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

osteopathy

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A long article on chiropractic casts doubt that chiropractic is useful. Here is an abbreviated version of it:

The chemistry and biology graduate from the University of Georgia, 28-year-old Caitlin Jensen, visited a chiropractor to sort out her lower back pain. During the session, the therapist performed an adjustment.  It severed four arteries in her neck. She collapsed shortly after, unable to speak or move. The injury had caused her to suffer a series of strokes. Today, she has regained some movement in her head, legs and arms but she is still unable to speak, is partially blind and relies on a wheelchair.

While shocking and extreme, experts say Caitlin’s story is evidence of the risks of chiropractic. And although such cases are rare, they are not unheard of. Yet despite these risks, the treatment has only become more popular recently. Currently it is being driven by a social media craze for videos of chiropractors manipulating spines to make terrifying cracking sounds. The more brutal the crack, the higher the views.
And now chiropractors in the UK are pushing for their services, which are largely private, to be rolled out on the NHS. According to a report commissioned by the British Chiropractic Association, employing chiropractors in the health service could save £1.5 billion and cut physiotherapist waiting lists. Last week The Mail on Sunday’s GP columnist Dr Ellie Cannon expressed concerns over the safety of the scheme, writing that she was worried that the forceful manipulation of the body involved can be dangerous, causing serious injuries. Dr Cannon asked readers for their own experiences – and was flooded with responses. Scores claimed they’d found relief from joint pain and other issues thanks to a chiropractor, when nothing else worked. Yet, disturbingly, among these were accounts from those who’d suffered horrific injuries.
  • One 66-year-old grandmother said a visit to a chiropractor to treat her sore shoulder left her covered in bruises, hearing ringing in her ears and with a splitting pain in her jaw. She was later diagnosed by doctors with trigeminal neuralgia – a chronic pain disorder caused by a trapped or irritated nerve in the neck that causes sudden, electric shock-like pain in the face. She believes the condition – which, three years later, still sometimes leaves her unable to open her mouth wide enough to speak to her grandchildren – was triggered by a chiropractic adjustment of her neck.
  • A 55-year-old woman was left with chronic neck and shoulder pain after visiting a chiropractor for a sore back. The pain was so bad she once spent 72 hours immobile and unable to sleep despite taking a concoction of painkillers.
  • And a 66-year-old man says his back went into spasm as he was leaving his first chiropractor appointment – which left him hospitalised and bedbound for weeks. The intense treatment, he later learned, had pushed one of the discs of his spine out of place, causing him to lose feeling in his right leg for ever.
In the UK, several film and TV shows – including Love Island – have bragged of having a resident chiropractor on set. And the number of British chiropractors has risen by more than 60 per cent in the past four years, according to regulatory board the General Chiropractic Council.
Orthopaedic surgeon Dr Simon Fleming worries that vulnerable patients are turning to chiropractors without knowing its risks. He says: ‘It’s not that there aren’t safe chiropractors, it’s that there’s such a high risk of potentially doing harm. Adults can make their own choices – but if they want to go down that route, we need to ensure they do it with their eyes open.’
The NHS currently lists neck, back, shoulder and elbow pain as issues that can be treated with chiropractic – adding that there’s little evidence it can help with more serious conditions, or problems that don’t affect the muscles or joints. It warns: ‘There is a risk of more serious problems, such as stroke, from spinal manipulation.’
Chiropractic is not widely available on the health service, other than in exceptional circumstances where no other options, such as physiotherapy, are available. But a report released by the University of York last week called for the practice to be brought under the NHS in order to cut the number of patients with musculoskeletal issues waiting for physiotherapy. And according to Mark Gurden, president of the Royal College of Chiropractors, it will help the NHS more generally by offering up a skilled and competent workforce during a national staffing crisis. ‘It’s a profession just like physiotherapy is a profession, and can offer a range of interventions that include both soft tissue techniques and spinal manipulation,’ he says. ‘Chiropractors are regulated healthcare professionals who undergo four-years training and must be registered with the General Chiropractic Council. It’s an entirely safe procedure when done by competent professionals.’
Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter and author of ‘Chiropractic: Not All That It’s Cracked Up To Be‘, says hundreds of patients have suffered a stroke after getting their necks manipulated – with some dying from the damage. Recent instances include the tragic case of 29-year-old Joanna Kowalczyk, who suffered a fatal tear of her blood vessels after having her neck adjusted by a chiropractor, as well as Playboy model Katie May, 34, who died after getting the treatment for a pinched nerve in her neck sustained during a photoshoot. And Professor Ernst believes even more patients may have sustained injuries than we know of.
____________________________
You might be interested in what I actually wrote in response to the questions posed by the journalist from the ‘Mail-online’. Here are his questions (Q) and my replies (R), both unabbreviated:
Q: Should chiropractic treatment be available on the NHS?
R: The NHS cannot even pay for all effective therapies; as chiropractic is of at best doubtful effectiveness, it should, in my view, not be reimbursed by the public purse.
Q: Are chiropractic therapies dangerous? If so, why?
R: Chiropractors manipulate the spine of virtually every patient. These manipulations often move the spine beyond its physiological range of motion and can thus cause severe structural damage.
Q: Are all chiropratic adjustments risky? Or just those that involve certain areas of the body (ie, neck)?
R: The neck is, of course, particularly vulnerable; but damage can occur along the entire spine.
Q: Equally, is it a case of some chiropractors just not being very good at their jobs?
R: Some chiropractors are surely more dangerous than others. Yet none are risk-free.
Q: I’ve seen stories of awful injuries / deaths at the hands of a chiropractor. But if the practice is so risky why don’t we see more injuries than we do?
R: There is no reporting system of side effects of chiropractic – so, if we don’t look, we don’t see.
Q: Lots of our readers have written in to say it’s helped massively with their pain or other ailment. Can it have any positive effect on our health and wellbeing?
R: True some people swear by chiropractic. But let’s not forget that having your bones cracked is bound to have a considerable placebo response.
Q: Should babies be getting chiropractic adjustments?
R: Most definitely no!
Q: Are some people more prone to injury from these treatments than others?
R: Yes, some people may, for instance, have fragile arteries that then might burst when the neck is being forcefully manipulated.
Q: What do you think needs to happen to reform the chiropractic industry?
R: If it wants to be called a valuable form of healthcare, chiropractic needs to abide by the principles of evidence-based medicine. In other words, it needs to demonstrate through rigorous research that it does more good than harm and for which condition. At present, chiropractic is very far from having achieved this. And that means, I fear, that it should not be part of rational healthcare.
_______________________
I am glad that, these days, I usually insist on doing interviews with journalists via email

