Osteopathy and chiropractic: risks and benefits of spinal manipulation
Last edited on : 9/09/2024
Osteopathy and chiropractic are paramedical disciplines which share the characteristic of using “spinal manipulations” in the course of their practice. It is beyond the scope of this article to define, differentiate and characterize these two practices or their different schools of thought, theory and practice. Nor is it our intention to claim any degree of expertise in these practices. We are here to discuss spinal manipulation solely through our own medical prism.
Indeed, it is essentially this practice that is the subject of debate within the medical world as to its efficacy and potential risks. This question is becoming increasingly acute in Western countries, for a number of reasons:
- Complaints of chronic osteomuscular pain and sub-acute and chronic headaches are becoming a major reason for consultation and a psycho-social issue. Whether the pain is secondary or, increasingly, idiopathic, medical management of these complaints is frequently disappointing. This phenomenon seems to be linked to the ageing of the population, on the one hand, and the increase in stress factors, on the other.
- Increasingly frequent recourse by patients to para-medical disciplines, with or without prior medical advice.
- Increasingly frequent use of various para-medical practices by doctors themselves, as an additional activity.
- Increasingly frequent case reports of medical and surgical complications resulting from these manipulations.
- Standardization of training, practice, legal recognition and public funding of osteopathic and chiropractic services varies widely by country.
Vertebral manipulation
The principle
Spinal manipulation is a manual therapy involving the mobilization of spinal joints at the limit of their physiological range of motion. These manipulations are frequently accompanied by audible “cracking” noises.
There are two main types of manipulation:
- Non-specific” manipulations, with long lever arms, which can be of low or high velocity. They use the long bones of the limbs as leverage to amplify the force exerted by the practitioner.
- Specific” manipulations, with short lever arms and high velocity. The force is usually applied to the transverse vertebral processes.
Physiotherapeutic hypotheses
Several theoretical hypotheses have been put forward regarding the positive impact of these manipulations on osteo-muscular pain:
- Improved muscle relaxation through abrupt stretching of chronically contracted muscles
- Improved muscular reactivity
- breaking down peri- or inter-articular adhesions
- “Unblocking of previously displaced mobile joint segments
- Sideration of proprioceptive receptors, leading to a reduction in pain-induced reflexes
- Modification of central pain pathways
However, there are currently no convincing studies demonstrating either of these hypotheses.
No theoretically plausible hypothesis has ever been formulated as to the positive impact of these manipulations on other pathological conditions.
What are the benefits?
Lower back pain
There is no quality evidence in this field. The literature shows short-term symptomatic improvement in sub-acute and chronic low-back pain, in addition to medical treatment alone. However, there is no evidence of any significant difference compared to other physical therapies.
Cervical pain, shoulder pain and chronic headaches
There is very little evidence in this field. There are a few small randomized controlled studies demonstrating greater medium-term improvement than for patients treated solely medically. Only one reached statistical significance, and none compared it with other physical (including physiotherapy) or psychological therapies.
Other pathological conditions
There are no data in the literature to support any benefit from spinal manipulation for other pathological conditions.
What are the risks?
Benign complaints
Large prospective series have demonstrated frequent (from 33 to 60% of patients, depending on the series) “benign” and transient complaints following spinal manipulation, whatever their type: dizziness, headaches, poorly systematized paresthesias, increased chronic pain, muscular pain, aspecific complaints (“empty head”, “not well”, etc.).
However, there is a lack of data (in particular, no randomized studies) demonstrating a direct relationship between these complaints and this specific treatment.
Serious complications
Unfortunately, there are currently no high-quality studies on this subject. However, several meta-analyses based on case reports and small series suggest a prevalence of serious complications of up to 1 per 20,000 spinal manipulations.
Herniated discs
Although there are no statistically significant data at present, many case-reports report herniated discs, whether complicated or not, in the weeks following spinal manipulation.
Cervical manipulations: cervico-encephalic artery dissections and secondary strokes
Carotid and vertebral artery dissections are a major cause of ischemic strokes in patients under 50. Although no series currently meets the threshold of statistical significance, a large number of case reports and small series associate the occurrence of such dissections, complicated or not by stroke, in the weeks following the performance of cervical manipulations. Despite this very low level of evidence, cervical manipulations are described, by consensus, as a classic cause of vertebral or carotid dissections by all guide-lines.
Lumbar manipulation: cauda equina syndrome
Resulting from compressive damage to the cauda equina within the lumbar canal, a few cases of this syndrome have been reported in the weeks following lumbar manipulations. Although there are too few data on this problem, the pre-existence of herniated discs, coagulation disorders or treatment with anticoagulants are considered by consensus to be favourable factors.
Illegal medical practice
Although these cases are fortunately exceptional given the number of spinal manipulations performed today, there are numerous case reports of patients having directly consulted a chiropractor or osteopath who had not advised them to consult a doctor at the same time, leading to dramatic omissions in the diagnosis of spinal tumours, whether primary or metastatic.
In conclusion...
Unfortunately, there is still no quality evidence on the benefits and risks of spinal manipulation. Considering the available data and the first principle of medicine, “Above all, do no harm”, it seems reasonable to us to recommend for the time being :
- Concerning the management of osteomuscular pain:
- As a general rule: prefer, as a first-line treatment, other physical therapy methods whose favorable benefit/risk ratio is better established, in association with medical management.
- Physicians should not recommend cervical manipulations. If patients express a wish to undergo cervical manipulation on their own initiative, they should be warned of the potential complications.
- The prescription of lumbar spinal manipulations should be discussed according to the preferences of each doctor and each patient. In any case, lumbar spinal manipulation should be avoided in the first instance, and in all cases, in patients with herniated discs and certain other joint anomalies, coagulation disorders or those on anticoagulants.
- Management of other pathological conditions:
- Whether it's asthma, functional digestive disorders or any problem other than osteomuscular pain, doctors should not recommend spinal manipulation.
Finally, we do not believe that it is appropriate for doctors to practise any paramedical discipline (this opinion is in no way specific to osteopathy or chiropractic) as an adjunct to their practice. Although the temptation is great, as these disciplines are generally far more remunerative on an hourly basis than the practice of medicine in Europe, doctors must bear in mind that such a practice raises a number of ethical issues: conflict of interest between prescription and execution, development of confusion among patients as to the boundaries between the different disciplines, risk of confusion among practitioners themselves as to the sometimes contradictory foundations of their different practices. More succinctly, and without any value judgement, we could sum up this opinion as follows: “To each profession its own specificities and to each his own profession”.
Author(s):
Dr Shanan Khairi, MD
Bibliography
Biller J et al., Cervical Arterial Dissections and Association With Cervical Manipulative Therapy. A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association, Stroke, 2014; 45: 3155-3174
Chou R, Subacute and chronic low back pain: Pharmacologic and noninterventional treatment, UpToDate, 2016
Licciardone JC et al., Recovery From Chronic Low Back Pain After Osteopathic Manipulative Treatment: A Randomized Controlled Trial, J Am Osteopath Assoc. 2016 Mar;116(3):144-55
Rosenquist EWK, Overview of the treatment of chronic pain, UpToDate, 2016
Shekelle P et al., Spinal manipulation in the treatment of musculoskeletal pain, UpToDate, 2016
Taylor FR et al., Tension-type headache in adults: Preventive treatment, UpToDate, 2016