Manipulative Physiotherapy

What is the Difference Between Manual Therapy and Joint Manipulation?

What is Manual Therapy?
Manual therapy is a method of assessment and treatment that is commonly used by trained musculoskeletal Registered Physiotherapists. It aims to quickly reduce pain and improve movement1 and is clinically and cost effective2. Manual therapy treatment can include techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints.

What are the effects of Manual Therapy?
Manual therapy rapidly reduces pain and muscle spasm and helps with movement. Additionally, manual therapy can help you use muscles that are not working due to the pain and this can help with your exercises.3 The effects of treatment can be short lived and it is important that you regularly undertake stretches and exercises, given to you by your Registered Physiotherapist, which will work well with the manual therapy treatment.

What is the effectiveness of Manual Therapy?
Manual therapy is effective in treating neck and back pain and is recommended in national and international treatment guidelines.4 The majority of patients with spinal pain can expect to see a reduction in pain and improvement in function following a course of manual therapy.

What are the risks of Manual Therapy?
The commonest adverse reaction to manual therapy is some post-treatment soreness, which can last a day or two.5 This is a normal, temporary response to having a stiff area of the spine stretched or weak muscles exercised.

What about quick manipulative thrust techniques of the neck?
Manipulative thrust techniques involve gapping joint surfaces to effectively reduce joint stiffness, muscle spasm and pain1. There are very rare cases of patients having serious adverse events, including stroke and death, following these techniques.6 These events are associated with damage to the arteries running through the neck. The ‘average’ risk of such events is estimated to be approximately 1.3 in 100,000 patients.6,7 Although it is difficult to be absolutely certain about your personal risk of a serious adverse event, your Registered Physiotherapist is able to use current evidence as a guide to make the best possible judgement for you, given your presenting features.8,9

What can be done to minimise risk and optimise benefit?
Your Registered Physiotherapist will be trained in Manual Therapy and will ask you a series of questions, before moving your neck, to consider if manual therapy is indicated and to consider if your risk of having a serious adverse event is higher than average.9 Techniques will be selected that minimise the risks to the neck arteries and optimise the effects of treatment. Manipulative thrusts will only be undertaken after a thorough discussion of these issues and after gaining your consent for the technique.

What are the alternatives to manipulative thrust techniques?
Similar levels of improvement can be obtained with slow speed “mobilisation” movements and specific exercises of the neck.10 These techniques have not been found to cause serious damage to the arteries of the neck. Your Registered Physiotherapist will discuss your treatment preferences before commencing treatment.

At Posture Plus we have several physiotherapists who have been trained to perform manipulations.

Ms. Milly Yu, Masters in Manipulation, Hong Kong University
Ms. Aime Moriarty, Manual Therapy Spinal Evaluation and Manipulation, University of St.Augustine, USA
Ms. Helen Real, Masters in Advanced Physiotherapy and member of MACP, King’s College London
Mr. Kenneth Yuen, Master of Physiotherapy (Manipulative), Queensland, Australia


  1. Herzog W. (2010) The Biomechanics of Spinal Manipulation. Journal of Bodyworks and Movement Therapies. 14:280-286.
  2. Michaleff A.Z., Lin C.-W.C.,Maher C.G., van Tulder M.W. (2012) Spinal Manipulation Epidemiology: Systematic Review of Cost Effectiveness Studies. Journal of Electromyography and Kinesiology. 22:655-662.
  3. Haavik H., Murphy B. (2012) The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control. Journal of Electromyography and Kinesiology. 22:768-77.
  4. Carragee E.J, van der Velde, et al., Carroll L.J. et al., (2009) Treatment Of Neck Pain: Noninvasive Interventions. Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of Manipulative and Physiological Therapeutics. 32:S141-S175.
  5. Carnes D., Thomas S, Mars T.S., Mullinger B., Froud R, Underwood M. (2010) Adverse events and manual therapy: A systematic review. 
Manual Therapy.15: 355–363.
  6. Miley M.L., Wellik K.E., Wingerchuk D.M., Demaerschalk B.M. (2008) Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist. 14:1, 66-73.
  7. Cassidy J.D., Boyle E., Côté P., He Y., Hogg-Johnson S., Silver F.L., Bondy S.L.(2008) Risk of Vertebrobasilar Stroke and Chiropractic Care. Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 33:4S. S176-S183.
  8. Kerry R., Taylor A.J., Mitchell J., McCarthy C., Brew, J. (2008) Manual Therapy and Cervical Arterial Dysfunction, Directions for the Future: A Clinical Perspective. The Journal of Manual & Manipulative Therapy. 16:1. 39-48.
  9. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. (2012) International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention. International Federation of Orthopaedic Manipulative Physical Therapists. Documentation available at
  10. Leaver A.M., Maher, C.G., Herbert, R.D., Latimer, J. McAuley, J.H., Jull, G., Refshauge, K.M. (2010) A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain. Archives Physical Medicine and Rehabilitation. 91:1313-8.

Provided by the Musculoskeletal Association of Chartered Physiotherapists (MACP)

The Musculoskeletal Association of Chartered Physiotherapists (MACP) is a group of over 1,100 physiotherapists, who are members of the Chartered Society of Physiotherapy, UK. In addition to their undergraduate training they have all undertaken extensive postgraduate study and reached a recognised standard of excellence in musculoskeletal physiotherapy. To obtain membership of the MACP clinicians have to complete a recognised postgraduate course of study, many of which are at a Master of Science level. MACP members will have ‘MMACP’ after their name.For further information:,,

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