Spinal Manipulation an Update of a Systematic Review of Systematic Reviews

Abstract

Objective. This article is aimed at critically evaluating the evidence from systematic reviews (SRs) of spinal manipulation in patients with pain.

Pattern. The report was designed every bit a SR of SRs.

Methods. 4 electronic databases were searched to identify all relevant articles of the effectiveness of spinal manipulation for pain. SRs were divers as articles employing a repeatable methods department.

Results. Xx-two SRs relating to the following pain weather condition: low dorsum hurting (North = 6), headache (North = 5), cervix pain (Northward = iv), any medical problem (N = 1), carpal tunnel syndrome (Due north = 1), dysmenorrhea (Northward = 1), fibromyalgia (N = 1), lateral epicondylitis (N = 1), musculoskeletal conditions (N = 1) and nonspinal pain (N = 1), were included. Positive or, for multiple SR, unanimously positive conclusions were drawn for none of the conditions mentioned earlier.

Limitation. Publication bias as a well-known phenomenon may have been inherited in this commodity.

Conclusion. Collectively, these data fail to demonstrate that spinal manipulation is an effective intervention for hurting management.

Introduction

Pain is prevalent and often difficult to treat. It is associated with a high burden of suffering and considerable socio-economic costs. Among the many treatments that are existence suggested is spinal manipulation (SM). SM is a technique commonly used by chiropractors, osteopaths, physiotherapists, physicians, os setters or other transmission therapists. SM can be defined as "the awarding of high-velocity, depression-amplitude manual thrusts to the spinal joints slightly across the passive range of joint motion"[1]. This technique aims to correct misalignments or so called subluxations of the joints (both spinal and peripheral) [2]. However, it has been suggested that subluxations lack biological plausibility [3,iv]. Safety and cost-effectiveness of SM have also been questioned [5–8]. Despite unproven rubber, debatable effectiveness and cost-effectiveness, SM is nonetheless widely used for a wide range of pain related atmospheric condition (among others).

Hundreds of randomized clinical trials (RCTs) of SM have been published in the literature; however, their information are less than uniform. To engagement, systematic reviews (SRs) are considered to be at the top of prove-base hierarchy and may therefore provide the most conclusive answer regarding the effectiveness of SM for pain management. Unfortunately, the evaluations of the effectiveness of SM ofttimes make it at contradictory conclusions. In order to make progress in this area, we need rigorous SRs, which include the totality of the bachelor evidence on a clearly defined population, precise therapeutic interventions and types of pain included. Until such SRs are available, it is highly problematic to describe firm conclusions regarding the therapeutic value of SM for pain.

The aim of this article was to critically evaluate the data from SRs of SM equally a hurting management pick.

Methods

The author conducted literature searches to place all SRs of SM for any pain-related status. Searches were conducted in the following electronic databases (from their inception to March 2011): Medline, Embase, AMED, and Cochrane Database. The following search terms were used: [Chiropract* OR spinal manipul* OR manual therap* OR osteopath*] AND [systematic ADJ review]. No language barriers were imposed.

After initial screening of abstracts, those meeting the inclusion criteria were retrieved for further evaluation past the writer. SRs were defined as articles that included an explicit and repeatable methods department. To be included, SRs had to pertain to the effectiveness of SM for any type of pain or hurting-related condition and to include evidence from at least one controlled clinical trial. Only SRs that included evidence from RCTs were included because this reduces the adventure of bias according to the Cochrane Collaboration. SRs of SM as a office of complex therapeutic interventions were excluded. Update reviews were also excluded.

I writer extracted the data from the identified articles according to predefined criteria (Table 1), and evaluated the methodological quality of each SR according to Oxman and Guyatt [9] (Table 2). The Oxman criteria for SRs evaluate the comprehensiveness and thoroughness of search strategy, eligibility criteria, validity cess, and quantitative analysis (a total of nine items is evaluated). Each question is scored as 1 (fulfilled), 0 (partially fulfilled), or −1 (not fulfilled). A score of 5 or less means the review has extensive or major flaws, and a score of 6–nine means that the review has minimal or no flaws.