The aim of this recent review was to investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo. It included all randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) suffering from non-specific low back pain.

Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain—(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain: (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain:

  • exercise,
  • spinal manipulative therapy,
  • taping,
  • antidepressants,
  • transient receptor potential vanilloid 1 (TRPV1) agonists)

were found to be efficacious. However, effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.

The authors concluded that the current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.

This is an important analysis, not least because of the fact that the research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The methodology is sound and the results thus seem reliable.

The findings are in keeping with what we have been discussing at nauseam here: no treatment works really well for back pain. For acute symptoms no so-called alternative medicine (SCAM) at all is efficacious. For chronic pain, spinal manipulation therapy (SMT) have small effects. As SMT is neither cheap nor free of risks, excercise is much preferable.

Considering that most SCAMs are heavily promoted for low back pain (e.g. acupuncture, Alexander technique, cupping, Gua Sha, herbal medicine, homeopathy, massage, mind-body therapies, reflexology, Reiki, yoga), this verdict is sobering indeed!

This systematic review was aimed at assessing whether spinal manipulative therapy (SMT) procedures (i.e., target, thrust, and region) impacted on pain and disability for adults with spine pain.

The investigators searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. They included randomized clinical trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. The authors included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables.

The researchers included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons.

The authors concluded that there was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant.

What does that mean?

It means that it is largely irrelevant which form of SMT is being used; the outcomes are more or less independet of the technique that is applied. You don’t need to be particularly skeptical to go one step further and conclude that:

  • The percieved effectiveness of SMT compared to other treatments is due to a placebo effect which is likely to be strong with a therapy involving touch, cracking bones, etc.
  • The effects of different types of SMT are all similar because these interventions are little more than theatrical placebos.
  • Since these placebos can cause consideraable harm, their risk/benefit balance is not positive.
  • Because their risk/benefit balance fails to be positive, SMT cannot be recommended as a treatment in routine care.

