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

The media have (rightly) paid much attention to the three Lancet-articles on low back pain (LBP) which were published this week. LBP is such a common condition that its prevalence alone renders it an important subject for us all. One of the three papers covers the treatment and prevention of LBP. Specifically, it lists various therapies according to their effectiveness for both acute and persistent LBP. The authors of the article base their judgements mainly on published guidelines from Denmark, UK and the US; as these guidelines differ, they attempt a synthesis of the three.

Several alternative therapist organisations and individuals have consequently jumped on the LBP  bandwagon and seem to feel encouraged by the attention given to the Lancet-papers to promote their treatments. Others have claimed that my often critical verdicts of alternative therapies for LBP are out of line with this evidence and asked ‘who should we believe the international team of experts writing in one of the best medical journals, or Edzard Ernst writing on his blog?’ They are trying to create a division where none exists,

The thing is that I am broadly in agreement with the evidence presented in Lancet-paper! But I also know that things are a bit more complex.

Below, I have copied the non-pharmacological, non-operative treatments listed in the Lancet-paper together with the authors’ verdicts regarding their effectiveness for both acute and persistent LBP. I find no glaring contradictions with what I regard as the best current evidence and with my posts on the subject. But I feel compelled to point out that the Lancet-paper merely lists the effectiveness of several therapeutic options, and that the value of a treatment is not only determined by its effectiveness. Crucial further elements are a therapy’s cost and its risks, the latter of which also determines the most important criterion: the risk/benefit balance. In my version of the Lancet table, I have therefore added these three variables for non-pharmacological and non-surgical options:

EFFECTIVENESS ACUTE LBP EFFECTIVENESS PERSISTENT LBP RISKS COSTS RISK/BENEFIT BALANCE
Advice to stay active +, routine +, routine None Low Positive
Education +, routine +, routine None Low Positive
Superficial heat +/- Ie Very minor Low to medium Positive (aLBP)
Exercise Limited +/-, routine Very minor Low Positive (pLBP)
CBT Limited +/-, routine None Low to medium Positive (pLBP)
Spinal manipulation +/- +/- vfbmae
sae
High Negative
Massage +/- +/- Very minor High Positive
Acupuncture +/- +/- sae High Questionable
Yoga Ie +/- Minor Medium Questionable
Mindfulness Ie +/- Minor Medium Questionable
Rehab Ie +/- Minor Medium to high Questionable

Routine = consider for routine use

+/- = second line or adjunctive treatment

Ie = insufficient evidence

Limited = limited use in selected patients

vfbmae = very frequent, minor adverse effects

sae = serious adverse effects, including deaths, are on record

aLBP = acute low back pain

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.

I imagine that chiropractors, osteopaths and acupuncturists will strongly disagree with my interpretation of the evidence (they might even feel that their cash-flow is endangered) – and I am looking forward to the discussions around their objections.

30 Responses to Low back pain: alternative practitioners feel encouraged by the recent Lancet-articles – wrongly so, I hasten to add

  • Today and tomorrow, I’m engaged in a local spinal health promotion which I can report at this time are one of my busiest days I ever encountered, with many members of the public commenting on the recent media Lancet low back pain publication. They understand the benefits of spinal manipulation combined with spinal remodelling traction exercises for the management of their spinal pain.
    Onwards and upwards!!

  • How is it possible that the authors of the Lancet article do not take the treatment risk into account?! This seems negligent, for every pill that you buy, side effects have to be listed. Even worse, the risk of spinal manipulation is certainly underestimated today, because many cases are never reported.
    Many people seem to be resistant to statistical facts, therefore I want to briefly share a story, which summarizes an experience that my brother had several years ago:
    He went to an orthopedist because of lower back pain. After having a look at his back, the “doctor” decided to do spinal manipulation. My brother immediatly felt a great pain. After this happened, the doctor made two x-rays of the back, put him on a heat bench, told him that he wanted to “make sure that he will leave with less pain than he came with” and tried to achieve this with acupunture. After some time, the “doctor” asked if the pain got better, my brother said “no, not really” and then left. He felt left alone and mistreated. The only good thing that the “doctor” did was to prescribe several sessions of physiotherapy, which my brother took at a different place. It took him several weeks until the pain got better.
    End of the (true) story.
    Did I mention that my brother was a private patient? In the German health system this means that doctors can make more money with additional treatments. Of course, the orthopedist sent a bill for all of his “treatments”, including the x-rays, heat bench and acupunture that were direct results of his mistreatment and that my brother never wanted.
    In my hometown, 54 orthopedist are listed. I tried to find just ONE who does not offer chirotherapy or other CAM treatments, but was not able to. They all seem to want that extra cash. All orthopedist that offer CAM should read the book on medical ethics from Ernst and Smith, maybe at least some would come to the conclusion that the extra money does not justify to endanger the health of the patients.
    Maybe one of the doctors in this forum could comment on if and how it could be possible to force orthopedist to report ALL adverse effects of their treatments, so that we can get a realistic picture of the real danger of chirotherapy.