Table 1

Systematic reviews of spinal manipulations for pain

Offset writer (year) (ref)	Interventions	Condition Treated	N (RCTs)	Meta-assay	Overall Outcome (quote)	Direction of Conclusion	Comment
Assendelft et al. (2004) [x]	Any type of SM	Low dorsum pain	39	Yes	No evidence that SM is superior to other standard treatments for acute or chronic low back pain	(−)	RCTs of mobilization were too included
Bronfort et al. (2004) [11]	SM and mobilization	Low back pain and neck pain	69	No	. . . recommendations can be made with some conviction regarding the use of SM and/or mobilization as a viable option for treatment of both low back pain and cervix pain	(+)	Conclusions based on 43 RCTs coming together admissibility criteria for testify
Dagenais et al. (2010) [12]	SM	Acute low back pain	14	No	Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods	(+)
Ernst and Canter (2003) [xiii]	Chiropractic SM	Low back pain	12	No	Effectiveness . . . non supported by compelling evidence from the majority of RCTs	(−)	Focus exclusively on SM as performed past chiropractors
Ferreira et al. (2002) [14]	SM	Chronic depression back	12	Yes	(SM) . . . is not substantially more than effective than sham handling in reducing hurting, nor is it more than effective than NSAIDs in improving disability in chronic low back pain patients. It is non clear whether. . . . (SM) . . . is more effective than NSAIDs in reducing pain in chronic low back pain patients	(−)	More often than not moderate quality data was included
Licciardone et al. (2005) [xv]	Osteopathic manipulative therapy	Depression back pain	vi	Yes	Osteopathic manipulative therapy significantly reduces low dorsum pain. The level of pain reduction is greater than expected from placebo effects lone and persists for at to the lowest degree iii months.	(+)	Pregnant heterogeneity of meta-analyzed data
Astin and Ernst (2002) [xvi]	Any type of SM	Headache disorders	8	No	The data available to date practice not support . . . that SM is an constructive handling for headache	(−)	Rigorous systematic review
Bronfort et al. (2001) [1]	SM	Chronic headache	9	No	SM appears to have a better issue than massage for cervicogenic headache . . . an effect comparable to commonly used get-go line prophylactic prescription medications for tension-blazon headache and migraine headache. This conclusion rests upon a few trials of acceptable methodological quality. Before any firm conclusions tin be drawn, further testing should be washed.	(+)	Only nine primary studies included
Fernández de las Peńas et al. (2006) [17]	Any blazon of transmission therapy including SM	Tension type headache	6	No	The author found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The near urgent need for further research is to constitute the efficacy beyond placebo of the different transmission therapies currently applied in patients with TTH.	(−)	Unlike transmission therapy modalities were included
Fernández de las Peńas et al. (2005) [18]	SM	Cervicogenic headache	2	No	Spinal manipulative therapy might exist effective in reducing headache intensity, headache duration, medication intake (level 1), and headache frequency (level 3) in patients with CeH.	(+)	Low quantity of the data
Lenssinck et al. (2004) [xix]	Physiotherapy and/or spinal manipulation	Tension blazon headache	8	No	At that place is insufficient evidence to either back up or refute the effectiveness of physiotherapy and (SM) compared with other treatments.	(−)	Included 5 RCTs of SM including ii high-quality RCTs of chiropractic with contradictory results
Ernst (2003) [20]	Chiropractic SM	Neck pain	iv	No	The notion that chiropractic SM is more constructive than conventional do . . . was non supported by rigorous trial data	(−)	Focus exclusively on SM as performed past chiropractors
Gross et al. (2004) [21]	Any type of SM and mobilization	Neck problems	33	Yep	The evidence did not favor manipulation and/or mobilization done lone or in combination with various other physical medicine agents; when compared with one another, neither was superior. In that location was insufficient evidence available to draw conclusions for neck disorder with radicular findings.	(−)	42% of the included information was of high quality
Gross et al. (2010) [22]	SM or mobilization	Neck pain, headache, whiplash injuries	27	Aye	Cervical manipulation and mobilization produced similar changes. Either may provide immediate- or short-term alter; no long-term information are available. Thoracic manipulation may improve hurting and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our conviction in the estimate of effect and is probable to modify the estimate.	(+/−)	Low to moderate quality evidence was included
Vernon et al. (2005) [23]	SM, manual therapy and TENS	Acute neck hurting not due to whiplash	4	No	At that place is limited testify of the benefit of spinal manipulation . . . in the treatment of acute cervix pain not due to whiplash injury.	(−)	Combination of modalities included
Posadzki (2010) [24]	Osteopathic manipulation	Musculoskeletal pain	16	No	The notion that osteopathic manipulative therapy alleviates musculoskeletal pain is currently not based on the evidence from independently replicated high quality clinical trials.	(−)	Various quality RCTs were considered
Ernst (2003) [25]	Chiropractic SM	Not-spinal pain syndromes	8	No	The merits that SM is constructive for such weather condition is not based on information from rigorous clinical studies	(−)	Atmospheric condition included fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhea and chronic pelvic pain
Ernst [2009][26]	Chiropractic SM	Fibromyalgia	3	No	In that location is no testify to suggest that chiropractic care is effective for fibromyalgia	(−)	Poor quality and depression quantity of the primary data
Herd (2008) [27]	SM or mobilization	Lateral epicondylitis	13	No	Currently, limited evidence exists to support a synthesis of any detail technique whether directed at the elbow or cervical spine.	(−)	The presence of consistent methodological flaws was reported
Hunt et al. (2009) [28]	Chiropractic SM	Carpal tunnel syndrome	1	No	There is insufficient show to suggest that chiropractic is effective for the treatment of CTS. Therapy should continue to focus on the use of NSAIDs, corticosteroid injection, splinting and surgical release of the median nerve. Further enquiry into the utility of chiropractic for CTS is required.	(−)
Proctor et al. (2001) [29]	Whatsoever type of SM	Primary and secondary dysmenorrhea	5	No	There is no evidence that SM is constructive	(−)	Four of the v RCTs were of high velocity, low amplitude thrusts

First author (yr) (ref)	Interventions	Condition Treated	N (RCTs)	Meta-analysis	Overall Result (quote)	Management of Conclusion	Comment
Assendelft et al. (2004) [10]	Whatever type of SM	Low back pain	39	Yes	No evidence that SM is superior to other standard treatments for acute or chronic low dorsum pain	(−)	RCTs of mobilization were likewise included
Bronfort et al. (2004) [11]	SM and mobilization	Low back hurting and cervix pain	69	No	. . . recommendations tin be fabricated with some conviction regarding the apply of SM and/or mobilization every bit a viable option for treatment of both low dorsum hurting and neck pain	(+)	Conclusions based on 43 RCTs meeting admissibility criteria for show
Dagenais et al. (2010) [12]	SM	Acute low dorsum pain	xiv	No	Several RCTs have been conducted to appraise the efficacy of SMT for acute LBP using various methods	(+)
Ernst and Canter (2003) [13]	Chiropractic SM	Low dorsum pain	12	No	Effectiveness . . . non supported by compelling evidence from the majority of RCTs	(−)	Focus exclusively on SM as performed past chiropractors
Ferreira et al. (2002) [xiv]	SM	Chronic low back	12	Yep	(SM) . . . is not substantially more than constructive than sham treatment in reducing pain, nor is it more than constructive than NSAIDs in improving disability in chronic low dorsum hurting patients. It is not clear whether. . . . (SM) . . . is more effective than NSAIDs in reducing pain in chronic low dorsum pain patients	(−)	Mostly moderate quality data was included
Licciardone et al. (2005) [xv]	Osteopathic manipulative therapy	Low back hurting	vi	Aye	Osteopathic manipulative therapy significantly reduces low dorsum pain. The level of pain reduction is greater than expected from placebo furnishings alone and persists for at least iii months.	(+)	Significant heterogeneity of meta-analyzed data
Astin and Ernst (2002) [16]	Whatsoever type of SM	Headache disorders	viii	No	The data bachelor to date do not support . . . that SM is an effective treatment for headache	(−)	Rigorous systematic review
Bronfort et al. (2001) [1]	SM	Chronic headache	9	No	SM appears to accept a ameliorate event than massage for cervicogenic headache . . . an event comparable to commonly used first line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of acceptable methodological quality. Before any firm conclusions tin be drawn, further testing should be done.	(+)	Only nine primary studies included
Fernández de las Peńas et al. (2006) [17]	Whatever type of manual therapy including SM	Tension type headache	six	No	The author constitute no rigorous evidence that manual therapies have a positive effect in the development of TTH. The most urgent need for farther research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.	(−)	Different manual therapy modalities were included
Fernández de las Peńas et al. (2005) [18]	SM	Cervicogenic headache	2	No	Spinal manipulative therapy might be effective in reducing headache intensity, headache duration, medication intake (level 1), and headache frequency (level 3) in patients with CeH.	(+)	Low quantity of the data
Lenssinck et al. (2004) [xix]	Physiotherapy and/or spinal manipulation	Tension blazon headache	eight	No	At that place is insufficient evidence to either support or refute the effectiveness of physiotherapy and (SM) compared with other treatments.	(−)	Included v RCTs of SM including ii loftier-quality RCTs of chiropractic with contradictory results
Ernst (2003) [xx]	Chiropractic SM	Neck pain	4	No	The notion that chiropractic SM is more effective than conventional practise . . . was not supported by rigorous trial data	(−)	Focus exclusively on SM as performed by chiropractors
Gross et al. (2004) [21]	Whatever type of SM and mobilization	Neck issues	33	Aye	The evidence did not favor manipulation and/or mobilization done solitary or in combination with various other physical medicine agents; when compared with one another, neither was superior. There was insufficient testify available to depict conclusions for neck disorder with radicular findings.	(−)	42% of the included data was of high quality
Gross et al. (2010) [22]	SM or mobilization	Cervix pain, headache, whiplash injuries	27	Aye	Cervical manipulation and mobilization produced similar changes. Either may provide immediate- or brusque-term change; no long-term data are bachelor. Thoracic manipulation may improve hurting and function. Optimal techniques and dose are unresolved. Further research is very likely to accept an important bear upon on our confidence in the estimate of issue and is likely to change the judge.	(+/−)	Low to moderate quality evidence was included
Vernon et al. (2005) [23]	SM, manual therapy and TENS	Acute cervix pain not due to whiplash	4	No	There is limited testify of the benefit of spinal manipulation . . . in the handling of astute cervix pain not due to whiplash injury.	(−)	Combination of modalities included
Posadzki (2010) [24]	Osteopathic manipulation	Musculoskeletal hurting	xvi	No	The notion that osteopathic manipulative therapy alleviates musculoskeletal hurting is currently non based on the evidence from independently replicated high quality clinical trials.	(−)	Various quality RCTs were considered
Ernst (2003) [25]	Chiropractic SM	Non-spinal pain syndromes	eight	No	The claim that SM is effective for such conditions is not based on data from rigorous clinical studies	(−)	Weather condition included fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhea and chronic pelvic pain
Ernst [2009][26]	Chiropractic SM	Fibromyalgia	three	No	At that place is no evidence to suggest that chiropractic care is effective for fibromyalgia	(−)	Poor quality and low quantity of the main data
Herd (2008) [27]	SM or mobilization	Lateral epicondylitis	13	No	Currently, express evidence exists to back up a synthesis of any particular technique whether directed at the elbow or cervical spine.	(−)	The presence of consistent methodological flaws was reported
Hunt et al. (2009) [28]	Chiropractic SM	Carpal tunnel syndrome	1	No	In that location is insufficient evidence to suggest that chiropractic is effective for the treatment of CTS. Therapy should go along to focus on the use of NSAIDs, corticosteroid injection, splinting and surgical release of the median nerve. Further enquiry into the utility of chiropractic for CTS is required.	(−)
Proctor et al. (2001) [29]	Any type of SM	Primary and secondary dysmenorrhea	v	No	In that location is no evidence that SM is effective	(−)	4 of the five RCTs were of high velocity, low amplitude thrusts