Two fatalities have been reported evidently caused by Thai massage. Thai singer Chayada Prao-hom, also known as Ping Chayada, 20, died in a hospital in the northeastern city of Udon Thani on December 8 after claiming she was left paralysed by a series of three “neck-twisting” massage sessions. Ping Chayada posted a poignant final message on social media as she battled ill-health following the massage: “The first time I got a massage, my symptoms were normal. I went for another massage, the same therapist in the same room, this time twisting my neck. After two weeks, I started to have very, very tight pain to the point that I couldn’t lie on my back or stomach. I’ve been learning massage since I was a child. I really like massage. I thought it was just another side effect of the massage, this kind of body pain. I went again. But this new person massaged hard and it was swollen and bruised for a week. After that, I took medicine to relieve the symptoms all the time.” The talented star died on Sunday December 8.Ping Chanada died after a neck massage. Picture: Ping Chanada/Facebook

Just a day earlier, on December 7, a male Singaporean tourist, 52-year-old Lee Mun Tuk, died in Phuket after a 45-minute oil body massage – following which he reportedly went into cardiac arrest and could not be revived.

Harnelis, a massage therapist with the White Swallow Massage School in the city of Medan in neighbouring Indonesia, said that, while the deaths were tragic, they were not surprising. “Neck and back massage is inherently dangerous and deals with the most vulnerable part of the body,” she said. “You can’t do it carelessly, you have to do it keeping in mind where all the veins and blood vessels are. If you get it wrong, it can be fatal.”

Singer Prao-hom wrote that she had endured two “neck-twisting” sessions and a “heavy handed” third massage at a local parlour before experiencing numbness which spread through her body. She reportedly first went to the parlour, which had the required certification under Thai law, to relieve stiffness in her neck, but found that her symptoms continued to worsen. She was rushed to intensive care but died just two weeks later. Following an autopsy, her cause of death was listed as sepsis, a swollen spinal cord and a fungal infection.

The death of the singer has sparked an urgent investigation by the Thai Department of Health Service Support (DHSS). In the meantime, medical experts are warning of the dangers posed by violent manoeuvres given by poorly trained or unlicensed practitioners.

Thai massage is a widely used massage technique in Thailand and is accepted by the Thai Ministry of Public Health. The technique can be described to be a kind of acupressure massage. Even though there is very little reliable evidence, it is said to be effective for a wide range of conditions, e.g.:

Increased range of motion. Thai massage combines compression, acupressure, and passive stretching. These increase the range of motion in your joints and muscles. This can also improve your posture.

Helps with back pain. Thai massage tends to focus on areas that can contribute to back pain, like the inner thigh and abdomen. However, if you have constant back pain, it’s best to visit a doctor before getting any type of massage.

Reduces headache intensity. One study showed that nine sessions of traditional Thai massage in a 3-week period can reduce painful headaches in people who have chronic tension headaches or migraines.

Lowers stress. In another study, researchers showed that Thai massage reduced stress, especially when combined with plenty of rest.

Helps stroke patients. A 2012 study suggested that stroke patients who get Thai massage regularly may be better able to recover the ability to do daily activities. They may also have lower pain levels and sleep better.

Other benefits of Thai massage may include:

  • Better sleep
  • Better relaxation
  • Improved digestion
  • Calm mind or increased mindfulness

As always with such news reports, many essential details are missing for the two cases reported above. What seems obvious, however, is that the massage itself, even tough occasionally forceful, is not the main danger of Thai massage. The fatal complications seem to occur after spinal manipulation and are thus akin to the ones of chiropractic manipulations.

The objective of this paper, as stated by its authors, was to develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain.

Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology.

The Delphi process was conducted January–February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions:

  • low-back pain (LBP),
  • neck pain,
  • tension headache,
  • osteoarthritis (knee and hip),
  • fibromyalgia.

