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Effects of Joint Mobilizations and Manipulations Audio

The effects of joint mobilizations and manipulations on kinematics and muscular changes. Identifying the use of joint mobs and manips on the cervical, thoracic, and lumbar spine, and the effects on range of motion, pain, nervous system response, and motion at the neck, shoulder, hip, knee, ankle. Research showing these effects are not placebo. 


Effects of Joint Mobilizations and Manipulations

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Integrated Manual Therapist

Physical rehabilitation professionals, including physical therapists, osteopaths, and chiropractors, have been refining joint mobilizations and joint manipulations for 100s of years. There are even depictions of joint mobilization treatment that are 1000s of years old. Joint mobilization strategies have been published for chronic pain of the low back, hand pain, extremity joint issues, and various sports injuries. Some practitioners have noted the effect of joint mobilizations and joint manipulations on muscle activity and have integrated these techniques into routines for muscle weakness, muscle strains, and recurring pain relief for active trigger points.

The neurophysiological and mechanical effects of mobilizations and manipulations are actually quite complex. However, the simplest and most effective recommendation for their use is the intent to reduce joint stiffness for specific joints that have been assessed as exhibiting a reduction in joint play (arthrokinematic motion). Despite outcome studies demonstrating the efficacy of this approach to using these techniques, it would be presumptive to imply that there is a single, or a simple reason, that these techniques are effective. Some studies even imply mechanisms that are similar to deep tissue massage, massage guns, and other muscle tissue and connective tissue techniques, that are related to nerve endings involved in neuromuscular reflexes like autogenic inhibition (relaxation response), and altered cortisol concentrations (stress hormone), and central nervous system mediated pain relief which may be particularly effective for the treatment of chronic pain.


We hope this course helps to build a foundation of knowledge regarding the effects of joint intended technique from a very large body of research and rich clinical history. Further, this course is pre-approved for credits toward the Integrated Manual Therapist (IMT) Certification, and pre-approved for continuing education credits for sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.).


Mobilizations and manipulations result in kinematic, neurophysiological, and muscular changes that have been correlated with the improvement of various subjective and objective patient outcomes, both short-term and long-term. Further, these changes have been demonstrated in randomized placebo/nocebo-controlled trials, implying the effects are not attributable to placebo or patient perceptions/expectations.

Joint Motion During Mobilization and Manipulation

Factors affecting force during mobilization and manipulations.

Central Nervous System (CNS) Mediated Changes

Joint Mobilization and Manipulation: Introduction

Joint Mobilizations and Manipulations: Risk of Adverse Events

Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

Course Description: Effects of Joint Mobilizations and Manipulations

Effects of Joint Mobilizations and Manipulations study guide

Course Study Guide: Effects of Joint Mobilizations and Manipulations

Course Webinar: Effects of Joint Mobilizations and Manipulations

Mobilizations and manipulations result in kinematic, neurophysiological, and muscular changes that have been correlated with the improvement of various subjective and objective patient outcomes, both short-term and long-term. Further, these changes have been demonstrated in randomized placebo/nocebo controlled trials, implying the effects are not attributable to placebo or patient perceptions/expectations.

Mobilizations and manipulations are likely to impart more arthrokinematic motion, but less osteokinematic motion, than an individual's active range of motion. The stiffness curve expressed during joint mobilizations and manipulations includes an initial non-linear toe, a peak representing arthrokinematic end range and/or application of peak force, and a tail that coincides with decreased stiffness during the duration of the technique as a result of viscoelastic creep. Neither mobilizations nor manipulations are likely to result in enough force to significantly increase the risk of tissue damage, and although manipulations impart more initial force, the total force is similar to mobilizations. Various factors may alter the force imparted by the clinician including intent, experience, and the amount of plinth padding; however, many variables, like gender and technique, have less influence than is commonly assumed. Improvements in patient outcomes following mobilizations and manipulations are correlated with increased range of motion (ROM), decreased joint stiffness, changes in muscle activity, increased nerve root space, and increased joint space, but are not correlated with an immediate decrease in damage to tissues, including intervertebral discs.

