I recently came across this paper by Prof. Dr. Chad E. Cook, a physical therapist, PhD, a Fellow of the American Physical Therapy Association (FAPTA), and a professor as well as director of clinical research in the Department of Orthopaedics, Department of Population Health Sciences at the Duke Clinical Research Institute at Duke University in North Carolina, USA. The paper is entitled ‘The Demonization of Manual Therapy‘.
Cook introduced the subject by stating: “In medicine, when we do not understand or when we dislike something, we demonize it. Well-known examples throughout history include the initial ridicule of antiseptic handwashing, percutaneous transluminal coronary angioplasty (i. e., balloon angioplasty), the relationships between viruses and cancer, the contribution of bacteria in the development of ulcers, and the role of heredity in the development of disease. In each example, naysayers attempted to discredit the use of each of the concepts, despite having no evidence to support their claims. The goal in each of the aforementioned topics: demonize the concept.”
Cook then discussed 8 ‘demonizations’ of manual therapy. Number 7 is entitled “Causes as Much Harm as Help“. Here is this section in full:
By definition, harms include adverse reactions (e. g., side effects of treatments), and other undesirable consequences of health care products and services. Harms can be classified as “none”, minor, moderate, serious and severe . Most interventions have some harms, typically minor, which are defined as a non-life-threatening, temporary harm that may or may not require efforts to assess for a change in a patient’s condition such as monitoring .
There are harms associated with a manual therapy intervention, but they are generally benign (minor). Up to 20 –40 % of individuals will report adverse events after the application of manual therapy. The most common adverse events were soreness in muscles, increased pain, stiffness and tiredness . There are rare occasions of several harms associated with manual therapy and these include spinal or neurological problems as well as cervical arterial strokes . It is critical to emphasize how rare these events are; serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients .
Cook then concludes that “manual therapy has been inappropriately demonized over the last decade and has been associated with inaccurate assumptions and false speculations that many clinicians have acquired over the last decade. This paper critically analyzed eight of the most common assumptions that have belabored manual therapy and identified notable errors in seven of the eight. It is my hope that the physiotherapy community will carefully re-evaluate its stance on manual therapy and consider a more evidence-based approach for the betterment of our patients.
REFERENCES Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100: 330–338.
doi:10.1177/014107680710000716  Paanalahti K, Holm LW, Nordin M et al. Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial. BMC Musculoskelet Disord 2014; 15: 77. doi:10.1186/1471-2474-15-77  Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap 2017; 25: 37. doi:10.1186/s12998-017-0168-5
Here are a few things that I find odd or wrong with Cook’s text:
- The term ‘demonizing’ seems to be a poor choice. The historical examples chosen by Cook were not cases of demonization. They were mostly instances where new discoveries did not fit into the thinking of the time and therefore took a long time to get accepted. They also show that sooner or later, sound evidence always prevails. Lastly, they suggest that speeding up this process via the concept of evidence-based medicine is a good idea.
- Cook then introduces the principle of risk/benefit balance by entitling the cited section “Causes as Much Harm as Help“. Oddly, however, he only discusses the risks of manual therapies and omits the benefit side of the equation.
- This omission is all the more puzzling since he quotes my paper (his reference ) states that “the effectiveness of spinal manipulation for most indications is less than convincing.5 A risk-benefit evaluation is therefore unlikely to generate positive results: with uncertain effectiveness and finite risks, the balance cannot be positive.”
- In discussing the risks, he seems to assume that all manual therapies are similar. This is clearly not true. Massage therapies have a very low risk, while this cannot be said of spinal manipulations.
- The harms mentioned by Cook seem to be those of spinal manipulation and not those of all types of manual therapy.
- Cook states that “up to 20 –40 % of individuals will report adverse events after the application of manual therapy.” Yet, the reference he uses in support of this statement is a clinical trial that reported an adverse effect rate of 51%.
