risk/benefit
The BBC stands for reliable information, at least that’s what I used to believe. After reading a recent article published on the BBC website, I have my doubts, however. See for yourself; here are a few excerpts:
On a holiday to Kerala on India’s south-western Malabar Coast, Shilpa Iyer decided to visit Kotakkal, a town that became famous after the establishment of Arya Vaidya Sala, Kerala’s best-known centre for the practice of Ayurveda, in 1902. Seven days later, she left the historical treatment centre after completeing panchakarma, a cleansing and rejuvenating programme for the body, mind and consciousness.
“There was nothing really wrong, but I was always busy with the demands of modern life and plagued with continual aches and pains. So, I decided to focus on my own health,” Iyer says.
Panchakarma, a holistic Ayurvedic therapy, involves a series of detoxifying procedures. It integrates herbal medicines, cleansing therapies, personalised diet plans and wellness activities to eliminate the root cause of disease, revive and rejuvenate the body, and ensure health and longevity.
Iyer says she left “feeling lighter, healthier and better than ever before”. She isn’t the only one who signed up for an Ayurvedic treatment in Kerala; the holistic system of medicine is a way of life in this coastal paradise.
… Ayurveda translates to “knowledge of life” and originated in India more than 3,000 years ago. It is based on the ideology that health and wellness depend on a delicate balance between the mind, body, spirit and environment, and places great emphasis on preventive strategies rather than curative ones. The ancient system of medicine is centred on the idea of universal interconnectedness between prakriti (the body’s constitution) and doshas (life forces). Varied combinations of the five elements — aakash (sky), jal (water), prithvi (earth), agni (fire) and vayu (air) – create the three doshas.
Dr Gaurang Paneri, an Ayurveda practitioner, explains every person has the three doshas, vata, pitta and kapha, in varying strength and magnitude. “The predominant dosha determines their prakriti. Diseases arise when doshas are affected because of an external or internal stimulus (typically linked to eating habits, lifestyle or physical exercise). Ayurveda works to ensure harmony between the three,” he says…
The small state has more than 100 Ayurvedic government-run hospitals, 800 Ayurvedic pharmaceutical factories and 800 Ayurvedic medicine dispensaries. As many as 120 holiday resorts and private wellness centres offer specialised treatments such as kasti vvasti, an oil-based treatment for back pain and inflammation in the lumbosacral region; elakkizhi, a treatment with heated herbal poultices to tackles aches, pains and muskoskeletal trauma; njavara kizhi, a massage therapy for arthritis or chronic musculoskeletal discomfort; and shirodhara, a restorative therapy to ease stress and anxiety and that involves pouring warm, medicated oil over the forehead.
Most treatment centres offer therapies and treatments for a range of health issues, including immunity, mental health, anxiety, pain management, weight loss, skin and health care, sleep issues, psoriasis, eczema, eye care, arthritis, sciatica, gastric problems and paralysis. The treatments typically include dietary changes, herbal medicines, massage therapies, poultices, meditation and breath exercises…
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I find such advertisements disguised as journalism disturbing:
- No mention that the treatments in question lack conclusive evidence of effectiveness.
- Not a word about the fact that many can be outright dangerous.
- No mention of the often exorbitant fees visitors are asked to pay.
Please do better next time you report about health matters, BBC!
This systematic review and meta-analysis investigated the effectiveness and safety of manual therapy (MT) interventions compared to oral or topical pain medications in the management of neck pain.
The investigators searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to oral or topical medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. Trials with usual care arms were also included if they prescribed medication as part of the usual care and they did not include a manual therapy component. The authors used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.
Nine trials with a total of 779 participants were included in the meta-analysis.
- low certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants),
- moderate certainty of evidence was found that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: −0.36; 95% CI −0.55 to −0.17; 6 trials, 567 participants),
- low certainty evidence that the risk of adverse events may be lower for patients who received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).
The authors conluded that MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.
Let’s have a look at the primary studies. Here they are with their conclusions (and, where appropriate, my comments in capital letters):
- For participants with acute and subacute neck pain, spinal manipulative therapy (SMT) was more effective than medication in both the short and long term. However, a few instructional sessions of home exercise with (HEA) resulted in similar outcomes at most time points. EXERCISE WAS AS EFFECTIVE AS SMT
- Oral ibuprofen (OI) pharmacologic treatment may reduce pain intensity and disability with respect to neural mobilization (MNNM and CLG) in patients with CP during six weeks. Nevertheless, the non-existence of between-groups ROM differences and possible OI adverse effects should be considered. MEDICATION WAS BETTER THAN MT
- It appears that both treatment strategies (usual care + MT vs usual care) can have equivalent positive influences on headache complaints. Additional studies with larger study populations are needed to draw firm conclusions. Recommendations to increase patient inflow in primary care trials, such as the use of an extended network of participating physicians and of clinical alert software applications, are discussed. MT DOES NOT IMPROVE OUTCOMES
- The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine. THIS IS A PILOT STUDY, A TRIAL TESTING FEASIBILITY, NOT EFFECTIVENESS
- The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.
- In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.
- Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up. MT IS NOT SUPERIOR [SAME TRIAL AS No 6]
- In this randomized clinical trial, for patients with chronic neck pain, Chuna manual therapy was more effective than usual care in terms of pain and functional recovery at 5 weeks and 1 year after randomization. These results support the need to consider recommending manual therapies as primary care treatments for chronic neck pain.
- In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit. SAME TRIAL AS No 5
- An impairment-based manual physical therapy and exercise (MTE) program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound. THIS STUDY DID NOT TEST MT ALONE AND SHOULD NOT HAVE BEEN INCLUDED
I cannot bring myself to characterising this as an overall positive result for MT; anyone who can is guilty of wishful thinking, in my view. The small differences in favor of MT that (some of) the trials report have little to do with the effectiveness of MT itself. They are almost certainly due to the fact that none of these studies were placebo-controlled and double blind (even though this would clearly be possible). In contrast to popping a pill, MT involves extra attention, physical touch, empathy, etc. These factors easily suffice to bring about the small differences that some studies report.
It follows that the main conclusion of the authors of the review should be modified:
There is no compelling evidence to show that MT is more effective for people with neck pain in both short and long-term when compared to patients receiving oral pain medications.
‘WORLD HOMEOPATHY DAY’ is upon us and the Internet is awash with pro-homeopathy comments, e.g.:
- World Homeopathy Day is observed annually on April 10th to commemorate the birth anniversary of Samuel Hahnemann, a prominent figure in the development of homeopathy. This day celebrates the principles and practices of homeopathy, an alternative medicinal approach that emphasizes treating ailments by utilizing natural substances and stimulating the body’s inherent healing abilities.
- The theme for World Homeopathy Day 2024 is ‘Empowering Research, Enhancing Proficiency: A Homeopathy Symposium”. This theme underscores the significance of continuous research in homeopathy and the need to upgrade capability in its training to give better medical care results.
Even slightly less biased sources cannot bring themselves to a more realistic approach, e.g.:
The significance of the World Homeopathy Day is said to be as follows:
- Raising Awareness: World Homeopathy Day has successfully brought homeopathy to the forefront of public attention, generating dialogue and interest in its principles and practices.
- Bridging Communities: The Day serves as a platform for bringing together homeopaths, practitioners, researchers, and individuals interested in alternative medicine, fostering collaboration and knowledge exchange.
- Focus on Education: World Homeopathy Day emphasizes the importance of education and ethical practices within the field, promoting responsible usage and informed choices for individuals seeking homeopathic care.
World Homeopathy Day is about understanding and exploring the potential of this alternative medicine system while keeping an open mind and prioritizing evidence-based healthcare practices.
So, let me try to counter-balance these texts by showing you what my recently published 7 key points about homeopathy tell us:
Homeopathy is popular, particularly in India, Germany, France and parts of South America. It was invented more than 200 years ago and still divides opinions like few other subjects in alternative medicine.
- Homeopathy was invented by the German physician, Samuel Hahnemann (1755–1843). At the time, our understanding of the laws of nature was woefully incomplete, and therefore Hahnemann’s ideas seemed less implausible than today. The conventional treatments of this period were often more dangerous than the disease they were supposed to cure. Consequently, homeopathy was repeatedly shown to be superior to ‘allopathy’ (a term coined by Hahnemann to denigrate conventional medicine) and Hahnemann’s treatments were an almost instant, worldwide success.[1]
- Many consumers confuse homeopathy with herbal medicine; yet the two are fundamentally different. Herbal medicines are plant extracts that contain potentially active ingredients. Homeopathic remedies are based on plants or any other material and they are typically so dilute that they contain not a single molecule of the substance advertised on the bottle. The most frequently used dilution (homeopaths call them ‘potencies’) is a ‘C30’; a C30-potency has been diluted 30 times at a ratio of 1:100. This means that one drop of the staring material is dissolved in 1 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 drops of diluent (usually a water/alcohol mixture)—and that equates to less than one molecule of the original substance per all the molecules of the universe.
