The article focused on a recent systematic review of the effectiveness of spinal manipulation for chronic low back pain. The Cochrane Collaboration review found that this popular treatment leads to rapid short-term pain relief and improvement in function.
But the magnitude of the treatment effect was modest at best. And manipulation did not provide a “clinically significant” advantage over other common treatments for chronic low back pain, according to this review.
The HealthDay article made a key observation about chronic back pain: that there is no “silver bullet” for it. And it provided a brief but fair description of the systematic review and the evidence it considered. Our reviewers could have gone either way on several of the graded criteria, so the 4-star final score may be a bit deceiving.
What were some of the shortcomings of this article? The article had a misleading title: “Study Questions Chiropractic’s Impact on Back Pain”.
This systematic review looked at the effects of manipulation as practiced by multiple professions rather than the impact of chiropractic per se. Since the review concluded that manipulation is a viable treatment for chronic back pain, one can argue that it supports rather than questions this manual therapy.
It might have been useful to ask an impartial expert how the new review on manipulation compares with other recent reviews of the evidence in this area. And how manipulation compares with other effective treatments for chronic back pain.
Readers of this article might well have come away with the impression that all treatments for chronic back pain offer similar results. This is not the case.
Of the 200 or so therapies for chronic back pain in the medical marketplace, no treatment consistently offers a major benefit. Only a few have been proven to provide a moderate benefit for chronic back pain.
The most influential U.S. guideline found only six treatments, including manipulation, where there was “good” evidence of a “moderate benefit” for chronic back pain (See Chou et al., 2007; Chou et al., 2009).
An influential British review concluded that three general approaches (exercise, manual therapy including manipulation, and acupuncture) provide roughly equal benefit in the early management of persistent back pain. (See NICE, 2009).
So the new review on manipulation is reasonably consistent with the larger evidence picture.
It would have been useful if the article could have highlighted this point—since it offers an important message for people with chronic back pain. Based on this body of evidence, they shouldn’t be expecting heroic cures. Rather, they should look for validated treatments that can help them stay comfortable and active—and that align with their values, expectations and tolerance for risk.
References:
Chou R et al., Diagnosis and treatment of low back pain: A Joint Clinical Practice
Guideline from the American College of Physicians and the American Pain Society, Annals of Internal Medicine, 2007; 147:478-491.
Chou R et al., Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain, Spine, 2009; 34(10): 1066-67.
NICE, Early management of persistent non-specific low back pain; 2009; see http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf
Spinal manipulation is one of the most popular treatments for low back pain in the United States and many other nations. The 2007 National Health Interview Survey concluded that roughly 8.6% of U.S. adults—close to 20 million individuals—utilized chiropractic or osteopathic manipulation.
Despite its popularity, spinal manipulation is still commonly referred to as a “complementary/alternative” therapy rather than a mainstream treatment. Though it enjoys considerable support in systematic reviews and guidelines, spinal manipulation remains somewhat controversial and is not widely available in primary care medical settings. It does not enjoy completely consistent support from insurance companies.
So determining the optimal role of manipulation in the management of chronic low back pain—in both chiropractic and conventional medical settings— is an important priority.
The article did attempt to offer information on the costs of manipulation by consulting a spokesman for the American Chiropractic Association. However, the article only offered the unsatisfactory observation that costs vary. The journalist could have dug deeper and documented the range of costs per manipulation treatment—and the typical number of visits per back pain episode.
The costs and cost-effectiveness of manipulation are important issues. If multiple treatments for chronic back pain provide similar benefit, then the value of the treatment modality is really dependent on the cost.
The article offered only broad characterizations about the treatment effects of spinal manipulation for chronic low back pain. It did not attempt to quantify the treatment effects in terms of pain relief or functional improvement.
However, the systematic review that served as the focus of the article is complex and somewhat difficult to decipher, with outcomes including pain and function at different time points.
And the story did provide the reader with a reasonable summary. Manipulation appears as good or bad as other treatment options—and it may lead to more rapid pain relief.
Any review of a treatment should discuss both the benefits and risks of the treatment. The story focused entirely on the comparative effectiveness of manipulation, and ignored discussion of potential harms and adverse effects.
Many people are scared away from spinal manipulation for low back pain over the potential risk of serious complications such as cauda equina syndrome, paralysis, and death—or the exacerbation of a disc herniation. However, as the new systematic review pointed out, serious complications related to manipulation for low back pain are extremely rare.
The article provided the reader with an adequate amount of information about the study design and the inherent difficulties in interpretation of existing studies.
There was no evidence of disease mongering in this article. This article was refreshingly free of the overheated rhetoric about the “agonies” of chronic low back pain—and the need for novel treatment breakthroughs— that often permeate media features. Instead it took a sober, matter-of-fact approach.
The article did include expert commentary by a spokesman for the American Chiropractic Association. He offered reasonable and interesting comments.
However, one could argue that a spokesman for a professional organization that is heavily involved in the provision of spinal manipulation is not a truly independent and impartial source. That spokesman might be viewed as having a conflict-of-interest in offering commentary on this topic. So it would have been useful for the article to include the views of another expert commentator as well.
The article did provide information on how spinal manipulation stacked up against other treatments for back pain, as reported in the systematic review.
However, it did not discuss the larger body of evidence on treatments for chronic low back pain—or what other reviews and guidelines have concluded about the role of spinal manipulation in its management.
We’ll give the story the benefit of the doubt on this criterion.
The article gets a “satisfactory” because it pointed out that manipulation is commonly performed by multiple healthcare professions. It would have been useful to mention that manipulation is not routinely available in conventional primary care medical settings. And despite its evidence record, it does not generally enjoy completely consistent insurance coverage. The same points apply to massage.
Manipulation is an age-old treatment. There was no reason for the article to discuss its novelty.
The article did not appear to rely on a news release.
Systematic, Criteria-Driven
Monday at #ADA2021, an infectious disease epidemiologist, a journalist, and a researcher shared perspectives on communication of risk in the era of COVID-19: http://ow.ly/ROfR30rMeE7 @AstleyCM @garyschwitzer @berthahidalgo @ADA_DiabetesPro
Shoutouts to @susan_bewley @drkevinknopf @MichaelBaum11 in this call for more than fawning coverage from press releases for these kinds of stories.
Also, linked history inside goes back 5 years just on Grail apparently trying to become Holy Grail. https://twitter.com/garyschwitzer/status/1408849696416841731
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