physiotherapists
Spinal manipulative therapies, including chiropractic and osteopathic maneuvers, are widely practiced for musculoskeletal complaints. However, serious complications such as cerebrospinal fluid (CSF) leak with subsequent intracranial hypotension (IH) have been described. The pathophysiological mechanism is presumed to involve mechanical stress on the spinal dura during high-velocity movements, leading to dural tears, particularly in the cervicothoracic region.
A team of Italian neuroscientists conducted a scoping review in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines, through a comprehensive search of PubMed and Scopus. They complemented the review with an illustrative case from their own institution.
The researchers identified 21 eligible papers, including 21 patients with IH following spinal manipulation. Most patients were women (81%), aged 29-54 years, and the majority underwent cervical maneuvers.
SMT techniques vary, most often involving high-velocity cervical maneuvers. The most frequent were axial tension with rotation in seven cases (33.3%), unspecified cervical manipulation in four cases (19%), and thoracic spinal manipulation in two cases (9.5%). Less common single-case techniques included rotation with hyperextension, combined cervical and thoracic mobilization, axial tension with lateral flexion, and occipital/shoulder tension technique (n = 1 case each).
Symptom onset was typically within the first week, and all presented with orthostatic headache, often accompanied by nausea, neck pain, tinnitus, or visual disturbances. Neuroimaging consistently revealed features of IH, with pachymeningeal enhancement and subdural collections as the most frequent findings; spinal imaging frequently demonstrated extradural CSF collections. Management was conservative in about one-third of cases, but most required epidural blood patching, which was effective in the majority. Surgical repair was necessary in rare, refractory cases, particularly in the presence of structural spinal abnormalities. Overall prognosis was favorable, with 95% of patients achieving full recovery.
The authors’ illustrative case highlights the potential for severe complications such as subdural hematomas and recurrence if the underlying leak is not addressed:
A 65-year-old patient without a previous history of headache presented with a progressively worsening headache, with orthostatic features, poorly responsive to medical therapy, that has lasted for the past 20 days. The patient denied any recent trauma. He reported having undergone cervical osteopathic manipulations within the past 3 months for recurrent cervicalgia. A brain MRI without contrast was performed, showing a large bilateral subdural hematoma with significant mass effect on the cortical gyri. The patient was admitted to the emergency department and underwent neurosurgical evacuation of a bilateral chronic subdural hematoma via burr holes. Subsequently, endovascular embolization of the middle meningeal arteries was performed as an adjunctive treatment to reduce the risk of recurrence. The surgical procedure was performed without complications. A cranial CT scan showed a reduction in the volume of the hematoma. Therefore, the patient was discharged. However, after a transient improvement in the symptoms, the patient continued to present a fluctuating headache without positional features, with four to five episodes per month. He was readmitted to our clinic and, upon arrival at the ER, a head CT scan showed an increase in pneumocephalus and a recurrence of the hematoma. The following day, an MRI of the neuraxis with contrast was performed, which revealed radiological findings suggestive of IH: pachimeningeal enhancement, subdural fluid collection, dural venous engorgement, cervical spinal longitudinal extradural collection, and effacement of the suprasellar cistern. The Bern score was 7. Given these findings, a surgical revision of the previous burr holes was performed without periprocedural complications. After the first day, a non-targeted epidural blood patch (EBP) was performed under local anesthesia by injecting 16 mL of autologous blood into the L3–L4 epidural space. The procedure was uneventful. A cranial CT scan showed satisfactory surgical outcomes, highlighting a reduction in the volume of the hematoma and of the pneumoencephalus. The patient was subsequently discharged with complete resolution of the headache.
The authors concluded that clinicians should recognize the possibility of CSF leaks after spinal manipulation, especially in patients with new-onset orthostatic headache.
I feel compelled to point out that, considering the multiple risks of upper spinal manipulations and the almost total lack of evidence of benefit from such treatments, the risk/benefit balance of spinal manipulation is clearly not positive. It follows, I think, that it would be wise for patients not to allow such therapies being carried out, and for healthcare professionals to discourage them.
