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Is there really a risk to having Osteopathic Treatment?

The short answer is that Osteopathy is really quite safe, but it isn’t completely risk free, even if the risks are incredibly small.
It’s worth remembering Captain Sir Tom Moore’s words from his posthumously released book ‘Life Lessons’, that “life itself is a risk”, so let’s have a look at some potential risks shall we?

Every day you are alive has a risk

It’s true to say that every day you walk this Earth, there is risk.
So before we get started on the official research data for Osteopathy, take a look at the table below and look at the risks you can encounter with common treatments for joint pain, and then take a look at the table below it for the list of risks you may endure day to day as a comparison. Apologies if the following data seems scary, but it’s all true and researched data, nothing here is fictional, it’s just the things that we can encounter during our day.

Taking Ibuprofen (over the counter pain relief and anti-inflammatory drug used for treating back, neck and other joint pains)1 in 4000
The best estimates available for serious patient incidents following spinal manipulation1 per 100,000 to 1,000,000 manipulations
Relative risks for common treatments for joint pain of all causes showing how safe Osteopathy really is

So how does this compare with other risks in your life?

Cause of Death in Everyday LifeRisk of Dying in Everyday Life
Heart disease1 in 6
Cancer1 in 7
Chronic lower respiratory disease1 in 27
Falling1 in 106
A Road Traffic Accident1 in 107
A Pedestrian Incident1 in 543
Being a Motorcyclist1 in 899
Drowning1 in 1,128
Fire or Smoke1 in 1,547
Choking on food1 in 2,535
Being a Cyclist1 in 3,825
Having Sunstroke1 in 8,248
Electrocution, radiation, extreme temperatures, and pressure1 in 13,394
Cataclysmic Storm1 in 58,669
Hornet, Wasp & Bee Stings1 in 59,507
Hot Surfaces & Substances1 in 63,113
Dog attack1 in 86,781
Being Struck by Lightning1 in 138,849
Note:This table is based on data for ‘Lifetime odds of death for selected causes, (United States, 2019)‘, no U.K. data readily available at time of writing.

Risks of Osteopathic Treatment

The current evidence base for risk relating to spinal manipulation includes studies from a number of different professional disciplines (e.g. chiropractic, physiotherapy, medicine as well as osteopathy); they may have different interpretations of manipulation and perform manipulations in slightly different ways but the information from these studies is still relevant to osteopathic practice (9,10,11,12)

What are the known common reactions to osteopathic treatment?

Reactions to any treatment can be described as positive, negative, physiological or psychological.

Approximately half of all manual therapy patients experience some mild to moderate short-lived reaction to treatment.  These can include, for example, a temporary increase in pain, aching after treatment, or post-treatment fatigue.

In a study of osteopathy patients, 10-20% patients reported an increase in pain or symptoms, however, 42% of those went on to make clinically significant improvements compared to base line (9). Most muscle soreness, aching and headache post treatment resolved within 24 hours.

Many patients who attend for osteopathic treatment take non-steroidal anti-inflammatory drugs (NSAIDs) to help with their symptoms.  Approximately 1 in 10 people who take NSAIDs on a daily basis experience persistent headaches (

Who is most likely to experience these common reactions?

Mild to moderate treatment reactions are more frequently reported by females after their first appointment1.

Treatment reactions can result from a range of manual therapy techniques and an increase in intensity of symptoms does not appear to be related to high velocity thrust (HVT) techniques (4).  They appear to be more common after a patient’s first treatment, and in patients presenting with multiple sites of pain (4).

What about other, more serious treatment reactions?

Symptoms that last for more than a few days that do not require medical treatment, such as increased pain or troublesome numbness or tingling are considered to be moderate treatment reactions. These types of reactions are uncommon and are estimated to occur in 1% of patients.

Reactions to treatment are serious if they require emergency medical care, or cause long term damage; they may be irreversible. Examples are stroke, nerve damage, muscular weakness, bowel and bladder weakness, or death. These would be described as a patient incident.

