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Joint manipulation

For extended detail of manipulation of spinal joints, see 3.1 Kinetics
Spinal manipulation.
Until recently, force-time histories measured during
spinal manipulation were described as consisting of three
Joint manipulation is a type of passive movement of a
distinct phases: the preload (or prethrust) phase, the
skeletal joint. It is usually aimed at one or more 'target'
thrust phase, and the resolution phase.[5] Evans and
synovial joints with the aim of achieving a therapeutic
Breen[6] 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 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 (MCP) joints, show no more than
gradually increasing load. This is probably because there
are many more tissues restraining a spinal motion segment than an independent MCP joint.

Practice of manipulation

A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with
the emergence of osteopathic medicine and chiropractic
medicine.[1] In the context of healthcare, joint manipulation is performed by several professional groups. In North
America and Europe, joint manipulation is most commonly performed by chiropractors (estimated to perform
over 90% of all manipulative treatments[2] ), Americantrained osteopathic physicians, occupational therapists,
physiotherapists, and European osteopaths. When ap- 3.2 Kinematics
plied to joints in the spine, it is referred to as spinal manipulation.
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
2 Terminology
synovial joint. Even so, the motion that occurs between
the articular surfaces of any individual synovial joint durManipulation is known by several other names. His- ing manipulation should be very similar and is described
torically, general practitioners and orthopaedic surgeons below.
have used the term “manipulation”.[3] Chiropractors refer to manipulation of a spinal joint as an 'adjustment'.
Following the labelling system developed by Geoffery
Maitland,[4] manipulation is synonymous with Grade V
mobilization, a term commonly used by physical therapists. Because of its distinct biomechanics (see section
below), the term high velocity low amplitude (HVLA)
thrust is often used interchangeably with manipulation.

Early models 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 in MCP joints. The cracking was
elicited by pulling the proximal phalanx away from the
metacarpal 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, was met and then broken. These
studies were therefore never designed to form models of
therapeutic manipulation, and the models formed were
3 Biomechanics of joint manipula- erroneous in that they described the target joint as being configured at the end range of a rotation movement,
during the orientation phase. The model then predicted
that this end range position was maintained during the
Manipulation can be distinguished from other manual prethrust phase until the thrust phase where it was moved
therapy interventions such as joint mobilization by its beyond the 'physiologic barrier' created by synovial fluid
biomechanics, both kinetics and kinematics.
resistance; conveniently within the limits of anatomical

but potentially serious side effects. Evans and Breen[6] argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint. JD Cassidy. and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is “both safe and effective. Y He. rather than the rolling or sliding that usually occurs during physiological motion).[8] The effects of this process will remain for a period of time termed the 'refractory period'. There is some evidence that ligament laxity around the target joint is associated with an increased probability of cavitation.2 6 integrity provided by restraining tissues such as the joint capsule and ligaments. cases were of action about three times more likely to see a chiropractor or The clinical effects of joint manipulation have been a PCP before their stroke than controls. some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave solution creating a bubble or cavity. In those aged <45 years. headache. The (Rand). especially manipulation of spinal joints. J. Positive associations were found between PCP visits and • Shortened time to recover from acute back sprains VBA stroke in all age groups. increased risks of VBA stroke associated with chiroprac• Temporary increase in passive range of motion tic and PCP visits is likely due to patients with headache (ROM).1 Risks of upper cervical manipulation The degree of serious risks associated with manipulation of the cervical spine is uncertain. there are risks associated with joint manipulation. or radiating discomfort. This deforms the joint capsule and intra-articular tissues. resulting in a 'clicking' sound. DC. strokes. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped. tiredness. This model still dominates the literature. investigated 818 VBA strokes that 5 Clinical effects and mechanisms were hospitalized in a population of more than 100 million person-years. Cassidy. The contents of this gas bubble are thought to be mainly carbon dioxide. spinal disc herniation. • Temporary relief of musculoskeletal pain. 4 Cracking joints Main article: Cracking joints Joint manipulation is characteristically associated with the production of an audible 'clicking' or 'popping' sound. Infrequent. which can range from a few minutes to more than an hour.[13] In a 1993 study.[13] 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 6 Safety issues As with all interventions. E Boyle. the applied force separates the articular surfaces of a fully encapsulated synovial joint. P Cote'. Results were similar in the case control and case cross over analyses. A 2008 study in the journal “Spine”. and cauda equina syndrome. while it is slowly reabsorbed back into the synovial fluid. after re-examining the original studies on which the kinematic models of joint manipulation were based. et al.[10] and neck pain from VBA dissection seeking care before . and that it is more mechanically efficient to do this when the joint is near to its neutral configuration. with widely differing results being published.[11] • No alteration of the position of the sacroiliac joint. vertebral and rib fractures.[7] In this low pressure environment. However. which in turn creates a reduction in pressure within the joint cavity.[9] SAFETY ISSUES • Physiological effects upon the central nervous system. When a manipulation is performed. The study concluded that VBA stroke is a very rare event in the population.D.”[14] 6. shown to include: There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. This sound is believed to be the result of a phenomenon known as cavitation occurring within the synovial fluid of the joint. which rapidly collapses upon itself.[12] Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort. which is the motion region of the joint where the passive osteoligamentous stability mechanisms exert little or no influence. include: vertebrobasilar accidents (VBA).

