The treatment involves locating, diagnosing and correcting.

Spinal Adjustments and Naturopathy

Naturopathic Physicians as well as chiropractors, are licensed in British Columbia to use spinal manipulations (adjustments) within their scope of practice.  This treatment involves locating, diagnosing and correcting joint and associated muscular dysfunction.  These joint disturbances are called subluxations or fixations, which indicates locking, or misalignment of spinal or extremity joints. Subluxations can result in abnormal joint movement and be a cause of pain.  The treatment involves the gentle re-setting of the joint restriction by adjustment.  The adjustment may cause a clicking sound, or may be a gentle low force maneuver, which is barely felt.  There are a great variety of techniques available to best address your needs.

Spinal Adjustment

The effect of the adjustment is to improve mobility and nerve function throughout the entire body. Consequently, you not only feel better, but also the improved autonomic nervous system effect will regulate circulation to all muscles and tissues as well as directly improve organ function, resulting in an overall health benefit.

The benefits of cervical spinal adjustments upon neck pain, whiplash, and headache have been extensively outlined in the Annals of Internal Medicine [1].  A systematic review of 20 randomized clinical trials has addressed this issue, with the majority indicating positive, and the remainder yielding equivocal results.  Neither negative results, nor significant adverse events to these cervical manipulations were shown [2,3].

Forty-three randomized trials of spinal manipulation for treatment of acute, subacute, and chronic low-back pain have been published.  Thirty favored manipulation over the comparison treatments in at least a subgroup of patients, and the other 13 found no significant differences [4].

Studies of the naturopathic approach to treating low back pain have demonstrated statistically significant benefits.

This study concluded that Naturopathic treatment was shown to have significant (95% CI) benefit in decreasing disability and pain due to chronic low back pain. Pain medication use was significantly reduced, and quality of life measures dramatically improved. The most significant changes occur within the first 4 weeks of Naturopathic treatment. In this industrialized setting, it appears that not only were Naturopathic treatments effective, but an individualized approach to back pain resulted in greater benefits compared with a physiotherapy equivalent previously shown to be effective.[27]

Risks of Manipulation Therapy

As with any therapeutic procedure there are possible side effects and risks involved.  Complications are rare and may include strain or sprain of spinal joints and muscles, fractures, or injury to discs or nerve roots.

Non-Serious Effects of Spinal Manipulation

50% of spinal manipulations will result in

mild and short term effects

A 2001 independent literature review of the most valid studies to identify the safety of spinal manipulation, suggests that about half of all patients will experience adverse events after spinal manipulation.  These events, although frequent, are usually mild and transient.  [26]

A 1997 study, reported in Spine, questioned 1058 new patients after 4712 treatments by 102 Norwegian chiropractors.  The results showed that at least one reaction was reported by 55% of the patients.  The most common were:

• Local discomfort (53%)
• Headache (12%)
• Tiredness (11%)
• Radiating discomfort (10%).
• Reactions were mild or moderate in 85% of patients.
• Sixty-four percent of reactions appeared within 4 hours of treatment
• 74% had disappeared within 24 hours.
• There were no reports of serious complications in this study.[25]

Serious Risks to Spinal Manipulation

The most serious, but rare risk, is that of a vertebral or coratid artery dissection or stroke following cervical manipulation.  A recent research article in the Canadian Medical Association Journal determined the risk of such a stroke to occur in 1 out 5.85 million cervical manipulations [5].  Another study determined that there was a risk of 1.3 strokes per 100,000 manipulations one week after a manipulation [6].  These authors state the bias in their study regarding the cause and effect nature of their analysis. That is there is no way to determine whether a manipulation one week before a stroke had any relationship to the onset.  As a comparison the rate of spontaneous vertebral artery dissection without manipulation is estimated to be about 1- 3 per 100,000 persons [7,8,9], about the same rate attributed to spinal manipulation.  Many persons suffer spontaneous stroke from everyday activities such as turning the head, looking at the sky, shoulder checking while driving, holding a telephone against the shoulder, getting a hair shampoo at the beauty parlour, doing yoga and many more common activities.  Other studies rank the risk of stroke from cervical manipulation to be 1 per 500,000 [10]; 0.65 per million [11]; 1per 3 million [12]; 0 in 5 million [13,14].

