Efficacy of SMT Questioned
by Jeb McAviney B.Sc. MS.Chiro

A study published in the Journal of the Royal Society of Medicine has raised serious questions about the efficacy of spinal manipulation treatment (1). “There is little evidence that spinal manipulation is effective in the treatment of any medical condition,” said Professor Edzard Ernst of the Peninsula Medical School at Exeter.

Professor Ernst’s paper claims to have examined all systematic reviews published on spinal manipulation between 2000 and May 2005. Sixteen papers were included in the research relating to the following condition: back pain, neck pain, primary and secondary dysmenorrhoea, infantile colic, asthma, allergy and cervicogenic dizziness.

“Collectively these data did not demonstrate that spinal manipulation is an effective intervention for any of these conditions, except for back pain where it is superior to sham manipulation but not better than conventional treatments,” write the authors.

“Considering the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.. . . . . SMT has been associated with frequent, mild adverse effects and with serious, probably rare implications therefore the risk-benefit balance does not favour SMT over other treatment options such as therapeutic exercise. This statement is not in agreement with several national guidelines…but we suggest that these guidelines be reconsidered in the light of the best available data.”

This paper has not been without its critics. Some feel that Canter and Ernst have not presented any new research on SMT. Further that it is a highly selective review of the available Randomised Control Trials. There is a significant body of available data and research on the topic that has selectively been weeded out including some RCT’s that dispute their preconceived ideas. Nearly 20% of the reviews/papers that they included were their own publications. This is raises the question of bias. They have limited the evidence to suit their own arguments and included so much of their own opinionated research that this paper may be viewed as being closer to personal opinion rather than being meta-analytic in nature. If it is more a “personal opinion type paper” and the author has no personal SMT expertise should it be warrant further consideration?

It is also a concern that at the time of the press release and media debate on their paper it had not even been published. The scientific community had not had an adequate opportunity to scrutinize the claims of this paper. It had not undergone the due process of right of reply, which is essential to determining the importance of new publications.

Professor Ernsts’ publishing history is dominated by papers that question the validity of alternative health treatments. Chiropractic, osteopathy and SMT in general have been the focus of many of his reviews (2-6). It is interesting to note that his figures for the risk of vertebrobasilar accidents are some of the highest claimed (1.3 in 100 000). In a recent review paper he recognises that serious complications of SMT are rare and that cases of vertebral artery dissection are more common as a result of sporting activity than spinal manipulation. Yet he uses this paper as evidence in his review to support the view that SMT does greater harm than good. Logically it would make sense that we should also abstain from sporting activities, yet I am not sure he would make this claim.

Despite Proffessor Ernsts’ best media efforts this paper appears to have had little public impact. It seems that the evidence relied on by our patients is their own experiences. However for a profession that is striving to become evidence based we should use these challenges as inspiration to better answer these key clinical questions. The majority of patients who seek our help do so for neck pain, back pain and headaches. As a profession we need a better understanding of how effective manipulation is for these conditions. As our academic programs evolve and the available research resources increase it should be our aim to conduct high quality studies that answer the question of the effectiveness of SMT and it is not left up to reviews based on personal opinion and political agendas.

References:

1. A systematic review of systematic reviews of spinal manipulation’ by E Ernst and P.H Canter is published in the April issue (Vol. 99) of the Journal of the Royal Society of Medicine
2. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 Nov 11;61(9):1314; author reply 1314-5.
3. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 Nov 11;61(9):1314.
4. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001. Med J Aust. 2002 Apr 15;176(8):376-80. Review.
5. Chiropractic spinal manipulation for neck pain: a systematic review. J Pain. 2003 Oct;4(8):417-21. Review.
6. Ophthalmological adverse effects of (chiropractic) upper spinal manipulation: evidence from recent case reports. Acta Ophthalmol Scand. 2005 Oct;83(5):581-5. Review.