MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

This week, I find it hard to decide where to focus; with all the fuzz about ‘Homeopathy Awareness Week’ it is easy to forget that our friends, the chiros are celebrating  Chiropractic Awareness Week (9-15 April). On this occasion, the British Chiropractic Association (BCA), for instance, want people to keep moving to make a positive impact on managing and preventing back and neck pain.

Good advice! In a recent post, I even have concluded that people should “walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.” The reason for my advice is based on the fact that there is precious little evidence that the spinal manipulations of chiropractors make much difference plus some worrying indications that they may cause serious damage.

It seems to me that, by focussing their PR away from spinal manipulations and towards the many other things chiropractors sometimes do – they often call this ‘adjunctive therapies’ – there is a tacit admission here that the hallmark intervention of chiros (spinal manipulation) is of dubious value.

A recent article entitled ‘Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative’ seems to confirm this impression. Its objective was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The specific aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a non-pharmacological intervention. The panel updated the search strategies in Medline and assessed admissible systematic reviews and randomized controlled trials. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

The authors concluded that a multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

I find this paper most interesting and revealing. Considering that it originates from the ‘Canadian Chiropractic Guideline Initiative’, it is remarkably shy about recommending SMT – after all their vision is “To enhance the health of Canadians by fostering excellence in chiropractic care.” They are thus not likely to be overly critical of the treatment chiropractors use most, i. e. SMT.

Perhaps this is also the reason why, in their conclusion, they seem to have rather a large blind spot, namely the risks of SMT. I have commented on this issue more often than I care to remember. Most recently, I posted this:

The reason why my stance, as expressed on this blog and elsewhere, is often critical about certain alternative therapies is thus obvious and transparent. For none of them (except for massage) is the risk/benefit balance positive. And for spinal manipulation, it even turns out to be negative. It goes almost without saying that responsible advice must be to avoid treatments for which the benefits do not demonstrably outweigh the risks.

 

HAPPY CHIROPRACTIC AWARENESS WEEK EVERYONE!

3 Responses to Chiropractic Awareness Week… or should this be ‘bewareness’?

    • from what I see, there were just 4 studies;
      in none of them was SMT the sole therapy added to the treatment package
      none controlled for placebo effects of SMT nor the additional attention
      all followed the A+B vs B design
      the benefit was only modest
      the overall outcome was a foregone conclusion.

  • The buffoonery of Chiroquackery is equaled only by the buffoonery of Chiroquackers.
    And the sweet smell of success that Chiropractic enjoys over the years….
    1992:
    Twenty years of RCTs of manipulative therapy for back pain: a review.
    Clin invest med. Dec 1992. Abenhaim, Bergeron.
    “It is not clear whether long-term benefits have been adequately evaluated…lack of specificity in the samples makes it impossible to conclude on the benefits…”.
    “Whether manipulation is solely responsible for any changes found is still a question open to debate”.
    1996:
    SMT for LBP: an updated systematic review of RCTs.
    Spine. Dec 1996. Koes et al.
    “The efficacy of SM for patients with acute or chronic back pain has not been demonstrated with sound RCTs”.
    1998:
    A comparison of chiropractic manipulation, McKenzie PT approach and provision of an educational booklet for patients with LBP.
    N Engl J of Med. Oct 1998. Cherkin, Deyo et al.
    “Chiropractic manipulation and McKenzie approach did not reduce short or long term pain or improve function in LBP. Both treatments were more expensive than an educational booklet”.
    2011:
    SMT for cLBP; an update of a Cochrane review.
    Spine. June 2011. Rubenstien et al.
    “High quality evidence suggests there is no clinically relevant difference between SMT and other interventions…”
    2012:
    Effectiveness of PT administered spinal manipulation for treatment of LBP.
    Int sports J of PT. Dec 2012. Kuckzynski et al.
    “SMT is not specific to one scope of practice…outcomes are identical across practitioners”.
    2016:
    SMT vs. sham manipulation for NSLBP.
    J Chiro Med. Sept 2016. Ruddock et al.
    “There is some evidence of specific effects of SM vs an effective sham though given the small number of studies we should be cautious of making strong inferences based on these studies”.
    WOWZA! Now THERE is an awesome intervention!

Leave a Reply

Your email address will not be published. Required fields are marked *

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories