MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Much has been written on this blog and elsewhere about the risks of spinal manipulation. It relates almost exclusively to the risks of manipulating patients’ necks. There is far less on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. A new paper focusses on this specific topic.

The purpose of this review was to retrospectively analyse documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine.

Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015.

Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. The authors only looked at serious complications, not at the much more frequent transient AEs after spinal manipulations. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish. Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted.

Ten cases, reported in 7 articles, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years. The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10); pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10) were also reported.

The authors point out that there were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases.

The authors concluded that serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces.

These are odd conclusions, in my view, and I think I ought to add a few points:

  • As I stated above, the actual rate of experiencing AEs after having chiropractic spinal manipulations is much larger; it is around 50%.
  • Most complications on record occur with chiropractors, while other professions are far less frequently implicated.
  • The authors’ statement about ‘excessive peak force’ is purely speculative and is therefore not a legitimate conclusion.
  • As the authors mention, it is  hardly ever the chiropractor who reports a serious complication when it occurs.
  • In fact, there is no functioning reporting scheme where the public might inform themselves about such complications.
  • Therefore their true rate is anyone’s guess.
  • As there is no good evidence that thoracic spinal manipulations are effective for any condition, the risk/benefit balance for this intervention fails to be positive.
  • Many consumers believe that a chiropractor will only manipulate in the region where they feel pain; this is not necessarily true – they will manipulate where they believe to diagnose ‘SUBLUXATIONS’, and that can be anywhere.
  • Finally, I would not call a review that excludes all languages other than English and Spanish ‘systematic’.

And my conclusion from all this? THORACIC SPINAL MANIPULATIONS CAN CAUSE CONSIDERABLE HARM AND SHOULD BE AVOIDED.

41 Responses to The risk of (chiropractic) spinal manipulations: a new article

  • Interesting. I prefer to use stretching exercises to relieve ouchies in the thoracic spine, which I suspect is a far gentler version of chiropractic manipulation. Are there any studies on this, apart from “a good stretch does you the power of good, just ask your cat”?

  • Really interesting article. However I have few points which are not clear.
    Are you stating that 50% of the thoracic manipulation results in AE admission?
    Did the review took articles in the period between 1950 and 2015? More than 60 years and only 10 admission to the AEs?

    As you mention in a previous post “Twenty Things Most Chiropractors Won’t Tell You” patients sign package of 50 to 100 treatments and I believe almost every patients goes back to the chiropractor more than once.

    If this is true, how is it possible to have 50% of chiropractic patients into AEs? I believe and please correct me if I am wrong, the chance of ending up in a hospital would be theoretically 100% if I carry on going to the chiropractor. Is it that right?

    The last point is that you discourage manipulation in the Cervical and Thoracic region, a recent article of the Harvard medicine was promoting chiropractic as treatment for certain disorder such as headache,…
    I believe chiropractors state that headache are due to misalignment to the neck and that’s the area they manipulate, so how is it possible that with all those contraindication, risks and adverse effects they are still considered valuable?

    • @M.d.c.

      ‘AE’ is here used as an abbreviation for ‘Adverse Event’ not ‘Accident and Emergency’.
       
      As I recall, Prof. Ernst has previously produced evidence that 50% of patients who receive “adjustments” to the thoracic and/or cervical spine experience at least some kind of discomfort (=AE) afterwards.
      The work that Prof. Ernst cites here only looks in part of the peer reviewed literature for well reported reports of serious AE’s. It is no surprise that they do not come up with many reports. AE’s to chiropractic are severely underreported. The true rate of serious AE’s is unknown. Chiropractors do not want to know and as has been said here, there is no systematic collection of reports like for example the VAERS database for suspected vaccine AE’s. Serious overreporting is of course a problem with VAERS but that is another matter and can be corrected for.

      …how is it possible that with all those contraindication, risks and adverse effects they are still considered valuable?

