This systematic review with meta-analysis of randomized clinical trials (RCTs) estimated the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. The authors searched the MEDLINE, Cochrane CENTRAL, EMBASE, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022.Image result for death by neck manipulation

RCTs evaluating SMT compared to guideline-recommended and non-recommended interventions, sham SMT, and no intervention for adults with neck pain were eligible. Pre-specified outcomes included pain, range of motion, disability, health-related quality of life.

A total of 28 RCTs could be included. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short-term (standardized mean difference [SMD] 0.66; confidence interval [CI] 0.35 to 0.97) and long-term (SMD 0.73; CI 0.31 to 1.16), and for reducing disability at short-term (SMD 0.95; CI 0.48 to 1.42) and long-term (SMD 0.65; CI 0.23 to 1.06). Only transient side effects were found (e.g., muscle soreness).

The authors concluded that there was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain.

Harms cannot be adequately investigated on the basis of RCT data. Firstly, because much larger sample sizes would be required for this purpose. Secondly, RCTs of spinal manipulation very often omit reporting adverse effects (as discussed repeatedly on this bolg). If we extend our searches beyond RCTs, we find many cases of serious harm caused by neck manipulations (also as discussed repeatedly on this bolg). Therefore, the conclusion of this review should be corrected:

Low certainty evidence exists supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. The evidence of harm is, however, substantial. It follows that the risk/benefit ratio is not positive. Cervical SMT should therefore be discouraged.

55 Responses to Cervical manipulation for neck pain: DON’T DO IT!

  • Having experienced the devastation of a neck manipulation gone horribly wrong, we are of the same opinion.
    Cervical SMT should be banned, let alone be discouraged.

  • The evidence is overwhelming that the benefit of neck manipulation is miniscule, approaching zero.
    Also, there is irrefutable evidence that neck manipulation is associated with serious complications, including death. Even if the causality is disputed by hard-core chiropractors, horrible risks obviously do exist. Thus the risk-to-benefit ratio is huge, approaching infinity. This fact has been known for decades. In this situation, is there any point at all doing yet another study or meta-study instead of simply banning the procedure and save lives?

    • not really. The above study looked at papers on manipulation and/or mobilization (assumed they have a similar mode of action, which they do not) for acute to chronic conditions (assumed these respond similarly to SMT which they do not). They found limited evidence that that approach is more effective than recommended approaches (very low to low). To establish a proper risk/benefit comparison one would need to look closely at these other “recommended” approaches.

      Most practitioners who use manipulation combine it with other approaches such as rehab and/or exercise. Evidence indicates this multi-modal approach may be better than either alone.

      Is adding spinal manipulation worth any additional risk of serious AE? That depends. Most published cases indicate that the associated serious AE was due to missed contraindications or improper techniques. Those are practitioner errors. That is an educational problem, not a procedural problem per se.

      IMO, and how I practice, typically cSMT may be used as a delayed option within a conservative approach.

      • Well DC…I can assure you there were no missed contraindications, health issues, or improper technique used in my young wife Sandy’s injury. Both her vertebral arteries were ripped.

        She had been seeing him for years. It was business as usual.

        So the question is perhaps WHY do they keep doing this procedure to healthy people? What is this dangerous and persistent need to do this for so called “maintenance” care?

        I’m frankly getting a little sick hearing this pre-existing condition excuse, used every time there is a chiropractic victim.

      • “improper techniques”

        We’ve been through this before. The so-called procedure — the supposed “proper technique” — IS NOT DOCUMENTED. All you came up with was a YouTube video that sort of depicted what you do.


        Another case of stroke due to chiropractic
        Published Wednesday 22 February 2023

        DC on Saturday 25 February 2023 at 14:04

        How I do cSMT is not easily explained in words. If I can find a decent video that closely represents my approach I will share it later.

        To which I replied:

        ‘DC’ wrote: “How I do cSMT is not easily explained in words.”

        Then you are not performing an adequately documented, auditable, procedure.

    • Språkdoktorn Olle Kjellin…WELL SAID!
      It’s time for the chiro’s to stop jaw flapping and reform their industry.

      I looked up the definition of insanity and the act of doing something over and over again while expecting different results.

      For chiropractors to insist on continuing this barbaric and senseless act of Rapid Upper Neck Manipulation, when we all know the risks far outweigh any real and lasting health benefit….well folks that’s just plain nuts.

