Spinal manipulation

Last updated
Spinal manipulation
Kiropraktisk ledd-korreksjon av rygg.jpg
A chiropractor performing a spinal manipulation of the thoracic spine on a patient.
Alternative therapy
NCCIH Classification Manipulative and body-based
Legality Legal in adults, treatment of children varies by jurisdiction
MeSH D020393

Spinal manipulation is an intervention performed on synovial joints of the spine, including the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints. It is typically applied with therapeutic intent, most commonly for the treatment of low back pain. [1]

Contents

Effectiveness

Back pain

Clinical guidelines from different countries come to different conclusions with respect to spinal manipulation. [2]

A 2012 Cochrane review found that spinal manipulation was as effective as other commonly used therapies. [3] A 2010 systematic review found that most studies suggest SM achieves equal or superior improvement in pain and function compared with other commonly used interventions for short-, intermediate-, and long-term follow-up. [4] A 2019 systematic review concluded that SM produced comparable results to recommended treatments for chronic low back pain, while SM appeared to give improved results over non-recommended therapies for short-term functional improvement. [5]

In 2007, the American College of Physicians and the American Pain Society jointly recommended that clinicians consider spinal manipulation for patients who do not improve with self-care options. [6] Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions. [7] [8] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain. [9] Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations. [10] A 2017 review concludes "for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy." [11]

Neck pain

For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies. [12] A 2015 Cochrane systematic review found that there is no high-quality evidence assessing the effectiveness of spinal manipulation for treating neck pain. [13] Moderate-to-low-quality evidence suggests that multiple spinal manipulation sessions may provide improved pain relief and an improvement in function when compared to certain medications. [13] Due to the potential risks associated with spinal manipulation, high-quality randomized controlled trials are needed to determine the clinical role of spinal manipulation. [13] A 2007 systematic review reported that there is moderate- to high-quality evidence that subjects with chronic neck pain, not due to whiplash and without arm pain and headaches, show clinically meaningful improvements from a course of spinal manipulation or mobilization. [14] There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash, but there are short-term benefits. [15]

Non-musculoskeletal disorders

Historically, some within the chiropractic profession have claimed that spinal adjustments have physiological effects on visceral functions and thus affect overall health beyond musculoskeletal conditions. This view originated in the 19th century with Daniel David Palmer's original thesis that subluxations caused many diseases. Over time, this hypothesis is inconsistent with our modern understanding of pathology and disease, and only "a small proportion of chiropractors, osteopaths, and other manual medicine providers use[ing] spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial." [16]

A 2019 global summit of "50 researchers from 8 countries and 28 observers from 18 chiropractic organizations" conducted a systematic review of the literature, and 44 of the 50 "found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function." [16]

Assistance of medication or anesthesia

As for manipulation with the assistance of medication or anesthesia, a 2013 review concludes that the best evidence lacks coherence to support its use for chronic spine pain. [17]

Safety

There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown. [18] [13] [19] Spinal manipulation is frequently associated with mild to moderate temporary adverse effects, and also rare serious outcomes which can result in permanent disability or death. [19] [20] [13] [21] The National Health Service in the UK notes that about half of people reported encountering adverse effects following spinal manipulation. [21] Adverse events are increasingly reported in randomized clinical trials of spinal manipulation but remain under-reported despite recommendations in the 2010 CONSORT guidelines. [22] [23] A 2015 Cochrane systematic review noted that more than half of the randomized controlled trials looking at the effectiveness of spinal manipulation for neck pain, did not include adverse effects in their reports. [13] However, more recent reports have reported spinal manipulation adverse events to be rare. [24]

Risks of neck manipulation

The degree of serious risks associated with manipulation of the cervical spine is uncertain, with little evidence of risk of harm but also little evidence of safety either. [25] [26] There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation. [25] Several deaths have been associated with this technique [19] and it has been suggested that the relationship is causative, [27] [28] but this is disputed by many chiropractors who believe it is unproven. [27]

Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that: [29]

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.

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. [30] [31] [32] [33]

Edzard Ernst found that there is little evidence for efficacy and some evidence for adverse effects, and due to that, the procedure should be approached with caution, particularly forceful manipulation of the upper spine with rotation. [34]

A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence. [19]

A 2016 systematic-review found the data supporting a correlation between neck manipulation and cervical artery dissection to be very weak and that there was no convincing evidence for causation. [35]

A 2024 narrative review noted the thromboembolic and thrombotic mechanisms of causation of immediate stroke after cervical spine manipulation that are in the existing peer-reviewed literature. [36]

Potential for incident under-reporting

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, Edzard 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 under-reporting 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." [34] The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. [37] Both NHS and Ernst noted that bias is a problem with the survey method of data collection.

