Ross Hauser, MD.
In this article we will discuss over manipulation syndrome, a condition characterized by chronic pain of the joints or vertebrae from spinal instability or hypermobility due to ligament laxity caused by excessive self-manipulation or manipulation by a practitioner.
Over-manipulation syndrome is a condition characterized by chronic pain of the joints or vertebrae from instability due to ligament laxity that is caused by excessive self-manipulation or manipulation by a practitioner. We use the term “manipulation” to refer to a sudden thrust of small amplitude, performed at a rapid speed accompanied by an audible crack. The goal of the manipulation is to adjust subluxed vertebrae to resolve the symptomatology caused by the vertebral subluxation complex.
The lumbar and cervical segments of the spine are the areas commonly affected by over-manipulation syndrome because they are most frequently targeted areas for high velocity manipulations. A high velocity manipulation consists of a violent thrust and contortion of the spine in order to produce audible popping sounds or cracking of the target areas of the spine in an attempt to realign or adjust the spinal column. Self-manipulation means performing this procedure on one’s own spine, generally for relief of pain.
Over manipulation syndrome is a constellation of symptoms that occur when the neck and spine undergo high velocity manipulation.
Over manipulation syndrome is a constellation of symptoms that occur when the neck and spine undergo high velocity manipulation. At the onset, we do want to acknowledge that in many instances osteopathic and chiropractic manipulation are extremely helpful. But in this article and the accompanying video below, we will show that in some instances a high velocity thrust especially with rotation will in cause injury to the C1-C2 facet joint and cause cervical instability.
Many people utilize chiropractic, physical therapy and osteopathic manipulation not just to treat localized areas of pain but also various health concerns such as chronic fatigue, digestive complaints, asthma and host of ailments. A cervical spine subluxation can clearly disrupt or interfere with the delicate balance between the sympathetic and parasympathetic nervous activity. Please see my article Ross Hauser, MD Reviews Cervical Spine Instability and Potential Effects on Brain Physiology for a more detailed description of these symptoms and conditions.
A subluxation (more commonly referred to as a “slight” dislocation of the vertebrae or joint) is normally thought of a restriction that will not go away unless some puts a specific force on it to move the bone “back into place.” Instability means too much motion in the spine or joints that allows the vertebrae to wander around compressing nerves, arteries and veins. This versus restriction, the natural means (ligaments) of holding the vertebrae in place.
High-velocity, low amplitude manipulation, as it is called, truly does help a lot of people, especially those with motion restrictions and subluxations. Not just their pain but also some internal organ or system complaints. This is most likely through its homeostatic effect through helping balance autonomic nervous system function.
The mechanism behind manipulation’s healing effect is that a specific joint subluxation is causing a malfunction in the body’s electric grid, thereby affecting an organ. The thought is that the body is out of alignment, and this bony subluxation is the cause of various musculoskeletal, neurologic and visceral disorders. This has been documented by large amounts of medical research.
It is now a fact that each organ and cell of the body and its various functions depend on the autonomic nervous system. Anything that improves the health of the autonomic nervous system typically improves the health of the organism and vice versa. Heavy metal toxicity, toxic relationship, poor diet, high blood sugars, infections such as Lyme disease, chemical poisonings and a host of other medical conditions impair the autonomic nervous system. We all know that when we rest more, eat healthy and have a balanced life (and thus balanced autonomic nervous system), then typically our health improves.
“Joint subluxation” and “joint instability” in Over Manipulation Syndrome
While the terms “joint subluxation” and “joint instability” technically mean different things, it can be assumed in the majority of cases that a person with a joint subluxation has a joint stabilizer that is weak and thus is prone to joint instability. Many of us have used (including myself) high velocity manipulation for one problem or another with various degrees of success. In our opinion, a good chiropractic or osteopathic physician is an invaluable asset to a person’s health and care. Many cases of chronic pain, headaches and health ailments can be resolved with manipulation. Yes, overly aggressive spinal manipulation can be the cause of spinal instability, but when done correctly it can cause immediate (or quick) relief of symptoms.
