MD, PhD, FMedSci, FSB, FRCP, FRCPEd

– Chronic low back pain (CLBP) is a condition which affects so many people that it represents a huge burden to individual patients’ suffering as well as to society in terms of loss of work time and increased economic cost. The number of therapies that have been claimed to be effective for CLBP can hardly be counted. Two of the most common treatments are spinal manipulation and exercise.

The purpose of this systematic review was to determine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with CLBP. Only RCTs that compared head-to-head spinal manipulation to an exercise group were included in this review.

A search of the current literature was conducted using a keyword process in CINAHL, Cochrane Register of Controlled Trials Database, Medline, and Embase. The searches included studies available up to August 2014. Studies were included based on PICOS criteria 1) individuals with CLBP defined as lasting 12 weeks or longer; 2) spinal manipulation performed by a health care practitioner; 3) prescribed exercise for the treatment of CLBP and monitored by a health care practitioner; 4) measurable clinical outcomes for reducing pain, disability or improving function; 5) randomized controlled trials. The methodological quality of all included articles was determined using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).

Only three RCTs met the inclusion criteria of this systematic review. The outcomes used in these studies included Disability Indexes, Pain Scales and function improvement scales. One RCT found spinal manipulation to be more effective than exercise, and the results of another RCT indicated the reverse. The third RCT found both interventions offering equal effects in the long term.

The author concluded that there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP. More studies are needed to further explore which intervention is more effective.

Whenever there are uncounted treatments for a given condition, one has to ask oneself whether they are all similarly effective or equally ineffective. The present review does unfortunately not answer this question, but I fear the latter might be more true than the former.

Considering how much money we spend on treating CLBP, it is truly surprising to see that just three RCTs are available comparing two of the most commonly used treatments for this condition. Equally surprising is the fact that we simply cannot tell, on the basis of these data, which of the two therapies is more effective.

What consequences should we draw from this information. Obviously we need more high quality trials. But what should we do in the meantime?

Whenever two treatments are equally effective (or, in this case, perhaps equally ineffective?), we must consider other important criteria such as safety and cost. Regular chiropractic care (chiropractors use spinal manipulation on almost every patient, while osteopaths and physiotherapists employ it less frequently)  is neither cheap nor free of serious adverse effects such as strokes; regular exercise has none of these disadvantages. In view of these undeniable facts, it is hard not to come up with anything other than the following recommendation: until new and compelling evidence becomes available, exercise ought to be preferred over spinal manipulation as a treatment of CLBP – and consequently consulting a chiropractor should not be the first choice for CLBP patients.

91 Responses to Chronic low back pain: exercise is better than spinal manipulation

  • Unlike some areas where the conclusion “more work needed” is an abdication from responsibility for drawing a definitive conclusion as to effectiveness of a complementary modality, in this instance it seems fair.

    However, for me, spinal manipulation and acupuncture share a feature that strains the limits of prior plausibility. Even if the intervention does ‘something’ to the biology of the system as it is applied, it is hard to see how sustained relief is likely to be obtained. We should not be surprised that cracking a back or sticking a needle into the skin has a physiological effect. To say that they do is tantamount merely to saying that the patient was alive rather than dead at the time of treatment. However both modalities are claimed to produce sustained effects that cumulatively generate benefit. By an additional miraculous coincidence the interval between required treatments neatly matches the 7-day cycle of our working week. This might be proof of Intelligent Design, but I suspect it’s more to do with convenience to the patient and creation of a reliable cash-flow for the practitioner.

    There are modes of acupuncture that entail maintaining needles in position for prolonged periods, but I believe that to be very much the exception. Chiropractic is self-evidently a brief intervention.

    Instant impact creating prolonged relief is not impossible, but it is not very likely and, while straining credibility is not definitive disproof, the pattern of application of both of these therapies does add somewhat to the weight of evidence that is required of them before we should accept the claims made for them.

    Compare and contrast an exercise regime that can be repeated daily or even multiple times each day. This has a much stronger rationale in biology.

    As I have commented before elsewhere, Mrs Monkey has s colleague who practices acupuncture and Mrs M has a ‘frozen hip’ problem, a painful condition often suffered by those who have also had a frozen shoulder. Her colleague dry-needled her and she was instantly able to sit cross-legged, a feat that had been impossible immediate before treatment. However, the effect was brief and the chronic course of the condition carried on. Examples such as this have led me to wonder whether there is a nugget of truth in the middle of the mess that is acupuncture but the claims made for it overall are far too wide-ranging and implausible when large treatment effects are claimed.

  • Osteopathy…
    HANDS-ON TREATMENT IMPROVES CHRONIC LOW BACK PAIN, REDUCES MEDICATION USE
    http://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf

  • One could equally argue that exercise is more of an effort, so patients should make use of chiropractors. Also, perhaps exercise programmes are more likely to encourage a greater sense of responsibility for symptoms, or a greater sense of control, they might be more likely to have problems with social desirability bias.

    To me it looks like we should not be making recommendations to people with CLBP about how they spend their time, as we just don’t have a good enough understanding of what is valuable for them.

    For a lot of conditions, the most appropriate response is “I’m sorry but we just don’t know.”

    • @Chucky,
      “One could equally argue that exercise is more of an effort, so patients should make use of chiropractors.”
      Are you seriously suggesting that because exercise is “more of an effort”, this is justification for chiropractic? My guess is you are a chiropractor.
      “To me it looks like we should not be making recommendations to people with CLBP about how they spend their time, as we just don’t have a good enough understanding of what is valuable for them.”
      What is valuable for them or what is best for their health? Is that what medicine is reduced too, ordering treatment according what takes the least time or effort?

      • LOL – I’m not defending chiropractors – I’m criticising those who tell patients that exercise is an effective treatment. If I had a choice between doing exercise that I did not want to do, or going to a chiropractor when I did not want to, and both had the same evidence of efficacy – the chiropractor sounds like less of a distortion of my preferences than the exercise. At the moment, seeing as both rely on non-blinded trials and seem to be no better than placebo, I think it would be best to just leave people alone.

