Chiropractic spinal manipulative therapy (CSMT) for migraine?
Why?
There is no good evidence that it works!
On the contrary, there is good evidence that it does NOT work!
A recent and rigorous study (conducted by chiropractors!) tested the efficacy of chiropractic CSMT for migraine. It was designed as a three-armed, single-blinded, placebo -controlled RCT of 17 months duration including 104 migraineurs with at least one migraine attack per month. Active treatment consisted of CSMT (group 1) and the placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region (group 2). The control group continued their usual pharmacological management (group 3). The results show that migraine days were significantly reduced within all three groups from baseline to post-treatment. The effect continued in the CSMT and placebo groups at all follow-up time points (groups 1 and 2), whereas the control group (group 3) returned to baseline. The reduction in migraine days was not significantly different between the groups. Migraine duration and headache index were reduced significantly more in the CSMT than in group 3 towards the end of follow-up. Adverse events were few, mild and transient. Blinding was sustained throughout the RCT. The authors concluded that the effect of CSMT observed in our study is probably due to a placebo response.
One can understand that, for chiropractors, this finding is upsetting. After all, they earn a good part of their living by treating migraineurs. They don’t want to lose patients and, at the same time, they need to claim to practise evidence-based medicine.
What is the way out of this dilemma?
Simple!
They only need to publish a review in which they dilute the irritatingly negative result of the above trial by including all previous low-quality trials with false-positive results and thus generate a new overall finding that alleges CSMT to be evidence-based.
This new systematic review of randomized clinical trials (RCTs) evaluated the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability.
The searches identified 6 RCTs eligible for meta-analysis. Intervention duration ranged from 2 to 6 months; outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability. Methodological quality varied across the studies. The results showed that spinal manipulation reduced migraine days with an overall small effect size as well as migraine pain/intensity.
The authors concluded that spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary. Methodologically rigorous, large-scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.
Bob’s your uncle!
Perhaps not perfect, but at least the chiropractic profession can now continue to claim they practice something akin to evidence-based medicine, while happily cashing in on selling their unproven treatments to migraineurs!
But that’s not very fair; research is not for promotion, research is for finding the truth; this white-wash is not in the best interest of patients! I hear you say.
Who cares about fairness, truth or conflicts of interest?
Christine Goertz, one of the review-authors, has received funding from the NCMIC Foundation and served as the Director of the Inter‐Institutional Network for Chiropractic Research (IINCR). Peter M. Wayne, another author, has received funding from the NCMIC Foundation and served as the co‐Director of the Inter‐Institutional Network for Chiropractic Research (IINCR)
And who the Dickens are the NCMIC and the IINCR?
At NCMIC, they believe that supporting the chiropractic profession, including chiropractic research programs and projects, is an important part of our heritage. They also offer business training and malpractice risk management seminars and resources to D.C.s as a complement to the education provided by the chiropractic colleges.
The IINCR is a collaborative effort between PCCR, Yale Center for Medical Informatics and the Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School. They aim at creating a chiropractic research portfolio that’s truly translational. Vice Chancellor for Research and Health Policy at Palmer College of Chiropractic Christine Goertz, DC, PhD (PCCR) is the network director. Peter Wayne, PhD (Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School) will join Anthony J. Lisi, DC (Yale Center for Medical Informatics and VA Connecticut Healthcare System) as a co-director. These investigators will form a robust foundation to advance chiropractic science, practice and policy. “Our collective efforts provide an unprecedented opportunity to conduct clinical and basic research that advances chiropractic research and evidence-based clinical practice, ultimately benefiting the patients we serve,” said Christine Goertz.
Really: benefiting the patients?
You could have fooled me!
33 Responses to Chiropractic spinal manipulation for migraine – torture the data until they confess!
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“Our collective efforts provide an unprecedented opportunity to conduct clinical and basic research that advances chiropractic research and evidence-based clinical practice…”.
The implication here is that ‘chiropractic’ provides a valid outcome. This pre-research determination of the outcome, and intention that it should “advance chiropractic research” rather than scientific knowledge, represents confirmation bias of the highest order – even before the ‘research’ is conducted.
