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.
The World Federation of Chiropractic, Strategic Plan 2019-2022 has just been published. It is an odd document that holds many surprises. Sadly, none of them are positive.
As the efficacy and safety of chiropractic spinal manipulations, the hallmark treatment that close to 100% of all chiropractic patients receive, are more than a little doubtful, one would expect that such a strategy would focus on the promotion of rigorous clinical research to create more certainty in these two important areas. If you are like me and were hoping for a firm commitment to such activities, you will be harshly disappointed.
Already in the introduction, the WFC sets an entirely different agenda:
We believe that everyone deserves access to chiropractic. We believe in chiropractors being accessible throughout the world. We believe that societies can thrive where chiropractors are available as a part of people’s health care teams.
If you are not put off by such self-serving, nauseous nonsense and read on, you find what the WFC call the ‘FOUR STRATEGIC PILLARS’
The text supporting the first three pillars consists of insufferable platitudes, and I will therefore not burden you with it. But the title of No4 did raise my hopes of finding something along the lines of an advancement of the evidence-base of chiropractic. Sadly, this turned out to be over-optimistic. Here is the 4th pillar in its full beauty:
Advancing the chiropractic profession together under the banner of evidence-based, people-centered, interprofessional and collaborative care.
Around the world health is delivered according to prevailing societal, cultural and political factors. These social determinants mean that chiropractors must adapt to the environment in which they practice.
As a global federation we must continuously strive to advance awareness of chiropractic under a banner of ethical, evidence-based, people-centered care.
Through consensus-building, shared understanding and respectful dialogue with partners in the health system, chiropractic should become a valued partner in contributing enhanced population health.
Throughout our 7 world regions, we must advance public utilization of chiropractors to optimize the health of nations.
Through the identification of common values and a commitment to patient-centered care, we can advance the identity of chiropractors as spinal health care experts in the health care system.
The WFC will:
– Advance awareness of chiropractic among the general public, within health systems and among health professionals.
– Advance access to chiropractors for all people and broaden the integration of chiropractic services
– Advance interprofessional collaboration and the integration of chiropractic into health systems
END OF QUOTE
The essence of the WFC strategy for the next 3 years thus seems to be as follows:
- Avoid any discussion about the lack of evidence of chiropractic.
- Promote chiropractic to the unsuspecting public at all cost.
- Make sure chiropractors’ cash flow is healthy.
There are some commentators on this blog who regularly try to make us believe that chiropractic is about to reform, leave obsolete concepts behind, and become a respectable, ethical and evidence-based healthcare profession. After reading the appalling drivel the WFC call their ‘strategic plan’, I am not optimistic that they are correct.
Guest post by Toby Katz
Who am I?
I’m a final-year graduate medic (also hold an Economics degree) studying at St George’s University. I founded the Integrative Medicine Society at the university, with the aim of hosting talks on evidence-based CAM. My interest in evidence-based CAM arose as many of my family members have benefitted from different CAM interventions (mostly due to chronic MSk pain), where conventional interventions (physiotherapy and chronic pain teams) have failed to resolve their issues.
When it comes to the CAM debate, I see myself as a centrist. I am both a CAM apologist and sceptic and in recent years I have looked to educate myself around this subject. I have read Ernst’s Desktop Guide to CAM and Moral Maze books, spoken to Professor Colquhoun and most recently I undertook the Foundation Course in CAM run by the College of Medicine. My review of the course follows.
Overall, there’s a lot to learn from both sides of the debate and the debate continues due to systematic issues in the UK. Ad hominem attacks don’t help anyone, but conversation can. I hope I can converse with many of you in the future.
The Foundation Course
Two days of fast-paced talks on Integrative/Complementary and Alternative Medicine. The topics included: Resilience, nutritional therapy, medical acupuncture, MSk methods for non-osteopaths, homeopathy, herbs and spices, imagery and relaxation, cancer, hypnotherapy and social prescribing.
The speakers included: Professor David Peters, Dr Catherine Zollman (Medical Director for Penny Brohn), Heather Richards (Nutritional Therapist), Dr Elizabeth Thompson (GP and homeopath), Trevor Hoskisson (Hypnotherapist), Dr Mike Cummings (BMAS), Simon Mills (Medical Herbalist) – at least two of these are already in the infamous Alt Med Hall of Fame!