        “Is that what medicine is reduced too, ordering treatment according what takes the least time or effort?”

        Yes. Do as little to distort people lives as possible while improving their health. Very often that means being honest that there is not good enough evidence to recommend any treatment to them.

        • @Chucky,
          I would rather do exercise because I know it also has other beneficial effects. There’s no accounting for human laziness though.

  • Is it me, or is ‘chronic lower back pain’ too broad a description? Surely there are many possible causes, so it’s the cause which needs to lead to treatment, and therefore the possible treatments should be judged according to the cause.

    • You are right, but I think many cases get lumped together into this broad functional syndrome because specific diagnosis is often hard and a significant proportion have frustrated diagnostic efforts.

      [i am not a doctor and I do not play one on the interwebs]

    • I have a hard time believing anyone would study ‘chronic lower back pain’. Surely, the studies get more specific. That would be as vague and useless as a study on ‘headache’, ‘irritable bowel syndrome’, or ‘high blood pressure’.

  • Interesting systematic review. Three RCT met criteria, one favoured SMT, one favoured exercise and one favoured both. I love investigating articles like this, they change the way I practice. Do chiropractors just manipulate? Do physiotherapists just prescribe exercises? In modern practice both physio’s and chiro’s use a multimodal approach using manipulation, mobilization, soft tissue therapies, lifestyle advice, ergonomic advice, behavior modification and prescriptive exercise. So what is the optimal combination? What is the optimal dose?
    This article investigates this very issue:
    http://www.ncbi.nlm.nih.gov/pubmed/20627797 It said:
    “Why combine manual therapy and exercise? The use of manipulation and mobilisation alone provides short-term pain relief. Exercise appears to improve pain and function over the long-term (Kay et al., 2008). The combination of manual therapy and exercise, however, seems to produce greater short-term pain reduction than exercise alone and longer-term changes across multiple outcomes in comparison to manual therapy alone.
    What is the best manipulation or mobilisation to utilize in combination with exercise? The answer to this question remains unclear. Evidence from our Cochrane Review suggests that mobilisation and manipulation produce similar changes in pain and function and that one mobilisation technique may be favored over another. Additional head to head comparisons of different manual therapy techniques alone and in combination with exercise are needed to determine the most effective approach.
    What is the best exercise to use in combination with manual therapy? Since the strength of evidence supporting the combination of manipulation, mobilisation, and exercise continues to grow, future investigations should look at which exercise techniques are optimally combined with manual therapy. A Cochrane review (Kay et al., 2008) has demonstrated the positive effect of specific cervicoscapular resisted exercises, C1/2 self-SNAG exercises, craniocervical endurance exercise and low load endurance exercise, and upper extremity stretching and strengthening exercises, but the optimal exercises to combine with manual therapy remain unknown.”
    These are questions I ask every day in practice.
    Prof Chris Maher of the George Institute in his presentation “Back Pain- Time to get it right” also discusses the issue and when it comes to which exercise to prescribe said “which branch of the religion do you belong”.
    Prof Ernst has made a point about safety, so the findings of this article will be of interest:
    Adverse events among seniors receiving spinal manipulation and exercise in a randomized clinical trial.
    http://www.ncbi.nlm.nih.gov/pubmed/20627797
    Exercise is not without risk!
    Prof Ernst also made a point about cost effectiveness and there have quite a few recent articles on this topic:
    Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials.
    http://www.ncbi.nlm.nih.gov/pubmed/24986566
    Setting the equation: establishing value in spine care.
    http://www.ncbi.nlm.nih.gov/pubmed/25299258
    Primary spine care services: responding to runaway costs and disappointing outcomes in spine care.
    http://www.ncbi.nlm.nih.gov/pubmed/25271662
    Cost analysis related to dose-response of spinal manipulative therapy for chronic low back pain: outcomes from a randomized controlled trial.
    http://www.ncbi.nlm.nih.gov/pubmed/24928639
    This whole field is rapidly changing and evolving. I find it fascinating and often frustrating

  • I’m confused. The title says chiropractic is crap but then describes SMT performed by physios vs exercise for CLBP. As far as I’m aware Chiro is a profession who uses multiple modalities for a condition. SMT would be one component, exercise rehab would be another, electrophysical therapies like TENS would be another possibility. I know this is anecdotal but I’m not aware of many chiros who would soley perform SMT, generally exercise rehab is always conducted in conjunction.

    • Alex Fielding said:

      I’m confused. The title says chiropractic is crap but then describes SMT performed by physios vs exercise for CLBP.

      The intervention being tested was “Intervention: spinal manipulative therapy, defined as high velocity and low amplitude thrust and/or manual mobilization of vertebral joints”. What’s the difference between HVLA thrusts performed by a physio and HVLA thrusts performed by a chiro?

      As far as I’m aware Chiro is a profession who uses multiple modalities for a condition. SMT would be one component, exercise rehab would be another, electrophysical therapies like TENS would be another possibility. I know this is anecdotal but I’m not aware of many chiros who would soley perform SMT, generally exercise rehab is always conducted in conjunction.

      Possibly, but irrelevant to this systematic review: its purpose was:

      The purpose of this systematic review was to examine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with CLBP. Studies that compared head-to-head spinal manipulation to an exercise group were included in this review.

      But, of course, the elephant in the room is that the authors were not able to find one single RCT that compared spinal manipulation by chiropractors that met their inclusion criteria to include in their review. Considering that treating CLBP with chiropractic manipulations would appear to be chiros’ ‘signature’ condition, don’t you find this situation somewhat curious?

      • @ Alan

        I would say that there is no difference between HVLA thrusts performed by a chiro or by a physio, whatever each profession might say.

