musculoskeletal problems
Chiropractic is a complementary medicine that has been growing increasingly in different countries over recent decades. It addresses the prevention, diagnosis and treatment of the neuromusculoskeletal system disorders and their effects on the whole body health.
This review aimed to evaluate the effectiveness of chiropractic in the treatment of different diseases. To gather data, scientific electronic databases, such as Cochrane, Medline, Google Scholar, and Scirus were searched and all systematic reviews in the field of chiropractic were obtained. Reviews were included if they were specifically concerned with the effectiveness of chiropractic treatment, included evidence from at least one clinical trial, included randomized studies and focused on a specific disease. The articles were excluded if:
- – they were concerned with a combination of chiropractic and other treatments (not specifically chiropractic treatment);
- – they lacked at least one clinical trial;
- – they lacked at least one randomized study;
- – and they studied chiropractic in the treatment of multiple diseases.
The research data including the article’s first author’s name, type of disease, intervention type, number and types of research used, meta-analysis, number of participants, and overall results of the study, were extracted, studied and analyzed.
Totally, 23 chiropractic systematic reviews were found, and 11 articles met the defined criteria. The results showed the influence of chiropractic on improvement of neck pain, shoulder and neck trigger points, and sport injuries. In the cases of asthma, infant colic, autism spectrum disorder, gastrointestinal problems, fibromyalgia, back pain and carpal tunnel syndrome, there was no conclusive scientific evidence. There is heterogeneity in some of the studies and also limited number of clinical trials in the assessed systematic reviews. Thus, conducting comprehensive studies based on more reliable study designs are highly recommended.
The authors stressed that three points should be emphasized. Firstly, there is a discrepancy between the development of chiropractic in different countries of the world and the quality and quantity of studies regarding the effectiveness and safety of chiropractic in treatment of diseases. Secondly, some of the systematic reviews regarding the effectiveness of chiropractic in treatment of diseases had a minimum quality of research methodology and were not useful for evaluation. Some of the excluded articles are examples of this problem. Finally, a limited number of studies (11 systematic review articles and 10 diseases) had the required criteria and were assessed in the study.
Assessment and analysis of the studies showed the impact of chiropractic on improvement of some upper extremity conditions including shoulder and neck trigger points, neck pain and sport injuries. In the case of asthma, infant colic and other studied diseases, further clinical trials with larger sample sizes and high quality research methodology are recommended.
So, is chiroprctic of proven effectiveness for any disease?
The conditions for which there is tentatively positive evidence (btw: most rely on my research!!!) are arguably not diseases but symptoms of undelying conditions. Therefore, the answer to my question above is:
NO.
This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017.
Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T0] and 2-7 days post-treatment [T2]) and one completed by the provider immediately post-treatment [T1]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious.
From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T0 and T1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care.
From the patients visits with a complete T2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which:
- 7.9% were mild,
- 6.2% moderate,
- 3.7% severe,
- 1.5% serious,
- 2.0% had missing severity rating.
The most common symptoms reported with moderate or higher severity were:
- discomfort/pain,
- stiffness,
- difficulty walking,
- headache.
The authors concluded that this study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.
They also note that:
- The incidence of AEs reported in their study was lower than the 30%-50% reported in a recent scoping review of 250 observational and experimental studies of manual treatments of the spine.
- A similar prospective clinic-based survey collected data from 4712 encounters from Norwegian chiropractors found that 55% of these encounters had an AE.
- A clinical trial of chiropractic care for patients with neck pain found that 30% reported an AE.
- The Scandinavian College of Naprapathic Manual Medicine collected AE information from 767 patients and found that 51% of those who had at least 3 SMT treatments reported an AE.
The authors did not mention our systematic review:
The aim of this systematic review was to summarize the evidence about the risks of spinal manipulation. Articles were located through searching three electronic databases (MEDLINE, EMBASE, Cochrane Library), contacting experts (n =9), scanning reference lists of relevant articles, and searching departmental files. Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist. Where available, systematic reviews were used as the basis of this article. All papers were evaluated independently by the authors. Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.
Whatever the true rate of AEs turns out to be, one thing is very clear: it is unacceptably high, particularly if we consider that the benefits of spinal manipulations are doubtful and at best small.
