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J R Soc Med. 2006 June; 99(6): 278–279.
PMCID: PMC1472731

Systematic review of spinal manipulation

Including different techniques
Ann Moore, Chair of NCOR and The members of the National Council for Osteopathic Research

If the paper by Ernst and Canter (April 2006 JRSM1) was produced in the name of science or to support evidence based practice then the quality of the paper is of serious concern.

The systematic reviews surveyed by Ernst and Canter used various terms for the intervention: `manipulation' and `manual therapy' and `mobilization'. The terms were usually poorly defined even in the original studies. These terms describe quite distinct types of manual intervention, producing differing physiological effects. They cannot be used interchangeably and are not equivalent to spinal manipulation. Moreover, the methodology is intrinsically remote from the primary data, and the data the authors reviewed did not justify the conclusions they drew.

It is unfortunate that Ernst and Canter's cut-off date excluded a recent rigorous systematic review and meta-analysis by Licciardone et al.2 which evaluated the effectiveness of osteopathic manipulative treatment for low back pain. This study concluded that osteopathic manipulative treatment `... significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months'.

The professions which utilize manual therapy recognize the need for more evidence to support the range of manual therapy techniques and are already engaged in this process; access to funding remains a considerable barrier to conducting as much research as the professions would like.


1. Ernst E, Carter P. A systematic review of systematic reviews of spinal manipulation. JR Soc Med 2006;99: 189-93
2. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders 2005;4: 43 [PMC free article] [PubMed]

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