Adverse events following thoracic spine joint manipulation: a systematic review and narrative synthesis


Thoracic spine manipulation (TSM) is recommended in clinical guidelines and widely used by practitioners for shoulder, neck and back complaints. The perceived relative safety of TSM makes this the most commonly manipulated region of the spine, yet severe adverse events (AE) have been documented. With just 40% of UK based physiotherapists using pre-TSM examination an evidence synthesis of AE is needed.

The primary aim was to report AE following TSM and secondarily to report characteristics of those affected to inform safe practice and further research.


A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42019123140).

A sensitive topic-based search strategy was designed from database inception to 1/09/18. Databases, grey literature and registers were searched using study population terms and keywords derived from scoping search.

Two reviewers independently searched information sources, assessed studies for inclusion using a priori criteria, and extracted data.

Data were tabulated to allow for semi-qualitative comparison and grouped according to AE. Per study level of evidence was evaluated using the Oxford Centre for Evidence-based Medicine (CEBM), and AE was classified using the Grades of Recommendations for each AE. Results were reported in the context of overall quality.


From 1013 studies, 19 were included, (10 single case studies, 5 case series and 4 surveys), reporting 29 unique cases of AE.

Originating from North America (n=11), Europe (n=4), Taiwan (n=2), South Africa (n=1) and New Zealand (n=1) most studies were published by emergency care physicians or neurosurgeons.

AE included spinal cord injuries (n= 19) including non-vascular (n=15) and vascular injuries (n=4), internal organ injuries (n=4) including 2 cases of hematothorax, one pneumothorax and one case of oesophageal rupture and spinal or rib fractures (n= 6).

In terms of long term outcomes 8 patients had a full recovery, 5 were left with a permanent neurological deficit, 4 died and 12 were not reported.

Therapists included chiropractors (n=14), physiotherapists (n=4), osteopaths (n=1), with 10 further reported cases not reported as attributable to a specific profession.


This is the first rigorous evidence synthesis of AE following TSM. Although thought to be rare in practice, serious AE like permanent neurological deficit are reported following TSM. Few details were provided regarding pre-manipulative examination, description of TSM technique which would be useful to inform future safe practice.


Whilst well supported as a management option TSM is not risk-free and findings from this review support the importance of high levels of clinical reasoning to inform practice involving TSM, including pre-manipulative examination.

Findings support the need for further research in order to enhance our understanding of AE reported to follow TSM, including reporting mechanisms to collect data on AE which would include accurate information on technique, patient characteristics etc.

Funding acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Additional notes

This work was presented at Physiotherapy UK 2019