spinal manipulation
Medical ethics rests on 4 core principles: autonomy, beneficence, non-maleficence, and justice, along with the crucial rule of veracity (truth-telling). In the realm of chiropractic, the most significant ethical issues/problems generally fall into the following ethical categories:
- Compromised Informed Consent & Veracity
Informed consent requires that a patient fully understands the nature, risks, benefits, and scientific backing of a treatment before proceeding.
1.1.The “Subluxation” Theory: A sizable segment of the chiropractic community still adheres to the erroneous belief that spinal “vertebral subluxations” cause a disruption in the body’s “innate intelligence,” leading to systemic disease. From an ethical standpoint, promoting an unproven, pseudo-scientific premise as medical fact violates veracity and compromises patient autonomy, as patients cannot give truly informed consent based on erroneous concepts.
1.2. Over-claiming Scope of Efficacy: While evidence might support spinal manipulation for acute lower back pain (if one were to interpret the dtat optimistically), most chiropractors claim they can treat many other illnesses, including non-musculoskeletal conditions such as asthma, allergies, infantile colic, ADHD, and high blood pressure. Marketing these services without robust clinical trial backing misleads vulnerable populations.
- Violations of Non-Maleficence
The principle of non-maleficence requires practitioners to avoid inflicting unnecessary harm or exposing patients to disproportionate risks.
2.1. Cervical Manipulation and Stroke Risk: One of the most severe ethical concerns involves high-velocity, low-amplitude (HVLA) thrusts to the upper neck, the hallmark modality of chiropractors. This procedure has been linked to vertebral artery dissection (VAD), which can cause strokes and deaths. The ethical failure is most obvious when chiropractors perform these adjustments without warning the patient of this and other adverse outcomes.
2.2. Paediatric Chiropractic: Performing spinal adjustments on infants and toddlers (whose spines are primarily cartilage and still developing) poses distinct physical risks. Because infants cannot consent and the evidence of benefit for childhood ailments is practically non-existent, this behaviour violates non-maleficence.
- Secondary Harm: Delay of Standard Medical Care
Harm does not only come from physical injury; it also comes from omitting or delaying necessary medical treatment.
3.1. Anti-Vaccine and Anti-Medicine Sentiments: A large proportion of the chiropractic profession advise patients against conventional medicine, pharmaceuticals, and vaccination. When a chiropractor discourages a patient from seeking standard medical care, they are actively contributing to potentially life-threatening delays in care.
- Violations of Beneficence and Justice
Beneficence means acting in the patient’s best interest, while justice involves the fair and equitable distribution of healthcare resources.
4.1. The “Maintenance Care” Business Model: A common predatory practice of chiropractors involves convincing patients that they require lifelong, regular spinal adjustments to “stay aligned” and prevent disease, often locked into expensive upfront contracts. Recommending continuous, costly treatments that lack clinical evidence of long-term benefit shifts the focus from patient welfare (beneficence) to practitioner financial gain.
4.2.Over-Utilization of X-rays: Some chiropractic clinics mandate full-spine X-rays for every new patient, regardless of symptoms, and repeat them frequently to “prove” alignment changes. Exposing patients to unnecessary ionizing radiation for marketing or diagnostic justification is a direct violation of both non-maleficence and the ethical use of healthcare resources.
For a more detailed account of the ethical problems in so-called alternative medicine, please see our book on this very subject.
The IGeL-Monitor is a German information portal that reviews self-pay medical services offered in doctors’ offices. It summarizes the likely benefit and harm of these services in plain language so patients can make more informed decisions. It is run by the “Medizinischer Dienst Bund” and uses evidence-based assessments rather than advertising or provider opinion.
The IGeL‑Monitor has recently focussed on osteopathy for non‑specific low back pain and judged the evidence as “unclear” stating that the current evidence does not reliably show a benefit, nor does it demonstrate meaningful harm. The reassessment pooled evidence from ten randomised clinical trials including about 1,160 participants. While some trials suggested small improvements in pain or function, the overall certainty of these findings was low due to methodological weaknesses in the primary studies. The reviewers therefore concluded that there is no convincing, high‑quality proof that osteopathic manual therapy provides a clinically relevant advantage over sham or usual care.
A further concern highlighted in the assessment is publication bias: positive trials may be preferentially published. This phenomenon that exaggerates apparent benefits.
