Evidence on effects of spinal manipulation

Chiropractic and osteopathy may be of limited help in back pain, argues Professor Edzard Ernst

The UK General Chiropractic Council defines chiropractic as a health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on nervous system function and general health.  

Misalignment or ‘subluxation’ of vertebral joints exerts pressure on nerves, which is seen as a main cause of disease. Correction of misalignment is thus viewed as a way of restoring health.  

Differing techniques  

Chiropractic spinal manipulation often entails high-velocity, low amplitude manual thrusts applied to spinal joints, which extend them slightly beyond their physiological range of motion.  

In contrast, osteopathic spinal mobilisation involves application of manual force to joints without thrust and within the normal passive range of motion.  

Back pain most frequently brings patients to consult a chiropractor or osteopath.  

Spinal mobilisation has been shown to have a number of physiological effects, such as reduction of muscle spasm and inhibition of nociceptive transmissions. It is also thought to improve joint function and alleviate pain related to spinal abnormalities.  

Chiropractors and osteo-paths attend musculoskeletal problems such as back or neck pain, but also treat asthma, cardiovascular problems, headache, infantile colic and irritable bowel syndrome.  

Practitioners take a patient’s history and conduct a physical exam, in many cases supplemented by spinal X-rays.  


A review of 39 trials found spinal manipulation improved short-term pain among patients with acute low back pain when compared with sham therapy. However, many studies specifically investigating chiropractic spinal manipulation for back pain are methodologically flawed. 

A review of four trials of chiropractic spinal manipulation for headache did not demonstrate effectiveness over controls, while a Cochrane review found that — when administered alone — spinal manipulation and mobilisation were not beneficial for neck pain.  

Researchers have found no evidence for the effectiveness of chiropractic spinal manipulation as a treatment for non-spinal pain, infantile colic, carpal tunnel syndrome, secondary dysmenorrhea or asthma.  

There is some evidence to suggest osteopathy may help lower back pain, particularly acute and subacute stages.  

The results of one small study suggested osteopathy after knee or hip arthroplasty was superior to conventional care in speeding up postoperative rehabilitation, but there was no convincing evidence that this approach was superior to standard care for treating shoulder pain or tennis elbow.  

High-velocity thrusts are contraindicated in a number of conditions. Mild and transient adverse effects of chiropractic manipulations occur in about half of patients. Adverse effects seem more frequent after chiropractic than after osteopathy.  

Risks associated with high velocity thrusts of the upper spine, which chiropractors may perform even if the patient’s problem is located in the lower back, could be considerable.  

Professor Edzard is director of complementary medicine at the Peninsula Medical School, Universities of Exeter and Plymouth

Contraindications and safety issues 

Chiropractic contraindications  

Advanced osteoporosis. 

Bleeding abnormalities. 

Malignant/inflammatory spinal disease. 

Patients on anticoagulants. 


Post-operative spinal instability. 

Cervical spondylotic myelopathy. 

Cauda equina syndrome. 

Elderly patients and those uncomfortable with close contact should use chiropractic cautiously. 

Serious adverse effects after spinal manipulation are rare but include:  

Arterial dissection and stroke (upper spinal manipulation). 

Cauda equine syndrome (lower spinal manipulation).  

Assendelft WJ, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003; 138: 871–81.  

Ernst E, Canter PH. Chiropractic spinal manipulation treatment for back pain? A systematic review of randomised clinical trials. Phys Ther Rev 2003; 8: 85–91.  

Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalalgia 2002; 22: 617–23.  

Bronfort G, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001; 24: 457–66.  

Ernst E. Chiropractic spinal manipulation for neck pain: a systematic review. J Pain 2003; 4: 417–21.  

Gross AR, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 2004; 29: 1,541–8.  

Williams NH, et al. Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care. Fam Pract 2003; 20: 662–9.

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