Spinal Manipulation Therapy – A Sham Procedure?

Spinal Manipulation Therapy – A Sham Procedure? | Medpage Today | Apr 2017

Proponents have proclaimed a slew of benefits of spinal manipulation therapy, but most data is anecdotal. Spinal manipulation therapy is one of those treatments that just thrives on anecdote.

If you’re like me, you’re skeptical about some of the claims certain providers make about spinal manipulation. Mostly because a lot of these claims lack biologic plausibility

So I was intrigued to see this meta-analysis appearing in the Journal of the American Medical Association: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis.  

Would spinal manipulation prove the panacea for painful posteriors? Or would the anecdotal evidence wash away amidst a torrent of hard data?

Twenty-six randomized trials were found. Most of them … weren’t great. No studies blinded the provider (though I admit that would be tough). And only four blinded the patients by using sham procedures.

Let’s look at the effect of spinal manipulation on pain scores.

Broadly speaking, spinal manipulation reduced pain scores by about 10 points out of a 100-point scale.

Is that meaningful?

Just one level on the usual 1-10 pain scale isn’t worth much by itself, but it might allow a patient to get by with a little lower opioid dose for a while after the therapy. 

We don’t really know, because the minimum clinically important difference for low back pain hasn’t been established yet. But that 10-point difference is about what you see when you use NSAIDs for low back pain.  [NSAIDs have already been proven ineffective for spinal pain -zyp]

The meta-analysis also found high heterogeneity of effect. What that means is that the results of the trials don’t hang together very well – they are all over the map.

Here’s another problem with standardization: practitioners are not and cannot be standardized. 

My theory on the heterogeneity?

Spinal manipulation is by no means a uniform treatment. It’s not like a chemical compound, where everyone gets exactly the same thing. Some providers use a “thrust” technique. Some don’t. Some have soft music playing in the room, some don’t. It may be any of these factors that actually help the back pain

But for a study to be reliable, it needs to be rigorous. And the most rigorous studies in this meta-analysis, those that randomized patients to spinal manipulation or sham spinal manipulation, showed no effect

Perry Wilson, MD, MSCE, is an assistant professor of medicine at the Yale School of Medicine. He is a MedPage Today reviewer, and in addition to his video analyses, he authors a blog, The Methods Man. You can follow @methodsmanmd on Twitter.
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