The aupractic Clinic in Chicago.000 deaths per mil.6% of reported indications for cervical manipulation was considered inappropriate. He concluded primary care. [21] riod. in a survey of 203 practitioners of manual medicine in Switzerland.[25] In very rare instances. gives beneficial results with few adverse side effects”. due to arterial trauma after cervical manipulation. After an extensive literature review performed to formu. timated “one in a million.sociations were found for those over 45 years.[26][27][28][29] 6. The rarity of VBAs Cassidy performed a survey at the Canadian Memorial makes this association difficult to[32]study despite high volThe NHS notes that Chiropractic College outpatient clinic where more than umes of chiropractic treatment.“According to the report .'" especially at the brain stem.. without a single case of ver. Coulter et al. 35 cases “The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors.[20] Henderson and positive association in young adults.” [16] the “master cervical” or “rotary break. without any reported deaths.propriate.” this study collected data objectively by using administraa half-million treatments were given over a nine-year petive data. cervical spinal surgery.[18] had a multidisciplinary group late practice guidelines. and 4. much additional scientific the efficacy of cervical spine manipulation are tive therapy emphasize the possibility of serious injury. again without a single significant complication. rendering estiA 1996 Danish chiropractic study confirmed the risk of mates “nonsensical. involving less recall bias than survey studies. The RAND study assumed that only 1 in 10 cases would have been reported. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that. the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence.” Reviews and Dissemination stated that the survey had Serious complications after manipulation of the cervical methodological problems with data collection. there is a 3-4% rate of complications for by chiropractors). 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.3 Misattribution problems Studies of stroke and manipulation do not always clearly identify what professional has performed the manipulation.1% could be labeled apthe major criticism of spinal manipulative therapy. [22] riod. However.000 cervical brobasilar accidents (VBAs) were five times more likely manipulations. compared to controls reported approximately 5 million cervical manipulations who had not visited a chiropractor. particularly passive rotation of the neck.. 4 DCs and 1 MD/DC look at 736 conditions risk of serious neurological complications (from cervical where it was used.6. 57. in experienced hands.vey method of data collection. of VBA stroke associated chiropractic care compared to but none of the cases had been reported.In 1996.. .3% uncertain. vascular accidents are responsible for with 31.”[18] Dvorak. DC.[19] Jaskoviak ropractor in the preceding week.[24] Understandably.[17] A RAND Corporation extensive review es. known as risk seems greatest: forceful manipulation [30] The NHS Centre for spine with a rotational element. and determined that the greatest risk is cians might tell their patients to adopt a cautious approach with manipulation of the first two vertebra of the cervical and avoid the type of spinal manipulation for which the of the upper spine. found A 2001 study in the journal Stroke found that vertea rate of one serious complication per 400. In a 1995 study. data about[33] needed. this is not accidental. chiropractic researcher Allan Terrett. The study found no evidence of excess risk had been seen by the 24 neurologists who responded.”[23] spine in those cases (including a few cases not performed In comparison.thors concluded: “While our analysis is consistent with a tebral artery stroke or serious injury.3 Misattribution problems 3 their stroke.5 million cervical manipulations.. No significant asfrom 1965 to 1980 at The National College of Chiro. How. and is approximately one priateness of manipulation or mobilization of the cervical or two per million cervical manipulations. lion neck surgeries.tioners concluded that '.in those aged less than 45 years who had visited a chitimated 1. The true incidence of such report- . A panel of chiropractors and medical practiever. In many cases. among an es. it has been pointed out that “critics of manipula. the authors had access to original reports that identified the practitioner involved as a nonchiropractor.000 cervical manipulations over a 28-year pe[31] contained inaccuracies.[31] Both spine are estimated to be 1 in 4 million manipulations NHS and Ernst noted that bias is a problem with the suror fewer. the authors concurred that “the of 4 MDs.” He therefore suggested that “clinistroke to be low.[15] that underreporting was close to 100%. Only 11.000-10. Their job was to evaluate the appromanipulation) is extremely low. again without serious incident. respected medical journals and medical organizations. pointed to this problem: Potential for incident underreporting Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary.2 6. Eder offered a rebut the data were collected retrospectively and probably port of 168. . In some cases this has led to confusion and improper placement of blame.

