MVIIIHealth The MVIII app
← Back

Research · Therapies

Chiropractic and spinal manipulation

For chronic low back pain, spinal manipulation relieved pain about as much as guideline-endorsed treatments, and sham-controlled trials were too weak to settle. Against sham, it did not reduce migraine days, colic crying or non-spine conditions. Brief soreness is common. Neck manipulation is linked to artery tears and stroke in younger adults, and case-crossover studies question whether it causes them.

Checked 2026-11-13
Status
A licensed health care profession. To practice in the US, chiropractors must earn a Doctor of Chiropractic degree, pass the National Board of Chiropractic Examiners exam and hold a state license [1]. Spinal manipulation is also given by osteopathic physicians and physical therapists [2].
Also called
chiropractic, chiropractor, chiropractic adjustment, adjustment, spinal manipulation, spinal manipulative therapy, SMT, cervical manipulation, neck cracking, back cracking, HVLA, high-velocity low-amplitude thrust, spinal mobilization, osteopathic manipulation, subluxation
Used for
low back pain, sciatica, neck pain, headache, migraine, cervicogenic headache, infant colic, asthma, high blood pressure, period pain, immunity, boosting immunity, posture, general wellness

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help5

Reported risks4

What it is used for, and what was found

Shown to help5

Moderate

Acute low back pain

Shown to ease acute low back pain by about 10 points on a 100-point scale and improve function modestly for up to 6 weeks, against sham or other treatments.

Compared with sham or alternative treatments [6]

The numbers and sources
Effect
Across 15 trials (1,711 patients), pain improved by 9.95 points on a 100-mm scale (95% CI -15.6 to -4.3). Across 12 trials (1,381 patients), function improved (effect size -0.39, 95% CI -0.71 to -0.07). Heterogeneity was not explained by who gave the manipulation or by type of manipulation [6].
Population
Adults with acute low back pain treated in ambulatory settings, 26 trials [6].
Sources
[6]
Caveats
The abstract pools sham and active comparisons together and calls heterogeneity large. Outcomes ran only to 6 weeks [6].
Moderate

Neck pain

Shown to ease acute and subacute neck pain more than inactive controls in the short term with thoracic manipulation. Neck manipulation and mobilization gave similar results.

Compared with inactive controls [7]; mobilization [7]; certain medications [7]

The numbers and sources
Effect
Thoracic manipulation against inactive control improved pain at short-term follow-up (SMD -1.26, 95% CI -1.86 to -0.66, 5 trials, 346 participants) and function (SMD -1.40, 4 trials), at moderate quality. A single neck manipulation relieved pain immediately but not at short-term follow-up, at low to very low quality. Multiple sessions of neck manipulation produced similar results to mobilization, and better pain and function than certain medications in one trial of 182 people [7].
Population
51 trials with 2,920 participants with neck pain [7].
Sources
[7]
Caveats
A funnel plot suggested publication bias for the thoracic manipulation results [7].
Moderate

Migraine, compared with other control conditions

Shown to reduce migraine days by a small amount in a meta-analysis of 5 trials, a result the authors called preliminary.

Compared with control conditions the source abstract does not describe [8]

The numbers and sources
Effect
Spinal manipulation reduced migraine days (Hedges' g -0.35, 95% CI -0.53 to -0.16) and migraine pain or intensity. One trial in chronic migraine was left out of the pooled analysis because it made heterogeneity high [8].
Population
677 people in 6 trials, with treatment lasting 2 to 6 months [8].
Sources
[8]
Caveats
Several trials were at high or unclear risk of bias for blinding, compliance and missing data [8].
Limited

Cervicogenic headache

Limited evidence: two low-quality trials suggested several sessions of neck manipulation eased cervicogenic headache pain more than massage.

Compared with massage [7]

The numbers and sources
Effect
For chronic cervicogenic headache, multiple sessions of neck manipulation may improve pain and function more than massage at short and intermediate-term follow-up [7].
Population
125 participants in 2 trials [7].
Sources
[7]
Caveats
Low-quality evidence from two trials, with no sham comparison [7].
ModerateStudied in children

Infant colic, all trials

Shown to cut infant crying by about 1 hour 12 minutes a day in pooled trials, many of them with parents who knew which treatment their baby had.