This study evaluated efficacy of krill oil supplementation, compared with placebo, on knee pain in people with knee osteoarthritis who have significant knee pain and effusion-synovitis. It was designed as a multicenter, randomized, double-blind, placebo-controlled clinical trial that took place in 5 Australian cities. Participants with clinical knee osteoarthritis, significant knee pain, and effusion-synovitis on magnetic resonance imaging were enrolled from December 2016 to June 2019; final follow-up occurred on February 7, 2020.
The patients received
- 2 g/d of krill oil (n = 130)
- or matching placebo (n = 132) for 24 weeks.
The primary outcome was change in knee pain as assessed by visual analog scale (range, 0-100; 0 indicating least pain; minimum clinically important improvement = 15) over 24 weeks.
Of 262 participants randomized (mean age, 61.6 [SD, 9.6] years; 53% women), 222 (85%) completed the trial. Krill oil did not improve knee pain compared with placebo (mean change in VAS score, -19.9 [krill oil] vs -20.2 [placebo]; between-group mean difference, -0.3; 95% CI, -6.9 to 6.4) over 24 weeks. One or more adverse events was reported by 51% in the krill oil group (67/130) and by 54% in the placebo group (71/132). The most common adverse events were musculoskeletal and connective tissue disorders, which occurred 32 times in the krill oil group and 42 times in the placebo group, including knee pain (n = 10 with krill oil; n = 9 with placebo), lower extremity pain (n = 1 with krill oil; n = 5 with placebo), and hip pain (n = 3 with krill oil; n = 2 with placebo).
The authors concluded that, among people with knee osteoarthritis who have significant knee pain and effusion-synovitis on magnetic resonance imaging, 2 g/d of daily krill oil supplementation did not improve knee pain over 24 weeks compared with placebo. These findings do not support krill oil for treating knee pain in this population.
This is a rigorous and well-presented study. Apart from the ineffectiveness of krill, it confirms two issues very clearly:
- Placebo effects plus regression to the mean can lead to symptomatic improvements.
- Adverse effects occur even with placebo therapy.
Krill is a small crustacean consumed by whales, penguins and other sea creatures. It is a source of omega 3 fatty acids. The alleged benefits of krill supplements include anti-inflammatory effects. So, it could theoretically help reducing the inflammation that is part of knee osteoarthritis.
A review including five trials with 700 patients using krill oil for knee pain was recently published. Results showed no significant difference between krill oil and placebo for knee pain, knee stiffness, and lipid profiles. However, krill oil demonstrated a significant small effect in improving knee physical function. Trial sequential analysis provided certainty that krill oil enhances knee physical function compared to placebo and indicated no improvement in knee pain, but the findings for knee stiffness need to be confirmed by further research. The authors concluded that krill oil supplementation did not significantly improve knee pain, stiffness, or lipid profile, although it may help knee physical function. Based on these findings, krill oil supplementation is not yet justified for knee pain.
The two papers should settle the issue: KRILL IS NOT EFFECTIVE FOR KNEE OSTEOARTHRITIS. Will this stop the many manufacturers of krill supplements selling their products to gullible consumers? I would not hold my breath.
Yesterday, I was sent this OfS press release and asked to comment:
Approval of proposed new name for AECC University College UKPRN: 10000163
The Office for Students (OfS) has approved the use of the word ‘university’ in the provider’s change of name from ‘AECC University College’ to ‘Health Sciences University’.
The Higher Education and Research Act 2017 amended relevant legislation to give the OfS the power to consent to the use of the word university in a registered higher education provider’s name. In consenting to the inclusion of the word ’university’ in any name, the OfS has regard to the need to avoid names which are, or may be, confusing.1
The OfS has published guidance for registered higher education providers that wish to use either ‘university’ or ‘university college’ title as part of their name. This states that we will consult on a provider’s proposed new name and assess the extent to which the proposed name is, or may be, confusing or misleading.2
AECC University College applied to the OfS for approval to use the word university in its proposed new name ‘Health Sciences University’ in June 2023. We consulted on the provider’s proposed new name and received 98 responses.3 Considering the responses:
• We took the view that the provider’s proposed new name did not appear to be like any other registered English higher education provider’s name because of similarity that could cause potential confusion or be misleading.