This is not ‘research’ – this is research fraud.
“Research is not for promotion, research is for finding the truth.” As a wise man recently said.
Sigh squared.
Very nice. Mrs. Goertz openly declares that she conducts confirmation research. For the benefit of the patients, of course!
This all seems so familiar to me …
Richard Rawlins wrote: “The implication here is that ‘chiropractic’ provides a valid outcome. This pre-research determination of the outcome, and intention that it should “advance chiropractic research” rather than scientific knowledge, represents confirmation bias of the highest order – even before the ‘research’ is conducted. This is not ‘research’ – this is research fraud.”
It can’t be viewed any other way, IMO.
Certainly, the president of the World Federation of Chiropractic (WFC), Laurie Tassell DC, seems to be indifferent to securing robust evidence. Less than a year ago he was saying:
QUOTE
“Chiropractic reform has failed…the profession is now more diverse than it’s ever been…chiropractors now practice in a range of different settings, using a wide range of interventions, and practicing from varying philosophical standpoints”
See page 3 here: https://www.wfc.org/website/images/wfc/qwr/2018/QWR_2018JUL.pdf
In January this year, he was saying:
QUOTE
“Our WFC strategy 2019-2022 has therefore sought to be applicable to our entire global community. We will advocate for the rights of chiropractors to practice free of persecution”
See page 4 here: https://www.wfc.org/website/images/wfc/qwr/2019/QWR2019JAN.pdf
And a few weeks earlier he was saying:
QUOTE
“…you will hear reports on the work that the WFC has been undertaking to pursue its mission of advancing awareness, utilization and integration of the chiropractic profession internationally”
See page 2 here: https://www.wfc.org/website/images/wfc/Assembly_2019/WFC_Assembly_of_Members_-_overview_and_provisional_agenda.pdf
Likewise, ex-British Chiropractic Association president, Richard Brown DC (now WFC Secretary-General), appears not to care that much about evidence:
QUOTE
“Our vision is a world where every person has access to chiropractic so that populations can thrive and reach their full potential…will only be achieved by increasing numbers of chiropractors”.
See page 5 here: https://www.wfc.org/website/images/wfc/qwr/2019/QWR042019B.pdf
Wowza! Who would have guessed Chiroquackers would try to cook-the-books? There are many quackers near me who strongly “suggest” your risks of developing cancer and “other dis-eases” are substantially reduced if your “nervous system” is working optimally…and that only occurs if you have a self-aggrandizing faux-doctor arbitrarily cracking your hyper-mobile vertebrae regularly. So at least real EB chiroquackers stick to pretending they solve pain-problems not cancer….problem is they all look exactly the same to the general public…and practice the same.
An interesting finding…
“At 12 months follow‐up, change in consumption of paracetamol was significantly lower in the CSMT group as compared with the placebo (P = 0.04) and control (P = 0.03) groups (Table 4).”
as I said: torture the data until they confess!!!
I am not sure how this is torturing the data as it was listed as a secondary outcome measure.
Regardless, how many chiropractors just do spinal manipulation for migraines? What is the usual chiropractic model approach for migraine?
please do tell us!
So you don’t know?
Interesting.
interesting that you seem to conclude this; logic mot your strong point perhaps?
So you know but you pretend not to know? Just playing games?
Regardless, you can start with this…
“The clinical management plans of chiropractors with a high migraine caseload more often included advice on diet/nutrition (p < 0.001), smoking/drugs/alcohol (p < 0.001), physical activity (p = 0.005), occupational health and safety (p < 0.001), pain counselling (p < 0.001), nutritional supplements (p < 0.001) and medications (including for pain/inflammation) (p < 0.001) than those chiropractors who less often managed patients with migraine."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715542/
how come they don’t mention cSMT?
“The treatment techniques/methods more often used by chiropractors with a high migraine caseload were high velocity, low amplitude (HVLA) spinal manipulation (p = 0.023),…”
yes, but this does not actually mean they use it for migraine patients, or do I misunderstand the sentence? very unclear!
@Edzard
“how come they don’t mention cSMT?”
