MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

spinal manipulation

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One of my recent posts prompted the following comment from a chiropractor: “… please don’t let me stop you…while we actually treat patients“. It was given in the context of a debate about the evidence for or against chiropractic spinal manipulations as a treatment of whiplash injuries. My position was that there is no convincing evidence, while the chiropractor argued that he has been using manipulations for this indication with good results. Here I do not want to re-visit the pros and cons of that particular debate. Since similar objections have been put to me so many times, I want rather to raise several more principal points.

Before I do this, I need to quickly get the personal stuff out of the way: the comment implies that I  don’t really know what I am talking about because I don’t see patients and thus don’t understand their needs. The truth is that I started my professional life as a clinician, then I went into basic science, then I went back into clinical medicine (while also doing research), and eventually, I became a full-time clinical researcher. I have thus seen plenty of patients, certainly enough to empathize with both the needs of patients and the reasoning of clinicians. In fact, these provided the motives for my clinical research during the last decades of my professional career (more details here).

Now about the real issue that is at stake here. When offered by a clinician to a scientist, the comment “… please don’t let me stop you…while we actually treat patients” is an expression of an arrogant feeling of superiority that clinicians often harbor vis a vis professionals who are not at the ‘coal face’ of healthcare. Stripped down to its core, the argument implies that science is fairly useless because the only knowledge worth having stems from dealing with patients. In other words, it is about the tension that so often exists between clinical experience and scientific evidence.

Many clinicians feel that experience is the best guide to correct decision-making.

Many scientists feel that experience is fraught with errors, and only science can lead us towards optimal decisions.

Such arguments emerge regularly on this blog and are constant company to almost any type of healthcare. The question is, who is right and who is wrong?

As I indicated, I can empathize with both positions. I can see that, in the context of making therapeutic decisions in a busy clinic, for instance, the clinician’s argument weighs heavily and can make sense, particularly in areas where the evidence is mixed, weak, or uncertain.

However, in the context of this blog and other discussions focused on critical evaluation of the science, I am strongly on the side of the scientist. In fact, in this context, the argument “… please don’t let me stop you…while we actually treat patients” seems ridiculous and resembles an embarrassing admission of having no rational argument left for defending one’s own position.

To put my view of this in a nutshell: it is not a question of either or; for optimal healthcare, we obviously need both clinical experience AND scientific evidence (an insight that is not in the slightest original, since it is even part of Sackett’s definition of EBM).

If you go on Twitter you will find that chiropractors are keen like mustard to promote the idea that, after a car accident, you should consult a chiropractor. Here is just one Tweet that might stand for hundreds, perhaps even thousands:

Recovering from a car accident? If you have accident-related injuries such as whiplash, chiropractic care may provide relief. Treatments like spinal manipulation and soft tissue therapy can aid in your recovery.

In case you don’t like Twitter, you could also go on the Internet where you find hundreds of websites that promote the same idea. Here are just two examples:

A frequent injury arising from an automobile accident … is whiplash. After an accident, a chiropractor can help treat resulting issues and pain from the whiplash… Proceeding reduction in swelling and pain, treatment will then focus on manipulation of the spine and other areas.

The primary whiplash treatment for joint dysfunction, spinal manipulation involves the chiropractor gently moving the involved joint into the direction in which it is restricted.

There is no question, chiropractors earn much of their living by treating patients suffering from whiplash (neck injury caused by sudden back and forth movement of the neck often causing neck pain and stiffness, shoulder pain, and headache) after a car accident with spinal manipulation.

Why?

There are two not mutually exclusive possibilities:

  1. They think it is effective.
  2. It brings in good money.

I have no doubt about the latter notion, yet I think we should question the first. Is there really good evidence that chiropractic manipulations are effective for whiplash?

When I was head of the PMR department at the University of Vienna, treating whiplash was my team’s daily bread. At the time, our strategy was to treat each patient according to the whiplash stage and to his/her individual signs and symptoms. Manipulations were generally considered to be contra-indicated. But that was about 30 years ago. Perhaps the evidence has now changed. Perhaps manipulation therapy has been shown to be effective for certain types of whiplash injuries?

