Is manipulative therapy more effective than sham manipulation in adults?: a systematic review and meta-analysis

Abstract

BackgroundManipulative therapy is widely used in the treatment of spinal disorders. Manipulative techniques are under debate because of the possibility of adverse events. To date, the efficacy of manipulations compared to sham manipulations is unclear. The purpose of the study is: to assess the efficacy of manipulative therapy compared to sham in adults with a variety of complaints.Study designSystematic review and meta-analysis.MethodsBibliographic databases (PubMed, EMBASE, CINAHL, PEDro, Central) along with a hand search of selected bibliographies were searched from inception up to April 2012.Two reviewers independently selected randomized clinical trials (RCTs) that evaluated manipulative therapy compared to sham manipulative therapy in adults, assessed risk of bias and extracted data concerning participants, intervention, kind of sham, outcome measures, duration of follow-up, profession, data on efficacy and adverse events. Pooled (standardized) mean differences or risk differences were calculated were possible using a random effects model. The primary outcomes were pain, disability, and perceived recovery. The overall quality of the body of evidence was evaluated using GRADE.ResultsIn total 965 references were screened for eligibility and 19 RCTs (n = 1080) met the selection criteria. Eight studies were considered of low risk of bias. There is moderate level of evidence that manipulative therapy has a significant effect in adults on pain relief immediately after treatment (standardized mean difference [SMD] - 0.68, 95% confidence interval (-1.06 to -0.31). There is low level of evidence that manipulative therapy has a significant effect in adults on pain relief (SMD - 0.37, -0.69 to -0.04) at short- term follow-up. In patients with musculoskeletal disorders, we found moderate level of evidence for pain relief (SMD - 0.73, -1.21 to -0.25) immediate after treatment and low level of evidence for pain relief (SMD - 0.52, -0.87 to -0.17) at short term-follow-up. We found very low level of evidence that manipulative therapy has no statistically significant effect on disability and perceived (asthma) recovery. Sensitivity analyses did not change the main findings. No serious adverse events were reported in the manipulative therapy or sham group.ConclusionsManipulative therapy has a clinical relevant effect on pain, but not on disability or perceived (asthma) recovery. Clinicians can refer patients for manipulative therapy to reduce pain.

Chiropractic spinal manipulative therapy for migraine: a three‐armed, single‐blinded, placebo, randomized controlled trial

“…Secondly, consensus on an inert placebo treatment is lacking . Thirdly, previous attempts to include a placebo group have omitted validating the blinding, thus, it remains unknown whether active and placebo treatment were concealed . Due to these challenges we decided to conduct a three‐armed, single‐blinded RCT, which also included a control group that continued usual pharmacological treatment in order to obtain an indication of the magnitude of the placebo response.…”

Validation of Placebo in a Manual Therapy Randomized Controlled Trial

“…Although most manual-therapy RCTs are pragmatic, a few manual-therapy studies have included a placebo intervention 11 , e.g., for mechanical neck pain 18 19 , low back pain 20 21 22 23 24 , and primary dysmenorrhoea 25 26 . However, all these studies omitted from validating blinding.…”

“…However, the study group failed in their attempt to blind the study participants to the group allocation 10 . Thus, significant challenges remain in the development of a valid manual placebo treatment 11 .…”

Chiropractor interaction and treatment equivalence in a pilot randomized controlled trial: an observational analysis of clinical encounter video-recordings

“…To our knowledge, this study is the first to assess the equivalence of verbal interactions and treatment delivery for a doctor of chiropractic providing active and sham chiropractic interventions within the context of a randomized controlled trial. Many studies of spinal manipulation or other chiropractic therapies have used sham adjustments as a comparator [ 36 , 56 ], including those using a detuned Activator adjusting instrument as the sham [ 37 , 57 ]. Researchers who conduct sham or placebo-controlled trials of complementary therapies, including chiropractic, have espoused the need for the standardization of the non-specific aspects of treatment, including treatment duration and the interventionists’ verbal and non-verbal communications, between study groups [ 37 , 52 , 58 ].…”