The comments by Meena Sran and Karim Khan offer an important clarification. The risks of mobilization seems indeed to be much smaller than those of spinal manipulation, though truly convincing data are not presently available. I was interested to learn that many Canadian physiotherapists have training in both methods and “select the most appropriate technique for the patient's problem.” This begs the question of how the most appropriate technique is determined. A recent analysis1 of 64 previously unpublished cases of complications after upper spinal manipulations demonstrated that no factors are identifiable from the clinical history or physical examination of the patients that would help isolate patients at risk. Essentially, this means everyone is at risk. Spinal manipulation is undoubtedly the mainstay of chiropractors, and it is not surprising that the vast majority of complications happen in the hands of chiropractors.2 In my personal experience, physiotherapists in Europe use spinal manipulation less frequently and with more discrimination than chiropractors in Canada.
Edzard Ernst Department of Complementary Medicine School of Sport and Health Sciences University of Exeter Exeter, UK