Mobilizations and manipulations may result in local and distal analgesia via attenuation of dorsal horn neurons and C-fiber innervated afferents proximal to the intended segment, a segment above or below the intended segment, and potentially more distal sites of the ipsilaterally innervated extremity. Further, manipulation (more than mobilization) may result in a transient decrease in H-reflex sensitivity and amplitude, and/or normalization of H-reflex latency in individuals exhibiting dysfunction. Sympatho-excitatory effects have been demonstrated in multiple studies, including changes in skin conductance, skin temperature, heart rate, respiratory rate, blood pressure, and pupil dilation. And, Central nervous system changes have been demonstrated including a reduction in the activity of the pain centers of the brain (especially the insular cortex), increased maximal motor-evoked potentials as demonstrated by transcranial magnetic stimulation, and alterations in hormone and neurotransmitter levels. In summary, studies have demonstrated that mobilizations and manipulations have a significant effect on sensory afferents, the peripheral nervous system, central nervous system, autonomic nervous system, and hormone/neurotransmitter levels.

Mobilization and manipulations, performed alone or integrated into a rehabilitation program, can have a significant effect on muscle activity, thickness, and strength, and these changes may be correlated with improvements in patient outcomes, both short-term and long-term. Similar to the analgesic effects described above, the muscles most affected are those with attachment-to or crossing the intended segment; further, muscles may be affected from the segment above or below, or more distal along the ipsilaterally innervated extremity. When considered relative to the altered EMG activity in those exhibiting dysfunction, the changes noted following mobilizations and manipulations imply that activity is "normalized" (over-active muscles exhibit a reduction in activity, under-active muscles exhibit an increase in activity). During mobilizations and manipulations, symptomatic individuals may exhibit larger changes in joint stiffness, but exhibit latent or inhibited reflexive increases in muscle activity. Thoracic mobilizations and manipulations may have an effect on maximal respiratory values, but will only improve resting respiratory values for individuals with compromised pulmonary function. Last mobilizations and manipulations may only improve proprioception and balance when added to a long-term (4 weeks or more) integrated program that includes exercise. In summary, mobilizations and manipulations may normalize muscle activity, and increase muscle thickness, strength, and/or endurance, and these changes may have a positive effect on short-term and long-term outcomes, especially when added to an integrated exercise program.

 Golgi tendon organ, muscle spindle, touch, and some forms of pain

 thermal pain sensitivity, cutaneous pain (pin-prick) tolerance, and pain pressure threshold

 an agent that diminishes the sensation of pain without loss of consciousness

 A reflexive reaction of muscles to an electrically induced stimulation of sensory fibers (Ia muscle spindle afferents), that may be considered a "lab version" of the stretch (monosynaptic) reflex. H-reflex replaces stretch reflex in research because inputs and outcomes can be better controlled, resulting in higher sensitivity and reliability.

 Muscle-wave, the tracing of the earliest electromyography (EMG) response to the stimulation of a motor nerve, generally recorded during H-reflex testing.

 Volitional wave, is a measure of maximum voluntary evoked potential recorded using electromyography (EMG).

 TMS is a non-invasive form of brain stimulation using a magnetic field to induce an electric current within specific areas of the brain. TMS can be used to measure the activity and function of specific brain circuits, most commonly with single or paired magnetic pulses.

 In research, changes in sympathetic nervous system activity are assessed using indirect measures including changes in skin conductance (an indicator of sweat gland activity), skin temperature, blood pressure, and heart rate variability, and less commonly used are changes in respiratory rate and pupil diameter.

Introduction

 Patient stress is unlikely to have an effect on sympatho-excitatory or analgesic effects, with the exception of attempting high-velocity manipulations on patients exhibiting a high level of stress.

 Messaging, education, and expectations may have an impact on immediate measures of subjective pain and patient satisfaction scores, but they are unlikely to have any effect on objective measures or long-term patient outcomes.

 Manipulations and mobilizations result in attenuation of C-fiber mediated afferents, but not A-fiber mediated afferents, and these changes are not observed following placebo control, extension exercise, or cycling exercise.

 H-reflex attenuation following lumbosacral manipulation is significantly larger than placebo, and cannot be attributed to patient positioning, loaded patient positioning, or cutaneous input.

 Placebo/sham-controlled RCTs have demonstrated that the addition of mobilizations and/or manipulations to an integrated intervention plan improves patient outcomes.

