MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

physiotherapists

A meta-analysis compared the effectiveness of spinal manipulation therapies (SMT), medical management, physical therapies, and exercise for acute and chronic low back pain. Studies were chosen based on inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated non-specific from treatment effects. Aggregate data were tested for evidential support as compared to shams.

The results suggest that, of 84% acute pain variance, 81% was from non-specific factors and 3% from treatment. No treatment was better than sham. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% out of 98% was non-specific, but treatments influenced 32% of outcomes. Chronic pain treatments also fitted within 95% confidence bands as predicted by natural history. The evidential support for treating chronic back pain as compared to sham groups was weak, but chronic pain appeared to respond to SMT, while whole systems of chiropractic management did not.

The authors of this intriguing paper conclude: Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority between treatment arms was equivalent to that expected by random selection. Treatments serve to motivate, reassure, and calibrate patient expectations – features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

This essentially indicates that none of these treatments for low back pain are convincingly effective. In turn this means we might as well stop using them. Alternatively, we could opt for the therapy that carries the least risks and cost. As the authors point out, this treatment is exercise.

Visceral Manipulation (VM) was developed by the French Osteopath and Physical Therapist Jean-Pierre Barral. According to uncounted Internet-sites, books and other promotional literature, VM is a miracle cure for just about every disease imaginable. On one of his many websites, Barral claims that: Comparative Studies found Visceral Manipulation Beneficial for Various Disorders

Acute Disorders Whiplash Seatbelt Injuries Chest or Abdominal Sports Injuries
Digestive Disorders Bloating and Constipation Nausea and Acid Reflux GERD Swallowing Dysfunctions
Women’s and Men’s Health Issues Chronic Pelvic Pain Endometriosis Fibroids and Cysts Dysmenorrhea Bladder Incontinence Prostate Dysfunction Referred Testicular Pain Effects of Menopause
Emotional Issues Anxiety and Depression Post-Traumatic Stress Disorder
Musculoskeletal Disorders Somatic-Visceral Interactions Chronic Spinal Dysfunction Headaches and Migraines Carpal Tunnel Syndrome Peripheral Joint Pain Sciatica
Pain Related to Post-operative Scar Tissue Post-infection Scar Tissue Autonomic Mechanisms
Pediatric Issues Constipation and Gastritis Persistent Vomiting Vesicoureteral Reflux Infant Colic

This sounds truly wonderful, and we want to learn more. The text goes on to explain that:

VM assists functional and structural imbalances throughout the body including musculoskeletal, vascular, nervous, urogenital, respiratory, digestive and lymphatic dysfunction. It evaluates and treats the dynamics of motion and suspension in relation to organs, membranes, fascia and ligaments. VM increases proprioceptive communication within the body, thereby revitalizing a person and relieving symptoms of pain, dysfunction, and poor posture.

Fascinating! Sceptics might think that such phraseology is a prime example of pseudo-scientific gobbledegook – but wait:

An integrative approach to evaluation and treatment of a patient requires assessment of the structural relationships between the viscera, and their fascial or ligamentous attachments to the musculoskeletal system. Strains in the connective tissue of the viscera can result from surgical scars, adhesions, illness, posture or injury. Tension patterns form through the fascial network deep within the body, creating a cascade of effects far from their sources for which the body will have to compensate. This creates fixed, abnormal points of tension that the body must move around, and this chronic irritation gives way to functional and structural problems.

Imagine an adhesion around the lungs. It would create a modified axis that demands abnormal accommodations from nearby body structures. For example, the adhesion could alter rib motion, which could then create imbalanced forces on the vertebral column and, with time, possibly develop a dysfunctional relationship with other structures. This scenario highlights just one of hundreds of possible ramifications of a small dysfunction – magnified by thousands of repetitions each day….the sinuvertebral nerves innervate the intervertebral disks and have direct connections with the sympathetic nervous system, which innervates the visceral organs. The sinuvertebral nerves and sympathetic nervous system are linked to the spinal cord, which has connections with the brain. In this way someone with chronic pain can have irritations and facilitated areas not only in the musculoskeletal system (including joints, muscles, fascia, and disks) but also the visceral organs and their connective tissues (including the liver, stomach, gallbladder, intestines and adrenal glands), the peripheral nervous system, the sympathetic nervous system and even the spinal cord and brain….

Visceral Manipulation is based on the specific placement of soft manual forces to encourage the normal mobility, tone and motion of the viscera and their connective tissues. These gentle manipulations can potentially improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body….Visceral Manipulation works only to assist the forces already at work. Because of that, trained therapists can be sure of benefiting the body rather than adding further injury or disorganization.

