Adverse effects of spinal manipulation: a systematic review. J R Soc Med

Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK.
Journal of the Royal Society of Medicine (Impact Factor: 2.12). 08/2007; 100(7):330-8. DOI: 10.1258/jrsm.100.7.330
Source: PubMed


To identify adverse effects of spinal manipulation.
Systematic review of papers published since 2001.
Six electronic databases.
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.
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.
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.

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Available from: Edzard Ernst, Jul 16, 2014
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    • "Mild to moderate adverse effects occur in a large proportion of patients receiving spinal manipulation [7]. Although the majority of the adverse effects are transient and nonserious [7], severe adverse events such as cerebrovascular accidents and paraplegia have been associated with SM [8]. These injuries are typically described following an upper-back CSM. "
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    ABSTRACT: Spinal manipulation (SM) is a manual therapy technique frequently applied to treat musculoskeletal disorders because of its analgesic effects. It is defined by a manual procedure involving a directed impulse to move a joint past its physiologic range of movement (ROM). In this sense, to exceed the physiologic ROM of a joint could trigger tissue damage, which might represent an adverse effect associated with spinal manipulation. The present work tries to explore the presence of tissue damage associated with SM through the damage markers analysis. Thirty healthy subjects recruited at the University of Jaén were submitted to a placebo SM (control group; n = 10), a single lower cervical manipulation (cervical group; n = 10), and a thoracic manipulation (n = 10). Before the intervention, blood samples were extracted and centrifuged to obtain plasma and serum. The procedure was repeated right after the intervention and two hours after the intervention. Tissue damage markers creatine phosphokinase (CPK), lactate dehydrogenase (LDH), C-reactive protein (CRP), troponin-I, myoglobin, neuron-specific enolase (NSE), and aldolase were determined in samples. Statistical analysis was performed through a 3 × 3 mixed-model ANOVA. Neither cervical manipulation nor thoracic manipulation did produce significant changes in the CPK, LDH, CRP, troponin-I, myoglobin, NSE, or aldolase blood levels. Our data suggest that the mechanical strain produced by SM seems to be innocuous to the joints and surrounding tissues in healthy subjects.
    Disease markers 12/2014; 2014:815379. DOI:10.1155/2014/815379 · 1.56 Impact Factor
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    • "The safety of manual treatment techniques has been discussed and the main concern being raised is the potential harmful consequences following spinal manipulation in the upper neck region [4,5]. Most studies show that unwanted adverse events due to manual treatments, like spinal manipulation are common, but the severity and duration of such events are mild and transient [5-8]. Several studies have failed to demonstrate that spinal manipulation causes cerebrovascular lesion [9-11]. "
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    ABSTRACT: The safety of the manual treatment techniques such as spinal manipulation has been discussed and there is a need for more information about potential adverse events after manual therapy. The aim of this randomized controlled trial was to investigate differences in occurrence of adverse events between three different combinations of manual treatment techniques used by manual therapists (i.e. chiropractors, naprapaths, osteopaths, physicians and physiotherapists) for patients seeking care for back and/or neck pain. In addition women and men were compared regarding the occurrence of adverse events. Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 767) were randomized to one of three treatment arms 1) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage) (n = 249), 2) manual therapy excluding spinal manipulation (n = 258) and 3) manual therapy excluding stretching (n = 260). Treatments were provided by students in the seventh semester of total eight. Adverse events were measured with a questionnaire after each return visit and categorized in to five levels; 1) short minor, 2) long minor, 3) short moderate, 4) long moderate and 5) serious adverse events, based on the duration and/or severity of the event. Generalized estimating equations were used to examine the association between adverse event and treatments arms. The most common adverse events were soreness in muscles, increased pain and stiffness. No differences were found between the treatment arms concerning the occurrence of adverse event. Fifty-one percent of patients, who received at least three treatments, experienced at least one adverse event after one or more visits. Women more often had short moderate adverse events (OR = 2.19 (95% CI: 1.52-3.15)), and long moderate adverse events (OR = 2.49 (95% CI: 1.77-3.52)) compared to men. Adverse events after manual therapy are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women reports more adverse events than men.Trial registration: This trial was registered in a public registry (Current Controlled Trials) (ISRCTN92249294).
    BMC Musculoskeletal Disorders 03/2014; 15(1):77. DOI:10.1186/1471-2474-15-77 · 1.72 Impact Factor
    • "However, treatment is highly operator-dependent. Therefore evidence supporting the efficacy of manipulation is largely equivocal.[813] The reported incidence of complications varies widely, largely due to near-complete underreporting of adverse outcomes.[713151618] "
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    ABSTRACT: There is a paucity of quality data on the incidence of adverse outcomes of chiropractic manipulation. Spontaneous intracranial hypotension (SIH) subsequent to cervical spinal manipulation has been documented. However, no imaging correlates have previously been presented demonstrating a clear causal relationship to manipulation with follow-up and correlating with clinical symptomatology. We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine. The patient is a 29-year-old female who received manipulation one week prior to developing symptoms of severe orthostatic headache, nausea, and vomiting. Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection. Symptomatic onset corresponded with the recent cervical chiropractic adjustment. We present serial imaging correlating with her symptomatology and review the pertinent literature on complications of chiropractic manipulation. Our case of ventral CSF leak with symptoms of intracranial hypotension demonstrated spontaneous symptomatic resolution without permanent neurological sequelae.
    Surgical Neurology International 03/2013; 4(Suppl 2):S118-20. DOI:10.4103/2152-7806.109456 · 1.18 Impact Factor
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