Some national and international guidelines advise physicians to use spinal manipulation for patients suffering from acute (and chronic) low back pain. Many experts have been concerned about the validity of this advice. Now an up-date of the Cochrane review on this subject seems to provide clarity on this rather important matter.
Its aim was to assess the effectiveness of spinal manipulative therapy (SMT) as a treatment of acute low back pain. Randomized controlled trials (RCTs) testing manipulation/mobilization in adults with low back pain of less than 6-weeks duration were included. The primary outcome measures were pain, functional status and perceived recovery. Secondary endpoints were return-to-work and quality of life. Two authors independently conducted the study selection, risk of bias assessment and data extraction. The effects were examined for SMT versus inert interventions, sham SMT, other interventions, and for SMT as an adjunct to other forms of treatment.
The researchers identified 20 RCTs with a total number of 2674 participants, 12 (60%) RCTs had not been included in the previous version of this review. Only 6 of the 20 studies had a low risk of bias. For pain and functional status, there was low- to very low-quality evidence suggesting no difference in effectiveness of SMT compared with inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence suggesting no difference in effectiveness of SMT compared with other interventions. Data were sparse for recovery, return-to-work, quality of life, and costs of care.
The authors draw the following conclusion: “SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.”
In other words, guidelines that recommend SMT for acute low back pain are not based on the current best evidence. But perhaps the situation is different for chronic low back pain? The current Cochrane review of 26 RCTs is equally negative: “High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.”
This clearly begs the question why many of the current guidelines seem to mislead us. I am not sure I know the answer to this one; however I suspect that the panels writing the guidelines might have been dominated by chiropractors and osteopaths or their supporters who have not exactly made a name for themselves for being impartial. Whatever the reason, I think it is time for a re-think and for up-dating guidelines which are out of date and misleading.
Similarly, it might be time to question for what conditions chiropractors and osteopaths, the two professions who use spinal manipulation/mobilisation most, do actually offer anything of real value at all. Back pain and SMT are clearly their domains; if it turns out that SMT is not evidence-based for back pain, what is left? There is no good evidence for anything else, as far as I can see. To make matters worse, there are quite undeniable risks associated with SMT. The conclusion of such considerations is, I fear, obvious: the value of and need for these two professions should be re-assessed.
The need for these two professions will always exist. That is until you can remove placebo, regression to the mean, nice clean and welcoming Chiro/osteo clinics that show empathy to their patients, anecdotal evidence of “go and see (insert name) they sorted my back out” or “my Doctors useless they didn’t even look at me and I was out the door in under 5 mins”
There are people who still think the Earth is flat and that the moon landings were filmed in a studio and probably always will. Likewise there are people who will always think that ‘their’ practitioner helped them and they probably always will. It won’t change regardless of any evidence produced.
Too true! Couldn´t agree more!
Edzard, you practiced SMT, why did it take so many years for you to figure out it was not a cure for back pain?
evidence evolves, only dogmas remain the same
Given that it is only of low quality evidence I wouldn’t be making any drastic changes just yet. The prof is correct – only dogmas remain the same. Edzard’s dogmatic attacks on Twitter to chiropractors and chiropractic clinics is evidence of this.
In the trial on acute LBP it does say that SMT for LBP is safe, however in your post you have highlighted “undeniable risks”. Who is more correct here?
given the low quality of the evidence, chiropractors and osteopaths should, at the very least, abandon their bogus claims. the risk is UNDENIABLE and the Cochrane review was not aimed at assessing it.
So you did not know whether you were helping them until you saw the evidence which told you you were not helping them, so you gave it up. Is that right .
As you say “evidence evolves” so as practitioners of SMT become more skilfull the scientific evidence may evolve in a positive way to reflect what practitioners like me see in practice. Dont you agree?
as clinicians we might treat patients who get better and we convinve ourselves that this is causally related to the treatment we applied. but this is a sikplistic assumption; as you (should?) know, there are many other factors involved, not just the placebo-effect but also the natural history of the condition, regression towards the mean etc.etc.etc.etc.