G. Peripheral Manipulation 2nd ed. Death occurred in 32 (18%) of the cases. PMID 1388006. Physical therapists were involved in less than 2% of the cases. there is convincing evidence to show that it is associated with frequent. Butterworths. It analyzed In emergency medicine joint manipulation can also refer 177 cases that were reported in 116 articles published be.”[34] REFERENCES 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 biomechanics of spinal manipulation. it seems debatable whether the benefits of spinal manipulation outweigh its risks.D.”. J Manipulative Physiol Ther.jmpt. of the brain stem.[36] and Figure 2 shows the type of practitioner involved in the resulting injury. "Backache from Occiput to Coccyx" Chapter 7 [4] Maitland. the types of injuries attributed to manipulation of the cervical spine are shown. [6] Evans DW. Crit Rev Phys Rehabil Med. J Manipulative Physiol Ther.1016/j. particularly those below 45 years of age.D.. prospective studies that can overcome the limitations of previous investigations are now a matter of urgency. On the other hand. PMID 16396734. [2] Shekelle PG.7326/0003-4819-117-7-590..2005. Special care was taken. 13 (2): 191–216.1016/S01614754(02)54125-7. 29 (1): 72–82. Specific risk factors for vascular accidents related to spinal manipulation have not been identified. Maitland. Such reporting adversely affects the reader’s opinion of chiropractic and chiropractors. Annals of Internal Medicine. [3] Burke. Brook RH (1992). as well as the type of manipulation responsible for any injuries and/or deaths. the type of practitioner was adjusted according to the findings by Terrett. “The most frequently reported injuries inThese procedures have no relation to the HVLA thrust volved arterial dissection or spasm. G. clinicians might • Chiropractic Adjustment 9 References [15] [1] Keating JC Jr (2003). “Several pathways in the evolution of chiropractic manipulation”.”.”[30] This error was taken into account in a 1999 review[35] of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). .11.”[35] Edzard Ernst has written: ". “Spinal manipulation for low-back pain”. Although the risk of injury associ• Orthopedic medicine ated with MCS appears to be small. London. this type of therapy has the potential to expose patients • Osteopathic manipulative medicine to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive • Physical therapy movements).there is little evidence to demonstrate that spinal manipulation has any specific therapeutic effects. 1986. doi:10. whenever possible..011.[34] The review concluded: “The literature does not demonstrate that the benefits of MCS outweigh the risks. and summarized: dislocated joints into normal anatomical alignment (otherwise known as 'reducing' the fracture or dislocation). mild adverse effects as well as with serious complications of unknown incidence. doi:10.L. 26 (5): 300–21.[37] For the purpose of comparison. doi:10. G. Vertebral Manipulation 5th ed. Symons B (2001). and no deaths have 8 See also been attributed to MCS provided by physical therapists. Butterworths. “A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone. to correctly identify all the 7 Emergency medicine professions involved. Breen AC (2006).to the process of bringing fragments of fractured bone or tween 1925 and 1997. which means that any patient may be at risk. Adams AH. PMID 12819626. and lesions procedure. Therefore. 117 (7): 590–598. 1977. Definitive.4 9 ing cannot be determined. Until they are available. Chassin MR. Several recommendations for future studies and for the practice of MCS are discussed. [5] Herzog W.”[35] • Small joint manipulation In Figure 1 in the review. London. Hurwitz EL.

