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

spinal manipulation

The media have (rightly) paid much attention to the three Lancet-articles on low back pain (LBP) which were published this week. LBP is such a common condition that its prevalence alone renders it an important subject for us all. One of the three papers covers the treatment and prevention of LBP. Specifically, it lists various therapies according to their effectiveness for both acute and persistent LBP. The authors of the article base their judgements mainly on published guidelines from Denmark, UK and the US; as these guidelines differ, they attempt a synthesis of the three.

Several alternative therapist organisations and individuals have consequently jumped on the LBP  bandwagon and seem to feel encouraged by the attention given to the Lancet-papers to promote their treatments. Others have claimed that my often critical verdicts of alternative therapies for LBP are out of line with this evidence and asked ‘who should we believe the international team of experts writing in one of the best medical journals, or Edzard Ernst writing on his blog?’ They are trying to create a division where none exists,

The thing is that I am broadly in agreement with the evidence presented in Lancet-paper! But I also know that things are a bit more complex.

Below, I have copied the non-pharmacological, non-operative treatments listed in the Lancet-paper together with the authors’ verdicts regarding their effectiveness for both acute and persistent LBP. I find no glaring contradictions with what I regard as the best current evidence and with my posts on the subject. But I feel compelled to point out that the Lancet-paper merely lists the effectiveness of several therapeutic options, and that the value of a treatment is not only determined by its effectiveness. Crucial further elements are a therapy’s cost and its risks, the latter of which also determines the most important criterion: the risk/benefit balance. In my version of the Lancet table, I have therefore added these three variables for non-pharmacological and non-surgical options:

EFFECTIVENESS ACUTE LBP EFFECTIVENESS PERSISTENT LBP RISKS COSTS RISK/BENEFIT BALANCE
Advice to stay active +, routine +, routine None Low Positive
Education +, routine +, routine None Low Positive
Superficial heat +/- Ie Very minor Low to medium Positive (aLBP)
Exercise Limited +/-, routine Very minor Low Positive (pLBP)
CBT Limited +/-, routine None Low to medium Positive (pLBP)
Spinal manipulation +/- +/- vfbmae
sae
High Negative
Massage +/- +/- Very minor High Positive
Acupuncture +/- +/- sae High Questionable
Yoga Ie +/- Minor Medium Questionable
Mindfulness Ie +/- Minor Medium Questionable
Rehab Ie +/- Minor Medium to high Questionable

Routine = consider for routine use

+/- = second line or adjunctive treatment

Ie = insufficient evidence

Limited = limited use in selected patients

vfbmae = very frequent, minor adverse effects

sae = serious adverse effects, including deaths, are on record

aLBP = acute low back pain

The reason why my stance, as expressed on this blog and elsewhere, is often critical about certain alternative therapies is thus obvious and transparent. For none of them (except for massage) is the risk/benefit balance positive. And for spinal manipulation, it even turns out to be negative. It goes almost without saying that responsible advice must be to avoid treatments for which the benefits do not demonstrably outweigh the risks.

I imagine that chiropractors, osteopaths and acupuncturists will strongly disagree with my interpretation of the evidence (they might even feel that their cash-flow is endangered) – and I am looking forward to the discussions around their objections.

We all know that there is a plethora of interventions for and specialists in low back pain (chiropractors, osteopaths, massage therapists, physiotherapists etc., etc.); and, depending whether you are an optimist or a pessimist, each of these therapies is as good or as useless as the next. Today, a widely-publicised series of articles in the Lancet confirms that none of the current options is optimal:

Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, and it is increasing—disability due to back pain has risen by more than 50% since 1990. Low back pain is becoming more prevalent in low-income and middle-income countries (LMICs) much more rapidly than in high-income countries. The cause is not always clear, apart from in people with, for example, malignant disease, spinal malformations, or spinal injury. Treatment varies widely around the world, from bed rest, mainly in LMICs, to surgery and the use of dangerous drugs such as opioids, usually in high-income countries.