To find out, I did a few Medline searches. These did, however, not locate compelling evidence for spinal manipulation as a treatment of any stage of whiplash injuries. Here is an example of the evidence I found:

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. Its findings show the following: Evidence from 15 evaluation studies suggests that for recent neck pain and associated disorders grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises.

But this is most puzzling!

Why do chiropractors promote their manipulations for whiplash, if there is no compelling evidence that it does more good than harm? Again, there are two possibilities:

  1. They erroneously believe it to be effective.
  2. They don’t care but are in it purely for the money.

Whatever it is – and obviously not all chiropractors would have the same reason – I must point out that, in both cases, they behave unethically. Not being informed about the evidence related to the interventions used clearly violates healthcare ethics, and so does financially not informing and exploiting patients.

 

It has been reported that the US Insurer ‘State Farm’ is fighting a fraudulent scheme that has been exploiting New Jersey’s personal injury protection (PIP) benefits law since 2014. The insurer is seeking to recover $2.6 million in what it claims are fraudulent auto injury claims and a declaratory judgment that it need not pay any further claims submitted by the providers involved in the alleged scheme.

State Farm’s suit accuses 12 chiropractic and spine clinics and doctors of fraud, unjust enrichment, and violations of the New Jersey Insurance Fraud Prevention Act. The insurer alleges these providers used a “predetermined protocol” for all patients and a patient referral system for services that were either not performed or were not medically necessary for the individual patients. Instead, the services were carried out to enrich the defendants by exploiting the patients’ eligibility for PIP benefits, according to the complaint.

The suit accuses the providers of failing to legitimately evaluate patients to determine the true nature of their injuries and of reporting the same or similar findings for all patients to justify a predetermined course of treatment that was substantially the same for all patients. Part of the “predetermined protocol” for patients with soft-tissue injuries of the neck and back consisted of

  • hot and cold packs,
  • chiropractic manipulations,
  • massage,
  • mechanical traction,
  • physical medicine and rehabilitation,
  • and manual therapy.

These treatments were administered to almost every patient on almost every visit, regardless of each patient’s unique circumstances and needs, according to the complaint. The chiropractors are also accused of referring patients to diagnostic clinics, some allegedly illegally owned by the chiropractors, for an “unnecessary and predetermined course of pain management and invasive treatments” including injections. State Farm says they would submit false documentation for each case representing that the treatments were legitimately performed and medically necessary.

The 80-page complaint details case after case where the patient’s responses to questions and tests were the same or similar, allegedly serving as a “pretext to justify” the chiropractors’ wide range of treatments. The defendants in the complaint filed in U.S. District Court for New Jersey are:

  • Tri-County Chiropractic and Rehabilitation Center,
  • Robert Matturro, D.C.,
  • Advanced Spine and Pain Management,
  • Varinder Dhillon, M.D.,
  • Nicholas Rosania, D.C.,
  • Bloomfield UAI,
  • Dov Rand, M.D.,
  • Primary Medical Services,
  • Louis J. Citarelli, M.D.,
  • Chiro Health Center P.C.,
  • Marc Matturro, D.C.
  • Marco Tartaglia, M.D.

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This story made me wonder: which of the listed treatments

  • hot and cold packs,
  • chiropractic manipulations,
  • massage,
  • mechanical traction,
  • physical medicine and rehabilitation,
  • and manual therapy

would ever be indicated for patients with soft-tissue injuries of the neck and back? Or more specifically, are chiropractic manipulations indicated or contra-indicated for such problems following a car accident? I fail to see any sound evidence that they are effective. If I am correct, should insurance companies not sue all chiropractors who routinely use manipulations for such cases? If the answer is YES, the sum of 2.6 million might need to be increased by several orders of magnitude.

Trevor Zierke is a D.C. who published several videos that have gone viral after saying that “literally 99% of my profession” is a scam. “When I say almost all the usual lines chiropractors tell you are lies, I mean almost all of them,” he stated. Zierke then went on to give examples of issues chiropractors allegedly make up, including someone’s spine being “misaligned,” tension on nerves causing health problems, and someone having back pain because their hips are off-center. “Almost all of these aren’t true,” he concluded.

