I was getting ready to write about health care workers and influenza vaccination when “Spinal Manipulation for Back and Neck Pain: Does It Work?” popped up in my feeds. I read it. Ugh. Duty calls, so perhaps influenza vaccination next time. For sake of openness, I am a paid Medscape blogger, but my tax returns will not be released until after the audit is complete.

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.

Remember that when any intervention is compared to usual care, the intervention always results in improvement in subjective symptoms. As Dr. Ernst points out, it is ‘A trial design that generates only ”positive” results.’

We conclude that the ‘A + B versus B’ design is prone to false positive results

Where A is an intervention (acupuncture, chiropractic, reiki, homeopathy) and B is standard care,

Tools required to examine the growing high quality chiropractic literature on efficacy.

Tools required to examine the growing high quality chiropractic literature on efficacy.

There are too-numerous-to-count pseudo-medical studies that use this methodology and all are useless for evaluating efficacy. The ‘A + B versus B’ study only demonstrates that the researchers either did not know what they are doing for study design or have no interest in anything beyond generating propaganda.

And if you apply a flawed study design to an intervention with a prior plausibility of zero, false positives are guaranteed.

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.

Paragraph 4.

But other therapies, particularly exercise, may work just as well.

And the other therapies lack the risk of stroke and other complications, oddly not mentioned in this article. There has been the American Heart Association/American Stroke Association Scientific Statement, on the positive association between neck manipulation and subsequent stroke. That warning is always ignored by those who manipulate necks; patient safety has never been a strong suit of pseudo-medical providers. And last month there was “Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review” which found

Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication. Cervical arterial dissection (CAD) was reported in 57% (P = 0.21) of the cases and 45.8% had immediate onset symptoms.

I’ll quickly help with the rest of the paragraph 4

And the research so far leaves big questions unanswered. For example, does one technique for spinal manipulation work better than another?

You mean is one form of theatrical placebo superior? Probably not.

What is the mechanism of these techniques?

Placebo. And in the US deliberately giving placebo outside of clinical trials is often unethical, relying, as it does, on deception.

Are patients better off being treated by physical therapists, chiropractors, osteopathic physicians, massage therapists, or some other category of practitioner?

None of the above. Manipulation has only serious, if rare, risk for a mild placebo effect.

How long should a patient keep trying spinal manipulation before deciding that no more benefits are likely?

Until they have a cervical artery tear? Not a good endpoint. I suggest don’t even try it.

See how easy that was? For those interested in more details concerning the answers to these questions, they can be found on this site.

There are some incomplete statements:

Daniel David Palmer, a practitioner of magnet healing (a pseudoscientific alternative medicine practice), founded chiropractic.

Forgetting the (a pseudoscientific alternative medicine practice) after ‘chiropractic’.

They continue with:

Some focus entirely on manual therapy, whereas many others incorporate other modes of alternative medicine into their practices, such as herbal medicine or acupuncture. Some chiropractors confine themselves to musculoskeletal and neuromuscular disorders, especially for back pain, but others treat a broader range of disorders.

Which is part of the danger of sending patients to chiropractor: the wide range of useless pseudo-medicines that are often incorporated into the chiropractic practice along with a propensity for anti-vaccine rhetoric.

And no, chiropractic has no efficacy for any process and chiropractors have no education and training that would allow then to ‘treat’ a broad range of disorders. They offer worthless, dangerous, and expensive interventions often combined with the unethical sales of supplements in the office.

No one knows for sure why spinal manipulation works.

That is certainly true for those who do not read the literature, but as noted above, based on gold standard evaluations, spinal manipulation doesn’t work beyond a weak placebo. I call it beer goggles.

Palmer said chiropractic manipulation corrects subluxations—misalignments of vertebrae that impinge nerves.

That’s the pseudo-scientific alternative medicine practice I was referring to. There is no chiropractic subluxation complex. And Palmer did not think it impinged nerves so much as the subluxation blocked a mystical innate intelligence, a form of non-existent energy, concepts divorced from good sound clinical reasoning and biology (these words were chosen as a form of foreshadowing) and still held as true by the majority of DC’s and taught in their schools.

