Medicine:Spinal manipulation

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Short description: Intervention performed on spinal joints

Template:Infobox:Alternative therapy Spinal manipulation is an intervention performed on spinal articulations, synovial joints, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints. National guidelines come to different conclusions with respect to spinal manipulation with some not recommending it, and others recommending a short course in those who do not improve with other treatments.[1]

A 2012 Cochrane review found that spinal manipulation was no more effective than other commonly used therapies.[2] There is not sufficient data to establish the safety of spinal manipulations.[3]

Effectiveness

Back pain

Cochrane reviews find that spinal manipulation (SM) are no more effective than other commonly used therapies.[2] A 2010 systematic review found that most studies suggest SM achieves equal or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up.[4] 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.[5] 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.[6] Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions.[7][8] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain.[9] Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations.[10] 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."[11]

Neck pain

For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies.[12] A 2015 Cochrane systematic review found that there is no high quality evidence assessing the effectiveness of spinal manipulation for treating neck pain.[13] 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.[13] Due to the potential risks associated with spinal manipulation, high quality randomized controlled trials are needed to determine the clinical role of spinal manipulation.[13] 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 important improvements from a course of spinal manipulation or mobilization.[14] There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits.[15]

Non-musculoskeletal disorders

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 many diseases were caused by subluxations. Over time, this hypothesis has been shown to be 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."[16]

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."[16]

Assistance of medication or anesthesia

Further information: 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.[17]

Safety

There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown.[3][13][18] 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.[18][19][13][20] The National Health Service in the United Kingdom notes that about half of people reported encountering adverse effects following spinal manipulation.[20] Adverse events are increasingly reported in randomized clinical trials of spinal manipulation but remain under-reported despite recommendations in the 2010 CONSORT guidelines.[21][22] 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.[13] However, more recent reports have reported spinal manipulation adverse events to be rare.[23]

Risks of neck manipulation

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.[24][25] There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation.[24] Several deaths have been associated with this technique[18] and it has been suggested that the relationship is causative,[26][27] but this is disputed by many chiropractors who believe it is unproven.[26]

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".[28] 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.[29][30][31][32]

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.[33]

A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence.[18]

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.[34]

Potential for incident under-reporting

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."[33] The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection.[35] 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."[36] 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.[35]

Mis-attribution 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."[37]

This error was taken into account in a 1999 review[38] 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 (non-thrust passive movements)."[38]

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown,[39] and Figure 2 shows the type of practitioner involved in the resulting injury.[40] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.[37]

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."[38]

History

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,[41] as did the ancient Egyptians and many other cultures.[42] A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic and chiropractic medicine.[43] Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s.[44][45]

Providers

In North America, it is most commonly performed by physical therapists, osteopathic physicians, occupational therapists, and chiropractors. In Europe, physiotherapists, osteopaths and chiropractors 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.[46] 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.[47]

Terminology

Manipulation is known by several other names. The British orthopedic surgeon A. S. Blundell Bankart used the term "manipulation" in his text Manipulative Surgery.[48] Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labeling system developed by Geoffery Maitland,[49] manipulation is synonymous with Grade V mobilization. Because of its distinct biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation.

Biomechanics

Spinal manipulation can be distinguished from other manual therapy interventions such as mobilization by its biomechanics, both kinetics and kinematics.

While spinal manipulations may pose as a therapeutic effect in pain management, their efficacy in promoting performance enhancement is inconclusive. The outcomes of individuals who undergo spinal manipulations vary on a patient-to-patient basis.

[50]

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.[jargon][51] Evans and Breen[52] 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.