We see a large number of hypermobility cases where the patients present with a history of excessive chiropractic manipulations. A short course of manipulation to relieve pain or tension is understandable. However, patients who sign up for long-term chiropractic packages that include thrusting manipulations often find themselves even more unstable after the treatment course. Good chiropractors treat each patient individually and conservatively.
Many people are not aware that a high velocity thrust by themselves, a self-manipulation, can injure the cervical ligament. They can injure their capsular (outer) ligaments of the mid cervical region.High velocity thrusts can hurt someone, especially if the muscles are in spasm. The greater the muscle spasm present, the more force that has to occur to “crack” your neck.
I was first really made aware of the dangers of some types of manipulation many years ago when I started seeing a group of patients from the same chiropractic clinic. I subsequently learned that the doctor would treat in upwards of 120 patients in one day with high velocity manipulation. He spent about two minutes per patient and would do a rotational whipping high velocity manipulation on many of the patients in their upper spine. Basically this doctor was making one patient after another unstable. So when they became unstable he would send them to me.
Over manipulation syndrome can cause any of these symptoms:
- anxiety
- blurred vision
- If you suffer from vision problems, please see the supporting research and treatment options in our article Chronic Neck Pain and Blurred Double Vision Problems – Is the answer in the neck ligaments?
- cognitive impairment
- dizziness and vertigo
- If you suffer from dizziness, please see the supporting research and treatment options in our article Can neck problems cause vertigo? Cervical Vertigo and Cervicogenic Dizziness
- ear pain
- facial pain
- Facial pain can come from many causes. In patients we see often one diagnosis is Trigeminal Neuralgia, a problem with the Trigeminal nerve that runs along on side of the face. Please see the connection between cervical neck instability and facial pain in our article The evidence for Trigeminal Neuralgia non-surgical treatments
- headaches/migraines andsuboccipital headaches
- Headaches can be significant manifestations of cervical neck instability. Often treating the neck problem will alleviate or in some cure the headache problem. The problem of headache is one that we discuss frequently in our articles. Please see these articles:
- Cervicogenic headaches – Migraines, tension headaches and cervical neck instability
- Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves
- Suboccipital headache Moving away from nerve blocks and getting results from ligament repair and treatment of muscle spasms
- Headaches can be significant manifestations of cervical neck instability. Often treating the neck problem will alleviate or in some cure the headache problem. The problem of headache is one that we discuss frequently in our articles. Please see these articles:
- insomnia
- light sensitivity
- lightheadedness and fainting
- These symptoms are among the many “mystery,” symptoms that brings patients to our clinis, the sudden feeling of lightheadedness when turning the head to one side or even passing out or fainting. In some patients this can be identified as having its cause in the cervical vertebrae compressing an artery. Please see this article Vertebrobasilar insufficiency – Hunter Bow Syndrome – Cervical neck instability
- memory problems
- nausea
- radiculopathy
- For more research and treatment options for cervical radiculopathy please see our article: The evidence for non-surgical cervical radiculopathy treatments
- tinnitus
- Please see our supportive research in our article: Making the case for cervical instability as a cause of Tinnitus
The problems of manipulation
A high velocity manipulation consists of a violent thrust and contortion of the spine to achieve the audible popping sounds or cracking of the cervical, lumbar, or even thoracic spine in an attempt to realign or adjust the spine.
Self-manipulation refers to high velocity manipulation achieved by contorting and thrusting one’s own spine to achieve the cracking and supposed adjustment of the spine.
The possible worsening of back and neck pain symptoms with overzealous chiropractic or self-manipulations.
Numerous studies have been published over the years which discusses the possible worsening of back and neck pain symptoms with overzealous chiropractic or self-manipulations.
And often cited study from 1996 from the Institute of Neurology, Catholic University of Rome published in the journal Spinal Cord (1) suggested:
- Spinal manipulation can worsen symptoms of spinal stenosis by provoking forced movements that exceed the physiological limits of the vertebra complex.
- In patients with pre-existing stenosis of the canal or those with vertebral instability, these movements may cause (or aggravate) myelopathy (pain and degenerative disc disease).