No clear pattern of harm from osteopathic treatment was identified. Adverse events were inconsistently and inadequately recorded in the trials. This fact not only limits the confidence about safety, but is also a clear breach of medical ethics.
The IGeL‑Monitor reiterates its previous (2018) position: with current data one cannot reliably endorse osteopathy as an effective out‑of‑pocket intervention for non‑specific low back pain, nor can one identify significant risk. Hence the label “unclear.” For patients considering osteopathy as a self‑paid service, the IGeL‑Monitor recommends being informed about the uncertain benefit and the weak evidence base when weighing potential costs against likely outcomes.
The new assessment is in agreement with much that I have been saying on this blog. I nevertheless would like to add one important point: back pain is the one condition for which the evidence is relatively sound. There are many other conditions for which osteopathy is being relentlessly promoted as an effective therapy with even less or no reliable evidence at all.
Spinal manipulative therapies, including chiropractic and osteopathic maneuvers, are widely practiced for musculoskeletal complaints. However, serious complications such as cerebrospinal fluid (CSF) leak with subsequent intracranial hypotension (IH) have been described. The pathophysiological mechanism is presumed to involve mechanical stress on the spinal dura during high-velocity movements, leading to dural tears, particularly in the cervicothoracic region.
A team of Italian neuroscientists conducted a scoping review in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines, through a comprehensive search of PubMed and Scopus. They complemented the review with an illustrative case from their own institution.
The researchers identified 21 eligible papers, including 21 patients with IH following spinal manipulation. Most patients were women (81%), aged 29-54 years, and the majority underwent cervical maneuvers.
SMT techniques vary, most often involving high-velocity cervical maneuvers. The most frequent were axial tension with rotation in seven cases (33.3%), unspecified cervical manipulation in four cases (19%), and thoracic spinal manipulation in two cases (9.5%). Less common single-case techniques included rotation with hyperextension, combined cervical and thoracic mobilization, axial tension with lateral flexion, and occipital/shoulder tension technique (n = 1 case each).
Symptom onset was typically within the first week, and all presented with orthostatic headache, often accompanied by nausea, neck pain, tinnitus, or visual disturbances. Neuroimaging consistently revealed features of IH, with pachymeningeal enhancement and subdural collections as the most frequent findings; spinal imaging frequently demonstrated extradural CSF collections. Management was conservative in about one-third of cases, but most required epidural blood patching, which was effective in the majority. Surgical repair was necessary in rare, refractory cases, particularly in the presence of structural spinal abnormalities. Overall prognosis was favorable, with 95% of patients achieving full recovery.
The authors’ illustrative case highlights the potential for severe complications such as subdural hematomas and recurrence if the underlying leak is not addressed:
A 65-year-old patient without a previous history of headache presented with a progressively worsening headache, with orthostatic features, poorly responsive to medical therapy, that has lasted for the past 20 days. The patient denied any recent trauma. He reported having undergone cervical osteopathic manipulations within the past 3 months for recurrent cervicalgia. A brain MRI without contrast was performed, showing a large bilateral subdural hematoma with significant mass effect on the cortical gyri. The patient was admitted to the emergency department and underwent neurosurgical evacuation of a bilateral chronic subdural hematoma via burr holes. Subsequently, endovascular embolization of the middle meningeal arteries was performed as an adjunctive treatment to reduce the risk of recurrence. The surgical procedure was performed without complications. A cranial CT scan showed a reduction in the volume of the hematoma. Therefore, the patient was discharged. However, after a transient improvement in the symptoms, the patient continued to present a fluctuating headache without positional features, with four to five episodes per month. He was readmitted to our clinic and, upon arrival at the ER, a head CT scan showed an increase in pneumocephalus and a recurrence of the hematoma. The following day, an MRI of the neuraxis with contrast was performed, which revealed radiological findings suggestive of IH: pachimeningeal enhancement, subdural fluid collection, dural venous engorgement, cervical spinal longitudinal extradural collection, and effacement of the suprasellar cistern. The Bern score was 7. Given these findings, a surgical revision of the previous burr holes was performed without periprocedural complications. After the first day, a non-targeted epidural blood patch (EBP) was performed under local anesthesia by injecting 16 mL of autologous blood into the L3–L4 epidural space. The procedure was uneventful. A cranial CT scan showed satisfactory surgical outcomes, highlighting a reduction in the volume of the hematoma and of the pneumoencephalus. The patient was subsequently discharged with complete resolution of the headache.