        • I asked Stephen M. Perle (Professor of Clinical Sciences at the University of Bridgeport College of Chiropractic and Associate editor of Chiropractic & Manual Therapies) about this on Twitter. He seemed to confirm that there is no difference between SMT performed by a chiro, osteo or a physio. Therefore, although the interventions in the RCTs in the review were performed by physios, there seems to be no reason why the conclusions don’t also apply to chiros and physios. So, it seems to me that all of the following are equally correct:

          Chronic low back pain: exercise is better than chiropractic/spinal manipulation
          Chronic low back pain: exercise is better than osteopathic/spinal manipulation
          Chronic low back pain: exercise is better than physiotherapy/spinal manipulation

          But he hasn’t addressed the elephant in the room yet.

          • @ Alan

            Can you explain what do you mean by “better” – more effective? cheaper? less adverse events?

            The study cited by Prof Ernst concluded the following “It is evident from the literature review that there is no conclusive evidence favouring either exercise (of various forms) or spinal manipulation as treatment of choice to provide effective improvements on patients with CLBP”

            How do you draw your conclusions exercise is better than SMT, when even the study hasn’t come to that conclusion?

          • AN Other

            I was mimicking Edzard’s title to show that it could – given Perle’s statement that they are all the same – be re-written in three equivalent ways.

          • @Alan Henness
            “I asked Stephen M. Perle (Professor of Clinical Sciences at the University of Bridgeport College of Chiropractic and Associate editor of Chiropractic & Manual Therapies) about this on Twitter. He seemed to confirm that there is no difference between SMT performed by a chiro, osteo or a physio.”
            Two questions;
            How and why would he know?
            How is “seemed” any sort of answer?

          • Frank Collins said:

            Two questions;
            How and why would he know?
            How is “seemed” any sort of answer?

            He appears to have some relevant knowledge, expertise and standing in the chiropractic community.

            I was tentative because of the nature of the short replies on Twitter. I did invite him to comment here so it could all be discussed in more detail. He has a major issue with the words Prof Ernst used in the title, but either he nor another chiro seemed able to address the issue that the authors of the study were unable to find any RCTs for chiro and exercise.

          • @ The elephant in the room

            I was surprised that only 3 RCTs were found to fit the criteria in the first place – quite a few RCTs done on CLBP

            Possible reasons why no chiros have done RCTs that could fit the criteria of the study above:
            1. Chiros too focused on SMT only RCT
            2. NOt enough chiros doing research
            3. Running a RCT is expensive
            4. More physios doing research (alot more physios than chiros too)
            5. Criteria set by study too narrow?

            More chiros should be doing research and also should be collaborating more with other professions.

            But also important to think that for the many physios doing research only 3 RCTs found on this area.

          • AN Other said:

            @ The elephant in the room
            I was surprised that only 3 RCTs were found to fit the criteria in the first place – quite a few RCTs done on CLBP

            That’s interesting. I wonder why the author was unable to find them?

            Possible reasons why no chiros have done RCTs that could fit the criteria of the study above:
            1. Chiros too focused on SMT only RCT
            2. NOt enough chiros doing research
            3. Running a RCT is expensive
            4. More physios doing research (alot more physios than chiros too)
            5. Criteria set by study too narrow?

            1. Do you mean that they are not comparing SMT to exercise?
            2. Quite possibly. Or the wrong research.
            3. How much does an RCT cost?
            4. Possibly. But there are thousands of chiros in the UK and 75,000 in the US, so is that not enough to do basic research?
            5. Again, possibly, but the dearth of chiro RCTs vs exercise is still concerning.

            More chiros should be doing research and also should be collaborating more with other professions.

            Possibly, particularly if there really is no difference between HVLA thrusts performed by chiros, osteos, physios or anyone else.

            But also important to think that for the many physios doing research only 3 RCTs found on this area.

            The impression I get is that chiros are known for – and seek to be known for – their chiro spinal manipulations as what defines them as a profession. There seems to be scant evidence for what they do and not much being done about that sorry state of affairs. Yet the training establishments continue to churn out new chiros and claims that are not based on what the best evidence says are still being made by chiros.

        • AN Other said:

          @ Alan
          I would say that there is no difference between HVLA thrusts performed by a chiro or by a physio, whatever each profession might say.

          Then what’s the difference between them all?

          • When a chiro, physio or osteo are performing a treatment there is no difference between the professions, as far as i am concerned

          • Indeed. Why are there different professions then do you think?

          • @ Alan you said “Indeed. Why are there different professions then do you think?”

            Because each profession was created at different times and no-one has had the bothered to combine them together.

          • @Alan Henness
            “He appears to have some relevant knowledge, expertise and standing in the chiropractic community.”
            Why would a chiropractor have any knowledge of physiotherapy? I don’t understand why you made the assumption that he would.

          • Frank

            You may well be right.

            Does anyone know what difference, if any, there is between HVLA thrusts as performed by these different groups?

          • @ Frank

            Because when a chiro and a physion are treating a musculoskeletal complaint they will generally perform some similar treatments.

          • not true!
            there is evidence that chiros would use SMT in > 90% of all patients; no other professionals do that.

          • @ Edzard

            So physios don’t use exercise in > 90% of all patients? Also i said that they generally perform some similar treatments not exactly the same treatments i.e. a physio may use exercise instead of SMT

            @ Alan

            Again, i would say that when a chiro, physio or osteo are performing HVLA there is no difference between the professions, as far as i am concerned

          • @An Other
            “When a chiro, physio or osteo are performing a treatment there is no difference between the professions, as far as i am concerned”
            How do you know? Is it just a sweeping statement that you think will get through because it is so audacious that no one will ask you to explain it? Wrong! Please explain?

            “Because each profession was created at different times and no-one has had the bothered to combine them together.”
            Come on! Chiro and osteo were invented with some vitalistic explanation for the implausible, whereas physio was formed out of the necessity to treat the sick in hospitals. “An Other” logical fallacy by a master.
            “Because when a chiro and a physion are treating a musculoskeletal complaint they will generally perform some similar treatments.”
            “An Other” sweeping statement without any evidence or substantiation. I will ask again; what makes you think you know, besides vague presumption?