CTS = carpal tunnel syndrome; LBP = depression dorsum pain; NSAIDs = nonsteroid anti-inflammatory drugs; SM = spinal manipulation; SMT = spinal manipulative therapy; RCT = randomized clinical trial; TENS = transcutaneous electrical nerve stimulation; TTH = tension blazon headache.

Table ane

Systematic reviews of spinal manipulations for pain

Outset author (year) (ref)	Interventions	Condition Treated	N (RCTs)	Meta-analysis	Overall Result (quote)	Management of Conclusion	Comment
Assendelft et al. (2004) [10]	Any blazon of SM	Depression back pain	39	Yes	No evidence that SM is superior to other standard treatments for acute or chronic low back hurting	(−)	RCTs of mobilization were also included
Bronfort et al. (2004) [11]	SM and mobilization	Low dorsum pain and cervix hurting	69	No	. . . recommendations can exist made with some confidence regarding the use of SM and/or mobilization as a viable choice for handling of both low dorsum pain and neck pain	(+)	Conclusions based on 43 RCTs coming together admissibility criteria for bear witness
Dagenais et al. (2010) [12]	SM	Acute low back pain	14	No	Several RCTs accept been conducted to assess the efficacy of SMT for acute LBP using various methods	(+)
Ernst and Amble (2003) [thirteen]	Chiropractic SM	Low dorsum pain	12	No	Effectiveness . . . not supported by compelling bear witness from the majority of RCTs	(−)	Focus exclusively on SM as performed by chiropractors
Ferreira et al. (2002) [14]	SM	Chronic low back	12	Yes	(SM) . . . is not essentially more constructive than sham treatment in reducing pain, nor is it more effective than NSAIDs in improving disability in chronic low back hurting patients. It is not clear whether. . . . (SM) . . . is more effective than NSAIDs in reducing pain in chronic low back pain patients	(−)	Generally moderate quality data was included
Licciardone et al. (2005) [15]	Osteopathic manipulative therapy	Low back pain	6	Yes	Osteopathic manipulative therapy significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at to the lowest degree three months.	(+)	Significant heterogeneity of meta-analyzed information
Astin and Ernst (2002) [16]	Any type of SM	Headache disorders	8	No	The data available to appointment do not back up . . . that SM is an constructive treatment for headache	(−)	Rigorous systematic review
Bronfort et al. (2001) [1]	SM	Chronic headache	nine	No	SM appears to have a better effect than massage for cervicogenic headache . . . an consequence comparable to unremarkably used get-go line prophylactic prescription medications for tension-type headache and migraine headache. This decision rests upon a few trials of adequate methodological quality. Before any firm conclusions tin be fatigued, farther testing should be done.	(+)	Merely nine master studies included
Fernández de las Peńas et al. (2006) [17]	Any blazon of transmission therapy including SM	Tension blazon headache	vi	No	The author found no rigorous evidence that transmission therapies take a positive effect in the evolution of TTH. The virtually urgent need for farther inquiry is to plant the efficacy beyond placebo of the different manual therapies currently practical in patients with TTH.	(−)	Different manual therapy modalities were included
Fernández de las Peńas et al. (2005) [eighteen]	SM	Cervicogenic headache	2	No	Spinal manipulative therapy might be effective in reducing headache intensity, headache duration, medication intake (level 1), and headache frequency (level three) in patients with CeH.	(+)	Depression quantity of the data
Lenssinck et al. (2004) [19]	Physiotherapy and/or spinal manipulation	Tension type headache	8	No	At that place is bereft evidence to either support or abnegate the effectiveness of physiotherapy and (SM) compared with other treatments.	(−)	Included five RCTs of SM including two high-quality RCTs of chiropractic with contradictory results
Ernst (2003) [20]	Chiropractic SM	Neck pain	four	No	The notion that chiropractic SM is more than effective than conventional do . . . was not supported past rigorous trial information	(−)	Focus exclusively on SM equally performed by chiropractors
Gross et al. (2004) [21]	Whatsoever blazon of SM and mobilization	Neck problems	33	Yes	The testify did not favor manipulation and/or mobilization washed alone or in combination with various other physical medicine agents; when compared with ane some other, neither was superior. There was insufficient evidence available to draw conclusions for cervix disorder with radicular findings.	(−)	42% of the included data was of loftier quality
Gross et al. (2010) [22]	SM or mobilization	Neck pain, headache, whiplash injuries	27	Yep	Cervical manipulation and mobilization produced similar changes. Either may provide immediate- or short-term alter; no long-term data are bachelor. Thoracic manipulation may meliorate pain and function. Optimal techniques and dose are unresolved. Further research is very likely to accept an of import impact on our confidence in the guess of issue and is likely to change the estimate.	(+/−)	Depression to moderate quality evidence was included
Vernon et al. (2005) [23]	SM, manual therapy and TENS	Acute neck pain not due to whiplash	4	No	There is limited show of the do good of spinal manipulation . . . in the treatment of acute neck pain non due to whiplash injury.	(−)	Combination of modalities included
Posadzki (2010) [24]	Osteopathic manipulation	Musculoskeletal pain	16	No	The notion that osteopathic manipulative therapy alleviates musculoskeletal pain is currently not based on the show from independently replicated loftier quality clinical trials.	(−)	Various quality RCTs were considered
Ernst (2003) [25]	Chiropractic SM	Non-spinal hurting syndromes	8	No	The claim that SM is effective for such conditions is non based on data from rigorous clinical studies	(−)	Conditions included fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhea and chronic pelvic pain
Ernst [2009][26]	Chiropractic SM	Fibromyalgia	iii	No	At that place is no evidence to suggest that chiropractic care is effective for fibromyalgia	(−)	Poor quality and low quantity of the primary information
Herd (2008) [27]	SM or mobilization	Lateral epicondylitis	13	No	Currently, express evidence exists to back up a synthesis of any particular technique whether directed at the elbow or cervical spine.	(−)	The presence of consistent methodological flaws was reported
Hunt et al. (2009) [28]	Chiropractic SM	Carpal tunnel syndrome	1	No	There is insufficient testify to suggest that chiropractic is effective for the treatment of CTS. Therapy should continue to focus on the employ of NSAIDs, corticosteroid injection, splinting and surgical release of the median nerve. Further research into the utility of chiropractic for CTS is required.	(−)
Proctor et al. (2001) [29]	Any type of SM	Primary and secondary dysmenorrhea	5	No	There is no evidence that SM is effective	(−)	Four of the v RCTs were of loftier velocity, low amplitude thrusts

