Chiropractic manipulation has been around long enough to be both revered and misunderstood in equal measure. For some, it’s the magic button that fixes everything from a sore back to a bad mood. For others, it’s a mysterious cracking ritual that must be avoided at all costs. In truth, spinal and extremity manipulation is a highly skilled, evidence-informed tool, but like any powerful tool, it requires wisdom, restraint, and a healthy dose of common sense.

Let’s start with a few common misconceptions. No, we don’t ‘put bones back in’. Your vertebra doesn’t go missing in action and need clicking back into place. And no, your spine is not now ‘aligned with the universe’. It’s a joint, not a solar system. And despite the internet’s enthusiasm, not every click, crack, or pop you see on social media is therapeutic; sometimes it’s just noise, clickbait, or a little harmless ASMR for the viewer and listener; best enjoyed with some doom-scrolling.

One of the reasons manipulation attracts such polarised opinions is that it produces an immediate, tangible sensation. Patients feel something happen. Clinicians hear something happen. In a healthcare world increasingly driven by slow-burn outcomes and delayed gratification, that immediacy can be both its greatest strength and its biggest trap. Humans are wired to associate instant feedback with effectiveness, even when long-term outcomes may tell a more nuanced story. A click can feel convincing; a quiet improvement over six weeks of rehab, less so. This doesn’t make manipulation ineffective, far from it, but it does mean we must be careful not to confuse impact with importance.

There’s also a performance element that’s hard to ignore. Manipulation looks confident. It looks decisive. It looks like you know what you’re doing, which is precisely why it should never be used to mask uncertainty. The real skill isn’t delivering a thrust; it’s being able to explain why you are or aren’t using one. Confidence built on clarity will always outlast confidence built on theatrics. Patients don’t need us to look impressive; they need us to be right often enough, honest always, and reflective when things don’t go to plan.

I’ve built a career around this exceptional tool, where I know the hands-on skills I’ve delivered, with precision, intent, and certainty, have genuinely helped lead patients out of pain. The change can be immediate. Shoulders drop. Faces soften. Someone stands up straighter than they walked in. Painkillers stopped. In those moments, it’s tempting to believe you’ve found the answer. The only answer, one might think. And sometimes, that confidence becomes contagious, for not only for the patient, but also the practitioner.

I’ve watched patients return with a familiar look: hopeful, expectant, already positioning themselves on the table before I’ve finished asking how they’ve been. “that crack was unreal!”, they’ll say. “That’s what fixed it last time.” Cue the affectionate but dangerous mythology, and the uphill task of convincing them to engage in load management, to change their habits, to take exercise snacks in the day, that will also help them.

That’s when the line becomes blurred. Not because manipulation is ineffective - far from it - but because it worked so well that it risks becoming the whole story rather than part of it. When relief is rapid and repeatable, patients can start chasing the sensation rather than the outcome. And if we’re not careful, clinicians can start supplying it, mistaking patient satisfaction for patient progress.

This is where certainty needs tempering with responsibility. The same confidence that makes manipulation powerful is the same confidence that can quietly undermine long-term resilience if it isn’t paired with education and restraint. Because our job isn’t to create repeat customers for a noise or a feeling, it’s to create people who don’t need us quite so much.

Used well, manipulation can open a door. Used carelessly, it can become a revolving one.

A chiropractor’s duty of care means knowing when not to adjust. That’s right - sometimes the best adjustment is no adjustment at all. Think of it like cooking: just because you own a spice rack doesn’t mean every dish needs a tablespoon of chilli powder. We’re responsible for screening, assessing, and deciding whether manipulation is appropriate, or whether other treatments (rehab, soft tissue therapy, education) might serve the patient better.

Part of the confusion stems from terminology. In chiropractic circles you’ll hear ‘adjustment’, in physio circles ‘manipulation’, and in sports medicine ‘high-velocity low-amplitude thrust’ (HVLA), because nothing says fun like a name that sounds like a rocket launch. Ultimately, the principles are the same: skilled joint mobilisation to restore motion, reduce pain, and improve function. In musculoskeletal (MSK) practice and elite sports, it’s often used as part of a wider plan, not a solo act.

Context matters enormously. In elite sport, for example, manipulation may be used to restore short-term range of motion or reduce protective tone or stimulate muscle proprioception before training or competition, in full knowledge that it’s a temporary window rather than a permanent fix. In primary care, the same technique might be used far more sparingly, prioritising reassurance, load management, and long-term self-efficacy instead. The technique hasn’t changed, the reason for using it has. This distinction is often lost in online debates, where manipulation is discussed as though it exists in a vacuum rather than within a broader clinical ecosystem.

Equally important is recognising the difference between can and should. Many joints are manipulable; far fewer genuinely need it. Clinical maturity often shows itself not in how many techniques you’ve mastered, but in how many you consciously choose not to use. This restraint isn’t a loss of skill, it’s evidence of it.

