Spinal Manipulation: What You Need To Know

• Sciatica is pain associated with the sciatic nerve, which controls muscles in the back of the knee and the lower leg; it also provides feeling to the back of the thigh, part of the lower leg, and the sole of the foot.
• Manipulation isn’t widely used to treat sciatica but it may help, a 2015 research review of a variety of sciatica treatments suggests. However, the studies had many limitations, the authors noted.
• In a 2014 study of 192 people with leg pain associated with back pain, participants who received spinal manipulation, personal instruction, and exercises had less pain after 12 weeks and used less medication a year later than participants who received only personal instruction and exercises. However, leg pain was the same for both groups after 1 year.

Many noninvasive treatments are available for low-back pain, and these include drugs and nondrug options. In its 2017 clinical guidelines, the American College of Physicians (ACP) suggests that spinal manipulation is one of a number of therapeutic options that may help people with acute or chronic low-back pain (although the ACP says the quality of the evidence is low).

• Spinal manipulation was better than placebo for immediate, short-term relief from acute or subacute low-back and neck pain, a 2010 research review concluded. Manipulation was also better than acupuncture for chronic low-back pain. However, the results of studies comparing spinal manipulation to massage, medication, or physical therapy were mixed.
• A 2011 review of 26 studies concluded that for chronic low-back pain, spinal manipulation works as well as other commonly recommended approaches, including exercise or physical therapy. However, the effect on pain was minimal.
• Twelve sessions of spinal manipulation may be the best “dose,” according to a 2014 NCCIH-funded study of 400 people with chronic low-back pain.
• In a 2014 study of 110 participants with chronic low-back pain, those who received spinal manipulation had less sensitivity to painful stimuli right after getting spinal manipulation, compared to people who got sham spinal manipulation. But after a couple of weeks the two groups had similar amounts of pain and disability, the study showed. The study was supported by NCCIH.
• The Agency for Healthcare Research and Quality (AHRQ) systematic review of noninvasive nonpharmacologic treatment for chronic pain reported that spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in the short term (i.e., 1-6 months following treatment) and intermediate term (i.e., 6-12 months). The report concluded the strength of the evidence was low. In addition, the report concluded that there was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain, but manipulation was associated with slightly greater effects than controls on intermediate-term pain. The standard of evidence was considered low for short-term effects and moderate for intermediate-term effects.
• The research on spinal manipulation for acute low-back pain is generally mixed and has many limitations.
  • Spinal manipulation is no more effective for acute low-back pain than sham (fake) spinal manipulation, or when added to another treatment such as standard medical care, a 2012 research review of 20 studies found. Spinal manipulation appeared to be safe when compared to other treatment options.
  • In a 2015 study of 220 people with acute low-back pain, participants who received physical therapy, which included spinal manipulation, fared no better than those who received standard care.
  • However, a 2015 NCCIH-funded study of 107 adults with recent-onset acute and subacute low-back pain found that those receiving spinal manipulation got greater short-term relief, compared to participants getting standard medical care. Furthermore, the study compared two different techniques—manual thrust manipulation (MTM) and mechanical assisted manipulation (MAM)—and found MTM led to greater short-term reductions in self-reported pain and disability than MAM or usual care.
  • A 2017 analysis examined data from 15 randomized controlled trials with almost 1,700 participants. The researchers concluded that spinal manipulative therapy can modestly improve pain and function in people with acute low-back pain.
• Results of a 2018 study with 750 active duty U.S. military personnel with low-back pain found that those who received chiropractic care in addition to usual care had better short-term improvements in low-back pain intensity and pain-related disability than those who only received usual medical care.

• For patients with acute neck pain, either spinal manipulation or home exercises appeared to be more effective than medication in the short and long term, an NCCIH-funded study of 272 patients showed in 2012. A 2015 research review that looked at results from 51 trials with 2,920 participants also reported that there’s weak evidence that spinal manipulation may provide short-term relief from acute or chronic neck pain.

• For preventing migraines, spinal manipulation may be one of several complementary health approaches (including massage therapy) that’s as helpful as medications used for migraine prevention, but the research isn’t conclusive.
• The AHRQ systematic review of noninvasive nonpharmacologic treatment for chronic pain reported spinal manipulation therapy was associated with slight to moderate improvements in function compared to usual care on the Headache Impact Test and the Headache Disability Inventory (scale 0-100) and in pain over the short term (i.e., 1-6 months) in one trial. The standard of evidence was rated as low.

• Researchers have studied spinal manipulation for many other conditions, including fibromyalgia, children’s ear infections, chronic obstructive pulmonary disease (COPD), infant colic, and bedwetting, but there’s too little evidence to know if it helps with these problems.
• Spinal manipulation doesn’t help with asthma, hypertension, or menstrual pain, studies show.

• A type of spinal manipulation that focuses on the neck has been linked to small, potentially dangerous tears in the artery walls in the neck, called cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.

• There are few reports of spinal manipulation causing problems during pregnancy or in the period after childbirth, a 2012 research review reported. The problems that have been reported ranged from mild, temporary pain to life-threatening injuries. Serious adverse events occurred only after cervical spinal manipulation.