Science-Based Medicine 7/7/2017 https://sciencebasedmedicine.

org/chiropractic-and-spinal-
manipulation-red-flags-a-comprehensive-review/

Chiropractic and Spinal Manipulation Red Flags: A Comprehensive Review

Sam Homola

Many people visit chiropractors’ offices seeking relief from back pain. Appropriate use of spinal
manipulation provided by a chiropractor can be helpful in treating mechanical-type back pain,
but there are good reasons to avoid chiropractic manipulation based on correction of “vertebral
subluxations,” and there are red flags to look for before undergoing any kind of manipulative
treatment for neck or back pain.

While generic spinal manipulation is an acceptable physical medicine modality, spinal

manipulation based on chiropractic vertebral subluxation theory is scientifically unacceptable.
Since a significant number of chiropractors base their practice on subluxation theory which
supports use of spinal manipulation as a primary treatment for a broad scope of health problems,
it continues to be necessary to inform the public about the controversial aspects of chiropractic
care and the role of spinal manipulation as a form of manual therapy.

This updated fully-referenced review of chiropractic past and present will be helpful in
connecting the dots for persons who have questions about chiropractic or who might be
concerned about the practice of chiropractic as an alternative healing method. This review also

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offers useful tips and warnings dealing with spinal manipulative treatment for neck and back
pain, including specific reasons why infants and small children should never be subjected to
spinal manipulation, especially “spinal adjustments” provided by subluxation-based
chiropractors.

Chiropractic subluxation theory: still no evidence

The vertebral subluxation theory that gave birth to the chiropractic profession in 1895 proposed
that 95 per cent of diseases are caused by displaced vertebrae that place pressure on spinal nerves
(Palmer 1910). Today, chiropractic is defined as a method of removing nerve interference to
restore and maintain health by adjusting a “vertebral subluxation complex,” which has been
described as “changes in nerve, muscle, connective, and vascular tissues which are understood to
accompany the kinesiologic aberrations of spinal articulations” (Rosner 1997).

There is no credible evidence to support the theory that a vertebral subluxation can affect general
health or cause internal organs to become diseased (Mirtz 2009). Spinal nerves are commonly
compressed by osteophyte formation or by a herniated disc. Even the most severe compression
of a spinal nerve, which may cripple the supplied musculoskeletal structures, does not cause
organic disease. In the absence of fracture or pathology, vertebral misalignments rarely affect
spinal nerves.

Organs are not supplied by spinal nerves

Spinal nerves supply the sensory and motor (voluntary) functions of musculoskeletal structures.
Involuntary function of the body’s organs is regulated by autonomic nerve ganglia and plexuses
located outside the spinal column and by autonomic cranial and sacral parasympathetic nerves
that pass through solid bony openings (where subluxations do not occur). The all-important
vagus nerves (cranial nerves that originate in the brain stem) pass through openings in the base of
the skull and travel down through the neck, thorax, and abdomen to supply organs along their
path. Preganglionic autonomic (sympathetic) fibers, which emerge from the spinal cord and pass
through spinal segments from the first thoracic vertebra to the second lumbar vertebra, terminate
in sympathetic trunk and splanchnic ganglia located outside the spinal column.

The vagus nerves along with autonomic ganglia and nerve plexuses provide overlapping
sympathetic and parasympathetic nerve supply from many directions and sources (in concert
with chemical, hormonal, and circulatory factors) to assure continued function of the body’s
organs, independent of spinal nerves (Homola 2006a). This is why severance of the spinal cord
in the neck area, shutting off brain impulses to spinal nerves, can cause paralysis of muscles from
the neck down while the body’s organs continue to function. (A serious transverse spinal cord
lesion above C5 [upper neck] can cause respiratory paralysis and often death.) Transplanted
organs, relying upon hormones supplied by blood flow, can function without reconnection of
severed nerves.