The Lancet publishes three papers on low back pain, by an international group of authors led by Prof Rachelle Buchbinder, Monash University, Melbourne, Australia, which address the issues around the disorder and call for worldwide recognition of the disability associated with the disorder and the removal of harmful practices. In the first paper, Jan Hartvigsen, Mark Hancock, and colleagues draw our attention to the complexity of the condition and the contributors to it, such as psychological, social, and biophysical factors, and especially to the problems faced by LMICs. In the second paper, Nadine Foster, Christopher Maher, and their colleagues outline recommendations for treatment and the scarcity of research into prevention of low back pain. The last paper is a call for action by Rachelle Buchbinder and her colleagues. They say that persistence of disability associated with low back pain needs to be recognised and that it cannot be separated from social and economic factors and personal and cultural beliefs about back pain.

Overview of interventions endorsed for non-specific low back pain in evidence-based clinical practice guidelines (Danish, US, and UK guidelines)

In this situation, it makes sense, I think, to opt for a treatment (amongst similarly effective/ineffective therapies) that is at least safe, cheap and readily available. This automatically rules out chiropractic, osteopathy and many others. Exercise, however, does come to mind – but what type of exercise?

The aim of this meta-analysis of randomized controlled trials was to gain insight into the effectiveness of walking intervention on pain, disability, and quality of life in patients with chronic low back pain (LBP) at post intervention and follow ups.

Six electronic databases (PubMed, Science Direct, Web of Science, Scopus, PEDro and The Cochrane library) were searched from 1980 to October 2017. Randomized controlled trials (RCTs) in patients with chronic LBP were included, if they compared the effects of walking intervention to non-pharmacological interventions. Pain, disability, and quality of life were the primary health outcomes.

Nine RCTs were suitable for meta-analysis. Data was analysed according to the duration of follow-up (short-term, < 3 months; intermediate-term, between 3 and 12 months; long-term, > 12 months). Low- to moderate-quality evidence suggests that walking intervention in patients with chronic LBP was as effective as other non-pharmacological interventions on pain and disability reduction in both short- and intermediate-term follow ups.

The authors concluded that, unless supplementary high-quality studies provide different evidence, walking, which is easy to perform and highly accessible, can be recommended in the management of chronic LBP to reduce pain and disability.

I know – this will hardly please the legions of therapists who earn their daily bread with pretending their therapy is the best for LBP. But healthcare is clearly not about the welfare of the therapists, it is/should be about patients. And patients should surely welcome this evidence. I know, walking is not always easy for people with severe LBP, but it seems effective and it is safe, free and available to everyone.

My advice to patients is therefore to walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.

On this blog, we had many chiropractors commenting that their profession is changing fast and the old ‘philosophy’ is a thing of the past. But are these assertions really true? This survey might provide an answer. A questionnaire was sent to chiropractic students in all chiropractic programs in Australia and New Zealand. It explored student viewpoints about the identity, role/scope, setting, and future of chiropractic practice as it relates to chiropractic education and health promotion. Associations between the number of years in the program, highest degree preceding chiropractic education, institution, and opinion summary scores were evaluated by multivariate analysis of variance tests.

A total of 347 chiropractic students participated. For identity, most students (51.3%) hold strongly to the traditional chiropractic theory but also agree (94.5%) it is important that chiropractors are educated in evidence-based practice. The main predictor of student viewpoints was a student’s chiropractic institution. Chiropractic institution explained over 50% of the variance around student opinions about role/scope of practice and approximately 25% for identity and future practice.

The authors concluded that chiropractic students in Australia and New Zealand seem to hold both traditional and mainstream viewpoints toward chiropractic practice. However, students from different chiropractic institutions have divergent opinions about the identity, role, setting, and future of chiropractic practice, which is most strongly predicted by the institution. Chiropractic education may be a potential determinant of chiropractic professional identity, raising concerns about heterogeneity between chiropractic schools.

Traditional chiropractic theory is, of course, all the palmereque nonsense about ‘95% of all diseases are caused by subluxations of the spine’ etc. And evidence-based practice means knowing that subluxations are a figment of the chiropractic imagination.

Imagine a physician who believes in evidence and, at the same time, in the theory of the 4 humours determining our health.

Imagine a geologist thinking that the earth is flat and also spherical.

Imagine a biologist subscribing to both creationism and evolution.

Imagine a surgeon earning his livelihood with blood-letting and key-hole surgery.

Imagine a doctor believing in vital energy after having been taught physiology.