My initial feelings upon hearing the talks were that most of these individuals are inherently good people, who want the best outcomes for their patients. Their aim is to operate in the areas of medicine where conventional medicine doesn’t hold the answers – chronic pain, idiopathic headache, IBS etc. But there were also people who were advocating the use of unproven alternative therapies.
These were some of my thoughts I jotted down during the two days:
Professor Peters – Constantly speaking in generalisations. Uses historic references, romantic and philosophical language to entice listeners but generally has little point to what he says. Suffers from tangential thinking. Loses track of his own point. Very Freudian-like thinking (everyone has gone through childhood trauma according to him).
Dr Catherine Zollman – Brilliant. Absolutely brilliant. The doctor I resonate most closely with out of everyone speaking. Promoting the holistic management of a cancer diagnosis; integrating (not undermining) conventional medicine with complementary ways of dealing with the stress surrounding the diagnosis and much more. Works for a non-for-profit organisation. She has many years of oncology experience and strives to create a patient-centred approach to management.
Dr Mike Cummings – promoting medical acupuncture mainly for myofascial pain syndrome. I volunteered to receive acupuncture in my shoulder (have had post-op muscular pain since April). He dry-needled one of my trigger points and it helped, for a few days – this is better than anything a physio has done for me so far. I don’t know why dry-needling isn’t taught at medical school to help with myofascial pain syndrome.
Dr Elizabeth Thompson – Very respectable but I do feel the homeopathy ship has well and truly sailed. Provided ‘evidence’ on how ‘succussion’ changes the make-up of water molecules. Though Dr Thompson is medically trained, there are many non-medical homeopaths who promote things such as homeoprophylaxis and anti-vaccine views and I’m more worried about these such homeopaths. I do respect Dr Thompson and believe her when she says she has helped many patients. Whether this is due to placebo or the get-better-anyway effect I don’t know.
What they were promoting
On reflection, it’s clear that there was a real mix in promoting evidence-based therapies and eyebrow-raising alternatives – this is often difficult for those with an untrained eye to spot the difference. There was a general air of distrust with modern science and EBM floating around the room at all times. Sure, there are things wrong with it, but I think it’s done us pretty well over the last few decades!
I irritated a few speakers when I asked about the evidence behind their claims!
What to take away
There were many GPs present, who stated they’re often in a difficult position in the current system of healthcare we have in the UK. Around half of all consultations are MSk based, many of which are associated with chronic, muscular pain. The WHO analgesic pathway does little for these patients (unless you want to knock them for six with oxycodone) and physiotherapists struggle to make a real difference in a 30-minute appointment. The truth is, we are not providing GPs with the right toolkit to cope with these “difficult” patients.
– Get a copy of Ernst et al.’s Desktop Guide for CAM
– Release more formal guidelines using this book as a base for any positive evidence
– Engage in conversation with those from both sides. We have a lot to learn from one another
– SCRAP the forms of CAM that have no plausibility
Food for thought
– If a patient’s pain improves after a session of acupuncture and not from physiotherapy, does it fit with a utilitarian ethical model to deny this person access to acupuncture if EBM shows acupuncture has rates similar to placebo?
– Chronic myofascial pain syndrome. Can we manage it better in primary care? Why not teach dry needling to healthcare professionals? (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107879/ – Desai et al suggest it works)
– What is the alternative for no CAM for many patients who suffer? If patient’s choice is reduced, does that not reduce their autonomy?
If anyone wishes to contact me, you can at firstname.lastname@example.org
Cupping is a so-called alternative medicine (SCAM) that has existed in several ancient cultures. It recently became popular when US Olympic athletes displayed cupping marks on their bodies, and it was claimed that cupping is used for enhancing their physical performance. There are two distinct forms: dry and wet cupping.
Wet cupping involves scarring the skin with a sharp instrument and then applying a cup with a vacuum to suck blood from the wound. It can thus be seen (and was traditionally used) as a form of blood-letting. Wet cupping is being recommended by enthusiasts for a wide range of conditions. But does it work?
