Chiropractic, Spinal Manipulation, Spinal Manipulation

There's evidence chiropractic may treat back and neck pain, but what about chiropractic treatment of phobias, addiction, ADHD and other psychiatric disorders?

Before engaging in any complementary medical technique, you should be aware that many of these techniques have not been evaluated in scientific studies. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

• Background
• Theory
• Evidence
• Unproven Uses
• Potential Dangers
• Summary
• Resources

Background

Chiropractic focuses on the relationship between musculoskeletal structure (primarily the spine) and bodily function (primarily nervous system function) and on how this relationship affects the maintenance or improvement of health. Chiropractors use multiple therapeutic techniques. Chiropractic encompasses spinal manipulative therapy, diet, exercise, X-rays, and other therapeutic techniques such as interferential and electrogalvanic muscle stimulation.

Spinal manipulative therapy (or spinal manipulation) — a method of adjusting the spinal cord using hand pressure, twists and turns — is broad and includes many types of techniques, including those used by chiropractors.

History: Rotation or movement of the spine plays a role in many healing traditions. Records of the use of spinal manipulative therapy date to ancient Chinese and Greek medicine.

The principles of modern chiropractic stem from the work of David Daniel Palmer in the late 1800s. Palmer believed that abnormal nerve function can cause medical disorders. He theorized that adjustment of the spine can improve health. Initially, Palmer's principles were not well received in the medical community, and some early chiropractors were imprisoned (including Palmer himself). A divide between chiropractors and medical doctors culminated in a successful antitrust lawsuit against the American Medical Association for bias against the chiropractic profession (1977-1987). Divisions have also existed in the chiropractic community regarding the extent to which chiropractic should be integrated with other health care fields.

Medicare has reimbursed for chiropractic since 1972. The Council on Chiropractic Education (CCE) adopted national standards in 1974, which are now recognized by the U.S. Department of Education.

Since 1975, the CCE has accredited all U.S. chiropractic colleges. Currently, all 50 U.S. states have statutes recognizing and regulating the practice of chiropractic. There are more than 60,000 licensed chiropractors in the United States, a number expected to reach 100,000 by 2010.

Techniques: Most visits to chiropractors are for musculoskeletal complaints, and almost half are for back pain. Clients usually lie facedown on a Cox table, which is similar to a massage table with an open space in which to place your face. Visits may last 15 minutes to one hour depending on the technique used. Chiropractors may see clients up to three times per week at first, then less frequently over time.

There are more than 100 chiropractic and spinal manipulative adjusting techniques, and practitioners may vary in their approaches. Techniques taught widely in chiropractic schools include:

• Diversified
• Extremity adjusting
• Activator
• Gonstead
• Cox flexion-distraction
• Thompson

Other techniques are taught outside of the established curriculum.

Diagnostic procedures such as X-ray, computed tomography, magnetic resonance imaging and thermography may be used, followed by treatment with ice packs, heat packs, electrical current or ultrasound therapy. Dietary counseling and nutritional support, plus exercise recommendations, may be offered.

Spinal manipulative therapy uses various techniques to apply force to an area of the spine or to a joint. Massage or mobilization of soft tissue is used in techniques such as myofascial trigger point therapy, cross-friction massage, active release therapy, muscle stripping or Rolfing® structural integration. Mechanical traction or the use of external resistance on an area of the spine or on an extremity may be used in certain people.

Theory

There are a number of traditional and scientific theories about the mechanism of action and potential health benefits of chiropractic and spinal manipulative therapy. However, the underlying effects of these therapies on the body are largely unknown.

Traditional hypotheses suggest that changes in normal relationships between the bones of the spine (vertebral bodies) or joints can result in health problems and that manipulation of these areas may correct these changes and improve function. There are more recent theories that nerve damage or compression, muscle spasm, soft-tissue adhesions or release of toxic chemicals from damaged soft tissues can be caused by abnormal spine or joint positioning, which can be improved with manipulation. Scientific research is limited in these areas.

Scientific studies in animals and humans report that abnormal positioning of the spine can alter the function of nerves coming from the spine and may alter heart rate and blood pressure. It is controversial whether spinal manipulative therapy affects the release of chemicals that influence pain and pleasure sensations, such as substance P and endorphins.

Evidence

Scientists have studied chiropractic and spinal manipulative therapy for the following health problems:  

Tension headache, migraine headache
There are several studies of chiropractic techniques or spinal manipulative therapy in humans for the relief of tension or migraine headache. Although most of this research is not well designed, overall the evidence does suggest some benefits for prevention of episodic tension headaches. Effects on migraine headaches have not been shown. Better-quality research is necessary to make a strong conclusion. Patients should be aware of the safety concerns about the use of cervical or neck manipulation before starting this type of therapy.

Low back pain
There are more than 400 published studies and case reports about the use of chiropractic manipulation in patients with low back pain. Results are variable, with some studies reporting benefits, and others suggesting no effects. Although most research is not well designed or reported, the available scientific evidence overall suggests improvements in pain in patients with subacute or chronic low back pain. However, it is not clear that there are any benefits in patients with acute low back pain. Better-quality research is necessary to make a definitive conclusion.

