Spinal manipulation is an intervention performed on spinal articulations which are synovial joints, which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral, sacroiliac, costotransverse and costovertebral joints. National guidelines come to different conclusions with respect to spinal manipulation with some not recommending it, and others recommending a short course in those who do not improve with other treatments.
|NCCIH Classification||Manipulative and body-based|
|Risks||Vertebral artery dissection, compression fracture, cauda equina syndrome|
|Legality||Legal in adults, treatment of children varies by jurisdiction|
A 2004 Cochrane review found that spinal manipulation was no more or less effective than other commonly used therapies such as pain medication, physical therapy, exercises, back school or the care given by a general practitioner. There is not sufficient data to establish the safety of spinal manipulations.
A 2004 Cochrane review found that spinal manipulation (SM) was no more or less effective than other commonly used therapies such as pain medication, physical therapy, exercises, back school or the care given by a general practitioner. A 2010 systematic review found that most studies suggest SM achieves equal or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. In 2007 the American College of Physicians and the American Pain Society jointly recommended that clinicians consider spinal manipulation for patients who do not improve with self care options. Reviews published in 2008 and 2006 suggested that SM for low back pain was equally effective as other commonly used interventions. A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain. Of four systematic reviews published between 2000 and 2005, one recommended SM and three stated that there was insufficient evidence to make recommendations. A 2017 review concludes "for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy."
For neck pain, manipulation and mobilization produce similar changes, and manual therapy and exercise are more effective than other strategies. A 2015 Cochrane systematic review found that there is no high quality evidence assessing the effectiveness of spinal manipulation for treating neck pain. Moderate to low quality evidence suggests that multiple spinal manipulation sessions may provide improved pain relief and an improvement in function when compared to certain medications. Due to the potential risks associated with spinal manipulation, high quality randomized controlled trials are needed to determine the clinical role of spinal manipulation. A 2007 systematic review reported that there is moderate- to high-quality evidence that subjects with chronic neck pain, not due to whiplash and without arm pain and headaches, show clinically important improvements from a course of spinal manipulation or mobilization. There is not enough evidence to suggest that spinal manipulation is an effective long-term treatment for whiplash although there are short term benefits.
There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.
Assistance of medication or anesthesiaEdit
As for manipulation with the assistance of medication or anesthesia, a 2013 review concludes that the best evidence lacks coherence to support its use for chronic spine pain.
There is not sufficient data to establish the safety of spinal manipulations, and the rate of adverse events is unknown. Spinal manipulation is frequently associated with mild to moderate temporary adverse effects, and also rare serious outcomes which can result in permanent disability or death. The National Health Service in the UK notes that about half of people reported encountering adverse effects following spinal manipulation. Adverse events are increasingly reported in randomized clinical trials of spinal manipulation but remain under–reported despite recommendations in the 2010 CONSORT guidelines. A 2015 Cochrane systematic review noted that more than half of the randomized controlled trials looking at the effectiveness of spinal manipulation for neck pain, did not include adverse effects in their reports.
Risks of neck manipulationEdit
The degree of serious risks associated with manipulation of the cervical spine is uncertain, with little evidence of risk of harm but also little evidence of safety either. There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation. Several deaths have been associated with this technique and it has been suggested that the relationship is causative, but this is disputed by many chiropractors who believe it is unproven.
Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that "critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects". In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which results in a very serious consequence.
Edzard Ernst found that there is little evidence for efficacy and some evidence for adverse effects, and due to that, the procedure should be approached with caution, particularly forceful manipulation of the upper spine with rotation.
A 2007 systematic-review found correlations of mild to moderate adverse effects and less frequently with cervical artery dissection, with unknown incidence.
A 2016 systematic-review found the data supporting a correlation between neck manipulation and cervical artery dissection to be very weak and that there was no convincing evidence for causation.
Potential for incident under-reportingEdit
Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The RAND study assumed that only 1 in 10 cases would have been reported. However, Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical spinal manipulation by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that under-reporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.
A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.
Studies of stroke and manipulation do not always clearly identify what professional has performed the manipulation. In some cases this has led to confusion and improper placement of blame. In a 1995 study, chiropractic researcher Allan Terrett, DC, pointed to this problem:
- "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a nonchiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors."
