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. A joint is the location at which two or more bones make contact. ... Synovial joints (or diarthroses, or diarthroidal joints) are the most common and most moveable type of joints in the body. ...

Biomechanics of joint manipulation

Manipulation can be distinguished from from other manual therapy interventions such as mobilization by its biomechanics, both kinetics and kinematics. Manual Therapy encompasses the diagnosis and treatment of the ailments of various etiologies through hands-on intervention. ... Joint mobilization is a type of passive movement of a skeletal joint. ... To meet Wikipedias quality standards, this article or section may require cleanup. ... Kinetics refers to two different areas of science: Chemical kinetics studies reaction rates. ... In physics, kinematics is the branch of classical mechanics concerned with describing the motions of objects without considering the factors that cause or affect the motion. ...

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.^[1] Evans and Breen^[2] 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. // Spinal manipulation is manipulation of synovial joints in the spinal column. ... Changing orientation is the same as moving the coordinate axes. ...

When individual peripheral synovial joints are manipulated, the distinct force-time phases that occur during spinal manipulation are not as evident. In particular, the rapid rate of change of force that occurs during the thrust phase when spinal joints are manipulated is not always necessary. Most studies to have measured forces used to manipulate peripheral joints, such as the metacarpophalangeal (MCP) joints, show no more than gradually increasing load. This is probably because there are many more tissues restraining a spinal motion segment than an independent MCP joint. Synovial joints (or diarthroses, or diarthroidal joints) are the most common and most moveable type of joints in the body. ... // Spinal manipulation is manipulation of synovial joints in the spinal column. ... In mathematics, the derivative of a function is one of the two central concepts of calculus. ... // Spinal manipulation is manipulation of synovial joints in the spinal column. ... The Metacarpophalangeal joint (MCP): The Metacarpophalangeal Articulations are of the condyloid kind, formed by the reception of the rounded heads of the metacarpal bones into shallow cavities on the proximal ends of the first phalanges, with the exception of that of the thumb, which presents more of the characters of... This article or section does not adequately cite its references or sources. ... A functional spinal unit (FSU) is the smallest physiological motion unit of the spine to exhibit biomechanical characteristics similar to those of the entire spine. ...

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. A functional spinal unit (FSU) is the smallest physiological motion unit of the spine to exhibit biomechanical characteristics similar to those of the entire spine. ... // Spinal manipulation is manipulation of synovial joints in the spinal column. ... Synovial joints (or diarthroses, or diarthroidal joints) are the most common and most moveable type of joints in the body. ...

Early models describing the kinematics of an individual target joint during the various phases of manipulation (notably Sandoz 1976) were based on studies that investigated joint cracking in MCP joints. The cracking was elicited by pulling the proximal phalanx away from the metacarpal bone (to separate, or 'gap' the articular surfaces of the MCP joint) with gradually increasing force until a sharp resistance, caused by the cohesive properties of synovial fuid, was met and then broken. These studies were therefore never designed to form models of therapeutic manipulation, and the models formed were erroneous in that they described the target joint as being configured at the end range of a rotation movement, during the orientation phase. The model then predicted that this end range position was maintained during the prethrust phase until the thrust phase where it was moved beyond the 'physiologic barrier' created by synovial fluid resistance; conveniently within the limits of anatomical integrity provided by restraining tissues such as the joint capsule and ligaments. This model still dominates the literature. However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen^[3] argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint, which is the motion region of the joint where the passive osteoligamentous stability mechanisms exert little or no influence. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped, rather than rotated), and that it is more mechanically efficient to do this when the joint is near to its neutral configuration. Model may refer to more than one thing : For models in society, art, fashion, and cosmetics, see; role model model (person) supermodel figure drawing modeling section In science and technology, a model (abstract) is understood as an abstract or theoretical representation of a phenomenon,see; geologic modeling model (economics) model... See also: Joint manipulation Cracking joints is the practice of manipulating ones joints such that it produces a sharp sound, likened to cracking (also likened to popping, etc. ... The Metacarpophalangeal joint (MCP): The Metacarpophalangeal Articulations are of the condyloid kind, formed by the reception of the rounded heads of the metacarpal bones into shallow cavities on the proximal ends of the first phalanges, with the exception of that of the thumb, which presents more of the characters of... The phalanges in a human hand Illustration of the phalalnges The name Phalanges is commonly given to the bones that form fingers and toes. ... The metacarpus is the intermediate part of the hand skeleton that is located between the fingers distally and the carpus which forms the connection to the forearm. ... The Metacarpophalangeal joint (MCP): The Metacarpophalangeal Articulations are of the condyloid kind, formed by the reception of the rounded heads of the metacarpal bones into shallow cavities on the proximal ends of the first phalanges, with the exception of that of the thumb, which presents more of the characters of... Mercury sticks together because of the cohesive forces. ... Range of motion or (ROM), as used in the medical and weightlifting communities, is the achievable distance between the flexed position and the extended position of a particular joint or muscle group, or more precisely, the measurement of that distance. ... A sphere rotating around its axis. ... Joint stability refers to the resistance offered by various musculoskeletal tissues that surround a skeletal joint. ...

