Manipulation Safety

Written by Dr. Damon Hendrickson
Published in Research
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Chiropractic is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of back pain, neck pain, joint pain of the arms or legs, headaches, and other neuromusculoskeletal complaints. Although chiropractic has an excellent safety record, no health treatment is completely free of potential adverse effects.

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The risks associated with chiropractic, however, are very small. Many patients feel immediate relief following chiropractic treatment, but some may sometimes experience mild soreness or aching, just as they do after some forms of exercise. Current literature shows that minor discomfort or soreness following spinal manipulation typically fades within 24 hours.

Essential Literature

SERIOUS ADVERSE EVENTS AND SPINAL MANIPULATIVE THERAPY OF THE LOW BACK REGION: A SYSTEMATIC REVIEW OF CASES
Herbert et. al. 2012
Conclusion:
This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed.

OUTCOMES OF USUAL CHIROPRACTIC. THE OUCH RANDOMIZED CONTROLLED TRIAL OF ADVERSE EVENTS
Walker et. al. 2013
Conclusion:
A substantial proportion of adverse events after chiropractic treatment may result from natural history variation and nonspecific effects.

ADVERSE EVENTS AND MANUAL THERAPY: A SYSTEMATIC REVIEW
Carnes et. al 2010
Conclusion:
The risk of major adverse events with manual therapy is low, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care.

ADVERSE EVENTS ASSOCIATED WITH THE USE OF CERVICAL MANIPULATION AND MOBILIZATION FOR THE TREATMENT OF NECK PAIN IN ADULTS: A SYSTEMATIC REVIEW
Carlesso et. al. 2010
Conclusion:
No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.

SAFETY OF CHIROPRACTIC INTERVENTIONS: A SYSTEMATIC REVIEW
Gouveia et. al. 2009
Conclusion:
Most of the adverse events reported were benign and transitory, however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.

THE BENEFITS OUTWEIGH THE RISKS FOR PATIENTS UNDERGOING CHIROPRACTIC CARE FOR NECK PAIN
Rubinstein et. al. 2007
Conclusion:
Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (<8%). Only 5 subjects (1%) reported to be much worse at 12 months. No serious adverse events were recorded during the study period. Of the patients who returned for a fourth visit, approximately half reported to be recovered, whereas approximately two thirds of the cohort were recovered at 3 and 12 months.
Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.

SAFETY OF CHIROPRACTIC MANIPULATION OF THE CERVICAL SPINE: A PROSPECTIVE NATIONAL SURVEY
Thiel et. al. 2007
Conclusion:
There were no reports of serious adverse events. This translates to an estimated risk of a serious adverse event of, at worse approximately 1 per 10,000 treatment consultations immediately after cervical spine manipulation, approximately 2 per 10,000 treatment consultations up to 7 days after treatment and approximately 6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common. The highest risk immediately after treatment was fainting/dizziness/light-headedness in, at worse approximately 16 per 1000 treatment consultations. Up to 7 days after treatment, these risks were headache in, at worse approximately 4 per 100, numbness/tingling in upper limbs in, at worse approximately 15 per 1000 and fainting/dizziness/light-headedness in, at worse approximately 13 per 1000 treatment consultations