evidence that high-velocity spinal ma-nipulation is more effective than low-velocity spinal mobilization, or that the profession of the manipulator affects the effectiveness of treatment.” 3 The reference they provide is not a systematic review of spinal manipula-tion at all and certainly not a systematic review of a comparison of thrust spinal manipulation vs mobilizations or the effects of the profession of the manip-ulator on outcomes. The study they cite is a review of NSAIDs: van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Non-steroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25: 2501–13. Here is what the authors conclude. “If patients have high rates of recovery with baseline care [paracetamol] and no clinically worthwhile benefit from peer-review, it is consistently rated as one of the highest quality studies of SMT in systematic reviews. Contrast this with the systematic review by Hidalgo et al. published in the Journal of Manual and Manipula-tive Therapy. This is the only systematic review that I am aware of that distin-guishes between thrust vs non-thrust SMT. “Two stages of LBP were cate-gorized; combined acute-subacute and chronic. Further sub-classification was made according to MT intervention: MT1 (manipulation); MT2 (mobiliza-tion and soft-tissue-techniques); and MT3 (MT1 combined with MT2). 4 The authors conclude that thrust manipulation is superior to non-thrust manipulation or mobilizations and to placebo for both acute-subacute and chronic low back pain. “Firstly, in comparison to previous reports of lim-ited evidence showing no difference “If we want valid answers...we need to conduct valid studies....” the addition of diclofenac or spinal manipulative therapy, then GPs can manage patients confidently without exposing them to increased risks and costs associated with NSAIDs or spinal manipulative therapy.” 3 The authors cite no evidence of in-creased risk or costs associated with SMT compared to paracetamol or NSAIDs, and they also fail to provide a shred of evidence of “high rates of recov-ery with baseline [paracetamol] care.” This is understandable: there has never been a shred of evidence for the effec-tiveness of paracetamol. One wonders how GPs “can manage patients confi-dently” with an intervention that has zero evidence of effectiveness. I guess they can at least feel confident knowing they are not exposing patients to the increased risk and costs of dangerous and ineffective SMT! Give me a break. The bias against SMT and for an inter-vention with not a shred of evidence is pathetically obvious, intellectually dis-honest, and scientifically unfounded. Keep in mind, this study not only passed between true and sham manipulation, the results of this systematic review show moderate to strong evidence for the beneficial effects of [thrust] manip-ulation in comparison to sham manip-ulation. “These differences are demon-strated in terms of pain relief, functional improvement, and overall-health and quality of life improvements in the short-term for all stages of LBP.” 4 This rating makes thrust SMT the most highly rated intervention for both acute-subacute and chronic low back pain. Imagine if they also controlled for valid doses of care. It’s not just that many “SMT” stud-ies do not include manipulation, many also include only 1-3 SMT treatments. The results of these studies then get pooled in systematic reviews with the very few studies that include valid doses of thrust SMT care. What do you think this does to the rating of the level of evidence of effectiveness for SMT in systematic reviews? I remind you again, neither dose of care nor timing of out-come measures, nor thrust vs non-thrust SMT is accounted for by the JADAD quality rating scale. For just a few of many examples: A study published in the Spine Journal in 2016 that concluded that SMT elicited no clinically meaningful benefit for pa-tients with chronic low back pain only included three once-weekly sessions of SMT over a month, and the outcomes were assessed a full month after cessa-tion of care. 5 Another study in 2015 published in JAMA included 3-4 ses-sions of SMT over four weeks, measured outcomes at three months and one year, and concluded SMT elicited no clini-cally meaningful benefit. 6 Not only are two to three SMT treat-ments not representative of clinical practice, this dose of care is not repre-sentative of the peer-reviewed literature. As Haas et al. point out in one of the few valid studies conducted on dose of care, “Therefore 12 sessions of SMT is the current best estimate for use in compar-ative effectiveness trials.” 7 If we want valid answers about the effectiveness of SMT we need to con-duct valid studies and write valid sys-tematic reviews with valid selection criteria and quality rating scales. We have failed on all accounts. You will be hard pressed to find more than a very few SMT studies that include a valid dose of thrust SMT care or systematic reviews that take these very significant variables into consideration. We need to standardize how we study chiropractic SMT. We need to opera-tionally define SMT as high-velocity low amplitude thrust SMT and not allow mobilizations to be defined as SMT. Mobilizations need to be defined and studied as a separate intervention. We also need a standardized frequency of SMT treatments or interventions for a standardized duration. My suggestion would be to make research mimic clini-cal practice and the conclusions of the Haas et al. study. Why not set a stand-ardized frequency of 3x/week for two weeks, measure outcomes, then, if im-provement is shown but not complete, do another period of 3x/wk for two weeks and then remeasure the outcomes. This would provide a lot of data re-garding whether or not, and how much, patients improve in terms of pain and function at two weeks, and, if they are not completely resolved, if a further www.Cndoctor.ca 18 Chiropractic and Naturopathic Doctor July/August 2020
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