To the EditorThe article by Goertz et al.1Goertz CM Hurwitz E Murphy B Coulter I. Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit [e-pub ahead of print]. presents a well-reasoned and thoroughly documented discussion on a recent systematic review of spinal manipulation for nonmusculoskeletal conditions. The comment that insufficient evidence is not evidence against an intervention definitely deserves to be heeded. This concept is often forgotten when policymakers are making judgments in the many cases where evidence is sparse. This is particularly important for policymakers to keep in mind. I also appreciate their discussion of the issue of hypotheses in designing and interpreting studies for this complex topic and would like to expand on this as a concept.Studies of spinal manipulation in isolation are based on 1 of many possible hypotheses. However, in practice, spinal manipulation is only 1 procedure applied by health care professionals who use manual therapy. This is demonstrated in a practice-based research study about migraines.2Moore C Adams J Leaver A Lauche R Sibbritt D. The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors. In this study, most of the doctors of chiropractic who reported treating a substantial number of patients with migraine headaches used a multimodal approach, not spinal manipulative therapy alone.3Skelly AC Chou R Dettori JR et al.Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. They also included therapies such as dry-needling, soft tissue techniques, other modalities, advice on lifestyle factors, and patient education about pain. The discussion in this practice-based research study includes an important point:While more high quality research is still needed to assess the effectiveness of individual manual therapies … understanding the use of these (multimodal) management approaches … may prove helpful in the design of future clinical trials that aim to assess the overall effectiveness of chiropractic migraine management.2Moore C Adams J Leaver A Lauche R Sibbritt D. The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors.The concept of investigating multimodal approaches for complex conditions may be extrapolated to other nonmusculoskeletal conditions as well. In fact, multimodal care is increasingly recommended for musculoskeletal conditions, particularly chronic pain.3Skelly AC Chou R Dettori JR et al.Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update., 4Hawk C Whalen W Farabaugh RJ et al.Best practices for chiropractic management of patients with chronic musculoskeletal pain: a clinical practice guideline., 5Qaseem A Wilt TJ McLean RM Forciea MA Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a Clinical Practice Guideline from the American College of Physicians., 6Skelly AC Chou R Dettori JR et al.Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Integrative care that combines conventional medical and nonpharmacological approaches to complex conditions might be a fruitful avenue of research rather than placing the sole emphasis on research into a single modality, which is not readily applied to real-life clinical practice.I commend Goertz et al.1Goertz CM Hurwitz E Murphy B Coulter I. Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit [e-pub ahead of print]. for articulately presenting a case for caution in the premature development of policies on appropriate patient care when those policies are based on evidence that is as yet insufficient to definitively determine effectiveness.ReferencesGoertz CM Hurwitz E Murphy B Coulter I.

Extrapolating beyond the data in a systematic review of spinal manipulation for nonmusculoskeletal disorders: a fall from the summit [e-pub ahead of print].

J Manipulative Physiol Ther. ()https://doi.org/10.1016/j.jmpt.2021.02.003Moore C Adams J Leaver A Lauche R Sibbritt D.

The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors.

BMC Complement Altern Med. 17: 519Skelly AC Chou R Dettori JR et al.

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update.

()Hawk C Whalen W Farabaugh RJ et al.

Best practices for chiropractic management of patients with chronic musculoskeletal pain: a clinical practice guideline.

J Altern Complement Med. 26: 884-901Qaseem A Wilt TJ McLean RM Forciea MA

Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a Clinical Practice Guideline from the American College of Physicians.

Ann Intern Med. 166: 514-530Skelly AC Chou R Dettori JR et al.

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review.

AHRQ, Rockland, MDArticle InfoPublication History

Published online: June 05, 2021

Accepted: April 19, 2021

Received: April 19, 2021

Publication stageIn Press Corrected ProofFootnotes

Conflict of Interest: Dr. Hawk receives consultation fees as chair of the Scientific Commission of the Clinical Compass.

Identification

DOI: https://doi.org/10.1016/j.jmpt.2021.04.008

Copyright

© 2021 by National University of Health Sciences.

ScienceDirectAccess this article on ScienceDirect Related Articles