pain
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.
Opioid withdrawal involves sympathetic hyperactivity and reduced parasympathetic tone, which standard pharmacological treatments may not adequately address, contributing to relapse vulnerability. This study evaluated yoga as adjuvant therapy to accelerate opioid withdrawal recovery and assess its impact on heart rate variability, anxiety, sleep, and pain.
This 2-arm, early-stage randomized clinical trial was conducted at an addiction medicine inpatient ward in India from April 30, 2023 to March 31, 2024. The outcome assessors and data analyst were blinded to group allocation. Participants included adults aged 18 to 50 years with opioid use disorder experiencing mild to moderate withdrawal symptoms (Clinical Opiate Withdrawal Scale [COWS] scores 4-24). Exclusion criteria included severe withdrawal, neurological conditions affecting autonomic function, severe psychiatric conditions, and recent yoga training. Of 68 individuals screened, 59 were randomized (30 yoga and 29 control participants).
Participants in the yoga group received (A) 10 supervised 45-minute sessions during 14 days alongside (B) standard buprenorphine treatment, including relaxation practices, postures, breathing techniques, and guided relaxation. Participants in the control group received (B) standard buprenorphine treatment only. Co-primary outcomes included time to withdrawal stabilization (COWS score <4) and heart rate variability parameters. Secondary outcomes included anxiety (Hamilton Anxiety Rating Scale), sleep latency, and pain scores. Assessments were conducted at baseline (day 1) and day 15.
Fifty-nine participants (59 male [100%]; mean [SD] age, 25.6 [3.9] years) completed intent-to-treat analysis. Participants in the yoga group recovered faster than those in the control group (hazard ratio [HR], 4.40; 95% CI, 2.40-8.07; P < .001), with a median stabilization time of 5 days (95% CI, 4-6 days) for those in the yoga group vs 9 days (95% CI, 7-13 days) for the control group. Participants in the yoga group showed superior heart rate variability improvements with large effects on low frequency (LF) power (ω2 = 0.16), high frequency (HF) power (ω2 = 0.14), and LF/HF ratio (ω2 = 0.12); all effects were statistically significant (P < .001). Mediation analysis showed that increases in parasympathetic activity accounted for 23% of the treatment effect (indirect HR, 1.38; 95% CI, 1.10-2.03). Anxiety reduction was significantly greater among those in the yoga group (ω2 = 0.28; P < .001), with moderate improvements in sleep latency (a 61-minute reduction; P = .008) and pain (P = .004).
The authors concluded that in this randomized clinical trial, yoga significantly accelerated opioid withdrawal recovery and improved autonomic regulation, anxiety, sleep, and pain. These findings support integrating yoga into withdrawal protocols as a neurobiologically informed intervention addressing core regulatory processes beyond symptom management.
This conclusion is demonstrably wrong, and I am dismayed that a reputable journal published it.
The study followed the infamous ‘A+B versus B’ design. It is infamous because it is seemingly rigorous (“A RANDOMIZED CLINICAL TRIAL”!!!), while invariably generating a positive result for the tested intervention – even if it happens to be nothing more than a placebo tretment. And because of this, it is, in my view, unethical to use it for concluding about the specific effects of the tested intervention. I have explained this so often that I hesitate to do it again:
- Imagine the treatments as two amounts of money.
- Amount (treatmet) A equals £1.
- Amount (treatment) B equals £2.
- If one (the verum) group gets A+B, it will have £3.
- If the other (control) group gets just £2, it will have £2.
- A+B is always more that B.
- If A is a placebo, the A+B > B still applies, due to the existance of placebo effects
- QED!
The crux is obviously that the A+B vs B design only appears to be rigorous but, in fact, does NOT control for placebo effects. Since placebo effects exist, the A+B vs B design must produce a positive result, even if the verum is ineffective and merely generates a placebo response.
As the type of yoga employed in this study is bound to generate a sizable placebo effect, it would easily be enought to cause the observed outcomes. Let me put it even more bluntly: this study design is unable to tell us whether the yoga therapy or a placebo response was responsible for the observed result*.
