MD, PhD, FMedSci, FSB, FRCP, FRCPEd

In a recent comment, US chiropractors stated that there is a growing recognition within the profession that the practicing chiropractor must be able to do the following: formulate a searchable clinical question, rapidly access the best evidence available, assess the quality of that evidence, determine if it is applicable to a particular patient or group of patients, and decide if and how to incorporate the evidence into the care being offered. In a word, they believe, that evidence-based chiropractic is possible, perhaps even (almost) a reality. For evidence-based practice to penetrate and transform a profession, the penetration must occur at two levels, they explain. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature.

The second level, the authors explain, relates to whether the therapeutic interventions commonly employed by a particular health care discipline are supported by clinical research. The authors believe that a growing body of randomized controlled trials provides evidence of the effectiveness and safety of manual therapies. Is this really true, I wonder.

In support of these fairly bold statements, they cite a paper by Bronfort et al which, in their view, is currently the most comprehensive review of the evidence for the efficacy of manual therapies. According to these authors, the ‘Bronfort-report’ stated that evidence is inconclusive for pneumonia, stage 1 hypertension, pre-menstrual syndrome, nocturnal enuresis, and otitis media. The authors also believe that it is unlikely manipulation of the neck is causally related to stroke.

When I read this article, I could not stop myself from giggling. It seems to me that it provides pretty good evidence for the fact that the chiropractic profession is nowhere near reaching the stage where anyone could reasonably claim that chiropractors practice evidence-based medicine – not even the authors themselves seem to abide by the rules of evidence-based medicine! If they had truly been able to access the best evidence available and assess the quality of that evidence surely they would not have (mis-) quoted the ‘Bronfort-report’.

Bronfort’s overview was commissioned by the General Chiropractic Council, it was hastily compiled by ardent believers of chiropractic, published in a journal that non-chiropractors would not touch with a barge pole, and crucially it lacks some of the most important qualities of an unbiased systematic review. In my view, it is nothing short of a white-wash and not worth the paper it was printed on. Conclusions, such as the evidence regarding pneumonia, bed-wetting and otitis is inconclusive are just embarrassing; the correct conclusion is that the evidence fails to be positive for these and most other indications.

Similarly, if the authors had really studied and quoted the best evidence, how on earth could they have stated that manipulation of the neck cannot cause a stroke? The evidence for that is fairly overwhelming, and the only open question here is, how often do such complications occur? And even the biased ‘Bronfort-report’ states: Adverse events associated with manual treatment can be classified into two categories: 1) benign, minor or non-serious and 2) serious. Generally those that are benign are transient, mild to moderate in intensity, have little effect on activities, and are short lasting. Most commonly, these involve pain or discomfort to the musculoskeletal system. Less commonly, nausea, dizziness or tiredness are reported. Serious adverse events are disabling, require hospitalization and may be life-threatening. The most documented and discussed serious adverse event associated with spinal manipulation (specifically to the cervical spine) is vertebrobasilar artery (VBA) stroke. Less commonly reported are serious adverse events associated with lumbar spine manipulation, including lumbar disc herniation and cauda equina syndrome.

Evidence-based practice? Who are these chiropractors kidding? This article very neatly reflects the exact opposite. It ignores hundreds of peer-reviewed papers which are critical of chiropractic. The best one can do with this paper, I think, is to use it as a hilarious bit of involuntary humour or as a classic example of cherry-picking.

Come to think of it, chiropractic and evidence-based practice are contradictions in terms. Either a therapist claims to adjust mystical subluxations, in which case he/she does not practice evidence-based medicine. Or he/she practices evidence-based medicine, in which case adjusting mystical subluxations cannot be part of their therapeutic repertoire.

Towards the end of the article, we learn further fascinating things: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article – oh, really?!?! Furthermore, we are told that this ‘research’ was funded by the ‘National Center of Complementary and Alternative Medicine’ (NCCAM) of the National Institutes of Health.

Can it be true? Does the otherwise most respectable NIH really give its name for such overt nonsense? Yes, it is true, and it is by no means the first time. In fact, our analysis shows that, when it comes to chiropractic, this organisation has sponsored almost nothing but utter rubbish, and our conclusion was blunt: the criticism repeatedly aimed at NCCAM seems justified, as far as their RCTs of chiropractic is concerned. It seems questionable whether such research is worthwhile.