Now, let’s talk about the ‘gurus’. Many of us were taught that THE adjustment is the ultimate, all-powerful treatment. And yes, done well, it can be transformative. But as a wise man in red and blue Lycra once said: “With great power comes great responsibility.” Spiderman probably wasn’t talking about the lumbosacral junction, but the point stands. If all you have is an adjustment, every problem starts to look like a subluxation, or, as the saying goes, if you’re a hammer, everything is a nail.

Growing up, I had a very simple engineering lesson passed down from my grandfather, Chuck. He worked out of a garage with a handwritten sign taped to the door: “Moving too much? Weld it. Not moving enough? WD-40. Otherwise, leave it alone.” Alongside it sat his personal motto: “If it ain’t broken, don’t fix it.” As crude as it sounds, that algorithm has served me surprisingly well in understanding when and why I use SMT. In my early chiropractic training, there were moments when the internal monologue behind an adjustment felt suspiciously like: “Why am I manipulating this part of the spine? Well… because chiropractic.” It wasn’t until I began applying my grandfather’s logic: intervention only when justified, that manipulation stopped being a default behaviour and started becoming a considered, rational clinical choice.

As clinicians develop, there’s often a quiet shift from technique obsession to outcome obsession. Early on, it’s tempting to chase the perfect setup, the perfect contact, the perfect cavitation or click. Later, the questions change: Did this meaningfully alter the patient’s symptoms? Did it help them move, train, sleep, or cope better? Did it move the plan forward? If the answer is no, then the elegance of the thrust becomes largely irrelevant. Manipulation earns its place not by tradition or identity, but by utility.

This is where reflective practice becomes essential. Reviewing outcomes, retesting, and being willing to say “that didn’t work as hoped” separates evidence-informed clinicians from ritual-based ones. Manipulation should survive scrutiny; if it doesn’t, it should be modified, replaced, or dropped altogether. Diagnostically the outcomes (or lack of) post-manipulation help to tell an important story of your patient.

And that brings us neatly to the idea of ‘bang for buck’. In patient management, it’s about choosing interventions that deliver the greatest benefit relative to effort, risk, and cost. Just because a treatment exists or your own practitioner bias exists, it doesn’t mean it deserves top billing in every plan. Sometimes a well-placed adjustment will provide immediate relief and functional improvement, but other times targeted exercises, posture education, or soft tissue work will give more lasting results for less fuss. A savvy clinician weighs the options, considers the patient’s goals and context, and selects what truly gives the most value; not what simply makes the loudest crack. It’s a reminder that effectiveness is about outcomes, not theatrics - patients deserve more than just one cute thing.

Let’s not leave patient safety out of this article either. A good chiropractor doesn’t just click and hope for the best, they continually evaluate its appropriateness. We explain what we’ve found, rule in or rule out manipulation as appropriate, and give patients clear advice on what to expect, including when to come back, and more importantly, provide the safety net of when to seek urgent medical help. Done properly, this process builds trust and ensures manipulation is used at the right time, for the right reason, in the right person. The wise words of my former boss, Ulrik Sandström, still resonate with me: “It works for some of the people, some of the time”, much like any other therapy, not just spinal manipulation.

Perhaps the most underappreciated role of manipulation is its ability to open a conversation rather than bring it to a close. When used appropriately, it can help build trust, reduce fear, and give patients a sense of momentum early in their care. However, that moment should act as a doorway, not a destination. The real work often happens afterwards — in the exercises patients actually complete, the beliefs they quietly reframe, and the confidence they rebuild in their own bodies.

Too often, this is undermined by what can only be described as a verbal chiropractic beat-down. Patients are told, “Your head is too far forward”, “Your hips are rotated inwards”, “You’ve got the flattest feet I’ve ever seen”, or “This muscle isn’t working — it’s very weak”. Faced with a list of perceived faults, it’s hardly surprising that the default conclusion becomes that spinal manipulation is the only solution. The problem isn’t the intervention itself, but the narrative built around it.

I often say to students when teaching communication skills: if your patient wasn’t body-dysmorphic when they walked in, there’s a real risk they will be by the time they leave. This kind of fear-based messaging is rarely ill-intentioned, but it reinforces a passive model of care. It keeps patients dependent on being ‘fixed’, rather than empowering them through a more active, collaborative, and resilient approach to recovery.

When framed this way, manipulation stops being the headline act and becomes what it arguably always should have been: a supporting character. Useful, sometimes impressive, occasionally indispensable, but never the entire story and a very essential working cog.

In short: manipulation is neither mystical nor malevolent. It’s a tool - a powerful one at that - but not the only one in the box. Our job is to use it wisely, avoid overuse, and remember that sometimes the most heroic thing we can do for a patient is advise, reassure, educate, signpost…or just leave it be.

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