MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

I was criticised for not referencing this article in a recent post on adverse effects of spinal manipulation. In fact the commentator wrote: Shame on you Prof. Ernst. You get an “E” for effort and I hope you can do better next time. The paper was published in a third-class journal, but I will nevertheless quote the ‘key messages’ from this paper, because they are in many ways remarkable.

  • Adverse events from manual therapy are few, mild, and transient. Common AEs include local tenderness, tiredness, and headache. Other moderate and severe adverse events (AEs) are rare, while serious AEs are very rare.
  • Serious AEs can include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.
  • Sports-related practice is often time sensitive; thus, the manual therapist needs to be aware of common and rare AEs specifically associated with spinal manipulative therapy (SMT) to fully evaluate the risk-benefit ratio.

The author of this paper is Aleksander Chaibi, PT, DC, PhD who holds several positions in the Norwegian Chiropractors’ Association, and currently holds a position as an expert advisor in the field of biomedical brain research for the Brain Foundation of the Netherlands. I feel that he might benefit from reading some more critical texts on the subject. In fact, I recommend my own 2020 book. Here are a few passages dealing with the safety of SMT:

Relatively minor AEs after SMT are extremely common. Our own systematic review of 2002 found that they occur in approximately half of all patients receiving SMT. A more recent study of 771 Finish patients having chiropractic SMT showed an even higher rate; AEs were reported in 81% of women and 66% of men, and a total of 178 AEs were rated as moderate to severe. Two further studies reported that such AEs occur in 61% and 30% of patients. Local or radiating pain, headache, and tiredness are the most frequent adverse effects…

A 2017 systematic review identified the characteristics of AEs occurring after cervical spinal manipulation or cervical mobilization. A total of 227 cases were found; 66% of them had been treated by chiropractors. Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57%, and 46% had immediate onset symptoms. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AEs using standardized terminology…

In 2005, I published a systematic review of ophthalmic AEs after SMT. At the time, there were 14 published case reports. Clinical symptoms and signs included:

  • central retinal artery occlusion,
  • nystagmus,
  • Wallenberg syndrome,
  • ptosis,
  • loss of vision,
  • ophthalmoplegia,
  • diplopia,
  • Horner’s syndrome…

Vascular accidents are the most frequent serious AEs after chiropractic SMT, but they are certainly not the only complications that have been reported. Other AEs include:

  • atlantoaxial dislocation,
  • cauda equina syndrome,
  • cervical radiculopathy,
  • diaphragmatic paralysis,
  • disrupted fracture healing,
  • dural sleeve injury,
  • haematoma,
  • haematothorax,
  • haemorrhagic cysts,
  • muscle abscess,
  • muscle abscess,
  • myelopathy,
  • neurologic compromise,
  • oesophageal rupture
  • pneumothorax,
  • pseudoaneurysm,
  • soft tissue trauma,
  • spinal cord injury,
  • vertebral disc herniation,
  • vertebral fracture…

In 2010, I reviewed all the reports of deaths after chiropractic treatments published in the medical literature. My article covered 26 fatalities but it is important to stress that many more might have remained unpublished. The cause usually was a vascular accident involving the dissection of a vertebral artery (see above). The review also makes the following important points:

  • … numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death. Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely. Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.
  • Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%. Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome. Incomplete reporting of outcomes might therefore further increase the true number of fatalities.
  • This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to a osteopath. A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors. This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.

Another review summarised published cases of injuries associated with cervical manipulation in China. A total of 156 cases were found. They included the following problems:

  • syncope (45 cases),
  • mild spinal cord injury or compression (34 cases),
  • nerve root injury (24 cases),
  • ineffective treatment/symptom increased (11 cases),
  • cervical spine fracture (11 cases),
  • dislocation or semi-luxation (6 cases),
  • soft tissue injury (3 cases),
  • serious accident (22 cases) including paralysis, deaths and cerebrovascular accidents.

