musculoskeletal problems
Chronic non-specific low back pain (CNSLBP) is a major cause of disability worldwide. Conventional pharmacological treatments offer limited benefits and carry potential risks, prompting interest in alternative approaches, including homeopathy. The objective of this study was to evaluate the short-term efficacy and safety of a standardised homeopathic biotherapic (Lumbar Vertebra, LM2 potency) for CNSLBP.
A randomised, double-blind, crossover, placebo-controlled clinical trial was conducted with 120 participants diagnosed with CNSLBP. Participants received both the biotherapic and placebo in two treatment phases separated by a washout period. The primary outcome was pain intensity (numeric rating scale); secondary outcomes included functional disability (Oswestry Disability Index), adverse events and use of pain medications. Data were analysed using random effects generalised linear models.
Both the biotherapic and placebo interventions led to significant within-group reductions in pain and disability (p = 0.001 and p < 0.001 respectively). However, no statistically significant differences were observed between the two interventions for either outcome (pain: p = 0.435; disability: p = 0.840). The magnitude of change in pain intensity did not reach the pre-defined minimal clinically important difference (MCID), and mean pain scores at the study endpoint remained above the inclusion threshold. Adverse events were mild and comparable across groups.
The authors concluded that no specific effect of the Lumbar Vertebra LM2 biotherapic was demonstrated. Improvements are likely due to non-specific effects such as the therapeutic environment, patient expectations and placebo response. Clinicians should consider the substantial role of non-specific responses in CNSLBP and avoid medications with unfavourable risk–benefit profiles.
One the one hand, the authors from the Department of Medicine, Federal University of São Carlos, São Carlos, Sao Paulo, the School Health Unit, Federal University of São Carlos, São Carlos, Sao Paulo, and the epartment of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil should be congratulated for publishing a squarely negative result in the journal ‘Homeopathy’ that is known for publishing even the most implausible positive findings.
On the other hand, one might criticise them: why on earth did they ever conceive the hypothesis that homeopathy in general or “Lumbar Vertebra LM2 biotherapic” in particular might be effective for CNSLBP (the study did not receive any funding or financial support, apart from the study medications donated by HN-Cristiano Pharmacy (Santana, São Paulo, Brazil), which had no role in the study design, data collection, analysis, interpretation or discussion of the results)? I have never met a homeopaths who would make such a claim, and one could easily argue that such a trial is an unethical waste of resources.
The aim of this study was to determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for adults with increased risk of chronic disabling LBP.
This 2 × 2 factorial randomized clinical trial enrolled participants in 3 research clinics at the Universities of Minnesota and Pittsburgh from November 2018 to May 2023; final follow-up was in June 2024. Adults with acute or subacute LBP at moderate to high risk of chronicity based on the STarT Back tool were randomized to 1 of 4 groups, with interventions lasting up to 8 weeks. Statistical analysis was conducted from November 2024 to June 2025.
These interventions were:
- Spinal manipulation therapy (n = 201),
- supported self-management (n = 305),
- combined supported self-management with spinal manipulation (n = 193),
- guideline-based medical care (n = 301).
Physical therapists and chiropractors provided spinal manipulation and supported self-management.
The 2 primary outcomes averaged over a follow-up of 1 year were monthly low back disability (Roland-Morris Disability Questionnaire) and weekly pain intensity (numerical rating scale). Secondary analysis examined the proportion of participants achieving a 50% or higher reduction in the primary outcome measures.
Among the 1000 participants randomized (mean [SD] age, 47 [16] years; 58% female), 93% completed the trial. The omnibus test for differences across the 4 treatment groups was statistically significant for disability (P = .001; supported self-management, 4.7; spinal manipulation, 5.5; combined supported self-management with spinal manipulation, 4.8; medical care, 5.9) but not pain intensity (P = .16; supported self-management, 2.8; spinal manipulation, 3.0; combined supported self-management with spinal manipulation, 2.8; medical care, 3.0). Averaged over 12 months, LBP disability was significantly lower compared with medical care for supported self-management (mean difference, −1.2 [95% CI, −1.9 to −0.5]) and supported self-management with spinal manipulation (mean difference, −1.1 [95% CI, −1.9 to −0.3]) but not spinal manipulation alone (mean difference, −0.4 [95% CI, −1.2 to 0.4]). Group differences in pain intensity were not statistically significant; point estimates ranged from −0.2 to 0. Both supported self-management groups had higher proportions of patients achieving a 50% or greater reduction in disability (supported self-management, 67%; spinal manipulation, 54%; combined supported self-management with spinal manipulation, 65%; medical care, 54%).