37 Responses to Evidence-based chiropractic is an oxymoron

  • Prof Ernst wrote: “Bronfort’s overview was commissioned by the General Chiropractic Council”

    …and the General Chiropractic Council (GCC) scored a spectacular own-goal with it. Having once dismissed a certain study by Hancock et al as being nothing to do with chiropractic (apparently because it didn’t suit its agenda), guess what study was included in the Bronfort Report…

    Quote
    “…why was the Hancock et al. study (which has nothing to do with chiropractic, remember) ever considered by Bronfort? The GCC has made it abundantly clear that Hancock et al. has nothing whatsoever to do with chiropractic. Even if Bronfort was not aware of this at the time, you’d have thought someone at the GCC would have read it and noticed this irrelevant Hancock study and either asked Bronfort to remove it or issue an amendment to it. Neither has happened… if the Hancock study is to be removed from Bronfort because it had nothing to do with chiropractic manipulation, then we must also remove all the other papers that Bronfort cited that were not explicitly to do with chiropractic and chiropractic manipulation…Chiropractors can’t have it both ways: chiropractors can’t claim to be unique amongst the manual therapists because of their techniques, yet claim any evidence for their particular ‘art’ from the studies that were not about chiropractic manipulations. The GCC has made this perfectly clear. So, the GCC can’t maintain that Hancock is irrelevant because it’s not about chiropractic manipulations, yet allow their prized Bronfort Report off the hook when it cites trials mainly not about chiropractic. Once all those non-chiropractic manipulations have been removed from the Bronfort Report, what’s left? Not a jot.”

    http://www.zenosblog.com/2010/11/where-the-evidence-leads/

  • Edzard, if I am licenced as a chiropractor, and in my best efforts to practice apply the best evidence based available to my patients (not detecting and removing non existent subluxations), am I still practicing chiropractic, or am I a chiropractor who is practicing medicine without a licence?

    • let me answer with a question:
      if someone does chiropractic and entirely rejects the existence of mystical subluxations, how does he/she differ from a physiotherapist?

      • With respect, and acknowledging that Physical Therapist may differ slightly from Physiotherapist, even a non-mystical-subluxation-chiro would not hold a candle to a credentialed PT.

      • That’s a good question. In reality, very little. As better and better quality evidence is produced and EBP’s of both professions develop their practice in such a fashion, I see a complete blurring of the lines and an invisible difference between the two.

        But then again, you’ve always got the philosophically driven chiros to drive the wedge between EBP and reality…

      • Do Chiropractors and Physiotherapists differ?
        1. Physiotherapists have a 3 year degree, Chiropractors take 5 to reach a Masters degree.
        2. All Chiropractic colleges here in the UK dismiss the idea of a subluxation out of hand.

        Don’t throw the baby out with the bathwater.

        • Alex Bowling wrote: “All Chiropractic colleges here in the UK dismiss the idea of a subluxation out of hand.”

          Nonsense. For example, the McTimoney Chiropractic College, up until the BCA/Simon Singh case in 2008, declared the following on its website:

          Quote:
          “McTimoney taught, as DD Palmer had before him, that health depends on healthy nerve messages, that subluxations of the vertebrae or other joints interfere with these, and that such subluxations can affect not only joints and muscles, but every cell and organ in the body”. The Objectives section of the site states that “By correctly training the hands as an instrument of innate intelligence, healing can be encouraged to take place by the detection and correction of bony subluxations (slight displacements)”.
          http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1181-mctimoney-chiropractic-association.html

          Although the current McTimoney curriculum appears to make no mention of ‘subluxations’, the college’s pre-2008 graduates *must* have been trained to detect them. Indeed, according to this link, they continue to be taught about them:
          http://www.mctimoneychiropractic.org/index.php?option=com_content&view=article&id=478:march-2013&catid=60:cpd-event-diary

          Also, in 2010, 82.9% of the (several hundred strong) Alliance for UK Chiropractors (the members of which include McTimoney chiropractors) felt that the Vertebral Subluxation was not an historical concept…
          http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1827-alliance-of-uk-chiropractors-october-2010-newsletter.html

          The upshot of the above is that just because UK chiropractors keep quiet about the chiropractic ‘subluxation’ it doesn’t mean that they don’t still administer potentially risky treatments based on their erroneous belief in it to thousands of unwitting patients.