Recommendations were made for non-pharmacological treatments, including:

  • acupuncture,
  • spinal manipulation/mobilization,
  • other manual therapy;
  • low-level laser (LLL);
  • interferential current;
  • exercise, including yoga;
  • mind–body interventions, including mindfulness meditation and cognitive behavior therapy (CBT);
  • lifestyle modifications such as diet and tobacco cessation.

Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.

Therapeutic recommendations for low back pain:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence.
  • Exercise
  • Yoga/qigong (which may also be considered “mind–body” interventions)
  • Lifestyle advice to stay active; avoid sitting; manage weight if obese; and quit smoking
  • Spinal manipulation/mobilization
  • Massage
  • Acupuncture
  • LLL therapy
  • Transcutaneous electrical nerve stimulation (TENS) or interferential current may be beneficial as part of a multimodal approach, at the beginning of treatment to assist the patient in becoming or remaining active.
  • Combined active and passive: multidisciplinary rehabilitation
  • CBT
  • Mindfulness-based stress reduction

Therapeutic recommendations for neck pain:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence.
  • Exercise (range of motion and strengthening).
  • Exercise combined with manipulation/mobilization.
  • Spinal manipulation and mobilization
  • Massage
  • Low-level laser
  • Acupuncture
  • These modalities may be added as part of a multimodal treatment plan, especially at the beginning, to assist the patient in becoming or remaining active:
  • Transcutaneous nerve stimulation (TENS), traction, ultrasound, and interferential current.
  • Yoga
  • Qigong

Therapeutic recommendations for tension headache:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence:
  • Reassurance that TTH does not indicate presence of a disease.
  • Advice to avoid triggers.
  • Exercise (aerobic).
  • Spinal manipulation
  • Acupuncture
  • Cold packs or menthol gels
  • Combined active and passive
  • CBT
  • Relaxation therapy
  • Biofeedback
  • Mindfulness Meditation

Therapeutic recommendations for knee osteoarthritis:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
  • Exercise
  • Manual therapy
  • Ultrasound
  • Acupuncture, using “high dose” (greater treatment frequency, at least 3 × week)
  • LLL therapy

Therapeutic recommendations for hip osteoarthritis:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence
  • Exercise
  • Manual therapy

Therapeutic recommendations for fibromyagia:

  • Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
  • Exercise (aerobic and strengthening)
  • Advice on healthy lifestyle
  • Education on the condition
  • Spinal manipulation
  • Myofascial release
  • Acupuncture
  • LLL therapy
  • multidisciplinary rehabilitation
  • CBT
  • mindfulness meditation
  • yoga
  • Tai chi,
  • Qigong

The authors concluded that these evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

This paper is an excellent example of a pseudo-scientific process resulting in unreliable outcomes.

  • The Delphi process was conducted some 4 years ago
  • Because of the truly weird inclusion criteria, the findings are based essentially on just 3 systematic reviews.
  • Anyone who has ever tried to conduct a consensus excercise knows that the outcome will almost entirely depend on who is chosen to sit on the panel. So, all you have to do to obtain pro-chiro recommendations is to select a few pro-chiro ‘experts’ who then write the recommendations!
  • A “best practices for chiropractic management” may sound reasonable but, looking at the therapeutic recommendation, one easily realizes that the authors cast their nets so wide that the result has little to do with what differentiates chiropractic from Physiotherapists or osteopaths.

It is therefore not surprising that the recommendations are laughably unreliable: can, for instance, anyone explain to me why “advice on healthy lifestyle and education on the condition” are recommended for fibromyalgia but not for any other condition?

This paper is, in my view, chiropractic pseudo-science at its most ridiculous!

All it really does is it tries to legitimise all sorts of therapies as part of the chiropractic toolbox. My advice to patients is to:

  • consult a physio if you need exercise therapy or LLL or manual therapy or ultrasound or interferential current or TENS or cold packs or massage;
  • consult a clinical psychologist if you need CBT, or mindfulness, biofeedback;
  • consult a doctor if you want rehab or education or lifestyle advice or reassurance;
  • etc. etc.

And please avoid chiropractors who pretend they can do all of the above, while merely wanting to manipulate your neck.

This update of a systematic review evaluated the effectiveness of spinal manipulations as a treatment for migraine headaches.