In a follow-up video, he claimed that the reasons most people are told they need to go to a chiropractor are “overblown or just flat out lies proven wrong by research.” He also noted that, while there are many scams, that “doesn’t mean you can’t get help from a chiropractor.”

In a third TikTok video, Zierke offered some valid reasons to see a chiropractor. He said that one can seek help from a chiropractor if one has musculoskeletal pain that has been ongoing for more than one to two days, and that’s about it. He stated that issues that a chiropractor couldn’t really fix include “GI pain, hormonal issues, nutrition,” among others.

In comments, users were largely supportive of Zierke’s message.

One said: “As a physiotherapist, I’ve been trying to tell this but I don’t want to like offend any chiropractor in doing so,” a commenter shared.

“Working in a chiropractic office, this is fair,” a further user wrote. “I have issues that I know an adjustment will help & other pain that would be better stretched/released.”

In an email, Zierke reiterated the intention of his videos: “I would just like to clarify that chiropractors, in general, are not a scam or are inherently scammers (I myself am a practicing chiropractor), but rather a lot of very popular sales tactics, phrases, and wording used to imply patients need treatment, and methods of treatment, have never been proven to be true,” he explained. “When chiropractors say & use these methods stating things that are not factually true—I believe it’s scammy behavior and practices. There are still a lot of very good, honest, and integral chiropractors out there,” he concluded. “They can provide a lot of help and relief to patients. But that’s unfortunately not the majority, and I’ve heard too many stories of people falling victim to some of these scam-like tactics from bad apple chiropractors.”

None of what DC Zierke said can surprise those who have been following my blog. On the contrary, I could add a few recent posts to his criticism of chiropractic, for example:

I rest my case.

It has been reported that a recent inspection from the Care Quality Commission (CQC) found that the diagnostic imaging service at AECC University College in Parkwood Road, Bournemouth, requires improvement in three out of four areas – including patient safety. This is surprising not least because the AECC prides itself on being “a leading higher education institution in healthcare disciplines, nationally and internationally recognised for quality and excellence.”

The unannounced inspection in May this year resulted in several demands for the service to improve upon. For example, the CQC report said staff “did not receive all of the training they needed to keep patients safe” and that patient chaperones “did not receive chaperone training”. Moreover, managers were reported as not always ensuring staff were competent to operate certain equipment. In fact, there was no record of staff competencies which meant inspectors “could not tell if staff had been trained to use equipment”. General cleanliness was also found lacking in relation to certain procedures, namely no sink in any of the site’s nine ultrasound rooms (including those for transvaginal scans) – meaning staff carrying out ultrasound scanning did not have access to a clinical handwashing facility.

The CQC states on its website that it “is the independent regulator of health and adult social care in England. We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. We monitor, inspect and regulate services. Then we publish what we find, including performance ratings, to help people choose care. Where we find poor care, we will use our powers to take action.”

No doubt, these are laudable aims. What I find, however, disappointing is that the CQC’s inspection of the AECC did not question the nature of some of the courses taught by the AECC. Earlier this year, I reported in a blog post that the AECC has announced a new MSc ‘Musculoskeletal Paediatric Health‘. This motivated me to look into the evidence for such a course. This is what I found with several Medline searches (date of the review on chiropractic for any pediatric conditions, followed by its conclusion + link [so that the reader can look up the evidence]):

2008

I am unable to find convincing evidence for any of the above-named conditions. 

2009

Previous research has shown that professional chiropractic organisations ‘make claims for the clinical art of chiropractic that are not currently available scientific evidence…’. The claim to effectively treat otitis seems to
be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim.

2009

The … evidence is neither complete nor, in my view, “substantial.”

2010

Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

2018

Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

What seems to emerge is rather disappointing:

  1. There are no really new reviews.
  2. Most of the existing reviews are not on musculoskeletal conditions.
  3. All of the reviews cast considerable doubt on the notion that chiropractors should go anywhere near children.

But perhaps I was too ambitious. Perhaps there are some new rigorous clinical trials of chiropractic for musculoskeletal conditions. A few further searches found this (again year and conclusion):

2019

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

2018

Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.

