Is spinal manipulation safe?
Spinal Manipulation is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal complaints. Although chiropractic has an excellent safety record, no health treatment is completely free of potential adverse effects.
Common Side Effects/Complications include (1,2):
Reactions most commonly reported are local soreness/discomfort (53%), headaches (12%), tiredness (11%), radiating discomfort (10%), dizziness, the vast majority of which resolve within 48 hours.
Rare Side Effects/Complications include (3,4):
Fractures or joint injuries in isolated cases with underlying physical defects, deformities or pathologies.
Burns due to some physiotherapy procedures (heat, therapeutic ultrasound, laser, etc).
Cauda equina Syndrome (2) (1 case per 100 million adjustments).
Vertebrobasilar artery (VBA) stroke (1 case per 400,000 to 1 million cervical spine adjustments [manipulations]).
Many patients feel immediate relief following spinal manipulation and other therapies, however the local soreness/discomfort felt after manipulation feels similar to post-exercise soreness and generally resolves within 24-48 hours.
A recent study has found that patients presenting with neck pain, stiffness of the neck and/or headache (all potential symptoms of a stroke in progress) had a stroke whether they saw a medical doctor or a chiropractor. The neck pain and headache symptoms are due to artery dissection (tearing of the inner layer of the artery). When the dissection occurs, it is only a matter or time until you have a stroke and therefore it can happen whether you visit a chiropractor's office or your primary care physician (3).
There are no orthopedic test (tests utilized prior to treatment to aid in diagnosis) that can determine if a patient is at risk for dissection.
The current "standard of care" to be suspicious of a dissection or stroke in progress includes identifying the 5Ds And 3Ns along with the neck pain and/or headache.
5Ds: Dizziness, Double Vision, Dysarthria (difficulty articulating your words), Dysphagia (difficulty swallowing) and Drop Attacks (sudden falls)
And: Ataxia (altered walking, loss of balance while walking, etc)
3Ns: Numbness (recent onset of numbness along with your headache), Nausea, and Nystagmus (abnormal eye movements)
Another telling indicator for the Primary Spine Practitioner is the presence of a headache that the patient describes as, "Unlike anything I've ever felt before." Therefore, if you are visiting your Primary Spine Practitioner with upper-neck pain or headache, be very specific about your symptoms. This will help your Primary Spine Practitioner offer the safest and most effective treatment, even if it involves referral to another health care provider.
The risk of stroke is a very real risk that should be discussed with your Primary Spine Practitioner prior to the initiation of spinal manipulation. Every medical procedure comes with a list of potential side effects and complications, spinal manipulation is no different.
For more information from another perspective please see
It is important for patients to understand the risks associated with some of the most common treatments for musculoskeletal pain -- prescription and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS) -- as these treatments may carry risks significantly greater than those of chiropractic manipulation. According to a study from the American Journal of Gastroenterology, approximately one-third of all hospitalizations and deaths related to gastrointestinal bleeding can be attributed to the use of aspirin or NSAID painkillers like ibuprofen (5).
Keep in mind that if you are concerned about the risk of stroke associated with high velocity, low amplitude manipulation that there other viable treatment available for the treatment of your neck pain.
1. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine. Oct 1 2007;32(21):2375-2378; discussion 2379.
2. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J Manipulative Physiol Ther. Jul-Aug 2007;30(6):408-418.
3. Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. Feb 15 2008;33(4 Suppl):S176-183.
4. Boyle E, Cote P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine. Feb 15 2008;33(4 Suppl):S170-175.
5. Wilcox C, Allison , Benzuly K, et al. Consensus Development Conference on the Use of Nonsteroidal Anti-Inflammatory Agents, Including Cyclooxygenase-2 Enzyme Inhibitors and Aspirin. Clinical Gastroenterology and Hepatology. Sept 2006;Volume 4, Issue 9 , Pages 1082-1089.e4.