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 by: Adrian Isaza, DC, DACBN, CCAP
ABSTRACT A recent systematic review of 35 randomized con- trolled trials found 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.
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, Macha- do, 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
14
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
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, Cyclo- oxygenase-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
risk of gastrointestinal reactions by 2.5 times.1 All NSAIDs increase the
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
Finally, in 2013,
THE ORIGINAL INTERNIST MARCH 2018 (Continued on next page)
In 2012, Haynes, et al, conducted a systematic
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44
