The safety of the manual treatments such as spinal manipulation is a frequent subject on this blog. Few experts would disagree with the argument that more good data are needed – and what could be better data than that coming from a randomised clinical trial (RCT)?

The aim of this RCT 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.

Participants were recruited among patients seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. 767 patients 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)
  3.  manual therapy excluding stretching (n = 260).

Treatments were provided by students in the seventh semester (of total 8). Adverse events were monitored via a questionnaire after each return visit and categorized in to five levels:

  1. short minor,
  2. long minor,
  3. short moderate,
  4. long moderate,
  5. serious

This was based on the duration and/or severity of the event.

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 these 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, and long moderate adverse events than men.

The authors conclude that 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.

What on earth is naprapathy? I hear you ask. Here is a full explanation from a naprapathy website:

Naprapathy is a form of bodywork that is focused on the manual manipulation of the spine and connective tissue. Based on the fundamental principles of osteopathy and chiropractic techniques, naprapathy is a holistic and integrative approach to restoring whole health. In fact, naprapathy often incorporates multiple, complimentary therapies, such as massage, nutritional counseling, electrical muscle stimulation and low-level laser therapy.

Naprapathy also targets vertebral subluxations, or physical abnormalities present that suggest a misalignment or injury of the spinal vertebrae. This analysis is made by a physical inspection of the musculoskeletal system, as well as visual observation. The practitioner will also conduct a lengthy interview with the client to help determine stress level and nutritional status as well. An imbalance along one or more of these lines may signal trouble within the musculoskeletal structure.

The naprapathy practitioner is particularly skilled in identifying restricted or stressed components of the fascial system, or connective tissue. It is believed that where constriction of muscles, ligaments, and tendons exists, there is impaired blood flow and nerve functioning. Naprapathy attempts to correct these blockages through hands-on manipulation and stretching of connective tissue. However, since this discipline embodies a holistic approach, the naprapathy practitioner is also concerned with their client’s emotional health. To that end, many practitioners are also trained in psychotherapy and even hypnotherapy.

So, now we know!

We also know that the manual therapies tested here cause adverse effects in about half of all patients. This figure ties in nicely with the ones we had regarding chiropractic: ~ 50% of all patients suffer mild to moderate adverse effects after chiropractic spinal manipulation which usually last 2-3 days and can be strong enough to affect their quality of life. In addition very serious complications have been noted which luckily seem to be much rarer events.

In my view, this raises the question: DO THESE TREATMENTS GENERATE MORE GOOD THAN HARM? I fail to see any good evidence to suggest that they do – but, of course, I would be more than happy to revise this verdict, provided someone shows me the evidence.

18 Responses to The risks of manual therapies like chiropractic seem to out-weigh the benefits

  • Poorly written criticism. Maybe you should hire some research assistants to help you sift through what you find on the web. as a source of information?
    Maybe you should read these first Herr Ernst:
    Very few American states license Naprapaths. You might want to check this to see if it says anything about spinal manipulation here:

    Because I don’t think it does. That’s because they claim to practice soft tissue manipulation. And their founder Oakley Smith rejected subluxation theory which is why he formed the profession ( 1907) in the first place. You might want to revise your article. By the way, you did write a book called Trick or Treatment claiming to be an expert on such things,right?

    • William said:

      Poorly written criticism.

      What, specifically, in your opinion, is poorly written?

      Very few American states license Naprapaths. You might want to check this to see if it says anything about spinal manipulation here:

      Because I don’t think it does. That’s because they claim to practice soft tissue manipulation. And their founder Oakley Smith rejected subluxation theory which is why he formed the profession ( 1907) in the first place.

      That may be, but you don’t say why you, or the sources you cite, should be taken as more reliable sources than the Scandinavian College of Naprapathic Manual Medicine.

      By the way, you did write a book called Trick or Treatment claiming to be an expert on such things,right?

      I can’t speak for Prof Ernst of course, but I suspect the answer to that is, no. You?

      By the way, do you agree with Prof Ernst’s summary of that RCT?

