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

Spinal manipulation is a treatment employed by several professions, including physiotherapists and osteopaths; for chiropractors, it is the hallmark therapy.

  • They use it for (almost) every patient.
  • They use it for (almost) every condition.
  • They have developed most of the techniques.
  • Spinal manipulation is the focus of their education and training.
  • All textbooks of chiropractic focus on spinal manipulation.
  • Chiropractors are responsible for most of the research on spinal manipulation.
  • Chiropractors are responsible for most of the adverse effects of spinal manipulation.

Spinal manipulation has traditionally involved an element of targeting the technique to a level of the spine where the proposed movement dysfunction is sited. This study evaluated the effects of a targeted manipulative thrust versus a thrust applied generally to the lumbar region.

Sixty patients with low back pain were randomly allocated to two groups: one group received a targeted manipulative thrust (n=29) and the other a general manipulation thrust (GT) (n=31) to the lumbar spine. Thrust was either localised to a clinician-defined symptomatic spinal level or an equal force was applied through the whole lumbosacral region. The investigators measured pressure-pain thresholds (PPTs) using algometry and muscle activity (magnitude of stretch reflex) via surface electromyography. Numerical ratings of pain and Oswestry Disability Index scores were collected.

Repeated measures of analysis of covariance revealed no between-group differences in self-reported pain or PPT for any of the muscles studied. The authors concluded that a GT procedure—applied without any specific targeting—was as effective in reducing participants’ pain scores as targeted approaches.

The authors point out that their data are similar to findings from a study undertaken with a younger, military sample, showing no significant difference in pain response to a general versus specific rotation, manipulation technique. They furthermore discuss that, if ‘targeted’ manipulation proves to be no better than ‘general’ manipulation (when there has been further research, more studies), it would challenge the need for some current training courses that involve comprehensive manual skill training and teaching of specific techniques. If simple SM interventions could be delivered with less training, than the targeted approach currently requires, it would mean a greater proportion of the population who have back pain could access those general manipulation techniques. 

Assuming that the GT used in this trial was equivalent to a placebo control, another interpretation of these results is that the effects of spinal manipulation are largely or even entirely due to a placebo response. If this were confirmed in further studies, it would be yet one more point to argue that spinal manipulation is not a treatment of choice for back pain or any other condition.

13 Responses to Is spinal manipulation a placebo therapy?

  • Let us not forget that manipulation is defined as part of Australian physiotherapy treatment for low back pain but chiropractic treatment is the only treatment for spinal dysfunction. Please explain? Have all the chiros been exterminated from manipulative therapy??? Sounds very German to me! https://www.dva.gov.au/factsheet-hsv19-physiotherapy-services

  • This study is of poor (if not embarrassing) quality to say the least. It has basic flaws that we can go into if you so wish but really it’s a mystery how such a paper passed peer review.

    Putting all this aside your last remark “Assuming that the GT used in this trial was equivalent to a placebo control” is completely irrelevant. The authors describe a general “lumbar roll” manipulation using “the same force” as the specific manipulation as their reference group.

    This is what most physio manipulation involves, a generalized role and a trust, we can argue its effectiveness but that is what they practice. This is NOT a placebo… in fact there is no placebo group in this study.

    I fail to see how you arrived at that title with regard to this poor study.

    • ” we can argue its effectiveness”. yes, let’s: I see now evidence that it is effective. so, it might be a reasonable placebo. hence my speculation.

    • DGA…in fact there is no placebo group in this study.

      Yes, the study was not designed to look for any placebo effect. Buy i agree, a poorly designed study considering what we know about nonspecific LBP and that the so called specific adjustment isn’t even specific.

  • Putting aside all scientific studies and emminent publications such as Lancet and Spine that all supoort the efficacy of spinal manipulation, my favorite anecdotal story is from one of my old professors. He saw some animal patients in his practice, and one dachsund (that is an acromegalic dwarf breed and prone to spine and hip problems due to the disproportional spine to leg ratio) used to come into the clinic, run up and down until he found an unoccupied adjustment table, then hop on his side and wait to be adjusted. Now you try and convince me THAT is placebo.

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