I might have missed one or two trials because I only conducted rather ‘rough and ready’ searches, but even if I did: would this amount to convincing evidence? Would it be good science?

No! and No!

So, why does the AECC offer a Master of Science in ‘Musculoskeletal Paediatric Health’?

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Isn’t that a question the CQC should have asked?

The UK Chiropractic Council is inviting you to help them re-formulate their educational standards. It is an occasion, some of my readers might find interesting. I, therefore, copy the relevant part of their announcement:

… Following a scoping review in 2021, which determined that the existing Education Standards, published in 2017, required development and updating, the GCC began revising the Education Standards in January 2022.

The revision will ensure that the Education Standards:

  • Provide a realistic and comprehensive set of outcomes to be met by graduates on approved qualifications, demonstrating an ability to practise in accordance with the GCC Code.
  • Take into account developments within the profession, increase focus on multi-disciplinary learning and different professions working more closely together across the UK, ensuring that graduates are well placed to meet the opportunities to care for patients in different contexts.
  • Remain consistent, as appropriate, with the outcomes set by other UK healthcare frameworks and standards.

Purpose: why we are consulting

This consultation sets out our draft Education Standards for providers and Learning Outcomes for students, which reflect and build on the evidence and feedback we have obtained through our scoping review.

We seek stakeholders’ views on these draft Education Standards to ensure our final proposals are future-proof and fit for purpose.

We welcome all responses to the consultation.


Documents

The draft Education Standards on which we invite comments.

The equality impact assessment of the Education Standards, with comments invited within the consultation.

The GCC Education Standards consultation document in Word format.


Ways to respond

Submissions to this consultation can be made online (see below) or by email at enquiries@gcc-uk.org (click here to download the consultation document).

It is advisable to make a copy of your submission to prevent the loss of information due to internet, portal or connectivity issues. This should be done before pressing the submit button.

Information in responses, including personal information, may need to be published or disclosed under the access to information regimes (mainly the Freedom of Information Act 2000, the General Data Protection Regulation, the Data Protection Act 2018, and the Environmental Information Regulations 2004).

The GCC is a data controller registered with the Information Commissioner’s Office. We use personal data to support our work as the regulatory body for chiropractors. We may share data with third parties to meet our statutory aims and objectives, and when using our powers and meeting our responsibilities.


Closing date

The deadline for responses to this consultation on the draft Education Standards is 16 September 2022 at noon. The consultation will be publicised and stakeholders will be invited to comment…

_________________

Personally, I think the GCC desperately needs to improve its educational (and other) standards. They claim that, “as the regulator for chiropractors, our role is to protect the public”. The case of the late John Lawler is one of many examples to show how unfit for this purpose the GCC truly is.

So, perhaps you might want to contribute to the consultation with a view to making UK chiropractors less of a danger to the public?

 

The purpose of this study was to examine the trends in the expenditure and utilization of chiropractic care in a representative sample of children and adolescents in the United States (US) aged <18 years.

The researchers evaluated serial cross-sectional data (2007-2016) from the Medical Expenditure Panel Survey. Weighted descriptive statistics were conducted to derive national estimates of expenditure and utilization, and linear regression was used to determine trends over time. Sociodemographic and clinical characteristics of chiropractic users were also reported.

A statistically significant increasing trend was observed for the number of children receiving chiropractic care (P <.05) and chiropractic utilization rate (P < .05). Increases in chiropractic expenditure and the number of chiropractic visits were also observed over time but were not statistically significant (P > .05). The mean annual number of visits was 6.4 visits, with a mean expenditure of $71.49 US dollars (USD) per visit and $454.08 USD per child. Children and adolescent chiropractic users in the United States were primarily 14 to 17 years old (39.6%-61.6%), White (71.5%-76.9%), male (50.6%-51.3%), and privately insured (56.7%-60.8%). Chiropractic visits in this population primarily involved low back conditions (52.4%), spinal curvature (14.0%), and head and neck complaints (12.8%).

