Spinal manipulation is a therapeutic intervention performed on spinal articulations which are synovial joints. 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, some describing manipulation as optional, and others recommending a short course in those who do not improve with other treatments.