Recent randomised clinical trials found manual therapy to be more effective than other methods of conservative management for low back and neck pain.^1–5 On the other hand, some randomised clinical trials,^6–13 systematic reviews,¹⁴ and meta-analyses¹⁵ concluded that there was no evidence that spinal manipulative therapy is superior to other standard treatments for patients with low back or neck pain. This provides the clinician with a Shakespearean quandary—to treat or not to treat using manual therapies? Therefore this leader addresses the question: what explains these apparently inconsistent data?.

DEFINITIONS AND SEARCH STRATEGY

The term manual therapy has many connotations, but for this leader it includes manually performed assessment and treatment methods (which can include joint, neural tissue, and/or muscle techniques). The term manipulation is typically used to describe small amplitude thrust techniques performed with speed.¹⁶

I searched Medline, Cinahl, and Embase databases for randomised clinical trials comparing spinal manual joint techniques (mobilisation with or without manipulation) or manipulation only with other conservative treatments for back or neck pain. Only studies published as full papers, in English, between 1 January 1998 and 31 December 2003 were included. Pilot studies were not included. Table 1 outlines search strategies for each database. Thirteen studies met the criteria (table 2). One study of bone setting by Finnish folk healers who lacked formal education¹⁷ was excluded as all other studies involved formally educated professionals.

Examining the trials for homogeneity revealed that the mean age of participants was similar among the studies and most participants were white (except for two studies^6,11). Thus factors related to the population studied did not appear to explain the conflicting results. …