The Foundation for Chiropractic
Education and Research

FCER Critiques Articles in Annals of Internal Medicine


Norwalk, Iowa— The June 3, 2003 issue of Annals of Internal Medicine featured two studies which questioned the clinical and cost-effectiveness of spinal manipulation. The first, authored by Willem J. J. Assendelft, et al, is titled “Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies.” The second study, authored by Daniel C. Cherkin, et al, is titled “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.”

After careful review of these articles, Anthony L. Rosner, Ph.D., Director of Research for the Foundation for Chiropractic Education and Research (FCER), authored critical responses on behalf of the chiropractic profession. In addition to sharing his understanding of what constitutes research of clinical utility, Dr. Rosner has been able to apply his knowledge of the better research offering significant support for spinal manipulation, helping the chiropractic profession and the public recognize potentially flawed conclusions.

The Assendelft study concludes:

“There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.” In his response, Dr. Rosner calls the meta-analysis “a troubling example of how clinical data is to be interpreted and presented for public consumption and policy development.”

Points of contention raised and discussed include:

1) Comparative Side Effects and Relative Safety,
2) Mix of Clinical Judgment with Data from the Literature,
3) Inadmissible Criterion of Quality,
4) Guideline Rationale,
5) Meta-Analyses Themselves are Subject to Bias and Omissions,
6) Contradictions in Design,
7) Contradictions in Evaluating Statistical and Clinical Significance,
8) Data are not Shown in Areas of Interest,
9) Clinical as Opposed to Fastidious Treatments, and
10) Lack of Long-Term Followup.

Dr. Rosner’s critique concludes,

“From a variety of perspectives, this meta-analysis appears to be both flawed and to have either obscured or overlooked the maximal clinical benefits that might be expected to have been conferred upon patients by spinal manipulation, particularly as performed by a chiropractor. The patients response to intervention is far more complex than the dimensions offered by the authors in their discussion.”


Regarding the Cherkin study, Dr. Rosner questions the authors conclusions that “Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. . . . Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.” The flaws in this study appear to be particularly egregious as some studies are inexplicably omitted from the “rigorous and balanced summary” and the lead author uses only one (his own) “widely discredited” paper to draw his conclusions regarding cost-effectiveness and spinal manipulation.

Dr. Rosner’s complete retorts are available at www.fcer.org. In addition to providing the chiropractic profession—and all other interested parties—with fair and responsible responses to reports published in medical journals and other media, FCER strives to provide the evidence to refute such erroneous conclusions, namely quality chiropractic research. More information on the mission of FCER, as well as means for contributing to the chiropractic research arsenal, is available at the FCER web site.


Return to the LOW BACK PAIN Section