- Cook then states that “there are rare occasions of several harms associated with manual therapy and these include spinal or neurological problems as well as cervical arterial strokes.” In support, he quotes one of my papers. In it, I emphasize that “the incidence of such events is unknown.” Cook not only ignores this fact but states in the following sentence that “it is critical to emphasize how rare these events are…”
Cook concludes that “manual therapy has been inappropriately demonized over the last decade and has been associated with inaccurate assumptions and false speculations …” He confuses, I think, demonization with critical assessment.
Cook’s defence of manual therapy is clumsy, inaccurate, ill-conceived, misleading and often borders on the ridiculous. In the age of evidence-based medicine, therapies are not ‘demonized’ but evaluated on the basis of their effectiveness and safety. Manual therapies are too diverse to do this wholesale. They range from various massage techniques, some of which have a positive risk/benefit balance, to high-velocity, low-amplitude thrusts, for which the risks do not demonstrably outweigh the benefits.
“Cook’s defence of manual therapy is clumsy, inaccurate, ill-conceived, misleading and often borders on the ridiculous. In the age of evidence-based medicine, therapies are not ‘demonized’ but evaluated on the basis of their effectiveness and safety.”
And nothing more to add…
Dr Cook referred to orthopaedic manual therapy, which involves patient education for autonomy, analgesic effects and improved function based entirely on neurophysiological effects sich as descending modulation and not on old and flawed mechanical concepts of subluxation as chiropractors do. in addition, every patient has prescriptions for mobility and strengthening exercises, all this in a maximum of 4-6 sessions, which is in accordance with the new Value-based Health Care model and finally Manual therapy is recommended in all the last NICE and ACP guidelines on low back pain. Dr Chad Cook is perhaps the greatest ambassador of the evidence-based practice movement in physical therapy and is treated here in this text as a quackery supporter… absurd!
“Dr Cook referred to orthopaedic manual therapy”
how do you know?
the literature he quoted in support of his claims did not!
Dr Edzard here is the quote from the article that you mentioned in your post “ Racional Use of Manual Therapy
At present, there are no “silver bullets” in the manage- ment of patients with musculoskeletal injuries or pain. Manual therapy is also not a silver bullet; when used cor- rectly, it may be an effective option for pain modulation. Manual therapy may be effective for use with patients who are pain adaptive, and who do not have notable harmful cognitions, centrally mediated pain, or other behavior- al considerations that may be best managed different- ly. Further, long-term use of manual therapy is an exam- ple of mismanagement of resources. At best, early pain modulation consisting of 2 to 4 visits is all that most indi- viduals would need to progress to treatment that is more active.
The use of manual therapy should have the same philo- sophical consideration as the use of analgesics. Analgesics provide short-term pain relief that allows one to progress forward to daily activities or exercise. Manual therapy may do the same and will not likely be beneficial in isolation. At best, it is part of a multi-modal approach to care, is more effective when patient expectations are high, and when patient experience is a consideration.”
additionally, I ask you to read items 4,5,6 which it seems you didn’t do and you were left with only the parts that fit your bias.
I think you fail to understand that I deliberately focussed on his comments on risks;
it is an issue that is close to my heart and that we have discussed frequently on this blog.
I am aware that other sections of his article were more reasonable [even though the section you cited is not brilliant either]
my name is Edzard or Dr. Ernst but not Dr Edzard
Edzard- Cook uses your paper as a reference for the contraindications due to possible medical hazards of certain spinal manipulations, contraindications that are explained and warned of in many texts on the subject for a long time now. You also say that ‘the incidence of such claims are unknown ‘ It seems Cook may disagree with that conclusion and quotes another reference for his claim that ‘it is critical to emphasize how rare these events are’. He doesn’t have to use your conclusion and you don’t have to agree with his.
He says ‘it is my hope that this paper will generate discussion and eventually reduce the ineffective, insufficient assumptions and false speculations that many clinicians have acquired over the last decade’. This aspiration and most of his paper hardly squares with your final conclusions of ‘clumsy, inaccurate, ill-conceived, misleading and bordering on the ridiculous,. I do agree that the word ‘demonize’ is out of place in critical discussion of these matters of manipulation of the MSK system.
