Spinal Manipulation for Low-Back Pain

Introduction
Low-back pain is a common condition that can be difficult to treat. Spinal manipulationThe application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage, and naturopathy. is among the treatment options used by people with low-back pain in attempts to relieve pain and improve functioning. It is performed by chiropractors and other health care professionals such as physical therapists, osteopaths, and some conventional medical doctors. This fact sheet summarizes the current scientific knowledge about the effects of spinal manipulation on low-back pain.

Key Points

 * Evidence indicates that spinal manipulation can provide mild-to-moderate relief from low-back pain. It appears to be as effective as conventional treatments, and recent guidelines for health care practitioners include it as a treatment option for pain that does not improve with self-care.
 * Spinal manipulation is generally a safe treatment for low-back pain. The most common side effects (e.g., discomfort in the treated area) are minor and go away within 1 to 2 days. Serious complications are very rare.
 * Recent research into spinal manipulation for low-back pain has begun to look at the effects of different forms of manipulation, as well as treatment duration and frequency.
 * Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Low-Back Pain
Each year, up to one-quarter of U.S. adults experience low-back pain. Most people have significant back pain at least once in their lives; often, the cause is unknown. Back pain varies widely. For many people, it lasts only a few weeks, no matter what treatment is used. But for others, the pain can become chronic and even debilitating. Low-back pain is a challenging condition to diagnose, treat, and study.

Spinal Manipulation and Low-Back Pain
Spinal manipulation—sometimes called "spinal manipulative therapy"—is practiced by health care professionals such as chiropractors, physical therapists, osteopaths, and some conventional medical doctors. Practitioners perform spinal manipulation by using their hands or a device to apply a controlled force to a joint of the spine, moving it beyond its passive range of motion. The amount of force applied depends on the form of manipulation used. The goal of the treatment is to relieve pain and improve physical functioning.

In the United States, spinal manipulation is often performed as part of chiropractic care. ChiropracticA whole medical system that focuses on the relationship between the body’s structure—mainly the spine—and function. Practitioners perform adjustments (also called manipulation) with the goal of correcting structural alignment problems to assist the body in healing. is a health care approach that focuses on the relationship between the body's structure—mainly the spine—and its functioning. In chiropractic, spinal manipulation is sometimes called "adjustment." Back problems are the most common reason people seek chiropractic care. (For background information on chiropractic, see the fact sheet Chiropractic: An Introduction.)

Study Findings to Date
Overall, studies have shown that spinal manipulation can provide mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments. In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care.

Research is under way to determine whether the effects of spinal manipulation depend on the duration and frequency of treatment. Recent studies have found that spinal manipulation provides relief from low-back pain at least over the short term (i.e., up to 3 months), and that pain-relieving effects may continue for up to 1 year. In one study funded by the National Center for Complementary and Alternative Medicine (NCCAM) that examines long-term effects in more than 600 people with low-back pain, results to date suggest that chiropractic care involving spinal manipulation is at least as effective as conventional medical care for up to 18 months. However, less than 20 percent of participants in this study were pain free at 18 months, regardless of the type of treatment used.

Challenges Facing Researchers
When considering the evidence on spinal manipulation for low-back pain, it is important to know about the research behind the evidence. Although many clinical trials have been conducted, earlier trials tended to be small and poorly designed, making their findings less reliable. Moreover, studies have differed in focus (the specific type of back pain treated and form of manipulation used) and design (comparisons with other treatments vs. placebos). It can be difficult to clearly interpret findings when what is being measured varies widely from one study to the next. Recent research has begun to address these issues.

Common Side Effects
Reviews have concluded that spinal manipulation is relatively safe when performed by a trained and licensed practitioner. The most common side effects are generally minor and include temporary discomfort in the treated area, headache, or tiredness. These effects usually go away in 1 to 2 days.

