spinal manipulation
If you assumed that the best management of a child by chiropractors is not to treat this patient and refer to a proper doctor, think again. This paper was aimed at building upon existing recommendations on best practices for chiropractic management of children by conducting a formal consensus process and best evidence synthesis. Its authors composed a best practice guide based on recommendations from current best available evidence and formal consensus of a panel of experienced practitioners, consumers, and experts for chiropractic management of pediatric patients. They thus syntheized results of a literature search to inform the development of recommendations from a multidisciplinary steering committee, including experts in pediatrics, followed by a formal Delphi panel consensus process.
The consensus process was conducted June to August 2022. All 60 panelists completed the process and reached at least 80% consensus on all recommendations after three Delphi rounds. Recommendations for best practices for chiropractic care for children addressed the following aspects of the clinical encounter:
- patient communication, including informed consent;
- appropriate clinical history, including health habits;
- appropriate physical examination procedures;
- red flags/contraindications to chiropractic care and/or spinal manipulation;
- aspects of chiropractic management of pediatric patients, including infants;
- modifications of spinal manipulation and other manual procedures for pediatric patients;
- appropriate referral and comanagement;
- appropriate health promotion and disease prevention practices.
The authors concluded that this set of recommendations represents a general framework for an evidence-informed and reasonable approach to the management of pediatric patients by chiropractors.
Whenever I read the term ‘evidence-informed’ I need to giggle. Why not evidence-based? Evidence-informed might mean that chiros are informed that their treatments are useless or even dangerous for children … but, on reflection and taking their own need for earning a living, they subsequently ignore these facts. And sure enough, the authors of the present paper do mention that a Cochrane review concluded that spinal manipulation is not recommended for children under 12, for a number of conditions, or for general wellness … only to then go on and ignore the very fact.
In doing so, the authors issue a string of self-evident platitudes which occasionally border on the irresponsible. For instance, under the heading of ‘primary prevention’, vaccinations are mentioned as the very last item with the following words:
If parents ask for advice or information about childhood vaccinations, explain that they have the right to make their own health decisions. They should be adequately informed about the benefits and risks to both their child and the broader community associated with these decisions. Consider referral to a health professional whose scope of practice includes vaccinations to address patient questions or concerns.
What that really means in practice, I fear, might be summarized like this: If parents ask for advice or information about childhood vaccinations, explain that they are dangerous, and that even D. D. Palmer recognized as early as 1894 that vaccination is ‘…the monstrous delusion … fastened on us by the medical profession, enforced by the state boards, and supported by the mass of unthinking people …’
Altogether, the ‘Clinical Practice Guideline for Best Practice Management of Pediatric Patients by Chiropractors’ is a thoroughly disreputable document. It was constructed in the way all charlatans tend to construct their consensus documents:
- convene a few people who are all in favour of a certain motion,
- discuss the motion,
- agree with it,
- write up the process
- publish your paper in a third class journal,
- boast that there is a consensus,
- stress that the motion must thereefore be ethical, correct and valuable.
Do chiropractors know that, using this methodology, the ‘flat earth society’ can easily pass a consensus that the earth is indeed flat?
I am sure they do!
‘The Cult of Chiropractic’ is the title of a video that has just been released. I think it is very good and, if you are interested in the subject at all, I recommend you have a look. You can watch it here:
The Cult of Chiropractic : r/h3h3productions (reddit.com)
The video is not just well-done, it also is fun and informative. I learned a few things from it that I did not yet know. It also brings Simon Singh and myself together after we had not met for several years; and that is always a pleasure!
But back to ‘The Cult of Chiropractic’ and the question whether this assumption is true. Some time ago, I published a post about so-called alternative medicine and cultism. I listed a few questions we should ask ourselves to determine whether chiropractic is a cult. Let me adapt them slightly:
- Is chiropractic based on dogma? The answer is yes – think, for instance, of the assumptions that subluxations exist.
- Does chiropractic demand acceptance of its dogma or doctrine as truth? For straight chiropractors, the answer is yes.
- Is the dogma set forth by a single guru or promulgator? Yes, DD Palmer.
- Is chiropractic supposed to cure all ills? For many chiros, the answer is yes.