I think it reasonable to assume that since Prof Chad E Cook is the director of clinical research in the Department of Orthopedics at Duke University then the manual therapy of which he writes is something that occurs in the Department and can logically and rationally be referred to as ‘orthopedic manual therapy’ even though others using the same technics and philosophies, but outside of a recognized orthopedic department, may refer to those manual therapies without the inclusive use of the word ‘orthopedic’.
Thank you, Rodrigo. I was happy to see your comment here. Prof. Cook is indeed one of the most reasonable voices in evidence-based PT, and the comments below from Prof. Ernst show that he is not aware of the context in which our area of physiotherapy resides:
“Cook concludes that “manual therapy has been inappropriately demonized over the last decade and has been associated with inaccurate assumptions and false speculations …” He confuses, I think, demonization with critical assessment.
Cook’s defence of manual therapy is clumsy, inaccurate, ill-conceived, misleading and often borders on the ridiculous. In the age of evidence-based medicine, therapies are not ‘demonized’ but evaluated on the basis of their effectiveness and safety. Manual therapies are too diverse to do this wholesale.”
Yes, indeed manual therapy HAS been demonized a LOT in the last decade by what you could call the “hands-off-radicals”. And yes, “Manual Therapy”, as a whole. Therefore, this generalized reply from Prof. Cook relies on the own generalization made by the MT-critics. I worked for 11 years in Germany, and now for 8 years in Brazil, and I can relate completely to the 8 points he mentions. How much have I heard them, to the point that you’re seen as a “dinosaur”, an obsolete user of “medieval pseudoscience” if you touch your patient. That you would only make him “dependent”, only provide short-term relief with no long-term consequence, that you’re ABUSING your patient financially if you do it. How many discussions have I had a long time ago with the folks of P*** M*** S***, a well-known channel for physiotherapists in Germany. I don’t know how the’yre nowadays, but at the beginning, I was blocked by merely disagreeing with them on this issue, stating that Manual Therapy could have, YES, a positive effect. They were radical AND influential, and many followers used their argumentation to justify a pure hands-off approach, therefore excluding by principle the use of a valuable intervention. (I think now it’s gotten better, and I have to say that they usually do a great job in sharing EBP).
Finally, the last paragraph seems pretty emotional – any historical problems with Dr. Cook that may justify this kind of language? I found his opinion piece a nice, personal evaluation of some arguments out there – and this is what it is. It’s not a guideline, it’s not a RCT, it’s not rocket science. Too much fuss about too little. I was really disappointed to have found it here (I just wanted to Google his paper and found this discussion), because I immensely value Prof. Ernst’ work, especially in the fight against homeopathic pseudoscience. Cheers!
I think you erase my last reply! I will try again!!!!
first i would like to apologize if i seemed to be disrespectful with the formality you demand. I am from Brazil and in my country it is extremely respectful and polite to use the professional title in front of the first name. Second I deeply respect your work as I am a physiotherapist I have a PhD in medical science and I am also skeptical of many things as you write and propagate with the intention of putting science first however we know that science is the humble exercise of the absence of ideological bias and that’s where you go wrong. Because as a doctor I don’t see you denouncing spine surgeons who earn fees off the records of surgical supplies companies or patient deaths from opioids that happen every day because doctors prescribe wrongly to patients with chronic pain. you accept without problems the risks that can occur in a spine surgery even with a good indication such as infection, nerve damage, death, etc. But you do not accept the risks of manipulation that every trained professional has to deal with even with evidence of its effectiveness supported by scientific work. And there appears your ideological bias against the professional physiotherapist, chiropractor, osteopath etc. It seems that for you we are a professional sub-race that only simple massage and the simplest exercises should be allowed for people like us
“first i would like to apologize”
no need to
” I deeply respect your work ”
“science is the humble exercise of the absence of ideological bias and that’s where you go wrong. Because as a doctor I don’t see you denouncing spine surgeons who earn fees off the records of surgical supplies companies or patient deaths from opioids that happen every day because doctors prescribe wrongly to patients with chronic pain”
You might have realized by now that this blog is about SO-CALLED ALTERNATIVE MEDICINE.
