Back Manipulation (Osteopathy and Chiropractic)

The 'manipulative therapies' include osteopathy and chiropractic. The two therapies have some similarities. Their practitioners use their hands to work with joints, muscles and connective tissue and to diagnose and treat soft tissue imbalances and abnormalities in skeletal function. Manipulation techniques are commonly used for low back pain, neck pain, shoulder pain, headache and sports injuries.

Osteopathy is regulated by the General Osteopathic Council. Chiropractic is regulated by the General Chiropractic Council. The practices were first introduced into the United Kingdom in the late 19th century.^1,2

Some common techniques used by both osteopaths and chiropractors include:

• High velocity thrusts: a short, sharp controlled movement with low amplitude is applied to the spine to restore local articular range and quality of movement. This produces the classic 'cracking' sound.
• Muscle energy technique: a soft tissue technique to increase a joint's range of movement.
• Functional technique: taking a joint into continuous different planes of movement that produce little tension and do not provoke pain. The idea is to eventually work back to the initial starting position, hopefully now with less or no pain. This technique reduces the stimulation through the local neuromuscular tissues and can lead to a release in tension.

Other techniques used by osteopaths include:

• Articulation: a joint is repeatedly and gently moved through its complete range of motion. The aim is to increase the range/freedom of movement of the joint.²
• Cranial/craniosacral osteopathy: the osteopath places their hands on the skull and the sacrum and gently handles the bones of the skull. Placing of the hands on the limbs and trunk is also adopted. The idea is that they can feel pulsations in the cerebrospinal fluid and correct problems in the neuromuscular system. The technique is reputed to treat colic, crying and behavioural problems in infants and children.

Both chiropractors and osteopaths also give advice about exercise, lifestyle, activity and prevention. A good practitioner will not only treat the patient but will discuss such problems as ergonomics at work, in the car, and at home, as well as exercise and mobility. The fact that someone is also taking a great interest in the patient, talking to him and discussing the problems is also very therapeutic. Interaction with the practitioner is certainly very important in terms of patient satisfaction.³

• The mode of action of manipulation in bringing relief is uncertain.
• The clicking, or popping, sound that often accompanies manipulation can be most impressive but it is thought to represent gas bubbles in the stretched joint. There appears to be no correlation between the presence, or impressiveness, of the sound and the outcome.
• One suggestion for the mode of action of manipulation is that it overstretches the nocioreceptors of the joints and, in doing so, closes the pain pathway as suggested by the 'gate theory' of pain.

Much has been made of the potential dangers of spinal manipulation but despite its widespread use, serious complications seldom occur. The risk of a serious complication due to manipulation is somewhere between 1 in 100,000⁴ and 1 in 5.8 million.^5,2

Where there have been problems from manipulation, they have more often been when manipulating the cervical spine.² The spinal cord fills more of the vertebral foramen in the neck than in the lumbar region and so any problem such as a small haematoma is more likely to impinge on the spinal cord. In addition, the shearing stresses of manipulation have been known to tear or cause dissection of the carotid or vertebrobasilar arteries. This can lead to stroke. In rheumatoid arthritis there is often weakness of the ligament holding the odontoid peg and manipulation may cause slippage of the atlanto-axial joint with high spinal cord compression. Active rheumatoid arthritis is a contraindication to manipulation, especially of the neck.

Spinal manipulation has led to:

