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Joint manipulation is the skilled passive movement of a skeletal joint that is applied at varying speeds and amplitudes. It may include a high velocity/low-amplitude (HVLA) therapeutic movement or thrust to move a joint past the physiological range of motion (ROM) without exceeding the anatomic limit, and may involve the following factors: controlled force, leverage, direction, amplitude, and velocity. It is performed by some medical doctors and osteopaths, many physical therapists, all chiropractors and bone setters, and many Indian barbers. Its performance may be intended to reduce pain and/or increase ROM. Regardless of the profession involved, there are questions related to its effectiveness and safety, especially as related to manipulation of the upper cervical spine.

Terminology: "manipulation" or "adjustment"

The terms "manipulation" and "adjustment" are often used interchangeably by chiropractors, while non-chiropractors rarely use the term "adjustment", but consistently use "manipulation" (except for the osteopathic Specific Adjustment Technique).

Joint manipulation may be general or specific, and therefore does not necessarily imply specificity or the correction of the chiropractic subluxation. It is therefore not entirely synonymous with the chiropractic "adjustment".

When performed by non-chiropractors it is termed "manipulation," and is not intended to treat the chiropractic vertebral subluxation. When performed by chiropractors (with the exception of reform chiropractors) it always includes the intention to correct vertebral subluxations, making the chiropractic adjustment a uniquely chiropractic technique. When a "straight" (foundational) chiropractor wishes to emphasize this intention, the expression "adjustment" is consistently used.

Mechanisms and effects

Joint manipulation is generally described as a high velocity, low amplitude, (HVLA) thrust, that usually causes an audible "popping" sound. The sound is theorized to be from nitrogen gas being released from the synovial fluid found in diarthrodial joints. When a manipulation is performed, the force applied separates the joint surfaces of the fully encapsulated joint cavity creating a relative vacuum within the joint space. In this low pressure environment, the naturally dissolved nitrogen found in all bodily fluids turns into a gas bubble and a sound is heard. This bubble will remain within the joint for hours while it is slowly reabsorbed by the body.

The effects of spinal manipulation have been shown to include: temporary increase in passive range of motion (ROM), temporary relief of musculoskeletal pain and shortened time to recover from acute back sprains (Rand). Common side effects include: soreness from minor, treatment induced joint strains, dependency on treatment, and neck hypermobility.

A Cochrane review of spinal manipulation and mobilisation for mechanical neck disorders evaluated 33 clinical trials. The authors found that, combined with exercise, these approaches were promising, but "the evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior."

Professor of Complementary Medicine Edzard Ernst, MD, has written:

"...there is little evidence to demonstrate that spinal manipulation has any specific therapeutic effects." and "...the proven benefit of chiropractic spinal manipulation is far less certain than chiropractors tend to admit and its risks are not negligible. This is true for back pain in general and for osteoporotic back pain in particular."

In 2006 Ernst and Cantor published the results of their analysis of "all systematic reviews of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005," and concluded:

"Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment."

Safety issues

As with all interventions, there are risks associated with spinal manipulative therapy (SMT). Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral and rib fractures, and cauda equina syndrome.

Powell, et al, have listed six risk factors associated with complications of SMT. These include: "misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine."

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

Serious complications after manipulation of the cervical spine are estimated to be 1 in 3-4 million manipulations or fewer. Less conservative treatments such as neck surgery are also commonly used for conditions very similar to the conditions treated using spinal manipulation. There is a 3-4% rate of complication for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries

Potential for incident underreporting

Statistics on the reliability of incident reporting for spinal manipulation 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 complication occurring within 24 hours of cervical spinal manipulation (not specifically by a chiropractor); 35 cases had been seen by the 24 who responded, but none had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." He concluded by suggesting 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 <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 aged >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.

There are also concerns about using cervical manipulation for conditions for which it is not indicated. In 1996, Coulter et al. surveyed 4 MDs, 4DCs and 1 MD/DC to evaluate the risks and benefits of manipulation or mobilization of the cervical spine (including a few cases not performed by chiropractors). After looking at more than 700 conditions, there was consensus in only 11% of those conditions that cervical manipulation or mobilization was appropriate.

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."

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."

Emergency medicine

In emergency medicine it 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).

Notes and references

1. ICA News and PR International Chiropractors Association.
2. The audible release associated with joint manipulation. Brodeur R., J Manipulative Physiol Ther. 1995 Mar-Apr;18(3):155-64.
3. Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial. Nilsson N., et al, J Manipulative Physiol Ther 1996 Mar-Apr;19(3):165-8.
4. ^ Gross AR, Hoving JL, Haines TA et al. Cervical overview group. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database Syst Rev 2002; 3: CD004249.
5. The value of chiropractic. Edzard Ernst, Focus Altern Complement Ther 2005; 10: 87–8
6. ^ Spinal manipulation: Its safety is uncertain. Edzard Ernst, CMAJ, January 8, 2002; 166 (1)
7. Chiropractic spinal manipulation for back pain. Edzard Ernst, Br J Sports Med 2003;37:195–196
8. Ernst E, Canter PH. A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine 2006;100:189-193.
9. Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy. Outcomes of Treatment (Adverse) Spine. 22(4):435-440, February 15, 1997.
10. Powell FC, Hanigan WC, Olivero WC. Neurosurgery. 1993 Jul;33(1):73-8; discussion 78-9.
11. Cassidy JD, Thiel H, Kirkaldy-Willis W (1993). "Side posture manipulation for lumbar intervertebral disk herniation". J Manip Physiol Ther. 16: 96–103. PMID 8445360.{{cite journal}}: CS1 maint: multiple names: authors list (link)
12. Lauretti W "What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from www.chiro.org
13. ^ NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors
14. Rothwell D, Bondy S, Williams J (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32: 1054–60. PMID 11340209.{{cite journal}}: CS1 maint: multiple names: authors list (link) Original article
15. Cite error: The named reference Coulter was invoked but never defined (see the help page).
16. ^ Terrett AGJ (1995) Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. J Manip Physiol Ther 18:203. PubMed - PMID: 7636409
17. ^ Di Fabio RP. "Manipulation of the Cervical Spine: Risks and Benefits" Phys Ther. 1999 Jan;79(1):50-65. PMID: 9920191 Current link
18. Figure 1. Injuries attributed to manipulation of the cervical spine.
19. Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury.

See also

• Cracking joints
• Orthopedic medicine
• Osteopathic Manipulative Medicine
• Physical therapy
• Spinal adjustment (Chiropractic)

External links

for links relating to chiropractic subluxation.

• 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)

• Manipulative therapy