Is physical therapy safe? No one really knows

PainSci » bibliography » Carlesso et al 2010
updated Apr 16, 2025

Tags: treatment, manual therapy, harms, neck pain, chiropractic, physical therapy, study_review, study_narrative-review, study_opinion, professions, pain problems, head/neck, anatomy, spine, spine pain, quackery

Four pages on PainSci cite Carlesso 2010: 1. The Complete Guide to Chronic Tension Headaches 2. The Complete Guide to Neck Pain & Cricks 3. Does Spinal Manipulation Work? 4. Bad science writer, bad! A major mea culpa

PainSci commentary on Carlesso 2010: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

Is orthopaedic physical therapy safe? The bottom line is that no one really knows. Although considered safe, this is mostly because bad reactions to therapy are probably mostly minor and aren’t properly documented: “harms have either been neglected or poorly defined in much of the available studies on the efficacy of orthopaedic physical therapy. This leaves practitioners and patients with imprecise information on the frequency and risks of mild, moderate, and severe adverse events.” Most research focuses on the benefits and there is “currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy,” and the patient perspective is generally neglected (see 2011 and 2013).

~ Paul Ingraham

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Orthopaedic physical therapy is considered safe, based on a lack of reported harms. Most of the research until now has focused on benefits. Consideration of benefits and harm involves informed consent, clinical decision making, and cost-benefit analyses. Benefits and harms are treatment and dosage specific. There is currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy. Published cases of severe adverse events following chiropractic manipulation illustrate the need for physical therapy to have high-quality data documenting the safety of orthopaedic physical therapy, including cervical manipulation. A recent systematic review identified poor reporting standards of harms within clinical research in this area. Lack of standardization of terminology has contributed to this problem. Pharmacovigilence provides a framework for terms that orthopaedic physical therapy can adapt and thereafter adopt into clinical practice and research. Adverse events are unexpected events that occur following an intervention without evidence of causality. Where temporality of an event is highly suggestive of causality, the term "adverse reaction" may be more appropriate. Future studies in orthopaedic physical therapy should adopt the CONSORT statement extension on the reporting of harms, published in 2004, to ensure better reporting. Consistent reporting of harms in both research and clinical practice requires professional consensus on terminology pertaining to harms, as well as defining what constitutes an adverse event or an adverse reaction. Widespread consultation and consensus should support optimal definitions and processes and facilitate their implementation into practice. This paper is focused on theoretical considerations and evidence in terms of harm reporting within physical therapy using cervical manual therapy as an example.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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