"By 1993 the British Medical Association was citing the chiropractic profession as the best example of a newer profession that was conducting good quality clinical research to establish its safety and effectiveness." 1

Safety

Spinal manipulation for back pain is safe, as is confirmed by the U.S. and U.K. guidelines.2,3 One of the reasons it is recommended as a first line of treatment in these guidelines is that, in comparison with all medication, including non-prescription anti-inflammatories and analgesics, it has very few risks and side effects if carried out by a trained practitioner.

There are of course a number of contraindications to manipulation, including fracture, risk of fracture because of a condition such as advanced osteoporosis, and spinal instability, but these are all well recognized.

Skilled manipulation for disc herniation is now also agreed by medical and chiropractic authorities to be both safe and effective.4,5 Appropriate skill and modification of technique is essential.

Some medical doctors express concern about the safety of neck manipulation. There are two authoritative reviews6,7 in recent years that have addressed the questions of benefit versus risk and compared the risk of standard medical treatments for neck pain. Both reviews have concluded that neck manipulation and mobilisation are safe, effective and appropriate for patients with various common forms of neck pain and headache. They also find that there is better evidence of effectiveness for manipulation than there is for common medical treatments for neck pain, including non-steroidal anti-inflammatory drugs (NSAIDs such as aspirin, nurofen, voltaren and ibuprofen) and other medication, and these medications have much higher risk rates than manipulation.

Comparative risk rates for neck manipulation and medical treatments:

• Cervical manipulation - 1.5 per million treatments (e.g., stroke from damage to a vertebral artery)
• Over the counter non-steroidal anti-inflammatory drugs (e.g. aspirin, nurofen, voltaren) - 1000 per million patients, and 3,200 per million patients age 65 and above (e.g., serious gastrointestinal perforation or bleeding causing hospitalisation and, for 10-20% of these patients, death).
• Cervical spine surgery - 15,600 per million surgeries (e.g., paralysis or stroke).

While it is important to take note of the above risks, it was brought to the attention of the medical community in the Medical Journal of Australia in 2002 that further investigation is necessary as there is considerable doubt about a causal relationship between the manipulation and the adverse event.8,9 Most artery problems occur in the absence of cervical spinal manipulation, spontaneously or after trivial trauma or common daily movements of the neck, such as backing out of a driveway, painting the ceiling, playing tennis, having your hair washed at the hairdressers or sneezing.10,11

The estimates of vertebral artery damage have also been found to be misleading as discovered in the Canadian Medical Association Journal in 2001. They estimate that it is only 1:5.85 million cervical manipulations which equates to 1 in 48 chiropractors careers.12

In summary, there are cases of serious injury following neck manipulation but the risk is extremely rare13 and remote compared with medical and surgical procedures given for the same health problems.

Effectiveness

There has been clear evidence from many studies that has confirmed the effectiveness of chiropractic manipulation, and chiropractic management, for patients with mechanical low back pain14-19 and neck pain.6,7

An additional study at The Townsville General Hospital, Queensland, in 1999 compared acupuncture (6 treatments in a 3-4 week period), anti-inflammatory drugs (3-4 weeks) and spinal manipulation (6 treatments in 3-4 weeks) for managing chronic spinal pain syndromes (low back, mid back and neck pain). Of all the treatments, spinal manipulation was the only intervention to have consistent and significant improvement over all outcomes.20

For further details of effectiveness see the appropriate sections on Conditions seen by Chiropractors and the Back Pain page.

Cost-Effectiveness

Chiropractic care for acute back pain or neck pain when compared to medical treatment was shown to be a substantially lower cost. In the same study it was recommended that the use of chiropractic should have a wider application and be used more by the medical physician community.20

There is now a convincing body of evidence showing a 20-60% saving in total health care and compensation costs for employers, governments and other third party payers when chiropractic care is substituted for medical care for patients with back pain.

The evidence is consistent and comes from worker's compensation studies in Australia and North America, clinical trials in various countries, individual employer experience and now sophisticated analysis of U.S. health insurance data by health economists.16,22

References
1. Complementary Medicine: new approaches to good practice. Oxford, England: British Medical Association, Oxford University Press, 1993; 138.
2. Bigos, S., Bowyer, O., Braen, G. et al. (1994) Acute low back problems in adults. Clinical practice guideline no. 14. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services: AHCPR Publication No. 95-0642.
3. Rosen, M., Breen, A. et al. (1994) Management guidelines for back pain. Appendix B In: Report of a clinical standards advisory group committee on back pain. London, England: Her Majesty's Stationery Office (HMSO).
4. Cassidy, J.D., Thiel, H.W., Kirkaldy-Willis, K.W. (1993) Side posture manipulation for lumbar intervertebral disc herniation. J. Manip. Physiol. Ther. 16: 96-103.
5. Nwuga, V.C.B. (1982) Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Am. J. Phys. Med. 6: 273-278.
6. Spitzer, W.O., Skovron, M.L. et al. (1995) Scientific monograph of the Quebec task force on whiplash-associated disorders: redefining whiplash and its management. Spine 20: 8S.
7. Coulter, I.D., Hurwitz, E.L. (1996) The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, California: RAND. Document No. MR-781-CR.
8. Ernst, E (2002) Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001. MJA 176: 376-380.
9. Breen, A (2002) Editorial: Manipulation of the neck and stroke: time for more rigorous evidence. MJA 176:364-365.
10. Haldeman, S. et al. (2002) Unpredictability of cerebrovascular ischaemia associated with cervical spine manipulation therapy. Spine 27: 49-55.
11. Terrett, A.G.J. (2002) Did the SMT practitioner cause the arterial injury? Chiropractic Journal of Australia 32: 99-110.
12. Haldeman, S. (2001) Arterial dissections following cervical manipulation: the chiropractic experience. Can. Med. Assoc. J. 165: 95-96.
13. Licht, P. (2000) Vertebral artery blood flow during chiropractic treatment of the cervical column. PhD Thesis. Odense University, Denmark. 63.
14. Hadler, N.M., Curtis, P. et al. (1987) A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified controlled trial. Spine 12: 703-706.
15. Meade, T.W., Dyer, S. et al. (1990) Low back pain of mechanical origin: a randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300: 1431-1437.
16. Meade, T.W., Dyer, S. et al. (1995) Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal 311: 349-351.
17. Shekelle, P.G., Adams, A.H., et al. (1991) The appropriateness of spinal manipulation for low back pain: project overview and literature review. Santa Monica, California: RAND; Monograph No. R-4025/1 - CCR/FCER.
18. Kirkaldy-Willis, W.H. & Cassidy, J.D. (1985) Spinal manipulation in the treatment of low back pain. Can. Fa. Phys. 31: 535-540.
19. Bronfort, G. (1997) Efficacy of manual therapies of the spine. Amsterdam: Vrije universiteit EMGO Institute.
20. Giles & Muller (1999) JMPT 22: 376-381.
21. Mosley, Cohen, Arnold (1996) Am. J. Man. Care. 2: 280-282.
22. Manga, P. & Angus, D. (1998) Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and improving the public's access to cost-effective health services. Ontario, Canada: University of Ottawa.