Spine J. 2001 (Mar); 1 (2): 121–130 ~ FULL TEXT
John J. Triano, DC, PhD
Texas Back Institute,
6300 W. Parker Road,
Plano, TX 75093, USA.
BACKGROUND CONTEXT: Modern scientific investigations into spinal manipulative therapy (SMT) began in 1975. Conditions often treated include acute and chronic low back pain, radicular pain, neck pain, and some forms of headache. The field of spinal manipulation has often been treated by the literature, incorrectly, as being homogeneous. Much of the confusion regarding this form of treatment can be traced to the ambiguity surrounding the procedures themselves. This report summarizes the clinical biomechanics of SMT and evidence for its associated manipulable lesion is reviewed. Finally, a classification system based on biomechanics is proposed that may facilitate more detailed research in the future.
PURPOSE: A categorization system for SMT was sought that would be more objective than is clinically available. Such a system may serve as a means to strengthen future studies, determine operating principles, applicability, treatment effectiveness, and nature of the manipulable lesion.
STUDY DESIGN: Literature synthesis.
METHODS: A search of the indexed biomechanical and medical literature as well as a hand search of published works was conducted. The criteria for article selection consisted of studies that included measurements of mechanical characteristics of treatment techniques used under the general headings of SMT or manual therapy. A second set of studies was identified that explored the biomechanics of buckling behavior of vertebral segments as a model of the manipulable lesion. Quantitative characteristics of SMT were extracted and grouped to form a basis for classification.
RESULTS: A total of 31 articles were identified that contained quantitative data on the biomechanical properties of SMT methods. An additional seven studies were found that quantified spinal buckling behavior. Common features of SMT procedures lead to a matrix that biomechanically characterizes the types of procedures in use. Buckling behavior was compared qualitatively with clinical observations to form a plausible and evidence-based hypothesis of the manipulable lesion.
CONCLUSIONS: There currently are a number of named systems of manual procedures. No current triage system is available that predicts which patient has the greater likelihood of benefiting from manual treatment or the procedure type. The biomechanical parameters of SMT form a systematic characterization of manual procedures. Such a system may be used in future studies to test hypotheses of treatment effect from quantitatively defined procedures.
Keywords: Spinal manipulation; Mobilization; Continuous passive motion; Manipulable lesion; Functional spinal lesion;
From the FULL TEXT Article:
Manipulation of the spine has ancient roots and popularity
that has varied over time. From the late nineteenth
through the twentieth century, its use has been embroiled as
a part of interprofessional medical controversies.  Modern
scientific investigations in this area began with a federally
supported conference in 1975.  For over two decades,
the scientific debate over the value of manipulation
in the treatment of spine-related disorders has been engaged.
Anecdote and opinion are slowly yielding to a preponderance
of evidence accumulated through basic science
and clinical studies. At the moment (as of 2000), over 50 randomized
controlled trials of spinal manipulative therapy (SMT) have
been conducted. Modern, evidence-based guidelines and
formal consensus documents on appropriate treatments list
manipulation as a recommended or optional approach. Conditions
where manipulation is offered include acute and
chronic low back pain [3, 4], radicular pain , neck pain [6–8], and some forms of headache.  Manipulation is being
offered to an increasingly broad case–mix, including
the elderly and postsurgical patients. Debate continues on
the relative effect strength and the appropriate indications
for use of this form of care. Do we have sufficient information
on SMT to move forward in understanding its operating
principles, applicability, and possible risk?
Much of the current confusion regarding the use and effectiveness
of SMT can be traced to the ambiguity surrounding
the treatment procedures themselves. Few of the
published reports provide a clear, objective description of
the manipulation techniques used, the identity of those administering
the procedures, or a means of assessing the skill
of the manipulators.  The field of spinal manipulation has
often been treated by the literature, incorrectly, as being homogeneous.
