The question whether spinal manipulative therapy (SMT) has any specific therapeutic effects is still open. This fact must irritate ardent chiropractors, and they therefore try everything to dispel our doubts. One way would be to demonstrate a dose-effect relationship between SMT and the clinical outcome. But, for several reasons, this is not an easy task.
This RCT was aimed at identifying the dose-response relationship between visits for SMT and chronic cervicogenic headache (CGH) outcomes; to evaluate the efficacy of SMT by comparison with a light massage control.
The study included 256 adults with chronic CGH. The primary outcome was days with CGH in the prior 4 weeks evaluated at the 12- and 24-week primary endpoints. Secondary outcomes included CGH days at remaining endpoints, pain intensity, disability, perceived improvement, medication use, and patient satisfaction. Participants were randomized to 4 different dose levels of chiropractic SMT: 0, 6, 12, or 18 sessions. They were treated 3 times per week for 6 weeks and received a focused light-massage control at sessions when SMT was not assigned. Linear dose effects and comparisons to the no-manipulation control group were evaluated at 6, 12, 24, 39, and 52 weeks.
A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/4 weeks per additional 6 SMT visits (p<.05); a maximal effective dose could not be determined. CGH days/4 weeks were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Mean differences in CGH days/4 weeks between 18 SMT visits and control were -3.3 (p=.004) and -2.9 (p=.017) at the primary endpoints, and similar in magnitude at the remaining endpoints (p<.05). Differences between other SMT doses and control were smaller in magnitude (p > .05). CGH intensity showed no important improvement nor differed by dose. Other secondary outcomes were generally supportive of the primary.
The authors concluded that there was a linear dose-response relationship between SMT visits and days with CGH. For the highest and most effective dose of 18 SMT visits, CGH days were reduced by half, and about 3 more days per month than for the light-massage control.
This trial would make sense, if the effectiveness of SMT for CGH had been a well-documented fact, and if the study had rigorously controlled for placebo-effects.
But guess what?
Neither of these conditions were met.
A recent review concluded that there are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization for TTH, CeH, and M in the last decade. In addition, the methodological quality of these papers is typically low. Clearly, there is a need for high-quality randomized controlled trials assessing the effectiveness of these interventions in these headache disorders. And this is by no means the only article making such statements; similar reviews arrive at similar conclusions. In turn, this means that the effects observed after SMT are not necessarily specific effects due to SMT but could easily be due to placebo or other non-specific effects. In order to avoid confusion, one would need a credible placebo – one that closely mimics SMT – and make sure that patients were ‘blinded’. But ‘light massage’ clearly does not mimic SMT, and patients obviously were aware of which interventions they received.
So, an alternative – and I think at least as plausible – conclusion of the data provided by this new RCT is this:
Chiropractic SMT is associated with a powerful placebo response which, of course, obeys a dose-effect relationship. Thus these findings are in keeping with the notion that SMT is a placebo.
And why would the researchers – who stress that they have no conflicts of interest – mislead us by making this alternative interpretation of their findings not abundantly clear?
I fear, the reason might be simple: they also seem to mislead us about their conflicts of interest: they are mostly chiropractors with a long track record of publishing promotional papers masquerading as research. What, I ask myself, could be a stronger conflict of interest?
(Pity that a high-impact journal like SPINE did not spot these [not so little] flaws)
Lock 10 bright people into a room and tell them they will not be let out until they come up with the silliest idea in healthcare. It is not unlikely, I think, that they might come up with the concept of visceral osteopathy.
