Letter to the Editor

To the Editor,

Case reports can provide valuable information about current clinical practice, or they can be used to highlight some of the issues in the management of patients’ pain, disease and disability. The publication and dissemination of clinical case reports can open important avenues for further research and offer an opportunity for clinicians to reflect and enhance their practice. Cicconi et al. ¹ present a case report of a patient who experienced an adverse event following osteopathic treatment. While case studies such as this are valuable methods by which adverse events following manual therapy (or any other intervention) can be described, the lack of detail about the patient, the interventions received and generalisations presented by the authors are problematic. Lack of patient detail has been highlighted previously as being an issue when investigating adverse effects of spinal manipulation. ² There are several other limitations of Cicconi et al.’s case report ¹ which we think are necessary to highlight.

There is a lack of detail about the patient and the presenting features of their condition when they sought osteopathic treatment. The consequence of a lack of these important clinical details severely limits the educational benefit of the case report. Beyond ‘complaining of neck pain’ and the identification of ‘torticollis by disc protrusions’ as a pre-existing condition, the reader is left to ponder which symptoms led the patient to seek osteopathic care. More detail about the presenting features and the examination undertaken by the osteopath would allow the reader to develop their own opinion as to whether osteopathic treatment (or particular osteopathic manipulative techniques) was contraindicated in this specific case. The authors support this clinical reasoning process by stating ‘ … the knowledge of the patient’s clinical conditions is essential before starting an OMT [osteopathic manipulative treatment]’. However, there is no detailed information provided by the authors in the case report on the patient’s presenting symptoms.

Further, the authors use the World Health Organisation Benchmarks for Training in Osteopathy ³ as a basis for a number of statements related to the lack of a working diagnosis and the risk of an adverse event ‘ … could have been lower if the osteopath adhered to the guidelines’. Such simplistic statements are unhelpful and fail to appreciate the ambiguity of musculoskeletal clinical practice. As a result, the authors fail to provide the reader with a valuable learning opportunity. The limited detail provided means it is difficult to establish whether the application of any manual therapy technique was contraindicated, or whether diagnostic imaging should have been obtained for this patient. Further, it would appear to the reader that the authors were advocating diagnostic imaging prior to the application of osteopathic treatment. Without the detail about the presenting features of the case, it is difficult to support such a position, given the lack of evidence for use of diagnostic imaging in non-specific cervical spine pain. ⁴

Although the authors report that the osteopathic treatment ‘ … included cervical spine manipulation … ’, there is no mention of the use of any other techniques. The authors appear to draw the conclusion immediately that the cervical manipulation was the cause of the disc herniation. Yet the reader does not know whether any other techniques were applied. Manual therapy techniques, beyond cervical spine manipulation, are known to have adverse effects, including disc herniation.^5,6 To conclude that the cervical spine manipulation alone was the cause of the herniation is spurious, given the lack of detail presented.

The causal relationship established by the authors between the intervention and the post-treatment symptoms is plausible ⁷ based on the timeline only. The lack of further detail in the case report limits the ability to draw any further conclusions, particularly as manipulation in the presence of diagnostically confirmed cervical spinal cord encroachment ⁸ and cervical radiculopathy^9,10 has been demonstrated to be beneficial in some cases. In no way can the actions of the osteopath after the treatment be condoned. Based on the information presented in the case report, the management of the patient once they had informed the osteopath of the adverse event could amount to professional misconduct (or similar).

As clinicians, we are acutely aware of the need to develop a comprehensive understanding of the patient’s presenting complaint and medical history, undertake a thorough examination, obtain informed consent (including a discussion of the risks and benefits of the proposed management) and choose to apply manual therapy techniques that are not contraindicated and that are within the scope of osteopathic practice. Authors submitting case reports in the future are encouraged to provide much greater detail about the patient who is the subject of the report so that students and practicing health professionals can learn from such adverse events in the hope of minimising them in the future. Unfortunately, the case report by Cicconi et al. ¹ adds little to the continually developing picture of adverse effects following manual therapy.