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Since the spinal cord ends at the level of the 2nd lumbar vertebra, spinal nerves travel down from
the spinal cord (like the hair on a horse’s tail) to pass out through openings (foramina) between
the lumbar vertebrae and through solid bony openings in the sacrum to supply bladder and bowel
sphincter muscles. Except in severe cases of lower lumbar spondylolisthesis (sliding forward of
a vertebra as a result of a fracture or a congenital defect in the bony bridges that connect the
vertebra with the spinal joints), sacral spinal nerves are not affected by vertebral misalignment
but can be compressed by protrusion of a lower lumbar disc into the spinal canal, affecting
voluntary control of sphincter muscles (cauda equina syndrome), a medical emergency requiring
the attention of a neurosurgeon.

The effect of spinal manipulation on joint mechanoreceptors and nociceptors might temporarily
relieve back pain, and mobility might be improved by releasing adhesions and stretching
connective tissues. But there is no evidence to indicate that such effects have a significant affect
on the body’s organs.

►A chiropractic vertebral subluxation or “joint dysfunction” alleged to cause disease by

interfering with nerve supply to organs has never been proven to exist and cannot be equated
with an orthopedic subluxation, a partial dislocation that causes musculoskeletal symptoms.

Tenuous subluxation theory

Generic spinal manipulation designed to relieve pain and restore mobility is not the same as a
chiropractic adjustment that is claimed to improve health. While some chiropractors use spinal
manipulation appropriately in a practice limited to treatment of musculoskeletal problems, many
“adjust” the spine to correct “subluxations” in an attempt to restore and maintain health by
removing “nerve interference.” The theory underlying such treatment is so tenuous that it cannot
be explained or tested, resulting in a number of vague and implausible definitions that are
supported only by placebo effects and anecdotal case reports.

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The first clue I had that the chiropractic vertebral subluxation theory was not a valid construct was provided in the
anatomy and physiology textbooks I used during my course of study at Lincoln Chiropractic College.

Resting on the principles of its founding father, chiropractic in the United States continues to be
defined as a method of correcting vertebral subluxations to restore and maintain health (Bellamy
2010). A 2015 publication of the National Board of Chiropractic Examiners (NBCE), Practice
Analysis of Chiropractic 2015, states that “The specific focus of chiropractic practice is known
as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that
manifests in the skeletal joints, and, through complex anatomical and physiologic relationships,
affects the nervous system and may lead to reduced function, disability, or illness” (Christensen
2015). This definition of chiropractic is in keeping with a paradigm formulated by the
Association of Chiropractic Colleges (ACC) in 1996, signed by 16 North American chiropractic
college presidents:

Chiropractic is concerned with the preservation and restoration of health, and focuses
particular attention on the subluxation…a complex of functional and/or structural and/or
pathological articular changes that compromise neural integrity and may influence organ
system function and general health (Association 2017a).

A new definition of the chiropractic subluxation, formulated by The Rubicon Group, an

international consortium of seven chiropractic colleges which includes three subluxation-based
chiropractic colleges in the United States (Life Chiropractic College West, Life University, and
Sherman College of Chiropractic), describes a “neurologically-centered model of subluxation”:

We currently define a chiropractic subluxation as a self-perpetuating, central segmental

motor control problem that involves a joint, such as a vertebral motion segment, that is
not moving appropriately, resulting in ongoing maladaptive neural plastic changes that
interfere with the central nervous system’s ability to self-regulate, self-organize, adapt,
repair and heal (Rubicon 2017).

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The International Federation of Chiropractors and Organizations (IFCO), disagreeing with the
Rubicon definition of a chiropractic subluxation, responded with this statement: “The IFCO
asserts strongly that any attempt to define chiropractic subluxation without emphasizing the
importance of vertebral subluxation is a diminution of the profession.” The IFCO offered this
definition of a chiropractic subluxation:

A vertebral subluxation is an alteration of the intervertebral relationships of one or more

articulations of the spinal column or the immediate weight bearing components of the
axial skeleton; accompanied by a change in the morphology of the tissue occupying the
neural canal and/or intervertebral foramina; as well as an alteration of neural function
sufficient to interfere with the transmission of organizing information, considered to be
homologous to the mental impulse (IFCO 2017).

A 2015 Position Statement on Clinical and Professional Chiropractic Education, representing

seven European chiropractic colleges, does not support chiropractic subluxation theory:

The teaching of vertebral subluxation complex as a vitalistic construct that claims that it
is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic
curriculum in anything other than an historical context is therefore inappropriate and
unnecessary (World 2015).