            “as far as i am concerned”
            Is that some form of evidence or substantiation? Do you have your sights on a Nobel Prize in the near future?

            @Alex, Chiro
            “This would be a strawman fallacy.” No, that would be you trying to create a strawman of your own to bolster your argument. That is the Fallacy Fallacy; falsely claiming a fallacy when none exists.

            “I would disagree that the main modality for a CLBP patient from a chiro would be SMT”
            Then what is the point of chiropractic? Why learn about spinal manipulation and not use it? Then again, why claim the title of doctor for something that doesn’t even come within cannon range of a medical doctor?
            “i know very few Chiro’s around where I am (Sydney) who would disagree.”
            If you know so many chiros, why don’t you all chip in to fund some research that might help define your “trade”?

          • @ Frank

            you said “How do you know? Is it just a sweeping statement that you think will get through because it is so audacious that no one will ask you to explain it? Wrong! Please explain?”

            Because i have worked with all the professions (physio, osteo and chiro) – have you? I will point out that i should have written HVLA instead of treatment. So, my evidence is just anecdote of watching each of these professions at work.

            You are right chiro and osteo were founded on unscientific notions but on a treatment and technique basis there is probably not much difference between them (chiro, physio and osteo). You could argue that physio, chiro and osteo can claim a common beginning with the use of manual therapies during the time of Hippocrates.

            I will say that it is important to have the right intention behind the treatment i.e. get patient better using the best evidence and care – not to use unfounded dogma. Chiro and osteo have been guilty of this (using dogma) but even physio can have some dogmatic moments i.e. using acupuncture

            Also i wouldn’t mind the Nobel Peace Prize – maybe i could get it if i could unite all the musculoskeletal professions together under an evidence based practice approach : )

            Can i ask what sort of logical fallacy have I committed?

            Thanks for calling me a master but i don’t think i am worthy of such praise ; )

          • @ Alan – you said

            1. Do you mean that they are not comparing SMT to exercise? – quite possibly

            2. Quite possibly. Or the wrong research. – i would say both

            3. How much does an RCT cost? – I think about £100,000

            4. Possibly. But there are thousands (3000) of chiros in the UK and 75,000 in the US, so is that not enough to do basic research? – there are about 185,000 physios in US and about 50,000 in the UK. But saying that there was not enough research being doing by chiros, more research being done now.

            5. Again, possibly, but the dearth of chiro RCTs vs exercise is still concerning. – I agree it is a concern but the points i was making are that there are many more physios conducting research and the study could only find 3 RCTs comparing SMT and exercise. The reason for this could be because of my second point, which was the criteria used by the study was too narrow – limiting the number of possible RCTs that could be used.

            You said – “Then what’s the difference between them all?”

            Physio came from the position of using exercise (primarily) and other techniques to help patients recover or manage various conditions (initially orthopaedic complaints).
            Chiro was invented under the belief of its founder that the casues of all disease (renamed dis-ease to avoid prosecution of practicing medicine without a license in the US) were subluxations. These subluxations were treated with SMT. However, some chiros now will use other techniques with SMT when treating patients with musculoskeletal complaints. This still means that some chiros still believe in subluxations and still only use SMT. This maybe explain the impression you have (quite rightly too) that chiros sought to be known for their SMT skills. This was a way of protecting their profession but also hindered the profession.
            But like any skill these can be taught and learnt by any profession eg physio, medical etc.
            Osteos have a founder too (AT Still), who also believed in the ability of the body to self heal. This ability to heal depended on the supply and removal of nervous energy, blood and lymph, to and from the body. If these pathways were blocked, this hinders the self-healing mechanism and the corresponding organs become sick. AT Still regarded the spinal column as the centre of peripheral supply and this is why he looked for displaced vertebral bodies in most diseases, even internal diseases. He assumed that malposition of the vertebral bodies inhibited the function of surrounding nerves and vessels and attempted to reposition them specifically by gentle manipulations. Again, like chiros, some osteos still believe in the founding principles and practice according to this. Whereas other osteos use a more evidence based perspective.

            So if each of the professions practice from an evidence based perspective they would generally use the same techniques as each other but maybe not in the same frequency eg physios use exercise more, chiros use HVLA SMT more and osteos use other manipulative techniques more.

            Difference can arise between chiro, physio and osteo not in what they are doing but more in why they are doing it.

          • AN Other said:

            3. How much does an RCT cost? – I think about £100,000

            So, assuming actually asking the right research questions is fairly straightforward, why aren’t more good RCTs being done? Is there some hold up somewhere or some other problem?

          • @An Other
            “Because i have worked with all the professions (physio, osteo and chiro) – have you? I will point out that i should have written HVLA instead of treatment. So, my evidence is just anecdote of watching each of these professions at work.”
            No, I haven’t. My anecdotal evidence is that chiropractors use that strange table thing, whereas physios use other techniques. When I had mid-thoracic pain from bending my back most of the day, I went to a physio who specialised in musculo-skeletal; he diagnosed, laid me down, put a heat pack on the area, and about ten minutes later crunched my back so forcefully that I felt unable to move for a couple of minutes. I felt the crunch through my whole chest and I also felt the area of pain sort of crack. When I did get up, I was pain free, and my whole back and chest felt mobile. I could arch my back, turn, twist, and felt great. I sort this treatment about 6 to 8 times and it was always successful, as well as traumatic.

            I find the HVLA term amusing; how do you get high velocity from such a short distance? Is it like cracking a macadamia nut?

            “You are right chiro and osteo were founded on unscientific notions but on a treatment and technique basis there is probably not much difference between them (chiro, physio and osteo).”
            Do physios use that theatrical table thing? Obviously, a rhetorical question but it demonstrtates that chiro is all about the “show”.