• We agreed with some consultation responses which stated that the proposed name could be potentially misleading, for the following reasons:
o Several respondents raised concerns that the proposed name implies a scope of offering that does not match the reality of the provider’s offering.
o Several respondents raised concerns that the proposed name may suggest that the provider is the sole provider of health sciences provision in the region and/or the UK. Respondents stated that the proposed name offers a broader portfolio than the provider has in reality, and therefore the name is anti-competitive, given other providers may offer a broader scope of provision in the relevant disciplines.
• We concluded, however, that issues raised by respondents during the consultation are unlikely to cause any detriment or harm as they could be mitigated by the university’s requirement to comply with its legal obligations under consumer protection law. This means that the university must ensure that students have clear information to enable them to make informed decisions about whether they want to study there. Information would include, for example, what is meant by the term ‘health sciences’ and clear and visible communication regarding the breadth and depth of courses offered.
• Therefore, we decided to approve the proposed new name of ‘Health Sciences University’.
1 See https://www.legislation.gov.uk/ukpga/2017/29/part/1/crossheading/powers-in-relation-to-university title/enacted.
2 See ‘Regulatory Advice 13: How to apply for university college or university title’ available at:
www.officeforstudents.org.uk/publications/regulatory-advice-13-how-to-apply-for-university-college-and university-title/.
3 Available at: www.officeforstudents.org.uk/publications/proposed-new-name-for-aecc-university-college/.
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A few years ago, I was invited to visit the ‘AECC’ and give a lecture to its students. Here is the post I published about this weird experience:
As I said, yesterday, I was asked (by ‘The Times Higher’) to comment on the above press release. Here is the comment I provided; I hope they publish it:
The change from ‘AECC University College’ to ‘Health Sciences University’ is an intriguing construct emphasizing the academic status by using the term ‘university’, while hiding the true content of the institution: AECC stands for ‘Anglo-European College of Chiropractic‘; in other words, the institution is a school of chiropractic, a form of treatment that is as far from science as bungee jumping and has never convincingly demonstrated to generate more good than harm. I wonder what might be next – a ‘Health Science University for Pole Dancing’ perhaps?
Subsequently, the journalist came back to me with two further questions which I answered:
Q1: Do you think it is concerning that the OfS has allowed it to use this title?
A: This title will almost inevitably mislead consumers who might assume that, if they are granted university status, chiropractic must be backed by strong evidence for efficacy and safety.
Q2: What do you worry will be the consequences?
A: Patients who are misled in this way are in danger of wasting their money, of delaying their recovery, or of suffering significant harm.
Since it is a rare occurance these days – I retired more than a decade ago – that I publish something in the peer-reviewed literature, please allow me to make some brief comments of this review just published by Spanish researchers and myself. The aim of this systematic review with meta-analysis was to evaluate the clinical effectiveness of visceral osteopathy (VO) in musculoskeletal and non-musculoskeletal disorders.
Two independent reviewers searched in PubMed, Physiotherapy Evidence Database, Cochrane Library, Scopus, and Web of Science databases in November 2023 and extracted data for randomized controlled trials evaluating the clinical effectiveness of VO. The risk of bias and the certainty of evidence were assessed using the Risk-of-Bias tool 2 and the GRADE Profile, respectively. Meta-analyses were conducted using random effect models using RevMan 5.4. software.
Fifteen studies were included in the qualitative and seven in the quantitative synthesis. For musculoskeletal disorders, the qualitative and quantitative synthesis suggested that VO produces no statistically significant changes in any outcome variable for patients with low back pain, neck pain or urinary incontinence. For non-musculoskeletal conditions, the qualitative synthesis showed that VO was not effective for the treatment of irritable bowel syndrome, breast cancer, and very low weight preterm infants. Most of the studies were classified as high risk of bias and the certainty of evidence downgraded to low or very low.
We concluded that VO did not show any benefit in any musculoskeletal or non-musculoskeletal condition.