Imagine an airline pilot considering the use of flying carpets.

Imagine a chemist engaging in alchemy.

Imagine a Brexiteer who is convinced of doing the best for the UK.

Imagine a homeopath who thinks he practices evidence-based medicine.

Imagine a plumber with a divining rod.

Imagine an expert in infectious diseases believing is the miasma theory.

Imagine a psychic hoping to use her skills for winning a fortune on the stock market.

————————————————————————————————————————————-

Once you have imagined all of these situations, I fear, you might know (almost) all worth knowing about chiropractic.

The question whether spinal manipulative therapy (SMT) has any specific therapeutic effects is still open. This fact must irritate ardent chiropractors, and they therefore try everything to dispel our doubts. One way would be to demonstrate a dose-effect relationship between SMT and the clinical outcome. But, for several reasons, this is not an easy task.

This RCT was aimed at identifying the dose-response relationship between visits for SMT and chronic cervicogenic headache (CGH) outcomes; to evaluate the efficacy of SMT by comparison with a light massage control.

The study included 256 adults with chronic CGH. The primary outcome was days with CGH in the prior 4 weeks evaluated at the 12- and 24-week primary endpoints. Secondary outcomes included CGH days at remaining endpoints, pain intensity, disability, perceived improvement, medication use, and patient satisfaction. Participants were randomized to 4 different dose levels of chiropractic SMT: 0, 6, 12, or 18 sessions. They were treated 3 times per week for 6 weeks and received a focused light-massage control at sessions when SMT was not assigned. Linear dose effects and comparisons to the no-manipulation control group were evaluated at 6, 12, 24, 39, and 52 weeks.

A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/4 weeks per additional 6 SMT visits (p<.05); a maximal effective dose could not be determined. CGH days/4 weeks were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Mean differences in CGH days/4 weeks between 18 SMT visits and control were -3.3 (p=.004) and -2.9 (p=.017) at the primary endpoints, and similar in magnitude at the remaining endpoints (p<.05). Differences between other SMT doses and control were smaller in magnitude (p > .05). CGH intensity showed no important improvement nor differed by dose. Other secondary outcomes were generally supportive of the primary.

The authors concluded that there was a linear dose-response relationship between SMT visits and days with CGH. For the highest and most effective dose of 18 SMT visits, CGH days were reduced by half, and about 3 more days per month than for the light-massage control.

This trial would make sense, if the effectiveness of SMT for CGH had been a well-documented fact, and if the study had rigorously controlled for placebo-effects.

But guess what?

Neither of these conditions were met.

A recent review concluded that there are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization for TTH, CeH, and M in the last decade. In addition, the methodological quality of these papers is typically low. Clearly, there is a need for high-quality randomized controlled trials assessing the effectiveness of these interventions in these headache disorders. And this is by no means the only article making such statements; similar reviews arrive at similar conclusions. In turn, this means that the effects observed after SMT are not necessarily specific effects due to SMT but could easily be due to placebo or other non-specific effects. In order to avoid confusion, one would need a credible placebo – one that closely mimics SMT – and make sure that patients were ‘blinded’. But ‘light massage’ clearly does not mimic SMT, and patients obviously were aware of which interventions they received.

So, an alternative – and I think at least as plausible – conclusion of the data provided by this new RCT is this:

Chiropractic SMT is associated with a powerful placebo response which, of course, obeys a dose-effect relationship. Thus these findings are in keeping with the notion that SMT is a placebo.

And why would the researchers – who stress that they have no conflicts of interest – mislead us by making this alternative interpretation of their findings not abundantly clear?

I fear, the reason might be simple: they also seem to mislead us about their conflicts of interest: they are mostly chiropractors with a long track record of publishing promotional papers masquerading as research. What, I ask myself, could be a stronger conflict of interest?

(Pity that a high-impact journal like SPINE did not spot these [not so little] flaws)

“MDs do not make false claims HAHAHA.”

This is from a comment I recently received on this blog.

It made me think.

Yes, of course, MDs do not always reveal the full truth to their patients; sometimes they might even tell lies (in this post, I shall use the term ‘lies’ for any kind of untruth).

So, what about these lies?

The first thing to say about them is obvious: THEY CAN NEVER JUSTIFY THE LIES OF OTHERS.