The 1996 study demonstrates that this has been a medical concern for over 25 years, actually quite longer than that, a December 2021 paper shows that this concern is still complexing.
Writing in the Journal of orthopaedic surgery and research, (1) doctors in this December 2021 study discuss the problems of injury from ill advised manipulation in the C1-C2 segments.
“(Doctors) should obtain a detailed medical history and perform a physical examination and primary radiographic evaluation before cervical rotatory manipulation. It was reported that cervical intradural disc herniation may cause progressive neurological dysfunction after cervical spine manipulation therapy. Similarly, in this study, we found that CRM may not be suitable if disc herniation or a vertebral osteophyte is present around the C1–C2 segments because the maximum stress of the spinal cord occurs at these segments after cervical rotatory manipulation, and disc herniation or a vertebral osteophyte (bone spur) may cause much higher stress, thereby leading to spinal cord injury.”
In our own research presented inThe Journal of Applied Research we made these points: (3)
What is manipulation?
- ‘Primarily the term refers to a sudden thrust of small amplitude, performed at a rapid speed accompanied by an audible crack. This manual procedure, also known as ‘Grade V Mobilization,’ ‘adjustment,’ and ‘spinal manipulation therapy (SMT)’ is used extensively in the chiropractic and osteopathic professions.
- With growing popularity comes the responsibility to analyze long-term therapeutic and physiologic effects of joint manipulation and the corollary risk Over-Manipulation Syndrome (OMS).
- Over Manipulation Syndrome is defined as a musculoskeletal condition characterized by a constellation of symptoms ranging from chronic pain to muscle spasms due to ligament laxity and joint instability, induced by manipulation performed by practitioner, and/or self-manipulation.
There are benefits to manipulation as well.
There are benefits to manipulation as well. On motion x-ray, a subluxation can be seen to be fixed or dynamic. A fixed subluxation is one that is there throughout the motion cycle and often responds to chiropractic and osteopathic mobilization/manipulation. The motion x-ray demonstrates not only which motion segments are moving too much but also which ones are not moving enough. Thus fixed or fused segments can also be mobilized with various techniques including manipulation, traction or deep tissue massage. Straightened or kyphotic curves or segments can also be seen.
Another important point regarding chiropractic care concerning the upper cervical spine, is while forceful manipulation can be tolerated to a large degree in the rest of the spine, the upper cervical articulations are essentially held in place by muscles and ligaments, as they are devoid of intervertebral discs. It is especially this part of the spine that does better with specific controlled lower-force thrusts. It is also this part of the spine that I see damaged most from chiropractors. The upper cervical spine cannot tolerate a lot of rotational force that some of the chiropractic techniques use. The specific upper cervical manipulation adjustments, whether done by hand or instrument, move the vertebrae a sixteenth of an inch to a quarter of an inch. This why the axiom “light is right” is appropriate when it comes to the upper cervical adjustment.
Side effects of cracking your spine
Generally, this cracking is not a one-time event. Self-manipulation often becomes excessive. It also becomes habit forming and may lead to the development of Over Manipulation Syndrome (OMS). With Over Manipulation Syndrome, a musculoskeletal condition, a person can develop chronic pain, muscle spasms, and other symptoms due to ligament laxity and joint instability. Excessive manipulation performed by a practitioner or by self-manipulation, causes the cervical and spinal supportive ligaments to become stretched as the manipulation continues, leading to more and more joint instability.
For example, a high velocity thrust to the atlanto-axial (C1, C2) area can cause this joint to become unstable. The thrust injures the cervical ligaments that stabilize these cervical vertebrae. There are no discs between the head and C1, or between C1 and C2, and thus the vertebrae are suspended by ligaments alone. The force of a high velocity thrust in this area puts a lot of stress on these ligaments, causing the ligaments to become stretched.
There are other ligaments in the spine called capsular ligaments that hold the joints of the spine or facet joints in place. Capsular ligaments are very small ligaments. They can even tear if stretched more than a centimeter. Therefore, it does not take much of a stretch for these ligaments to become lax.