Despite the obvious implausibility of chiropractic subluxation theory, explained in the

scientifically incomprehensible language of pseudoscience, studies done by chiropractors rarely
dispute the basic tenets of subluxation theory. One exceptional landmark study by a team of
academic chiropractors, however, concluded that “No supportive evidence is found for the
chiropractic subluxation being associated with any disease process or of creating suboptimal
health conditions requiring intervention” (Mirtz 2009). But belief in subluxation theory persists.
An independent study by chiropractic researchers revealed that “Despite the controversies and
paucity of evidence the term subluxation is still found often within the chiropractic curricula of
most North American chiropractic programs” (Mirtz 2011). A survey of North American
chiropractic students published in 2015 reported that a majority “would like to see an emphasis
on correction of vertebral subluxations” (Gliedt 2015).

The American Chiropractic Association (ACA), the leading association representing

chiropractors, says that “Chiropractic is a health care profession that focuses on disorders of the
musculoskeletal system and the nervous system, and the effects of these disorders on general
health.” With no mention of the word “subluxation,” the ACA advises prospective patients that
“Doctors of Chiropractic (DCs) care for patients of all ages, with a variety of health conditions”
(ACA 2017). Embracing a broad scope of practice based on the effect of musculoskeletal
problems on the nervous system (a position that leaves the door open for advocates of
subluxation theory), it appears that the ACA might be refraining from renouncing subluxation

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theory in order to preserve its membership─a dilemma that compromises the association’s
credibility in representing chiropractic as a science-based profession.

The International Chiropractic Association (ICA), the smaller of the two American chiropractic
associations, clearly defends subluxation theory:

The basic premise of chiropractic science is that abnormalities and misalignments of the
spine, defined as subluxations(s) in chiropractic science, can and do disrupt the normal
function of the nervous system and may create negative health consequences. The
correction and/or reduction of subluxation(s) through the adjustment of spinal structures
can remove nervous system interference and restore the optimal function of the body
(ICA 2013).

Subluxation deniers vs. subluxation believers

Controversy surrounding the validity of subluxation theory has divided chiropractors into camps
of “subluxation deniers” and “subluxation believers.” Chiropractors often deny that subluxation
believers are in the majority, even though state laws and the National Board of Chiropractic
Examiners in the United States define chiropractic as a profession “focused on the chiropractic
subluxation” (Christensen 2015). It certainly appears that subluxation deniers in the chiropractic
profession may be in the minority, making it difficult to find a chiropractor who does not
subscribe to subluxation theory or who does not offer spinal manipulation as a treatment for
anything other than a musculoskeletal problem.

Making an effort to separate themselves from the stigma associated with chiropractic subluxation
theory, some subluxation believers no longer use the “subluxation” word, instead substituting
vague descriptions of a spinal problem, such as a “joint dysfunction” or a “neuro-biomechanical
lesion.” Some of these descriptions do not involve displacement of a vertebra, but all are alleged
to have an adverse affect on the nervous system and general health. You cannot rely upon the
care of a chiropractor who claims to have abandoned the vertebral subluxation theory but who
continues to manipulate the spine in an attempt to restore and maintain health by removing nerve
interference─care that is no different from that of a subluxation believer.

Consumers should be wary of the rhetoric of chiropractors who say “I do not treat disease. I
simply remove nerve interference so that the body can heal itself.” Such chiropractors assume
that for every disease there is a corresponding vertebral subluxation, requiring life-long treatment
to correct or prevent subluxations.

Spinal manipulation as a treatment option for back pain

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Although there is considerable literature dealing with the use of spinal manipulation as a
treatment for neck and back pain, there are few reliable studies providing adequate proof
supporting such treatment. A 2015 Cochrane review, for example, dealing with manipulation for
neck pain, reported that “No high-quality evidence was found, so uncertainty about the
effectiveness of mobilization or manipulation for neck pain remains” (Gross 2015).

