The manipulation solution

[Jon Newman]

I am currently reading a textbook on microeconomics that, to my surprise, has an awful lot to say about what I do for a living. Even though the following selection is not specific to microeconomics, its early appearance in the book caught my attention.

Many people don't understand the role of theory. Perhaps you have heard, "Oh, that's fine in theory, but in practice it's another matter." The implication is that the theory provides little aid in practical matters. People who say this fail to realize that they are merely substituting their own theory for a theory they either do not believe or do not understand. They are really saying, "I have my own theory that works better."

All of us employ theories, however poorly defined or understood. Someone who pounds on the Pepsi machine that just ate a quarter has a crude theory about how that machine works and what went wrong. One version of that theory might be "The quarter drops through a series of whatchamacallits, but sometimes it gets stuck. IF I pound on the machine, THEN I can free up the quarter and send it on its way." Evidently, this theory is pervasive enough that many people continue to pound on machines that fail to perform (a real problem for the vending machine industry and one reason newer machines are fronted with glass.) Yet, if you were to ask these mad pounders to explain their "theory" about how the machine operates, they would look at you as if you were crazy.

Or at least they would think you’re incorrigible if you kept asking about theory. None the less I believe, whether it is admitted or not, a therapist who manipulates has a theory “however poorly defined or understood” behind why they need to perform the HVLA thrust and what it is doing.

It may be of benefit to start by specifying the variables that are relevant to the solution. John Childs has recently established some of the variables associated with the solution (with at least one particular manipulation). These variables are (hopefully) well known but may not be the only variables that people feel are relevant to the solution. After we develop a working list of variables I think it would be important to specify some assumptions we are making. Lastly we could come up with some hypotheses to test.

I’m hoping to encourage people to come up with the solution to manipulation; a free market of ideas if you will. I hope the discussion remains largely on task in coming up with the manipulation solution and any fierce conversation is toward this end. Please support your thoughts as you can.

I look forward to your thoughts.

[Diane]

the manipulation solution

Please clarify. To me, manipulators ARE like

Someone who pounds on the Pepsi machine

...

[Jon Newman]

Hi Diane,

We all are like people who pound on Pepsi machines in the sense that our theory drives our practice, but you can see how the analogy caught my eye.

I guess what I mean is that manipulation clearly works for some people. The idea here is to talk about why. To find the correct answer, the best we can, to the puzzle. Many are quite concerned about the "exact mechanism" as if there is only one to begin with but I'm more concerned about applying what we already now about how the body works and applying that info as best we can. I've heard some people begin to explain this phenomena we observe and I'm hoping to encourage that.

I think subluxation theory has already been deemed insufficient at best if not completely wrong but if someone has some reason they feel they can run with it, feel free.

[EricM]

Are you hoping the discussion will include lower grade mobilisation as well? Or is the intent to lump them together as Diane's mobilipulators? Just want to be clear.

eric

[Jon Newman]

Hi Eric,

Good question. I'm quite sure some variables used to explain manipulation will also explain other approaches to care. I think these should be included in the whole of the explanation. After the thread goes on maybe we can pare down aspects that may be particular to manipulation if there are any such unique offerings.

[nari]

A wee bit of history - in the 1980s, movement = reduction of pain. So everyone mobilised joints from Gr1-4, and those with the appropriate piece of paper sometimes added a Gr5 (HVLA). People got better. Looking back, nobody knew why; but the meme stayed - free up a joint and pain will decrease or go away.
The fact that to get to a joint one has to touch/palpate with varying force through skin and subdermal structures was never considered until the last several years; and now the speculation that the pain relieving mechanism is neuromodulation seems logical. People still crack interphalangeal joints - and it feels good; people perform self manips and they feel good. The stiffness=pain meme was still loking good, but doubts crept in. Why weren't ALL stiff people in pain?? So stiffness/poor posture looked poor candidates for the pain experience; and this has been more or less shown to be accurate.

A rotated or "subluxed" joint in the spine is under severe questioning; Maitland describes the distinct changes in the topography of a vertebral joint in relation to its neighbours to be "thickening". No-one knew why thickening occured. After a manip or even a Gr3,4, the 'thickening' vanished. Why?

With an awful lot of unanswered questions, the big question remains: what gives the instantaneous pain relief? The only logical possibility is: rapid neuromodulation through mechanoreceptors...surface and subdermal.
If there is strong argument for "putting the joint back in place" - I would need some convincing to swallow that bottle of Pepsi.