 Cervical manipulations are comprised of lateral flexion, rotation, and flexion/extension. The pre-manipulative ROM for each joint action is relatively small, with the highest values reported being 25° of lateral flexion or 35° of rotation (one joint action being dominant, and the other being 10° or less), in addition to 10° or less of flexion/extension. Regional (segmental) ROM for lateral flexion and rotation is less than half of total ROM. Further, the velocity of cervical manipulations may be relatively high (up to 194.7°/s); however, the magnitude is relatively small, including 0.9cm ± 0.40 facet gap, 8° (SD 2°) lateral flexion, 5° (SD 2°) axial rotation, and 3° (SD 2°) flexion/extension.

Cervical Manipulations Use Less ROM than Available Active ROM: 

Several studies demonstrate that pre-manipulative and thrust ROM is less than a participant's active ROM.

 The kinematics of mobilization are less complex than manipulation, with PA cervical mobilizations resulting in significant soft tissue deformation and vertebral motion that is likely to increase the cervical lordosis. The motion of increased cervical lordosis includes anterior displacement of the target segment, upper cervical extension, lower cervical flexion, and either flexion or extension of middle segments.

 Lumbar manipulation is comprised of a combination of ipsilateral rotation, contralateral flexion, and extension. Lumbar mobilizations result primarily in anterior displacement with some flexion or extension depending on the segment. During mobilization, anterior displacement is relatively insensitive to PA force angle; however, segmental flexion/extension increased significantly (2x's +) when PA force angle was adjusted by as little as 5°. Further, unilateral PA mobilizations result in some additional contralateral rotation and contralateral flexion.

Spine Manipulation, Kinematics, and Outcomes: 

Research suggests that manipulations are effective, at least in part, due to increased ROM, nerve root space, and facet gap, but not necessarily morphological changes of the disk.

 Mobilization is likely to result in 5 - 10mm of glenohumeral arthrokinematic motion in the direction of mobilization, which is approximately 5 - 10 times the amount of arthrokinematic motion noted during passive motion. Further, arthrokinematic motion is likely to increase with the amount of force used during mobilization from grades I - IV.

 Significant motion of adjacent segments occurs during mobilization and manipulation; however, the target segment is likely most affected. Additionally, studies suggest that the benefit of oscillations during mobilization, and/or the increased velocity during manipulation, may be a relative decrease in accommodation by adjacent segments.

 Manipulation imparts more stress on annular fibers than the nucleus pulposus, increasing flexion increases stress on posterior fibers, and rotation imparts more stress to the fibers on the posterior/contralateral side.

Stresses During Mobilization and Manipulation Techniques on Healthy and Degenerative Disks:

 Force increases over the duration of the manipulation in an arc from the anterior/ipsilateral to posterior/contralateral portions of the disk, and distension of the disk may place additional stress on the contralateral nerve root. Further, force characteristics are similar for healthy disks and degenerative disks; however, distension is greater in healthy disks, intradiscal pressure may be greater in degenerative disks, and the amount of force imparted on each segment may be altered by the presence of healthy and degenerative disks.

 Based on the forces imparted on disks, there are only subtle differences between various mobilization and manipulation techniques. These subtle differences may include, more force on disks during techniques involving more lumbar flexion, manipulations imparting more instant initial force, and manipulations imparting more force on the posterior/contralateral side of the disk; whereas, unilateral PA mobilizations result in more force on the posterior/ipsilateral side of the disk.

Amount of Force Necessary for Failure of Tissue: 

Based on the few studies currently available, it may be reasonable to suggest that the mean force used during manipulation and mobilization techniques is well below the minimum threshold for increased risk of tissue injury. However, some care may be warranted for osteoporotic patients based on a presumed increase in the risk of laminar fracture and the potential for neurologic injury.

 Although we may be able to establish norms based on the average forces imparted by a group of experienced therapists, without comparing these forces and correlating them with outcomes and risk of injury, it is not possible to know whether average forces are optimal forces.

Research suggests that modeling the stiffness curve of joint mobilizations should consider an initial non-linear (toe) component, a curve influenced by the amount of force administered, and change in force with repeated oscillations due to viscoelastic creep. These studies also suggest that a more complex model of joint stiffness does not negatively influence a practitioner's ability to differentiate stiffness levels, and the use of a wider range of forces may increase reliability.

The Direction of Force During Mobilization: 

The direction of force and angle of inclination have a significant effect on stiffness, including vertical loads resulting in less stiffness than horizontal loads, vertical inclination reducing stiffness when compared to "pure" vertical loads, and a practitioner bias toward caudal inclination in the lumbar spine and cranial inclination in the cervical spine.