Yes, I agree: these findings are hardly surprising. Visceral osteopathy (or visceral manipulation) is an expansion of the general principles of osteopathy and involves the manual manipulation by a therapist of internal organs, blood vessels and nerves (the viscera) from outside the body. Visceral osteopathy was developed by the osteopath Jean-Piere Barral. He stated that through his clinical work with thousands of patients, he created this modality based on organ-specific fascial mobilization. And through work in a dissection lab, he was able to experiment with visceral manipulation techniques and see the internal effects of the manipulations.[1] According to its proponents, visceral manipulation is based on the specific placement of soft manual forces looking to encourage the normal mobility, tone and motion of the viscera and their connective tissues. These gentle manipulations may potentially improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body.[2]
Visceral osteopathy is being practised mostly by osteopaths and less commonly chiropractors and physiotherapists. It comprises of several different manual techniques firstly for diagnosing a health problem and secondly for treating it. Several studies have assessed the diagnostic reliability of the techniques involved. The totality of this evidence fails to show that they are sufficiently reliable to be od practical use.[3] Other studies have tested whether the therapeutic techniques used in visceral osteopathy are effective in curing disease or alleviating symptoms. The totality of this evidence fails to show that visceral osteopathy works for any condition.[4] The treatment itself seems to be safe, yet the risks of visceral osteopathy are nevertheless considerable: if a patient suffers from symptoms related to her inner organs, the therapist is likely to misdiagnose them and subsequently mistreat them. If the symptoms are due to a serious disease, this would amount to medical neglect and could, in extreme cases, cost the patient’s life.
[all references in brackets [] can be found in my recent book]While the results of our review might be unsurprising, one thing about it did, after all, surprise me a great deal: the journal that published it, the ‘INTERNATIONAL JOURNAL OF OSTEOPATHIC MEDICINE‘. I even lost a bet for a bottle of wine with the lead author, because I said they would never accept it for publication!
For many years, Dale Thompson has been one of our most loyal commentators, often defending the indefensible, or willfully misleading us, or deliberately distracting us from the topic at hand. He has made his comments under several names or pseudomyms, sometimes with and sometines without using the doctor-title, sometimes disclosing that he is a chiropractor and someimes not disclosing either this information or his most obvious conflicts of interest.
Recently, several readers became more interested in Dale and his activities. I therefore thought it would be relevant to find out how he is being presented on the Internet. Here are the mentions I found that include some relevant information about Dale:
- Dr. Dale Thompson. Over 20 years of delivering a conservative approach to muscle and joint issues. Trained in approaches that don’t require the typical adjustment but it is available when needed. Use a whole body approach and consider other factors that may be contributing to problems such as diet, ergonomics, lifestyles, etc.
- Dr. Dale Thompson is a Stratford, Iowa based male chiropractor with 22 years of experience in General Chiropractor. He completed his graduation from Logan College Of Chiropractic in 2002. He accepts the Medicare-approved amount. Patients will not be billed for any more than the Medicare deductible and coinsurance. Active license number of Dr. Dale Thompson as General Chiropractor is 06631 in Iowa. Dr. Dale Thompson is qualified as a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems.
- Dr. Thompson graduated from the Logan College of Chiropractic in 2002. He works in Stratford, IA and specializes in Chiropractor.
- DALE THOMPSON, D.C. practices at 813 SHAKESPEARE AVE, STRATFORD, IA 50249. Chiropractors diagnose and treat common spinal misalignments that can occur from lifestyle or injuries causing pain, discomfort and degenerative conditions. DALE THOMPSON, D.C. may be able to treat; back pain, sciatica, neck pain, shoulder pain, headaches, sports injuries, and auto accident injuries.
- Dr. Dale Thompson – Why I Like Being An Evidence-Based Chiropractor. Today we’re going to talk about being an evidence-based chiropractor. What does it mean to be practicing evidence-based chiropractic and we’re going to be talking about with Dr. Dale Thompson from Iowa. USA.
As we see, these texts are not always entirely clear about the fact that Dale has no medical degree. Dale recently posted: “Here in the USA it would be a board violation to ‘conceal’ that one is a doctor of chiropractic.” And in August 2021, he made this comment: “There are several professions that use the title doctor which aren’t earned from a medical college: dentists, optometrists, physical therapists. Within chiropractic, when we advertise, at least in the USA, we are required to identify that we are a doctor of chiropractic. Of course the word doctor originally was used by a religious sect but the medical profession decided they wanted it … “Several authors have recently lamented the continued chiropractic inclination to use outdated and anatomically incorrect language to describe the nature of the manipulable lesion (“subluxation”) and the method of treatment (“adjustment”).2,3,11 J Chiropr Educ. 2020 Oct; 34(2): 172–176.”
