When Should Manipulation Be Avoided?

Samuel Homola, D.C.
January 22, 2004

What are the risk factors for chiropractic care; and would you please define what techniques cause these risks?


Spinal manipulation is relatively safe. Manipulation of the thoracic (chest) and lumbar (low back) spine is rarely dangerous unless (a) the vertebrae or ribs have been softened by osteoporosis, malignancy, or prolonged use of corticosteroids; (b) the patient takes anticoagulant medication; or (c) when spinal joints have been damaged by ankylosing spondylitis or another inflammatory condition. Despite claims by chiropractors that “pinched nerves” cause most human ailments, manipulation is usually contraindicated when pain or numbness radiate down an arm or a leg because of nerve root pressure caused by disc herniation or spur formation. Cauda equina syndrome (loss of bladder or bowel control) can occur when excessively forceful or inappropriate manipulation forces a herniated disc near the bottom of the spine into the spinal canal, compressing spinal nerves that control the voluntary function of bladder and anal sphincter muscles.

Neck manipulation can cause a strokes in apparently healthy people. Although such strokes are uncommon, no one really knows the incidence because definitive studies have not been done and most cases are not been reported or recognized as such. A recent review indicates that stroke can occur in patients under the age of 45 as a result of excessive rotation of the top two vertebrae (atlas and axis).

Any decision about neck manipulation should weigh risks against benefits. Neck manipulation should not be done unless absolutely necessary in carefully selected cases—and only then with the informed consent of the patient; it should never be done for an asymptomatic patient or as a “preventive” measure. Neck manipulation with head rotation greater than 50 degrees should probably never be done. Mobilization, massage, and traction are safer than any kind of neck manipulation.

Stay away from chiropractors who say that every patient needs neck manipulation, especially those chiropractors who believe that most ailments are caused by “subluxated” or misaligned upper cervical vertebrae. Such chiropractors often say that they “analyze” the spine rather than offer a diagnosis. They may also say that they do not treat disease; they simply use spinal adjustments to correct subluxations so that “the body can heal itself.”


Dr. Homola is a second-generation chiropractor who has dedicated himself to defining the proper limits on chiropractic and to educating consumers and professionals about the field. His 1963 book Bonesetting, Chiropractic, and Cultism supported the appropriate use of spinal manipulation but renounced chiropractic dogma. His 1999 book Inside Chiropractic: A Patient’s Guide provides an incisive look at chiropractic’s history, benefits, and shortcomings. Now retired after 43 years of practice, he lives in Panama City, Florida.

This article was posted on January 22, 2004.