Much has been written about the safety of Chiropractic Care and Spinal Manual Therapy. Below is a link to the New Zealand Chiropractors Association website that discusses the safety of chiropractic care. 

When in doubt, contact the chiropractor or the NZCA.

The-Safety-of-Chiropractic-Care-review-2020-NZCA.pdf

The Safety of Chiropractic Care

(NZCA Discussion Paper - Updated June 2020)

Introduction

Chiropractic care has been shown to be effective1-3 and it is associated with high

levels of patient satisfaction.4 A number of studies have reported that chiropractic

care is at least as effective as, if not more effective than, traditional medical

management for many spine related injuries.1 3 5 Chiropractic care also has an

enviable safety record compared to most other healthcare interventions.6-8 That

being said, virtually all forms of healthcare are associated with some risk.9

Chiropractic care may involve a variety of manual therapy procedures, including

manipulation, mobilisation, or other instrument or table assisted delivery of specific

forces to joints (all referred to as adjustments by many chiropractors), which are

known to have a small risk of causing physical harm.10 Trying to ascertain the true

risk associated with any particular intervention is challenging.9 11 12 Some authors

suggest there has been an under-reporting of adverse events associated with

interventions such as chiropractic care,13 while others have pointed out that

over-reporting routinely occurs when clinicians are wrongly identified as

chiropractors.11 14 To confound the assessment of the safety of chiropractic care, it

has been suggested that a large portion of the adverse events commonly attributed

to chiropractors may be due to non-specific effects, or natural history, unrelated to

the care that is provided.15 This review will discuss the published literature that has

assessed the safety of chiropractic care and will summarise treatment injury

information reported to government agencies such as the Accident Compensation

Corporation (ACC).

NZCA Discussion Paper : The Safety of Chiropractic Care

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Systematic Reviews

A number of systematic reviews have been published that have investigated safety

aspects of chiropractic care.10 13 16

In 2009, Gouveia, et al. 10

reviewed the literature

to evaluate the tolerability and safety of chiropractic procedures. In this review, the

authors identified 46 articles that included data concerning adverse events related to

chiropractic care. Most of the adverse events were considered to be benign and

transitory, but their review did uncover anecdotal reports of serious complications,

such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural

hematoma that had a temporal association with chiropractic care (e.g. occurring

within 24 hours of a chiropractic consultation). Of course, a temporal relationship

does not imply causality, and the extremely rare occurrence of serious events

following chiropractic care meant that the authors could not estimate the true risk of

injury due to spinal manipulation. They reported speculative ranges of between 1

serious event per 20,000 manipulations to 1.46 serious events per 10 million

manipulations. The studies that reported serious complications in this systematic

review were retrospective in nature and therefore were susceptible to many forms of

bias.17 18

Interestingly, the 6 prospective studies that were included, reported no

serious adverse events from almost 8000 chiropractic consultations. These findings

are supported by a large prospective survey performed by Thiel, et al. 19

in 2007 that

followed almost 29,000 chiropractic treatment consultations by UK chiropractors, and

included over 50,000 cervical manipulations, yet identified no serious adverse

events.19

In 2015, Hebert, et al.16 published a systematic review of the literature relating to

studies reporting serious adverse events following lumbopelvic spinal manipulation.

Their findings were similar to those reported by Gouveia, et al.10 Although a number

of serious adverse events were identified in the literature, important details of most

cases were missing or were poorly reported and the design of most of the included

studies meant causality could not be assessed. The authors concluded that a

detailed understanding of the risk profile of spinal manipulation was difficult to

achieve.

Another similar review was published in 2015 that looked at the safety of thrust joint

manipulation in the thoracic spine.20

In this review, the authors identified 10 case

reports, over a 65 year period, of serious adverse events following thoracic

manipulation. The same issues were present in this study as the previously

mentioned studies. The authors acknowledged that there may have been

discrepancies between what was reported and what actually occurred, since

physicians dealing with the effects of the adverse event, rather than the clinician

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performing the manipulation, published the cases. It also wasn’t clear if the adverse

event was due to the manipulation itself or a pre-existing condition.