Have no problem with what you say there and just because some condition resolves it does not follow it happened because of the manipultion. However we also know that if joints do not function properly they degenerate with all the associated health problems, so there must be some kind of benefit from maintaining spinal joint function.
As an academic you are perfectly entitled to ask for more “proof”. The public on the other hand are willing to take a chance, to see if the intervention might help them, as they will have heard lots of positive accounts of maintaining spinal joint function and comparatively few adverse ones. I can give a physiological explanation to a client as to why they feel better after an adjustment, to be honest they are not that interested in the why, just happy they feel better.
it seems to me that your argument is a gallop back into the dark ages when everyone more or less blindly tried what was available because it was available. thankfully, we have moved on, and since we did, we also made progress.
Professor Ernst wrote: “…it might be time to question for what conditions chiropractors and osteopaths, the two professions who use spinal manipulation/mobilisation most, do actually offer anything of real value at all. Back pain and SMT are clearly their domains; if it turns out that SMT is not evidence-based for back pain, what is left?”
I suspect that what is left is a lot of widespread infighting in the wings as it’s now perfectly clear that the statutory regulation of chiropractors and osteopaths was premature. No doubt both professions thought that they could hide behind their veneers of spurious legitimacy indefinitely. However, it looks like they failed to foresee the arrival of the internet and its capacity to expose and devastate pseudoscientific practices on a global scale as negative data pour in.
The fact that so many people use chiros/osteos isn’t it a good thing they are regulated? Surely that means the public are better protected in cases of disputes against them?
the “regulation” is a perfect example of MISREGULATION – it does not prevent bogus claims (on the contrary Simon Singh was sued for exposing them), it does not stop even the most obvious breaches of medical ethics (e.g. lack of informed consent) etc.etc.
Readers might be interested to know that the seeds of the (mis)regulation of chiropractors in the UK appear to have been sown at dinner parties attended by Prince Charles:
Readers might also be interested to know that a former Chairman of the General Chiropractic Council admitted that “in spite of strong mutual suspicion and distrust” chiropractors in the UK “united under a group formed specifically to pursue regulation”. Indeed, he went on to confess…
“Regulation for a new profession will literally ‘legitimise it’, establishing its members within the community, making them feel more valued. In turn, this brings greater opportunity for more clients and a healthier bank balance.”
For a true, current picture of the regulation of the chiropractic and osteopathy industries in the UK, one doesn’t have to look any further than the work of the Nightingale Collaboration. In May 2012 it submitted a response to a Consultation on the Regulation of Health Care Professions and the following is a summary of its findings:
“Our interest lies in the regulation of chiropractors and osteopaths because of the lack of a robust evidence base for chiropractic and osteopathic spinal manipulation. Statutory regulation rightly confers respectability and trustworthiness in the eyes of the public and these need to be protected to maintain that trust. For chiropractic and osteopathy, we do not believe statutory regulation is deserved or necessary and it gives a false imprimatur that misleads the public. Because of this, our overall view is that statutory regulation of chiropractors and osteopaths is not appropriate and recommend that this statutory regulation be abolished. We believe that adequate protection of the public can be achieved by existing regulations (such as The Consumer Protection from Unfair Trading Regulations 2008) as are applied to any other alternative therapies and businesses. However, we appreciate that this may not fall within the scope of the present consultation and we offer our responses regardless. We are concerned that some of the claims made by these practitioners are not founded in robust evidence and that they can therefore mislead. We are concerned that current statutory regulation is failing by not adequately protecting the public from such claims. We are aware that the situation regarding claims made on practitioners’ websites has significantly improved in the past three years, but we believe that much more still needs to be done and that the current regulatory framework is not fit for purpose in this regard. The Law Commissioners’ consultation on the reform of the legislation is a welcome opportunity to greatly improve the protection of the public and we hope that the Law Commissioners will note and act on our recommendations. We therefore restrict our views to those proposals and questions that directly affect the regulation of chiropractors and osteopaths and we make recommendations that we believe will enhance public protection.”