• Artery dissection or spasm - vertebral artery dissection in the neck may present with neck pain, vomiting, headache, vertigo and ataxia. Risk factors include migraine, hypertension, oral contraceptive pills, smoking.⁶
• Stroke - a case-control and case-crossover study looked at the association between chiropractor visits and vertebro-basilar artery stroke, contrasting this with primary care physician visits and vertebro-basilar artery stroke.⁷ It found no evidence of excess risk of vertebrobasilar stroke associated with chiropractic care compared to primary care. The study concluded that any increased risk of vertebro-basilar artery stroke associated with visits to either a chiropractor or a primary care physician is likely to be due to patients with neck pain and headache due to vertebrobasilar artery dissection seeking care before their stroke.
• Spinal cord injury due to disc herniation - a case report of a person with disc herniations following cervical manipulation commented that it was doubtful that the manipulation caused the herniations but that it was possible that it did cause pre-existing asymptomatic herniations to become symptomatic.⁸
• Spinal epidural haematoma - a case report describes a man who developed a lumbar epidural haematoma after chiropractic manipulation of the lower spine for back pain. He was taking warfarin for atrial fibrillation.⁹ It highlighted that caution is needed in patients on anticoagulation therapy. Other case reports have described a man who developed a cervical epidural haematoma¹⁰ and a woman who developed a cervicothoracic epidural haematoma¹¹ after cervical spine manipulation. A case report and review of the literature published in 2006 found 7 reported cases of spinal epidural haematoma after manipulation. Five of these patients had cervical manipulation and one was on anticoagulant treatment.¹²
• Oesophageal rupture - this has been reported following chiropractic manipulation of the thoracic and lumbar spine for back pain.¹³

Before manipulating, it is important to form a working diagnosis. This will involve taking a history and performing an examination. Any 'red flags' in the history should be highlighted. Sinister causes of back pain must be excluded. Manipulating a back that is weakened by Paget's disease, multiple myeloma or metastatic carcinoma may produce vertebral collapse. The ability to recognise 'red flags' and to refer on rather than manipulating inappropriate cases is one reason for professional regulation.

The following are contraindications to manipulation at any level:

• Any potential sinister cause of back pain, including a history of malignancy that may involve bone such as breast cancer or a haematological malignancy.
• Patient on anticoagulants or who have a clotting disorder.¹² (Some suggest that this is a relative contraindication and depends on the patient's age and where the practitioner is wanting to manipulate. Cervical spine manipulation carries a higher risk. Thoracic and lumbar spine carry a lower risk, especially in a younger patient.)
• A patient with neurological disease. (Again, this may be a relative contraindication depending on the neurological problem present. Manipulation is contraindicated if there are upper motor neurone signs. However, some practitioners would be happy to perform manipulation at adjacent joints in those with lower motor neurone signs in order to unload the strain at the nerve root affected.)
• Presence of cauda equina syndrome.
• Active inflammatory arthritis.

In addition, the following are contraindications to manipulation of the neck:

• Known cerebrovascular disease.
• Hypertension that is not well controlled.
• Rheumatoid arthritis.

In view of the increasing risk of sinister causes of back pain with advancing age and the increased incidence of arterial disease, increasing age should be seen as a relative contraindication to manipulation, especially for the neck. There is also increased risk of compression fractures in someone with osteoporosis.¹⁴

• The UK(BEAM) trial was a randomised trial based on 181 general practices. BEAM stands for back pain, exercise and manipulation. It concluded that relative to 'best care' in general practice, manipulation followed by exercise achieved a moderate benefit at 3 months and a small benefit at 12 months. Spinal manipulation achieved a small to moderate benefit at 3 months and a small benefit at 12 months. Exercise achieved a small benefit at 3 months but not at 12 months.¹⁵ In terms of value for money it concluded that spinal manipulation is a cost effective addition to 'best care' for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.¹⁶
• A Cochrane review in 2004 concluded that there was no evidence that spinal manipulative therapy was superior to other standard treatments for patients with acute or chronic low back pain.¹⁷
• In one study, active chiropractic manipulation was shown to be more effective than simulated manipulation in the treatment of acute back pain and sciatica with disc protrusion.¹⁸
• An article looking at the history and overview of theories and methods of chiropractic stated that 'as of 2002, 43 randomised trails of spinal manipulation for low back pain had been published with 30 showing more improvement than with comparison treatment, and none showing it to be less effective'.¹⁹
• Another study compared outcomes in perception of pain and disability in patients with low back pain when managed in an NHS outpatient clinic by either a regional pain team or a chiropractor. It was a small study but it found that the chiropractic group did better in terms of reduced levels of disability and perceived pain.²⁰
• A systematic review has looked at the use of chiropractic care, including spinal manipulation, for pregnancy-related low back pain. There were positive results but the conclusion was that higher quality trials are needed to determine efficacy.²¹
• The European Back Pain Guidelines have recommended the use of manipulation for acute non-specific low back pain²² and chronic non-specific low back pain.²³

