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

pain

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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.

______________________

I wish to express my thanks to Jay for his courage and honesty in writing these lines.

This review was aimed at quantifying the proportion attributable to contextual effects of physical therapy interventions for musculoskeletal pain. Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain.

Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (ROB 2.0). The proportion of physical therapy interventions effect that is explained by contextual effects was calculated, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method).

Sixty-eight studies were included in the systematic review (total number of participants: n=5,238), and 54 placebo-controlled trials informed our meta-analysis (participants: n=3,793). Physical therapy interventions included:

  • soft tissue techniques,
  • mobilization,
  • manipulation,
  • taping,
  • exercise therapy,
  • dry needling.

Placebo interventions included manual, non-manual interventions, or both.

The results show the following:

  • The type of treatment with the largest proportion not attributable to the specific effects (PCE) for pain intensity assessed immediately after the intervention was mobilization, which represented 87% of the overall treatment effect (PCE = 0.87, 95% CI: 0.54, 1.19).
  • For soft tissue techniques, the PCE was 81% of the overall treatment effect (PCE = 0.81, 95% CI: 0.64, 0.97).
  • For dry needling, the PCE was 75% (PCE = 0.75, 95% CI: 0.36, 1.15).
  • For manipulation techniques the PCE was 74% (PCE = 0.74, 95% CI: 0.33, 1.14).
  • For taping the PCE was 69% of the overall treatment effect (PCE = 0.69, 95% CI: 0.48, 0.89).
  • The smallest proportion not attributable to the specific intervention itself for pain intensity was exercise therapy accounting for 46% of the overall treatment effect (PCE = 0.46, 95% CI: 0.41, 0.52).

The authors concluded that the outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by contextual effects. Boosting contextual effects consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients.

This sounds as though most of the treatments in question rely mainly on placebo effects. But what about conventional therapies? The authors point out that the PCEs of general medicine and surgery in pain-related conditions are also large. In particular, the overall proportion not attributable to the specific effects of general medicine interventions is high (PCE = 65%), with higher values observed in semi-objective and objective outcomes (PCE = 78 and 94%, respectively) than in subjective outcomes (PCE = 50%).

What does that mean for healthcare routine?

As placebo and other context effects are unreliable, usually short-lived, and not normally affecting the cause of the problem (but merely the symptoms), I would say that those treatments with a very high PCE are of limited value, paticularly if they are also expensive or burdened with risks. Of the treatments studied here, I would – based on the current analysis – avoid the following therapies for pain management:

  • mobilization,
  • soft tissue techniques,
  • dry needling,
  • manipulation,
  • taping.

By and large, these are also the conclusions drawn from various other strands of evidence that we have repeatedly discussed in previous posts.

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

We have recently heard much about spinal manipulations for kids. It might therefore be relevant to learn about an international taskforce of clinician-scientists formed by specialty groups of World Physiotherapy – International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) – to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.

1. It is not recommended to perform:

• Spinal manipulation and mobilisation on infants.

• Cervical and lumbar spine manipulation on children.

•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.

2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:

• Spinal mobilisation and manipulation on adolescents;

• Spinal mobilisation on children; or

• Thoracic manipulation on children for neck-back pain only.

3. No high certainty evidence to recommend these interventions was available.

Reports of mild to severe harms exist; however, risk rates could not be determined.

It was concluded that specific directives to guide physiotherapists’ clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Whether one agrees with these directions or not (and I am not sure I fully do), I have always thought that people who, despite the largely lacking or flimsy evidence for spinal manipulations, insist on having manual therapy should consult a physiotherapist, rather than a chiropractor or osteopath.

Why?

Because, in my experience, physiotherapist:

  • display less cult-dependent behaviours,
  • do not follow the gospel of charlatans, like Palmer and Still,
  • do not believe in the fiction of subluxation,
  • are not so money-minded,
  • less prone to use un- or disproven methods, like applied kinesiology, homeopathy, cranial osteopathy, etc.,
  • unlikely to try to sell you useless dietary supplements,
  • tend to judge better their limits of professional competence,
  • are far less likely to try to persuade you of BS related to anti-vax, anti-drug, anti-science, anti-EBM, etc.