The entire 12-page response from the Nightingale Collaboration can be read here:
I am interested to know what would you put in the guidelines for acute, subacute and chronic low back pain, if we are using the cochrane collaboration as our guide?
I cannot even attempt to write guidelines single handedly on my blog.
it is not only Cochrane that is negative about osteo http://www.ncbi.nlm.nih.gov/pubmed/23570655 or chiro http://www.ncbi.nlm.nih.gov/pubmed/15989112
i would not just consider such reviews.
here are some of the interventions a team of experts might consider:
This article doesn’t offer anything new to me. If anything, it’s a rehash (or re-organisation) of previously existing information that was previously available. What it does is group it all together in one little package.
To me what it shows is – for the lower back, at worst, SMT is safe and no better than sham. At best, SMT if done well can be beneficial and a tool to be used along with other modalities such as exercise therapy, cognitive training, mobilisation, etc. Not as a stand-alone, 3 times a week for life only option panacea that many people see it as.
any evidence for your thepry that SMT might, after all, be useful when combined with other treatments – or is it just wishful thinking?
In terms of being better than nothing (and in this case diclofenac) I would have chosen this:
However I haven’t read the full Cochrane Review (haven’t had time to go past the abstract yet – that’s a Wednesday for me) to see if this was either a) not yet published b) included or c) excluded for bias. Perhaps you could enlighten me.
I’ll open end-note later and get the others – who knows a read of the full version Cochrane Review might save me some time…
I do notice this part of the conclusion:
“Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation”
It is hardly the death-knell for SMT. Rather, it places the onus on those professions to stump up and contribute some high quality, meaningful research and do it QUICKLY. Otherwise, everyone will be forced to rely solely on reviews such as this. This includes me – otherwise I could be headed back to university…
Please note, this is not an attack on you for bringing it up or the researchers for the conclusions they drew.
This is from the conclusion in the paper under the title “Implications for Practice”
“No high-quality evidence was provided for any comparison, outcome, or time interval; therefore, no strong conclusions or recommendations can be made for the use of SMT for acute low back pain. SMT seems to be no better than other existing therapies for pain reduction and improvement of functional status. The decision to refer for SMT should be based upon costs, preferences of the patient and providers, and relative safety of the various treatment options.”
Interesting. I had a patient come through the other day for whom SMT was a contraindication. They INSISTED on “being cracked and it’ll be good. Just do it.”
The patient had strong indicators in the history that meant SMT would be a very bad idea. The patient ended up quite upset following treatment. Such is life.
It’s not clear to me: what treatment did you give him/her?
Alan: Soft tissue massage, stretching and gentle mobilisation. I think most people would call that physiotherapy..
They didn’t include the study you linked to because the cochrane review only included studies up to March 2011.
They also excluded this one http://www.sciencedirect.com/science/article/pii/S1529943010011149
because “the contribution of SMT to the overall treatment effect could not be determined”
As a point of interest (at least to me), the one study that the authors use to compare SMT v Sham did demonstrate a greater reduction in pain in the chiropractic group, but not enough to reach statistical significance when compared directly to the control. Given that the mean baseline pain scores on the VAS were around 4 – 4.5, that is probably not surprising. The “change” in pain however was significant in the SMT, because the SMT group started with higher mean scores on the VAS (18% higher) and end up with lower final scores (23% lower). My reading of the cochrane review was that the authors only extracted final scores, not change scores.
This is my understanding, and I may be corrected. The sham group at the beginning of the study had mean VAS scores of 3.84 and after 4 weeks was 2.21. The SMT group however began the study with a mean VAS of 4.52 and after 4 weeks was 1.71. So when you compare the final scores after 4 weeks 2.21 (sham) and 1.71 (SMT) there is no statistically significant difference, however when you compare the “change” in pain over that time (SMT = 2.81 v’s Sham = 1.63) there is a statistically significant difference.
“SMT v Sham did demonstrate a greater reduction in pain in the chiropractic group, but not enough to reach statistical significance when compared directly to the control”….this is to say there was no difference!!!