Compared with no treatment, and control conditions the source abstract does not otherwise describe [11]

The numbers and sources
Effect
Across 5 trials, manipulative therapies reduced daily crying by 1.20 hours (95% CI -1.89 to -0.51). Parents reporting full recovery did not differ significantly (OR 11.12, 95% CI 0.46 to 267.52, 3 trials) [11].
Population
325 infants with colic in 6 trials [11].
Sources
[11]
Caveats
Crying was mostly recorded by parents, and only 2 of 6 trials were at low risk of performance bias. The review covers manipulative therapies given by chiropractors and osteopaths [11].

Mixed results3

Strong

Chronic low back pain, compared with other treatments

Shown to relieve chronic low back pain about as much as other guideline-endorsed treatments, with a small gain in function and a pain edge too small to matter clinically.

Compared with other therapies that guidelines endorse [3]; therapies that guidelines do not endorse [3]; other interventions [4]

The numbers and sources
Effect
Against other guideline-endorsed therapies, short-term pain did not differ (mean difference -3.17 on a 100-point scale, 95% CI -7.85 to 1.51) and function improved slightly (SMD -0.25, 95% CI -0.41 to -0.09). Against therapies guidelines do not endorse, pain fell 7.48 points more (95% CI -11.50 to -3.47), which the reviewers did not count as clinically better, and function improved (SMD -0.41). Results were similar at intermediate and long-term follow-up [3]. An earlier Cochrane review found a small, not clinically relevant, short-term effect on pain (mean difference -4.16, 95% CI -6.97 to -1.36) and function (SMD -0.22) against other interventions [4].
Population
47 trials with 9,211 adults, mostly aged 35 to 60 [3]. 26 trials with 6,070 participants [4].
Sources
[3], [4]
Caveats
The two reviews come from overlapping author groups and share trials. Heterogeneity could not be explained [3].
Moderate

Chronic low back pain, compared with sham manipulation

Mixed results: one small meta-analysis found manipulation eased low back pain more than sham, and two larger reviews rated the sham evidence too weak to settle.

Compared with sham manipulation [3][4][5]; inert interventions [4]

The numbers and sources
Effect
In 4 trials pooled against sham, symptoms improved more with manipulation (SMD -0.36, 95% CI -0.59 to -0.12) [5]. A review of 47 trials rated the evidence against sham low to very low in quality and called its effects uncertain [3]. An earlier Cochrane review found very low-quality evidence that manipulation was not significantly better than inert interventions or sham for short-term pain or function [4].
Population
9 trials, 4 pooled, in nonspecific low back pain [5]. 9,211 adults [3]. 6,070 participants [4].
Sources
[5], [3], [4]
Caveats
The practitioner cannot be blinded, several sham trials were small, and some had high dropout [5].
Moderate

Immune markers in blood

Mixed results: in 6 trials, manipulation did not change lymphocyte levels against sham, while some immune markers changed briefly in people without symptoms.

Compared with sham manipulation [13]; a lecture series [13]; blood draw only [13]

The numbers and sources
Effect
Spinal manipulation was not associated with changes in lymphocyte levels or physiological markers in people with low back pain or without symptoms. It was associated with short-term changes in selected immune biomarkers in people without symptoms. The reviewers found no clinical evidence that manipulation changes immune system outcomes [13].
Population
529 participants in 6 high- and acceptable-quality trials [13].
Sources
[13]
Caveats
The reviewers call the clinical relevance of the short-term biomarker changes unknown [13].

Not shown to help3

Moderate

Migraine, compared with sham manipulation

Not shown to reduce migraine days more than sham manipulation. Migraine days fell in both groups, and the trial authors attributed the effect to a placebo response.

