Safety

Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83. CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

Thiel, Haymo W. DC, PhD *; Bolton, Jennifer E. PhD *; Docherty, Sharon PhD *; Portlock, Jane C. PhD.  Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey.Health Services Research.Spine. 32(21):2375-2378, October 1, 2007. Objective. To estimate the risk of serious and relatively minor adverse events following chiropractic manipulation of the cervical spine by a sample of U.K. chiropractors. This study involved 19,722 patients. Results. Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. Conclusion. The risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.

Rubenstein SM, Haldeman S, Van Tulder MW. An Etiologic Model to Help Explain the Pathogenesis of Cervical Artery Dissection: Implications for Cervical Manipulation. J Manipulative Physiol Therapeutics. 2006. 29:336-338. Manual treatments of the cervical spine, though malaligned by some, are much safer than commonly used medical and surgical treatments for neck and head pain. The incidence of cervical artery dissection and stroke associated with manipulation/mobilization is generally accepted as one incident in 1 million treatments.

Wenban AB. Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer reviewed biomedical literature. Chiropractic and Osteopathy 2006: Aug 22; 14:16. The results of this year-long prospective review suggests that the words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing 'letters to editors', and to a lesser extent 'corrections', when authors had inappropriately used the title 'chiropractor' and/or term 'chiropractic manipulation'.

Symons, Bruce, DC MSc, Leonard Tim, Herzog Walter, PhD.  Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Canada, 2002.  Study was performed to quantify the strains and elongations of the vertebral artery (VA) during spinal manipulative therapy (SMT) and then to compare these values against the ultimate failure loading strain of the VA.  This was to test the hypothesis that SMT may place strains on the VA capable of causing injury.  This study showed that in normal circumstances a VA could not be damaged by cervical manipulation and for the average person the VA is stretched much more by normal daily movements of the head and neck than it is during neck manipulation-often twice as much. 

Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy.  Spine 2002: 27(1), pp. 49-55.  The growing acceptance of cervical manipulation as an effective treatment for head and neck conditions has necessitated the determination of possible side effects of this treatment and ways to avoid them.  Over the past 60 years, CVA’s have been reported to be associated with cervical manipulation in 117 cases that have been published in the English literature.  These events are rare, only occurring after one in 400,000-4 million manipulations.  Due to the rarity of CVA’s it is difficult to conduct such studies.  Conclusions were CVA following manipulation seems to be unpredictable and there are few warning signs to identify patients at higher risk. 

Haldeman S, Kohlbeck FJ, McGregor M.  Spine 1999: 24 (8): 785-794.  Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation. This study suggests that those rare patients suffering significant harm from manipulation may have a connective tissue disease that weakens the vertebral arteries.  This may be why many other common neck movements also lead to vertebral artery injury- kneeling at prayer, yoga, washing walls and ceilings, turning the head while driving or sneezing.

Hurwitz, D.C., Ph.D. et al.  Spine 1996; 21(15):  1746-1760.  Scientific Paper of RAND Study of Appropriateness of Spinal Manipulation (SM) and Mobilization (MO) of the Cervical Spine.  Of 1457 articles identified only 67 were used.  Conclusions:  1) MO is probably of at least short-term benefit for patients with acute neck pain; 2) SPINAL MANIPULATION is probably slightly more effective than MO and PT for some patient with sub acute or chronic neck pain.  All three treatments are probably superior to usual medical care; 3) SPINAL MANIPULATION and or MO may be beneficial for muscle tension headaches; 4) MO results in fewer complications than does SM.

Coulter, Ph.D.  et al.  RAND Corporation 1996: Table 6, page 36.  The Appropriateness  of Manipulation and Mobilization of the Cervical Spine.  This was a comparative study, which shows the extreme safety of spinal manipulation in the hands of trained individuals.  1) Non steroidal anti inflammatories (NSAIDS): Serious gastrointestinal complications were 3,200/million for those greater than 65 and 390/million for those less than 65.  1000/million for all ages.  2) Cervical Spinal Surgery: Neurologic Complications, 15,600/million.  Deaths, 6,900/million.  3) Spinal Manipulation:  Cerebral Vascular Accident and other complications, 1.46/million.  Major Impairment, 6.3/10 million.  Death, 2.6/10 million. 

Wiesel, M.D.  1997; 12(8): 87.  Survey by the National Council on Aging.  NSAIDS Use and Risk in Senior Citizens.  “The serious side effects NSAIDS result in 200,000 hospitalizations and 20,000 deaths annually,” says Thomas Schnitzer, MD, rheumatologist and geriatrician at NorthwesternUniversity.  Over 20% of seniors age 60 and older regularly take medication for chronic pain.  (arthritis and low back pain).

Heigh, M.D.  Postgraduate Medicine 1994; 96(6): 63-6.  The prevalence of ulcers in patients taking NSAIDS ranges from 10% to 30%.  In the Aspirin for Myocardial Infarction Trial, risk of hospital admission for duodenal ulcer was 10.7 times greater in aspirin vs. Placebo patients.  Gastric ulcers develop in 26% of patients who take aspirin regularly.  Patients who take NSAIDS for a total of 30 or fewer days had the highest risk.  Most gastroduodenal injury occurs during the first several weeks of treatment.

Dabbs, D.C. and Lauretti, D.C.  Journal of Manipulative and Physiological Therapeutics 1995; 18(8): 530-535.  Risk of cervical Spinal Manipulation vs. Non steroidal anti inflammatories (NSAIDS).  The most reasonable estimate of risk of stroke from cervical spinal manipulation is 0.5 to 2 per million.  Risk of gastric ulcer is 10-20%, 5-10 times the rate of non-users.  Based on the literature, the risk of serious complications or deaths is 100 to 400 times greater for the use of NSAIDS than for cervical spinal manipulation in the treatment of similar conditions.

Senstad, D.C., Leboef-Yde, D.C., MPH, Ph.D., Borchgrevink, M.D.  Spine 1997; 22(4): 435-440.  Unpleasant Side Effects after Spinal Manipulation.  Based on data from 4712 treatments of 1058 new patients by 102 Norwegian D.C.’s.  55% of patients had an unpleasant effect within the first 6 visits. 25% of all treatments over the first 7 visits will result in at least one reaction.  Less than 20% of reactions arise within 10 minutes of treatment, suggesting that the SPINAL MANIPULATION itself is rarely painful.  Reactions are short, with symptoms usually disappearing on the day of their appearance.  89% of the patients did not curtail their activities of daily living.  Common and benign reactions follow a distinct pattern and can be considered “normal”.

Terrett AG. J. “Vascular Accidents from Cervical Spine Manipulation:  Report of 107 Cases.”  Journal of the Australian Chiropractors Association, Volume 17, Number 1, March 1987, Pages 15-23.  Fifty-year review of chiropractic treatment shows low risk of injury.  This study shows when chiropractors perform adjustment/manipulation, it is very rare that injury happens and there are few side effects.

Terrett Ag.J.  Kleynhams AM.  “Complications form Manipulation of the Low Back” Chiropractic Journal of Australia, Volume 22, Number 4, December 1992, Pages 129-140.  This study reviewed all reported injuries from 1911-1991.  There was only one injury per year caused by chiropractic manipulation.