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Right, Wrong or Incomplete?
March 30, 2014 by Dr Matthew D. Long
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Right, Wrong or Incomplete?
March 30, 2014 by Dr Matthew D. Long
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Right, Wrong or Incomplete?
March 30, 2014 by Dr Matthew D. Long
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The day-to-day pursuit of clinical practice is often frustrating. Not only are we challenged by the demands and complexities of our patients, but we also face the constant scrutiny of those who view spinal manipulation as unproven. There are even those who see the science of manipulation as ‘done'. For these individuals the argument has been settled and manipulation has been shown to be of no value. Indeed, just this week a paper in the journal SPINE has looked at the comparative effectiveness of spinal manipulation for lower back pain (1), and on the surface, it paints a fairly bleak picture:
"Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham’s effectiveness. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not… Treatments serve to motivate, reassure, and calibrate patient expectations - features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain."
In essence, the authors found that any positive effect of spinal manipulation was overwhelmingly due to 'non-specific effects’. These would include patient expectation, placebo and context.
But are such assertions correct? Might they be wrong? Or are they actually just incomplete?
The truth is, biological science is always incomplete. We strive to make observations, come up with theories to explain them, and build models to help us make informed judgements and render useful treatment. But a model is only an approximation, and it simply cannot explain everything that is happening under all circumstances. We could draw a parallel with the world of physics. Newtonian physics cannot explain many phenomena of our universe, especially when a body approaches the speed of light or becomes infinitesimally small. But does this mean that Newton’s observations and formulae have been wrong all these years and that we should just throw them out? Or are they merely incomplete, and still relevant under certain conditions in which they they still hold up. Most scientists would appreciate that theories always remain incomplete and must evolve when new information comes to light. Unfortunately this is an area in which chiropractors sometimes struggle. As new information comes to light we need to reflect upon and refine our models.
Interestingly, for every comparative effectiveness study that tells us that we are barely moving the dial, comes another that fills in some of our conceptual gaps. One of these was a paper by Wand et al in the British Journal of Sports Medicine in 2013 that tried to ascertain whether the effectiveness of acupuncture for lower back pain could be enhanced by a novel tweak of its application.
Similarly to spinal manipulation, there is an open question within the scientific community as to whether acupuncture is simply a placebo treatment. Indeed, there have been a number of studies that appear to show that sham acupuncture and true acupuncture have equivalent results (3,4). However, there is a well-reasoned argument that ‘sham’ acupuncture is not an inert control at all and that it still exerts biological effects (5,6). The question is, what exactly are these biological effects and, if we understand them better, can we enhance them? Perhaps there are variables that we can manage that will lead to a better response from our patients.
The paper by Wand et al sought to elucidate one of these possible variables in the chronic low back pain patient - that of poor sensory discrimination.
I have written extensively in the past about the proprioceptive deficiencies exhibited by those with chronic lumbar pain (here, here, here and here). In short, there is a growing body of evidence that those with persistent spinal problems suffer from a distortion of the normal sensory representation of their spine within the cortex (7,8,9,10). As a consequence these individuals have difficulties sensing and controlling their spinal structures, increasing their risk of tissue damage and pain. This further brings about an increased level of limbic vigilance and movement-related anxiety, which might heighten pain responses and alter movement patterns (substituting stiffer protective behaviours for the normal fluid motions of the spine). Wand and colleagues theorised that if this is true, then perhaps acupuncture could be used to heighten awareness of the dysfunctional lumbar segments and reestablish appropriate motor control.
In their paper Wand et al described how they compared usual acupuncture with a novel form of sensory discrimination training. After inserting 14 needles into predetermined sites in the lower back, patients were given a picture showing them the locations of the needles, each with a corresponding number. The examiner then rotated one of the needles and asked the subject to concentrate upon which was was being stimulated, and then announce the number of the needle being moved. If they got the answer wrong they were told which needle was correct, and asked to focus upon it. This task forced the individual to concentrate upon the stimulation they were receiving and discriminate upon its location. In contrast, the control group were asked to simply lie prone and not think about the needles as they were being moved.
So what happened? According to the authors:
But are such assertions correct? Might they be wrong? Or are they actually just incomplete?
