Some further thoughts on SMT and hypocrisy

When I have a sore throat, I like to drink hot tea. I don’t for a minute believe that the tea is “curing” my sore throat. But it provides me with symptomatic relief, so I like it. I don’t have an RCT to prove to me it’s reducing pain, so it might even be a placebo effect. I don’t care. Tea is cheap, it’s non-invasive, it has relatively few adverse effects (although I’m sure you can find me an anecdote or two showing someone who burned themselves terribly or something), and I’m not asking insurance to pay for it.

When some people have back pain, they go for spinal manipulation therapy. They shouldn’t for a minute believe that SMT is “curing” their bad back. It may provide them with symptomatic relief, though. There are RCTs to show that SMT works as well as other therapies we prescribe. It’s cheaper than many traditional therapies, it’s non-invasive, it has relatively few adverse effects (although you can find anecdotes of harm, especially if people have their neck manipulated), and it’s pretty much all out-of-pocket spending.

What’s the difference between the first and the second paragraph? The cost? Where you get the intervention? The fact that there’s more evidence for the SMT than for tea?

I’ve gotten a lot of anger from this last column, mostly from physicians. Osteopaths are angry I didn’t single them out as already knowing about the benefits of SMT and naming them good deliverers of it. MDs are angry at me for saying that anyone should think about SMT in the first place.

The latter argue that the evidence is weak. I agree, the data could be better. The data are crappy on almost every single back pain intervention, though. They argue that I’m giving SMT an easier bar to hurdle because it’s an alternative therapy. That’s not why. I’m giving it a lower hurdle to pass because it’s non-invasive, has few adverse effects if done right, it’s OOP and entirely up to individuals to buy, and it appears to work as well as the many other things we recommend for back pain all the time.

It’s like tea. I could take a pain med for my sore throat (which doesn’t work that well), or I could drink the tea. I choose the latter.

If you don’t want the SMT, that’s fine. Really. You could try heat. Or accupuncture, massage, yoga, etc. They’re all pretty safe, cheap, non-invasive, and it’s your money. Or, you could try some short term NSAIDS. Feel free. Guess what? It really doesn’t matter. The back pain is likely to resolve on its own, no matter what you do, and these things all seem to help equally along the way.

That’s what I said. That’s what I stand by. If you disagree, and think traditional medicine is better here, then I encourage you to find the evidence saying that’s so. Otherwise, shrug like me, and admit that maybe you don’t know.


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