In November 2022, we discussed a dodgy acupuncture review. Let me show you my post from back then again:

Acupuncture is emerging as a potential therapy for relieving pain, but the effectiveness of acupuncture for relieving low back and/or pelvic pain (LBPP) during pregnancy remains controversial. This meta-analysis aimed to investigate the effects of acupuncture on pain, functional status, and quality of life for women with LBPP pain during pregnancy.

The authors included all RCTs evaluating the effects of acupuncture on LBPP during pregnancy. Data extraction and study quality assessments were independently performed by three reviewers. The mean differences (MDs) with 95% CIs for pooled data were calculated. The primary outcomes were pain, functional status, and quality of life. The secondary outcomes were overall effects (a questionnaire at a post-treatment visit within a week after the last treatment to determine the number of people who received good or excellent help), analgesic consumption, Apgar scores >7 at 5 min, adverse events, gestational age at birth, induction of labor and mode of birth.

Ten studies, reporting on a total of 1040 women, were included. Overall, acupuncture

  • relieved pain during pregnancy (MD=1.70, 95% CI: (0.95 to 2.45), p<0.00001, I2=90%),
  • improved functional status (MD=12.44, 95% CI: (3.32 to 21.55), p=0.007, I2=94%),
  • improved quality of life (MD=−8.89, 95% CI: (−11.90 to –5.88), p<0.00001, I2 = 57%).

There was a significant difference in overall effects (OR=0.13, 95% CI: (0.07 to 0.23), p<0.00001, I2 = 7%). However, there was no significant difference in analgesic consumption during the study period (OR=2.49, 95% CI: (0.08 to 80.25), p=0.61, I2=61%) and Apgar scores of newborns (OR=1.02, 95% CI: (0.37 to 2.83), p=0.97, I2 = 0%). Preterm birth from acupuncture during the study period was reported in two studies. Although preterm contractions were reported in two studies, all infants were in good health at birth. In terms of gestational age at birth, induction of labor, and mode of birth, only one study reported the gestational age at birth (mean gestation 40 weeks).

The authors concluded that acupuncture significantly improved pain, functional status and quality of life in women with LBPP during the pregnancy. Additionally, acupuncture had no observable severe adverse influences on the newborns. More large-scale and well-designed RCTs are still needed to further confirm these results.

What should we make of this paper?

In case you are in a hurry: NOT A LOT!

In case you need more, here are a few points:

  • many trials were of poor quality;
  • there was evidence of publication bias;
  • there was considerable heterogeneity within the studies.

The most important issue is one studiously avoided in the paper: the treatment of the control groups. One has to dig deep into this paper to find that the control groups could be treated with “other treatments, no intervention, and placebo acupuncture”. Trials comparing acupuncture combined plus other treatments with other treatments were also considered to be eligible. In other words, the analyses included studies that compared acupuncture to no treatment at all as well as studies that followed the infamous ‘A+Bversus B’ design. Seven studies used no intervention or standard of care in the control group thus not controlling for placebo effects.

Nobody can thus be in the slightest surprised that the overall result of the meta-analysis was positive – false positive, that is! And the worst is that this glaring limitation was not discussed as a feature that prevents firm conclusions.

Dishonest researchers?

Biased reviewers?

Incompetent editors?

Truly unbelievable!!!

In consideration of these points, let me rephrase the conclusions:

The well-documented placebo (and other non-specific) effects of acupuncture improved pain, functional status and quality of life in women with LBPP during the pregnancy. Unsurprisingly, acupuncture had no observable severe adverse influences on the newborns. More large-scale and well-designed RCTs are not needed to further confirm these results.

PS

I find it exasperating to see that more and more (formerly) reputable journals are misleading us with such rubbish!!!

Now, it has been announced that the paper has been retracted:

The research “Acupuncture for low back and/or pelvic pain during pregnancy: a systematic review and meta-analysis of randomised controlled trials,” published in the open access journal BMJ Open in 2022, has been retracted.

