View source for Joint manipulation

{{For|extended detail of manipulation of spinal joints|Spinal manipulation}}
'''Joint manipulation''' is a type of passive movement of a skeletal [[joint]]. It is usually aimed at one or more 'target' [[synovial joint]]s with the aim of achieving a therapeutic effect.

== Definition of manipulation ==

Many definitions of joint manipulation have been proposed.<ref name="evans_lucas_2010">{{Cite journal |vauthors=Evans DW, Lucas N |year=2010 |title=What is 'manipulation'? A reappraisal. |journal=Man Ther |volume=15 |issue=3 |pages=286–91 |doi=10.1016/j.math.2009.12.009 |pmid=20080431 |s2cid=12195189}}</ref> The most rigorous definition, based on available empirical research is that of Evans and Lucas:<ref name="evans_lucas_2023">{{Cite journal |vauthors=Evans DW, Lucas N |year=2023 |title=What is manipulation? A new definition. |journal=BMC Musculoskelet Disord |volume=15;24(1) |issue=1 |pages=194 |doi=10.1186/s12891-023-06298-w |pmc=10015914 |pmid=36918833 |doi-access=free}}</ref> "Separation (gapping) of opposing articular surfaces of a synovial joint, caused by a force applied perpendicularly to those articular surfaces, that results in cavitation within the synovial fluid of that joint." The corresponding definition for the mechanical response of a manipulation is: "Separation (gapping) of opposing articular surfaces of a synovial joint that results in cavitation within the synovial fluid of that joint." In turn, the action of a manipulation can be defined as: "A force applied perpendicularly to the articular surfaces."

== 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]].<ref name="Keating-pathways">{{Cite journal |last=Keating JC Jr |year=2003 |title=Several pathways in the evolution of chiropractic manipulation |journal=J Manipulative Physiol Ther |volume=26 |issue=5 |pages=300–21 |doi=10.1016/S0161-4754(02)54125-7 |pmid=12819626}}</ref> 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<ref name="shekelle">{{Cite journal |vauthors=Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH |year=1992 |title=Spinal manipulation for low-back pain |journal=Annals of Internal Medicine |volume=117 |issue=7 |pages=590–598 |doi=10.7326/0003-4819-117-7-590 |pmid=1388006 |s2cid=35702578}}</ref>), American-trained [[Doctor of Osteopathic Medicine|osteopathic physicians]], [[occupational therapists]], [[physiotherapy|physiotherapists]], and European [[Osteopathy|osteopaths]]. When applied to joints in the [[vertebral column|spine]], it is referred to as [[spinal manipulation]].{{cn|date=August 2024}}

== Terminology ==

Manipulation is known by several other names. Historically, general practitioners and orthopaedic surgeons have used the term "manipulation".<ref name="Burke">Burke, G.L., "[http://www.macdonaldpublishing.com/Chapter_7.html Backache from Occiput to Coccyx] {{Webarchive|url=https://web.archive.org/web/20140714125304/http://www.macdonaldpublishing.com/Chapter_7.html |date=2014-07-14 }}" Chapter 7</ref> Chiropractors refer to manipulation of a spinal joint as an '[[spinal adjustment|adjustment]]'. Following the labelling system developed by Geoffery Maitland,<ref>Maitland, G.D. ''Peripheral Manipulation'' 2nd ed. Butterworths, London, 1977.<br>Maitland, G.D. ''Vertebral Manipulation'' 5th ed. Butterworths, London, 1986.</ref> manipulation is synonymous with Grade V [[joint mobilization|mobilization]], a term commonly used by [[physical therapists]]. Because of its distinct biomechanics (see [[Joint manipulation#Biomechanics of joint manipulation|section below]]), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation.{{cn|date=August 2024}}

== Biomechanics ==

Manipulation can be distinguished from other [[manual therapy]] interventions such as [[joint mobilization]] by its [[biomechanics]], both [[Dynamics (physics)|kinetics]] and [[kinematics]].

