Spinal manipulation

Clinical guidelines from different countries come to different conclusions with respect to spinal manipulation.{{Cite journal |vauthors=Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C |date=December 2010 |title=An updated overview of clinical guidelines for the management of non-specific low back pain in primary care |journal=European Spine Journal |volume=19 |issue=12 |pages=2075–94 |doi=10.1007/s00586-010-1502-y |pmc=2997201 |pmid=20602122}}

A 2012 Cochrane review found that spinal manipulation was as effective as other commonly used therapies.{{Cite journal |last=Rubinstein |first=Sidney M |last2=Terwee |first2=Caroline B |last3=Assendelft |first3=Willem JJ |last4=de Boer |first4=Michiel R |last5=van Tulder |first5=Maurits W |date=2012-09-12 |editor-last=Cochrane Back and Neck Group |title=Spinal manipulative therapy for acute low-back pain |journal=Cochrane Database of Systematic Reviews |language=en |volume=2012 |issue=9 |pages=CD008880 |doi=10.1002/14651858.CD008880.pub2 |pmc=6885055 |pmid=22972127 |quote=SMT is no more effective in participants with acute low‐back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.}} A 2010 systematic review found that most studies suggest SM achieves equal or superior improvement in pain and function compared with other commonly used interventions for short-, intermediate-, and long-term follow-up.{{Cite journal |vauthors=Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM |date=October 2010 |title=NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain |journal=The Spine Journal |volume=10 |issue=10 |pages=918–40 |doi=10.1016/j.spinee.2010.07.389 |pmid=20869008}} 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.{{Cite journal |vauthors=Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW |date=March 2019 |title=Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials |journal=BMJ |volume=364 |pages=l689 |doi=10.1136/bmj.l689 |pmc=6396088 |pmid=30867144}}

In 2007, the American College of Physicians and the American Pain Society jointly recommended that clinicians consider spinal manipulation for patients who do not improve with self-care options,{{Cite journal |last8=Clinical Efficacy Assessment Subcommittee of the American College of Physicians |last9=American College Of |first9=Physicians |name-list-style=vanc |vauthors=Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK |date=October 2007 |title=Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society |journal=Annals of Internal Medicine |volume=147 |issue=7 |pages=478–91 |doi=10.7326/0003-4819-147-7-200710020-00006 |pmid=17909209 |doi-access=free}} and the Clinical Guideline Committee for the American College of Physicians updated the guideline in 2017 to include that non-pharmacological approaches to pain management should be considered, however, that there is only low-quality evidence supporting effectiveness of spinal manipulation.{{Cite journal |last=Qaseem |first=Amir |last2=Wilt |first2=Timothy J. |last3=McLean |first3=Robert M. |last4=Forciea |first4=Mary Ann |last5=for the Clinical Guidelines Committee of the American College of Physicians |date=2017-04-04 |title=Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians |url=https://www.acpjournals.org/doi/10.7326/M16-2367?_ga=2.90002588.621768841.1744301529-1367590114.1744301529& |journal=Annals of Internal Medicine |volume=166 |issue=7 |pages=514–530 |doi=10.7326/M16-2367 |issn=0003-4819|doi-access=free }} Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions.{{Cite journal |vauthors=Murphy AY, van Teijlingen ER, Gobbi MO |date=September 2006 |title=Inconsistent grading of evidence across countries: a review of low back pain guidelines |journal=Journal of Manipulative and Physiological Therapeutics |volume=29 |issue=7 |pages=576–81, 581.e1-2 |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948}}{{Cite journal |vauthors=Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |year=2008 |title=Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |journal=The Spine Journal |volume=8 |issue=1 |pages=213–25 |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469}} A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain.{{Cite web |year=2007 |title=Chiropractic management of low back pain and low back related leg complaints |url=http://ccgpp.org/lowbackliterature.pdf |access-date=2008-03-13 |publisher=Council on Chiropractic Guidelines and Practice Parameters |vauthors=Meeker W, Branson R, Bronfort G, etal}} Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations.{{Cite journal |vauthors=Ernst E, Canter PH |date=April 2006 |title=A systematic review of systematic reviews of spinal manipulation |journal=Journal of the Royal Society of Medicine |volume=99 |issue=4 |pages=192–6 |doi=10.1177/014107680609900418 |pmc=1420782 |pmid=16574972}}

