Should cervical manipulations be abandoned?

TRANSFER FROM POSTEROUS: ORIGINALLY POSTED ON POSTEROUS JUNE 8, 2012

This is really for physiotherapists, but please feel free to read whoever you are.

The Chartered Society of Physiotherapy (CSP) today reported on a British Medical Journal (BMJ) article by Wand et al about the practice of cervical manipulations.

The news report can be found here, and the original article can be found here.

There is a formal rapid response to the paper found here, which is from a group of physiotherapists.
This brief blog represents my opinions and not necessarily those of the co-authors of the response.

Wand et al conclude with a proposition that “manipulation of the cervical spine should be abandoned”, and call on professional bodies to adopt this stance as a formal policy. This is a strong conclusion which you would hope would be based on firm and conclusive data.  However, this is not the case. The data on risk, by self-admission of the BMJ paper authors, is inconsistent and provides nothing but uncertainty. The best of the data would suggest that adverse events to manipulation is extraordinarily low. The benefits of the intervention are, at worst, comparable with alternatives. The maths is simple at this level. Extremely low risk versus likely benefit. If the logic used to argue for the abandonment of manipulation in the BMJ paper was taken seriously (which is very unlikely), then most interventions in medicine and allied therapies would be scrapped. Take, for example oral contraceptives: risk of thrombosis (much higher than manipulation risks) versus comparable benefit.  Let alone non-medical interventions, like hotel hair-dryers, coffee, pencils, and tampons.

Anyway, these are old and tired arguments and not really central to the issues of the current paper and news story. This isn’t about manipulation. Personally, I have no interested in manipulations per se other than wondering, like anything health professionals do, whether it is of likely benefit for patients.  The concept of manipulations is, however, for some bizarre reason, the source of disproportionate concern and emotion.  And it seems it is this that continues to drive the ‘manipulations’ debate. The evidence is merely (mis)used as a tool to support some fixed, pre-established view-point. The ‘Head to Head’ stand-off in today’s BMJ was contrived and non-informative to all involved.  In some ways, the authors were victims of some mis-guided editorial whim.

The real issues at hand though are deeper. This is about the fervent, over-enthusiasm to drag something meaningful out of meaningless data in attempts to appear scientific and contribute to evidence-based practice, whilst paradoxically being pseudo-scientific and missing the point of evidence-based practice.  The potential harmful effects on associated professions and their patients are irreparable.  Physiotherapy is slowly but surely becoming stripped of all its worth.  A hundred-plus years of development and progress based on logic, intellect and science is undergoing painful erosion.  Interventions once the realm of the profession are being thrown out and taken up by others; exercise prescription, manual therapy, electro-therapy. We are becoming experts in handing out advice pamphlets. This is NOT because the interventions are ineffective. It is because they are deemed to have questionable efficacy based on sorry scraps of ‘evidence’ salvaged to adhere to the rhetoric of evidence-based practice.  Remember, most research findings are false (J.P.A. Ioannidid PLoSMed. 2, el124;2005), and this is more-so the case in physiotherapy (R. Kerry et al J Eval Clin Prac).

Very rarely is data considered in a scientific manner: in context of a priori beliefs; in context of the professional background for which it is intended; in the context of the dynamism of scientific discovery; in context of what we understand by cause and effect; in context of individual patients. Today’s claim of “abandoning manipulations” is simply another ludicrous reminder of the state we are in.  The CSP’s reporting is another example of a body blind to the deterioration of its very own profession.

POSTEROUS VIEWS: 670

POSTEROUS COMMENTS

Kevin Kelly responded:
I am in total agreement. It is unfortunate that the drugs industry is a multi-billion pound industry with tremendous lobbying power….any treatment that reduces the amount of drugs prescribed and helps patients should be used not criticised.The cherry-picking of poor quality research needlessly raises alarm in patients and does little to help the people suffering from neck pain and headaches to choose the most appropriate treatment.Neck manipulation has been shown to be safe and effective and benefits thousands of people suffering from neck pain and headaches. In fact, the risk of a stroke after treatment is the same whether you see a GP and get a prescription or see a chiropractor and get your neck adjusted.http://www.ncbi.nlm.nih.gov/pubmed/18204390