1097/00007632-199805150-00010. “Risk of Vertebrobasilar Stroke and Chiropractic Care:Results of a PopulationBased Case-Control and Case-Crossover Study”. Williams JI (May 2001). Christensen H.STR. 19 (3): 165–8. [24] The cervical spine research society editorial committee. 3: 213-19. doi:10. PMC 99224 . [29] Haldeman S.32. [12] Tullberg T. CT. “Side posture manipulation for lumbar intervertebral disk herniation. Bondy S. Chapman-Smith D. Journal of Manipulative and Physiological Therapeutics. “Spinal manipulation: its safety is uncertain”.”.1161/01. J Manipulative Physiol Ther.1054. Terrett AG. [30] Ernst E (January 2002). Spine.4. PMID 9615363. Williams J (2001). Kohlbeck FJ.”. In: Haldeman S. Townsend M. [20] Jaskoviak P. McGregor M (January 2002). PMID 11800245. further studies of the effects of manipulation should focus on the soft tissue response. Bondy SJ. 27 (1): 49–55. “The effect of talocrural joint manipulation on range of motion at the ankle”. J Manip Physiol Ther. PMID 9055373. East Norwalk. doi:10.1067/mmt. 19 (6): 371–7. PMC 1005793 . PMID 11805635. J. doi:10. Cerebrovascular complications of manipulation. 16 (2): 96–103. 23 (10): 1124–8. Gaithersburg. PMC 81498 . 18 (3): 155–64. 30 (4): 348–58. Md: Aspen Publishers. Baltimore: Williams and Wilkins. “Manipulation does not alter the position of the sacroiliac joint. 2 (5): 334–42. 17 (Suppl 1): S176–S183. org [18] Coulter ID.1097/00007632-19970215000017. PMID 8864967. PMID 8728459. Upper cervical syndrome: chiropractic diagnosis and treatment. Slack JR (March 1995). “Chiropractic manipulation and stroke: a population-based case-control study.B. doi:10.5 [7] Brodeur R. doi:10. [14] Cassidy JD. Complications arising from manipulation of the cervical spine. In: Vernon H. Spine. The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. Rasmussen L (1996). Carey P. [10] Nilsson N. (1995). Leboeuf-Yde C.”. discussion 440–1.STR.”.1097/00007632-20020101000012. doi:10. Principles and practice of chiropractic. Thiel H. Original article . [17] Lauretti W “What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from www. PMID 11340209.1161/01. [27] Rothwell DM. Rockville. “Chiropractic manipulation and stroke: a population-based case-control study”.1136/ard. PMID 14589464. A bioengineering study of cavitation in the metacarpophalangeal joint. Carey P. [8] Unsworth A. Md: Aspen Publishers. “Sacroiliac joint manipulation decreases the H-reflex”. CMAJ. Borchgrevink C (February 1997). David. Stroke. Johnsson R (May 1998).”. PMID 8445360. [22] Eder M.1016/S1529-9430(02)00411-4. PMID 7790795. [9] Fryer GA. 22 (4): 435–40. PMID 11599329. 166 (1): 40–1. Ann Rheum Dis. Papadopoulos C (October 2001). 25 (6): 384–90. J Manipulative Physiol Ther.348. Hartvigsen J (1996). Part I. PMID 11340209. Petersen DM. “Arterial dissections following cervical manipulation: the chiropractic experience”. CMAJ. Mudge JM. Rand Corp: xiv [RAND MR-781-CCR]. doi:10. Cassidy JD. Orelli F. blind. “Safety in chiropractic practice. 2nd ed. a journal of cerebral circulation. Dawson NJ.chiro. Appleton Lang. PMID 12183696. Chiropractic therapy: diagnosis and treatment (English translation).5. et al. [28] Haldeman S. Lippincott Company 1990: 834.1007/s00586-0080634-9. Townsend M. J Manip Physiol Ther 1980. 35 (2): 87–94. “Lasting changes in passive range motion after spinal manipulation: a randomized. Because the supposed positive effects are not a result of a reduction of subluxation. Blomberg S.”. Tilscher H. CA. Second edition. discussion 1129. [21] Henderson DJ. doi:10. “Frequency and characteristics of side effects of spinal manipulative therapy”. Dowson D. “Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias”. 1992. Papadopoulos C (2002). 2: 1-4. (1996) The appropriateness of manipulation and mobilization of the cervical spine 'Santa Monica. 32 (5): 1054–60. Philadelphia: J. 1988: 195-222. Current link [19] Dvorak J. et al.30. controlled trial. Spine. Vertebral Artery syndrome. doi:10. Leboeuf-Yde C. McLaughlin PA (2002). Spine. Branth B. Wright V (1971). [31] NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors [32] Rothwell D. 32 (5): 1054–60. “The audible release associated with joint manipulation. J Manip Physiol Ther. [11] Murphy BA. (2008). 1993: 170-2. 165 (7): 905–6. [23] Haldeman S. 1990: 61. How dangerous is manipulation to the cervical spine? Manual Medicine 1985. [16] Klougart N. "'Cracking joints’. [15] Cassidy.32. Adams AH. PMID 7781578. The Cervical Spine. The Spine Journal. [13] Senstad O.126129. [26] Haldeman S. Guidelines for chiropractic quality assurance and practice parameters.5. Stroke. Kirkaldy-Willis W (1993). Electromyography and clinical neurophysiology. Hurwitz EL. ed. PMID 5557778.2002.1054. A roentgen stereophotogrammetric analysis”. [25] Kleynhans AM. “Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation”.