Low-back pain is most often the subject of credible reviews and studies that examine the effects
of spinal manipulation, a treatment now being provided by physical therapists, osteopaths,
physiatrists, orthopedists, and chiropractors. Scientifically oriented reviews dealing with use of
generic spinal manipulation as a treatment for back pain, however, do not offer strong support
for such treatment:

A 2011 Cochrane Systematic Review of spinal manipulative therapy for chronic low-back pain
reported that “High-quality evidence suggests that there is no clinically relevant difference
between SMT [spinal manipulative therapy] and other interventions for reducing pain and
improving function in patients with chronic back pain” (Rubinstein 2011).

A 2013 Cochrane review of spinal manipulative therapy for acute low-back pain concluded that
“SMT is no more effective for acute low back pain than inert interventions, sham SMT or as an
adjunct therapy. SMT also seems to be no better than other recommended therapies. Our
evaluation is limited by the few numbers of studies; therefore, future research is likely to have an
important impact on these estimates” (Rubinstein 2013).

A 2012 National Center for Complementary and Alternative Medicine review of back-pain
studies reported that “Overall, studies have shown that spinal manipulation is one of several
options─including exercise, massage, and physical therapy─that can provide mild-to-moderate
relief from low-back pain. Spinal manipulation also appears to work as well as conventional
treatments such as applying heat, using a firm mattress, and taking pain-relieving medications”
(National 2012).

A systematic review and meta-analysis of the use of spinal manipulative therapy in the treatment
of acute low-back pain published in the Journal of the American Medical Association in 2017
concluded that such treatment resulted in “modest improvements in pain and function at up to 6
weeks” (Paige 2017).

Some chiropractic colleges offer decent instruction in the care of musculoskeletal problems,

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including skillful use of spinal manipulation as a treatment for back pain. But such treatment is
tainted by subluxation theory that encompasses a broad scope of ailments. For this reason,
physicians who refer back-pain patients to chiropractors for spinal manipulative therapy must be
cautious in selection of a chiropractor, and they must take responsibility for the diagnosis, lest
inappropriate treatment makes them vulnerable to liability for damages. Care must also be taken
to make it clear that referral to a selected chiropractor who uses manipulation appropriately is not
an endorsement of chiropractic subluxation theory.

Unfortunately, manipulative techniques used by chiropractors may vary from one practitioner to
another. While some chiropractors may use generic spinal manipulation in an appropriate
manner, many of their colleagues use subluxation-based proprietary manipulative techniques that
have no known value and no reciprocal compatibility in working with other health-care
professionals. The techniques and goals of mobilization or generic spinal manipulation, however,
when properly performed and based on the science of anatomy, are always basically the same, no
matter who the provider might be.

►Although evidence supporting use of spinal manipulation as a treatment for back pain may be
weak, and the benefits of such treatment modest or temporary, it is important to understand that
while chiropractic manipulation based on subluxation theory has been rejected by the scientific
community, generic spinal manipulation is a plausible and acceptable treatment option that can
be beneficial in the care of carefully selected mechanical-type back problems.

Manipulation/mobilization/adjustment

Mobilization of joints has been traditionally identified as a physical therapy procedure. Most
physical therapists who use manual therapy use manipulation as well as mobilization.
Chiropractors, on the other hand, are identified primarily by their use of a “spinal adjustment,” a
procedure that is used for a reason that differs from the principles supporting use of standard
manipulation or mobilization.

On the physical therapy side, mobilization and manipulation are used to improve range of motion
in any joint that does not function normally. Grade I through Grade IV mobilization, for
example, moves joints through normal ranges of movement, while Grade V mobilization (thrust-
type manipulation) forces movement of joints beyond their normal end-range of motion. A
chiropractic adjustment based on subluxation theory is a thrust-type manipulation directed at a
specific vertebra to remove “nerve interference.”

Manipulation (a high velocity, low amplitude thrust) that forces slight separation of joint surfaces
can produce cavitation (popping sounds). Although cavitation or “gapping” of joints during
spinal manipulation may temporarily increase range of movement or signal release of joint
adhesions, the sound associated with such treatment (which can occur in normal joints) is
generally not considered to be significant. In the case of a chiropractic adjustment, however, in

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which the stated goal is to correct a subluxation causing nerve interference, the popping sound
can have a powerful placebo effect. Taking advantage of the power of suggestion, some
chiropractors lead their patients to believe that the popping sound heard during a spinal
adjustment means that vertebral subluxations are always present, requiring regular adjustments to
keep selected vertebrae properly aligned. The nocebo effect (fear of illness) that occurs as a
result of not getting regular adjustments further perpetuates unnecessary treatment.

