Joint Manipulation
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Joint manipulation is a type of passive movement of a skeletal
joint A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw ...
. It is usually aimed at one or more 'target'
synovial joint A synovial joint, also known as diarthrosis, joins bones or cartilage with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones' articulat ...
s with the aim of achieving a therapeutic effect.


Practice of manipulation

A modern re-emphasis on
manipulative therapy Manual therapy, or manipulative therapy, is a physical treatment primarily used by physical therapists, physiotherapists, occupational therapists to treat musculoskeletal pain and disability; it mostly includes kneading and manipulation of mus ...
occurred in the late 19th century in North America with the emergence of
osteopathic medicine Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques in ...
and chiropractic medicine. In the context of
healthcare Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...
, joint manipulation is performed by several professional groups. In
North America North America is a continent in the Northern Hemisphere and almost entirely within the Western Hemisphere. It is bordered to the north by the Arctic Ocean, to the east by the Atlantic Ocean, to the southeast by South America and the Car ...
and Europe, joint manipulation is most commonly performed by
chiropractors Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudosc ...
(estimated to perform over 90% of all manipulative treatments), American-trained
osteopathic physicians Doctor of Osteopathic Medicine (DO or D.O., or in Australia DO USA) is a medical degree conferred by the 38 osteopathic medical schools in the United States. DO and Doctor of Medicine (MD) degrees are equivalent: a DO graduate may become licen ...
,
occupational therapists Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use scientific bases and a holistic perspective to promote a person's abilit ...
,
physiotherapists Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
, and European
osteopaths Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques in ...
. When applied to joints in the spine, it is referred to as
spinal manipulation Spinal manipulation is an intervention performed on spinal articulations, synovial joints, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto ...
.


Terminology

Manipulation is known by several other names. Historically, general practitioners and orthopaedic surgeons have used the term "manipulation".Burke, G.L.,
Backache from Occiput to Coccyx
Chapter 7
Chiropractors 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 Mobilization is the act of assembling and readying military troops and supplies for war. The word ''mobilization'' was first used in a military context in the 1850s to describe the preparation of the Prussian Army. Mobilization theories and ...
, a term commonly used by
physical therapists Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
. Because of its distinct biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation.


Biomechanics

Manipulation can be distinguished from other
manual therapy Manual therapy, or manipulative therapy, is a physical treatment primarily used by physical therapists, physiotherapists, occupational therapists to treat musculoskeletal pain and disability; it mostly includes kneading and manipulation of mus ...
interventions such as
joint mobilization Joint mobilization is a manual therapy intervention, a type of straight-lined, passive movement of a skeletal joint that addresses arthrokinematic joint motion (joint gliding) rather than osteokinematic joint motion. It is usually aimed at a 'tar ...
by its
biomechanics Biomechanics is the study of the structure, function and motion of the mechanical aspects of biological systems, at any level from whole organisms to organs, cells and cell organelles, using the methods of mechanics. Biomechanics is a branch of ...
, both
kinetics Kinetics ( grc, κίνησις, , kinesis, ''movement'' or ''to move'') may refer to: Science and medicine * Kinetics (physics), the study of motion and its causes ** Rigid body kinetics, the study of the motion of rigid bodies * Chemical ki ...
and
kinematics Kinematics is a subfield of physics, developed in classical mechanics, that describes the Motion (physics), motion of points, Physical object, bodies (objects), and systems of bodies (groups of objects) without considering the forces that cause ...
.


Kinetics

Until recently, force-time histories measured during
spinal manipulation Spinal manipulation is an intervention performed on spinal articulations, synovial joints, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto ...
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 oriented into the appropriate position in preparation for the prethrust phase. When individual peripheral
synovial joints A synovial joint, also known as diarthrosis, joins bones or cartilage with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones' articulat ...
are manipulated, the distinct force-time phases that occur during spinal manipulation are not as evident. In particular, the rapid rate of change of force that occurs during the thrust phase when spinal joints are manipulated is not always necessary. Most studies to have measured forces used to manipulate peripheral joints, such as the
metacarpophalangeal The metacarpophalangeal joints (MCP) are situated between the metacarpal bones and the proximal phalanges of the fingers. These joints are of the condyloid kind, formed by the reception of the rounded heads of the metacarpal bones into shallow cav ...
(MCP) joints, show no more than gradually increasing
load Load or LOAD may refer to: Aeronautics and transportation *Load factor (aeronautics), the ratio of the lift of an aircraft to its weight *Passenger load factor, the ratio of revenue passenger miles to available seat miles of a particular transpo ...
. This is probably because there are many more tissues restraining a spinal motion segment than an independent MCP joint.