The authors concluded that for patients with acute or subacute LBP at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome.
These findings are very bad news for chiropractors (the profession that uses spinal manipulations more than any other): spinal manipulation does not generate effects that are in the least convincing. This is particularly remarkable, since the study was not blinded. It means that, even the undoubtedly powerful placebo effect associated with spinal manipulation did not render the outcome more favourable.
I said it many times, and I will say it again: For LBP, many therapies generate similarly marginally positive effects but no treatment is truly convincing. In this situation, we should choose one that is at least inexpensive and free of severe adverse effects. And that evidently cannot be spinal manipulation!
Non-specific low back pain is a common condition with substantial socioeconomic implications. Pulsed electromagnetic field (PEMF) therapy is said to generate benefits in pain reduction and improvement of physical function in patients with pain-associated disorders like osteoarthritis. However, studies had heterogeneous settings. The aim of this systematic review was to assess the effects of PEMF on pain and function on patients with non-specific low back pain.
A systematic literature search of randomized controlled trials in PubMed, MEDLINE, EMBASE, Cochrane Library, and PEDro was performed (from inception until 15/5/2023). Outcome measures assessed pain and function.
Nine randomized controlled trials with 420 participants (n = 420) were included. The studies compared PEMF vs. placebo-PEMF, PEMF and conventional physical therapy vs. conventional physical therapy alone, PEMF and conventional physical therapy vs. placebo-PEMF and conventional physical therapy, PEMF vs. high-intensity laser therapy (HILT) vs. conventional physical therapy, and osteopathic manipulative treatment (OMT) and PEMF vs. PEMF alone vs. placebo-PEMF vs. OMT alone. Five of the nine included studies showed statistically significant pain reduction and improvement in physical function in comparison to their control groups (p < 0.05). There was substantial heterogeneity among the groups of the study, with a wide range of duration (10-30 min), treatments per week (2-7/week), applied frequencies (3-50 Hz), and intensities (2mT-150mT). No serious adverse event had been reported in any study. The included studies showed solid methodological quality, with an overall score of 7.2 points according to the PEDro scale.
The authors concluded that the results of the present systematic review suggest that the use of PEMF for patients with non-specific low back pain is beneficial in terms of pain reduction and enhancement of physical function, particularly if used as an addition to conventional physical therapy modalities. It has also been shown that PEMF is a safe therapy for the treatment of non-specific low back pain. Further high-quality studies with larger sample sizes and standardized protocols are necessary. The studies should also focus on determining the optimal parameters of frequency and intensity to advance PEMF application for all pain disorders.
PEMF therapy is a non-invasive treatment widely used by physiotherapist and some practitioners of so-called alternative medicine (SCAM). It applies low-frequency electromagnetic waves to the body. PEMF therapy acts like a wireless charger for your body, sending pulses of energy that penetrate deep into your tissues to jumpstart cellular recovery. Because your body contains conductive fluids (like blood) and charged ions (like calcium and potassium), the PEMF device is said to induce very small electrical currents within your tissues. In turn, the induced current is claimed to stimulate the mitochondria. This, according to proponents, boosts the production of ATP. The pulses are also said to influence the movement of ions across cell membranes, particularly calcium which triggers a cascade of beneficial biochemical reactions, such as the release of nitric oxide, which dilates blood vessels to improve circulation. Lastly, PEMF are claimed to help “calm” the chemical signals that cause chronic inflammation, switching the cellular environment from a state of stress to a state of healing.