This error was taken into account in a 1999 review of the scientific literature on the risks and benefits of manipulation of the cervical spine (MCS). Special care was taken, whenever possible, to correctly identify all the professions involved, as well as the type of manipulation responsible for any injuries and/or deaths. It analyzed 177 cases that were reported in 116 articles published between 1925 and 1997, and summarized:
- "The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (non-thrust passive movements)."
In Figure 1 in the review, the types of injuries attributed to manipulation of the cervical spine are shown, and Figure 2 shows the type of practitioner involved in the resulting injury. For the purpose of comparison, the type of practitioner was adjusted according to the findings by Terrett.
The review concluded:
- "The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed."
Spinal manipulation is a therapeutic intervention that has roots in traditional medicine and has been used by various cultures, apparently for thousands of years. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of osteopathic and chiropractic medicine. Spinal manipulative therapy gained recognition by mainstream medicine during the 1960s.
In North America, it is most commonly performed by physical therapists, osteopathic physicians, occupational therapists, and chiropractors. In Europe, physiotherapists, osteopaths and chiropractors are the majority providers, although the precise figure varies between countries. In 1992, chiropractors were estimated to perform over 90% of all manipulative treatments given for low back pain treatment. A 2012 survey in the US found that 99% of the first-professional physical therapy programs that responded were teaching some form of thrust joint manipulation.
Manipulation is known by several other names. The British orthopedic surgeon A. S. Blundell Bankart used the term "manipulation" in his text Manipulative Surgery. Chiropractors often refer to manipulation of a spinal joint as an 'adjustment'. Following the labeling system developed by Geoffery Maitland, manipulation is synonymous with Grade V mobilization. Because of its distinct biomechanics (see section below), the term high velocity low amplitude (HVLA) thrust is often used interchangeably with manipulation.
Until recently, force-time histories measured during spinal manipulation were described as consisting of three distinct phases: the preload (or prethrust) phase, the thrust phase, and the resolution phase.[jargon] Evans and Breen added a fourth 'orientation' phase to describe the period during which the patient is oriented into the appropriate position in preparation for the prethrust phase.
The kinematics of a complete spinal motion segment, when one of its constituent spinal joints is manipulated, are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint.
The effects of spinal manipulation have been shown to include:
- Temporary relief of musculoskeletal pain
- Shortened time to recover from acute back pain
- Temporary increase in passive range of motion (ROM)
- Physiological effects on the central nervous system (specifically the sympathetic nervous system)
- Altered sensorimotor integration
- No alteration of the position of the sacroiliac joint
- Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C (December 2010). "An updated overview of clinical guidelines for the management of non-specific low back pain in primary care". European Spine Journal. 19 (12): 2075–94. doi:10.1007/s00586-010-1502-y. PMC 2997201. PMID 20602122.
- Assendelft, WJJ; Morton, SC; Yu, EI; Suttorp, MJ; Shekelle, PG (2004). Assendelft, Willem JJ (ed.). "Spinal manipulative therapy for low-back pain". Cochrane Database of Systematic Reviews. 2004 (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. Retrieved 2009-03-19. (Retracted, see doi:10.1002/14651858.cd000447.pub3. If this is an intentional citation to a retracted paper, please replace
- Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review" (PDF). Spine. 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.
Safety in chiropractic manipulation is far from being achieved. Further investigations are urgent to assess definite conclusions regarding this issue. ... There is insufficient data to produce a robust conclusion on safety of chiropractic interventions.
- Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (2010). "NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain". Spine J. 10 (10): 918–940. doi:10.1016/j.spinee.2010.07.389. PMID 20869008.
- Chou R, Qaseem A, Snow V, et al. (October 2, 2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Annals of Internal Medicine. 147 (7): 478–91. doi:10.7326/0003-4819-147-7-200710020-00006. PMID 17909209.
- Murphy AYMT; van Teijlingen ER; Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948.
- Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469.
- Meeker W, Branson R, Bronfort G, et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13.
- Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972. Lay summary – BBC News (2006-03-22).
- Rothberg, Samantha; Friedman, Benjamin W. (2017). "Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review". The American Journal of Emergency Medicine. 35 (1): 55–61. doi:10.1016/j.ajem.2016.10.001. ISSN 0735-6757. PMID 27751598.
- Hurwitz EL, Carragee EJ, van der Velde G, et al. (February 2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.
- Gross, Anita; Langevin, Pierre; Burnie, Stephen J.; Bédard-Brochu, Marie-Sophie; Empey, Brian; Dugas, Estelle; Faber-Dobrescu, Michael; Andres, Cristy; Graham, Nadine (2015-09-23). "Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment". The Cochrane Database of Systematic Reviews (9): CD004249. doi:10.1002/14651858.CD004249.pub4. ISSN 1469-493X. PMID 26397370.