      The entire organization must be held to account for this buffoonery. My fear is without intervention from Government and public outcry, nothing will change. These days and for decades past, it’s still a case of will…and the will is not there.

    • Would you apply this same rationale to medical interventions with similar risk:benefit ratio?
      What are examples of surgical procedures, for example, that have been banned due to lack of benefit and presumption of harm?

  • I encountered a chiropractor promoting this meta-analysis with a very different conclusion: I would be interested in your analysis of it.

    • Try using the DOI: 10.1016/j.ctcp.2023.101751

      “Chinese massage, also known as Tuina, is a part of traditional Chinese medicine that mainly consists of two components: soft tissue manipulation and backbone manipulation. According to a previous study, Chinese massage can be used as an alternative therapy for patients with neck pain.”

      There is no mention of “chiropractic”.


      • Chiropractic isn’t a recognized profession in China.

        • “Please remember: if you make a claim in a comment, support it with evidence.”

          • That doesn’t support what you claimed, which was “Chiropractic isn’t a recognized profession in China”.

            World Federation of Chiropractic
            Legal Status of Chiropractic by Country

            China: Legal status unclear, but de facto recognition.


          • De facto: existing in fact, although perhaps not intended, legal, or accepted (Cambridge)

          • LOL!

            Yes, your claim that “Chiropractic isn’t a recognized profession in China.” turns out to be nothing other than de facto BS 🤣

            Bill London stated “one of the search terms used to find RCTs in the study I cited is chiropractic”, which clearly indicates that chiropractic is indeed recognized in China.

            Now, have you finished your trolling and your pathetic attempts at diversion and distraction from the subject of the article on which you are posting:
            Cervical manipulation for neck pain: DON’T DO IT!

          • de facto describes practices that exist in reality but are not officially recognized by laws.

            If you want to believe otherwise, so be it.

          • You initially wrote “Chiropractic isn’t a recognized profession in China.”

            Now you write “de facto describes practices that exist in reality but are not officially recognized by laws.”

            Yes, chiropractic is, IN REALITY, recognized in China.


            Blue Wode on Saturday 03 August 2019 at 09:30

            @ Andy

            Aren’t you confusing ‘recognise’ with ‘recommend’ and ‘chiropractic’ with ‘chiropractors’?

            Prof. Ernst is, apparently, correct when he says that NICE guideline NG59 no longer *recommends* ‘chiropractic’. For example, he has previously responded to your criticism with:

            “No, I use these terms not to describe professions but sets of modalities [the respective professions would be chiropractors and osteopaths] – just as I used ‘acupuncture’ in the same sentence.”


          • It’s funny on how you spend so much time trying to prove me wrong over the silliest stuff. It makes you look desperate IMO.

            Moving on.

          • It’s odd how much time you devote to trolling, pathetic attempts at diversion and distraction, and deploying various forms of lying.

            The source from which you quoted only the first sentence — quote mining combined with lying by omission:
            Chu E, Lin A, Chu V (August 07, 2023).
            The Inclusion of Chiropractic Care in the Healthy China Initiative 2030.
            Cureus 15(8): e43068. doi:10.7759/cureus.43068

            The state of chiropractic care in China

            Chiropractors are not officially recognized as medical professionals in mainland China. Despite the lack of official recognition, some chiropractic clinics that largely serve expatriate communities and wealthier Chinese citizens have been established in major cities, such as Beijing, Shanghai, and Guangzhou. Many chiropractors work in private or local hospitals; some chiropractors serve on national sports teams and manage sports injuries. However, comprehensive and current data on the number of practitioners, clinics, and patients are not readily available because of the informal status of the profession. Furthermore, the lack of a formal regulatory framework has implications for the quality of care, as it is difficult to ensure that all practitioners have the necessary qualifications. In Hong Kong, however, chiropractors are registered by law under the Chiropractors Registration Ordinance 1993 and can practice in China through the mainland and Hong Kong Closer Economic Partnership Arrangement.
            END OF QUOTE

            DC on Saturday 19 August 2023 at 14:49

            Chiropractic isn’t a recognized profession in China.

            Very clearly, your statement is incorrect: chiropractic has both de facto and de jure recognition in China.

            Perhaps you have finished your trolling and your pathetic attempts at diversion and distraction from the subject of the article on which you are commenting:
            Cervical manipulation for neck pain: DON’T DO IT!