Nari

[EricM]

Putting pain aside for a moment, is there any evidence that manipulation decreases joint stiffness or improves movement?
I have been manipulated a number of times in the past but not once has the manipulator ever repeated the clinical 'motion' tests that were used to determine I needed a good cracking. I'm not personally aware of any such studies that look at this measure either.

Eric

[Jon Newman]

Hi Nari,

I happen to be one of those people who cracks their knuckles with infrequent regularity. It feels good and I have no idea what exactly prompts me to do it but I do know that it is not pain. I'm sort of the same way with massage though. It seems to feel the best when I'm not actually in pain. Perhaps it's just me.

Eric, my fingers don't move better before or after a crack them. Perhaps others have a different experience.

As far as variables that predict success with manipulation (that list I referred to) we know we can include, at least:

1. No symptoms distal to knee
2. Short duration of LBP (<16 days)
3. Normal hip rotation of at least one hip
4. Low FABQ score (<19)
5. Spinal hypomobility at any level of lumbar spine
6. Oswestry LBP questionnaire of a 30% or greater

Other variables can be explored but because of limited studies rational speculation will have to occur. What other variables do you feel might predict pain relief?

[nari]

I am a knucklecracker too, and it is rarely for pain reasons. Just feels good to hear the pops and cracks. But I won't buy placebo effect alone....I don't think.
Expectation?...maybe.

Adding to the list:

Expectation of a quick fix
Anticipation of a quick fix.
Placebo
Neuromodulation through tissues where the most movement would occur - roughly in the area of hypomobility and / or pain....-->
torsion of the dermal and subdermal structures producing lengthening prior to the HVLA - a prerequisite to 'success'?

As for evidence that manips increase ROM, ??? Anecdotally, that seems to be the case. Haven't found anything to support that hypothesis, but maybe I haven't looked hard enough.

Nari

[matt c]

The Spine Journal 2 (2002) 357–371
Review Article
Neurophysiological effects of spinal manipulation
Joel G. Pickar, DC, PhD*
Palmer Center for Chiropractic Research, 1000 Brady Street, Davenport, IA 52803, USA
Received 23 February 2001; accepted 15 May 2002
Abstract
Background context:

Despite clinical evidence for the benefits of spinal maniputation and the apparent wide usage of it, the biological mechanisms underlying the effects of spinal manipulation are not known. Although this does not negate the clinical effects of spinal manipulation, it hinders acceptance
by the wider scientific and health-care communities and hinders rational strategies for improving the delivery of spinal manipulation.
Purpose: The purpose of this review article is to examine the neurophysiological basis for the effects of spinal manipulation.
Study design :
A review article discussing primarily basic science literature and clinically oriented basic science studies.
Methods: This review article draws primarily from the peer-reviewed literature available on Med- line. Several textbook publications and reports are referenced. A theoretical model is presented de-
scribing the relationships between spinal manipulation, segmental biomechanics, the nervous system and end-organ physiology. Experimental data for these relationships are presented.
Results: Biomechanical changes caused by spinal manipulation are thought to have physiological consequences by means of their effects on the inflow of sensory information to the central nervous system.
Muscle spindle afferents and Golgi tendon organ afferents are stimulated by spinal manipulation. Smaller-diameter sensory nerve fibers are likely activated, although this has not been demonstrated di-
rectly. Mechanical and chemical changes in the intervertebral foramen caused by a herniated intervertebral disc can affect the dorsal roots and dorsal root ganglia, but it is not known if spinal manipulation directly affects these changes. Individuals with herniated lumbar discs have shown clinical improvement in response to spinal manipulation. The phenomenon of central facilitation is known to increase the receptive field of central neurons, enabling either subthreshold or innocuous stimuli access to cen-
tral pain pathways. Numerous studies show that spinal manipulation increases pain tolerance or its threshold. One mechanism underlying the effects of spinal manipulation may, therefore, be the manipulation’s ability to alter central sensory processing by removing subthreshold mechanical or chemical stimuli from paraspinal tissues. Spinal manipulation is also thought to affect reflex neural outputs to both muscle and visceral organs. Substantial evidence demonstrates that spinal manipulation evokes
paraspinal muscle reflexes and alters motoneuron excitability. The effects of spinal manipulation on these somatosomatic reflexes may be quite complex, producing excitatory and inhibitory effects.
Whereas substantial information also shows that sensory input, especially noxious input, from paraspinal tissues can reflexively elicit sympathetic nerve activity, knowledge about spinal manipulation’s effects on these reflexes and on end-organ function is more limited.
Conclusions: A theoretical framework exists from which hypotheses about the neurophysiological effects of spinal manipulation can be developed. An experimental body of evidence exists indicating that spinal manipulation impacts primary afferent neurons from paraspinal tissues, the motor control system and pain processing. Experimental work in this area is warranted and should be encouraged to help better understand mechanisms underlying the therapeutic scope of spinal manipulation. © 2002
Elsevier Science Inc. All rights reserved.

