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Spinal Manipulation: What You Need To Know

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What is spinal manipulation? 

  • Spinal manipulation is also called spinal manipulative therapy. It’s a technique where practitioners use their hands or a device to apply a controlled thrust (that is, a force of a specific magnitude or degree in a specific direction) to a joint of your spine. The amount of force can vary, but the thrust moves the joint more than it would on its own. Spinal manipulation is different from spinal mobilization, which doesn’t involve a thrust (and is performed within a joint’s natural range of motion and can be controlled by the patient).
  • Most spinal manipulations are done by chiropractors (chiropractic treatment often involves spinal manipulation), although other licensed professionals including osteopathic physicians and physical therapists also do spinal manipulations. 
  • Spinal manipulation is one of the most common complementary health approaches used by adults and children in the United States, the 2012 National Health Interview Survey (NHIS) showed. 
  • For more information on what chiropractors do, see the National Center for Complementary and Integrative Health (NCCIH) webpage Chiropractic.

Why do people use spinal manipulation?

Among U.S. adults who used chiropractic or osteopathic manipulation, about 67 percent used it to treat a specific health condition, and 53 percent used it for wellness, the 2012 NHIS found. Specifically: 

  • 43 percent used it for general wellness or disease prevention 
  • 25 percent used it because it focuses on the whole person—their mind, body, and spirit 
  • 16 percent used it for improved energy 
  • 11 percent used it for better immune function 
  • 5 percent used it to improve memory or concentration.

Previous research found that people report positive experiences and reduced pain as a result of receiving spinal manipulation, the NHIS authors noted.

Who uses spinal manipulation and has usage changed?

Between 2012 and 2017, U.S. adults’ use of chiropractic care (which usually involves spinal manipulation) during the past year increased slightly, from 9.1 percent to 10.3 percent, a comparison of NHIS data from the two years showed. The data also show that women were more likely than men to see a chiropractor, and that adults between the ages of 45 and 64 were more likely than people aged 18-44 or 65 and over to have visited one during the past year. According to the same national survey (by the Centers for Disease Control and Prevention’s National Center for Health Statistics), non-Hispanic white adults were much more likely to visit a chiropractor (12.7 percent) than Hispanic (6.6 percent) or non-Hispanic black (5.5 percent) adults. 

Among children, there was no significant difference in the use of chiropractic care between 2012 and 2017 (3.5 percent versus 3.4 percent). Older children (age 12 to 17) were more likely than younger ones (age 4 to 11) to have seen a chiropractor, but there was no significant difference in the use of chiropractic care between girls and boys. Non-Hispanic white children were more likely than non-Hispanic black or Hispanic children to have seen a chiropractor.

What are some of the pain conditions for which spinal manipulation has been used?

For Sciatica

  • 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.

For Low-Back Pain

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 Neck Pain

  • 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 Headache

  • 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.

For Other Conditions

  • 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.

Is spinal manipulation safe?

Spinal manipulation is relatively safe when performed by a trained and licensed practitioner. The most common side effects of spinal manipulation are temporary muscle soreness, stiffness, or a temporary increase in pain. 

Serious complications, deaths, and delays in diagnosis of serious illnesses have been associated with spinal manipulation, including in children, but are very rare.

Strokes and Artery Tears

  • 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.

Spinal Manipulation and Pregnancy

  • 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.

NCCIH-Funded Research

NCCIH-supported studies have been investigating:

  • The clinical impact spinal manipulation/chiropractic may have on chronic low-back pain in U.S. veterans
  • How spinal manipulation compares with prescription drug therapy for long-term management of chronic low-back pain in older adults
  • How to optimize spinal manipulation treatment protocols for patients with low-back pain
  • Patients’ experiences and satisfaction with chiropractic care for chronic neck pain
  • How to best provide chiropractic care for veterans with musculoskeletal pain and mental health disorders.

