The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR), a painful condition caused by the compression or irritation of the nerves that supply the shoulders, arms and hands.
A multidisciplinary team autors searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were:
- randomized trials,
- had at least one conservative treatment arm,
- diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests.
Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.
Of the 2561 records identified, 59 trials met the inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively.
There is very-low certainty evidence supporting the use of:
- cervical manipulation,
- low-level laser therapy
for pain and disability in the immediate to short-term, and
- thoracic manipulation,
- low-level laser therapy
for improvements in cervical range of motion in the immediate term.
There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion.
There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.
The authors concluded that there is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.
Yet, to patients suffering from CR, this is hardly constructive advice. What should they do vis a vis such disappointing evidence?
They might speak to a orthopedic surgeon; but often there is no indication for an operation. What then?
Patients are bound to try some of the conservative options – but which one?
- Cervical manipulation,?
- Low-level laser therapy?
My advice is this: be patient – the vast majority of cases resolves spontaneously regardless of therapy – and, if you are desperate, try any of them except cervical manipulation which is burdened with the risk of serious complications and often makes things worse.
The concept that the outcomes of spinal manipulation therapy (SMT) – the hallmark intervention of chiropractors which they use on practically every patient – are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use of chiropractic. But is the assumption true?
This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere. Eligible study designs were randomized controlled trials that investigated the effect of SMT applied to candidate versus non-candidate sites for spinal pain.
The authors obtained studies from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. Between-group differences were extracted for any reported outcome or, when not reported, calculated from the within-group changes. Outcomes were compared for SMT applied at a ‘relevant’ site to SMT applied elsewhere. The authors prioritized methodologically robust studies when interpreting results.
Ten studies were included. They reported 33 between-group differences; five compared treatments within the same spinal region and five at different spinal regions.
None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI – 1.9 to – 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.
The authors concluded that the current evidence does not support that SMT applied at a supposedly “clinically relevant” candidate site is superior to SMT applied at a supposedly “not clinically relevant” site for individuals with spinal pain.
I came across this study when I searched for the published work of Prof Stephen Perle, a chiropractor and professor at the School of Chiropractic, College of Health Sciences, University of Bridgeport, US, who recently started trolling me on this blog. Against my expectation, I find his study interesting and worthwhile.
His data quite clearly show that the effects of SMT are non-specific and mainly due to a placebo response. That in itself is not hugely remarkable and has been suspected to some time, e.g.:
- Chiropractic manipulation for migraine is a placebo therapy
- Chiropractic treatments are placebos
- Chiropractic spinal manipulation = placebo!
- Manual therapy (mainly chiropractic and osteopathy) does not have clinically relevant effects on back pain compared with sham treatment
- Manual therapies for back pain: not better than a placebo
- Is spinal manipulation a placebo therapy?
What is remarkable, however, is the fact that Perle and his co-authors offer all sorts of other explanation for their findings without even seriously considering what is stareing in their faces:
SPINAL MANIPULATIONS ARE PLACEBOS
CHIROPRACTIC IS A PLACEBO THERAPY
This might be almost acceptable, if chiropractic would not also be burdened with significant risks (as we have discussed ad nauseam on this blog) – another fact of which chiros like Perle are in denial.
What does all that mean for patients?
The practical implication is fairly straight forward: the risk/benefit balance of chiropractic is negative. And this surely means the only responsible advice to patients is this:
NEVER CONSULT A CHIRO!
The ‘University College of Osteopathy’ announced a proposal to merge with the AECC University College (AECC UC). Both institutions will seek to bring together the two specialist providers to offer a “unique inter-disciplinary environment for education, clinical practice and research in osteopathy, chiropractic, and across a wide range of allied health and related disciplines”.
The partnership is allegedly set to unlock significant opportunities for growth and development by bringing together the two specialist institutions’ expertise and resources across two locations – in Dorset and central London.
As a joint statement, Chair of the Board of Governors at AECC UC, Jeni Bremner and Chair of the Board of Governors at UCO, Professor Jo Price commented:
“We believe the proposed merger would further the institutional ambitions for both of our organisations and the related professional groups, by allowing us to expand our educational offering, grow student numbers and provide a unique inter-disciplinary training environment, providing students the opportunity to be immersed in multi-professional practice and research, with exposure to and participation in multi-disciplinary teams.