[bernard]

Neurophysiological effects of spinal manipulation
Joel G. Pickar, DC, PhD*
Palmer Center for Chiropractic Research

[Luke Rickards]

Welcome Matty.

Bernard,
I'm sure there are some DCs who are genuinely interested in a plausible explanation for the mechanisms of their technique.

Looks like he agrees with Nari.

One aspect of manipulation that intrigues me is the fact that most research shows that cavitation (the pop) is not associated with better outcomes, yet without it you don't get that acute 'feel good' sensation immediately after. Is there a difference between the neuromodulation mechanisms for manipulation analgesia and those for manipulation euphoria?

Luke

[bernard]

Originally Posted by Luke

Bernard,
I'm sure there are some DCs who are genuinely interested in a plausible explanation for the mechanisms of their technique.

I totally agree. Welcome Matt.

[Luke Rickards]

Matt,
Do you have access the pdf or reference list of that paper?

[bernard]

Luke,
many abstracts but few full texts. See related links.
Neurophysiological effects of spinal manipulation.

http://dx.doi.org/10.1016/S1529-9430(02)00400-X

[Jon Newman]

Hi Nari,

I think expectation is a player in the equation. The difficulty is assessing this feature. Many people are willing to admit or know they have an expectation but plenty of people simply have an implicit expectations. As I consider expectations, they are quite similar to personal theories of how things work and the difficulty of assessing this is highlighted in my opening analogy. If we add it to our list I think it would be best to have some literature supporting that expectations are important in pain relief.

Luke,

Thanks for the contribution. I think it is helpful to rule out variables that are otherwise potential elements of the theory. I've read that and I'll try to post the reference unless someone beats me to it.

Matt,

I'm glad to see someone is looking to describe manipulation's neurophysiological effects. I know there is some literature out there but it is few and far between. I'd like to see more if you have anything other than the suggestion that the affect might be neurophysiological. I think Tim Flynn's study points toward that factor being a strong player amongst explanations given the lack of mechanical problems in the final predictor variables and the sheer number of mechanical problems that were considered but excluded in the study.

[Gil Haight]

Jon,
I appreciate your efforts here particularly with regards to your comment on implicit expectation. At the risk of being glib however I have to ask- how do we know whether or not a manipulation occured?
Gil

[Jon Newman]

Hi Gil,

I'll have to leave the answer to that question to those who make this their preferred approach to care. I can only presume that if a high velocity thrust is performed after taking up slack of a composite ROM that "a manipulation" has occurred, whatever that means. As far as I know, no one who actually uses this technique has chimed in. Matt might but I don't know.

[Jon Newman]

J Manipulative Physiol Ther. 2006 Jan;29(1):40-5.

The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain.

Flynn TW, Childs JD, Fritz JM.

OBJECTIVE: To determine the relationship between an audible pop with spinal manipulation and improvement in pain and function in patients with low back pain. METHODS: In this pragmatic study, 70 patients from a multicenter clinical trial were randomly assigned to receive high-velocity thrust manipulation and included in this secondary analysis. Patients were managed in physical therapy twice the first week, then once a week for the next 3 weeks, for a total of 5 sessions. A single high-velocity thrust manipulative intervention purported to affect the lumbopelvic region was used during the first two sessions. Therapists recorded whether an audible pop was heard by the patient or therapist. Outcome was assessed with an 11-point pain rating scale, the Oswestry Disability Questionnaire, and measurement of lumbopelvic flexion range of motion. Repeated measures analyses of variance were used to examine whether achievement of a pop resulted in improved outcome. RESULTS: An audible pop was perceived in 59 (84%) of the patients. No differences were detected at baseline or at any follow-up period in the level of pain, the Oswestry score, or lumbopelvic range of motion based on whether a pop was achieved (P > .05). The odds ratios and 95% confidence intervals for achieving a successful outcome at each of the follow-up periods all approximated a value of 1, suggesting no improvement in the odds of successful outcome among patients in which an audible pop occurred. CONCLUSIONS: The results of this pragmatic study suggest that a perceived audible pop may not relate to improved outcomes from high-velocity thrust manipulation for patients with nonradicular low back pain at either an immediate or longer-term follow-up.