  • LBP is a licence to print money. Clinical evidence must be spun – unless it confirms what is being sold is effective. And if it is clinically demonstrated to be effective it isn’t CAM any more. Spin the evidence, push the anecdotes. Pain is the name of the game. Pain is good for business. As long as there is self-limiting pain there will be CAM.

  • Not to appear obsequious but I would like to point out the unbridled enthusiasm I and several colleagues have for your newest book “more harm than good”….
    ????? I mentioned this in a previous blog. But,
    my point here is to deliver the strongest suggestion AND admonition to EVERY reader that hasn’t already done so to buy and thoroughly READ THIS BOOK! Your depth of coverage of all these matters of research, ethics, bias, skewing etc etc are so adeptly covered as to make most arguments and retorts regarding “alternative treatments” moot…or at least in the realm of: “been there, done that”.
    I say shame on the bloggers (pro & con) who haven’t bought it (and put their review up on Amazon (or wherever)) to get more people the enlightenment THAT IS SO DESPERATELY NEEDED in these matters! Sorry for shouting…!
    As a final comment; I suspect I like many bloggers here (those who, for whatever reason don’t read your books) may be UNDERESTIMATING your acumen, insights, knowledge and logic. The arguments levied by many of the regular contrarians seems to prove that point. Ignorance & illogic for them, as you point out is a necessity for their monetary rewards. BUY THE BOOK & open your mind!

  • The Lancet papers conflate ‘therapies’ with ‘therapists’. The practices with the practitioners. These are distinct elements which must not be confused

    A variety of therapies are set out, and a rationale for selecting them, but there are no reasons given for any patient to place themselves in the hands of a practitioner who intends releasing their ‘innate intelligence’ by ‘adjusting spinal subluxations’, decongesting arterial blood flow or pricking imaginary lines of force.

    I only found the word ‘complementary’ once, and ‘alternative’ not at all.
    (Apologies if my word check, and reading, is duff.)

    And here, ‘integrated’ refers to the collaborative working of regular professions, not mixing cow pie with apple pie. CAMs are what is indicated on the tin – alternative. By, with, and from folks with an alternative mind set and understanding of the nature of nature.
    Sorry.

    These papers provide a clear rationale for chiropractors, osteopaths, acupuncturists and other camists, to progress from their out-moded philosophies and faiths, and study, train, and qualify as doctors, psychologists, councillors or physiotherapists.

    If they try jumping on the bandwagon provided by these papers, they will deservedly fall off.

  • It so happened that there was an article in today’s Times very relevant to the topic.

    “Doctors turn to herbal remedies when the drugs just don’t work”.
    https://www.thetimes.co.uk/article/doctors-turn-to-herbal-remedieswhen-the-drugs-just-don-t-work-65z8wksk9

    According to the article doctors are turning to quackery in droves. They quote a doctor/homeopathist, who spends a lot of time talking to people who have sore throats – which must be quite painful for them – to get to the homeopathic heart of the matter; and Dr Michael Dixon, chair of the College of Medicine, who recommends herbal “remedies”, acupressure and self-hypnosis, saying he doesn’t care if they are only placebos. Doctors are “healers”. The treatment for headache – a metaphor for unhappiness, he says – is symbolic. He likes to treat what he views as pseudo-medical conditions with pseudo-medical treatments or like with like, so to speak.

    The article states that doctors “seem recptive to alternative approaches” and quotes a recent BMJ website poll where 70% agreed that doctors should recommend acupuncture for pain. I checked this and found it to be correct, but I also found that anyone can vote. The poll had a noticeably higher rate of response than normal. I smell a fishy smell.

