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How does manipulation work

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In European and North American populations about one-third of adults will experience neck pain in the course of a year,1 and many will seek manual therapy. This author 2 offers the following definition of manipulation;


A skilled, passive, high velocity and low amplitude force directed at specific spinal segment3,4 performed at the point slightly before the limit of clinical physiological range called the closed pack position5 is often accompanied by an audible crack or pop6–8. It is different from mobilisation which refers to a repetitive passive movement either physiological or accessory, of varying amplitude and of low acceleration2,9 which can be stopped by the patient, unlike manipulation which does not allow the patient to prevent the joint movement.10


How does manipulation work 1

How does manipulation work

There are nine popular theories of how manipulation works for neck pain, to see them all click here. For healthcare professional who finds themselves within the challenging situation when a patient asks how manipulation works? or how did the manipulation actually make me better?  Here’s the option to offer the following theory10,11,12 accepted by over 70% of Chartered Physiotherapists in UK;

Current theory of manipulation

Spinal manipulation activates mechanoreceptors and proprioceptors of several structures such as the facet joints, joint capsules, ligaments, muscles, cutaneous receptors, muscle spindles, golgi tendon organs, which subsequently exerts a mechanical hypoalgesic effect10,11,12 .

This however isn’t the only theory which received approval, and uniquely the most highly qualified physiotherapists who had passed additional strenuous postgraduate musculoskeletal exams (SOMM or MACP associations) there is a more appropriate theory, to see this click here

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  1. Croft PR, Lewis M, Papageorgiou AC, Thomas E, Jayson MI, Macfarlane GJ, et al. Risk factors for neck pain: a longitudinal study in the general population. Pain. 2001 Sep;93(3):317–25.

  2. Kennedy I, A cross-sectional postal survey of musculoskeletal physiotherapists’ opinions towards the published theory of cervical spine manipulation. International Musculoskeletal Medicine. Jan 2015. Vol 37 pages 1-11.

  3. Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manipulation or mobilisation for neck pain: A Cochrane Review. Man Ther [Internet]. 2010 Aug [cited 2014 Dec 23];15(4):315–33. Available from:

  4. Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review. Man Ther [Internet]. 2010 Oct [cited 2014 Dec 23];15(5):434–44. Available from:

  5. Vernon HT, Dhami MS, Howley TP, Annett R. Spinal manipulation and betaendorphin: a controlled study of the effect of a spinal manipulation on plasma beta-endorphin levels in normal males. J Manipulative Physiol Ther. 1986 Jun;9(2):115–23.

  6. Sandoz R. The significance of the manipulative crack and of other articular noises. Ann Swiss Chiro Assoc. 1969;4:47–68.

  7. Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, et al. A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain. Arch Phys Med Rehabil [Internet]. 2010 Sep [cited 2014 Dec 23];91(9):1313–8. Available from:

  8. Atkins E, Kerr J, Goodlad E. A Practical Approach to Orthopaedic Medicine: Assessment, Diagnosis, Treatment, 3e. 3 edition. Edinburgh ; New York: Churchill Livingstone; 2010. 480 p.

  9. Rivett D, Magarey M, Refshauge K, Shirley D. Clinical Guidelines for assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine disorders. Aust Physiother Assoc [Internet]. 2006 [cited 2014 Dec 23]; Available from: %202006.pdf

  10. Fabio RPD. Manipulation of the Cervical Spine: Risks and Benefits. Phys Ther [Internet]. 1999 Jan 1 [cited 2014 Dec 22];79(1):50–65. Available from:

  11. Miller J, Gross A, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010 Aug;15(4):334–54.

  12. Cramer G, Budgell B, Henderson C, Khalsa P, Pickar J. Basic science research related to chiropractic spinal adjusting: the state of the art and recommendations revisited. J Manipulative Physiol Ther. 2006 Dec;29(9):726– 61.

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