Other recent systematic reviews echo the sentiment that, although mild adverse

events, meaning transient soreness after an adjustment, may be fairly common,

serious adverse events are rare. 2 21-25 A number of studies have recently been

published that have investigated the safety of spinal manipulation. 2 22-24 One of these

was a review of the risks of manual treatment of the spine that was published in

2017. 22 The conclusions of this review were that existing literature indicates that

benign adverse events following manual treatments to the spine are common, while

serious adverse events are rare. The authors highlighted the point that the incidence

and causal relationships with serious adverse events are challenging to establish,

with gaps in the literature and inherent methodological limitations of studies. 22 A

‘review of reviews’ was also published in 2017 23

that concluded that, due to their

rare nature, “it is currently not possible to provide an overall conclusion about the

safety of SMT; however, the types of serious adverse events reported can indeed be

significant, sustaining that some risk is present.”

In the same year, a systematic review in the Journal of the American Medical

Association24

investigated the use of spinal manipulative therapy (SMT) for low back

pain and found no randomised controlled trials that reported any serious adverse

events. They did however conclude that that minor transient adverse events, such as

increased pain, muscle stiffness, and headache were reported 50% to 67% of the

time in large case series of patients treated with SMT. 24

In 2019, Coulter et al 2 published a systematic review of manipulation and

mobilisation for treating chronic neck pain. The conclusions from their review of harm

were that “According to the published trials reviewed, manipulation and mobilization

appear safe. However, given the low rate of serious adverse events, other types of

studies with much larger sample sizes would be required to fully describe the safety

of manipulation and/or mobilization for nonspecific chronic neck pain.” 2

Also in 2019, Rubenstein et al 21 published a similar review in the British Medical

Journal that investigated SMT for chronic low back pain. From their extensive search

of the literature, they found studies reporting a number of mild to moderate adverse

events and 1 serious adverse event that was possibly related to SMT. They identified

only 1 good quality study that was designed to assess the risk of adverse events,

which reported no increase in risk after manipulation compared to sham.26

Edzard Ernst, a vocal critic of chiropractic care and many other forms of

complementary care,27-34 published a systematic review in 2007 that investigated the

adverse effects of spinal manipulation.13

In this review Ernst concluded that spinal

manipulation is frequently associated with mild to moderate adverse events and can

result in serious complications such as vertebral artery dissections followed by

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stroke. Ernst acknowledged that the incidence of such events is unknown but was

critical of the chiropractic profession and questioned the safety of spinal

manipulation. Tuchin 11 subsequently replicated the study conducted by Ernst13 and

reported numerous errors and omissions that brought into question the validity and

conclusions of the study. These errors and omissions included misrepresentation of

the long term response of the patient to the adverse event, incorrectly assigning a

chiropractor as the treatment provider, and omitting to report the plausible alternative

explanations for why an event may have occurred.11

The consistent message from these reviews appears to be that minor soreness can

occur relatively frequently after chiropractic adjustments, but serious adverse events

are rare, so rare that it is impossible to make accurate assumptions about how

common they are.

Cause or Association?

One issue that confounds many of the studies included in these systematic reviews

is that reported adverse events associated with chiropractic care may not be caused

by the care itself. Walker, et al. 15 conducted a randomised controlled trial that

investigated the frequency of adverse events from chiropractic care compared to a

benign sham treatment. No serious adverse events occurred during this trial, but a

number of events that were termed either minor or severe were reported. There was

no significant difference in the frequency of adverse events that occurred in the

chiropractic vs sham groups and the authors concluded that ‘a substantial portion of

adverse events after chiropractic treatment may result from natural history variation

and nonspecific effects.’15

Case-control studies that have investigated a potential link between chiropractic care

and vertebral artery dissection have come to the same conclusion.35 36

In 2009

Cassidy, et al. 35 published a case-control and case-crossover study that investigated

the association between chiropractic visits or primary care physician visits and

subsequent vertebrobasilar artery (VBA) stroke. They reported on 818 VBA strokes

in a population of more than 100 million person-years. They found that in patients

under the age of 45 who had suffered from a VBA stroke there was a positive

association with chiropractic visits before the stroke occurred. However, they also

found the same association existed with primary contact physician visits prior to the

stroke. In patients over the age of 45 there was no association between chiropractic

care and VBA stroke. They concluded that the increased risk of VBA artery stroke

associated with chiropractic and primary contact physician visits is likely due to

patients with headache and neck pain from VBA dissection seeking care before the

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stroke occurred, and not as a result of the chiropractic care itself.35 This conclusion

was supported by a similar large scale study conducted by Kosloff, et al. 36

that

included 1,829 VBA artery strokes amongst almost 40 million health plan members

in the USA over a 3 year period. Kosloff et al reported no significant association

between chiropractic care and the risk of VBA stroke, even in those under the age of