The anatomy of the joint and adjacent/supporting structures has a significant effect on joint stiffness, but cannot completely account for the variability between joints or individuals.

Position of the Spine, Pelvis, and Rib Cage: 

Lumbar spine stiffness during PA mobilization increases with increased flexion, extension, and/or a posterior pelvic tilt, when the pelvis or ribs are "fixed", and during forced inspiration or expiration.

Participant's Physical Characteristics: 

Being male, being older, having a higher body mass index, and/or being heavier, may be correlated with increased joint stiffness.

Muscle Activity, Fascia, and Joint Stiffness:

 This study suggests that extensor activity may alter lumbar spine stiffness, and have implications for practitioners treating lumbar dysfunction, especially acute low back pain.

Currently available research does not suggest that a single grip or hand position results in superior outcomes. However, research does suggest that different hand positions and grips result in differences in force characteristics, force may be influenced by thumb pain, and there may be a correlation between contact area and the ability to discriminate stiffness. Based on these findings it may be recommended that a consistent hand configuration with sufficient contact area, that minimizes thumb stress, should be developed with the intent to optimize reliability and accuracy.

 Research implies that differences in mean force when comparing men and women are exhibited in force characteristics requiring the most strength from the practitioner, specifically initial force, peak force, and rate of force development. No difference was demonstrated for most force characteristics including mean force, oscillation speed, differentiation between grades, and further, women may exhibit less variability. It is unlikely that any of the differences demonstrated have any significant effect on patient outcomes.

 Students and experienced clinicians exhibit similar accuracy of perception of error, and similar inter-therapist and intra-therapist reliability; however, peak force and rates of force development generally increase with experience.

 Practitioners may significantly and purposefully modify force characteristics by altering intent, speed, direction, posture, and technique.

 Research comparing techniques suggest that a few significant differences may be identified; however, most techniques exhibit similar force characteristics or differences in characteristics that still cluster around a relatively narrow range. The one exception may be techniques using the Activator which results in approximately half the force as other techniques with the same intent. These studies do not imply a superior technique based on outcomes; however, it may be recommended that professionals develop a consistent repertoire of techniques to optimize reliability and accuracy.

Research suggests that various fixation techniques (segmental, locked, and multi-segmental) are likely similarly effective for significantly reducing lateral flexion and rotation of lower segments, without restricting motion of the intended segment.

Additional Variables Affecting Force and Interpretation of Force Data: 

Evaluation of force characteristics should consider visual occlusion, the amount of plinth padding, whether local or global forces were reported, the normal stiffness of the joint being assessed relative to other joints, and whether force was recorded on a cadaver or living participant.

 Mobilization and manipulation, performed on either symptomatic or asymptomatic individuals, may have significant local analgesic effects including changes in thermal pain sensitivity, temporal sensory summation, cutaneous pain (pin-prick) tolerance, and pain pressure threshold. These analgesic effects may not reduce experimentally induced pain or delayed onset muscle soreness (DOMS).

 Some of the analgesic effects resulting from mobilization and manipulation of the spine result in "quasi-distal" changes. That is they are effects that extend beyond the intended segment but only by a few segments above or below.

Research has demonstrated that mobilizations and manipulations have analgesic effects distal from the intended joint, including increased pain pressure threshold, decreased superficial pain sensitivity, and decreased thermal pain sensitivity. This may imply systemic effects, and/or effects that radiate to regions with a neural relationship. The neural relationships demonstrated in the research include cervical techniques affecting the upper extremity, lumbar techniques affecting the lower extremity, and extremity techniques affecting the contralateral extremity.

 Hypoalgesia has been demonstrated for local and distal trigger points following mobilization and manipulation, suggesting that at least some of the analgesic effects of these techniques affect the same mechanisms responsible for increased trigger point sensitivity.

A-fiber versus C-fiber Mediated Analgesia: 

Manipulations have a significant effect on C-fiber mediated pain afferents but not A-fiber mediated pain afferents, in both symptomatic and asymptomatic individuals regardless of participant expectations.

Some research suggests that asymptomatic individuals experience more analgesia than symptomatic individuals, or potentially that symptomatic individuals exhibit larger local analgesic effects than distal analgesic effects, potentially mobilizations have a larger effect on local pain pressure threshold than manipulations, and thoracic manipulations may not have an effect on extremity analgesia. However, it is likely that more research is needed to determine the complex relationship between local and distal analgesic effects, the effect of symptomology, and the effect of different techniques.