- Homeopaths claim that their remedies work via some ‘energy’ or ‘vital force’ and that the process of preparing the homeopathic dilutions (it involves vigorous shaking the mixtures at each dilution step) transfers this ‘energy’ or information from one to the next dilution. They also believe that the process of diluting and agitating their remedies, which they call potentisation, renders them not less or not more potent. Homeopathic remedies are usually prescribed according to the ‘like cures like’ principle: if, for instance, a patient suffers from runny eyes, a homeopath might prescribe a remedy made of onion, because onion make a healthy person’s eyes water. This and all other assumptions of homeopathy contradict the known laws of nature. In other words, we do not fail to comprehend how homeopathy works, but we understand that it cannot work unless the known laws of nature are wrong.
- According to Hahnemann’s classical homeopathy, homeopaths are focussed on the symptoms and characteristics of the patient. They conduct a lengthy medical history, and they show little or no interest in a physical examination of their patient or other diagnostic procedures. Once they are confident to have all the information they need, they try to find the optimal homeopathic remedy. This is done by matching the symptoms with the drug pictures of homeopathic remedies. Any homeopathic drug picture is essentially based on what has been noted in homeopathic provings where healthy volunteers take a remedy and monitor all that symptoms, sensations and feelings they experience subsequently. Thus, the optimal homeopathic remedy can be seen as a diagnosis which makes homeopathy also a diagnostic method.[2]
- Today, around 500 clinical trials of homeopathy have been published. The totality of this evidence fails to show that homeopathic remedies are more than placebos.[3] Numerous official statements from various countries confirm the absurdity of homeopathy, for instance:
- “The principles of homeopathy contradict known chemical, physical and biological laws and persuasive scientific trials proving its effectiveness are not available” (Russian Academy of Sciences, Russia)
- “Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.” (National Health and Medical Research Council, Australia)
- “Homeopathic remedies don’t meet the criteria of evidence-based medicine.” (Hungarian Academy of Sciences, Hungary)
- “The incorporation of anthroposophical and homeopathic products in the Swedish directive on medicinal products would run counter to several of the fundamental principles regarding medicinal products and evidence-based medicine.” (Swedish Academy of Sciences, Sweden)
- “There is no good-quality evidence that homeopathy is effective as a treatment for any health condition” (National Health Service, England)
- Yet, many patients undeniably do get better after taking homeopathic remedies. The best evidence available today clearly shows that this improvement is unrelated to the homeopathic remedy per se. It is the result of a lengthy, empathetic, compassionate encounter with a homeopath, a placebo-response or other factors which experts often call ‘context effects’.[4]
- Whenever homeopaths advise their patients (as they often do) to forgo effective conventional treatments, they are likely to do harm. This phenomenon is best documented in relation to the advice of many homeopaths against immunisations.[5]
I do not expect fans of homeopathy to be impressed by my evidence-based assessment of their cult. In fact, just looking what is currently being posted on ‘X’ today about the ‘WORLD HOMEOPATHY DAY’ seems to justify my expectation. Here are the 10 first postings that appeared on my screen about an hour ago:
- Today, on #WorldHomeopathyDay, we celebrate the birth anniversary of Dr. Samuel Hahnemann, the founder of homeopathy. Let’s embrace the principles of natural healing and holistic well-being.
- On #WorldHomeopathyDay President #DroupadiMurmu to inaugurate 2-day Homeopathic Symposium at Yashobhoomi Convention Centre Dwarka, New Delhi. Organized by Central Council for Research in Homoeopathy (CCRH) based on theme of ‘Empowering Research, Enhancing Proficiency.’
- Dr. Ashvini Kumar Dwivedi, Member, Scientific Advisory Board, Central Council for Research in Homeopathy, Ministry of Ayush, Government of India, and #ASSOCHAM Ayush task force member, underlined the significance of #WorldHomeopathyDay, observed on April 10th each year
- Today, we celebrate #WorldHomeopathyDay 2024, embracing the gentle healing power of nature.