“There is also an exciting and compelling opportunity to expedite the development of a nationally unique, and internationally-leading MSK Centre of Excellence for Education and Research, developed and delivered across our two sites.”
The announcement is accompanied by further uncritical and promotional language:
Established as the first chiropractic training provider in Europe, AECC UC has been at the forefront of evidence-based chiropractic education, practice and research for more than 50 years. The institution is on an exciting journey of growth and development, having expanded and diversified its academic portfolio and activity beyond its traditional core offering of chiropractic across a broad range of allied health courses and apprenticeships, working closely with NHS, local authority and other system partners across Dorset and the south-west. The proposed merger with UCO would allow AECC UC to enhance the breadth and depth of its offer to support the expansion and development of the health and care workforce across a wider range of partners.
Now in its 106th year, UCO is one of the UK’s leading providers of osteopathic education and research with an established reputation for creating highly-skilled, evidence-informed graduates. UCO research is recognised as world-leading, delivering value to the osteopathic and wider health care community.
Sharon Potter, Acting Vice-Chancellor of UCO, said:
“As an institution that has long been at the forefront of osteopathic education and research, we are committed to ensuring further growth and development of the osteopathic profession.
“UCO has been proactively considering options to future-proof the institution. Following a review of strategic options, UCO is delighted by the proposed merger, working closely with AECC UC to ensure that UCO and osteopathy thrives as part of the inter-professional health sciences landscape, both academically and clinically. There is significant congruence between UCO and AECC UC in our strong aligned values, commitment to and delivery of excellent osteopathic education, clinical care and research, and opinion leadership.
“AECC UC has a strong track record of respecting the differences in professions, evidenced by the autonomy across the 10 different professional groups supported by the institution. The merger will not only mean we are protecting UCO through preserving its osteopathic heritage and creating a sustainable future, but that our staff and students can collaborate with other professional groups such as physiotherapy, chiropractic, sport rehabilitation, podiatry and diagnostic imaging, in a multidisciplinary MSK and rehabilitation environment unlike anywhere else in the UK.”
Professor Lesley Haig, Vice-Chancellor of AECC UC, commented:
“Preserving the heritage of UCO and safeguarding its future status as the flagship osteopathy training provider in the UK will be critical, just as it has been to protect the chiropractic heritage of the AECC brand. UCO is seen as synonymous with, and reflective of, the success of the osteopathy profession and we fully recognise and respect the important role that UCO plays not only as a sector-leading provider of osteopathic education, research and clinical care, but as the UK’s flagship osteopathy educational provider.
“Overall it is clear that UCO and AECC UC already have a common values base, similar understanding of approaches to academic and clinical delivery, and positive relationships upon which a future organisational structure and opportunities can be developed. It’s an exciting time for both institutions as we move forward in partnership to create something unique and become recognised nationally and internationally as a centre of excellence.”
The proposed merger would continue the already founded positive relations between the institutions, where regular visits, sharing of good practice, and collaborative research work are already taking place. Heads of terms for the potential merger have now been agreed and both institutions are entering into the next phase of discussions, which will include wide consultation with staff, students and other stakeholders to produce a comprehensive implementation plan.
In case this bonanza of platitudes and half-truths has not yet overwhelmed you, I might be so bold as to ask 10 critical questions:
- What is an “evidence-based chiropractic education”? Does it include the messages that 1) subluxation is nonsense, 2) chiropractic manipulations can cause harm, 3) there is little evidence that they do more good than harm?
- How an an “expansion and development of the health and care workforce” be anticipated on the basis of the 3 points I just made?
- What does the term “evidence-informed graduates” mean? Does it mean they are informed that you teach them nonsense but instruct them to practice this nonsense anyway?
- Do “options to future-proof the institution” include the continuation of misleading the public about the value of chiropractic/osteopathy?
- Does the”delivery of excellent osteopathic education, clinical care and research, and opinion leadership” account for the fact that the evidence for osteopathy is weak at best and for most conditions negative?