The authors concluded that clinicians should recognize the possibility of CSF leaks after spinal manipulation, especially in patients with new-onset orthostatic headache.
I feel compelled to point out that, considering the multiple risks of upper spinal manipulations and the almost total lack of evidence of benefit from such treatments, the risk/benefit balance of spinal manipulation is clearly not positive. It follows, I think, that it would be wise for patients not to allow such therapies being carried out, and for healthcare professionals to discourage them.
Pediatric vertebral artery dissection (VAD) following chiropractic cervical manipulation (CCM) is a rare phenomenon. As chiropractic care of pediatric populations increases internationally, it is imperative to increase awareness of this cause of VAD.
This case-report describes a patient encountered in the Department of Neurological Surgery, Indiana University School of Medicine, USA. He was a 20-month-old male who presented nonspecifically with acute onset of
- lethargy,
- vomiting,
- cyanosis,
- respiratory distress.
Cerebrovascular imaging revealed a luminal irregularity in the V4 segment of the right vertebral artery, consistent with dissection. The patient’s guardian later provided history of taking the child for cervical chiropractic corrections immediately prior to the patient’s presentation to the emergency department.
The patient was managed non-operatively. Intubation was performed due to respiratory distress and managed with fluids, vasopressors, antimicrobials, and high-flow oxygen. The patient was extubated four days after presentation, and pressors were discontinued upon achievement of hemodynamic stability. A few days after extubation, the patient was ambulating and able to interact with objects and caretakers. Aspirin therapy was initiated and continued after discharge. The patient was followed with annual appointments and imaging. At two-year follow-up, CTA demonstrated an asymmetrically small right vertebral artery, accompanied by encephalomalacia of the right posterior occipital lobe. MRA demonstrated diffuse narrowing of the V4 segment of the right vertebral artery, albeit less pronounced than prior MRAs. Aspirin was discontinued by an outside following team due to stability of imaging findings. The parents were advised to avoid contact sports to avoid trauma and recurrent stroke.
The authors found 2 further cases of pediatric VAD in the published literature following CCM. Non-specific presentations were noted in both of them. Appropriate diagnosis of pediatric VAD requires increased surveillance in response to a thorough history and an acknowledgment of the plethora of possible patient presentations and etiologies.
The authors concluded that there is an increasing utilization of chiropractors among the pediatric population. In a pediatric patient with nonspecific symptoms, VAD should be considered as a differential diagnosis when there is a history of CCM.
The authors’ statement that “pediatric vertebral artery dissection (VAD) following chiropractic cervical manipulation (CCM) is a rare phenomenon” should be taken with a pinch of salt. As there is no monitoring, the frequency of adverse effects and complications is essentially unknown. Crucially. the risks of CCM for children is by no means confined to VADs. For a fuller account, I recomment reading my book which has an entire chapter on this very subject.
The key messages about CCM for kids might be summarised in the following simple three facts:
- CCM has no true benefit for children.
- Thus the risk/benefit balance fails to be positive.
- Therefore we should discourage partents from taking their kids to see chiropractors.
The aim of this study was to determine the effectiveness of spinal manipulation and clinician-supported biopsychosocial self-management vs medical care for adults with increased risk of chronic disabling LBP.
This 2 × 2 factorial randomized clinical trial enrolled participants in 3 research clinics at the Universities of Minnesota and Pittsburgh from November 2018 to May 2023; final follow-up was in June 2024. Adults with acute or subacute LBP at moderate to high risk of chronicity based on the STarT Back tool were randomized to 1 of 4 groups, with interventions lasting up to 8 weeks. Statistical analysis was conducted from November 2024 to June 2025.
These interventions were:
- Spinal manipulation therapy (n = 201),
- supported self-management (n = 305),
- combined supported self-management with spinal manipulation (n = 193),
- guideline-based medical care (n = 301).
Physical therapists and chiropractors provided spinal manipulation and supported self-management.
The 2 primary outcomes averaged over a follow-up of 1 year were monthly low back disability (Roland-Morris Disability Questionnaire) and weekly pain intensity (numerical rating scale). Secondary analysis examined the proportion of participants achieving a 50% or higher reduction in the primary outcome measures.
