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01.12.2017 | Research | Ausgabe 1/2017 Open Access

Systematic Reviews 1/2017

The risk associated with spinal manipulation: an overview of reviews

Systematic Reviews > Ausgabe 1/2017
Sabrina Mai Nielsen, Simon Tarp, Robin Christensen, Henning Bliddal, Louise Klokker, Marius Henriksen
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Electronic supplementary material

The online version of this article (doi:10.​1186/​s13643-017-0458-y) contains supplementary material, which is available to authorized users.



Spinal 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.


We 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.


We 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.


It 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 registration

PROSPERO CRD42015030068.
Additional file 1: Protocol for the overview. (PDF 283 kb)
Additional file 2: PRISMA harm checklist. (PDF 28 kb)
Additional file 3: Search strategy. (PDF 179 kb)
Additional file 4: Reference lists for the excluded reviews. (PDF 365 kb)
Additional file 5: Reference lists for the included reviews in the overview. (PDF 177 kb)
Additional file 6: Table showing further study characteristics including conclusions extracted from each reviews. (PDF 416 kb)
Additional file 7: Table showing which studies the estimates for the incidence of SAEs are based on. (DOCX 25 kb)
Additional file 8: Table showing the calculations of RRs of having the opinion that spinal manipulative therapy is safe or harmful, respectively, if a ‘yes’ was obtained in the individual AMSTAR items, for the 33 reviews, whose objective was to investigate adverse events. (PDF 186 kb)
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