A few authors have attempted to segregate the
procedures selected for study by using such categorical
names as Maitland, Gonstead, or diversified methods. Such
classification, cumbersome in like manner to the naming of
some new surgical techniques, fails to clarify the nature of
the treatment intervention. It introduces confusion by preventing
experimental methodology to be replicated easily
for future study. A small number of publications (e.g., [10, 11]) have attempted to provide a more scientifically
based description focusing on the perception of differences,
velocity, and depth of local tissue displacement achieved by
Quantification of procedural differences in SMT, for the
most frequently used forms, has begun to appear. Thus far,
no systematic effort has been undertaken to organize this
new information into clinically meaningful categories that
may serve to clarify procedure descriptions in future manipulation
research. Concise categories could improve quality
of outcomes from care by empowering research into subpopulations
that may receive more favorable benefit from
specific types of procedures than others. This report summarizes
the state of the art in clinical biomechanics of spinal
manipulation. Based on clinical and laboratory evidence,
the pathomechanics of the manipulable lesion are reviewed,
a classification system based on biomechanical principles is
proposed, and the substantive literature reviewed.
This work sought to consolidate more recent biomechanical
information that might serve as a model of the manipulable
lesion and to characterize quantitatively SMT. A
search of the indexed biomechanical and medical literature
as well as a hand search of published works was conducted.
The criteria for article selection consisted of studies that included
measurements of mechanical characteristics of treatment
techniques used under the general headings of SMT or
manual therapy. A second set of studies was identified that
explored the biomechanics of buckling behavior of vertebral
segments as a model of the manipulable lesion. Quantitative
characteristics of SMT were extracted and grouped to
form a basis for classification.
A total of 31 articles were identified that contained quantitative
data on the biomechanical properties of SMT methods.
An additional seven works were found that quantified spinal
buckling behavior. Common features of SMT procedures
lead to a matrix that biomechanically characterizes the types
of procedures in use. Buckling behavior was compared
qualitatively with clinical observations to form a plausible
and evidence-based hypothesis of the manipulable lesion.
Rationale of the treatment construct
Understanding the rationale behind any treatment approach
requires knowledge of its underlying assumptions
and supportive evidence. Spinal manipulation is thought to
act on a manipulable lesion (often called a functional spinal
lesion [FSL] or subluxation) that itself is conformable to
specific forces and moments in such a way that the internal
mechanical stresses that generate symptoms are reduced.  The ability to sustain these effects is supported by case
management that promotes healing of nociceptive pain generators
and promotes return to normal activity. Classic clinical
management steps include a temporary reduction of spinal
joint loads during daily activity, attention to comorbid
conditions that may affect the body’s capacity to accommodate
or to repair, and systematic use of exercise to restore
the pre-injury distribution of loads through the tissues.
Given the historical presumption of the FSL, it is somewhat
surprising that there is not more information on its
pathomechanical properties. The state of art with respect to
the FSL is analogous to that of diabetes mellitus in the early
twentieth century. General clinical characteristics were
known, but the nature of the pathology remained a mystery,
waiting further technological development. Over the past
two decades, biomechanical and physiological studies have
yielded supportive information. However, a pathognomonic
diagnostic presentation remains elusive, requiring a successful
trial of therapy to confirm its presence. Clinicians view
the FSL as a set of individual disorders responsible for the
patient’s symptoms [12, 13] or as a comorbid condition in
common with classical pathoanatomical lesions (Table 1).
A brief review of modern theory provides the context in
which spinal manipulation is currently used. The concepts
of functional lesions of the spine are similar to that regarding
the occurrence of compressive buckling injury to the
wrist. [14–16] The functional spinal unit (FSU) fits the biomechanical
criteria for a multimuscular, biarticular chain
that may be subject to “zigzag” collapse [16, 17] or buckling.
