physiotherapists
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 evidence6
- 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!
Dry needling (DN) is a treatment used by various healthcare practitioners, including physical therapists, physicians, and chiropractors. It involves the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. DN is mainly used to treat myofascial trigger points, but it is also used to target connective tissue, neural ailments, and muscular ailments. There is conflicting evidence regarding the effectiveness of DN for any condition.
Orofacial pain (OFP) typically has a musculoskeletal, dental, neural, or sinogenic origin. Our systematic review was aimed at evaluating the evidence base for the effectiveness of DN for OFP.
We searched Medline, Cochrane Central, and Web of Science (from their respective inceptions to February 2024) for RCTs evaluating the effectiveness of DN in patients with OFP. Studies with patients suffering from cervicogenic or tension type headaches as well as observational studies were excluded. Primary outcomes were pain intensity and severity; secondary outcomes were disability, quality of life, and adverse effects (AEs). The review adhered to the methods described by in the Cochrane Handbook.
Twenty-four RCTs with a total of 1,318 patients suffering from OFP could be included. Most had an unclear or high risk of bias, and the quality of the evidence ranged from very low to low for all comparisons and outcomes. A meta-analysis suggested that, compared with usual care alone, DN + usual care had no effect on pain intensity (visual analogue scale) (standardized mean difference = −1.89, 95% confidence intervals −5.81 to 2.02, very low certainty evidence) at follow-ups of up to 6 weeks. Only 6 RCTs (25%) mentioned AEs, and none of them reported that AEs had occurred. The remaining 18 (75%) studies failed to report AEs.
We concluded that DN cannot be considered as an effective treatment option for OFP. This is due to the uncertainties of the available evidence. We believe that larger, rigorous, and better reported trials with more homogeneous comparators might potentially reduce the current uncertainties. Such trials should strictly adhere to the classifications provided by the International Headache Society and published in the International Classification of Orofacial Pain.
Yet again, I need to stress that the vast majority od RCTs failed to mention AEs. When will the last (pseudo-) researcher have learnt that the non-reporting of AEs is a violation of research ethics?
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.
This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017.
Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T0] and 2-7 days post-treatment [T2]) and one completed by the provider immediately post-treatment [T1]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious.
From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T0 and T1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care.
From the patients visits with a complete T2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which:
- 7.9% were mild,
- 6.2% moderate,
- 3.7% severe,
- 1.5% serious,
- 2.0% had missing severity rating.
The most common symptoms reported with moderate or higher severity were:
- discomfort/pain,
- stiffness,
- difficulty walking,
- headache.
The authors concluded that this study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.
They also note that:
- The incidence of AEs reported in their study was lower than the 30%-50% reported in a recent scoping review of 250 observational and experimental studies of manual treatments of the spine.
- A similar prospective clinic-based survey collected data from 4712 encounters from Norwegian chiropractors found that 55% of these encounters had an AE.
- A clinical trial of chiropractic care for patients with neck pain found that 30% reported an AE.
- The Scandinavian College of Naprapathic Manual Medicine collected AE information from 767 patients and found that 51% of those who had at least 3 SMT treatments reported an AE.
The authors did not mention our systematic review:
The aim of this systematic review was to summarize the evidence about the risks of spinal manipulation. Articles were located through searching three electronic databases (MEDLINE, EMBASE, Cochrane Library), contacting experts (n =9), scanning reference lists of relevant articles, and searching departmental files. Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist. Where available, systematic reviews were used as the basis of this article. All papers were evaluated independently by the authors. Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.
Whatever the true rate of AEs turns out to be, one thing is very clear: it is unacceptably high, particularly if we consider that the benefits of spinal manipulations are doubtful and at best small.
Since it is a rare occurance these days – I retired more than a decade ago – that I publish something in the peer-reviewed literature, please allow me to make some brief comments of this review just published by Spanish researchers and myself. The aim of this systematic review with meta-analysis was to evaluate the clinical effectiveness of visceral osteopathy (VO) in musculoskeletal and non-musculoskeletal disorders.
Two independent reviewers searched in PubMed, Physiotherapy Evidence Database, Cochrane Library, Scopus, and Web of Science databases in November 2023 and extracted data for randomized controlled trials evaluating the clinical effectiveness of VO. The risk of bias and the certainty of evidence were assessed using the Risk-of-Bias tool 2 and the GRADE Profile, respectively. Meta-analyses were conducted using random effect models using RevMan 5.4. software.
Fifteen studies were included in the qualitative and seven in the quantitative synthesis. For musculoskeletal disorders, the qualitative and quantitative synthesis suggested that VO produces no statistically significant changes in any outcome variable for patients with low back pain, neck pain or urinary incontinence. For non-musculoskeletal conditions, the qualitative synthesis showed that VO was not effective for the treatment of irritable bowel syndrome, breast cancer, and very low weight preterm infants. Most of the studies were classified as high risk of bias and the certainty of evidence downgraded to low or very low.
We concluded that VO did not show any benefit in any musculoskeletal or non-musculoskeletal condition.