Among the 1000 participants randomized (mean [SD] age, 47 [16] years; 58% female), 93% completed the trial. The omnibus test for differences across the 4 treatment groups was statistically significant for disability (P = .001; supported self-management, 4.7; spinal manipulation, 5.5; combined supported self-management with spinal manipulation, 4.8; medical care, 5.9) but not pain intensity (P = .16; supported self-management, 2.8; spinal manipulation, 3.0; combined supported self-management with spinal manipulation, 2.8; medical care, 3.0). Averaged over 12 months, LBP disability was significantly lower compared with medical care for supported self-management (mean difference, −1.2 [95% CI, −1.9 to −0.5]) and supported self-management with spinal manipulation (mean difference, −1.1 [95% CI, −1.9 to −0.3]) but not spinal manipulation alone (mean difference, −0.4 [95% CI, −1.2 to 0.4]). Group differences in pain intensity were not statistically significant; point estimates ranged from −0.2 to 0. Both supported self-management groups had higher proportions of patients achieving a 50% or greater reduction in disability (supported self-management, 67%; spinal manipulation, 54%; combined supported self-management with spinal manipulation, 65%; medical care, 54%).
The authors concluded that for patients with acute or subacute LBP at increased risk of chronic disabling LBP, clinician-supported biopsychosocial self-management showed statistically significant but small reductions in disability, but not pain, vs medical care over 1-year follow-up, and spinal manipulation alone showed no significant difference for either outcome.
These findings are very bad news for chiropractors (the profession that uses spinal manipulations more than any other): spinal manipulation does not generate effects that are in the least convincing. This is particularly remarkable, since the study was not blinded. It means that, even the undoubtedly powerful placebo effect associated with spinal manipulation did not render the outcome more favourable.
I said it many times, and I will say it again: For LBP, many therapies generate similarly marginally positive effects but no treatment is truly convincing. In this situation, we should choose one that is at least inexpensive and free of severe adverse effects. And that evidently cannot be spinal manipulation!
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and predisposes patients to hemorrhagic complications following trauma or invasive procedures. Chiropractic spinal manipulation is widely used for musculoskeletal pain; however, serious complications have been reported, particularly in patients with underlying coagulopathies.
Iliopsoas hematoma with secondary femoral neuropathy is an uncommon but potentially disabling condition. A team of US doctors present a clinical case highlighting this rare complication following chiropractic manipulation in a patient with VWD and review the relevant literature. They describe the clinical course and follow-up of a 32-year-old female patient with known VWD who developed acute neurological deficits after chiropractic manipulation. Imaging findings were analyzed using radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Hematoma volume was calculated using the ABC/2 formula, which has been well validated and shows a high correlation with volumes calculated using planimetric techniques.
After chiropractic manipulation, the patient developed severe lumbar and inguinal pain, followed by progressive weakness and sensory impairment of the left lower limb. Imaging revealed a large left iliopsoas hematoma measuring approximately 896 cc, causing femoral nerve compression. Management included coagulation factor replacement, pain control, and interventional radiology-guided drainage, resulting in significant hematoma reduction and neurological improvement. At the six-month follow-up, residual neuropathy and muscle atrophy persisted, although functional recovery was evident.
The uthors concluded that patients with VWD are at high risk for severe hemorrhagic complications even after seemingly minor manipulative therapies. Chiropractic spinal manipulation may precipitate life-threatening or disabling bleeding events in this population. Early recognition, appropriate imaging, correction of the coagulopathy, and multidisciplinary management are crucial to optimize outcomes. This case highlights the importance of patient counseling, risk stratification, and caution when considering alternative therapies in individuals with inherited bleeding disorders.
The list of complications, including fatal ones, after chiropractic manipulations is long – very long. That they can cause iliopsoas hematoma with secondary femoral neuropathy was new to me. The lesson here seems relatively simple: if you have a bleeding abnormality, avoid chiropractic manipulations at all costs!
This, of course, raises an interesting question:
Considering that ~25% of the general population have some sort of clotting abnormality, do chiropractors routinely check whether their pations have normal blood clotting?
Somehow, I doubt it.
The authors found very low‐certainty evidence (downgraded for study limitations, inconsistency, and imprecision) that SMT may result in a medium reduction in pain compared to no treatment at one month (MD ‐13.99, 95% CI ‐27.33 to ‐0.66; I2 = 89%; 4 studies, 325 participants), but the evidence is very uncertain. They found low‐certainty evidence (downgraded for study limitations and imprecision) that SMT may result in a large improvement in functional status compared to no treatment at one month (SMD ‐0.84, 95% CI ‐1.32 to ‐0.35; I2 = 71%; 4 studies, 312 participants).