=== 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.<ref>{{Cite journal |vauthors=Herzog W, Symons B |year=2001 |title=The biomechanics of spinal manipulation. |journal=Crit Rev Phys Rehabil Med |volume=13 |issue=2 |pages=191–216 |doi=10.1615/CritRevPhysRehabilMed.v13.i2-3.50}}</ref> Evans and Breen<ref name="pmid16396734">{{Cite journal |vauthors=Evans DW, Breen AC |year=2006 |title=A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone. |journal=J Manipulative Physiol Ther |volume=29 |issue=1 |pages=72–82 |doi=10.1016/j.jmpt.2005.11.011 |pmid=16396734}}</ref> added a fourth 'orientation' phase to describe the period during which the patient is [[orientation (geometry)|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 manipulation|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 [[structural load|load]]. This is probably because there are many more tissues restraining a [[functional spinal unit|spinal motion segment]] than an independent MCP joint.{{cn|date=August 2024}}

=== Kinematics ===

The kinematics of a complete [[functional spinal unit|spinal motion segment]] when one of its constituent [[spinal manipulation|spinal joints are manipulated]] are much more complex than the kinematics that occur during manipulation of an independent peripheral [[synovial joint]]. 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.{{cn|date=August 2024}}

Early [[Scientific modelling|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 [[metacarpophalangeal|MCP]] joints. The cracking was elicited by pulling the proximal [[phalanx bone|phalanx]] away from the [[metacarpal]] bone (to separate, or 'gap' the articular surfaces of the [[metacarpophalangeal|MCP]] joint) with gradually increasing force until a sharp resistance, caused by the [[cohesion (chemistry)|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 erroneous in that they described the target joint as being configured at the end [[range of motion|range]] of a [[rotation]] movement, during the orientation phase.<ref name="pmid36494698">{{Cite journal |vauthors=Evans DW |year=2022 |title=Why is the prevailing model of joint manipulation (still) incorrect? |journal=Chiropr Man Ther |volume=30 |issue=1 |pages=51 |doi=10.1186/s12998-022-00460-2 |pmc=9733235 |pmid=36494698 |doi-access=free}}</ref> 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.<ref name="pmid36494698" /> However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen<ref name="pmid16396734" /> 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 [[joint stability|stability]] 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]] or [[sliding (motion)|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.{{cn|date=August 2024}}

== Cracking joints ==

{{anchor|Audible click}}
{{Main article|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]] occurring within the [[synovial fluid]] of the joint. When a manipulation is performed, the applied force separates the articular surfaces of a fully encapsulated synovial joint. This [[deformation (mechanics)|deforms]] the joint capsule and intra-articular tissues, which in turn creates a reduction in pressure within the joint cavity.<ref>{{Cite journal |last=Brodeur R. |year=1995 |title=The audible release associated with joint manipulation. |journal=J Manipulative Physiol Ther |volume=18 |issue=3 |pages=155–64 |pmid=7790795}}</ref> In this low pressure environment, some of the [[gas]]es that are dissolved in the [[synovial fluid]] (which are naturally found in all bodily fluids) leave solution creating a [[liquid bubble|bubble]] or [[Cavitation|cavity]], which rapidly [[Implosion (mechanical process)|collapses upon itself]], resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly [[carbon dioxide]].<ref>{{Cite journal |vauthors=Unsworth A, Dowson D, Wright V |year=1971 |title='Cracking joints'. A bioengineering study of cavitation in the metacarpophalangeal joint. |journal=Ann Rheum Dis |volume=30 |issue=4 |pages=348–58 |doi=10.1136/ard.30.4.348 |pmc=1005793 |pmid=5557778}}</ref> The effects of this process will remain for a period of time termed the '[[refractory period (physiology)|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 [[Ligamentous Laxity|ligament laxity]] around the target joint is associated with an increased probability of cavitation.<ref name="Fryer">{{Cite journal |vauthors=Fryer GA, Mudge JM, McLaughlin PA |year=2002 |title=The effect of talocrural joint manipulation on range of motion at the ankle |url=http://vuir.vu.edu.au/504/1/Ankle_manipulation_-_revised.pdf |journal=[[Journal of Manipulative and Physiological Therapeutics]] |volume=25 |issue=6 |pages=384–90 |doi=10.1067/mmt.2002.126129 |pmid=12183696}}</ref>

