Beyond spinal manipulation
Article Outline
- 1. Is SM evidence-based healthcare?
- 2. What are the risks from SM?
- 3. Beyond spinal manipulation
- 4. Summary
- References
- Biography
- Copyright
Arguably, spinal manipulation (SM) is the term most universally associated with osteopathy, or is seen in the eyes of other health professionals and the general public as a defining feature of osteopathy. It is where our ‘power’ starts, where we begin to talk and interact with the world. It is possibly the only area of knowledge that we feel sufficiently confident to enable us to develop a discourse, to communicate with society. But as with most language, it creates different meaning for different people, there is not one absolute definition. So, when we read ‘spinal manipulation’, we may neither agree with what is being said, nor understand what the message is. This requires osteopaths to work harder then to develop ‘common ground’ and to develop knowledge that can be useful to society, and at the same time useful to them. A recent example in the scientific literature using the term spinal manipulation (SM) can be found in the UKBEAM clinical trial.2 This definition of SM was agreed by the chiropractic, physiotherapy and osteopathic professions, based on an osteopathic definition.5
Spinal manipulation has been criticised in the UK medical press recently,1 albeit not by researchers in the musculoskeletal community! This has produced responses of varying quality from the manipulating professions,4 however, the evidence base for SM is variable.
1. Is SM evidence-based healthcare?
The foundational principles and concepts of osteopathy promulgated by the osteopathic profession present a view that musculoskeletal disorders are caused or maintained by musculoskeletal faults, and that osteopathic intervention can alter this state significantly. Concepts such as asymmetric spinal mobility, intersegmental stiffness and soft tissue tenderness, generally termed somatic dysfunction (SD), are given as evidence for intervention requiring SM. Other musculoskeletal clinicians such as physiotherapists, chiropractors and manipulating medical practitioners also use the model of SD as both evidence for and cause of musculoskeletal disorders – if analysed objectively, the difference between these professions appears to be very little. But what is the evidence to support the concept of somatic dysfunction as a cause of pain and disability or musculoskeletal disorders? What is the benefit of SM in dealing with musculoskeletal disorders? And what are the risks to patients from the use of SM?
If we take low back pain (LBP) as a useful example, the evidence for somatic dysfunction as a significant cause of pain and disability is limited. The dominant model for understanding musculoskeletal pain and disability related to the low back is the biopsychosocial model.8 The evidence supporting the biopsychosocial model suggests that traditional biomechanical diagnosis and intervention is not optimal care. The initial cause of the back pain may well have been biomechanical, but the effect of pain and the effect of other people on an individual in pain, including care-seeking itself, can have significant consequences for that individual, and these psychological and social influences need to be recognized and acted on.8
On a positive note though, recent scientific evidence suggests SM is as effective as other traditional health interventions (physiotherapy, medication, GP care) for LBP and may be the most cost effective option if combined with exercise advice and guidance on being active and returning to work.3, 6, 7
However, the evidence so far does not tell us which LBP patients benefit most from SM. Attempts are being made by researchers to classify low back pain in some useful way, which may help in future research design for clinical trials.
2. What are the risks from SM?
Research data on the risks from SM are sparse, and most of the data are from studies of SM in the chiropractic, medical and physiotherapy professions, although a recent contribution from the osteopathic community is available.9 There is an urgent need to collect primary data about the risk of SM from osteopathic clinical sources. Sufficient evidence is available, however, to suggest cervical manipulation could have serious side effects, rare, but of concern. A significant research project on adverse effects of SM is in planning stages in the UK, funded by the General Osteopathic Council.
3. Beyond spinal manipulation
A final comment is targeted at primary healthcare more generally. Why do people consult, what do people expect from primary healthcare, and from osteopathy in particular? These are fundamental questions that are only beginning to be asked. Consumerism is a reality in healthcare, the market is gaining power and the power of professionals is decreasing (de-professionalisation). With these social changes, researchers need to think hard about their previous assumptions. It is time to ask the consumer what our research questions should be, instead of assuming as professionals that ‘we know’. This will require significant qualitative research as a prerequisite to understanding what the priorities are, and what future primary care research design should be.
Perhaps SM will assume less importance within our profession as patient-led issues rise to the fore. Osteopaths are well placed philosophically, with their particular emphasis on patient-centered healthcare and holism, to take a lead here in primary care research, but, this requires vision to a future of patient-centered evidence-based healthcare: a future that may well require the rejection of historical professional rhetoric, acceptance of new evidence as it becomes available, and the acquisition of new skills. All this whilst maintaining – or perhaps not – a unique identity for osteopathy.
4. Summary
References
- . A systematic review of systematic reviews of spinal manipulations. J R Soc Med. 2006;99:192–196
- . Spinal manipulation for low back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations. Man Ther. 2003;8:46–51
- . Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005;4:43
- Letters. J R Soc Med. 2006;99:277–279
- . Osteopathic management of mechanical low back pain. In: Giles L, Singer K editor. The clinical anatomy and management of back pain series, vol. 1: Clinical anatomy and management of low back pain. Oxford: Butterworth-Heinemann; 1997;p. 358–368
- . United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. Br Med J. 2004;329:1377
- . United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. Br Med J. 2004;329:1381
- . The back pain revolution. 2nd edition. Edinburgh: Churchill Livingstone; 2004;
- . HVLA thrust techniques: What are the risks?. Int J Osteopathic Med. 2006;9:4–12
Tim McClune, DO, a practicing osteopath since 1989, researcher at the Spinal Research Unit Huddersfield University, UK since 1993, Member of the National Council for Osteopathic Research since 2003, Elected member of the General Osteopathic Council, UK since May 2006 and currently researching history and professionalisation of osteopathy in the UK for Ph.D. thesis at University of Brighton.
PII: S1746-0689(07)00010-7
doi:10.1016/j.ijosm.2007.02.001
© 2007 Elsevier Ltd. All rights reserved.