This research was press released in November 2022 under the title of “Acupuncture can relieve lower back/pelvic pain often experienced during pregnancy.”

Following publication of the research, various issues concerning its design and reporting methods came to light, none of which was amenable to correction, prompting the decision to retract.

The full wording of the retraction notice, which will be published at 23.30 hours UK (BST) time Tuesday 11 June 2024, is set out below:

“After publication, multiple issues were raised with the journal concerning the design and reporting of the study. The editors and integrity team investigated the issues with the authors. There were fundamental flaws with the research, including the control group selection and data extraction, not amenable to correction.” doi:10.1136/bmjopen-2021-056878ret

Please ensure that you no longer cite this research in any future reporting.

One down, dozens of further SCAM papers to go!

Phantom pain (pain felt in an amputated limb) affects the lives of individuals in many ways and can negatively affect the well-being of individuals. Distant Reiki is sometimes used in the management of these problems. But does it work?

This study was conducted to examine the effect of distant Reiki applied to individuals  suffering from phantom pain on:

1) pain level,

2) holistic well-being.

This study was designed as a single group pre-test/post-test comparison. The research was conducted between September 2022 and April 2023 and included 25 individuals with extremity amputations. Distant Reiki was performed for 20 minutes every day for 10 days. Data were collected at the beginning of the study and at the end of the 10th day. The measurements included an Introductory Information Form, the Visual Analog Scale for Pain, and Holistic Well-Being Scale (HWBS).

The results show that there was a significant difference between pre-test and post-test pain levels of the participants (p < .05) and HWBS subscale scores (p < .05). Accordingly, it was determined that after 20-minute distant Reiki sessions for 10 consecutive days, the pain levels of the individuals were significantly reduced and their holistic well-being improved.

The authors concluded that distant Reiki has been found to be easy to administer, inexpensive, non-pharmacological, and appropriate for independent nursing practice to be effective in reducing phantom pain levels and increasing holistic well-being in people with limb amputation.

Yes, I agree that Reiki might have been easy to administer.

I also agree that it is inexpensive and non-pharmacological.

I disagree, however that it is an appropriate therapy for an independent nursing practice.

And I disagree even more that this study shows or even suggests that Reiki is effective.

Why?

You probably kow the reason: this study had no control group. The observed outcomes can have several explanations that are unrelated to Reiki. For instance, the 200 minutes of attention, empathy and encouragement are likely to have generated an impact.

My conclusion: it is high time that researchers, peer-reviewers, editors, etc. stop trying to mislead the public with offensively poor-quality research and false conclusions. Reiki is an utterly implausible therapy for which no sound evidence exist.

Many forms of so-called alternative medicine (SCAM) involve touch, and touch is of critical importance: many studies have shown that it promotes mental and physical well-being.

A team of researchers conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review (n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy.

Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias.

The results show that touch interventions were especially effective in:

  • regulating cortisol levels (Hedges’ g = 0.78, 95% confidence interval (CI) 0.24 to 1.31),
  • increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns,
  • reducing pain (0.69, 95% CI 0.48 to 0.89),
  • reducing feelings of depression (0.59, 95% CI 0.40 to 0.78),
  • reducing state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults.

Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55).

The authors found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered.

The authors concluded that leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

It seems obvious to me that these findings are relevant to several SCAMs, e.g.:

  • acupuncture,
  • Alexander technique,
  • applied kinesiology,
  • aromatherapy,
  • Bowen technique,
  • chiropractic,
  • craniosacral therapy,
  • cupping,
  • Dorn method,
  • Feldenkrais method,
  • gua sha,
  • kinesiology taping,
  • lymph drainage,
  • massage in all its variations,
  • naprapathy,
  • osteopathy,
  • rebirthing,
  • reflexology,
  • Rolfing,
  • shiatsu,
  • slapping therapy,
  • therapeutic touch.

