Is SMT Safe for Your Older Patients? An Updated Systematic Review Gives a Reassuring Answer

Safety is often the first question that comes up when treating older patients with spinal manipulation – from patients themselves, from family members, and sometimes from other healthcare providers. An updated systematic review just published in Chiropractic and Manual Therapies (2026) provides the most current answer to that question, and the findings are reassuring – with important clinical caveats that every practicing chiropractor should understand.

What the Study Found

The review screened over 2,200 titles and included 25 studies – 6 randomized controlled trials, 4 observational studies, and 15 case reports/series – capturing 412 adverse events (AEs) in older adults (55+) receiving chiropractic treatment including SMT.

The key findings by study type:

• Most common AEs overall: Mild to moderate soreness, increased pain, stiffness, numbness, fatigue, and dizziness/lightheadedness – the familiar transient reactions seen across the broader SMT literature
• RCTs: No severe or catastrophic AEs were reported in any randomized trial
• Observational studies: No catastrophic AEs were reported; in the largest dataset (61,882 patients), only 6 AEs involved adults 55 and older – all rated as mild
• Case reports: 6 severe AEs were identified, including vertebral artery dissection, epidural hematoma, atlantoaxial dislocation, and dislodged pacemaker leads – but none were catastrophic, and case reports by nature represent rare and exceptional occurrences

For context, older Medicare beneficiaries receiving chiropractic care have previously been shown to have an injury probability of 40 per 100,000 patients – compared to 153 per 100,000 for those with primary care encounters.

What This Means in Practice

This review supports a clinically confident but appropriately cautious approach to treating older adults. The absence of catastrophic AEs across RCTs and large observational studies is meaningful reassurance – but the case report findings are a useful reminder that certain comorbidities in older patients warrant heightened clinical reasoning.

The conditions that specifically increase AE risk in this population include:

• Osteoporosis — elevated fracture risk with forceful manipulation; consider lower-velocity techniques and DEXA status
• Anticoagulant use — increased bleeding risk with any musculoskeletal intervention
• Inflammatory spondylopathy — risk of dislocation
• Frailty — reduced tissue tolerance and recovery capacity
• Implanted cardiac devices — rare but documented risk with thoracic manipulation

📋 Clinical Takeaway: No catastrophic AEs were reported in RCTs or observational studies of chiropractic care in older adults. Most AEs are mild to moderate and transient. Be confident treating this population – but screen carefully for osteoporosis, anticoagulant use, frailty, inflammatory conditions, and implanted devices, as these increase AE susceptibility and warrant modified technique and thorough documentation.

This post complements our recent review on SMT efficacy in older adults with chronic spinal conditions (JCCA, 2026) – which found SMT produces outcomes comparable to other conservative care, with modest advantages for neck pain and lumbar spinal stenosis. Together, these two papers give you a complete, evidence-based picture of both the benefitsand safety profile of SMT in your older patients. [see SMT efficacy post]

This Week’s Research Review

Adverse Events Among Older Adults Receiving Chiropractic SMT and Related Treatments” — published in Chiropractic and Manual Therapies (2026), reviewed by Dr. Michael Haneline.

📄 Access the full review — including complete AE breakdowns by study type, the case report details, and clinical application guidance: [Access the review here]📚 

Or subscribe for access to the entire catalogue of new and existing reviews: [Subscription options here]

About the Author

Dr. Shawn Thistle, DC – 20+ years in clinical practice, founder of RRS Education and www.shawnthistle.com, research review and knowledge transfer specialist.