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The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review

PainSci » bibliography » Lenssinck et al 2004
Tags: chiropractic, physical therapy, manual therapy, treatment, controversy, debunkery, spine

Two articles on PainSci cite Lenssinck 2004: 1. The Complete Guide to Chronic Tension Headaches2. Does Spinal Manipulation Work?

PainSci notes on Lenssinck 2004:

This is a classic example of a “garbage-in, garbage out” review with only possible conclusion: insufficient evidence, more study needed. It was not even very much garbage: a motley little crew of eight scientific trials of a variety of treatments for tension headaches, six of them “poor quality.” The two higher quality trials were both tests of spinal manipulation, one straight up negative, the other claiming good results but “there were insufficient data presented for the reviewers to verify this,” which makes me wonder how they even knew it was a higher quality test?

(Three of the lower quality trials rather pointlessly compared physiotherapy to acupuncture, and showed nothing important. The remainder aren’t worth of any comment at all.)

Reviews like this are only good for one thing: the absence of good news is probably bad news. Genuinely effective treatments should pass tests with flying colours. This is similar to being “damned with faint praise,” but worse: damned with insufficient evidence. True absence of evidence is different. This is a case of crappy evidence produced by researchers who were probably biased and yet still couldn’t show a clear benefit.

Not much has changed since. For instance, a 2011 review of spinal manipulation for headache was similarly murky (Fernández-de-Las-Peñas, Posadzki).

A small review of a sad batch of mostly poor quality trials of manual therapy treatments for tension headache, especially chiropractic manipulation, none of which clearly showed anything, which is not promising. Not much has changed since (e.g. Posadzki 2011).

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

The study design is a systematic review of randomised clinical trials (RCTs). The objectives of the present study are to assess the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache (TTH). No systematic review exists concerning the effectiveness of physiotherapy and (spinal) manipulation primarily focussing on TTH. Literature was searched using a computerised search of MEDLINE, EMBASE and the Cochrane library. Only RCTs including physiotherapy and/or (spinal) manipulation used in the treatment of TTH in adults were selected. Two reviewers independently assessed the methodological quality of the RCTs using the Delphi-list. A study was considered of high quality if it satisfied at least six points on the methodological quality list. Twelve publications met the inclusion criteria, including three dual or overlapping publications resulting in eight studies included. These studies showed a large variety of interventions, such as chiropractic spinal manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered to be of high quality, but showed inconsistent results. Because of clinical heterogeneity and poor methodological quality in many studies, it appeared to be not possible to draw valid conclusions. Therefore, we conclude that there is insufficient evidence to either support or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with TTH.

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