Even though the chiropractic subluxation and its correction are, at its core, rank pseudo-medicine.

Contemporary theories on the mechanism of spinal manipulation include the disruption of articular or periarticular adhesions; release of entrapped synovial folds; unbuckling of motion segments that have undergone disproportionate displacements; relaxation of hypertonic muscle; alteration of mechanoreceptors in the spinal apophyseal joints; and release of endorphins.

Just like the mechanism of acupunctures, it sounds all science-y with little to support for a mechanism for what is a poor placebo effect. More tooth fairy science.

And the coupe de grace:

However spinal manipulation works, it’s at least better than nothing when it comes to chronic low back pain, says Dr Chou.

No, it doesn’t work and everything, and anything, is always better than nothing. See that whole ‘A + B versus B’ thing above. I think you need to have more responsibility for patients’ health, wealth and lives than to use such a lame reason to send patients off for expensive and dangerous placebos.

And after all that Kellyanne-ish spin the best they can say is:

The effects of spinal manipulation appeared to be not only modest but also short in duration.

Just like a placebo. All that build-up for such a tepid conclusion?

And then they say the same about neck pain:

Gross and her colleagues reached similar conclusions about improving pain, function, and quality of life related to neck complaints.

After all that, I would quote the Bard:

spinal manipulation efficacy is a tale told by an chiropractor, full of sound and fury, signifying nothing

Then they say

Spinal manipulation is difficult to study because patients and practitioners can’t be effectively blinded to the treatment.

Yes they can.

Most effects are subjective.

And so very sensitive to biased reporting, all the more reason to evaluate efficacy using strict methodologies rather than those that generate false positives.

And it’s hard to standardize treatments from one practitioner to another.

In other words, like acupuncturists, chiropractors make it up as they go along. Another suggestion that the effects of manipulation are all placebo, you get the same outcome from a wide variety of dissimilar interventions. It is no wonder why:

…researchers couldn’t find much evidence for the superiority of any particular spinal manipulation technique or any category of practitioner. Nor could they determine the optimum frequency or duration.

Just what would be expected from a pseudo-medical placebo.

But the main reason to avoid high quality randomized, double blind sham controlled studies is that the study will be negative.

When he does refer patients for spinal manipulation, Dr Chou tries to make sure the practitioner is not going to apply additional therapies that are unproven.

LOL. As constructed the sentence reads like chiropractic is also unproven. Which it is. Paging Dr Freud. Despite that:

He advises patients to try spinal manipulation for 3-4 weeks, then move on to something else if it isn’t helping.

In my opinion that is unethical: wasting patients’ time and money on a worthless and dangerous pseudo-medical placebo.

she adds that no literature review or evidence-based algorithm can provide all of the guidance a practitioner needs to treat a patient’s back or neck pain.

Yes, but the literature can guide you to know when a therapy is useless. And understanding basic science would let a practitioner know when an intervention is almost certainly fanciful.

That is true of all of medicine, but a lousy excuse to sending patients off for what I would consider a form of fraud. The special pleading of all pseudo-medicine; that there is something in their particular intervention that makes it immune to reality-based evaluations and data.

The decision to use spinal manipulation “always has to be based on more than just research evidence”

Especially when the research evidence is negative? I wish I could get away with that in my practice, but infections have a nasty habit of progressing and killing my patients if I were to give ineffective therapy.

Gross insists. “It has to be based on good sound clinical reasoning [not present for chiropractic manipulation], biology [not present for chiropractic manipulation], the psychosocial elements around you, and the individual you are helping.”

So chiropractic manipulation has no foundation in basic science, its placebo effects are minimal and transient at best, it is dangerous, costly, and time consuming for the patient, but if one tries hard enough you can rationalize an excuse to give it a try.


Just the solution for the chronic pain problem in the US.

I wonder if I can get Kate McKinnon to read this for the Quackcast?

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.