• The volume of evidence for the treatment of neck pain by manipulation is less than that for low back pain.²⁴
• A Cochrane review²⁵ found that mobilisation and/or manipulation, when used with exercise, are beneficial for persistent mechanical neck disorders with or without headache. Done alone, they were not beneficial. Compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorders with radicular findings.
• A prospective, multicentre, observational cohort study with 529 subjects undergoing chiropractic care for neck pain had no serious adverse events. It also showed that two thirds were recovered at 3 and 12 months. It concluded that the benefit of chiropractic care for neck pain seem to outweigh the potential risks.²⁶
• A prospective national survey carried out in the UK²⁷ looked at treatment outcomes from 19,722 patients who had undergone cervical spine manipulation. It showed no serious adverse events. It did show that there were minor side effects reported up to 7 days after treatment:
  • Headache (4 per 100 treatment consultations)
  • Numbness/tingling in upper limbs (15 per 1000 treatment consultations)
  • Fainting/dizziness/lightheadedness (13 per 1000 treatment consultations)

• A literature review of quality clinical trials published in 2006 showed that there are few published randomised controlled trials looking at the effectiveness of spinal manipulation and/or mobilisation for tension-type headache, migraine and cervicogenic headache in the last decade. It called for high-quality randomised controlled trials to assess manipulation treatment for headache.²⁸

• Dysmenorrhoea: one theory is that vertebral dysfunction reduces spinal mobility, affecting the sympathetic nerve supply to the blood vessels of the pelvic viscera, and leading to vasoconstriction and dysmenorrhoea. A 2006 Cochrane review concluded that there was no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea.²⁹ A prospective case series recently published concluded that primary dysmenorrhoea may be alleviated with the specific chiropractic technique of motion segment restrictions of the lumbosacral spine with drop table technique.³⁰
• Constipation: a case report describes the successful treatment of an 8 year old boy with chronic constipation. He was treated with sacral manipulation and external massage of the abdomen.³¹
• Asthma: a Cochrane review found no evidence of benefit from manual therapies in asthma.³²
• Upper limb problems: a study looking at the quantity and type of research conducted on the chiropractic treatment of upper extremity conditions concluded that more research, including randomised controlled trials, is needed.³³
• Lower limb problems: a study looking at the quantity and type of research conducted on the chiropractic treatment of lower extremity conditions concluded that more research, including randomised controlled trials, is needed.³⁴
• Generalised studies:
  • A systematic review of systematic reviews of spinal manipulation published in 2006 concluded that 'data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, the review does not suggest that spinal manipulation is a recommendable treatment.'³⁵ However, this review has been criticised as being misleading and discrediting to professionals using spinal manipulation.³⁶ Criticism was in terms of its methodology, validity and the fact that it did not include comparison to other therapies.
  • A systematic review in 2003 of chiropractic for pathology outside the spinal column included treatment of fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhoea and chronic pelvic pain. No evidence was found to support its use in any of these conditions.³⁷
  • Another systematic review concluded that evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo and infantile colic.³⁸

• Manipulation has been used extensively for a very long time.
• The risk of adverse events is extremely low but is more likely to follow manipulation of the cervical than the lumbar spine.
• The negative reviews of manipulation have perhaps been very rigorous in their expectations. They have interpreted failure to demonstrate clear and convincing benefit by vigorous methodology as evidence for lack of efficacy. It should be remembered that lack of evidence of effect and evidence of lack of effect are not the same.
• Spinal manipulation has been included in European treatment regimens for non-specific back pain.