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Safety of Chiropractic Interventions: A Systematic Review

Gouveia, Liliana Olim, MD*; Castanho, Pedro, MD; Ferreira, Joaquim J., MD

doi: 10.1097/BRS.0b013e3181a16d63
Literature Review

Study Design. Systematic review of reported adverse events.

Objective. To evaluate the tolerability and safety of chiropractic procedures.

Summary of Background Data. Despite the increasing popularity of chiropractic, there are few properly designed prospective controlled trials, and there is a disproportionate lack of evaluation of its safety profile. The literature reports multiple neurologic complications of spinal manipulation, some of which are clinically relevant and even life threatening.

Methods. We performed an electronic search in 2 databases: Pubmed and the Cochrane Library for the years 1966 to 2007. All articles that reported adverse reactions associated with chiropractic were included irrespective of type of design. The outcome measures were the type of adverse events associated or attributed to chiropractic interventions and their frequency.

Results. A total of 376 potential relevant articles were identified, 330 of which were discarded after abstract or complete article analysis. The search identified 46 articles that included data concerning adverse events: 1 randomized controlled trial, 2 case-control studies, 7 prospective studies, 12 surveys, 3 retrospective studies, and 115 case reports.

Most of the adverse events reported were benign and transitory, however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations.

Conclusion. There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.

A systematic review evaluating the safety of chiropractic interventions concluded that there are insufficient data to conclude about the incidence of adverse reactions following these procedures. Adverse events induced by chiropractic interventions were frequent. Although some events could be life threatening, the majority were benign and transitory.

From the *Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal; †Department of Neurosurgery, Hospital de São José, Lisbon, Portugal; and ‡Neurological Clinical Research Unit, Institute of Molecular Medicine, Lisbon, Portugal.

Acknowledgment date: February 20, 2008. Revision date: December 1, 2008. Acceptance date: December 4, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Liliana Olim Gouveia, MD, Department of Neurology, Hospital de Santa Maria, Ave, Prof Egas Moniz, 1649–035 Lisbon, Portugal; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.