One could say that there was no significant difference in pain scores at the end of the 4 week trial of SMT v Sham. One could also say that patients in the SMT group experience significantly greater decreases in pain compared to sham manipulation over a 4 week period. Both would be correct. I am sure you will correct me if I have it wrong, but the cochrane review on NSAID’s seems to use the ‘change in pain intensity’ as their outcome, not final scores.
Could the NHS cope without chiros/osteos seeing people for back pain?
“This article doesn’t offer anything new to me. If anything, it’s a rehash (or re-organisation) of previously existing information that was previously available.”
nothing new? so you already knew that the guidelines are misleading and need re-writing?
a systematic review is not a REHASH! and this blog aims to report on new articles – the Cochrane review is new!
On an anecdotal basis, spinal manipulation is like Manna from the Gods.
Of course, on its own it is not sustainable; but then again nothing is.
You need to up your game in diet and exercise stakes at the same time so the muscle tissue carrying the weight of your spine has more muscle than fat as it is with half the Western population these days.
Not to mention stress control, removal and avoidance of pollutants, etc.
It really is laughable when Cochrane, etc seriously say, “Nay, it does not work!”
Of course nothing works on its own; health is more than spinal manipulation or taking drugs.
But from a patient who has had it as part of a “return to healthy lifestyle” regimen; it does wonders when everything else falls by the wayside…
but isn’t the chiropractic/osteopathic claim that SMT is effective for LBP?
“as part of a “return to healthy lifestyle” regimen” … i can think of many things that work in this context; even bungee-jumping might work, if you also change your life-style.
What if (and you may see it as a big IF) that researches follow the recommendations the the cochrane review made and looked into sub groups and SMT and found that with certain sub groups it is effective? Or that more high quality data is produced that changes the outcome of review. Would you change your view then?
of course, sub-group analyses might be valuable. so far, however, all attempts have failed to identify a group of people who can be predicited to respond.
I think these days ALL health profs whomever they are, need to promote lifestyle changes or they are wasting time and resources.
In my case, nothing was permanent until the SMT; the debilitating pains were always there in some form or another.
We definitely need the health pros when we are stuck at any level to start us off even if we have got the best of intentions to improve our lot.
The Cochrane review on SMT for chronic low back pain does not tell us that it is ineffective but rather that it is as good (but not superior) to other forms of treatment. Therefore, given that it is safe (this was addressed by NICE) then it is a useful addition to the care package used by physiotherapists, osteopaths and chiropractors. In reality, low back pain is a condition for which there are no “magic bullets” and it is important to have a range of treatment options available.
Andy wrote about spinal manipulation for low back pain: “given that it is safe (this was addressed by NICE)”
Chiropractic spinal manipulation for low back pain is not safe. NICE overlooked the following when it was developing its guidelines:
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009)
Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.
the notion that SMT is safe is not based on evidence, it is based on the wishful thinking of those who earn their living by SMT
Perhaps you should take your evidence of how unsafe/dangerous SMT is to the police. It sounds like the evidence you have gathered is so overwhelming there must be a case to answer?
i am not sure about the police – but there have been quite a few cases in the courts, as you probably know.
it tells us that SMT is no better that sham. therefore we should tell people that it is a sham. in medicine, we don’t give the benefit of the doubt to interventions: we don’t say THIS MIGHT WORK AND THEREFORE WE SHOULD USE IT. we provide the evidence that it works and then we should use it. UNTIL CONVINCING EVIDENCE IS AVAILABLE, WE MUST CONSIDER ALL INTERVENTIONS AS UNPROVEN.