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." [38] 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. [37]

Mis-attribution 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: [39]

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.

This error was taken into account in a 1999 review [40] 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: [40]

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 (non-thrust passive movements).

In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown, [41] and Figure 2 shows the type of practitioner involved in the resulting injury. [42] For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett. [39]

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." [40]

History

Spinal manipulation is a therapeutic intervention that has roots in folk medicine such as the traditional bone-setting and has been used by various cultures, apparently for thousands of years. Hippocrates, the "father of medicine" used manipulative techniques, [43] as did the ancient Egyptians and many other cultures. [44] A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic and chiropractic medicine. [45] Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s. [46] [47]

Providers

In North America, it is most commonly performed by chiropractors, osteopathic physicians, and physical therapists. In Europe, osteopaths, chiropractors, and physiotherapists are the majority providers, although the precise figure varies between countries. In 1992, chiropractors were estimated to perform over 90% of all manipulative treatments given for low back pain treatment in the USA. [48] A 2012 survey in the US found that 99% of the first-professional physical therapy programs that responded were teaching some form of thrust joint manipulation. [49]

Terminology

Manipulation has been known by several other names. Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labeling system developed by Geoffery Maitland, [50] manipulation is synonymous with Grade V mobilization. Because of its distinct segmental biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation. However, it is important to note that the magnitude of neither force, velocity, or amplitude are regarded as defining attributes. [51] [52]

Biomechanics

Spinal manipulation can be distinguished from other manual therapy interventions such as mobilization by its biomechanics, both kinetics and kinematics.[ citation needed ]

Kinetics

Force-time profiles measured during spinal manipulation were originally described as consisting of three distinct phases: the 'preload' phase, the 'thrust' (or 'impulse') phase, and the 'resolution' phase. [53] Evans and Breen [54] added a fourth 'orientation' phase to describe the first period, during which the patient is oriented into the appropriate position in preparation for the preload phase.

Kinematics

The kinematics of a complete spinal motion segment, when one of its constituent spinal joints is manipulated, are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint. However, the events that take place in a manipulated synovial joint are the same, irrespective of whether the synovial joint in the spine or the periphery. Evans and Lucas defined manipulation using these events: [51] "Separation (gapping) of opposing articular surfaces of a synovial joint, caused by a force applied perpendicularly to those articular surfaces, that results in cavitation within the synovial fluid of that joint." The corresponding definition for the mechanical response of a manipulation is: "Separation (gapping) of opposing articular surfaces of a synovial joint that results in cavitation within the synovial fluid of that joint." In turn, the action of a manipulation can be defined as: "A force applied perpendicularly to the articular surfaces."

Suggested mechanisms

The effects of spinal manipulation have been shown[ citation needed ] to include:

Common side effects of spinal manipulation are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort. [58]

See also

Related Research Articles

<span class="mw-page-title-main">Chiropractic</span> Form of pseudoscientific alternative medicine

Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It is based on several pseudoscientific ideas.

<span class="mw-page-title-main">Vertebral subluxation</span> Chiropractic concept

In chiropractic, a vertebral subluxation means pressure on nerves, abnormal functions creating a lesion in some portion of the body, either in its action or makeup. Chiropractors claim subluxations are not necessarily visible on X-rays.

<span class="mw-page-title-main">Low back pain</span> Medical condition

Low back pain or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute, sub-chronic, or chronic. The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense, it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

Manual therapy, or manipulative therapy, is a treatment primarily used by physical therapists and occupational therapists to treat musculoskeletal pain and disability. It mostly includes kneading and manipulation of muscles, joint mobilization and joint manipulation. It is also used by Rolfers, massage therapists, athletic trainers, osteopaths, and physicians.

<span class="mw-page-title-main">Spinal adjustment</span> Chiropractic technique

Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Despite anecdotal success, there is no scientific evidence that spinal adjustment is effective against disease.

<span class="mw-page-title-main">Traction (orthopedics)</span> Process for straightening broken bones

Traction is a set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system. There are two types of traction: skin traction and skeletal traction. They are used in orthopedic medicine.

