Adverse effects of spinal manipulation: a systematic review - PMC

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J R Soc Med<br>. 2007 Jul;100(7):330–338. doi: 10.1258/jrsm.100.7.330

Adverse effects of spinal manipulation: a systematic review

E Ernst<br>E Ernst

1Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK Email: Edzard.Ernst@pms.ac.uk

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1Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK Email: Edzard.Ernst@pms.ac.uk

Copyright © 2007, The Royal Society of Medicine

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PMCID: PMC1905885  PMID: 17606755

Abstract

Objective To identify adverse effects of spinal manipulation.

Design Systematic review of papers published since 2001.

Setting Six electronic databases.

Main outcome measures Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.

Results The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

Conclusions Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

Spinal manipulation or adjustment is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its normal integrity, though a universally accepted definition does not seem to exist.1 It is occasionally used by osteopaths, physiotherapists and physicians, and it is the hallmark treatment of chiropractors. Practically all chiropractors use spinal manipulation regularly to treat low back and other musculoskeletal pain.2 It often involves a high velocity thrust, a technique in which the joints are adjusted rapidly, often accompanied by popping sounds. This results in transient stretching of joint capsules which, according to chiropractic belief, resets the position of the spinal cord and nerves, allowing the nervous system to function optimally and improving the body's biomechanical efficiency.3 The thrust is exerted through either a long lever arm, in which force is applied distant from the joint, or a short lever arm, when force is applied close to the joint. Many experts see spinal manipulation as an effective form of treating back pain:4 the evidence from randomized clinical trials (RCTs), however, remains contradictory and often unconvincing.5 For conditions other than back pain, there is no good evidence for the effectiveness of spinal manipulation.5

Many authors have voiced doubt about the safety of spinal manipulation. A particular concern is stroke after upper spinal manipulation. The systematic review by Ernst and Stevinson, published in 2002, summarized safety data available up to 2001.6 Since then, an abundance of new evidence has emerged. The aim of this article is therefore to identify adverse effects of spinal manipulation published since 2001.

METHODS

Computerized literature searches were performed using MEDLINE (PubMed), EMBASE, Amed, CINHAL, the British Nursing Index and the Cochrane Library up to June 2006. The search terms used were ‘adverse effects’, ‘adverse events’, ‘arterial injury’, ‘cervical manipulation’, ‘chiropractic’, ‘complications’, ‘manual therapy’, ‘osteopathy’, ‘risk’, ‘safety’, ‘spinal manipulation’, ‘stroke’, ‘vascular accident’, and ‘vertebral artery...