Spinal Manipulation for Back Pain

Spinal manipulation is one of the most ancient forms of treatment for musculoskeletal complaints, primarily for back pain and neck pain.

This article originally appeared in the DKChiroBlog found at www.dkchiroblog.com on August 1, 2020. All references can be found in the original article. It is reprinted here for a more in-depth look at how spinal manipulation for back pain and neck pain works for the person who happens by the clinic website instead of the blog.

In 1992, Robert Anderson, MD, PhD, DC, was the Director of Manual Medicine at the San Francisco Spine Institute, as well as Professor of Anthropology at Mills College in Oakland, California.

At that time (1992), Scott Haldeman, DC, PhD, MD, was Associate Clinical Professor of Neurology at the University of California, Irvine, California.

In 1992, the second edition of Dr. Haldeman’s book, Principles and Practice of Chiropractic, was published. Dr. Anderson wrote the first chapter of Dr. Haldeman’s book, titled:

“Spinal Manipulation Before Chiropractic”

Spinal manipulation for back pain is one of the oldest treatments in the world. While many people think of chiropractic adjustments today, manipulation has been practiced for thousands of years in cultures across the globe. From ancient healers to modern science, spinal manipulation has consistently been used to relieve pain, restore movement, and improve quality of life.

This article explores the history of spinal manipulation, why people choose it for back pain, how it works, the scientific evidence that supports it, and what it means for patients today.

A History of Manipulative Therapy

Spinal manipulation is not a new idea. In fact, records show it was practiced more than 2,500 years ago. Ancient civilizations across Greece, Egypt, India, China, and Japan described manual therapies for spine-related pain.

• In Greece, Hippocrates — often called the father of medicine — described techniques to adjust the spine in 400 BCE.

• Roman surgeon Claudius Galen continued the tradition around 200 CE, documenting the use of manipulation for musculoskeletal disorders.

• Avicenna, a physician in Baghdad around 1000 CE, included descriptions of spinal manipulation in his famous medical text The Book of Healing.

Many other cultures also practiced their own versions, from shamans in Central Asia to bone setters in Norway, Mexico, and Nepal.

The modern era of spinal manipulation began in the United States. In 1874, Andrew Taylor Still founded osteopathy, emphasizing the musculoskeletal system’s importance in overall health. A few years later, D.D. Palmer established chiropractic in 1895, reasoning that spinal misalignments placed pressure on nerves and affected health. His son, B.J. Palmer, introduced X-rays to chiropractic care in 1910, advancing the field.

By the mid-1900s, chiropractic care had spread worldwide. After World War II, many veterans used the G.I. Bill to study chiropractic, helping it grow into the second-largest primary health care profession in the Western world.

The lesson is clear: spinal manipulation for back pain has a long and respected history across cultures.

“Nobody questions these early origins of manipulative therapy.”

Back pain is one of the most common health problems globally. Research shows that 80% of adults will experience it at some point in their lives, and at any given moment, about 20–30% of people are suffering from it.

A 2017 study published in Spine examined why people seek chiropractic care. The results were clear:

• 93% of patients visit chiropractors for musculoskeletal problems.

• 63% go specifically for low back pain.

• 30% go for neck pain.

When asked about effectiveness:

• 65% reported chiropractic care helped them “a great deal.”

• 26% said it helped “somewhat.”

• Only 3% said it did not help.

This shows why spinal manipulation for back pain continues to grow in popularity. Compared with medications, adjustments are drug-free, safe, and provide lasting relief without the risks of side effects or dependency.

Patients don’t just seek spinal manipulation because of pain — they choose it because it improves function, mobility, and quality of life.

How Does Spinal Manipulation Work?

So how does spinal manipulation actually relieve pain? There are two main explanations: restoring motion and controlling pain signals.

Restoring Joint Motion

When spinal joints stop moving properly — often due to injury, posture problems, or prolonged sitting — pain develops. Tissues tighten, adhesions form, and the body loses flexibility. Chiropractic adjustments restore motion by breaking down adhesions and stretching tight tissues. This improves mobility and reduces mechanical stress on the spine.