In view of this, I will re-formuate the first sentence of the conclusion as follows:
In this randomized clinical trial, a placebo effect accelerated opioid withdrawal recovery and improved autonomic regulation, anxiety, sleep, and pain.
But what about the 2nd sentence of the conclusion?
Arguably, it is even worse!
To claim that the findings of one single study sufiice for calling for the integration of the tested treatment into routine healthcare ignores the need for independent replications and is therefore dangerous nonsense.
*(Btw: this is also the reason why it is so popular with pseudoscientists trying to show that their pet therapy works.]
This study aimed to evaluate the comparative effectiveness of “fire cupping therapy” (FC) versus electroacupuncture for reducing pain and improving cervical spine range of motion in patients with neck pain due to cervical spondylosis. FC is essentially nothing else than the TCM version of cupping.
Eighty-two participants with neck pain caused by cervical spondylosis were randomly allocated in 1:1 ratio to either the fire cupping (FC) or the electroacupuncture (EA) group. Both groups received treatment at the EX-B2, A-shi, and GB21 acupuncture points. The two-week study assessed pain levels using the Visual Analog Scale (VAS) at 2 points in time post-intervention and evaluated adverse effects weekly.
After 2 weeks of intervention, VAS scores significantly decreased in both the FC group (from 6 (6–7) to 3 (2–3)) and the EA group (from 6 (6–7) to 2 (1–3)) (p<0.001). However, inter-group pain relief was not statistically significant (p = 0.5794, Cohen’s d = 21 0.12; 95% CI [-0.31–0.6]). Both groups showed statistically significant ROM improvement (p<0.001), though the EA group demonstrated better improvement in flexion, extension, and left/right lateral flexion (p<0.05). No adverse effects of FC were reported.
The authors concluded that FC appears to be an effective and safe therapy for neck pain due to cervical spondylosis, showing similar pain relief efficacy with no statistically significant difference compared to electroacupuncture despite a lower treatment dosage. However, due to methodological limitations, these findings should be interpreted with caution and warrant further validation in rigorously designed studies.
I do agree with the authors’ call for caution – but with little else of what they state. Here are some of my concerns:
- A trial comparing two supposedly active treatments is an ‘equivalence study’; and such investigations require much larger sample sizes that 80.
- Equivalence studies only make sense, if one of the two treatments has been shown beyond doubt to be effective; this is not the case for electroacupuncture nor for FC.
- As it stands, the study does not control for placebo effects; thus the findings are in accordance with both treatments being pure placebos.
- A study with 80 patients tells us as good as nothing about the safety of the iterventions; to draw conclusions about safety is thus unwarranted
My conclusion (yet again) is this:
If you design a nonsense study, you are asking for a nonsense result.
Colic in infants causes excessive crying in an otherwise healthy and thriving baby. Colic is a common but poorly understood and often frustrating problem for caregivers. The objective of this trial was to study whether osteopathic treatments of infants with infantile colic / excessive crying (IC/EC) have an impact on the subjectively perceived psychological stress of caregivers compared to usual care.
The study was designed as a prospective, multicenter, randomized controlled trial. Infants aged 1 week to 3 months and who met Rome IV criteria for IC/EC were included. By means of external randomization, infants were allocated to an intervention group or a control group. Infants in the intervention group received three osteopathic treatments at intervals of one week. The treatments were custom-tailored and based on osteopathic principles. Controls received their osteopathic treatment after a 3 week untreated period. The primary outcome parameter was the assessment of parental psychological stress (three questions), measured using a numeric rating scale (NRS; 0-10). Furthermore, the average daily crying time (measured using the Likert scale), the crying intensity (measured using the NRS) and the parents’ self-confidence (measured using the Karitane Parenting Confidence Scale) were assessed.