While these assumptions look like wild extrapolations, the more crucial question is whether PEMF is clinically effective. The present review seems to tell us that it works for back pain. Yet, I am not convinced.
Most of the RCTs are not of good quality. Many did not blind patients or therapists. Only 2 made a direct comparison against a placebo, and those did not blind patients or check the success of blinding them. As the authors noted, there is plenty of heterogeneity in the included RCTs. All this adds up to a high level of uncertainty about the effectiveness of PEMF.
In summary, I fear that the authors of this review are too optimistic and lack critical thinking in evaluating the existing evidence. My conclusion therefore differs from theirs:
Many RCTs suggest that PEMF is effective for non-specific low back pain. Yet, due to serious limitations of the primary studies, no firm conclusion can be drawn.
The authors found very low‐certainty evidence (downgraded for study limitations, inconsistency, and imprecision) that SMT may result in a medium reduction in pain compared to no treatment at one month (MD ‐13.99, 95% CI ‐27.33 to ‐0.66; I2 = 89%; 4 studies, 325 participants), but the evidence is very uncertain. They found low‐certainty evidence (downgraded for study limitations and imprecision) that SMT may result in a large improvement in functional status compared to no treatment at one month (SMD ‐0.84, 95% CI ‐1.32 to ‐0.35; I2 = 71%; 4 studies, 312 participants).
SMT versus other conservative interventions
Low‐certainty evidence (downgraded for inconsistency) indicated that SMT may result in little to no difference in pain (MD ‐4.72, 95% CI ‐8.26 to ‐1.17; I2 = 89%; 31 studies, 4109 participants) and may result in a small improvement in functional status (SMD ‐0.25, 95% CI ‐0.38 to ‐0.11; I2 = 73%; 28 studies, 3940 participants) compared to other conservative interventions at one month.
These effects, however, should be interpreted with caution due to the substantial statistical heterogeneity for which there is no clear explanation.
Less than half of the studies (47%) reported on adverse events, of which 12 studies reported these systematically. Adverse events in the SMT group were limited to muscle soreness, stiffness, and/or transient increase in pain. None of the studies registered any serious complications related to either the experimental or control group treatment. The evidence is very uncertain about the adverse effects of SMT.
Authors’ conclusions: When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it.
Once again, it has been confirmed that most trials of SMT are, because of their failure to report adverse effects, in violation of ethical standards. But the importance of this excellent review lies elsewhere. Despite 76 published RCTs, there is huge uncertainty about the benefits of SAM. What should we make of this fact?
In my view, it highlights that:
- the studies are often of poor quality;
- the effect of SMT are so small that they are negligibel;
- patients with back pain should look for treatments that are safe and effective;
- the choice can therefore not be SMT.
Spinal epidural hematoma is a rare but potentially devastating condition that can result in permanent neurologic deficits if not diagnosed promptly. This case report presents a 48-year-old female patient with a medical history of systemic lupus erythematosus, renal transplantation, and hypertension who developed spinal epidural hematoma (SEH) after chiropractic manipulation, leading to acute quadriplegia. She came to the emergency department with progressively worsening midline back pain that had started 2 days earlier. The patient reported undergoing chiropractic manipulation at a private clinic for neck pain, after which she developed back pain that gradually worsened. The cause of the patients problems turned out to be a spinal epidural hematoma.
The objective of this report is to highlight the potential for spinal epidural hematoma development in patients with comorbidities or underlying risk factors, such as systemic autoimmune disease, hypertension, or organ transplantation, after chiropractic manipulation and to emphasize the importance of early recognition to prevent serious neurologic sequelae.
The authors concluded that SEH is a rare but serious condition that must be considered as a potential complication of chiropractic manipulation, particularly in patients with comorbidities that increase bleeding risk.
Such cases are rare, we hope (as there is no monitoring, we cannot be sure), but not unheard of. Similar cases have been described before, e.g.:
Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.
Spinal epidural hematoma is a rare but potentially devastating complication of spinal manipulation therapy. This is a case report of a healthy pregnant female who presented to the emergency department with a cervical epidural hematoma resulting from chiropractic spinal manipulation therapy that responded to conservative treatment rather than the more common route of surgical management.