- Happy #WorldHomeopathyDay! Let’s celebrate the holistic approach to health that homeopathy offers, honoring its contributions to alternative medicine and its focus on individualized care. Here’s to exploring natural remedies and supporting wellness for all! #HolisticHealth
- Happy World Homeopathy Day Embracing the gentle yet powerful healing of homeopathy, let’s cherish its holistic essence, promoting balance and well-being worldwide. Here’s to the harmony it brings to mind, body, and spirit.
- #WorldHomeopathyDay: President #DroupadiMurmu to inaugurate 2-day Homeopathic Symposium at Yashobhoomi Convention Centre Dwarka, New Delhi. Organized by Central Council for Research in Homoeopathy (CCRH) based on theme of ‘Empowering Research, Enhancing Proficiency.’
- Celebrate #WorldHomeopathyDay with us & enter to win these two enlightening reads by renowned homeopath Dr. Mukesh Batra. What inspired you to explore homeopathy? Share your story in the comments section & get a chance to win a copy of #HealWithHomeopathy and #FeelGoodHealGood!
- #WorldHomeopathyDay is celebrated on April 10th, promoting awareness of the principles and benefits of homeopathic medicine. It aims to address the whole body, including hereditary predispositions and disease history, and encourages people to pursue homeopathy as a profession.…
- On World Homeopathy Day, we celebrate Dr. Samuel Hahnemann, the pioneer of homeopathy. His gentle remedies, made from natural substances, have helped countless people heal without side effects.
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In view of this volume of pure BS, I encourage everyone to post (here, or on ‘X’, or elsewhere) some evidence-based comments on homeopathy, Hahnemann and the ‘World Homeopathy Day’.
Let me make a start:
Homeopaths are as deluded as their remedies are diluted
Spinal manipulation is usually performed by a therapist (chiropractor, osteopath, physiotherpist, doctor, etc.). But many people do it themselves. Self-manipulation is by no means safer than the treatment by a therapist, it seems. We have previously seen cases where the results were dramatic:
- Spinal epidural haematoma after neck manipulation (edzardernst.com)
- A ‘Self-Chiropractic Spinal Manipulation’ that resulted in death (edzardernst.com)
Now, a further case has been reported. In this paper, American pathologists present a tragic case of fatal vertebral artery dissection that occurred as the result of self-manipulation of the cervical spine.
The decedent was a 40-year-old man with no significant past medical history. He was observed to “crack his neck” while at work. Soon after, he began experiencing neck pain, then developed stroke-like symptoms and became unresponsive. He was transported to a local medical center, where imaging showed bilateral vertebral artery dissection. His neurological status continued to decline, and brain death was pronounced several days later.
An autopsy examination showed evidence of cerebellar and brainstem infarcts, herniation, and diffuse hypoxic-ischemic injury. A posterior neck dissection was performed to expose the vertebral arteries, which showed grossly visible hemorrhage and dilation. There was no evidence of traumatic injury to the bone or soft tissue of the head or neck. Bilateral dissection tracts were readily appreciated on microscopic examination. Death was attributed to self-manipulation of the neck, which in turn led to bilateral vertebral artery dissection, cerebellar and brainstem infarcts, herniation, hypoxic-ischemic injury, and ultimately brain death.
It seems clear to me that only few and spectacular cases of this nature are being published. In other words, the under-reporting of adverse effects of self-manipulation must be close to 100%. It follows that the risk of sel-manipulation is impossible to quantify. I suspect it is substancial. In any case, the precautionary principle compells me to re-issue my warning:
do not allow anybody to manipulate your neck, not even yourself!
Cervical spondylosis is a chronic degenerative process of the cervical spine characterized by pain in neck, degenerative changes in intervertebral disc and osteophyte formation. The present study was aimed at evaluating the effect of wet cupping (Ḥijāma Bish Sharṭ) in the pain management of cervical spondylosis.
This Open, randomized, clinical study was conducted on 44 patients.
- Subjects in the test group (n = 22) received a series of three-staged wet cupping treatment, performed on 0, 7th and 14th day.
- Subjects in the control group (n = 22) received 12 sittings of Transcutaneous Electrical Nerve Stimulation (TENS): 6 sittings per week for two weeks.
The outcomes were assessed with the help of VAS, Neck Disability Index (NDI) and Cervical range of motion.
Intra group comparison in test group from baseline to 21st day were found highly significant (p < 0.001) in terms of VAS, NDI, Flexion, Extension and Left rotation score. While in Right rotation, Left rotation and Left lateral flexion score were found moderately significant (p < 0.01). Statistically significant difference was observed between two groups at 21st day in VAS scale, NDI, and Cervical range of motion score (p < 0.001).