        • In North America it is 7 years to be a DC

        • You can not be serious. Chiropracty is quackery, and it matters little how many years that a chiropractor has spent studying bullshit; it is still just bullshit.

          Let me give you a little insight to this chiropractic bullshit; here in Western Australia, at the Aquarium of Western Australia, some poorly trained and ill informed “animal expert” thought that one of their sharks was looking a tad poorly, so she got a chiropractor to fix it. This charlatan manipulated the shark’s spine and fixed the shark’s problems.

          This “miracle” was reported in the West Australian newspaper. I’d like to point out that sharks have a cartilaginous skeleton that does not respond to chiropractic manipulations. So the treatment was total bullshit. Like all chiropractic treatment.

          What part of the word “bullshit” is so difficult for a chiropractor to understand?

          “Don’t throw the baby out with the bathwater?”

          Don’t believe any of the bullshit that chiropractors spew out; it is all crap. None of it is scientifically proven, and all of it is shit.

      • A chiropractor is a doctor, with more extensive training, who is trained to diagnose any disease (not just musculoskeletal) and able to interpret lab tests and imaging, with a scope of practice that is more broad than a PT. At least that is how it is in North America.

  • It is disappointing to read that you don’t view the effort of going in a more evidence based direction as a positive thing. Instead, you only look at chiropractic as the ones treating subluxation, which is a smaller portion of the profession. Every profession going towards a more evidence based approach should be applauded. The evidence-based ones do, and are similar to physios and manual therapists in the way they work. Does your constant accusations against the profession cloud your mind in this matter? Criticism against how they understand the research is of course fine. But you clearly don’t read the research correct yourself, if you find the evidence for neck manipulation causing stroke overwhelming. But looking at your conclusions that you draw from your own studies, which cannot be drawn due to the design of the studies, this is not very surprising. Interestingly, you don’t seem to have this problem when it comes to debunking research claiming treatment-benefits from some treatment method you don’t approve. Before you go into attack-mode, I hope you consider some self-reflection.

    • of course, I applaud anyone in health care becoming evidence-based!
      if a chiropractor does this fully, he/she no longer practices chiropractic. he/she might still be called A CHIROPRACTOR but, in fact, he/she is much more a physiotherapist.
      and…whether I approve of a treatment or not is utterly irrelevant; what counts is the evidence.

      • This is a bit of circular logic Dr Ernst. You are attempting to predicate that if chiropractic is evidence-based it is no longer chiropractic. Then you are claiming that chiropractic is not evidence-based.

        You are certainly, despite your experience, in no position to define our profession. Criticize: yes, define: no.

        • Gary Barone wrote: “This is a bit of circular logic Dr Ernst. You are attempting to predicate that if chiropractic is evidence-based it is no longer chiropractic. Then you are claiming that chiropractic is not evidence-based.”

          Professor Ernst’s reasoning is totally sound – i.e. evidence-based chiropractic is physiotherapy, and true chiropractic (as practiced by the majority of chiropractors) is pseudoscience.

          Gary Barone wrote: “You are certainly, despite your experience, in no position to define our profession. Criticize: yes, define: no.”

          As an impartial academic scientist, Professor Ernst is perfectly placed to define chiropractic. On the other hand, chiropractic seems to be whatever most chiropractors need it to be in order to earn a lucrative living.

          • “Pseudoscience” is a bit harsh… How about “protoscience?” Anyone? No? OK.

            @prof Ernst re “7 years of nonsense” …. Ouch! For your information less than half that seven years was nonsense! ;)

      • I read the whole episode with sadness…while people like myself was saved from unbearable pain and the wheel chair..by Chiropractic,
        Someone ,…. for whatever your agenda is goes on and on discrediting chiropractors ….is there really so much for you to lose if Chiropractor are CURING PEOPLE ..!

        Just because you guys have no knowledge how people are cured..it doesn’t give you the right to VICIOUSLY call
        others names. DO YOU GUYS REALLY… KNOW EVERYTHING THERE IS… IN THIS UNIVERSE..?

        In 1980 if someone says.. talking on” devices with images “…is possible ..I can imagine SOMEONE LIKE YOU would say…LOOK AT THE BULLSHIT..IT’S STUPID..

