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Spinal manipulation for chronic back pain?

Edzard Ernst discusses the effectiveness of spinal manipulation for patients with recurrent back pain.

NICE recently sanctioned chiropractic and osteopathy for recurrent back pain. The positive verdict was subsequently harshly criticised. Two new Cochrane reviews might now re-ignite this debate.

The authors of the first (actually an update of a previous review) evaluated 26 RCTs (18 more than the previous version) and found strong evidence that, compared to other treatments, the effect of spinal manipulation on pain and function is not clinically relevant. They also found weak evidence to suggest that the effects of spinal manipulation are mainly due to placebo [1]. Here is what the authors conclude from their findings:

'High quality evidence suggests that there is no clinically relevant difference between spinal manipulation therapy and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham spinal manipulation therapy, and data related to recovery.'

Chiropractors usually counter that they do more than just spinal manipulation. In this context, a second new Cochrane review is relevant. It was specifically aimed at determining whether combination treatments used by chiropractors are effective. Its conclusions are sobering:

'Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute lower back pain. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with lower back pain when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.' 2

Taken together these reviews provide little reason to send back pain patients to chiropractors or osteopaths, particularly if we consider the risks and costs of spinal manipulation. I'm sure, however, that some will claim the opposite. What do you think?

Professor Edzard Ernst is professor of complementary medicine at the Peninsula Medical School, University of Exeter

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