;382(9894):769-79.

(6.) Harbin M, Turgeon RD, Kolber MR. Cardiovascular safety of NSAIDs. Can Fam Physician. 2014;60(3):el66.

(7.) Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther. 1995; 18(8):530-6.

(8.) Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. Assessing the risk of stroke from neck manipulation: a systematic review. Int J Clin Pract. 2012;66(10):940-7.

(9.) Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Metaanalysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498.

(10.) Gross AR, Kay T, Hondras M, et al. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002;7(3): 131-49.

(11.) Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. European Spine Journal. 2008;17(Suppl 1): 123-152. doi: 10.1007/s00586-008-0631-z.

(12.) Miller J, Gross A, D'sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010; 15(4):334-54.

(13.) Zhu L, Wei X, Wang S. Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis. Clin Rehabil. 2016;30(2):145-55.

(14.) Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012;2012:953139.

(15.) Wong JJ, Cote P, Ameis A, et al. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(1):34-61.

(16.) Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS ONE. 2015;10(2):e0117146.

(17.) Isaza, A. (2016, December) Review of Systematic Reviews of Acupuncture and Chiropractic with an emphasis on the combination of the two modalities to treat chronic low back pain as an alternative to NSAIDS. Original Internist, Volume 23 issue 4, pages 179-185.

(18.) Fu LM, Li JT, Wu WS. Randomized controlled trials of acupuncture for neck pain: systematic review and meta-analysis. J Altern Complement Med. 2009;15(2):133-45.

(19.) Trinh K, Graham N, Irnich D, Cameron ID, Forget M. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016;(5):CD004870.

by: Adrian Isaza, DC, DACBN, CCAP
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Author:Isaza, Adrian
Publication:Original Internist
Article Type:Report
Date:Mar 1, 2018
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