Manipulation including rotation was involved in 42% of all cases. In total, 5 patients died…

To sum up … chiropractic SMT can cause a wide range of very serious complications which occasionally can even be fatal. As there is no AE reporting system of such events, we nobody can be sure how frequently they occur.

[references from my text can be found in the book]

32 Responses to “Adverse events from manual therapy are few, mild, and transient” … best not to listen to chiros, I think

  • sorry just a question… other than you saying so, do you have any EVIDENCE that Chiropractic SMT (interesting that you exclude physio manipulating but don’t let this trouble you) is:
    Not rare?
    Not mild in most cases?
    Not transient in most cases?

    Does not “… include spinal cord injuries with severe neurological consequences and cervical artery dissection (CAD), but the rarity of such events makes the provision of epidemiological evidence challenging.”

    I can understand the urge to criticize but this time the author was 100% correct…

    • Possibly, you asking these question is already fairly good evidence!
      If not it might help to read the chapter [https://www.amazon.co.uk/Chiropractic-Not-All-That-Cracked/dp/3030531171] and the articles referenced it it.

  • so you have no evidence… that is ok, Everyone is entitled to a personal biased opinion

  • Sorry but the science is not with you… there are no evidence that Chiropractic SMT AE are:
    1. Not rare
    2. Not mild in most cases
    3. Not transient in most cases

    And please reference real studies not your own book please.

    I am sorry to trouble you with the burden of proof… this is something us EBP people tend to like…

  • Great so the author was correct… the AE are MINOR and TRANSIENT and the serious AE that you present are so rare that you can not even quote their frequency (that does not mean they do not exist or we should not consider them).

    By the way these are the same numbers as presented by Thiel and colleagues in the study you like to dismiss.

  • Critical_Chiro wrote on Saturday 09 January 2021 at 23:55 “Then read this:
    https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125804

    That link records Critical_Chiro writing: “Harriet Hall’s blog not once refers to the authors as neurosurgeons. All the way through it is ‘they’.”

    @ Critical_Chiro

    One merely has to click on the link to the paper provided by Dr Hall and then click on the authors’ names below its title to read their credentials.

    For the sake of extra transparency, click here:
    https://sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/
    In the first paragraph, the words ‘A systematic review found a small association between stroke and chiropractic care’ provide an embedded link to the paper:
    https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation

    Critical_Chiro wrote on Saturday 09 January 2021 at 23:55 “Then read this:
    https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125804

    That link records Critical_Chiro writing: “She [Harriet Hall, MD] even references Edzard’s blog on phrenic nerve injury from chiropractic neck manipulation. That blog cites a paper where the patient clearly described to the doctor what treatment was performed by the chiro. It was a bog standard levator scapulae stretch used by just about every profession (chiro/physio,osteo/massage/etc) then called it a “chiropractic neck manipulation”. Very poor science.”

    @ Critical_Chiro

    Here’s a closer look at the content of that blog piece by Professor Ernst and why it’s relevant:
    https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64573

    Also see:

    “All but one of these cases clearly state that the culprit in each case was a practitioner of the ‘chiropractic’ kind. Does that not say something about the methods used and adverse results caused by practitioners identifying themselves with the term?”
    https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64597

    ______________________________________________________________________

    “Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”

    Björn Geir Leifsson, MD

    • @BW wrote:
      “Here’s a closer look at the content of that blog piece by Professor Ernst and why it’s relevant:
      https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64573
      Reply to Bjorn Geir here:
      https://edzardernst.com/2015/02/phrenic-nerve-injury-a-rare-but-serious-complication-of-chiropractic-neck-manipulation/#comment-64591

      Harriet Hall’s blog is poor science trying to put spin on the systematic review and sidesteps the fact that the reviews authors are neurosurgeons and the POOR SCIENCE they discuss are medical case studies not chiropractic.
      Imagine the outcry if chiropractors wrote this:
      “In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical DOGMA. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.”

