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What is Manual Therapy, Part 4

This is the final chapter of the What is Manual Therapy series. Today we are going to talk about manipulation. What it is, why it is used and when it should not be used.


A manipulation is known by many different names; an adjustment, grade V mobilization or a high velocity low amplitude (HVLA) thrust (short, fast thrust).

A manipulation is a technique that is similar to a mobilization but there is an important aspect that is different. A manipulation of a joint is performed in the same joint positions, in which a mobilization is done. The big difference between and mobilization and manipulation is that the manipulation is done under the physiotherapists control. A manipulation can be viewed as a more dangerous technique as there is a lot more force being put into/through the client's joints. The speed of the technique could also be seen as a potential danger factor because the technique is applied so fast to the client, they do not have a chance to reacted until after it is over. In my mind, manipulations are a very useful technique to use but it must be used with caution.

The gif to the left called Seated Thoracic spine manipulation to see a quick video of what a manipulation could look like.

When performing a manipulation, the stuck joint, possibly facet joint in the spine, is taken to the end point and held for a couple of seconds and then taken out of that position. This is called the pre-manipulation hold (other tests should be done before manipulating a joint, not just that test). If the pre-manipulation hold is alright with the client, it should be almost uncomfortably tight, the client’s stiff joint is put back into that position and a high velocity, low amplitude thrust is applied. Sometimes there is a little ‘pop’ felt in the joint. The ‘pop’ sound/sensation is known as cavitation. Some people feel if cavitation did not occur then the manipulation did not work. There are numerous studies in the scientific literature that show this is plainly wrong. Manipulations do work, even without the ‘pop’ as long as the manipulation as performed correctly. What seems to be the most important aspect is the quick, short thrust performed. We are not sure why, perhaps it is the quick stretch on muscles that cause the muscles to relax and let the joint open up?

After a manipulation, the practitioner should recheck the joint mobility and possibly the joint stability. If there is a single joint that always feels as if it is getting stuck it might be an issue of a joint that moves too much and gets stuck at the end of the range of motion. A manipulation can free the joint from being stuck but does not solve the larger issue. This is where exercise comes in to help stabilize the joint, to not let the bones move so far as to get ‘stuck’ again. Normally, these exercises are not very exciting, so many people stop doing them after a week or so. In reality, most people should be doing the exercises for 6-8 weeks, possibly longer.

When should you NOT manipulate (adjust) a joint? In the case of a possible fracture, any type of septic arthritis in the joint, recent trauma to the joint, any joint that is red, hot and swollen, anytime the pre-manipulation hold brings on distal symptoms (for example, going into a pre-manipulation hold and the clients leg goes numb) and many other reasons.

I hope you found this blog series interesting about what manual therapy is and the some of the different manual therapy techniques used by physiotherapists to help their clients.

If you have any questions, contact New Leaf Physiotherapy, a mobile Kelowna physio clinic.

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