Spinal Manipulation for Back and Neck Pain: Does It Work?

Laird Harrison


February 15, 2017

In This Article

Evidence for Cervical Manipulation

Gross and her colleagues reached similar conclusions about improving pain, function, and quality of life related to neck complaints. "There is some immediate pain relief—not necessarily long-term," she says. And most of the evidence was for chronic rather than acute symptoms.

Results for mobilization and manipulation were similar, and both might work best in combination with exercise. "Across our different Cochrane reviews, we can say that probably the combination of manual therapy and exercise seems to be a dominant piece that's coming out as being a wise choice," Gross says.

In acute and subacute neck pain, cervical manipulation was more effective than various combinations of analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs for improving pain and function in the short and intermediate term. The evidence for treating neck pain with cervical spinal manipulation was not as strong as the evidence for treating it with thoracic spinal manipulation, Gross and her colleagues found.[1]

But the research left many gaps. Spinal manipulation is difficult to study because patients and practitioners can't be effectively blinded to the treatment. Most effects are subjective. And it's hard to standardize treatments from one practitioner to another. "This is more complicated than looking at whether acetaminophen works, for example," says Dr Chou.

In part for this reason, the researchers couldn't find much evidence for the superiority of any particular spinal manipulation technique or any category of practitioner. Nor could they determine the optimum frequency or duration. "In the trials that have been done, it's hard to see clear differences, whether it's chiropractic or osteopathy, or whether somebody is doing it once vs five times a week," Dr Chou says.

Dr Chou doesn't practice any manual therapies, and his research has extended to all noninvasive therapies for low back pain. He considers exercise and cognitive-behavioral therapy as first-line therapies for chronic low back pain. "I view manipulation and such things as acupuncture as being more passive" on the part of the patient, he says. "Active treatments get people engaged and involved in their care."

When to Refer, and to Whom

Many people with low back pain are afraid to move. But bed rest causes deconditioning that can actually increase the risk for further injury, Dr Chou says. By prescribing both exercise and cognitive-behavioral therapy, a physician can "get the muscles and soft tissues moving, and get people to understand that if they have some pain, that's not a bad thing."

When he does refer patients for spinal manipulation, Dr Chou tries to make sure the practitioner is not going to apply additional therapies that are unproven. "There are some chiropractors who do manipulation, and they are also doing things that may be counterproductive, such as getting radiography that isn't necessary and telling people there is something wrong with their alignment that makes people worry about things they shouldn't be worried about," says Dr Chou. "Those are folks I try to avoid if I can."

He advises patients to try spinal manipulation for 3-4 weeks, then move on to something else if it isn't helping. But he acknowledges that he has no research to support that recommendation.

Gross, who practices manual therapy, refers practitioners to an online "neck pain toolkit" developed by a collaboration of physiotherapists.[7] For low back pain, she recommends "Low Back Pain Strategy," a similar resource developed by the Ontario Ministry of Health and Long-Term Care.[8] But she adds that no literature review or evidence-based algorithm can provide all of the guidance a practitioner needs to treat a patient's back or neck pain.

The decision to use spinal manipulation "always has to be based on more than just research evidence," Gross insists. "It has to be based on good sound clinical reasoning, biology, the psychosocial elements around you, and the individual you are helping."


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