Spinal Manipulation: What You Need To Know

Spinal manipulation is one of several nondrug approaches that may be used to treat acute and chronic low-back pain. It may lead to small improvements in both pain and function. Function means how low-back pain affects various aspects of people’s lives, such as walking, standing, sleeping, and doing household tasks. In research studies, function is assessed using questionnaires.

• For adults with acute low-back pain (pain that has lasted for no more than 6 weeks), a 2017 analysis of data from 15 studies (1,699 participants) provided moderate-quality evidence that spinal manipulation is associated with a modest improvement in pain (similar to the benefit produced by nonsteroidal anti-inflammatory drugs). In the same report, data from 12 studies (1,381 participants) provided moderate-quality evidence that spinal manipulation is also associated with a modest improvement in back function. For both pain and function, the evidence was viewed to be of moderate rather than high quality because it was not completely consistent.
• For adults with chronic (long-lasting) low-back pain, a 2019 review of 47 studies (9,211 participants) compared spinal manipulation or mobilization with other therapies recommended in various countries, such as exercise or drug therapy. The review found moderate-quality evidence that the short-term (1 month) pain relief from manipulation or mobilization was similar to that produced by the other recommended therapies. For back function, there was moderate-quality evidence that manipulation or mobilization was slightly better than other therapies. For both pain and function, the evidence was viewed to be of moderate rather than high quality because it was not completely consistent. In all the studies included in this review, over half of the participants had pain for more than 3 months. 
• In its 2017 clinical guidelines, the American College of Physicians stated that spinal manipulation is one of several therapeutic options that may help people with acute or chronic low-back pain (although the strength of the evidence favoring spinal manipulation is low).
• A 2020 analysis by the Agency for Healthcare Research and Quality examined the evidence on noninvasive, nonpharmacologic treatments for common chronic pain problems to determine which treatments improved pain and/or function for at least 1 month. Eight studies of spinal manipulation for low-back pain, with 2,580 total participants, were included. In these studies, spinal manipulation was associated with small improvements in function in the short term (at least 1 month but less than 6 months) and intermediate term (at least 6 months but less than 12 months), as well as with small improvements in pain in the intermediate term. The strength of the evidence was low for function and moderate for pain.

Spinal manipulation can be helpful for acute neck pain, and manipulation or mobilization can be helpful for chronic neck pain.

• For acute neck pain (pain that has lasted less than 6 weeks), a 2021 combined analysis of 6 studies (446 participants) showed that spinal manipulation, alone or in combination with other treatments, was helpful in reducing pain intensity. However, the reviewers said that the results should be interpreted with caution because of the small amount of evidence and varied design of the studies.
• For chronic neck pain (lasting 12 weeks or longer), a 2019 review of 47 trials (4,460 participants) of either spinal manipulation or mobilization, alone or combined with other interventions, concluded that these treatments may reduce pain and improve function. The evidence was viewed to be of low-to-moderate quality because most of the studies were small and their results were inconsistent.

• A 2020 review of 7 studies (601 participants) found that spinal manipulation may reduce the frequency and intensity of cervicogenic headache (head pain that originates from a problem in the neck).
• A 2019 review of 6 studies (677 participants) of spinal manipulation for migraine found that spinal manipulation may reduce the number of days with migraine as well as migraine pain/intensity. However, because of limitations in the design of some of the studies, the reviewers considered the results to be preliminary.
• A 2020 analysis by the Agency for Healthcare Research and Quality examined the evidence on noninvasive, nonpharmacologic treatments for common chronic pain problems to determine which treatments improved pain and/or function for at least 1 month. For chronic tension headache, spinal manipulation was associated with small improvements in function and moderate improvements in pain in the short term (at least 1 month but less than 6 months). Little evidence was available; the conclusion was based on a single study with 75 participants.

• Sciatica is pain associated with the sciatic nerve, which controls muscles in the back of the knee and the lower leg. This nerve 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 according to a 2015 review of a variety of sciatica treatments. 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 along with advice and a home exercise program had less pain after 12 weeks and used less medication a year later than participants who only received home exercise and advice. However, leg pain was the same for both groups after 1 year.

• Only a small amount of high-quality research has looked at the effects of spinal manipulation on conditions other than musculoskeletal problems. A comprehensive 2021 review identified only 6 studies (534 total participants) of high or acceptable quality that evaluated spinal manipulation for nonmusculoskeletal conditions, such as high blood pressure or menstrual cramps. None of the studies showed a clear benefit of spinal manipulation.

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 those involved in 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, and there is disagreement about whether manipulation can actually cause CAD. Nevertheless, patients need to be informed of this potential risk.

Reports of serious adverse events from spinal manipulation during pregnancy are very rare, but there has not been much rigorous research on this topic. If you are pregnant and you are interested in using spinal manipulation, discuss the potential risks and benefits with your health care provider.