If you have been to a musculoskeletal therapist or clinician, you may have been offered a mobilization or a manipulation as a treatment. Both are treatment techniques which involves moving a joint. There are various ways to perform these techniques, but there are certain distinctions. In this blog, we discuss various common mechanisms of how the technique works.
Mobilisations usually involve low-speed and either high or low amounts of movement (amplitude). Manipulations usually involve high-speed but low amount of movement (amplitude) that aims to gap/open joint surfaces – sometimes resulting in a familiar ‘pop/click’ sound. It is understood that a successful manipulation may not produce a ‘pop/click’ sound, while a manipulation that produces a ‘pop/click’ sound may be unsuccessful to produce the desired effects of treatment (e.g. reduce pain, improve mobility) (Bialosky et al., 2010)
There have been concerns regarding risks around manipulations since it is a high-speed technique despite its low amplitude of movement. There has been consistent evidence that manipulation does not cause nor cure long term joint issues such as osteoarthritis – considering it is a very short duration“ stretch” this makes sense mechanically. The main precautions for manipulations now revolve around structural integrity and major medical conditions. Structural integrity that make it risky to manipulate include fragile bones(fracture or osteoporosis), blood vessel compromise, and major structural (e.g. ligament/disc) damage.
Medical conditions that makes it risky to perform manipulations are one with similar effects, such as nerve damage, cancer leading to fragile bones and disc herniations – mainly physical structure issues. These conditions are screened for prior to manipulation by your clinician via the questions they ask and/or physical examination. They would only perform manipulation if it is safe to do so.
When the risks are understood and controlled, we now need to understand why we do it in the first place: What are the benefits? Generally, it is accepted that manipulation has some local biomechanical effects on the joint, such as “loosening up” or “reducing stiffness” of the joint, similar to low-speed mobilization. There is still a debate if manipulation would “reposition” a joint that is in a “wrong position”. Some would argue joints don’t get into a “wrong position” in the first place. Reduction in stiffness can improve pain or movement locally or globally as it may improve general movement. It may also reduce muscular pain and/or tension in the area as the muscle is no longer protecting or moving a stiff joint.
A lesser known but now better understood mechanism of how manipulation works is that it changes neurophysiology around the manipulated area (Pickar,2002). In the context of pain, this is commonly understood to reduce sensitivity of the nerves and reduces the pain experience. This doesn’t just occur locally, but in the downstream nerves of the manipulated segment (e.g. arm pain/sensitivity for a neck manipulation and leg pain/sensitivity for a low back manipulation). This is because the nerves that originate from the spine receive signals from the more peripheral parts of our body: the nerves that goes to our arms come for the neck and the nerves that go to our legs come from our low back.
As a result of the neurophysiological effects at the spinal level, some have also suggested it affects the autonomic nerves that reside close to the spine (Sampath et al., 2017). The autonomic nerves control more “central/global effects”. Most common noticeable effects of the autonomic nerves are sweat, heart rate changes, skin coolness/warmth from changes in blood flow. This may or may not be related to the condition you have come to your clinician for.
Due to these effects, manipulation can be a choice of treatment that your clinician would recommend. Generally, this would also mean most of the risk has been assessed and deemed minimum. Manipulation is rarely a must but often gives better result than a low-speed mobilization where indicated. Should you have any questions regarding manipulations, don’t hesitate to ask your clinician.
Bialosky et al., 2010: https://www.sciencedirect.com/science/article/pii/S0161475409003200
Pickar 2002: https://www.ncbi.nlm.nih.gov/pubmed/14589467
Sampath et al., 2017: https://www.jospt.org/doi/abs/10.2519/jospt.2017.7348
Our clinicans are highly trained and have post graduate qualifications in Orthopedic Manipulative Therapy.