- Is belief used by chiropractors as a substitute for evidence? Yes.
- Do chiropractors determine their patients’ lifestyle? Yes.
- Do chiros exploit their patients financially? Yes.
- Does chiropractors impose rigid rules and regulations? Yes.
- Do chiros practice deception? Yes.
- Do chiropractors have their own sources of information/propaganda? Yes.
- Do chiros cultivate their own lingo? Yes.
- Do chiros discourage or inhibit critical thinking? Yes.
- Are questions about the values of chiropractic discouraged or forbidden? Yes.
- Do the proponents of chiropractic reduce complexities into platitudinous buzz words? Yes
- Do chiros assume that health problems are the result of not adhering to the dogma? Yes.
- Do chiros instill fear into members who consider leaving? Yes.
- Do chiros depict conventional medicine as ineffective or harmful? Yes.
- Do chiros ask others to recruit new members to their cult? Yes.
Based on these 18 questions, I conclude that chiropractic is indeed a cult. What about you? Even if you disagree, please have a look at the excellent video, ‘THE CULT OF CHIROPRACTIC’.
The ‘University College of Osteopathy’ announced a proposal to merge with the AECC University College (AECC UC). Both institutions will seek to bring together the two specialist providers to offer a “unique inter-disciplinary environment for education, clinical practice and research in osteopathy, chiropractic, and across a wide range of allied health and related disciplines”.
The partnership is allegedly set to unlock significant opportunities for growth and development by bringing together the two specialist institutions’ expertise and resources across two locations – in Dorset and central London.
As a joint statement, Chair of the Board of Governors at AECC UC, Jeni Bremner and Chair of the Board of Governors at UCO, Professor Jo Price commented:
“We believe the proposed merger would further the institutional ambitions for both of our organisations and the related professional groups, by allowing us to expand our educational offering, grow student numbers and provide a unique inter-disciplinary training environment, providing students the opportunity to be immersed in multi-professional practice and research, with exposure to and participation in multi-disciplinary teams.
“There is also an exciting and compelling opportunity to expedite the development of a nationally unique, and internationally-leading MSK Centre of Excellence for Education and Research, developed and delivered across our two sites.”
The announcement is accompanied by further uncritical and promotional language:
Established as the first chiropractic training provider in Europe, AECC UC has been at the forefront of evidence-based chiropractic education, practice and research for more than 50 years. The institution is on an exciting journey of growth and development, having expanded and diversified its academic portfolio and activity beyond its traditional core offering of chiropractic across a broad range of allied health courses and apprenticeships, working closely with NHS, local authority and other system partners across Dorset and the south-west. The proposed merger with UCO would allow AECC UC to enhance the breadth and depth of its offer to support the expansion and development of the health and care workforce across a wider range of partners.
Now in its 106th year, UCO is one of the UK’s leading providers of osteopathic education and research with an established reputation for creating highly-skilled, evidence-informed graduates. UCO research is recognised as world-leading, delivering value to the osteopathic and wider health care community.
Sharon Potter, Acting Vice-Chancellor of UCO, said:
“As an institution that has long been at the forefront of osteopathic education and research, we are committed to ensuring further growth and development of the osteopathic profession.
“UCO has been proactively considering options to future-proof the institution. Following a review of strategic options, UCO is delighted by the proposed merger, working closely with AECC UC to ensure that UCO and osteopathy thrives as part of the inter-professional health sciences landscape, both academically and clinically. There is significant congruence between UCO and AECC UC in our strong aligned values, commitment to and delivery of excellent osteopathic education, clinical care and research, and opinion leadership.
“AECC UC has a strong track record of respecting the differences in professions, evidenced by the autonomy across the 10 different professional groups supported by the institution. The merger will not only mean we are protecting UCO through preserving its osteopathic heritage and creating a sustainable future, but that our staff and students can collaborate with other professional groups such as physiotherapy, chiropractic, sport rehabilitation, podiatry and diagnostic imaging, in a multidisciplinary MSK and rehabilitation environment unlike anywhere else in the UK.”