“you accept without problems the risks that can occur in a spine surgery even with a good indication such as infection, nerve damage, death, etc.”
what on earth makes you think that???
” there appears your ideological bias against the professional physiotherapist, chiropractor, osteopath etc.”
are you sure you don’t confuse ‘ideological bias’ with critical assessment?
EE: You might have realized by now that this blog is about SO-CALLED ALTERNATIVE MEDICINE.”
Yet you link to a paper (you as the author) which states:
“…the efficacy of NSAIDs is undoubted…”
Yet a recent review states NSAIDs probably aren’t clinically relevant:
“ NSAIDs seemed slightly more effective than placebo for short-term pain reduction (moderate certainty), disability (high certainty), and global improvement (low certainty), but the magnitude of the effects is small and probably not clinically relevant.”
And of course regarding spinal manipulation risks, association (your word in the paper) is not the equivalent of causation.
Nor do we know, as stated in that paper, that in all those case the condition was “self-limiting”. We need to know if contraindications were present or not, that the condition, in some cases, was not pre-existing or that it would have occurred in spite of the intervention.
But I do agree upper cervical spine manipulation (or in any other region) should not be used routinely in clinical practice, but for other reasons.
Regarding benefits of cSMT, one simply has to search the more current reviews.
“Yet you link to a paper (you as the author) which states:
“…the efficacy of NSAIDs is undoubted…””
I SAID FOCUS!!!
I am focused on what is best for my patients.
But this statement is interesting:
“Finally, it should be mentioned that other therapeutic options (e.g. exercise therapy or massage) have not been associated with significant risks at all.”
“There were three times as many musculoskeletal events in the intervention compared to the usual care group.”
The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain.
“And of course regarding spinal manipulation risks, association (your word in the paper) is not the equivalent of causation.”
thanks – that’s a nice attempt at white-washing
white-washing? It’s the word you used, which simply means there is a relationship.
Yes, one could state that relationship is that some of those with neck pain and a headache, due to a VAD, go to a chiropractor. If the neck pain and headache aren’t resolved they then seek medical care.
Of course, the MD may erroneously conclude that the spinal manipulation caused the VAD when it is only an association.
White-washing? It’s the word you used.
I have been a Physio for over 30 years. I did not interpret the comments that we are a sub race. Only that we should use our brains and be open to evidence and critically appraise. My practise has changed dramatically over the years, as the science changes. We need to identify with a profession, not with an intervention. That allows us to step back and ask what is beneficial for the patient. For is that not what we are all about?
, I Will write again that Dr Chad Cook is one of the cornerstones of the evidence-based practice principles used by modern physiotherapists who use manual therapy as just one of their tools. it was a mistake to use only a small part of the cited scientific article to discredit his effort ! below is a summary of our profession’s current practice and these 11 items are within the mainstream medicine and science and not in alternative treatments sections.
“I Will write again that Dr Chad Cook is one of the cornerstones of the evidence-based practice principles used by modern physiotherapists”
HE COULD HAVE FOOLED ME!
Perhaps Ernst will enlighten us who he thinks are the leaders in the field of conservative care of non pathological spinal conditions.
Nonspecific chronic low back pain would be a nice start…his top three names will suffice.
DC- don’t hold yer breaf guvner in anticipation of a rapid, or even any reply. This forum, although very interesting at times is not one where a frequent expansive rational dialogue occurs with a detailed examination and exchange of differing facts and views. This of course Edzard has every right to control and we are not being coerced to participate, but his worthy cause should involve a more nuanced contribution when challenged. ‘One liners’, or nothing as a response is just lazy.
Edzard- although definitive clinical trials have yet to be performed that explore the myriad of possible presentations of patients in the therapists domain, the manipulators arsenal can still be guided by numerous areas of scientific knowledge. If the science negates any of the therapist’s clinical efforts and philosophies then, correctly, these should be jettisoned- and they often are, if not by all. Much of what is practiced on specific painful, reduced mobility joint problems has yet to be negated by scientific knowledge and indeed has much support of scientific knowledge. The good textbooks are full of it. I declare no financial vested interest in any of what I write. If I had I wouldn’t be earning much!