They do, but DC cherry-picked for his comment.
“The treatment techniques/methods more often used by chiropractors with a high migraine caseload were high velocity, low amplitude (HVLA) spinal manipulation (p = 0.023), drop-piece techniques (p = 0.015), sacro-occipital techniques (p < 0.001), instrument adjusting (p = 0.001), biophysics (p = 0.040), applied kinesiology (p = 0.001), functional neurology (p < 0.001), dry needling (p = 0.006), heat/cryotherapy (p = 0.002), orthotics (p < 0.001) and extremity joint manipulation methods (p < 0.001)."
I wonder what 'biophysics' means as a chiropractic technique? I always thought the word referred to the application of methods from traditional physics to biological systems, as opposed to biochemistry.
yes, but this does not actually mean they use it for migraine patients, or do I misunderstand the sentence? very unclear!
EE…but this does not actually mean they use it for migraine patients
as I stated, start here (with that study)…look at the purpose of the study. It is an indication of practice styles and approaches for those that see more migraine sufferers than other chiropractors.
FO…They do, but DC cherry-picked for his comment.
EE asked specificially about cSMT, my response was in regards to that question.
Off topic slightly but the Manitoba Chiropractors Association (MCA) has launched legal action ( for the 2nd time) against the Manitoba College of Physicians and Surgeons (CPSM)because the CPSM broke a previous legally binding confidentiality agreement not to comment or criticize the Chiropractic profession in the province. The CPSM did so, for a. 2nd time, in a 2017 literature review sponsored by the government on high neck manipulation. The chiropractors are saying that they just found out that the CPSM’s submission went public….and the CPSM are saying that they did not know it would be made public. The Manitoba Chiropractic Stroke Survivors were instrumental in “nagging” the provincial government to conduct this review, We find the confidentiality agreements that come with and put an end to legal action most disturbing and most certainly do not lead to truth finding.
CBP or chiropractic biophysics was the brainchild of a very intelligent DC with both a degree in mechanical engineering and a PhD in math. He proposed “subluxation” as a global, postural distortion phenomenon not an intervertebral one. Thus they assess the saggital and frontal alignment of the centers-of-mass of the skull, torso and pelvis as well as the (theoretic) spinal curves of the cervical, thoracic and lumbar regions. When distortions are found (deviations from his proposed normal) mirror-image adjusting, exercise and sustained “postural traction” are used to overcome the elastic and plastic components of the bad-posture. Or so I read on their website…..I think the illustrious “Dr” Epstein practices this….thus deluding himself into believing he is more lofty than his intersegmental “subluxation” brethren. It sounds painful and dogmatic. Perhaps like trying to “pray the gay away”?
Thanks.
Few questions please… Professor
1. “One can understand that, for chiropractors, this finding is upsetting”… do you have any support for such claim? If anything I am sure many of us are delighted to see the collaboration between Akershus hospital, Oslo Hospital and the Norwegian Chiropractic association in performing such a study.
2. Other than the claim of some kind of deliberate conspiracy to fool the world do you have any professional critique against the methodology of Rist review?
3. Do you know of a better way to present (preliminary) conclusions for a clinical issue other than systemic review? Should we stop all systemic reviews in fear of diluting the data?
1) why do I need support for a statement starting with ‘one can understand…’?
2) read my post!
3) a systematic review must point out what the most reliable data shows; in this case, it shows that CSMT is not effective for migraine!
“why do I need support for a statement starting with ‘one can understand…’?”
When accusing an entire profession at placing their financial interests before their patient’s health that is a very SEVERE accusation. I would have expected you to present some kind of evidence for such a statement.
“read my post!”
I did read your post and enjoyed it very much, I also went and read the original papers. I still don’t understand where you find any “torturing of data”.
“a systematic review must point out what the most reliable data shows; in this case, it shows that CSMT is not effective for migraine!”
I think the jury is still out on this one but personally I tend to agree. Although I believe that in many RCT’s the outcome is highly affected by inclusion/exclusion and patients selection criteria, but that is a different discussion all together
I did read your post and enjoyed it very much, I also went and read the original papers. I still don’t understand where you find any “torturing of data”.
