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.

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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

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


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