Audible click

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 cavitation occurring within the synovial fluid of the joint. When a manipulation is performed, the force applied separates the articular surfaces of a fully encapsulated synovial joint, which in turn creates a reduction in pressure within the joint cavity. In this low pressure environment, some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave solution creating a bubble or cavity, which rapidly collapses upon itself, resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly carbon dioxide.^[4] The effects of this process will remain for a period of time termed the 'refractory period', which can range from a few minutes to more than an hour while it is slowly reabsorbed back into the synovial fluid. There is some evidence that ligament laxity may be associated with an increased tendency to cavitate.^[5] Look up clicking in Wiktionary, the free dictionary. ... This article or section does not cite its references or sources. ... Synovial fluid is a thin, stringy fluid found in the cavities of synovial joints. ... -1... Synovial fluid is a thin, stringy fluid found in the cavities of synovial joints. ... Bubbles of air in a soft drink For specific types of bubbles, and metaphors of the word bubble, see Bubble (disambiguation). ... The word cavity in English means a hollow or a hole. ... Carbon dioxide is a chemical compound composed of one carbon and two oxygen atoms. ... A refractory period, in physiology, is a period of time during which an organ or cell is incapable of performing a particular action. ... Ligamentous Laxity Ligamentous laxity is a condition that can be summarised succinctly as Loose ligaments. In a normal body, ligaments are naturally tight in such a way that the permitted range of movement for a joint is restricted to normal ranges. ...

Mechanisms of action and clinical effects

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

The clinical effects of joint manipulation have been shown to include:

• Temporary relief of musculoskeletal pain.

• Shortened time to recover from acute back sprains (Rand).

• Temporary increase in passive range of motion (ROM).^[6]

• Physiological effects on the central nervous system, probably at the segmental level.^[7]

• No alteration of the position of the sacroiliac joint.^[8]

Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.^[9] For other uses, see Pain (disambiguation). ... Look up acute in Wiktionary, the free dictionary. ... Look up Back in Wiktionary, the free dictionary. ... To meet Wikipedias quality standards, this article or section may require cleanup. ... Side-effect can mean: Side-effect (computer science), a state change caused by a function call Adverse drug reaction, an unintended consequence specifically arising from drug therapy Therapeutic effect (medicine), a desirable consequence of any kind of medical treatment, even though resulting as an unintended, unexpected consequence of the treatment...

Practice of manipulation

In the context of healthcare, joint manipulation is performed by several professional groups. In North America, it is most commonly performed by chiropractors, physical therapists, and osteopaths. When applied to joints in the spine, it is referred to as spinal manipulation. Health care or healthcare is one of the worlds largest and fastest growing professions. ... Chiropractic, or chiropractic care, is a Complementary and Alternative Medicine (CAM) health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. ... ... Osteopathy is the body of medicine that originally used strictly manipulative techniques for correcting somatic abnormalities thought to cause disease and inhibit recovery. ... The vertebral column seen from the side Different regions (curvatures) of the vertebral column The vertebral column (backbone or spine) is a column of vertebrae situated in the dorsal aspect of the abdomen. ... // Spinal manipulation is manipulation of synovial joints in the spinal column. ...

Terminology

Manipulation is known by several other names. Chiropractors refer to manipulation of a spinal joint as an 'adjustment'. Following the labelling system developed by Geoffery Maitland,^[10] manipulation is synonymous with Grade V mobilization. Because of its distinct biomechanics (see section above), the term high velocity low amplitude (HVLA) is often used interchangeably with manipulation. Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe chiropractic approaches to spinal manipulation. ... Joint mobilization is a type of passive movement of a skeletal joint. ... Joint manipulation is a type of passive movement of a skeletal joint. ... High velocity low amplitude thrust (HVLA) is a manipulative therapy technique used by practitioners in several professions, among them chiropractors, osteopaths, physical therapists, and medical doctors, to treat somatic dysfunction and joint-related problems. ...

Safety issues

As with all interventions, there are risks associated with joint manipulation, especially manipulation of spinal joints. Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral and rib fractures, and cauda equina syndrome.^[11] // Spinal manipulation is manipulation of synovial joints in the spinal column. ... A stroke, also known as cerebrovascular accident (CVA),[1] is an acute neurological injury in which the blood supply to a part of the brain is interrupted. ... A spinal disc herniation, commonly called a slipped disc, is a medical condition affecting the spine, in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc allows the soft, central portion (nucleus pulposus) to bulge out. ... A diagram of a thoracic vertebra. ... The human rib cage. ... It has been suggested that this article or section be merged with Bone healing. ... Cauda equina syndrome is a serious neurologic condition in which there is compression of the vertebral column (spine) affecting the S1-S4 nerve roots. ...

