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Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study

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Chiropractic spinal manipulation treatment (SMT) is common for back pain and has been reported to increase the risk for lumbar disc herniation (LDH), but there is no high quality evidence about this. In the absence of good evidence, clinicians can have knowledge and beliefs about the risk. Our purpose was to determine clinicians’ beliefs regarding the risk for acute LDH associated with chiropractic SMT.


Using a belief elicitation design, 47 clinicians (16 chiropractors, 15 family physicians and 16 spine surgeons) that treat patients with back pain from primary and tertiary care practices were interviewed. Participants’ elicited incidence estimates of acute LDH among a hypothetical group of patients with acute low back pain treated with and without chiropractic SMT, were used to derive the probability distribution for the relative risk (RR) for acute LDH associated with chiropractic SMT.


Chiropractors expressed the most optimistic belief (median RR 0.56; IQR 0.39–1.03); family physicians expressed a neutral belief (median RR 0.97; IQR 0.64–1.21); and spine surgeons expressed a slightly more pessimistic belief (median RR 1.07; IQR 0.95–1.29). Clinicians with the most optimistic views believed that chiropractic SMT reduces the incidence of acute LDH by about 60% (median RR 0.42; IQR 0.29–0.53). Those with the most pessimistic views believed that chiropractic SMT increases the incidence of acute LDH by about 30% (median RR 1.29; IQR 1.11–1.59).


Clinicians’ beliefs about the risk for acute LDH associated with chiropractic SMT varied systematically across professions, in spite of a lack of scientific evidence to inform these beliefs. These probability distributions can serve as prior probabilities in future Bayesian analyses of this relationship.

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We thank Drs. Sindhu Johnson and Ivan Diamond for their assistance with the development of the belief elicitation interview and questionnaire. We acknowledge Drs. Jeremy Oakley and Anthony O’Hagan for their development and open source sharing of the SHELF elicitation framework. We thank all the clinician experts who participated in the belief elicitation interviews.

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Authors and Affiliations



CAH conceived and designed the study, acquired, cleaned and analysed the data, interpreted the results, and drafted and revised the paper. GT conceived and designed the study, analysed the data, interpreted the results, and revised the paper. PC, YRR, ARJ and JDC designed the study, interpreted the results, and revised the paper. CAH acts as guarantor.

Corresponding author

Correspondence to Cesar A. Hincapié.

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Funding sources

Canadian Institutes of Health Research [Grant ID: 200902KPD-205299-111612], and Canadian Chiropractic Research Foundation.

Conflict of interest

All authors have completed the ICMJE uniform disclosure form at (available from the corresponding author) and declare: CAH was funded by Fellowship Awards in the Area of Knowledge Translation from Canadian Institutes of Health Research [Grant ID: 200902KPD-205299-111612] and Canadian Chiropractic Research Foundation, PC is funded by a Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology; PC consults for European Spine Society, National Judicial Institute of Canada, Canadian Memorial Chiropractic College, Canadian Chiropractic Protective Association, Society of Musculoskeletal Manual Practitioners of Saskatchewan, Société des experts en évaluation médico-légale du Québec, YRR consults for Medtronic, outside the submitted work; no other relationships or activities that could appear to have influenced the submitted work. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Ethical approval

This study was approved by the research ethics board at the University Health Network (REB #11-0240-AE).

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No additional data available.

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Hincapié, C.A., Cassidy, J.D., Côté, P. et al. Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study. Eur Spine J 27, 1517–1525 (2018).

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