Spinal manipulation is an intervention performed on spinal articulations,
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 ...
, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the
z-joints, the
atlanto-occipital,
atlanto-axial,
lumbosacral
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 ...
,
sacroiliac
The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The ...
,
costotransverse and
costovertebral joints.
National guidelines come to different conclusions with respect to spinal manipulation with some not recommending it, and others recommending a short course in those who do not improve with other treatments.
A 2012
Cochrane review
Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
found that spinal manipulation was no more effective than other commonly used therapies.
There is not sufficient data to establish the safety of spinal manipulations.
[
]
Effectiveness
Back pain
Cochrane review
Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
s find that spinal manipulation (SM) are no more effective than other commonly used therapies. 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. A 2019 systematic review concluded that SM produced comparable results to recommended treatments for chronic low back pain, while SM appeared to give improved results over non-recommended therapies for short term functional improvement. In 2007 the American College of Physicians
The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults.Sokanu "What is an Internist?" Retrieved October 20, 2014 With 161,000 members, ACP is the largest ...
and the American Pain Society
The American Pain Society (APS) was a professional membership organization and a national chapter of the International Association for the Study of Pain (IASP).
History
Around the time of Purdue Pharma
Purdue Pharma L.P., formerly the Purdue ...
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. A 2017 review concludes "for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy."
Neck pain
For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies. A 2015 Cochrane systematic review found that there is no high quality evidence assessing the effectiveness of spinal manipulation for treating neck pain.[ Moderate to low quality evidence suggests that multiple spinal manipulation sessions may provide improved pain relief and an improvement in function when compared to certain medications.][ Due to the potential risks associated with spinal manipulation, high quality randomized controlled trials are needed to determine the clinical role of spinal manipulation.][ A 2007 systematic review reported that there is moderate- to high-quality evidence that subjects with chronic neck pain, not due to ]whiplash
Whiplash may refer to:
* The long flexible part of a whip
* Whiplash (medicine), a neck injury
** Whiplash Injury Protection System (WHIPS), in automobiles
Film and television
* ''Whiplash'' (1948 film), a US film noir about a boxer
* ''Whiplas ...
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 disorders
Historically, some within the chiropractic profession have claimed that spinal adjustment
Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Despite anecdotal success, there is no scientific evidence ...
s have physiological effects on visceral functions, and thus affect overall health, beyond musculoskeletal conditions. This view originated in the 19th century with Daniel David Palmer
Daniel David Palmer (March 7, 1845 – October 20, 1913) was a Canadian American chiropractor who was the founder of chiropractic. Palmer was born in Pickering, Ontario, but emigrated to the United States in 1865. He was also an avid proponent ...
's original thesis that many diseases were caused by subluxations. Over time, this hypothesis has been shown to be inconsistent with our modern understanding of pathology and disease and only "a small proportion of chiropractors, osteopaths, and other manual medicine providers use ngspinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial."
A 2019 global summit of "50 researchers from 8 countries and 28 observers from 18 chiropractic organizations" conducted a systematic review of the literature, and 44 of the 50 "found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function."
Assistance of medication or anesthesia
As for manipulation with the assistance of medication or anesthesia, a 2013 review concludes that the best evidence lacks coherence to support its use for chronic spine pain.
Safety
There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown. Spinal manipulation is frequently associated with mild to moderate temporary 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 ...
, and also rare serious outcomes which can result in permanent disability or death. The National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
in the UK notes that about half of people reported encountering adverse effects following spinal manipulation.[ Adverse events are increasingly reported in ]randomized clinical trial
A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...
s of spinal manipulation but remain under-reported despite recommendations in the 2010 CONSORT __NOTOC__
Consort may refer to:
Music
* "The Consort" (Rufus Wainwright song), from the 2000 album ''Poses''
* Consort of instruments, term for instrumental ensembles
* Consort song (musical), a characteristic English song form, late 16th–earl ...
guidelines. A 2015 Cochrane systematic review noted that more than half of the randomized controlled trials looking at the effectiveness of spinal manipulation for neck pain, did not include adverse effects in their reports.[ However, more recent reports have reported spinal manipulation adverse events to be rare.]
Risks of neck 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 little evidence of risk of harm but also little evidence of safety either.[ There is controversy regarding the degree of risk of ]vertebral artery dissection
Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening t ...
