MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Regular readers of this blog will be aware of the many bogus claims made by chiropractors. One claim, however, namely the one postulating chiropractors can effectively treat low back pain with spinal manipulation, is rarely viewed as being bogus. Chiropractors are usually able to produce evidence that does suggest the claim to be true, and therefore even most critics of chiropractic back off on this particular issue.

But is the claim really true?

A recent trial might provide the answer.

The purpose of this study was to compare the effectiveness of chiropractic spinal manipulative therapy (cSMT) to a sham intervention on pain (Visual Analogue Scale, SF-36 pain subscale), disability (Oswestry Disability Index), and physical function (SF-36 subscale, Timed Up and Go) by performing a randomized placebo-controlled trial at 2 Veteran Affairs Clinics.

Older veterans (≥ 65 years of age) who were naive to chiropractic were recruited. A total of 136 who suffered from chronic low back pain (LBP) were included in the study – with 69 being randomly assigned to cSMT and 67 to the sham intervention. Patients were treated twice per week for 4 weeks. The outcomes were assessed at baseline, 5, and 12 weeks post baseline.

Both groups demonstrated significant decrease in pain and disability at 5 and 12 weeks. At 12 weeks, there was no significant difference in pain and a statistically significant decline in disability scores in the cSMT group when compared to the control group. There were no significant differences in adverse events between the groups.

The authors concluded that cSMT did not result in greater improvement in pain when compared to our sham intervention; however, cSMT did demonstrate a slightly greater improvement in disability at 12 weeks. The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect.

Hold on, I hear you say, this does not mean that cSMT is a placebo in the treatment of LBP! There are other studies that yield positive results. Let’s not cherry-pick our evidence!

Absolutely correct! To avoid cherry-picking, lets see what the current Cochrane review tells us about cSMT and chronic LBP. Here is the conclusion of this review based on 26 RCTs: 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.

Convinced?

33 Responses to Chiropractic spinal manipulation = placebo!

  • Studies ought to be about the treatment for a diagnosed condition, surely, to be useful. We don’t hear about studies into the treatment for “a pain in the lower abdomen” or “a rash” – so why is “lower back pain” considered as if it’s one problem?

    • Joyce Beck – can you direct us to the chiropractic research that describes what therapies work for specific pathological conditions causing low back pain?

      • That was my point. Any time a quackery study is concerned with the treatment of a symptom that can have a long list of possible causes, I more or less dismiss it without further reading.

    • @Joyce,
      A couple of the study group are chiropractors, so they had the choice to be specific. Chiropractors do, however, claim it is beneficial for “low back pain” so such a study which invalidates this claim is very illuminating.

  • Interesting paper.
    There were several confounders. The patients who averaged 77 years old, 1/3 who did not exercise, came to the centres for treatment twice per week for four weeks. Both groups were also given a standard pamphlet that explained pain and included strength and conditioning exercises. Whether they read the pamphlet, did the exercises or whether just the act of coming in to the two centres was exercise was partly discussed. Interestingly, both groups reported similar levels of adverse events, that being temprorary soreness which may indicate that just being involved was exercise. The design of the study, sham intervention, blinding, scripting of the chiropractor/patient interaction etc was well done. The chiro’s did use three different techniques (HVLA, Flexion/distraction and manip/mob) though that was surprising.
    As Edzard has said above there are quite a few articles that support chiropractic for cLBP, so this article will stimulate some interesting debate.

    • @TC (aka Thinking Charlatan),
      You must have missed this most important bit, repeated now for your usual capacity for cherry-picking;

      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.

      Can it be any plainer or clearer?

  • I had a friend who was new to the area ask me to recommend a good chiropractor. I told her that that was an oxymoron. I guess that explains why I have few friends. The alt-med consumers do not welcome criticism of their purveyors of special pampering.

  • In reply to Frank Collins:
    I have to admit that you were right on that last thread where you repeatedly tried to reason with me and finally gave me both barrels. I had that coming! I apologise! Name change required!
    Your point about “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.” is correct, which leads into the next sentence of that review which is “Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.”
    SMT is not the be all and end all that some espouse! I utilise it less in my practice and spend more time on patient education, rehabilitation, exercise, advice etc. Reconciling an outdated purely biomechanical approach with current pain science and neuroscience is a challenge and the way forward.
    Some recent papers on cost-effectiveness subsequent to the cochrane review:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369074/?tool=pmcentrez
    http://www.ncbi.nlm.nih.gov/pubmed/25599287
    http://www.trialsjournal.com/content/15/1/102
    http://www.ncbi.nlm.nih.gov/pubmed/24986566
    Physiotherapists I work with and also those I interact with online are asking the same questions and are frustrated with business as usual.

  • @CC,
    “SMT is not the be all and end all that some espouse! I utilise it less in my practice and spend more time on patient education, rehabilitation, exercise, advice etc. Reconciling an outdated purely biomechanical approach with current pain science and neuroscience is a challenge and the way forward.”