In case you wonder what visceral osteopathy (or visceral manipulation) is, one ‘expert’ explains it neatly: Visceral Osteopathy is an expansion of the general principles of osteopathy which includes a special understanding of the organs, blood vessels and nerves of the body (the viscera). Visceral Osteopathy relieves imbalances and restrictions in the interconnections between the motions of all the organs and structures of the body. Jean-Piere Barral RPT, DO built on the principles of Andrew Taylor Still DO and William Garner Sutherland DO, to create this method of detailed assessment and highly specific manipulation. Those who wish to practice Visceral Osteopathy train intensively through a series of post-graduate studies. The ability to address the specific visceral causes of somatic dysfunction allows the practitioner to address such conditions as gastroesophageal reflux disease (GERD), irritable bowel (IBS), and even infertility caused by mechanical restriction.
But, as I have pointed out many times before, the fact that a treatment is based on erroneous assumptions does not necessarily mean that it does not work. What we need to decide is evidence. And here we are lucky; a recent paper provides just that.
The purpose of this systematic review was to identify and critically appraise the scientific literature concerning the reliability of diagnosis and the clinical efficacy of techniques used in visceral osteopathy.
Only inter-rater reliability studies including at least two raters or the intra-rater reliability studies including at least two assessments by the same rater were included. For efficacy studies, only randomized-controlled-trials (RCT) or crossover studies on unhealthy subjects (any condition, duration and outcome) were included. Risk of bias was determined using a modified version of the quality appraisal tool for studies of diagnostic reliability (QAREL) in reliability studies. For the efficacy studies, the Cochrane risk of bias tool was used to assess their methodological design. Two authors performed data extraction and analysis.
Extensive searches located 8 reliability studies and 6 efficacy trials that could be included in this review. The analysis of reliability studies showed that the diagnostic techniques used in visceral osteopathy are unreliable. Regarding efficacy studies, the least biased study showed no significant difference for the main outcome. The main risks of bias found in the included studies were due to the absence of blinding of the examiners, an unsuitable statistical method or an absence of primary study outcome.
The authors (who by the way declared no conflicts of interest) concluded that the results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent.
It is hard not to appreciate the scientific rigor of this review or to agree with the conclusions drawn by the French authors.
But what consequences should we draw from all this?
The authors of this paper state that more and better research is needed. Somehow, I doubt this. Visceral osteopathy is not plausible and the best evidence available to date does not show it works. In my view, this means that we should declare it an obsolete aberration of medical history.
To this, the proponents of visceral osteopathy will probably say that they have tons of experience and have witnessed wonderful cures etc. This I do not doubt; however, the things they saw were not due to the effects of visceral osteopathy, they were due to chance, placebo, regression towards the mean, the natural history of the diseases treated etc., etc. And sometimes, experience is nothing more that the ability to repeat a mistake over and over again.
- If it looks like a placebo,
- if it behaves like a placebo,
- if it tests like a placebo,
IT MOST LIKELY IS A PLACEBO!!!
And what is wrong with a placebo, if it helps patients?
GIVE ME A BREAK!
WE HAVE ALREADY DISCUSSED THIS AD NAUSEAM. JUST READ SOME OF THE PREVIOUS POSTS ON THIS SUBJECT.
The chiropractor Oakley Smith had graduated under D D Palmer in 1899. Smith was a former Iowa medical student who also had investigated Andrew Still’s osteopathy in Kirksville, before going to Palmer in Davenport. Eventually, Smith came to reject the Palmer concept of vertebral subluxation and developed his own concept of “the connective tissue doctrine” or naprapathy. Today, naprapathy is a popular form of manual therapy, particularly in Scandinavia and the US.
But what exactly is naprapathy? This website explains it quite well: Naprapathy is defined as a system of specific examination, diagnostics, manual treatment and rehabilitation of pain and dysfunction in the neuromusculoskeletal system. The therapy is aimed at restoring function through treatment of the connective tissue, muscle- and neural tissues within or surrounding the spine and other joints. Naprapathic treatment consists of combinations of manual techniques for instance spinal manipulation and mobilization, neural mobilization and Naprapathic soft tissue techniques, in additional to the manual techniques Naprapaths uses different types of electrotherapy, such as ultrasound, radial shockwave therapy and TENS. The manual techniques are often combined with advice regarding physical activity and ergonomics as well as medical rehabilitation training in order to decrease pain and disability and increase work ability and quality of life. A Dr. of Naprapathy is specialized in the diagnosis of structural and functional neuromusculoskeletal disorders, treatment and rehabilitation of patients with problems of such origin as well as to differentiate pain of other origin.