            “You could argue that physio, chiro and osteo can claim a common beginning with the use of manual therapies during the time of Hippocrates.” I suppose you could if you wanted to draw a really long bow, and be laughed at for making such a preposterous suggestion that is devoid of any support.

            “but even physio can have some dogmatic moments i.e. using acupuncture”
            Agreed, but such is the influence of the reporting of such weirdnesses, these nonsenses creep in. I have a friend, who had shoulder surgery and still feels discomfort and restriction of movement, tell me two days ago that she had acupuncture and her shoulder is now pain free. I tried to tell her that it is a placebo and she should be careful she doesn’t risk further injury. The “problem” is that many such people are reasonably smart (but not smart enough), and have little understanding of reason and logic (as well as their own shortcomings), that they believe they wouldn’t be susceptible to a placebo.

            “Can i ask what sort of logical fallacy have I committed?”
            You are fond of the “Sweeping Generalisation”, having used that a few times.

          • @ Alan

            Have you tried to raise £100,000 – not easy to do in my opinion – ask other scientist about trying to get research grants. Low back pain is a complex field – have a read of the body in mind (www.bodyinmind.org) website and you will start to see how complex it is, especially with devising the right research questions.

            @ Frank

            When you went to the physio for your mid-thoracic pain the treatment you describe is HVLA manipulation. Also, remember that the process of being diagnosed, examined and being cared for can be all forms of placebo – therefore don’t be too dismissive of other peoples reports of associating a treatment with care (look for the evidence for manipulation in mid-thoracic pain).

            The American Physical Therapist Association describe that the techniques used by physical therapist derived from the Hippocratic era – please see http://www.apta.org/uploadedFiles/APTAorg/Practice_and_Patient_Care/PR_and_Marketing/Market_to_Professionals/TodaysPhysicalTherapist.pdf
            Remember to separate the intetion behind the treatment from the technique being used and you will find that these techniques used by physio, chiro and osteo all have a common root.

            I think we are both fond of the “Sweeping Generalisation” which can easily be done 🙂

          • AN Other said:

            @ Alan

            Have you tried to raise £100,000 – not easy to do in my opinion – ask other scientist about trying to get research grants.

            How many chiros are there? Just over 3,000 in the UK and 75,000 in the US. How many of them are interested in raising money to fund good trials for what they charge their customers for?

            Low back pain is a complex field – have a read of the body in mind (www.bodyinmind.org) website and you will start to see how complex it is, especially with devising the right research questions.

            It’s up to chiros to decide what they need to test, but it does seem they are more interested in customer surveys than getting to grips with the fundamentals such as whether SMT is better than exercise for uncomplicated cLBP. Is it really that difficult?

          • MUCH EASIER TO MAKE BOGUS CLAIMS THAN TO GET FUNDS AND DO SOME RESEARCH !!!

          • @ Alan

            You are right that there should be more money directed to research. For example Chiros in Denmark use a percentage (can’t remember how much) of each patient fee to go towards a research fund. Should be copied by all professions.

            If it was that easy to find what is best for uncomplicated cLBP or even low back pain in general, it would have been discovered by now 😉 Have a look on the body in mind website for just a flavour of how difficult it is!

          • @AN Other

            Good to see the Danes at least trying to do something, but why isn’t this being done everywhere? How much do you think could be raised for research in the UK or US?

      • This issue would be to say that SMT is not superior to exercise rehab therefore chiro doesn’t work. This would be a strawman fallacy. For CLBP exercise rehab would be the main treatment modality as well as looking at the more psych issues of chronic pain (Psychological referral may be of use). I would disagree that the main modality for a CLBP patient from a chiro would be SMT, it may be a component but exercise rehab would be the main part I’d say. Understandably this is anecdotal however, as i Chiro most of what I do is rehab and i know very few Chiro’s around where I am (Sydney) who would disagree.

  • Quote from page 2 of the paper linked by Gart on 15 January:
    ““For more than 100 years, osteopathic physicians have focused on the relationship between structure and function in the human body. Using these interrelationships to diagnose and treat patients has helped patients get better, and now we have scientific evidence that these methods produce moderate to substantial benefits in treating chronic low back pain, which is notoriously difficult to manage,” he added.”

    This made me laugh for the wrong reasons; it says that ostoepaths have practised for over 100 years with NO proof that their methods had any scientific basis and validity. How long would a real doctor continue a practise for there was no evidence that it actually worked, apart from some mild anecdotes. Would a real doctor be so enthused about “moderate” benefits? Would a real doctor be allowed to continue to offer such unproven treatments? If this isn’t damning, I can’t think what is. It illustrates the paucity of any really understanding of medicine, ethics, morality, and science.

    Just over 30 years, I was referred to a chiropractor because of right sciatica, only because (I hope) the doctor didn’t know about chiropractors, because they were new to Western Australia. I went many times (weekly, surprise, surprise because cash flow is important to my health) but it did nothing, despite the theatrics of the “treatment”.

    Not long after, I had severe sciatica, incredibly intense pain and an inability to stand up straight, if that properly describes being in a foetal ball position. I was referred to a neurosurgeon who diagnosed the problem, two disc ruptures at L5-S1 and operated. It is now over 30 years that I have been totally pain free, have played physical sport and done whatever I’ve wanted to do with no limitations. I don’t even think about the long scar on my lower back.

    THAT is the difference between real medicine and this witchdoctor nonsense.

  • @Alex Fielding
    “I know this is anecdotal but I’m not aware of many chiros who would soley (sic; correctly, solely) perform SMT, generally exercise rehab is always conducted in conjunction.”

    Mmmmmmm, there are a few clues but this is the most striking. Really, you swap anecdotes with people about the working practises of chiropractors? i think you should declare your interest or, more correctly, your bias. The lack of authenticity is obvious.

    • Frank. I’m not trying to be sneaky just outlining how I do thing and how my colleagues describe to me what they do. In regards to declaration not a problem. I’m a state boardmember of the chiro association (CAA), do the twitter feed for COCA and I’m a big supporter of evidence based practice. It’s how I practice, always have always will.

