The risk associated with spinal manipulation: an overview of reviews

Sabrina Mai Nielsen,Louise Klokker,Henning Bliddal,Robin Christensen,Simon Tarp,Marius Henriksen

doi:10.1186/s13643-017-0458-y

Sabrina Mai Nielsen, Louise Klokker + Show 4 more

Open Access

https://doi.org/10.1186/s13643-017-0458-y

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Abstract

BackgroundSpinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.MethodsWe searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.ResultsWe identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.ConclusionsIt is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.Systematic review registrationPROSPERO CRD42015030068.

Highlights

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT
SMT is included in many guidelines for primary care, such as the management of non-specific low back pain [5], and several evidence-based guidelines exist on the practice of SMT [6,7,8,9,10]
The calculations of Risk ratios (RRs) show a higher chance of a review communicating that SMT is safe, when having a higher methodological quality, compared to reviews of lower methodological quality

Summary

Introduction

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. Spinal manipulative therapy (SMT) is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its anatomic range, though a universally accepted definition does not seem to exist [1]. SMT is included in many guidelines for primary care, such as the management of non-specific low back pain [5], and several evidence-based guidelines exist on the practice of SMT [6,7,8,9,10]. Various professional groups are performing SMT including chiropractors, osteopaths and manual therapists [14]. SMT is used for a wide range of diseases and conditions with frequent indications being neck and back pain [13]

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