Spinal manipulation as a treatment for neck and back problems has been used for thousands of
years (Hippocrates -400 B.C.). A specific chiropractic adjustment, a thrust-type manipulation
directed at selected vertebrae in an effort to restore and maintain health by removing nerve
interference, is a fairly recent development, invented by D.D. Palmer in 1895 (Palmer 1910).
Subluxation-based chiropractors are quick to explain that long-lever spinal manipulation or
mobilization is not the same as a specific short-lever chiropractic adjustment applied to a
vertebral subluxation, thus clinging to a belief system that continues to define the practice of
chiropractic.

►A physical therapist who uses mobilization or manipulation (Grade V mobilization) to relieve

pain and restore mobility in a compromised area of the spine is more likely to use manipulation
appropriately than a subluxation-based chiropractor who uses “specific adjustments” up and
down the spine to correct asymptomatic “subluxations” or to remove “nerve interference.”

Complementary vs. alternative

In observing the web sites and promotional materials of newly graduated chiropractors, it
appears that many of these chiropractors are combining science-friendly treatment methods with
the pseudoscience of subluxation theory in order to “remove nerve interference and improve
health.” Some are claiming to be primary care providers, combining “spine care” with “health-
and-wellness care” in a holistic approach that entails treatment and prevention of the gamut of
human ailments, often including “functional medicine” and other questionable healing methods
under the banner of “alternative medicine” or “integrative medicine.”

Although the public generally thinks of chiropractors as back specialists, few chiropractors limit
their care to treatment of back pain. According to the Association of Chiropractic Colleges,
“chiropractic is associated with the field of complementary and alternative medicine as a method
of improving and preserving health” (Association 2017b). Apparently, the chiropractic
profession at its core has chosen the complementary-alternative-medicine (CAM) route rather
than seek development as a scientifically acceptable back-care musculoskeletal specialty, despite
the fact that back pain and musculoskeletal conditions are the No. 1 and No. 2 causes of
disability worldwide (Vos 2012).

Substituting an unproven spinal adjustment for a variety of proven or reasonably effective

treatment methods for a variety of health problems places subluxation-based chiropractic care

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squarely in the camp of alternative medicine where bogus and unproven treatment methods
gather for undeserved recognition.

►It is important not to confuse a nonsensical unproven alternative treatment method (such as
homeopathy or subluxation-based chiropractic) with scientifically acceptable massage or generic
spinal manipulation that can be described as a primary or complementary form of treatment for
some musculoskeletal problems.

It is time for the scientific community to stop giving alternative medicine a free
ride….There cannot be two kinds of medicine─conventional and alternative. There is
only medicine that has been adequately tested and medicine that has not, medicine that
works and medicine that may or may not work. Once a treatment has been tested
rigorously, it no longer matters whether it was considered alternative at the outset. If it is
found to be reasonably safe and effective, it will be accepted (Angell 1998).

Back care vs. spine care

Generic spinal manipulation can sometimes be helpful in treating mechanical-type low-back pain.

While a good chiropractor can offer a service of value in conservative care for uncomplicated
mechanical-type back pain, a chiropractor is not a “spine specialist” capable of providing care
for complicated conditions affecting the spine. Isolated from the mainstream of healthcare, solo
chiropractors do not have access to the multiple medical facilities and the pharmaceuticals
needed to diagnose and treat spinal problems involving severe injury, disease, infection, or pain
of unknown origin─a service now being provided by some orthopedic surgeons who identify
themselves as a spine specialist.

I have always believed that the chiropractic profession would be more acceptable socially and
scientifically as a conservative back-care specialty or as a subspecialty of medicine─contingent,
of course, upon changes in state laws and the curriculum of chiropractic colleges. Low back pain,
the fifth most common reason for all physician visits in the United States (Chou 2007), is
difficult to diagnose and treat─a time-consuming responsibility that few physicians are qualified

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to handle or willing to accept and who would probably welcome a back-care specialty.

Physical therapy offers care and rehabilitation for a broad scope of neuromusculoskeletal
problems─care that includes use of manual therapy. But there is not yet a certified physical-
medicine specialty or subspecialty limited to conservative care for neck and back pain.

