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J R Soc Med. 2006 June; 99(6): 277–278.
PMCID: PMC1472728

Systematic review of spinal manipulation

Flaws in the review

We are extremely disappointed at the level of scientific reporting demonstrated by the Ernst and Canter paper on spinal manipulation (April 2006 JRSM1). As a result, this publication does not appear to add anything to the extensive knowledge base in this area. In our opinion, there are a number of significant flaws in their review which casts an extremely negative light on both authors of the publication and the journal review process.


  1. The reviews included in the paper represent a broad mix of conditions from low back pain to infantile colic with little justification for aggregating musculoskeletal and non-musculoskeletal conditions. It should be pointed out that a very small percentage of patients present for spinal manipulation with non-musculoskeletal complaints. This has been recorded to be between 2%-5% of patients.2 Therefore, comparing intervention effectiveness across such a wide range is methodologically unsound and does not produce a constructive outcome in the best interests of patient care.
  2. The authors chose to exclude systematic reviews of spinal manipulation where it was part of a complex package of interventions. This selection bias excludes the better studies,3,4 which have incorporated education and advice about medication, resuming daily activities and work and reassuring patients, all of which are known to be of crucial importance in the management of spinal pain patients. This `packaging' is in accordance with national and international clinical guidelines published concerning back pain5 [].
  3. In concluding, the authors report finding `no convincing evidence from systematic reviews to suggest that spinal manipulation is a recommendable treatment option for any medical condition'. Does the use of the term `medical', specifically relate to non-musculoskeletal conditions, or is this also encapsulating musculoskeletal? If the latter is included, this would again be at odds with current European guidelines based on multidisciplinary systematic reviews [].5 If the former definition was meant, this was not explicit and therefore open to confusion.


1. Ernst E, Canter P H. A systematic review of systematic reviews of spinal manipulations. J R Soc Med 2006;99: 192-6 [PMC free article] [PubMed]
2. Meeker WC, Haldeman, S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Internal Med 2002, 136: 216-7 [PubMed]
3. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004. [doi:10.1136/bmj.38282.607859.AE]
4. Hurwitz E, Morgenstern H, Korninski GF, Yu F, Chiang L. A randomised trial of chiropractic and medical care for patients for low back pain: eighteen-month follow up of outcomes from the UCLA low back pain study. Spine 2006;31: 611-21 [PubMed]
5. Assendelft WJJ, Morton SC, Yu Emily I, Suttorp M, Shekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004; Issue 1 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press