Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines

"The guidelines considered 'a total of seven RCTs on manipulation/mobilisation techniques' for evaluating effectiveness. A Cochrane review included 39 RCTs. The methods section of the guidelines informs us that 'articles not relevant to the subject in question were excluded'. It is unclear to me why so many RCTs of spinal manipulation were excluded from the NICE guidelines…

Perhaps more crucially, the risks were under-estimated. The risk of mild to moderate adverse effects is undisputed even by chiropractors: about 50% (!) of all patients suffer from such adverse effect after spinal manipulations (10). These effects (mostly local or referred pain) are usually gone after 1–2 days but, considering the very moderate benefit, they might already be enough to tilt the risk-benefit balance in the wrong direction. In addition, several hundred (I estimate 700) cases are on record of dramatic complications after spinal manipulation. Most frequently they are because of vertebral arterial dissection (5). Considering these adverse events, the risk-benefit balance would almost certainly fail to be positive. It is true, however, that the evidence as to a causal relationship is not entirely uniform. Yet applying the cautionary principle, one ought to err on the safe side and view these complications at least as possibly caused by spinal manipulations.

So why were these risks not considered more seriously? The guideline gives the following reason: ‘The review focussed on evidence relevant to the treatment of low back pain, hence cervical manipulation was outside our inclusion criteria’. It is true that serious complications occur mostly (not exclusively) after upper spinal manipulation. So the guideline authors felt that they could be excluded. This assumes that a patient with lower back pain will not receive manipulations of the upper spine. This is clearly not always the case.

Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment of spinal manipulation for back pain.

The guidelines have a number of serious flaws. I contend that they over-estimated the effectiveness of spinal manipulation and under-estimated the risks of this treatment. If evaluated on the basis of the best current evidence by applying the cautionary principle, one will arrive at the following conclusion: it is uncertain whether spinal manipulation generates more benefit than harm for patients suffering from back pain."

Edzard Ernst, Int J Clin Pract (18th August 2009) [No abstract or full text — reprints available from author]