Spinal Manipulation for Back and Neck Pain: Does It Work?

Two American traditions of spinal manipulation.  Osteopathy, developed by a physician and surgeon.  Chiropractic, developed by a magnet healing quack who may have modified osteopathy or got ideas from his spirit guides.  Laird Harrison explains in the Medscape article, Spinal Manipulation for Back and Neck Pain: Does It Work?

In the comments that follow, Dr Mark Crislip has critically analysed claims in the article that such practices work.

Pubmed shows a gradually increasing number of low-quality studies supposedly validating the effects of ISO accreditation.  Just like spinal manipulation and the shift in wealth derived from it, the evidence for accreditation “keeps growing and growing”.  As UKAS spreads the ISO disease through laboratories and hospitals, this is the sort of analysis we need doctors to be doing for the claims of accreditation:

Dr. Mark Crislip,  Infectious Diseases
Feb 17, 2017

An excerpt from  Spinal Manipulation for Back and Neck Pain: Does It Work? Annotated.  https://sciencebasedmedicine.org/spinal-manipulation-for-back-and-neck-pain-does-it-work-annotated/

The article starts with:

In her office at McMaster University in Toronto, Anita Gross, MSc, has logged paper after paper showing that spinal manipulation can help control neck pain. “The evidence keeps growing and growing,” she says.

I have a eponymous law on RationalWiki. Another law of pseudo-medicine, eponymous 2, states that when a pseudo-medical intervention says there is growing evidence, there isn’t. It is a corollary to Betteridge’s law of headlines.

Well, perhaps the growing evidence is more of a Kellyanne Conway statement, an alternative fact, because while it is true that there is growing evidence, it is usually terrible evidence.

The question is whether an intervention is better than a sham or placebo intervention. To really know if an intervention is effective, especially an intervention that is not based in the known reality of anatomy, physiology, and biochemistry, you want to do placebo/sham controlled studies, preferably blind.

Let’s check out the ‘growing’ literature of chiropractic manipulation compared with sham chiropractic for neck pain.

And if you think there is no valid sham chiropractic manipulation, think again.

There is “Short-term usual chiropractic care for spinal pain: a randomized controlled trial” from 2013:

Short-term chiropractic treatment was superior to sham; however, treatment effects were not clinically important.

And it was those who knew they were getting treatment who had the most improvement. A classic placebo effect.

That’s it for manipulation vs. sham manipulation for neck pain. But that is growth. From zero to one.

Manipulation vs. sham manipulation for back pain? There is “Spinal Manipulation A Systematic Review of Sham-Controlled, Double-Blind, Randomized Clinical Trials” which included two studies of back pain. They found:

The most rigorous of these studies suggest that spinal manipulation is not associated with clinically-relevant specific therapeutic effects.

Or the recent review “The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain: A systematic review with meta-analysis” where:

Meta-analyses found positive effects for manual therapy on pain intensity when compared to usual care and relaxation but not when compared to sham interventions.

Here is the classic interpretation: When an intervention is equal to sham/placebo, it is not effective; the intervention does not work. It is why, for example, we no longer do mammary artery ligation for angina.

Or “Spinal Manipulative Therapy for Chronic Lower Back Pain in Older Veterans: A Prospective, Randomized, Placebo-Controlled Trial.”

The SMT did not result in greater improvement in pain when compared to our sham intervention; however, SMT did demonstrate a slightly greater improvement in disability at 12 weeks. The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect.

Again. Not better than sham equals no efficacy. And “nonspecific therapeutic effect” is code for placebo effect.

That’s it for the growing literature of clinical trials with meaningful methodologies, sham controlled studies, that I

found on Pubmed. There are numerous ‘A + B versus B’ studies, but they tell you nothing.

So the literature that is growing and growing is less than impressive in numbers or outcomes.

On to the second paragraph:

Gross, a physiotherapist and associate professor of rehabilitation science, helped write a 2015 Cochrane review of the literature and is already at work on updating that paper.

It implies, and maybe this is just me, that the Cochrane review is favorable for manipulation, since it follows the growing and growing quote. Just what does that review say?

No high-quality evidence was found, so uncertainty about the effectiveness of mobilisation or manipulation for neck pain remains.

Color me unimpressed.

The third paragraph?

Mounting evidence also supports spinal manipulation for low back pain, says Roger Chou, MD, professor of medicine at Oregon Health & Science University in Portland, Oregon, who led a similar review for the Agency for Healthcare Research and Quality last year.

And that similar review?

These include exercise, yoga, and tai chi; various psychological therapies; multidisciplinary rehabilitation; acupuncture; spinal manipulation (vs. an inert treatment); and low-level laser therapy. Effects were small to moderate in magnitude.

And they point to a table.

In that table there is spinal manipulation vs. inert treatment (7 trials) which had “small” effects BUT spinal manipulation vs. sham manipulation (1 SR (3 RCTs) 1 RCT), the gold standard for showing efficacy, had…

*…pause for dramatic effect while we decide which baker has to leave the tent…*

No effect.

Let me repeat: manipulation and sham manipulation are equal. That means it doesn’t work.

And that begs the question. You have back pain. I am going to send you for manipulation, but how do I order the manipulation that is vs an inert treatment and avoid the manipulation that is vs sham because it is the former works and the latter that does not. I can do that how? Puh-lease.

Kellyanne, Kellyanne, did it rain at the inauguration? Were the crowds yuuuuge? Was it the greatest Electoral College victory ever? Does chiropractic work better than sham? Is supportive literature growing and growing? Do these:

findings counter decades of accusations of quackery mounted against healers who massage or manipulate patients’ muscles or joints[?]

No. It is, at least in its chiropractic form, still quackery. But more on that later. But it does support the accusations that manipulation does nothing.



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