DOCTOR OF NAPRAPATHY? I hear you shout.
Yes, in the US, the title exists: The National College of Naprapathic Medicine is chartered by the State of Illinois and recognized by the State Board of Higher Education to grant the degree, Doctor of Naprapathy (D.N.). Graduates of the College are eligible to take the Naprapathic Medicine examination for licensure in the State of Illinois. The D.N. Degree requires:
- 66 hours – Basic Sciences
- 64 hours – Naprapathic Sciences
- 60 hours – Clinical Internship
Things become even stranger when we ask, what does the evidence show?
I found all of three clinical trials on Medline.
A 2016 clinical trial was designed to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy (spinal manipulation, spinal mobilization, stretching and massage) to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain.
Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathögskolan – the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes.
At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately.
The authors concluded that the effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option.
Even though this study is touted as showing that naprapathy works by advocates, in all honesty, it tells us as good as nothing about the effect of naprapathy. The data are completely consistent with the interpretation that all of the outcomes were to the natural history of the conditions, regression towards the mean, placebo, etc. and entirely unrelated to any specific effects of naprapathy.
A 2010 study by the same group was to compare the long-term effects (up to one year) of naprapathic manual therapy and evidence-based advice on staying active regarding non-specific back and/or neck pain.
Subjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires.
89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p < or = 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group.
The authors concluded that combined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain.
This study is hardly impressive either. The results are consistent with the interpretation that the extra attention and care given to the index group was the cause of the observed outcomes, unrelated to ant specific effects of naprapathy.
The last study was published in 2017 again by the same group. It was designed to compare naprapathic manual therapy with evidence-based care for back or neck pain regarding pain, disability, and perceived recovery.
Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks.
At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results.
The authors thought that this trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.
As the study suffers from the same limitations as the one above (in fact, it might be a different analysis of the same trial), they might be mistaken. I see no good reason to assume that any of the three studies provide good evidence for the effectiveness of naprapathy.
So, what should we conclude from all this?
If you ask me, naprapathy is something between chiropractic (without some of the woo) and physiotherapy (without its expertise). There is no good evidence that it works. Crucially, there is no evidence that it is superior to other therapeutic options.
I was going to finish on a positive note stating that ‘at least the ‘naprapathologists’ (I refuse to even consider the title of ‘doctor of naprapathy’) do not claim to treat conditions other than musculoskeletal problems’. But then I found this advertisement of a ‘naprapathologist’ on Twitter:
And now, I am going to finish by stating that A LOT OF NAPRAPATHY LOOKS VERY MUCH LIKE QUACKERY TO ME.
Some of you will remember the saga of the British Chiropractic Association suing my friend and co-author Simon Singh (eventually losing the case, lots of money and all respect). One of the ‘hot potatoes’ in this case was the question whether chiropractic is effective for infant colic. This question is settled, I thought: IT HAS NOT BEEN SHOWN TO WORK BETTER THAN A PLACEBO.
Yet manipulators have not forgotten the defeat and are still plotting, it seems, to overturn it. Hence a new systematic review assessed the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants.
The authors reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). The inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change. The authors included the following types of peer-reviewed studies in our search: RCTs, prospective cohort studies, observational studies, case–control studies, case series, questionnaire surveys and qualitative studies.
Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. Only 5 studies were rated as high quality: four RCTs (low risk of bias) and a qualitative study.
The authors found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect).
Reduction in crying: RCTs mean difference.
The risk of reported adverse events was low (only 8 studies mentioned adverse effects at all, meaning that the rest were in breach of research and publication ethics): seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed.
