Manipulation Risks

This paper reviews the risks of manipulation. Primary risks are the familiar ones; stroke and vertebral artery. When you consider that 1:100 patients develop significant side effects from NSAIDs this study demonstrated that risk from manipulation is low – 1:20,000 to 1:250,000,000. So, subgroup, screen and applied effectively the evidence supports it as a suitable treatment for selected patients. See what you think!

The risk associated with spinal manipulation: an overview of reviews

Neilsen, S et al2017



Spinal manipulative therapy (SMT) is a widely used, but reviews exist with conflicting conclusions about the safety.


5 databases from inception to December 8, 2015, included reviews on any type of studies, patients, and SMT technique. Primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.


283 reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present. Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.


It is currently not possible to provide an overall conclusion about the safety of SMT; but some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

  • J Chiropr Educ 2017 Vol. 00 No. 0  DOI 10.7899/JCE-16-8