Focus on Spinal Manipulation

You may have seen that one of the recommendations made by the recent Lancet series of papers on low back pain was spinal manipulation. It just so happens, chiropractors are experts in spinal manipulation, often referred to as “chiropractic adjustments” but it is essentially the same thing. Generally speaking, spinal manipulative therapy (SMT) is a therapeutic intervention applied to a joint, often the spine where pressure is applied by hand, in a very specific and controlled way that may result in a “pop” or “crack” sound. Spinal Manipulation is usually a high velocity, low amplitude technique (HVLA) technique and takes many years of training to develop the skill. It is commonly used in combination with other therapeutic techniques to treat spinal and musculoskeletal pain, injuries and dysfunction. The technique is NOT exclusive to chiropractors, other professions who are trained in manipulation include osteopathy and some physiotherapists, GPs and medical specialists.

Chiropractors start developing their hands-on skills the very first week of university (I still remember my first skills class vividly!), we start specifically developing the motor skill from 2nd year, and start practicing spinal manipulation in 3nd year, which means that by the time a chiropractor has finished university, they have been learning and practicing spinal manipulation for at least 3 years! Even then it can take some time on top of that to really master the skill.

Despite the evidence supporting the safety and efficacy of manipulation, there are many misconceptions and “horror stories” out there. Without the proper education and understanding of the technique It can be difficult to fathom why someone would suggest pushing at your body until it cracked as a treatment option, especially when you come into the office in pain and can hardly move. However, when indicated, spinal manipulation is a powerful tool that has wide reaching benefits. Over recent years research studies have given us a better insight around why manipulation can be beneficial and what actually happens when it is applied.  We have now shifted our understanding from what once was a simplistic assumption of a bone being out of place causing problems to a much more sophisticated model involving peripheral and central nervous system changes. More on the modern chiropractic approach and research here.

I’ve outlined a few comments and questions I commonly get in clinic and attempted to clear them up. I always encourage patients to ask questions, especially if they are unsure or concerned about something. This can be an empowering process, and will put patients in a position to make better and more informed choices about their own health care.


“It’s unnatural!”: This is true, SMT is not “natural”. Neither is remedial massage or taking turmeric in highly concentrated crushed up tablet form, or medications like ibuprofen or codeine. Going for a walk would be considered natural, the rest are therapeutic interventions. However, your nervous system is designed to prioritize and respond to fast movement changes as this could mean you are falling or something sudden or threatening is happening. When we apply that type of input as a therapeutic intervention we can rapidly improve the way your muscles hold your whole spine to protect you. A very fast manipulation is rapidly transmitted to the balance system and creates a greater and improved stability response.


“Manipulation can only be done if the patient doesn’t know or by surprise”: This is just not true! Manipulation is performed when a patient is relaxed and comfortable, however they MUST always be fully aware and informed about the type of treatment they are receiving. This is called informed consent.


“Cracking causes arthritis”: Another one that’s not true. The noise associated with manipulation is called a “cavitation” and occurs is in response to a pressure change within a synovial joint (moveable joint). This process is characterized by rapid separation of surfaces with subsequent cavity formation seen on real time MRI (1). It is thought that the noise is a reflection of a healthy joint, and habitual knuckle cracking has not been shown to increase joint degeneration (2)


“Is it safe?”: Spinal manipulation, when performed by a trained health professional is extremely safe. We see this time and time again in scientific studies of high quality and know the serious risks of spinal manipulation are far lower than alternatives including medication, injections and surgery. A recent systematic review discussed that benign adverse events following manual treatments (including SMT) are common (3) however these are mild and transient, similar to the feeling you get from going to the gym for the first time in a long time. Serious adverse events are extremely rare but have been reported in the literature. These include stroke or stroke like symptoms, disc herniation and nerve damage. However, there is no excess risk of these events occurring when seeing a chiropractor compared to other health professionals. The association that has been made between manipulation and vertebral/carotid artery dissection is not one of causation, rather it is likely due to patients with headache and neck pain from the dissection itself seeking care before their stroke (4).  Lastly, elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuromusculoskeletal problems (3). However, some underlying conditions (such as bone weakening conditions, connective tissue disorders) may increase the risk, thus highlighting the importance of a through history and exam.

Bottom line is make sure whoever is performing manipulative techniques is a professional and discuss any concerns or worries you may have with your provider. You should be the one that ultimately decides what type of treatment you should have based on the evidence, and if you are uncomfortable, ask for alternative treatment options.






1) Kawchuk GN, et al. Real-Time Visualization of Joint Cavitation. PLoS ONE (2015) .

2) Deweber K, Olszewski M, Ortolano R. Knuckle cracking and hand osteoarthritis. J Am Board Fam Med. 2011

3) Swait G, et al. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropractic and Manual Therapies. December 2017

4) Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008