The aim of this study was to determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for adults with increased risk of chronic disabling LBP.
This 2 × 2 factorial randomized clinical trial enrolled participants in 3 research clinics at the Universities of Minnesota and Pittsburgh from November 2018 to May 2023; final follow-up was in June 2024. Adults with acute or subacute LBP at moderate to high risk of chronicity based on the STarT Back tool were randomized to 1 of 4 groups, with interventions lasting up to 8 weeks. Statistical analysis was conducted from November 2024 to June 2025.
These interventions were:
- Spinal manipulation therapy (n = 201),
- supported self-management (n = 305),
- combined supported self-management with spinal manipulation (n = 193),
- guideline-based medical care (n = 301).
Physical therapists and chiropractors provided spinal manipulation and supported self-management.
The 2 primary outcomes averaged over a follow-up of 1 year were monthly low back disability (Roland-Morris Disability Questionnaire) and weekly pain intensity (numerical rating scale). Secondary analysis examined the proportion of participants achieving a 50% or higher reduction in the primary outcome measures.
Among the 1000 participants randomized (mean [SD] age, 47 [16] years; 58% female), 93% completed the trial. The omnibus test for differences across the 4 treatment groups was statistically significant for disability (P = .001; supported self-management, 4.7; spinal manipulation, 5.5; combined supported self-management with spinal manipulation, 4.8; medical care, 5.9) but not pain intensity (P = .16; supported self-management, 2.8; spinal manipulation, 3.0; combined supported self-management with spinal manipulation, 2.8; medical care, 3.0). Averaged over 12 months, LBP disability was significantly lower compared with medical care for supported self-management (mean difference, −1.2 [95% CI, −1.9 to −0.5]) and supported self-management with spinal manipulation (mean difference, −1.1 [95% CI, −1.9 to −0.3]) but not spinal manipulation alone (mean difference, −0.4 [95% CI, −1.2 to 0.4]). Group differences in pain intensity were not statistically significant; point estimates ranged from −0.2 to 0. Both supported self-management groups had higher proportions of patients achieving a 50% or greater reduction in disability (supported self-management, 67%; spinal manipulation, 54%; combined supported self-management with spinal manipulation, 65%; medical care, 54%).
The authors concluded that for patients with acute or subacute LBP at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome.
These findings are very bad news for chiropractors (the profession that uses spinal manipulations more than any other): spinal manipulation does not generate effects that are in the least convincing. This is particularly remarkable, since the study was not blinded. It means that, even the undoubtedly powerful placebo effect associated with spinal manipulation did not render the outcome more favourable.
I said it many times, and I will say it again: For LBP, many therapies generate similarly marginally positive effects but no treatment is truly convincing. In this situation, we should choose one that is at least inexpensive and free of severe adverse effects. And that evidently cannot be spinal manipulation!
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and predisposes patients to hemorrhagic complications following trauma or invasive procedures. Chiropractic spinal manipulation is widely used for musculoskeletal pain; however, serious complications have been reported, particularly in patients with underlying coagulopathies.
Iliopsoas hematoma with secondary femoral neuropathy is an uncommon but potentially disabling condition. A team of US doctors present a clinical case highlighting this rare complication following chiropractic manipulation in a patient with VWD and review the relevant literature. They describe the clinical course and follow-up of a 32-year-old female patient with known VWD who developed acute neurological deficits after chiropractic manipulation. Imaging findings were analyzed using radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Hematoma volume was calculated using the ABC/2 formula, which has been well validated and shows a high correlation with volumes calculated using planimetric techniques.
After chiropractic manipulation, the patient developed severe lumbar and inguinal pain, followed by progressive weakness and sensory impairment of the left lower limb. Imaging revealed a large left iliopsoas hematoma measuring approximately 896 cc, causing femoral nerve compression. Management included coagulation factor replacement, pain control, and interventional radiology-guided drainage, resulting in significant hematoma reduction and neurological improvement. At the six-month follow-up, residual neuropathy and muscle atrophy persisted, although functional recovery was evident.
