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Chapter 41 Manipulation

image Therapeutic Keys

Manipulation is a passive manual maneuver that introduces movement beyond the passive range of motion (ROM) through the elastic barrier, but does not exceed the anatomic barrier.1 Mobilizations are passive stretches with or without oscillations over which the patient can exert control.2 Chiropractic adjustments are techniques that range in force from a near imperceptible force to high-velocity thrusts causing joint cavitation (popping noise).

As a prudent starting point, initial evaluation should determine if manipulation of the patient is appropriate, seeking out “red flags” that contraindicate manipulation, such as fracture, infection, neoplasm, progressive neurologic deficit, cord pressure, or cauda equina syndrome.3,4

A correct differential diagnosis is key to selection of patients, and the functional assessment is key to the selection of appropriate manual medicine techniques.5

If gross signs of inflammation are present in a joint (heat, swelling, redness, and pain), and repeated movement to end range (ER) worsens the signs, manipulation in that direction would most likely aggravate the condition.

When bringing the joint complex to tension, if the pain peripheralizes, it is a relative contraindication to manipulation.

The practitioner should be alerted that an adverse outcome is likely from manipulation when repetitive motion with progressive force in the direction of the manipulation peripheralizes pain and reduces function.

Relaxation techniques (heat, muscle work, and calming environment) are helpful to patients complaining of anxiety, muscle tension, stiffness, and aching before manipulation.6

If pain is the chief complaint, icing the area for 5 minutes causes surface anesthesia and 20 minutes causes sedation of the actions of the muscle spindle cells. Sedation of a muscle reflex arc before manipulation of a fixated painful joint may facilitate treatment.2

If the patient reports an increase in pain or stiffness after manipulation, ice the area of treatment for 10 to 30 minutes to reduce spasm and pain.7,8 The patient should be placed into a position that centralizes pain when icing.

“The goal of manipulation is to restore maximal pain-free movement of the musculoskeletal system and postural balance.”9

Do not treat muscle spasm as a primary condition. Muscle spasm is almost always a response of the body to a noxious stimulus. Find the cause and treat it.10

Trigger points are myofascial irritations that are frequently caused by underlying joint fixations. Manipulation can irritate a trigger point and can precipitate a muscle spasm later that day.11

image Historical Perspective

Manipulations are depicted in prehistoric cave drawings and Chinese statues, circa 2700 BC,12 but Hippocrates is credited with the earliest recorded written physician’s prescription of manipulative treatment methods, which changed little until the sixth century. He advocated key principles of judicious use of force, direction of thrust, and proper levering of joints.13

During the Dark Ages, priests provided medical treatment at their monasteries. Kessler stated: “Friar Moultan, of the order of St. Augustine, wrote The Complete Bonesetter. The text, which was revised by John Turner in 1656, suggests that manipulation was practiced in medical settings throughout the Middle Ages and Renaissance.”14

Three main concepts developed during the 1700s still have a major influence on manipulation today. The first held that “vertebral luxation” (bone out of place) was responsible for spinal deformity. The second, the mainstream medical opinion, maintained that “caries of the spine” caused spinal deformity, which was treated with bloodletting and rest, while condemning extension and manipulation as both useless and dangerous and citing concerns about the potentially disastrous effects of manipulating tuberculous, neoplastic, rheumatic, or fractured joints. The third held that muscles were the main cause of problems, and treatment should be complete rest or active exercise, as the case warranted.13

More recently, questions of vertebral disc herniation, precipitation of cerebral vascular accidents, controversial issues of cost-effectiveness and efficacy of manipulative treatment, and the lack of a differential diagnosis by many nonallopathic manipulators have become the cause célèbre.

It is interesting to note the following:

image Schools of Thought in Manipulation


James Cyriax, James Mennell, and John Mennell were brilliant physicians who worked to reintegrate manipulation into medical practice. They wrote valuable texts on manipulative therapy, although they did not totally agree on the effects they achieved with manipulation. Mennell held to the correction of lost joint play and denied the effect on the intervertebral disc,21 whereas Cyriax claimed reduction of a protruding disc.10

“Controversy and contention” best describe the higher levels of the respective schools of medical thought. The impression one gets in reading through the literature is intolerance of others’ ideas expressed in ad hominem attacks. The mistake “lay” manipulators and “nonphysicians” make is not ineffectiveness, but in their willingness to seek training outside the fraternal order of the “medical” brotherhood; to address the public directly rather than communicating exclusively within the order; and, worst of all, to openly compete, economically and politically, against the fraternal order.13,15

