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Spinal manipulation

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"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,[1] 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.[2] Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.[3]

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. In Europe, chiropractors, osteopaths and physiotherapists are the majority providers, although the precise figure varies between countries.


Manipulation is generally considered by the Chiropractic profession to refer to gross manipulation of joints, as distinguished from Chiropractic's 'adjustment'. Following the labeling system developed by Geoffery Maitland,[4] 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.


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 phaseTemplate:Technical-statement.[5] Evans and Breen[6] 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.
  • Temporary increase in passive range of motion (ROM).[7]
  • Physiological effects on the central nervous system, probably at the segmental level.[8]
  • Altered sensorimotor integration.[9]
  • No alteration of the position of the sacroiliac joint.[10]

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.[11]


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.[12] 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.[13] 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.[14] Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions.[8][15] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain.[16] Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations.[17]

Neck pain

For neck pain manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies.[18][19] 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.[20] There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits.[21]


There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.[22]


  1. Dean C. Swedlo, "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
  2. Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626. 
  3. "International MUA Academy of Physicians - Historical Considerations". Retrieved 2008-03-24. 
  4. Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
    Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
  5. Herzog W, Symons B. (2001). "The biomechanics of spinal manipulation.". Crit Rev Phys Rehabil Med 13 (2): 191–216. 
  6. Evans DW, Breen AC. (2006). "A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone.". J Manipulative Physiol Ther 29 (1): 72–82. doi:10.1016/j.jmpt.2005.11.011. PMID 16396734. 
  7. Nilsson N, Christensen H, Hartvigsen J (1996). "Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial.". J Manipulative Physiol Ther 19 (3): 165–8. PMID 8728459. 
  8. 8.0 8.1 Murphy BA, Dawson NJ, Slack JR (March 1995). "Sacroiliac joint manipulation decreases the H-reflex". Electromyogr Clin Neurophysiol 35 (2): 87–94. PMID 7781578. 
  9. Elsevier
  10. Tullberg T, Blomberg S, Branth B, Johnsson R (May 1998). "Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis". Spine 23 (10): 1124–8; discussion 1129. doi:10.1097/00007632-199805150-00010. PMID 9615363. "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.". 
  11. Senstad O, Leboeuf-Yde C, Borchgrevink C (February 1997). "Frequency and characteristics of side effects of spinal manipulative therapy (Adverse)". Spine 22 (4): 435–40; discussion 440–1. doi:10.1097/00007632-199702150-00017. PMID 9055373. 
  12. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). Assendelft, Willem JJ. ed. "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  13. Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (2010). "NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain". Spine J 10 (10): 918–940. doi:10.1016/j.spinee.2010.07.389. PMID 20869008. 
  14. Chou R, Qaseem A, Snow V et al. (October 2, 2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med 147 (7): 478–91. PMID 17909209. 
  15. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469. 
  16. Meeker W, Branson R, Bronfort G et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13. 
  17. Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMID 16574972. PMC 1420782. Lay summary – BBC News (2006-03-22). 
  18. Gross A, Miller J, D'Sylva J et al. (2010). Gross, Anita. ed. "Manipulation or mobilisation for neck pain". Cochrane Database Syst Rev (1): CD004249. doi:10.1002/14651858.CD004249.pub3. PMID 20091561. 
  19. Hurwitz EL, Carragee EJ, van der Velde G et al. (February 2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386. 
  20. Vernon H, Humphreys K, Hagino C (2007). "Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials". J Manipulative Physiol Ther 30 (3): 215–27. doi:10.1016/j.jmpt.2007.01.014. PMID 17416276. 
  21. Martín Saborido C, García Lizana F, Alcázar Alcázar R, Sarría-Santamera A (May 2007). "[Effectiveness of spinal manipulation in treating whiplash injuries]" (in Spanish; Castilian). Aten Primaria 39 (5): 241–6. PMID 17493449. 
  22. Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C (December 2007). "Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials". Complement Ther Med 15 (4): 271–83. doi:10.1016/j.ctim.2007.01.008. PMID 18054729. 

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