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I am relieved that Ernst does not include spinal manipulation in his grouping of such therapies, as it is well known to be of ancient lineage, having been practiced ‘throughout human history’.1 It was indeed taught by Hippocrates; little could be more orthodox. Even so, Ernst does write one sentence on the subject. He refers to ‘standard care’ without defining its scope, and he asserts that spinal manipulation is ‘associated with frequent, moderately severe adverse effects and less frequent, serious risks’.2
In our first book,1 critically guided by the one-time Director of Neurology of the Royal College of Surgeons, Burn and I included references to 20-odd papers detailing injury due to manipulation. The majority of these referred to isolated cases, the overall total being very small. In view of the many thousands of spinal manipulations practised every day over much of the world, it is abundantly clear that the incidence of harm is minute. In nearly 40 years using many manipulative techniques I am aware of doing harm on one occasion! Of course there may have been others, but I think I would have noticed if it had been of frequent occurrence, as Ernst suggests.
The scientific bases and the limitations of musculoskeletal medicine are documented in accessible form.3,4 It is the awareness of the contraindications to manipulation and their meticulous observance that in fact make it so remarkably safe a therapy.