WHY AM I NOT SURPRISED?
When accusing an entire profession at placing their financial interests before their patient’s health that is a very SEVERE accusation. I would have expected you to present some kind of evidence for such a statement.
GO ON THE INTERNET OR TEITTER AND SEE FOR YOURSELF
I think the jury is still out
I DON’T. BUT EVEN IF THE JURY WERE OUT, IT OUGHT TO BE SAID THAT THERE IS NO GOOD EVIDENCE FOR IT
One has to look at the external validity of the research. How many chiropractors (or others) use spinal manipulation as a sole modality in the care of migraine patients?
I am not aware of any surveys that directly ask the approaches chiropractors use in these cases. However, surveys indicate that most chiropractors use a multimodal approach for other conditions.
What the above research indicates is that SMT may have an effect on some of the variables measured…but it’s not very effective overall as a sole modality. From my clinical experience I would agree. At best SMT deals with a symptom and not the cause. One must dig deeper into the case to find the triggers as well as what type of migraine one is dealing with. Research on subgrouping is also needed which may help guide future interventional research. (example…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615079/)
Thus, a multicare approach, when appropriate, should include exercises (specifically addressing the cervical spine), relaxation techniques, stress management and dietary counseling. Does SMT have some type of additive effect within this approach? Maybe.
any multi-factorial approach still need to demonstrate that each factor is effective; if not, there is no reason to include it.
Agreed. However, the above paper suggests that SMT may have a positive effect on some of the measured outcomes. Thus, it may have an additive effect. A RCT pragmatic approach can help determine if SMT has any added benefit.
it worries me, when you agree with me!
Yes, that bothers me too. I may even agree with Blue Wode on a topic. I should probably leave.
Meh, sounds nothing more like what Medicine and collaborating drug companies do every day of the week to be honest, they just hide it better as they have more money to grease more hands.
If you think we are better (MD here myself) you have got to be kidding me as we as a medical industry are responsible for more deaths than any other industry, again we just know gow to cover it up.
I will finish now on a few words stolen from what was said above “We wouldn’t want to lose paying customers now would we, or have them lose faith in the system.”
even if you are correct, do you think one wrong justifies another?
What continues to keep chiroquackery in the world of bizzaro is 2-fold: firstly The 4 ubiquitous methods of “determining WHERE to manipulate (or Activate)”: motion-palpation, leg-checks, AK muscle-challenges and X-ray analysis are ALL proven invalid and ultimately unreliable….thus the application of this supposedly profound intervention (SMT) is at root always desultory and mere opinion.
Secondly, the most horrific adverse events of manipulation (stroke, herniation, nerve root injury) have often been delivered by VERY experienced manipulators.
Ergo WHY is it a “profession”? And why is it so damn expensive to deliver? I learned how to manipulate from my ex-wife in a few weeks. An “Activator” or “drop-table-adjustments” could be learned in a matter of minutes since they’re nothing but made up nonsense, requiring absolutely no skill or education.
IF SMT has some contribution to some pain-symptoms there is no good reason it should be delivered by quacks who never reveal its realities with the gullible payees.
@MK
Skipped over a few important details.
What is the most important part of any consultation? The history.
Most tests have poor sensitivity if stand alone including the majority of orthopedic tests used by everyone.
AK muscle-challenges? I checked their website and they represent 0.02% of the profession in Australia and even fewer internationally so “ubiquitous” I think not.
X-rays overuse has been covered in the Choosing Wisely campaign and national guidelines for all professions including chiropractic. Even modic changes on CT and MRI equating to higher incidence of back pain was debunked in a paper just this month. I rarely refer for xrays unless there is a valid clinical reason and fishing for mythical subluxations is not one of them.
“delivered by quacks who never reveal its realities with the gullible payees.”
You are aware of informed consent?
It has been a statutory requirement here since 2000 and clearly spells out what must be covered. I have had a informed consent form as standard since 1995 and its now on it’s 7th revision.
“never”?????
Is informed consent mandatory in your neck of the woods and do you have it with every patient?