Public health

‘Back cracking’ review a bit of a stretch

A meta-analysis that concludes spinal manipulation offers the same benefits as NSAIDs for people with acute low back pain is a bit of stretch, an Australian expert says.

The meta-analysis of 26 randomised clinical trials of spinal manipulation versus sham or other treatments concluded patients experienced improvements in both pain and function.

“The size of the benefit for pain (−9.95 mm) is about the same as the benefit for nonsteroidal anti-inflammatory drugs in acute low back pain (−8.39 mm) according to the Cochrane review on this topic,” they wrote in the latest JAMA.

But Professor Chris Maher, from the George Institute for Global Health, told the limbic the authors’ conclusions were ‘mischievous’ as the two reviews could not be compared directly.

“Is spinal manipulation better than sham interventions? No. Is spinal manipulation better than almost everything else? There may be a small effect but some of these comparison therapies may not be effective.”

“My view is they have overspun the findings and I am disappointed that JAMA couldn’t see through that.”

The review found only minor adverse events such as increased pain, muscle stiffness and headache.

The studies included spinal manipulation provided by a range of health professionals – physical therapists, chiropractors, medical doctors and osteopaths.

An accompanying editorial by Professor Richard Deyo said spinal manipulation of the lumbar spine did have the advantage of fewer known side effects than NSAIDs.

“For example, among patients taking nonsteroidal anti-inflammatory drugs, renal function abnormalities occur in approximately 1% of patients, and superficial gastric erosions or asymptomatic ulcers may occur in up to 5% to 20% of users,” he wrote.

Professor Deyo, a member of the Editorial Board of the Cochrane Collaboration’s Back Review Group, said the costs of care associated with spinal manipulation might be higher than pharmacological intervention but likely to be offset by less overall harm.

Professor Maher said many patients could be encouraged to self-manage their low back pain with advice such as avoiding bed rest, finding relief in heat packs and gradually increasing physical activity.

“With just a little bit of sensible advice, there is a good chance that 50% of patients will recover in two to three weeks,” he said.

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