Spinal manipulation

Spinal manipulation is an intervention performed on

Clinical guidelines from different countries come to different conclusions with respect to spinal manipulation.[2]

A 2012

In 2007 the American College of Physicians and the American Pain Society jointly recommended that clinicians consider spinal manipulation for patients who do not improve with self care options.^[6] Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions.^[7][8] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain.^[9] Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations.^[10] A 2017 review concludes "for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy."^[11]

Neck pain

For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies.^[12] A 2015 Cochrane systematic review found that there is no high quality evidence assessing the effectiveness of spinal manipulation for treating neck pain.^[13] Moderate to low quality evidence suggests that multiple spinal manipulation sessions may provide improved pain relief and an improvement in function when compared to certain medications.^[13] Due to the potential risks associated with spinal manipulation, high quality randomized controlled trials are needed to determine the clinical role of spinal manipulation.^[13] A 2007 systematic review reported that there is moderate- to high-quality evidence that subjects with chronic neck pain, not due to whiplash and without arm pain and headaches, show clinically important improvements from a course of spinal manipulation or mobilization.^[14] There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits.^[15]

Non-musculoskeletal disorders

Historically, some within the chiropractic profession have claimed that spinal adjustments have physiological effects on visceral functions, and thus affect overall health, beyond musculoskeletal conditions. This view originated in the 19th century with Daniel David Palmer's original thesis that many diseases were caused by subluxations. Over time, this hypothesis has been shown to be inconsistent with our modern understanding of pathology and disease and only "a small proportion of chiropractors, osteopaths, and other manual medicine providers use[ing] spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial."^[16]

A 2019 global summit of "50 researchers from 8 countries and 28 observers from 18 chiropractic organizations" conducted a systematic review of the literature, and 44 of the 50 "found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function."^[16]

Assistance of medication or anesthesia

As for manipulation with the assistance of medication or anesthesia, a 2013 review concludes that the best evidence lacks coherence to support its use for chronic spine pain.^[17]

Safety

There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown.

Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that:[29]

critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects.

In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence.^{[30][31][32][33]}

Edzard Ernst found that there is little evidence for efficacy and some evidence for adverse effects, and due to that, the procedure should be approached with caution, particularly forceful manipulation of the upper spine with rotation.^[34]

A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence.^[19]

A 2016 systematic-review found the data supporting a correlation between neck manipulation and cervical artery dissection to be very weak and that there was no convincing evidence for causation.^[35]

A 2024 narrative review noted the thromboembolic and thrombotic mechanisms of causation of immediate stroke after cervical spine manipulation that are in the existing peer-reviewed literature.^[36]

Potential for incident under-reporting

Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The

A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment."[38] The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.^[37]

Mis-attribution problems

Studies of stroke and manipulation do not always clearly identify what professional has performed the manipulation. In some cases this has led to confusion and improper placement of blame. In a 1995 study, chiropractic researcher Allan Terrett, DC, pointed to this problem:^[39]

The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors.

This error was taken into account in a 1999 review^[40] of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of manipulation responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized:^[40]

The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (non-thrust passive movements).

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown,^[41] and Figure 2 shows the type of practitioner involved in the resulting injury.^[42] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.^[39]

The review concluded: "The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed."^[40]

History

Spinal manipulation is a therapeutic intervention that has roots in

Force-time profiles measured during spinal manipulation were originally described as consisting of three distinct phases: the 'preload' phase, the 'thrust' (or 'impulse') phase, and the 'resolution' phase.^[53] Evans and Breen^[54] added a fourth 'orientation' phase to describe the first period, during which the patient is oriented into the appropriate position in preparation for the preload phase.

Kinematics

The kinematics of a complete spinal motion segment, when one of its constituent spinal joints is manipulated, are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint. However, the events that take place in a manipulated synovial joint are the same, irresepctive of whether the synovial joint in the spine or the periphery. Evans and Lucas defined manipulation using these events:^[51] "Separation (gapping) of opposing articular surfaces of a synovial joint, caused by a force applied perpendicularly to those articular surfaces, that results in cavitation within the synovial fluid of that joint." The corresponding definition for the mechanical response of a manipulation is: "Separation (gapping) of opposing articular surfaces of a synovial joint that results in cavitation within the synovial fluid of that joint." In turn, the action of a manipulation can be defined as: "A force applied perpendicularly to the articular surfaces."

Suggested mechanisms

The effects of spinal manipulation have been shown^{[citation needed]} to include:

• Temporary relief of musculoskeletal pain^{[citation needed]}
• Shortened time to recover from
  acute back pain^{[citation needed}
  ]
• Temporary increase in passive range of motion (ROM)^[citation needed]
• Physiological effects on the central nervous system (specifically the sympathetic nervous system)^[55][56]
• Altered sensorimotor integration^{[citation needed]}
• No alteration of the position of the sacroiliac joint^[57]
• Sham or placebo manipulation^[58]

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.^[59]

See also

• Joint manipulation
• Joint mobilization
• Osteopathic manipulation
• Spinal adjustment

References