I taught yoga for quite a few years before training as an osteopath in the ealy 90’s.. I was surprised to find many of my patients were my yoga students who had developed problems while practicing yoga. So I changed the postures until I was sure they didn’t harm people, I stripped away the myths around yoga, chakras energy etc.. And lost a lot of students. Later I learned and believe that manipulation probably is no better than placebo, I’ve pretty well removed it from my practice these days, and I lost a lot of patients. People are complex, they seem to need myth and story telling, they actively seek it out because it fills a need. As someone who does not want to deal in deception, but recognises the power of both positive and negative stories I feel in a quandary caught between what I recognise are human needs, and what is proven by science, there is a gulf there that needs bridging, I’m not sure it’s a simpe a the arguments outlined above.
this sounds a bit like the story of an honest second hand car dealer who lost clients to another dealer who was dishonest by providing false data for the cars he sold. he too lost customers to this dishonest fraudster. but i do not believe there is an ethical alternative to being responsible, ethical and honest.
Can we include core exercises along with mobilisation and manipulation as non evidence based for lower back pain? Ref: http://www.cpdo.net/Lederman_The_myth_of_core_stability.pdf
I think it’s important to note that osteopaths don’t JUST do SMT, it’s one of many tools in the toolbox such as exercise advice, lifestyle advice, massage, even suggesting analgesics such as ice and over-the-counter meds.
SMT has never, as far as I know, been held up as a wonder cure. As anyone who has suffered low back pain knows, it can often be a slow, multi-factorial approach that works. But it can help in some situations.
And don’t forget that physios, manipulative therapists also can use SMT with often much less training, experience and expertise.
i think it is important to note that osteopaths’ hallmark intervention is SMT. to argue like you do seems to me like saying a useless surgical intervention is fine because surgeons also give pain-killers, anticoagulants etc. which doubtlessly do work.
Do you have any numbers for the amount of osteopaths there are that use SMT compared to the number of physios (or chiros) that use it? If not I’d be interested to know how you know that the osteopath’s hallmark is SMT?
This is a quote from the GOC’s website: “Osteopathy focuses on the diagnosis, treatment, prevention and rehabilitation of musculoskeletal disorders (MSDs). Using a combination of osteopathic and conventional diagnostic techniques, treatment is based on mobilising and manipulative procedures tailored to the individual patient, reinforced by guidance on diet, lifestyle and exercise.”
No actual numbers though?
The quote would satisfy you if manipulation (although it doesn’t say spinal and may infact refer to soft tissue manipulation or massage) was removed? Everything else seems plausible.
if i am not mistaken, it was you who brought in numbers – i merely wrote HALLMARK. the quote confirms this; if it is, however, not enough for you, please read the writings of A Still.
so far, after ~40 comments, i have not yet seen a valid argument by chiros/osteos against my notion that the current guidelines are misleading and should be re-considered.
Have any manual, medical or exercise interventions been shown to be unequivocally successful and safe in resolving back pain? Should re-considered guidelines offer nothing?
nothing in this area might ever be unequivocal, but for physiotherapeutic exercise and massage the evidence is encouraging, particularly in view of the low risks of these interventions.
Techniques are not professions and vice versa. I’m an osteopath and can count on one half of one hand how many times I have ‘manipulated’ (and never a cspine and never an lspine). I work more actively – soft tissue, treat people on feet, exercise. But physios lately manipulate way more than I do. But – because I’m an osteopath, in this I get painted with a ‘quack’ brush, but a physio who does TENS and manipulates is OK because of the profession they belong to. Bonkers to me. I’m all for re-evaluating guidelines (but am not sure that will matter to those who seek care of any ‘io/eo’) – boils down to a practitioner needing to be honest and ethical. Hey maybe that is why I’m broke!
you are right, of course, about the importance of being honest and ethical and about the fact that chiros and osteos are not the only professions who use SMT. i am delighted to hear that some osteos think like you do – however, look what therapeutic claims your colleagues make on the internet and elsewhere. this is why osteos are often labled as quacks.
Urg I seem to be behind the moderation approval otherwise would have also tagged on that I absolutely agree!! And it makes me feel ill sometimes to be associated with such rubbish! I do find it a very enlightening and somewhat rewarding position to be in, in some respects – a certain group of people who seek osteopathic care are really deep into the woo – and a careful and educated approach to communicating with them can really help them see some ‘light’ precisely because they come with a certain frame of mind. That always makes my day.
Lil raises some good points especially re physics practicing what they please in some cases and not being called quacks.