Professor Lesley Haig, Vice-Chancellor of AECC UC, commented:
“Preserving the heritage of UCO and safeguarding its future status as the flagship osteopathy training provider in the UK will be critical, just as it has been to protect the chiropractic heritage of the AECC brand. UCO is seen as synonymous with, and reflective of, the success of the osteopathy profession and we fully recognise and respect the important role that UCO plays not only as a sector-leading provider of osteopathic education, research and clinical care, but as the UK’s flagship osteopathy educational provider.
“Overall it is clear that UCO and AECC UC already have a common values base, similar understanding of approaches to academic and clinical delivery, and positive relationships upon which a future organisational structure and opportunities can be developed. It’s an exciting time for both institutions as we move forward in partnership to create something unique and become recognised nationally and internationally as a centre of excellence.”
The proposed merger would continue the already founded positive relations between the institutions, where regular visits, sharing of good practice, and collaborative research work are already taking place. Heads of terms for the potential merger have now been agreed and both institutions are entering into the next phase of discussions, which will include wide consultation with staff, students and other stakeholders to produce a comprehensive implementation plan.
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In case this bonanza of platitudes and half-truths has not yet overwhelmed you, I might be so bold as to ask 10 critical questions:
- What is an “evidence-based chiropractic education”? Does it include the messages that 1) subluxation is nonsense, 2) chiropractic manipulations can cause harm, 3) there is little evidence that they do more good than harm?
- How an an “expansion and development of the health and care workforce” be anticipated on the basis of the 3 points I just made?
- What does the term “evidence-informed graduates” mean? Does it mean they are informed that you teach them nonsense but instruct them to practice this nonsense anyway?
- Do “options to future-proof the institution” include the continuation of misleading the public about the value of chiropractic/osteopathy?
- Does the”delivery of excellent osteopathic education, clinical care and research, and opinion leadership” account for the fact that the evidence for osteopathy is weak at best and for most conditions negative?
- By “preserving its osteopathic heritage”, do you intend to preserve also the reputation of your founding father, Andrew Taylor Still, who did many dubious things. In 1874, for instance, he was excommunicated by the Methodist Church because of his “laying on of hands”; specifically, he was accused of trying to emulate Jesus Christ, labelled an agent of the Devil, and condemned as practicing voodoo. Or do you prefer to white-wash the osteopathic heritage?
- You also want “to protect the chiropractic heritage”; does that mean you aim at white-washing the juicy biography of the charlatan who created chiropractic, DD Palmer, as well?
- “UCO and AECC UC already have a common values base” – what are they? As far as I can see, they mainly consist in hiding the truth about the uselessness of your activities from the public.
- How do you want to “recognised nationally and internationally as a centre of excellence”? Might it be a good idea to begin by critically assessing your interventions and ask whether they do more good than harm?
- Crucially, what is really behing the merger that you are trying to sell us with such concentrated BS?
The history of so-called alternative medicine (SCAM) is rich with ‘discoveries’ that are widely believed to be true events but that, in fact, never happened. Here are 10 examples:
- DD Palmer is believed to have cured the deafness of a janitor by manipulating his neck. This, many claim, was the birth of chiropractic. BUT IT NEVER HAPPENED! How can I be so sure? Because the nerve responsible for hearing does not run through the neck.
- Samuel Hahnemann swallowed some Cinchona officinalis, a quinine-containing treatment for malaria, and experienced the symptoms of malaria. This was the discovery of the ‘like cures like’ assumption that forms the basis of homeopathy. BUT IT NEVER HAPPENED! How can I be so sure? Because Hahnemann merely had an intolerance to quinine, and like does certainly not cure like.
- Edward Bach, for the discovery of each of his flower remedies, suffered from the state of mind for which a particular remedy was required; according to his companion, Nora Weeks, he suffered it “to such an intensified degree that those with him marvelled that it was possible for a human being to suffer so and retain his sanity.” This is how Bach discovered the ‘Bach Flower Remedies‘. BUT IT NEVER HAPPENED! How can I be so sure? His experience was not caused by by the remedy, which contain no active ingredients, but by his imagination.
- William Fitzgerald found that pressure on specific areas on the soles of a patient’s feet would positively affect a specific organ of that patient. This was the birth of reflexology. BUT IT NEVER HAPPENED! How can I be so sure? Because there are no nerve connections from the sole of our feet to our inner organs.
