This systematic review assessed the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development.

Different databases were screened up to 20 August 2020. Randomized controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included. Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology, and reflexology) and to no treatment. Primary outcomes were BP improvement, the success of blinding, and adverse effects (AE). Secondary outcomes were the number of drop-outs. Dichotomous outcomes were analyzed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score.

A total of 24 trials were included involving 2019 participants. Most of the trials were of chiropractic manipulation. Very low evidence quality suggests clinically insignificant pain improvement in favor of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI -20.46 to 8.78).ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation is the most recognized technique. Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55).

The authors concluded that MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings. Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects.

The optimal therapy for back pain does not exist or has not yet been identified; there are dozens of different approaches but none has been found to be truly and dramatically effective. Manual therapies like chiropractic and osteopathy are often used, and some data suggest that they are as good (or as bad) as most other options. This review confirms what we have discussed many times previously (e.g. here), namely that the small positive effect of MT, or specifically spinal manipulation, is largely due to placebo.

Considering this information, what is the best treatment for back pain sufferers? The answer seems obvious: it is a therapy that is as (in)effective as all the others but causes the least harm or expense. In other words, it is not chiropractic nor osteopathy but exercise.

My conclusion:

avoid therapists who use spinal manipulation for back pain.

54 Responses to Manual therapies for back pain: not better than a placebo

  • EE: This review confirms what we have discussed many times previously (e.g. here), namely that the small positive effect of MT, or specifically spinal manipulation, is largely due to placebo.

    No. What this review reveals is there is a lot of very low quality evidence which doesn’t give us enough insight to make any detetminations.

    • the default position is that any therapy that is not supported by sound evidence for effectiveness is considered ineffective until good data show otherwise.

      • How much of modern medicine is supported by “sound evidence”? How about within physical therapy? Shall we stop all those therapies until we have “sound evidence”? Good luck with that.

        • How much of modern medicine is supported by “sound evidence”?

          you should really learn to control your urge to indulge in logical fallacies!

          • Oh, so you have a double standard?

          • that I can safely leave to you

          • you refuse to answer the question…typical

          • I have a suggestion:
            look up the definition of a ‘troll’ and ask yourself whether you are one.

          • I am not a troll because I could care less if you have an emotional response or not.

            But if you have a criteria of “sound evidence” (whatever that entails) that should include all therapeutic approaches…medicine or alternative medicine.

            Your avoidance indicates that you do have different standards, which I suppose being a MD, is expected, as it would bring into question various current medical approaches.

      • Case in point, EE. The use of Paracetemol in the treatment of low back pain. No better than a placebo. See Lancet March 2018 issues. Of course, you never look into these types of issues. Your scorecard still remains the same,
        “A” for inconsistency
        “F”(fail) for ethics and integrity.

  • Eleven trials used a single therapy session with a single technique performed in eight of those trials.

    Trials involved physiotherapists (N=8), physical therapists (N=4), osteopaths (N=3) and osteopathic students (N=1).

    This review included generally small trials. Only 14 of 24 studies performed a sample size calculation but just two of these considered MCID in this computation.

    placebo effect might be influenced by chronic pain, nevertheless, in this review, this analysis could not be performed due to the range of pain duration in trials included (from acute to chronic in the same trial).

    most of the trials included did not evaluate an objective outcome

    In MT trials, a true placebo is impossible to achieve

  • Edzard,

    Use common sense. chiropractic is worthless, had they done the study with true osteopathy, the outcomes would be different. People with chronic back pain for 10 years are often cured with Osteo.. my methods anyway.

    You’re just a bitter little sheytan . People come to me for one appointment and are cured of pain. You should come visit sometime . Or not you stay stiff and in pain walking like u need a shit


    Elite Osteo

  • Another review where Ernst forgets to say the inconvenient part: physiotherapy, which is the standard therapy, does not seem to work better than placebo to soothe back pain. Ernst may think that the findings of the review are a disaster for osteopaths, but he forgets that many of the “anti-pseudoscience activists” are physiotherapists. Ernst, you have a double standard. Weren’t you the one who laughed at acupuncturists when they compared inserting needles to placebo needles? Well, now your enemies can laugh at you because according to that review, physiotherapy “the sound standard of evidence” has no better effect than any other manual technique and placebo effect. What’s next? Antibiotics? vaccines such as flu that are not more effective than placebo and most trials are of low quality?

  • Spinal manipulation used as an adjunct with physiologic therapeutic modalities appears to obtain the best results. This systematic review and pairwise meta-analysis appear to conclude with similar outcomes of short term research results. That result is that many manual treatments seem to get the same results over the short term but when compared with structural rehabilitation that changes skeletal alignment, patient groups that only receive standard physiotherapy treatment do not obtain long term benefit compared to spinal remodelling traction. It’s time to compare spinal remodelling traction with generic exercise protocols.

  • EE…Most of the trials were of chiropractic manipulation.

    “Characteristics of the practitioner who administrated treatments were provided by 16 trials. Trials involved physiotherapists (N=8), physical therapists (N=4), osteopaths (N=3) and osteopathic students (N=1).”

  • Of course manual therapists including chiropractors may combine SMT with exercise. It appears it may have an additive effect for some conditions. Example:

    Manipulation and exercise showed greater improvement compared to ultrasound and exercise for participants with chronic low back pain, both at the end of treatment and at six months follow-up. Australian Journal of Physiotherapy Volume 52, Issue 4, 2006, Page 306

    From the Job Analysis of Chiropractic

    98.5 % of chiropractors recommended physical fitness/exercise (2014) several times a day.
    96.8% utilize corrective or therapeutic exercise and 92.3% use rehabilitation/stabilization exercises for the spine (2009)

    Heck, DD Palmer was recommending exercise as early at 1916 or so and his son BJ had a rehabilitation center at the college around the 1940s for “when spinal manipulation and the medical approach isn’t enough.” (Not an exact quote)

    What was the medical profession recommending during that time period? Was it drugs and bed rest?

      • Troll? Nah. I think the word you’re looking for is pedantic.

        But when looking at research little details do matter.

        • “But when looking at research little details do matter.”
          exactly, my chiro-troll!
          and the little detail that counts is this: spinal manipulation is not backed by good evidence for effectiveness [or safety].

          • EE, You calling DC a “chirotroll”, is amusing and sad at the same time. You have reverted to “name calling”, which is a sure sign of defeat. As a child, we had a playground nursery rhyme. It went like this,
            “Sticks and stones may break my bones, but names will never hurt me”.
            Grow up EE, stick to the facts and stop calling people names. DC is far more eloquent, resourceful and ethical than you are. It is time for you to retire.

          • chiro-troll is a factual description of what he was doing
            if I had wanted some name-calling, I would have surely thought of something better [his courageous pseudonym ‘DC’ is inviting enough]

          I do like clearly and concisely expressed views and am often as outspoken as politeness allows. I hope that commentators will do the same, no matter whether they agree or disagree with me. However, I will now insist that we all observe a minimum of courtesy towards each other.

          Twelve simple rules must be observed when commenting on my blog.

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  • If there was anywhere near conclusive evidence that there was a benefit worth reading through the ego-driven drama on comments sections that refer to manual therapy, there would be no need for the comments to begin with. The very fact that the silly “debate” has been raging for so long is the existential angst experienced by proponants who are petrified of being exposed as modern day charlatans. I would bet good money that such silly, sandbox jousting involves exclusively male egos, or pretty close. Such quackery.

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