  • the lies of the Tories cannot justify the lies of Labour party members,
  • the lies of a plaintiff in court  cannot justify any lies of the defendant,
  • the lies of MDs cannot justify the lies of alternative practitioners.

The second thing to say about the lies of MDs is that, in my experience, most are told in the desire to protect patients. In some cases, this may be ill-advised or ethically questionable, but the motivation is nevertheless laudable.

  • I might not tell the truth when I say (this really should be ‘said’, because I have not treated patients for many years) THIS WILL NOT HURT AT ALL. In the end, it hurt quite a bit but we all understand why I lied.
  • I might claim that this treatment is sure to work (knowing full well that such a prediction is impossible), but we all know that I said so in order to maximise my patient’s compliance and expectation in order to generate the best possible outcome.
  • I might dismiss a patient’s fear that his condition is incurable (while strongly suspecting that it is), but I would do this to improve his anxiety and well-being.

Yet, these are not the type of lies my commentator referred to. In fact, he provided a few examples of the lies MDs tell, in his opinion. He claimed that:

  • They tell them that diabetes is not curable. False claim
  • They compare egg intake with smoking on their affect to your health. False claim
  • They say arthroscopic surgery of the knee is beneficial. False claim
  • They state that surgery, chemo, and radiation is the only treatment for cancer. False claim
  • They say that family association is the cause of most inflammatory conditions. False claim

I don’t want to go into the ‘rights or wrongs’ of these claims (mostly wrongs, as far as I can see). Instead, I would argue that any MD who makes a claim that is wrong behaves unethical and should retrain. If he erroneously assumes the claim to be correct, he is not fully informed (which, of course is unethical in itself) and needs to catch up with the current best evidence. If he makes a false claim knowing that it is wrong, he behaves grossly unethical and must justify himself in front of his professional disciplinary committee.

As this blog focusses on alternative medicine, let’s briefly consider the situation in that area. The commentator made his comments in connection to a post about chiropractic, so let’s look at the situation in chiropractic.

  • Do many chiropractors claim to be able to treat a wide array of conditions without good evidence?
  • Do they misadvise patients about conventional treatments, such as vaccinations?
  • Do they claim that their spinal manipulations are safe?
  • Do they tell patients they need regular ‘maintenance treatment’ to stay healthy?
  • Do they claim to be able to diagnose subluxations?
  • Do they pretend that subluxations cause illness and disease?
  • Do they claim to adjust subluxations?

If you answered several of these questions with YES, I probably have made my point.

On reflection, it turns out that clinicians of all types do tell lies. Some are benign/white lies and others are fundamental, malignant lies. Most of us probably agree that the former category is largely negligible. The latter category can, however, be serious. In my experience, it is hugely more prevalent in the realm of alternative medicine. When it occurs in conventional medicine, appropriate measures are in place to prevent reoccurrence. When it occurs in alternative medicine, nobody seems to bat an eyelash.

My conclusion from these random thoughts: the truth is immeasurably valuable, and lies can be serious and often are damaging to patients. Therefore, we should always pursue those who tell serious lies, no matter whether they are MDs or alternative practitioners.

Some of you will remember the saga of the British Chiropractic Association suing my friend and co-author Simon Singh (eventually losing the case, lots of money and all respect). One of the ‘hot potatoes’ in this case was the question whether chiropractic is effective for infant colic. This question is settled, I thought: IT HAS NOT BEEN SHOWN TO WORK BETTER THAN A PLACEBO.

Yet manipulators have not forgotten the defeat and are still plotting, it seems, to overturn it. Hence a new systematic review assessed the effect of manual therapy interventions for healthy but unsettled, distressed and excessively crying infants.

The authors reviewed published peer-reviewed primary research articles in the last 26 years from nine databases (Medline Ovid, Embase, Web of Science, Physiotherapy Evidence Database, Osteopathic Medicine Digital Repository , Cochrane (all databases), Index of Chiropractic Literature, Open Access Theses and Dissertations and Cumulative Index to Nursing and Allied Health Literature). The inclusion criteria were: manual therapy (by regulated or registered professionals) of unsettled, distressed and excessively crying infants who were otherwise healthy and treated in a primary care setting. Outcomes of interest were: crying, feeding, sleep, parent-child relations, parent experience/satisfaction and parent-reported global change. The authors included the following types of peer-reviewed studies in our search: RCTs, prospective cohort studies, observational studies, case–control studies, case series, questionnaire surveys and qualitative studies.