  • The treatment effects are equal. Neither superior, equally effective. NO serious side effects of manipulation for LBP, as there are probably none for exercise, although I might suggest that a slight rise in cardiovascular accidents may be seen with sudden unsupervised exercise, and if not done correctly, possible injury. Cost?. Well evidence suggests that supervised exercise is better and increases compliance. ” go home and do these exercises” as well, and one might suggest that if delivered by a Physio on a one to one basis this would significantly increase costs of this type of exercise. I am unaware of any cost analysis in a direct comparison of exercise and chiropractic care ( which by the way will probably include either supervised or home exercise anyhow as well as manipulation, something probably not provided by the average Physio) in terms of cost per QUALY. I think this would indeed be a good study to do. Your opening title is just not surpported by the evidence you then provide I’m afraid Edzard. I and many others ( including multiple guidelines ) interpret such evidence quite differently, and as has we have already discussed, given the complex nature of LBP, no one treatment is likely to be adequate for every patinet, and given patinet choice, chiropractic care (a multi modality approach to MSK problems) for cLBP remains as legitimate a choice as any other approach. Kindest regards Edzard. Dave Newell

  • So why did you write this:

    “Regular chiropractic care is neither cheap nor free of adverse effects; regular exercise has none of these disadvantages.”

    This clearly implies that exercise has no adverse events, doesn’t it?

  • If cLBP patients were regularly experiencing serious adverse events from the adjunctive, and speculative on your part (evidence please), additional neck adjustments, given the number of these interventions across Europe per day, don’t you think we might have an epidemic of serious side effects, complaints, newspaper stories ect. Where are they E?…or is everyone keeping conspiratorially quiet?………..Exercise has mild to moderate side effects, NSAIDS and paracetamol can have moderate to severe to fatal side effects, a vast range of interventions as offered by a plethora of practitioners from across orthodox medicine has side effects………as we all know and you articulate its really the harm/benefit/cost that needs to be looked at and the informed and consenting patient choice for particular approaches to their care.
    Your assumption of neck adjustments is entirely speculative and even it it were true, cause and effect has NOT been shown. Cassidys paper was NOT fatally flawed by misclassification of cases (Cai et al) (any misclassification was non differential and applied to both the physician and chiropractic data set) thereby not altering Cassidys conclusion one jot. Further, 2 of the authors make a living out of litigation in stroke cases, so implying causality for them is surely a nice little earner. Edzard, we can all cut and slice the data and studies how we want. But that is exactly your accusation of those that disagree with you. I’m certain you may feel certain that your are right. But as you pointedly said to me once, that doesn’t make it so.

    • “If cLBP patients were regularly experiencing serious adverse events from the adjunctive, and speculative on your part (evidence please), additional neck adjustments, given the number of these interventions across Europe per day, don’t you think we might have an epidemic of serious side effects, complaints, newspaper stories ect. Where are they E?”
      is the 50% figure which is very well documented not enough for you?
      “Your assumption of neck adjustments is entirely speculative and even it it were true, cause and effect has NOT been shown.” I do not agree that it is entirely speculative. there is evidence, as you know. and there is a debate, as we know. in other words, there is considerable uncertainty – and whenever there is such uncertainty, responsible health care providers have to err on the safe side (remember: THE PRECAUTIONARY PRINCIPLE!!!)

  • Dear Frank

    Your comment..’How long would a real doctor continue a practise for there was no evidence that it actually worked, apart from some mild anecdotes’

    I can confirm that leeches were used for at least 2,800 years and that’s a conservative figure. So in answer to your question….quite a long time it seems….and before you tell me that they were not ‘real’ doctors perhaps you might define one of those for me in a way that isn’t ambiguous. (http://www.bcmj.org/premise/history-bloodletting).

    Further to another comment, moderate benefits are in fact hugely important when applied to large numbers of people. That’s epidemiology.

    I am sorry that your experience with the chiropractor you saw was not what you had hoped. I genuinely am. But of course there are many qualitative studies in the literature that document equally disappointing personal stories in the context of MSK conditions with what you might call ‘real’ doctors. And as disappointing and saddening as they are, they are not evidence of a lack, or a presence of, clinical effects. I hope your back has remained unproblematic.

    • “…moderate benefits are in fact hugely important when applied to large numbers of people. That’s epidemiology.” are you sure? clinically irrelevant benefits do not become relavant because they are experienced by thousands, i’d say.

    • Dave,
      The leech argument is a Red Herring (http://en.wikipedia.org/wiki/Red_herring), as you should know and is irrelevant. Real medicine, as in science-based is, largely, a product of the late 19th and 20th centuries. I thought that was self-evident. To cite leeches is odd, to say the least.

      I agree moderate benefits are important; however, these benefits should be recognised and validated by research before they are applied, not the result of anecdotes or as the basis of a business dispensing unvalidated “treatments”.

      You should know from the history of chiropractic that it was “invented” by D. D. Palmer in 1895 in strange circumstances. Palmer later wrote a letter saying he wanted chiropractic to be a religion. In part, he succeeded because some people follow it blindly without ever crtically examining their beliefs. Science-based medicine does not invent treatments and dispense them without evidence that they work.

      In relation to my back, the chiropractor took X-rays and didn’t find the two ruptures. She didn’t find subluxations either, because no one else has either on anyone. She knew I had sciatica and still did the theatrical bash-crash on that strange table thing, probably making it worse. The only “benefit” was that it forced me to go to a medical specialist who diagnosed my injury and fixed it. The point of my story is to illustrate that chiropractors have little understanding of real medicine, and why would they? If you are taught and buy into the idea that back manipulation cures nearly all ills, their understanding is skewed, and, I would argue, of little value anyway.

      In regard to chiropractors generally, the main thing I see on this thread is a lack of logic; there are logical fallacies everywhere because, I believe, they (chiropractors) are scrambling to rationalise their beliefs when the basis of that belief is crumbling around them. I feel sorry for them in one way since they have built their lives and finacial security on a false premise, but few, if any, are prepared to accept that when the evidence is clear.