First author (twelvemonth) (ref)	Interventions	Status Treated	N (RCTs)	Meta-analysis	Overall Consequence (quote)	Management of Determination	Annotate
Assendelft et al. (2004) [x]	Any type of SM	Low back pain	39	Yeah	No evidence that SM is superior to other standard treatments for acute or chronic depression back hurting	(−)	RCTs of mobilization were too included
Bronfort et al. (2004) [11]	SM and mobilization	Low back pain and neck hurting	69	No	. . . recommendations tin can be made with some confidence regarding the use of SM and/or mobilization equally a viable option for treatment of both depression back pain and cervix pain	(+)	Conclusions based on 43 RCTs meeting admissibility criteria for evidence
Dagenais et al. (2010) [12]	SM	Acute low back pain	fourteen	No	Several RCTs have been conducted to assess the efficacy of SMT for astute LBP using various methods	(+)
Ernst and Canter (2003) [13]	Chiropractic SM	Low dorsum pain	12	No	Effectiveness . . . not supported by compelling testify from the majority of RCTs	(−)	Focus exclusively on SM as performed by chiropractors
Ferreira et al. (2002) [14]	SM	Chronic low back	12	Yes	(SM) . . . is not essentially more constructive than sham treatment in reducing pain, nor is it more effective than NSAIDs in improving disability in chronic low back pain patients. Information technology is not articulate whether. . . . (SM) . . . is more effective than NSAIDs in reducing pain in chronic depression back pain patients	(−)	More often than not moderate quality information was included
Licciardone et al. (2005) [15]	Osteopathic manipulative therapy	Depression back pain	6	Yeah	Osteopathic manipulative therapy significantly reduces low back hurting. The level of pain reduction is greater than expected from placebo effects lone and persists for at least three months.	(+)	Significant heterogeneity of meta-analyzed data
Astin and Ernst (2002) [sixteen]	Any type of SM	Headache disorders	8	No	The data available to date exercise not support . . . that SM is an effective handling for headache	(−)	Rigorous systematic review
Bronfort et al. (2001) [1]	SM	Chronic headache	9	No	SM appears to have a better event than massage for cervicogenic headache . . . an outcome comparable to usually used first line prophylactic prescription medications for tension-type headache and migraine headache. This determination rests upon a few trials of adequate methodological quality. Before any business firm conclusions can be drawn, further testing should be done.	(+)	Only nine primary studies included
Fernández de las Peńas et al. (2006) [17]	Any type of manual therapy including SM	Tension blazon headache	6	No	The author found no rigorous prove that transmission therapies have a positive effect in the development of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.	(−)	Different manual therapy modalities were included
Fernández de las Peńas et al. (2005) [18]	SM	Cervicogenic headache	2	No	Spinal manipulative therapy might be effective in reducing headache intensity, headache duration, medication intake (level one), and headache frequency (level 3) in patients with CeH.	(+)	Low quantity of the data
Lenssinck et al. (2004) [19]	Physiotherapy and/or spinal manipulation	Tension blazon headache	eight	No	At that place is insufficient evidence to either support or refute the effectiveness of physiotherapy and (SM) compared with other treatments.	(−)	Included 5 RCTs of SM including two high-quality RCTs of chiropractic with contradictory results
Ernst (2003) [20]	Chiropractic SM	Neck pain	4	No	The notion that chiropractic SM is more effective than conventional exercise . . . was non supported past rigorous trial data	(−)	Focus exclusively on SM as performed past chiropractors
Gross et al. (2004) [21]	Any type of SM and mobilization	Cervix problems	33	Yep	The evidence did not favor manipulation and/or mobilization washed alone or in combination with various other physical medicine agents; when compared with i another, neither was superior. There was insufficient show available to draw conclusions for neck disorder with radicular findings.	(−)	42% of the included information was of loftier quality
Gross et al. (2010) [22]	SM or mobilization	Cervix pain, headache, whiplash injuries	27	Yes	Cervical manipulation and mobilization produced like changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may ameliorate pain and function. Optimal techniques and dose are unresolved. Further enquiry is very likely to accept an important impact on our confidence in the estimate of effect and is likely to alter the estimate.	(+/−)	Depression to moderate quality evidence was included
Vernon et al. (2005) [23]	SM, transmission therapy and TENS	Acute cervix pain not due to whiplash	four	No	There is limited testify of the do good of spinal manipulation . . . in the treatment of astute neck hurting not due to whiplash injury.	(−)	Combination of modalities included
Posadzki (2010) [24]	Osteopathic manipulation	Musculoskeletal pain	sixteen	No	The notion that osteopathic manipulative therapy alleviates musculoskeletal hurting is currently non based on the prove from independently replicated high quality clinical trials.	(−)	Various quality RCTs were considered
Ernst (2003) [25]	Chiropractic SM	Not-spinal pain syndromes	8	No	The claim that SM is effective for such conditions is not based on data from rigorous clinical studies	(−)	Conditions included fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhea and chronic pelvic pain
Ernst [2009][26]	Chiropractic SM	Fibromyalgia	3	No	There is no show to suggest that chiropractic care is effective for fibromyalgia	(−)	Poor quality and low quantity of the primary data
Herd (2008) [27]	SM or mobilization	Lateral epicondylitis	xiii	No	Currently, express evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine.	(−)	The presence of consistent methodological flaws was reported
Chase et al. (2009) [28]	Chiropractic SM	Carpal tunnel syndrome	1	No	In that location is bereft bear witness to suggest that chiropractic is effective for the treatment of CTS. Therapy should go along to focus on the utilize of NSAIDs, corticosteroid injection, splinting and surgical release of the median nervus. Farther research into the utility of chiropractic for CTS is required.	(−)
Proctor et al. (2001) [29]	Any blazon of SM	Primary and secondary dysmenorrhea	5	No	In that location is no bear witness that SM is effective	(−)	Four of the five RCTs were of high velocity, low amplitude thrusts