Serious Complications
The rate of serious complications from spinal manipulation, although not definitely known, appears to be very low overall. A potential complication from low-back manipulation is cauda equina syndrome, a condition in which nerves in the lower part of the spinal cord become compressed, resulting in pain, weakness, and loss of feeling in one or both legs. Other functions—such as bowel or bladder control—may also be affected. Reports indicate that cauda equina syndrome is an extremely rare complication. In people whose pain is caused by a herniated disc, manipulation of the low back also appears to have a very low chance of either causing or worsening cauda equina syndrome.

NCCAM Research
Projects supported by NCCAM to study spinal manipulation for low-back pain include studies of:


 * The optimal number and frequency of treatments, and the duration of care
 * Estimated use, costs, and outcomes of chiropractic care for recurrent back pain
 * What happens in the body during manipulation of the low back.

Selected References

 * Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Annals of Internal Medicine. 2003;138(11):871–881.
 * Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. CDC Advance Data Report #343. 2004.
 * Bronfort G, Haas M, Evans R, et al. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine Journal. 2008;8(1):213–225.
 * Bronfort G, Haas M, Evans RL, et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine Journal. 2004;4(3):335–356.
 * Cagnie B, Vinck E, Beernaert A, et al. How common are side effects of spinal manipulation and can these side effects be predicted? Manual Therapy. 2004;9(3):151–156.
 * Cambron JA, Gudavalli MR, Hedeker D, et al. One-year follow-up of a randomized clinical trial comparing flexion distraction with an exercise program for chronic low-back pain. Journal of Alternative and Complementary Medicine. 2006;12(7):659–668.
 * Centers for Disease Control and Prevention. Health, United States, 2006. Hyattsville, MD: Centers for Disease Control and Prevention; 2006. Publication no. 2007–1232. Accessed on March 27, 2008.
 * Cherkin DC, Sherman KJ, Deyo RA, et al. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine. 2003;138(11):898–906.
 * Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low-back pain: a review of the evidence for and American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2007;147(7):492–504.
 * Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low-back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7):478–491.
 * Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002;27(3):291–296.
 * Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain. 2007;131(1–2):31–37.
 * Ferreira ML, Ferreira PH, Latimer J, et al. Efficacy of spinal manipulative therapy for low back pain of less than 3 months' duration. Journal of Manipulative and Physiological Therapeutics. 2003;26(9):593–601.
 * Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal. 2006;15(7):1070–1082.
 * Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. Journal of Neurology. 2002;249(8):1098–1104.
 * Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics. 2004;27(6):388–398.
 * Hurwitz EL, Morgenstern H, Kominski GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine. 2006;31(6):611–621.
 * Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Archives of Internal Medicine. 1998;158(20):2215–2224.
 * Kinkade S. Evaluation and treatment of acute low back pain. American Family Physician. 2007;75(8):1181–1188.
 * National Institute of Arthritis and Musculoskeletal and Skin Disorders. Handout on Health: Back Pain. Bethesda, MD: National Institute of Arthritis and Musculoskeletal and Skin Disorders; 2005. NIH publication no. 05–5282. Accessed on March 27, 2008.
 * Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. Journal of Manipulative and Physiological Therapeutics. 2004;27(3):197–210.
 * Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal. 2006;6(2):131–137.
 * Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997;22(4):435–440.
 * Tindle HA, Davis RB, Phillips RS, and Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Alternative Therapies in Health and Medicine. 2005;11(1):42–49.
 * van Tulder MW, Koes B, Malmivaara A. Outcome of non-invasive treatment modalities on back pain: an evidence-based review. European Spine Journal. 2006;15(suppl 1):S64–S81.

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Acknowledgments
NCCAM thanks the following people for their technical expertise and review of this publication: Gert Bronfort, Ph.D., D.C., Northwestern Health Sciences University; William Meeker, D.C., M.P.H., Palmer College-West; and Partap Khalsa, D.C., Ph.D., NCCAM.