    The College of Medicine has 5 alternative type members out of 20 on its scientific advisory group. 25% then. That’s overloaded in my opinion, as as reflection amongst GPS in general. I would be interested to see a scientific poll amongst doctors on whether they would consider recommending acpuncture for pain – whether or not it is a placebo.

    • Coincidentally, in the letters section, today’s Times also had several anecdotal accounts of healing treatments for back pain: Exercise and psychological treatment; steroid injections; decompression surgery; exercises from a booklet supplied by a physiotherapist.

      Whether it is private medicine or NHS, “conventional” or “complemenatry” real or metaphorical, back pain is keeping a lot of people in employment.

    • The ‘College of Medicine’ emerged from the ashes of the Prince of Wales’s ‘Foundation for Integrated Health’. It claims to promote ‘integrative’ medicine, and — to judge from its current website — has become very slick at downplaying the reality that it’s a ‘College of quackery’. I’m astonished that only 25% of its scientific advisors are clearly definable as ‘alternative types’.

  • Unfortunately accidents and incidents of spinal manipulations with high velocity low amplitude are considered as malpractice not as an inherent problem of the manual techniques of OMM or chiropractic. (VM with a risk of internal bleedings is a similar problem). This is the result of phone calls to several departments of the German Ministary of Health I took the last months. Therefore there are no adverse reactions or adverse moments per definition and no permanent monitoring like in adverse drug reactions. So there is a problem with statistics in all of this cases. It is left to the patients to sue a physician or German Heilpractiker or a physical therapist if something went wrong with high velocity low amplitude spinal manipulations. Only in cases caused by physicians the accidents / incidents will be reported to the German chambers of physicians and only if a patient is sueing them and I don’t know by now if they do any statistics about such cases on a regularly base. There is no statistics about cases caused by Heilpraktikers or physical therapists using such techniques.

    • Thank you for the info. In the case of my brother, it was not, to my knowlede, “high velocity manipulation”, but it seemed to have been a standard procedure (for chiropractors, that is…) .
      As it turned out, he has a form of Spondylolisthesis, i.e. an instability of the spine. As I see it, the spinal manipulation done by the orthopedist put him in serious danger. What a great job.
      I wonder how often such “close calls” happen.

      • spondylolisthesis does not seem to stop chiros recommending manipulation for it (https://www.ncbi.nlm.nih.gov/pubmed/19703668):
        “lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.”

        • This is terrifying…
          After just reading the abstract, let me give a quick E.E. impersonation:

          The article is entitled `Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report.´ and was published in the Journal of Chiropractic Medicine.
          In this paper, a case report of a 43-year-old patient with 20-year history of mechanical back pain was described. A conservative management was applied, consisting of 10 treatments including lumbar flexion/distraction and activity modification over an 8-week period.
          According to the authors of the paper, “lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.”

          A few points raised my suspicions about this study:
          *The article was publish in a journal with a very low impact/bad citation index.
          *The first author is a Staff Chiropractor at the New York Chiropractic College, indicating a conflict of interest.
          *Since it was a case study of just one person, no placebo control was included.
          *It is not possible to draw general conclusions based on a single case study.

          • all of your points are correct.

          • Lumbar flexion/distraction is a whimsical chiropractic-“traction-like”intervention when the well-trained DC believes a disc is the pain source. It’s based on the work of James Cox a well heeled charlatan who usurped the flexion table idea from a 100 year old osteopathic treatment (McManus table).
            The prone patient has their lower body flexed whilst the DC adds palm tension to the spine thus “tractioning it”. There are innumerable “drop-adjustments” and capricious movements added….Nonsense of course and in 50 years driven exclusively by anecdotes….and though reporting of adverse events with it don’t “show up” it’s not without its share I’ll wager.
            Cox Technique and it’s apologists have done yeoman’s work filling journals with these acrid case reports. Keeps his name in the limelight and his followers drooling for more.

  • @ Edzard
    Just a few comments about your table shown above:

    1. Superficial heat can’t have the same cost as CBT. I would presume that CBT would have to be given by a professional = $$$. Whereas superficial heat can come from a hot water bottle which probably costs just $5.

