MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

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.

13 Responses to Spinal manipulation for back pain: who does it best – chiros, physios or osteos?

  • Apparently the conclusion from “Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial” revealed: “The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain. It was safe, parsimonious, and well accepted by patients”

    http://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf
    http://annfammed.org/content/11/2/122.full

  • And if the conclusions re chiropractors are not proof that ‘Regulation’ is meaningless, what is?

  • Dear Prof Ernst,

    The “Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial” links ( http://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf and http://annfammed.org/content/11/2/122.full) reveal the following

    “This study, conducted at UNTHSC, used osteopathic manual treatment (OMT) and ultrasound therapy to treat chronic low back pain in 455 adults. Patients in the study who received ultrasound therapy did not see any improvement, but the patients who received OMT did see significant improvement in pain, used less prescription medication and were more satisfied with their care over the 12 weeks of the study than those patients who did not receive OMT.”

    • How were some of the conclusions reached? They seem very subjective. Were the practitioners blinded (were the patients?), how was “improvement” measured, how was patient “satisfaction” scored? Is there any underlying, scientific plausibility for osteopathic manual treatment?

      More than anything, I’d love to know why we keep on testing things that never produce significant evidence or have any plausibility to even make them worth testing. Believers will keep on believing regardless of evidence or lack of evidence, so the motivation seems to be that the practitioners want to get paid by insurance or government

  • Cards on the table I am a physio but I do very little manipulation for various different reasons. In response to Irene the conclusions are subjective because that is all we have to measure things we can’t do a blood test or scan to measure pain. All the measures out there seem to either be entirely subjective or, even with the functional ones, rely on a subjective perception of activity.

  • Ernst knows. This time who is the BEST (-: So scientific, so brilliant, so Ed.

  • Being I DPT I have seen many patients in the acute care setting post surgery due to chiro “adjustments”. Thank you for the business fellow chiros. I have yet to see a patient from a physiotherapist needing surgery from manipulation. I utilize manipulation on a daily basis in my own practice and it is a great adjunct to care but NOT a cure all. Oh, and I’m not using it to “cure” diseases like our chiro counterparts make claim.

  • One thing that this discussion hasn’t taken seriously is that of intra-professional variability of practice. As a PT there are a number of schools of manual therapy (eg, Maitland/Grieve, Kaltenborn, Mulligan, Edwards, McKenzie to name just some of the players) and therapists are free to choose training in one or more of these over and above their professional training. Is this not the same to some extent in Chiro and Osteopathy? (I don’t know the answer to that for sure but I suspect there would be much variation depending on the school of education). Some practitioners take a more eclectic approach to manual therapy while others hold loyally to a particular school.

    Does it matter? Is the specificity of one approach over another really of clinical importance? Manual therapy zealots of any persuasion often like to claim the superiority of their particular approach. And what of overlap in practice between the three professions.

    The matter is further complicated as physiotherapists who have taken on Evidence-based practice have moved away to some extent from passive approaches to treating low back pain. Such approaches as exercise therapy, motor control and cognitive-behavioural therapies hold much more promise, particularly when pain persists. As Professor Ernst states the evidence for manipulation generally is not very compelling in the acute setting and not at all in the chronic phase.

    Of course it isn’t just evidence based practice; the area is still rife with fads and the latest in this part of the world seems to be Pilates. Manual therapy is certainly not the in thing these days.

    After over 30 years of practice has passed by in my life and with such a wealth of good science now applied to practice I find it someone depressing that there seems no resolve to this inter-professional rivalry.

    • Geoffrey Cor wrote: “As a PT there are a number of schools of manual therapy (eg, Maitland/Grieve, Kaltenborn, Mulligan, Edwards, McKenzie to name just some of the players) and therapists are free to choose training in one or more of these over and above their professional training. Is this not the same to some extent in Chiro and Osteopathy?”

      The subject of this blog post is spinal manipulation for back pain and who does it best – chiros, physios or osteos. As far as I know, there are very few PTs (if any) who follow a vitalistic philosophy (as chiros do), so that would make them the first choice for performing spinal manipulation as they will use it far more judiciously. In the UK, the scope of practice for chiros and osteos isn’t limited so they are free to choose whatever methods they want and many stick with ones which are known to be pure quackery.

      Geoffrey Cor wrote: “Does it matter? Is the specificity of one approach over another really of clinical importance?”

      In answer to that, I think it’s worth highlighting the conclusion reached by Professor Ernst at the end of his post:

      Quote
      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.

      Geoffrey Cor wrote: “After over 30 years of practice has passed by in my life and with such a wealth of good science now applied to practice I find it someone depressing that there seems no resolve to this inter-professional rivalry.”

      It seems to boil down to turf wars. While chiropractors, and to some extent osteopaths, continue to be mired in quackery and need to shout from the rooftops about their dubious interventions in order to find and convince (some might say hoodwink) fee-paying customers, I think that their rivalry with physios will continue. With regard to the UK, it’s worth remembering that chiros and osteos aren’t universally accepted by the NHS whereas physiotherapists are and therefore enjoy greater respect and more security due to a steady income stream.

  • Having had an MUA by an Orthopaedic surgeon after a year of chronic back pain (to the point where I had a permanent limp) due to a ruptured dick (obtained by being forced to move a patient in a bad way for my back onto an operating table) I persuaded the Orthopod to go ahead. They say about 50/50 for a good outcome. I was one of the lucky ones I guess. It worked and I was immediately able to get my life back.
    All pain measurement is and has to be subjective and clearly the personality and ability of the practitioner will influence this, regardless of which profession they have been trained in.
    Subjectively I prefer an Osteopath for whiplash and damage post violent trauma such as a car accident. The muscles splint damaged joints and need time to repair themselves which then allows the manipulations to work. This is subjective but works for me whereas a Physiotherapy course, post a 40mph hit from behind in a car, did not improve the way my neck felt unfortunately

  • Nigel Harris – did you seriously rupture your dick while moving a patient? That is terrible! A ruptured disc would be bad bad enough 😉

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