Review queries benefits of spinal manipulation

GPs should continue to refer patients with musculoskeletal problems to chiropractors or osteopaths where necessary, experts say, despite a damning review of the efficacy of such treatments.

NICE's draft guidance on stabilisation procedures for low back pain state that: 'Chiropractic intervention and posture training can limit episodes of acute pain.'

But a review of 16 previous reviews of the effect of spinal manipulation for a variety of conditions carried out by Professor Edzard Ernst, the UK's only professor of complementary medicine, recommended that spinal manipulation should be removed from treatment guidelines because there was no evidence to support its effectiveness.

The 16 reviews included studies on back pain, neck pain, non-spinal pain, primary and secondary dysmenorrhoea, infantile colic, asthma, allergy, cervicogenic dizziness, and any medical problem.

Although one review did support the effectiveness of manipulation for the treatment of back pain, the meta-review's authors concluded that there was 'no convincing evidence to suggest spinal manipulation is a recommendable treatment option for any medical condition'.

They also warned that spinal manipulation was associated with frequent mild adverse effects and serious rare complications.

Dr David Byfield, a chiropractor and lecturer at University of Glamorgan's school of applied sciences, said that the methodology of the review was flawed.

'Aggregating all these conditions is a big mistake,' he said. 'Many are not musculoskeletal conditions. And they have omitted some relevant positive trials.'

He added that the 2004 European Back Pain Guidelines recommended manipulation as part of a package of care for acute and chronic back pain.

Dr Leslie Wootton, a GP and osteopath in Gravesend, told GP that the reviewers had ignored good evidence showing manipulation was effective, such as the UK Back pain Exercise And Manipulation (BEAM) trial.

'This work could find no evidence to suggest spinal manipulation is not effective,' he said.

Dr Wootton added that other treatment options, such as NSAIDs, were not free of side-effects.

The General Osteopathic Council, which has 69 GPs on its register, is working on developing a greater evidence base for manipulation.

The final draft NICE low back pain guidance is due out this year.

- J R Soc Med 2006 99: 189-93

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