The authors concluded that the number of children visiting a chiropractor and percent utilization showed a statistically significant, increasing trend from 2007 to 2016; however, total expenditure and the number of chiropractic visits did not significantly differ during this period. These findings provide novel insight into the patterns of chiropractic utilization in this understudied age group.

Why are these numbers increasing?

Is it because of increasing and sound evidence showing that chiropractors do more good than harm to kids?

No!

A recent systematic review of the evidence for effectiveness and harms of specific spinal manipulation therapy (SMT) techniques for infants, and children suggests the opposite.

Its authors searched electronic databases up to December 2017. Controlled studies, describing primary SMT treatment in infants (<1 year) and children/adolescents (1–18 years), were included to determine effectiveness. Controlled and observational studies and case reports were included to examine harms. One author screened titles and abstracts and two authors independently screened the full text of potentially eligible studies for inclusion. Two authors assessed the risk of bias in included studies and the quality of the body of evidence using the GRADE methodology. Data were described according to PRISMA guidelines and CONSORT and TIDieR checklists. If appropriate, a random-effects meta-analysis was performed.

Of the 1,236 identified papers, 26 studies were eligible. In all but 3 studies, the therapists were chiropractors. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication, and treatment comparison were scarce. Due to very low-quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in 4 infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children and could be interpreted as a side effect of treatment.

The authors concluded that, based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.

But chiros do more than just SMT, I hear some say.

Yes, they do!

But they nevertheless manipulate virtually every patient, and the additional treatments they use are merely borrowed from other disciplines.

So, why are the numbers increasing then?

I suggest this as a main reason:

chiropractors are systematically misleading the public about the value of their trade.

It has been reported by several outlets that a young woman is fighting for her life after a chiropractic adjustment went horribly wrong. Caitlin Jensen had only recently graduated from University. When she went for what was meant to be a simple chiropractic adjustment on June 16, she suffered four dissected arteries in her neck, this damage led to cardiac arrest, stroke and her being without a pulse for over 10 minutes, requiring resuscitation.

She was rushed to the Memorial Hospital in Savannah, Georgia, where she was operated on. She was then taken to the neuro ICU in a critical condition with a traumatic brain injury. Every day since she’s been fighting. Currently, she is conscious and able to respond to verbal commands by blinking her eyes, as well as wiggling the toes of her left foot. However, most of her body remains paralyzed.

Her mother Darlene has been posting updates about her daughter’s condition on Facebook. On Saturday Darlene shared the latest news on the condition of her daughter. “She gave her best effort to smile today, and it was the most beautiful thing I’ve ever seen,” Darlene said. “She is progressing with her movements on the left side – wiggling and flexing. She can’t lift her arm yet, or turn her head. Her right side is unchanged – still no movement. Her face doesn’t move very much yet, but she can open her eyes widely to show surprise, and the left corner of her mouth tries to smile. Adorable. Still working on the pneumonia. The antiplatelet therapy seems to be going OK. We don’t see any signs of internal bleeding and are praying that it stays that way.”

And the day before, Darlene posted: “Two weeks ago tonight we didn’t know if Caitlin would make it through the night,” Darlene said. “Dire and catastrophic are two of the words that we heard from our ICU team. We knew they didn’t casually throw around words like that. But – she is alive, and every day is a little better. The accomplishments are both small and monumental at the same time. Today, she gave us a thumbs up. We have been working on this, and she got it! She also nodded again today. It helps to see these things because it reassures us that she is working hard to stay with us and recover. Caitlin is strong, disciplined, and well practised in exercising her brain, and I truly believe that her science background and all of her time studying is going to help her in this long journey. “

Studies have found that traumatic cervical artery dissection is one of the leading causes of stroke in patients under the age of 45, and recent chiropractic neck manipulation is among factors that can be associated with risk of vertebral artery dissection.

Following the tragedy, Caitlin’s mother, Darlene, launched a GoFundMe and has raised more than US$20,000 (AU $29,334 or £16,512) for her ongoing medical expenses.

It is clear that these news reports lack important medical details. What is equally clear is the fact that most such cases are never reported in the medical literature and are thus available only in this fragmented form. The reason for this lamentable situation is obvious: there is no post-marketing surveillance system for chiropractic (such a safeguard would be bad for business, of course).