CTS = carpal tunnel syndrome; LBP = depression back pain; NSAIDs = nonsteroid anti-inflammatory drugs; SM = spinal manipulation; SMT = spinal manipulative therapy; RCT = randomized clinical trial; TENS = transcutaneous electrical nerve stimulation; TTH = tension blazon headache.

Tabular array 2

Quality ratings for included systematic reviews of spinal manipulations for pain

Study, yr (ref)	Search Methods? (a)	Search Comprehensive? (b)	Inclusion Criteria? (c)	Bias Avoided? (d)	Validity Criteria? (e)	Validity Assessed? (f)	Methods for Combining Studies? (g)	Appropriately Combined? (h)	Conclusions Supported? (i)	Sum
Assendelft et al.(2004) [ten]	one	one	one	i	1	1	1	1	one	9
Astin and Ernst (2002) [16]	i	1	one	i	1	1	1	1	1	9
Bronfort et al. (2001) [1]	1	1	1	i	one	0	1	0	1	7
Bronfort et al. (2004) [eleven]	1	i	1	0	1	ane	one	0	0	6
Dagenais et al. (2010) [12]	i	−1	0	one	1	i	−1	−1	0	i
Ernst and Harkness (2001) [30]	1	1	1	one	ane	1	one	−1	1	eight
Ernst and Canter (2003) [13]	1	one	1	ane	1	1	i	−1	i	8
Ernst (2003) [twenty]	1	1	1	1	1	i	1	−1	ane	8
Ernst (2003) [25]	1	1	ane	one	1	1	1	−1	1	viii
Ernst (2009) [26]	1	1	ane	1	1	1	−1	−one	ane	7
Fernández de las Peńas et al. (2006) [17]	1	i	0	0	1	0	1	1	ane	6
Fernández de las Peńas et al. (2005) [xviii]	ane	0	−1	−1	i	0	−1	−1	−1	−iii
Ferreira (2002) [14]	1	1	one	1	ane	ane	1	one	i	9
Gross et al. (2004) [21]	1	1	one	0	1	1	1	1	1	eight
Gross et al. (2010) [22]	1	0	ane	0	1	1	1	1	one	7
Herd (2008) [27]	1	1	one	one	0	0	0	0	0	4
Chase et al. (2009) [28]	i	one	1	1	1	1	1	1	1	9
Lenssinck et al. (2004) [xix]	1	ane	1	one	1	1	1	0	1	8
Licciardone et al. (2005) [15]	1	1	1	0	−1	−1	one	ane	−i	2
Posadzki (2010) [24]	1	1	1	i	ane	1	1	0	1	viii
Proctor et al. (2001) [29]	1	one	1	one	1	1	one	0	1	8
Vernon et al. (2005) [23]	1	1	0	−one	0	0	0	0	0	ane

Study, year (ref)	Search Methods? (a)	Search Comprehensive? (b)	Inclusion Criteria? (c)	Bias Avoided? (d)	Validity Criteria? (e)	Validity Assessed? (f)	Methods for Combining Studies? (1000)	Appropriately Combined? (h)	Conclusions Supported? (i)	Sum
Assendelft et al.(2004) [10]	one	i	one	1	one	1	1	1	1	9
Astin and Ernst (2002) [16]	one	i	i	1	one	1	1	ane	1	9
Bronfort et al. (2001) [1]	i	1	1	1	one	0	1	0	1	7
Bronfort et al. (2004) [11]	one	1	1	0	ane	i	1	0	0	half-dozen
Dagenais et al. (2010) [12]	one	−one	0	1	1	1	−i	−1	0	1
Ernst and Harkness (2001) [thirty]	ane	1	1	1	1	ane	1	−1	1	8
Ernst and Canter (2003) [13]	1	one	1	1	ane	1	1	−1	1	eight
Ernst (2003) [xx]	ane	1	1	1	1	i	1	−1	1	8
Ernst (2003) [25]	one	1	i	1	i	1	1	−1	1	viii
Ernst (2009) [26]	i	1	1	1	one	1	−one	−i	i	7
Fernández de las Peńas et al. (2006) [17]	1	1	0	0	1	0	one	one	1	6
Fernández de las Peńas et al. (2005) [18]	one	0	−ane	−i	i	0	−i	−1	−1	−3
Ferreira (2002) [14]	1	ane	1	1	i	1	ane	1	ane	nine
Gross et al. (2004) [21]	1	1	1	0	1	1	one	1	one	8
Gross et al. (2010) [22]	1	0	1	0	1	1	i	1	1	7
Herd (2008) [27]	ane	1	1	1	0	0	0	0	0	iv
Hunt et al. (2009) [28]	1	ane	one	1	one	1	i	1	1	9
Lenssinck et al. (2004) [19]	i	1	1	1	1	1	1	0	1	8
Licciardone et al. (2005) [xv]	1	i	1	0	−1	−1	i	1	−i	two
Posadzki (2010) [24]	i	ane	1	ane	one	1	one	0	1	viii
Proctor et al. (2001) [29]	one	i	1	1	one	ane	1	0	1	8
Vernon et al. (2005) [23]	ane	1	0	−1	0	0	0	0	0	1