<span class="mw-page-title-main">Disc herniation</span> Injury to the intervertebral disc

A spinal disc herniation or simply a disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatments may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

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.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

Manipulation under anesthesia (MUA) or fibrosis release procedures is a multidisciplinary, chronic pain-related manual therapy modality which is intended for the purpose of improving articular and soft tissue movement. This is a non-invasive procedure purported to help regain mobility accomplished by way of a combination of controlled joint mobilization/manipulation and myofascial release techniques while under sedation. MUA is used by osteopathic/orthopedic physicians, chiropractors and specially trained physicians. It aims to break up adhesions on or around spinal joints or extremity joints to which a restricted range of motion can be painful and limit function. Failed attempts at other standard conservative treatment methods, over a sufficient time-frame, is one of the principal patient qualifiers.

<span class="mw-page-title-main">Neck pain</span> Medical condition

Neck pain, also known as cervicalgia, is a common problem, with two-thirds of the population having neck pain at some point in their lives.

Chiropractors use their version of spinal manipulation as their primary treatment method, with non-chiropractic use of spinal manipulation gaining more study and attention in mainstream medicine in the 1980s. There is no evidence that chiropractic spinal adjustments are effective for any medical condition, with the possible exception of treatment for lower back pain. The safety of manipulation, particularly on the cervical spine has been debated. Adverse results, including strokes and deaths, are rare.

Throughout its history, chiropractic has been the subject of internal and external controversy and criticism. According to magnetic healer Daniel D. Palmer, the founder of chiropractic, "vertebral subluxation" was the sole cause of all diseases and manipulation was the cure for all disease. Internal divisions between "straights," who adhere strictly to Palmer’s original philosophy, and "mixers," who incorporate broader medical practices, have further complicated the profession’s identity. A 2003 profession-wide survey found "most chiropractors still hold views of Innate Intelligence and of the cause and cure of disease consistent with those of the Palmers". A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today." Chiropractors, including D.D. Palmer, were jailed for practicing medicine without a license. D.D. Palmer considered establishing chiropractic as a religion to resolve this problem. For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as vertebral subluxation.

<span class="mw-page-title-main">Veterinary chiropractic</span>

Veterinary chiropractic, also known as animal chiropractic, is chiropractic for animals – a type of spinal manipulation. Veterinary chiropractors typically treat horses, racing greyhounds, and pets. Veterinary chiropractic is a controversial method due to a lack of evidence as to the efficacy of chiropractic methods. Contrary to traditional medicine, chiropractic therapies are alternative medicine. There is some degree of risk associated with even skilled manipulation in animals as the potential for injury exists with any technique used. The founder of chiropractic, Daniel David Palmer, used the method on animals, partly to challenge claims that the placebo effect was responsible for favorable results in humans. Chiropractic treatment of large animals dates back to the early 1900s. As of 2019, many states in the US provide statutory or regulatory guidelines for the practice of chiropractic and related treatments on animals, generally requiring some form of veterinary involvement.

Osteomyology is a multi-disciplined form of alternative medicine found almost exclusively in the United Kingdom and is loosely based on aggregated ideas from other manipulation therapies, principally chiropractic and osteopathy. It is a results-based physical therapy tailored specifically to the needs of the individual patient. Osteomyologists have been trained in osteopathy and chiropractic, but do not require to be regulated by the General Osteopathic Council (GOsC) or the General Chiropractic Council (GCC).

<span class="mw-page-title-main">McKenzie method</span> Method of physical therapy

The McKenzie method is a technique primarily used in physical therapy. It was developed in the late 1950s by New Zealand physiotherapist Robin McKenzie. In 1981 he launched the concept which he called "Mechanical Diagnosis and Therapy (MDT)" – a system encompassing assessment, diagnosis and treatment for the spine and extremities. MDT categorises patients' complaints not on an anatomical basis, but subgroups them by the clinical presentation of patients.

Primary spine practitioners are health care professionals who are specially trained to provide primary care for patients with spinal disease.

Cervical manipulation, commonly known as neck manipulation, is a procedure involving adjustment of the upper seven vertebrae of the spinal column. This procedure is most often utilized by chiropractors, as well as osteopathic physicians who practice osteopathic manipulation. This type of manipulation may increase the risk of stroke and other issues, with studies suggesting the relationship is causative.

<span class="mw-page-title-main">Forward head posture</span> Spinal condition

Forward head posture (FHP) is an excessively kyphotic (hunched) thoracic spine. It is clinically recognized as a form of repetitive strain injury. The posture can occur in dentists, surgeons, and hairdressers, or people who spend time on electronic devices. It is one of the most common postural issues. There is a correlation between forward head posture and neck pain in adults, but not adolescents.