Overstretched ligaments in neck and spine
When the ligaments are exposed to continued stress, they will slowly stretch. Repeated stretching such as from excessive high velocity manipulations will cause them to elongate and deform. The stretched out cervical and capsular ligaments of the spine will cause instability of the spine. When this goes on for too long, the ligaments stretch to the point of no return, and are unable to hold the vertebrae in place. The vertebrae shift and start to cause pain and other symptoms of spinal instability.
You can see how this could lead to a pattern of even more manipulations, because the vertebrae are now shifting more frequently. But manipulations at this point will only make things worse. The attempt at realignment with manipulations will not hold, but will stretch the ligaments further, potentiating the symptoms of over-manipulation syndrome.
If I can’t crack my spine, then how can I deal with the symptoms of OMS?
We see a large number of hypermobility cases after the person has had excessive chiropractic manipulations. In many instances traditional chiropractic is very helpful. A short course of manipulation to relieve pain or tension is understandable. However, repeated visits for a hypermobile patient is not helpful in many cases, and as stated previously will worsen the hypermobility and instability. If after 10 visits, the joint is still not staying in place after manipulation, then there is an obvious ligament injury. Manipulation should stop at this point. Treatment to stabilize the vertebrae by strengthening the ligaments is necessary. Prolotherapy is a treatment that strengthens and repairs injured ligaments.
Over Manipulation Syndrome can be reversed with Prolotherapy
Prolotherapy injections
Over-manipulation syndrome can begin after high velocity adjustments from a chiropractor or through self-manipulation. While chiropractors provide wonderful care in many cases, there is a risk of damaging the ligament structures and causing joint instability with continued high-velocity adjustments. If these manipulations are done over and over to the point where the area is continuously subluxing, it proves that the ligaments are overstretched and must be addressed. Prolotherapy should be sought to repair the ligaments and stabilize the joints. Additionally, it is important for the patient to stop receiving and performing manipulation of the joint, especially while receiving Prolotherapy.
The good news is that this process can be reversed with Prolotherapy. It is very important, however, for the patient to stop receiving and performing manipulation of the joint, especially while receiving Prolotherapy to that joint.
Comprehensive Prolotherapy is a treatment involving a series of regenerative injections to stimulate the healing of damaged joints and ligaments. Prolotherapy works because it causes a localized inflammation similar to what happens in the body when called upon to heal a wound. Blood supply and cells that the body uses for repair are boosted in the area of the stretched out and injured ligament. The body also sends deposits of collagen. Ligaments are made up of a very high amount of collagen. When these collagen cells mature, the ligaments get thicker and stronger.
Perhaps no other discipline of medicine thinks most like a Prolotherapist as does an experienced chiropractor. Both understand that bony alignment, movement and forces is what determines proper functioning of joints, joint structures and the nerve supply of and to the body!
When manipulation does not resolve a particular condition, Prolotherapy is one of the therapeutic options available. When someone has joint instability that has been longstanding, high velocity manipulation is sometimes helpful but typically not curative. In our opinion the more longstanding the problem, the more likely Prolotherapy will be needed to resolve it.
Summary
Chiropractic techniques vary. Too hard a manipulative force can cause a joint to become unstable. This is especially true about the upper cervical region, as there just isn’t bony or disc support to limit motion. The stability is provided by the ligaments. If a chiropractor wants to use a lot of force and whip your head around you might end up with upper cervical instability. If you feel like the manipulation is making you worse, tell the chiropractor.
1 Padua L, Padua R, LoMonaco M, Tonali PA. Radiculomedullary complications of cervical spinal manipulation. Spinal Cord. 1996 Aug;34(8):488-92.[Google Scholar]
2 Xue F, Chen Z, Yang H, Chen T, Li Y. Effects of cervical rotatory manipulation on the cervical spinal cord: a finite element study. Journal of Orthopaedic Surgery and Research. 2021 Dec;16(1):1-2. [Google Scholar]
3 Gordin K, Hauser R. The Case for Utilizing Prolotherapy as a Promising Stand-Alone or Adjunctive Treatment for Over-Manipulation Syndrome. Journal of Applied Research. 2013 Jan 1;13(1). [Google Scholar]