      Chiropractors understand only one definition for “valuable” – The commercial one.
      They also know only one “contraindication” – That the patient cannot or will not pay.
      “Risks and adverse effects” do not seem to bother chiro’s as they never[sic] follow up on patients that do not return. And they never do audits to find out their true efficacy.
      Only the satisfied patient’s return and that makes the chiro happy and falsely confident in their abilities.
      A few of their customers do not return because of adverse events that are not always coupled to the recent „adjustment“
      Even if some (here or here or here… there are more) experience the symptoms right away, others may not start to experience the serious AE’s until some time after the neck-cracking. And they may not live to tell or be able to tell that they just recently had an “adjustment”

      • Thanks so much for your lengthy and detailed comment.
        I may have mistaken at the beginning the reference AE; with this new light I could say that an injection of any sort is likely to cause an AE (from the sting to other serious effects). I totally agree with you when you say that chiropractors do not have a systematic report of AE like the one you shown me, however I know the British Chirpractoc Associatiom has started to implement one.
        If chiropractors understand only the commercial value I do not know, it looks like an opinion and everybody is free to have one.
        The cases you post are serious one and I am deeply sorry about those. However are isolated cases and most of the time we are fooled by “bombing news”. We are much more attracted by the emotional case rather than looking at the hard fact. Aspirin alone, to give you an example, killed and kills many innocent people every single day and you can buy it over the counter.

  • @ Edzard

    I just want to highlight some errors or issues in relation to the points you raised

    Adverse events after spinal manipulation can occur regardless the profession performing it. In fact a study by physiotherapists looking at adverse events from spinal manipulation done by physiotherapists, showed adverse events occured in 60.9% of patients – http://www.ncbi.nlm.nih.gov/pubmed/15245709

    Also the article does state that it is severe adverse events that they are looking at not just adverse events. Therefore, the rate of experiencing a severe adverse event would be less than the more common adverse events as shown in the article i cited above.

    There is evidence for thoracic manipulation for the treatment of a specific subgroups of patients with neck conditions, please see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813505/. So, maybe the risk/benefit analysis needs re-assessing?

    Finally, in the past you have commented on a systematic review (http://edzardernst.com/2013/04/some-alternative-therapies-are-effective-and-safe/). In this systematic review only articles from English and Chinese were selected. Is this systematic review, also not a ‘systematic’ review, because it excludes all languages other than English and Chinese ‘

    Will this mean your conclusion will be revised or left as it is, and if you do (or don’t) change your conclusion, why have you made that choice?

    • I did not claim that AEs happen ONLY with chiro
      the massage review was not one of mine, just one I reported on – and I do not always pick up on all the flaws

      • @ Edzard

        You are correct in stating that you did not state that AEs ONLY happen with chiros. However, there is no mention in the post of any other profession(s) that perform spinal manipulations. Spinal manipulations can be performed by a wide variety of professions so the term “chiropractic spinal manipulation” is incorrect, there is only spinal manipulation.

        In addition you wrote the following ” the actual rate of experiencing AEs after having chiropractic spinal manipulations is much larger; it is around 50%”. This sentence implies that it is ONLY chiropractors performing spinal manipulations that are the cause of AEs. Again, no mention that other professions perform spinal manipulation. The consistent use of “chiropractic spinal manipulation” is very misleading because it implies that it is ONLY chiropractors that perform spinal manipulation.

        I do acknowledge that chiros use spinal manipulation the most but it does not mean that spinal manipulation is only associated or used by that profession. In fact, the full article does state that 70% of the servere AEs found were attributed to chiros. The rest were attributed to other professions. But from reading your article you would not know that other professions were even involved in this systematic review.

        Also, the authors do note that the high usage of spinal manipulation by chiros is probably the reason for the high %age of AEs associated to them.

        I would also point out that the flaw in the other systematic review was hardly difficult to spot as it was presented in the study selection portion of the methods section. So your last point on your list in the article is rather poor.

        Finally, you never answered my questions regarding changing your conclusion and re-assessing the risk benefit anaylsis, in the light of the study i posted which showed that spinal manipulation of the thoracic spine is effective for some neck conditions. I look forward to your response.

        • this is why I put chiropractic in the title in brackets
          no, my risk/benefit analysis would never be based on a single trial – always look at the totality of the available evidence [as pointed out so many times on this blog].

          • @ Edzard

            The link i posted was to an article on The Effectiveness of Thoracic Spine Manipulation for the Management of Musculoskeletal Conditions: A Systematic Review and Meta-Analysis of Randomized Clinical Trials – so not a single study. Will you then re-assess you risk/benefit analysis?

            Also why the need to put chiropractic in brackets – i don’t see the need to focus on one profession when spinal manipulation is performed by a wide variety of professions.

            p.s. i should have said article instead of study in my comment above but you should have also read the link i was referring to before commenting yourself.

