Manipulation

Injury type: Acute/ Chronic

Category: Allied Health Options

Rating: No Research

What is it?

Technically, manipulation is defined as a localised force of high velocity and low amplitude thrust directed at a spinal joint. Manipulation is also known as ‘adjustment’ or ‘cracking’. It involves a qualified professional (i.e. chiropractor, physiotherapist) positioning your body and then applying a small, fast movement, resulting commonly in a cracking sound in a spinal joint. The force may be applied with the therapists hands or using a tool or piece of equipment. It is different from soft tissue manipulation/massage and mobilization, both of which are covered in separate pages on this site.

How does it work?

It is thought that manipulation of a spinal joint may provide a temporary increase in joint range of movement by acting on the soft tissues around the joint itself. It may also correct spinal alignment and give relief from musculoskeletal pain. Manipulation may also have physiological effect on the nervous system and provide pain relief via this means.

Is it effective?

The evidence for manipulation for whiplash is inconsistent. A systematic review of existing whiplash guidelines¹ found that passive joint manipulation was recommended across all guidelines. However, a rapid review² synthesising evidence from highest level of primary studies, systematic reviews, and well-conducted clinical practice guidelines identified that manipulation is not recommended. An update systematic review³ concluded that there is ‘not enough or inconsistent evidence to make determination’ regarding the use of manipulation for recent and persistent grades I-II whiplash.

On the other hand, evidence on the use of manipulation for neck pain in general has been more widely researched. Overall, the evidence suggests that manipulation seems to be most effective for pain relief and function improvement when it is used in conjunction with other treatments (i.e. as a multimodal treatment), such as exercise. This evidence comes from a review⁴ synthesising findings from three systematic reviews on acute and chronic neck pain, and a recently published systematic review and meta-analysis⁵ on chronic non-specific neck pain.

Are there any disadvantages?

Some of the disadvantages of manipulation may be local discomfort, increased neck pain, headache, thoracic pain, altered sensation, dizziness, tiredness, or radiating discomfort. Infrequent, but potentially serious side effects, may include: vertebrobasilar accidents (VBA)[1], strokes, spinal disc herniation, vertebral and rib fractures, and cauda equina syndrome. Therefore appropriate assessment and tests should be carried out by the therapist prior to manipulation.

[1] A vertebrobasilar accident results in verterbrobasilar insufficiency, which is an obstruction or blockage of an important group of blood vessels called vertebral-basilar system. Blockage of these blood vessels result in problems with consciousness, headache, dizziness, paralysis of legs and/or arms, difficulty speaking and paralysis of face muscles.

Where do you get it?

Spinal manipulation (including the neck) must be provided only by qualified professionals such as chiropractors, physiotherapists, osteopaths and doctors.

Recommendations

The use of manipulation following whiplash cannot be recommended due to a lack of current research evidence. More research is required.

References contributing to the treatment rating

Coulter, I 1996, ‘Manipulation and mobilization of the cervical spine: the results of a literature survey and consensus panel’, Journal of Musculoskeletal Pain, vol. 4, no. 4, pp. 113-123.

5. Coulter ID, Crawford C, Vernon H, Hurwitz EL, Khorsan R, Booth MS, Herman PM. Manipulation and mobilization for treating chronic nonspecific neck pain: a systematic review and meta-analysis for an appropriateness panel. Pain physician. 2019 Mar;22(2):E55.

Dehner, C, Elbel, M, Strobel, P, Scheich, M, Schneider, F, Krischak, G & Kramer, M 2009, ‘Grade II whiplash injuries to the neck: what is the benefit for patients treated by different physical therapy modalities?’, Patient Safety in Surgery , vol. 3, no. 2, doi: 10.1186/1754-9493-3-2.

Ernst, E & Canter, PH 2006, ‘A systematic review of systematic reviews of spinal manipulation’, Journal of the Royal Society of Medicine, vol. 99, pp. 192–196.

Fernandez-de-las-Penas, C, Fernandez-Carnero, J, Fernandez, AP, Lomas-Vega, R & Miangolarra-Page JC 2004, ‘Dorsal manipulation in whiplash injury treatment: a Randomized Controlled Trial’, Journal of Whiplash & Related Disorders, vol. 3, no. 2, pp. 55-72.

Fernandez-de-las-Penas, C, Fernandez-Carnero, J, Palomeque Del Cerro, L & Miangolarra-Page, JC 2004, ‘Manipulative treatment vs conventional physiotherapy treatment in whiplash injury: A Randomized Controlled Trial’, Journal of Whiplash & Related Disorders, vol. 3, no. 2, pp.73-90.

Guzman, J, Haldeman, S, Carroll, LJ, Carragee, EJ, Hurwitz, EL, Peloso, P, Nordin, M, Cassidy, JD, Holm, LW, Côté, P, Velde, G & Hogg-Johnson, S 2009, ‘Task force on neck pain and its associated disorders’, Journal of Manipulative and Physiological Therapeutics, vol. 32, pp. 227-243.

Hurwitz, E, Carragee, E, Van der Velde, G, Carroll, L, Nordin, M, Guzman, J, Peloso, P, Holm, L, Coˆte, P, Hogg-Johnson, S, Cassidy, D & Haldeman, S 2008, ‘Treatment of neck pain: noninvasive interventions; results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders’, European Spine Journal, vol. 17, no. 1, pp. 123-152.

Leaver, AM, Refshauge, KM, Maher, CG & McAuley, JH 2010, ‘Conservative interventions provide short-term relief for non-specific neck pain: a systematic review’, Journal of Physiotherapy, vol. 56, pp. 73-85.

Poorbaugh, K, Brismée, J, Phelps, V & Sizer, P 2008, ‘Late whiplash syndrome: a clinical science approach to evidence-based diagnosis and management’, Pain Practice, vol. 8, no. 1, pp. 65-89.

Schofferman, J, Bogduk, N & Slosar, P 2007, ‘Chronic whiplash and whiplash associated disorders: an evidence based approach’, Journal of the American Academy of Orthopaedic Surgeons, vol. 15, no. 10, pp. 596-606.

4. Smith MS, Olivas J, Smith K. Manipulative therapies: what works. American family physician. 2019 Feb 15;99(4):248-52.

2. Strudwick K, McPhee M, Bell A, Martin‐Khan M, Russell T. Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series). Emergency Medicine Australasia. 2018 Dec;30(6):754-72.

1. Wong JJ, Côté P, Shearer HM, Carroll LJ, Yu H, Varatharajan S, Southerst D, van der Velde G, Jacobs C, Taylor-Vaisey A. Clinical practice guidelines for the management of conditions related to traffic collisions: a systematic review by the OPTIMa Collaboration. Disability and rehabilitation. 2015 Mar 13;37(6):471-89.

3. Wong JJ, Shearer HM, Mior S, Jacobs C, Côté P, Randhawa K, Yu H, Southerst D, Varatharajan S, Sutton D, van der Velde G. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. The Spine Journal. 2016 Dec 1;16(12):1598-630.