Amed, Embase, MEDLINE, CINAHL, Mantis, Index to Chiropractic Literature, and Cochrane Central were searched from inception to September 2023. Randomized clinical trials (RCTs) investigating spinal manipulations (performed by various healthcare professionals including physiotherapists, osteopaths, and chiropractors) for treating migraine headaches in human subjects were considered. Other types of manipulative therapy, i.e., cranial, visceral, and soft tissue were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

Three more RCTs were published since our first review; amounting to a total of 6 studies with 645 migraineurs meeting the inclusion criteria. Meta-analysis of six trials showed that, compared with various controls (placebo, drug therapy, usual care), SMT (with or without usual care) has no superior effect on migraine intensity/severity measured with a range of instruments (standardized mean difference [SMD] − 0.22, 95% confidence intervals [CI] − 0.65 to 0.21, very low certainty evidence), migraine duration (SMD − 0.10; 95% CI − 0.33 to 0.12, 4 trials, low certainty evidence), or emotional quality of life (SMD − 14.47; 95% CI − 31.59 to 2.66, 2 trials, low certainty evidence) at post-intervention. A meta-analysis of two trials showed that compared with various controls, SMT (with or without usual care) increased the risk of adverse effects (risk ratio [RR] 2.06; 95% CI 1.24 to 3.41, numbers needed to harm = 6; very low certainty evidence). The main reasons for downgrading the evidence were study limitations (studies judged to be at an unclear or high risk of bias), inconsistency (for pain intensity/severity), imprecision (small sizes and wide confidence intervals around effect estimates) and indirectness (methodological and clinical heterogeneity of populations, interventions, and comparators).

We cocluded that the effectiveness of SMT for the treatment of migraines remains unproven. Future, larger, more rigorous, and independently conducted studies might reduce the existing uncertainties.

The only people who might be surprised by these conclusions are chiropractors who continue to advertise and use SMT to treat migraines. Here are a few texts by chiropractors (many including impressive imagery) that I copied from ‘X’ just now (within less that 5 minutes) to back up this last statement:

  • So many people are suffering with Dizziness and migraines and do not know what to do. Upper Cervical Care is excellent at realigning the upper neck to restore proper blood flow and nerve function to get you feeling better!
  • Headache & Migraine Relief! Occipital Lift Chiropractic Adjustment
  • Are migraines affecting your quality of life? Discover effective chiropractic migraine relief at…
  • Neck Pain, Migraine & Headache Relief Chiropractic Cracks
  • Migraine Miracle: Watch How Chiropractic Magic Erases Shoulder Pain! Y-Strap Adjustments Unveiled
  • Tired of letting migraines control your life? By addressing underlying issues and promoting spinal health, chiropractors can help reduce the frequency and severity of migraines. Ready to experience the benefits of chiropractic for migraine relief?
  • Did you know these conditions can be treated by a chiropractor? Subluxation, Back Pain, Chronic Pain, Herniated Disc, Migraine Headaches, Neck Pain, Sciatica, and Sports Injuries.
  • When a migraine comes on, there is not much you can do to stop it except wait it out. However, here are some holistic and non-invasive tips and tricks to prevent onset. Check out that last one! In addition to the other tips, chiropractic care may prevent migraines in your future!

Evidence-based chiropractic?

MY FOOT!

 

Spanish colleagues and I just published an article entitled “Is Osteopathic Manipulative Treatment Clinically Superior to Sham or Placebo for Patients with Neck or Low-Back Pain? A Systematic Review with Meta-Analysis”. Here is its abstract:

The aim of this systematic review and meta-analysis was to compare whether osteopathic manipulative treatment (OMT) for somatic dysfunctions was more effective than sham or placebo interventions in improving pain intensity, disability, and quality of life for patients with neck pain (NP) or low-back pain (LBP). Methods: A systematic review and meta-analysis was carried out. Searches were conducted in PubMed, Physiotherapy Evidence Database, Cochrane Library, and Web of Science from inception to September 2024. Studies applying a pragmatic intervention based on the diagnosis of somatic dysfunctions in patients with NP or LBP were included. The methodological quality was assessed with the PEDro scale. The quantitative synthesis was performed using random-effect meta-analysis calculating the standardized mean difference (SMD) with RevMan 5.4. The certainty of evidence was evaluated using GRADEPro. Results: Nine studies were included in the qualitative synthesis, and most of them showed no superior effect of OMTs compared to sham or placebo in any clinical outcome. The quantitative synthesis reported no statistically significant differences for pain intensity (SMD = −0.15; −0.38, 0.08; seven studies; 1173 patients) or disability (SMD = −0.09; −0.25, 0.08; six studies; 1153 patients). The certainty of evidence was downgraded to moderate, low, or very low. Conclusions: The findings of this study reveal that OMT is not superior to sham or placebo for improving pain, disability, and quality of life in patients with NP or LBP.