The authors concluded that Ḥijāma Bish Sharṭ was found better in the management of pain due to cervical spondylosis than TENS. It can be concluded that Ḥijāma Bish Sharṭ may a better option for the pain management of cervical spondylosis.
Wet cupping is the use of a vacuum cup applied to the skin which has previously been lacerated. It draws blood and can thus be seen as a form of blood letting. It has been used in various cultures for the treatment of joint pain and many other conditions since antiquity.
The authors point out that, in Unani medicine, it is believed to reduce pain and other symptoms by diverting and evacuating the causative pathological humours (akhlāṭ-e-fasida). Galen (Jalinoos) mentioned wet cupping as a very useful modality in evacuating the thick humours (akhlāṭ-e-Ghaleez) (Nafeesi, 1954; Qamri, 2008). Wet cupping works on the principle of diversion and evacuation of morbid matter (imala wa tanqiya-i-mawād-i-fasida). It opens the pores of the skin, enhances the blood circulation, nourishes the affected area with fresh blood, improves the eliminative function and facilitates the evacuation of morbid matter from the body.
There are several studies of wet cupping, most of which are as flawed as the one above. This new trial has several limitations, e.g.:
- It makes no attempt to control for placebo effects which could well be more prominent for wet cupping than for TENS.
- It did not inhibit the influence of verbal or non-verbal communications between therapists and patients which are likely to influence the results.
- The sample size is far too small, particularly as the study was designed as an equivalence study.
But some might say that my arguments a petty and argue that, regardless of a flimsy study, wet cupping is still worth a try. I would disagree – not because of the flaws of this study, nor the implausibility of the long-obsolete assumptions that underpin the therapy, but because wet cupping is associaated with infections of the skin lacerations which occasionally can be serious.
It does not happen often, but when it does, it should be aknowledged. I am speaking of papers from chiropractors that make sense. If you are interested in chiropractic, I do encourage you to read the articles of which I will here only present bits of the conclusions:
The chiropractic profession is weighed down by the burden of historical theories regarding spinal manipulative therapy (SMT), which, for some in the profession, have all the characteristics of dogmatic articles of faith. In our opinion, the unlimited scope of practice, which is still advocated by some chiropractors, and which has not been met with unequivocal political rejection, an over-reliance on SMT in the management of MSK disorders, and an over-emphasis on the technical intricacies of SMT represent weaknesses within chiropractic. We argue that these are obstacles to professional development and the major causes of professional stagnation both intellectually and in the market place.
We also discussed what we consider to be threats to the chiropractic profession. Science, the impact of EBM, and accountability to authorities and third party-payers all pose threats to the traditional chiropractic paradigm and, thus, to those within the profession, who practice within such a paradigm. In the marketplace, competition from other professions that provide care of patients with MSK disorders, including SMT, and are better positioned to be integrated into the wider health-care system/market represent a threat. Moreover, finally, the internal schism in chiropractic represents a threat to professional development, as it prevents the profession moving forward in unison with a coherent external message.
We have described those weaknesses and threats, knowing full well, that we do so from our perspective of chiropractic as EBM with a limited MSK scope of practice, i.e. from outside the subluxation frame of reference.
We recognize that for those who look at SMT from the perspective of traditional, subluxation-based chiropractic, things will look very different: What we identify as weaknesses may be seen by others as the pillars of chiropractic practice, and what we see as threats could appear as just peripheral and ephemeral distractions to the enduring core of chiropractic ideas. Such is the character of the schism at the heart of chiropractic.
None-the-less, having described what we identify as serious weaknesses and threats arising from the profession’s relationship to SMT, it has not escaped our attention that it also gives rise to several strengths, which serve the profession and its patients well. In turn, it follows that a number of opportunities are presenting themselves for the future of SMT and chiropractic.
The onus is now on the chiropractic profession itself to redefine its raison d’être in a way that plays to those strengths and delivers in terms of the needs of patients and the wider healthcare system/market. We suggest chiropractors embrace and cultivate a role as coordinators of long-term and broad-focused management of musculoskeletal disorders. We make specific recommendations about how the profession, from individual clinicians to political organizations, can promote such a development.
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For readers in a hurry:
Progress is an inevitable threat to obsolete and useless practices of any kind. In that, chiropractic is no exception.
The aim of this study was to establish an international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale.
Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:
● Manipulation is not recommended: (1) for infants across all conditions, impairments, and
spinal levels; and (2) for children and adolescents across most conditions and spinal levels.
● Manipulation may be recommended for adolescents to treat spinal region-specific joint
hypomobility (thoracic, lumbar), and pain (thoracic).
● Mobilisation may be recommended for children and adolescents with hypomobility, joint
pain, muscle/myofascial pain, or stiffness at all spinal levels.
The authors of this paper concluded that consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.
Various forms of spinal manipulations are the hallmark therapy of chiropractors. Almost 100% of their patients recieve these interventions. So, what will our friends, the chiros, say about the consensus? Might it be this:
- Physiotherapists are not the experts on spinal manipulation.
- Only chiropractors can do them properly.
- And when WE do them, they are very good*!
(* for our income)
These days, it has become a rare event – I am speaking of me publishing a paper in the peer-reviewed medical literature. But it has just happened: Spanish researchers and I published a meta-analysis on the effectiveness of craniosacral therapy. Here is its abstract:
The aim of this study was to evaluate the clinical effectiveness of craniosacral therapy (CST) in the management of any conditions. Two independent reviewers searched the PubMed, Physiotherapy Evidence Database, Cochrane Library, Web of Science, and Osteopathic Medicine Digital Library databases in August 2023, and extracted data from randomized controlled trials (RCT) evaluating the clinical effectiveness of CST. The PEDro scale and Cochrane Risk of Bias 2 tool were used to assess the potential risk of bias in the included studies. The certainty of the evidence of each outcome variable was determined using GRADEpro. Quantitative synthesis was carried out with RevMan 5.4 software using random effect models.
Fifteen RCTs were included in the qualitative and seven in the quantitative synthesis. For musculoskeletal disorders, the qualitative and quantitative synthesis suggested that CST produces no statistically significant or clinically relevant changes in pain and/or disability/impact in patients with headache disorders, neck pain, low back pain, pelvic girdle pain, or fibromyalgia. For non-musculoskeletal disorders, the qualitative and quantitative synthesis showed that CST was not effective for managing infant colic, preterm infants, cerebral palsy, or visual function deficits.
We concluded that the qualitative and quantitative synthesis of the evidence suggest that CST produces no benefits in any of the musculoskeletal or non-musculoskeletal conditions assessed. Two RCTs suggested statistically significant benefits of CST in children. However, both studies are seriously flawed, and their findings are thus likely to be false positive.
So, CST is not really an effective option for any condition.
Not a big surprise! After all, the assumptions on which CST is based fly in the face of science.
Since CST is nonetheless being used by many healthcare professionals, it is, I feel, important to state and re-state that CST is an implausible intervention that is not supported by clinical evidence. Hopefully then, one day, these practitioners will remember that their ethical obligation is to treat their patients not according to their beliefs but according to the best available evidence. And, hopefully, our modest paper will have helped rendering healthcare a little less irrational and somewhat more effective.
An article about chiropractic caught my attention. Let me show you its final section which, I think, is relevant to what we often discuss on this blog:
If chiropractic treatment is unscientific, then why do I feel better? Because lots of things alleviate pain. Massage, analgesia and heat – but also a provider who listens, empathises and bothers to examine a patient. Then there is the placebo effect. For centuries, doctors have recognised that different interventions with unclear pathways result in clinical improvement. Among the benefits patients attributed to placebo 100 years ago: “I sleep better; my appetite is improved; my breathing is better; I can walk further without pain in my chest; my nerves are steadier.” Nothing has changed. Pain is a universal assignment; no one has a monopoly on its relief.
The chiropractic industry owes its existence to a ghost. Its founder, David Palmer, wrote in his memoir The Chiropractor that the principles of spinal manipulation were passed on to him during a séance by a doctor who had been dead for half a century. Before this, Palmer was a “magnetic healer”.
Today, chiropractors preside over a multibillion-dollar regulated industry that draws patients for various reasons. Some can’t find or afford a doctor, feel dismissed, or worse, mistreated. Others mistrust the medical establishment and big pharma. Still others want natural healing. But none of these reasons justifies conflating a chiropractor with a doctor. The conflation feels especially hazardous in an environment of health illiteracy, where the mere title of doctor confers upon its bearer strong legitimacy.
Chiropractors don’t have the same training as doctors. They cannot issue prescriptions or order advanced imaging. They do not undergo lifelong peer review or open themselves to monthly morbidity audits.