          • sorry I did not even look at the link. now I have and the answer is still negative.
            the trials were mostly of poor quality, and I prefer to trust the evidence from Cochrane reviews: “Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior.” http://www.ncbi.nlm.nih.gov/pubmed/15247576

          • @ Edzard

            The latest cochrane review (see link below) has the following conclusion – “Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.”

            http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004249.pub3/abstract;jsessionid=401E2DE9AD211C00B3C95ED353C98463.f04t01

            Does this review help change your mind on re-assessing the risk/benefit analysis? If it does or doesn’t, why?

  • @ Edzard

    Also, when reading the full article the author states that there can be a maximum peak force of 125 lb-force to the thoracic spine during spinal manipulation. This info comes from the following study – Gudavalli MR. Instantaneous rate of loading during manual high-velocity, low-amplitude spinal manipulations.
    J Manipulative Physiol Ther. 2014;37(5):294–9

    It would seem logical that reducing the force applied during spinal manipulation would reduce the risk of AE’s occurring.

    • UNLESS, OF COURSE, INJURIES OCCUR ALSO AT LOWER FORCES IN PREDISPOSED INDIVIDUALS.

      • @ Edzard

        In those cases where it not appropriate to do manipulation e.g a person with osteoporosis, lower forces could cause an AE. Therefore, it is important know when to use manipulation or another form of treatment depending on the person presenting for treatment. Manipulation should not be used on every patient!

    • @AN Other

      I can’t read the full study, but it’s interesting (although why it uses such antiquated units…).

      However, it simply raises the question: what is the result of this (550 N) force? How much does it move a vertebra?

      • @ Alan,

        My understanding of spinal manipulation is that it is not about moving bones back into place, it is about stretching the joint and the neurophysiological reaction that could occur when this happens. When manipulation is done any increase in movement that could occur is temporary. I am not sure how much movement occurs but the most important effect of manipulation is on the neurophysiology.

        This neurophysiological reaction could have an effect on the local “circuitry” and this could have an effect on pain in that area.

        So manipulation can sometimes have an effect on the neurophysiology but this doesn’t always happen. Also it maybe possible that other forms of treatment can produce similar effects e.g. mobilisation, exercise.

        I hope this helps

        • AN Other said

          My understanding of spinal manipulation is that it is not about moving bones back into place, it is about stretching the joint…

          Regardless, applying a force will move vertebrae and movement is required for stretching the joint, so my question still stands: how much do vertebrae move (temporarily or otherwise) when this force of 550 N is applied and if you don’t know, where is the research into this?

          • Alan,

            Could you put 550 N in context please? How much force is involved, and how much vertebral movement results from “normal” activities like driving over bumps in the road, digging a hole, sneezing, percussive massage, martial arts…things like that. What about a car accident?

            Is 550 N more than normal? Less? And, how was it measured? It would be interesting to see how spinal manipulation compares to something like riding a ferry on choppy seas, for instance.

          • @ Alan

            Try this link

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2485097/pdf/jcca00037-0013.pdf

            it may explain a bit more of what you want to know.

            Why do you want to know how much do vertebrae move during manipulation?

          • @jm

            Yes it would be interesting. Have chiros looked into this?

          • @AN Other

            I’m interested in knowing whether the movement is measurable and significant and what determines the force used.

            That paper looks interesting – I’ve printed it out to read later. Thanks.

          • Alan,

            Not sure why chiros would look into it, since they don’t seem to consider it dangerous. Mainstream medicine seems a bit concerned, though. Maybe GPs should pool their funds and get some data on risk/benefit for patients commuting to their office via the ferry system.

          • @jm

            You mean chiros claim their ‘signature’ treatment is safe but don’t even know how much it moves a vertebra?

          • Alan,

            I’m actually wondering how safe it is to take the bus see your GP. Or get on an airplane (does turbulence produce more force than spinal manipulation? It is certainly less controlled…).

            Seems that GPs would want to know before recommending patients take a vacation. Or a bus for their ‘signature’ treatment of an anual physical.

            .

          • @jm

            I believe the data on buses and airplanes are fairly easily available and reliable. Not so much for chiro, I think.

          • Alan,

            You say 550 N for chiro. What is it for buses? What about turbulence? And if the data on buses and airplanes is fairly easily available and reliable, how much do vertebrae move (temporarily or otherwise) when this force (potholes, turbulence, etc) is applied?

            Since it’s easily available to you, could you post it? I can’t seem to find it anywhere.

          • @ Alan

            Also try typing into pub med “spinal manipulation and Walter Herzog”. This may give you some more papers on you current area of interest and may answer your query.