This also means that the effects of these SCAMs will be at least to some extend non-specific, i.e. not related to the treatment per se but to touch. Finally, it means that clinical trials testing these SCAMs need to be designed such that the touch element is adequately accounted for.

This study aims to appraise the utility, accuracy, and quality of information available on YouTube on acupuncture for chronic pain treatment. Using search terms such as “acupuncture for chronic pain” and “acupuncture pain relief”, the top 54 videos by view count were selected. Videos were included if they were:

  • > 1 minute duration,
  • contained audio in English,
  • had > 7000 views,
  • related to acupuncture.

Each video was categorised as either:

  • useful,
  • misleading,
  • or neither.

Another primary outcome of interest was the quality and reliability of each video using validated instruments, including the modified DISCERN (mDISCERN) tool and the Global Quality Scale (GQS). The means were calculated for the video production characteristics, production sources, and mDISCERN and GQS scores. Continuous and categorical outcomes were compared using Student’s t-test and chi-square test, respectively.

The results show that, of the 54 videos,

  • 57.4% were categorized as useful,
  • 14.8% were misleading,
  • and 27.8% were neither.

Useful videos had a mean GQS and mDISCERN score of 3.77± 0.67 and 3.48± 0.63, respectively, while misleading videos had mean GQS and mDISCERN score of 2.50± 0.53 and 2.38± 0.52, respectively. 41.8% of the useful videos were produced by a healthcare institution while none of the misleading videos were produced by a healthcare institution. However, 87.5% of the misleading videos were produced by health media compared to only 25.8% of useful videos from health media.

The authors concluded that their analysis of the highest viewed acupuncture videos for chronic pain reveals only about half provide useful information, indicating a significant misinformation challenge for viewers. This underscores the urgent need for more high-quality, unbiased videos from healthcare institutions and physicians on complementary health practices like acupuncture.

This new analysis confirms what we and others have shown numerous times before: information about so-called alternative medicine (SCAM), which is abundantly available on the Internet, needs to be taken with a healthy pinch of salt. Whenever we studied the issue, our conclusions were even less optimistic than those of the present authors. In fact, most of the time we concluded that following such advice is a risk factor to our health.

This systematic review and meta-analysis investigated the effectiveness and safety of manual therapy (MT) interventions compared to oral or topical pain medications in the management of neck pain.
The investigators searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to oral or topical medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. Trials with usual care arms were also included if they prescribed medication as part of the usual care and they did not include a manual therapy component. The authors used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.

Nine trials  with a total of 779 participants were included in the meta-analysis.

  • low certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants),
  • moderate certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: −0.36; 95% CI −0.55 to −0.17; 6 trials, 567 participants),
  • low certainty evidence that the risk of adverse events may be lower for patients who received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).

The authors conluded that MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.

Let’s have a look at the primary studies. Here they are with their conclusions (and, where appropriate, my comments in capital letters):

  1. For participants with acute and subacute neck pain, spinal manipulative therapy (SMT) was more effective than medication in both the short and long term. However, a few instructional sessions of home exercise with (HEA) resulted in similar outcomes at most time points. EXERCISE WAS AS EFFECTIVE AS SMT
  2.  Oral ibuprofen (OI) pharmacologic treatment may reduce pain intensity and disability with respect to neural mobilization (MNNM and CLG) in patients with CP during six weeks. Nevertheless, the non-existence of between-groups ROM differences and possible OI adverse effects should be considered. MEDICATION WAS BETTER THAN MT
  3. It appears that both treatment strategies (usual care + MT vs usual care) can have equivalent positive influences on headache complaints. Additional studies with larger study populations are needed to draw firm conclusions. Recommendations to increase patient inflow in primary care trials, such as the use of an extended network of participating physicians and of clinical alert software applications, are discussed. MT DOES NOT IMPROVE OUTCOMES
  4. The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine. THIS IS A PILOT STUDY, A TRIAL TESTING FEASIBILITY, NOT EFFECTIVENESS
  5. The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.
  6. In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
  7. Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up. MT IS NOT SUPERIOR [SAME TRIAL AS No 6]
  8. In this randomized clinical trial, for patients with chronic neck pain, Chuna manual therapy was more effective than usual care in terms of pain and functional recovery at 5 weeks and 1 year after randomization. These results support the need to consider recommending manual therapies as primary care treatments for chronic neck pain.
  9. In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit. SAME TRIAL AS No 5
  10. An impairment-based manual physical therapy and exercise (MTE) program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound. THIS STUDY DID NOT TEST MT ALONE AND SHOULD NOT HAVE BEEN INCLUDED