Nineteen studies were selected for full review: seven randomised controlled trials, seven case series, three cohort studies, one service evaluation study and one qualitative study. Only 5 studies were rated as high quality: four RCTs (low risk of bias) and a qualitative study.

The authors found moderate strength evidence for the effectiveness of manual therapy on: reduction in crying time (favourable: -1.27 hours per day (95% CI -2.19 to -0.36)), sleep (inconclusive), parent-child relations (inconclusive) and global improvement (no effect).

Reduction in crying: RCTs mean difference.

The risk of reported adverse events was low (only 8 studies mentioned adverse effects at all, meaning that the rest were in breach of research and publication ethics): seven non-serious events per 1000 infants exposed to manual therapy (n=1308) and 110 per 1000 in those not exposed.

The authors concluded that 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.

For several reasons, I find this review, although technically sound, quite odd.

Why review uncontrolled data when RCTs are available?

How can a qualitative study be rated as high quality for assessing the effectiveness of a therapy?

How can the authors categorically conclude that there were benefits when there were only 4 RCTs of high quality?

Why do they not explain the implications of none of the RCTs being placebo-controlled?

How can anyone pool the results of all types of manual therapies which, as most of us know, are highly diverse?

How can the authors conclude about the safety of manual therapies when most trials failed to report on this issue?

Why do they not point out that this is unethical?

My greatest general concern about this review is the overt lack of critical input. A systematic review is not a means of promoting an intervention but of critically assessing its value. This void of critical thinking is palpable throughout the paper. In the discussion section, for instance, the authors state that “previous systematic reviews from 2012 and 2014 concluded there was favourable but inconclusive and weak evidence for manual therapy for infantile colic. They mention two reviews to back up this claim. They conveniently forget my own review of 2009 (the first on this subject). Why? Perhaps because it did not fit their preconceived ideas? Here is my abstract:

Some chiropractors claim that spinal manipulation is an effective treatment for infant colic. This systematic review was aimed at evaluating the evidence for this claim. Four databases were searched and three randomised clinical trials met all the inclusion criteria. The totality of this evidence fails to demonstrate the effectiveness of this treatment. It is concluded that the above claim is not based on convincing data from rigorous clinical trials.

Towards the end of their paper, the authors state that “this was a comprehensive and rigorously conducted review…” I beg to differ; it turned out to be uncritical and biased, in my view. And at the very end of the article, we learn a possible reason for this phenomenon: “CM had financial support from the National Council for Osteopathic Research from crowd-funded donations.”

Recently, I was asked about the ‘Dorn Method’. In alternative medicine, it sometimes seems that everyone who manages to write his family name correctly has inaugurated his very own therapy. It is therefore a tall order to aim at blogging about them all. But that’s been my goal all along, and after more than 1 000 posts, I am still far from achieving it.

So, what is the Dorn Method?

A website dedicated to it provides some first-hand information. Here are a few extracts (numbers in brackets were inserted by me and refer to my comments below):

START OF QUOTE

Developed by Dieter Dorn in the 1970’s in the South of Germany, it is now fast becoming the widest used therapy for Back Pain and many Spinal Disorders in Germany (1).

The Dorn Method ist presented under different names like Dornmethod, Dorntherapy, Dorn Spinal Therapy, Dorn-Breuss Method, Dorn-XXname-method and (should) have as ‘core’ the same basic principles.

There are many supporters of the Dorn Method (2) but also Critics (see: Dorn controversy) and because it is a free (3) Method and therefore not bound to clear defined rules and regulations, this issue will not change so quickly.

The Method is featured in numerous books and medical expositions (4), taught to medical students in some universities (5), covered by most private medical insurances (6) and more and more recognized in general (7).

However because it is fairly new and not developed by a Medical Professional it is often still considered an alternative Healing Method and it is meant to stay FREE of becoming a registered trademark, following the wish of the Founder Dieter Dorn (†2011) who did NOT execute his sole right to register this Method as the founder, this Method must become socalled Folk Medicine.