  • Many of these alternative therapies inappropriately medicalize normal tension and postural patterns. Many of them theorize that these normal variations predispose to more serious diseases or psychological disorders. But I’ve seen such theories create psychological disorders as the “worried well” keep going back to the alternative practitioners spending their pocket money to have things adjusted and rubbed to try and make them more ideal and symmetrical. For me, the final verdict about spinal curvatures and subluxations comes from research around scoliosis. Not only can chiropractors not fix scoliosis, but people with scoliosis live 2% longer than the ‘normal’ population and don’t have a higher incidence of internal organ diseases as long as their lungs aren’t too crushed. Here’s the Wikipedia reference page and quote:

    “A 50-year follow-up study published in the Journal of the American Medical Association (2003) asserted the lifelong physical health, including cardiopulmonary and neurological functions, and mental health of idiopathic scoliosis patients are comparable to those of the general population. Scoliosis that interferes with normal systemic functions is “exceptional”[68] and “rare”, and “untreated [scoliosis] patients had similar death rates and were just as functional and likely to lead productive lives 50 years after diagnosis as people with normal spines”.[69][70] In an earlier University of Iowa follow-up study, 91 percent of idiopathic scoliosis patients displayed normal pulmonary function, and their life expectancy was 2% longer than that of the general population.[71]”

    In my years as an acupuncturist, I had both wealthy and poor patients. Some of the poor ones (especially from the hippy/New Age subcultures) would spend hundreds of dollars a month (when they had it) on chiropractic, acupuncture, supplements, etc. As my awareness grew I tried to counsel many of them out of such patterns, especially as their “problems” never seemed to go away permanently from those treatments, just their money. (I often did barter and sliding scale for those of low income.) It’s sad to realize that the most dedicated patients of those who practice implausible and disproven therapies are desperately sick people with poor critical thinking skills and an inability to find and evaluate good quality research. This is doubly sad as it describes most of the practitioners as well. That’s where I was several years ago.

  • This study seems to suggest that following any form of manual therapy patients report transient “adverse effects” that is not dependent on who delivers the treatment. This is our experience of working with physiotherapists and chiropractors. Patients are also accepting of this and indeed expect manual therapy to cause such events. This is not unlike going to the gym or undertaking a new exercise. Treatment should also be coupled with the monitoring of outcome measures that preferably should be patient reported so that the benefit to the individual patient can also be assessed.

  • Oh by the way I am interested as to why your title highlights chiropractic and not physiotherapy since the latter are a larger group (particularly in the UK) who frequently use manual therapy and therefore would therefore be causing the greater number of “adverse events”.

    • Andy, but physiotherapy =/ manual therapy. Do you have any evidence on manual therapy use by physiotherapists? On the other hand, chiropractic is by definition manual therapy (from the Greek chiro =by means of the hand). I cannot imagine a chiropractor not doing manual therapy. Having said that, I have no doubt that physiotherapists who treat aggressively with their hands also help create adverse effects in patients. I’m not sure that we can say that soreness experienced after exercise is equivalent to the adverse effects experienced after aggressive manual therapy. Even if it was equivalent, it’s easier to argue that exercise generates more good than harm vs. manual therapy. Just my opinion.

      • Evan I did not say that physiotherapy equates with just manual therapy but in the UK national guideline for the treatment of low back pain recommend manual therapy and physiotherapists are providers of such treatment. This is clearly not all that they do although sadly in some settings they have been reduced to providing an advice service only and this has resulted in patient dissatisfaction. Interestingly, whilst I accept your literal definition of chiropractic, once again many chiropractors offer more than just manual therapy and will utilise exercise, modalities, advice etc.

        On the evidence on the side effects of manual therapy (I wouldn’t use the term aggressive) I understand that this has been well researched and it is generally agreed that side mild effects are common and they are independent of the profession of the provider, indeed I understand that even sham manual therapy has been shown to be associated with adverse events.

        • Hi Andy,
          But you are interested “as to why your title highlights chiropractic and not physiotherapy”. Manual therapy is not the signature intervention of physiotherapy so that takes care of your question I suppose.

          If not “aggressive” then what word would you choose to describe manual therapy that helps create adverse effects in patients?

          Also, what is “sham” manual therapy? According to the the manual therapy literature the mechanisms of effectiveness of manual therapy (assuming any effectiveness) are unknown, and furthermore, effectiveness is not predictable and depends on context. It follows that there is no “right way” of delivering manual therapy in the context of effectiveness.This study suggests the same

  • Professor, I’d like to suggest you should consider some other questions as well, like – since you kind of fell into the “spiritual” aspect without my help – do these cultists generate more good than harm? Let me explain:

    I have been here before, so I assume you remember my plight – without immediate intervention I will be homeless by the end of the month. But this is not a plea for money. It is a plea for you to understand me.