This study compared the effects of wet-cupping therapy with conventional therapy on persistent nonspecific low back pain (PNSLBP). In this randomized clinical trial, 180 participants with the mean age of 45±10 years old, who had been suffering from PNSLBP were randomly assigned to wet-cupping or conventional treatment. The wet-cupping group was treated with two separate sessions (4 weeks in total) on the inter-scapular and sacrum area. In the conventional treatment group, patients were conservatively treated using rest (6 weeks) and oral medications (3 weeks). The primary and the secondary outcome were the quantity of disability using Oswestry Disability Index (ODI), and pain intensity using Visual Analogue Scale (VAS), respectively.
The results show that there was no significant difference in demographic characteristics (age, gender, and body mass index) between the two groups. Therapeutic effect of wet-cupping therapy was comparable to conventional treatment in the 1st month follow-up visits. The functional outcomes of wet-cupping at the 3rd and 6th month visits were significantly superior compared to the conventional treatment group. The final ODI scores in the wet-cupping and conventional groups were 16.7 ± 5.7 and 22.3 ± 4.5, respectively (P<0.01).
The authors concluded that wet-cupping may be a proper method to decrease PNSLBP without any conventional treatment. The therapeutic effects of wet-cupping can be longer lasting than conventional therapy.
Perhaps the authors were joking? In any case, their conclusions cannot be taken seriously. Why? There are several reasons, but the most obvious ones are:
- There was no adequate control of the presumably substantial placebo effects of wet cupping.
- The control group received a treatment that is known to be ineffective or even detrimental.
For people with acute low back pain, advice to rest in bed is less effective than advice to stay active. Thus comparing wet cupping to a control group treated with bed rest is bound to generate a false-positive outcome for wet cupping.
My final point is perhaps the most important: wet cupping can lead to serious complication, and I therefore do not recommend it to anyone – other than masochists, perhaps.
This paper reports a survey amongst European chiropractors during early 2017. Dissemination was through an on-line platform with links to the survey being sent to all European chiropractic associations regardless of European Chiropractors’ Union (ECU) membership and additionally through the European Academy of Chiropractic (EAC). Social media via Facebook groups was also used to disseminate links to the survey.
One thousand three hundred twenty and two responses from chiropractors across Europe representing approximately 17.2% of the profession were collected. Five initial self-determined chiropractic identities were collapsed into 2 groups categorised as orthodox (79.9%) and unorthodox (20.1%); by the latter term, the investigators mean the subluxationists/vitalists.
When comparing the percentage of new patients chiropractors x-rayed, 23% of the unorthodox group x-rayed > 50% of their new patients compared to 5% in the orthodox group. Furthermore, the proportion of respondents reporting > 150 patient encounters per week in the unorthodox group were double compared to the orthodox (22 v 11%). Lastly the proportion of those respondents disagreeing or strongly disagreeing with the statement “In general, vaccinations have had a positive effect on global public health” was 57 and 4% in unorthodox and orthodox categories respectively. Logistic regression models identified male gender, seeing more than 150 patients per week, no routine differential diagnosis, and not strongly agreeing that vaccines have generally had a positive impact on health as highly predictive of unorthodox categorisation.
The authors concluded that despite limitations with generalisability in this survey, the proportion of respondents adhering to the different belief categories are remarkably similar to other studies exploring this phenomenon. In addition, and in parallel with other research, this survey suggests that key practice characteristics in contravention of national radiation guidelines or opposition to evidence based public health policy are significantly more associated with non-orthodox chiropractic paradigms.
N (%) Orthodox
N (%) Unorthodox
I am being told to educate myself and rethink the subject of NAPRAPATHY by the US naprapath Dr Charles Greer. Even though he is not very polite, he just might have a point:
Edzard, enough foolish so-called scientific, educated assesments from a trained Allopathic Physician. When asked, everything that involves Alternative Medicine in your eyesight is quackery. Fortunately, every Medically trained Allopathic Physician does not have your points of view. I have partnered with Orthopaedic Surgeons, Medical Pain Specialists, General practitioners, Thoracic Surgeons, Forensic Pathologists and Others during the course, whom appreciate the Services that Naprapaths provide. Many of my current patients are Medical Physicians. Educate yourself. Visit a Naprapath to learn first hand. I expect your outlook will certainly change.
