Safety and Adverse Events

Use of Chiropractic and Decreased Risk from Adverse Drug Events

  • A 2018 cohort study found that among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling an opioid prescription was significantly lower for recipients of chiropractic services compared with nonrecipients.1
  • A 2018 cohort study found that among New Hampshire adults with office visits for low back pain, the adjusted likelihood of an adverse drug event was significantly lower for recipients of chiropractic services compared to nonrecipients.2

Spinal Manipulation Risks

  • A 2019 crossover randomized controlled trial is the first to show that cervical manipulation does not result in brain perfusion changes compared with a neutral neck position or maximal rotation. It suggests that cervical manipulation may not increase risk of cerebrovascular events via a hemodynamic mechanism.3
  • A 2017 scoping review found that non-serious adverse events following manual treatments to the spine are common, while serious adverse events are rare. Serious adverse events could result from pre-existing pathologies, so assessment for signs or symptoms of these is important.4
  • A 2017 overview of reviews on spinal manipulative therapy (SMT) assessed the risk of serious adverse events (SAEs). Of 118 included reviews, the most frequently described adverse events were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, from 1 in 20,000 to 1 in 250,000,000 manipulations.5

Adults Low back pain

  • A 2019 systematic review of randomized controlled trials examined the effect of spinal manipulation or mobilization in adults with chronic low back pain with or without referred pain. About half of the 47 included studies examined adverse events, finding that most were transient, mild to moderate severity and musculoskeletal-related.6
  • A 2017 systematic review examined 26 randomized controlled trials to assess effectiveness and harms of spinal manipulation for acute LBP (<6 weeks). It found only transient minor musculoskeletal harms.7

Neck pain and cervical spine manipulation

  • A 2018 article summarized current knowledge about cervical spine manual therapy and provided guidance to minimize potential, but rare, serious adverse events.8
  • A 2018 systematic review examined case reports/ series and surveys of adverse events related to neck manipulation. For the 227 cases reported in 144 articles, the most common symptoms were: disturbance of control of voluntary movements (104), altered sensation (97), pain (82), paresis (71), visual disturbance (54), nausea (48), headache (47), vomiting (44), and vertigo (43).9

Children and Adolescents

  • A 2019 systematic review examined the evidence for effectiveness and harms of specific spinal manipulative therapy (SMT) techniques for infants, children and adolescents. Of the 18 studies which reported on harms/adverse events, 5 case reports reported severe adverse events after high velocity, low amplitude (HVLA) manipulations in 4 infants and 1 child. Chiropractic care was not involved in the 2 reported deaths; it was involved in a case of temporary quadriplegia in an infant with congenital torticollis with a spinal cord astrocytoma. Mild, transient adverse effects were reported after gentle spinal mobilizations in infants and children. Overall, severe harms were rare and likely associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents.10

Older Adults

  • A 2017 systematic review examined 4 randomized controlled trials to assess the effectiveness and safety of manual therapy for pain and disability in older adults with chronic low back pain. No serious adverse events were reported in any of the included studies.11

Patient Safety Assessment

  • A 2018 article reports the development of the first instrument measuring patient safety attitudes and opinions of community-based spinal manipulation providers providers.12


  1. Whedon JM, Toler AWJ, Goehl JM, Kazal LA. Association between utilization of chiropractic services for treatment of low-back pain and use of prescription opioids. J Altern Complement Med. 2018;24(6):552-556.
  2. Whedon JM, Toler AWJ, Goehl JM, Kazal LA. Association between utilization of chiropractic services for treatment of low back pain and risk of adverse drug events. J Manipulative Physiol Ther. 2018;41(5):383-388.
  3. Moser N, Mior S, Noseworthy M, et al. Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial. BMJ open. 2019;9(5):e025219. FREE FULL TEXT
  4. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017;25:37. FREE FULL TEXT
  5. Nielsen SM, Tarp S, Christensen R, et al. The risk associ ated with spinal manipulation: an overview of reviews. Syst Rev. 2017;6(1):64. FREE FULL TEXT
  6. Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ (Clinical research ed). 2019;364:l689. FREE FULL TEXT
  7. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460. FREE FULL TEXT
  8. Hutting N, Kerry R, Coppieters MW, et al. Considerations to improve the safety of cervical spine manual therapy. Musculoskelet Sci Pract. 2018;33:41-45.
  9. Kranenburg HA, Schmitt MA, Puentedura EJ, et al. Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review. Musculoskelet Sci Pract. 2017;28:32-38.
  10. Driehuis F, Hoogeboom TJ, Nijhuis-van der Sanden MWG, et al. Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes. PLoS One. 2019;14(6):e0218940. FREE FULL TEXT
  11. de Luca KE, Fang SH, Ong J, et al. The effectiveness and safety of manual therapy on pain and disability in older persons with chronic low back pain: a systematic review. J Manipulative Physiol Ther. 2017;40(7):527-534.
  12. Funabashi M, Pohlman KA, Mior S, et al. SafetyNET Community-based patient safety initiatives: development and application of a Patient Safety and Quality Improvement Survey. J Canadian Chiropr Assoc. 2018;62(3):130-42. FREE FULL TEXT