Systematic reviews · 2024

This updated systematic review and meta-analysis examined whether spinal manipulative therapy (SMT), quick thrusts to the spinal joints delivered by chiropractors, osteopaths or physiotherapists, effectively treats migraine. Migraine affects more than one billion people worldwide (about 14% of the population) and is the second most common cause of disability globally. SMT is sometimes used for it, but its biological plausibility and safety have been questioned, and several hundred severe complications after upper-spine manipulation, including arterial dissections, strokes and deaths, have been reported. The review updated a 2011 version with three new trials and searched databases up to September 2023. Six randomized or quasi-randomized trials with 645 people with migraine were included; five tested chiropractic SMT and one osteopathic manipulation, and controls included sham treatment, drug therapy, usual care and mobilization. The studies came from Australia, Norway, Spain and the United States and spanned about 45 years. Outcomes were migraine days, migraine duration, pain intensity, disability, emotional quality of life and adverse effects. One reviewer screened and extracted data and a second validated, results were pooled with random-effects models, and certainty of evidence was graded with GRADE. Pooled results showed small reductions in migraine days (SMD -0.24, 95% CI -0.47 to -0.02; four trials) and disability (SMD -0.27, -0.54 to -0.01; three trials), but no clear effect on pain intensity (SMD -0.22, -0.65 to 0.21; six trials), migraine duration (SMD -0.10, -0.33 to 0.12) or emotional quality of life (two trials). Certainty was very low for every outcome. SMT roughly doubled the risk of adverse effects (risk ratio 2.06, 1.24 to 3.41; number needed to harm 6), for example 83 adverse events in 355 SMT sessions versus 32 in 348 sham sessions in one trial, and 52% versus 34% of participants in another. Only three trials reported adverse effects at all. Only two of the six trials used a sham procedure, and their results were contradictory. The osteopathic trial showed a larger pain effect and lower heterogeneity than the chiropractic trials. The authors conclude that the effectiveness of SMT for migraine remains unproven and that it cannot be considered an evidence-based therapy for this condition, given very low-quality evidence and a twofold higher risk of adverse effects. Limitations include flawed methods in two thirds of trials, small samples, mixed populations and comparators, little long-term safety data, and few comparisons with established migraine treatments. The searches targeted English-language papers, although studies in any language were considered. The authors call for larger, more rigorous and independently conducted trials.

BMC musculoskeletal disorders · 2014

This systematic review and meta-analysis pooled 15 randomized trials with 1502 adults to test whether osteopathic manipulative treatment (OMT), a hands-on approach in which osteopaths choose techniques to suit each patient, improves pain and function in nonspecific low back pain (back pain with no specific underlying cause such as a fracture, tumor or infection). Low back pain is common, disabling and costly. The review counted only "authentic" osteopathic care, where practitioners used clinical judgment rather than one technique or a fixed protocol, and it analyzed pregnant and postpartum women separately. The authors searched seven databases and a trial register in October 2013 without language limits and also included unpublished grey literature, finding 307 records. Trials could compare OMT with sham treatment, usual care, physiotherapy or no treatment. Studies were independently reviewed with a standardized form, and only patient-reported outcomes were evaluated. Pain and functional status were pooled at about three months after treatment, and each trial was checked for risk of bias and graded for quality of evidence. In acute and chronic nonspecific low back pain, OMT lowered pain by 12.91 points on a 0-100 scale (95% CI -20.00 to -5.82) and improved function (SMD -0.36, -0.58 to -0.14), based on moderate-quality evidence. In chronic back pain alone, pain fell by 14.93 points (-25.18 to -4.68). In pregnancy, low-quality evidence showed pain reductions of 23.01 points (-44.13 to -1.88) and function gains (SMD -0.80), while moderate-quality evidence in postpartum women showed a 41.85-point pain reduction (-49.43 to -34.27) and an SMD of -1.78 for function. Effects were larger for pain than function and met the Cochrane threshold for clinical relevance. The largest trial, with 455 people, supplied only medians, so its values were estimated, and results were nearly identical with or without it. Only four of 15 trials reported adverse events, which were minor (stiffness, tiredness) with no treatment-related serious events. Heterogeneity was considerable. The authors conclude that OMT had clinically relevant effects on pain and functional status at three months posttreatment and recommend larger, high-quality trials with robust comparison groups. Limitations include small samples, different comparison groups, heterogeneity, no long-term measurement, blinding problems in every trial, and fewer than 400 participants in the pregnancy and postpartum comparisons. The authors also say future studies should report adverse events and describe the treatment approach clearly. The search ran in October 2013, so later trials are not included.

American journal of obstetrics and gynecology · 2015

This randomized, placebo-controlled trial of 400 pregnant women, called PROMOTE, explored whether osteopathic manipulative treatment (OMT), a hands-on approach in which physicians apply guided forces to muscles and joints, eases low back pain and protects back-related function late in pregnancy. Low back pain is reported by about 70% of pregnant women, and most pain medications are not recommended during pregnancy, leaving few safe options. Pregnancy changes posture and biomechanics through ligament strain, increased muscle tension and reduced range of motion. The study also checked whether OMT reduces meconium-stained amniotic fluid, a possible sign of fetal stress. Women aged 18 to 35 in their third trimester at three Texas clinics were randomly assigned to usual prenatal care only, usual care plus OMT, or usual care plus a placebo ultrasound treatment with the machine switched off. Across seven visits from week 30 to week 39, the OMT group received about 20 minutes of treatment to the neck, back, pelvis and hips. Pain was rated on a 0-100 scale combining four pain ratings, and back-related disability was scored on the 24-item Roland-Morris questionnaire. Pain and back-related functioning differed significantly across groups (p < .001 for both). Women receiving OMT improved or stayed stable, while women receiving usual care only had worsening pain and function. OMT did not differ significantly from placebo ultrasound, and both beat usual care. Only 99 of 400 women (25%) completed all seven visits, but results were consistent among the 357 who completed at least four. Meconium staining appeared in 18.5% of 329 deliveries with data and was not linked to treatment group (p = .611). Gestational age at delivery averaged 39 weeks 2 days in every group. About 12.5% of women were reclassified as high-risk during the study (OMT 11, placebo ultrasound 19, usual care 20), with no higher likelihood in any group (p = .141), which the authors used as an indirect safety measure. The authors conclude that OMT mitigated pain and functional decline compared with usual care alone, but its similarity to placebo ultrasound may reflect the placebo's own touch and attention. They describe OMT as a safe, effective add-on for third-trimester back pain. Baseline characteristics were similar across groups except pre-pregnancy BMI, which was lower in the OMT group. Limitations include the large share of women who missed visits, the lack of an attention-matched usual-care arm, and effect sizes that the stored text does not report.