As of now only licensed Therapists, Non Medical Practitioners (in Germany called Heilpraktiker (Healing Practitioners with Government recognition) (8), Physical Therapists or Medical Doctors are authorized to practice with government license, but luckily the Dorn Method is mainly a True Self Help Method therefore all other Dorn Method Practitioners can legally help others by sharing it in this way (9).

What conditions can be treated with the Dorn Method? Every disease, even up to the psychological domain can be treated (positively influenced) unless an illness had already led to irreversible damages at organs (10). The main areas of application are: Muscle-Skeletal Disorders (incl. Back Pain, Sciatica, Scoliosis, Joint-Pain, Muscular Tensions, Migraines etc.)

END OF QUOTE

My brief comments:

  1. This is a gross exaggeration.
  2. Clearly another exaggeration.
  3. Not ‘free’ in the sense of costing nothing, surely!
  4. Yet another exaggeration.
  5. I very much doubt that.
  6. I also have difficulties believing this statement.
  7. I see no evidence for this.
  8. We have repeatedly discussed the Heilpraktiker on this blog, see for instance here, here and here.
  9. Sorry, but I fail to understand the meaning of this statement.
  10. I am always sceptical of claims of this nature.

By now, we all are keen to know what evidence there might be to suggest that the Dorn Method works. The website of the Dorn Method claims that there are 4 different strands of evidence:

START OF QUOTE

1. A new form of manual therapy and self help method which is basically unknown in conventional medicine until now, with absolutely revolutionary new knowledge. It concerns for example the manual adjustment of a difference in length of legs as a consequence of a combination of subluxation of the hip-joint (subluxation=partly luxated=misaligned) and a subluxation of the joints of sacrum (Ilio-sacral joint) and possible knee and ankle joints. The longer leg is considered the ‘problem’-leg and Not the shorter leg as believed in classical medicine and chiropractic.

2. The osteopathic knowledge that there is a connection of each vertebra and its appropriate  spinal segment to certain inner organs. That means that when there are damages at these structures, disturbances of organic functions are the consequence, which again are the base for the arising of diseases.

3. The knowledge of the Chinese medicine, especially of acupuncture and meridian science that the organic functions are stirred and leveled, also among each other, via the vegetative nervous system

4. The natural-scientific  knowledge of anatomy, physiology, physics, chemistry and other domains.

END OF QUOTE

One does not need to be a master in critical thinking to realise that these 4 strands amount to precisely NOTHING in terms of evidence for the Dorn Method. I therefore conducted several searches and have to report that, to the best of my knowledge, there is not a jot of evidence to suggest that the Dorm Method is more than hocus-pocus.

In case you wonder what actually happens when a patient – unaware of this lack of evidence – consults a clinician using the Dorn Method, the above website provides us with some interesting details:

START OF QUOTE

First the patients leg length is controlled and if necessary corrected in a laying position. The hip joint is brought to a (more or less) 90 degree position and the leg is then brought back to its straight position while guiding the bones back into its original place with gentle pressure.

picture link to dorn therapy pictures

This can be done by the patient and it is absolutely safe, easy and painless!

The treatment of Knees and Ankles should then follow with the same principals: Gentle pressure towards the Joint while moving it from a bended to a more straight position.

After the legs the pelvis is checked for misalignment and also corrected if necessary in standing position.

Followed by the lumbar vertebrae and lower thoracic columns, also while standing upright.

Then the upper thoracic vertebrae are checked, corrected if necessary, and finally the cervical vertebrae, usually in a sitting position.

The treatment often is continued by the controlling and correction of other joints like the shoulders, elbow, hands and others like the jaw or collarbone.

END OF QUOTE

Even if we disregard the poor English used throughout the text, we cannot possibly escape the conclusion that the Dorn Method is pure nonsense. So, why do some practitioners practice it?

The answer to this question is, of course, simple: There is money in it!

“Average fees for Dorn Therapy sessions range from about 40€ to 100€ or more…  Average fees for Dorn Method Seminars range from about 180€ to 400€ in most developed countries for a two day basic or review or advanced training.”

SAY NO MORE!