            Good luck

            p.s. whether movement of vertebra is important in the treatment of spinal conditions, i don’t know if it is. But it surprising how common people think that a bone is out of place when a back injury occurs.

            Also try Stuart McGill he has done lots of work on spinal biomechanics

          • @jm

            I didn’t say it was easily available to me; I said I believed it was easily available. I don’t think I’m that interested in that at the moment – I’d like to know how much the force of a chiro, not a bus, moves a vertebra.But once you find it, please feel free to post your findings here and then how you think that is applicable to what chiros do.

          • AN Other said:

            whether movement of vertebra is important in the treatment of spinal conditions, i don’t know if it is.

            It certainly seems to be what chiros do quite a lot of, so presumably they think it’s important.

          • As usual, “jm” fails predictably in his/her attempts at logic and reason.

            People need to travel. To their GP, to their job… walking, by bus, car, aeroplane… etc. The perils of travel are justified by need and furthermore, minimised by all kinds of safety measures developed with help of science and experience.

            People do not need to have “adjustments” or similar manipulations of their cervical column or for that matter of any other part. Particularly not as preemptive measures. These activities have not been shown to have purported effects and are based on ungrounded fantasies of a lunatic magnet-healer and propagated not by scientific process but by business considerations.

            If chiropractors were a type of motor vehicle or other consumer item or service, they would have been recalled a long time ago because of safety concerns.
            But the prefix “Health-“ has a magically protective effect, no matter how dubious the practices or products might be.

          • Alan,

            Ah, I skimmed over the belief part. I thought you had some actual data (or knew if it even existed). If you find some, let me know. It would be interesting small talk at parties. (“A bus hitting a pothole at 15mph produces more movement in vertebra than a chiropractic adjustment”…for instance.) Interesting, but not really relavant to treatment. Probably more relevant to research – did the subjects take the bus? What was their route? What were the road conditions? Etc.

            I’m not that interested in chiro data on the movement of vertebra. Actually, I’m not sure why you are either, since you say “…so presumably they think it’s important.” I think you’re making quite the presumption.

            Of every treatment I’ve received that involved spinal manipulation (PT, chiro, massage therapists, GP, martial artists, etc), not a single practitioner cared about the measurement of force or whether the force moved vertebra. All they cared about was getting my body back to it’s normal state of movement, and using the appropriate amount of force for my body, at that moment.

          • jm said:

            Actually, I’m not sure why you are either, since you say “…so presumably they think it’s important.” I think you’re making quite the presumption.

            Because it’s what chiros do? Back cracking and using their clicky-stick?

            Of every treatment I’ve received that involved spinal manipulation (PT, chiro, massage therapists, GP, martial artists, etc), not a single practitioner cared about the measurement of force or whether the force moved vertebra. All they cared about was getting my body back to it’s normal state of movement, and using the appropriate amount of force for my body, at that moment.

            Now why might that be?

          • Alan,

            This is great: “Because it’s what chiros do? Back cracking and using their clicky-stick?”

            All you need to know, really. But maybe add in a wikipedia page, some youtube videos, and a personal anecdote…you know, to be thorough. Ups your street cred and all.

  • Do you have a list of references for the papers that were included? It’s unfortunate that these rare AEs occur, but do you know if the AE’s reported here were surely chiropractors or is it possible there has been some form of ignorant misattribution? I only ask because often times when one looks, it is uncovered that the procedure was performed by a different profession, then misattributed to Chiropractic for some reason. Here is one example (was this included, I can’t see the references as I don’t have access to the paper):

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3808802/#__ffn_sectitle , which was performed by an entirely different profession, yet chiropractic is a keyword, and Chiropractic Manipulation is used throughout.

    “A 17 year-male patient was referred to our institution with a massive hematothorax after ambulant high velocity spinal manipulation for acute thoracolumbar pain by an osteopathic physician two days before. The osteopathic physician used the so called Bauerngriffmaneuver which consists of a high velocity thrust to the middle portion of the thoracic spine and the adjacent costo-vertebral joints.”

    It would be nice to have an AE reporting system for all professions, not just chiropractic. That way each profession could learn how to improve its safety culture for the benefit of patients.

    • …to improve its safety culture for the benefit of patients.

      The best improvement to the safety culture would be that of admitting what the totality of evidence clearly indicates – That any kind of cervico-thoracal manipulation is clinically useless and can be hazardous albeit the hazard ratio is smaller than can readily be quantified.