The truth is, biological science is always incomplete. We strive to make observations, come up with theories to explain them, and build models to help us make informed judgements and render useful treatment. But a model is only an approximation, and it simply cannot explain everything that is happening under all circumstances. We could draw a parallel with the world of physics. Newtonian physics cannot explain many phenomena of our universe, especially when a body approaches the speed of light or becomes infinitesimally small. But does this mean that Newton’s observations and formulae have been wrong all these years and that we should just throw them out? Or are they merely incomplete, and still relevant under certain conditions in which they they still hold up. Most scientists would appreciate that theories always remain incomplete and must evolve when new information comes to light. Unfortunately this is an area in which chiropractors sometimes struggle. As new information comes to light we need to reflect upon and refine our models.
Interestingly, for every comparative effectiveness study that tells us that we are barely moving the dial, comes another that fills in some of our conceptual gaps. One of these was a paper by Wand et al in the British Journal of Sports Medicine in 2013 that tried to ascertain whether the effectiveness of acupuncture for lower back pain could be enhanced by a novel tweak of its application.
Similarly to spinal manipulation, there is an open question within the scientific community as to whether acupuncture is simply a placebo treatment. Indeed, there have been a number of studies that appear to show that sham acupuncture and true acupuncture have equivalent results (3,4). However, there is a well-reasoned argument that ‘sham’ acupuncture is not an inert control at all and that it still exerts biological effects (5,6). The question is, what exactly are these biological effects and, if we understand them better, can we enhance them? Perhaps there are variables that we can manage that will lead to a better response from our patients.
The paper by Wand et al sought to elucidate one of these possible variables in the chronic low back pain patient - that of poor sensory discrimination.
I have written extensively in the past about the proprioceptive deficiencies exhibited by those with chronic lumbar pain (here, here, here and here). In short, there is a growing body of evidence that those with persistent spinal problems suffer from a distortion of the normal sensory representation of their spine within the cortex (7,8,9,10). As a consequence these individuals have difficulties sensing and controlling their spinal structures, increasing their risk of tissue damage and pain. This further brings about an increased level of limbic vigilance and movement-related anxiety, which might heighten pain responses and alter movement patterns (substituting stiffer protective behaviours for the normal fluid motions of the spine). Wand and colleagues theorised that if this is true, then perhaps acupuncture could be used to heighten awareness of the dysfunctional lumbar segments and reestablish appropriate motor control.
In their paper Wand et al described how they compared usual acupuncture with a novel form of sensory discrimination training. After inserting 14 needles into predetermined sites in the lower back, patients were given a picture showing them the locations of the needles, each with a corresponding number. The examiner then rotated one of the needles and asked the subject to concentrate upon which was was being stimulated, and then announce the number of the needle being moved. If they got the answer wrong they were told which needle was correct, and asked to focus upon it. This task forced the individual to concentrate upon the stimulation they were receiving and discriminate upon its location. In contrast, the control group were asked to simply lie prone and not think about the needles as they were being moved.
So what happened? According to the authors:
"We found that the average pain intensity after participants had received acupuncture with sensory discrimination training (2.8 ± 2.5) was less than when they received acupuncture without sensory discrimination training (3.6 ± 2.0). This difference was statistically significant (after adjustment; mean difference=−0.8, 95% CI −1.4 to −0.3; p=0.011)… Our findings are consistent with the idea that acupuncture may offer specific benefit that is not dependent on precisely where the needles are inserted so much as that the patient attends to where they are inserted.”
So it seems that one of the essential ingredients for an improved outcome is patient attention upon the stimulus being applied. If so, then we have seen yet another example of science helping to expand our incomplete models of spinal pain and dysfunction.
But how does this relate to chiropractic? It would seem to me that science is only now starting to understand the nature of spinal disorders and the possible role for spinal manipulation. And as it does so, we must take stock of our working models and appreciate that they are most certainly incomplete. We need to ask ourselves, "What is manipulation actually doing?"
Spinal manipulation is clearly complex, having both local physical and distant neurological effects. Could it be that it too acts as a sensory discrimination tool? If we think about the breadth of research dedicated to spinal manipulation we see a number of repeated themes.
But how does this relate to chiropractic? It would seem to me that science is only now starting to understand the nature of spinal disorders and the possible role for spinal manipulation. And as it does so, we must take stock of our working models and appreciate that they are most certainly incomplete. We need to ask ourselves, "What is manipulation actually doing?"
Spinal manipulation is clearly complex, having both local physical and distant neurological effects. Could it be that it too acts as a sensory discrimination tool? If we think about the breadth of research dedicated to spinal manipulation we see a number of repeated themes.
