Systematic review of studies on effects of manipulative therapy

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

Manipulative therapy (MT) is the subject of ongoing research investigating its effectiveness and safety. The nature of the intervention, however, presents challenges regarding blinding of study participants and introduction of a sham control group. The current review was undertaken to evaluate the efficacy of manipulative therapy when compared with a “sham manipulative therapy.”

Study methods
Medline, Embase, Cinahl, Central and Pedro electronic databases were searched, from inception to April 2012. Search terms relating to intervention, comparison and design were combined in the final search.

Randomized, controlled trials comparing MT with sham MT in adult patients, regardless of condition treated, outcomes measured or additional/adjunctive interventions were deemed eligible for this study.

Risk of bias was evaluated using the Cochrane Back Review Group criteria. A study was considered to have low risk of bias if it fulfilled at least six of the 12 criteria items established by the Cochrane Group.

Pertinent results
Initial searches yielded 965 potentially eligible studies. Thirty-five studies were assessed in full text and 19 studies comparing manipulative therapy with a sham manipulation were chosen for inclusion in the review. 

Effect of manipulative therapy
Pain: Data from seven studies was pooled, demonstrating a low level of evidence indicating that manipulative therapy provided a statistically significant decrease in pain scores in short-term follow-up. Moderate evidence was provided to indicate that MT provides superior pain relief compared to sham treatment in an intermediate follow-up time. In the long-term follow-up, there was low-level evidence in support of MT versus sham treatment.  

Condition: For patients with general musculoskeletal (MSK) complaints, there was low-to-moderate level support for use of MT versus sham MT. For patients with neck and/or low back pain, only a low level of evidence was provided to support MT over sham MT. For non-MSK complaints, a non-significant improvement was noted with MT versus sham MT. 

Profession: No statistically significant difference was noted between the four professions providing MT treatment in any of the included studies.

Disability: A low level of evidence indicated that MT had no effect on disability versus sham MT.

Range of Motion: A very low level of evidence suggested that MT is no more effective at improving range of motion as compared with sham MT. 

Adverse Events: Eleven studies did not report on adverse events, while four studies reported no adverse events occurred. Any adverse events reported in the remainder of the studies were limited to minor aggravation of neck pain or headaches, muscle soreness or local discomfort. Similar adverse events were reported in the sham MT group in some studies. No serious complications were reported in any study utilizing MT or sham MT.

Conclusions and practical applications
MT was found to be effective at relieving pain in short-, intermediate- and long-term follow-up periods after treatment when compared with sham MT. No effects were noted on disability or pulmonary conditions. Further, no serious adverse effects were noted in any of the included studies. Minor adverse effects such as muscle soreness or other MSK aggravations were noted in both the MT and sham MT groups, suggesting no greater risk of adverse effects when using actual MT.

The body of literature – now including this systematic review – suggests that MT is a safe and effective intervention for MSK complaints, while providing further understanding of the superiority of actual versus sham MT.

For practitioners who do not offer MT, consider establishing a potential partnership or referral option with a clinician who does offer this type of intervention. (This review was written by Dr. Jeff Muir) 

Dr. SHAWN THISTLE owns and operates Research Review Service Inc., helping clinicians integrate scientific evidence into practice through subscription-based service (researchreviewservice.com ), online courses (onlinecourses.researchreviewservice.com ) and seminars (epicureanscholar.com ).