Scoring: Each Question is Scored equally 1, 0, or −1.

ane = (a) the review states the databases used, date of well-nigh contempo searches, and some mention of search terms; (b) the review searches at least two databases and looks at other sources; (c) the review states the criteria used for deciding which studies to include in the overview; (d) the review reports how many studies were identified past searches, numbers excluded, and appropriate reasons for excluding them; (e) the review states the criteria used for assessing the validity of the included studies; (f) the review reports validity assessment and did some type of analysis with it; (g) the written report mentions that quantitative analysis was not possible and reasons that it could non be done; (h) the review performs a test for heterogeneity earlier pooling or does appropriate subgroup testing, advisable sensitivity analysis, or other such analysis; (i) the conclusions made by the author(southward) are supported past the data and/or analysis reported in the review; 0 = the above mentioned criteria were partially fulfilled; −one = none of the above criteria were fulfilled.

A score of i or less means the review has extensive flaws, 2–5 major flaws, and 6–9 minimal or no flaws.

Operationalization of the Oxman criteria [9], adjusted from Chou and Huffman [37].

Table 2

Quality ratings for included systematic reviews of spinal manipulations for pain

Report, twelvemonth (ref)	Search Methods? (a)	Search Comprehensive? (b)	Inclusion Criteria? (c)	Bias Avoided? (d)	Validity Criteria? (e)	Validity Assessed? (f)	Methods for Combining Studies? (g)	Appropriately Combined? (h)	Conclusions Supported? (i)	Sum
Assendelft et al.(2004) [10]	1	ane	ane	1	1	1	ane	one	one	9
Astin and Ernst (2002) [16]	1	1	1	one	1	1	1	1	1	9
Bronfort et al. (2001) [1]	i	ane	1	1	1	0	1	0	one	vii
Bronfort et al. (2004) [11]	ane	1	1	0	1	ane	one	0	0	6
Dagenais et al. (2010) [12]	i	−one	0	1	1	i	−i	−1	0	1
Ernst and Harkness (2001) [thirty]	1	1	ane	1	1	one	1	−1	ane	8
Ernst and Amble (2003) [13]	i	1	1	1	i	1	1	−i	1	8
Ernst (2003) [20]	i	1	1	i	1	1	ane	−1	1	8
Ernst (2003) [25]	ane	1	1	1	ane	1	1	−1	ane	8
Ernst (2009) [26]	1	one	i	one	1	1	−i	−one	1	vii
Fernández de las Peńas et al. (2006) [17]	1	1	0	0	1	0	1	ane	ane	6
Fernández de las Peńas et al. (2005) [eighteen]	one	0	−one	−1	1	0	−1	−ane	−1	−3
Ferreira (2002) [14]	1	1	1	1	1	ane	1	1	i	nine
Gross et al. (2004) [21]	ane	i	1	0	1	i	1	one	1	eight
Gross et al. (2010) [22]	1	0	1	0	1	i	1	one	1	7
Herd (2008) [27]	ane	1	1	1	0	0	0	0	0	iv
Hunt et al. (2009) [28]	i	1	ane	1	ane	1	1	1	1	ix
Lenssinck et al. (2004) [19]	1	one	1	1	i	1	ane	0	ane	8
Licciardone et al. (2005) [xv]	1	one	i	0	−i	−1	ane	i	−one	ii
Posadzki (2010) [24]	1	1	one	one	1	i	1	0	1	viii
Proctor et al. (2001) [29]	i	1	1	1	1	i	1	0	1	8
Vernon et al. (2005) [23]	i	1	0	−1	0	0	0	0	0	i

Report, year (ref)	Search Methods? (a)	Search Comprehensive? (b)	Inclusion Criteria? (c)	Bias Avoided? (d)	Validity Criteria? (e)	Validity Assessed? (f)	Methods for Combining Studies? (g)	Appropriately Combined? (h)	Conclusions Supported? (i)	Sum
Assendelft et al.(2004) [10]	1	1	ane	1	1	ane	1	1	1	9
Astin and Ernst (2002) [16]	i	one	1	ane	ane	i	ane	one	1	9
Bronfort et al. (2001) [1]	i	1	i	1	1	0	1	0	1	seven
Bronfort et al. (2004) [11]	1	i	1	0	1	1	i	0	0	6
Dagenais et al. (2010) [12]	i	−1	0	i	ane	1	−1	−1	0	ane
Ernst and Harkness (2001) [thirty]	ane	one	1	1	1	i	ane	−1	i	8
Ernst and Canter (2003) [13]	one	one	one	1	one	i	ane	−1	1	8
Ernst (2003) [20]	i	ane	1	i	1	i	i	−i	1	eight
Ernst (2003) [25]	ane	1	1	ane	1	1	ane	−1	i	8
Ernst (2009) [26]	one	1	i	1	1	one	−i	−1	1	7
Fernández de las Peńas et al. (2006) [17]	1	1	0	0	i	0	1	1	1	vi
Fernández de las Peńas et al. (2005) [18]	i	0	−1	−i	1	0	−1	−1	−one	−three
Ferreira (2002) [fourteen]	1	1	i	1	1	1	1	ane	ane	9
Gross et al. (2004) [21]	1	ane	1	0	i	1	ane	1	1	8
Gross et al. (2010) [22]	one	0	1	0	1	ane	1	one	1	vii
Herd (2008) [27]	1	1	1	1	0	0	0	0	0	4
Hunt et al. (2009) [28]	1	1	1	one	1	ane	ane	one	1	9
Lenssinck et al. (2004) [nineteen]	i	one	i	i	ane	1	one	0	1	8
Licciardone et al. (2005) [15]	i	1	1	0	−one	−1	1	1	−i	2
Posadzki (2010) [24]	1	i	ane	1	1	1	1	0	one	viii
Proctor et al. (2001) [29]	1	1	ane	i	i	i	1	0	ane	eight
Vernon et al. (2005) [23]	one	1	0	−1	0	0	0	0	0	1

Scoring: Each Question is Scored as ane, 0, or −i.

one = (a) the review states the databases used, date of most recent searches, and some mention of search terms; (b) the review searches at least two databases and looks at other sources; (c) the review states the criteria used for deciding which studies to include in the overview; (d) the review reports how many studies were identified by searches, numbers excluded, and appropriate reasons for excluding them; (eastward) the review states the criteria used for assessing the validity of the included studies; (f) the review reports validity assessment and did some blazon of analysis with information technology; (1000) the report mentions that quantitative analysis was not possible and reasons that it could non be done; (h) the review performs a exam for heterogeneity before pooling or does appropriate subgroup testing, appropriate sensitivity analysis, or other such analysis; (i) the conclusions made by the author(s) are supported by the data and/or analysis reported in the review; 0 = the in a higher place mentioned criteria were partially fulfilled; −i = none of the to a higher place criteria were fulfilled.