Kinematics

The kinematics of a complete spinal motion segment when one of its constituent spinal joints are manipulated are much more complex than the kinematics that occur during manipulation of an independent peripheral
synovial joint A synovial joint, also known as diarthrosis, joins bones or cartilage with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones' articulat ...
. Even so, the motion that occurs between the articular surfaces of any individual synovial joint during manipulation should be very similar and is described below. Early
models A model is an informative representation of an object, person or system. The term originally denoted the plans of a building in late 16th-century English, and derived via French and Italian ultimately from Latin ''modulus'', a measure. Models c ...
describing the kinematics of an individual target joint during the various phases of manipulation (notably Sandoz 1976) were based on studies that investigated
joint cracking Joint cracking is the manipulation of joints to produce a sound and related "popping" sensation. It is sometimes performed by physical therapists, chiropractors, osteopaths, and masseurs in Turkish baths pursuing a variety of outcomes. The cr ...
in MCP joints. The cracking was elicited by pulling the proximal
phalanx The phalanx ( grc, φάλαγξ; plural phalanxes or phalanges, , ) was a rectangular mass military formation, usually composed entirely of heavy infantry armed with spears, pikes, sarissas, or similar pole weapons. The term is particularly use ...
away from the
metacarpal In human anatomy, the metacarpal bones or metacarpus form the intermediate part of the skeletal hand located between the phalanges of the fingers and the carpal bones of the wrist, which forms the connection to the forearm. The metacarpal bones ...
bone (to separate, or 'gap' the articular surfaces of the MCP joint) with gradually increasing force until a sharp resistance, caused by the cohesive properties of
synovial fluid Synovial fluid, also called synovia, elp 1/sup> is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its egg white–like consistency, the principal role of synovial fluid is to reduce friction between the articular ...
, was met and then broken. These studies were therefore never designed to form models of therapeutic manipulation, and the models formed were erroneous in that they described the target joint as being configured at the end
range Range may refer to: Geography * Range (geographic), a chain of hills or mountains; a somewhat linear, complex mountainous or hilly area (cordillera, sierra) ** Mountain range, a group of mountains bordered by lowlands * Range, a term used to i ...
of a
rotation Rotation, or spin, is the circular movement of an object around a '' central axis''. A two-dimensional rotating object has only one possible central axis and can rotate in either a clockwise or counterclockwise direction. A three-dimensional ...
movement, during the orientation phase. The model then predicted that this end range position was maintained during the prethrust phase until the thrust phase where it was moved beyond the 'physiologic barrier' created by synovial fluid resistance; conveniently within the limits of anatomical integrity provided by restraining tissues such as the joint capsule and ligaments. This model still dominates the literature. However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint, which is the motion region of the joint where the passive osteoligamentous
stability Stability may refer to: Mathematics *Stability theory, the study of the stability of solutions to differential equations and dynamical systems **Asymptotic stability **Linear stability **Lyapunov stability **Orbital stability **Structural stabilit ...
mechanisms exert little or no influence. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped, rather than the
rolling Rolling is a type of motion that combines rotation (commonly, of an axially symmetric object) and translation of that object with respect to a surface (either one or the other moves), such that, if ideal conditions exist, the two are in contact ...
or sliding that usually occurs during physiological motion), and that it is more mechanically efficient to do this when the joint is near to its neutral configuration.


Cracking joints

Joint manipulation is characteristically associated with the production of an audible 'clicking' or 'popping' sound. This sound is believed to be the result of a phenomenon known as
cavitation Cavitation is a phenomenon in which the static pressure of a liquid reduces to below the liquid's vapour pressure, leading to the formation of small vapor-filled cavities in the liquid. When subjected to higher pressure, these cavities, cal ...
occurring within the
synovial fluid Synovial fluid, also called synovia, elp 1/sup> is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its egg white–like consistency, the principal role of synovial fluid is to reduce friction between the articular ...
of the joint. When a manipulation is performed, the applied force separates the articular surfaces of a fully encapsulated synovial joint. This deforms the joint capsule and intra-articular tissues, which in turn creates a reduction in pressure within the joint cavity. In this low pressure environment, some of the
gas Gas is one of the four fundamental states of matter (the others being solid, liquid, and plasma). A pure gas may be made up of individual atoms (e.g. a noble gas like neon), elemental molecules made from one type of atom (e.g. oxygen), or ...
es that are dissolved in the
synovial fluid Synovial fluid, also called synovia, elp 1/sup> is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its egg white–like consistency, the principal role of synovial fluid is to reduce friction between the articular ...
(which are naturally found in all bodily fluids) leave solution creating a
bubble Bubble, Bubbles or The Bubble may refer to: Common uses * Bubble (physics), a globule of one substance in another, usually gas in a liquid ** Soap bubble * Economic bubble, a situation where asset prices are much higher than underlying fundame ...
or
cavity Cavity may refer to: Biology and healthcare *Body cavity, a fluid-filled space in many animals where organs typically develop **Gastrovascular cavity, the primary organ of digestion and circulation in cnidarians and flatworms *Dental cavity or too ...
, which rapidly collapses upon itself, resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly
carbon dioxide Carbon dioxide (chemical formula ) is a chemical compound made up of molecules that each have one carbon atom covalently double bonded to two oxygen atoms. It is found in the gas state at room temperature. In the air, carbon dioxide is transpar ...
. The effects of this process will remain for a period of time termed the ' refractory period', which can range from a few minutes to more than an hour, while it is slowly reabsorbed back into the synovial fluid. There is some evidence that ligament laxity around the target joint is associated with an increased probability of cavitation.