Manipulation of the lumbar spine results in a transient (20-60 second) attenuation of the H-reflex for muscles of the ipsilateral innervated extremity in both symptomatic and asymptomatic individuals. Further, the attenuation is not significantly influenced by cutaneous input and occurs regardless of patient position (side-lying or prone).

 A study by Floman et al. demonstrated that lumbar manipulation performed on patients with unilateral L5-S1 disc herniation who exhibited H-reflex latency, responded with a significant improvement in H-reflex latency/threshold on the affected side (90), suggesting a benefit of manipulation may be normalization of stretch reflex for innervated muscles.

 Flexion/extension mobilizations of the spine likely have a similar effect on H-reflex threshold/amplitude as manipulations; however, mobilizations that are predominantly rotation or lateral flexion may not alter H-reflex.

 Manipulation and mobilization result in a transient (approximately 20 minutes) decrease in the H-reflex threshold, an increase in the V-wave amplitude, and no significant effect on the M-wave threshold.

The attenuation of H-reflex is likely dependent on a manipulation achieving a minimum threshold velocity in which muscle spindle velocity sensitivity dominates over length sensitivity; further, H-reflex is likely not influenced by manipulation amplitude or duration.

 Some of the effects of mobilization and manipulation result from cerebellar inhibition, changes to the motor cortex and somatosensory processing, and a reduction in the activation of the "pain matrix", especially the insular cortex. Additionally, manipulation results in some CNS facilitation that may increase descending cortical drive and/or postsynaptic facilitation of 

motorneurons and/or corticomotor neurons.

 Humphries et al. demonstrated that lower cervical manipulation resulted in a slight increase in made free-throw percentage in a group of basketball players (51).

 Although current comparative research is limited to techniques applied to the ankle, these studies imply that manipulation, but not mobilizations, result in corticospinal facilitation and increased maximal motor-evoked potentials.

An RCT by Fryer et al. demonstrated that lumbar manipulation resulted in an increase in H-reflex amplitude, but a small decrease in motor-evoked potentials (93). These findings may suggest that the CNS response to manipulations is primarily mediated by the spinal cord, with less influence from supraspinal structures.

Manipulation does not alter plasma levels of catecholamines, endorphins, norepinephrine, or epinephrine. However, manipulation may increase serotonin, substance P, and neutrophils primed for enhanced endotoxin-stimulated tumor necrosis factor, as well as reduced salivary cortisol (including increasing testosterone/cortisol ratio), and potentially increase plasma levels of KDGPF2a in menstruating women. Further, mobilizations and manipulations have a significant effect on levels of brain metabolites including N-acetyl aspartate, choline, glutamate, and glutamine, however, levels of endogenous opioids may be unaffected.

Mobilizations and manipulations of the spine and extremity joints may increase skin conductance, skin temperature, respiratory rate, and heart rate, in both symptomatic and asymptomatic individuals. Further, in symptomatic individuals, these sympatho-excitatory effects occur in conjunction with improvements in patient outcome measures including pain, range of motion (ROM), and muscle recruitment.

: Mobilizations and manipulations may result in larger sympatho-excitatory effects than therapeutic exercise, mobilizations may result in larger changes than traction techniques, higher-velocity mobilizations and manipulations may result in larger effects, and cervical and lower lumbar manipulations may result in different sympatho-excitatory effects than upper lumbar and thoracic manipulations.

Mobilizations and manipulations of the spine result in transient changes in blood pressure, heart rate, and respiratory rate, without affecting O2 saturation. It may be noteworthy that transient alterations in blood pressure may include increases, decreases, changes to systolic pressure only, or changes of both systolic and diastolic blood pressure.

 Research suggests that thoracic manipulations and mobilizations may not consistently result in sympatho-excitatory effects, regardless of the technique or speed of oscillation; however, the majority of the studies resulting in contradictory findings were performed with asymptomatic participants.

 Sympatho-excitatory effects may be anticipated following both mobilization and manipulation techniques, cervical and thoracic techniques may result in opposite effects, symptomatic individuals may exhibit larger changes than asymptomatic individuals, and these effects are only influenced by patient stress when stress results in high levels of catastrophizing during manipulation techniques.

