Should I have spinal manipulative therapy for low back pain?

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Spinal manipulative therapy is adjustment of the spine using twisting, pulling, or pushing movements. These movements can loosen and move the spinal bones and joint structures that may be causing pain. This is the basis of chiropractic treatment, but not only chiropractors are trained to do spinal manipulation.

See a chiropractor, an osteopathic doctor, a physiatrist, or a physical therapist who performs spinal manipulation. Your insurance coverage may be a factor in deciding who to see for treatment.

When deciding about spinal manipulation, consider the following:

• You may need only home treatment, such as ice, moist heat, pain relievers, and mild exercise. For most people, these home treatments usually relieve low back pain within 4 to 6 weeks.
• Before you try spinal manipulation, have your symptoms evaluated. Certain symptoms, such as sharp pain, or low back pain with leg pain or numbness, can be a sign of a serious condition that needs immediate medical treatment or that could be made worse by spinal manipulation.
• You can't count on spinal manipulation alone to treat low back pain. Good spinal manipulative therapy includes self-care information and strength and conditioning exercises that help your muscles better support your troubled joints.
• If you choose spinal manipulation, find a practitioner who is willing to coordinate care with your other health professionals.

What is spinal manipulative therapy for low back pain?

Spinal manipulative therapy is based on the theory that your spinal health is central to your overall health. It relies on spinal manipulation, or spinal manual therapy, to increase a joint's range of motion. Different practitioners use different manipulation techniques, ranging from massage and slow pressing or twisting to rapid movement or forceful pressure on the head, shoulder, back, or hips. If you have tight or spasming muscles, your practitioner may first use a technique such as heat, ultrasound, or electrical current to relax your muscles before manipulating the spine. Practitioners who are not medical doctors do not use medicines or surgery to treat conditions.

People who benefit from spinal manipulative therapy usually notice improvement after one visit, and additional manipulation is not needed.¹ At most, 2 to 3 weeks of spinal manipulative therapy is considered to be enough to treat acute low back pain. Although some practitioners encourage long-term spinal manipulation for "maintenance" or "preventive" reasons, this practice has no proven value.

Chiropractors are not your only choice for providing spinal manipulation. Osteopathic doctors (DOs) are fully credentialed doctors whose training includes an emphasis on manual therapy. Some physiatrists and physical therapists also provide spinal manipulation. Health insurance coverage varies for this type of treatment, so it's wise to check—before starting treatment—to find out whether your practitioner of choice is covered.

How effective is spinal manipulation?

Like other treatments, spinal manipulation helps relieve acute low back pain for some people, but not for others. Spinal manipulation success is influenced by both the practitioner's diagnostic and treatment skill, and the cause of low back pain. Results from randomized controlled trials comparing spinal manipulation and placebo suggest that for acute low back pain spinal manipulation is more helpful than placebo in the short term. In the long term (more than 6 weeks) there was no difference between spinal manipulation and placebo. For chronic low back pain, the pain improved for more than 6 weeks, but the level of activity was the same as with a placebo.^{2, 3}

Comparisons between spinal manipulation and other low back pain treatments have produced conflicting results, but most show that spinal manipulation is no better than usual care such as physical therapy or exercise.^{2, 3} According to some experts, it's difficult to show that one treatment is better than another, because most low back pain improves within the first month regardless of treatment.⁴

A UCLA study has suggested that people are nearly equally satisfied with chiropractic versus medical low back pain care when they are given clear treatment information and at least four suggestions for home treatment. (The study did not include other practitioners such as osteopaths or physical therapists.)⁵

What are the risks of spinal manipulative therapy?

Perhaps the most common risks of seeking spinal manipulative therapy are related to a lack of standard practice in this field. Be a smart consumer (as you would be when considering a surgical or experimental back treatment). Ask your medical doctor or physical therapist to explain the risks and benefits of spinal manipulative therapy. Particularly if you have no referral, interview a practitioner or two before starting treatment.

Slow "mobilizing" movement has no known risks. But if a practitioner offers to work on your neck, remember that forceful neck manipulation, as performed by some practitioners, has been linked to rare but serious cases of neurological damage and sometimes death. Rapid neck manipulation can injure vertebral arteries, leading to stroke. It can also cause disc herniation that can lead to disability. You can avoid this type of risk with an experienced practitioner who uses slow, gentle manipulation techniques to treat carefully diagnosed conditions. Talk to your doctor or physical therapist before trying manual treatment for your neck.

If manipulation leads to increased pain or new pain in the legs or anywhere else, do not continue this treatment.

Practices to look for in a spinal manipulative therapy practitioner:

• Is willing to coordinate treatment with your other health professional(s)
• Provides educational information about home treatment and exercises
• Diagnoses musculoskeletal problems with physical examination and interview, using X-ray in unusual circumstances
• Is willing to refer you to a specialist when necessary, such as to an orthopedist, neurosurgeon, or oncologist for further testing, or to a registered dietitian for nutritional counseling
• Uses slow, gentle manual therapy techniques

Practices to avoid in a spinal manipulative therapy practitioner:

• Uses X-rays as a standard diagnostic test, particularly full-body X-rays or X-rays of children, which give unnecessarily high levels of radiation
• Practices based on the unproven theory that "subluxation" (partial dislocation of two joint surfaces) is responsible for many medical diseases
• Uses joint manipulation to treat such conditions as respiratory and ear infections, skin conditions, eye problems, and learning disabilities
• Promotes long-term spinal manipulative therapy to prevent illness or joint problems
• Sells other products or services, such as herbal or dietary supplements or counseling, without proper training and credentials

If you need more information, see the topic Low Back Pain.

Your choices for treating low back pain in the first month are:

• Use home treatment and perhaps work with a physical therapist for acute low back pain.
• Use home treatment and see a chiropractor, osteopathic doctor, physiatrist, or physical therapist for spinal manipulation.

See your doctor if you have severe symptoms or symptoms that are getting worse.

The decision about whether to try spinal manipulative therapy for acute low back pain takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about using spinal manipulative therapy for low back pain. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use spinal manipulative therapy for acute low back pain.

Check the box below that represents your overall impression about your decision.

Return to the topic Low Back Pain.

Citations

1. Hadler NM (2005). Low back pain. In WJ Koopman, ed., Arthritis and Allied Conditions, 15th ed., vol. 2, pp. 2073–2086. Philadelphia: Lippincott Williams and Wilkins.

2. Koes B, Van Tulder M (2006). Low back pain (acute), search date November 2004. Online version of Clinical Evidence (15).

3. Van Tulder M, Koes B (2006). Low back pain (chronic), search date November 2004. Online version of Clinical Evidence (15).

4. Andersson GB, et al. (1999). A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine, 341(19): 1426–1431.

5. Hertzman-Miller RP, et al. (2002). Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: Results from the UCLA low back pain study. American Journal of Public Health, 92(10): 1628–1633.