• {{lay source |template=cite news |title=Back treatment 'has few benefits' |url=http://news.bbc.co.uk/2/hi/health/4824594.stm |date=2006-03-22 |work=BBC News}} 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."{{Cite journal |vauthors=Rothberg S, Friedman BW |date=January 2017 |title=Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review |url=https://zenodo.org/record/891043 |journal=The American Journal of Emergency Medicine |volume=35 |issue=1 |pages=55–61 |doi=10.1016/j.ajem.2016.10.001 |pmid=27751598 |s2cid=34520820}}

For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies.{{Cite journal |display-authors=6 |name-list-style=vanc |vauthors=Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S |date=February 2008 |title=Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |journal=Spine |volume=33 |issue=4 Suppl |pages=S123-52 |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386 |s2cid=27261997 |doi-access=free}} 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 and without arm pain and headaches, show clinically meaningful improvements from a course of spinal manipulation or mobilization.{{Cite journal |vauthors=Vernon H, Humphreys K, Hagino C |year=2007 |title=Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials |journal=Journal of Manipulative and Physiological Therapeutics |volume=30 |issue=3 |pages=215–27 |doi=10.1016/j.jmpt.2007.01.014 |pmid=17416276}} There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash, but there are short-term benefits.{{Cite journal |vauthors=Martín Saborido C, García Lizana F, Alcázar Alcázar R, Sarría-Santamera A |date=May 2007 |title=[Effectiveness of spinal manipulation in treating whiplash injuries] |journal=Atencion Primaria |language=es |volume=39 |issue=5 |pages=241–6 |doi=10.1157/13101798 |pmc=7659500 |pmid=17493449}}

Historically, some within the chiropractic profession have claimed that spinal adjustments 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's original thesis that subluxations caused many diseases. Over time, this hypothesis is inconsistent with our modern understanding of pathology and disease, and only "a small proportion of chiropractors, osteopaths, and other manual medicine providers use[ing] spinal 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."{{Cite journal |display-authors=6 |vauthors=Côté P, Hartvigsen J, Axén I, Leboeuf-Yde C, Corso M, Shearer H, Wong J, Marchand AA, Cassidy JD, French S, Kawchuk GN, Mior S, Poulsen E, Srbely J, Ammendolia C, Blanchette MA, Busse JW, Bussières A, Cancelliere C, Christensen HW, De Carvalho D, De Luca K, Du Rose A, Eklund A, Engel R, Goncalves G, Hebert J, Hincapié CA, Hondras M, Kimpton A, Lauridsen HH, Innes S, Meyer AL, Newell D, O'Neill S, Pagé I, Passmore S, Perle SM, Quon J, Rezai M, Stupar M, Swain M, Vitiello A, Weber K, Young KJ, Yu H |date=February 2021 |title=The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature |journal=Chiropractic & Manual Therapies |publisher=Springer Science and Business Media LLC |volume=29 |issue=1 |pages=8 |doi=10.1186/s12998-021-00362-9 |pmc=7890602 |pmid=33596925 |doi-access=free}}

{{see|Manipulation under 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.{{Cite journal |vauthors=Digiorgi D |date=May 2013 |title=Spinal manipulation under anesthesia: a narrative review of the literature and commentary |journal=Chiropractic & Manual Therapies |volume=21 |issue=1 |pages=14 |doi=10.1186/2045-709X-21-14 |pmc=3691523 |pmid=23672974 |doi-access=free}}

{{see also|Spinal adjustment#Safety}}

There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown.{{Cite journal |vauthors=Gouveia LO, Castanho P, Ferreira JJ |date=May 2009 |title=Safety of chiropractic interventions: a systematic review |url=http://www.chiropratiquelasource.com/recherches/safety.pdf |journal=Spine |volume=34 |issue=11 |pages=E405-13 |doi=10.1097/BRS.0b013e3181a16d63 |pmid=19444054 |s2cid=21279308 |quote=Safety in chiropractic manipulation is far from being achieved. Further investigations are urgent to assess definite conclusions regarding this issue. ... There is insufficient data to produce a robust conclusion on safety of chiropractic interventions.}}{{Cite journal |display-authors=6 |vauthors=Gross A, Langevin P, Burnie SJ, Bédard-Brochu MS, Empey B, Dugas E, Faber-Dobrescu M, Andres C, Graham N, Goldsmith CH, Brønfort G, Hoving JL, LeBlanc F |date=September 2015 |title=Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=9 |pages=CD004249 |doi=10.1002/14651858.CD004249.pub4 |pmc=10883412 |pmid=26397370}}{{Cite journal |vauthors=Ernst E |date=July 2007 |title=Adverse effects of spinal manipulation: a systematic review |journal=Journal of the Royal Society of Medicine |volume=100 |issue=7 |pages=330–8 |doi=10.1177/014107680710000716 |pmc=1905885 |pmid=17606755}}