== Clinical effects and mechanisms of action ==

The clinical effects of joint manipulation have been shown to include:
* Temporary relief of musculoskeletal [[Pain and nociception|pain]].<ref>{{Cite journal |vauthors=Sutlive TG, Mabry LM, Easterling EJ, Durbin JD, Hanson SL, Wainner RS, Childs JD |year=2009 |title=Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in a military beneficiary population. |journal=Mil Med |volume=174 |issue=7 |pages=750–756 |doi=10.7205/milmed-d-02-4908 |pmid=19685848 |doi-access=free}}</ref>
* Shortened time to recover from [[Acute (medical)|acute]] [[back]] [[sprains]] (Rand).{{Citation needed|date=July 2014}}
* Temporary increase in passive range of motion (ROM).<ref>{{Cite journal |vauthors=Nilsson N, Christensen H, Hartvigsen J |year=1996 |title=Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial. |journal=J Manipulative Physiol Ther |volume=19 |issue=3 |pages=165–8 |pmid=8728459}}</ref>
* Physiological effects upon the central nervous system.<ref name="Murphy">{{Cite journal |vauthors=Murphy BA, Dawson NJ, Slack JR |date=March 1995 |title=Sacroiliac joint manipulation decreases the H-reflex |journal=Electromyography and Clinical Neurophysiology |volume=35 |issue=2 |pages=87–94 |pmid=7781578}}</ref>
* No alteration of the position of the sacroiliac joint.<ref name="Tullberg">{{Cite journal |vauthors=Tullberg T, Blomberg S, Branth B, Johnsson R |date=May 1998 |title=Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis |journal=Spine |volume=23 |issue=10 |pages=1124–8; discussion 1129 |doi=10.1097/00007632-199805150-00010 |pmid=9615363 |s2cid=36480639 |quote=Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.}}</ref>

Common [[adverse effect|side effect]]s of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.<ref name="pmid9055373">{{Cite journal |vauthors=Senstad O, Leboeuf-Yde C, Borchgrevink C |date=February 1997 |title=Frequency and characteristics of side effects of spinal manipulative therapy |journal=Spine |volume=22 |issue=4 |pages=435–40; discussion 440–1 |doi=10.1097/00007632-199702150-00017 |pmid=9055373 |s2cid=7482895}}</ref>

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 [[spinal manipulation|manipulation of spinal joints]]. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), [[stroke]]s, [[spinal disc herniation]], [[vertebral]] and [[rib]] [[bone fracture|fracture]]s, and [[cauda equina syndrome]].<ref name="pmid9055373" />

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."<ref>{{Cite journal |vauthors=Cassidy JD, Thiel H, Kirkaldy-Willis W |year=1993 |title=Side posture manipulation for lumbar intervertebral disk herniation. |journal=J Manip Physiol Ther |volume=16 |issue=2 |pages=96–103 |pmid=8445360}}</ref> In a 2019 study, L.M. Mabry, PT, and colleagues reported joint manipulation adverse events to be rare.<ref name="Mabry-2019">{{Cite journal |vauthors=Mabry LM, Notestine JP, Moore JH, Bleakley CM, Taylor JB |year=2019 |title=Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study |journal=Mil Med |volume=185 |issue=1–2 |pages=e290–e297 |doi=10.1093/milmed/usz176 |pmid=31322706 |doi-access=free}}</ref>

=== Risks of upper cervical manipulation ===

The degree of serious [[risk]]s associated with [[Cervical manipulation|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.<ref name="ReferenceA">{{Cite journal |last=Cassidy |first=J. David |display-authors=etal |year=2008 |title=Risk of Vertebrobasilar Stroke and Chiropractic Care:Results of a Population-Based Case-Control and Case-Crossover Study |journal=Spine |volume=17 |issue=Suppl 1 |pages=S176–S183 |doi=10.1007/s00586-008-0634-9 |pmc=2271108}}</ref>

A 1996 Danish [[chiropractic]] 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]] of the neck, known as the "master cervical" or "rotary break."<ref>{{Cite journal |vauthors=Klougart N, Leboeuf-Yde C, Rasmussen L |year=1996 |title=Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. |journal=J Manip Physiol Ther |volume=19 |issue=6 |pages=371–7 |pmid=8864967}}</ref>

Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer.<ref>Lauretti W "What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from [http://www.chiro.org/chimages/chiropage/cva-1.html www.chiro.org]</ref> A RAND Corporation extensive review estimated "one in a million."<ref name="Coulter">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 [RAND MR-781-CCR]. Current [http://www.rand.org/pubs/monograph_reports/MR781/ link]</ref> Dvorak, in a survey of 203 practitioners of [[manual medicine]] 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.<ref>Dvorak J, Orelli F. ''How dangerous is manipulation to the cervical spine?'' Manual Medicine 1985; 2: 1-4.</ref> 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.<ref>Jaskoviak P. ''Complications arising from manipulation of the cervical spine''. J Manip Physiol Ther 1980; 3: 213-19.</ref> 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.<ref>Henderson DJ, Cassidy JD. Vertebral Artery syndrome. In: Vernon H. ''Upper cervical syndrome: chiropractic diagnosis and treatment''. Baltimore: Williams and Wilkins, 1988: 195-222.</ref> Eder offered a report of 168,000 cervical manipulations over a 28-year period, again without a single significant complication.<ref>Eder M, Tilscher H. ''Chiropractic therapy: diagnosis and treatment'' (English translation). Rockville, Md: Aspen Publishers, 1990: 61.</ref> 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."<ref>Haldeman S, Chapman-Smith D, Petersen DM. ''Guidelines for chiropractic quality assurance and practice parameters.'' Gaithersburg, Md: Aspen Publishers, 1993: 170-2.</ref>

In comparison, there is a 3-4% rate of complications for cervical spinal [[surgery]], and 4,000-10,000 deaths per million neck surgeries.<ref>''The cervical spine research society editorial committee''. The Cervical Spine, Second edition. Philadelphia: J.B. Lippincott Company 1990: 834.</ref>

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".<ref>Kleynhans AM, Terrett AG. Cerebrovascular complications of manipulation. In: Haldeman S, ed. ''Principles and practice of chiropractic'', 2nd ed. East Norwalk, CT, Appleton Lang, 1992.</ref> 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.<ref>{{Cite journal |vauthors=Haldeman S, Kohlbeck FJ, McGregor M |date=January 2002 |title=Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation |journal=Spine |volume=27 |issue=1 |pages=49–55 |doi=10.1097/00007632-200201010-00012 |pmid=11805635 |s2cid=11271986}}</ref><ref>{{Cite journal |vauthors=Rothwell DM, Bondy SJ, Williams JI |date=May 2001 |title=Chiropractic manipulation and stroke: a population-based case-control study |url=http://stroke.ahajournals.org/cgi/pmidlookup?view=long&pmid=11340209 |journal=Stroke: A Journal of Cerebral Circulation |volume=32 |issue=5 |pages=1054–60 |doi=10.1161/01.STR.32.5.1054 |pmid=11340209 |doi-access=free}}</ref><ref>{{Cite journal |vauthors=Haldeman S, Carey P, Townsend M, Papadopoulos C |year=2002 |title=Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias |journal=The Spine Journal |volume=2 |issue=5 |pages=334–42 |doi=10.1016/S1529-9430(02)00411-4 |pmid=14589464}}</ref><ref>{{Cite journal |vauthors=Haldeman S, Carey P, Townsend M, Papadopoulos C |date=October 2001 |title=Arterial dissections following cervical manipulation: the chiropractic experience |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=11599329 |journal=CMAJ |volume=165 |issue=7 |pages=905–6 |pmc=81498 |pmid=11599329}}</ref>

=== 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, [[Edzard Ernst|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."''<ref name="ernst_safety">{{Cite journal |last=Ernst E |date=January 2002 |title=Spinal manipulation: its safety is uncertain |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=11800245 |journal=CMAJ |volume=166 |issue=1 |pages=40–1 |pmc=99224 |pmid=11800245}}</ref> The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection.<ref name="NHS Chiro Maim">[http://www.nelh.nhs.uk/hth/chiro.asp NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors] {{webarchive|url=https://web.archive.org/web/20060530110614/http://www.nelh.nhs.uk/hth/chiro.asp |date=2006-05-30 }}</ref> 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."''<ref>{{Cite journal |vauthors=Rothwell D, Bondy S, Williams J |year=2001 |title=Chiropractic manipulation and stroke: a population-based case-control study. |journal=Stroke |volume=32 |issue=5 |pages=1054–60 |doi=10.1161/01.STR.32.5.1054 |pmid=11340209 |doi-access=free}} Original [http://stroke.ahajournals.org/cgi/content/full/32/5/1054 article]</ref> 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.<ref name="NHS Chiro Maim" />