45, but they did find a significant association between primary contact physician

visits and VBA stroke.36 Like Cassidy, et al. 35

they concluded that this association

was likely due to the patients seeking care for headache and neck pain symptoms

that were in fact related to the early stages of arterial dissection.36

Chiropractic care has also been implicated as a potential cause of internal carotid

artery (ICA) dissection.37 A recent systematic review appraised the literature relating

to cervical spine manipulation and ICA dissection.37 The authors found no

epidemiological studies that measured the incidence of ICA dissection following

cervical spine manipulation, no studies were found that concluded cervical spine

manipulation is linked to ICA dissection, and it is unknown if chiropractic care is any

safer or more dangerous than any other healthcare intervention when it comes to

ICA dissection.37

Treatment Data from ACC and Related Schemes

A review of treatment injury data from the ACC in New Zealand revealed that there

were 283 treatment injuries associated with chiropractic care over a 10 year period,

or 28.3 injuries per year.38 Based on the average number of practicing chiropractors

over this time period, this equates to one treatment injury every 15 years in practice

for a chiropractor in New Zealand.38 39

In comparison there were 8175 treatment

injuries associated with general practice over this same 10 year period which

equates to one treatment injury every 4 years per general practitioner in New

Zealand.12 38 With the average chiropractor in New Zealand performing approximately

6000 consultations per year these estimates suggest there is roughly one treatment

injury for every 90,000 chiropractic consultations in New Zealand.38 40 The majority of

the treatment injuries attributed to chiropractic care were a strain or sprain (64%),

followed by spinal injury (9.5%), bruising (5.3%), nerve injury (4.6%), and a fracture

(4.6%).38 Of the 2374 sentinel or serious events that were reported to the Director

General of Health over this same 10 year period only 10 of them were chiropractic

events.41 This extrapolates to approximately one serious or sentinel event for every

2.5 million chiropractic consultations in New Zealand.40 41

Similar treatment injury risks have been made in Scandinavia.9 Denmark and

Norway have central agencies that are similar to the ACC that are responsible for

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assessing patient compensation claims associated with care provided by registered

health professionals.9 A recent study reported on the number of claims following

consultation with a chiropractor in Denmark and Norway between 2004 and 2012.9

Three hundred claims were analysed in this report, only 41 of which were approved

to receive compensation. The most frequent complaint category was for cases where

symptoms worsened following treatment (30%), followed by alleged disc herniation

(19%) and delayed referral (15%). The authors of this study reported that many of

the claims were filed because of unrealistic expectations of treatment or because the

clinician had failed to inform the patient about commonly occurring benign reactions

to treatment.9 This supports the previous research already mentioned that suggests

many of the adverse events for which claims were lodged were due to non-specific

effects or natural history variation.9 15 Based on the claims that were analysed the

authors calculated that approximately one compensation claim is made for every

100,000 consultations performed by chiropractors in these countries. If only

accepted claims are considered, there is approximately one compensable adverse

event for every 730,000 chiropractic consultations performed in Denmark and

Norway, which is lower than the rates observed for both general practitioners and

physiotherapists.9

The Safety of Chiropractic Care for Children

Recently, the safety of chiropractic care for children has received a significant

amount of international attention.42 43 One reason for this attention was due to a

social media outcry in Australia that followed a video emerging online of a

chiropractor adjusting a 2-week-old baby. Interestingly, the mother of the baby

reported benefit from the chiropractic care, however a number of online

commentators claimed that what the chiropractor did was unsafe and was not

evidence based. The Victorian Minister of Health then announced that she was

calling for a review42

into chiropractic care for children and that ‘we won’t rest until

babies are protected from practices we know to be harmful, and that we can be sure

children under 12 are not being exposed to harm.’ This was a somewhat unusual

statement to make before the review had taken place and suggested that the review

may be biased and would potentially be based on a political agenda.

The Safer Care Victoria ‘review of harm’ reported that an extensive search was

undertaken to identify evidence of harm sustained by children who had received

spinal manipulation. This included a literature review performed by Cochrane

Australia, as well as a public campaign that sought to capture patient complaints and

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practitioner notification data from Australian complaints and regulatory agencies, as

well as insurance claim data for registered chiropractors, and stakeholder feedback.

Following this comprehensive review of harm, the panel concluded that “This

extensive search identified very little evidence of patient harm occurring in Australia.