- By “preserving its osteopathic heritage”, do you intend to preserve also the reputation of your founding father, Andrew Taylor Still, who did many dubious things. In 1874, for instance, he was excommunicated by the Methodist Church because of his “laying on of hands”; specifically, he was accused of trying to emulate Jesus Christ, labelled an agent of the Devil, and condemned as practicing voodoo. Or do you prefer to white-wash the osteopathic heritage?
- You also want “to protect the chiropractic heritage”; does that mean you aim at white-washing the juicy biography of the charlatan who created chiropractic, DD Palmer, as well?
- “UCO and AECC UC already have a common values base” – what are they? As far as I can see, they mainly consist in hiding the truth about the uselessness of your activities from the public.
- How do you want to “recognised nationally and internationally as a centre of excellence”? Might it be a good idea to begin by critically assessing your interventions and ask whether they do more good than harm?
- Crucially, what is really behing the merger that you are trying to sell us with such concentrated BS?
This systematic review and meta-analysis was aimed at analyzing the effectiveness of craniosacral therapy in improving pain and disability among patients with headache disorders.
PubMed, Physiotherapy Evidence Database, Scopus, Cochrane Library, Web of Science, and Osteopathic Medicine Digital Library databases were searched in March 2023. Two independent reviewers searched the databases and extracted data from randomized clinical trials comparing craniosacral therapy with control or sham interventions. The same reviewers assessed the methodological quality and the risk of bias using the PEDro scale and the Cochrane Collaboration tool, respectively. Grading of recommendations, assessment, development, and evaluations was used to rate the certainty of the evidence. Meta-analyses were conducted using random effects models using RevMan 5.4 software.
The searches retrieved 735 papers, and 4 studies were finally included. The craniosacral therapy provided statistically significant but clinically unimportant change on pain intensity (Mean difference = –1.10; 95% CI: –1.85, –0.35; I2: 44%), and no change on disability or headache effect (Standardized Mean Difference = –0.34; 95% CI –0.70, 0.01; I2: 26%). The certainty of the evidence was downgraded to very low.
The authors concluded that very low certainty of evidence suggests that craniosacral therapy produces clinically unimportant effects on pain intensity, whereas no significant effects were observed in disability or headache effect.
I find it strange that researchers seem so frequently unable to formulate their conclusions clearly. Is it political correctness? Or are they somehow favorably inclined (i.e. biased) towards the treatment that they pretend to critically evaluate?
Let’s look at the facts related to this review:
- Craniosacral therapy (CST) is utterly implausible.
- Only 4 RCTs were found.
- They were of poor quality.
- They were published mostly by people who want to promote CST.
- Therefore the overall statistically significant effect is most likely a false-positive result.
- This means that the conclusion should be much more straight forward.
I suggest something along the following lines:
A critical evaluation of the existing RCTs failed to find convincing evidence that CST is an effective treatment for headache disorders.
The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or symptomatic population.
Various databases were searched (inception till May 2023) and fifteen trials (737 participants) that met the inclusion criteria were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. Outcome measure data were synthesized using standard mean differences and meta-analysis for the primary outcome (biochemical markers). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.
There was low-quality evidence that spinal manipulation influenced various biochemical markers (not pooled). There was low-quality evidence of significant difference that spinal manipulation is better (SMD -0.42, 95% CI – 0.74 to -0.1) than control in eliciting changes in cortisol levels immediately after intervention. Low-quality evidence further indicated (not pooled) that spinal manipulation can influence inflammatory markers such as interleukins levels post-intervention. There was also very low-quality evidence that spinal manipulation does not influence substance-P, neurotensin, oxytocin, orexin-A, testosterone and epinephrine/nor-epinephrine.
The authors concluded that spinal manipulation may influence inflammatory and cortisol post-intervention. However, the wider prediction intervals in most outcome measures point to the need for future research to clarify and establish the clinical relevance of these changes.
The majority of the studies were of low or very low quality. This means that the collective evidence is less than reliable. In turn, this means, I think, that the conclusions are misleading. A more honest conclusion would be this:
There is no reliable evidence that spinal manipulation influences inflammatory and cortisol levels.