- Vernon H, Humphreys K, Hagino C (2007). "Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials". J Manipulative Physiol Ther. 30 (3): 215–27. doi:10.1016/j.jmpt.2007.01.014. PMID 17416276.
- Martín Saborido C, García Lizana F, Alcázar Alcázar R, Sarría-Santamera A (May 2007). "[Effectiveness of spinal manipulation in treating whiplash injuries]". Aten Primaria (in Spanish). 39 (5): 241–6. PMID 17493449.
- Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C (December 2007). "Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials". Complement Ther Med. 15 (4): 271–83. doi:10.1016/j.ctim.2007.01.008. PMID 18054729.
- DiGiorgi, Dennis (2013). "Spinal manipulation under anesthesia: a narrative review of the literature and commentary". Chiropractic & Manual Therapies. 21 (1): 14. doi:10.1186/2045-709X-21-14. PMC 3691523. PMID 23672974.
- Ernst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med. 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. PMC 1905885. PMID 17606755. Lay summary – Med News Today (2007-07-02).
- "Safety and regulation of chiropractic". NHS Choices. 20 August 2014. Retrieved 22 September 2016.
- Gorrell, LM; Engel, RM; Brown, B; Lystad, RP (September 2016). "The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review". The Spine Journal (Systematic Review). 16 (9): 1143–51. doi:10.1016/j.spinee.2016.05.018. PMID 27241208.
- Ernst E, Posadzki P (2012). "Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review". N Z Med J. 125 (1353): 87–140. PMID 22522273.
- Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice. 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC 3506737. PMID 22994328.
- Carlesso, LC; Gross, AR; Santaguida, PL; Burnie, S; Voth, S; Sadi, J (October 2010). "Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review". Manual Therapy. 15 (5): 434–44. doi:10.1016/j.math.2010.02.006. PMID 20227325.
- Ernst E (2010). "Deaths after chiropractic: a review of published cases". Int J Clin Pract. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.
- Ernst E (2010). "Vascular accidents after neck manipulation: cause or coincidence?". Int J Clin Pract. 64 (6): 673–7. doi:10.1111/j.1742-1241.2009.02237.x. PMID 20518945.
- Kleynhans AM, Terrett AG. Cerebrovascular complications of manipulation. In: Haldeman S, ed. Principles and practice of chiropractic, 2nd ed. East Norwalk, CT, Appleton Lang, 1992.
- Haldeman S, Kohlbeck F, McGregor M (2002). "Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty‐four cases after cervical spine manipulation". Spine. 27 (1): 49–55. doi:10.1097/00007632-200201010-00012. PMID 11805635.
- Rothwell D, Bondy S, Williams J (2001). "Chiropractic manipulation and stroke: a population-based case‐controlled study". Stroke. 32 (5): 1054–60. doi:10.1161/01.str.32.5.1054. PMID 11340209.
- Haldeman S; et al. (2002). "Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias". Spine. 2 (5): 334–342. doi:10.1016/s1529-9430(02)00411-4. PMID 14589464.
- Haldeman S; et al. (2001). "Arterial dissections following cervical manipulation: the chiropractic experience". Journal of the Canadian Medical Association. 165 (7): 905–906.
- Spinal manipulation: Its safety is uncertain. Edzard Ernst, CMAJ, January 8, 2002; 166 (1)
- Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE (2016). "Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation". Cureus. 8 (2): e498. doi:10.7759/cureus.498. PMC 4794386. PMID 27014532.
- NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors Archived 2006-05-30 at the Wayback Machine
- Rothwell D, Bondy S, Williams J (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. doi:10.1161/01.STR.32.5.1054. PMID 11340209. Original article
- Terrett A (1995). "Misuse of the literature by medical authors in discussing spinal manipulative therapy injury". J Manipulative Physiol Ther. 18 (4): 203–10. PMID 7636409.
- Di Fabio R (1999). "Manipulation of the cervical spine: risks and benefits". Phys Ther. 79 (1): 50–65. PMID 9920191. Retrieved 2011-11-24.