Clinical effects and mechanisms of action

The clinical effects of joint manipulation have been shown to include: * Temporary relief of musculoskeletal
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
. * Shortened time to recover from
acute Acute may refer to: Science and technology * Acute angle ** Acute triangle ** Acute, a leaf shape in the glossary of leaf morphology * Acute (medicine), a disease that it is of short duration and of recent onset. ** Acute toxicity, the adverse eff ...
back The human back, also called the dorsum, is the large posterior area of the human body, rising from the top of the buttocks to the back of the neck. It is the surface of the body opposite from the chest and the abdomen. The vertebral column run ...
sprains A sprain, also known as a torn ligament, is an acute soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers ...
(Rand). * Temporary increase in passive range of motion (ROM). * Physiological effects upon the central nervous system. * No alteration of the position of the sacroiliac joint. Common
side effect In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequence ...
s of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort. Shekelle (1994) summarised the published theories for mechanism(s) of action for how joint manipulation may exert its clinical effects as the following: * Release of entrapped synovial folds or plica * Relaxation of hypertonic muscle * Disruption of articular or periarticular adhesions * Unbuckling of motion segments that have undergone disproportionate displacement


Safety issues

As with all interventions, there are risks associated with joint manipulation, especially manipulation of spinal joints. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA),
stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
s,
spinal disc herniation Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
,
vertebral The vertebral column, also known as the backbone or spine, is part of the axial skeleton. The vertebral column is the defining characteristic of a vertebrate in which the notochord (a flexible rod of uniform composition) found in all chordates ...
and
rib In vertebrate anatomy, ribs ( la, costae) are the long curved bones which form the rib cage, part of the axial skeleton. In most tetrapods, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the ches ...
fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displa ...
s, and
cauda equina syndrome Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around th ...
. 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." In a 2019 study, L.M. Mabry, PT, and colleagues reported joint manipulation adverse events to be rare.


Risks of upper cervical manipulation

The degree of serious
risk In simple terms, risk is the possibility of something bad happening. Risk involves uncertainty about the effects/implications of an activity with respect to something that humans value (such as health, well-being, wealth, property or the environme ...
s associated with manipulation of the cervical spine is uncertain, with widely differing results being published. A 2008 study in the journal "Spine", JD Cassidy, E Boyle, P Cote', Y He, et al. investigated 818 VBA strokes that were hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case cross over analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. The study concluded that VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. A 1996 Danish
chiropractic Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudosci ...
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 Rotation, or spin, is the circular movement of an object around a '' central axis''. A two-dimensional rotating object has only one possible central axis and can rotate in either a clockwise or counterclockwise direction. A three-dimensional ...
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."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 AND MR-781-CCR Curren
link
/ref> Dvorak, in a survey of 203 practitioners of
manual medicine Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudosc ...
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." In comparison, there is a 3-4% rate of complications for cervical spinal
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
, and 4,000-10,000 deaths per million neck surgeries. 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.


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.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."'' 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 Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudosci ...
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."
Edzard Ernst Edzard Ernst (born 30 January 1948) is a retired British-German academic physician and researcher specializing in the study of complementary and alternative medicine. He was Professor of Complementary Medicine at the University of Exeter, alleged ...
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 An adverse effect is an undesired harmful effect resulting from a medication or other intervention, such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. The term complica ...
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."


Emergency medicine

In
emergency medicine Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians (often called “ER doctors” in the United States) continuously learn to care for unsche ...
joint manipulation can also refer to the process of bringing fragments of fractured bone or
dislocated A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet.Dislocations. Lucile Packard Children’s Hospital at Stanford. Retrieved 3 March 2013 A partial dislocation is refe ...
joints into normal
anatomical Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having it ...
alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure.


See also

*
Orthopedic medicine Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
*
Osteopathic manipulative medicine Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques in ...
*
Physical therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
*
Small joint manipulation Small joint manipulation, in grappling, refers to twisting, pulling or bending fingers, toes, wrists and ankles to cause joint locks in the various joints in those appendages. Technique Most small joint manipulation is done on the hands or fe ...


References

{{reflist, 2


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. * Burke, G.L. ''Backache from Occiput to Coccyx.'' Macdonald Publishing., Vancouver 1964,2008.


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)

European Association of Advanced Manual and Manipulative Therapy
Manual therapy Chiropractic treatment techniques Osteopathy Physical therapy Osteopathic manipulative medicine Manual medicine