Monthly Archives: October 2017

Is Manipulation Safe?

Every now and then a news story breaks that questions the safety of manual therapy, particularly the safety of neck manipulations. As with any form of treatment, manipulation comes with a risk, but it is examined and discussed with the patient in the treatment room. Consent can only be given if the patient is informed.

What is a manipulation?

Manipulation is another term for a High Velocity Low Amplitude Thrust (HVLAT). High velocity means that it’s a quick movement, and low amplitude means that it’s a small movement. It’s a controlled and specific motion used on restricted joints to improve movement. Other terms you may have heard of include clicking, cracking, or adjusting. See the video below from Ross at Alpha Health demonstrating the technique.

Osteopaths learn how to manipulate joints during their standard training. This technique comes at the end of the degree, after learning how to examine and gently articulate (or mobilise) joints. The student’s knowledge of anatomy is very good by this point, and constantly reviewed while learning the techniques. Students learn with each other, so feedback can be given and received, and everyone knows what it feels like to be on the other end of the techniques.

Why we manipulate joints

Compared to gentle, repeated articulation of a joint, manipulations give quicker results and can be more comfortable for the patient. Mild soreness within 48 hours of the technique affects up to 50% of patients, which can be managed by 10 minutes of cold therapy, although many are happy to just let it pass.

When compared to mobilisation or articulation, results are similar.

Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up.

However the technique itself takes much less time, making treatment more efficient. There is a lot to be said for the psychological benefit of hearing the change taking place, and some patients are not satisfied until they’ve felt the click.

Risk Assessment

Vertebral arteries diagram

The most severe risk from neck manipulation is of damage to the vertebral arteries. These are the blood vessels that supply the brain (along with the carotid arteries), which sit in the spaces either side of each vertebra in the neck. The image to the right demonstrates this. Because of their location, they are put under tension on neck movements, particularly rotation.

More than half of the neck’s capacity for rotation comes from the highest joint in the neck: C1/2 or the atlanto-axial joint. This rotation combined with extension (tipping the head back) puts excessive strain on the vertebral arteries and can lead to dissection within the vessel, or stroke. To minimise this risk, extension is avoided in manipulation techniques, and some osteopaths choose to avoid manipulating the C1/2 joint altogether.


Informed consent is of the utmost importance at any point during consultation or treatment. In order to give informed consent, you must know the benefits and risks of the proposed treatment, and you should also be offered alternative treatments and the option for no treatment at all. The patient is in complete control of the route their treatment takes.

Your osteopath will take a comprehensive case history and examine you thoroughly before deciding that a manipulation is appropriate and safe. You must also give consent for this before it happens, and you are free to say no right up until the manipulation itself. Osteopaths have a variety of techniques to treat the same issue, so saying “no” to a manipulation doesn’t mean saying “no” to improving your symptoms.

“The ability to choose a preferred treatment can be empowering to patients and contribute positively to the recovery experience.”

Take-away statistics from NCOR

  • Nearly half of patients after manual therapy experience adverse events that are short-lived and minor; most will occur within 24 hours and resolve within 72 hours.
  • The risk of major adverse events is very low, lower than that from taking medication. Risk is inherent in all health interventions and should be weighed against patient-perceived benefit and alternative available treatments.
  • An estimate of the risk of spinal manipulation causing a clinically worsened disc herniation in a patient presenting with a lumbar disc herniation is calculated from published data to be less than 1 in 3.7 million

National Council of Osteopathic Research

Lower back and pelvic pain during and after pregnancy (Franke et al, 2017)

PregnancyRoughly 50% of pregnant women suffer from lower back pain or posterior pelvic pain; this increases towards the end of the pregnancy and through the first year after giving birth. The most widely accepted explanation for this is that these areas provide the most compensation for the increase in weight in the abdomen.

This research study is a systematic review, meaning it incorporates a large number of existing studies to draw the most accurate conclusions. This includes unpublished theses, and studies not written in the English language.

Does osteopathy work for lower back and pelvic pain associated with pregnancy?

Osteopathy provides significant reduction of pain, and improvement in function, for lower back and pelvic pain associated with pregnancy.

The key findings were:

  • Osteopathic Manual Therapy (OMT) was significantly more effective than usual care alone, or no treatment.
  • There were no serious side effects of OMT. Tiredness after treatment was a minor side effect.