 Research suggests that the sympatho-excitatory effects following mobilization and manipulation are transient, and do not have a therapeutic benefit relevant to the treatment of high blood pressure.

 Cervical and thoracic spine mobilizations/manipulations may have a significant effect on cervical muscle activity and endurance, but do not have an effect on masticatory muscle activity or extensibility.

 Thoracic mobilizations and manipulations may have an immediate effect on 

 Thoracic mobilizations and lumbar mobilizations are likely to result in a reduction in extensor muscle activity; although, asymptomatic individuals may not exhibit a change in 

 activity. Lumbar manipulations are likely to decrease 

 thickness is correlated with a decrease in disability.

 Lumbosacral mobilizations and manipulations likely have a transient effect on 

 thickness and a positive effect on activity during functional tasks. However, changes in activity may vary depending on the muscle. Further, lumbosacral manipulation and mobilization may not affect core muscle thickness or activity in asymptomatic individuals or individuals exhibiting signs of instability.

 Studies suggest that lumbar spine pain/dysfunction can inhibit 

 performance, and lumbar mobilizations may be an effective treatment, resulting in an immediate increase in 

 strength with carry-over to functional tasks.

 Lumbosacral manipulations have a significant effect on pelvic floor activity; however, whether activity increases or decreases are likely dependent on the muscle tested, and whether maladaptive over-activity or under-activity was present prior to manipulation.

 Lumbosacral joint mobilizations may decrease hamstring activity and increase hamstring extensibility for both symptomatic and asymptomatic individuals.

 Lumbosacral mobilizations can have a significant effect on 

 strength in asymptomatic individuals and individuals exhibiting signs of dysfunction; however, in asymptomatic individuals, these effects may not transfer to functional tasks. Conversely, SIJ manipulations (and lumbar mobilizations) may have a larger effect on 

 torque and activity than lumbar manipulations, and/or lumbosacral manipulation may only result in transient increases in 

 Hip mobilization alone may have a significant effect on 

 Shoulder mobilizations have a significant effect on muscle activity during the intervention; however, the effects on muscle activity may not persist.

 Knee mobilizations have a significant and lasting effect on 

 activity, in both symptomatic and asymptomatic individuals.

Only one study was found investigating the effect of ankle mobilization on ankle muscle activity and strength. An RCT by Ersoy et al. demonstrated that grade III ankle mobilizations performed on asymptomatic individuals resulted in a significant increase in dorsiflexor muscle strength for at least 30 minutes when compared to sham control (grade I mobilizations) (63).

 Cervical and thoracic manipulations may have a significant effect on scapula and shoulder muscle activity, and may improve pain-free grip strength of patients with lateral epicondylalgia. Additionally, thoracic and lumbosacral manipulations performed on either symptomatic or asymptomatic individuals are likely to result in at least short-term improvements in lower extremity muscle activity, extensibility, and strength.

A reflexive increase in core muscle activity may be expected during manipulations of the spine, the amount of increase in activity may be correlated with the rate of force development, and dysfunction/pain may reduce or inhibit these reflexive responses.

Symptomatic individuals may exhibit larger changes in stiffness and resting muscle activity post manipulation; however, they may also exhibit inhibited or delayed reflexive responses during manipulation.

Mobilization and manipulations, performed alone or integrated into a rehabilitation program, can have a significant effect on muscle activity, thickness, and strength, and these changes may be correlated with improvements in patient outcomes, both short-term and long-term. Additionally, research has demonstrated that the addition of mobilizations and manipulations to an intervention plan is likely to improve outcomes.

 Mobilizations and manipulations, or the addition of mobilizations and manipulations to an intervention plan, may improve joint position sense or improve the threshold to detect joint motion. Additionally, mobilizations and manipulations may contribute to better long-term improvements in balance; however, immediate effects on balance are likely to be small or insignificant unless combined with exercise.

 Thoracic manipulations (and potentially cervical manipulations) performed on healthy individuals may increase maximal respiratory values, but have little or no effect on resting pulmonary function. However, manipulations may improve resting pulmonary values for individuals exhibiting compromised pulmonary function.

