Thoracic adverse events following spinal manipulative therapy: a systematic review and narrative synthesis

ABSTRACT

Objectives: Spinal manipulative therapy (SMT) is widely used by manual therapists to manage spinal complaints. Notwithstanding the perceived relative safety of SMT, instances of severe thoracic adverse events (AE) have been documented. An evidence synthesis is required to understand the nature, severity and characteristics of thoracic AE following all SMT. The primary objective of this study was to report thoracic AE following SMT and secondly to report patient characteristics to inform further research for safe practice.

Methods: A systematic review and data synthesis were conducted according to a registered protocol (PROSPERO CRD42019123140). A sensitive topic-based search strategy for key databases, gray literature and registers used study population terms and keywords, to search to 12/6/19. Two reviewers were involved at each stage. Using the Oxford Center for Evidence-based Medicine (CEBM) the level evidence was evaluated with grade presented for each AE. Results were reported in the context of overall quality.

Results: From 1013 studies identified from searches, 19 studies (15 single case studies and 4 case series) reporting 21 unique thoracic AE involving the spinal cord tissues [nonvascular (n = 7), vascular (n = 6)], pneumothorax or hemothorax (n = 3), fracture (n = 3), esophageal rupture (n = 1), rupture of thoracic aorta (n = 1), partial pancreatic transection (n = 1). Reported outcomes included fully recovery (n = 8), permanent neurological deficit (n = 5), and death (n = 4).

Conclusion: Although causality cannot be confirmed, serious thoracic AE to include permanent neurological deficit and death have been reported following SMT. Findings highlight the importance of clinical reasoning, including pre-thrust examination, as part of best and safe practice for SMT.

KEYWORDS:

• Spinal manipulative therapy
• thoracic
• adverse events
• systematic review

Disclosure statement

No potential conflict of interest was reported by the authors.

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Additional information

Notes on contributors

Nicola R. Heneghan

Nicola R. Heneghan is a Senior Lecturer in Musculoskeletal Rehabilitation Sciences in the Centre of Precision Rehabilitation for Spinal Pain, University of Birmingham, UK. Nicola has a strong research profile, with >£1M career funding, >65 publications in high impact journals, several invited international keynote presentations and >90 conference presentations. Nicola has previously held key positions within the Musculoskeletal Association of Chartered Physiotherapists (UK) which recognises her expertise and contribution to musculoskeletal physiotherapy research/education in the UK.

Ciprian Pup

Ciprian Pup is an experienced physiotherapist who is specialised in the treatment of musculoskeletal conditions. He is currently working for Healthshare Oxfordshire and is the head of physiotherapy at Oxford Harlequins Rugby Football Club. He was graduated from the West University of Timisoara with BSc in Physiotherapy and the University of Birmingham in 2019 with an MSc in Advanced Manipulative Physiotherapy. This article reports on work conducted as his Master's dissertation.

Konstantinos Koulidis

Konstantinos Koulidis is a senior Physiotherapist, currently working at the Royal Orthopaedic Hospital of Birmingham, as well as an academy physiotherapist at Birmingham City Football Club. He graduated from the Alexander Technological Educational Institute of Thessaloniki (with a BSc in Physiotherapy) and the University of Birmingham in 2016 with an MSc in Advanced Manipulative Physiotherapy. Konstantinos is a published author and a teaching fellow at the Royal Orthopaedic Hospital.

Alison Rushton

Alison Rushton is Reader in Musculoskeletal Rehabilitation Sciences in the Centre of Precision Rehabilitation for Spinal Pain, University of Birmingham, UK. Alison has a strong research profile, with £426K active funding, >£1.6M previous funding, £10M research centre funding, £1M internal investment, >125 publications in high impact journals, multiple invited international keynote presentations and >140 conference presentations. Alison has been awarded fellowships from the Chartered Society of Physiotherapy and Musculoskeletal Association of Chartered Physiotherapists (UK) for national/international contribution to musculoskeletal physiotherapy research/education.