- Max Gerson observed that his special diet with added liver juice, vitamin B3, coffee enemas, etc. cures cancer. This is how Gerson found the Gerson therapy. BUT IT NEVER HAPPENED! How can I be so sure? Because he never could demonstrate this effect and others never were able to replicate his alleged finfings.
- George Goodheart was convinced that the strength of a muscle group provides information about the health of inner organs. This formed the basis for applied kinesiology. BUT IT NEVER HAPPENED! How can I be so sure? Because applied kinesiology has been disclosed as a simple party trick.
- Paul Nogier thought that the function of inner organs can be influenced by stimulating points on the outer ear. This was the discovery that became auricular therapy. BUT IT NEVER HAPPENED! How can I be so sure? Because Nogier’s assumptions fly in the face of anatomy and physiology.
- Antom Mesmer discovered that by moving a magnet over a patient, he would move her vital fluid and affect her health. This discovery became the basis for Mesmer’s ‘animal magnetism‘. BUT IT NEVER HAPPENED! How can I be so sure? Because there is no vital fluid and neither real nor animal magnetism have specific therapeutic effects.
- Reinhold Voll observed that the electric resistance over acupuncture points provides diagnostic information about the function of the corresponding organs. He thus invented his ‘electroacupuncture according to Voll‘ (EAV). BUT IT NEVER HAPPENED! How can I be so sure? Because EAV and the various methods derived from it are not valid and fail to produce reproducible results.
- Ignatz von Peczely discovered that discolorations on the iris provide valuable information about the health of inner organs. This was the birth of iridology. BUT IT NEVER HAPPENED! How can I be so sure? Because discolorations develop spontaneously and Peczely’s assumptions about nerval connections between the iris and the organs of the body are pure fantasy.
I hope that you can think of further SCAM discoveries that never happened. If so, please elaborate in the comments section below; you will see, it is good fun!
PS
By sating ‘IT NEVER HAPPENED’, I mean to say that it never happened as reported/imagined by the inventor of the respective SCAM and that the explanations perpetuated by the enthusiasts of the SCAM regarding cause and effect are based on misunderstandings.
The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or symptomatic population.
Various databases were searched (inception till May 2023) and fifteen trials (737 participants) that met the inclusion criteria were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. Outcome measure data were synthesized using standard mean differences and meta-analysis for the primary outcome (biochemical markers). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.
There was low-quality evidence that spinal manipulation influenced various biochemical markers (not pooled). There was low-quality evidence of significant difference that spinal manipulation is better (SMD -0.42, 95% CI – 0.74 to -0.1) than control in eliciting changes in cortisol levels immediately after intervention. Low-quality evidence further indicated (not pooled) that spinal manipulation can influence inflammatory markers such as interleukins levels post-intervention. There was also very low-quality evidence that spinal manipulation does not influence substance-P, neurotensin, oxytocin, orexin-A, testosterone and epinephrine/nor-epinephrine.
The authors concluded that spinal manipulation may influence inflammatory and cortisol post-intervention. However, the wider prediction intervals in most outcome measures point to the need for future research to clarify and establish the clinical relevance of these changes.
The majority of the studies were of low or very low quality. This means that the collective evidence is less than reliable. In turn, this means, I think, that the conclusions are misleading. A more honest conclusion would be this:
There is no reliable evidence that spinal manipulation influences inflammatory and cortisol levels.
As for the clinical relevance, I would like to point out that it would not be surprising if chiropractors could one day convincingly show that spinal manipulation do influence various biochemical markers. Many things do! If you fall down a staircase, for instance, plenty of biochemical markers will be affected. This, however, does not mean that throwing our patients down the stairs is of therapeutic value.
This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).
In a single-blind randomized clinical trial, the researchers randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). They evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. Mixed-model ANOVA was used to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.
CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.
The authors concluded that this study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.