Kinematics

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. This may explain why studies have found that regional vs. targeted spinal manipulation result in similar patient outcomes.[53]

Suggested mechanisms

The effects of spinal manipulation have been shown[citation needed] to include:

  • Temporary relief of musculoskeletal pain[citation needed]
  • Shortened time to recover from acute back pain[citation needed]
  • Temporary increase in passive range of motion (ROM)[citation needed]
  • Physiological effects on the central nervous system (specifically the sympathetic nervous system)[54][55]
  • Altered sensorimotor integration[citation needed]
  • No alteration of the position of the sacroiliac joint[56]
  • Sham or placebo manipulation[57]

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.[58]

See also

References

  1. ↑ "An updated overview of clinical guidelines for the management of non-specific low back pain in primary care". European Spine Journal 19 (12): 2075–94. December 2010. doi:10.1007/s00586-010-1502-y. PMID 20602122. 
  2. ↑ 2.0 2.1 Rubinstein, Sidney M; Terwee, Caroline B; Assendelft, Willem JJ; de Boer, Michiel R; van Tulder, Maurits W (2012-09-12). Cochrane Back and Neck Group. ed. "Spinal manipulative therapy for acute low-back pain" (in en). Cochrane Database of Systematic Reviews 2012 (9): CD008880. doi:10.1002/14651858.CD008880.pub2. PMID 22972127. ""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."". 
  3. ↑ 3.0 3.1 "Safety of chiropractic interventions: a systematic review". Spine 34 (11): E405-13. May 2009. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054. http://www.chiropratiquelasource.com/recherches/safety.pdf. "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.". 
  4. ↑ "NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain". The Spine Journal 10 (10): 918–40. October 2010. doi:10.1016/j.spinee.2010.07.389. PMID 20869008. 
  5. ↑ "Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials". BMJ 364: l689. March 2019. doi:10.1136/bmj.l689. PMID 30867144. 
  6. ↑ "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Annals of Internal Medicine 147 (7): 478–91. October 2007. doi:10.7326/0003-4819-147-7-200710020-00006. PMID 17909209. 
  7. ↑ "Inconsistent grading of evidence across countries: a review of low back pain guidelines". Journal of Manipulative and Physiological Therapeutics 29 (7): 576–81, 581.e1-2. September 2006. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948. 
  8. ↑ "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". The Spine Journal 8 (1): 213–25. 2008. doi:10.1016/j.spinee.2007.10.023. PMID 18164469. 
  9. ↑ "Chiropractic management of low back pain and low back related leg complaints". Council on Chiropractic Guidelines and Practice Parameters. 2007. http://ccgpp.org/lowbackliterature.pdf. 
  10. ↑ "A systematic review of systematic reviews of spinal manipulation". Journal of the Royal Society of Medicine 99 (4): 192–6. April 2006. doi:10.1177/014107680609900418. PMID 16574972. 
  11. ↑ "Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review". The American Journal of Emergency Medicine 35 (1): 55–61. January 2017. doi:10.1016/j.ajem.2016.10.001. PMID 27751598. https://zenodo.org/record/891043. 
  12. ↑ "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine 33 (4 Suppl): S123-52. February 2008. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386. 
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 "Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment". The Cochrane Database of Systematic Reviews (9): CD004249. September 2015. doi:10.1002/14651858.CD004249.pub4. PMID 26397370. 
  14. ↑ "Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials". Journal of Manipulative and Physiological Therapeutics 30 (3): 215–27. 2007. doi:10.1016/j.jmpt.2007.01.014. PMID 17416276. 
  15. ↑ "[Effectiveness of spinal manipulation in treating whiplash injuries"] (in es). Atencion Primaria 39 (5): 241–6. May 2007. doi:10.1157/13101798. PMID 17493449. 