Localized joint buckling of the spine is opposed only
by adequate timing in the recruitment of attached muscles
appropriate to a biomechanical task at hand. The FSL begins
with a mechanical overload (Figure 1) as either a single
traumatic or cumulative event. Experiments in vitro have
produced these effects under conditions where a single FSU
is incrementally loaded at the balance point. [18–21] When
a critical buckling load is reached, the linear force-displacement
behavior is interrupted by a disproportionately large
displacement. The total distance, however, remains within
the normal intersegmental range. That is, when buckling occurs,
the affected area of the spine reaches its maximum
range under lower load conditions and is operating at its extreme,
out of phase with the demands of the task. It is assumed
that such a functional configuration may result in altered
stress distribution within the FSU. 
Mechanical irritation to the tissues in and around the spinal
joints results in neurogenic or nonneurogenic pain. [22, 23]
Neuroactive chemicals (e.g., substance P, 11-amino
neuropeptides) may generate inflammatory response. Vasoactive
byproducts of tissue damage (bradykinin, serotonin,
histamine, prostaglandins, and potassium ions) may trigger
nerve-ending sensitivity and reduced response threshold.
Mechanically, the motion segment behavior also is affected.
Individual structural elements (disc, facet, ligament, nerve,
muscle) may experience concentration of local stresses with
reduced functional limits and symptom production specific
to the tissue affected. The result is a state of dysfunction [24, 25]
that leads to local inflammatory or biomechanical
changes. If neural elements become inflamed or compromised,
then remote symptoms may also appear. Consequently,
the clinical presentation may be multifaceted and
Spinal manipulation uses controlled forces and moments
applied to the spine along with inertial forces generated by
acceleration of relevant body segment mass. The algebraic
sum of these loads are transmitted to the spine in a controlled
manner and are designed to “unbuckle” motion segments
and reduce local mechanical stresses within the functional
spinal unit. [26–28]
Functional spinal lesions (FSL)
Biomechanical studies from cadaver spines, computer
simulations, and in vivo experiments give support to the
concepts of the FSL. Wilder et al. [19–21] were among the
first to demonstrate buckling behavior in isolated motion
segments, depending on the load application point, load
vector, load rate, and load magnitude.  Similar results
have been shown to occur for the lumbar region as a whole
with extreme displacements at all levels under the correct
loading conditions.  In the case of regional spine function,
Crisco et al.  also demonstrated buckling behavior.
Moreover, damage to the L5–S1 disc resulted in the ability
to create a buckled condition earlier, reaching maximum
displacement of each segment at much lower total loads.
Cholewicki and McGill  captured the occurrence of a
painful buckling event while using videofluoroscopy to
monitor lumbar spine kinematics during heavyweight lifting
in a young volunteer.
The conditions that can accelerate spinal buckling resemble
common circumstances reported by patients at the onset
of their pain. It may arise from a single overload event or
from prolonged static posture followed by a small increment
in load. Overload events that result in buckling may be
rate dependent, requiring about 500 pounds per second.
Exposure to vibration, a known risk factor for back disorder,
also enhances FSU buckling.  As mentioned earlier,
previous disc injury may facilitate the buckling event.
Types of spinal manipulative therapy
The core concept of SMT is the application of controlled
load vectors to the spine in effort to restore normal behavior
and reduce  harmful mechanical stresses to the local tissues.
The target lesion is identified through use of provocative
maneuvers that reproduce the patient’s symptoms. The
procedure selection is accomplished by matching the results
of testing with consideration of comorbid factors, including
patient age, stature, degenerative state, and pathology. Table
2 lists treatment options grouped by common biomechanical
characteristics that lend themselves to quantification and scientific
description. This new basis of classification involves
quantifiable characteristics, including whether the procedure
is applied manually, the type and the frequency of load
application, and amplitude of displacement.
Quantifying manipulation forces and moments can be
technically challenging. The total loads acting on the spine
are the sum of applied treatment loads, inertial loads from
accelerating the body segment mass, and the internal muscular
tensions that may arise. Two experimental approaches
have been taken. Direct load measurements use sensors imposed
between the hand of the operator and the patient’s
body. They have the advantage of providing the amplitude
of force acting in a direction perpendicular to the surface.
