Editing Chiropractic (section)

=== Safety ===
[[File:Chiropractic adjustment on child.jpg|thumb|Chiropractic adjustment on children]]

The [[World Health Organization]] found chiropractic care in general is safe when employed skillfully and appropriately.<ref name=WHO-guidelines /> There is not sufficient data to establish the safety of chiropractic manipulations.<ref name=Gouveia /> Manipulation is regarded as relatively safe but complications can arise, and it has known adverse effects, risks and contraindications.<ref name=WHO-guidelines /> Absolute [[contraindication]]s to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include [[rheumatoid arthritis]] and conditions known to result in unstable joints.<ref name=WHO-guidelines /> Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include [[osteoporosis]].<ref name=WHO-guidelines /> Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to [[emergency medical services]]; these include sudden and severe headache or [[neck pain]] unlike that previously experienced.<ref name=CCA-CFCREAB-CPG>{{cite journal | vauthors = Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, Stein JG, White E | title = Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash | journal = The Journal of the Canadian Chiropractic Association| volume = 49 | issue = 3 | pages = 158–209 | year = 2005 | pmid = 17549134 | pmc = 1839918 }}<br />• {{cite journal | vauthors = Anderson-Peacock E, Bryans R, Descarreaux M, Marcoux H, Potter B, Ruegg R, Shaw L, Watkin R, White E | title = A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG | journal = The Journal of the Canadian Chiropractic Association| volume = 52 | issue = 1 | pages = 7–8 | year = 2008 | pmid = 18327295 | pmc = 2258235 | url = http://jcca-online.org/ecms.ashx/PDF/2008/2008-1/ClinicalPracticeGuidelineUpdatefromTheCCACFCREABCPG.pdf  | archive-url = https://www.webcitation.org/5sVyyGVET?url=http://jcca-online.org/ecms.ashx/PDF/2008/2008-1/ClinicalPracticeGuidelineUpdatefromTheCCACFCREABCPG.pdf | archive-date = 2010-09-05 }}</ref> Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.<ref name=Ernst-eval />

Spinal manipulation is associated with frequent, mild and temporary [[Adverse effect (medicine)|adverse effects]],<ref name=Ernst-adverse /><ref name=CCA-CFCREAB-CPG /> including new or worsening pain or stiffness in the affected region.<ref>{{cite journal |vauthors=Thiel HW, Bolton JE, Docherty S, Portlock JC | title = Safety of chiropractic manipulation of the cervical spine: a prospective national survey | journal = Spine| volume = 32 | issue = 21 | pages = 2375–78 | year = 2007 | pmid = 17906581 | doi = 10.1097/BRS.0b013e3181557bb1 | s2cid = 42353750 }}</ref> They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;<ref name=Gouveia>{{cite journal |vauthors=Gouveia LO, Castanho P, Ferreira JJ | title = Safety of chiropractic interventions: a systematic review | journal = Spine| volume = 34 | issue = 11 | pages = E405–13 | year = 2009 | pmid = 19444054 | doi = 10.1097/BRS.0b013e3181a16d63 | s2cid = 21279308 | url= http://www.chiropratiquelasource.com/recherches/safety.pdf |archive-url=https://web.archive.org/web/20160919152855/http://www.chiropratiquelasource.com/recherches/safety.pdf |archive-date=2016-09-19 |url-status=live}}</ref> adverse reactions appear to be more common following manipulation than mobilization.<ref>{{cite journal |vauthors=Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM | title = Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study | journal = Spine | volume = 30 | issue = 13 | pages = 1477–84 | date = July 2005 | pmid = 15990659 | doi = 10.1097/01.brs.0000167821.39373.c1 | s2cid = 45678522 }}</ref> The most frequently stated adverse effects are mild headache, soreness, and briefly elevated pain fatigue.<ref name=NHSChoicesChiropracticSafety>{{cite web |url=http://www.nhs.uk/Conditions/chiropractic/Pages/Safetyandregulation.aspx |title=Safety and regulation of chiropractic |publisher=[[NHS Choices]] |date=20 August 2014 |access-date=22 September 2016}}</ref> Chiropractic is correlated with a very high [[Incidence (epidemiology)|incidence]] of minor adverse effects.<ref name=Ernst-eval /> Rarely,<ref name=WHO-guidelines /> spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults<ref name=Ernst-adverse/> and children.<ref name=Vohra>{{cite journal |vauthors=Vohra S, Johnston BC, Cramer K, Humphreys K | title = Adverse events associated with pediatric spinal manipulation: a systematic review | journal = Pediatrics | volume = 119 | issue = 1 | pages = e275–83 | year = 2007 | pmid = 17178922 | doi = 10.1542/peds.2006-1392 | s2cid = 43683198 | url = http://pediatrics.aappublications.org/cgi/content/full/119/1/e275 }}</ref> Estimates vary widely for the incidence of these complications,<ref name=Gouveia /> and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.<ref name=Ernst-adverse /> Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.<ref name=Ernst-2012>{{cite journal |vauthors=Ernst E, Posadzki P | title = Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review | journal = The New Zealand Medical Journal| volume = 125 | issue = 1353 | pages = 87–140 | year = 2012 | pmid = 22522273 }}</ref> A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable.<ref name=GorrellEngel2016>{{cite journal| vauthors=Gorrell LM, Engel RM, Brown B, Lystad RP| title=The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review | journal=The Spine Journal| year= 2016 | volume= 16 | issue= 9 | pages= 1143–51 | pmid=27241208 | doi=10.1016/j.spinee.2016.05.018 | type= Systematic Review }}</ref> Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region.<ref>{{cite journal |vauthors=Hebert JJ, Stomski NJ, French SD, Rubinstein SM | title = Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases | journal = Journal of Manipulative and Physiological Therapeutics| volume = 38 | issue = 9 | pages = 677–91 | year = 2013 | pmid = 23787298 | doi = 10.1016/j.jmpt.2013.05.009 | url = http://researchrepository.murdoch.edu.au/id/eprint/15912/ }}</ref> Estimates for serious adverse events vary from 5 strokes per 100,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations, though it was determined that there was inadequate data to be conclusive.<ref name=Gouveia /> Several case reports show temporal associations between interventions and potentially serious complications.<ref name=Hurwitz-2008 /> The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished.<ref name=Ernst-death />

