Health: Have you got the backbone?

Spinal manipulation, by chiropractors and osteopaths, is growing in popularity - but its effectiveness is disputed, and how exactly is it supposed to work? Professor Edzard Ernst concludes our series on complementa ry treatments
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The Independent Culture
Bone-setters have been practising in Europe for millennia. More recently, two distinct North American schools have evolved and have been subsequently re-imported to Europe: chiropractic and osteopathy. They collectively represent the most popular of all complementary therapies in the UK. They are, of course, not identical, but share enough common ground to be summarised as spinal manipulation.

What is it?

n In the words of a therapist, spinal manipulation "is a skilled passive movement to a joint or spinal motion segment, either within or beyond its active range of motion".

Both chiropractors and osteopaths used to insist that the cause of practically all illness and disease lay in the malfunction of the spine and other joints of the body. Even today, the belief is that some "malalignment" or "subluxation" of the vertebral column is at the root of many health problems, most prominently back pain. This basic assumption is still the source of much controversy. On one side, proponents are keen to show evidence suggesting that spinal malalignment exists with back problems. On the other, opponents are adamant that these have no clinical relevance and can be demonstrated in many individuals who do not have back pain.

What happens during therapy?

n Responsible therapists would take a detailed history and carry out a thorough physical examination focused on the spine. Very often, X-rays of the spine represent the next step. Eventually a diagnosis would be established; it may, however, not be as reliable as one would hope: one patient sent to five different chiropractors got five different diagnoses.

The main aim of the therapy is usually to manually re-adjust "malalignments" or "subluxations" of spinal joints, and to restore proper joint function. Various methods are used for this purpose. Osteopaths frequently restrict their treatment to gentle mobilisation techniques, while chiropractors use more forceful manipulations - "high velocity thrusts".

During treatment, the patient would normally lie on a treatment bench and the therapist would use her hands for manipulations and mobilisations. The treatment itself is not normally painful, but the patient may hear a somewhat disturbing cracking noise from their back. Chiropractors and osteopaths also tend to employ treatments "borrowed" from other therapies. These range from massage to dietary advice.

Few British doctors practice spinal manipulation. The chiropractors' and osteopaths' professions are in the process of acquiring statutory regulation. Physiotherapists, who have been properly regulated for a long time, may also practice spinal manipulation. The consumer can therefore be confident that therapists are adequately trained.

Usually, treatment needs to be repeated, and about 10 sessions, each taking 15-40 minutes, would normally constitute a full series. On average, UK chiropractors charge pounds 39 for a first visit and pounds 22 for a follow-up, while for osteopaths these figures amount to pounds 20 and pounds 18.50.

What is it for?

n By far the most important indication is back pain (followed by neck pain). Proponents claim that chiropractic and osteopathy are helpful for many other conditions (see Box 1).

Because of the huge sums of money at stake, the big issue is whether or not spinal manipulation is effective for back pain. In 1992, an influential US medical journal published a systematic review, apparently showing that the evidence was positive for acute uncomplicated low-back pain; for other types of back pain it was not compelling. This article eventually led to the integration of chiropractic into the guidelines of several countries (including the UK) of how acute back pain should be treated. Much doubt has since been cast on this notion.

A critically important new study convincingly shows that patients with acute low-back pain, who have received either a series of chiropractic manipulations or physiotherapy, or no treatment at all, experience roughly the same outcome. Only the total healthcare costs were remarkably different: in the two years that followed, they were about three times higher for the former two groups compared to the latter group.

Chiropractors often cite the trial of the UK Medical Research Council in defence. They say it favoured chiropractic over physiotherapy. This trial, however, is much misinterpreted as both its treatment groups received spinal manipulation.

Many therapists claim that spinal manipulation will also prevent further back problems. Considering the huge economic burden which back pain represents to society, this is a testable hypothesis of some importance. The unfortunate, yet undeniable, fact is that, so far, it has not been properly tested.

So the hard evidence for or against the efficacy of spinal manipulation for back pain is still highly inconclusive. But this does not mean it is proven to be ineffective. We need more and better trials to make sure.

What are the potential risks?

n Manipulation of the upper spine can damage blood vessels which run up this part of the spine and supply the brain with vital oxygen. If this happens, a stroke or even death ensues. Forceful manipulation can also cause a spinal fracture in patients with brittle bones. This, in turn, can leave the patient paralysed. Such complications seem to be extremely rare, but no convincing data exist to demonstrate exactly how often this, or other serious side-effects, happen. Two Scandinavian studies of high quality agree that mild, transient, unwanted side-effects occur in about half of all patients (see Box 2).

Chiropractic is also associated with much neglected, but potentially important, indirect risks (see Box 2). Chiropractors make liberal use of X-rays. Critics argue that this does not meaningfully contribute to the diagnosis, causes unnecessary expense, and can harm patients.


n Spinal manipulation therapies are complementary treatments, mostly used to treat back pain. Research has not shown whether they do more good than harm.

Addresses of some professional organisations: British Chiropractic Association, 29 Whitley Street, Reading RG2 0EG; General Council & Register of Osteopaths, 56 London Street, Reading, RG1 4SQ. Further reading: Murtagh J, Kenna C. `Back Pain and Spinal Manipulation', Butterworth Heinemann, 1997.

This is the last part in the series. Here are some recommended books for lay people, covering all complementary medicine: Cassileth B R,`TheAlternative Medicine Handbook', W W Norton, New York 1997; Fugh-Berman A. `Alternative Medicine: What Works'. Odonian Press, Tucson, Arizona 1996; Ernst E (Ed), `The Complete Book of Symptoms and Treatment', Element, 1998

Clinical Trials

Side-effects and risks of spinal manipulation:


n distant pain

n dizziness

n fatigue

n headache

n local pain

n nausea


n bone fracture

n paralysis

n stroke

Indirect risks

n delaying or hindering access to conventional treatment

n over-use of X-rays

Individuals with osteoporosis are particularly at risk of bone fracture

Complementary Techniques

Some conditions claimed to respond to spinal manipulation therapies:

n asthma

n bedwetting

n bronchitis

n headache

n hypertension

n intestinal colics

n menstrual problems

n migraine

n neck pain

n pulmonary disease

n ulcers

n vertigo

Trial data exists, but is inconclusive. In some studies, chiropractic was shown to be no more effective than a dummy treatment