• {{lay source |template=cite news |title=Spinal Manipulation Should Not Be Routinely Used, New Study Warns |url=http://www.medicalnewstoday.com/articles/75754.php |date=2007-07-02 |work=Medical News Today}} Spinal manipulation is frequently associated with mild to moderate temporary adverse effects, and also rare serious outcomes which can result in permanent disability or death.{{Cite journal |last=Chu |first=Eric Chun-Pu |last2=Trager |first2=Robert J. |last3=Lee |first3=Linda Yin-King |last4=Niazi |first4=Imran Khan |date=2023-01-23 |title=A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy |journal=Scientific Reports |language=en |volume=13 |issue=1 |pages=1254 |bibcode=2023NatSR..13.1254C |doi=10.1038/s41598-023-28520-4 |issn=2045-2322 |pmc=9870863 |pmid=36690712}}{{Cite web |date=20 August 2014 |title=Safety and regulation of chiropractic |url=http://www.nhs.uk/Conditions/chiropractic/Pages/Safetyandregulation.aspx |access-date=22 September 2016 |publisher=NHS Choices}} The National Health Service in the UK notes that about half of people reported encountering adverse effects following spinal manipulation. Adverse events are increasingly reported in randomized clinical trials of spinal manipulation but remain under-reported despite recommendations in the 2010 CONSORT guidelines.{{Cite journal |vauthors=Gorrell LM, Engel RM, Brown B, Lystad RP |date=September 2016 |title=The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review |journal=The Spine Journal |type=Systematic Review |volume=16 |issue=9 |pages=1143–51 |doi=10.1016/j.spinee.2016.05.018 |pmid=27241208}}{{Cite journal |vauthors=Ernst E, Posadzki P |date=April 2012 |title=Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review |journal=The New Zealand Medical Journal |volume=125 |issue=1353 |pages=87–140 |pmid=22522273}} 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.{{Cite journal |vauthors=Mabry LM, Notestine JP, Moore JH, Bleakley CM, Taylor JB |date=February 2020 |title=Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study |journal=Military Medicine |volume=185 |issue=1–2 |pages=e290–e297 |doi=10.1093/milmed/usz176 |pmid=31322706 |doi-access=free}}

The degree of serious risks associated with manipulation of the cervical spine is uncertain, with little evidence of risk of harm but also little evidence of safety either.{{Cite journal |vauthors=Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J |date=October 2010 |title=Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review |journal=Manual Therapy |volume=15 |issue=5 |pages=434–44 |doi=10.1016/j.math.2010.02.006 |pmid=20227325}} There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation.{{Cite journal |vauthors=Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ |date=October 2012 |title=Assessing the risk of stroke from neck manipulation: a systematic review |journal=International Journal of Clinical Practice |volume=66 |issue=10 |pages=940–7 |doi=10.1111/j.1742-1241.2012.03004.x |pmc=3506737 |pmid=22994328}} Several deaths have been associated with this technique and it has been suggested that the relationship is causative,{{Cite journal |vauthors=Ernst E |date=May 2010 |title=Vascular accidents after neck manipulation: cause or coincidence? |journal=International Journal of Clinical Practice |volume=64 |issue=6 |pages=673–7 |doi=10.1111/j.1742-1241.2009.02237.x |pmid=20518945 |s2cid=38571730 |doi-access=free}} but this is disputed by many chiropractors who believe it is unproven.{{Cite journal |vauthors=Ernst E |date=July 2010 |title=Deaths after chiropractic: a review of published cases |journal=International Journal of Clinical Practice |volume=64 |issue=8 |pages=1162–5 |doi=10.1111/j.1742-1241.2010.02352.x |pmid=20642715 |s2cid=45225661 |doi-access=free}}

Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that: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.