Objective: We report on the case of a patient with spinal epidural hematoma (SEH) after spinal manipulative therapy and review features of reported cases of a similar nature. Clinical features: The patient was undergoing Coumadin anticoagulant therapy for atrial fibrillation and presented to the chiropractor complaining of a stiff neck. After cervical manipulation, he developed paresthesia in both feet, progressing to motor deficits in all 4 extremities. He required a laminectomy and evacuation of a clot indenting the spinal cord. Results: Review of the literature revealed 7 reported cases of SEH after manipulation; 5 patients underwent cervical manipulation and 1 patient received Coumadin therapy. Conclusion: Practitioners of spinal manipulative therapy should be aware of SEH as a possible complication of manipulation in patients at risk and should exercise caution in the care of patients undergoing anticoagulant therapy.
Introduction: Spinal epidural hematoma is a rare complication after chiropractic manipulation. In the literature, only three cases have been reported, which all necessitated surgical treatment. Case report: A 27-year-old woman was treated with cervical chiropractic manipulation (C5/6) and facet joint infiltration. 10 minutes later the patient presented signs of intracranial pressure with nausea, vertigo, headache and vomiting. The magnetic resonance imaging of the spine demonstrated an epidural hematoma extending from the cervical to the sacral spine. As the patient had no sensible or motor deficits and recovered quickly, surgical treatment was not necessary. A few days later the patient had a complete persisting remission of symptoms. Conclusion: If neurological deficits occur after chiropractic manipulation, a spinal epidural hematoma should be considered to provide adequate therapy without delay. The current case report shows an unusual expansion of the hematoma which has not described so far after chiropractic manipulation. But, in contrast to the three cases reported before, a surgical intervention was not necessary.
Conclusion?
Well, I suppose you know mine: As chiropractic spinal manipulations are of uncertain (to put it mildly!) effectiveness, even rare but serious risks weigh heavily and make the risk/benefit balance tilt into the negative. In practical terms, this obviously means this: avoid chiros where you can!
Low back pain (LBP) is a significant public health issue due to its high prevalence and associated disability burden. Clinical practice guidelines recommend non-pharmacological/non-surgical interventions for managing pain and function in people with LBP. This overview of Cochrane review is aimed ato providing accessible, high-quality evidence on the effects of non-pharmacological and non-surgical interventions for people with LBP and to highlight areas of remaining uncertainty and gaps in the evidence regarding the effects of these interventions for people with LBP.
the team searched the Cochrane Database of Systematic Reviews from inception to 15 April 2023, to identify Cochrane reviews of randomised controlled trials testing the effect of non-pharmacological/non-surgical interventions, unrestricted by language. Major outcomes were pain intensity, function and safety. Two authors independently assessed eligibility, extracted data and assessed the quality of the reviews using AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) and the certainty of the evidence using GRADE. The primary comparison was placebo/sham.
