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

Recently, we discussed the findings of a meta-analysis which concluded that walking, which is easy to perform and highly accessible, can be recommended in the management of chronic LBP to reduce pain and disability.

At the time, I commented that

this will hardly please the legions of therapists who earn their daily bread with pretending their therapy is the best for LBP. But healthcare is clearly not about the welfare of the therapists, it is/should be about patients. And patients should surely welcome this evidence. I know, walking is not always easy for people with severe LBP, but it seems effective and it is safe, free and available to everyone.

My advice to patients is therefore to walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.

Now, there is new evidence that seems to confirm what I wrote. An international team of researchers requested individual participant data (IPD) from high-quality randomised clinical trials of patients suffering from persistent low back pain. They conducted descriptive analyses and one-stage IPD meta-analysis. They received IPD for 27 trials with a total of 3514 participants.

For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up.

Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care.

But you cannot dismiss so-called alternative medicine (SCAM), just like that, I hear my chiropractic and other manipulating friends exclaim – at the very minimum, we need direct comparisons of the two approaches!!!

Alright, you convinced me; here you go:

The purpose of this systematic review was to determine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with chronic low back pain (CLBP). Only RCTs that compared head-to-head spinal manipulation to an exercise group were included in this review. Only three RCTs met the inclusion criteria. The outcomes used in these studies included Disability Indexes, Pain Scales and function improvement scales. One RCT found spinal manipulation to be more effective than exercise, and the results of another RCT indicated the reverse. The third RCT found both interventions offering equal effects in the long term. The author concluded that there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP. More studies are needed to further explore which intervention is more effective.

Convinced?

No?

But I am!

Exercise is preferable to chiropractic and other manipulating SCAMs because:

  1. It is cheaper.
  2. It is safer.
  3. It is readily available to anyone.
  4. And you don’t have to listen to the bizarre and often dangerous advice many chiros offer their clients.

17 Responses to Suffering from persistent low back pain? Forget about Chiropractic or other SCAMs

  • Do try and stay professional… walking is great indeed and hydrowalk is possibly even better… what does that have to do with your obsession with Chiropractic?

  • Full marks to “Dr G. Almog” for not using a pseudonym on this post (at least I assume it is not).
    Zero marks for trying to kid us he’s a ‘doctor’ – when he has no primary medical qualification.

    Given he appears not to have studied and qualified in medicine, can he enlighten us as to why not?
    Why qualify in chiropractic (“a different system to medicine” – DD Palmer) and not osteopathy, physiotherapy or medicine?

    And given styles and titles usually denote the profession professed (‘Doctor’; ‘Captain’; ‘General’; ‘President’; ‘Judge’; Rabbi’ etc., why do not chiropractors designate themselves for example: ‘Chiropractor Almog’ – ‘Ch. Almog’?

    Who are chiropractors trying to kid, and why?

    • Meanwhile, whilst Richard Rawlins is scrabbling to find the word “doctor”on his initial medical qualification, and whilst he uses the courtesy title “doctor”, the following are some very recent article about medical practitioners who have erred:

      https://www.medscape.com/viewarticle/922085?nlid=132893_1842&src=WNL_mdplsfeat_191206_mscpedit_wir&uac=121842PR&spon=17&impID=2194057&faf=1

      and whilst Michael Kenny is joining E.E., Rawlins et al in the pot of hypocrisy, the following article had recently appeared:

      https://www.medpagetoday.com/publichealthpolicy/healthpolicy/83711?xid=nl_badpractice_2019-12-06&eun=g528268d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=BadPractice_120619&utm_term=NL_Gen_Int_Bad_Practice%20-%20Active

      Another perfect example of the “Pot calling the kettle black”.

      In regard to your profession of physiotherapy, Michael. I have had three physios tell me that the average time a physio lasts in practice is seven years before they give up. Why do you thing that is? Do you think that the “hands-on homeopathy” and the “shake, bake and fake”of physiotherapy becomes too much for them?