I have to say, I am not normally bowled over by anyone who calls me an ‘allopath’ (does Greer not know that Hahnemann coined this term to denigrate his opponents? Is he perhaps also in favour of homeopathy?). But, never mind, perhaps I was indeed too harsh on naprapathy in my previous post on this subject.
So, let’s try again.
Just to remind you, naprapathy was developed by the chiropractor Oakley Smith who had graduated under D D Palmer in 1899. Smith was a former Iowa medical student who also had investigated Andrew Still’s osteopathy in Kirksville, before going to Palmer in Davenport. Eventually, Smith came to reject Palmer’s concept of vertebral subluxation and developed his own concept of “the connective tissue doctrine” or naprapathy.
Dr Geer published a short article explaining the nature of naprapathy:
Naprapathy- A scientific, Evidence based, integrative, Alternative form of Pain management and nutritional assessment that involves evaluation and treatment of Connective tissue abnormalities manifested in the entire human structure. This form of Therapeutic Regimen is unique specifically to the Naprapathic Profession. Doctors of Naprapathy, pronounced ( nuh-prop-a-thee) also referred to as Naprapaths or Neuromyologists, focus on the study of connective tissue and the negative factors affecting normal tissue. These factors may begin from external sources and latently produce cellular changes that in turn manifest themselves into structural impairments, such as irregular nerve function and muscular contractures, pulling its’ bony attachments out of proper alignment producing nerve irritability and impaired lymphatic drainage. These abnormalities will certainly produce a pain response as well as swelling and tissue congestion. Naprapaths, using their hands, are trained to evaluate tissue tension findings and formulate a very specific treatment regimen which produces positive results as may be evidenced in the patients we serve. Naprapaths also rely on information obtained from observation, hands on physical examination, soft tissue Palpatory assessment, orthopedic evaluation, neurological assessment linked with specific bony directional findings, blood and urinalysis laboratory findings, diet/ Nutritional assessment, Radiology test findings, and other pertinent clinical data whose information is scrutinized and developed into a individualized and specific treatment plan. The diagnostic findings and results produced reveal consistent facts and are totally irrefutable. The deductions that formulated these concepts of theory of Naprapathic Medicine are rationally believable, and have never suffered scientific contradiction. Discover Naprapathic Medicine, it works.
What interests me most here is that naprapathy is evidence-based. Did I perhaps miss something? As I cannot totally exclude this possibility, I did another Medline search. I found several trials:
1st study (2007)
Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks.
At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results.
This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.
2nd study (2010)
Subjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires.
89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p < or = 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group.
Combined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain.
3rd study (2016)
Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathögskolan – the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes.
At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately.
The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option.
I don’t know about you, but I don’t call this ‘evidence-based’ – especially as all the three trials come from the same research group (no, not Greer; he seems to have not published at all on naprapathy). Dr Greer does clearly not agree with my assessment; on his website, he advertises treating the following conditions:
Chronic Neck Pain
Hip Muscle Strain
Knee Ligament Injuries
Lower Back Injuries
Lumbar Herniated Disc
Lumbar Spinal Stenosis
Sciatica (Not Due to Disc Displacement)
Sciatica (Not Due to Disc Displacement)
Sports Injuries of the Knee
Tennis Elbow (Lateral Epicondylitis)
Thoracic Disc Disorders
Thoracic Outlet Syndrome
Odd, I’d say! Did all this change my mind about naprapathy? Not really.
But nobody – except perhaps Dr Greer – can say I did not try.
And what light does this throw on Dr Greer and his professionalism? Since he seems to be already quite mad at me, I better let you answer this question.
Power Point therapy (PPT) is not what you might think it is; it is not related to a presentation using power point. Power According to the authors of the so far only study of PPT, it is based on the theories of classic acupuncture, neuromuscular reflexology, and systems theoretical approaches like biocybernetics. It has been developed after four decades of experience by Mr. Gerhard Egger, an Austrian therapist. Hundreds of massage and physiotherapists in Europe were trained to use it, and apply it currently in their practice. The treatment can be easily learned. It is taught by professional PPT therapists to students and patients for self-application in weekend courses, followed by advanced courses for specialists.