        No sir ..it’s YOU… your knowledge …LACK OF IT.
        Please do not write and write..your irresponsible writing may be depriving someone SUFFERING IN PAIN the possible chance of living a life without the pain.

        The constant suffering I dread but cannot put into words….THAT……YOU HAVE NOT EXPERIENCE.

        • Francis said:

          I read the whole episode with sadness…while people like myself was saved from unbearable pain and the wheel chair..by Chiropractic,

          That could possibly be correct and I’m glad you are not now in pain, but I’m afraid we only have your word for it.

          for whatever your agenda is goes on and on discrediting chiropractors

          It’s the independent, robust evidence that discredits chiropractic – and the chiros themselves who frequently claim much more than than that supported by that evidence.

          ….is there really so much for you to lose if Chiropractor are CURING PEOPLE ..!

          If only there was the robust, independent evidence for that…

          Just because you guys have no knowledge how people are cured..

          Do you have that evidence, perchance?

          it doesn’t give you the right to VICIOUSLY call others names.

          Who are you accusing of viscously calling someone names and why?

          DO YOU GUYS REALLY… KNOW EVERYTHING THERE IS… IN THIS UNIVERSE..?

          I don’t think I would be out of place in speaking for Prof Ernst or anyone else here by saying that none of us is claiming any such thing! You just made it up.

          In 1980 if someone says.. talking on” devices with images “…is possible ..I can imagine SOMEONE LIKE YOU would say…LOOK AT THE BULLSHIT..IT’S STUPID..

          Someone in the 70s said we’d be travelling to work in flying cars by now…

          No sir ..it’s YOU… your knowledge …LACK OF IT.

          What, precisely, is lacking in Prof Ernst’s knowledge?

          Please do not write and write..your irresponsible writing may be depriving someone SUFFERING IN PAIN the possible chance of living a life without the pain.

          If you have the evidence, please provide it so we can all have a look at it and be as convinced as you seem to be…

          The constant suffering I dread but cannot put into words….THAT……YOU HAVE NOT EXPERIENCE.

          Putting it into words should consist of providing the evidence. I see you have provided none.

  • Subluxations are about as mystical as the sun rising. Perhaps you should review anatomical structure and the function of the nervous system, which as a highly educated person, you should already understand. Chiropractic is not a belief or a religion. It IS based upon scientific facts about how the human body works and if chiropractors are starting to perform clinical trials and gather evidence to better guide their practicing it should be viewed as a decent effort a step in the right direction. Maybe you should visit a chiropractor a actually see that it is about more than cracking necks and backs to relieve pain.

    • any evidence?

    • @Jennifer

      Please list a few “scientific facts” that apply to chiropractic. I know the names of the bones in the body and most of the muscles and tendons as well. That does not make me a doctor or even an anatomist. I am a pretty good physical anthropologist, though and good at identifying bone fragments.

      • Hi Jennifer. The DC (usa/canada) chiropractic curriculum is very similar to a medical school content and duration, (some 80 percent overlap) with more emphasis on anatomy and biomechanics, less on microbiology and pharmacy. We also learn “physiological therapeutics” (physiotherapy). There is heavy emphasis on bone pathology (reading X-rays) and physical diagnosis.

        So you can see that many scientific facts apply to chiropractic.

        Then we are anointed and entrusted with our magic power crystal so we can enlighten the masses. Just kidding… (I wish!)

        Congratulations on your career. It sounds very interesting.

  • @Irene
    An anthropologist certainly ought to be an expert anatomist more so than a healthcare professional. Should you really be making comments here?

  • @ Dr.Ernst
    Do you think these German medical doctors:
    http://www.jaoa.org/content/109/6/293.full

    and of course Cyriax, Mennell,Calliet to name a few were all full of BS?

  • Jennifer,
    Check out “An epidemiological examination of the subluxation construct using Hill’s criteria of causation” open access http://www.chiromt.com/content/17/1/13 by a chiropractor.
    >>>”Conclusion
    There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.”

    Diane Jacobs PT

  • Gary Barone wrote: “Pseudoscience” is a bit harsh… How about “protoscience”?

    Protoscience definition: An unscientific field of study which later becomes a science.

    Chiropractic will be 118 years old next month. How long do we have to wait for the science?

