General Physiotherapy

Part 2: Physiotherapy V Chiropractors


Damien Cummins

Physiotherapist, Practice Director

Friday, November 8, 2019

In this instalment we will be talking about safety features between chiropractic practices and physiotherapy practices specifically related to the use of thrust spinal manipulation techniques... otherwise known as “cracking the spine”.

If you have not yet read Part 1 of this series, we suggest you give it a look.

Within physiotherapy there is an inbuilt system of gradual progression of force application which provides a strong safety factor for preventing unnecessary and potentially dangerous forces being applied to unknown weak soft tissue. The way we apply the progression of forces is as follows:

  1. Patient Generated
  2. Patient Applied Overpressure
  3. Clinician Overpressure
  4. Clinician Mobilisation (pressure applied to the joints)
  5. Clinician Applied Manipulation (sudden thrusting force to the joints often creating a cracking sound)
Physiotherapists explore patient generated forces before considering therapist overpressure or manipulation. In many cases, chiropractors start with manipulation.

There are two clear benefits from using patient generated forces as an introduction to recovering movement.

  1. Safety
  2. Independence in self-treatment


Tissue injury is at risk when manipulation is applied early in the treatment process. The sharp sudden thrust force of manipulation renders the body unable to protect itself. This means that the body’s inbuilt protective reflexes are unable to respond fast enough to prevent any potentially excessive and dangerous soft tissue loading. Therefore, the risk of tissue overload increases with manipulation techniques.

Tissue injury is at risk when manipulation is applied early in the treatment process. The sharp sudden thrust force of manipulation renders the body unable to protect itself.
The sudden forces of manipulation are also often painful and can aggravate other adverse symptoms such as dizziness in the neck or spasm in the lower back. Upper neck manipulations also have an inherent risk of stroke and even death. Arteries traversing the neck may be inadvertently stressed during the application of these manipulation techniques (Ernst, 2007).

If soft tissue is deconditioned and unknowingly weak, gradual loading with repeated patient generated movements will safely test its integrity while simultaneously encouraging tissue strengthening over time. This system of progressive loading of soft tissue provides a fool proof way of building strength and encouraging movement that is safe and effective.

As already mentioned in Part 1, physios generally use slower, gradual and more sustained forces. Once the tissue responds to a certain level of force with improvements in movement and pain reduction, the force application will be maintained and repeated over multiple cycles until no further progress is achieved. This can be done over consecutive treatments to ensure the tissue is loaded safely.

Physiotherapists generally use slower, gradual and more sustained forces.

Independence in Self Treatment

Under the guidance of physiotherapists, patients learn how best to apply repeated movements in specific directions to improve movement and reduce pain. This creates independence in self-management and reduces the reliance on health care practitioners. This saves untold amounts of money and time both for patients and therapists.

Manipulation is used judiciously by physiotherapists as a last resort if all other treatment alternatives have been exhausted.


Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 2007;100(7):330–338. doi:10.1177/014107680710000716

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Damien Cummins

Physiotherapist, Practice Director

Damien Cummins has been practicing physiotherapy for 29 years, having graduated from Sydney University in 1990. His junior years as a physio began at John Hunter...

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