I cannot bring myself to characterising this as an overall positive result for MT; anyone who can is guilty of wishful thinking, in my view. The small differences in favor of MT that (some of) the trials report have little to do with the effectiveness of MT itself. They are almost certainly due to the fact that none of these studies were placebo-controlled and double blind (even though this would clearly be possible). In contrast to popping a pill, MT involves extra attention, physical touch, empathy, etc. These factors easily suffice to bring about the small differences that some studies report.

It follows that the main conclusion of the authors of the review should be modified:

There is no compelling evidence to show that MT is more effective for people with neck pain in both short and long-term when compared to patients receiving oral pain medications.

 

Cervical spondylosis is a chronic degenerative process of the cervical spine characterized by pain in neck, degenerative changes in intervertebral disc and osteophyte formation. The present study was aimed at evaluating the effect of wet cupping (Ḥijāma Bish Sharṭ) in the pain management of cervical spondylosis.

This Open, randomized, clinical study was conducted on 44 patients.

  • Subjects in the test group (n = 22) received a series of three-staged wet cupping treatment, performed on 0, 7th and 14th day.
  • Subjects in the control group (n = 22) received 12 sittings of Transcutaneous Electrical Nerve Stimulation (TENS): 6 sittings per week for two weeks.

The outcomes were assessed with the help of VAS, Neck Disability Index (NDI) and Cervical range of motion.

Intra group comparison in test group from baseline to 21st day were found highly significant (p < 0.001) in terms of VAS, NDI, Flexion, Extension and Left rotation score. While in Right rotation, Left rotation and Left lateral flexion score were found moderately significant (p < 0.01). Statistically significant difference was observed between two groups at 21st day in VAS scale, NDI, and Cervical range of motion score (p < 0.001).

The authors concluded that Ḥijāma Bish Sharṭ was found better in the management of pain due to cervical spondylosis than TENS. It can be concluded that Ḥijāma Bish Sharṭ may a better option for the pain management of cervical spondylosis.

Wet cupping is the use of a vacuum cup applied to the skin which has previously been lacerated. It draws blood and can thus be seen as a form of blood letting. It has been used in various cultures for the treatment of joint pain and many other conditions since antiquity.

The authors point out that, in Unani medicine, it is believed to reduce pain and other symptoms by diverting and evacuating the causative pathological humours (akhlāṭ-e-fasida). Galen (Jalinoos) mentioned wet cupping as a very useful modality in evacuating the thick humours (akhlāṭ-e-Ghaleez) (Nafeesi, 1954; Qamri, 2008). Wet cupping works on the principle of diversion and evacuation of morbid matter (imala wa tanqiya-i-mawād-i-fasida). It opens the pores of the skin, enhances the blood circulation, nourishes the affected area with fresh blood, improves the eliminative function and facilitates the evacuation of morbid matter from the body.

There are several studies of wet cupping, most of which are as flawed as the one above. This new trial has several limitations, e.g.:

  • It makes no attempt to control for placebo effects which could well be more prominent for wet cupping than for TENS.
  • It did not inhibit the influence of verbal or non-verbal communications between therapists and patients which are likely to influence the results.
  • The sample size is far too small, particularly as the study was designed as an equivalence study.

But some might say that my arguments a petty and argue that, regardless of a flimsy study, wet cupping is still worth a try. I would disagree – not because of the flaws of this study, nor the implausibility of the long-obsolete assumptions that underpin the therapy, but because wet cupping is associaated with infections of the skin lacerations which occasionally can be serious.

 

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