  • An interesting discussion as always between the skeptics and the deluded! As a licensed Chiropractor in the UK, I am under no illusion that as an evidence based Chiropractor I am essentially practicing in a similar fashion to modern Physiotherapists. My ‘profession’, in no way determines how I practice musculoskeletal medicine pain management, it merely identifies the type of undergraduate training I received.

    I use a range of manual therapy techniques including the Chiropractors ‘favourite’, the high velocity thrust, but only very sparingly as there are often safer and more effective evidence based tools available! Honestly, I feel very uncomfortable with my professions gimmicks, tainted dogma and numerous ‘quack’ chirorpractic treatment techniques! A quick visit to Youtube will identify dozens of examples of quack techniques in short order.

    I intend to continue to re-educate my patients regarding appropriate evidence based interventions for treatment of primarily non-specific spinal pain and challenge their misconeption that manipulation is the panacea they believe it to be! I wont elaborate about how these misconceptions arise but the skeptics out their can readily identify them!

    And before I go, I strongly believe that the placebo effect influences outcomes to a lesser or greater degree. Those Chiropractors who fail to recognise its significance in patient interactions are not only deluded but in my opinion dangerous!

  • A cervical adusmtjent would have been perfect to demonstrate. It would have been better if the Oz would not have propagated that adusmtjent hurt. Did you see the audience members cringe witht he adusmtjents?The stigma of an adusmtjent causing pain really needs to end, and Dr. Oz poking fun at it does nothing but continue the misinformation.

  • As a previous skeptic of chiropractic care, I often criticized many chiropractors for their less than ability to clarify what it is that they do. A few years ago I suffered from a L4-L5 disc protrusion that was causing radical pain down my leg. I could not practice medicine and any movement was unbearable. Having met with a orthopedist I was given the option of surgery. My Knowledge of the literature has shown me that not only is the success rate for surgery very low the requirement for another one is quite high. So, as I questioned my options and went through my emotions, I elected to see a chiropractor from the advice of a pharmacist whose own sibling practices evidence based model of care. One month later consisting of 3 treatments a week, my pain has centralized. The leg symptoms regressed. I was off of my opioid medication. I was back to work. I was me. Intrigued by this I enlisted in chiropractic college. I was impressed with the evidence curriculum that was taught to me. Throughout my clinical rotations at VA hospitals co managing patient care with fellow MDs, research and evidence review dissertations were required to graduate. I did not have to do this in medical school. There is a shift in conservative based chiropractic care. Whether a few bad incidences that you have witnessed is unfortunate. But as a professional in both fields we have to remain humble about the things we do not know. In the end I still practice medicine and chiropractic. The factor that determines which treatment option I chose is based on the patient. I feel you have failed to realize what we do is for them. And them alone.
    Regards.

  • As a first year chiropractic student my opinion is probably rather biased, seeing as I am training to be what is being criticized, but in my albeit limited reading I have come to know that chiropractic is divided in many ways. One of which is the separation of practitioners into ‘believers’ and ‘questioners’ (according to Phillips, 1995). Believers deducing practice from the the major premise of chiropractics (the existence of a universal intelligence that governs all matter and gives to it all its properties), while questioners outright ignore this premise, instead making use of inductive reasoning to develop practices through evidence and research. The inductive-chiropractors if you will, do not subscribe to the archaic chiropractic teachings of “mysterious subluxations” causing all manner of disease around the body, and instead focus on promoting well-being, if I may use that term loosely, by improving joint health of the spine as well as other freely move-able joints around the body, and allowing a better quality of life (by improving freedom of movement). (I won’t say anything on the subject of nervous system as I know very little on this subject and the interaction chiropractors have with it)

  • SMT IS EVIDENCE BASED ACCORDING TO THE NHS WEBSITE! I AM CONFUSED.

    Also I know a Physio who performs spinal manipulations.

    Is he still a physio.?!! I AM CONFUSED. MAYBE I SHOULD CALL HIM A CHIROPHYSIO. I AM CONFUSED.

    Please explain the first point. Please rectify this mistake…someone’s health could be at risk!

    Also what should I call my physio.?!!!!!

  • “There is good evidence that spinal manipulation – as practised by chiropractors – can be an effective treatment for persistent lower back pain.”

    NHS

    I AM CONFUSED THE NHS IS SAYING ONE THING AND I AM READING THE OPPOSITE. THIS IS SOOOOOO JUXTAPOSING. WHO SHOULD I BELIEVE ERNST OR THE NHS.?!

