Joint manipulation
Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect.
Definition of manipulation
Many definitions of joint manipulation have been proposed.[1] The most rigorous definition, based on available empirical research is that of Evans and Lucas:[2] "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
Terminology
Manipulation is known by several other names. Historically, general practitioners and orthopaedic surgeons have used the term "manipulation".
Biomechanics
Manipulation can be distinguished from other
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.[7] Evans and Breen[8] added a fourth 'orientation' phase to describe the period during which the patient is oriented into the appropriate position in preparation for the prethrust phase.
When individual peripheral
Kinematics
The kinematics of a complete spinal motion segment when one of its constituent 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.
Early
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
Clinical effects and mechanisms of action
The clinical effects of joint manipulation have been shown to include:
- Temporary relief of musculoskeletal pain.[13]
- Shortened time to recover from sprains (Rand).[citation needed]
- Temporary increase in passive range of motion (ROM).[14]
- Physiological effects upon the central nervous system.[15]
- No alteration of the position of the sacroiliac joint.[16]
Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.[17]
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
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."[18] In a 2019 study, L.M. Mabry, PT, and colleagues reported joint manipulation adverse events to be rare.[19]
Risks of upper cervical manipulation
The degree of serious
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.[20]
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."[21]
Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer.
In comparison, there is a 3-4% rate of complications for cervical spinal surgery, and 4,000-10,000 deaths per million neck surgeries.[29]
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".[30] 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.[31][32][33][34]
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, 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."[35] The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection.[36] 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."[37] 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.[36]
In 1996, Coulter et al.[23] 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.'"[38]
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."[39]
This error was taken into account in a 1999 review[40] 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)."[40]
In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown,[41] and Figure 2 shows the type of practitioner involved in the resulting injury.[42] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.[39]
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."[40]
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 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."[35]
Emergency medicine
In
See also
- Orthopedic medicine
- Osteopathic manipulative medicine
- Physical therapy
- Small joint manipulation
References
- S2CID 12195189.
- PMID 36918833.
- PMID 12819626.
- S2CID 35702578.
- ^ Burke, G.L., "Backache from Occiput to Coccyx Archived 2014-07-14 at the Wayback Machine" Chapter 7
- ^ Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986. - .
- ^ PMID 16396734.
- ^ PMID 36494698.
- PMID 7790795.
- PMID 5557778.
- PMID 12183696.
- PMID 19685848.
- PMID 8728459.
- PMID 7781578.
- S2CID 36480639.
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.
- ^ S2CID 7482895.
- PMID 8445360.
- PMID 31322706.
- PMC 2271108.
- PMID 8864967.
- ^ Lauretti W "What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from www.chiro.org
- ^ a b 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 link
- ^ Dvorak J, Orelli F. How dangerous is manipulation to the cervical spine? Manual Medicine 1985; 2: 1-4.
- ^ Jaskoviak P. Complications arising from manipulation of the cervical spine. J Manip Physiol Ther 1980; 3: 213-19.
- ^ Henderson DJ, Cassidy JD. Vertebral Artery syndrome. In: Vernon H. Upper cervical syndrome: chiropractic diagnosis and treatment. Baltimore: Williams and Wilkins, 1988: 195-222.
- ^ Eder M, Tilscher H. Chiropractic therapy: diagnosis and treatment (English translation). Rockville, Md: Aspen Publishers, 1990: 61.
- ^ Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters. Gaithersburg, Md: Aspen Publishers, 1993: 170-2.
- ^ The cervical spine research society editorial committee. The Cervical Spine, Second edition. Philadelphia: J.B. Lippincott Company 1990: 834.
- ^ 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.
- S2CID 11271986.
- PMID 11340209.
- PMID 14589464.
- PMID 11599329.
- ^ PMID 11800245.
- ^ a b NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors Archived 2006-05-30 at the Wayback Machine
- PMID 9443693. Archived from the originalon 2011-07-16.
- ^ PMID 7636409.
- ^ PMID 9920191. Retrieved 2006-11-17.
- ^ "Figure 1. Injuries attributed to manipulation of the cervical spine". Archived from the original on 2007-09-27. Retrieved 2006-11-05.
- ^ "Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury". Archived from the original on 2007-02-25. Retrieved 2006-11-05.
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
- American Academy of Orthopedic Manual Physical Therapy (AAOMPT)
- Canadian Academy of Manipulative Therapy (CAMT)
- Canadian Orthopractic Manual Therapy Association (COMTA)
- International Federation of Orthopaedic Manipulative Therapists (IFOMT)
- Journal of Manual and Manipulative Therapy (JMMT)
- European Association of Advanced Manual and Manipulative Therapy