Not trying to go off topic here but worth seeing what the governing body of the physios seem happily to promote with little uproar
EE have you seen this?
Forgot to note that I do see that you were discussing treatment modalities and not professions in your last comment.
The more I think about these findings the more questions come up. I imagine back pain covers a lot of bases, most osteo’s and chiro’s will go through a series of orthopaedic test to try to establish the cause of pain. They may come up withSIJ dysfunction, ligament strain, facet joint involvement etc…are these tests also useless, if treatment as you suggest boils down to movement and massage? Eyal lederman recently published an article pointing out that many conditions, disc herniation, spondylitis arthritis are poorly correlated with pain, as are most postural ‘defects’ if all this turns out to be true, I think it probably will, manual therapy courses could be shortened considerably massage and movement aren’t difficult to teach.. It might pop a few pompous ego’s!
One thing that I think is deeply problematic for both practitioners and patients is things like disc herniation hysteria (as I call it). ‘They found a slipped disc in my MRI, that must be causing my back pain’ and practitioner being overly reliant on a 1:1 relationship between those things OR a patient who refuses clinical advice to be referred for further examination (say, prostate exam) and something gets missed because they are ‘sure’ it must be the ‘slipped disc’ (because you know life is over when that happens, right? etc etc). So take the clinical testing unreliability plus poor correlation between radiological findings and pain and layer on the social stuff and phew! I personally think movement is crucial – and it may not be ‘specific’ movement (ie, someone’s patented move that they sell you a costly course to learn). It also helps with reducing fear avoidance and other factors associated with chronicity.
I hadn’t seen that CSP page. Phew! I think it is also interesting that Physiotherapy advertising regulation (not that it is the ‘great standard’) is not terribly different to that of Osteopaths http://www.cap.org.uk/Advice-Training-on-the-rules/Advice-Online-Database/Therapies-Physiotherapy.aspx vs http://www.cap.org.uk/Advice-Training-on-the-rules/Advice-Online-Database/Therapies-Osteopathy.aspx – but osteopaths often get hammered (quite rightly) for ‘advertising off list’ and advertising stuff that isn’t appropriate for treatment…whereas physiotherapists do not. Here again it really should come down to ‘what people do’ not ‘what profession they are’ when deciding who is being a numpty.
Another factor is that not that many physios are private (I’m not sure the proportion who work privately), but a far higher proportion of osteos are and many of them advertise to the public. This is where they fall within the ASA’s remit.
But osteos cannot say they are not aware of what they can and can’t claim in their advertising: the GOsC has highlighted the requirements of the CAP Code to their registrants on several occasions, yet many still seem to be ignoring it.
It is what they do that also counts – getting them to abide by the same advertising rules as every other advertiser has to is just one step – they need to apply the evidence to what they tell customers and what they actually do in practice as well.
So, lets get this right. You want NICE to change its guidelines for LBP based on the addition of 12 RCT’s that they didn’t deem fit to include in the in the original review and 50% of these have “a low risk of bias” ?
And just so you know, from YOUR list of suggested interventions, all with the exception of analgetics (which patients self administer as a rule) would be included in most chiropractors treatment or advice.
1)i want guideline writers, not just NICE, to re-consider the existing evidence which clearly fails to show that SMT is effective – that’s all.
2) my post is about SMT, not chiropractic, and i am sure many do useful things (as long as they abstain from SMT – which very few do)
More evidence emerges all the time, I’m sure you’ve read and ignored this already though http://www.ncbi.nlm.nih.gov/pubmed/23060056
yes i have read this: it is a PILOT study and does not control for non-specific effects. do you really think that this “evidence” would alter the totality of all available evidence on the subject?
This is to me very strange to read. I had very serious backpains (almost couldn’t move for many years, lets say a couple of times a year. To put it short, only kiroparaters were able to get me on my feet again, with a few tratments (physiotherapeuts could not help, doctors could not help). After some time a kiroparactor and an osteopat worked together on me with great success, and I have not had backpains for 15 years.
good for you – but please do not assume that this is evidence.