FCER Critiques Articles in Annals of Internal Medicine
Norwalk, Iowa— The June 3, 2003 issue of Annals of
Internal Medicine featured two studies which questioned the clinical
and cost-effectiveness of spinal manipulation.
The first, authored by
Willem J. J. Assendelft, et al, is titled
Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies.
The second study, authored by Daniel C. Cherkin, et al, is
A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.
careful review of these articles, Anthony L. Rosner, Ph.D., Director of
Research for the Foundation for Chiropractic Education and Research (FCER),
authored critical responses on behalf of the chiropractic profession. In
addition to sharing his understanding of what constitutes research of
clinical utility, Dr. Rosner has been able to apply his knowledge of the
better research offering significant support for spinal manipulation,
helping the chiropractic profession and the public recognize potentially
The Assendelft study concludes:
“There is no evidence that spinal
manipulative therapy is superior to other standard treatments for patients
with acute or chronic low back pain.” In his response, Dr. Rosner calls
the meta-analysis “a troubling example of how clinical data is to be
interpreted and presented for public consumption and policy
Points of contention raised and discussed include:
1) Comparative Side Effects and Relative Safety,
2) Mix of Clinical Judgment with Data from the Literature,
3) Inadmissible Criterion of Quality,
4) Guideline Rationale,
5) Meta-Analyses Themselves are Subject to Bias and Omissions,
6) Contradictions in Design,
7) Contradictions in Evaluating Statistical and Clinical Significance,
8) Data are not Shown in Areas of Interest,
9) Clinical as Opposed to Fastidious Treatments, and
10) Lack of Long-Term Followup.
Rosner’s critique concludes,
“From a variety of perspectives, this
meta-analysis appears to be both flawed and to have either obscured or
overlooked the maximal clinical benefits that might be expected to have
been conferred upon patients by spinal manipulation, particularly as
performed by a chiropractor. The patients response to intervention is far
more complex than the dimensions offered by the authors in their
the Cherkin study, Dr. Rosner questions the authors conclusions that
“Spinal manipulation has small clinical benefits that are equivalent to
those of other commonly used therapies. . . . Preliminary evidence
suggests that massage, but not acupuncture or spinal manipulation, may
reduce the costs of care after an initial course of therapy.” The flaws
in this study appear to be particularly egregious as some studies are
inexplicably omitted from the “rigorous and balanced summary” and the
lead author uses only one (his own) “widely discredited” paper to draw
his conclusions regarding cost-effectiveness and spinal manipulation.
Rosner’s complete retorts are available at www.fcer.org. In addition
to providing the chiropractic profession—and all other interested
parties—with fair and responsible responses to reports published in
medical journals and other media, FCER strives to provide the evidence to
refute such erroneous conclusions, namely quality chiropractic research.
More information on the mission of FCER, as well as means for contributing
to the chiropractic research arsenal, is available at the FCER web site.
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