Next, I looked on Medline to find out wether Dale has ever published any research on his subject. I failed to find a single article in his name. This is remarkable because, all too often, he presents himself as THE expert in research.
Subsequently, I looked at some of the claims made by Dale. Here are a few of them:
- I can go to a conference and know if the speaker is generally telling the truth or is trying to sell a lie.
- I can read a research paper and know if it’s good or bad and how it may apply to what I do.
- I can take the best evidence and apply it and yet also have the freedom to find novel ways to approach a problem.
- I can take a seemly complex problem and find a simple solution as well as understand the complexity of an apparently simple problem.
- I know my clinical strengths and limitations as well as the strengths and limitations of other healthcare professionals.
- I do not have to jump on board the latest health fad but I can, and may, scrutinize it using logic, reasoning and supporting evidence.
- I can respect my colleagues desire to practice different than me but I still demand they do so in an evidence-based chiropractor and ethical manner.
- My patients come first, my profession second and I am last.
So, what should we conclude about Dale Thompson?
I don’t know about you, but I get the impression that Dale lacks the ability to be critical of his own abilities and of the value of chiropractic. He likes to post comments that are aimed at misleading us. He might not be a ‘straight chiropractor‘ in the usual sense of the term, but in my view he also is still far from straight. Personally, I have not taken much notice of his deeply biased, often pompous and smug comments for some time. I suggest you consider doing the same.
But Dale is just one chiro!
He hardly has any wider significance.
So, why even bother and write a whole blog post about him?
I certainly agree that such a man does not deserve the attention we have been giving him. But Dale stand for so many of his colleagues. In fact, he is a prime example of a chiro victim of the ‘Dunning Kruger Effect‘. These people have a thin veneer of respectability which allows them to pretend to be veritable ‘know alls’. They remain entirely oblivious to the fact that they have been brain-washed at chiro school and have become a life-time members of a cult unable to see how deluded they truly are. As such they are dangerous, and I feel that the public needs to be aware of the danger.
And here you have the true reason why I am writing these lines.
Jay Kennedy is an experienced chiropractor of some standing.
In “2018, ‘The American Chiropractor’ wrote this about Jay Kennedy:
Jay Kennedy, DC, is a 1987 graduate of Palmer Chiropractic College and maintains afull time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.
‘The Dynamic Chiropractor’ published plenty of articles authored by Jay Kennedy.
I am telling you this because Jay Kennedy recently posted a comment which is far too important to be burried in the many other comments on this blog. I think it deserves full recognition and loud applause. I have therefore decided to take the unusual step and re-post it here as an entirely seperate post.
Here we go:
I was a DC for 30+ years and a notable one for the last 20 years. I taught 200+ seminars, wrote innumerable articles and taught at many chiropractic colleges. I had (3) private practices and was a technique “guru”: “Kennedy decompression technique” or KDT. We “certified” nearly 5000 DCs to be “decompression experts”!
Kdt still sells farcical traction-tables I developed and designed (labeled as “decompression systems”) as well as useless lasers, ultrasonic vibrators and other scam modalities to confound the DCs and milk the public. (I have been out of it for several years now).
I am not proud of the fact I made a lot of money both in practice and as a lying cultist-entrepreneur.
I have read your blog for several years and many of your books, especially related to Chiropractic. You are not mistaken and I do NOT believe you are biased, the fact that you define the practice as SCAM and a cult is absolutely the case. As has been said before it is “the world’s largest non-scientific healthcare delivery system”. I was fortunate many years ago to meet Stuart McGill PhD. It changed my practice considerably. I opened a gym and focused dramatically on exercise. I also had other income steams from selling bullshit equipment. The regrettable feature is chiropractors sell “treatments”…. Some of which superficially alter pain signals temporarily like many OTHER less expensive and less mendacious things. This “traps” many patients into an erroneous paradigm….one a DC is ready, willing and able to exploit. “Chiropractic treatments” NEVER get to the root of a problem, alter any disease-process or substantially improve a patient. Regrettably selling exercise simply WILL NOT garner the income that selling (and coercing) subluxation-elimination treatments will (and virtually NO DC has the experience or expertise a PT PhD has in that arena).