The core hypothesis of the PPT system is that various pain syndromes have its origin, among others, in a functional pelvic obliquity. This in turn leads to a static imbalance in the posture of the body. This may result in mechanical strain and possible spinal nerve irritation that may radiate and thus affect dermatomes, myotomes, enterotomes, sclerotomes, and neurotomes of one or more vertebra segments. Therefore, treating reflex zones for the pelvis would reduce and possibly resolve the functional obliquity, improve the statics, and thus cure the pain through improved function. In addition, reflex therapy might be beneficial also in patients with unknown causes of back pain. PPT uses blunt needle tips to apply pressure to specific reflex points on the nose, hand, and feet. PPT has been used for more than 10 years in treating patients with musculoskeletal problems, especially lower back pain.
Sounds more than a little weird?
Yes, I agree.
Perhaps we need some real evidence.
The aim of this RCT was to compare 10 units of PPT of 10 min each, with 10 units of standard physiotherapy of 30 min each. Outcomes were functional scores (Roland Morris Disability, Oswestry, McGill Pain Questionnaire, Linton-Halldén – primary outcome) and health-related quality of life (SF-36), as well as blinded assessments by clinicians (secondary outcome).
Eighty patients consented and were randomized, 41 to PPT, 39 to physiotherapy. Measurements were taken at baseline, after the first and after the last treatment (approximately 5 weeks after enrolment). Multivariate linear models of covariance showed significant effects of time and group and for the quality of life variables also a significant interaction of time by group. Clinician-documented variables showed significant differences at follow-up.
The authors concluded that both physiotherapy and PPT improve subacute low back pain significantly. PPT is likely more effective and should be studied further.
I was tempted to say ‘there is nothing fundamentally wrong with this study’. But then I hesitated and, on second thought, found a few things that do concern me:
- The theory on which PPT is based is not plausible (to put it mildly).
- It would have been easy to conduct a placebo-controlled trial of PPT. The authors justify their odd study design stating this: This was the very first randomized controlled trial of PPT. Therefore, the study has to be considered a pilot. For a pivotal study, a clearly defined primary outcome would have been essential. This was not possible, as no previous experience was able to suggest which outcome would be the best. In my view, this is utter nonsense. Defining the primary outcome of a back pain study is not rocket science; there are plenty of validated measures of pain.
- The study was funded by the Foundation of Natural Sciences and Technical Research in Vaduz, Liechtenstein. I cannot find such an organisation on the Internet.
- The senior author of this study is Prof H Walach who won the prestigious award for pseudoscientist of the year 2012.
- Walach provides no less than three affiliations, including the ‘Change Health Science Institute, Berlin, Germany’. I cannot find such an organisation on the Internet.
- The trial was published in a less than prestigious SCAM journal, ‘Forschende Komplementarmedizin‘ – its editor in-chief: Harald Walach.
So, in view of these concerns, I think PPT might not be nearly as promising as this study implies. Personally, I will wait for an independent replication of Walach’s findings.
A new update of the current Cochrane review assessed the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. The authors included all randomised controlled trials (RCTs) examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded.
The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months.
Forty-seven RCTs including a total of 9211 participants were identified. Most trials compared SMT with recommended therapies. In 16 RCTs, the therapists were chiropractors, in 14 they were physiotherapists, and in 5 they were osteopaths. They used high velocity manipulations in 18 RCTs, low velocity manipulations in 12 studies and a combination of the two in 20 trials.
Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief and a small, clinically better improvement in function. High quality evidence suggested that, compared with non-recommended therapies, SMT results in small, not clinically better effects for short term pain relief and small to moderate clinically better improvement in function.
In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy.
Low quality evidence suggested that SMT does not result in a statistically better effect than sham SMT at one month. Additionally, very low quality evidence suggested that SMT does not result in a statistically better effect than sham SMT at six and 12 months. Low quality evidence suggested that SMT results in a moderate to strong statistically significant and clinically better effect than sham SMT at one month. Additionally, very low quality evidence suggested that SMT does not result in a statistically significant better effect than sham SMT at six and 12 months.