      • Pete Atkins, one of the search terms used to find RCTs in the study I cited is chiropractic.

        • So, you went fishing for something, anything, that seems to support chiropractic and you managed to find a positive study of tuina, produced in China. Bravo!

          • I am an outspoken critic of chiropractic. You did not read my initial post carefully. I asked a question to Dr. Ernst about a meta-analysis similar to what he wrote about but with a different conclusion. I hope to eventually get an answer from him.

          • I am a critic of chiropractic and no advocate of tuina. You didn’t read my initial post carefully and made unwarranted assumptions. In my initial comment, I asked Dr. Ernst to comment on a meta-analysis of studies on neck manipulation that was touted by a chiropractor because of its favorable conclusions unlike the meta-analysis Dr. Ernst wrote about. I don’t think he replied yet. I think his comments would be more insightful than yours were.

          • I replied by posting a new article today about the SR.

          • Bill London,

            I have very little patience with commentators who can’t even be bothered to spell my name correctly. Usually, they are quacks. Irrespective, they are too damned lazy and arrogant to use the copy and paste facility that is available on their computing device; the very device that enables them to post comments on this website.

            “In my initial comment, I asked Dr. Ernst to comment on…”

            No, you didn’t mention Dr. Ernst in your initial comment. Had you done so, I would have waited for him to reply to you.

          • I apologize for misspelling your name.

            I was right to expect that Dr. Ernst would do a better job than you in responding to my initial comment. See Unlike you, Pete Attkins, he didn’t err by saying “chiropractic” was not mentioned in the paper.

            My initial comment was: “I encountered a chiropractor promoting this meta-analysis with a very different conclusion: I would be interested in your analysis of it.” By “your” I meant Dr. Ernst, whose piece I was commenting on. I didn’t mean a collective your even though others are free to chime in. I certainly didn’t mean you as I didn’t know of your existence (and since you were so sarcastic to me simply because I misspelled your name, I don’t want to know who you are). It’s good not to make assumptions about anyone’s motives or character when they misspell your name and correct your misstatement of fact.

          • LOL!

  • What is the estimated incidence of cerebral artery dissection due to cervical spine manipulation?

  • Perhaps it is time once again for a highly qualified team of Lawyers, to consider teaming up with the excellent and knowledgably contributors on this blog?

    The valuable input provided within these various posts from esteemed Medical Doctors, Scientists, and BRILLIANT Researchers, is absolutely priceless and would prove beneficial for a reconsideration of a class action being brought against all the various organizations who promote and provide insurance coverage for their Chiropractic members. For any organization who fails to properly regulate ones members, there must be accountability on some level , if not from within.

    I wish we knew now, what we didn’t know then. Much has been enlightened over the last fifteen plus years since our own personal experience and the spotlight continues to be pointed directly on the dangers of upper rapid neck manipulation.

    I have tried to keep an open mind here but it is obvious to me, that the few chiropractors who have attempted to respond and explain their stubborn positions, have failed to make their case. Just continual Red Herrings and diversion tactics.

    If the Chiropractors wont act in a responsible and safe manner….we must.

    • I’ve decided to post and share a just a few “before and after pictures” , that reflect a bit of Sandy’s (our) journey of “recovery” here on my profile. As you can she she was young, vibrant, perfect weight, and even her skin prior to the Chiropractic injury reveals her clean lifestyle choices. We have many pictures but a vast majority would not be suitable for general viewing.

      Next month , September 13th, 2023 we enter 16 years since that fateful day. This time of year I always reflect and wish I could turn back the hands of time. Many said she would never leave the Hospital. There were times throughout her year in Hospital where I started to believe them but I would not share these inner feelings with Sandy.

      The thing many patients/victims of Chiropractic do not know, is if they end up stroking-out like my wife, and vertebral arteries are damaged, the long term recovery process can take years and the outcome not always favorable even if you do survive.
      Sandy was paralyzed for quite some time, hence she ended up having to have both her legs rebuilt. The amazing Doctors reversed the feet inversions and much of the extreme curvatures in her arches. Achilles tendons modified to help her stand.