Canadian orthopedic surgeon Dr. William Kirkaldy-Willis explained that spinal manipulation works by:

• Restoring lost range of motion.

• Breaking up adhesions and fibrosis around the joints.

• Reducing stiffness and improving posture.

Closing the Pain Gate

The second explanation comes from the Gate Control Theory of Pain, developed in 1965 by Ronald Melzack and Patrick Wall. They discovered that when joints move properly, proprioceptive signals (feedback from muscles and joints) increase. These signals can actually “close the gate” in the nervous system, blocking pain messages from reaching the brain.

This means spinal manipulation doesn’t just restore movement — it changes how the brain perceives pain. When motion returns, the gate closes, pain decreases, and function improves.

Together, these mechanisms explain why spinal manipulation for back pain is effective for so many people.

How does chiropractic spinal manipulation
benefit people with spinal pain complaints?

The Concept of Proprioception

Proprioception is a sensory input from the peripheral musculoskeletal body (muscles, joints, tendons, ligaments, etc.) to the brain (central nervous system). Proprioceptive signals transmit mechanical information, especially mechanical factors such as position and movement. This concept is well-stated by attorney Chris Crowley and physician Henry Lodge, MD, in their book Younger Next Year, in a section they refer to as:

“The Balancing Act”

“Now it’s time to think about your brain and a concept called proprioception—the deceptively simple notion that you have to know where the different parts of your body are at all times.”

“Your body is aware of exactly where each limb is in space every second, because each muscle, tendon, ligament and joint sends thousands of nerve fibers back to the brain through the spinal cord. Those fibers signal every nuance gradation of contraction, strength, muscular tone, orientation, position and movement at every moment of the day.”

“Your brain keeps careful track of the location of every muscle and joint in you body every second, all day, every day, waiting for you to need the information.”

Proprioception is both conscious and subconscious. In 1965, researchers discovered an incredibly important function for proprioception: pain control.

In 1965, pain researchers became aware that the proprioceptive signals to the brain could block the pain signal to the brain. This concept was originally proposed by pain researchers Ronald Melzack and Patrick Wall. Their theory is known as the Gate Control Theory of Pain. Ronald Melzack, PhD, is a Canadian psychologist. Patrick Wall, MD (d. 2001), was a British neuroscientist and pain expert, as well as the first editor of the journal Pain.

In 2002, the British Journal of Anaesthesia published a study reaffirming the validity of the Gate Theory of Pain in an article titled:

Gate Control Theory of Pain Stands the Test of Time

An oversimplified explanation of their Gate Control Theory of Pain is that the pain electrical signal to the brain can be blocked by non-painful electrical signals arising from other sensory afferents, especially from joint proprioceptors. Practically, this would mean that prolonged or static positions would reduce proprioception, allowing the pain signal to more readily enter the brain for pain perception. Similarity, if a person’s joints lost or reduced their normal movement arc, there would be a proportionate reduction of the proprioceptive sensory input to the brain. This would allow pain signals to enter the brain because the pain gate would be open.

As noted above, chiropractic’s Daniel David Palmer believed that when a vertebra was out of alignment, it caused pressure on nerves (2). A specific directional manipulation (the chiropractic spinal adjustment) would improve alignment and reduce nerve pressure.

Palmer’s “nerve pressure” theory is probably correct in only a minority of chiropractic patients. It was officially challenged by a vocally pro-chiropractic orthopedic surgeon from Saskatchewan, CAN. Dr. William H. Kirkaldy-Willis published his theory as to how/why chiropractic spinal manipulation helped those suffering from back pain in the journal Canadian Family Physician in 1985 (35 years prior to this writing), titled:

Spinal Manipulation in the Treatment of Low Back Pain

Today, advanced research continues to confirm what chiropractors and patients have observed for decades: spinal manipulation works.

• 2019 (Spine Journal): A review of 18 studies involving nearly 1,000 participants concluded that high-velocity, low-amplitude spinal manipulation reduces both acute and chronic low back pain. It also improves proprioception, supporting the Gate Control Theory of Pain.