Interestingly when you do seminars as a chiropractor, most states make you sign a waiver stating that you will not disparage Chiropractic or discuss information that minimize the value of Chiropractic. Can you imagine medical seminars or a scientific seminar having such a waiver? Chiropractic is and has always been a moneymaking scheme. That doesn’t exclude the fact there are many chiropractors who buy into it as a supreme truth….just like Muslims who murder with the thought of getting directly to Heaven to start porking some virgins.
I have discovered most DCs are on the low IQ scale, have poor critical thinking skills and rarely question their golden-goose (or perhaps more sympathetically; never venture outside the bounds of the profession and its rhetoric and hyperbole. They have been effectively able to compartmentalize Chiropractic from rightful and accurate criticism). Most of the successful ones are of course entrepreneurs with ravenous appetites for money, prestige and approval (and have little or no interest in the “truth”…..oops I described myself I guess).
The majority however struggle to get by and are constantly seeking SOMETHING that might actually work. Thus 70%+ use and advertise “decompression”, Activators (and other ridiculous “adjusting guns”), drop-tables, energy-techniques, orthotics and whatever other nonsense some company advertises in Chiropractic Economics with a testimonial of how much money can be made. It always fascinated me that if “subluxation-reduction or elimination” was the solution for disease and pain WHY did the profession embrace all of these other nonsensical modalities? If your guess is: “chiropractic doesn’t really work”…give yourself a beer.
When you graduate as a DC you CAN ONLY be in private SCAM practice….no other opportunities exist. Is it really any wonder that lying is the only avenue available to support a practice and an income stream? Nope.
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I wish to express my thanks to Jay for his courage and honesty in writing these lines.
This study aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain.
WalkBack was a two-armed, randomised clinical trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112)
Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60–0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149–295) in the intervention group and 112 days (89–140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group).
The authors concluded that an individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed.
Rigorous clinical trials of excercise therapy are difficult to conceive and conduct because of a range of methodological issues. For instance, there is no obvious placebo and thus it is hardly possible to control for placebo effects. Nonetheless, the benefits of exercise therapy for back pain is undoubted. As previously discussed on this blog, a recent systematic review concluded that “the relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance.”
I have always been convinced of the health benefits of excercise. In fact, 40 years ago, when I did my inaugural lecture at the University of Munich (LMU), excercise was its topic and I concluded that, if exercise were a pharmaceutical product, it would out-sell any drug. The new study only confirms my view. It adds to our knowledge by suggesting that exercise also reduces the risk of recurrences.
Forget about spinal manipulation, acupuncture, etc., despite the undeniable weaknesses in the evidence, exercise is by far the most promissing treatment for back pain
An article about chiropractic caught my attention. Let me show you its final section which, I think, is relevant to what we often discuss on this blog:
If chiropractic treatment is unscientific, then why do I feel better? Because lots of things alleviate pain. Massage, analgesia and heat – but also a provider who listens, empathises and bothers to examine a patient. Then there is the placebo effect. For centuries, doctors have recognised that different interventions with unclear pathways result in clinical improvement. Among the benefits patients attributed to placebo 100 years ago: “I sleep better; my appetite is improved; my breathing is better; I can walk further without pain in my chest; my nerves are steadier.” Nothing has changed. Pain is a universal assignment; no one has a monopoly on its relief.
The chiropractic industry owes its existence to a ghost. Its founder, David Palmer, wrote in his memoir The Chiropractor that the principles of spinal manipulation were passed on to him during a séance by a doctor who had been dead for half a century. Before this, Palmer was a “magnetic healer”.
Today, chiropractors preside over a multibillion-dollar regulated industry that draws patients for various reasons. Some can’t find or afford a doctor, feel dismissed, or worse, mistreated. Others mistrust the medical establishment and big pharma. Still others want natural healing. But none of these reasons justifies conflating a chiropractor with a doctor. The conflation feels especially hazardous in an environment of health illiteracy, where the mere title of doctor confers upon its bearer strong legitimacy.
Chiropractors don’t have the same training as doctors. They cannot issue prescriptions or order advanced imaging. They do not undergo lifelong peer review or open themselves to monthly morbidity audits.
I know that doctors could do with a dose of humility, but I can’t find any evidence (or the need) for the assertion on one website that chiropractors are “academic overachievers”. Or the ambit claim that most health professionals have no idea how complicated the brain is, but chiropractors do.