Research Summary

A new myth has been trending suggesting the effects of joint manipulations and mobilizations are nothing more than placebo. This myth likely started from an assumption that studies investigating some of the transient neurophysiological effects following mobilizations and manipulations were representative of all the effects, including the false presumption that decreases in pain were transient. This myth has gained momentum despite the publication of dozens, and possibly hundreds, of peer-reviewed randomized placebo-controlled trials (RCTs), which is the study design developed to account for placebo effects. Many of these RCTs are discussed in this review; however, this section covers a few selected studies with methodological designs that account for additional confounding variables that further decrease the likelihood of the effects of manipulations and mobilizations being attributable to placebo.

Two studies investigating the effects of mobilizations and manipulations recorded patient stress, a potential contributor to nocebo effects. Vicenzino et al. demonstrated that cervical lateral glide mobilizations performed on asymptomatic individuals resulted in sympathoexcitatory effects, and there was no correlation between the magnitude of effects and the level of stress or pain reported by the participant. This includes similar sympathoexcitatory effects from session to session, despite stress decreasing from session to session (187). An RCT by Alonso-Perez compared cervical manipulations, cervical mobilizations, and cervical lateral glide mobilizations, demonstrating that all techniques decreased pain pressure sensitivity at the cervical spine and elbow, mobilizations resulted in larger decreases in pain pressure sensitivity than manipulation, and catastrophizing by the patient only significantly reduced the effectiveness of manipulations when the levels of stress were high (no significant effects were demonstrated for low and moderate levels) (186). These studies demonstrate that patient stress is unlikely to have an effect on sympathoexcitatory or analgesic effects, with the exception of attempting high-velocity manipulations on patients who exhibit a high level of stress.

Effect of Patient Education and Messaging (Nocebo Control Trials)

Recent studies investigating the effects of patient education and messaging on outcomes following mobilizations and manipulations add nocebo groups to several placebo-control RCTs. An RCT by Bialosky et al. demonstrated that messaging designed to result in negative expectations preceding lumbar manipulation had no effect on local and ipsilateral lower extremity C-fiber mediated cutaneous hypoalgesia; however, the messaging did have an effect on subjective reports of lumbar pain following treatment (99). Riley et al. demonstrated that education regarding the positive effects of manipulations received prior to treatment of shoulder pain with a combination of thoracic manipulation and home exercise, significantly improved the patient's perception of treatment; however, improvements in pain and disability were similar for groups that did not receive education (257). An RCT by Niemistö et al. demonstrated that the treatment of chronic low back pain with mobilizations and stabilization exercise resulted in larger improvements in pain and disability than a combination of physician advice and an education booklet during 5- and 12-month follow-ups (258). Another RCT by Niemisto et al. with 1-year follow-up demonstrated major recovery of 60% of patients receiving a combination of mobilizations, exercise, and physician consultation/education, compared to 51% of patients in a group that received similar treatment without mobilizations. Despite this study demonstrating psychosocial issues having a strong correlation with failure to recover, the study clearly demonstrates that the addition of mobilizations resulted in significantly better outcomes (259). In summary, these studies demonstrate that messaging, education, and expectations may have an impact on immediate measures of subjective pain and patient satisfaction scores, but is unlikely to have any effect on objective measures or long-term patient outcomes. Further, adding mobilization and manipulation techniques to an integrated intervention including education is likely to result in further improvements in patient outcomes.

Randomized Placebo-Controlled (and More) Trials

Several studies include placebo-control groups, as well as additional experimentation that may account for confounding variables that could be attributed to placebo-like effects. An RCT by George et al. demonstrated that lumbar manipulation performed on asymptomatic individuals altered C-fiber afferent activity but not A-fiber afferent activity. Further, this study also compared the experimental group to a cycling group to demonstrate that the hypoalgesia was not correlated with physiological changes (98). A similar RCT by Bialosky et al. demonstrated that lumbar manipulation had a significant effect on temporal summation of thermal pain (c-fiber mediated afferents). Additionally, the experimental group was compared to groups performing stationary cycling and lumbar extension exercise, and neither group exhibited the same alterations (110). These studies clearly demonstrate altered c-fiber mediated analgesia when compared to placebo control, and further account for the confounding variables of motion, exercise, and changes in physiology associated with cardiovascular exercise. It may also be worth noting that there is no record of placebo resulting in selective alteration of C-fiber mediated afferents, without an effect on A-fiber mediated afferents.