In 1996, Coulter ''et al.''<ref name="Coulter" /> 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.'"<ref name="Finding">{{Cite journal |last=Homola S |year=1998 |title=Finding a good chiropractor |url=http://archfami.ama-assn.org/cgi/pmidlookup?view=long&pmid=9443693 |url-status=dead |journal=Archives of Family Medicine |volume=7 |issue=1 |pages=20–3 |doi=10.1001/archfami.7.1.20 |pmid=9443693 |archive-url=https://archive.today/20110716135333/http://archfami.ama-assn.org/cgi/pmidlookup?view=long&pmid=9443693 |archive-date=2011-07-16}}</ref>

=== 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."<ref name="Terrett">{{Cite journal |last=Terrett A |year=1995 |title=Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. |journal=J Manipulative Physiol Ther |volume=18 |issue=4 |pages=203–10 |pmid=7636409}}</ref>

This error was taken into account in a 1999 review<ref name="Di Fabio">{{Cite journal |last=Di Fabio R |year=1999 |title=Manipulation of the cervical spine: risks and benefits. |url=http://www.rand.org/pubs/monograph_reports/MR781/ |journal=Phys Ther |volume=79 |issue=1 |pages=50–65 |pmid=9920191 |access-date=2006-11-17}}</ref> 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)."<ref name="Di Fabio" />

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown,<ref>{{Cite web |title=Figure 1. Injuries attributed to manipulation of the cervical spine. |url=http://www.ptjournal.org/cgi/content/full/79/1/50/F1 |url-status=dead |archive-url=https://web.archive.org/web/20070927011638/http://www.ptjournal.org/cgi/content/full/79/1/50/F1 |archive-date=2007-09-27 |access-date=2006-11-05}}</ref> and Figure 2 shows the type of practitioner involved in the resulting injury.<ref>{{Cite web |title=Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury. |url=http://www.ptjournal.org/cgi/content/full/79/1/50/F2 |url-status=dead |archive-url=https://web.archive.org/web/20070225062108/http://www.ptjournal.org/cgi/content/full/79/1/50/F2 |archive-date=2007-02-25 |access-date=2006-11-05}}</ref> For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.<ref name="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."<ref name="Di Fabio" />

[[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 effect (medicine)|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."<ref name="ernst_safety" />

== Emergency medicine ==

In [[emergency medicine]] joint manipulation can also refer to the process of bringing fragments of [[Fracture (bone)|fractured]] bone or [[dislocation (medicine)|dislocated]] joints into normal [[Anatomy|anatomical]] alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure.{{cn|date=August 2024}}

== See also ==

* [[Orthopedic medicine]]
* [[Osteopathic manipulative medicine]]
* [[Physical therapy]]
* [[Small joint manipulation]]

== 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 ==

* [https://web.archive.org/web/19981206122239/http://www.aaompt.org/ American Academy of Orthopedic Manual Physical Therapy (AAOMPT)]
* [http://www.manipulativetherapy.org/ Canadian Academy of Manipulative Therapy (CAMT)]
* [http://orthopractic.org/ Canadian Orthopractic Manual Therapy Association (COMTA)]
* [https://web.archive.org/web/20080828022608/http://www.ifomt.org/ International Federation of Orthopaedic Manipulative Therapists (IFOMT)]
* [http://jmmtonline.com/ Journal of Manual and Manipulative Therapy (JMMT)]
* [https://web.archive.org/web/20080812125442/http://www.manual-med.com/ European Association of Advanced Manual and Manipulative Therapy]

[[Category:Manual therapy]]
[[Category:Chiropractic treatment techniques]]
[[Category:Osteopathic techniques]]
[[Category:Physical therapy]]
[[Category:Manual medicine]]