By now, we are all wondering how Barral was able to dream up this truly fantastic panacea. Reading on, we learn that it was not ‘dreamt up’ at all – it was developed through painstaking research and rigorous science:

Jean-Pierre Barral first became interested in biomechanics while working as a registered physical therapist of the Lung Disease Hospital in Grenoble, France. That’s where he met Dr. Arnaud, a recognized specialist in lung diseases and a master of cadaver dissection. Working with Dr. Arnaud, Barral followed patterns of stress in the tissues of cadavers and studied biomechanics in living subjects. This introduced him to the visceral system, its potential to promote lines of tension within the body, and the notion that tissues have memory. All this was fundamental to his development of Visceral Manipulation. In 1974, Barral earned his diploma in osteopathic medicine from the European School of Osteopathy in Maidstone, England. Working primarily with articular and structural manipulation, he began forming the basis for Visceral Manipulation during an unusual session with a patient he’d been treating with spinal manipulations.

During the preliminary examination, Barral was surprised to find appreciable movement. The patient confirmed that he felt relief from his back pain after going to an “old man who pushed something in his abdomen.”

This incident piqued Barral’s interest in the relationship between the viscera and the spine. That’s when he began exploring stomach manipulations with several patients, with successful results gradually leading him to develop Visceral Manipulation. Between 1975 and 1982, Barral taught spinal biomechanics at England’s European School of Osteopathy. In collaboration with Dr. Jean-Paul Mathieu and Dr. Pierre Mercier, he published Articular Vertebrae Diagnosis.

With all this serious science, we are, of course, keen to learn about the studies of VM published in peer-reviewed journals. Amazingly, there seems to be an acute shortage of that sort of thing. You can buy many books by Barral, but to the best of my knowledge, there are no studies of VM by Barral or anyone else in medical journals. My own searches resulted in precisely zero papers, and Medline returns not a single article of Barral J-P on VM, osteopathy or manipulation.

This is odd, I must say!

Could all this important-sounding scientific (some might say pseudo-scientific) text be a complete fake? Where are the ‘COMPARATIVE STUDIES’ mentioned above? Could it be that VM is nothing more than a rip-off for gullible half-wits?

I really cannot imagine – after all, VM is even being taught at some universities! And one could never make all this up; that would be dishonest!!!

I hope my readers can point me to the proper science of VM and thus put my suspicions to rest.

If we ask how effective spinal manipulation is as a treatment of back pain, we get all sorts of answers. Therapists who earn their money with it – mostly chiropractors, osteopaths and physiotherapists – are obviously convinced that it is effective. But if we consult more objective sources, the picture changes dramatically. The current Cochrane review, for instance, arrives at this conclusion: SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.

Such reviews tend to pool all studies together regardless of the nature of the practitioner. But perhaps one type of clinician is better than the next? Certainly many chiropractors are on record claiming that they are the best at spinal manipulations. Yet it is conceivable that physiotherapists who do manipulations without being guided by the myth of ‘adjusting subluxations’ have an advantage over chiropractors. Three very recent systematic reviews might go some way to answer these questions.

The purpose of the first systematic review was to examine the effectiveness of spinal manipulations performed by physiotherapists for the treatment of patients with low back pain. The authors found 6 RCTs that met their inclusion criteria. The most commonly used outcomes were pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favouring spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported significantly less medication use, health care utilization, and lost work time. The authors concluded that there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.

The second systematic Review was of osteopathic intervention for chronic, non-specific low back pain (CNSLBP). Only two trials met the authors’ inclusion criteria. They had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up. The authors drew the following conclusions: There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.

The third systematic review sought to determine the benefits of chiropractic treatment and care for back pain on well-being, and aimed to explore to what extent chiropractic treatment and care improve quality of life. The authors identified 6 studies (4 RCTs and two observational studies) of varying quality. There was a high degree of inconsistency and lack of standardisation in measurement instruments and outcome measures. Three studies reported reduced use of other/extra treatments as a positive outcome; two studies reported a positive effect of chiropractic intervention on pain, and two studies reported a positive effect on disability. The authors concluded that it is difficult to defend any conclusion about the impact of chiropractic intervention on the quality of life, lifestyle, health and economic impact on chiropractic patients presenting with back pain.

Yes, yes, yes, I know: the three reviews are not exactly comparable; so we cannot draw firm conclusions from comparing them. Five points seem to emerge nevertheless:

  1. The evidence for spinal manipulation as a treatment for back pain is generally not brilliant, regardless of the type of therapist.
  2. There seem to be considerable differences according to the nature of the therapist.
  3. Physiotherapists seem to have relatively sound evidence to justify their manipulations.
  4. Chiropractors and osteopaths are not backed by evidence which is as reliable as they so often try to make us believe.
  5. Considering that the vast majority of serious complications after spinal manipulation has occurred with chiropractors, it would seem that chiropractors are the profession with the worst track record regarding manipulation for back pain.