      The phrenic nerve blog is another classic example of what the neurosurgeons are discussing. The patient described to the doctor what the chiropractor did which was a bog standard levator scapulae stretch used by just about every profession. The doctor has the correct information yet makes an assumption, called it a chiropractic neck manipulation and wrote a poor case study. This poor quality paper is then published. This poor paper is then quoted by Radiopedia ascribing chiropractic neck manipulation to phrenic nerve injury (Edzard does the same) and it has now entered the realm of medical folk lore and dogma.
      See the pattern Blue?
      Then you wrote:
      “One merely has to click on the link to the paper provided by Dr Hall and then click on the authors’ names below its title to read their credentials.”
      Sadly Blue you and others just quote the blog as evidence or even worse read the abstract only without reading the full paper.

      ““Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”
      Björn Geir Leifsson, MD”

      Thank you for making the point Blue that this echo chamber/blog/regular commenters use similar arguments as the vitalistic chiropractors “If it not subluxation then it’s not chiropractic”. The irony seems to escape you.
      Both the vitalistic chiropractors and the critics are stuck in the past and resistant to change.
      Again the irony seems to evade you.
      Not unexpected though as it is human nature.
      You have spent too much time making public statements on one extreme and are now locked in to defending them.

      • Well, you’ve spent too little time yourself editing this comment, dear, CC. You seem to be confusing comments and replies and are not making any sense..

  • Could a serious AE occur due to cSMT? Perhaps, if the person was predisposed to such an event or cSMT was not properly performed. That is why we have contraindications to cSMT and training.

    “It is now thought that vertebral artery dissection is a multifactorial disease process where certain intrinsic factors are present in the setting of an exacerbating extrinsic factor such as a low speed car accident, direct trauma, heavy lifting, or a rotational sports injury.” The American Journal of Emergency Medicine, 16 November 2020

    “Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as ‘unknown’. CSM was performed appropriately in 80.6% of cases.” J Man Manip Ther. 2012 May; 20(2): 66–74.

    Hence, if someone doesn’t know what they are doing they could cause a serious AE. That is probably practitioner error, not procedural error.

    • DC wrote: “Could a serious AE occur due to cSMT? Perhaps, if the person was predisposed to such an event or cSMT was not properly performed. That is why we have contraindications to cSMT and training.”

      @ DC

      The bottom line is that the evidence of benefit for cSMT is pitiful and there are no reliable screening methods available to determine who might be predisposed to injury. Ergo, the Precautionary Principle applies (i.e. cervical spine manipulations should be viewed as too risky regardless of who does them).

      • Nonspecific neck pain, compared to what?

        Exercise, Yoga, steriod injections? They all have been associated with VAD and really aren’t that effective.

        NSAIDs? Not very good with known serious AE

        Opioids? Yah, how did that pan out?

        Nerve ablation? Darn sprouting and possible serious AE

        Botox? Doesn’t seem to help and some possible serious AE

        So, what do you purpose as the best approach to non specific neck pain, that with the best risk:benefit profile?

  • DC wrote: “you mean stuff like this?”

    What I mean is that patients should be fully informed about all treatments available (including coping strategies). Of course, being fully informed about treatments would need to include a thorough explanation of the chiropractic ‘bait and switch’:
    https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

    It’s also important to remember that healthcare doesn’t have the answers for everything, so some patients, unfortunately, after exhausting all interventions, will likely not find any relief for their pain.

    • “Active coping was not associated with recovery of neck pain or disability.”

      Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability
      Linda J Carroll et al. Clin J Pain. 2014 Jan

      • I don’t think there is currently an optimal treatment for neck pain.
        this, however, does not mean that SMT is ok.
        accepting this wrong conclusion would only hinder our research to find one.