A total of 31 Cochrane reviews were included of 644 trials that randomised 97,183 adults with LBP. The team had high confidence in the findings of 19 reviews, moderate confidence in the findings of two reviews, and low confidence in the findings of 10 reviews. They present results for non-pharmacological/non-surgical interventions compared to placebo/sham or no treatment/usual care at short-term (≤ three months) follow-up. Placebo/sham comparisons Acute/subacute LBP Compared to placebo, there is probably no difference in function (at one-week follow-up) for spinal manipulation (standardised mean difference (SMD) -0.08, 95% confidence interval (CI) -0.37 to 0.21; 2 trials, 205 participants; moderate-certainty evidence). Data for safety were reported only for heated back wrap. Compared to placebo, heated back wrap may result in skin pinkness (6/128 participants versus 1/130; 2 trials; low-certainty evidence). Chronic LBP Compared to sham acupuncture, acupuncture probably provides a small improvement in function (SMD -0.38, 95% CI -0.69 to -0.07; 3 trials, 957 participants; moderate-certainty evidence). Compared to sham traction, there is probably no difference in pain intensity for traction (0 to 100 scale, mean difference (MD) -4, 95% CI -17.7 to 9.7; 1 trial, 60 participants; moderate-certainty evidence). Data for safety were reported only for acupuncture. There may be no difference between acupuncture and sham acupuncture for safety outcomes (risk ratio (RR) 0.68, 95% CI 0.42 to 1.10; I2 = 0%; 4 trials, 465 participants; low-certainty evidence). No treatment/usual care comparisons Acute/subacute LBP Compared to advice to rest, advice to stay active probably provides a small reduction in pain intensity (SMD -0.22, 95% CI -0.02 to -0.41; 2 trials, 401 participants; moderate-certainty evidence). Compared to advice to rest, advice to stay active probably provides a small improvement in function (SMD -0.29, 95% CI -0.09 to -0.49; 2 trials, 400 participants; moderate-certainty evidence). Data for safety were reported only for massage. There may be no difference between massage and usual care for safety (risk difference 0, 95% CI -0.07 to 0.07; 1 trial, 51 participants; low-certainty evidence). Chronic LBP Compared to no treatment, acupuncture probably provides a medium reduction in pain intensity (0 to 100 scale, mean difference (MD) -10.1, 95% CI -16.8 to -3.4; 3 trials, 144 participants; moderate-certainty evidence), and a small improvement in function (SMD -0.39, 95% CI -0.72 to -0.06; 3 trials, 144 participants; moderate-certainty evidence). Compared to usual care, acupuncture probably provides a small improvement in function (MD 9.4, 95% CI 6.15 to 12.65; 1 trial, 734 participants; moderate-certainty evidence). Compared to no treatment/usual care, exercise therapies probably provide a small to medium reduction in pain intensity (0 to 100 scale, MD -15.2, 95% CI -18.3 to -12.2; 35 trials, 2746 participants; moderate-certainty evidence), and probably provide a small improvement in function (0 to 100 scale, MD -6.8, 95% CI -8.3 to -5.3; 38 trials, 2942 participants; moderate-certainty evidence). Compared to usual care, multidisciplinary therapies probably provide a medium reduction in pain intensity (SMD -0.55, 95% CI -0.83 to -0.28; 9 trials, 879 participants; moderate-certainty evidence), and probably provide a small improvement in function (SMD -0.41, 95% CI -0.62 to -0.19; 9 trials, 939 participants; moderate-certainty evidence). Compared to no treatment, psychological therapies using operant approaches probably provide a small reduction in pain intensity (SMD -0.43, 95% CI -0.75 to -0.11; 3 trials, 153 participants; moderate-certainty evidence). Compared to usual care, psychological therapies (including progressive muscle relaxation and behavioural approaches) probably provide a small reduction in pain intensity (0 to 100 scale, MD -5.18, 95% CI -9.79 to -0.57; 2 trials, 330 participants; moderate-certainty evidence), but there is probably no difference in function (SMD -0.2, 95% CI -0.41 to 0.02; 2 trials, 330 participants; moderate-certainty evidence). It is uncertain whether there is a difference between non-pharmacological/non-surgical interventions and no treatment/usual care for safety (very low-certainty evidence).
The authors concluded that spinal manipulation probably makes no difference to function compared to placebo for people with acute/subacute LBP. Acupuncture probably improves function slightly for people with chronic LBP, compared to sham acupuncture. There is probably no difference between traction and sham traction for pain intensity in people with chronic LBP. Compared to advice to rest, advice to stay active probably reduces pain intensity slightly and improves function slightly for people with acute LBP. Acupuncture probably reduces pain intensity, and improves function slightly for people with chronic LBP, compared to no treatment. Acupuncture probably improves function slightly for people with chronic LBP, compared to usual care. Exercise therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to no treatment/usual care. Multidisciplinary therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to usual care. Compared to usual care, psychological therapies probably reduce pain intensity slightly, but probably make no difference to function for people with chronic LBP.