To include conventional health care professionals amongst those who significantly contribute to the ‘sea of misinformation’ on alternative medicine might come as a surprise. But sadly, they do deserve quite a prominent place in the list of contributors. In fact, I could write one entire book about each of the various professions’ ways to mislead patients about alternative medicine.

There are, of course, considerable national differences and other peculiarities which render each specific profession quite complex to evaluate. The material is huge – far to big to fit in a short comment. All I will therefore try to do with this post is to throw a quick spotlight on some of the mainstream professions mentioning just one or two relevant aspects in each instant.

Nurses

Particularly in North America, many nurses seem to be besotted with ‘Therapeutic Touch’, an implausible and unproven ‘energy-therapy’. For instance, the College of Nurses of Ontario includes Therapeutic Touch as a therapy permitted for its members. In other regions, other alternative treatments might be more popular with nurses but, in general, many seem to have a weakness for this sector. Researchers from Aberdeen  recently conducted a survey to establish the use of alternative medicine by registered nurses, as well as their knowledge-base and attitudes towards it. They sent a questionnaire to 621 nurses and achieved a remarkable response rate of 86%. Eighty per cent of the responders admitted to employ alternative medicine and 41% were using it currently. Only five nurses believed that alternative medicine was not effective and 74% would recommend it to others. In other words, there is a strong likelihood of patients being misinformed by nurses.

Midwives

A recent article in the UK journal THE PRACTISING MIDWIFE (Sept 2013) by Valerie Smith (not Medline-listed) claimed that the Royal College of Midwives supports the use of homeopathic remedies during childbirth. This does come to no surprise to those who know that several surveys have suggested that midwives are particularly fond of un- or dis-proven therapies and that they employ them often without the knowledge of obstetricians. We investigated this question by conducting a systematic review of all surveys of alternative medicine use by midwives. In total,19 surveys met our inclusion criteria. Most were recent and many originated from the US. Prevalence data varied but were usually high, often close to 100%. Much of this practice was not supported by sound evidence for efficacy and some of the treatments employed had the potential to put patients at risk. It seems obvious that, in order to employ unproven treatment, midwives first need to misinform their patients.

Physiotherapists

Some physiotherapists promote and practise a range of unproven treatments, e.g. craniosacral therapy. I am not aware of statistics on this, but it is not difficult to find evidence on the Internet: One website boldly states that Physiotherapy & Craniosacral Therapy available with Charetred Physiotherapist with 20 years of experience in the NHS. Another one proudly announces:  Our main methods of treatment are through Physiotherapy and Craniosacral Therapy. A third site claims that Craniosacral Therapy is attracting increasing interest for its gentle yet effective approach, working directly with the body’s natural capacity for self-repair to treat a wide range of conditions. And a final example: Catherine is a registered Cranio-Sacral Therapist, a Physiotherapist, and is a tutor at the London College of Cranio-Sacral Therapy.  She is also qualified in acupuncture for pain relief and a member of the Craniosacral Therapy Association, the Chartered Society of Physiotherapy and Acupuncture Association for Chartered Physiotherapists.

Pharmacists

If you go into any pharmacy in the UK, you do not need to search for long to find shelves full of homeopathic remedies, Bach flower remedies, aromatherapy-oils or useless herbal slimming aids, to mention just 4 of the many different bogus treatments on offer. If you do the same in Germany, France, Switzerland or other countries, the amount of bogus remedies and devices for sale might even be greater. Pharmacists, it seems to me, have long settled to be shopkeepers who have few scruples misleading their customers into believing that these useless products are worth buying. Their code of ethics invariably forbids them such promotion and trade, but most pharmacists seem to pay no or very little attention. The concern for profit has clearly won over the concern for customers or patients.

Doctors

I have left my own profession for last – not because they are the least contributors to the ‘sea of misinformation, but because, in some respects, they are the most important ones. The general attitude amongst doctors today seems to be ‘I don’t care how it works, as long as it helps my patients’. I have dedicated a previous post on explaining that this is misleading nonsense; therefore there is no reason to not repeat myself. Instead, I might just mention how many doctors practice homeopathy thus misleading patients into believing that it is an effective therapy. Alternatively, I could refer to those charlatans with a medical degree who promote bogus cancer cures. In my view, misinformation by doctors is the most serious form of misinformation of them all: physicians involved in such activities violate their ethical code and betray patients who frequently trust doctors almost blindly.

Conclusion

It would be a misunderstanding to assume that, with this post, I am accusing all conventional health care professionals of misinforming us about alternative medicine. But some clearly do; and when they do abuse their positions of trust in this way, they do a serious disservice to us all. I hope that exposing this problem will contribute to conventional health care professionals behaving more responsibly in future.

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