Their disadvantage is that they do not include estimates of
the applied moments or knowledge with respect to the direction
of the applied loads. The second method consists of
an inverse dynamics approach that monitors body segment
motions and the resulting forces and moments that pass
through the body during the treatment procedure. Myoelectric
activities, simultaneously recorded, permit an estimate
of internally developed tensions from muscle activity.
Loads acting on the spine are then calculated. The advantage
of inverse dynamics is that it provides estimates of the
moments and gives the directions of loads. The disadvantage
is a sacrifice in accuracy of the estimated load amplitudes,
particularly for moments.
Figure 2 shows typical forces and moments passing through
the lumbosacral region during continuous passive motion of
the lumbar spine from a study of six volunteers (unpublished
data). With the patient prone on a continuous passive
motion (CPM) treatment table (Leader Health Technologies,
Inc., Port Orchard, WA), the lower body was set in periodic
motion at a rate of 0.224 Hz. An inverse dynamics
model published previously [27, 28] was used to estimate
the loads transmitted through the lumbar spine. The primary
effect is an intermittent traction load ranging from a minor
compressive force of 17.2 N to a maximum distraction force
of 144.5 N. A small secondary flexion moment (10.1 Nm)
was induced. Increasing the speed of CPM to 0.5 Hz increases
the axial loads by 10% and the flexion moment by
30%. Separate fluoroscopic monitoring of spine motion
demonstrates flexion of four degrees (Figure 3). Complex
loads from altering the direction of motion, including extension
and lateral bending, remain to be quantified.
Seated continuous passive motion (B>CPM also has been studied.  Small alternating rotational motions were imposed over a 0.6–degree
range at a rate of 12.5 seconds per cycle by a motorized seat
pan with a moment of 23.1 Nmm. Patients reported reduction
of back pain. The authors concluded that minor stimulation
is sufficient to mobilize the lumbar spine. In separate
work the effects on sitting comfort were studied by Reinecke
et al.  They evaluated the effects of cyclical posteroanterior
pressure to the lumbar spine, alternately increasing
and decreasing the lumbar lordosis.
Mobilization procedures differ from CPM by nature of
the method by which movement is imposed. While CPM
generally uses a treatment table powered mechanically or
manually, mobilization manually applies loads to the local
spinal tissues. The displacements resulting from forces of
150 N cycling between 0.5 and 2.0 Hz have been studied.
Effects are discussed separately under the section on vertebral
Most studies have been conducted with respect to high-velocity,
low-amplitude (HVLA) methods. By direct measurement
and inverse dynamics methods, the uniaxial forces
applied to the patient from simple procedures have been determined. [33, 37–45 Peak amplitudes have ranged widely
(41–889 N) depending on the spinal regions treated. Applied
forces rise quickly with slopes ranging between 519
N/s and — 2907 N/s.
Complex HVLA procedures have been studied by Triano  and Triano and Schultz  in both the cervical and
lumbar regions. The assumption of symmetry in treatment
delivery was studied by randomly applying 35 procedures
to the C2 vertebral segment from the left and 31 from the
right. Differences in mean forces and moments were insignificant,
ranging from 1% to 16%. Their findings of mean
peak forces at 111 N and 123 N reported for left- and right-sided
maneuvers were similar to those of Kawchuk.  As
a first effort to test ability to control amplitude, operators
were randomly instructed to perform procedures with maximal
permissible effort or with minimally effective effort,
based on clinical judgment. Mean amplitudes stratified in
this way were significantly different (.0000 < P < .0294). Table
3 gives the mean and standard deviation for transmitted
Manipulation control strategies were evaluated further in
the lumbar spine by contrasting the differences in loads
transmitted through the lumbosacral region by systematic
changes in initial posture (axial twist) and in selection of the
HVLA procedure. Results demonstrated differences between
three commonly used methods and between patient
positions.  Evaluation of combined postural variation in
flexion, lateral bending, and axial twist were studied further  using computer models. Figure 4 shows the effects on
transverse loads across the spine from systematic changes
affecting multiple axes. A complete reversal in direction of
the applied load can be achieved.