1. Manipulation creates a novel blend of sensory stimuli that largely depends upon proprioceptive afferents.
2. Chiropractors typically take the time to explain their treatment to patients and have a culture of communication.
3. Chiropractors encourage patients to move and use their spines.
4. The results shown by studies that allow a chiropractor to perform their ‘usual care’ (i.e. multiple manipulations and explanation to the patient) seem to demonstrate greater benefit than those that limit the active ingredient to a single manipulation without any additional engagement of the patient. In other words, in an attempt to be ’scientific’ and limit the number of variables, we might be removing one of the most important facets of a successfully delivered manipulation (priming the patient’s sensory awareness).
Could it be that spinal manipulation, like acupuncture, might work better if the chiropractor can firstly engage the patient, palpate the area of concern, and ask the patient if they can feel the problem? Having asked the patient to focus upon the origin of their pain, a manipulation can be delivered that creates a unique sensory stimulus to the already-primed discrimination system. If this is true, then we should aim to replicate such methods in future comparative effectiveness studies, before science decides that manipulation has no benefits.
Something to think about…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Something to think about…
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Menke, J. M. (2014). Do Manual Therapies Help Low Back Pain? A Comparative Effectiveness Meta-analysis. Spine, 39(7), E463–E472. doi:10.1097/BRS.0000000000000230
2. Wand, B. M., Abbaszadeh, S., Smith, A. J., Catley, M. J., & Moseley, G. L. (2013). Acupuncture applied as a sensory discrimination training tool decreases movement-related pain in patients with chronic low back pain more than acupuncture alone: a randomised cross-over experiment. British journal of sports medicine, 47(17), 1085–1089. doi:10.1136/bjsports-2013-092949
3. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139.
4. Hutchinson AJP, Ball S, Andrews JCH, et al. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res 2012;7:36.
5. Langevin HM, Hammerschlag R, Lao L, et al. Controversies in acupuncture research: selection of controls and outcome measures in acupuncture clinical trials. J Altern Complement Med 2006; 12:943–53.
6. Lund I, Lundeberg T. Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls? Acupunct Med 2006; 24:13–15.
7. Bray, H., & Moseley, G. L. (2011). Disrupted working body schema of the trunk in people with back pain. British journal of sports medicine, 45(3), 168–173. doi:10.1136/bjsm.2009.061978
8. Moseley, G. L. (2008). I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain, 140(1), 239–243. doi:10.1016/j.pain.2008.08.001
9. Moseley, G. L., Gallagher, L., & Gallace, A. (2012). Neglect-like tactile dysfunction in chronic back pain. Neurology, 79(4), 327–332. doi:10.1212/WNL.0b013e318260cba2
10. Luomajoki, H., & Moseley, G. L. (2011). Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. British journal of sports medicine, 45(5), 437–440. doi:10.1136/bjsm.2009.060731
1. Menke, J. M. (2014). Do Manual Therapies Help Low Back Pain? A Comparative Effectiveness Meta-analysis. Spine, 39(7), E463–E472. doi:10.1097/BRS.0000000000000230
2. Wand, B. M., Abbaszadeh, S., Smith, A. J., Catley, M. J., & Moseley, G. L. (2013). Acupuncture applied as a sensory discrimination training tool decreases movement-related pain in patients with chronic low back pain more than acupuncture alone: a randomised cross-over experiment. British journal of sports medicine, 47(17), 1085–1089. doi:10.1136/bjsports-2013-092949
3. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139.
4. Hutchinson AJP, Ball S, Andrews JCH, et al. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res 2012;7:36.
5. Langevin HM, Hammerschlag R, Lao L, et al. Controversies in acupuncture research: selection of controls and outcome measures in acupuncture clinical trials. J Altern Complement Med 2006; 12:943–53.
6. Lund I, Lundeberg T. Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls? Acupunct Med 2006; 24:13–15.
7. Bray, H., & Moseley, G. L. (2011). Disrupted working body schema of the trunk in people with back pain. British journal of sports medicine, 45(3), 168–173. doi:10.1136/bjsm.2009.061978
8. Moseley, G. L. (2008). I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain, 140(1), 239–243. doi:10.1016/j.pain.2008.08.001
9. Moseley, G. L., Gallagher, L., & Gallace, A. (2012). Neglect-like tactile dysfunction in chronic back pain. Neurology, 79(4), 327–332. doi:10.1212/WNL.0b013e318260cba2
10. Luomajoki, H., & Moseley, G. L. (2011). Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. British journal of sports medicine, 45(5), 437–440. doi:10.1136/bjsm.2009.060731