  16. ↑ 16.0 16.1 "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". Chiropractic & Manual Therapies (Springer Science and Business Media LLC) 29 (1): 8. February 2021. doi:10.1186/s12998-021-00362-9. PMID 33596925. 
  17. ↑ "Spinal manipulation under anesthesia: a narrative review of the literature and commentary". Chiropractic & Manual Therapies 21 (1): 14. May 2013. doi:10.1186/2045-709X-21-14. PMID 23672974. 
  18. ↑ 18.0 18.1 18.2 18.3 "Adverse effects of spinal manipulation: a systematic review". Journal of the Royal Society of Medicine 100 (7): 330–8. July 2007. doi:10.1177/014107680710000716. PMID 17606755. 
  19. ↑ Chu, Eric Chun-Pu; Trager, Robert J.; Lee, Linda Yin-King; Niazi, Imran Khan (2023-01-23). "A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy" (in en). Scientific Reports 13 (1): 1254. doi:10.1038/s41598-023-28520-4. ISSN 2045-2322. PMID 36690712. Bibcode: 2023NatSR..13.1254C. 
  20. ↑ 20.0 20.1 "Safety and regulation of chiropractic". NHS Choices. 20 August 2014. http://www.nhs.uk/Conditions/chiropractic/Pages/Safetyandregulation.aspx. 
  21. ↑ "The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review". The Spine Journal 16 (9): 1143–51. September 2016. doi:10.1016/j.spinee.2016.05.018. PMID 27241208. 
  22. ↑ "Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review". The New Zealand Medical Journal 125 (1353): 87–140. April 2012. PMID 22522273. 
  23. ↑ "Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study". Military Medicine 185 (1–2): e290–e297. February 2020. doi:10.1093/milmed/usz176. PMID 31322706. 
  24. ↑ 24.0 24.1 "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice 66 (10): 940–7. October 2012. doi:10.1111/j.1742-1241.2012.03004.x. PMID 22994328. 
  25. ↑ "Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review". Manual Therapy 15 (5): 434–44. October 2010. doi:10.1016/j.math.2010.02.006. PMID 20227325. 
  26. ↑ 26.0 26.1 "Deaths after chiropractic: a review of published cases". International Journal of Clinical Practice 64 (8): 1162–5. July 2010. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715. 
  27. ↑ "Vascular accidents after neck manipulation: cause or coincidence?". International Journal of Clinical Practice 64 (6): 673–7. May 2010. doi:10.1111/j.1742-1241.2009.02237.x. PMID 20518945. 
  28. ↑ 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.
  29. ↑ "Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation". Spine 27 (1): 49–55. January 2002. doi:10.1097/00007632-200201010-00012. PMID 11805635. 
  30. ↑ "Chiropractic manipulation and stroke: a population-based case-control study". Stroke 32 (5): 1054–60. May 2001. doi:10.1161/01.str.32.5.1054. PMID 11340209. 
  31. ↑ "Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias". The Spine Journal 2 (5): 334–42. 2002. doi:10.1016/s1529-9430(02)00411-4. PMID 14589464. 
  32. ↑ "Arterial dissections following cervical manipulation: the chiropractic experience". Journal of the Canadian Medical Association 165 (7): 905–906. 2001. PMID 11599329. 
  33. ↑ 33.0 33.1 Spinal manipulation: Its safety is uncertain. Edzard Ernst, CMAJ, January 8, 2002; 166 (1)
  34. ↑ "Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation". Cureus 8 (2): e498. February 2016. doi:10.7759/cureus.498. PMID 27014532. 
  35. ↑ 35.0 35.1 NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors
  36. ↑ "Chiropractic manipulation and stroke: a population-based case-control study". Stroke 32 (5): 1054–60. May 2001. doi:10.1161/01.STR.32.5.1054. PMID 11340209.  Original article
  37. ↑ 37.0 37.1 "Misuse of the literature by medical authors in discussing spinal manipulative therapy injury". Journal of Manipulative and Physiological Therapeutics 18 (4): 203–10. May 1995. PMID 7636409. 
  38. ↑ 38.0 38.1 38.2 "Manipulation of the cervical spine: risks and benefits". Physical Therapy 79 (1): 50–65. January 1999. PMID 9920191. http://ptjournal.apta.org/content/79/1/50.full. Retrieved 2011-11-24. 
  39. ↑ Figure 1. Injuries attributed to manipulation of the cervical spine.
  40. ↑ Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury.