Lumbar disk herniation
Multiple studies have examined the effects of spinal manipulative therapy in patients with herniated lumbar disks. Results are variable, with some studies reporting benefits, and others finding no effects. Better-quality research is necessary to make a clear conclusion.

Neck pain
Multiple studies have examined the effects of spinal manipulative therapy in patients with acute or chronic neck pain. Overall, the quality of studies has been poor. Better-quality research is necessary to make a clear conclusion.

Asthma
There are several studies of the effects of chiropractic spinal manipulative therapy on breathing and quality of life in children and adults with asthma. However, because of weaknesses in this research, no clear conclusions can be drawn.

Carpal tunnel syndrome
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with carpal tunnel syndrome.

Cervical disk herniation
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with cervical disk herniation.

Chronic obstructive lung disease
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with chronic obstructive lung disease.

Chronic pelvic pain
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with chronic pelvic pain. Duodenal ulcers Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with ulcers.

Dysmenorrhea (painful menstruation)
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with dysmenorrhea.

Fibromyalgia
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with fibromyalgia.

High blood pressure
The effects of spinal manipulative techniques on blood pressure are controversial. There are many published studies and reviews in this area. Overall, the existing research is unclear. Better research is necessary to draw a clear conclusion. However, patients with low blood pressure or taking medications that may lower blood pressure should use caution because of a risk of additional decreases in blood pressure with manipulative therapies.

HIV/AIDS
Because there are a limited number of studies in humans and weaknesses in existing research, the effects of chiropractic techniques on CD4 count or quality of life in patients with HIV/AIDS is unclear.

Colic
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in infants with colic.

Jet lag
Early research suggests that chiropractic manipulation may not be helpful for the prevention of jet lag. However, because there are a limited number of studies in humans and weaknesses in existing research, the effects of chiropractic are unclear.

Nocturnal enuresis (bed-wetting)
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people who experience nocturnal enuresis.

Otitis media
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in patients with otitis media.

Parkinson's disease
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with Parkinson's disease.

Phobias
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with phobias.

Pneumonia
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with pneumonia.

Premenstrual syndrome
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with premenstrual syndrome.

Respiratory tract infections
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with respiratory tract infections.

Seizure disorders
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people who experience seizures.

Shoulder pain
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with shoulder pain.

Sprained ankle
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with ankle sprains.

Temporomandibular joint disorders
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with temporomandibular joint disorders.

Visual field loss
Because there are a limited number of studies in humans and weaknesses in existing research, it is unclear if chiropractic techniques are beneficial in people with visual field loss.

Whiplash injuries
Despite promising preliminary results, there is not enough reliable scientific evidence to draw firm conclusions about the effects of chiropractic techniques in patients with whiplash injuries.

Tennis elbow
Preliminary evidence suggests that manipulation of the wrist may be effective for the management of tennis elbow. Additional study is warranted before a conclusion can be made.

Unproven Uses

Chiropractic and spinal manipulative therapy have been suggested for many other uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially life-threatening. Consult with a health care provider before using chiropractic or spinal manipulative therapy for any use.

Potential Dangers

The safety of chiropractic techniques and spinal manipulative therapy is controversial. The most common side effects are thought to be discomfort in the area of treatment, stiffness, headache, and fatigue. These symptoms may occur in more than half of people undergoing spinal manipulation.

There is scientific evidence that cervical spine or neck manipulation increases the chances of having a stroke. There are numerous published cases of stroke associated with cervical spine manipulation, affecting people aged anywhere from 20 to 60 years old. Death is reported very rarely.

There are rare reports of bleeding and blood clots in the spine with manipulation of the neck and back. Patients with blood-clotting disorders and those taking anticoagulant (blood-thinning) drugs such as warfarin (Coumadin) are at increased risk of side effects such as spinal bleeding after manipulative therapy.

Fractures to bones in the spine and nerve damage after manipulation have been reported in patients with osteomyelitis (bone infection), cancer involving bone, prior vertebral fractures, severe degenerative joint disease (osteoarthritis), osteoporosis and ankylosing spondylitis. Muscle strains, sprains and spasm after chiropractic manipulation have been reported, although it is not clear if these problems were related to the therapy or were pre-existing.

The effects of spinal manipulative techniques on blood pressure are controversial. Some studies report decreases in blood pressure, but better research is necessary to make a firm conclusion. There is a report of a heart attack that occurred during cervical spine manipulation, but it is not clear if manipulation played a role in this event. People with heart disease should check with their doctor before beginning spinal manipulative therapy.

Use of spinal manipulative therapy should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss spinal manipulative therapy or chiropractic with their primary care provider before starting treatment.