    As I’ve said before; all this means is that you are a wannabe physio, with inadequate training and an undeserved grandiose moniker.

    • Hi Mr Collins,

      Have you managed to find out any research for the use of spinal manipulation for thoracic spine pain?

      Also, the highly trained physio that you went to for your thoracic spine pain and then treated you with spinal manipulation, where was that physios consideration of the evidence base for that treatment and the condition. Also what would you think the benefit/risk analysis would be for spinal manipulation when treating thoracic spine pain?

      Looking forward to your reply

      All the best

      Mr Other

      • No, and I’ve said so before. I also said I won’t because you are a contrarian troll.

        Keep trolling but remember, I don’t give a stuff what you have to say.

  • In reply to Frank Collins:
    “As I’ve said before; all this means is that you are a wannabe physio, with inadequate training and an undeserved grandiose moniker.”
    You make some large assumptions, like any evidence used by chiro’s is swiped from the physio’s, as is any rehab and therapies/techniques.
    Here are some chiropractic researchers that may be of interest to you:
    http://www.researchgate.net/profile/Charlotte_Leboeuf-Yde
    http://www.researchgate.net/profile/Gert_Bronfort
    http://www.researchgate.net/profile/Greg_Kawchuk
    http://www.researchgate.net/profile/Scott_Haldeman
    http://www.researchgate.net/profile/Joel_Pickar
    http://www.researchgate.net/profile/Bruce_Walker3
    http://www.researchgate.net/profile/Martin_Descarreaux
    https://rehab.queensu.ca/people/faculty/simon_french
    http://www.researchgate.net/profile/Barry_Humphreys
    There is a lot of cross pollination and collaboration going on at present between the two professions. Additionally, the issues within chiropractic are mirrored within physiotherapy, with many physio’s I know frustrated with their own guru’s!

    • @Critical_Chiro
       
      I wish I could see the point of your listing links to web pages of chiropractors. Perhaps you have never heard of the ‘argument from authority’ fallacy. I prefer medical practice to be based on evidence, not on gurus.

  • @FrankO:
    We both have issues with the guru’s within chiropractic. The above list of links is to the ResearchGate profiles of some prominent chiropractic researchers who I follow closely and lists of their research. It is a good starting point when talking about evidence. The critics tend to focus on the BS within the profession and largely ignore the chiropractors that are doing the research and answering the critics call to show us the evidence. Hammering the BS merchants is an important part of the reform process, but supporting the researchers and reformers is equally as important.

    • @Critical_Chiro
      This blog is run by a person who has spent many years running trials of various forms of alternative medicine and assimilating the entirety of published trial evidence in systematic reviews. Your ‘prominent chiropractic researchers’ may or may not be doing research of quality. The systematic reviews of chiropractic research, from Professor Ernst and from others, indicate consistently that chiropractic performs no better than placebo, regardless of the condition under study.
       
      As a critic, I’ll sometimes snipe at ‘BS within the profession’ but that’s mainly when proponents insist their approach to therapy is founded on a sound theoretical basis. You talk of a ‘reform process’ but, sadly, that sounds like religious organizations undergoing reforms without ever acknowledging that their ground base is unsupportable. Imagine reformed astrologers or reformed flat-earthists and you just might get the point.

  • @FrankO
    Never adopted the dogma/beliefs/religion of the BS merchants, have consistently acknowledged that subluxation theory is a load of BS, have consistently publicly criticised it, have been a member of an organization that advocates against it right from the outset (COCA/CA) and have been consistently frustrated with the entrenched, blinkered behavior of both the subluxation true believers and the vocal critics. Critics within the profession get hammered by the subbies for being traitors and the external critics for not being critical enough. I was taught subluxation theory in its historical context only at uni 25+ years ago, never adopted it and moved on. The way I practice now is different to the way I practiced 5 years ago and vastly different to the way I practiced 25 years ago. As best evidence appears, I change!

  • @Frank Collins
    “Then why are you still doing chiropractic?”
    Good question! Grew up in a medical family with 4 surgeons, 1GP, 1RN, 1PhD and I played Rugby Union which resulted in a referral to a chiropractor by a family member/surgeon. Additionally, right from the outset I was mentored by that same chiropractor who was critical of the BS and sent me down the right path. Was never interested in medicine as I grew up with it warts and all discussed over the dinner table. Wasn’t interested in physio as my perception of physio was probably clouded by family medico’s comments in regards to physio’s. As for “why I am still a chiropractor?”, its probably a case of bias, time and effort invested in it, enjoy change, enjoy working with doctors, enjoy my work, enjoy reading latest research and applying it in practice, enjoy and push reform and enjoy engaging with the critics (both internal and external). This more that outweighs the frustrations!

    • @Critical_Chiro
      Bravo for keeping your cool and staying polite in the face of rudeness.

    • “Then why are you still doing chiropractic?”