(Mean difference in reduction of pain at 1, 3, 6, and 12 months (0-100; 0=no pain, 100 maximum pain) for spinal manipulative therapy (SMT) versus recommended therapies in review of the effects of SMT for chronic low back pain. Pooled mean differences calculated by DerSimonian-Laird random effects model.)
About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event or duration of the event compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.
The authors concluded that SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
This paper is currently being celebrated (mostly) by chiropractors who think that it vindicates their treatments as being both effective and safe. However, I am not sure that this is entirely true. Here are a few reasons for my scepticism:
- SMT is as good as other recommended treatments for back problems – this may be so but, as no good treatment for back pain has yet been found, this really means is that SMT is as BAD as other recommended therapies.
- If we have a handful of equally good/bad treatments, it stand to reason that we must use other criteria to identify the one that is best suited – criteria like safety and cost. If we do that, it becomes very clear that SMT cannot be named as the treatment of choice.
- Less than half the RCTs reported adverse effects. This means that these studies were violating ethical standards of publication. I do not see how we can trust such deeply flawed trials.
- Any adverse effects of SMT were minor, restricted to the short term and mainly centred on musculoskeletal effects such as soreness and stiffness – this is how some naïve chiro-promoters already comment on the findings of this review. In view of the fact that more than half the studies ‘forgot’ to report adverse events and that two serious adverse events did occur, this is a misleading and potentially dangerous statement and a good example how, in the world of chiropractic, research is often mistaken for marketing.
- Less than half of the studies (45% (n=21/47)) used both an adequate sequence generation and an adequate allocation procedure.
- Only 5 studies (10% (n=5/47)) attempted to blind patients to the assigned intervention by providing a sham treatment, while in one study it was unclear.
- Only about half of the studies (57% (n=27/47)) provided an adequate overview of withdrawals or drop-outs and kept these to a minimum.
- Crucially, this review produced no good evidence to show that SMT has effects beyond placebo. This means the modest effects emerging from some trials can be explained by being due to placebo.
- The lead author of this review (SMR), a chiropractor, does not seem to be free of important conflicts of interest: SMR received personal grants from the European Chiropractors’ Union (ECU), the European Centre for Chiropractic Research Excellence (ECCRE), the Belgian Chiropractic Association (BVC) and the Netherlands Chiropractic Association (NCA) for his position at the Vrije Universiteit Amsterdam. He also received funding for a research project on chiropractic care for the elderly from the European Centre for Chiropractic Research and Excellence (ECCRE).
- The second author (AdeZ) who also is a chiropractor received a grant from the European Chiropractors’ Union (ECU), for an independent study on the effects of SMT.
After carefully considering the new review, my conclusion is the same as stated often before: SMT is not supported by convincing evidence for back (or other) problems and does not qualify as the treatment of choice.
Osteopathy is a tricky subject:
- Osteopathic manipulations/mobilisations are advocated mainly for spinal complaints.
- Yet many osteopaths use them also for a myriad of non-spinal conditions.
- Osteopathy comprises two entirely different professions; in the US, osteopaths are very similar to medically trained doctors, and many hardly ever employ osteopathic manual techniques; outside the US, osteopaths are alternative practitioners who use mainly osteopathic techniques and believe in the obsolete gospel of their guru Andrew Taylor Still (this post relates to the latter type of osteopathy).
- The question whether osteopathic manual therapies are effective is still open – even for the indication that osteopaths treat most, spinal complaints.
- Like chiropractors, osteopaths now insist that osteopathy is not a treatment but a profession; the transparent reason for this argument is to gain more wriggle-room when faced with negative evidence regarding they hallmark treatment of osteopathic manipulation/mobilisation.
A new paper authored by osteopaths is an attempt to shed more light on the effectiveness of osteopathy. The aim of this systematic review evaluated the impact of osteopathic care for spinal complaints. Only randomized controlled trials conducted in high-income Western countries were considered. Two authors independently screened the titles and abstracts. Primary outcomes included ‘pain’ and ‘functional status’, while secondary outcomes included ‘medication use’ and ‘health status’.