More to Consider

  • In a 2017 clinical practice guideline, the ACP suggested that spinal manipulation remains a recommended treatment option for chronic low-back pain, saying that it is one of several options that show some evidence of effectiveness. 
  • For information on finding a chiropractor, see the NCCIH webpage How To Find a Complementary Health Practitioner.
  • Before selecting a chiropractor:
    • Ask about the chiropractor’s education and licensure. 
    • Tell the chiropractor about all of your medical conditions. 
    • Ask if the chiropractor has specialized training or experience treating your condition. 
    • Ask about how many sessions you’ll need and typical out-of-pocket costs and insurance coverage. (Medicare Part B covers manual manipulation of the spine if it is determined to be medically necessary.) For more information, see NCCIH’s fact sheet Paying for Complementary and Integrative Health Approaches
    • Tell the chiropractor about any medications (prescription or over-the-counter) and dietary supplements you take. If the chiropractor suggests a dietary supplement, ask about potential interactions with your medications or other supplements.
  • Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

For More Information

NCCIH Clearinghouse

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 
1-888-644-6226
TTY (for deaf and hard-of-hearing callers): 
1-866-464-3615

PubMed®

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed.

National Institute of Neurological Disorders and Stroke (NINDS)

NINDS conducts and supports research on how the brain and nervous system function and on treatments for neurological diseases.

Toll-free in the U.S.: 
1-800-352-9424

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The mission of NIAMS is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases.

Toll-free in the U.S.: 
1-877-22-NIAMS

MedlinePlus

To provide resources that help answer health questions, MedlinePlus (a service of the National Library of Medicine) brings together authoritative information from the National Institutes of Health as well as other Government agencies and health-related organizations.

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Key References

Other References

  • Beliveau PJH, Wong JJ, Sutton DA, et al. The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropractic & Manual Therapies. 2017;25:35.
  • Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4–17 years in the United States: National Health Interview Survey, 2007–2012. National health statistics reports; no 78. Hyattsville, MD: National Center for Health Statistics. 2015.
  • Bronfort G, Hondras MA, Schulz CA, et al. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Annals of Internal Medicine. 2014;161(6):381-391.
  • Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2017;166:493-505.
  • Chung CL, Côté P, Stern P, et al. The association between cervical spine manipulation and carotid artery dissection: a systematic review of the literature. Journal of Manipulative and Physiological Therapeutics. 2015;38(9):672-676.
  • Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States, 2002–2012. National health statistics reports; no 79. Hyattsville, MD: National Center for Health Statistics. 2015.
  • Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews. 2012;(12):CD004796. Accessed at www.cochranelibrary.com on August 13, 2018. 
  • Fritz JM, Magel JS, McFadden M, et al. Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial. JAMA. 2015;314(14):1459-1467.
  • Huang T, Shu X, Huang YS, et al. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2011;(12):CD005230. Accessed at www.cochranelibrary.com August 13, 2018. 
  • Levi JR, Brody RM, McKee-Cole K, et al. Complementary and alternative medicine for pediatric otitis media. International Journal of Pediatric Otorhinolaryngology. 2013;77(6):926-931.
  • Stuber KJ, Wynd S, Weis CA. Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. Chiropractic & Manual Therapies. 2012;20:8.
  • Tamburrelli FC, Genitiempo M, Logroscino CA. Cauda equina syndrome and spine manipulation: case report and review of the literature. European Spine Journal. 2011;20 Suppl 1:S128-131.
  • Wearing J, Beaumont S, Forbes D, et al. The use of spinal manipulative therapy in the management of chronic obstructive pulmonary disease: a systematic review. Journal of Alternative and Complementary Medicine. 2016;22(2):108-114.

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Acknowledgments

NCCIH thanks Helene Langevin, M.D., David Shurtleff, Ph.D., Lanay Mudd, Ph.D., and Merav Sabri, Ph.D. NCCIH, for their review of the 2019 update of this publication. 

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCIH has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCIH.

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NCCIH Pub No.: 
D409
Last Updated: 
July 2019

This page last modified August 08, 2019