SMT versus other conservative interventions
Low‐certainty evidence (downgraded for inconsistency) indicated that SMT may result in little to no difference in pain (MD ‐4.72, 95% CI ‐8.26 to ‐1.17; I2 = 89%; 31 studies, 4109 participants) and may result in a small improvement in functional status (SMD ‐0.25, 95% CI ‐0.38 to ‐0.11; I2 = 73%; 28 studies, 3940 participants) compared to other conservative interventions at one month.
These effects, however, should be interpreted with caution due to the substantial statistical heterogeneity for which there is no clear explanation.
Less than half of the studies (47%) reported on adverse events, of which 12 studies reported these systematically. Adverse events in the SMT group were limited to muscle soreness, stiffness, and/or transient increase in pain. None of the studies registered any serious complications related to either the experimental or control group treatment. The evidence is very uncertain about the adverse effects of SMT.
Authors’ conclusions: When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it.
Once again, it has been confirmed that most trials of SMT are, because of their failure to report adverse effects, in violation of ethical standards. But the importance of this excellent review lies elsewhere. Despite 76 published RCTs, there is huge uncertainty about the benefits of SAM. What should we make of this fact?
In my view, it highlights that:
- the studies are often of poor quality;
- the effect of SMT are so small that they are negligibel;
- patients with back pain should look for treatments that are safe and effective;
- the choice can therefore not be SMT.
Reliable reporting and publication practices are essential for trustworthy evidence synthesis and clinical decision-making. This analysis aimed to identify latent classes of randomized controlled trials (RCTs) evaluating spinal manipulative therapy (SMT) based on trial reporting and publication practices, and to examine whether these classes influenced treatment effects.
Trials were evaluated on whether they met criteria for trial reporting and publication practices across six domains. Latent class analysis was used to identify trial subgroups. Random-effects meta-regression models assessed whether class membership predicted pooled estimates of treatment effects for pain and disability.
The international team included 239 RCTs and identified four classes: Dated (23 %), older trials (mostly pre-2010) with consistently low proportions of criteria met; Non-contributing (30 %), newer trials that inconsistently met the criteria, had small samples, and short follow-ups; SMT-focused (15 %), which reported SMT details and fidelity more consistently but otherwise resembled the Non-contributing class; and Pragmatic (33 %), consisting of larger trials, meeting most criteria, but often underreported SMT-specific and fidelity details. Reporting practices had larger impact on class membership than publication practices. Despite differences class membership was not associated with treatment effect estimates and explained minimal outcome variability (R2 ∼1 %).
The authors concluded that, although trial reporting and publication practices varied substantially across SMT trials, these differences were not associated with differences in treatment effects. The widespread failure to meet key criteria raises concerns about the interpretability and credibility of the SMT evidence base. To strengthen transparency and scientific value, future trials should adhere more rigorously to reporting guidelines.
What does this mean?
The authors state that editors and peer reviewers should more rigorously enforce established reporting standards, including CONSORT (with its Harms extension), TIDieR, and the CIRCLe SMT checklist.
Undoubtedly, this is true.
But what does it mean for patients?
In my view, it is a reminder for all of us to be skeptical about the claims made by chiropractors, osteopaths and other providers of SMT – even if they claim to be based on evidence.
This article explores how the sociological concept of trust, both externally and internally, presents challenges to the legitimacy and credibility of the chiropractic profession. This ethnographic study consisted of systematic observation and interviews of 40 chiropractors in South Carolina from Fall 2016 to Fall 2017. Additionally, interviews were conducted with staff members, patients, and other medical providers, such as physicians, physical therapists, massage therapists, and representatives from the insurance industry, about their understanding and experiences with chiropractic medicine. Phone interviews were also conducted with deans and provosts at seven chiropractic colleges around the country.
In total, over 100 interviews and informal conversations occurred during the course of the project. All identifiers of participants and chiropractic colleges in the study were removed to ensure anonymity. Instead, pseudonyms were created that were known only by the author of the study. Additionally, data from the South Carolina Department of Labor, Licensing and Regulation was obtained to document changes in the number of chiropractors who are no longer in practice in the state between 2016 and 2017.
