A systematic review of systematic reviews of spinal manipulation

J R Soc Med 2006;99:192-196
doi:10.1258/jrsm.99.4.192
© 2006 Royal Society of Medicine

 

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J R Soc Med 2006;99:192-196
© 2006 The Royal Society of Medicine


E Ernst
P H Canter


Complementary Medicine, Peninsula Medical School, Universities of Exeter
& Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK

Correspondence to: Professor E Ernst
E-mail:
Edzard.Ernst{at}pms.ac.uk

 




SUMMARY

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Objectives: To systematically collate and evaluate the evidence from recent
systematic reviews of clinical trials of spinalmanipulation.

Design: Literature searches were carried out in four electronic databases
for all systematic reviews of the effectiveness of spinal manipulation in any
indication, published between 2000 and May 2005. Reviews were defined as
systematic if they included an explicit and repeatable inclusion and exclusion
criteriafor studies.

Results: Sixteen papers were included relating to the following conditions:
back pain (n=3), neck pain (n=2), lower back pain and neck
pain (n=1), headache (n=3), non-spinal pain (n=1),
primary and secondary dysmenorrhoea (n=1), infantile colic
(n=1), asthma (n=1), allergy (n=1), cervicogenic
dizziness (n=1), and any medical problem (n=1). The
conclusions of these reviews were largely negative, except for back pain where
spinal manipulation was considered superior to sham manipulation but not
betterthan conventional treatments.

Conclusions: Collectively these data do not demonstrate that spinal
manipulation is an effective intervention for any condition. Given the
possibility of adverse effects, this review does not suggest that spinal
manipulation is a recommendable treatment.




INTRODUCTION

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Spinal manipulation (SM) is a traditional form of treatment practised by
chiropractors, osteopaths, physiotherapists and other healthcare providers
mostly (but not exclusively) to treat musculoskeletal problems. A precise
definition of SM is still under
debate1 but most
experts would probably agree that SM can be described as `the use of hands
applied to the patient incorporating the use of instructions and manoeuvres to
achieve maximal painless movement and exposure of the musculoskeletal
system’2 or as `the
application of a load (force) to specific body tissues with therapeutic
intent’.3 The
postulated modes of action of SM include: increase of joint movement, changes
in joint kinematics, increase of pain threshold, increase of muscle strength,
attenuation of alpha-motoneuron activity, enhanced proprioceptive behaviour,
as well as release of beta-endorphins and substance
P3.

Spinal manipulation is popular. About 70 000 chiropractors are licensed in
the US, 10 000 in Japan, 6000 in Canada, 2500 in Australia and 16 000 in the
UK.4 The costs
associated with SM are
substantial.5 It is
therefore desirable to define the effectiveness of this approach as closely as
possible. Numerous systematic reviews of SM are available but they frequently
arrive at vastly different conclusions. This article summarizes the evidence
from recent systematic reviews and aims at clearing some of the existing
confusionabout the effectiveness of SM.




METHODS

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Electronic literature searches were conducted to identify all systematic
reviews of spinal manipulation for any indication. The search
[Chiropract* OR spinal manipul* OR manual
therap* OR osteopath*] AND [systematic ADJ review] was
carried out in the following electronic databases: Medline, Embase, AMED,
Cochrane Database. In those databases which allowed it, searches were further
limited to articles classified as reviews or meta-analyses and, in all cases,
the search was restricted to articles published between 2000 and May 2005. No
language restrictions were applied. Abstracts of reviews thus located were
inspected by one author (PC) and those appearing to meet the inclusion
criteria were retrieved and read in full by both authors. Reviews were defined
as systematic if they included an explicit and repeatable method for searching
the scientific literature and if there were explicit and repeatable inclusion
and exclusion criteria for studies. These criteria are the first two items
from a scoring system previously used to assess the methodological quality of
reviews of spinal
manipulation.6

To be included, systematic reviews had to be concerned specifically with
the effectiveness of SM and to include evidence from at least two controlled
clinical trials. Systematic reviews were considered regardless of the medical
condition they referred to. Systematic reviews of complex packages of
interventions which happened to include SM were excluded. Reviews which
depended upon previous systematic reviews for their primary data were also
excluded.

Data were extracted independently by two researchers (PC & EE) using
pre-defined criteria (Table 1).
Disagreements wereresolved by discussion between the authors.