Compared with sham manipulation [9][10]; usual drug treatment [9]

The numbers and sources
Effect
In 104 people with migraine, migraine days fell from baseline in the manipulation, sham and usual care groups, and the reduction did not differ between groups. Migraine duration and headache index fell more with manipulation than with usual care by the end of follow-up [9]. A systematic review of high- and acceptable-quality trials found manipulation was not superior to sham for migraine [10].
Population
104 adults with at least one migraine a month in Norway [9]. 6 trials with 534 participants across several conditions [10].
Sources
[9], [10]
Caveats
One trial of migraine passed the review's quality bar [10]. Blinding was sustained throughout the trial [9].
ModerateStudied in children

Infant colic, when parents did not know the treatment

Not shown to reduce infant crying when parents did not know whether their baby had been treated, and not shown to differ from sham in a systematic review.

Compared with control conditions with parents blinded [11]; sham interventions [10]

The numbers and sources
Effect
In trials at low risk of performance bias, where parents were blinded, crying did not fall significantly (mean difference -0.57 hours a day, 95% CI -2.24 to 1.09) [11]. A systematic review of high- and acceptable-quality trials found manipulation was not superior to sham for infantile colic [10]. A second review rated the evidence for gentle mobilization in colic very low and the effect uncertain [12].
Population
Infants in 2 trials with parents blinded [11]. Trials of infantile colic among 6 trials of non-spine conditions [10]. 26 studies of manual therapy in infants, children and adolescents [12].
Sources
[11], [10], [12]
Caveats
Few small trials. The two reviews of sham-controlled and blinded trials agree with each other and differ from the pooled result of all trials [10][11].
Moderate

Asthma, high blood pressure and period pain

Not shown to treat asthma in children, high blood pressure or period pain. Every high- or acceptable-quality trial found manipulation no better than sham.

Compared with sham interventions [10]

The numbers and sources
Effect
All randomized trials of acceptable or high quality found spinal manipulation was not superior to sham for infantile colic, childhood asthma, hypertension, primary dysmenorrhea and migraine. No trial tested whether manipulation prevents any of these conditions [10].
Population
6 randomized trials with 534 participants [10].
Sources
[10]
Caveats
Few trials for each condition. Six of the 50 researchers at the review summit did not approve the final report [10].

Claimed, not studied in people1

Untested

Preventing infections or boosting immunity

Not studied in people. A systematic review found no clinical study of spinal manipulation preventing infectious disease or improving its outcomes.

No study in people. This rests on how it acts in the body.

The numbers and sources
Effect
Reports posted by a chiropractic trade association in March 2020 claimed adjustments affect the immune system. More than 150 researchers from 11 countries reviewed the reports and found no valid clinical evidence for the claim [14]. A systematic review searching to April 2020 found no clinical studies of manipulation for preventing infectious disease or improving outcomes in people with one [13].
Population
No study population. Two association reports reviewed [14], and 13 studies screened [13].
Sources
[14], [13]
Caveats
The claim rests on a proposed link between the spine, the nervous system and immunity, not on any trial in people [14].

Protocols studied

The back pain reviews pooled high-velocity, low-amplitude thrusts and other manipulation given by chiropractors, physical therapists, osteopaths and physicians [3][6]. The neck pain review separated single sessions from multiple sessions, and neck from thoracic manipulation [7]. Migraine trials lasted 2 to 6 months [8], and the sham-controlled migraine trial gave 3 months of chiropractic manipulation against a sham push on the edge of the shoulder blade or the buttock [9]. Infant trials used gentle, low-velocity mobilizations more often than thrusts [12].

Risks

Reported risks4

ModerateVery common

Soreness, stiffness and headache after treatment

Shown in 50% to 67% of patients in large case series, as brief soreness, stiffness or headache. Pooled trials found mild events no more often than with control treatments.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Minor, transient adverse events such as increased pain, muscle stiffness and headache were reported 50% to 67% of the time in large case series [6]. In 14 trials of neck manipulation, the rate of adverse events did not differ from control interventions, and every reported event was mild [15]. In one trial powered to look at harm, adverse events did not differ from sham manipulation (RR 1.24, 95% CI 0.85 to 1.81) [3].
Population
Large case series of patients treated with manipulation [6]. 14 randomized trials [15]. 183 participants in one trial [3].
Sources
[6], [15], [3]
Caveats
Most trials did not record adverse events systematically [3].
ModerateHow often is not known