The authors concluded that some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.
For several reasons, I find this review, although technically sound, quite odd.
Why review uncontrolled data when RCTs are available?
How can a qualitative study be rated as high quality for assessing the effectiveness of a therapy?
How can the authors categorically conclude that there were benefits when there were only 4 RCTs of high quality?
Why do they not explain the implications of none of the RCTs being placebo-controlled?
How can anyone pool the results of all types of manual therapies which, as most of us know, are highly diverse?
How can the authors conclude about the safety of manual therapies when most trials failed to report on this issue?
Why do they not point out that this is unethical?
My greatest general concern about this review is the overt lack of critical input. A systematic review is not a means of promoting an intervention but of critically assessing its value. This void of critical thinking is palpable throughout the paper. In the discussion section, for instance, the authors state that “previous systematic reviews from 2012 and 2014 concluded there was favourable but inconclusive and weak evidence for manual therapy for infantile colic. They mention two reviews to back up this claim. They conveniently forget my own review of 2009 (the first on this subject). Why? Perhaps because it did not fit their preconceived ideas? Here is my abstract:
Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.
Towards the end of their paper, the authors state that “this was a comprehensive and rigorously conducted review…” I beg to differ; it turned out to be uncritical and biased, in my view. And at the very end of the article, we learn a possible reason for this phenomenon: “CM had financial support from the National Council for Osteopathic Research from crowd-funded donations.”
This survey assessed chiropractic (DC) and naturopathic “doctors”‘ (ND) knowledge, attitudes, and behaviour with respect to the pediatric patients in their practice. Cross-sectional surveys were developed in collaboration with DC and ND educators. Surveys were sent to randomly selected DCs and NDs in Ontario, Canada in 2004, and a national online survey was conducted in 2014. Data were analyzed using descriptive statistics, t-tests, non-parametric tests, and linear regression.
Response rates for DCs were n = 172 (34%) in 2004, n = 553 (15.5%) in 2014, and for NDs, n = 171 (36%) in 2004, n = 162 (7%) in 2014. In 2014, 366 (78.4%) of DCs and 83 (61%) of NDs saw one or more paediatric patients per week. Paediatric training was rated as inadequate by most respondents in both 2004 and 2014, with most respondents (n = 643, 89.9%) seeking post-graduate training by 2014. About half of DCs (51.7% in 2004, 49.2% in 2014) and one fifth of NDs (21% in 2004 and 23% in 2014) reported they received no hands-on clinical paediatric training. Only a minority of practitioners felt their hands-on paediatric training was adequate (somewhat or very) for their needs: DCs: 10.6% in 2004, 15.6% in 2014; NDs: 10% in 2004 and 19% in 2014. Respondents’ comfort in treating children and youth is based on experience and post-graduate training. Both DCs and NDs that see children and youth in their practices address a broad array of paediatric health concerns, from well child care and preventative health, to mild and serious illness.
The authors included two ‘case studies’ of conditions frequently treated by DCs and NDs:
Case study 1: colic
DC practitioners’ primary treatment focus (314 respondents) would be to use spinal manipulation (78.3%) if physical assessment suggests utility, diet changes (14.6% for child, 6.1% for mom if breast feeding), and massage (16.9%). ND practitioners (95 respondents) would assess and treat primarily with diet changes (62% for child including prescribing probiotics; 48% for mom if breast feeding), homeopathy (46%), weak herbal or tea preparations (19%), and use topical castor oil (packs or massage) (18%). In 2014, 65.9% of DCs and 59% of NDs believe (somewhat or very much) that concurrent treatment by a medical practitioner would be of benefit; 64.0% of DCs and 60% of NDs would refer the patient to another health care practitioner (practitioner type not specified).