{{blockquote| 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.{{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}}{{Cite journal |vauthors=Rothwell DM, Bondy SJ, Williams JI |date=May 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}}{{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}}{{Cite journal |display-authors=etal |vauthors=Haldeman S |year=2001 |title=Arterial dissections following cervical manipulation: the chiropractic experience |journal=Canadian Medical Association Journal |volume=165 |issue=7 |pages=905–906 |pmc=81498 |pmid=11599329}}

Edzard Ernst 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.{{Cite journal |vauthors=Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE |date=February 2016 |title=Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation |journal=Cureus |volume=8 |issue=2 |pages=e498 |doi=10.7759/cureus.498 |pmc=4794386 |pmid=27014532 |doi-access=free}}

A 2024 narrative review noted the thromboembolic and thrombotic mechanisms of causation of immediate stroke after cervical spine manipulation that are in the existing peer-reviewed literature.{{Cite journal |last=Brown |first=Steven P. |date=March 2024 |title=Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review |journal=Cureus |volume=16 |issue=3 |pages=e56565 |doi=10.7759/cureus.56565 |issn=2168-8184 |pmc=10954208 |pmid=38510520 |doi-access=free}}

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 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."{{Cite journal |last=Ernst |first=E. |date=2002 |title=Spinal manipulation: its safety is uncertain |url=http://www.cmaj.ca/cgi/content/full/166/1/40 |journal=Canadian Medical Association Journal |volume=166 |issue=1 |pages=40–41 |pmc=99224 |pmid=11800245}} The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection.[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 }} 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."{{Cite journal |vauthors=Rothwell DM, Bondy SJ, Williams JI |date=May 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] 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.

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:{{Cite journal |vauthors=Terrett AG |date=May 1995 |title=Misuse of the literature by medical authors in discussing spinal manipulative therapy injury |journal=Journal of Manipulative and Physiological Therapeutics |volume=18 |issue=4 |pages=203–10 |pmid=7636409}}

{{blockquote| 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{{Cite journal |vauthors=Di Fabio RP |date=January 1999 |title=Manipulation of the cervical spine: risks and benefits |url=http://ptjournal.apta.org/content/79/1/50.full |journal=Physical Therapy |volume=79 |issue=1 |pages=50–65 |pmid=9920191 |access-date=2011-11-24}} 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:

{{blockquote| 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,[http://www.ptjournal.org/cgi/content/full/79/1/50/F1 Figure 1. Injuries attributed to manipulation of the cervical spine.] {{webarchive|url=https://web.archive.org/web/20070927011638/http://www.ptjournal.org/cgi/content/full/79/1/50/F1 |date=2007-09-27 }} and Figure 2 shows the type of practitioner involved in the resulting injury.[http://www.ptjournal.org/cgi/content/full/79/1/50/F2 Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury.] {{webarchive|url=https://web.archive.org/web/20070225062108/http://www.ptjournal.org/cgi/content/full/79/1/50/F2 |date=2007-02-25 }} 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."

Spinal manipulation is a therapeutic intervention that has roots in folk medicine such as the traditional bone-setting and has been used by various cultures, apparently for thousands of years. Hippocrates, the "father of medicine" used manipulative techniques,Dean C. Swedlo, "[http://www.hom.ucalgary.ca/Dayspapers2002.pdf The Historical Development of Chiropractic.] {{webarchive|url=https://web.archive.org/web/20080625173624/http://www.hom.ucalgary.ca/Dayspapers2002.pdf |date=2008-06-25 }}" 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., "[http://www.macdonaldpublishing.com Backache from Occiput to Coccyx]" Chapter 1 A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic and chiropractic medicine.{{Cite journal |vauthors=Keating JC |date=June 2003 |title=Several pathways in the evolution of chiropractic manipulation |journal=Journal of Manipulative and Physiological Therapeutics |volume=26 |issue=5 |pages=300–21 |doi=10.1016/S0161-4754(02)54125-7 |pmid=12819626}} Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s.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{{Cite web |title=International MUA Academy of Physicians - Historical Considerations |url=http://www.muaphysicians.com/historical.html |access-date=2008-03-24}}

In North America, it is most commonly performed by chiropractors, osteopathic physicians, and physical therapists. In Europe, osteopaths, chiropractors, and physiotherapists 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 in the USA.{{Cite journal |vauthors=Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH |date=October 1992 |title=Spinal manipulation for low-back pain |journal=Annals of Internal Medicine |volume=117 |issue=7 |pages=590–8 |doi=10.7326/0003-4819-117-7-590 |pmid=1388006 |s2cid=35702578}} 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.{{Cite journal |vauthors=Noteboom JT, Little C, Boissonnault W |date=June 2015 |title=Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update |journal=The Journal of Orthopaedic and Sports Physical Therapy |volume=45 |issue=6 |pages=471–6 |doi=10.2519/jospt.2015.5273 |pmid=25899212}}

