Safety in osteopathy: red flags and differential diagnosis

How common are side effects?

Adverse reactions immediately after osteopathic treatment were recorded in about 2.5% of visits, mainly pain and discomfort. According to a review of manual therapy, mild or moderate, short-lived reactions are observed in about 41% of patients in observational studies and in about 22% in randomised trials. The frequency of serious events is estimated at about 0.13%.

Serious complications

Serious events are rare, but they have been described, particularly after manipulation of the neck and in patients with an undiagnosed disease. The American Heart Association recommends that patients be informed of the statistical association between neck manipulation and dissection of the cervical arteries.

Contraindications

The WHO document lists absolute and relative contraindications separately: bleeding disorders, diseases that weaken bone and connective tissue, aortic aneurysm, acute head injury, cerebral haemorrhage, acute abdominal pain, disc herniation with progressive neurological signs, cauda equina syndrome, tumours, bone infections and others. A fuller list is given in the safety section of the “What is osteopathy?” page.

Red flags

The following signs require urgent referral of the patient to a doctor:

• severe pain following trauma;
• fever;
• unexplained weight loss;
• a history of cancer;
• pain that does not ease at rest or at night;
• progressive weakness in the limbs;
• disturbance of urination or defecation;
• dizziness, double vision, speech or swallowing difficulty accompanied by neck pain;
• sudden severe headache.

International frameworks

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has developed clinical frameworks for screening for serious disease of the spine and for risks related to the vessels of the neck.

Sources

1. Degenhardt B. F. et al. (2018). Adverse reactions after osteopathic treatment. J Am Osteopath Assoc. DOI: 10.7556/jaoa.2018.033 (opens in a new window)
2. Carnes D. et al. (2010). Adverse events in manual therapy: a systematic review. Man Ther. DOI: 10.1016/j.math.2009.12.006 (opens in a new window)
3. Swait G., Finch R. (2017). The risks of spinal manipulation. Chiropr Man Therap. DOI: 10.1186/s12998-017-0168-5 (opens in a new window)
4. Biller J. et al. (2014). Cervical arterial dissection and cervical manipulation: a statement of the American Heart Association. Stroke. DOI: 10.1161/STR.0000000000000016 (opens in a new window)
5. World Health Organization (2010). Benchmarks for training in osteopathy. ISBN 978-92-4-159966-5. who.int (opens in a new window)
6. Finucane L. M. et al. (2020). Recognising serious pathology of the spine: the IFOMPT framework. J Orthop Sports Phys Ther. DOI: 10.2519/jospt.2020.9971 (opens in a new window)
7. Rushton A. et al. (2023). Assessing cervical vascular risk before manual therapy: the IFOMPT framework. J Orthop Sports Phys Ther. DOI: 10.2519/jospt.2022.11147 (opens in a new window)

This article is for educational purposes and does not replace a physician's advice.