Neck artery tears and stroke after neck manipulation

Linked to artery tears and stroke in adults under 45 in case-control studies. Case-crossover studies found the same link with doctor visits, attributed to tears already present.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
In Ontario, people under 45 with a vertebrobasilar stroke were 5 times as likely as matched controls to have seen a chiropractor in the week before (95% CI 1.32 to 43.87) [16]. In a US case-control study, vertebral artery dissection was associated with spinal manipulation in the previous 30 days (OR 6.62, 95% CI 1.4 to 30), after adjusting for neck pain [17]. In 818 vertebrobasilar strokes over more than 100 million person-years, people under 45 were about 3 times as likely to have seen a chiropractor, and also a primary care doctor, before their stroke. The same held when each case was compared with their own earlier periods, and there was no excess risk with chiropractic care over primary care [18]. In 15,523 carotid strokes, associations with chiropractic and primary care visits were similar [19]. In 1,829 US strokes, chiropractic visits were not significantly associated with vertebrobasilar stroke [20]. A meta-analysis of 6 studies found a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26 to 2.41), at very low quality, and no convincing evidence of causation [21]. The American Heart Association states that most population studies found an association in young patients, that it is unclear whether this reflects unrecognized existing dissections or trauma from manipulation. It advises informing patients of the association before neck manipulation [22].
Population
582 cases and 2,328 controls in Ontario [16]. 51 patients with dissection and 100 controls under 60 [17]. 818 vertebrobasilar strokes [18]. 15,523 carotid strokes [19]. 1,829 strokes in US health plans [20]. 6 studies [21].
Sources
[16], [17], [18], [19], [20], [21], [22]
Caveats
Dissection itself causes neck pain and headache, the symptoms that bring people to a chiropractor, so people may arrive with a tear already forming. Billing records do not show whether manipulation was actually given [20]. Neither study design can give the number of strokes caused per treatment, and no rate has been established [22].
ModerateHow often is not known

Serious adverse events overall

Serious events are rare in published estimates, from 1 per 2 million manipulations to 13 per 10,000 patients, and none was reported in trials of acute back pain.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
A scoping review of 250 articles found serious adverse event estimates ranging from 1 per 2 million manipulations to 13 per 10,000 patients, including spinal or neurological problems and cervical artery strokes [23]. No trial of acute low back pain reported a serious adverse event [6]. In older adults, stroke of any type within 7 days was 1.2 per 1,000 after chiropractic visits and 1.4 per 1,000 after primary care visits for neck pain (HR 0.39), and slightly higher at 30 days (HR 1.10) [24]. In one chronic back pain trial, a safety board judged one serious adverse event possibly related to manipulation [3].
Population
250 articles [23]. 26 trials [6]. 1,157,475 Medicare beneficiaries aged 66 to 99 [24]. 47 trials [3].
Sources
[23], [6], [24], [3]
Caveats
The estimates span two frequency bands and come from different designs. The reviewers write that incidence and cause are hard to establish [23].
LimitedStudied in childrenHow often is not known

Harms in infants and children

Case reports: 9 serious events, including brain bleeding and paralysis, and 20 delayed diagnoses were reported after spinal manipulation in children.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
A review of 13 studies found 14 direct adverse events in children, 9 of them serious, including subarachnoid hemorrhage and paraplegia. Another 20 cases involved delayed diagnosis of conditions such as diabetes, neuroblastoma and meningitis [25]. A later review found 5 case reports of severe harm after high-velocity thrusts in 4 infants and 1 child, and mild, transient harms after gentle mobilizations [12].
Population
Children aged 18 or younger in 13 studies [25]. 26 studies in infants, children and adolescents [12].
Sources
[25], [12]
Caveats
Neither causation nor incidence can be drawn from these reports [25]. The later reviewers write that severe harms were scarce, poorly described and likely tied to missed underlying disease [12].

Claims tested and not found

  1. That chiropractic manipulation reduces migraine days more than sham. In 104 people, migraine days did not differ between manipulation and sham [9].
  2. That spinal manipulation treats asthma, high blood pressure or period pain. High- and acceptable-quality trials found it no better than sham [10].
  3. That manipulation reduces colic crying when parents do not know the treatment. Crying did not fall significantly in trials with parents blinded [11].
  4. That spinal manipulation raises lymphocyte levels. Lymphocyte levels did not change against sham in 6 trials [13].