Manipulation has been known by several other names. Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labeling system developed by Geoffery Maitland,Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986. manipulation is synonymous with Grade V mobilization. Because of its distinct segmental biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation. However, it is important to note that the magnitude of neither force, velocity, or amplitude are regarded as defining attributes.{{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}}{{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}}

Spinal manipulation can be distinguished from other manual therapy interventions such as mobilization by its biomechanics, both kinetics and kinematics.{{cn|date=August 2024}}

Force-time profiles measured during spinal manipulation were originally described as consisting of three distinct phases: the 'preload' phase, the 'thrust' (or 'impulse') phase, and the 'resolution' phase.{{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}} Evans and Breen{{Cite journal |vauthors=Evans DW, Breen AC |date=January 2006 |title=A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone |journal=Journal of Manipulative and Physiological Therapeutics |volume=29 |issue=1 |pages=72–82 |doi=10.1016/j.jmpt.2005.11.011 |pmid=16396734}} added a fourth 'orientation' phase to describe the first period, during which the patient is oriented into the appropriate position in preparation for the preload phase.

The kinematics 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. However, the events that take place in a manipulated synovial joint are the same, irrespective of whether the synovial joint in the spine or the periphery. Evans and Lucas defined manipulation using these events: "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."

The effects of spinal manipulation have been shown{{citation needed|date=October 2017}} to include:

• Temporary relief of musculoskeletal pain{{citation needed|date=July 2014}}
• Shortened time to recover from acute back pain{{citation needed|date=July 2014}}
• Temporary increase in passive range of motion (ROM){{citation needed|date=July 2014}}
• Physiological effects on the central nervous system (specifically the sympathetic nervous system){{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}}{{Cite journal |vauthors=Kingston L, Claydon L, Tumilty S |date=August 2014 |title=The effects of spinal mobilizations on the sympathetic nervous system: a systematic review |journal=Manual Therapy |volume=19 |issue=4 |pages=281–7 |doi=10.1016/j.math.2014.04.004 |pmid=24814903}}
• Altered sensorimotor integration{{citation needed|date=July 2014}}
• No alteration of the position of the sacroiliac joint{{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.}}
• Sham or placebo manipulation

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.{{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}}

• Joint manipulation
• Joint mobilization
• Osteopathic manipulation
• Spinal adjustment

{{Reflist|30em}}

{{refbegin}}

• {{Cite book |title=Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions |vauthors=Cyriax J |date=1982 |publisher=Bailliere Tindall |edition=8th |volume=I |location=London}}
• {{Cite book |title=Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection |vauthors=Cyriax J |date=1983 |publisher=Bailliere Tindall |edition=10th |volume=II |location=London}}
• {{Cite book |title=Modern Manual Therapy of the Vertebral Column |vauthors=Greive |date=1994 |publisher=Harcourt Publishers Ltd.}}
• {{Cite book |title=Peripheral Manipulation |vauthors=Maitland GD |date=1977 |publisher=Butterworths |edition=2nd |location=London}}
• {{Cite book |title=ertebral Manipulation |vauthors=Maitland GD |date=1986 |publisher=Butterworths |edition=5th |location=London}}
• {{Cite book |title=The Lumbar Spine; Mechanical Diagnosis and Therapy |vauthors=McKenzie RA |date=1981 |publisher=Spinal Publications |location=Waikanae, New Zealand}}
• {{Cite book |title=The Cervical and Thoracic Spine; Mechanical Diagnosis and Therapy |vauthors=McKenzie RA |date=1990 |publisher=Spinal Publications |location=Waikanae, New Zealand}}
• {{Cite book |title=Joint Pain; Diagnosis and Treatment Using Manipulative Techniques |vauthors=Mennel JM |date=1964 |publisher=Little Brown and Co. |location=Boston}}

{{refend}}

• [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)]
• [http://www.sofmmoo.com/english_section/2_neck_pain/Cervical%20Manip.%20Recommandation%20SOFMMOO.htm Prevention of the vertebrobasilar accidents following cervical thrust manipulations]: recommendations of the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO).
• [http://www.manual-med.com European Association of Advanced Manual and Manipulative Therapy]

{{Chiropractic}}

Category:Manual therapy

Category:Chiropractic treatment techniques

Category:Osteopathic techniques

Category:Physical therapy