Additional studies demonstrate that mobilizations and manipulations have a significant effect on H-reflex (stretch reflex), and several of these studies account for additional confounding variables. Dishman et al. demonstrated that lumbar manipulation had a larger effect on the attenuation of 

 H-reflex than the side-lying loaded position used during set-up (117). And, a more recent RCT by Dishman et al. demonstrated similar findings, noting high-velocity lumbar rotation manipulation resulted in significant attenuation of H-reflex compared to side-positioning and loaded side-positioning, and further that the attenuation was similar for both symptomatic and asymptomatic individuals (118). An RCT by Murphy et al. demonstrated that sacroiliac joint manipulation resulted in a significant attenuation of H-reflex of the ipsilateral leg, had no effect on the H-reflex of the contralateral leg, and sham intervention had no effect on either leg. Further, the study was repeated with anesthetic cream over the SIJ to determine if the decrease in H-reflex was related to cutaneous afferent stimulation, and the findings were similar, suggesting that H-reflex attenuation was not the result of cutaneous input (120). In summary, the H-reflex attenuation following lumbosacral manipulation is significantly larger than placebo, and cannot be attributed to patient positioning, loaded patient positioning, or cutaneous input. Further, there is no evidence that a placebo could result in unilateral changes in reflex activity.

Finally, an RCT by Kamel et al. demonstrated that postpartum females with low back pain receiving lumbar mobilizations, infrared and ultrasound, 3 sessions/week for 4 weeks, exhibited a larger reduction in pain, increase in function, and reduction in 

 resting EMG activity when compared to infrared and ultrasound alone or in combination with "placebo mobilization" (237). This study clearly demonstrates that lumbar mobilization is more effective than placebo, even when mobilization is added to an integrated intervention plan.

Myth Busting: The Effects are Not Placebo

Cervical Spine

Lumbar Spine

Shoulder

Movement of Adjacent Segments

Effect on Structures

Kinematics: Joint Motion During Mobilizations and Manipulations

Mechanical Factors Affecting Joint Stiffness

Anatomical Factors Affecting Joint Stiffness

Kinematics: Factors Affecting Joint Stiffness

Practitioner Factors

Technique Factors

Kinematics: Factors Affecting Force During Mobilizations and Manipulations

Analgesia

H-reflex, M-wave and V-wave Response

Sympatho-excitatory Effects

Nervous System

Muscle Activity: Spine

Muscle Activity: Extremities

Muscle Activity: Additional Considerations

Muscle Activity

Anderst, W. J., Gale, T., LeVasseur, C., Raj, S., Gongaware, K., & Schneider, M. (2018). Intervertebral kinematics of the cervical spine before, during, and after high-velocity low-amplitude manipulation. 

Dugailly, P. M., Sobczak, S., Sholukha, V., Jan, S. V. S., Salvia, P., Feipel, V., & Rooze, M. (2010). In vitro 3D-kinematics of the upper cervical spine: helical axis and simulation for axial rotation and flexion extension. Surgical and radiologic anatomy, 32(2), 141-151.

Dugailly, P. M., Sobczak, S., Moiseev, F., Sholukha, V., Salvia, P., Feipel, V., ... & Jan, S. V. S. (2011). Musculoskeletal modeling of the suboccipital spine: kinematics analysis, muscle lengths, and muscle moment arms during axial rotation and flexion extension. 

Dugailly, P. M., Bonnechère, B., Maroye, L., Van Geyt, B., Salvia, P., & Feipel, V. (2013). Kinematics analysis and helical axis computation during high velocity-low amplitude cervical spine manipulation: a preliminary study. 

Dugailly, P. M., Beyer, B., Sobczak, S., Salvia, P., & Feipel, V. (2014). Global and regional kinematics of the cervical spine during upper cervical spine manipulation: a reliability analysis of 3D motion data. 

Williams, J. M., & Cuesta-Vargas, A. I. (2013). An investigation into the kinematics of 2 cervical manipulation techniques. Journal of manipulative and physiological therapeutics, 36(1), 20-26.

Manipulation results in less ROM than Active ROM

Van Geyt, B., Dugailly, P. M., Klein, P., Lepers, Y., Beyer, B., & Feipel, V. (2017). Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise. 

Liguo, Z., Minshan, F., Xunlu, Y., Shangquan, W., & Jie, Y. (2017). Kinematics Analysis of Cervical Rotation-Traction Manipulation Measured by a Motion Capture System. 

Evidence-Based Complementary and Alternative Medicine

Effects of Joint Mobilizations and Manipulations

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