Donald B. Tower, in the chairman’s summary at the National Institute of Neurological and Communicative Diseases and Stroke conference in 1975,22 noted a physician who received little credit for his early contribution to the field: J. Evans Riadore, a London physician who wrote a treatise on the irritation of spinal nerves in 1843. He attributed many diseases to this condition, stating: “If any organ is deficiently supplied with nervous energy of blood, its functions immediately, and sooner or later its structure, become deranged.” This was a viewpoint subsequently echoed by osteopaths and chiropractors.22

The fifth edition of Spinal Manipulation by Bourdillion et al,23 the first authors who were medical manipulators, has been largely reworked from previous editions and heavily influenced by osteopathic methods.

Awareness of manual medicine has been fostered by Calliet, McNabb, Maigne, Maitland, Kaltenborn, Williams, Jirout, Lewit, Janda, Bogduk, McKenzie, and many others.

Physical Therapy

James Cryiax influenced Robin McKenzie, a New Zealand physical therapist who subsequently developed a systematic approach called mechanical diagnosis and treatment (MDT) of musculoskeletal conditions. It is a process of evaluation and treatment of musculoskeletal disorders based on a mechanical history and the patient’s symptomatic and mechanical response to movement, positions, and loading.4 McKenzie’s approach is often prejudicially dismissed as “extension exercises for the low back.” He proposed a new tack in the approach to back pain that was found to be highly effective in populations with acute and chronic back pain as well as low in cost.24 MDT includes McKenzie’s observations that most conditions are self-resolving and that focus should be on prevention and recovery of function by teaching patients proper posture and self management. After years of studying, performing, and researching manipulation, he felt that only 20% of patients needed manipulative therapy, and 80% could self-treat using ER loading strategies learned from books or practitioners.25

image Is Manual Medicine the Right Treatment?

Patients with somatic pain caused by psychosocial factors often seek a physical cause and treatment for their pain. If the presenting complaints do not seem to follow a mechanical pattern and the pain diagram is nonanatomic, consider the possibility of psychosocial factors. Psychosocial workplace factors associated with risk of spinal injury include job dissatisfaction, stressful working conditions as perceived by the employee, employer practices reported as being unfair, poor coping skills, lack of recognition at work, low supervisor support, a high frequency of job problems, and negative beliefs of or attitudes toward the consequences of having “low back trouble.”26,27 A major factor in identifying the incidence of future pain is the patient’s perception of being disabled.28 If the patient’s history and records include previous evaluation by multiple providers with conflicting and confusing reports from the patient, caution is advised in approaching the management of the patient. If in doubt, seek a consultation with an astute colleague, physiatrist, or appropriate specialist.

Is It Safe to Move?

A clinician must answer the question, “Is it safe to ‘move the patient’ using conservative therapies, exercise, mobilizations, and manipulations?” Red flags have been shown to have many false positives, resulting in unnecessary additional diagnostic testing. Recent studies showed less than 1% of patients presenting to general practitioners with conditions that warranted further diagnostic evaluation. Red flags are a source of unnecessary medical interventions. When the medical history and examination indicate a serious disease, neurologic compromise, or progressive neurologic deficit, further evaluation or consultation is warranted. Although the question of safety is usually answered by the provider’s clinical training, a general outline of triage is presented as a starting point to help determine if further evaluation is indicated before initiating or continuing care.29

Signs of Neurologic Disorder or Progressive Neurologic Deficit

A loss of sensation, decreased or absent deep tendon reflex, loss of muscle strength, and positive nerve root tension are signs of nerve root involvement. If only these neurologic findings are present and do not become progressively worse, appropriate conservative care may be effective.34 Dizziness, drop attacks, diplopia, dysarthria, dysphagia, numbness, nystagmus, and nausea are more concerning signs of central nervous system involvement. Loss of bladder or bowel control or saddle anesthesia requires urgent evaluation with magnetic resonance imaging of the lumbar spine. If progressive neurologic deficit of weakness, loss of sensation, and loss of function, or the previously mentioned signs and symptoms are present, a consultation with a competent colleague, physiatrist, or neurosurgeon is indicated.

Is the Best Treatment Movement or Rest?

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