A score of ane or less ways the review has extensive flaws, 2–5 major flaws, and 6–9 minimal or no flaws.

Operationalization of the Oxman criteria [ix], adapted from Chou and Huffman [37].

Data were analyzed using Predictive Analytics Software Statistics eighteen.0.ane.

Results

After removal of duplicates, the searches generated 62 articles. Forty articles were excluded (Figure 1). The reasons for exclusion were: not SRs (N = 14), not pain-related condition (North = 13) based on previous SR (North = 7), and SRs that did non include RCTs only (N = 6). Twenty-two SRs met the inclusion criteria mentioned earlier [1,10–thirty]. Cardinal data of these reviews are summarized in Table 1. These SRs related to the following conditions: depression back pain (LBP) (Northward = 6), headache (N = 5), cervix pain (Northward = 4), any medical problem (North = 1), carpal tunnel syndrome (N = i), dysmenorrhea (Northward = 1), fibromyalgia (N = 1), lateral epicondylitis (Due north = 1), musculoskeletal weather condition (North = 1), and nonspinal pain (N = 1). In that location was some overlap betwixt these categories (Tabular array 3).

Figure ane

Flowchart of eligibility cess and inclusion. RCT = randomized control trials; SR = systematic review.

Figure 1

Flowchart of eligibility assessment and inclusion. RCT = randomized command trials; SR = systematic review.

Table 3

Weather with multiple systematic reviews

	Determination
Condition	Positive	Negative	Neutral or unclear
Headache	two	3	0
Low dorsum pain	3	iii	0
Neck pain	0	3	1

	Conclusion
Status	Positive	Negative	Neutral or unclear
Headache	two	3	0
Low back pain	three	3	0
Cervix pain	0	three	1

Tabular array three

Atmospheric condition with multiple systematic reviews

	Conclusion
Condition	Positive	Negative	Neutral or unclear
Headache	two	3	0
Low dorsum hurting	3	3	0
Neck pain	0	3	1

	Determination
Status	Positive	Negative	Neutral or unclear
Headache	2	3	0
Low back hurting	3	3	0
Neck pain	0	3	1

The SRs included chiropractic or osteopathic manipulations equally well as manual therapy or any blazon of SM. Nine SRs included more than than 10 principal studies [10–fourteen,21,22,24,27]; and five included a meta-analytic approach [ten,xiv,fifteen,21,22]. The conclusions fatigued from most SRs were frequently cautious or negative (Table i).

For example, for LBP three SRs arrived at positive conclusions [11,12,15], and three arrived at negative conclusions [ten,thirteen,14]. For headaches, 2 reached positive conclusions [i,18] whereas iii reached negative conclusions [16,17,19]. For neck pain, three arrived at negative conclusions [twenty,21,23] and one arrived at equivocal conclusions [22]. Thus, there was an undeniable degree of contradiction between these SRs.

The methodological quality of SRs was predominantly high—17 SRs were of high quality and 5 were of poor quality (Hateful = vi.23, standard difference = 3.23). Withal, the quality of SRs published by contained authors was significantly higher than those published by chiropractors/osteopaths. There was a statistically significant difference between groups as determined past one-mode analysis of variance (F [i,3] = 82.371, P = 0.003).

Discussion

In the recent years, dozens of SRs investigating the therapeutic value of SM in a broad variety of pain-related weather have been published. The present article was aimed at critically evaluating the data for or against the notion that SM is effective in treating pain in human subjects.

Twenty-two SRs met the eligibility criteria [ane,ten–30]. Five of those 22 SRs suggested that SM is effective [ane,xi,12,fifteen,eighteen], and 17 failed to do so [10,thirteen,14,16,17,19–30]. Therefore, almost of these SRs (77%) failed to produce convincing evidence to propose that SM is of effective therapeutic value for hurting.

Information technology is suggested that the conclusions of SRs of SM for back pain appear to be influenced by authorship. Osteopaths or chiropractors seem to publish depression methodological-quality SRs associated with positive conclusions (Table iv). 4 (80%) of the five SRs published either by chiropractors or osteopaths arrived at overtly positive conclusions [1,11,12,xv] and only one arrived at negative conclusions [23]. Sixteen (94%) of the 17 SRs past independent inquiry groups reached negative or equivocal conclusions [10,13,xiv,16,17,xix–30]. Only i (6%) arrived at positive conclusions [18]. Therefore, this review shows that SM is of debatable clinical usefulness in hurting management.

Table 4

Summary of findings

Study (year) (ref)	Quality of systematic review (Oxman criteria)	Chiropractors or osteopaths as first authors	Conclusions
Assendelft et al. [2004][10]	9	No	(−)
Astin and Ernst (2002) [xvi]	9	No	(−)
Bronfort et al. (2001) [1]	7	Yeah	(+)
Bronfort et al. (2004) [11]	6	Yes	(+)
Dagenais et al. (2010) [12]	1	Yes	(+)
Ernst and Harkness (2001) [xxx]	eight	No	(−)
Ernst and Amble (2003) [thirteen]	8	No	(−)
Ernst (2003) [20]	8	No	(−)
Ernst (2003) [25]	8	No	(−)
Ernst (2009) [26]	7	No	(−)
Fernández de las Peńas et al. (2006) [17]	6	No	(−)
Fernández de las Peńas et al. (2005) [18]	−three	No	(+)
Ferreira (2002) [14]	nine	No	(−)
Gross et al. (2004) [21]	8	No	(−)
Gross et al. (2010) [22]	7	No	(+/−)
Herd (2008) [27]	iv	No	(−)
Hunt et al. (2009) [28]	9	No	(−)
Lenssinck et al. (2004) [xix]	8	No	(−)
Licciardone et al. (2005) [15]	2	Yes	(+)
Posadzki (2010) [24]	viii	No	(−)
Proctor et al. (2001) [29]	eight	No	(−)
Vernon et al. (2005) [23]	1	Yeah	(−)