The research is not clear as to whether neck manipulations may be a cause of stroke or a triggering factor in already vulnerable arteries.

Recent biomechanical research has studied the strain, if any, that cervical adjustment may place on the vertebral arteries.  The preliminary findings indicate that the movement of joints during cervical adjustment is done well within the normal range of motion and that cervical adjustment is " very unlikely to mechanically disrupt the vertebral artery" [15].

It is not possible to predict who specifically would be at risk for a stroke from cervical manipulation, but it is possible to recognize possible risk factors in your case history and examination and advise you appropriately.  These may include a history of stroke, transient ischemic attacks (TIA), severe hypertension, and vascular disease.

Although spinal manipulation is associated with a very small but serious risk of complication, some patients occasionally choose to forgo high velocity low amplitude manipulation even with the precautions described in the side bar.  In these cases, there are many other options for correcting spinal fixations/subluxations and relieving pain and discomfort without the use of conventional manipulation techniques, Often utilizing what are referred to as "low force techniques". These might include using Muscle release techniques, Activator Methods, Toggle adjustments, or other methods.

Other therapies that would be alternative methods of spinal correction or complement the effectiveness of manipulation therapy include:

Activator adjustment, toggle adjustment, acupuncture, Muscle Release Techniquesart, applied kinesiology, life style counselling, therapeutic exercises, prolotherapy. trigger point injection, neural therapy, scar therapy, hyaluronic acid injection, NET.

Risks of Remaining Untreated

Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes.  These changes can reduce skeletal mobility and induce and maintain a chronic pain condition.  Delay of appropriate treatment may complicate a condition, impede future recovery and prevent healing of the underlying injury.  Impaired mobility will restrict activity and limit exercise that will consequently have a serious negative impact on your health and well being.  As one of my teachers used to say: "use it or lose it".

Comparative Risks

The risk of spinal manipulation needs to be put into perspective compared to no treatment at all and to the risks of other treatments available.

As explained earlier the risk of stroke from vertebral artery dissection following cervical manipulation is similar to the risk of spontaneous dissection.  An editorial in the Canadian Journal of Neurological Science indicates that no clear cause and effect relationship has been established [18].  Clearly more study is required to determine whether there is a risk relationship between cervical manipulation and stroke, what that risk might be and what screening methods are most reliable.  

 Many people with untreated neck pain and headaches take NSAIDS (non-steroid anti-inflammatory drugs).  These include Aspirin, Ibutrophen, and Advil etc.  The New England Journal of Medicine claims that in the U.S. 16,500 people die each year from the use of these medications [19].  That is about 1 death for every 20,000 Americans per year (not all Americans are using NSAIDS). Recently the New York Times [20] reported that the FDA announced that 450 Americans die each year from the use of acetaminophen (Tylenol).  There are 1 billion pills sold annually, calculations show us that there is one death per 2.22 million acetaminophen pills sold. Note that these statistics question the safety of using medication as opposed to cervical manipulation.  In fact there is a greater risk of death from power boating, pregnancy, taking birth control pills, driving a car and other normal activities than from receiving a neck adjustment [21].  Less conservative treatments such as neck surgery are also used for conditions very similar to the conditions treated with spinal manipulation.  There is a 3-4% rate of complication for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries [22].

If you are considering lumbar spinal surgery, realize that there is a risk of death of 7 persons per 10,000 surgeries [23].  

In risk management practices, 1 per million risks are considered acceptable, where as 1 per 100,000 risks are generally considered unacceptably high [24].  

Let's put the concept of risk into perspective. This 2007 article in the Vancouver Sun looks at many risks that we are prone to on a daily basis without serious consideration.  For example, a Canadian has a one in 226,165 chance of dying in a lawnmower accident, or a 1 in 255 chance of dying from poisoning.  Consider that you are 65 times more likely to be killed in an automobile crash than an airplane crash.

The History of Manipulation

REFERENCES