As always, it seems important to stress that our review has several limitations. Firstly, the searches were conducted in the most relevant databases; however, some studies not indexed in these sources may have been missed. Secondly, the diverse NP and LBP diagnosis, as well as the lack of data reported by some studies, complicates the interpretation of the results and may weaken our conclusion. Thirdly, the primary studies pragmatically applied interventions based on diagnoses of various somatic dysfunctions, resulting in a high degree of heterogeneity among the treatments applied.

Despite these limitations, it is fair to say, I think, that OMT is not nearlly as solidly supported by reliable evidence as most osteopaths try to make us believe. In essence, this means that, if you suffer from NP or LBP, you best concult a proper doctor or physiotherapist.

Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in numerous case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). This study‘s hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.

A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts:

  • (1) LBP patients receiving CSM,
  • (2) LBP patients receiving PT evaluation without spinal manipulation.

Propensity score matching controlled for confounding variables associated with CES.

67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05–0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09–0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42–0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up.

The authors concluded that the present study involving over 130,000 propensity-matched patients found that CSM is not a risk factor for CES. The incidence of CES in both CSM and PT evaluation cohorts aligns with previous estimates of CES incidence among patients with LBP, indicating a heightened risk of CES compared to asymptomatic individuals regardless of intervention. Moreover, these findings underscore the increased CES incidence within the first two weeks after either CSM or PT evaluation, emphasizing the need for clinicians’ vigilance in identifying and emergently referring patients with CES for surgical evaluation. Further real-world evidence is needed to corroborate these findings using alternative case-control and case-crossover designs, and different clinician comparators.

This is an interesting and well-reported investigation. Its particular strength is the huge sample size. Its weakness, on the other hand, is the fact that, despite the researchers best efforts, the two groups might not have been entirely comparable and that there could be a host of relevant factors that the propensity matching was unable to control for.

It is, I think, to the credit of the authors that they abstain from overrating their results and correctly emphasize in their conclusions that: Further real-world evidence is needed to corroborate these findings using alternative case-control and case-crossover designs, and different clinician comparators.

Advocates of so-called alternative medicine (SCAM) almost uniformly stress the importance of prevention and pride themselves to make much use of SCAM for the purpose of prevention. SCAM, they often claim, is effective for prevention, while conventional medicine tends to neglect it. Therefore, it seems timely to ponder a bit about the subject.

It makes sense to differentiate three types of prevention:

  1. Primary prevention aims to prevent disease or injury before it ever occurs.
  2. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred.
  3. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects.

Here I will includes all three and I will ask what SCAM has to offer in any form of prevention. I will do this by looking at what we have previously discussed on this blog in relation to several specific SCAM and add in each case a very brief evaluation of the evidence.

Acupuncture

Chiropractic

Herbal medicine

Homeopathy

Mind-body therapies

Osteopathy

Does Osteopathy Prevent Motion Sickness? – NO CONVINCING EVIDENCE

Supplements

Yoga

I hope you agree: this list is impressive!

  • Impressive in the way of showing how often we have discussed SCAM for prevention in one form or another.
  • Impressive also to see how little positive evidence there is for effective prevention with SCAM

Of course, this is merely based on posts that were published on my blog. Some will argue that I missed out on some effective SCAMs for prevention. Others might claim that I judged some of the the above cited articles too harshly. If you share such sentiments, I invite you to show me the evidence – and I promise to look at it and evaluate it critically.

Meanwhile, I will draw the following conclusion:

Despite the prominent place prevention assumes in discussions about SCAM, the actual evidence fails to show that it has an important role to play in primary, secondary or tertiary prevention.