I know that doctors could do with a dose of humility, but I can’t find any evidence (or the need) for the assertion on one website that chiropractors are “academic overachievers”. Or the ambit claim that most health professionals have no idea how complicated the brain is, but chiropractors do.
Forget doctors, patients deserve more respect.
My friend’s back feels better for now. When it flares, I wonder if she will seek my advice – and I am prepared to hear no. Everyone is entitled to see a chiropractor. But no patient should visit a chiropractor thinking that they are seeing a doctor.
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I would put it more bluntly:
- chiropractors are poorly trained; in particular, they do not learn to question their own, often ridiculous beliefs;
- they are poorly regulated; in the UK, the GCC seems to protect the chiros rather than the public;
- chiropractors regularly disregard essential rules of medical ethics, e.g. informed consent;
- many try to mislead us by pretending they are physicians;
- their hallmark intervention, spinal manipulation, can cause considerable harm;
- it generates hardly any demonstrable benefit for any condition;
- chiropractors also cause considerable harm, e.g. by interfering with real medicine, e.g. vaccinations;
- thus, in general, chiropractors do more harm than good;
- yes, everyone is entitled to see a chiropractor, but before they do, reliable information should be mandatory.
Dry needling is a therapy that is akin to acupuncture and trigger point therapy. It is claimed to be safe – but is this true?
Researchers from Ghent presented a series of 4 women aged 28 to 35 who were seen at the emergency department (ED) with post-dry needling pneumothorax between September 2022 and December 2023. None of the patients had any relevant medical history. All had been treated for a painful left shoulder, trapezius muscle or neck region in outpatient physiotherapist practices. At least three different physiotherapists were involved.
One patient presented to the ER on the same day as the dry needling procedure, the others presented the day after. All mentioned thoracic pain and dyspnoea. Clinical examination in all of these patients was unremarkable, as were their vital signs. Diagnosis was confirmed with ultrasound (US) and chest X-ray (CXR) in all patients. The latter exam showed left-sided apical pleural detachment with a median of 3.65 cm in expiration.
Two patients were managed conservatively. One patient (initial pneumothorax 2.5 cm) was discharged. The US two days later displayed a normally expanded lung. One patient with an initial apical size of 2.8 cm was admitted with 2 litres of oxygen through a nasal canula and discharged from the hospital the next day after US had shown no increase in size. Her control CXR 4 days later showed only minimal pleural detachment measuring 6 mm. The two other patients were treated with US guided needle aspiration. One patient with detachment initially being 4.5 cm showed decreased size of the pneumothorax immediately after aspiration. She was admitted to the respiratory medicine ward and discharged the next day. Control US and CXR after 1 week showed no more signs of pneumothorax. In the other patient, with detachment initially being 5.5 cm, needle aspiration resulted in complete deployment on US immediately after the procedure, but control CXR showed a totally collapsed lung 3 hours later. A small bore chest drain was placed but persistent air leakage was seen. Several trials of clamping the drain resulted in recurrent collapsing of the lung. After CT-scan had shown no structural deformities of the lung, suction was gradually reduced and the drain was successfully removed on the sixth day after placement. The patient was then discharged home. Control CXR 3 weeks later was normal.
The authors concluded that post-dry needling pneumothorax is, contrary to numbers cited in literature, not extremely rare. With rising popularity of the technique we expect complications to occur more often. Patients and referring doctors should be aware of this. In their informed consent practitioners should mention pneumothorax as a considerable risk of dry needling procedures in the neck, shoulder or chest region.
The crucial question, in my view, is this: do the risks of dry-needling out weigh the risks of this form of therapy? Let’s have a look at some of the recent evidence that we discussed on this blog:
- Spinal Manipulation and Electrical Dry Needling for Subacromial Pain Syndrome: A Nonsensical Trial
- Dry needling is useless for rehabilitation after shoulder surgery
- High velocity, low amplitude techniques are not superior to no treatment in the management of tension-type headache
- Which treatments are best for acute and subacute mechanical non-specific low back pain? A systematic review with network meta-analysis
- Acupuncture for chronic pain: the new NICE guideline
- Acupuncture for the Relief of Chronic Pain? A new, thorough synthesis fails to produce strong evidence that acupuncture works
The evidence is clearly mixed and unconvincing. I am not sure whether it is strong enough to afford a positive risk/benefit balance. In other words: dry needling is a therapy that might best be avoided.