    2. According to your table the risks with massage are very minor. However, you have conducted two systematic reviews into the safety of massage therapy, with the most recent concluding “Evidence suggests that massage may occasionally lead to moderately severe adverse effects” (https://onlinelibrary.wiley.com/doi/abs/10.1111/fct.12007).
    So, to me this suggest that the risks of massage are not very minor. Also, Paul Ingraham on his website (https://www.painscience.com/articles/whats-the-harm.php) describes that “While serious side effects in massage therapy are extremely rare, minor side effects are downright common.”
    Maybe you need to re-consider your risk rating for massage and I think that this would change massages risk/benefit from positive to negative.

    3. According to your table the risks with exercise are very minor. However, a study by Carnes et al (https://www.sciencedirect.com/science/article/pii/S1356689X09002112) highlighted that “The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar”. Therefore shouldn’t the risk classification for exercise be the same for manual therapy (massage and spinal manipulation) except exercise doesn’t have any serious adverse events reported.

    Looking forward to your reply.

    • 1. i did not say it had the same cost.
      2. this is keeping with ‘minor adverse effects’
      3. manual therapy is not the same as SMT which has caused several 100 vascular accidents.

      • @ Edzard

        1. Actually, you did say they had the same cost, as you placed superficial heat and CBT in the same cost bracket (low to medium). CBT should be in a different cost bracket altogether.

        2. So, your conclusion of moderately severe adverse effects is in keeping with minor adverse effect? Are you making this up?

        3. Manual therapy includes SMT – do read the study Edzard.

        Maybe you need to be more transparent with your classification system. What are the criteria’s you used for assigning treatments to the risk and cost categories?

        Also, in a separate but associated issue, a study done by yourself on acupuncture stated “Several large prospective studies have shown that such adverse events are extreme rarities, provided acupuncture is carried out by well‐trained practitioners. These studies also show that mild, transient adverse effects, e.g. needling pain or bleeding at the site of needling, occur in about 7–11% of all cases.” This is very similar to risks associated with massage therapy but you assigned different classifications in your table.

        Please explain why you have done this?

        • 1. same category does not mean same cost; it means same order of magnitude.
          2. i combined severity with frequency in that column for all treatments listed.
          3. yes it does but it also includes several other therapies.
          “What are the criteria’s you used for assigning treatments to the risk and cost categories?” i tried to make it clear that these are ESTIMATES.
          “This is very similar to risks associated with massage therapy but you assigned different classifications in your table.” NO IT’S NOT
          https://www.ncbi.nlm.nih.gov/pubmed/?term=ERNST+E%2C+DEATH+ACUPUNCTURE
          https://www.ncbi.nlm.nih.gov/pubmed/21093944
          https://www.ncbi.nlm.nih.gov/pubmed/20929887
          https://www.ncbi.nlm.nih.gov/pubmed/22936058
          https://www.ncbi.nlm.nih.gov/pubmed/21124716
          https://www.ncbi.nlm.nih.gov/pubmed/14718331
          https://www.ncbi.nlm.nih.gov/pubmed/11444889
          https://www.ncbi.nlm.nih.gov/pubmed/11331060
          https://www.ncbi.nlm.nih.gov/pubmed/10575398

          • Dear Prof. Ernst,
            I have had a look at papers published in the New England Journal of Medicine (since it is one of the most prestigious medical journals in the world) regarding acupuncture as a treatment option for lower back pain and was very surprised to find the following article (” Acupuncture for Chronic Low Back Pain” 07/2010):
            http://www.nejm.org/doi/full/10.1056/NEJMct0806114

            The authors of this article basically recommend treatment of chronic low back pain with acupuncture.
            Although the authors agree that “real” acupuncture has pretty much the same effect as sham acupuncture, they still recommend it because both treatments seem to be more effective than than conventional therapy treatment.
            I am sure that you know this paper and wonder what you make of it. Why did the authors arrive at a diffenrent conclusion than you do? Did the evidence chance since 2010 to further reduce the benefit vs. risk ratio regarding acupuncture?

          • the NEJM paper is not an evidential article but describes in some detail a case report. in addition, the evidence has change since 2010; this is why NICE changed their recommendations for back pain/acupuncture.

          • Thank you for the clarification. However, the situation appears to be different in Germany and not that clear. According to the medical guidelines from the AWMF:
            “5-1:
            Akupunktur kann zur Behandlung akuter nicht-spezifischer Kreuzschmerzen bei unzureichendem Erfolg symptomatischer und medikamentöser Therapien in Kombination mit aktivierenden Maßnahmen in möglichst wenigen Sitzungen angewendet werden.”
            5-2:
            Akupunktur kann zur Behandlung chronischer nicht-spezifischer Kreuzschmerzen angewendet werden.”