      Youtube is chock full of frightening examples of chiropractic absurdity. I know this does not constitute much evidence but it sure is enlightening
      Here’s a chiropractor who pretends to cure a bout of lumbago and associated muscle spasms with neck adjustment. Note especially at 04:20.

      Another frightening aspect of chiropractic’s behaviour is their adherence to health-nonsense, ignorance and paranoia. Especially the unbelievably common anti-vaccine attitude. Also their disregard for exceedingly well established scientific truth such as germ theory denial.

      • That doesn’t answer my question about the references, and trails off quickly into internetland, social media and all sorts of crazy stuff that are really off target.

        As for your comments that “Cervico-Thoracic manipulation is clinically useless,” here is a study done by a group of PTs that found it useful in an RTC. http://www.jospt.org/doi/full/10.2519/jospt.2012.3894#.Vey5VPmqpBc Is this procedure only useful when PTs do it? Or could it also be useful when Chiropractors, Osteopaths and other manual therapists perform it?

        If it’s so clinically useless, why are PT’s performing it more and more? http://www.ncbi.nlm.nih.gov/pubmed/26254852

        Reading this thread, sounds like 30% of these extremely rare and unfortunate adverse events were performed by other manual therapists, and 70% from chiropractors. But chiropractors traditionally perform more SMT. Now that PTs are adopting it more and more…perhaps there should be an Adverse Event reporting system for all manual therapies to improve the safety culture and for the benefit of patients.

        As for your comments about lunacies in the chiropractic profession, I guess that could be true for any profession. There will be some good and some bad. As for commercial interests, again, that is true in every area of healthcare and some will use it justifiably, while others will use it solely for their commercial gain. What about one of the most commonly performed but clinically useless procedures for the knee? http://www.arthritis.org/living-with-arthritis/treatments/joint-surgery/types/knee/arthroscopic-knee-surgery.php

  • “Chiropractor says she didn’t use unusual force in neck adjustment”:

    Excerpt from the article:

    “…Saskatoon chiropractor Stacey Kramer says she “had a gut instinct something was not right” moments after manipulating Laurie Jean Mathiason’s neck on Feb. 4, she testified Wednesday.

    Under questioning, however, she insisted the procedure she administered was not unusually forceful.

    Mathiason, 20, slipped into a coma after the procedure and died in hospital shortly after.”

    Now, how do we interpret this?

    A. Does this mean that it could NOT have been the adjustment that caused the immediate event and resulted in the death of a 20 year old woman because the chiropractor was educated and did not exert more force than normal?

    B. Or do we deduce that even the use of “normal” force by a trained chiropractor may be enough to cause a stroke?

    Now which is it? Is the glass half-full or half empty?
    What would be the normal safety procedure had this been a motor vehicle involved in a deadly accident and one of the possibilities pointed to a serious safety risk?

    In this case, the chiropractor was miraculously acquitted by jury, despite incriminating expert testimony but apparently due to peculiar evidence that the patient had practiced “self-adjustments” (!?) Lucky for her but does not alter the obvious fact that the event occurred immediately after her repeat “adjustment”. There are hundreds of similar case histories of young people succumbing to stroke immediately or shortly after “adjustments”.
    As I said before. If chiropractors were motor vehicles they would have been pulled off the market long ago.

  • The issue of AE reporting was discussed here in the Medical Journal of Australia.
    https://www.mja.com.au/insight/2014/7/support-chiropractor-reporting
    There is no systematic AE reporting system for chiro’s, osteo’s, physio’s, GP’s in private practice etc. Chiropractic has just highlighted the need for such a system across all professions. The proposal to have a standardised AE reporting form within hospital Emergency departments that accurately collects all relevant information and sends it on to the appropriate board for investigation is a good idea. The CPiRLS system in the UK is the right idea, but it should be the board that advocates for patients doing it, not The Royal College of Chiropractors that advocates for the profession.

    As for anti-vaccination attitudes/ignorance I have to agree with Björn Geir. The chiropractic board clamped down on it here and made its position clear. The 120 chiro’s out of 4500 in Australia who were reported to the board and diciplined was a good result, long overdue and 120 too many in my opinion.

    As for germ theory denialists, again I have to agree with Björn Geir. If that vitalist who said on his facebook page “If the germ theory of disease were true there would be no one living to believe it” used the same logic and applies it to “we are all born subluxated” humanity should be extinct or if someone discontinues chiropractic care they will die!

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