Case study 2: acute otitis media
In 2014, almost all practitioners identified this as otitis media (in 2004, the DCs had a profession-specific question); DCs were more cautious about the value of their care for it relative to the NDs (DCs, 46.2% care will help patient very much, NDs, 95%). For treatment, DCs would primarily use spinal manipulation (98.5%) if indicated after assessment, massage (19.5%), dietary modifications (17.6%), and 3.8% would specifically refer to an MD for an antibiotic prescription. ND-preferred treatments were NHP products (79%), dietary modifications (66%), ear drops (60%), homeopathic remedies (18%), and 10% would prescribe antibiotics right away or after a few days. In 2014, 86.3% of DCs and 75% of NDs believe the patient would benefit (somewhat or very much) from concurrent treatment by a conventional medical practitioner; 81.7% of DCs and 58% of NDs would refer the patient to another health care provider.
The authors concluded that although the response rate in 2014 is low, the concerns identified a decade earlier remain. The majority of responding DCs and NDs see infants, children, and youth for a variety of health conditions and issues, but self-assess their undergraduate paediatric training as inadequate. We encourage augmented paediatric educational content be included as core curriculum for DCs and NDs and suggest collaboration with institutions/organizations with expertise in paediatric education to facilitate curriculum development, especially in areas that affect patient safety.
I find these data positively scary:
- Despite calling themselves ‘doctors’, they are nothing of the sort.
- DCs and NCs are not adequately educated or trained to treat children.
- They nevertheless often do so, presumably because this constitutes a significant part of their income.
- Even if they felt confident to be adequately trained, we need to remember that their therapeutic repertoire is wholly useless for treating sick children effectively and responsibly.
- Therefore, harm to children is almost inevitable.
- To this, we must add the risk of incompetent advice from CDs and NDs – just think of immunisations.
The only conclusion I can draw is this: chiropractors and naturopaths should keep their hands off our kids!
The question whether chiropractic is a truly valuable option for people suffering from back pain has been addressed repeatedly on this blog. My answer was usually negative, but proponents of chiropractic tended to argue that I am biased. Therefore I find it constructive to see what an organisation that hardly can be accused of bias says on this topic. An article by ‘SHOW ME THE EVIDENCE’ has recently provided a comprehensive overview of treatments for back pain. This is what they wrote about chiropractic:
START OF QUOTE
Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.
There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.
First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back pain found that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.
The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.
“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”
As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.
“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”
While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.
The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).
END OF QUOTE
This all seems fairly reasonable to me – except for the following not entirely unimportant points:
- I am not sure where the evidence about risks of spinal manipulation comes from. In my view, it is not entirely correct: as there is no effective post-marketing surveillance, we cannot possibly name the incidence figures.
- Neck manipulations are clearly more risky than manipulations lower down. But this does not necessarily mean that back patients are safer than those with neck pain. Chiropractors view the spine as a whole organ and will regularly manipulate the neck (if they sense ‘subluxations’ in this area), even if the patient comes with low back pain.
- There are also indirect risks with consulting a chiropractor; for instance, they often give incompetent advice about healthcare. This can include discouraging immunisations or treating serious diseases, such as asthma, colic etc., with chiropractic.
- I think the article should point out that exercise is not just as effective (or as ineffective) as chiropractic, but it is much safer and less expensive.
- What Rubinstein says about responders is debatable, in my view. In particular, most chiropractors will convince their patients to continue treatment, even if they do not ‘respond’. And ‘responding’ might be simply the natural history of the condition and therefore totally unrelated to the therapy.
The bottom line: Chiropractic is not the best treatment for back pain!
The common cold is a perfect condition for providers of alternative medicine:
- it is prevalent (good money to be earned),
- it is not normally dangerous,
- it nevertheless reduces quality of life and thus patients look for a treatment,
- there probably is not a single alternative therapy that does not claim to be effective for it,
- it is gone after about a week, treated or not.