Sources

  1. National Center for Complementary and Integrative Health. Chiropractic: In Depth. 2019. https://www.nccih.nih.gov/health/chiropractic-in-depth
  2. National Center for Complementary and Integrative Health. Spinal Manipulation: What You Need To Know. 2022. https://www.nccih.nih.gov/health/spinal-manipulation-what-you-need-to-know
  3. Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019. https://doi.org/10.1136/bmj.l689
  4. Rubinstein SM, van Middelkoop M, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews. 2011. https://doi.org/10.1002/14651858.CD008112.pub2
  5. Ruddock JK, Sallis H, Ness A, et al. Spinal Manipulation Vs Sham Manipulation for Nonspecific Low Back Pain: A Systematic Review and Meta-analysis. Journal of Chiropractic Medicine. 2016. https://doi.org/10.1016/j.jcm.2016.04.014
  6. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017. https://doi.org/10.1001/jama.2017.3086
  7. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database of Systematic Reviews. 2015. https://doi.org/10.1002/14651858.CD004249.pub4
  8. Rist PM, Hernandez A, Bernstein C, et al. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache. 2019. https://doi.org/10.1111/head.13501
  9. Chaibi A, Benth JŠ, Tuchin PJ, et al. Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. European Journal of Neurology. 2016. https://doi.org/10.1111/ene.13166
  10. Côté P, Hartvigsen J, Axén I, et al. The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropractic & Manual Therapies. 2021. https://doi.org/10.1186/s12998-021-00362-9
  11. Dobson D, Lucassen PL, Miller JJ, et al. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews. 2012. https://doi.org/10.1002/14651858.CD004796.pub2
  12. Driehuis F, Hoogeboom TJ, Nijhuis-van der Sanden MWG, et al. Spinal manual therapy in infants, children and adolescents: A systematic review and meta-analysis on treatment indication, technique and outcomes. PLOS ONE. 2019. https://doi.org/10.1371/journal.pone.0218940
  13. Chow N, Hogg-Johnson S, Mior S, et al. Assessment of Studies Evaluating Spinal Manipulative Therapy and Infectious Disease and Immune System Outcomes: A Systematic Review. JAMA Network Open. 2021. https://doi.org/10.1001/jamanetworkopen.2021.5493
  14. Côté P, Bussières A, Cassidy JD, et al. A united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity. Chiropractic & Manual Therapies. 2020. https://doi.org/10.1186/s12998-020-00312-x
  15. Pankrath N, Nilsson S, Ballenberger N. Adverse Events After Cervical Spinal Manipulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Pain Physician. 2024. https://doi.org/10.36076/ppj.2024.7.185
  16. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001. https://doi.org/10.1161/01.STR.32.5.1054
  17. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003. https://doi.org/10.1212/01.WNL.0000063305.61050.E6
  18. Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008. https://doi.org/10.1097/BRS.0b013e3181644600
  19. Cassidy JD, Boyle E, Côté P, et al. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. Journal of Stroke and Cerebrovascular Diseases. 2017. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.10.031
  20. Kosloff TM, Elton D, Tao J, et al. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropractic & Manual Therapies. 2015. https://doi.org/10.1186/s12998-015-0063-x
  21. Church EW, Sieg EP, Zalatimo O, et al. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016. https://doi.org/10.7759/cureus.498
  22. Biller J, Sacco RL, Albuquerque FC, 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. https://doi.org/10.1161/STR.0000000000000016
  23. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropractic & Manual Therapies. 2017. https://doi.org/10.1186/s12998-017-0168-5
  24. Whedon JM, Song Y, Mackenzie TA, et al. Risk of stroke after chiropractic spinal manipulation in Medicare B beneficiaries aged 66 to 99 years with neck pain. Journal of Manipulative and Physiological Therapeutics. 2015. https://doi.org/10.1016/j.jmpt.2014.12.001
  25. Vohra S, Johnston BC, Cramer K, et al. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007. https://doi.org/10.1542/peds.2006-1392

Everything in the library