  • As you have said E, you enjoy these arguments and I dont see an end to them if I’m honest. Suffice to say the precautionary principle, if applied as rigorously as you might want, would eat into an extensive proportion of the health care delivered every day by most GPs and hospitals. I guess I would feel that theses sorts f arguments, while having obvious veracity should be applied fairly across health care in general, which is where I feel you don’t E. That’s where the pitch seems to be permanently on a slope when it comes to the ways you interpret the evidence. I guess that’s what many feel, and I guess you will feel otherwise, and again we are at an impasse. Still, it’s good healthy debate for sure, when I have the time. 😉

    • Dave,
      It seems impossible to read your posts without finding at least one logical fallacy, and sometimes more. I don’t know whether it is of any value pointing them out because that would require a logical mindset to understand and appreciate.

  • If there is to be reduced bias in these articles shouldn’t you tag this article ” alternative medicine, chiropractic, osteopathy” and PHYSIOTHERAPY. Additionally, posted in PHYSIOTHERAPY as well. That would show an unbiased approach!

    • The title and tags used give a clear indication of the bias of the author. The studies reviewed comprised treatments provided by physiotherapists. The treatment investigated were SMT and exercise. Both of these treatments can are provided by physiotherapists, chiropractors and osteopaths yet the title only mentions chiropractors, why? I suspect we can all draw our own conclusions.

      • More red herrings and unsound logic. Physiotherapy (and occupations therapy) are not based on an invented belief system, and they deal with all of the body, not specific elements. They also don’t make claims about their professional skills being able to cure unrelated diseases, as chiropractic and osteopathy do.

        In Australia, we have a game called (oddly enough) Australian Rules Football. It is a hard physically demanding game played on a cricket pitch sized oval, involving 18 players from each team on the ground at any time. The players are the fittest athletes in the world, as shown by a few studies. They can run about 14 to 18 kilometres a game, much at halfspeed and sprinting. They ned to be highly agile, jump, turn, twist, and are tackled or bumped at speed. It is the best game in the world and the toughest on the body. The point of all this; when they have injuries during the game, they are treated by physiotherapists and most return to the game. They are not treated by chiropractors or osteopaths because football clubs need treatments that work and keep their players fit. They are no bound by anything other than keeping the players in the best physical condition.

        • I fail to see the relevance of the sport references. You may be interested to know that in the UK chiropractors work with premier football and rugby teams and at all other levels of sport and increasingly so. Chiropractors were used by many teams in the London Olympics and will also be present in Rio. Modern chiropractors treat a range of musculoskeletal conditions and do practice in a vitalistic way. The origins of chiropractic have very little relevance to the practice of most modern practice just as physiotherapy has developed from its origins as a form of massage.

          • @ andy,
            I am surprised that you would use a self-defeating argument.
            “Modern chiropractors treat a range of musculoskeletal conditions and do practice in a vitalistic way.”
            Wikipedia; http://en.wikipedia.org/wiki/Vitalism
            “Vitalism is no longer philosophically and scientifically viable, and is sometimes used as a pejorative epithet.”

            “The origins of chiropractic have very little relevance to the practice of most modern practice just as physiotherapy has developed from its origins as a form of massage.”
            Not quite right either, from http://en.wikipedia.org/wiki/Physical_therapy#History;
            “Modern physical therapy was established towards the end of the 19th century due to events that had an effect on a global scale, which called for rapid advances in physical therapy. Soon following American orthopedic surgeons began treating children with disabilities and began employing women trained in physical education, massage, and remedial exercise.” I suppose if you make enough statements, one is bound to be correct; I’m just wondering when that might be.

            “I fail to see the relevance of the sport references.” Really? I’m sorry but this site doesn’t have crayons. (I’m sorry but you are being so abstruse, you need that one.)

            “You may be interested to know that in the UK chiropractors work with premier football and rugby teams and at all other levels of sport and increasingly so.” You also have a prince who advocates this nonsense.

            “Modern chiropractors treat a range of musculoskeletal conditions”. The only thing this says to me is that chiropractors needed to do domething else to try to maintain their relevance (and income). Have chiropractors abandoned that silly noise-making table, “applied kinesiology”, the little box with nothing in it to detect disease, or X-ray machines used to detect a problem that doesn’t exist? If any of them still use these things, how can chiropractic have any credibilty at all?

            What of the chiropractors who are anti-vaccination (dangerous loons who will kill people)? What about “pediatric” chiropractors (the greatest nonsense of all time to suggest babies have spinal conditions that require manipulation)?

        • Frank.

          I’m a chiro and have worked with various rugby union teams (club level), state netball team, state/national squash events, national beach volleyball, crossfit and swimming. Some of these have been in teams of chiros and physios. No AFL but that’s because Rugby Union is way more fun 😉

          And to clarify. There is no such thing as a subluxation. There is no evidence to prove it exists.

          • @Alex Fielding
            That’s not what this fellow says, and he says he has certified many chiropractors in his technique.
            http://www.neuroimpulse.net/

            In this one, he talks about nerves having something, akin to a volume control, in the spine that regulates the amplitude of nerve signals transmitted to the body.
            http://www.kirokids.com.au/patients/chiropractic-treatment

            When ALL chiropractors stop making such unvalidated claims, and there is evidence that all of its practises are substantiated by science, then it may develop credibility. Anecdotes are not evidence.

            “No AFL but that’s because Rugby Union is way more fun ;)”
            That’s an opinion I don’t share. The comments from rugby players who have tried Aussie Rules tell the story, as does those by Mike Pike who rucks for the Swans.