            Brief translation:
            5-1: Acupuncture can be applied as treatment for non-specific lower back pain if other treatments are not effective, in combination with further activating treatments and in as few sessions as possible .
            5-2: Acupuncture can be used as treatment for chronic, non-specific lower back pain.”

            This is not at all a clear statement against acupuncture, as NICE has done.
            Maybe it is time to change the guideline…

          • yes, I think so.

      • EE, surely you must look at the considerable risks involved with taking anti-inflammatory medication for low back pain. I note that you did not look at the waste of money spent on the shake, bake and fake of physical therapy, which none of their therapies e.g. tens, ultrasound, specific back exercises even rated a mention. Compare horses with horses, please.

  • My uncle used to say an idiot repeats themselves without ever adding anything new.
    Thus we have gibletgiblet and his Tu Quoque sword of impotence.
    An example: “shake, bake and fake”.
    Perhaps you can contemplate that “physical-therapy” actually describes something and was developed for good reasons for a medically feasible purpose (whether ultimately successful or not is still an open question BUT it isn’t supported ONLY by dogma). Perhaps you’ve heard of nephrology, neurology, endocrinology etc etc….perhaps you SEE the point? Real science actually uses real names to name shit! Amazing but true!!
    “Chiropractic” describes nothing but the rantings of a messianic lunatic hoping for a slice of infamy. And IF “chiropractic” hadn’t taken-hold perhaps he may have come up with “Scientology” before LRH? Sounds REALLY sciency!
    It’s a portmanteau created to usurp an existing modality, pollute it with idiotic dogma regarding finding and fixing vertebral-subluxation to allow “innate expression”….PERIOD. That over time “it” shamelessly usurps other possibly beneficial methods developed by reputable physical therapy and medicine and claims it as it’s own, doesn’t change anything.
    A non-profession of idiots expert in hegemony and self-aggrandizement.

    • Michael Kenny: who mentioned “chiropractic”, I did not. I was emphasising that there was nothing in the list of treatments that work that could be ascribed to the physiotherapy profession, of which you are a strong advocate. So, if there is nothing a physiotherapist can do for low back pain (according to the Lancet), then there will be little that physios can do for any other neuro-musculo-skeletal condition, with the same aetiology, as the mechanism of pain is identical.

      • @gibletgiblet: if you give me your phone number I’ll call you before I post anything to make sure it’s proper and in alignment with your high standards.
        But you just reiterated your Tu Quoque argument…..
        Poor performance by PT/DPTs doesn’t mitigate ‘chiroquackery’s’ assault on reason and decency.
        They (physical medicine) didn’t decide 100 years ago ONE of them discovered the essence of ALL health-issues.
        That aside I personally do not have any faith in the paradigm that pain can be “treated away”….it’s a chimera whose magical thinking is most suited to and in line with chiroquackery BUT also perpetuated by anyone whose income is dependent on “patient retention”.
        Many PTs in my experience are apologetic in only being able to give temporary pain-relief and advice. However good advice can often lessen the odds of back-pain chronicity….and supervised exercise improves compliance.
        The don’t sell religion and nonsense suggesting they know the “true cause of dis-ease” …..and maintenance-of-pointless treatments should persist ad infinitum as their standard business model.

  • I think that it’s important that readers know about the following:

    On 22nd March 2018, in the replies section of his Twitter account, David Newell (@NewellDave), Research and Reader at the Anglo European College of Chiropractic University, and a member of its Senior Management Group and chair of the Staff Development and Research Committee, wrote “I would with respect gravitate to massive evidence synthesis by multiple research groups in @TheLancet as more trustworthy than Edzard’s blog. I think thats self evident to any serious thinker Blue”.

    Today, he has tweeted “Edzard’s appeal to risk/ benefit is unfounded for LBP” – yet the data and lack of reliable adverse reporting systems would contradict that, e.g. http://edzardernst.com/2017/02/opioid-over-use-chiropractic-megalomania-and-six-probing-questions/#comment-86336

  • GibletGiblet, like chiroquacktic, which has absolutely no affect on nerves or the CNS you have no affect on my nerves, raw or not. My apologies if that was your intention.

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