The uthors concluded that patients with VWD are at high risk for severe hemorrhagic complications even after seemingly minor manipulative therapies. Chiropractic spinal manipulation may precipitate life-threatening or disabling bleeding events in this population. Early recognition, appropriate imaging, correction of the coagulopathy, and multidisciplinary management are crucial to optimize outcomes. This case highlights the importance of patient counseling, risk stratification, and caution when considering alternative therapies in individuals with inherited bleeding disorders.
The list of complications, including fatal ones, after chiropractic manipulations is long – very long. That they can cause iliopsoas hematoma with secondary femoral neuropathy was new to me. The lesson here seems relatively simple: if you have a bleeding abnormality, avoid chiropractic manipulations at all costs!
This, of course, raises an interesting question:
Considering that ~25% of the general population have some sort of clotting abnormality, do chiropractors routinely check whether their pations have normal blood clotting?
Somehow, I doubt it.
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.
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!
Gua Sha is a form of so-called alternative medicine (SCAM) that I have reoprted about before, e.g.:
- Gua sha: who cares how it works, when it is unproven that it works?
- Gua sha, a reasonable therapy?
- Gua Sha: torture or treatment?
Chronic nonspecific low back pain (CNSLBP) is associated with thoracolumbar fascia (TLF) dysfunction. However, the structural effects of Gua Sha, a Traditional Chinese Medicine technique, remain unclear.
This study aimed to explore the acute and short-term effects of Gua Sha therapy on TLF thickness, pain intensity, and related physiological parameters in patients with CNSLBP.
Thirty-two participants with CNSLBP were randomized to receive Gua Sha or hot pack therapy, a commonly used conservative treatment for low back pain, once a week for 4 weeks. The effects of the two treatments were compared. TLF thickness, pain, and related parameters were measured at baseline and immediately after the first and fourth interventions. A 2 (group) × 3 (time) repeated measures ANOVA was used for data analysis.
With increasing intervention, both groups showed significant improvements in pain intensity and dysfunction (P < .001), significant reductions in tissue hardness and pressure pain threshold (P < .05), and significant increases in skin temperature and lumbar flexibility (P < .001). However, only the Gua Sha group significantly reduced TLF thickness immediately after the first intervention (MD = 0.388, 95% CI: 0.101-0.675; P = .01) and immediately after the fourth session (MD = 0.607, 95% CI: 0.199-1.015, P = .005). The heart rate variability-related indicators did not reach statistical significance (P > .05), but their trends were favorable.
The authors concluded that Gua Sha can effectively relieve pain, improve function, and regulate tissue mechanical properties in CNSLBP patients and its effects may be achieved through multiple pathways. Although the single and 4-session interventions were not significantly better than heat in improving fascial thickness, it performs better in pain and flexibility clinical outcomes, supporting its potential value as a complementary therapy. Future studies with larger samples and longer periods are needed to clarify its mechanism of action and optimize treatment options.
Gua sha, sometimes referred to as “scraping”, “spooning” or “coining”, is a traditional Chinese treatment that has
spread to several other Asian countries. It has long been popular in Vietnam and is now also becoming well-known in the West. The treatment consists of scraping the skin with a smooth edge placed against the pre-oiled skin surface, pressed down firmly, and then moved downwards along muscles or meridians. According to its proponents, gua sha stimulates the flow of the vital energy ‘chi’ and releases unhealthy bodily matter from blood stasis within sore, tired, stiff or injured muscle areas.
It is easy to imagine that Gua Sha is associated with sizable placebo effects. This means one needs to think carefully about how to control for tham in clinical trials, if we want to know whether the treatment works beyond placebo. I am not sure how to achieve this, but I am quite certain that the current study failed to do it. Thus its results merely showed that Gua Sha is just as useless as another therapy thay is unproven for CNSLBP.