 

 

 

The question whether chiropractic is a truly valuable option for people suffering from back pain has been addressed repeatedly on this blog. My answer was usually negative, but proponents of chiropractic tended to argue that I am biased. Therefore I find it constructive to see what an organisation that hardly can be accused of bias says on this topic. An article by ‘SHOW ME THE EVIDENCE’ has recently provided a comprehensive overview of treatments for back pain. This is what they wrote about chiropractic:

START OF QUOTE

Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.

There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.

First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back pain found that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.

The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.

“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”

As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.

“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”

While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.

The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).

END OF QUOTE

This all seems fairly reasonable to me – except for the following not entirely unimportant points:

  • I am not sure where the evidence about risks of spinal manipulation comes from. In my view, it is not entirely correct: as there is no effective post-marketing surveillance, we cannot possibly name the incidence figures.
  • Neck manipulations are clearly more risky than manipulations lower down. But this does not necessarily mean that back patients are safer than those with neck pain. Chiropractors view the spine as a whole organ and will regularly manipulate the neck (if they sense ‘subluxations’ in this area), even if the patient comes with low back pain.
  • There are also indirect risks with consulting a chiropractor; for instance, they often give incompetent advice about healthcare. This can include discouraging immunisations or treating serious diseases, such as asthma, colic etc., with chiropractic.
  • I think the article should point out that exercise is not just as effective (or as ineffective) as chiropractic, but it is much safer and less expensive.
  • What Rubinstein says about responders is debatable, in my view. In particular, most chiropractors will convince their patients to continue treatment, even if they do not ‘respond’. And ‘responding’ might be simply the natural history of the condition and therefore totally unrelated to the therapy.

The bottom line: Chiropractic is not the best treatment for back pain!

The common cold is a perfect condition for providers of alternative medicine:

  • it is prevalent (good money to be earned),
  • it is not normally dangerous,
  • it nevertheless reduces quality of life and thus patients look for a treatment,
  • there probably is not a single alternative therapy that does not claim to be effective for it,
  • it is gone after about a week, treated or not.

But is there an alternative therapy that does actually work? An article by the Cochrane Collaboration provides an excellent overview. It includes conventional as well as alternative treatments; here I have merely copied the passages related to the latter:

VITAMIN C

There was great excitement in the 1970s when Linus Pauling, (a Nobel laureate twice over), concluded from placebo-controlled trials that Vitamin C could prevent and alleviate the common cold. Further research followed and a Cochrane review, published in 2013, found 29 clinical trials, involving 11,306 participants. Unfortunately, the review did not confirm Pauling’s findings. Taking regular Vitamin C did not reduce the incidence of colds in the general population, although there was a modest reduction in the duration and severity of symptoms. The only people who appeared to derive some benefit were those who undertook short bursts of extreme exercise, such as marathon runners and skiers. In this group the risk of getting a cold was halved.

Trials looking at taking high dose Vitamin C at the onset of cold symptoms showed no consistent effect on the duration and severity of symptoms and more research is needed to clarify these findings.

ECHINACEA

Echinacea is widely used in Europe and North America for common colds. A Cochrane review (2014) showed that some Echinacea products may be more effective than placebo in treating colds but the overall evidence for clinically relevant effects was weak. There was some evidence of a small preventative effect.

INHALATIONS

Inhaled steam has been used for decades (see earlier reference to my childhood humiliation!) thinking that it helps drain away mucus more effectively and possibly destroys the cold virus. A Cochrane review (2017) of six trials with 387 participants showed no consistent benefit for this intervention.

GARLIC

A single trial with 146 participants showed that taking garlic every day for three months might prevent occurrences of the common cold but the evidence was of low quality and more research is needed to validate this finding. (Cochrane review 2014.)

END OF QUOTE

The article obviously focuses only on such therapies for which Cochrane reviews have been published. What about other treatments? As I already mentioned, if we believe the promoters of alternative medicine, the list is long. But fortunately, we do not believe them and want to see the evidence.

HOMEOPATHY

Unsurprisingly, the evidence is not good. One of my posts even expressed the fear that it might involve scientific misconduct.

CHIROPRACTIC

Yes, some chiropractors claim that their manipulations are effective for the common cold. But, as with almost all of their claims, this cannot be taken seriously; the assumption is bogus.