The path of chiropractic

At the present time, there are no indications that chiropractic colleges in the United States will
seek specialization in conservative care for back problems, retreating from the definition of
chiropractic as a form of alternative medicine. The National University of Health Sciences, for
example, formerly the National College of Chiropractic (a leading chiropractic college), offers
programs in naturopathic medicine, acupuncture, and oriental medicine as well as a degree in
chiropractic medicine (National 2017). Such dubious alternative healing methods are gaining
acceptance as a form of “integrative medicine,” a designation that bends the rules of science in
order to meet public demand for questionable care that can be financially lucrative when
combined with conventional care.

There is no reason to believe that the subluxation theory will ever be discarded by all
chiropractors. Adjustment of chiropractic vertebral subluxations, a belief system perpetuated by
pseudoscience and monetary returns, will continue to be guided by whimsical thinking and
misinformation. Chiropractic subluxations that are not detectable by conventional diagnostic
procedures, for example, are allegedly being located by such dubious procedures as
thermography, surface electromyography, applied kinesiology, and leg-length checks. Dozens of
different antithetical manipulative techniques are used to correct such subluxations.

A 1995 publication endorsed by the Association for the History of Chiropractic listed 97 “named
chiropractic techniques” used by chiropractors (Peterson 1995), most of which are too
implausible to warrant consideration. For example, some chiropractors use a spring-loaded stylus
in an attempt to tap vertebrae into alignment in order to “help the body heal itself” (Homola
2006b). A few use “reflex” techniques to realign vertebrae without manipulating the spine.
Upper cervical chiropractors believe that aligning the atlas (the vertebra at the top of the spine)
will “influence the central nervous system and brain stem function” as well as realign vertebrae
from the neck down (Homola 2009). And so on.

An adjusting instrument used by some chiropractors to tap alleged vertebral subluxations into alignment.

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While the chiropractic profession continues to be mired in the pseudoscience of vertebral
subluxation theory, use of spinal manipulation is gaining greater acceptance as a physical
treatment option in the armamentarium of physical medicine, providing competition for
chiropractic treatment of back pain. On a path of no return as a form of alternative medicine
competing with conventional medical care, the chiropractic profession is becoming increasingly
more dependent upon its spinal nerve-interference theory to justify its existence and its
independence as a healing art.

Red flags and back-pain symptoms that warn against use of spinal manipulation

The next time you have back pain and you want to try using spinal manipulation to relieve your
symptoms, there are some red flags you should know about in order to avoid inappropriate use of
such treatment, no matter who does it. You cannot always depend upon a chiropractor or a
manual therapist to inquire about subjective symptoms that might be helpful in planning
treatment. It is always a good idea to be as well informed as possible when submitting to any
form of treatment, especially spinal manipulation or a spinal adjustment that might be potentially
harmful.

It goes without saying that spinal manipulation for acute back pain should not be done
immediately following injury or without a definitive diagnosis.

● If you are on a treatment program requiring prolonged ingestion of a corticosteroid or a thyroid

hormone, especially if you are past middle age, sudden appearance of back pain that restricts
movement might be an indication that an osteoporotic vertebra has collapsed. Manipulation
should not be considered.

● If you have a history of lung, breast, or prostate cancer and you develop a gradual onset of
back pain, or if you have persistent back pain for no apparent reason, you should be tested for
bone disease. Some forms of malignancy commonly metastasize to the ribs or the vertebrae,
making them vulnerable to fracture during manipulation.

● Backache can be caused by a kidney infection that may go undetected until an elevation in
temperature is discovered. Always take your temperature when you have a backache. If you have
a fever, you should always see your family physician, regardless of what you think might be
causing your backache.

● Mechanical-type back pain that originates in musculoskeletal structures is relieved by rest and
aggravated by movement. Back pain that has an internal origin is unaffected by movement. If
you develop constant back pain that is not affected by movement of your body, you should see
your family physician to rule out such things as organic disease, infection, or an aortic aneurysm.

● Persistent backache that defies diagnosis should undergo testing and observation in a search
for such elusive diseases as ankylosing spondylitis or rheumatoid arthritis, which could be

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aggravated by manipulation.