To understand this study, we need to know what CFT and MSI exactly entailed. Here is the information that the authors provide:
Movement system impairment-based treatment
The movement system impairment-based treatment group received 11 sessions of MSI-based treatment over the 8 weeks for 60 min per session with a supervision of a native speaker experienced (above 5 years) physical therapist with the knowledge of MSI-based treatment. The researchers designed the MSI-based treatment uniquely for each patient based on the interview, clinical examination, and questionnaires, just like they did with the CFT intervention. First, they administered standardized tests to characterize changes in the patient’s low back pain symptoms, and then they modified the treatment to make it more specific based on the participant’s individual symptoms. Depending on the participant’s direction-specific low back pain classification, they performed the intervention following one of the five MSI subgroups namely [1] rotation, [2] extension, [3] flexion, [4] rotation with extension, and [5] rotation with flexion. Finally, Patients treated using the standardized MSI protocol as follows: [1] education regarding normal postures and movements such as sitting, walking, bending, standing, and lying down; [2] education regarding exercises to perform trunk movements as painlessly as possible; and [3] prescription of functional exercises to improve trunk movement [32].
Cognitive functional therapy
Cognitive functional therapy was prescribed for each patient in CFT group based the CFT protocol conducted by O’Sullivan et al. (2015). Patients received supervised 12 sessions of training over the 8-week period with 60 min per session provided with another physical therapist who had been trained in CFT treatment. In this protocol, a physical therapist with more than 5 years of experience conducted an interview and physical examination of the patients to determine their own unique training programs, considering modifiable cognitive, biopsychosocial, functional, and lifestyle behavior factors. The intervention consists of the following 3 main stages: [1] making sense of pain that is completely reflective, where physical therapist could use the context of the patient’s own story to provide a new understanding of their condition and question their old beliefs [2] exposure with control which is designed to normalize maladaptive or provocative movement and posture related to activities of daily living that is integrated into each patient’s functional impairments, including teaching how to relax trunk muscles, how to have normal body posture while sitting, lying, bending, lifting, moving, and standing, and how to avoid pain behaviors, which aims to break poor postural habits; and [3] lifestyle change which is investigating the influence of unhealthy lifestyles in the patient’s pain context. Assessing the individual’s body mass, nutrition, quality of sleep, levels of physical activity or sedentary lifestyle, smoking, and other factors via video calls. Identifying such lifestyle factors helped us to individually advise and design exercise programs, rebuild self-confidence and self-efficacy, promote changes in lifestyle, and design coping strategies.
I must admit that I am not fully convinced.
Firstly, the study was not large and we need – as the authors state – more evidence. Secondly, I am not sure that the results show CFT to be more effective that MSI. They might merely indicate 1) that the bulk of the improvement is due to non-specific effects (e.g. reression towards the mean, natural history of the condition, placebo) and 2) that CFT is less harmful than MSI.
My conclusion:
we need not just more but better evidence.
The case of a 91-year old male patient developing acute neuropathic pain along the sciatic nerve distribution following spinal manipulation has been reported. Manipulative treatment with an Activator Adjusting Instrument (AAI) had been performed. During this treatment, three applications of the AAI were administered. The applications were bilateral (1) over the sacroiliac joint, (2) gluteal area, and (3) paraspinal region just above the iliac crest.
Within 24 hours, the patient developed severe 10/10 pain originating from the left gluteal area at the site of one of the activator deployments with radiation all the way down his left leg to the foot. He was able to maintain distal left leg strength and sensation. Subsequently, the patient developed insomnia, confusion, and adrenal gland dysfunction in response to changes in steroids, gabapentin, and other drugs, thus highlighting some nuances of managing elderly patients with back pain.
Relief was achieved with subsequent physical therapy techniques aimed at relaxing the patient’s deep gluteal muscles, raising the hypothesis of temporary injury to the deep gluteal muscles, with painful contractions resulting in gluteal region pain as well as sciatic nerve inflammation as the nerve passed through that region.
The authors concluded that this clinical case illustrates some of the perils and risks of spinal manipulation, particularly in the elderly, and the need for careful patient selection.
The authors of this (stranely incomplete) case report discuss whether any manipulation was truly necessary or indicated as part of his initial chiropractic treatment plan. They state that, given that complications associated with similar practices are not often reported in the literature, this case highlights important considerations to be made in the elderly given the potential impact of transient/permanent neuropathic pain in that population subset.
