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Pick a joint, any joint!

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Spinal manipulative therapy (SMT) is the “popping” or wiggling of spinal joints — the staple of nearly all chiropractic and osteopathic therapy (and also utilized by physiotherapists). But a 2021 study shows that it doesn’t much matter which joints are manipulated, which is not a great look.

More specifically, the study showed that there’s no benefit to SMT based on skilled joint selection, which is a nifty angle.

How else would joints be selected? Is there some other kind of joint selection? In theory, all SMT is applied to joints chosen with expertise and skill — especially SMT performed in the context of scientific trials, one would hope. (And yet, ironically, studying only the most mediocre manipulation might actually be more pragmatic: most patients, by definition, can only access average quality care.)

Nim et al. evaluated tests of SMT where adjustment of “clinically relevant joints” was compared to SMT applied “elsewhere” to “non-candidate” joints. Obviously the expertly selected joints should have produced better results. But they didn’t.

That result was based on data from 10 studies “all of acceptable quality” (SMT has been studied quite a bit). Nine of them reported no statistically significant differences. The only paper that did report a difference reported only a small one… and had a high risk of bias (which usually leads inexorably to errors in the researchers’ favour).

If it doesn’t matter what joint you “adjust,” then it doesn’t matter if you adjust joints at all. This data is quite damning to SMT. Obviously.

How this fits into the bigger SMT picture

These results are not exactly surprising. The body of evidence on this topic has relentlessly shown that, on average, SMT is just as underwhelming an intervention as everything else: minor benefits at best.

There are, of course, lots of anecdotes that manipulation is extremely helpful for at least some patients, just the right stimulus at the right time to really do something. I actually believe that some of those are true (partly because I once experienced great relief from an adjustment once myself). But there are not enough believable anecdotes for them to be anything more than the exception to the rule.

Of course, there are many anecdotes about manipulation being super helpful for at least some patients — just the right stimulus at the right time to really make a difference. I believe some of those are true, partly because one of them is my own: I once experienced great relief from an adjustment.

But there are not enough believable anecdotes for them to be anything more than the exception to the rule.

By focusing on joint selection, this study highlights and reinforces existing knowledge in an interesting new way.

Plus, it’s in the freakin' journal Nature! It’s right there on! Right? The ultimate scientific journal! Um… well… about that…

Photo of a pair of hands pressing down on a man’s lower back, suggesting chiropractic treatment.

Consider the source: the journal “Nature”?

At first glance, this paper might seem to be published in the highly prestigious journal Nature, because of the domain it’s on — which is exactly how it was originally presented to me by a reader.

But no! It’s from the same publisher, but this is Scientific Reports … which is about as different as it could possibly be.

SR is an open-access mega-journal, the largest scientific journal in the world by article count, with a business model that results in some quality control and credibility issues. Contributors literally pay to be published in SR (“article processing fees”). What could possibly go wrong? 🤷🏻‍♂️

There are certainly many good papers in SR. But there is obviously a lot of junk, too — and they certainly do benefit from the reputation of Nature. Which is a teensy bit gross.

But, welp, this paper confirms my bias against SMT, so it must be a good one despite the source! 🤣

Flow chart time! I will describe it nicely for you. First cell says: new study published. Second cell: does it confirm my beliefs? If yes… must be a GOOD study. If no… must be a BAD study, so nitpick and find flaws, bad study confirmed! And then both pathways then ultimately lead to the inevitable conclusion: “I was right all along!”

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