  41. ↑ Dean C. Swedlo, "The Historical Development of Chiropractic. " pp. 55-58, The Proceedings of the 11th Annual History of Medicine Days, Faculty of Medicine, The University of Calgary
  42. ↑ Burke, G.L., "Backache from Occiput to Coccyx" Chapter 1
  43. ↑ "Several pathways in the evolution of chiropractic manipulation". Journal of Manipulative and Physiological Therapeutics 26 (5): 300–21. June 2003. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626. 
  44. ↑ Burke, G.L., "Backache from Occiput to Coccyx " Chapter 7
  45. ↑ "International MUA Academy of Physicians - Historical Considerations". http://www.muaphysicians.com/historical.html. 
  46. ↑ "Spinal manipulation for low-back pain". Annals of Internal Medicine 117 (7): 590–8. October 1992. doi:10.7326/0003-4819-117-7-590. PMID 1388006. 
  47. ↑ "Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update". The Journal of Orthopaedic and Sports Physical Therapy 45 (6): 471–6. June 2015. doi:10.2519/jospt.2015.5273. PMID 25899212. 
  48. ↑ "Manipulative surgery. By A. S. Blundell Bankart, M.A., M.Ch. (Cantab.), F.R.C.S., Orthopædic Surgeon to the Middlesex Hospital, etc. Modern Surgical Monographs, edited by G. Gordon-Taylor, O.B.E., M.A., F.R.C.S. Demy 8vo. Pp. 150 + xii, with 21 illustrations. 1932. London: Constable & Co. Ltd. 7s. 6d. Net". British Journal of Surgery 20 (78): 353–354. 1932. doi:10.1002/bjs.1800207825. 
  49. ↑ Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
    Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
  50. ↑ "The effects of spinal manipulation on performance-related outcomes in healthy asymptomatic adult population: a systematic review of best evidence". Chiropractic & Manual Therapies 27 (1): 25. December 2019. doi:10.1186/s12998-019-0246-y. PMID 31183076. 
  51. ↑ "The biomechanics of spinal manipulation.". Crit Rev Phys Rehabil Med 13 (2): 191–216. 2001. doi:10.1615/CritRevPhysRehabilMed.v13.i2-3.50. 
  52. ↑ "A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone". Journal of Manipulative and Physiological Therapeutics 29 (1): 72–82. January 2006. doi:10.1016/j.jmpt.2005.11.011. PMID 16396734. 
  53. ↑ "Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in a military beneficiary population". Military Medicine 174 (7): 750–6. July 2009. doi:10.7205/milmed-d-02-4908. PMID 19685848. 
  54. ↑ "Sacroiliac joint manipulation decreases the H-reflex". Electromyography and Clinical Neurophysiology 35 (2): 87–94. March 1995. PMID 7781578. 
  55. ↑ "The effects of spinal mobilizations on the sympathetic nervous system: a systematic review". Manual Therapy 19 (4): 281–7. August 2014. doi:10.1016/j.math.2014.04.004. PMID 24814903. 
  56. ↑ "Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis". Spine 23 (10): 1124–8; discussion 1129. May 1998. doi:10.1097/00007632-199805150-00010. PMID 9615363. "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.". 
  57. ↑ "Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials". BMJ 364: l689. March 2019. doi:10.1136/bmj.l689. PMID 30867144. 
  58. ↑ "Frequency and characteristics of side effects of spinal manipulative therapy". Spine 22 (4): 435–40; discussion 440-1. February 1997. doi:10.1097/00007632-199702150-00017. PMID 9055373. 

Further reading

  • Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions. I (8th ed.). London: Bailliere Tindall. 1982. 
  • Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection. II (10th ed.). London: Bailliere Tindall. 1983. 
  • Modern Manual Therapy of the Vertebral Column. Harcourt Publishers Ltd.. 1994. 
  • Peripheral Manipulation (2nd ed.). London: Butterworths. 1977. 
  • ertebral Manipulation (5th ed.). London: Butterworths. 1986. 
  • The Lumbar Spine; Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications. 1981. 
  • The Cervical and Thoracic Spine; Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications. 1990. 
  • Joint Pain; Diagnosis and Treatment Using Manipulative Techniques. Boston: Little Brown and Co.. 1964. 

External links



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