● Kidney stones can cause acute back pain. Unlike mechanical-type back pain that restricts
movement, the referred pain of a kidney stone produces pain that will not allow you to rest or sit
still. If you have the misfortune of experiencing back pain that causes you to squirm about or roll
around on the floor, you should go to a hospital emergency room as soon as possible.

● Pain, numbness, and other symptoms radiating down one or both legs, or weakness in one leg
or foot may be an indication of encroachment upon spinal nerves in the lower portion of the
spine. Such symptoms can be caused by disc herniation, osteophyte formation, or some other
pathological process. When a spinal disc is herniated or when a spinal nerve is pinched, spinal
manipulation is not indicated. (A pinched spinal nerve in the thoracic area of the spine can refer
pain into musculoskeletal structures in thoracic and abdominal areas, often mimicking angina or
an organic disease. Pain anywhere in the torso should be brought to the attention of a physician.)

● Loss of bladder or bowel control with numbness in the perineal (saddle area) of your pelvis is a
medical emergency (cauda equina syndrome) requiring the immediate attention of a
neurosurgeon. Such symptoms can be caused by a lumbar disc protrusion that has entered the
spinal canal.

The clear and hidden dangers of neck manipulation

Numerous reports have associated upper cervical manipulative therapy with stroke involving
injury to vertebral or internal carotid arteries (Biller 2014). Such strokes have occurred in young,
healthy persons, some of which have been confirmed by imaging studies that show dissection of
healthy vertebral arteries due to trauma (Jones 2015). Although strokes believed to be caused by
neck manipulation are rare, there is good reason to warn against use of neck manipulation that
involves rotation of head and upper cervical (occiput-atlas and atlanto-axial) structures beyond
normal ranges of movement.

►The vertebral arteries in particular are vulnerable to injury when mobilization and
manipulation techniques involve a rotatory component greater than 45 degrees at the atlanto-
axial level (Magee 2014). Risk always outweighs benefit when neck manipulation of any kind is
used to correct alleged chiropractic subluxations (Homola 2014).

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Forced passive rotation of the atlas on the axis past 45 or 50 degrees stretches the vertebral artery. Normally, during
active cervical rotation, all of the cervical vertebrae move together, a little movement in each joint, allowing about
80 degrees of rotation right and left. The atlantoaxial joint, where there is no intervertebral disc, is capable of about
50 degrees of independent rotation right and left, allowing excessive rotation during upper cervical rotatory
manipulative techniques.

The normal anatomical configuration of the top two cervical vertebrae that provide a bony
pathway for the vertebral arteries places these arteries at risk when there is extreme head or
upper neck rotation. In addition to possible disease or malformation in the network of
vertebrobasilar and internal carotid arteries in the base of the skull, there are some rare, often
undetected, structural abnormalities that threaten the vertebral arteries when the head and neck
are rotated.

Obvious contraindications for cervical spine manipulation include atlas instability in rheumatoid
arthritis, nerve root impingement or disc herniation, osteoporosis, use of blood thinners, carotid
bruits, atherosclerosis, symptoms of vascular insufficiency (such as fainting) on active and
passive head rotation within a normal range of movement, the short neck of basilar invagination
(congenital migration of the upper cervical spine into the base of the skull), and so on.

Often undetected structural contraindications for upper neck manipulation include these cervical
spine abnormalities:

● A retrolenticular vertebral artery ring, an abnormal bony bridge that encompasses the vertebral
artery where it passes over the posterior arch of the atlas, can severely compress a vertebral
artery during rotatory upper cervical manipulation (Rao 2015).

● Chiari malformation, a structural defect that allows a portion of the cerebellum to pass down
through the foramen magnum and enter the spinal canal, can cause headache that begins on the
back of the head and neck, resembling a cervicogenic headache or a muscle-contraction
headache. Upper cervical manipulation in such a case would be dangerous.