    Until October 2005, I was a moderately successful black recording artist in San Francisco, a critic’s darling. Then I discovered my wife had been initiated into a Reiki cult, an Ashtar cult, and many more over the course of our 20 year marriage. She was also sleeping with a homeopath in France. His patient? My mother-in-law. I had no idea what homeopathy was and, when I found out, contacted the authorities in America and France. No one took me seriously, assuming I was merely a jealous husband. I then became a basket case.

    Two and a half years later, I am contacted by doctors in France, asking if I had been trying to warn them about a killer homeopath. He had killed two more people – with my wife’s assistance.

    His practice was suspended for only two and a half years for that.

    Since then, the major twists of my life have been determined, downward, and always by people who share two common traits – the NewAge belief system and a desire for revenge on me for not being part of it.

    Some have accused me of sexual harassment on the job, including a gay masseuse, upon discovery of my reluctance to indulge in the ubiquitous NewAge banter, which has resulted in – if not firing – a suspicion, which is not good if you’re a black male. (I’ve been celibate since being cuckolded, so I’ll let you decide on the truth of their claims.)

    Another was my chiropractor/landlady (advertises herself as a doctor) who kicked me out of the house, after I hurt my back in two places doing physical labor, because I didn’t show enthusiasm for her offer of “help”. She even threatened me with physical violence, saying she’d send bikers over to beat me up if I didn’t get out. How spiritual.

    Now I’m on my way into the streets over a misunderstanding with another “believer”. Which, take my word for it, isn’t hard to do. Ignorance and arrogance are their calling cards and – coupled with their evangelical nature – they’re more than happy to dismiss boundary issues, when and if they can, and then, whatever happens,…happens. Their message is trust me – to screw with you.

    Since my discovery of this cult, I have found it impossible to avoid them, or their influence, and it has been disastrous to my life. Their beliefs, which I know intimately now, are in books (The Secret) movies (Pick one) television shows (in the U.S. anyway, sold by Oprah, James Arthur Ray (Arizona’s killer “sweat lodge” guy) the late Sylvia Browne, National Public Radio, and so much more.) and music. But nobody’s talking about it that way (The “spiritual but not religious” get lumped in with atheists and skeptics in national religious surveys when NewAgers include the likes of the anti-vaccine Jenny McCarthy – how many lives has she helped claim?).

    I won’t go on. I merely want to give you some food for thought before I, possibly, won’t be able to again. I remember you offered me a platform once, and I didn’t take it because, honestly, I get exhausted and quite jaded beyond belief that anything significant will ever get done. Today, Wikipedia’s Boss Called “Holistic Healers” Crazy Liars and I considered that, alone, a major step forward. It’s also a sad statement on how desperate I am for anything I can deem rational in the face of this.

    Off topic: what do homeopaths, such as those in France’s multi-billion dollar Boiron, do all day? Can you imagine? It has to be hilarious – or frightening. Undercover camera gig, for sure.

    Anyway, keep up the good work, Doc and thanks for your work and time. Please consider what I’ve said – it’s worthless treatments, yes, but also how the beliefs animate the actions of equally worthless practitioners and their followers.

    Take care,


  • I was just re-reading what I wrote and saw I wasn’t clear: My wife’s homeopath was treating my mother-in-law for an illness. It was not successful.

  • EE, your titles are misleading and lead public into ashtray.

    Here is for you an example piece of evidence, please comment and criticise. I’m sure you MUST know better than multidisciplinary expert group.

    Do you Olle think title is leading reader against one profession?

    What do you think title Björn?

    • @Jorma…
      You ask for my opinion of what? The title??? Is it interesting? What is your point?
      Your link leads to an abstract that is not telling me anything useful in the context of this discussion. I also seem to recall that EE has dealt with this paper before?
      The abstract gives a rather disorganized and foggy message. I do not see that it would be worthwhile for me to buy a copy of this article for further reading?

      And, I believe the term you wanted to use was: “lead people astray”
      An “ashtray” is where you deposit the residue of your smoking paraphernalia 😉

      • Jätte bra comment. It’s better play stupid when an honest opinion is needed.

        You lead people into ashtray too (-;

  • Jorma hits nail again. Chiropractic = Naprapathy. Bill Clinton = Ed.

  • I would like to see this study done, not by students performing the treatments, but by clinicians who have been performing manual therapy consistently for at least 5 years.

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