• 2019 (Journal of Pain, Stanford University): Using fMRI brain scans, researchers showed that spinal manipulation activates brain regions associated with pain inhibition. This provided direct evidence that adjustments don’t just affect the spine — they change brain activity.

• 2019 (Follow-up Study): The same researchers found that spinal manipulation reduced pain-related brain activity in patients with neck pain as well as healthy volunteers, confirming both spinal and central nervous system effects.

• 2020 (Cureus Journal): A systematic review found that cervical and thoracic manipulations improve pain, strength, and mobility in musculoskeletal conditions.

The growing body of evidence shows that spinal manipulation provides both mechanical relief (improving joint movement) and neurological relief (reducing how the brain processes pain).

.Dr. Kirkaldy-Willis begins his explanation by noting that with positional (alignment) problems there is a shortening of periarticular connective tissues and intra-articular adhesions may form. This orthopedic principle is supported by many others. This intra-articular and periarticular fibrosis would reduce joint motion. He proposes that a specific line-of-drive manipulation (chiropractic spinal adjustment) could break these adhesions and/or remodel fibrosis, also supported by others. He cites support for these concepts, including:

• Following joint manipulation, there is consistently a measureable increase in the range of motion.

• As a rule, there is an initial increase in symptoms after the first few manipulations probably as a result of breaking adhesions and tissue fibrosis. He states:

“In almost all cases, however, this increase in pain is temporary and can be easily controlled by local application of ice.”

“Patients undergoing manipulative treatment must therefore be reassured that the initial discomfort is only temporary.”

“However, the gain in mobility must be maintained during this period to prevent further adhesion formation.”

Dr. Kirkaldy-Willis then applies the improved articular motion to Melzack and Wall’s Gate Theory of Pain. He notes that this theory has “withstood rigorous scientific scrutiny,” stating:

“The central transmission of pain can be blocked by increased proprioceptive input.”

Pain is facilitated by “lack of proprioceptive input.”

“Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”

Dr. Kirkaldy-Willis notes that at the end of the manipulation range of motion, “the limit of anatomical integrity is encountered. Movement beyond this limit results in damage to the capsular ligaments.” Consequently, joint manipulation “requires precise positioning of the joint at the end of the passive range of motion and the proper degree of force to overcome joint coaptation” (to overcome the resistance of the joint surfaces in contact). He concludes:

“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”

“The physician who makes use of this resource will provide relief for many back pain patients.”

Today (2020) this “Orthopedic Gate Theory” explanation for the mechanism of benefits from manipulation for pain control is widely popular. Yet, Dr. Kirkaldy-Willis also offers a concomitant reflex neurological model. He supports that during manipulation, the stretching of joint ligaments (capsules) will trigger a reflex that inhibits local musculature, also improving motion and closing the pain gate.

• •••••••••

An update to the effects of spinal manipulation was published last year (2019) in the journal Spine, titled:

Neurophysiological Effects of High Velocity and Low Amplitude
Spinal Manipulation in Symptomatic and Asymptomatic Humans:
A Systematic Literature Review

The objective of this study was to summarize the evidence of the neurophysiological effects of spinal manipulative therapy (SMT) with high velocity low amplitude thrust (HVLA-SMT). The authors searched the literature until July 2018 and only used controlled studies of at least moderate quality. They found 18 studies that met their inclusion criteria that involved 932 participants. Most studies on spinal manipulation focus on pain mechanisms and pain control.

The authors note that spinal manipulative therapy with high-velocity low amplitude thrust (HVLA-SMT) is effective in reducing low back pain (LBP), and applies to both acute and chronic nonspecific LBP. They agree that spinal manipulation has both neurophysiological and biomechanical influences, and support that manipulation increases proprioception, stating:

“The mechanical force of spinal manipulation primarily affects afferent neurons in the paraspinal tissue and triggers neurophysiological responses in the peripheral and central nervous system, eventually leading to pain inhibition.”

The evidence presented in this study supports that spinal manipulation increases proprioception, which eventually leads to pain inhibition. This is consistent and supportive of Dr. Kirkaldy-Willis’s application of Melzack and Wall’s Gate Theory of Pain, above.

• •••••••••

Also in 2019 (April), a study was published in the Journal of Pain titled:

Decreased Neurologic Pain Signature Activation Following Thoracic Spine Manipulation in Healthy Volunteers

In this study, researchers from Stanford University employed functional magnetic resonance imaging (fMRI) on ten healthy volunteers to objectively measure pain intensity following spinal manipulation. This study was funded by the National Institute of Health, USA.

The authors note that: “Spinal manipulation is commonly used when managing patients with neck and back pain.” Although they support the rationale that spinal manipulation elicits a mechanical effect on the spine that leads to therapeutic mechanical changes within the spine, they wanted to explore if central (brain) mechanisms were also being activated. The results of this study showed that spinal manipulation activates brain regions associated with pain inhibition.

It has been observed for decades that spinal manipulation helps control pain. This study adds to the evidence, using the best available evidence (functional MRI), showing that spinal manipulation works in pain reduction, in part, by inhibiting pain-processing regions of the brain. Once again, the results of this study are consistent and supportive of Dr. Kirkaldy-Willis’s application of Melzack and Wall’s Gate Theory of Pain.

• •••••••••

A few months later in 2019 (October), this same group published a follow-up study titled:

 

Evidence for Decreased Neurologic Pain Activation Following Thoracic Spinal Manipulation

In 2019, researchers set out to answer a fascinating question: does spinal manipulation change the way the brain processes pain? To find out, they used functional magnetic resonance imaging (fMRI) to look directly at the brain in action.

Study Design and Participants

The study included two groups of participants:

• 16 people with acute or subacute neck pain, meaning their pain was new or had developed within the last few weeks.

• 10 healthy volunteers with no current pain complaints.

Each person received a thoracic spinal manipulation, delivered as a high-velocity, low-amplitude (HVLA) thrust applied to the T4–T5 area of the spine. This is a common technique chiropractors use to restore joint motion and reduce discomfort.

The researchers then performed brain scans using a 3T fMRI scanner. This advanced technology measures blood flow in the brain, allowing scientists to map which regions become more or less active during different activities — in this case, before and after spinal manipulation.

Understanding Pain in the Brain

The authors pointed out something important: pain perception is not located in one single “pain center” of the brain. Instead, pain is processed across multiple brain regions, each contributing to how we feel and respond to discomfort.

This makes studying pain complex — but also makes the findings from spinal manipulation more meaningful. If manipulation could influence activity in several of these areas, it could help explain why adjustments reduce pain so effectively.

Key Findings

The results showed that spinal manipulation triggered measurable changes in pain-related brain activity:

• Brain regions involved in processing pain signals became less active after manipulation.

• This suggested that adjustments do more than mechanically free up a stiff joint — they also produce a central (brain-mediated) therapeutic effect.

• Patients with neck pain showed changes similar to those seen in healthy volunteers, meaning that both painful and pain-free spines respond neurologically to manipulation.

The authors concluded:

“The findings provide evidence that spinal manipulation may alter the processing of pain-related brain activity within specific pain-related brain regions.”

They also highlighted that this fits into a broader body of research showing that spinal manipulation for back pain and neck pain works through both spinal and supraspinal (brain-level) mechanisms.

Connection to Proprioception and the Pain Gate

This study also supports earlier theories, such as Melzack and Wall’s Gate Control Theory of Pain, which explains how proprioceptive signals from moving joints can “close the gate” to pain signals in the nervous system.

By restoring joint motion and stimulating large mechanoreceptors in the spine, spinal manipulation increases proprioceptive input to the brain. In turn, this input inhibits the transmission of pain signals at both the spinal cord level and in the brain itself.

The authors summed this up by noting:

“Spinal manipulation is known to activate large-diameter mechanoreceptors that in turn can inhibit the transmission of nociceptive (pain) signals at the spinal cord.”

Why This Matters for Patients

What does this mean for someone experiencing chronic back pain or neck pain? It means chiropractic adjustments may reduce pain not only by fixing mechanical problems in the joints, but also by retraining the nervous system to process pain differently.

Spinal manipulation is therefore a two-in-one therapy:

• Mechanically, it restores joint mobility and relieves stiffness.

• Neurologically, it dials down the brain’s sensitivity to pain.

This dual action explains why so many patients report improved mobility, less pain, and better overall function after chiropractic care — benefits that medications alone cannot provide.

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✅ Now this version has the same amount of context as your original, but:

• It’s reorganized into Study → Methods → Findings → Theory → Why It Matters.

• Still includes all your original details (participants, scanner, quotes, theory, mechanoreceptors).

• Uses patient-friendly language and keeps your keyword “spinal manipulation for back pain and neck pain” throughout.

Would you like me to restructure ALL the study-heavy sections of your article (like this one and the “Cureus” review) into this same format so the entire blog feels uniform and balanced?

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Earlier this year (2020), another study on this topic was published in the journal Cureus titled:

The Effect of High Velocity Low Amplitude
Cervical Manipulations on the Musculoskeletal System:
Literature Review

In 2020, a literature review published in Cureus examined how cervical spinal manipulation can affect musculoskeletal conditions. The researchers systematically reviewed randomized controlled trials published between 2005 and 2020, focusing on patients of all ages. These studies compared the effects of cervical manipulation with placebo or other treatment methods.

The review began by highlighting a growing problem: the number of people experiencing musculoskeletal pain is steadily rising. Much of this increase is linked to modern work habits — especially prolonged sitting, repetitive movements, and poor posture that place constant stress on the muscles and joints.

What the Authors Found

The review confirmed several important points about high velocity, low amplitude (HVLA) cervical manipulation:

• Widely practiced: Spinal manipulation is a common therapy performed by chiropractors, osteopaths, physiotherapists, and some medical doctors.

• Growing in use: HVLA cervical manipulation techniques are increasingly chosen as a therapeutic option.

• Effective for multiple conditions: Cervical manipulations are effective in managing neck pain (cervicalgia), shoulder pain, temporomandibular joint disorders (TMJ), and even tennis elbow (epicondylalgia).

The review also noted that both cervical and thoracic manipulations can lead to significant improvements in neck pain, making them versatile tools in musculoskeletal care.

How It Works on the Nervous System

Perhaps the most interesting part of the findings was the neurological explanation. Spinal manipulation doesn’t just free up stiff joints — it also activates the supraspinal pain control system in the brain and brainstem.

This means that manipulation influences the way the central nervous system processes pain. The authors explained:

• Manipulation activates inhibitory pathways in the nervous system that reduce pain sensitivity.

• These effects are not just local — they can change pain thresholds even in areas away from where the adjustment is performed.

• HVLA techniques appear to produce stronger local pain reduction (hypoalgesia) than other manual therapy approaches.

Why This Matters

For patients, the takeaway is simple: spinal manipulation for back pain and neck pain works on both mechanical and neurological levels. By restoring proper motion in the cervical and thoracic spine, chiropractors not only reduce stiffness but also help the nervous system “dial down” pain signals.

This explains why many patients report that adjustments don’t just help their neck — they often notice improvements in other areas of the body as well.

“The results of the research show that HVLA techniques, on subjects with musculoskeletal disorders, are able to influence pain modulation, mobility, and strength both in the treated area and at a distance.”

For thousands of years and throughout the world there are observations that spinal manipulation helps people with musculoskeletal pain, especially spinal pain. For more than one hundred years, chiropractors, patients, governments, insurance companies, and scientists have realized that chiropractic spinal adjusting (specific manipulation) not only helps people with a variety of musculoskeletal pain syndromes, but that it probably works, at least in part, as a consequence of the activation of brain pain control circuitry.

When spinal joints have reduced movement, the pain gate at that level is open. Chiropractic adjusting (specific manipulation) increases the firing of the proprioceptors, creating a neurological sequence of events that closes the pain gate.

Proprioceptive integrity is a significant factor in the state of the pain gate. Improved proprioception closes the pain gate. Chiropractic adjusting improves proprioception.