, which can lead to 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 ...
and death, from cervical manipulation
Cervical manipulation, commonly known as neck manipulation, is a procedure involving adjustment of the upper seven vertebrae of the spinal column. This procedure is most often utilized by chiropractors, as well as osteopathic physicians who practi ...
. Several deaths have been associated with this technique and it has been suggested that the relationship is causative
In linguistics, a causative (abbreviated ) is a valency-increasing operationPayne, Thomas E. (1997). Describing morphosyntax: A guide for field linguists'' Cambridge: Cambridge University Press. p. 173–186. that indicates that a subject either ...
, but this is disputed by many chiropractors who believe it is unproven.
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
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 ...
found that there is little evidence for efficacy and some evidence for adverse effects, and due to that, the procedure should be approached with caution, particularly forceful manipulation of the upper spine with rotation.
A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence.[
A 2016 systematic-review found the data supporting a correlation between neck manipulation and cervical artery dissection to be very weak and that there was no convincing evidence for causation.
]
Potential for incident under-reporting
Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The RAND
The RAND Corporation (from the phrase "research and development") is an American nonprofit global policy think tank created in 1948 by Douglas Aircraft Company to offer research and analysis to the United States Armed Forces. It is financed ...
study assumed that only 1 in 10 cases would have been reported. However, 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 ...
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 under-reporting 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."''[Spinal manipulation: Its safety is uncertain](_blank)
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.[NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors](_blank)
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.
Mis-attribution 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 (non-thrust 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."
History
Spinal manipulation is a therapeutic intervention that has roots in folk medicine
Traditional medicine (also known as indigenous medicine or folk medicine) comprises medical aspects of traditional knowledge that developed over generations within the folk beliefs of various societies, including indigenous peoples, before the ...
such as the traditional bone-setting and has been used by various cultures, apparently for thousands of years. Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history of ...
, the "father of medicine" used manipulative techniques,[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 as did the ancient Egyptians and many other cultures.[Burke, G.L.,]
Backache from Occiput to Coccyx
Chapter 1 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
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 i ...
and 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 ...
medicine. Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s.[Burke, G.L.,]
Backache from Occiput to Coccyx
" Chapter 7
Providers
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 ...
, it is most commonly performed by physical therapist
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 ...
s, 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 ...
, and chiropractor
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 pseudoscie ...
s. In Europe
Europe is a large peninsula conventionally considered a continent in its own right because of its great physical size and the weight of its history and traditions. Europe is also considered a Continent#Subcontinents, subcontinent of Eurasia ...
, 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 ...
, 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 ...
and 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 ...
are the majority providers, although the precise figure varies between countries. In 1992, chiropractors were estimated to perform over 90% of all manipulative treatments given for low back pain treatment. A 2012 survey in the US found that 99% of the first-professional physical therapy programs that responded were teaching some form of thrust joint manipulation
Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect.
Practice of manipulation
A modern re-emphasis on manipulative ther ...
.
Terminology
Manipulation is known by several other names. The British orthopedic 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 labeling 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 ...
. 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
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 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 ...
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 ...
.
While spinal manipulations may pose as a therapeutic effect in pain management, their efficacy in promoting performance enhancement is inconclusive. The outcomes of individuals who undergo spinal manipulations vary on a patient-to-patient basis.
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 oriented into the appropriate position in preparation for the prethrust phase.
Kinematics
The 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 ...
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
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 ...
. This may explain why studies have found that regional vs. targeted spinal manipulation result in similar patient outcomes.
Suggested mechanisms
The effects of spinal 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 pain
Back pain is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area is the most common area ...
* Temporary increase in passive range of motion (ROM)
* Physiological effects on the central nervous system (specifically the sympathetic nervous system
The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...
)
* Altered sensorimotor integration
* No alteration of the position of the sacroiliac joint
*Sham or placebo
A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures.
In general ...
manipulation
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 manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.
See also
* Osteopathic manipulation
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 ...
* Joint manipulation
Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect.
Practice of manipulation
A modern re-emphasis on manipulative ther ...
* 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 ...
* Spinal adjustment
Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Despite anecdotal success, there is no scientific evidence ...
References
Further reading
*
*
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*
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)
recommendations of the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO).
European Association of Advanced Manual and Manipulative Therapy
{{Chiropractic
Manual therapy
Chiropractic treatment techniques
Osteopathy
Physical therapy
Osteopathic manipulative medicine