joint manipulationDescription: Joint manipulation is a hands-on movement technique applied to a stiff spinal or peripheral joint. Your clinician will use a specifically directed manual thrust which is often accompanied by an audible ‘pop’ or ‘crack’ (Van Zoest and Gosselin 2003).

Aims: Spinal manipulation aims to restore full range of motion to the joint by activating mechanoreceptors within the capsule of the joints. It also has the effect of altering the neuromuscular (nerve) firing within muscles to cause a reflex relaxation of the surrounding tight musculature. Simply, it helps to restore normal pain free motion.

Effects: Spinal manipulations can relieve back pain by taking pressure off sensitive nerves or tissue, restoring blood flow, reducing muscle tension, and promoting the release of chemicals like endorphins and serotonin within the body to act as natural painkillers.

Sam Whiteson with patientKey Evidence: Researchers continue to study spinal manipulation for low-back pain. The use of spinal manipulation as part of treatment for low back pain is recommended by several clinical practice guidelines, including the recently published NICE guidelines (2009).

A 2011 Cochrane review (Rubinstein et al 2011) of 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function.

A Clinical Prediction Rule for Manipulation: The following five factors are the criteria included in a five factor predictor rule that was published for the use of manipulation (Flynn et al 2002):

  • Pain lasting lesymptoms ss than 16 days
  • No distal to the knee
  • FABQ score less than 19
  • Internal Rotation of greater than 35 degrees for at least one hip
  • Hypomobility of a least one level of the lumbar spine


Patient massageThe patients that received the most benefit from spinal manipulation for LBP are those that met at least four out of the five criteria for spinal manipulation. The positive likelihood ratio for those exhibiting four out of five of the factors is 24.3 (Flynn et al 2002).

Contra-indications: The following scenarios are contraindications to low back pain (Gibbons and Tehal 2001):

  • Any pathology that leads to significant bone weakening
  • Neurological: cord compression, cauda equina compression, nerve root compression with increasing neurological deficit
  • Vascular: aortic aneurism, bleeding into joints
  • Lack of diagnosis
  • Patient positioning can not be achieved because of pain or resistance.

Back pain manipulation

Adverse effects: Manipulation is generally very safe. You will be fully screened for any contraindications before undergoing treatment.

Much has been made of the potential dangers of Manipulation, but despite its widespread use, serious complications seldom occur (Atchison, Stoll and Gilliar 1995). The highest risk of a serious complication such as: vertebral artery dissection or cerebro vascular accidents due to manipulation has been reported as between 1 in 100,000 (Rothwell, Bondy and Williams 2001).

Shoulder manipulationHurwitz et al. (1996) reports the risk of mild complications (dizziness, nausea, tiredness and headaches) following spinal SMTT is 1 in 40,000, and death < 3 per 10,000,000. Eighty-nine percent of the complications reported above, were related to the cervical-spine (Hurwitz et al. 1996).

A common side-effect from these techniques is a temporary area of local discomfort. This has been reported in some studies to occur in up to 55% of participants following a spinal manipulation (Senstad, Leboeuf-Yde and Borchgrevink 1997). The authors concluded that whilst the participant should be informed of the possibility of mild adverse effects, these reactions are benign and should be considered normal events.

1. Atchison, J. W., Stoll, S. T., Gilliar, W. G. (1995) ‘Manipulation, traction and massage’, in: Physical Medicine and Rehabilitation. ed. by Braddom, E. D., Saunders, W. B. Philadelphia, 421–448.
2. Brodeur, R. (1995) ‘The audible release associated with joint manipulation.’ Journal of Manipulative and Physiological Therapeutics, 18,155-164.
3. Flynn, T., Fritz, J., Whitman, J., et al (2002) ‘A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation’. Spine, 27(24), 2835-2843.
4. Gibbons, P., Tehan, P. (2001) ‘Patient positioning and spinal locking for lumbar spine rotation manipulation’. Manual Therapy, 6(3),130-138.
5. Herzog, W., Conway, P. J. W., Kawchuk, G. N., Zhang, Y., Hasler, E. M. (1993) ‘Forces exerted during spinal manipulation’. Spine, 18, 1206-1212.
6. Hurwitz, E. L., Aker, P. D., Adams, A. H., Meeker, W. C., Shekelle, P. G. (1996) ‘Manipulation and mobilization of the cervical spine: A systematic review of the literature’. Spine, 21, 1746-1759.
7. National Institute of Clinical Excellence guidelines. Low Back Pain: [Online] available from: (May 2009).
8. Rothwell, D. M., Bondy, S. J., Williams, J. I. (2001) ‘Chiropractic manipulation and stroke: a population-based case-control study’. Stroke, 32(5), 1054-1060.
9. Rubinstein, S.M., van Middelkoop, M., Assendelft, W.J., de Boer, M.R., van Tulder, M.W. (2011) ‘Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review’. Spine, 36, 825-846.
10. Senstad O., Leboeuf-Yde, C., Borchgrevink, C. (1997) ‘Frequency and characteristics of side-effects of spinal manipulative therapy. Spine, 22, 435-440
11. Unsworth, A., Dowson, D., Wright, V. (1971) ‘A bioengineering study of cavitation in the metacarpophalangeal joint’. Annals of the Rheumatic Diseases, 30, 348-358.
12. Van Zoest, G. G., Gosselin, G. (2003) ‘Three-dimensionality of direct contact forces in chiropractic spinal manipulative therapy’. Journal of Manipulative and Physiological Therapeutics, 26(9), 549-556.