Manipulation of the neck is at least as effective as other medical treatments and is safer than many of the drugs used to treat similar conditions.http://www.ncbi.nlm.nih.gov/pubmed/17258728

11 months agoreid_heather (Twitter) responded:
Here hereAs a lecturer and teacher of spinal manipulation for 20years one can only assume that such articles are fuelled by ignorance.manipulation is a highly effective method of alleviating pain whose cause or source lies within the cervical spine. It is a skill we as physiotherapists should embrace rather than through fear discard. Whilst it has been shown that manipulation of the thoracic spine for some patients with cervical symptoms can be effective one must note the SOME. If we don’t continue to use these skills we will lose them. I certainly have not been a member of this profession for over 30 years to become reduced to leaflet giving.

I don’t usually have a rant about such matters but having just revised the history of medicine with my 16 year old daughter it seems that myths about health can be so powerful and disabling that it can prevent further progress. Whilst I do not suggest we reconsider Hippocrates take on the four humours and the balance of opposites he did give us a philosophical base to progress,whilst others thought illness was due to the anger of the Gods or evil spirits.

Benefits can be risky, however physiotherapists are also highly qualified in assessing the risk, and would only act when the risk is absolutely minimal.

11 months agoTaylorAlanJ (Twitter) responded:
So it all becomes clear! The BMJ have just made the web pages ‘pay per view’ . . . So it truly was a cynical marketing ploy that some folks fell for . . . Hook line and sinker!But where were the CSP when we needed them? . . . Sucking it all in and regurgitating it for good measure. None of this is helpful to a dying profession!It is ALL cumulative . . . In the last 2 months G.P’s have been given the impression that Whiplash injury doesn’t exist and now manipulation is harmful . . .

Who is standing up??

I have published my views in more detail onhttp://alteredhaemodynamics.blogspot.co.uk/

AJT

11 months agoHoward Turner responded:
Roger: beautifully put and a grave concern; there is no way to reverse this agenda if it goes too far. Has it gone too far already?My jubilee was a very wet tent in Wales – excellent thank you!
11 months agoRoger Kerry responded:
Hi Howard
Thanks for your supportive comments. Has it gone too far already? I think we are starting to see a generation of ‘de-skilled’ practioners coming through. If there was overwhelmeing evidence to confidently refute skill-based interventions, this would be fine, but there’s not.Hope your tent has dried out – Stick to leafy Cheshire!
10 months agoSteve Robson responded:
Roger makes many good points here about the erosion of skills within physiotherapy. This discourse regarding the safety of manipulation has come and gone many times over the years without resolution. But are we overlooking some fundamental issues here? Before those interested parties within physiotherapy once again ‘lock horns’ in an intra and inter professional struggle to retain their status as manipulators, what is it we as a profession feel is so valuable about manipulation?In circumstances of patient centred treatment and evidence based medicine, any treatment or mode of clininical management logically has to engage with the biopsychosocial status of each patient.
In terms of clinical reasoning, isn’t it essential that we attempt to answer some fundamental questions central to the use of manipulation? After all, decisions based on the use of manipulation as a technique come before an estimation of its safety is even necessary. From this perspective;(1) Essentially what is manipulation? (a definition if you like).
(2) Why are we using it, in other words, what do we hope to achieve by using manipulation?
(3) What are the mechanisms of manipulation, or quite simply, how does it work?

The answers to the above should drive the clinical reasoning process, and as such, what is best for the patient. Without this information evdence based clinical reasoning is not possible.
I would be genuinely interested to hear answers to the three questions above from those of us in physiotherapy who use manipulation.

Essentially, without this information the whole discussion regarding the use of manipulation at all is null and void.

10 months agoRoger Kerry responded:
Thanks for these comments Steve.
I agree that there are fundamental questions to be asked about all aspects of practice. Perhaps reducing the discussion to this level will help in understanding precisely what we are aiming for in clinical practice and research. Did you used to do a MT course exploring these issues?
10 months agoAlan responded:
I am a physiotherapist myself and it seems more and more that in order to continue with manual therapy in Britain I should have qualified in osteopathy or other related profession.It is no wonder that most of the private practice jobs in this country are being filled with our colleagues from the southern hemisphere, renowned for their manual therapy skills.I worry that the UK trained physiotherapist will be having more of an identity crisis in the years ahead!

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