Nineteen studies were included and qualitatively synthesized. Nine studies were from the US, followed by Germany with 7 studies. The majority of studies (n = 13) focused on low back pain.
In general, mixed findings related to the impact of osteopathic care on primary and secondary outcomes were observed. For the primary outcomes, a clear distinction between US and European studies was found, where the latter RCTs reported positive results more frequently. Studies were characterized by substantial methodological differences in sample sizes, number of treatments, control groups, and follow-up.
The authors concluded that “the findings of the current literature review suggested that osteopathic care may improve pain and functional status in patients suffering from spinal complaints. A clear distinction was observed between studies conducted in the US and those in Europe, in favor of the latter. Today, no clear conclusions of the impact of osteopathic care for spinal complaints can be drawn. Further studies with larger study samples also assessing the long-term impact of osteopathic care for spinal complaints are required to further strengthen the body of evidence.”
Some of the most obvious weaknesses of this review include the following:
- In none of the studies employed blinding of patients, care provider or outcome assessor occurred, or it was unclear. Blinding of outcome assessors is easily implemented and should be standard in any RCT.
- In three studies, the study groups differed to some extent at baseline indicating that randomisation was not successful..
- Five studies were derived from the ‘grey literature’ and were therefore not peer-reviewed.
- One study (the UK BEAM trial) employed not just osteopaths but also chiropractors and physiotherapists for administering the spinal manipulations. It is therefore hardly an adequate test of osteopathy.
- The study was funded by an unrestricted grant from the GNRPO, the umbrella organization of the ‘Belgian Professional Associations for Osteopaths’.
Considering this last point, the authors’ honesty in admitting that no clear conclusions of the impact of osteopathic care for spinal complaints can be drawn is remarkable and deserves praise.
Considering that the evidence for osteopathy is even far worse for non-spinal conditions (numerous trials exist for all sorts of other conditions, but they tend to be flimsy and usually lack independent replications), it is fair to conclude that osteopathy is NOT an evidence-based therapy.
Chronic back pain is often a difficult condition to treat. Which option is best suited?
A review by the US ‘Agency for Healthcare Research and Quality’ (AHRQ) focused on non-invasive nonpharmacological treatments for chronic pain. The following therapies were considered:
- mind-body practices,
- psychological therapies,
- multidisciplinary rehabilitation,
- mindfulness practices,
- manual therapies,
- physical modalities,
Here, I want to share with you the essence of the assessment of spinal manipulation:
- Spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in short-term function (3 trials, pooled SMD -0.34, 95% CI -0.63 to -0.05, I2=61%) and intermediate-term function (3 trials, pooled SMD -0.40, 95% CI -0.69 to -0.11, I2=76%) (strength of evidence was low)
- There was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control or a placebo intervention in short-term pain (3 trials, pooled difference -0.20 on a 0 to 10 scale, 95% CI -0.66 to 0.26, I2=58%), but manipulation was associated with slightly greater effects than controls on intermediate-term pain (3 trials, pooled difference -0.64, 95% CI -0.92 to -0.36, I2=0%) (strength of evidence was low for short term, moderate for intermediate term).
This seems to confirm what I have been saying for a long time: the benefit of spinal manipulation for chronic back pain is close to zero. This means that the hallmark therapy of chiropractors for the one condition they treat more often than any other is next to useless.
But which other treatments should patients suffering from this frequent and often agonising problem employ? Perhaps the most interesting point of the AHRQ review is that none of the assessed nonpharmacological treatments are supported by much better evidence for efficacy than spinal manipulation. The only two therapies that seem to be even worse are traction and ultrasound (both are often used by chiropractors). It follows, I think, that for chronic low back pain, we simply do not have a truly effective nonpharmacological therapy and consulting a chiropractor for it does make little sense.
What else can we conclude from these depressing data? I believe, the most rational, ethical and progressive conclusion is to go for those treatments that are associated with the least risks and the lowest costs. This would make exercise the prime contender. But it would definitely exclude spinal manipulation, I am afraid.
And this beautifully concurs with the advice I recently derived from the recent Lancet papers: walk (slowly and cautiously) to the office of your preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.