 

When I still worked as a clinician, I have looked after athletes long enough to know that they go for everything that promises to improve their performance. It is thus hardly surprising that Olympians would try all sorts of so-called alternative medicine (SCAM) regardless of whether the therapy is supported by evidence or not. Skeptics are tempted to dismiss all of SCAM for improving fitness. But is that fair? Is it true that no evidence evists for any of them?

The short answer to this question is NO.

Here I have looked at some of the possibilities and show you some of the Medline-listed papers that seem to support SCAM as a means of improving fitness:

Acupuncture

Healthy physically active adults significantly improved their endurance running performance after 4 weeks of AC treatment.

Ashwagandha

The present findings suggest that Ashwagandha root extract can successfully enhance cardiorespiratory endurance and improve the quality of life in healthy athletic adults.

Balneology

The effects of balneological factors on cardiovascular system, external respiration, muscular performance, neuromuscular system and blood biochemistry give grounds to believe that inclusion of these factors in one-year training cycle extends the armery of effective tools recovering and improving muscular performance, preventing diseases and traumas in sportsmen.

Cupping

No explicit recommendation for or against the use of cupping for athletes can be made. More studies are necessary for conclusive judgment on the efficacy and safety of cupping in athletes.

Ginkgo biloba

Our results show that six weeks’ supplementation with Ginkgo biloba extract in physically active young men may provide some marginal improvements in their endurance performance expressed as VO₂max and blood antioxidant capacity, as evidenced by specific biomarkers, and elicit somewhat better neuroprotection through increased exercise-induced production of BDNF.

Ice

From a biochemical point of view, whole-body cryotherapy not always induces appreciable modifications, but the final clinical output (in terms of pain, soreness, stress, and post-exercise recovery) is very often improved compared to either the starting condition or the untreated matched group. 

Kinesiology tape

Kinesiology tape does not reduce loading patterns in healthy dancers during a fatigue protocol. However, triaxial accelerometers provide adequate sensitivity when detecting changes in loading, suggesting the LL may be deemed as a more relevant method of monitoring training load in dancers.

Massage guns

Massage guns can help to improve short-term range of motion, flexibility and recovery-related outcomes, but their use in strength, balance, acceleration, agility and explosive activities is not recommended.

Percussion massage

Percussive massage therapy would be an alternative that can be used to increase the performance and balance of individuals before exercise.

Sports massage

The combination of intermittent exercise with sports massages further enhanced the performance of sit-ups and standing long jump, improve blood pressure, BMI, and self-confidence, as well as reducing suicidal tendencies (experimental group > control group). However, intermittent exercise participants still experienced fatigue, headache, emotional loss, and fear of depression, and the addition of sports massage did not significantly improve flexibility and cardiorespiratory endurance (control group > experimental group).

Tai massage

All the physical fitness tests were significantly improved after a single session of Thai massage, whereas only the sit and reach, and the sit-ups tests were improved in the control group.

Vibrational massage

Based on available knowledge about proprioceptive spinal reflexes-that feedback from the primary endings of motor spindles produces a stimulatory effect via increased discharge of a-motoneurons, and activation of Golgi tendon organs (GTO) evokes inhibition of muscle action-a hypothesis has been proposed that VT enhances excitatory inflow from muscle spindles to the motorneuron pools and depresses inhibitory impact of GTO due to the accommodation to vibration stimuli. The intensity and duration of vibration used in VT dramatically exceed the standards for occupational vibration established by the International Organization for Standardization.

Yoga

Thai yoga exercises appeared useful, in particular, on body and right shoulder joint flexibility. Regular stretching exercise of Thai yoga and/or in combination with exercises could promote health-related physical fitness.

Please do not mistake this for anything resembling a systematic review of the evidence; it is merely a list to give you a flavour of what is out there. And please don’t assume that the list is complete; I am sure that there is much more.

Looking at the articles that I found, one could get the impression that there is plenty of good evidence to support SCAM for improving fitness. This, however, would be wrong. The evidence for almost every of the above listed therapies is flimsy to say the least. But – as I stated already at the beginning – in my experience, this will not stop athletes to use them.

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