Mechanically assisted procedures include the use of impulse
hammers, adapted from instruments designed to apply
orthodontic appliances. These devices deliver a uniaxial
load directed to a small area (1 cm square), effectively
avoiding applied moments. In a study of 20 healthy subjects,
Keller  demonstrated a range of loads to the lumbar
spine from 83 N to 120 N with impulse duration of less
than 20 ms. Kawchuk and Herzog  showed much lower
amplitudes in the study of the cervical spine with mean amplitudes
from 17 subjects of 41 N. Other forms of mechanical
assistance are derived by combining the controlled motions
from CPM with manually applied loads. Figure 5 shows
the algebraic summation of loads that can be manipulated
by varying the timing of the HVLA with respect to the
phase of the passive motion.
The behaviors of neck and torso muscles have the potential
to alter the net loads acting on the spine during manual
treatments. Clinical observations from patient care suggest
that there are three intervals (Table 4) of muscle tension
that, theoretically, may alter the action of a treatment procedure.
Muscle activity may result from voluntary or reflex
contraction. Increased spinal stiffness is likely to alter the
ability of the doctor to obtain the desired initial joint positioning.
Muscle action during the procedure would alter the
amplitudes and direction of the loads transmitted through
the spine and, if sufficiently strong, may stiffen the joint to
prevent relative motions. Tension developed subsequent to
the loading phase would be equivalent to applying a second
or successor load of unknown amplitude and direction.
Unfortunately, little quantitative information is available
with respect to the muscular behavior in patient populations.
Studies, to date, have focused on healthy subjects and reveal
myoelectric activity that is unpredictable both in terms of
amplitude of response and muscular recruitment. No significant
muscle activity has been observed in healthy subjects
during the preload phase. Twitch responses have been reported
for HVLA procedures during the loading and resolution
phases [27, 28, 48–51] Onset of apparent reflex response
occurs within 50 to 200 ms after impulse initiation
and may last as long as 400 ms. Using a myoelectric and
double-linear optimization model, Triano  found that
muscle tension developed during twitch reaction in the neck
was insufficient to significantly influence spinal loads.
The spine is a viscoelastic system of linkages that are
mechanically coupled. Forces and moments applied to a local
site will result in different displacements along the
length of the spine that are based both on the mechanical
characteristics of the applied load and the properties of the
tissues that concatenate the individual vertebral segments.  At higher rates of loading, the spine elastic stiffnesses
increase and the time-dependent viscous behavior acts more
as a nonviscous solid. Slower rates provide sufficient time
for fluid compartments within the ligaments, muscles, and
discs to respond. At high loading rates, the relative displacement
will be dependent on the relative elastic tissue stiffnesses
(bone versus disc versus ligament). Conversely,
slower loads will allow loads to be transmitted between segments
viscoelastically, effectively spreading the displacements
across a broader spinal region.
Some direct measurements of vertebral displacement, both
translation and rotation, have been measured on cadavers and
conscious volunteers. For low velocity forces, as seen with
CPM and mobilization, displacement is distributed along a
series of vertebra in a progressive manner. Maximum displacement
occurs at the target segment and decreases with
increasing distance from the application point (Table 5).
In contrast, high velocity procedures resulted in statistically
significant differences in the intersegmental motions
indicating a target-specific, greater amplitude of motion.  Unfortunately, the vertebral movement distances observed
in volunteers cannot be compared directly with those
obtained from cadaver studies because of the changes in
stiffness that occur after death. Cadaver measures may underestimate
in vivo motions by as much as 30%. 
