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Key points
- Spinal manipulation gives similar results to other recommended treatments for chronic low back pain. It is an option, not a superior one.
- NICE says manual therapy should only be considered as part of a package that includes exercise, never on its own.
- Minor side effects such as soreness and stiffness are common. Serious harm is rare, but neck manipulation has a recognised link with artery tears and stroke that you should know about before agreeing to it.
- In the UK, chiropractors and osteopaths must be registered by law. Check the register before you book.
What chiropractors and osteopaths do
Chiropractic and osteopathy are separate professions with their own training and history, but for back and neck pain they overlap a great deal. Both use hands-on techniques: massage and stretching of soft tissues, mobilisation (slow, repeated movement of a joint) and manipulation (a quick, small thrust to a joint, sometimes with a click). The NHS describes chiropractic as using massage and stretching to try to keep bones, joints and muscles healthy, and osteopathy as using massage and stretching to treat injuries, improve movement and relieve pain.[1]
Most people see a chiropractor or osteopath privately. The NHS lists them among complementary therapies, which are not tested in the same way as standard medicines.[1]
Regulation in the UK
Unlike many complementary therapies, both professions are regulated by law. The General Chiropractic Council (GCC) regulates chiropractors in the UK, and it is a criminal offence to describe yourself as a chiropractor without being registered with it.[2] The General Osteopathic Council (GOsC) does the same job for osteopaths, and it is against the law to call yourself an osteopath unless you are on its register.[3] Both councils have free online registers. Checking takes a minute and is worth doing.
What NICE recommends
NICE guidance on low back pain and sciatica (NG59) says to consider manual therapy, including spinal manipulation, mobilisation or soft tissue techniques such as massage, but only as part of a treatment package that includes exercise.[4] NICE also advises against traction. In practice this means a course of manipulation on its own, without a plan to get you moving and exercising, falls short of what the guideline supports.
What the evidence shows
Low back pain
A systematic review in the BMJ pooled 47 trials with over 9,000 people with chronic low back pain.[5] Moderate-quality evidence showed that spinal manipulation had similar effects on pain to other recommended treatments, with a small extra improvement in function. Compared with treatments that are not recommended, manipulation did slightly better. Put simply, manipulation is a reasonable option alongside other recommended care, but not a better one. Two of the authors declared funding from chiropractic organisations, which the review reports openly.
Neck pain
For neck pain, a Cochrane review of 51 trials found that the results for neck manipulation and mobilisation compared with no treatment were few and inconsistent.[6] Manipulation and mobilisation produced similar results to each other. Manipulation of the upper back (thoracic spine) had more support. The reviewers pointed out that because rare but serious adverse events from manipulation exist, more research comparing it with gentler options is needed.
Side effects and risks
Most side effects are minor: soreness, stiffness or a headache that settles within a day or two. In the BMJ review, most adverse events were musculoskeletal, short-lived and mild to moderate.[5]
Neck manipulation and stroke
The concern that matters most is cervical artery dissection: a small tear in the lining of one of the arteries in the neck, which can lead to a stroke. The American Heart Association reviewed this in 2014.[7] It found that most population studies show an association between neck manipulation and this type of stroke in younger patients, although the evidence is not strong enough to prove that manipulation causes it. The risk is probably low. The statement recommends that patients are told about this association before neck manipulation.
There is another side to the story. A dissection often causes neck pain and headache before the stroke happens, so some people may already have a tear when they go for treatment. A large Canadian study found that people under 45 with this type of stroke were about three times more likely to have seen either a chiropractor or a GP in the year before, and found no extra risk with chiropractic compared with GP visits.[8] The authors thought early symptoms of the dissection were driving both.
If you have a sudden, severe or unusual neck pain or headache, especially with dizziness, double vision, slurred speech, difficulty swallowing or weakness, you need a medical assessment, not a manipulation. If you choose neck treatment, it is reasonable to ask for mobilisation and exercise rather than a high-velocity thrust.
Who should avoid manipulation
The NHS says chiropractic or osteopathy may not be safe if you:[1]
- take blood-thinning medicines or have an increased risk of bleeding or stroke
- have bones or joints that are very weak or seriously damaged
- have a condition affecting your nerves, such as peripheral neuropathy
We would add anyone with progressive weakness or numbness in the legs, recent spinal surgery, or suspected nerve compression from a slipped disc or spinal stenosis. These need a proper medical assessment first.
Getting good value from treatment
- Check registration with the GCC or GOsC before your first visit.
- Expect a full history and examination, and a clear explanation of what is proposed and why.
- Ask how many sessions are planned and how you will judge whether it is working. Be cautious about large prepaid packages.
- Make sure exercise and advice on staying active are part of the plan.
- You can say no to neck manipulation and ask for gentler techniques.
- Be wary if you are told you need X-rays before treatment for straightforward back pain. NICE advises against routine imaging outside specialist settings.[4]
Seek urgent medical help (A&E or 999) if you have:
- Sudden severe neck pain or headache with dizziness, double vision, slurred speech, difficulty swallowing, or weakness or numbness of the face or limbs
- Numbness around the genitals or bottom, or new problems with bladder or bowel control
- New or worsening weakness in the legs
- See our guide to cauda equina syndrome
References
- NHS. Herbal medicines and complementary therapies. Page last reviewed 1 May 2026. Link
- General Chiropractic Council. What we do. Link
- General Osteopathic Council. Protecting the title ‘osteopath’. Link
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, last updated 2026. Link
- Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. Link
- Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249. Link
- Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155-3174. Link
- Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008;33(4 Suppl):S176-S183. Link
This guide is general information and is not a substitute for advice about your own situation. Please speak to your GP, physiotherapist or specialist before starting a new treatment.
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