[37] Figure 2. I: Diagnosis of Soft Tissue Lesions 8th ed. • Burke. Diagnosis and Treatment Using Manipulative Techniques. Little Brown and Co. PMID 9443693. London. Waikanae. Butterworths. London. [36] Figure 1. 79 (1): 50–65.. 11 External links • American Academy of Orthopedic Manual Physical Therapy (AAOMPT) • Canadian Academy of Manipulative Therapy (CAMT) EXTERNAL LINKS • 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 . 7 (1): 20–3. The Lumbar Spine. • Mennel. Retrieved 2006-11-17. “Finding a good chiropractor”. G. New Zealand. Harcourt Publishers Ltd. R. Archives of Family Medicine. 1983. Mechanical Diagnosis and Therapy. 18 (4): 203–10. G.. Vol. Vertebral Manipulation 5th ed. Vol. “Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. Textbook of Orthopaedic Medicine. Bailliere Tindall. II: Treatment by Manipulation. • McKenzie. Practitioners providing manipulation of the cervical spine that resulted in injury. 1964. Mechanical Diagnosis and Therapy. J. 1982. 1981.7.D. London. 1994 • Maitland. Vancouver 1964.A. [34] Terrett A (1995). Backache from Occiput to Coccyx. • Maitland.M. Peripheral Manipulation 2nd ed.A. R.1001/archfami. London. Butterworths. doi:10. G.L. 1977. Massage and Injection 10th ed. Bailliere Tindall.D. 10 Further reading • Cyriax. J Manipulative Physiol Ther. Textbook of Orthopaedic Medicine. Spinal Publications. • McKenzie. Joint Pain. • Cyriax. [35] Di Fabio R (1999). Boston.20. The Cervical and Thoracic Spine. Injuries attributed to manipulation of the cervical spine. PMID 7636409. 1986. Waikanae.1. Phys Ther. PMID 9920191. 1990..”. Macdonald Publishing. J.”.6 11 [33] Homola S (1998). J. “Manipulation of the cervical spine: risks and benefits.2008. Spinal Publications. • Greive Modern Manual Therapy of the Vertebral Column. New Zealand.

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