The best estimate for the frequency of patient incidents in osteopathy are 1 in 36,079 osteopathic treatments; these are not all associated with spinal manipulation (4).

How often do serious treatment reactions occur?

Treatment reactions can be experienced from any form of treatment whether that is medication, surgery, or non-invasive manual therapies like osteopathy.  The evidence that we have suggests that patient incidents do occur in manual therapy, including osteopathy, but they are very rare; the causal link is unclear also. The following table gives some best estimates for risk relating to spinal manipulation:

The best estimates available for serious patient incidents following manipulation are:1 per 100,000 to 1,000,000 manipulations
Major cerebrovascular insult incidents, accidents (Stroke) following cervical spine manipulation:1 in every 120,000 to 1 in every 1,666,666 
Lumbar disc herniation (commonly incorrectly referred to as a slipped disc) following manipulation:1 in every 38,013 
Cauda Equina (numbness in legs &/or loss of bowel & bladder control) following manipulation:1 in every 3.7 million to 1 in every 100million
Available To Read From NCOR

How does this compare to the risks associated with day-to-day activities?

Stroke can occur with accidental impacts, during sport and leisure activities.

Risks in day-to-day life that could be compared with the risk of serious events following osteopathic treatment are:

Death from surgery to the neck1 person in around 145 operations
Death by road traffic accident1 person per 20,000 people in any one year
Death from long-term (years) using anti-inflammatory painkillers for osteoarthritis1 person per 1,000 people
First time stroke1 person per 1,000 people in the general population in any one year
Spontaneous strokes0.03-5 person per 100,000 people in the general population over one year
Available To Read From NCOR

Some patients have indicated that they don’t like this type of comparative information.  It is provided for information purposes should you require it for your reference.

Estimated risk of serious adverse event (death) over 1 year for: Risk
Non-steroidal anti-inflammatory drugs (NSAIDs for osteoarthritis)1 in every 4000 people
Course of manipulative treatment
1 in every 400,000 people
The risk of having an adverse event with manual therapy (HVT) is less than taking medication (NSAIDs, diclofenac and amitriptyline)1 
Available To Read From NCOR

What can serious treatment reaction/patient incidents include? – please note: these are incredibly rare as you can see from reading the figures in the above tables. They are just included below because I want you to be 100% aware of even the rarest of possibilities.

Information gathered from the CROaM study identified a range of different treatment reactions and incidents.  These included:

  • Central neurological symptoms e.g. stroke.
  • Peripheral neurological symptoms e.g. disc prolapse and sciatic pain.
  • Non-specific musculoskeletal symptoms e.g. spasm.
  • Symptoms related to underlying pathology e.g. fracture due to undiagnosed metastases.
  • Fractures e.g. rib fracture.
  • Unallocated e.g. worsening of low back symptoms, which led to 3 days hospitalisation (4)


1. Carnes D, Mars T, Mullinger B, Underwood M. Adverse events in manual therapy: a systematic review. 2009. Available at:

4. Vogel S, Mars T, Keeping S, Barton T, Marlin N, Froud R, Eldridge S, Underwood M, Pincus T. Clinical Risk Osteopathy and Management Scientific Report: The CROaM Study. 2013.  Available at

9. Licciardone, J., S. Stoll, et al. (2003). “Osteopathic manipulative treatment for chronic low back pain: A randomized controlled trial.” Spine 28(13): 1355-62.

10. UK BEAM Trial team (2004). “United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.” Bmj 329(7479): 1377.

11. Licciardone, J., A. Brimhall, et al. (2005). “Osteopathic manipulative treatment for low back pain: A systematic review and meta-analysis of randomsied controlled trials.” BioMedCentral Musculoskeletal Disorders 6: 43.

12. Gross, A., J. Miller, et al. (2010). “Manipulation or mobilisation for neck pain: a Cochrane Review.” Man Ther 15(4): 315-33.

This article is available to read direct from the NCOR website.

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