But is there an alternative therapy that does actually work? An article by the Cochrane Collaboration provides an excellent overview. It includes conventional as well as alternative treatments; here I have merely copied the passages related to the latter:
There was great excitement in the 1970s when Linus Pauling, (a Nobel laureate twice over), concluded from placebo-controlled trials that Vitamin C could prevent and alleviate the common cold. Further research followed and a Cochrane review, published in 2013, found 29 clinical trials, involving 11,306 participants. Unfortunately, the review did not confirm Pauling’s findings. Taking regular Vitamin C did not reduce the incidence of colds in the general population, although there was a modest reduction in the duration and severity of symptoms. The only people who appeared to derive some benefit were those who undertook short bursts of extreme exercise, such as marathon runners and skiers. In this group the risk of getting a cold was halved.
Trials looking at taking high dose Vitamin C at the onset of cold symptoms showed no consistent effect on the duration and severity of symptoms and more research is needed to clarify these findings.
Echinacea is widely used in Europe and North America for common colds. A Cochrane review (2014) showed that some Echinacea products may be more effective than placebo in treating colds but the overall evidence for clinically relevant effects was weak. There was some evidence of a small preventative effect.
Inhaled steam has been used for decades (see earlier reference to my childhood humiliation!) thinking that it helps drain away mucus more effectively and possibly destroys the cold virus. A Cochrane review (2017) of six trials with 387 participants showed no consistent benefit for this intervention.
A single trial with 146 participants showed that taking garlic every day for three months might prevent occurrences of the common cold but the evidence was of low quality and more research is needed to validate this finding. (Cochrane review 2014.)
END OF QUOTE
The article obviously focuses only on such therapies for which Cochrane reviews have been published. What about other treatments? As I already mentioned, if we believe the promoters of alternative medicine, the list is long. But fortunately, we do not believe them and want to see the evidence.
Yes, some chiropractors claim that their manipulations are effective for the common cold. But, as with almost all of their claims, this cannot be taken seriously; the assumption is bogus.
CHINESE HERBAL MEDICINES
A systematic review concluded that their use for common cold is not supported by robust evidence.
Ages ago, I published a small study with promising results:
Twenty-five volunteers were submitted to sauna bathing, with 25 controls abstaining from this or comparable procedures. In both groups the frequency, duration and severity of common colds were recorded for six months. There were significantly fewer episodes of common cold in the sauna group. This was found particularly during the last three months of the study period when the incidence was roughly halved compared to controls. The mean duration and average severity of common colds did not differ significantly between the groups. It is concluded that regular sauna bathing probably reduces the incidence of common colds, but further studies are needed to prove this.
Sadly, the findings were never replicated.
Grin and bear it!
(That is the cold as well as the myriad of false claims made by enthusiasts of alternative medicine)
This overview by researchers from that Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, UK, was aimed at summarising the current best evidence on treatment options for 5 common musculoskeletal pain presentations: back, neck, shoulder, knee and multi-site pain. Reviews and studies of treatments were considered of the following therapeutic options: self-management advice and education, exercise therapy, manual therapy, pharmacological interventions (oral and topical analgesics, local injections), aids and devices, other treatments (ultrasound, TENS, laser, acupuncture, ice / hot packs) and psychosocial interventions (such as cognitive-behavioural therapy and pain-coping skills).
Here are the findings for those treatments most relevant in alternative medicine (it is interesting that most alternative medicines were not even considered because of lack of evidence and that the team of researchers can hardly be accused of an anti-alternative medicine bias, since its senior author has a track record of publishing results favourable to alternative medicine):
Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.
The evidence from a good quality individual patient data meta-analysis suggests that acupuncture may be effective for short-term relief of back pain and knee pain with medium summary effect sizes respectively compared with usual care or no acupuncture. However, effects on function were reported to be minimal and not maintained at longer-term follow-up. Similarly for neck and shoulder pain, acupuncture was only found to be effective for short-term (immediately post-treatment and at short-term follow-up) symptom relief compared to placebo.
