physiotherapists
The aim of this recent review was to investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo. It included all randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) suffering from non-specific low back pain.
Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain—(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.
A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain: (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain:
- exercise,
- spinal manipulative therapy,
- taping,
- antidepressants,
- transient receptor potential vanilloid 1 (TRPV1) agonists)
were found to be efficacious. However, effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.
The authors concluded that the current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.
This is an important analysis, not least because of the fact that the research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The methodology is sound and the results thus seem reliable.
The findings are in keeping with what we have been discussing at nauseam here: no treatment works really well for back pain. For acute symptoms no so-called alternative medicine (SCAM) at all is efficacious. For chronic pain, spinal manipulation therapy (SMT) have small effects. As SMT is neither cheap nor free of risks, excercise is much preferable.
Considering that most SCAMs are heavily promoted for low back pain (e.g. acupuncture, Alexander technique, cupping, Gua Sha, herbal medicine, homeopathy, massage, mind-body therapies, reflexology, Reiki, yoga), this verdict is sobering indeed!
This systematic review was aimed at assessing whether spinal manipulative therapy (SMT) procedures (i.e., target, thrust, and region) impacted on pain and disability for adults with spine pain.
The investigators searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. They included randomized clinical trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. The authors included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables.
The researchers included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons.
The authors concluded that there was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant.
What does that mean?
It means that it is largely irrelevant which form of SMT is being used; the outcomes are more or less independet of the technique that is applied. You don’t need to be particularly skeptical to go one step further and conclude that:
- The percieved effectiveness of SMT compared to other treatments is due to a placebo effect which is likely to be strong with a therapy involving touch, cracking bones, etc.
- The effects of different types of SMT are all similar because these interventions are little more than theatrical placebos.
- Since these placebos can cause consideraable harm, their risk/benefit balance is not positive.
- Because their risk/benefit balance fails to be positive, SMT cannot be recommended as a treatment in routine care.
The Internet is increasingly used as a primary source of information for patients. Many private physiotherapy practices provide informative content on low back pain (LBP) and neck pain (NP) on their websites, but the extent to which this information is biopsychosocial, guidelines-consistent, and fear-inducing is unknown. The aim of this study was to analyse the information on websites of private physiotherapy practices in the Netherlands about LBP and NP regarding consistency with the guidelines and the biopsychosocial model and to explore the use of fear-inducing language.
The content of all existing Dutch private physiotherapy practice websites was examined in a cross sectional study design. Content analysis was based on predetermined criteria of the biopsychosocial model and evidence-based guidelines. Descriptive statistics were applied.
After removing duplicates and sites without information, 834 (10%) of 8707 websites remained. Information about LBP was found on 449 (54%) websites and 295 (35%) websites informed about NP. A majority of websites (LBP: n = 287, 64%; NP: n = 174, 59%) were biomedically oriented. Treatment advice was given 1855 times on n = 560 (67%) websites. Most of the recommended interventions were inconsistent with or not mentioned in the guidelines. Fear-inducing language was provided n = 1624 (69%) times.
The interventions that were inconsistent with the guidelines included several so-called alternative medicine (SCAM) options, including:
- dry needling (for LBP),
- medical tape (for LBP),
- trigger point therapy (for LBP),
- dry needling (for NP),
- trigger point therapy (for NP).
The authors concluded that their study shows that most Dutch private physiotherapy practice website are not a reliable source of information for patients with LPB and NP. The Dutch physiotherapy community needs to take action to comprehensively review and update the information on their websites to align with high‐quality best practice recommendations and guidelines for LBP and NP. It is important to strive for better information for patients to reduce fear, to support them in making better recovery choices, to achieve less disability, and to improve their quality of life.
To be honest, I would never have expected Dutch private physiotherapy practice website to be a reliable source of information for patients with LPB and NP. In general, private websites from healthcare practitioners are not reliable sources for anything, as we have so often seen on this blog. They are promotional by nature and have the purpose of boosting business.