Consequently, chiropractors across the globe continue to be able to say that such reports are unreliable. The medical literature, they are keen to point out, holds only very few case studies of serious risks of chiropractic spinal manipulation. Hence they falsely claim on every possible occasion that their adjustments are safe. The end effect is that many consumers continue to wrongly assume that chiropractic manipulations might be worth a try.

Many systematic reviews have summarized the evidence on spinal manipulative therapy (SMT) for low back pain (LBP) in adults. Much less is known about the older population regarding the effects of SMT. This paper assessed the effects of SMT on pain and function in older adults with chronic LBP in an individual participant data (IPD) meta-analysis.

Electronic databases were searched from 2000 until June 2020; reference lists of eligible trials and related reviews were also searched. Randomized controlled trials (RCTs) were considered if they examined the effects of SMT in adults with chronic LBP compared to interventions recommended in international LBP guidelines. The authors of trials eligible for the IPD meta-analysis were contacted and invited to share data. Two review authors conducted a risk of bias assessment. Primary results were examined in a one-stage mixed model, and a two-stage analysis was conducted in order to confirm the findings. The main outcomes and measures were pain and functional status examined at 4, 13, 26, and 52 weeks.

A total of 10 studies were retrieved, including 786 individuals; 261 were between 65 and 91 years of age. There was moderate-quality evidence that SMT results in similar outcomes at 4 weeks (pain: mean difference [MD] – 2.56, 95% confidence interval [CI] – 5.78 to 0.66; functional status: standardized mean difference [SMD] – 0.18, 95% CI – 0.41 to 0.05). Second-stage and sensitivity analysis confirmed these findings.

The authors concluded that SMT provides similar outcomes to recommended interventions for pain and functional status in the older adult with chronic LBP. SMT should be considered a treatment for this patient population.

This is a fine analysis. Unfortunately, its results are less than fine. Its results confirm what I have been saying ad nauseam: we do not currently have a truly effective therapy for back pain, and most options are as good or as bad as the rest. This is most frustrating for everyone concerned, but it is certainly no reason to promote SMT as usually done by chiropractors or osteopaths.

The only logical solution, in my view, is to use those options that:

  • are associated with the least risks,
  • are the least expensive,
  • are widely available.

However you twist and turn the existing evidence, the application of these criteria does not come up with chiropractic or osteopathy as an optimal solution. The best treatment is therapeutic exercise initially taught by a physiotherapist and subsequently performed as a long-term self-treatment by the patient at home.

 

Naprapathy is an odd variation of chiropractic. To be precise, it has been defined as a system of specific examination, diagnostics, manual treatment, and rehabilitation of pain and dysfunction in the neuromusculoskeletal system. It is aimed at restoring the function of the connective tissue, muscle- and neural tissues within or surrounding the spine and other joints. The evidence that it works is wafer-thin. Therefore rigorous studies are of interest.

The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working-age persons with nonspecific back and/or neck pain.

The two interventions were:

  • a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage, and stretching, performed by a naprapath (index group),
  • information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, on 2 occasions within 3 weeks (control group).

A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health-related QoL was calculated, and sensitivity analyses were performed.

The difference in QoL gains was 0.007 (95% CI – 0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068-1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person were estimated at – 437 EUR (95% CI – 1302 to 371) and for the pain outcome the difference was – 635 EUR (95% CI – 1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results.

Cost-effectiveness plane using bootstrapped incremental cost-effectiveness ratios for QoL and pain intensity outcomes

The authors concluded that these results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted.

This is an interesting and well-conducted study. The differences between the groups seem small and of doubtful relevance. The authors acknowledge this fact by stating: “together with the clinical results from previously published studies on the same population the results suggest that manual therapy may be as cost-effective a treatment as evidence-based advice from a physician, for back and neck pain”. Moreover, the data do not convince me that the treatment per se was effective; it might have been the non-specific effects of touch and attention.

I have said it before: there is currently no optimal treatment for neck and back pain. Therefore, the findings even of rigorous cost-effectiveness studies will only generate lukewarm results.

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