PMID: 16396728

Also by some of the same authors

Arch Phys Med Rehabil. 2003 Jul;84(7):1057-60.

The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain.

Flynn TW, Fritz JM, Wainner RS, Whitman JM.

OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted.Main Outcome Measures: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.

PMID: 12881834

[junglelord]

the answer is easy as to why it works only sometimes.
#1 was it truly subluxed
#2 that sublux was the primary restriction.

that is the answer as to why any individual treatment approach corrects a portion of the population....usually instantly.
they really had what the treatment proposes to correct, and that restriction was the primary restriction in the body.

thats why i do

Joint mobilizations
Fascial
Muscle
whats the patient primary restriction?...the rest are secondaries...
and nothing goes on without the neurological model added....of course!
nothing!
Neurological is not the only way to effect change...some joints do need to be moved.
especially if it is subluxed and the primary.
otherwise it is useless.

when i was a kid in school if you banged on a lot of things they gave free stuff, or returned your change!
especially drink machines...
that of course is giving away my age, and how much better pepsi machines are!
now if you find a really old pepsi machine, and it takes your change, give it a shot, it might work, otherwise, wise up and quit banging!

we are all handymen/women and if you have all the tools you can fix anything (that is not organic) but if you use a hammer for everything, i bet your work is hit and miss, and not always works the way you want...
wrong tool, wrong job.
the belief that any one tool is the perfect tool...makes one a tool.
the ability to identify the primary and have the tools to treat it, makes you a handyman, not a tool man.
right tool, right job, instant success each and everytime, why?
primary and correct tool and the knowledge nothing stands alone.
ever look at a handymans collection?
they got things in there you don't even know what it's for....but for just one certain job, you need that tool...hardly ever, but sometimes, you get a call for that job, and if you do not have that tool, then lets not take out the hammer!
therefore I bet any therapy that has success is because someone had what they said they had, and that guy knew what to do for that job....
so why so much debate over this does not work, that does not work...
it only works for the patient that requires it, it is not the fix all to end all.
if you fail to include the tools, and believe that other therapies are not effective, then how can you do a good job all the time?
if you recognize the simple elegant truth in what i have said, your ego will die, your mind will open up and you will be able to be the handyman, you wish you could be.
the primary, the correct tool...
lots of good therapies...if it is not beyond your scope of practice, then get in their man and throw away the disbelief and see who needs which tool...
instant success every time, open mind, full tool box, handyman.

and again everything is neurological wrapped around a primary of either joint, fascia, muscle...loaded with tons of secondaries!

now back away from the pepsi machine!

[Barrett Dorko]

I thought you were leaving.

This stream of consciousmess (pun intended) type of posting probably isn't going to help your cause, assuming you actually have a coherent thought in here or a line of reasoning that would best be articulated in something other than an unpunctuated sonnet pattern of your own invention.

Unless rudimentary sentence structure is something foreign to you I'd suggest you consider using it convey whatever the heck it is you're talking about. I read constantly and I can't figure it out.

Oh yes, I don't think it's my ego, in case you were thinking about that sort of comeback.

[Jon Newman]

I'm trying to catch up on some citations. Here's a few references (only some of which I had or could read the full text) as it pertains to expectation.

Author: Brodal P.
Title: [The neurobiology of pain]. [Norwegian]
Source: Tidsskrift for Den Norske Laegeforening. 125(17):2370-3, 2005 Sep 8.