The data from this study suggests that there may be a number of trust issues between the public and chiropractors, between chiropractors and physicians, and among chiropractors themselves. For example, comments and observations from respondent interviews suggests many patients do not fully trust their provider. Additionally, physicians claim the reason for the lack of trust is due to the absence of any meaningful accountability measures to control rogue chiropractors and the wide variance in types of treatment they offer. Among chiropractors themselves, there appears to be an absence of trust, as many providers see their colleagues as competitors and potential threats.
Trust is a key component to the success of any social relationship. Given the inability or unwillingness of the chiropractic profession to hold members accountable for questionable practices, along with the perception that chiropractic treatments may not be effective, the public, patients, and the medical profession will likely continue to view chiropractic medicine with suspicion.
In the paper, the author (Robert Hartmann McNamara, Ph.D. Department of Criminal Justice ) makes several further valuable points:
- The need for autonomy is a critical component to understanding why so many providers are unwilling to allow their profession to be regulated. It also seems apparent that there is no collective conscience, no real sense of solidarity, and there remain questions about the trustworthiness of chiropractors by patients, the public, the medical community and even among chiropractors themselves.
- Chiropractors point to some level of persecution by insurance companies—indicating that others in medicine engage in inappropriate billing and fraud, but that insurance companies target chiropractors because of their limited ability to stand up to them. While there may be some truth to these criticisms, there is also evidence to indicate that the identification of chiropractors for audits may be justified. For example, in a 2016 report by the Office of Inspector General, a division of the U.S. Department of Health and Human Services, the agency responsible for overseeing health programs like Medicare and Medicaid, of all the providers who were cited for fraud, abuse, and errors in Medicare billing, chiropractors were overwhelmingly the largest set of offenders. In fact, the report showed that for 2013, an estimated $359 million in Medicare payments for chiropractic services did not comply with Medicare requirements. Thus, one of the primary reasons for the creation of Medicare accountability teams is because the data indicated that chiropractors are at the center of the problem when it comes to inaccurate and fraudulent billing for treatment.
- The sociological literature points out that the development and enhancement of trust is a crucial component to establishing and sustaining social relationships, and thereby creating a sense of solidarity and morality. To the extent that chiropractors can better foster the development of trust, they will likely earn the respect of their colleagues in medicine and not be seen in a negative light by the public or their patients. This is accomplished, of course, by setting reasonable expectations of what chiropractors can legitimately do and holding the members of the profession accountable in adhering to those standards.
All of this ties in well with many of my previous posts on chiropractic. I might therefore just add this:
What can you expect from a profession that was founded by one of the most infamous snake oil salesmen in US history?
Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. The efficacy of medical treatments such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) is considerable. However the failure rate can still be as high as 20-25% and there are also a number of associated adverse effects. Many women are thus seeking alternatives to conventional medicine. One popular treatment modality is spinal manipulation.
The objectives of this Cochrane review were to determine the safety and efficacy of spinal manipulations for the treatment of primary or secondary dysmenorrhoea when compared to:
- each other,
- placebo,
- no treatment,
- or other medical treatments.
Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, Psyclit and SPORTDiscus were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field’s Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information.
Included were any RCTs including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD.
Five RCTs were identified that fulfilled the inclusion criteria for this review. Four trials involving high velocity, low amplitude manipulation (HVLA), and one involving the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects.
Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however, the only trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations.
The authors concluded that overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.
Probably the first question that springs in one’s mind is, WHY ON EARTH COULD SPINAL MANIPULATIONS BE EFFECTIVE FOR THIS CONDITION? Unsurprisingly, the proponents of this approach have come up with several rationales:
- The parasympathetic and sympathetic pelvic nerve pathways are closely associated with the spinal vertebrae, in particular the 2nd-4th sacral segments and the 10th thoracic to the 2nd lumbar segments. One hypothesis is that mechanical dysfunction in these vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply through an influence on the autonomic nerve supply to the blood vessels.
- Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation.
I think we can all agree that these theories are very long shots! As it stands, we also do not need to shoot long at all. There is simply no good evidence that spinal manipulations work for dysmenorrhoea. There is thus no need to embark on implausible explanations to justify the notions of Palmer and Still claiming that spinal manipulation is a panacea. The idiocy of this claim has long been established.
The only question that does remain, in my view, is this:
WHEN WILL CHIROPRACTORS AND OSTEOPATHS FINALLY GIVE UP THEIR OUTLANDISHLY WISHFUL THINKING OF THEIR FOUNDING FATHERS?
