Over Manipulation Syndrome (OMS)

In this article Ross Hauser, MD. 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 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 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.

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 and suboccipital 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
• 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.

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).

In our own research presented in The Journal of Applied Research we made these points:

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).
• OMS 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.2

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. Don’t get us wrong. We like chiropractors. And in many instances 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, 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

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.

1 Padua L, Padua R, LoMonaco M, Tonali PA. Radiculomedullary complications of cervical spinal manipulation. Spinal Cord. 1996 Aug;34(8):488-92

2 Gordin K, Hauser RA. Ross Hauser, MD. The Case for Utilizing Prolotherapy as a Promising Stand-Alone or Adjunctive Treatment for Over-Manipulation Syndrome The Journal of Applied Research. 2013;13(1).

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