Study (twelvemonth) (ref)	Quality of systematic review (Oxman criteria)	Chiropractors or osteopaths as kickoff authors	Conclusions
Assendelft et al. [2004][10]	9	No	(−)
Astin and Ernst (2002) [16]	nine	No	(−)
Bronfort et al. (2001) [1]	7	Aye	(+)
Bronfort et al. (2004) [11]	vi	Yeah	(+)
Dagenais et al. (2010) [12]	ane	Yes	(+)
Ernst and Harkness (2001) [30]	8	No	(−)
Ernst and Amble (2003) [13]	8	No	(−)
Ernst (2003) [xx]	8	No	(−)
Ernst (2003) [25]	eight	No	(−)
Ernst (2009) [26]	7	No	(−)
Fernández de las Peńas et al. (2006) [17]	6	No	(−)
Fernández de las Peńas et al. (2005) [xviii]	−three	No	(+)
Ferreira (2002) [14]	ix	No	(−)
Gross et al. (2004) [21]	eight	No	(−)
Gross et al. (2010) [22]	7	No	(+/−)
Herd (2008) [27]	4	No	(−)
Hunt et al. (2009) [28]	9	No	(−)
Lenssinck et al. (2004) [19]	viii	No	(−)
Licciardone et al. (2005) [15]	2	Yes	(+)
Posadzki (2010) [24]	8	No	(−)
Proctor et al. (2001) [29]	8	No	(−)
Vernon et al. (2005) [23]	ane	Yes	(−)

Score vi–9 indicates high quality; score 5 or less indicates low quality.

(−) negative; (+) positive; (+/−) equivocal.

Table four

Summary of findings

Written report (year) (ref)	Quality of systematic review (Oxman criteria)	Chiropractors or osteopaths as starting time authors	Conclusions
Assendelft et al. [2004][10]	9	No	(−)
Astin and Ernst (2002) [16]	9	No	(−)
Bronfort et al. (2001) [1]	vii	Yep	(+)
Bronfort et al. (2004) [eleven]	6	Yes	(+)
Dagenais et al. (2010) [12]	one	Yes	(+)
Ernst and Harkness (2001) [30]	8	No	(−)
Ernst and Canter (2003) [13]	8	No	(−)
Ernst (2003) [xx]	8	No	(−)
Ernst (2003) [25]	8	No	(−)
Ernst (2009) [26]	7	No	(−)
Fernández de las Peńas et al. (2006) [17]	6	No	(−)
Fernández de las Peńas et al. (2005) [eighteen]	−iii	No	(+)
Ferreira (2002) [14]	9	No	(−)
Gross et al. (2004) [21]	eight	No	(−)
Gross et al. (2010) [22]	7	No	(+/−)
Herd (2008) [27]	4	No	(−)
Hunt et al. (2009) [28]	ix	No	(−)
Lenssinck et al. (2004) [19]	eight	No	(−)
Licciardone et al. (2005) [xv]	2	Yes	(+)
Posadzki (2010) [24]	8	No	(−)
Proctor et al. (2001) [29]	8	No	(−)
Vernon et al. (2005) [23]	i	Yes	(−)

Study (yr) (ref)	Quality of systematic review (Oxman criteria)	Chiropractors or osteopaths as commencement authors	Conclusions
Assendelft et al. [2004][10]	9	No	(−)
Astin and Ernst (2002) [sixteen]	9	No	(−)
Bronfort et al. (2001) [1]	7	Yeah	(+)
Bronfort et al. (2004) [xi]	6	Yes	(+)
Dagenais et al. (2010) [12]	1	Yes	(+)
Ernst and Harkness (2001) [30]	8	No	(−)
Ernst and Canter (2003) [13]	viii	No	(−)
Ernst (2003) [20]	viii	No	(−)
Ernst (2003) [25]	8	No	(−)
Ernst (2009) [26]	7	No	(−)
Fernández de las Peńas et al. (2006) [17]	6	No	(−)
Fernández de las Peńas et al. (2005) [18]	−three	No	(+)
Ferreira (2002) [xiv]	9	No	(−)
Gross et al. (2004) [21]	eight	No	(−)
Gross et al. (2010) [22]	seven	No	(+/−)
Herd (2008) [27]	iv	No	(−)
Chase et al. (2009) [28]	9	No	(−)
Lenssinck et al. (2004) [nineteen]	viii	No	(−)
Licciardone et al. (2005) [15]	2	Yes	(+)
Posadzki (2010) [24]	8	No	(−)
Proctor et al. (2001) [29]	8	No	(−)
Vernon et al. (2005) [23]	1	Yes	(−)

Score 6–nine indicates high quality; score 5 or less indicates low quality.

(−) negative; (+) positive; (+/−) equivocal.

The highest degree of ambiguity in the included SRs has been noticed for LBP. There was a iii/3 ratio of positive vs negative SRs, meaning that more research need to be done in order to determine the effectiveness of SM for that condition. A less favorable ratio has been noticed for headaches (2/3), meaning that for some types of headaches and in sure groups of patients, SM is ineffective. The worst ratio has been noticed for cervix pain. There was one equivocal SR vs three negative ones, meaning that SM should not be the recommended treatment option for patients with neck hurting. For other weather such as musculoskeletal pain, nonspinal pain syndromes, fibromyalgia, lateral epicondylitis, carpal tunnel syndrome, or principal and secondary dysmenorrhea, the conclusions from SRs were all negative.

Condom of each therapeutic intervention should be of paramount importance. Unfortunately, several hundred severe complications later on upper SM have been reported, due east.g., [31,32] although the estimates as to the incidence of these complications vary hugely [viii]. A item business organisation relates to vascular accidents caused by arterial dissection afterward upper SM [33–36]. Therefore, if the harms outweigh benefits, SM should be discouraged equally a treatment selection for hurting in the cervical area.

All the same, the present assay has several limitations. Outset, although searches were wide, the author cannot be certain that all relevant articles were located. Second, all SRs are prone to a well-known phenomenon—publication bias—which may have been inherited in this study. Too, the fact that only one reviewer extracted the information and performed quality cess might have acquired additional bias.

Future inquiry in this area should control for placebo furnishings by employing sham SM, using blinded design, and being of adequate sample size based on power calculations. Allotment to groups should be concealed, data analyzed based on intention to treat, and validated outcome measures ought to be used to increase internal validity in future research on SM in pain direction.

Conclusion

Clinical decisions always have to be based on weighing the potential benefits of an intervention with its risks when managing pain patients. Until recently, information technology was relatively unclear whether SM is an effective therapeutic option for pain management. This review demonstrates rather assuredly that SM is an ineffective option in the management of some types of pain such as neck hurting; and the risks outweigh the benefits. Further inquiry in other areas such as LBP or headache may seem justified.

Acknowledgments

The writer would like to thank Professor Edzard Ernst for his valuable contribution to this manuscript.

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Disharmonize of interest: None declared.

Source of funding: None.

Wiley Periodicals, Inc.

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Source: https://academic.oup.com/painmedicine/article/13/6/754/1839832

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