References

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  31. ↑ Rothwell DM, Bondy SJ, Williams JI (May 2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. doi: 10.1161/01.str.32.5.1054 . PMID   11340209.
  32. ↑ Haldeman S, Carey P, Townsend M, Papadopoulos C (2002). "Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias". The Spine Journal. 2 (5): 334–42. doi:10.1016/s1529-9430(02)00411-4. PMID   14589464.
  33. ↑ Haldeman S, et al. (2001). "Arterial dissections following cervical manipulation: the chiropractic experience". Canadian Medical Association Journal. 165 (7): 905–906. PMC   81498 . PMID   11599329.
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  35. ↑ Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE (February 2016). "Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation". Cureus. 8 (2): e498. doi: 10.7759/cureus.498 . PMC   4794386 . PMID   27014532.
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  37. 1 2 NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors Archived 2006-05-30 at the Wayback Machine
  38. ↑ Rothwell DM, Bondy SJ, Williams JI (May 2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. doi: 10.1161/01.STR.32.5.1054 . PMID   11340209. Original article
  39. 1 2 Terrett AG (May 1995). "Misuse of the literature by medical authors in discussing spinal manipulative therapy injury". Journal of Manipulative and Physiological Therapeutics. 18 (4): 203–10. PMID   7636409.
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  41. ↑ Figure 1. Injuries attributed to manipulation of the cervical spine. Archived 2007-09-27 at the Wayback Machine
  42. ↑ Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury. Archived 2007-02-25 at the Wayback Machine
  43. ↑ Dean C. Swedlo, "The Historical Development of Chiropractic. Archived 2008-06-25 at the Wayback Machine " pp. 55-58, The Proceedings of the 11th Annual History of Medicine Days, Faculty of Medicine, The University of Calgary
  44. ↑ Burke, G.L., "Backache from Occiput to Coccyx" Chapter 1
  45. ↑ Keating JC (June 2003). "Several pathways in the evolution of chiropractic manipulation". Journal of Manipulative and Physiological Therapeutics. 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID   12819626.
  46. ↑ Burke, G.L., "Backache from Occiput to Coccyx Archived 2014-07-14 at the Wayback Machine " Chapter 7
  47. ↑ "International MUA Academy of Physicians - Historical Considerations" . Retrieved 2008-03-24.
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  49. ↑ Noteboom JT, Little C, Boissonnault W (June 2015). "Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update". The Journal of Orthopaedic and Sports Physical Therapy. 45 (6): 471–6. doi:10.2519/jospt.2015.5273. PMID   25899212.
  50. ↑ Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
    Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
  51. 1 2 Evans DW, Lucas N (2023). "What is manipulation? A new definition". BMC Musculoskelet Disord. 15, 24(1) (1): 194. doi: 10.1186/s12891-023-06298-w . PMC   10015914 . PMID   36918833.
  52. ↑ Evans DW (2022). "Why is the prevailing model of joint manipulation (still) incorrect?". Chiropr Man Ther. 30 (1): 51. doi: 10.1186/s12998-022-00460-2 . PMC   9733235 . PMID   36494698.
  53. ↑ Herzog W, Symons B (2001). "The biomechanics of spinal manipulation". Crit Rev Phys Rehabil Med. 13 (2): 191–216. doi:10.1615/CritRevPhysRehabilMed.v13.i2-3.50.
  54. ↑ Evans DW, Breen AC (January 2006). "A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone". Journal of Manipulative and Physiological Therapeutics. 29 (1): 72–82. doi:10.1016/j.jmpt.2005.11.011. PMID   16396734.
  55. ↑ Murphy BA, Dawson NJ, Slack JR (March 1995). "Sacroiliac joint manipulation decreases the H-reflex". Electromyography and Clinical Neurophysiology. 35 (2): 87–94. PMID   7781578.
  56. ↑ Kingston L, Claydon L, Tumilty S (August 2014). "The effects of spinal mobilizations on the sympathetic nervous system: a systematic review". Manual Therapy. 19 (4): 281–7. doi:10.1016/j.math.2014.04.004. PMID   24814903.
  57. ↑ Tullberg T, Blomberg S, Branth B, Johnsson R (May 1998). "Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis". Spine. 23 (10): 1124–8, discussion 1129. doi:10.1097/00007632-199805150-00010. PMID   9615363. S2CID   36480639. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.
  58. ↑ Senstad O, Leboeuf-Yde C, Borchgrevink C (February 1997). "Frequency and characteristics of side effects of spinal manipulative therapy". Spine. 22 (4): 435–40, discussion 440-1. doi:10.1097/00007632-199702150-00017. PMID   9055373. S2CID   7482895.

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