Forget doctors, patients deserve more respect.
My friend’s back feels better for now. When it flares, I wonder if she will seek my advice – and I am prepared to hear no. Everyone is entitled to see a chiropractor. But no patient should visit a chiropractor thinking that they are seeing a doctor.
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I would put it more bluntly:
- chiropractors are poorly trained; in particular, they do not learn to question their own, often ridiculous beliefs;
- they are poorly regulated; in the UK, the GCC seems to protect the chiros rather than the public;
- chiropractors regularly disregard essential rules of medical ethics, e.g. informed consent;
- many try to mislead us by pretending they are physicians;
- their hallmark intervention, spinal manipulation, can cause considerable harm;
- it generates hardly any demonstrable benefit for any condition;
- chiropractors also cause considerable harm, e.g. by interfering with real medicine, e.g. vaccinations;
- thus, in general, chiropractors do more harm than good;
- yes, everyone is entitled to see a chiropractor, but before they do, reliable information should be mandatory.
Dry needling is a therapy that is akin to acupuncture and trigger point therapy. It is claimed to be safe – but is this true?
Researchers from Ghent presented a series of 4 women aged 28 to 35 who were seen at the emergency department (ED) with post-dry needling pneumothorax between September 2022 and December 2023. None of the patients had any relevant medical history. All had been treated for a painful left shoulder, trapezius muscle or neck region in outpatient physiotherapist practices. At least three different physiotherapists were involved.
One patient presented to the ER on the same day as the dry needling procedure, the others presented the day after. All mentioned thoracic pain and dyspnoea. Clinical examination in all of these patients was unremarkable, as were their vital signs. Diagnosis was confirmed with ultrasound (US) and chest X-ray (CXR) in all patients. The latter exam showed left-sided apical pleural detachment with a median of 3.65 cm in expiration.
Two patients were managed conservatively. One patient (initial pneumothorax 2.5 cm) was discharged. The US two days later displayed a normally expanded lung. One patient with an initial apical size of 2.8 cm was admitted with 2 litres of oxygen through a nasal canula and discharged from the hospital the next day after US had shown no increase in size. Her control CXR 4 days later showed only minimal pleural detachment measuring 6 mm. The two other patients were treated with US guided needle aspiration. One patient with detachment initially being 4.5 cm showed decreased size of the pneumothorax immediately after aspiration. She was admitted to the respiratory medicine ward and discharged the next day. Control US and CXR after 1 week showed no more signs of pneumothorax. In the other patient, with detachment initially being 5.5 cm, needle aspiration resulted in complete deployment on US immediately after the procedure, but control CXR showed a totally collapsed lung 3 hours later. A small bore chest drain was placed but persistent air leakage was seen. Several trials of clamping the drain resulted in recurrent collapsing of the lung. After CT-scan had shown no structural deformities of the lung, suction was gradually reduced and the drain was successfully removed on the sixth day after placement. The patient was then discharged home. Control CXR 3 weeks later was normal.
The authors concluded that post-dry needling pneumothorax is, contrary to numbers cited in literature, not extremely rare. With rising popularity of the technique we expect complications to occur more often. Patients and referring doctors should be aware of this. In their informed consent practitioners should mention pneumothorax as a considerable risk of dry needling procedures in the neck, shoulder or chest region.
The crucial question, in my view, is this: do the risks of dry-needling out weigh the risks of this form of therapy? Let’s have a look at some of the recent evidence that we discussed on this blog:
- Spinal Manipulation and Electrical Dry Needling for Subacromial Pain Syndrome: A Nonsensical Trial
- Dry needling is useless for rehabilitation after shoulder surgery
- High velocity, low amplitude techniques are not superior to no treatment in the management of tension-type headache
- Which treatments are best for acute and subacute mechanical non-specific low back pain? A systematic review with network meta-analysis
- Acupuncture for chronic pain: the new NICE guideline
- Acupuncture for the Relief of Chronic Pain? A new, thorough synthesis fails to produce strong evidence that acupuncture works
The evidence is clearly mixed and unconvincing. I am not sure whether it is strong enough to afford a positive risk/benefit balance. In other words: dry needling is a therapy that might best be avoided.