Current evidence regarding manual therapy is beset by heterogeneity. Due to paucity of high quality evidence, it is uncertain whether the efficacy of manual therapy might be different for different patient subgroups or influenced by the type and experience of professional delivering the therapy. On the whole, the available evidence suggests that manual therapy may offer some beneficial effects on pain and function, but it may not be superior to other non-pharmacological treatments (e.g. exercise) for patients with acute or chronic musculoskeletal pain.
Overall. the authors concluded that the best available evidence shows that patients with musculoskeletal pain problems in primary care can be managed effectively with non-pharmacological treatments such as self-management advice, exercise therapy, and psychosocial interventions. Pharmacological interventions such as corticosteroid injections (for knee and shoulder pain) were shown to be effective treatment options for the short-term relief of musculoskeletal pain and may be used in addition to non-pharmacological treatments. NSAIDs and opioids also offer short-term benefit for musculoskeletal pain, but the potential for adverse effects must be considered. Furthermore, the optimal treatment intensity, methods of application, amount of clinical contact, and type of provider or setting, are unclear for most treatment options.
These findings confirm what we have pointed out many times before on this blog. There is very little that alternative therapies have to offer for musculoskeletal pain. Whenever it is possible, I would recommend exercise therapy initiated by a physiotherapist; it is inexpensive, safe, and at least as effective as acupuncture or chiropractic or osteopathy.
Practitioners of alternative medicine will, of course, not like this solution.
Acupuncturists may not be that bothered by such evidence: their focus is not necessarily on musculoskeletal but on a range of other conditions (with usually little evidence, I hasten to add).
But for chiropractors and osteopaths, this is much more serious, in my view. Of course, some of them also claim to be able to treat a plethora of non-musculoskeletal conditions (but there the evidence is even worse than for musculoskeletal pain, and therefore this type of practice is clearly unethical). And those who see themselves as musculoskeletal specialists have to either accept the evidence that shows little benefit and considerable risk of spinal manipulation, or go in a state of denial.
In the former case, the logical conclusion is to look for another job.
In the latter case, the only conclusion is that their practice is not ethical.
This is a fascinating new review of upper neck manipulation. It raises many concerns that we, on this blog, have been struggling with for years. I take the liberty of quoting a few passages which I feel are important and encourage everyone to study the report in full:
The Minister of Health, Seniors and Active Living gave direction to the Health Professions Advisory Council (“the Council”) to undertake a review related to high neck manipulation.
Specifically, the Minister directed the Council to undertake:
1) A review of the status of the reserved act in other Canadian jurisdictions,
2) A literature review related to the benefits to patients and risks to patient safety associated with the procedure, and
3) A jurisprudence review or a review into the legal issues that have arisen in Canada with respect to the performance of the procedure that touch upon the risk of harm to a patient.
In addition, the Minister requested the Council to seek written input on the issue from:
- Manitoba Chiropractic Stroke Survivors
- Manitoba Chiropractic Association
- College of Physiotherapists of Manitoba
- Manitoba Naturopathic Association
- College of Physicians and Surgeons of Manitoba
- other relevant interested parties as determined by the Council
… The review indicated that further research is required to:
- strengthen evidence for the efficacy of cervical spinal manipulations (CSM) as a treatment for neck pain and headache, “as well as for other indications where evidence currently does not exist (i.e., upper back and should/arm pain, high blood pressure, etc.)”
- establish safety and efficacy of CSM in infants and children
- assess the risk versus benefit in consideration of using HVLA cervical spine manipulation, which also involve cost-benefit analyses that compare CSM to other standard treatments.
… the performance of “high neck manipulation” or cervical spine manipulation does present a risk of harm to patients. This risk of harm must be understood by both the patient and the practitioner.
Both the jurisprudence review and the research literature review point to the need for the following actions to mitigate the risk of harm associated with the performance of cervical spine manipulation:
- Action One: Ensure that the patient provides written informed consent prior to initiating treatment which includes a discussion about the risk associated with cervical spine manipulation.
