Contradictions in the literature exist in terms of the use of spinal manipulation
in the management of disc herniation, with some authors advocating its usefulness,
and others suggesting it is contraindicated.
To determine whether there is evidence from published reports on the clinical efficacy
of spinal manipulation in the management of disc herniation, and to relate this to
published data on harms.
The major databases (MEDLINE, AHMED, Cochrane and Clinical Evidence) up to February
2006 were searched, and four UK insurance companies used by osteopaths and chiropractors
were approached for information on incidence of adverse events.
Four randomised controlled trials (RCT) relevant to the clinical question of efficacy
were located. Three suggested some early benefit of manipulation compared to treatment
controls. One suggested no benefit, and none suggested any long-term benefit. Three
were of low methodological quality however, and one of better quality had very low
patient numbers. Evidence for harms is based primarily on case reports, and incidences
would appear to be rare, though underreporting may be a significant problem. No data
was available from the insurance companies on incidences of adverse events. Some of
the research on the effects of manipulation on the disc and the role of the disc in
the generation of symptoms is briefly reviewed.
There is a lack of strong evidence to support the role of spinal manipulation in disc
herniation, though some weak evidence suggests it may be beneficial in the early stages.
Some of the difficulties in gaining evidence on rare events and determining causality
is discussed. The underlying pathophysiological mechanisms of benefit or harm are
There is an urgent need for more research in this area in order to help practitioners
make decisions on benefit versus harm. It is likely to be safe when used by appropriately-trained
practitioners, however some of the reports discussed highlight the importance of a
thorough case history and physical examination. It would seem reasonable that patients
are warned of potential risk. Clinical guidelines within the osteopathic profession
on the management of disc herniation are needed, for the protection of both patients