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

In their 2019 systematic review of spinal manipulative therapy (SMT) for chronic back pain, Rubinstein et al included 7 studies comparing the effect of SMT with sham SMT.

They defined SMT as any hands-on treatment of the spine, including both mobilization and manipulation. Mobilizations use low-grade velocity, small or large amplitude passive movement techniques within the patient’s range of motion and control. Manipulation uses a high-velocity impulse or thrust applied to a synovial joint over a short amplitude near or at the end of the passive or physiological range of motion. Even though there is overlap, it seems fair to say that mobilization is the domain of osteopaths, while manipulation is that of chiropractors.

The researchers found:

  • low-quality evidence suggesting that SMT does not result in a statistically better effect than sham SMT at one month,
  • very low-quality evidence suggesting that SMT does not result in a statistically better effect than sham SMT at six and 12 months.
  • low-quality evidence suggesting that, in terms of function, SMT results in a moderate to strong statistically significant and clinically better effect than sham SMT at one month. Exclusion of an extreme outlier accounted for a large percentage of the statistical heterogeneity for this outcome at this time interval (SMD −0.27, 95% confidence interval −0.52 to −0.02; participants=698; studies=7; I2=39%), resulting in a small, clinically better effect in favor of SMT.
  • very low-quality evidence suggesting that, in terms of function, SMT does not result in a statistically significant better effect than sham SMT at six and 12 months.

This means that SMT has effects that are very similar to placebo (the uncertain effects on function could be interpreted as the result of residual de-blinding due to a lack of an optimal placebo or sham intervention). In turn, this means that the effects patients experience are largely or completely due to a placebo response and that SMT has no or only a negligibly small specific effect on back pain. Considering the facts that SMT is by no means risk-free and that less risky treatments exist, the inescapable conclusion is that SMT cannot be recommended as a treatment of chronic back pain.

13 Responses to Spinal manipulative therapy (SMT) for chronic back pain is a mere placebo therapy

  • Usually wise to look closely at the references. For example:

    SMT as adjuvant therapy

    35 Background therapy of codeine phosphate was administered throughout.
    45 subacute low back pain
    49 continue their usual care for low back pain
    56 extension exercises only
    64 lumbar mobilisation
    65 in obese patients
    73 Spinal manipulation is a cost effective addition to “best care” for back pain in general practice.

    • A look at comparison with other recommended treatments is interesting. SMT seems to be as good or better.

      If SMT is “mere placebo” does this mean the recommended therapies are also placebo, or worse are they nocebo if the SMT is shown to be better?

      Some references, IDK, seems fishy, not sure it was even SMT…one can look them up in they wish. Most comments below is what SMT was compared to and/or findings.

      28  There seemed to be a sustained reduction in medication use at the 1-yr follow-up in the SMT/TSE group

      29  high-dose, supervised low-tech trunk exercise

      31 Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

      32  group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

      34 Active Exercise Therapy

      36 general exercise, motor control exercise

      39 (spinal stabilization?)

      40 (flexion–distraction?)

      42 Traditional bone-setting seemed more effective than exercise or physiotherapy on back pain and disability, even 1 year after therapy.

      44 both SM procedures were associated with small yet clinically important changes in functional status

      45 subacute low back pain

      47  Both physiotherapy and manual therapy decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner.

      48 (spinal mobilization?)

      51 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups.

       52 (orthopaedic manual therapy?)

       53 McKenzie method to be slightly more effective 

       55 (not even an abstract online)

      57 stabilizing training 

      59 Maitland and Mulligan lumbar mobilization

      61 This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.

      62 spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months;

      63  Inter group analyses, there was more reduction in pain and improvement in functional status in favor of MG

      68 (Mulligan SNAGs?)

      69  RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). 

      71 conventional physical and exercise therapy 

      75 medical care

      • nice try to distract from the finding that SMT is a placebo therapy;
        I would have expected nothing less from you.

        • Interesting that IF SMT is a placebo that many of the above approaches (exercise, PT, MD usual care) had an equal or worse outcome….in other words they can’t even beat a placebo.

          But sure, I could pull up those sham studies and take a critical look. Oh wait, they are very low to low quality studies.

          Hmmm…seems like none of the above work or some things work some and the goal is to find the best approaches for the patient in front of you (well, for those of us on the frontline addressing CLBP).

          Of course it’s also interesting that IF SMT is a placebo (based on very low to low quality research) that all the MDs and PhDs who write clinical guidelines are apparently to dumb to know that SMT is a placebo and they are ignorantly put it in their guidelines. Or do they know this and they are intentionally putting a placebo in the guidelines?

          Or, could it be that some people have such a strong bias against SMT that they jump on even very low quality research just to confirm their bias?

          I’ll let the readers decide.

          • there is no doubt that, at present, a really good therapy for chronic back pain has not been identified. so, you are not far from the truth when you assume they are all placebos.
            BUT AT LEAST, LET’S USE PLACEBOS THAT ARE BENIGN!!!

          • EE… there is no doubt that, at present, a really good therapy for chronic back pain has not been identified.

            Maybe they need to focus therapy on reversing cortical changes in CLBP?

            https://www.hindawi.com/journals/np/2021/6666024/

            But that’s a topic beyond the scope of this blog.

          • maybe we need to focus on using more or less useless therapies like SMT which also cause lots of adverse effects?

          • It’s a little more complicated than “causes lots of adverse effects.”

            “Adverse events are graded on a scale from 1 to 5. (Grade 0 refers to not having a symptom or problem, so someone with grade 0 pain has no pain at all.) Grade 1 adverse events are mild and generally not bothersome. Grade 2 events are bothersome and may interfere with doing some activities but are not dangerous. Grade 3 events are serious and interfere with a person’s ability to do basic things like eat or get dressed. Grade 3 events may also require medical intervention. Grade 4 events are usually severe enough to require hospitalization. Grade 5 events are fatal.” DIPG.org

            Heck, some low grade events may actually be part of reversing tissue reorganization in CLBP and be considered beneficial. But again, a topic beyond the scope of this blog.

          • you don’t need to teach me about the grading of AEs.
            “low grade events may actually be part of reversing tissue reorganization in CLBP…”
            this is another chiro favorite for which there is no evidence. Bayer might as well claim that Aspirin works best after a little stomach bleed.

          • Work on a chronic shoulder adhesive capsulitis and see if there aren’t some “mild adverse effects”. Is an initial temporary increase in pain and inflammation an expected result? Is it part of the healing process?

            It’s not a chiropractic thing. It’s well known with those who work with chronic MSK conditions.

          • if you say it is well known in quackery, it must be right. you are the expert.

          • Talk to PTs who rehab chronic MSK conditions.

            Apparently you don’t know much about “adverse effects” when dealing with chronic MSK conditions.

            Here are some basics on CLBP with mention of deconditioning and hypo fusion of muscles.

            https://www.frontiersin.org/articles/10.3389/fmed.2018.00077/full

            Hmmm….one has to wonder if one begins to increase fusion and reconditions skeletal muscles if there may be a “washout” period resulting in temporary increase in pain? Not to mention any facet capsule adhesions.

            But your comments do shed some light on your confusion on the topic. Apparently for you school is in session.

  • So if SMT has the same effect as exercise (be it placebo or not) and yet exercise is better than “standard medical care” it seems both should be offered before “standard medical care” (which may be a placebo anyway?).

    “ There is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.” Clint T Miller et al. Sports Med. 2021.

    Unless the fact that it is very low quality evidence is now relevant.

    Of course combining SMT and exercise, for example, may be a better approach.

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