The findings of this overview might surprise some chiropractors, however, it did not surprise me at all*. I have stated more often than I care to remember that, for LBP, we currently have no approach that is truly convincing. One form of so-called alternative medicine (SCAM) seems to be roughly as effective (or ineffective) as the next. Where they might differ is safety and cost. On both of these measures chiropractic spinal manipulation is less convincing than some of the other options available, as we have discussed ad nauseam on this blog.
So, in a nutshell, the message to LBP patients can be put simply: stay away from chiros, keep active and, if you insist, use whatever other form of SCAM that you fancy, that is safe and inexpensive.
PS
*I was, however, surprised that the authors had low confidence in the findings of 10 of the 31 reviews. Cochrane reviews should be the most reliable evidence available to date!!!
- The authors claim to evaluate OMT for managing headaches associated with musculoskeletal dysfunction. Yet few of the trials were specifically aimed at this aim.
- Comparator treatment included sham manipulation, waitlist or no treatment, treatment as usual, a different type of OMT technique or protocol that was not the same as the experimental intervention, or any standard of care intervention, such as exercise therapy or medication. Most of these do not allow conclusions about specific effects of OMT.
- There was no attempt to control for placebo effects which might be significant in the case of OMT.
- In general, the methodological quality of the primary studies was low.
- There are too few studies to adequately assess the multitude of different OMT techniques.
- The fact that multiple forms of headache exist is not adequately addressed.
Yes, the authors try to be cautious in their conclusions and admit that the evidence is weak. Yet, I simply do not see enough compelling evidence to agree with them that the data are even suggestive of a positive effect.
Gua Sha is a form of so-called alternative medicine (SCAM) that I have reoprted about before, e.g.:
- Gua sha: who cares how it works, when it is unproven that it works?
- Gua sha, a reasonable therapy?
- Gua Sha: torture or treatment?
Chronic nonspecific low back pain (CNSLBP) is associated with thoracolumbar fascia (TLF) dysfunction. However, the structural effects of Gua Sha, a Traditional Chinese Medicine technique, remain unclear.
This study aimed to explore the acute and short-term effects of Gua Sha therapy on TLF thickness, pain intensity, and related physiological parameters in patients with CNSLBP.
Thirty-two participants with CNSLBP were randomized to receive Gua Sha or hot pack therapy, a commonly used conservative treatment for low back pain, once a week for 4 weeks. The effects of the two treatments were compared. TLF thickness, pain, and related parameters were measured at baseline and immediately after the first and fourth interventions. A 2 (group) × 3 (time) repeated measures ANOVA was used for data analysis.
With increasing intervention, both groups showed significant improvements in pain intensity and dysfunction (P < .001), significant reductions in tissue hardness and pressure pain threshold (P < .05), and significant increases in skin temperature and lumbar flexibility (P < .001). However, only the Gua Sha group significantly reduced TLF thickness immediately after the first intervention (MD = 0.388, 95% CI: 0.101-0.675; P = .01) and immediately after the fourth session (MD = 0.607, 95% CI: 0.199-1.015, P = .005). The heart rate variability-related indicators did not reach statistical significance (P > .05), but their trends were favorable.
The authors concluded that Gua Sha can effectively relieve pain, improve function, and regulate tissue mechanical properties in CNSLBP patients and its effects may be achieved through multiple pathways. Although the single and 4-session interventions were not significantly better than heat in improving fascial thickness, it performs better in pain and flexibility clinical outcomes, supporting its potential value as a complementary therapy. Future studies with larger samples and longer periods are needed to clarify its mechanism of action and optimize treatment options.
Gua sha, sometimes referred to as “scraping”, “spooning” or “coining”, is a traditional Chinese treatment that has
spread to several other Asian countries. It has long been popular in Vietnam and is now also becoming well-known in the West. The treatment consists of scraping the skin with a smooth edge placed against the pre-oiled skin surface, pressed down firmly, and then moved downwards along muscles or meridians. According to its proponents, gua sha stimulates the flow of the vital energy ‘chi’ and releases unhealthy bodily matter from blood stasis within sore, tired, stiff or injured muscle areas.
