Should Your Chiropractor Adjust Your Neck?

Cervical spine manipulation is controversial, should it be abandoned?

If you’ve been to a chiropractor for neck pain, shoulder pain, headaches, or other musculoskeletal ailments, part of your treatment plan may have included having your neck adjusted.

Adjustments or joint manipulation by a chiropractor or other health care provider (DO, DPT, MD sometimes perform them as well) entails a quick but short impulse into a joint to move the joint just beyond its normal range of motion. This high velocity but low amplitude thrust may result in the characteristic “crack” so commonly associated with the chiropractic profession.

If you’ve never had an adjustment or had your neck adjusted, the whole process can be scary and produce anxiety. “Will this hurt?” “Can you break my neck?” “Is this my only option?” are some of the questions I get when I propose this intervention for a patient’s health complaint.

Will This Hurt?

Hopefully not. The goal of therapeutic interventions should be to make you feel better, not worse. However, the most commonly reported side effect of joint manipulation is local soreness. Neck manipulation does carry with it an association with a type of stroke, but the relationship has never been deemed causal. Still, as with any health care intervention, the risk of mild/moderate/severe adverse events is never zero. I’ve never fractured anyone’s rib by adjusting their middle back but I know of other chiropractors who have. The point is even seemingly benign things can cause harm to a certain person or patient population.

Is the fact that there is an association with a potentially deadly adverse event, cervical artery dissection leading to stroke, enough to abandon performing cervical spine manipulation altogether? In my opinion, the answer is no, some others would say yes.

Some patients in my experience have been at their wit’s end and have tried medications, yoga, PT, steroid packs, and neck manipulation was the only thing that worked for them. Could they have tried other things that may have worked? Sure, but when dealing with pain, the consumer has a whole supermarket of options available. Creams, injections, medications both prescription and OTC, physical therapy, general or specific exercise programs, the list goes on and on.

If you’re at the chiropractor though I’m going to assume you value a few things.

1. You want to know what is wrong, will a chiropractor help, how long will it take, and how much will it cost. A good chiropractor is going to listen to you, perform an exam, offer a diagnosis and a plan, and receive approval from the patient before beginning treatment. Costs vary by region and practitioner but when it has been studied, the cost of chiropractic care tends to be very cost-effective.
2. You value that the treatment will be conservative. By that, I mean gentle, non-invasive, and without drugs or surgery. These things do not equate to “better”, I have no problem with medications or surgery, I’ve referred for them and utilized them myself, but again, if you’re in my office I’m going to assume you value one or more aspects of conservative care.
3. You are hoping that a hands-on treatment will be effective where maybe other interventions haven’t or would not be effective. There is a lot to be said for the healing power of touch, and it is my opinion, as well as being supported in the scientific literature, that a large part of what makes patients better, irrespective of the actual treatment used, is twofold: you as the health care provider listen to their story and you acknowledge their pain points. Those pain points can be biological, social, psychological, or a combination. One way to acknowledge a person’s pain is through touch, which is one reason why I think chiropractors have been so effective throughout the decades.

Coming back to neck adjustments.

Do I perform them in my office? Almost every day. Do I think they are absolutely necessary? No.

Evidence-based practice can be envisioned as a three-legged stool.

On one leg there is the best available evidence. In terms of cervical spine manipulation, the best available evidence suggests an association between neck cracking and a rare type of stroke. The second leg can be thought of as clinical expertise. Chiropractors receive more training and practice at joint manipulation than any of the other providers who may offer this service. That doesn’t make us experts automatically, I have colleagues I wouldn’t let anywhere near my neck (cough YouTube cough).

That training doesn’t let us off the hook if a practitioner (whether that be a chiro, PT, or other professional licensed to perform the technique) performs a shoddy history or exam, misses the signs of a stroke in progress, and decides to adjust the patient’s neck anyway.

This could be catastrophic to the patient, even resulting in death, but as far as I know, from the scientific literature I’ve seen, these rare events likely result from the failure to recognize a patient in the beginning stages of a stroke who is then adjusted. The neck manipulation alone has been studied and does not appear to supply enough force to damage healthy arteries.

This brings us to the third leg, patient preference, and values. Some of my patients swear by having their necks adjusted. It’s what has worked for them in the past, or has been recommended to them by a loved one or colleague.

They’ve often tried and failed to get relief from a host of over options. If after I perform my history and exam, inform the patient about possible side effects and risks, and offer them alternatives, they still wish to have their cervical spine adjusted, I don’t have a problem with it at all.

I’ve also declined to adjust patients before, I’ve even lost patients to other providers for not treating them in the way they expected, and I’m fine with that. If someone with osteoporosis and a pack-a-day smoking habit wants me to adjust their neck, it’s not happening. If their PCP just put them on a blood-thinning medication, it’s not happening. I’m aware that accidents happen, but I’m not looking for them to happen in my office.

Final Thoughts

Cervical spine adjustments or neck manipulation is a fraught topic in manual treatment of spine-related disorders. Some wish to abandon it completely, and some have chosen it as a hill to plant their flag.

As a practicing chiropractic physician, I’ve got to weigh the current evidence, which identifies an association between neck adjustments and a very rare type of stroke, with my patient’s preferences and my skill at performing the procedure.

Honestly, I could easily go the rest of my career never performing one of these adjustments again, there is after all research pointing to the efficacy of upper thoracic spine manipulation positively affecting neck pain in some patients, there are also other interventions besides manipulation or even hands-on treatment at all.

In the end, some patients are just going to prefer having their necks cracked, and they will seek out practitioners who are able and willing to perform the techniques — as evidenced by the truly horrifying neck adjustments rabbit hole on YouTube.

I’d rather have them come to me where I know they will at least receive a history and exam, assessment, and plan and I will get consent before the treatment occurs.

Unfortunately, I can’t make that assumption about some of my colleagues.