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Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints.

History

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, 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 and chiropractic medicine. Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s.

Current providers

Spinal manipulation is now most commonly provided various health care disciplines. In North America, it is most commonly performed by chiropractors, osteopathic physicians, occupational therapists and physical therapists. In Europe, chiropractors, osteopaths and physiotherapists are the majority providers, although the precise figure varies between countries.

Terminology

Manipulation is known by several other names. The British orthopaedic surgeon A. S. Blundell Bankart used the term "manipulation" in his text Manipulative Surgery. Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labelling system developed by Geoffery Maitland, 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

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

Kinetics

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. Evans and Breen 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.

Kinematics

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

• Temporary increase in passive range of motion (ROM)

• Physiological effects on the central nervous system, probably at the segmental level

• Altered sensorimotor integration

• No alteration of the position of the sacroiliac joint

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.

Effectiveness

Manual therapies commonly used by chiropractors are as effective as other manual therapies for the treatment of low back pain, and might also be effective for the treatment of lumbar disc herniation with radiculopathy, neck pain, some forms of headache, and some extremity joint conditions. While guidelines issued by the WHO state that chiropractic care may be considered safe when employed skillfully and appropriately, chiropractic spinal manipulation is frequently associated with mild to moderate adverse effects, and with serious or fatal complications in rare cases. The efficacy and cost-effectiveness of maintenance chiropractic care are unproven.

Many controlled clinical studies of spinal manipulation have been conducted, but their results often disagree and they are typically of low methodological quality. A 2010 report found that manual therapies commonly used by chiropractors are effective for the treatment of low back pain, neck pain, some kinds of headaches and a number of extremity joint conditions.

A 2008 critical review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition.Health claims made by chiropractors regarding use of manipulation for pediatric health conditions are supported by only low levels of scientific evidence that does not demonstrate clinically relevant benefits.

Most research has focused on spinal manipulation in general, rather than solely on chiropractic manipulation. A 2002 review ofrandomized clinical trials of spinal manipulation was criticized for not making this distinction; however, the review's authors stated that they did not consider this difference to be a significant point as research on spinal manipulation is equally useful regardless of which practitioner provides it.

There is a wide range of ways to measure treatment outcomes. Chiropractic care, like all medical treatment, benefits from the placebo response. It is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree about whether a proposed placebo actually has no effect. The efficacy of maintenance care in chiropractic is unknown.

Available evidence covers the following conditions:

• Low back pain. Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain remain inconsistent between countries.A 2011 Cochrane review found strong evidence that there is no clinically meaningful difference between spinal manipulation and other treatments for reducing pain and improving function for chronic low back pain. A 2010 Cochrane review found no current evidence to support or refute a clinically significant difference between the effects of combined chiropractic interventions and other interventions for chronic or mixed duration low back pain. A 2010 systematic review found that most studies suggest spinal manipulation achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration. A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks.In 2007 the American College of Physicians and the American Pain Society recommended that clinicians consider the addition of spinal manipulation for patients who do not improve with self care options.Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.

• Radiculopathy. There is no overall consensus on the effectiveness of manual therapies for radiculopathies. There is moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy and acute lumbar disc herniation with associated radiculopathy. The evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low and no evidence exists for the treatment of thoracic radiculopathy.

• Whiplash and other neck pain. There is no overall consensus on the effectiveness of manual therapies for neck pain. Systematic reviews have concluded that thoracic spine manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain; although the body of literature is still weak. A 2010 Cochrane review found low evidence that manipulation was more effective than a control for neck pain, and moderate evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction. A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash. A 2009 systematic review of controlled clinical trials found no evidence that chiropractic spinal manipulation is effective for whiplash injury. A 2008 review found evidence that suggests that manual therapy and exercise are more effective than alternative strategies for patients with neck pain. A 2007 review found that spinal manipulation and mobilization are effective for neck pain. A 2005 review found evidence supporting spinal mobilization, and limited evidence supporting spinal manipulation for whiplash.

• Headache. There is no overall consensus on the effectiveness of manual therapies for headaches. Of two systematic reviews published in 2011, one found evidence that spinal manipulation might be as effective as propranolol or topiramate in the prevention of migraine headaches, the other concluded that evidence does not support the use of spinal manipulation for the treatment of migraine headaches. A 2004 Cochrane review found evidence that suggests spinal manipulation may be effective for migraine, tension headache and cervicogenic headache. A 2006 review found inconclusive evidence supporting manual therapies for tension headache. A 2005 review found that spinal manipulation showed a trend toward benefit in the treatment of tension headache, but the evidence was weak.

• Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief then a supervised exercise program alone and suggested that manual therapists consider adding manual mobilisation to optimise supervised active exercise programs.There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive. A 2008 systematic review found that the addition of cervical spine mobilization to a treatment regimen for lateral epicondylosis (tennis elbow) resulted in significantly better pain relief and functional improvements in both the short and long-term. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, limited to low level evidence supporting chiropractic management of shoulder pain and limited or fair evidence supporting chiropractic management of leg conditions.

• Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension. A systematic review in 2011 found moderate evidence to support the use of manual therapy for cervicogenic dizziness. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathicadolescent scoliosis.A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with cervicogenic dizziness, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities,dizziness, high blood pressure, and vision conditions. Other reviews have found no evidence of significant benefit for asthma, baby colic, bedwetting,carpal tunnel syndrome, fibromyalgia, gastrointestinal disorders,kinetic imbalance due to suboccipital strain (KISS) in infants, menstrual cramps, or pelvic and back pain during pregnancy.

Safety

Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications. Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints.

Sustained chiropractic care is promoted as a preventative tool, but unnecessary manipulation could present a risk to patients. Some chiropractors are concerned by the routine unjustified claims chiropractors have made.

Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications includeosteoporosis. Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.

Spinal manipulation is associated with frequent, mild and temporary adverse effects, including new or worsening pain or stiffness in the affected region. They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;adverse reactions appear to be more common following manipulation than mobilization. Chiropractors are more commonly associated with serious manipulation related adverse effects than other professionals.

Rarely, spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults and children.Estimates vary widely for the incidence of these complications, and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke.Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.

Rate for adverse events varied between 33% and 60.9%. The study reported frequency of serious adverse effect as between strokes 50 per 100,000, 1.46 per 10milloin serious adverse events and death rate of 2.68 per 10 million, though it was determined that there was inadequate data to be conclusive.

Several case reports show temporal associations between interventions and potentially serious complications. The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke. A 2012 systematic review determined that there is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.

Chiropractors, like other primary care providers, sometimes employ diagnostic imaging techniques such asX-rays and CT scans that rely on ionizing radiation.Although there is no clear evidence for the practice, some chiropractors may still X-ray a patient several times a year. Research suggests that most chiropractors in Canada are taught and follow stringent radiography guidelines, which were developed to reduce unnecessary radiography.

Back pain

A 2004 Cochrane review found that spinal manipulation (SM) was no more or less effective than other commonly used therapies such as pain medication, physical therapy, exercises, back school or the care given by a general practitioner. A 2010 systematic review found that most studies suggest SM achieves equal or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. In 2007 the American College of Physicians and the American Pain Society jointly recommended that clinicians consider spinal manipulation for patients who do not improve with self care options. Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions. A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain. Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations.

Neck pain

For neck pain manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies. 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. There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits.

Non-musculoskeletal

There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.

Safety

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.

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."

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."

Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer. A RAND Corporation extensive review estimated "one in a million." 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. 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. 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. Eder offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication. 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."

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". 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.

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."

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." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. 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." 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.'"

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."

This error was taken into account in a 1999 review 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, and Figure 2 shows the type of practitioner involved in the resulting injury. For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.

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

• Osteopathic Manipulative Medicine
• Joint manipulation
• Joint mobilization

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72. Ernst E (2011). "Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials". Can J Gastroenterol. 25 (1): 39–49. PMC 3027333. PMID 21258667.
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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

• American Academy of Orthopedic Manual Physical Therapy (AAOMPT)
• Canadian Academy of Manipulative Therapy (CAMT)
• Canadian Orthopractic Manual Therapy Association (COMTA)
• International Federation of Orthopaedic Manipulative Therapists (IFOMT)
• Journal of Manual and Manipulative Therapy (JMMT)
• Prevention of the vertebrobasilar accidents following cervical thrust manipulations: recommendations of the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO).
• European Association of Advanced Manual and Manipulative Therapy

• Manipulative therapy
• Chiropractic treatment techniques
• Osteopathy
• Physical therapy
• Osteopathic manipulative medicine