CHINESE HERBAL MEDICINES

A systematic review concluded that their use for common cold is not supported by robust evidence.

SAUNA

Ages ago, I published a small study with promising results:

Twenty-five volunteers were submitted to sauna bathing, with 25 controls abstaining from this or comparable procedures. In both groups the frequency, duration and severity of common colds were recorded for six months. There were significantly fewer episodes of common cold in the sauna group. This was found particularly during the last three months of the study period when the incidence was roughly halved compared to controls. The mean duration and average severity of common colds did not differ significantly between the groups. It is concluded that regular sauna bathing probably reduces the incidence of common colds, but further studies are needed to prove this.

Sadly, the findings were never replicated.

 

MY CONCLUSION

Grin and bear it!

(That is the cold as well as the myriad of false claims made by enthusiasts of alternative medicine)

 

This overview by researchers from that Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, UK, was aimed at summarising the current best evidence on treatment options for 5 common musculoskeletal pain presentations: back, neck, shoulder, knee and multi-site pain. Reviews and studies of treatments were considered of the following therapeutic options: self-management advice and education, exercise therapy, manual therapy, pharmacological interventions (oral and topical analgesics, local injections), aids and devices, other treatments (ultrasound, TENS, laser, acupuncture, ice / hot packs) and psychosocial interventions (such as cognitive-behavioural therapy and pain-coping skills).

Here are the findings for those treatments most relevant in alternative medicine (it is interesting that most alternative medicines were not even considered because of lack of evidence and that the team of researchers can hardly be accused of an anti-alternative medicine bias, since its senior author has a track record of publishing results favourable to alternative medicine):

EXERCISE

Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.

ACUPUNCTURE

The evidence from a good quality individual patient data meta-analysis suggests that acupuncture may be effective for short-term relief of back pain and knee pain with medium summary effect sizes respectively compared with usual care or no acupuncture. However, effects on function were reported to be minimal and not maintained at longer-term follow-up. Similarly for neck and shoulder pain, acupuncture was only found to be effective for short-term (immediately post-treatment and at short-term follow-up) symptom relief compared to placebo.

MANUAL THERAPY

Current evidence regarding manual therapy is beset by heterogeneity. Due to paucity of high quality evidence, it is uncertain whether the efficacy of manual therapy might be different for different patient subgroups or influenced by the type and experience of professional delivering the therapy. On the whole, the available evidence suggests that manual therapy may offer some beneficial effects on pain and function, but it may not be superior to other non-pharmacological treatments (e.g. exercise) for patients with acute or chronic musculoskeletal pain.

Overall. the authors concluded that the best available evidence shows that patients with musculoskeletal pain problems in primary care can be managed effectively with non-pharmacological treatments such as self-management advice, exercise therapy, and psychosocial interventions. Pharmacological interventions such as corticosteroid injections (for knee and shoulder pain) were shown to be effective treatment options for the short-term relief of musculoskeletal pain and may be used in addition to non-pharmacological treatments. NSAIDs and opioids also offer short-term benefit for musculoskeletal pain, but the potential for adverse effects must be considered. Furthermore, the optimal treatment intensity, methods of application, amount of clinical contact, and type of provider or setting, are unclear for most treatment options.

These findings confirm what we have pointed out many times before on this blog. There is very little that alternative therapies have to offer for musculoskeletal pain. Whenever it is possible, I would recommend exercise therapy initiated by a physiotherapist; it is inexpensive, safe, and at least as effective as acupuncture or chiropractic or osteopathy.

Practitioners of alternative medicine will, of course, not like this solution.

Acupuncturists may not be that bothered by such evidence: their focus is not necessarily on musculoskeletal but on a range of other conditions (with usually little evidence, I hasten to add).

But for chiropractors and osteopaths, this is much more serious, in my view. Of course, some of them also claim to be able to treat a plethora of non-musculoskeletal conditions (but there the evidence is even worse than for musculoskeletal pain, and therefore this type of practice is clearly unethical). And those who see themselves as musculoskeletal specialists have to either accept the evidence that shows little benefit and considerable risk of spinal manipulation, or go in a state of denial.

In the former case, the logical conclusion is to look for another job.

In the latter case, the only conclusion is that their practice is not ethical.

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