Spinal Manipulation for Tension-type Headache

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.