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  • Caroline Gill

Spinal manipulation - Is my back 'out of alignment'?

‘I’ve been told my spine is out of alignment’ …. A sentence that we physiotherapists hear regularly and triggers a deep, 'must be patient' breath. Sadly, too many people are told this and it's worrying and misleading.

Naturally, this is a bit of a controversial topic for both therapists and patients. Before we continue I will be completely transparent. I am a Physiotherapist and I am NOT anti-manual therapy. I utilise it on a daily basis but only when appropriate and more importantly, I do not rely on it.

The purpose of this article is not to bash the benefits of hands on treatment but instead to give you a better understanding of what manual therapy is really doing, without all the smoke and mirrors, and magic pain relieving snap, crack and pop.

A therapist’s role is to properly educate their patients, not mislead you into believing there is something fundamentally wrong with the structure of your spine. Quite frankly this approach is unprofessional, unethical and VERY outdated.

You deserve better than to be scared into believing that manipulation or hands on treatment is keeping your spine or pelvis 'in alignment'.

What effect is manual therapy having?

Manual therapy does not correct disc herniations or spinal curvatures, or break down scar tissue. None of these claims have held up well in research.

What we do know is that there are TEMPORARY changes to soft tissue following manual therapy that can be beneficial, but no permanent changes.

We also see a neurophysiological effect, meaning our nervous system becomes less sensitive and very simplistically sends less pain messages to your brain. For example its responsible for letting you know there is a hole in your oven gloves or tells your husband not to kick the coffee table that hard…again. In addition, we see chemical changes in dopamine (the chemical that makes us happy) and the natural opioids within our bodies, like endorphins (which also help to make us happy) and also in our adrenaline (fight/flight) receptors. As a result of manual therapy.

All of these changes occur for minutes to hours but haven't been shown to have longer lasting effects. Meaning manual therapy could be used to create a ‘schedule of treatment’ that results in reliance on a therapist … not necessarily convenient, productive or cost effective.

So what’s the point of all that ‘back cracking’?

Well manual therapy should only be used the same way we take pain killers, they help take the edge off when we’re really struggling with pain and may enable us to do more and use that window of opportunity to rehab ourselves. Because the effects are short lived however, using that window is important and finding movement based exercises that create the same sensation of relief is just as crucial.

What's the take home message?

Clinical guidelines do not advocate the use of manual therapy on it’s own. From years of experience, I have learnt that too much hands-on treatment creates a passive reliance on it and can take patients longer to progress. Now that’s not to say that manual therapy is bad but if used inappropriately or too much, is a sign that your therapist hasn't made clear its purpose. Instead manual therapy can be utilised effectively but only in addition to education, advice and exercises, to normalise movement and reduce pain.


If you find manual therapy techniques helpful then great, but remember they are there for short term pain relief to get back to normal. When looking for a therapist make sure they offer you the whole package including pain management, education and exercise. Not just a temporary, quick fix that leaves you coming back for more.

Most importantly, remember your spine and pelvis is one of the strongest and most resilient parts of your body but from the moment you wake up it rarely gets a rest. So if its starts to protest don’t panic, you were made beautifully and are almost certainly NOT out of alignment...

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