      Years later she would undergo major Maxiofacial surgery ( s) in order to aid her in opening her mouth wider. Both TMJ joints were eventually replaced. This corrected the mouth opening substantially but because of the ongoing throat paralysis, she still chokes on food even when carefully prepared. And of course her speech although able to communicate by voice, will never be the same and takes a lot out of her.

      Having been so long on tube feeding her teeth have sustained massive deterioration. Sandy will begin complete restoration over the coming months. This alone will be in the tens and tens of thousands of dollars in costs.

      The millions of dollars in re-building Sandy and trying to maintain something of a resemblance of a “quality of Life” for Sandy still remains my top priority. But it is the mental challenges that also closes ones world in and rips apart ones life. The loss of privacy. The depression. The dreams not fulfilled. The pain endured through each and every surgery.

      We know this catastrophic stroke has taken years off her longevity but remain determined to do everything we can to give our little Sandy the best life possible. Whatever time remains.


      • QUOTE
        Chiropractic abuse and how we can protect ourselves from it
        Published Monday 25 November 2013

        [Preston] Long is right, I think, when he states: the most efficient way to protect against chiropractic mistreatment is to avoid chiropractors altogether.

        • Yes indeed. Preston Long has it 100% when he states that the best course of action would be to essentially “avoid chiropractic altogether”.

          That said, many people who frequent this type of “care” either still seem to just don’t know the risks and dangers, or they are being misinformed by the chiro community as a whole.

          I for one, think given all the evidence on the dangers of rapid upper neck manipulation, a push needs to come from external forces. In Canada the Provincial and Federal Governments need to step in and put the hammer down.

          If the Government remains on the sidelines and takes no affirmative action, then perhaps a Class Action needs to be reconsidered and these idiots who insist on twisting the necks of otherwise healthy people, reined in once and for all.

          Given all the mounting carnage….the culpability surely is growing.

          I would be interested to know who’s head should be on the chopping block here? My personal views are that there should be pressure on both the Government and the governing bodies for the various Chiropractor Associations.

          It’s pretty obvious the Chiropractors themselves will never change without direct orders.

  • David. I am truly saddened by what happened to your wife. As I mentioned I had a good friend stroke out during an adjustment. He died. My desire has been, and continues to be, to educate chiropractors and spur research into this area to hopefully avoid these tragic cases in the future. Our means are just different.

    I will miss Julian’s comments but he now seems to be absent from this place. He is a true skeptic. For that he earned my respect.

    With that, I bid you all farewell. There is too much hostility and abuse in here to continue so, I suppose for some, you can feel as if you won.

    • Thank you, DC for your compassion and kind words!
      Given you have personally experienced a similar fate with your dear friend at the hands of ( I am assuming ) a Chiropractor, I can empathize with you as well. Losing someone for no real logical reason is like a gut punch.

      Our means of resolve are indeed different but both Sandy and I appreciate when anyone strives to improve our health care system and make positive change. Perhaps what you are doing from within your inside circle will ultimately change the hearts and minds of other Chiropractors.

      To be clear, as mentioned before also, I do not have a hate-on for Chiropractors. I just have disgust and frustration that boils over, given the time it seems to be taking to abolish these ridiculous rapid upper neck manipulations.

      I heard from yet another victim. We get these emails from around the world. I suppose it’s because of the Internet and our own story, that we still receive news of other Chiropractic strokes and injuries. There are many times when we wish we were not as well known as we are, as with each victim we are brought back to many of our own dark memories.

      There are no winners here DC, but sadly until Chiropractors stop doing these neck manipulations the needless carnage will continue.

    • DC wrote: “I had a good friend stroke out during an adjustment. He died. My desire has been, and continues to be, to educate chiropractors and spur research into this area to hopefully avoid these tragic cases in the future.”

      This seems to indicate that you do have a secret, gnawing thought that maybe, just MAYBE, the chiropractor’s manipulation could indeed cause stroke, so they have to be better educated “to hopefully avoid these tragic cases in the future”.

      I understand that you are reluctant to admit it here and lose face, but hopefully you can understand where the “hostility” here comes from, and you will be very careful in your daily practice “to hopefully avoid these tragic cases in the future”. Thank you in advance!

      • Well said Språkdoktorn Olle Kjellin!
        Thank you for sharing your thoughts on this very important topic.
        Unfortunately as victims of a neck manipulation gone horribly wrong, we can only hope for change from within the Chiropractic community itself we fear.

        Be well.
        Dave & Sandy

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