Somehow, I doubt that we can be certain that the patient improved due to the physical therapy and not due to the drugs he received. Moreover, I question the authors’ repeated assertions that such adverse effects of chiropractic spinal manipulation are truly rare. Here is a section from our own 2002 systematic review of the subject:
A systematic review of five prospective investigations of the risks of spinal manipulation concluded that mild-to moderate transient adverse reactions occur in approximately half of patients who undergo spinal manipulation. The largest of these studies involved 1058 patients who received a total of 4712 treatments from 102 chiropractors in Norway. At least one adverse reaction was reported by 55% (n 580) of patients. About one quarter (n 1174) of treatments resulted in at least one adverse reaction. The most common reaction reported was local discomfort. Eighty-five percent (n 824) of reactions were described as “mild or moderate” and 1% (n 14) as “unbearable.” Seventy-four percent (n 1052) of reactions disappeared within 24 hours. No serious, permanent complications of spinal manipulation were reported, but follow-up was not described. These results were confirmed by a similar study in Sweden with 625 patients and a smaller one (68 patients) from the United Kingdom …
Non-life-threatening adverse effects after spinal manipulations are not rare – they are merely rarely reported!
Manual therapy is considered a safe and less painful method and has been increasingly used to alleviate chronic neck pain. However, there is controversy about the effectiveness of manipulation therapy on chronic neck pain. Therefore, this systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to determine the effectiveness of manipulative therapy for chronic neck pain.
A search of the literature was conducted on seven databases (PubMed, Cochrane Center Register of Controlled Trials, Embase, Medline, CNKI, WanFang, and SinoMed) from the establishment of the databases to May 2022. The review included RCTs on chronic neck pain managed with manipulative therapy compared with sham, exercise, and other physical therapies. The retrieved records were independently reviewed by two researchers. Further, the methodological quality was evaluated using the PEDro scale. All statistical analyses were performed using RevMan V.5.3 software. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment was used to evaluate the quality of the study results.
Seventeen RCTs, including 1190 participants, were included in this meta-analysis. Manipulative therapy showed better results regarding pain intensity and neck disability than the control group. Manipulative therapy was shown to relieve pain intensity (SMD = -0.83; 95% confidence interval [CI] = [-1.04 to -0.62]; p < 0.0001) and neck disability (MD = -3.65; 95% CI = [-5.67 to – 1.62]; p = 0.004). However, the studies had high heterogeneity, which could be explained by the type and control interventions. In addition, there were no significant differences in adverse events between the intervention and the control groups.
The authors concluded that manipulative therapy reduces the degree of chronic neck pain and neck disabilities.
Only a few days ago, we discussed another systematic review that drew quite a different conclusion: there was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain.
How can this be?
Systematic reviews are supposed to generate reliable evidence!
How can we explain the contradiction?
There are several differences between the two papers:
- One was published in a SCAM journal and the other one in a mainstream medical journal.
- One was authored by Chinese researchers, the other one by an international team.
- One included 17, the other one 23 RCTs.
- One assessed ‘manual/manipulative therapies’, the other one spinal manipulation/mobilization.
The most profound difference is that the review by the Chinese authors is mostly on Chimese massage [tuina], while the other paper is on chiropractic or osteopathic spinal manipulation/mobilization. A look at the Chinese authors’ affiliation is revealing:
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China.
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China; Department of Tuina, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China. Electronic address: [email protected].
- Department of Tuina and Spinal Diseases Research, The Third School of Clinical Medicine (School of Rehabilitation Medicine), Zhejiang Chinese Medical University, Hangzhou, China; Department of Tuina, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China. Electronic address: [email protected].
What lesson can we learn from this confusion?
Perhaps that Tuina is effective for neck pain?
No!
What the abstract does not tell us is that the Tuina studies are of such poor quality that the conclusions drawn by the Chinese authors are not justified.
What we do learn – yet again – is that
- Chinese papers need to be taken with a large pintch of salt. In the present case, the searches underpinning the review and the evaluations of the included primary studies were clearly poorly conducted.
- Rubbish journals publish rubbish papers. How could the reviewers and the editors have missed the many flaws of this paper? The answer seems to be that they did not care. SCAM journals tend to publish any nonsense as long as the conclusion is positive.
This systematic review with meta-analysis of randomized clinical trials (RCTs) estimated the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. The authors searched the MEDLINE, Cochrane CENTRAL, EMBASE, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022.