  • In Reply to Frank Collins:
    I have 3 friends who are chiro’s for AFL teams, one for NRL (Rugby League) and one for gods game Rugby Union. As for claims in regards to curing unrelated diseases, reasearch shows their numbers consistently around 15-18% of the profession. I share your frustrations in regards to those vocal dinosaurs but the majority have consigned subluxation to the dusty shelved of the history museum. This blog/site is ultimately pushing a reform agenda that I support 100%. Reformers like Dave Newell need to be acknowledged and helped.

    • @Thinking_Chiro,
      “I have 3 friends who are chiro’s for AFL teams, one for NRL (Rugby League) and one for gods game Rugby Union.”
      I have an idea; if you tell me which teams they are, I will email the clubs and send links to Edzard’s and Barrett’s articles about chiropractic. Since you maintain that chiropractic is a legitimate form of treatment of many musculo-skeleto injuries, no one has anything to fear from the clubs being given some information from medical doctors?

      Can’t be fairer than that.

      • In reply to Frank Collins:
        Do you actually think that those elite teams don’t have large medical support facilities with Dr’s, specialists, Chiro’s, Physio’s, exercise physiologists, strength and conditioning coaches etc all work together? Do you know what would happen if any one of them ponced it around or thought that they know more than everyone else? Medical support for elite teams is extremely collaborative! Facepalm!

  • Re professional sports’ teams employing chiros: so do some horse trainers, but it doesn’t mean the stuff works in either species. As for exercise? Yeah, go for it (anecdote alert) that’s how I got rid of sciatica etc….you have to show your back who’s boss!

  • Chiropractors prescribe exercises. Ernst is under an illusion that the profession is a one trick pony and not multi-modal. More assumptions not grounded in facts or reality.

    • no, he isn’t.
      SM is the hallmark therapy of chiros; they use it in over 90% of all patients.
      surgeons also do much more than operate, yet it is fair to judge their usefulness by their surgery!

  • Dear Frank

    I am indeed capable of thinking logically. Thank you. And I suspect you may be on the cusp of crossing Edzards red line and descending into ad hominem attack when you presume to know the capabilities or otherwise of my mindset….maybe you could list the logical,fallacies one by one so I may counter them. In addition saying ‘science based medicine ‘ doesn’t really offer any definition at all. We could all say we are science based. What does that mean? Evidence? Well, we could discuss the evidence for the sorts of things that chiropractors can provide to MSK patients if you desire?……you do realise Chiropractic is a profession and not a modality I guess. There are lots of things chiropractors do. It’s not just SMT……I wonder whether discussing this with you is of any value, as that would require a mindset that includes an understanding of the veracity or otherwise of the evidence at hand ?

    • “And I suspect you may be on the cusp of crossing Edzards red line and descending into ad hominem attack when you presume to know the capabilities or otherwise of my mindset”
      I’ll let Edzard make that judgement rather than relying on your claims at mind-reading.

      “Evidence? Well, we could discuss the evidence for the sorts of things that chiropractors can provide to MSK patients if you desire?” Why? The only thing that would substantiate chiropractic would be properly conducted trial. When that happens, there will be a case. As researchers say, anecdotal evidence is the worse kind, though it seems to be the only thing chiros’ have and cling to it precariously.

      “you do realise Chiropractic is a profession and not a modality I guess” When there is enough evidence to justify its existence, then it will be a “profession”, which its adherents so desperately want it to be considered.

      “There are lots of things chiropractors do. It’s not just SMT……I wonder whether discussing this with you is of any value, as that would require a mindset that includes an understanding of the veracity or otherwise of the evidence at hand ?” Do you really think that ploy will work? When, if, chiropractic can provide evidence? It has had 119 years and still nothing worth considering. Isn’t that long enough?

  • Ps…Frank……I do acknowledge that some of the things you point out are indeed the sorts of areas the profession need to move forward on…..as I did some of Edzards comments in his talk regarding the future of the profession…..I think Thinking Chiro has pointed this out as well……please do not tar us all with the same brush….all professions could be unfairly labeled such if one really wanted to………..

    • Logical fallacy alert; “all professions could be unfairly labelled such if one really wanted to”.

      I’m not trying to tar all chiropractors with the cliched same brush in that sense; the problem with chiropractic are its roots, basis for existence, and its practises. It was invented by a charlatan on a dodgy premise, and has not shown enough evidence to justify its existence as a mode of healthcare. There are many chiros in “clinics” with naturopaths, homeopaths, and other weirdnesses, so self-selection puts them very much in the “alternative” arena.

  • Dave Newell, I was trained (decades ago) to write my science and engineering reports in the passive voice. I never understood the reason for that until I read your comments.

    Facts are objective (impersonal); opinions are subjective (personal). When I read your comments it seems that you make everything personal. In other words, you seem unable to be objective about your profession. Perhaps this is why I was very surprised that you wrote: “In addition saying ‘science based medicine’ doesn’t really offer any definition at all. We could all say we are science based. What does that mean? Evidence?”

    Yes, we could all say that we are science based and that we use evidence, but evidence-based medicine takes this concept much further: the evidence is classified by its epistemological strength and only the strongest types are used to provide strong recommendations. The strongest types are RCTs, meta-analyses, systematic reviews. Case-controlled studies are an example of a weak type that can lead to only weak recommendations.

    In order to write comments in support or defence of a profession, the writer must remain objective and provide an argument that has epistemological strength. Commentators who question that profession do not have to be objective, neither do they have to counter with epistemological strength, because the burden of proof lies with the person(s) making the claim for effectiveness/efficacy.

  • This study is flawed! Nothing was done by a D.C. There is no room for biased research! The U.S. spends more money on health than another country and the U.S. isn’t even in the top 30 for health. It’s biased research like this that is troubling all our health!

  • The paucity of data is certainly disappointing for those of us affected by lower back pain. In the absence of a clear result I would suggest looking at what professional athletes and dancers do to alleviate conditions of this sort: primarily exercise under the guidance of a physio. This is what people do when their livelihoods depend on addressing the problem, and when they have a high level of body awareness and are skilled in developing and maintaining body fitness. Certainly a passive approach is not an option for people in those professions.

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