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Table 1. Systematic reviews of spinal manipulation (SM)

 




RESULTS

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 RESULTS
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After accounting for duplicate publications, the searches described
resulted in the identification of 24 unique articles. Eight reviews were
excluded. The reasons for exclusion were: protocol only (n=1),
practise guideline (n=1), based on previous systematic reviews
(n=2), no explicit inclusion and exclusion criteria (n=3),
no conclusion regarding effectiveness (n=1). Sixteen systematic
reviews were included (Table
1
). There was some overlap in relation to indications and the
following conditions were included: back pain, neck pain, headache, any
non-spinal pain, primary and secondary dysmenorrhoea, infantile colic, asthma,
allergy, cervicogenic dizziness, any
condition.722
The reviews tended to include either any type of SM or specifically focused on
chiropractic SM. Five systematic reviews included more than 10 primary
studies712
and two had opted for a meta-analytical
approach.9,12

Generally speaking, the conclusions drawn from these systematic reviews
were disappointing. The meta-analysis by Assendelft et
al
.9 suggested
that SM was superior to sham therapy or to ineffective/harmful interventions
for low back pain. The meta-analysis by Gross et
al
.12 implied
that combining SM with other treatments, particularly exercise, is effective
in reducing neck pain but demonstrated that SM is not effective as a singular
treatment.
Bronfort10
concluded that SM and/or mobilization are viable options for treating low back
and neck pain.
Bronfort13
concluded that SM has a better effect than massage and a comparable effect to
prophylactic drugs for headache.
Reid21 found only
limited evidence from methodologically poor trials for effectiveness in
cervicogenic dizziness. All other conclusions agreed that the effectiveness of
SM is not supported by the results from rigorous clinicaltrials.




DISCUSSION

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Go to previous sectionSUMMARY

Go to previous sectionINTRODUCTION

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 DISCUSSION
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Overall, there is little evidence in recent systematic reviews that SM is
effective in any medical condition. We found 4 systematic reviews of SM for
low back
pain710
of which only one10
recommended its use. The remaining three systematic
reviews,79
concluded that there was little evidence to support such advice.
Ferreira7 concluded
that SM is not substantially more effective than sham treatment for pain and
no better than NSAIDs in improving disability in chronic back pain. The most
recent, most comprehensive and most authoritative
review9 states that
SM or mobilization is superior to sham treatment and to detrimental or
ineffective treatments but not better than other interventions for back
pain.

Three systematic reviews were related to SM for neck
pain1012
of which one reached a a
positive10 overall
conclusion and this was the same review which reached a positive conclusion
regarding back pain. The most authoritative of the three
reviews12 stated
that SM/mobilization is effective only when combined with other interventions
such as exercise and as a sole treatment for neck pain, it is not of
demonstrable effectiveness.

Similarly, there are three systematic reviews of SM for
headache.1315
While Bronfort et
al
.13
concluded that SM is as effective as other interventions, the other two teams
of
reviewers14,15
did notfind conclusive evidence in favour of SM.

The evidence from the other systematic reviews of SM for non-spinal
pain,16
dysmenorrhoea,17
infantile colic,18
asthma,19,20
cervicogenic dizziness and any
condition21 is
uniformly negative.

Overall, the demonstrable benefit of SM seems to be minimal in the case of
acute or chronic back pain; controversial in the case of headache; or absent
for all other indications. Other interventions, e.g. exercise therapy, may
therefore be
preferable.2325
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.

All systematic reviews are prone to publication bias within the primary
research data which they include and because our study is a systematic review
of systematic reviews, any such bias may have been inherited in our study. In
our view, such effects would have tended to favour SM. Our own search strategy
was thorough, and although we cannot be absolutely sure that all relevant
systematic reviews were located, we believe that publication bias is likely to
have been less of a problem in identifying systematic reviews than in
identifying all relevant clinical trials. Our previous
work6 has shown that
the conclusions of reviews of SM for back pain appear to be influenced by
authorship and methodological quality such that authorship by osteopaths or
chiropractors and low methodological quality are associated with a positive
conclusion. It is perhaps relevant to note that all three of the overtly
positive recommendations for SM in the indications back
pain,10 neck
pain10 and
headache13
originate from the same chiropractor. Ernst and/or Canter, the present
authors, conducted three of the systematic reviews
included8,11,16
and all three reviews reached negative conclusions about the effectiveness of
spinal manipulation. However, these systematic reviews were themselves carried
out in a rigorous and systematic fashion and we therefore do not believe that
their inclusion representsa source of any additional bias.

We do not have other systematic reviews of systematic reviews of spinal
manipulation with which to compare our conclusions, but they are consistent
with the conclusions of 13 of the 16most recent systematic reviews.

Spinal manipulation has been associated with frequent, mild adverse
effects26 and with
serious (probably) rare
complications.27
Therefore the risk-benefit balance does not favour SM over other treatment
options such as physiotherapeutic exercise. This statement is not in agreement
with several national guidelines, for instance, for the treatment of back
pain.2830
We suggest that these guidelines be reconsidered in the light of the best
available data.

In conclusion, we have found no convincing evidence from systematic reviews
to suggest that SM is a recommendable treatment option for any medical
condition. In several areas, where there is a paucity of primary data, more
rigorous clinical trials couldadvance our knowledge.




Footnotes


Competing interests None.




REFERENCES

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Go to previous sectionSUMMARY

Go to previous sectionINTRODUCTION

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 REFERENCES

 

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