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.