Spinal Manipulation For Low Back Pain

Treatment Ratings


RISK: 5/5

Spinal manipulation is one of the safest forms of care available to treat low back pain. Many patients experience transient soreness, but serious complications appear to be extremely rare.

One recent review noted, “ Approximately one half of patients who undergo spinal manipulation have mild to moderate undesirable effects; these include local discomfort (occurred in 53 percent of patients in one series of 4,712 patients); headache (12 percent); tiredness (11 percent); and radiating discomfort (10 percent). Most (74 percent) of these reactions resolved within one day. Similar results were found in other series.”

Cauda Equina Syndrome ( CES) is estimated to occur in less than 1 per 1 million treatments.(Cauda equine syndrome is a serious medical condition requiring surgery. It is an extremely rare complication of manipulation.)

Other studies suggest that many patients experience transient soreness. “ Although the occurrence rate of these complications is unknown, it is probably low.”

Hebert JJ, Stomski NJ, French SD, Rubinstein SM. Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases. J Manipulative Physiol Ther. Jun 17 2013.



According to current research, spinal manipulation has good evidence of efficacy, meaning scientific studies have shown that it not only works for low back pain, but is as good as or better than other treatment options, including physical therapy, exercise and medications.

Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. Feb 25 2010;18(1):3.

A Consumer Reports survey of more than 14,000 people published in May 2009 found that 88% of patients who tried chiropractic manipulation found it helpful, and 59% were “completely” or “very” satisfied with their chiropractor.

A 2006 survey by Gaumer of 400 respondents who had received chiropractic care and an equal number who had not revealed that 83% of those who had seen a chiropractor were satisfied or very satisfied with their care, while only 9% were not satisfied

Factors Associated With Patient Satisfaction With Chiropractic Care: Survey and Review of the Literature;Gaumer G. Journal of Manipulative & Physiological Therapeutics , Volume 29 , Issue 6 , 455 – 462

Another study, published in the Western Journal of Medicine revealed back pain patients were more satisfied with their chiropractor compared to MD by three to one. (Cherkin DC, MacCornack FA: Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989 Mar; 150:351-355)

A Medicare demonstration project survey conducted by the US Department of Health and Human Services revealed that 60% of participants obtained “complete’ or “a lot” of relief, and 87% rated their satisfaction 8 out of 10 or higher. Notably, 56% gave their chiropractor a perfect 10/10. (http://www.chiro.org/LINKS/FULL/Medicare_Demonstration_Project_Report.pdf; thanks to Dr Frank Painter for his excellent website resources.)



While some people will manipulate themselves (“twist” their neck or back) we do not recommend it. Skilled manual manipulation requires years of study, an excellent familiarity with the relevant anatomy, and extensive practice. For this reason we give spinal manipulation 2/5 for self-care. Leave it to the professionals!


COST: 4/5

Typically, a doctor of chiropractic will obtain a history of the condition and perform a relevant examination. This will typically include an assessment of range of motion, motor function, reflexes, and sensory function. Common orthopedic tests will also be done to rule out more serious conditions and to help define the nature of the problem. Xrays are typically not needed for an acute condition unless there are “red flags.” Most evidence-based Doctors of Chiropractic (D.C.) will recommend an initial therapeutic trial. Current evidence-based guidelines recommend a trial of 6-12 visits with additional care based on improvements in pain and ability to perform various activities, such as work.

Typically initial evaluations cost between $50 and $120, and subsequent visits for manipulation average $40-60. Additional treatments can include a variety of other modalities and procedures, including therapeutic exercise, therapies such as electrical stimulation or ultrasound and other conservative approaches. Many of these are often used by physical therapists as well.

One recent retrospective claims analysis found that Tennessee Blue Cross/Blue Shield beneficiaries initiating care with chiropractic physicians had lower treatment costs for low back pain episodes than those initiating care with medical physicians.

A 2012 systematic review found spinal manipulation was cost-effective for neck and back pain, used either alone or combined with other therapies. A prospective cohort study of Washington state workers found that 1.5% of workers who saw a chiropractor first for work-related back pain review later had surgery, compared to 42.7% of those who first saw a surgeon.

Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. Nov-Dec 2010;33(9):640-643.

Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State.

In comparison to many other treatment approaches to low back pain, manipulation appears to be a reasonably priced option. Many treatment guidelines recommend an initial trial of 6-12 visits. Further care beyond that should be based on demonstrating progress, particularly in ability to return to work or activities.


USEFULNESS (overall rating): 4/5

Based on scientific literature, spinal manipulation has good evidence of effectiveness when compared to other treatments for low back pain. It is clear from multiple studies that patients give high satisfaction ratings, especially to Doctors of Chiropractic. Costs are generally more expensive than over-the-counter medications, but less than other forms of treatment, especially epidural or other injections, and of course surgery. Risks, especially for low back manipulation, are extremely low compared to other options. Overall spinal manipulation is safe, effective, low cost and patients like it. It may deserve your consideration.



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