Injury type: Acute

Category: Allied Health Options

Rating: Promising

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 suggests that manipulation is not effective for improving neck pain (not just after whiplash) if it is the only treatment that is provided, regardless of who provides it. It may be effective however if it us used in conjunction with other treatments (i.e. multimodal treatment), especially exercise. This evidence comes from a large review of all the systematic reviews of manipulation for any spinal condition, including 2 systematic reviews on neck pain.

A lower quality literature review concluded that neck manipulation may provide short term benefit to some patients with neck pain and headache (not specifically whiplash related). Two recent studies have also found that manipulation (either of the thoracic spine or neck) in conjunction with other techniques was better than conventional therapy without manipulation.

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.


Manipulation may be a useful adjunct to other therapies, provided it is performed in a safe manner by a qualified professional. It does not appear to be effective as a sole treatment.


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.

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.