Spinal Manipulation Once Again Proves Worthless

A recent study published in the Journal of the Royal Society of Medicine has concluded that spinal manipulation is so worthless that it cannot be recommended for any medical condition and the risks associated outweigh any potential benefit. The title, " A Systematic Review of Systematic Reviews of Spinal Manipulation," immediately aroused my suspicion that this might be motivated by politics rather than the search for best evidence. The conclusion was obviously preconceived in light of the included studies. When you look at the heterogeneity of the studies and the downplay of multimodal treatment these authors appear to be intent to veil their agenda in the cloak of science, rather than objective truth.

Michael

Download spiinal_manipulation_sr.pdf

Comments

[Jason Silvernail]

What!!?? Manipulation doesn't help infantile colic??

Yet another poorly constructed systematic review that relies on disparate studies of poor quality and produces an unsurprising result.
Garbage in, garbage out.

J

[Britt]

Michael,
Wonderful find with this article. I am reminded that Ernst is one of the authors upbraided by Gordon Waddell in the 1999 BMJ editorial. He cited their bias and nearly prejudiced attitude towards manipulation in general and chiropractic in particular. Waddell's letter included now classic lines such as "Indeed, there is stronger evidence for manipulation than for most orthodox medical treatments" & "orthodox medicine has a long way to go to reduce the rate of serious complications of most of our investigations and treatments to the order of 1:0.2-1 million."
I've included Waddell's letter to the editor below.
Thanks again.
Britt

Evidence for manipulation is stronger than that for most orthodox medical treatments

EDITORAs one of the coauthors of the Clinical Standards Advisory Group's report on back pain1 and the Royal College of General Practitioners' guidelines on acute low back pain,2 I am disappointed by Ernst and Assendelft's editorial on chiropractic.3 The authors present a critical view of chiropractic under the guise of scientific objectivity, but I had hoped that we had got beyond that stage of interprofessional confrontation.

Burton and I recently reviewed international guidelines for low back pain, and none of them specifically recommend chiropractic.4 What they do all say, and what all recent reviews conclude to varying degrees, is that considerable evidence now exists that manipulation is an effective treatment for low back pain. Indeed, there is stronger evidence for manipulation than for most orthodox medical treatments. The guidelines also advise that manipulation should be performed by a trained professional but that there is no clear evidence whether it is better performed by a chiropractor, an osteopath, a physiotherapist, or a doctor with special training.

Ernst and Assendelft's review of the risks of manipulation is particularly biased. Although the subject of this editorial is low back pain, they concentrate on the admittedly higher risks of cervical manipulation. Even then, orthodox medicine has a long way to go to reduce the rate of serious complications of most of our investigations and treatments to the order of 1:0.2-1 million. The adverse reactions to which the authors refer are temporary aggravations of symptoms or minor subjective reactions; in a personal series, that rate is comparable to figures for every other orthodox treatment for back pain. What matters is the balance of effectiveness versus risk, and that is strongly in favour of manipulation. The politics and costs of any NHS provision of a service are a completely separate and more relevant debate.

None of us have a good answer for low back painorthodox medicine, professors, and methodologists least of all. Chiropractic is not the magic answer for back pain, and it should and can stand up to fair criticism, but orthodox medicine could potentially also learn a lot from chiropractic.5 The needs of patients with back pain should override our professional dignities, and the real need is for us all to work together. That cooperation is not likely to be helped by this kind of editorial.

Gordon Waddell, Orthopaedic surgeon.
Glasgow Nuffield Hospital, Glasgow G12 0PJ

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Clinical Standards Advisory Group. Report on back pain. London: HMSO , 1994.
Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London: RCGP , 1996.
Ernst E, Assendelft WJJ. Chiropractic for low back pain. BMJ 1998; 317: 160[Free Full Text]. (18 July.)
Burton AK, Waddell G. Clinical guidelines in the management of low back pain. In: Nordin M, ed. New approaches to the low back pain patient. London: Baillière Tindall, 1998:17-35. (Baillière's clinical rheumatology.)
Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone , 1998.

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[Jeff Hebert, DC]

Excellent article Britt, thanks. For those of you that are interested, here are a couple of counterpoints:

1. The Brittish chiropractic association's response: http://tinyurl.com/pb6cu

2. An audio file with a brief debate between Ernst and a UK chiropractor on BBC: http://news.bbc.co.uk/1/hi/health/4824594.stm

Jeff

[Britt Smith]

Jeff,
I enjoyed the audio...good to put a voice to a name. Ernst contradicts himself towards the end, then back steps by stating the improvements from manipulation are the course of time and placebo. The chiro does a nice job of counter-point and discussing the confounding factors of heterogeneity in many LBP/manip studies (Subgroups, subgroups, subgroups).

One other point about Ernst. I've read another of his reviews on manip and chiropractic. He insists on a sham control, or the study is fatally flawed. I know Koes and others have commented on how difficult (probably impossible) to do a sham treatment of manipulation (like surgery...where shams most likely are borderline unethical). Indeed, Jull commented last year that the difficulty in carrying out a sham will cause many, or most, PT RCTs not to ranked in the highest eschelon of RCTs in terms of methodology. Koes has commented that this doesn't need be a concern, but a fact of limitation of study design that should be accepted (or embraced).
The chiro makes some nice points about 'packages' of care etc (I assume he was part of the BEAM trials).
Thanks, again,
Britt

[Jon Newman]

I think there is a difference between not being able to recommend a treatment and saying that it is “worthless”. The authors of the paper never suggest that manipulation is "worthless". They even concede:

“We do, however, note that the absence of evidence is not the same as evidence of absence of an effect. None of the reviews conclusively demonstrates that SM is ineffective.”

The reasons for not recommending manipulation seem more complex than "effectiveness" alone.

I listened to that interview and what jumped out at me was Prof. Greene’s comment:

“The way to look at manipulation--I think a fair conclusion-- is that it is a useful treatment to be considered in patients who are not recovering from common musculoskeletal problems. There’s not very much evidence that it works on organic problems of course but the jury is still out—we have to wait to do more research to find out”

Earlier in the interview he made it a point to discuss how manipulation is only an adjunct to other therapies.

What is he trying to say about manipulation not working on "organic" problems and needing to be coupled with other things?

p.s. I couldn't find any sort of reference to "Professor Greene" from the audio so apologies if I misspelled the name--I did try to look it up.