And what about the thoracolumbar fascia thickness? I think that its significance is entirely speculative. Moreover, the reliability of its measurement seems questionable. Most likely, it is yet another red herring in a paper already more than full of fishy stuff.
PS
I stated it many times before, but I must say it again: almost any odd SCAM (e.g. chiropractic!) works a little for back pain – particularly if you test it in lousy studies and don’t control for placebo effects.
- (1) SMT,
- (2) ambulatory ibuprofen prescription,
using propensity matching for OUD risk factors. The primary outcome was the risk ratio (RR) of OUD. The RR for long-term opioid use, and opioid prescription RR and mean count were also explored. Primary analyses conducted in TriNetX and R used logistic regression for matching, standardized mean difference to assess between-cohort balance (threshold of ≤ 0.1), and contingency tables for RRs, using a significance threshold of p < 0.05.
This systematic review was aimed at evaluating if musculoskeletal manipulations (MMs), including osteopathic manipulation and chiropractic care, are effective to improve quality of life, pain intensity and function in older adults with musculoskeletal disorders.
Randomised controlled trials, controlled non-randomised trials and open label trials evaluating the efficacy and safety of MM such as osteopathic manipulation, chiropractic manipulation, myofascial release, craniosacral therapy, as monotherapy or adjunctive therapies in older people (age ≥65 years) with musculoskeletal disorders. The main outcomes included pain intensity, functionality and quality of life. Additionally, other related outcomes were considered, such as medical use duration, mood, mobility, motion, strength and endurance. Finally, we considered any adverse events.
Selection and data extraction were performed independently by two authors. The effect estimates for each study were performed using Review Manager V.5.14. Continuous outcomes were analysed using the mean difference (95% CI). The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool 2 (RoB 2). No meta-analysis was performed.
Five parallel randomised controlled trials were included, with a total sample size of 676 participants (41.6% women with a mean age of 77.3 years): 34 with chronic pain, 265 with neck pain and 377 with low back pain. MMs were not effective in patients with chronic pain, neither in pain intensity nor in functionality.
For neck pain, considering the main outcomes, only in one of the two studies was there a statistically significant improvement in neck pain intensity only at week 12 for spinal manipulative treatment (SMT)+home exercise (HE) compared with HE alone (ES=-0.90 (95% CI -1.46 to -0.34); p=0.002).
For low back pain, SMT+HE showed a statistically significant reduction in pain at 12 weeks compared with HE (ES=-0.79 (95% CI -1.39 to -0.19) p=0.010.
For neck pain and low back pain, no statistically significant improvement in functional status and quality of life was observed with MM compared with any control group.
RoB 2 showed a high risk of bias in three studies and some concerns in the others. At the domain level, the lowest risk was observed in the randomisation process (80% with some concerns). All five studies reported adverse events, none of which were serious.
The authors concluded that this systematic review highlights the need for further investigation into complementary therapies, particularly osteopathy, for chronic pain management and prevention in elderly individuals. The results of the current work emphasise that there is a need to further investigate this topic and move the focus more on the promotion of healthy and management behaviours (eg, more physical activity, self-efficacy and adaptive coping, less healthcare utilisation, medication use) and less on the pain symptoms. The fundamental need for complementary medicine, and in particular MM such as chiropractic care and osteopathic manipulative treatment, is the development of clinical trials and RCTs to assess efficacy on quality of life, pain, functionality and general health of the elderly patient. These will help us to determine where MM can be significant.
This, it seems to me, is merely a polite way of stating that neither chiropractic nor osteopathy are supported by sound evidence, and that therapeutic claims by chiropractors and osteopaths are usually hugely exaggerated. Therefore, the prudent thing to do, if you are suffering from back or neck pain, is to use treatments that are less expensive and less likely to cause severe, sometimes life-threatening adverse effects.
