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Experts highlight dangers of spinal manipulation for neck pain


Neil O’Connell and colleagues at the Centre for Research in Rehabilitation at Brunel University have argued that cervical spine manipulation “may carry the potential for serious neurovascular complications” and claim that the technique is “unnecessary and inadvisable.”

In a debate on the British Medical Journal website, experts disagree over the effectiveness of spinal manipulation for patients who suffer from neck pain, and debate whether such manipulation should be abandoned because of its potential risks.

The technique involves the application of various types of thrusts to the lumbar spine (lower back) or cervical spine (neck) to reduce back pain, neck pain and other musculoskeletal conditions.

O’Connell explained: “Neck manipulation is associated with a small risk of very serious complications that might result in permanent disability or death. Manipulation does not offer impressive clinical results and since there are a range of equally effective alternative treatments available for which there are no such concerns there is little reason to continue putting patients at risk.”

He added: “We strongly suggest that neck manipulation should be abandoned. Studies provide consistent evidence of an association between neurovascular injury and recent exposure to cervical manipulation.” Such injuries include vertebral artery dissection (a tear to the lining of the vertebral artery, which is located in the neck and supplies blood to the brain) and stroke. Other trials reinforce this message, suggesting that manipulation is does not results in superior outcomes when directly compared with other physical interventions such as exercise.

However, Professor David Cassidy and colleagues at the Dalla Lana School of Public Health, University of Toronto, argue that neck manipulation is a valuable addition to patient care. They point to evidence that “clearly suggests that manipulation benefits patients with neck pain” which raises doubt about any causal (direct) relation between manipulation and stroke. They conclude: “We say no to abandoning manipulation and yes to more rigorous research on the benefits and harms of this and other common interventions for neck pain.”

Notes to Editors

View the O’Connell paper

View the Cassidy paper

For further information contact Emma Dickinson, BMJ Group Press Officer, on +44 (0)20 7383 6529 or +44 (0)7825 118107, or visit the BMJ website. Alternatively please contact Brunel University Press Office on +44 (0)1895 26585 or by email at