Risky Business

Risk- A Risky Business

Last week I did a discussion piece based on a Telegraph article, headlined- RAF contractor sues Physiotherapist he claims left him paralysed. It raises the important subject of risk in manual therapy.


Risk is defined as a situation involving exposure to danger. Risk involved in pretty much anything including all elements of medicine. To me, if a treatment modality has the potential to do good, you have to accept it has the potential to do harm as well. Of course, some techniques, surgeries or medications will carry more risk than others, or pose more risk to one individual and their circumstances than they will to another. Managing this risk is part of what makes one healthcare provider more professional than another.

Risk of Cervical Manipulation

The main subject of the court case in the above article was repeated cervical manipulation performed by a physiotherapist. in 2010 there was a systematic review of all of the evidence around the risks of manual therapy. It concluded that the risk of serious adverse effect following spinal manipulation was 1 patient in every 50,000-100,000. This stat includes adverse effects following chiropractic and physiotherapy spinal manipulations as well as osteopathic. In isolation, it is hard to understand those figures but we can get a sense of how risky it is by comparing it to other options.

From this week’s clinic board you can see that adverse effects of spinal manipulation are comparatively low risk compared to deaths by road traffic accidents, neck surgery and even the long term risks of taking anti-inflammatory medications for arthritis.

Many assume that because treatments such as anti-inflammatories are very common that makes them a safe long term option. It is important to say, that anti-inflammatories are in many cases the best and most appropriate treatment for many complaints. But because they are a common treatment option it does not mean that they come without risks. Death from long term use of anti inflammatories affects 1 per 1000 patients in the UK per year, meaning the risk of death is significantly higher than the risk of adverse effects following spinal manipulation. It isn’t the fairest comparison as long-term anti inflammatory use most likely relates to one or more daily over several months/ years and it’s unlikely that someone will daily spinal manipulations over the course of years. If they did there is unlikely to be sufficient statistical evidence to draw any meaningful conclusions from it.

Risks worth taking

Every treatment should be considered in terms of risk/ benefit. Short term use of anti inflammatories for an acute neck pain, headache or other ailments is likely to be much lower risk than the majority of the things listed in the table above. Ultimately if the potential for benefit out weighs the risk and the patient is informed, giving their consent most treatments can be justified. Nowadays elective surgeries like joint replacements are performed on a quality of life basis- is the need for the operation great enough to justify the risk or the operation and the side effects of the anaesthetic. If the answer is yes and it is affordable, then the likelihood is that the operation can be performed.

Managing risks

In my clinic when choosing what technique to use with a particular patient you have to start with what is indicated. Ask “what is this patient’s problem?”. If it is a restricted joint I would ask myself, what techniques do I know that might help increase the range of movement. These techniques will carry their own positives and negatives. COnsiderations might include, risk, patient comfort in the technique, a time taken to perform the technique, practitioner proficiency at that given technique and vitally important are the patient’s circumstances. If a patient has poor underlying health or particular conditions, the risk of using certain techniques will increase dramatically. Personally, I wouldn’t use HVT manipulation techniques on someone who has osteoporosis, a condition that undermines the strength and integrity of the bones.

How techniques are performed can also change the risk of serious adverse effects. For example, some osteopaths might do the same techniques as me, but use more force in the application of them. This is likely to increase the risk of some effects, mild or serious. I try to be as conscious of patient comfort through all my appointments. Treatment doesn’t have to be painful to be effective, and pain does not necessarily equal gain. I will only ever use the amount of force that I think will be effective without compromising the patients’ safety or comfort and this discretion is what I think makes me both safe and effective as a practitioner.

Remember- “professionalism is knowing how do do it, when to do it and doing it”- but also knowing when NOT to do it.

Closing thoughts

Ultimately anything that has the potential to help in my opinion has the potential to do harm. It is the identification, mitigation and management of these risks that helps reduce risk and improve safety. Always ask about the risks if your therapist doesn’t inform you of them. Its their obligation to inform you of them, whether they are a GP, dentist, physio, osteopath or any other healthcare professional. Get informed ans stay safe!

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