It is easy to imagine that Gua Sha is associated with sizable placebo effects. This means one needs to think carefully about how to control for tham in clinical trials, if we want to know whether the treatment works beyond placebo. I am not sure how to achieve this, but I am quite certain that the current study failed to do it. Thus its results merely showed that Gua Sha is just as useless as another therapy thay is unproven for CNSLBP.
And what about the thoracolumbar fascia thickness? I think that its significance is entirely speculative. Moreover, the reliability of its measurement seems questionable. Most likely, it is yet another red herring in a paper already more than full of fishy stuff.
PS
I stated it many times before, but I must say it again: almost any odd SCAM (e.g. chiropractic!) works a little for back pain – particularly if you test it in lousy studies and don’t control for placebo effects.
- (1) SMT,
- (2) ambulatory ibuprofen prescription,
using propensity matching for OUD risk factors. The primary outcome was the risk ratio (RR) of OUD. The RR for long-term opioid use, and opioid prescription RR and mean count were also explored. Primary analyses conducted in TriNetX and R used logistic regression for matching, standardized mean difference to assess between-cohort balance (threshold of ≤ 0.1), and contingency tables for RRs, using a significance threshold of p < 0.05.
This systematic review was aimed at evaluating if musculoskeletal manipulations (MMs), including osteopathic manipulation and chiropractic care, are effective to improve quality of life, pain intensity and function in older adults with musculoskeletal disorders.
Randomised controlled trials, controlled non-randomised trials and open label trials evaluating the efficacy and safety of MM such as osteopathic manipulation, chiropractic manipulation, myofascial release, craniosacral therapy, as monotherapy or adjunctive therapies in older people (age ≥65 years) with musculoskeletal disorders. The main outcomes included pain intensity, functionality and quality of life. Additionally, other related outcomes were considered, such as medical use duration, mood, mobility, motion, strength and endurance. Finally, we considered any adverse events.
Selection and data extraction were performed independently by two authors. The effect estimates for each study were performed using Review Manager V.5.14. Continuous outcomes were analysed using the mean difference (95% CI). The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool 2 (RoB 2). No meta-analysis was performed.
Five parallel randomised controlled trials were included, with a total sample size of 676 participants (41.6% women with a mean age of 77.3 years): 34 with chronic pain, 265 with neck pain and 377 with low back pain. MMs were not effective in patients with chronic pain, neither in pain intensity nor in functionality.
For neck pain, considering the main outcomes, only in one of the two studies was there a statistically significant improvement in neck pain intensity only at week 12 for spinal manipulative treatment (SMT)+home exercise (HE) compared with HE alone (ES=-0.90 (95% CI -1.46 to -0.34); p=0.002).
For low back pain, SMT+HE showed a statistically significant reduction in pain at 12 weeks compared with HE (ES=-0.79 (95% CI -1.39 to -0.19) p=0.010.
For neck pain and low back pain, no statistically significant improvement in functional status and quality of life was observed with MM compared with any control group.
RoB 2 showed a high risk of bias in three studies and some concerns in the others. At the domain level, the lowest risk was observed in the randomisation process (80% with some concerns). All five studies reported adverse events, none of which were serious.
The authors concluded that this systematic review highlights the need for further investigation into complementary therapies, particularly osteopathy, for chronic pain management and prevention in elderly individuals. The results of the current work emphasise that there is a need to further investigate this topic and move the focus more on the promotion of healthy and management behaviours (eg, more physical activity, self-efficacy and adaptive coping, less healthcare utilisation, medication use) and less on the pain symptoms. The fundamental need for complementary medicine, and in particular MM such as chiropractic care and osteopathic manipulative treatment, is the development of clinical trials and RCTs to assess efficacy on quality of life, pain, functionality and general health of the elderly patient. These will help us to determine where MM can be significant.
This, it seems to me, is merely a polite way of stating that neither chiropractic nor osteopathy are supported by sound evidence, and that therapeutic claims by chiropractors and osteopaths are usually hugely exaggerated. Therefore, the prudent thing to do, if you are suffering from back or neck pain, is to use treatments that are less expensive and less likely to cause severe, sometimes life-threatening adverse effects.
