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J R Soc Med. 2007 October; 100(10): 445.
PMCID: PMC1997266

Adverse effects of spinal manipulation

Ann Moore, Professor

The National Council for Osteopathic Research (NCOR) welcomes Professor Ernst's interesting paper1 concerning safety and spinal manipulation (JRSM 2007;100:330-338). This is a topic taken very seriously by all osteopaths.

Unfortunately, the term ‘adverse event’ does have negative connotations and wasn't clearly defined; minor increases in soreness are an anticipated treatment response experienced by many patients following examination and treatment when provocation tests are used routinely to reach an accurate diagnosis. A serious adverse event could be viewed more accurately as a reaction requiring urgent medical intervention.

Spinal manipulation is described as being of ‘unproven effectiveness’ compared with non-steroidal anti-inflammatories (NSAIDs) but, unfortunately, some more recent high-quality work seems to have been overlooked.2,3 While it is true that spinal manipulation is not currently subject to post-marketing surveillance, osteopaths are developing a standardized data collection tool, through NCOR, to gather long-term prospective data concerning all responses to osteopathic treatment.

Risks associated with spinal manipulation are not a new phenomenon to osteopaths. Pre-manipulative screening is routinely used, although this is not without difficulties; recent work published in the International Journal of Osteopathic Medicine reviewed the literature to highlight risk factors for spinal manipulation.4

Osteopaths are currently funding a series of research proposals, through the General Osteopathic Council, investigating safety related to osteopathic treatment (call announced 20 February 2007). This information will allow osteopaths to fulfil the mandatory requirement of obtaining informed consent prior to examination and treatment.5 The areas of current investigation include:

  • Adverse events associated with physical interventions in osteopathy and relevant manual therapies;
  • Communicating risk and obtaining consent in osteopathic practice;
  • Insurance claim trends and patient complaints to the profession's regulator;
  • Investigating osteopaths' attitudes to managing and assessing risk in clinical settings and patients' experiences and responses to osteopathic treatment.

Patient safety remains of paramount importance to practising osteopaths.


Competing interests AM is Chair of the NCOR.


1. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007;100: 330-338 [PMC free article] [PubMed]
2. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskeletal disorders 2005;6: 43. [PMC free article] [PubMed]
3. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic recurrent headache. Cochrane Database of Systematic Reviews 2004;3:CD001878 [PubMed]
4. Gibbons P, Tehan P. HVLA thrust techniques: what are the risks? Int J Osteopath Med 2006;9: 4-12
5. General Osteopathic Council. Fitness to Practise Guidelines. London: May 2005

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press