As for the clinical relevance, I would like to point out that it would not be surprising if chiropractors could one day convincingly show that spinal manipulation do influence various biochemical markers. Many things do! If you fall down a staircase, for instance, plenty of biochemical markers will be affected. This, however, does not mean that throwing our patients down the stairs is of therapeutic value.
This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).
In a single-blind randomized clinical trial, the researchers randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). They evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. Mixed-model ANOVA was used to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.
CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.
The authors concluded that this study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.
To understand this study, we need to know what CFT and MSI exactly entailed. Here is the information that the authors provide:
Movement system impairment-based treatment
The movement system impairment-based treatment group received 11 sessions of MSI-based treatment over the 8 weeks for 60 min per session with a supervision of a native speaker experienced (above 5 years) physical therapist with the knowledge of MSI-based treatment. The researchers designed the MSI-based treatment uniquely for each patient based on the interview, clinical examination, and questionnaires, just like they did with the CFT intervention. First, they administered standardized tests to characterize changes in the patient’s low back pain symptoms, and then they modified the treatment to make it more specific based on the participant’s individual symptoms. Depending on the participant’s direction-specific low back pain classification, they performed the intervention following one of the five MSI subgroups namely  rotation,  extension,  flexion,  rotation with extension, and  rotation with flexion. Finally, Patients treated using the standardized MSI protocol as follows:  education regarding normal postures and movements such as sitting, walking, bending, standing, and lying down;  education regarding exercises to perform trunk movements as painlessly as possible; and  prescription of functional exercises to improve trunk movement .
Cognitive functional therapy
Cognitive functional therapy was prescribed for each patient in CFT group based the CFT protocol conducted by O’Sullivan et al. (2015). Patients received supervised 12 sessions of training over the 8-week period with 60 min per session provided with another physical therapist who had been trained in CFT treatment. In this protocol, a physical therapist with more than 5 years of experience conducted an interview and physical examination of the patients to determine their own unique training programs, considering modifiable cognitive, biopsychosocial, functional, and lifestyle behavior factors. The intervention consists of the following 3 main stages:  making sense of pain that is completely reflective, where physical therapist could use the context of the patient’s own story to provide a new understanding of their condition and question their old beliefs  exposure with control which is designed to normalize maladaptive or provocative movement and posture related to activities of daily living that is integrated into each patient’s functional impairments, including teaching how to relax trunk muscles, how to have normal body posture while sitting, lying, bending, lifting, moving, and standing, and how to avoid pain behaviors, which aims to break poor postural habits; and  lifestyle change which is investigating the influence of unhealthy lifestyles in the patient’s pain context. Assessing the individual’s body mass, nutrition, quality of sleep, levels of physical activity or sedentary lifestyle, smoking, and other factors via video calls. Identifying such lifestyle factors helped us to individually advise and design exercise programs, rebuild self-confidence and self-efficacy, promote changes in lifestyle, and design coping strategies.
I must admit that I am not fully convinced.
Firstly, the study was not large and we need – as the authors state – more evidence. Secondly, I am not sure that the results show CFT to be more effective that MSI. They might merely indicate 1) that the bulk of the improvement is due to non-specific effects (e.g. reression towards the mean, natural history of the condition, placebo) and 2) that CFT is less harmful than MSI.
we need not just more but better evidence.
This study aimed to compare the effectiveness of three distinct interventions – Yoga, Naturopathy, and Conventional medical management – in alleviating pain, reducing disability, enhancing spinal mobility, and improving the quality of life in individuals with low back pain. Ninety participants were recruited and randomly divided into three groups.
- The first group (group 1) received Yoga,
- the second group (group 2) received Naturopathy treatments,
- the third group served as the control and received conventional medications.
Visual Analogue Scale (VAS) scores, Oswestry Disability Index (ODI), Flexion Test-Finger to Floor Test (FTFT) results, and Quality of Life (QOL) were assessed at baseline and after a 10-day intervention period for all groups.
Overall comparisons between the groups, utilizing ANOVA, revealed marked differences in pain severity, disability index, daily functional capacity, and Quality of Life (QoL) improvements following respective interventions. Substantial improvements were also noted within the yoga and naturopathic medicine groups across multiple variables.