- Figure 1. Injuries attributed to manipulation of the cervical spine. Archived 2007-09-27 at the Wayback Machine
- Figure 2. Practitioners providing manipulation of the cervical spine that resulted in injury. Archived 2007-02-25 at the Wayback Machine
- Dean C. Swedlo, "The Historical Development of Chiropractic. Archived 2008-06-25 at the Wayback Machine" pp. 55-58, The Proceedings of the 11th Annual History of Medicine Days, Faculty of Medicine, The University of Calgary
- Burke, G.L., "Backache from Occiput to Coccyx" Chapter 1
- Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther. 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626.
- Burke, G.L., "Backache from Occiput to Coccyx" Chapter 7
- "International MUA Academy of Physicians - Historical Considerations". Retrieved 2008-03-24.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992). "Spinal manipulation for low-back pain". Annals of Internal Medicine. 117 (7): 590–598. doi:10.7326/0003-4819-117-7-590. PMID 1388006.
- Noteboom JT, Little C, Boissonnault W (2015). "Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update". J Orthop Sports Phys Ther. 45 (6): 471–476. doi:10.2519/jospt.2015.5273. PMID 25899212.
- "Manipulative surgery. By A. S. Blundell Bankart, M.A., M.Ch. (Cantab.), F.R.C.S., Orthopædic Surgeon to the Middlesex Hospital, etc. Modern Surgical Monographs, edited by G. Gordon-Taylor, O.B.E., M.A., F.R.C.S. Demy 8vo. Pp. 150 + xii, with 21 illustrations. 1932. London: Constable & Co. Ltd. 7s. 6d. Net". British Journal of Surgery. 20 (78): 353–354. 1932. doi:10.1002/bjs.1800207825.
- Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
- Herzog W, Symons B (2001). "The biomechanics of spinal manipulation". Crit Rev Phys Rehabil Med. 13 (2): 191–216. doi:10.1615/CritRevPhysRehabilMed.v13.i2-3.50.
- Evans DW, Breen AC (2006). "A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone". J Manipulative Physiol Ther. 29 (1): 72–82. doi:10.1016/j.jmpt.2005.11.011. PMID 16396734.
- Murphy BA, Dawson NJ, Slack JR (March 1995). "Sacroiliac joint manipulation decreases the H-reflex". Electromyogr Clin Neurophysiol. 35 (2): 87–94. PMID 7781578.
- Kingston L, Claydon L, Tumilty S (August 2014). "The effects of spinal mobilizations on the sympathetic nervous system: A systematic review". Man Ther. 19 (4): 281–287. doi:10.1016/j.math.2014.04.004. PMID 24814903.
- Tullberg T, Blomberg S, Branth B, Johnsson R (May 1998). "Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis". Spine. 23 (10): 1124–8, discussion 1129. doi:10.1097/00007632-199805150-00010. PMID 9615363.
Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.
- Senstad O, Leboeuf-Yde C, Borchgrevink C (February 1997). "Frequency and characteristics of side effects of spinal manipulative therapy (Adverse)". Spine. 22 (4): 435–40, discussion 440–1. doi:10.1097/00007632-199702150-00017. PMID 9055373.
- Cyriax, J. Textbook of Orthopaedic Medicine, Vol. I: Diagnosis of Soft Tissue Lesions 8th ed. Bailliere Tindall, London, 1982.
- Cyriax, J. Textbook of Orthopaedic Medicine, Vol. II: Treatment by Manipulation, Massage and Injection 10th ed. Bailliere Tindall, London, 1983.
- Greive Modern Manual Therapy of the Vertebral Column. Harcourt Publishers Ltd., 1994
- Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
- Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
- McKenzie, R.A. The Lumbar Spine; Mechanical Diagnosis and Therapy. Spinal Publications, Waikanae, New Zealand, 1981.
- McKenzie, R.A. The Cervical and Thoracic Spine; Mechanical Diagnosis and Therapy. Spinal Publications, Waikanae, New Zealand, 1990.
- Mennel, J.M. Joint Pain; Diagnosis and Treatment Using Manipulative Techniques. Little Brown and Co., Boston, 1964.
- American Academy of Orthopedic Manual Physical Therapy (AAOMPT)
- Canadian Academy of Manipulative Therapy (CAMT)
- Canadian Orthopractic Manual Therapy Association (COMTA)
- International Federation of Orthopaedic Manipulative Therapists (IFOMT)
- Journal of Manual and Manipulative Therapy (JMMT)
- Prevention of the vertebrobasilar accidents following cervical thrust manipulations: recommendations of the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO).
- European Association of Advanced Manual and Manipulative Therapy