Adverse events among older adults receiving chiropractic spinal manipulation and related treatments: an updated systematic review.

backgroundThis systematic review updated adverse events (AEs) reporting in persons aged > 55 years who received chiropractic treatment, including spinal manipulation.

methodsProtocol was registered prospectively with the Prospective Register of Systematic Reviews (PROSPERO)(CRD42024629286). Search strategy was audited with Peer Review of Electronic Search Strategies (PRESS) methodology. We searched PubMed, Cochrane Central Register of Controlled Trials, CINAHL, AMED, and Index to Chiropractic Literature on December 12, 2025. We included AEs attributed to treatment provided by chiropractors reported in randomized clinical trials (RCTs), observational studies, and case reports/series. We excluded non-clinical, pilot/feasibility studies, surveys, reviews, populations ≤ 55 years,and papers lacking chiropractic treatment or AE descriptions. Articles were screened and results synthesized by study design and AE characteristics. Study risk of bias (RoB) was assessed in duplicate using Scottish Intercollegiate Guideline Network checklists. Clinical Compass and NCMIC Foundation partially funded this study.

resultsWe screened 2295 titles/abstracts, reviewed 125 full-text, and included 25 articles from 6 RCTs, 4 observational studies, and 15 case reports/series. One RCT had low RoB and five acceptable. Three observational cohorts had low RoB and 1 had acceptable. There were 412 study-related adverse events affecting older adult patients, of which 9 were severe, and none were catastrophic. Most adverse events were rated as mild-to-moderate in severity. Reported adverse events consisted of changes in pain quality, muscle or joint soreness or stiffness, numbness, weakness, fatigue, headache, dizziness, or lightheadedness. Several studies lacked AE definitions and/or data collection processes. Case reports described 6 severe AEs; four were vascular in nature. Twenty case reports involved spinal manipulation, one followed TENS application, and one repetitive shoulder abduction, while no case reports described AEs following chiropractor treatment with soft tissue techniques, exercise, or other modalities.

conclusionNo catastrophic AEs were reported in older adults receiving chiropractic treatment services. Mild-to-moderate symptoms such as muscle soreness and stiffness were common. The lack of standardized AE definitions, severity classifications, and data collection processes across reports limits the certainty. Notable study limitations included a search strategy focused on spinal manipulation, exclusion of administrative database studies that may detect rare AEs, and numerical scoring of RoB checklists.