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The Chiropractic Association (Singapore) statement in response to recent media focus on Thailand case reportedly involving cervical spine manipulation
PRESS RELEASE
20 December 2024
The Chiropractic Association (Singapore) statement in response to recent media
focus on Thailand case reportedly involving cervical spine manipulation
The Chiropractic Association (Singapore) [TCA(S)] has been concerned to learn of recent
media reports linking the death of a young woman in Thailand to a neck manoeuvre
allegedly carried out by a masseuse. Despite comments attributed to the Thai Minister of
Public Health confirming that the woman’s unfortunate death appears unrelated to any form
of manual therapy, reports have continued to focus on alleged “neck twisting”, raising
unfounded fears that all forms of spinal manipulation carry the risk of serious harm.
Every year in Singapore, thousands of patients here receive safe and effective chiropractic
care from TCA(S) member chiropractors, enabling them to live healthier, happier, and more
active lives. Chiropractic management may include gentle spinal manipulation and a range
of other interventions, which are recommended for spinal health by leading bodies, including
the World Health Organization (WHO), on the basis of their safety and effectiveness [1,2].
Since it was established in 1988, TCA(S) is unaware of any serious adverse events known
to have been caused by the actions of its members. In the absence of a government register
in Singapore, TCA(S) maintains a professional register of its association’s chiropractors at
TCA(S) takes matters of patient safety extremely seriously.
Its members are all graduates of internationally accredited chiropractic training programmes,
all of which meet strict standards to ensure graduates are safe and competent to practise.
Importantly, chiropractors are educated to a standard where they are qualified to obtain a
comprehensive case history, as well as perform a detailed orthopaedic and neurological examination,
with referral for further investigations (including diagnostic imaging and blood tests)
where clinically appropriate.
This comprehensive assessment ensures that contraindications to spinal manipulation, a
technique that chiropractors are highly skilled to perform, are identified. These include the
presence of bony fragility (osteoporosis), some connective tissue disorders, and other
underlying pathologies that would make the risks of manipulation outweigh the potential
benefits.
Serious adverse events from chiropractic are “reassuringly very rare”, as concluded by
numerous studies including a 2023 study which analysed outcomes of 960,140 chiropractic
spinal manipulation sessions for 54,846 patients across 30 chiropractic clinics in Hong Kong
over a 5.5-year period [3,4]. Individual case reports have associated manipulation of the
neck with cervical artery dissection and subsequent stroke, although numerous studies
published in the scientific literature have failed to identify causation [5,6,7]. This is supported
by studies showing that the forces associated with manipulation of the neck by trained
chiropractors are of insufficient magnitude to cause damage to a healthy vertebral artery [8].
Instead, experts conclude that it is more likely that patients present to chiropractors with
existing damage to the arteries which progresses irrespective of whether chiropractic
manipulation is applied, and that the incidence of this rare type of stroke was as likely to
occur following a patient visit to another healthcare practitioner as it was to a chiropractor
[9,10].
TCA(S) is a longstanding member of the World Federation of Chiropractic (WFC),
a nongovernmental organization in official relations with the WHO. In 2023, the WFC launched its
Global Patient Safety Initiative, aligning with WHO’s focus on reducing harm related to health
care interventions. The initiative monitors reported incidents, encourages national reporting
and learning initiatives, and provides advice to its national association members.
In conclusion, TCA(S) urges members of the public seeking manual therapy, including spinal
manipulation for spinal-related management, to make every effort to ensure that anyone
they consult is appropriately trained, qualified, and insured to provide safe, evidence-based
care.
References for TCA(S) Statement dated 20 December 2024
1. World Health Organization. Guidelines on basic training and safety in chiropractic. 2005.
Access here: https://iris.who.int/handle/10665/43352
2. World Health Organization. WHO guideline for non-surgical management of chronic
primary low back pain in adults in primary and community care settings. Access here:
https://www.who.int/publications/i/item/9789240081789
3. Chu E, Trager RJ, Lee L, Niazi I. A retrospective analysis of the incidence of severe
adverse events among recipients of chiropractic spinal manipulative therapy. Scientific
Reports. 2023 Jan; 13(1254). Access here: https://www.nature.com/articles/s41598-023-
28520-4
4. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic
Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence
for Causation. Cureus. 2016 Feb; 8(2):e498. Access here.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4794386/
5. Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following
cervical manipulation: the chiropractic experience. Canadian Medical Association Journal.
2001 Oct; 165(7):905-906. Access here: https://pubmed.ncbi.nlm.nih.gov/11599329/
6. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery
dissection in spinal manual-therapy: a comprehensive review. Annals of Medicine. 2019 Mar;
51(2), 118-127. Access here: https://pmc.ncbi.nlm.nih.gov/articles/PMC7857472/
7. Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of
vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare
Advantage populations. Chiropractic & Manual Therapies. 2015 Jun; 23:19. Access here:
https://pmc.ncbi.nlm.nih.gov/articles/PMC4470078/
8. Herzog W, Symons B, Leonard T. Internal forces sustained by the vertebral artery during
spinal manipulative therapy. Journal of Manipulative & Physiological Therapeutics. 2002 Oct;
25(8), 504-510. Access here: https://www.jmptonline.org/article/S0161-4754(02)00048-
9/abstract
9. World Federation of Chiropractic. Press release: Statement in response to recent media
focus on cervical artery dissection, stroke and cervical spine manipulation. 18 Jul 2022.
Access here: https://www.wfc.org/news/documents/725_cad_and_smt_2022_07_18.pdf
10. Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of
Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control
and Case-Crossover Study. European Spine Journal. 2008 Apr; 17(Suppl 1), 176-183.
Access here. https://pmc.ncbi.nlm.nih.gov/articles/PMC2271108