[[Vertebrobasilar artery stroke]] (VAS) is [[Association (statistics)|statistically associated]] with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.<ref name=Hurwitz-2008>{{cite journal |vauthors=Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S | title = Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders | journal = Spine| volume = 33 | issue = 4 Suppl | pages = S123–52 | year = 2008 | pmid = 18204386 | doi = 10.1097/BRS.0b013e3181644b1d | s2cid = 27261997 | doi-access = free }}</ref><ref>{{cite journal |vauthors=Paciaroni M, Bogousslavsky J | title = Cerebrovascular complications of neck manipulation | journal = European Neurology| volume = 61 | issue = 2 | pages = 112–18 | year = 2009 | pmid = 19065058 | doi = 10.1159/000180314 | doi-access = free }}</ref> Weak to moderately strong evidence supports causation (as opposed to statistical association) between [[cervical manipulation|cervical manipulative therapy]] (CMT) and VAS.<ref>{{cite journal |vauthors=Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM | title = Does cervical manipulative therapy cause vertebral artery dissection and stroke? | journal = [[The Neurologist|Neurologist]] | volume = 14 | issue = 1 | pages = 66–73 | year = 2008 | pmid = 18195663 | doi = 10.1097/NRL.0b013e318164e53d | s2cid = 18062970 }}</ref> There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.<ref name=Haynes>{{cite journal |vauthors=Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ | title = Assessing the risk of stroke from neck manipulation: a systematic review | journal = International Journal of Clinical Practice| volume = 66 | issue = 10 | pages = 940–47 | year = 2012 | pmid = 22994328 | pmc = 3506737 | doi = 10.1111/j.1742-1241.2012.03004.x }}</ref> While the biomechanical evidence is not sufficient to support the statement that CMT causes cervical artery dissection (CD), clinical reports suggest that mechanical forces have a part in a substantial number of CDs and the majority of population controlled studies found an association between CMT and VAS in young people.<ref name=Biller2014 /> It is strongly recommended that practitioners consider the plausibility of CD as a symptom, and people can be informed of the association between CD and CMT before administering manipulation of the cervical spine.<ref name=Biller2014>{{cite journal|last1=Biller|first1=J.|last2=Sacco|first2=R. L.|last3=Albuquerque|first3=F. C.|last4=Demaerschalk|first4=B. M.|last5=Fayad|first5=P.|last6=Long|first6=P. H.|last7=Noorollah|first7=L. D.|last8=Panagos|first8=P. D.|last9=Schievink|first9=W. I.|last10=Schwartz|first10=N. E.|last11=Shuaib|first11=A.|last12=Thaler|first12=D. E.|last13=Tirschwell|first13=D. L.|title=Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association|journal=Stroke|year=2014|doi=10.1161/STR.0000000000000016|pmid=25104849|volume=45|issue=10|pages=3155–74|doi-access=free}}</ref> There is controversy regarding the degree of risk of stroke from cervical manipulation.<ref name=Haynes /> Many chiropractors state that, the association between chiropractic therapy and vertebral arterial dissection is not proven.<ref name=Ernst-death /> However, it has been suggested that the [[causality]] between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable<ref name=Ernst-death /> or definite.<ref name=Ernst-2010>{{cite journal | author = Ernst E | title = Vascular accidents after neck manipulation: cause or coincidence? | journal = International Journal of Clinical Practice| volume = 64 | issue = 6 | pages = 673–77 | year = 2010 | pmid = 20518945 | doi = 10.1111/j.1742-1241.2009.02237.x | s2cid = 38571730 | doi-access = free }}</ref> There is very low evidence supporting a small association between internal [[carotid artery dissection]] and chiropractic neck manipulation.<ref>{{cite journal|last1=Church|first1=Ephraim W|last2=Sieg|first2=Emily P|last3=Zalatimo|first3=Omar|last4=Hussain|first4=Namath S|last5=Glantz|first5=Michael|last6=Harbaugh|first6=Robert E|title=Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation|journal=Cureus|year=2016|doi=10.7759/cureus.498|pmid=27014532|volume=8|issue=2|pmc=4794386|page=e498|doi-access=free }}</ref> The incidence of internal carotid artery dissection following cervical spine manipulation is unknown.<ref>{{cite journal |vauthors=Chung CL, Côté P, Stern P, L'espérance G | title = The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature | journal = Journal of Manipulative and Physiological Therapeutics| volume = 38 | issue = 9 | pages = 672–6 | year = 2014 | pmid = 24387889 | doi = 10.1016/j.jmpt.2013.09.005 }}</ref> The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke.<ref>{{cite journal |vauthors=Wynd S, Westaway M, Vohra S, Kawchuk G | title = The quality of reports on cervical arterial dissection following cervical spinal manipulation | journal = PLOS ONE| volume = 8 | issue = 3 | page = e59170 | year = 2013 | pmid = 23527121 | pmc = 3604043 | doi = 10.1371/journal.pone.0059170 | bibcode = 2013PLoSO...859170W | doi-access = free }}</ref> The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of [[intracranial hypotension]].<ref>{{cite journal|last1=Tuchin|first1=P.|title=A systematic literature review of intracranial hypotension following chiropractic|journal=International Journal of Clinical Practice|volume=68|issue=3|year=2014|pages=396–402|doi=10.1111/ijcp.12247|pmid=24372942|s2cid=5315779|doi-access=free}}</ref> Cervical intradural [[disc herniation]] is very rare following spinal manipulation therapy.<ref name=YangOh2016>{{cite journal|last1=Yang|first1=Hwan-Seo|last2=Oh|first2=Young-Min|last3=Eun|first3=Jong-Pil|title=Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal Manipulation Therapy|journal=Medicine|volume=95|issue=6|year=2016|page=e2797|doi=10.1097/MD.0000000000002797|pmc=4753938|pmid=26871842}}</ref>

Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and [[CT scan]]s that rely on [[ionizing radiation]].<ref name=Bussieres /> Although there is no clear evidence to justify the practice, some chiropractors still X-ray a patient several times a year.<ref name=Trick-or-Treatment/> Practice guidelines aim to reduce unnecessary radiation exposure,<ref name=Bussieres>{{cite journal |vauthors=Bussières AE, Taylor JA, Peterson C | title = Diagnostic imaging practice guidelines for musculoskeletal complaints in adults&nbsp;– an evidence-based approach&nbsp;– part 3: spinal disorders | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 1 | pages = 33–88 | year = 2008 | pmid = 18308153 | doi = 10.1016/j.jmpt.2007.11.003 | url = http://jmptonline.org/article/S0161-4754(07)00314-4/fulltext }}</ref> which increases cancer risk in proportion to the amount of radiation received.<ref>{{cite book |author=Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation: Board on Radiation Effects Research" [[U.S. National Research Council|US National Research Council]] |title=Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2 |publisher=The National Academies Press |location=Washington, DC |year=2006 |isbn=978-0-309-09156-5 |doi=10.17226/11340 }}</ref> Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based.<ref name=Ammendolia /> Although, there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease, which may contribute to chiropractic overuse of radiography for low back pain.<ref name=Ammendolia>{{cite journal |vauthors=Ammendolia C, Taylor JA, Pennick V, Côté P, Hogg-Johnson S, Bombardier C | title = Adherence to radiography guidelines for low back pain: A survey of chiropractic schools worldwide | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 6 | pages = 412–18 | year = 2008 | pmid = 18722195 | doi = 10.1016/j.jmpt.2008.06.010 }}</ref>