In particular, there were no patient complaints or practitioner notifications that arose

from significant harm to a child following spinal manipulation.” The only harm they

identified was 3 individual case reports related to spinal manipulative techniques

performed outside of Australia and not limited to chiropractors. The panel also stated

that practices described in these reports were not reflective of Australian chiropractic

techniques. In their report, they did include the caveat that this doesn’t mean spinal

manipulation in children is not associated with any risk of any adverse effects. They

pointed out that their review did identify transient or minor adverse events, such as

crying or soreness after chiropractic care, but even for these minor adverse events,

the prevalence was very low.

One interesting aspect of this Safer Care Victoria review was the panel also

conducted a survey of parents and guardians of children who had accessed

chiropractic spinal care, to explore their experiences, both positive and negative.

They received 21,824 responses from members of the public who had accessed

chiropractic care for a child under 12 years. Of these parent responses, 99.7%

reported a positive experience with the chiropractic care of their children. A very

small minority of respondents – 0.3% (74) – reported a negative experience. These

experiences mostly related to concerns about the cost of treatment with no

improvement in the condition, excessive use of X-rays, or perceived pressure to

avoid medications or advice previously provided by other practitioners, including

medical practitioners.

The results of this review support the conclusions from a number of studies

published over recent years that have investigated the safety of chiropractic care for

children and infants. 43-48 These studies overwhelmingly suggest that chiropractic

care can be safely provided to even the youngest members of our society.6 12 33 44-46

In 2009 a study was published by Alcantara, et al. 44

that reported the results of a

survey conducted through a chiropractic practice based research network. This

survey included almost 5,500 chiropractic office visits for children up to the age of

18. From these visits there were only 3 reported adverse events which were

described as muscle or spine stiffness or soreness following chiropractic care. All

cases were self-limiting and the patients continued under care.44

In 2011, Doyle 46 published a review on the safety of paediatric chiropractic care. In

this review Doyle searched the literature up until 2010 for articles that reported on

the safety or adverse events associated with paediatric chiropractic care. The results

of this literature review suggested about one in every 100 or 200 children who see a

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chiropractor will experience a mild adverse event. With a mild adverse event

meaning irritability or soreness lasting less than a day that requires no additional

treatment to resolve.46 The review identified a small number of serious adverse

events that have been reported in the literature. The most recent of these reported

events had occurred more than 30 years prior to the publication of the review, so

details regarding identified cases were difficult to corroborate. The cases tended to

involve children with significant pre-existing conditions and treatment options that

don’t conform to usual chiropractic care.46 49

In 2014, Todd, et al. 45 published a literature review of adverse events due to

chiropractic care and other manual therapies for infants and children. In their review,

Todd, et al. discussed seven serious adverse events in children or infants that were

reported to be associated with chiropractic care. These were the same adverse

events that Doyle 46

included in his review. The conclusion that Todd, et al. came to

was that chiropractors should modify their techniques to suit the age, anatomy, and

unique physiology of their young patients.45

In 2019, Driehuis et al47 published a systematic review of spinal manual therapy in

infants, children and adolescents. With respect to harm, the conclusions of this

review were that “severe harms were relatively scarce, poorly described and likely to

be associated with underlying missed pathology. Gentle, low-velocity spinal

mobilizations seem to be a safe treatment technique in infants, children and

adolescents.” Also in 2019, Parnell Prevost et al 48 published a comprehensive

review of manual therapy for the paediatric population. They reported that “no lasting

or significant adverse events were reported for children receiving any form of manual

therapy.” In 2020, Corso et al 43 conducted a review of the safety of spinal

manipulative therapy in children under 10 on behalf of the College of Chiropractors

of British Colombia. They reported that “the risk of moderate and severe adverse

events is unknown in children treated with SMT.” They came to this conclusion

because they could find so little evidence of serious harm that they couldn’t make

any accurate assessment of what that risk may be.

Summary

The key finding from this review of the safety of chiropractic care is that chiropractic

care is associated with a very low risk of serious adverse events.10 16 The risks are so

rare that they cannot be accurately estimated. 10 16 Of the risk estimates that have

been made, most suggest that a serious adverse event associated with chiropractic

care may occur perhaps every several hundred thousand chiropractic visits.9 10 Like

any healthcare intervention, some adverse events do occur that are associated with

chiropractic care.9 These adverse events are generally benign and transitory10 and

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don’t detract from the high levels of patient satisfaction associated with chiropractic

care.4 44

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