The authors concluded that the results of this comparative analysis emphasize the effectiveness of Yoga, Naturopathy, and Conventional Medical Treatment in managing low back pain. All three interventions demonstrated significant improvements in pain intensity, disability, spinal mobility, and quality of life. This study contributes valuable insights into the diverse therapeutic approaches for low back pain management, highlighting the potential of holistic and alternative treatments to enhance patients’ well-being.
This is a remarkably poor study. Its flaws are too numerous to account for them all here. Let me focus on just a three that stand out.
- All we learn about the 3 treatment regimen is this (and it clearly not enough to do an independent replication of this trial):
Participants in the Yoga Group underwent a specifically designed integrated approach of Yoga therapy (IAYT) for back pain, incorporating relaxation techniques, spinal movements, breathing exercises, pranayama, and deep relaxation techniques. The intervention was conducted by qualified yoga instructors at SDM College of Naturopathy and Yogic Sciences.
Participants in the Naturopathy Group received neutral spinal baths and partial massages. The spinal bath was administered at Government Yoga & Nature Cure Out Patient Center, Puttur, and massages were performed by trained naturopathy therapists.
Conventional Medicine Group:
Participants in the Conventional Medicine Group received standard medical treatments for low back pain as recommended by orthopedic physicians from S.D.M Medical College, Dharward
- As an equivalence trial, the sample size of this study is far too small. This means that its findings are most likely caused by coincidence and not by the interventions applied.
- There was no attempt of blinding the patients. Therefore, the results – if they were otherwise trustworthy – would be dominated by expectations and not by the effects of the treatments.
Altogether, this study is, I think, a good example for the fact that
poor research often is worse than no research at all.
The case of a 91-year old male patient developing acute neuropathic pain along the sciatic nerve distribution following spinal manipulation has been reported. Manipulative treatment with an Activator Adjusting Instrument (AAI) had been performed. During this treatment, three applications of the AAI were administered. The applications were bilateral (1) over the sacroiliac joint, (2) gluteal area, and (3) paraspinal region just above the iliac crest.
Within 24 hours, the patient developed severe 10/10 pain originating from the left gluteal area at the site of one of the activator deployments with radiation all the way down his left leg to the foot. He was able to maintain distal left leg strength and sensation. Subsequently, the patient developed insomnia, confusion, and adrenal gland dysfunction in response to changes in steroids, gabapentin, and other drugs, thus highlighting some nuances of managing elderly patients with back pain.
Relief was achieved with subsequent physical therapy techniques aimed at relaxing the patient’s deep gluteal muscles, raising the hypothesis of temporary injury to the deep gluteal muscles, with painful contractions resulting in gluteal region pain as well as sciatic nerve inflammation as the nerve passed through that region.
The authors concluded that this clinical case illustrates some of the perils and risks of spinal manipulation, particularly in the elderly, and the need for careful patient selection.
The authors of this (stranely incomplete) case report discuss whether any manipulation was truly necessary or indicated as part of his initial chiropractic treatment plan. They state that, given that complications associated with similar practices are not often reported in the literature, this case highlights important considerations to be made in the elderly given the potential impact of transient/permanent neuropathic pain in that population subset.
Somehow, I doubt that we can be certain that the patient improved due to the physical therapy and not due to the drugs he received. Moreover, I question the authors’ repeated assertions that such adverse effects of chiropractic spinal manipulation are truly rare. Here is a section from our own 2002 systematic review of the subject:
A systematic review of five prospective investigations of the risks of spinal manipulation concluded that mild-to moderate transient adverse reactions occur in approximately half of patients who undergo spinal manipulation. The largest of these studies involved 1058 patients who received a total of 4712 treatments from 102 chiropractors in Norway. At least one adverse reaction was reported by 55% (n 580) of patients. About one quarter (n 1174) of treatments resulted in at least one adverse reaction. The most common reaction reported was local discomfort. Eighty-five percent (n 824) of reactions were described as “mild or moderate” and 1% (n 14) as “unbearable.” Seventy-four percent (n 1052) of reactions disappeared within 24 hours. No serious, permanent complications of spinal manipulation were reported, but follow-up was not described. These results were confirmed by a similar study in Sweden with 625 patients and a smaller one (68 patients) from the United Kingdom …
Non-life-threatening adverse effects after spinal manipulations are not rare – they are merely rarely reported!