Biomechanics of safety
Most evidence on serious safety concerns come from
epidemiologic inference. [55–58] The primary complications
consist of self-limiting symptomatic exacerbation or
new local symptoms. Rarely, serious complications are attributed
to spinal manipulation, including cauda equina
syndrome and cerebrovascular accidents. Biomechanical
evidence has been reported that benchmarks the loads transmitted
through the spine during high-velocity, low-amplitude
procedures with experimental data or activities of daily
Triano and Schultz  measured the loads transmitted
through the torso at the lumbosacral spine for 66 HVLA
procedures. Results were compared with spinal loads predicted
by three-dimensional biomechanical models  for
various activities of daily living. The asymmetrical task of a
single-handed, 50–pound lift (20 degrees of flexion, 30 degrees
axial twist, 12 degrees lateral bending) produced the
same spinal loads as were observed for the entire trunk during
The experimental neck loads from spinal manipulation
are given in Table 3. Loads were modeled using an inverse
dynamics approach  and compared with moment loads
tolerated by human volunteers under test conditions. [60–62] Volunteers tolerated sudden neck moments as high as
94 Nm in the sagittal plane and 143 Nm in the coronal plane
without incident. These moment levels exceed those observed
during the spinal manipulation to the neck.
Spinal manipulation is a manual procedure that requires
some level of skill to be performed expertly. Differences in
novice versus expert performance have been recorded. [63, 64]
Statistically significant differences occur in terms of amplitude,
rate of force/moment development, and duration of
loading. Moreover, like many psychomotor skills, manipulation
performance is not transportable. That is, ability to
skillfully perform one procedure does not imply ability to
perform a new procedure equally well without substantial
rehearsal.  Skillful operators are able to provide forces
within 20% of desired levels over a range from 20% to
100% of maximum effort. 
Conclusions and future directions
Spinal tissues are consistently exposed to varying rates
and amplitudes of loads. Manual treatment differs by the intent
to apply loads locally, in an effort to alter mechanical
stresses thought to contribute to symptoms. Studies over the
past 10 to 15 years have provided some understanding of
the different procedures used in treating spine-related disorders,
including spinal manipulation/adjustment. Based on
the little biomechanical evidence available and clinical observations,
a biomechanical theory of the manipulable lesion
has begun to emerge.
Most physicians are aware of the fact that some of their
patients avail themselves of manipulative treatment. However,
they may be uncertain of the mechanisms of action or
the anticipated therapeutic effects. Spinal manipulation, by
its very nature, is a physical process. In this article, the theoretical
basis for using manipulation, the types of clinical
procedures, and their biomechanical actions are described.
Questions of loads that are applied and transmitted through
the body during the procedures, motions that occur, skill of
performance, and safety have been addressed. The size of
loads that are observed range widely according to the region
under treatment and are able to be controlled by the skillful
operator. Control strategies include procedure type; selected
load amplitudes, direction, and speed; patient posture; and
mechanical assistance. The upper limits of loads have the
potential to be significant but remain within the bounds of
The clinical literature shows symptomatic relief with
small spinal segment displacements and loads [35, 36],
while others have been benefited with more intense procedures
using higher velocity and loads (e.g., [3, 9, 11]). There
currently are over 90 different named systems of manual
procedures. The problem is that there is no current triage
system available that predicts which patient has the greater
likelihood of benefiting from manual treatment or the procedure
type. Table 2 begins a systematic characterization of
manual procedures that are detailed more completely in the
review that follows. Such a system may be used in future
studies to test hypotheses of treatment effect from quantitatively
defined procedures. The operating principles of SMT
are emerging. Many questions remain to be answered. What
are the characteristics of patients that respond best to continuous
passive motion, mobilization, or manipulation? Can
knowledge of the mechanics of procedures that benefit subcategories
of patients give insight as to the elusive nature of
the pain generator that responds favorably to SMT? What are
the dosage–duration characteristics of effective treatment? Can
clinical effect sizes be optimized by systematic treatment
modification or ancillary rehabilitative care? Refinement of
our knowledge of patient care begins, on the one hand, with
quantitative knowledge of the manipulable lesion and, on
the other, with understanding of the methods that are used.
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