        • Current evidence suggests a two week/forth visit to determine if manual therapy is an appropriate intervention (below). If I recall NSAIDs and opioids have around a four day recommended usage with no certainty of alleviating the condition. Of course other interventions are not reversible (ablation, Botox, steroids injections, etc) which may or not help.

          Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4545558/

          Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months. http://www.jmptonline.org/article/S0161-4754(04)00158-7/fulltext

          Improvement at the fourth visit is a predictor of long-term outcome. https://www.ncbi.nlm.nih.gov/pubmed/?term=16182020

          The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. https://www.ncbi.nlm.nih.gov/pubmed/?term=22445052

          Of the 115 patients in the most favorable prognostic group, 84% (95% confidence interval, 77-91) reported to be “definitely improved” by the 4th visit… https://www.ncbi.nlm.nih.gov/pubmed/12214186

          Those who experienced a ≥33% pain reduction by 2 weeks had 6.98 (95% CI = 1.29, 37.53) times higher odds of 50% improvement on the GRoC and 4.74 (95% CI = 1.31, 17.17) times higher odds of 50% improvement on the ODI (at 6 months). Subjects who reported a ≥50% pain reduction at 2 weeks had 5.98 (95% CI = 1.56, 22.88) times higher odds of a 50% improvement in the GRoC and 3.99 (95% CI = 1.23, 12.88) times higher odds of a 50% improvement in the ODI (at 6 months). https://www.tandfonline.com/doi/full/10.1080/09593985.2017.1345025

          • DC wrote: “Current evidence suggests a two week/forth visit to determine if manual therapy is an appropriate intervention”

            Even so, there’s still this to resolve with regard to chiropractic manual therapy:

            “The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.”

            Ref: ‘Chiropractic, one big unhappy family: better together or apart?’
            https://chiromt.biomedcentral.com/articles/10.1186/s12998-018-0221-z

          • Red herring.

  • @ DC

    The unvarnished truth:

    “Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine. The deception begins with the name itself – ‘chiropractic’ fails the basic test of transparency because it is not unambiguously defined…Therefore someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing.”

    Ref https://sciencebasedmedicine.org/the-bait-and-switch-of-unscientific-medicine/

    • The topic was AE. I let it slide into evidence of benefit as the two are often considered together. You can either stick to the topic or move along.

      • DC wrote: “The topic was AE.”

        Then here’s a timely reminder from Prof. Ernst’s post:

        “the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive”

        NB. There are no reliable chiropractic adverse events reporting systems in the United States where the vast majority of chiropractors practice:
        https://www.ebm-first.com/chiropractic/risks/1842-letter-from-britt-harwe-president-chiropractic-stroke-awareness-group-csag.html

        A more comprehensive look at the problem here: https://edzardernst.com/2020/08/chiropractic-not-all-that-its-cracked-up-to-be/#comment-125800

        • Yep, and then you switched the topic…see your posts from Friday 15 January 2021 at 09:44 and Friday 15 January 2021 at 13:41. Red Herring.

          If you don’t want to stick on topic, sobeit. But that doesn’t mean I have to address any topic you decide to bring up.

          • DC wrote: “Yep, and then you switched the topic…see your posts from Friday 15 January 2021 at 09:44 and Friday 15 January 2021 at 13:41. Red Herring. If you don’t want to stick on topic, sobeit. But that doesn’t mean I have to address any topic you decide to bring up.”

            @ DC

            What I wrote in those posts was very relevant to the topic in hand – i.e. when discussing the risk/benefit of chiropractic spinal manipulation it’s imperative to understand that many chiropractors mislead their customers with plausible-sounding interventions that, in reality, amount to little more than blatant quackery. In essence, here’s the problem:

            QUOTE
            “… chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words ‘manipulation’ and ‘subluxation’ in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic ‘spinal lesion’ that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is ‘adjusted’ by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.”

            Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf

            I have yet to see a chiropractor regulator issue widespread information about the above to the general public.

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