Spinal Manipulation: Where Does It Fit in Modern Sports Therapy?
Spinal manipulation can be a controversial subject.
Some people swear by it.
Others question whether someone should be "putting their spine back into place".
The reality is considerably more nuanced.
Your spine probably isn't "out of place"
One of the most important things to understand is that spinal manipulation shouldn't be explained using the idea that a vertebra has simply "popped out" and needs putting back in.
The human spine is strong, mobile and constantly adapting to movement.
Manipulation involves applying a controlled manual force to a spinal joint. It can produce an audible popping or clicking sound, but that sound isn't evidence that a bone has been put back into position.
Can manipulation help back pain?
There is evidence that spinal manipulative therapy can provide some benefit for people with chronic low back pain.
A recent Cochrane review found that spinal manipulative therapy may slightly reduce pain and improve function compared with sham treatment, and may provide greater benefits compared with no treatment. Temporary muscle soreness or an increase in back pain can occur.
But the effects shouldn't be exaggerated.
For many people, manipulation is best considered one tool within a broader rehabilitation programme, rather than a standalone cure.
What does NICE recommend?
NICE recommends that manual therapy, including spinal manipulation, mobilisation and soft-tissue techniques, can be considered for low back pain — but only as part of a treatment package that includes exercise, with or without psychological therapy.
That is an important principle.
If someone receives a manual treatment and then goes home without any plan to improve their physical capacity, the underlying problem may not be fully addressed.
What does WHO say?
The World Health Organization's 2023 guideline for chronic primary low back pain says spinal manipulative therapy may be offered to adults, including older adults.
However, it describes the recommendation as conditional, with very low certainty evidence.
Again, this doesn't mean the treatment should never be used.
It means practitioners and patients should have realistic expectations.
Where can it fit into rehabilitation?
Imagine someone develops persistent back pain and becomes nervous about movement.
A suitable treatment programme might include:
Education: Understanding that movement is generally beneficial.
Manual therapy: Potentially helping symptoms and making movement easier in the short term.
Exercise: Developing strength, mobility and confidence.
Functional training: Gradually returning to lifting, walking, sport or other activities.
Self-management: Giving the person tools they can continue using independently.
The ultimate objective is not to make someone dependent on treatment.
It's to help them become more confident and physically capable.
Is spinal manipulation suitable for everyone?
No.
A thorough assessment should come first, particularly in older adults or people with significant medical conditions, osteoporosis risk, neurological symptoms, unexplained symptoms or other potential contraindications.
The treatment should be delivered by an appropriately trained professional who can determine whether it is appropriate.
Spinal manipulation should be viewed as one possible component of care — not as a replacement for exercise, education and progressive rehabilitation.
References
National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59).
World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. 2023. WHO low back pain guideline
WHO/NCBI Bookshelf. Evidence and recommendations — spinal manipulative therapy.
Cochrane. What are the benefits and risks of spinal manipulative therapy for chronic low back pain?
NICE. Osteoarthritis in over 16s: diagnosis and management. NICE recommends that manual therapy for hip or knee osteoarthritis should only be considered alongside therapeutic exercise.
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