    • Henry quoted: “There is good evidence that spinal manipulation – as practised by chiropractors – can be an effective treatment for persistent lower back pain.” NHS

      It looks like you’ve lifted that quote from here:
      http://www.nhs.uk/Conditions/chiropractic/Pages/Introduction.aspx

      It links to this page http://www.nhs.uk/Conditions/chiropractic/Pages/Evidence.aspx which says:

      QUOTE
      “A 2011 Cochrane review of studies of chiropractic intervention – treatments offered by chiropractors, including spinal manipulation – found that it is not possible to confirm or refute that chiropractic treatments are any more effective than conventional treatments for persistent lower back pain. Conventional treatments include painkillers, exercise and physiotherapy.”

      And that 2011 Cochrane review appears to be the same one as this:

      ‘Combined chiropractic interventions for low-back pain’

      QUOTE
      “Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.” Walker BF, French SD, Grant W, Green S., Cochrane Database Systematic Review 2010; 4: CD 005427

      Here, FYI, is some comment on the above review from Professor Edzard Ernst: “The hallmark treatment of chiropractors is spinal manipulation. If critical evaluations of spinal manipulation fail to show what chiropractors had hoped for, defendants may argue that chiropractic typically combines a wide range of modalities in practice, including manipulation, mobilisation, massage, exercise and heat. Thus, it might not be fair to judge the value of chiropractic solely by the effectiveness of spinal manipulation. This Cochrane review is an attempt to overcome this pitfall. Its results show that, for the most prevalent indication for chiropractic treatment (i.e. LBP), very few studies are available. Those that do exist are often seriously flawed. For acute and subacute LBP, chiropractic seems to be as good or marginally better than conventional treatments. However, I recommend taking this result with a pinch of salt; what is still required is independent replication through high-quality studies, which also account for the risks and costs associated with chiropractic. For chronic LBP, chiropractic does not seem to be any better than conventional treatments. All in all, this review serves as a poignant reminder that chiropractic may not be as soundly based on evidence as it is often made out to be.” [Subscription to Focus on Alternative and Complementary Therapies required.]
      Link: http://www.ebm-first.com/chiropractic/research-and-efficacy/1898-combined-chiropractic-interventions-for-low-back-pain.html

      Going back to the NHS evidence for chiropractic page, at the foot of it it says that it was last reviewed on 01/05/2012 and that the next review is due on 01/05/2014. In view of the above, hopefully the next review will take into account the following:

      Spinal manipulative therapy for chronic low-back pain
      “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.” Cochrane Systematic Review (16th February 2011)
      http://www.ebm-first.com/chiropractic/research-and-efficacy/1899-spinal-manipulative-therapy-for-chronic-low-back-pain.html

      Spinal manipulation: an update of a systematic review of systematic reviews
      “The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition…Conclusion: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.” Paul Posadzki, Edzard Ernst, New Zealand Medical Journal (August 2011)
      http://www.ebm-first.com/chiropractic/research-and-efficacy/1987-spinal-manipulation-an-update-of-a-systematic-review-of-systematic-reviews.html

      Spinal manipulative therapy for acute low-back pain: update of the earlier Cochrane review, first published in January 2004
      Conclusions: “SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.” (12th September 2012)
      http://www.ebm-first.com/chiropractic/research-and-efficacy/2163-spinal-manipulative-therapy-for-acute-low-back-pain-update-of-the-earlier-cochrane-review-first-published-in-january-2004.html

      And finally, here’s Professor Ernst on this blog last year:

      Time to re-write the guidelines on spinal manipulation for low back pain
      “…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.”
      http://edzardernst.com/2013/04/time-to-re-write-the-guidelines-on-spinal-manipulation-for-acute-low-back-pain/

      NB Henry, even if there was good evidence for chiropractic SMT for low back pain, chiropractors couldn’t be recommended as administering practitioners due to this:

      Quote
      “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.

      • Silly me. I figured that Henry was kidding, based on “Please rectify this mistake…someone’s health could be at risk!”.

        And of course this “Is he still a physio.?!! I AM CONFUSED. MAYBE I SHOULD CALL HIM A CHIROPHYSIO. I AM CONFUSED.”

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