- Action Two: Provide patients with information to assist in the early recognition of a serious adverse event.
Chiropractic is hugely popular, we are often told. The fallacious implication is, of course, that popularity can serve as a surrogate measure for effectiveness. In the United States, chiropractors provided 18.6 million clinical services under Medicare in 2015, and overall spending for chiropractic services was estimated at USD $12.5 billion. Elsewhere, chiropractic seems to be less commonly used, and the global situation has not recently been outlined. The authors of this ‘global overview‘ might fill this gap by summarizing the current literature on the utilization of chiropractic services, reasons for seeking care, patient profiles, and assessment and treatment provided.
Systematic searches were conducted in MEDLINE, CINAHL, and Index to Chiropractic Literature from database inception to January 2016. Eligible articles
1) were published in English or French (not all that global then!);
2) were case series, descriptive, cross-sectional, or cohort studies;
3) described patients receiving chiropractic services;
4) reported on the following theme(s): utilization rates of chiropractic services; reasons for attending chiropractic care; profiles of chiropractic patients; or, types of chiropractic services provided.
The literature searches retrieved 328 studies (reported in 337 articles) that reported on chiropractic utilization (245 studies), reason for attending chiropractic care (85 studies), patient demographics (130 studies), and assessment and treatment provided (34 studies).
Globally, the median 12-month utilization of chiropractic services was 9.1% (interquartile range (IQR): 6.7%-13.1%) and remained stable between 1980 and 2015. Most patients consulting chiropractors were female (57.0%, IQR: 53.2%-60.0%) with a median age of 43.4 years (IQR: 39.6-48.0), and were employed.
The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7%, IQR: 43.0%-60.2%), neck pain (22.5%, IQR: 16.3%-24.5%), and extremity problems (10.0%, IQR: 4.3%-22.0%). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3%, IQR: 55.4%-91.3%), soft-tissue therapy (35.1%, IQR: 16.5%-52.0%), and formal patient education (31.3%, IQR: 22.6%-65.0%).
The authors concluded that this comprehensive overview on the world-wide state of the chiropractic profession documented trends in the literature over the last four decades. The findings support the diverse nature of chiropractic practice, although common trends emerged.
My interpretation of the data presented is somewhat different from that of the authors. For instance, I fail to share the notion that utilization remained stable over time.
The figure might not be totally conclusive, but I seem to detect a peak in 2005, followed by a decline. Also, as the vast majority of studies originate from the US, I find it difficult to conclude anything about global trends in utilization.
Some of the more remarkable findings of this paper include the fact that 3.1% (IQR: 1.6%-6.1%) of the general population sought chiropractic care for visceral/non-musculoskeletal conditions. Some of the reasons for attending chiropractic care reported by the paediatric population are equally noteworthy: 7% for infections, 5% for asthma, and 5% for stomach problems. Globally, 5% of all consultations were for wellness/maintenance. None of these indications is even remotely evidence-based, of course.
Remarkably, 35% of chiropractors used X-ray diagnostics, and only 31% did a full history of their patients. Spinal manipulation was used by 79%, 31% sold nutritional supplements to their patients, and 10% used applied kinesiology.
In general, this is an informative paper. However, it suffers from a distinct lack of critical input. It seems to skip over almost all areas that might be less than favourable for chiropractors. The reason for this becomes clear, I think, when we read the source of funding for the research: PJHB, AEB, SAM and SDF have received research funding from the Canadian national and provincial chiropractic organizations, either as salary support or for research project funding. JJW received research project funding from the Ontario Chiropractic Association, outside the submitted work. SDF is Deputy Editor-in-Chief for Chiropractic and Manual Therapies; however, he did not have any involvement in the editorial process for this manuscript and was blinded from the editorial system for this paper from submission to decision.