      None of the “answers” actually answer the question, except for “its probably a case of bias, time and effort invested in it”, and which is no justification at all.

  • @Frank Collins
    +
    “enjoy change, enjoy working with doctors, enjoy my work, enjoy reading latest research and applying it in practice, enjoy and push reform and enjoy engaging with the critics (both internal and external). This more that outweighs the frustrations!”

    • Still no answer, only rationalisation for an unjustifiable position.

      How can anyone reform something which has little, if any, value as a healthcare modality? Why not just be honest enough to say you have too much invested in it?

  • Chiropractic is a profession not a treatment. Chiropractors provide an approach to care that includes a number of different modalities that all have evidence of efficacy. Specific exercise, guided movement, advice, education, psychological support and modulation of beliefs, a raft of manual modalities and of course manipulation. The whole point of such a conservative approach to MSK now endorsed by guidelines globally is its ability to construct an envelope of components for patients in a way that is focused and tailored for the individual patient. Such an approach as a package has been shown to be effective, cost efficient and extremely safe. For the vast majority of patients that receive it, over 90% are extremely satisfied and over 60 % show improvement within 90 days, most within 14 days. In the face of extreme pressure on the NHS, the very high work load imposed by MSK conditions on primary care and the costs, lack of efficacy and harm associated with other approaches (Pharmaceuticals (shown to be no better that placebo but with significantly increased harm) and surgery, with effectiveness weak except in a tiny proportion of patients and with huge costs and risk of harm) it is absolutely a legitimate route of care for most LBP and NP patients, placebo or no placebo and should be far more widely accesible.

    • VERY NICE DAVID!
      they should give you a salary increase for that.
      https://www.ncbi.nlm.nih.gov/pubmed/18280103
      in this article I have listed several definitions of chiropractic; you might want to read it.
      I know that chiros prefer the definition you cite, but personally I refuse to change each time they change their mind.

      • Ha ha…I’m genuinely flattered E. From you that means a lot. I do agree that there is an unhelpful diversity of definitions and descriptions within the profession, some untenable in the context of evidence and very rarely some that drive unacceptable behaviour. You concatenate these in your paper into 2 major groups ‘those religiously adhering to the gospel of its founding fathers and those open to change’. I would concur with that division still hobbling the profession and much effort and education, particularly those colleges signed to these statements (http://www.aecc.ac.uk/cdn/Undergraduate/MChiro/Educational%20Statements%20Updtaed%20with%20Immunisation.pdf) is brought to bear on shifting the 80:20 (change:gospel) ratio even further toward the ‘willing to change’ as evidence accrues as to what, in who and how the delivery of a package of chiropractic care has the positive effects seen in most trials and in day to day practice. This effort as far as I can tell is increasingly marginalising those that wish to look backwards and empowering those that wish to go forwards. As you have rightly said in the past this is our journey and these are our battles. All I ask, as I think you increasingly do is fairly note where success is gained as well as continuing to critique where it isnt.

        • Dave Newell wrote: “…much effort and education, particularly those colleges signed to these statements (http://www.aecc.ac.uk/cdn/Undergraduate/MChiro/Educational%20Statements%20Updtaed%20with%20Immunisation.pdf) is brought to bear on shifting the 80:20 (change:gospel) ratio even further toward the ‘willing to change’ as evidence accrues as to what, in who and how the delivery of a package of chiropractic care has the positive effects seen in most trials and in day to day practice. This effort as far as I can tell is increasingly marginalising those that wish to look backwards…”

          @ Dave Newell

          1. What does the “much effort and education” involve with regard to the (alleged) 20% of ‘gospelists’?
          2. What criteria are you using to measure the “increasingly marginalising those that wish to look backwards…”?
          3. When chiropractors say ‘chiropractic care’ instead of ‘chiropractic’, is that a deliberate attempt to disassociate from true ‘chiropractic’? If so, shouldn’t UK chiropractors be regulated by the General Chiropractic Care Council?
          4. What aspects of chiropractic ‘care’ distinguish it from the care already being provided by physiotherapists?

          ______________________________________________________________________

          “Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”
          Björn Geir Leifsson, MD

    • Making a better-than-average living (generally) from an education costing well over $180,000 (which is utterly un-transferable to any reputable arena other than private practice) to simply coddle and nurse those without an internet connection, a heating-pad, Ice pack, Estim unit or a tube of Ben-Gay (or unwilling to self-administer said modalities) seems like an indefensible position from which to argue a raison d’ etre.
      “Whether placebo or not…” is NEVER fully explicated in any Chiropractic report-of-finding to a paying customer. It’s ALWAYs a promulgation of treatment aimed at some biomechanical or etheral “true cause” of the patients’ condition.
      If NOT why pray tell would anyone ‘invest’ in a typical, elongated treatment scheme consisting of a mish-mosh of incoherent methodologies? The most ‘successful’ practices learn marketing & and psychological strategies not biomechanical ones.

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