RCTs evaluating SMT compared to guideline-recommended and non-recommended interventions, sham SMT, and no intervention for adults with neck pain were eligible. Pre-specified outcomes included pain, range of motion, disability, health-related quality of life.
A total of 28 RCTs could be included. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short-term (standardized mean difference [SMD] 0.66; confidence interval [CI] 0.35 to 0.97) and long-term (SMD 0.73; CI 0.31 to 1.16), and for reducing disability at short-term (SMD 0.95; CI 0.48 to 1.42) and long-term (SMD 0.65; CI 0.23 to 1.06). Only transient side effects were found (e.g., muscle soreness).
The authors concluded that there was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain.
Harms cannot be adequately investigated on the basis of RCT data. Firstly, because much larger sample sizes would be required for this purpose. Secondly, RCTs of spinal manipulation very often omit reporting adverse effects (as discussed repeatedly on this bolg). If we extend our searches beyond RCTs, we find many cases of serious harm caused by neck manipulations (also as discussed repeatedly on this bolg). Therefore, the conclusion of this review should be corrected:
Low certainty evidence exists supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. The evidence of harm is, however, substantial. It follows that the risk/benefit ratio is not positive. Cervical SMT should therefore be discouraged.
The World Federation of Chiropractic (WFC) has recently launched a new Global Patient Safety (GPS) initiative:
Unanimously approved by the WFC Board at its May meeting, the project will be overseen by the Research Committee and involve the establishment of an expert task force. Planned projects will include a scoping review, identification of best practices in incident reporting and learning, risk management in chiropractic practice and knowledge translation activities.
In recent years, patient safety has increasingly been in the spotlight as health systems strive to reduce unnecessary incidents and iatrogenic injury.
“With adverse events having the potential to impact trust and confidence in the chiropractic profession, it is important that we do as much as possible to inform ourselves in relation to the risks and benefits of chiropractic treatments and related activities,” said Prof. Richard Brown DC, LL.M, WFC Secretary- General.
“While we know that serious adverse events are rare, patients with multiple co-morbidities and known risk factors require special attention. The WFC GPS Task Force will highlight key areas of patient safety to support chiropractors, build and strengthen the existing safety culture and help to meet the expectations of patients and the public.”
Chiropractors use a package of interventions in their treatment of patients, including hands-on care, adjunct therapies, health promotion, advice and exercise prescription. The process of shared decision-making involves consideration by the chiropractor of the suitability and safety of each intervention. In addition to direct patient care, chiropractors also have a duty to consider the safety of their offices and clinics.
A WHO resolution on patient safety, passed in 2019 at the World Health Assembly, made a commitment to take global action in tackling avoidable harm.
Its subsequent publication, Global Action on Patient Safety, set out goals and targets to reduce morbidity from healthcare related incidents.
Chair of the Task Force and Research Committee vice-chair, Dr Katie Pohlman DC, PhD, said: “With the current global focus on patient safety, I’m proud to be leading this WFC Task Force, which will support the chiropractic profession but, most importantly, work to minimize adverse events and protect patients.
“The creation of an open, transparent culture of patient safety is key to maintaining trust and credibility. The Task Force is looking forward to adding to the body of knowledge and advancing safe, evidence-based, people-centered practice.”
The WFC GPS Task Force will report to Research Committee Chair, Assoc. Prof Sidney Rubinstein. It will include members of the existing Research Committee as well as external experts.
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At first, most people will think: WHAT A GOOD IDEA!
After a bit of reflection, however, some might ponder: WHY ONLY NOW AND NOT DECADES AGO?
And after reading the above text carefully, skeptics might feel that the exercise can already be classified as a PR gimmick that will not generate the needed information:
- The WFC has yet again failed to establish a monitoring system of adverse effects; without it ‘patient safety’ is not achievable.
- They claim that “we know that serious adverse events are rare”. How do they know this? And if they already are convinced of this, the new task force is bound to be a pure ‘white wash’.
- They think an “existing safety culture” exists in chiropractic. This is wishful thinking and far from reality.
- They speak of the “expectations of patients and the public” but ignore the need for a monitoring system accessible to the public.