Manual therapy is considered a safe and less painful method and has been increasingly used to alleviate chronic neck pain. However, there is controversy about the effectiveness of manipulation therapy on chronic neck pain. Therefore, this systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to determine the effectiveness of manipulative therapy for chronic neck pain.
A search of the literature was conducted on seven databases (PubMed, Cochrane Center Register of Controlled Trials, Embase, Medline, CNKI, WanFang, and SinoMed) from the establishment of the databases to May 2022. The review included RCTs on chronic neck pain managed with manipulative therapy compared with sham, exercise, and other physical therapies. The retrieved records were independently reviewed by two researchers. Further, the methodological quality was evaluated using the PEDro scale. All statistical analyses were performed using RevMan V.5.3 software. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment was used to evaluate the quality of the study results.
Seventeen RCTs, including 1190 participants, were included in this meta-analysis. Manipulative therapy showed better results regarding pain intensity and neck disability than the control group. Manipulative therapy was shown to relieve pain intensity (SMD = -0.83; 95% confidence interval [CI] = [-1.04 to -0.62]; p < 0.0001) and neck disability (MD = -3.65; 95% CI = [-5.67 to – 1.62]; p = 0.004). However, the studies had high heterogeneity, which could be explained by the type and control interventions. In addition, there were no significant differences in adverse events between the intervention and the control groups.
The authors concluded that manipulative therapy reduces the degree of chronic neck pain and neck disabilities.
Only a few days ago, we discussed another systematic review that drew quite a different conclusion: there was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain.
How can this be?
Systematic reviews are supposed to generate reliable evidence!
How can we explain the contradiction?
There are several differences between the two papers:
- One was published in a SCAM journal and the other one in a mainstream medical journal.
- One was authored by Chinese researchers, the other one by an international team.
- One included 17, the other one 23 RCTs.
- One assessed ‘manual/manipulative therapies’, the other one spinal manipulation/mobilization.
The most profound difference is that the review by the Chinese authors is mostly on Chimese massage [tuina], while the other paper is on chiropractic or osteopathic spinal manipulation/mobilization. A look at the Chinese authors’ affiliation is revealing:
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China.
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China; Department of Tuina, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China. Electronic address: [email protected].
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China; Department of Tuina, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China. Electronic address: [email protected].
What lesson can we learn from this confusion?
Perhaps that Tuina is effective for neck pain?
What the abstract does not tell us is that the Tuina studies are of such poor quality that the conclusions drawn by the Chinese authors are not justified.
What we do learn – yet again – is that
- Chinese papers need to be taken with a large pintch of salt. In the present case, the searches underpinning the review and the evaluations of the included primary studies were clearly poorly conducted.
- Rubbish journals publish rubbish papers. How could the reviewers and the editors have missed the many flaws of this paper? The answer seems to be that they did not care. SCAM journals tend to publish any nonsense as long as the conclusion is positive.
This systematic review with meta-analysis of randomized clinical trials (RCTs) estimated the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. The authors searched the MEDLINE, Cochrane CENTRAL, EMBASE, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022.
RCTs evaluating SMT compared to guideline-recommended and non-recommended interventions, sham SMT, and no intervention for adults with neck pain were eligible. Pre-specified outcomes included pain, range of motion, disability, health-related quality of life.
A total of 28 RCTs could be included. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short-term (standardized mean difference [SMD] 0.66; confidence interval [CI] 0.35 to 0.97) and long-term (SMD 0.73; CI 0.31 to 1.16), and for reducing disability at short-term (SMD 0.95; CI 0.48 to 1.42) and long-term (SMD 0.65; CI 0.23 to 1.06). Only transient side effects were found (e.g., muscle soreness).
The authors concluded that there was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain.
Harms cannot be adequately investigated on the basis of RCT data. Firstly, because much larger sample sizes would be required for this purpose. Secondly, RCTs of spinal manipulation very often omit reporting adverse effects (as discussed repeatedly on this bolg). If we extend our searches beyond RCTs, we find many cases of serious harm caused by neck manipulations (also as discussed repeatedly on this bolg). Therefore, the conclusion of this review should be corrected: