Spinal manipulation

Spinal manipulation

Spinal manipulation is a therapeutic intervention performed on synovial joints in the spinal column. The most commonly cited of these are the zygapophysial joints. However, the occipitoatlantal, atlantoaxial, lumbosacral, sacroiliac, costotransverse and costovertebral joints are also synovial joints of the spine that may be manipulated.


Spinal manipulation is a therapeutic intervention that has roots in traditional medicine and has been used by various cultures, apparently for thousands of years. Hippocrates, the "father of medicine" used manipulative techniques,Dean C. Swedlo, " [http://www.hom.ucalgary.ca/Dayspapers2002.pdf The Historical Development of Chiropractic.] " pp. 55-58, "The Proceedings of the 11th Annual History of Medicine Days", Faculty of Medicine, The University of Calgary] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic medicine and chiropractic.cite journal |journal= J Manipulative Physiol Ther |date=2003 |volume=26 |issue=5 |pages=300–21 |title= Several pathways in the evolution of chiropractic manipulation |author= Keating JC Jr |doi=10.1016/S0161-4754(02)54125-7 |pmid=12819626] Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.cite web |url=http://www.muaphysicians.com/historical.html |title=International MUA Academy of Physicians - Historical Considerations |accessdate=2008-03-24 |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote=]

Current Providers

Spinal manipulation is now most commonly provided by organized professional groups. In North America, it is most commonly performed by chiropractors, osteopathic physicians, and physical therapists. Chiropractors perform over 90% of all manipulative treatments in the U.S.cite web |url=http://nccam.nih.gov/health/chiropractic/chiropractic05.pdf |title=About Chiropractic and Its Use in Treating Low-Back Pain |accessdate=2008-03-24 |format= |work=] In Europe, chiropractors, osteopaths and physiotherapists are the majority providers, although the precise figure varies between countries.


Manipulation is known by several other names. Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labelling system developed by Geoffery Maitland, [Maitland, G.D. "Peripheral Manipulation" 2nd ed. Butterworths, London, 1977.
Maitland, G.D. "Vertebral Manipulation" 5th ed. Butterworths, London, 1986.
] manipulation is synonymous with Grade V mobilization. Because of its distinct biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation.

Biomechanics of spinal manipulation

Spinal manipulation can be distinguished from other manual therapy interventions such as mobilization by its biomechanics, both kinetics and kinematics.


Until recently, force-time histories measured during spinal manipulation were described as consisting of three distinct phases: the preload (or prethrust) phase, the thrust phase, and the resolution phase. [cite journal | author = Herzog W, Symons B. | title = The biomechanics of spinal manipulation. | journal = Crit Rev Phys Rehabil Med | volume = 13 | issue = 2 | pages = 191–216 | year = 2001] Evans and Breen [cite journal | author = Evans DW, Breen AC. | title = A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone. | journal = J Manipulative Physiol Ther | volume = 29 | issue = 1 | pages = 72–82 | year = 2006 | pmid = 16396734 | doi = 10.1016/j.jmpt.2005.11.011] added a fourth ‘orientation’ phase to describe the period during which the patient is orientated into the appropriate position in preparation for the prethrust phase


The kinematics of a complete spinal motion segment, when one of its constituent spinal joints is manipulated, are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint.

Suggested mechanisms of action and clinical effects

The effects of spinal manipulation have been shown to include:

* Temporary relief of musculoskeletal pain.

* Shortened time to recover from acute back pain (RAND).

* Temporary increase in passive range of motion (ROM). [cite journal | author = Nilsson N, Christensen H, Hartvigsen J | title = Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial. | journal = J Manipulative Physiol Ther | volume = 19 | issue = 3 | pages = 165–8 | year = | pmid = 8728459]

* Physiological effects on the central nervous system, probably at the segmental level.cite journal |author=Murphy BA, Dawson NJ, Slack JR |title=Sacroiliac joint manipulation decreases the H-reflex |journal=Electromyogr Clin Neurophysiol |volume=35 |issue=2 |pages=87–94 |year=1995 |month=Mar |pmid=7781578 |doi= |url=]

* Altered sensorimotor integration. [ [http://www.jmptonline.org/article/S0161-4754(07)00344-2/abstract Elsevier] ]

* No alteration of the position of the sacroiliac joint.cite journal |author=Tullberg T, Blomberg S, Branth B, Johnsson R |title=Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis |journal=Spine |volume=23 |issue=10 |pages=1124–8; discussion 1129 |year=1998 |month=May |pmid=9615363 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=23&issue=10&spage=1124 |quote=Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.]

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort. [cite journal |author=Senstad O, Leboeuf-Yde C, Borchgrevink C |title=Frequency and characteristics of side effects of spinal manipulative therapy (Adverse) |journal=Spine |volume=22 |issue=4 |pages=435–40; discussion 440–1 |year=1997 |month=Feb |pmid=9055373 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=22&issue=4&spage=435]


Neck Pain

Therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain. [cite journal |author=Hurwitz EL, Carragee EJ, van der Velde G, "et al" |title=Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |journal=Spine |volume=33 |issue=4 Suppl |pages=S123–52 |year=2008 |month=Feb |pmid=18204386 |doi=10.1097/BRS.0b013e3181644b1d |url=] There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization. [cite journal |author=Vernon H, Humphreys K, Hagino C |title=Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials |journal=J Manipulative Physiol Ther |volume=30 |issue=3 |pages=215–27 |year=2007 |pmid=17416276 |doi=10.1016/j.jmpt.2007.01.014 |url=] There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits. [cite journal |author=Martín Saborido C, García Lizana F, Alcázar Alcázar R, Sarría-Santamera A |title= [Effectiveness of spinal manipulation in treating whiplash injuries] |language=Spanish; Castilian |journal=Aten Primaria |volume=39 |issue=5 |pages=241–6 |year=2007 |month=May |pmid=17493449 |doi= |url=http://db.doyma.es/cgi-bin/wdbcgi.exe/doyma/mrevista.pubmed_full?inctrl=05ZI0105&rev=27&vol=39&num=5&pag=241]

Non Musculoskeletal

There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions. [cite journal |author=Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C |title=Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials |journal=Complement Ther Med |volume=15 |issue=4 |pages=271–83 |year=2007 |month=Dec |pmid=18054729 |doi=10.1016/j.ctim.2007.01.008 |url=]


As with all interventions, there are risks associated with spinal manipulation. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), strokes, death, spinal disc herniation, vertebral and rib fractures, and cauda equina syndrome. [ [http://www.spinejournal.com/pt/re/spine/abstract.00007632-199702150-00017.htm;jsessionid=FH9Bf7CrSQgjsWn2H8t45y8QJp9zmTyWRddxKvBbhCb1tQjJnQNX!1408571515!-949856144!8091!-1 Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy. Outcomes of Treatment (Adverse)] "Spine." 22(4):435-440, February 15, 1997.]

In a 1993 study, J.D. Cassidy, DC, and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is "both safe and effective." [cite journal | author = Cassidy JD, Thiel H, Kirkaldy-Willis W | title = Side posture manipulation for lumbar intervertebral disk herniation. | journal = J Manip Physiol Ther | volume = 16 | pages = 96–103 | year = 1993 | pmid = 8445360]

Risks of upper cervical manipulation

The degree of serious risks associated with manipulation of the cervical spine is uncertain, with widely differing results being published.

A 1996 Danish chiropractic study confirmed the risk of stroke to be low, and determined that the greatest risk is with manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break." [cite journal | author = Klougart N, Leboeuf-Yde C, Rasmussen L | title = Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. | journal = J Manip Physiol Ther | volume = 19 | pages = 371–7 | year = | pmid = 8864967]

Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer. [Lauretti W "What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from [http://www.chiro.org/chimages/chiropage/cva-1.html www.chiro.org] ] A RAND Corporation extensive review estimated "one in a million."Coulter ID, Hurwitz EL, Adams AH, "et al." (1996) The appropriateness of manipulation and mobilization of the cervical spine 'Santa Monica, CA, Rand Corp: xiv [RAND MR-781-CCR] . Current [http://www.rand.org/pubs/monograph_reports/MR781/ link] ] Dvorak, in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations. [Dvorak J, Orelli F. "How dangerous is manipulation to the cervical spine?" Manual Medicine 1985; 2: 1-4.] Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury. [Jaskoviak P. "Complications arising from manipulation of the cervical spine". J Manip Physiol Ther 1980; 3: 213-19.] Henderson and Cassidy performed a survey at the Canadian Memorial Chiropractic College outpatient clinic where more than a half-million treatments were given over a nine-year period, again without serious incident. [Henderson DJ, Cassidy JD. Vertebral Artery syndrome. In: Vernon H. "Upper cervical syndrome: chiropractic diagnosis and treatment". Baltimore: Williams and Wilkins, 1988: 195-222.] Eder offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication. [Eder M, Tilscher H. "Chiropractic therapy: diagnosis and treatment" (English translation). Rockville, Md: Aspen Publishers, 1990: 61.] After an extensive literature review performed to formulate practice guidelines, the authors concurred that "the risk of serious neurological complications (from cervical manipulation) is extremely low, and is approximately one or two per million cervical manipulations." [Haldeman S, Chapman-Smith D, Petersen DM. "Guidelines for chiropractic quality assurance and practice parameters." Gaithersburg, Md: Aspen Publishers, 1993: 170-2.]

In comparison, there is a 3-4% rate of complications for cervical spinal surgery, and 4,000-10,000 deaths per million neck surgeries. ["The cervical spine research society editorial committee". The Cervical Spine, Second edition. Philadelphia: J.B. Lippincott Company 1990: 834.]

Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that "critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects". [Kleynhans AM, Terrett AG. Cerebrovascular complications of manipulation. In: Haldeman S, ed. "Principles and practice of chiropractic", 2nd ed. East Norwalk, CT, Appleton Lang, 1992.] In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence. [Haldeman S, Kohlbeck F, McGregor M. "Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty‐four cases after cervical spine manipulation". Spine, 2002, 27(1):49‐55.] [Rothwell D, Bondy S, Williams J. "Chiropractic manipulation and stroke: a population-based case‐controlled study". Stroke, 2001, 32:1054‐60.] [Haldeman, S et al. "Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias". Spine, 2002, 2(5):334‐342.] [Haldeman S et al. "Arterial dissections following cervical manipulation: the chiropractic experience". Journal of the Canadian Medical Association, 2001, 2, 165(7):905‐906.]

Edzard Ernst has written:

:"...there is little evidence to demonstrate that spinal manipulation has any specific therapeutic effects. On the other hand, there is convincing evidence to show that it is associated with frequent, mild adverse effects as well as with serious complications of unknown incidence. Therefore, it seems debatable whether the benefits of spinal manipulation outweigh its risks. Specific risk factors for vascular accidents related to spinal manipulation have not been identified, which means that any patient may be at risk, particularly those below 45 years of age. Definitive, prospective studies that can overcome the limitations of previous investigations are now a matter of urgency. Until they are available, clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element."

In a 2007 followup report in the Journal of the Royal Society of Medicine, Ernst concluded: "Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation." [ [http://www.jrsm.org/cgi/content/full/100/7/330?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=ernst,+edzard&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Adverse effects of spinal manipulation: a systematic review - Ernst 100 (7): 330 - Journal of the Royal Society of Medicine] ]

Potential for incident underreporting

Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The RAND study assumed that only 1 in 10 cases would have been reported. However, Prof Ernst surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical spinal manipulation by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element." [http://www.cmaj.ca/cgi/content/full/166/1/40 Spinal manipulation: Its safety is uncertain] . Edzard Ernst, "CMAJ", January 8, 2002; 166 (1)] The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. [http://www.nelh.nhs.uk/hth/chiro.asp NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors] ] Both NHS and Ernst noted that bias is a problem with the survey method of data collection.

A 2001 study in the journal "Stroke" found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." [cite journal | author = Rothwell D, Bondy S, Williams J | title = Chiropractic manipulation and stroke: a population-based case-control study. | journal = Stroke | volume = 32 | pages = 1054–60 | year = 2001 | pmid = 11340209 Original [http://stroke.ahajournals.org/cgi/content/full/32/5/1054 article] ] The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.

In 1996, Coulter "et al." had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at 736 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors).

: "According to the report ... 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that '. . . much additional scientific data about the efficacy of cervical spine manipulation are needed.'" [http://archfami.ama-assn.org/cgi/content/full/7/1/20 Finding A Good Chiropractor.] Samuel Homola, DC. "Arch Fam Med." 1998;7:20-23.]

Misattribution problems

Studies of stroke and manipulation do not always clearly identify what professional has performed the manipulation. In some cases this has led to confusion and improper placement of blame. In a 1995 study, chiropractic researcher Allan Terrett, DC, pointed to this problem:

:"The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors."cite journal | author = Terrett A | title = Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. | journal = J Manipulative Physiol Ther | volume = 18 | issue = 4 | pages = 203–10 | year = 1995 | pmid = 7636409]

This error was taken into account in a 1999 reviewcite journal | author = Di Fabio R | title = Manipulation of the cervical spine: risks and benefits. | journal = Phys Ther | volume = 79 | issue = 1 | pages = 50–65 | year = 1999 | pmid = 9920191 | url = http://www.rand.org/pubs/monograph_reports/MR781/ | accessdate=2006-11-17] of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of manipulation responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized:

: "The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements)."

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown, [ [http://www.ptjournal.org/cgi/content/full/79/1/50/F1 Figure 1. Injuries attributed to manipulation of the cervical spine.] ] and Figure 2 shows the type of practitioner involved in the resulting injury. [ [http://www.ptjournal.org/cgi/content/full/79/1/50/F2 Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury.] ] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett. cite journal | author = Terrett A | title = Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. | journal = J Manipulative Physiol Ther | volume = 18 | issue = 4 | pages = 203–10 | year = 1995 | pmid = 7636409]

The review concluded:

: "The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed."

Emergency medicine

In emergency medicine joint manipulation can also refer to the process of bringing fragments of fractured bone or dislocated joints into normal anatomical alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure.

See also

* Chiropractic
* Cracking joints
* High velocity low amplitude thrust
* Joint manipulation
* Joint mobilization
* Orthopedic medicine
* Osteopathic Manipulative Medicine
* Physical therapy
* Spinal adjustment


Further reading

* Cyriax, J. "Textbook of Orthopaedic Medicine, Vol. I: Diagnosis of Soft Tissue Lesions" 8th ed. Bailliere Tindall, London, 1982.
* Cyriax, J. "Textbook of Orthopaedic Medicine, Vol. II: Treatment by Manipulation, Massage and Injection" 10th ed. Bailliere Tindall, London, 1983.
* Greive "Modern Manual Therapy of the Vertebral Column." Harcourt Publishers Ltd., 1994
* Maitland, G.D. "Peripheral Manipulation" 2nd ed. Butterworths, London, 1977.
* Maitland, G.D. "Vertebral Manipulation" 5th ed. Butterworths, London, 1986.
* McKenzie, R.A. "The Lumbar Spine; Mechanical Diagnosis and Therapy." Spinal Publications, Waikanae, New Zealand, 1981.
* McKenzie, R.A. "The Cervical and Thoracic Spine; Mechanical Diagnosis and Therapy." Spinal Publications, Waikanae, New Zealand, 1990.
* Mennel, J.M. "Joint Pain; Diagnosis and Treatment Using Manipulative Techniques." Little Brown and Co., Boston, 1964.

External links

* [http://www.aaompt.org/ American Academy of Orthopedic Manual Physical Therapy (AAOMPT)]
* [http://www.manipulativetherapy.org/ Canadian Academy of Manipulative Therapy (CAMT)]
* [http://orthopractic.org/ Canadian Orthopractic Manual Therapy Association (COMTA)]
* [http://www.ifomt.org/ International Federation of Orthopaedic Manipulative Therapists (IFOMT)]
* [http://jmmtonline.com/ Journal of Manual and Manipulative Therapy (JMMT)]
* [http://www.sofmmoo.com/english_section/2_neck_pain/Cervical%20Manip.%20Recommandation%20SOFMMOO.htm Prevention of the vertebrobasilar accidents following cervical thrust manipulations] : recommendations of the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO).

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