      • @GibletGiblet & AN: you and your ilk argue in a similar format every time you put down your Activator and nerve chart and approach the keypad….pointing to others’ bad behavior to either mitigate your own or to simply try to confound the playing field. Like chiroquackery it’s childish, unprofessional and demeaning. Analogy is not argument.
        As to Physical Therapy I would argue it’s the best that can be offered in the realm of “physical modes” of trying to do the impossible: treat away pain. PT is big business and certainly has its problems, one of its biggest is having to demean itself in trying to compete with quacks. I believe MacKenzie observed 75% of PT treatments are either unnecessary or even useless, often “addicting” susceptible patients to the therapist. He admitted it and attempted to change things…addicting the gullible to life-time “adjustments” is the chiroquackery shibboleth. Pushing around skin-&-muscle receptors to transiently alter pain is not a terrible thing to offer….it becomes terrible when it’s exorbitantly priced, surrounded in hyperbole and administered in a shroud of pseudoscience, religiosity and by faux-doctors. I’m sorry but PTs en mass DO NOT practice that way. They may be utterly ineffective in many cases but they alter their premise as research comes forward because the practice of physical-medicine is not inherently dogmatic. If you quacks wish to play by those rules I’d suggest getting into the right arena.
        Adding a few quarts of fresh motor oil to an old crankcase serves little purpose…but it is cheaper and easier than doing the job right. I opted for law school.

        • @ Michael,

          Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

          https://bmjopen.bmj.com/content/9/10/e032329

          Good luck with Law school

        • Meanwhile, whilst Michael Kenny is wallowing in the large pot calling the kettle black, some recent articles like this are appearing in the scientific literature.

          https://ejhp.bmj.com/content/23/4/187?fbclid=IwAR3_4w0n-JnuCA4wLCCb64RASf2OgK9L7wFkejLAcf-AvsDUF5F1w__Kqtc

          If you think that the chiropractic profession are dangerous, look at the statistics quoted here.

          Best wishes with your studies in law.

          • Dear chiroquackers: When I read your “responses” to anything I or other non-charlatans write I’m left dumbfounded (much like I was for a decade watching my ex-wife check legs, do PI/AS drop pelvic “adjustments”, palpate subluxations wherever her adroit fingers would find them…and tying it all together with the philosophical vomitus that spinal-misalignments, which come to find out have no reliable or valid tests to determine….are related to human health)…how your answers are utterly disconnected to the comments. Much like chiropractic is disconnected from science.
            Next time you pull yourselves away from your Green books PLEASE try to tell us philosophical tyros what advances in human knowledge have been contributed BY & FROM “chiropractic science”. Your “doctorate” is in “Chiropractic” isn’t it? There MUST surely be something to it in order to get a doctorate, correct?

      • “Do you think that the ‘hands-on homeopathy’ and the “shake, bake and fake”of physiotherapy becomes too much for them?”

        What in the world is “hands-on homeopathy?”

  • Great post! Clearly there is NO reputable science called “chiropractic”, just a mishmosh of entrepreneurial theatrics masquerading as healthcare. The more strident one becomes regarding defending the artifice the more successful one becomes. As to RRs post it seems clear a DC chooses chiroquackery because they do NOT have a proper mentor in their nascent search for a career OR (most likely) do not possess the intellectual capacity and/or confidence to pursue a reputable healthcare profession. Giving transient “relief”, placebo-effects or care-giving to those suffering from (often lifestyle-based) back Pain (a self-limiting phenomenon itself) isn’t inherently a malevolent or misguided pursuit….however suggesting there is a “source” or “cause” to be deduced and fixed via their nonsensical charade of “tests”, gizmos, procedures and farcical education leading to faux-doctor status IS….it’s tantamount to fraud. Irrespective of how many people die from opioids, MERSA or botched surgeries. In fact it appears they are best trained in Tu Quoque, red herring and strawman argumentation.
    Manipulation has been around for eons, it’s just another old scam for new eyes. If it is truly able to rectify pain better than anything else (or just walking) it’s sure takin a circuitous, expensive and unimpressive route proving itself.
    And probably has hurt a lot of people along the way.

    • @ Michael

      Are you still a physical therapist?

      What are your thoughts on the above study and its implications for physical therapists who treat low back pain (As Prof Ernst says “My advice to patients is therefore to walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.” – no need for physical therapy)

  • “Exercise therapy was observed to be similarly effective to other included comparison treatments (here including manual therapy, education or psychological therapy) for all outcomes.“ Hayden JA, et al. Br J Sports Med 2019;0:1–16. doi:10.1136/bjsports-2019-101205 1

    But medication may be needed to perform the exercise?

    “One could hypoth- esise that characteristics that may facilitate compliance with an active treatment programme (eg, using medication to alleviate low back pain symptoms, and not having physical demands at work which could lead to strain and/or a flare up of symp- toms) may be associated with improved outcomes with exercise compared with other treatments.”

  • I think the article is spot on. Exercising or just walking can help a lot to conditions from back pain to obesity if done regularly. Combine that with a healthy diet and most people would be living a disease-free life.

  • Interesting question for the regulars here.
    “What is the effect size of exercise on chronic pain, function etc?”
    For those who don’t venture past blogs here is the Cochrane Review:
    Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461882/
    Food for thought.

    • “The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies.”

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