Summary

Chiropractic techniques and manipulative therapies have been suggested and used for many conditions. Preliminary evidence suggests benefits in patients with tension headache or low back pain. Better research is needed to make a strong conclusion. No other conditions have been sufficiently tested scientifically, partially because of technical difficulties involved with conducting research in this area. Many severe complications have been reported, including stroke, spinal cord damage, nerve compression, spinal bleeding, fracture and, very rarely, death. Patients with certain underlying medical conditions may be at increased risk. Speak with your health care provider if you are considering treatment. If you decide to begin therapy, be sure to inform the practitioner if you have an underlying medical condition.

The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.

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Resources

1. Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
2. National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research

Selected Scientific Studies: Chiropractic, Spinal Manipulative Therapy, Spinal Manipulation

Natural Standard reviewed more than 1,440 articles to prepare the professional monograph from which this version was created.

Some of the more recent English-language studies are listed below:

1. Brealey S, Burton K, Coulton S, et al. UK Back pain Exercise And Manipulation (UK BEAM) trial: national randomized trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578].
2. BMC Health Serv Res 2003;3(1):16.
3. Bronfort G, Assendelft WJ, Evans R, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001;24(7):457-466.
4. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther 2004;9(3):151-156.
5. Cooper RA, McKee HJ. Chiropractic in the United States: trends and issues. Milbank Q 2003;81(1):107-138.

1. Di Duro JO. Stroke in a chiropractic patient population. Cerebrovasc Dis 2003;15(1-2):156. Ernst E. Spinal manipulation: its safety is uncertain. CMAJ 2002;166(1):40-41.
2. Ernst E, Harkness E. Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials. J Pain Symptom Manage 2001;22(4):879-889.
3. Evans W. Chiropractic care: attempting a risk-benefit analysis. Am J Public Health 2003;93(4):522-523.
4. Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine 2002;27(21):2383-2389.
5. Ferreira ML, Ferreira PH, Latimer J, et al. Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. J Manipulative Physiol Ther 2003;26(9):593-601.
6. Foster J, Gates T, Van Arsdel G. A randomized controlled trial of chiropractic spinal manipulative therapy for migraines. J Manipulative Physiol Ther 2001;24(2):143.
7. Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine 2003;28(14):1490-1502.
8. Haas M, Groupp E, Kraemer DF. Dose-response for chiropractic care of chronic low back pain. Spin J 2004;4(5):574-583.
9. Haldeman S, Carey P, Townsend M, et al. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001;165(7):905-906.
10. Hartvigsen J, Bolding-Jensen O, Hviid H, et al. Danish chiropractic patients then and now: a comparison between 1962 and 1999. J Manipulative Physiol Ther 2003;26(2):65-69.
11. Hayden JA, Mior SA, Verhoef MJ. Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study. J Manipulative Physiol Ther 2003;26(1):1-8.
12. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study. Am J Public Health 2002;92(10):1628-1633.
13. Hestoek L, Leboeuf-Yde C. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manipulative Physiol Ther 2000;23(4):258-275.
14. Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther 2004;27(6):388-398.
15. Hurley DA, McDonough SM, Baxter GD, et al. A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain. Man Ther 2005;10(1):61-67.
16. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996;21(15):1746-1760.
17. Hurwitz EL, Meeker WC, Smith M. Chiropractic care: a flawed risk-benefit analysis? Am J Public Health 2003;93(4):523-524.
18. Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health 2002;92(10):1634-1641.
19. Jeret JS, Bluth M. Stroke following chiropractic manipulation: report of 3 cases and review of the literature. Cerebrovasc Dis 2002;13(3):210-213.
20. Koes BW, Assendelft WJ, van der Heijden GJ, et al. Spinal manipulation for low back pain: an updated systematic review of randomized clinical trials. Spine 1996;21(24):2860-2871.
21. Licht PB, Christensen HW, Hoilund-Carlsen PF. Is cervical spinal manipulation dangerous? J Manipulative Physiol Ther 2003;26(1):48-52.
22. Nadgir RN, Loevner LA, Ahmed T, et al. Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature. Neuroradiology 2003;45(5):311-314.
23. Plaugher G, Long CR, Alcantara J, et al. Practice-based randomized controlled-comparison clinical trial of chiropractic adjustments and brief massage treatment at sites of subluxation in subjects with essential hypertension: pilot study. J Manipulative Physiol Ther 2002;25(4):221-239.
24. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2004;(3):CD002119.
25. Schneider J, Vuckovic N, DeBar L. Willingness to participate in complementary and alternative medicine clinical trials among patients with craniofacial disorders. J Altern Complement Med 2003;9(3):389-401.
26. Shekelle PG, Coulter I. Cervical spine manipulation: summary report of a systematic review of the literature and a multidisciplinary expert panel. J Spinal Disord 1997;10(3):223-228.
27. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60(9):1424-1428.
28. Struijs PA, Damen PJ, Bakker EW, et al. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Phys Ther 2003;83(7):608-616.
29. Wenban AB. Is chiropractic evidence based? A pilot study. J Manipulative Physiol Ther 2003;26(1):47.
30. Williams LS, Biller J. Vertebrobasilar dissection and cervical spine manipulation: a complex pain in the neck. Neurology 2003;60(9):1408-1409.

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