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● Bow hunter’s syndrome, a rare vertebral artery insufficiency caused by an abnormal fibrous
band or an osseous prominence that compresses the vertebral artery at the atlantoaxial level
during active or passive head rotation in a certain direction, often within a normal range of
movement. Such symptoms detected during range of motion testing in the cervical spine are an
obvious contraindication for cervical spine manipulation. Any symptom of circulatory
insufficiency, such as dizziness or drop attack, caused by rotation of the head or by extension of
the cervical spine warns against use of cervical spine manipulation or any form of manual
therapy applied to the neck (Helton 2009).

● Os odontoideum is a congenital absence or lack of fusion of the odontoid process, a dowel-like

projection of bone from the axis that serves as a pivoting point for rotation of the atlas. Since
there is no intervertebral disc between the atlas and the axis, a defective odontoid process would
allow dislocation of the atlas when the upper cervical spine is forcefully manipulated, with or
without rotation.

Bottom line: There is no credible evidence to support use of spinal manipulation for anything
other than uncomplicated mechanical-type neck or back pain and related neuromusculoskeletal
problems. Upper neck manipulation, however, is so risky (with little evidence of benefit) that I
usually advise against submitting to such treatment.

If you are looking for a chiropractor who treats back pain, look for one who does not subscribe to
subluxation theory and who limits care to musculoskeletal problems─one who is willing to
exchange office notes with your family physician. Remember that most of the time, acute low-
back pain is a self-limiting condition that will resolve in four to six weeks, with or without
treatment. Appropriate manipulative treatment may, however, relieve symptoms and reduce need
for medication.

If acute back pain grows progressively worse or persists unrelieved for longer than a week, or if
there is no measured improvement after two to four weeks, manipulation should be discontinued.
Uncomplicated back pain that lasts longer than three months may be classified as chronic,
requiring use of self-help measures (such as exercise and postural ergonomics) and occasional
treatment for symptomatic relief as needed.

Chiropractic and children

According to the International Chiropractic Association’s Council on Chiropractic Pediatrics

(ICPA), “Chiropractic care can never start too early.” Patient education provided by the council
advises that “A 1992 survey showed that the most common conditions for which children visit a
chiropractor are: earaches, neck pain, check-up, headache, upper respiratory, low back pain,
allergies, asthma, enuresis, and thoracic pain. Other reasons are ADD and ADHD, colic,
torticollis, insomnia, growing pains, and persistent crying in infants” (ICA Council 2017).

►I do not know of any medically acceptable diagnosis that would warrant manipulating the
spine of a pre-adolescent child. The cartilaginous, immature spine of an infant or a small child
should never be manipulated, as some chiropractors are doing to correct alleged “subluxations”

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(Homola 2010, Homola 2016).

When British author Simon Singh stated in an April 19, 2008, issue of the Guardian that the
British Chiropractic Association’s (BCA) claims that chiropractors can help treat children with
“colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying”
were bogus, he was sued for libel by the BCA. The BCA was unable to present adequate
scientific evidence to support chiropractic treatment for children. The suit was withdrawn in
2010 when the court ruled that Singh’s comments were legally permissible as “fair comment”
(BCA 2017).

There has been some speculation that manipulating the spine of a child younger than 6 to 8 years
of age might fracture or damage cartilaginous epiphyseal growth centers, an occult injury that
could result in development of pre-adolescent spinal deformity such as scoliosis or
Scheuermann’s kyphosis (O’Neal 2003).

Ossification centers in the thoracic vertebra of a child age 1 and age 6.

“Potential complications and unknown benefits indicate that SMT [spinal manipulative therapy]
should not be used in the pediatric population” (Powell 1993).

The above statement was made by a neurosurgeon. I have not seen any credible medical
publications that recommend use of spinal manipulation for children. When the U.S. Department
of Health and Human Services published Acute Low Back Problems in Adults, suggesting that
spinal manipulation might be helpful for patients with acute low back problems without
radiculopathy, it excluded children younger than 18 years of age, “since diagnostic and treatment
considerations for this group are often different than for adults” (Bigos 1994).

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______________________
Samuel Homola is a retired chiropractor who specialized in the care of back pain. He is the
author of 15 books, including Bonesetting, Chiropractic, and Cultism (Critique Books, 1963),
Inside Chiropractic (Prometheus Books, 1999), and The Chiropractor’s Self-Help Back and
Body Book (Hunter House, 2002). He lives in Panama City, Florida. His email address is
samhomola@comcast.net.

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