Yes, I agree: these findings are hardly surprising. Visceral osteopathy (or visceral manipulation) is an expansion of the general principles of osteopathy and involves the manual manipulation by a therapist of internal organs, blood vessels and nerves (the viscera) from outside the body. Visceral osteopathy was developed by the osteopath Jean-Piere Barral. He stated that through his clinical work with thousands of patients, he created this modality based on organ-specific fascial mobilization. And through work in a dissection lab, he was able to experiment with visceral manipulation techniques and see the internal effects of the manipulations.[1] According to its proponents, visceral manipulation is based on the specific placement of soft manual forces looking to encourage the normal mobility, tone and motion of the viscera and their connective tissues. These gentle manipulations may potentially improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body.[2]
Visceral osteopathy is being practised mostly by osteopaths and less commonly chiropractors and physiotherapists. It comprises of several different manual techniques firstly for diagnosing a health problem and secondly for treating it. Several studies have assessed the diagnostic reliability of the techniques involved. The totality of this evidence fails to show that they are sufficiently reliable to be od practical use.[3] Other studies have tested whether the therapeutic techniques used in visceral osteopathy are effective in curing disease or alleviating symptoms. The totality of this evidence fails to show that visceral osteopathy works for any condition.[4] The treatment itself seems to be safe, yet the risks of visceral osteopathy are nevertheless considerable: if a patient suffers from symptoms related to her inner organs, the therapist is likely to misdiagnose them and subsequently mistreat them. If the symptoms are due to a serious disease, this would amount to medical neglect and could, in extreme cases, cost the patient’s life.
[all references in brackets [] can be found in my recent book]While the results of our review might be unsurprising, one thing about it did, after all, surprise me a great deal: the journal that published it, the ‘INTERNATIONAL JOURNAL OF OSTEOPATHIC MEDICINE‘. I even lost a bet for a bottle of wine with the lead author, because I said they would never accept it for publication!
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.
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.
On 8 March 2019, the Council of Australian Governments (COAG) Health Council (CHC) noted community concerns about spinal manipulation on children performed by chiropractors and agreed that there was a need to consider whether public safety was at risk.
On behalf of the CHC, the Victorian Minister for Health, the Hon. Jenny Mikakos MP, instructed Safer Care Victoria (SCV) to undertake an independent review of the practice of chiropractic spinal manipulation on children under 12 years. The findings of this review are to be provided to the Minister for reporting to the CHC. To provide expert guidance and advice to inform the review, SCV established an independent advisory panel. The panel included expertise in chiropractic care, academic allied health, health practitioner regulation, healthcare evidence, governance, paediatrics and paediatric surgery, and musculoskeletal care, and had consumer representation.
The main conclusions were as follows:
- … spinal manipulation in children is not wholly without risk. Any risk associated
with care, no matter how uncommon or minor, must be considered in light of any potential or likely
benefits. This is particularly important in younger children, especially those under the age of 2 years in
whom minor adverse events may be more common. - … the evidence base for spinal manipulation in children is very poor. In particular, no studies have been performed in Australia … The possible, but unlikely, benefits of spinal manipulation in the management of colic or enuresis should be balanced by the possibility, albeit rare, of minor harm.
The main recommendation was straight forward: “Spinal manipulation, as defined in Section 123 of National Law, should not be provided to children under 12 years of age, by any practitioner, for general wellness or for the management of the following conditions: developmental and behavioural disorders, hyperactivity disorders, autism spectrum disorders, asthma, infantile colic, bedwetting, ear infections, digestive problems, headache, cerebral palsy and torticollis.”
The Chiropractic Board of Australia nevertheless decided they would re-start manipulationg babies. On 11/6/2024 The Sydney Morning Harald reported:
Chiropractors have given themselves the green light to resume manipulating the spines of babies following a four-year interim ban supported by the country’s health ministers. In a move slammed by doctors as irresponsible, the Chiropractic Board of Australia has quietly released new guidelines permitting the controversial treatment for children under two. The Royal Australian College of General Practitioners (RACGP) hit out at the decision, saying there was no evidence supporting the spinal manipulation of babies and children and that the practice should be outlawed. ‘‘There is no way in the world I would let anyone manipulate a child’s spine,’’ said Dr James Best, the college’s Specific Interests Child and Young Person’s Health chair. ‘‘The fact that it hasn’t been ruled out by this organisation is very disappointing and concerning. It’s irresponsible.’’ …
Subsequently, it was reported that the federal health minister has intervened in the Chiropractic Board of Australia’s controversial decision to allow practitioners to resume spinal manipulation of children under two and is seeking an urgent explanation.
As pressure mounts on chiropractors to ditch the treatment, federal Health Minister Mark Butler confirmed on Thursday that he would also raise the issue with his state and territory colleagues at a meeting of health ministers in South Australia on Friday.
“The Health Minister is writing to the Chiropractic Board seeking an urgent explanation on its decision to allow a resumption of spinal manipulation of infants under two, in spite of two reviews concluding there was no evidence to support that practice,” a spokeswoman said.
___________________________
This course of events can only be surprising to those who are not familiar with the chiropractors’ general attitude. Chiropractors have always put income before ethics and safety. This, I fear, is not a phenomenon confined to Australia or to the care of children but one that beleagues this profession worldwide from the days of DD Palmer to the present.