I fear that the only thing positive I can say about the private physiotherapy practice websites is that they are not nearly as bad as those of:
- acupuncturists,
- aromatherapists,
- chiropractors,
- energy healers,
- herbalists,
- homeopaths,
- naturopaths,
- osteopath,
- reflexologists,
- etc, etc.
(If you need evidence for these bold statements, please look through the last 3 000 posts of this blog.)
As misinformation can cause untold harm, we need to ask: what is the solution to this problem? I think it’s disarmingly simple: for health-related information, stay away from websites that are evidently promotional by nature!
Two fatalities have been reported evidently caused by Thai massage. Thai singer Chayada Prao-hom, also known as Ping Chayada, 20, died in a hospital in the northeastern city of Udon Thani on December 8 after claiming she was left paralysed by a series of three “neck-twisting” massage sessions. Ping Chayada posted a poignant final message on social media as she battled ill-health following the massage: “The first time I got a massage, my symptoms were normal. I went for another massage, the same therapist in the same room, this time twisting my neck. After two weeks, I started to have very, very tight pain to the point that I couldn’t lie on my back or stomach. I’ve been learning massage since I was a child. I really like massage. I thought it was just another side effect of the massage, this kind of body pain. I went again. But this new person massaged hard and it was swollen and bruised for a week. After that, I took medicine to relieve the symptoms all the time.” The talented star died on Sunday December 8.
Just a day earlier, on December 7, a male Singaporean tourist, 52-year-old Lee Mun Tuk, died in Phuket after a 45-minute oil body massage – following which he reportedly went into cardiac arrest and could not be revived.
Harnelis, a massage therapist with the White Swallow Massage School in the city of Medan in neighbouring Indonesia, said that, while the deaths were tragic, they were not surprising. “Neck and back massage is inherently dangerous and deals with the most vulnerable part of the body,” she said. “You can’t do it carelessly, you have to do it keeping in mind where all the veins and blood vessels are. If you get it wrong, it can be fatal.”
Singer Prao-hom wrote that she had endured two “neck-twisting” sessions and a “heavy handed” third massage at a local parlour before experiencing numbness which spread through her body. She reportedly first went to the parlour, which had the required certification under Thai law, to relieve stiffness in her neck, but found that her symptoms continued to worsen. She was rushed to intensive care but died just two weeks later. Following an autopsy, her cause of death was listed as sepsis, a swollen spinal cord and a fungal infection.
The death of the singer has sparked an urgent investigation by the Thai Department of Health Service Support (DHSS). In the meantime, medical experts are warning of the dangers posed by violent manoeuvres given by poorly trained or unlicensed practitioners.
Thai massage is a widely used massage technique in Thailand and is accepted by the Thai Ministry of Public Health. The technique can be described to be a kind of acupressure massage. Even though there is very little reliable evidence, it is said to be effective for a wide range of conditions, e.g.:
Increased range of motion. Thai massage combines compression, acupressure, and passive stretching. These increase the range of motion in your joints and muscles. This can also improve your posture.
Helps with back pain. Thai massage tends to focus on areas that can contribute to back pain, like the inner thigh and abdomen. However, if you have constant back pain, it’s best to visit a doctor before getting any type of massage.
Reduces headache intensity. One study showed that nine sessions of traditional Thai massage in a 3-week period can reduce painful headaches in people who have chronic tension headaches or migraines.
Lowers stress. In another study, researchers showed that Thai massage reduced stress, especially when combined with plenty of rest.
Helps stroke patients. A 2012 study suggested that stroke patients who get Thai massage regularly may be better able to recover the ability to do daily activities. They may also have lower pain levels and sleep better.
Other benefits of Thai massage may include:
- Better sleep
- Better relaxation
- Improved digestion
- Calm mind or increased mindfulness
As always with such news reports, many essential details are missing for the two cases reported above. What seems obvious, however, is that the massage itself, even tough occasionally forceful, is not the main danger of Thai massage. The fatal complications seem to occur after spinal manipulation and are thus akin to the ones of chiropractic manipulations.
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.