A total of 103 infants (average age 39.4 ±19.2 days) were included, 52 in the intervention group and 51 in the control group. An inter-group comparison of changes revealed clinically relevant improvements in favor of the intervention group for the main outcome – parameter psychological stress – for all 3 questions (e.g., for question 2 respectively 3, NRS: between group difference of means 3.5; 95% CI: 2.6 to 4.4; p < 0.001). For the secondary outcome parameters of crying intensity and crying time/day, the changes were of similar magnitude.
The authors concluded that three osteopathic treatments given over a period of two weeks led to statistically significant and clinically relevant positive changes of parental psychological stress.
This is a cleverly designed study. I say ‘cleverly’ because the casual reader might not even notice that it compared osteopathic treatments with doing nothing. It is well-documented that just hadling babies with IC/EC has an effect on outcomes. Thus the positive effect may not have anything to do with osteopathy and be due simply to the extra attention given to the child. In other words, the positive result of the study was sure even before the 1st baby was entered into the trial.
I am impressed!
Perhaps this study should be in the textbook entitled:
HOW TO CHEAT WITH SEEMINGLY RIGOROUS CLINICAL TRIALS?
Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. The efficacy of medical treatments such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) is considerable. However the failure rate can still be as high as 20-25% and there are also a number of associated adverse effects. Many women are thus seeking alternatives to conventional medicine. One popular treatment modality is spinal manipulation.
The objectives of this Cochrane review were to determine the safety and efficacy of spinal manipulations for the treatment of primary or secondary dysmenorrhoea when compared to:
- each other,
- placebo,
- no treatment,
- or other medical treatments.
Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, Psyclit and SPORTDiscus were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field’s Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information.
Included were any RCTs including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD.
Five RCTs were identified that fulfilled the inclusion criteria for this review. Four trials involving high velocity, low amplitude manipulation (HVLA), and one involving the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects.
Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however, the only trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations.
The authors concluded that overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.
Probably the first question that springs in one’s mind is, WHY ON EARTH COULD SPINAL MANIPULATIONS BE EFFECTIVE FOR THIS CONDITION? Unsurprisingly, the proponents of this approach have come up with several rationales:
- The parasympathetic and sympathetic pelvic nerve pathways are closely associated with the spinal vertebrae, in particular the 2nd-4th sacral segments and the 10th thoracic to the 2nd lumbar segments. One hypothesis is that mechanical dysfunction in these vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply through an influence on the autonomic nerve supply to the blood vessels.
- Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation.
I think we can all agree that these theories are very long shots! As it stands, we also do not need to shoot long at all. There is simply no good evidence that spinal manipulations work for dysmenorrhoea. There is thus no need to embark on implausible explanations to justify the notions of Palmer and Still claiming that spinal manipulation is a panacea. The idiocy of this claim has long been established.
The only question that does remain, in my view, is this:
WHEN WILL CHIROPRACTORS AND OSTEOPATHS FINALLY GIVE UP THEIR OUTLANDISHLY WISHFUL THINKING OF THEIR FOUNDING FATHERS?
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!!!
- Reiki,
- sham Reiki (i.e., Feiki),
- mindfulness meditation,
- waitlist control.
Treatments were delivered in four weekly 30-minute sessions.
- Reiki was superior to doing nothing (waiting list) which can be expected due to a placebo effect.
- Mindfulness was superior to doing nothing (waiting list) which can be expected not least due to a placebo effect.
- Mindfulness was superior to Feiki which can be expected as mindfulness might work.
- Reiki demonstrated effects comparable to mindfulness which is due to an inadequate sample size; for comparing two allegedly effective treatments, one would need a proper equivalence study with much larger sample sizes.
- The above argument also applies to the fact that “reductions in symptoms (>30 %) were reported by 55 % of participants in the Reiki and mindfulness groups, compared to 20 % in the Feiki group”.
The most interesting result is not mentioned in the abstract: there was no difference between Reiki and Feiki interventions. Thus, if this trial shows anything meaningful at all, it must be this:
THE CLINICAL EFFECTS OF REIKI RELY ON PLACEBO.
Or to put it differently:
REIKI HAS NO SPECIFIC EFFECTS.
Or to put it bluntly:
REIKI IS BOGUS!
- 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.
