Draft guidelines from NICE on treatments for chronic primary pain. Part 2: MANUAL THERAPY

As mentioned already yesterday, NICE published a draft report on pain treatments. The draft is now open to public consultation until 14 September 2020, and some of my readers might want to comment. It suggests that people with chronic primary pain (CPP) should not get pain-medication of any type, but be offered supervised group exercise programmes, some types of psychological therapy, or acupuncture.

No recommendation is made for manual therapy, but a lengthy document evaluates with the subject in some detail. Here are what I consider to be the key passages from its clinical evidence section:

Mixed modality manual therapy versus usual care/acupuncture/dry needling
Pain reduction
Low quality evidence from 2 studies with a total of 52 participants showed no clinically important difference between mixed modality manual therapy and usual care at time points up to 3 months. Low quality evidence from 1 study with a total of 33 participants showed a clinically important benefit of mixed modality manual therapy over usual care at time points after 3 months. Low quality evidence from 1 study with a total of 26 participants showed no clinically important difference between mixed modality manual therapy and acupuncture/dry needling at time points up to 3 months.

Soft tissue technique versus usual care/acupuncture/dry needling
Pain reduction
Low quality evidence from 3 studies with a total of 286 participants showed a clinically important benefit of soft tissue technique over usual care at time points up to 3 months. Very low quality evidence from 2 studies with a total of 115 participants showed a clinically important benefit of acupuncture/dry needling over soft tissue technique at time points up to 3 months.

Manipulation/mobilisation versus usual care/acupuncture/dry needling

Pain reduction
Low quality evidence from 1 study with a total of 30 participants showed a clinically important benefit of manipulation/mobilisation over usual care at time points up to 3 months. Very low quality evidence from 1 study with a total of 24 participants showed no clinically important difference between manipulation/mobilisation and acupuncture/dry needling at time points up to 3 months.

Manual therapy interventions compared with each other
Pain reduction
Moderate quality evidence from 1 study with a total of 63 participants showed a clinically important benefit of mixed modality manual therapy over soft tissue technique at time points up to 3 months. Low quality evidence from 1 study with a total of 63 participants showed a clinically important benefit of mixed modality manual therapy over soft tissue technique at time points after 3 months. Low quality evidence from 1 study with a total of 30 participants showed a clinically important benefit of mixed modality manual therapy over manipulation/mobilisation at time points up to 3 months. Very low quality evidence from 3 studies with a total of 125 participants showed a clinically important benefit of manipulation/mobilisation over soft tissue technique at time points up to 3 months. Low quality evidence from 1 study with a total of 68 participants showed no clinically important difference between manipulation/mobilisation and soft tissue technique at time points after 3 months.

In my view, this is a sound assessment of effectiveness. Nonetheless, I should to mention a few critical points.

Manual therapy is a very heterogeneous group of interventions. Massage and spinal manipulation, for instance, are very different in almost every respect. It would therefore be more constructive to name the techniques more precisely. Evaluating them together makes little sense to me and is hardly different from an assessment of all pharmacological treatments.

Much more important is the fact that the document lacks an assessment of harms. All I did find was a comment saying ‘THERE WAS NO EVIDENCE OF HARM’. This statement is certainly misleading. Perhaps the clinical trials did not report adverse effects, but this is (as I have often pointed out) because these studies usually defy research ethics by failing to mention them. As we have discussed ad nauseam on this blog (for instance here, here and here), spinal manipulation has regularly been associated with severe harms many times.

As NICE do not suggest to recommend manual therapy for CPP, this is perhaps not so crucial in this particular instance. However, I do believe that, for completeness of the evidence as well as for the credibility of the research, an in-depth assessment of the risks is paramount when it comes to the assessment of any therapy.