Techniques that fell under the umbrella of OMT included structural, visceral, and cranial techniques. Specifically, structural techniques were listed as soft tissue manipulation, stretching, joint mobilisation, muscle energy techniques, and spinal manipulation. It is important to note that these techniques were used along with the philosophies of osteopathy. They were not just applied locally to the lower back and pelvis, but holistically, wherever needed to improve the body as a whole.

The study recognised that there was a limited amount of high quality evidence, but that the papers analysed were still significant with regards to OMT. Evidence was low to moderate for the benefit of exercise for pain and function. There was also low quality evidence to support craniosacral therapy, use of a lumbopelvic belt, and acupuncture. Due to the low quality of the evidence, it was difficult to compare to osteopathic treatment. The authors suggested that further research on the topic should involve more long-term follow-up for better quality evidence.

In the discussion, the point is raised that although there is clear benefit of osteopathic treatment, the exact reasons why are unclear. The authors draw the hypothesis that, as manual techniques have repeatedly been shown to reduce pain sensitivity, that these mechanisms allow for better neuromuscular function and control. This leads to the patient beginning to feel better, improving pain beliefs, and and allowing for further pain reduction and benefits to function.

Franke, H., Franke, J., Belz, S. and Fryer, G. (2017). Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy: A systematic review and meta-analysis. Journal of Bodywork and Movement Therapies, 21(4), pp.752-762.

I found Herts Osteopathy to be a professional and high quality service. The treatment I have received has helped me immensely with injuries I sustained in a car accident. I had seen several practitioners previously and I had lost hope that my injuries would get better. However, since seeing Jo I am in less pain and have increased movement and flexibility. I am also relying on prescription pain relief far less. Jo’s positive attitude and patience in explaining to me clearly what she is doing has helped me to believe that I will fully recover and understand how my body is responding to treatment. I strongly recommend Herts Osteopathy for a friendly and professional service that is excellent value for money.

Miss C
Patient at Herts Osteopathy

Cervicogenic Headaches (Biondi, 2005)

The Cervicogenic Headache International Study Group Diagnostic Criteria

The Cervicogenic Headache International Study Group Diagnostic Criteria

A cervicogenic headache is one that is caused by structures in the neck, such as muscles, joints, nerves, and blood vessels. It is estimated that up to 2.5% of the general population in the USA are experiencing a cervicogenic headache at any one time. Women are four times as likely to experience this than men.

By definition, neck movement or sustained awkward positioning will aggravate or bring on the headache. It is common to also find restriction in neck movement, and a change in neck posture. Pressure over the joints of the neck, or into the muscular trigger points around the neck and shoulder are also common aggravating factors.

Biondi’s paper is a review of a selection of previously published research, covering diagnostic criteria, guidelines, and the pathophysiology of cervicogenic headaches. Despite the research being funded by pharmaceutical companies, it reiterates the benefit of manual therapy for the treatment of cervicogenic headaches.

Does osteopathy work for cervicogenic headaches?

The paper regards physical and manual therapies to be important parts of the treatment program.

A controlled trial testing the effectiveness of therapeutic exercise and manipulative treatment for cases of cervicogenic headache found that efficacy was not substantially affected by age, gender, or headache chronicity in patients with moderate to severe pain intensity. This finding suggests that all patients with cervicogenic headache could benefit from manual modes of therapy and physical conditioning.

Categories of recommended treatment include

  • Pharmacologic
  • Non-pharmacologic
  • Interventional
  • Surgical

Osteopathic treatment comes under “non-pharmacologic”, along with physical therapy, use of a TENS machine, relaxation therapy, and psychotherapy.

A combination of both exercise and manipulation had better results than either modality alone. Both significantly reduced the frequency and intensity of cervicogenic headaches with long lasting results. It was also found that long term benefits are most substantial in patients who continute to participate in exercise programs.

Recommended techniques include craniosacral therapy, strain-counter strain, and muscle energy techniques. HVLA thrusts (or “clicking”) may suit some individuals, but can cause an increase in pain, particularly if the treatment is strong. The paper suggests that gentle techniques such as stretching should be used initially, leading up to strengthening. It also notes that other modalities that give temporary relief can aid the progress made through physical therapy.

Early diagnosis and management by way of a comprehensive, multidisciplinary pain treatment program can significantly decrease the protracted course of costly treatment and disability that is often associated with this challenging pain disorder.

Biondi, D. (2005). Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. The Journal of the American Osteopathic Association, [online] 105(4_suppl), pp.16S-22S. Available at: [Accessed 12 Oct. 2017].