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."^[12]

Risks of upper cervical manipulation

The degree of serious risks associated with manipulation of the cervical spine is uncertain, with widely differing results being published. For other uses, see Risk (disambiguation). ...

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."^[13] A sphere rotating around its axis. ...

Serious complications after manipulation of the cervical spine are estimated to be 1 in 4 million manipulations or fewer.^[14] A RAND Corporation extensive review estimated "one in a million."^[15] Dvorak, in a survey of 203 practitioners of manual medicine in Switzerland, found a rate of one serious complication per 400,000 cervical manipulations, without any reported deaths, among an estimated 1.5 million cervical manipulations.^[16] Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury.^[17] Henderson and Cassidy performed a survey at the Canadian Memorial Chiropractic College outpatient clinic where more than a half-million treatments were given over a nine-year period, again without serious incident.^[18] Eder offered a report of 168,000 cervical manipulations over a 28 year period, again without a single significant complication.^[19] After an extensive literature review performed to formulate practice guidelines, the authors concurred that "the risk of serious neurological complications (from cervical manipulation) is extremely low, and is approximately one or two per million cervical manipulations."^[20]

In comparison, there is a 3-4% rate of complications for cervical spinal surgery, and 4,000-10,000 deaths per million neck surgeries.^[21] A cardiothoracic surgeon performs a mitral valve replacement at the Fitzsimons Army Medical Center. ...

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".^[22] 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.^{[23][24][25][26]}

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."^[27] The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection.^[28] Both NHS and Ernst noted that bias is a problem with the survey method of data collection. Professor Edzard Ernst is notable for being the first Professor of Complementary Medicine in the United Kingdom. ...

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."^[29] 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.^[28]

In 1996, Coulter et al.^[15] 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.'"^[30]

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."^[31]

This error was taken into account in a 1999 review^[32] 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)."^[32]

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown,^[33] and Figure 2 shows the type of practitioner involved in the resulting injury.^[34] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.^[31]

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."^[32]

Edzard Ernst has written: Professor Edzard Ernst is notable for being the first Professor of Complementary Medicine in the United Kingdom. ...

"...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."^[27]

Adverse effect, in medicine, is an abnormal, harmful, undesired and/or unintended side-effect, although not necessarily unexpected, which is obtained as the result of a therapy or other medical intervention, such as drug/chemotherapy, physical therapy, surgery, medical procedure, use of a medical device, etc. ...

Emergency medicine

In emergency medicine joint manipulation can also refer to the process of bringing fragments of fractured bone or dislocated joints into normal anatomical alignment (otherwise known as 'reducing' the fracture or dislocation). These procedures have no relation to the HVLA thrust procedure. This article or section does not adequately cite its references or sources. ... A fractured bone in a living person is typically treated by restoring the fractured pieces of bone to their natural positions (if necessary), and maintaining those positions while the bone heals. ... Dislocation (joint dislocation) occurs when bones at a joint move from their normal position. ... Anatomical drawing of the human muscles from the Encyclopédie. ...

See also

• Spinal manipulation
• High velocity low amplitude thrust
• Cracking joints
• Joint mobilization
• Orthopedic medicine
• Osteopathic Manipulative Medicine
• Physical therapy

// Spinal manipulation is manipulation of synovial joints in the spinal column. ... High velocity low amplitude thrust (HVLA) is a manipulative therapy technique used by practitioners in several professions, among them chiropractors, osteopaths, physical therapists, and medical doctors, to treat somatic dysfunction and joint-related problems. ... Cracking joints is the practice of manipulating ones joints such that it produces a sharp sound, likened to cracking (also likened to popping, etc. ... Joint mobilization is a type of passive movement of a skeletal joint. ... Orthopedic surgery or orthopedics (BE: orthopaedics) is the branch of surgery concerned with acute, chronic, traumatic and recurrent injuries and other disorders of the locomotor system, its musclular and bone parts. ... Osteopathic Manipulative Medicine (abbreviated as OMM) is a manual modality of treatment used to improve the impaired or altered function of the musculo-skeletal system (somatic dysfunction). ... Physical therapy (or physiotherapy[1]) is the provision of services to people and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. ...

References

For the Manfred Mann album, see 2006 (album). ... 17 November is also the name of a Marxist group in Greece, coinciding with the anniversary of the Athens Polytechnic uprising. ...

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.

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)