Abstract

The nociceptive system enables us to respond in time to external threats that otherwise would produce tissue damage. By monitoring tissue composition the system also contributes to bodily homeostasis. Nociceptors signal mechanical stress, extreme temperatures, cell injury and inflammation. Powerful modulation of nociceptive signals occurs in the spinal dorsal horn, so that their further transmission to the brain can be enhanced or inhibited. A vast array of transmitters and receptors are responsible for complex synaptic interactions in the dorsal horn. Synaptic plasticity alters neuronal excitability for hours to months (years?), contributing to hyperalgesia and chronic pain. Descending monoaminergic connections from the brain stem can inhibit or facilitate the signal transmission from nociceptors. These systems are partly controlled by ascending signals from the dorsal horn, partly by descending connections from amygdala, hypothalamus and the cerebral cortex. The latter are thought to contribute to context-dependent pain modulation. The subjective experience of pain correlates with increased activity in a cortical network including the insula, the cingulate gyrus and some other areas. The activity of the network is also positively correlated with expectation of pain, and negatively correlated with expectation of pain relief--independent of nociceptor stimulation.

Another

Unique Identifier 15745708
Authors Haour F.
Title [Mechanisms of placebo effect and of conditioning: neurobiological data in human and animals]. [Review] [42 refs] [French]
Source M S-Medecine Sciences. 21(3):315-9, 2005 Mar.
Abstract
A placebo is a sham treatment such as pill, liquid, injection, devoid of biological activity and used in pharmacology as a control for the activity of a drug. In many cases, this placebo induces biological or psychological effects in the human. Two theories have been proposed to explain the placebo effect: the conditioning theory which states that the placebo effect is a conditioned response, and the mentalistic theory for which the patient expectation is the primary basis of the placebo effect. The mechanisms involved in these processes are beginning to be understood through new techniques of investigation in neuroscience. Dopamine and endorphins have been clearly involved as mediators of the placebo effect. Brain imaging has demonstrated that the placebo effect activates the brain similarly as the active drug and in the same brain area. This is the case for a dopamine placebo in the Parkinson'disease, for analgesic-caffeine- or antidepressor-placebo in the healthy subject. It remains to be understood how conditioning and expectancy are able to activate, in the brain, memory loops that reproduce the expected biological response.

Here's one describing the difficulty assessing this phenomena

Authors Stone DA. Kerr CE. Jacobson E. Conboy LA. Kaptchuk TJ.

Title Patient expectations in placebo-controlled randomized clinical trials.
Source Journal of Evaluation in Clinical Practice. 11(1):77-84, 2005 Feb.

Abstract
OBJECTIVE: To explore participants' experience in placebo-controlled randomized clinical trials (RCTs) specifically in relationship to their expectations. BACKGROUND: Aspects of being in RCTs, such as informed consent, perception of benefit and understanding of randomization, have been examined. In contrast, little is known concerning the formation of patient expectations before and during trials. METHODS: Qualitative methods using in-depth interviews with a semi-structured interview guide of nine patients from four different RCTs. Data analysis was conducted using a codebook format arranging participant responses under broad analytical headings. The interviewer used a semi-structured interview guide to direct the conversation from one broad topic to the next within the context of the ongoing conversation. A checklist of topics encouraged participants to describe their experiences in RCTs. Narratives concerning expectation, blinding and placebo were compared to identify common themes. RESULTS: Patient anticipatory processes were influenced and modified both before and during the trial from multiple inputs. Such factors as past experiences in RCTs, past experiences of ineffective treatment, stress of being off regular medications, fear of being a 'placebo responder', input of non-study doctors or other health professionals, the experience of other participants, measurements of health parameters made during the trial and the presence or absence of side-effects all affected patient expectation. CONCLUSION: Expectations in RCTs are not fixed and instead may be viewed as continuously shaped by multiple inputs that include experience and information received both before and during the trial. Variability in placebo response observed in previous studies may be related to the fluid nature of expectations. Trying to control and equalize expectations in RCTs may be more difficult than previously assumed.

Finally, I thought this article had some interesting insights as it pertains to expectations.

Spine. 2002 Feb 1;27(3):291-6; discussion 297-8.

Patients using chiropractors in North America: who are they, and why are they in chiropractic care?

Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG.

SUMMARY OF BACKGROUND DATA AND OBJECTIVES: Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why. METHODS: The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient's reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors. RESULTS: More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care. CONCLUSION: These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

PMID: 11805694

A particular point from the last citation above seems pertinent here:

both the patients and chiropractors in our sample tended to agree with some of the key tenets of chiropractic theory, with the patients holding them more strongly than the chiropractors. Because we have no comparative data to determine if these beliefs are unique to chiropractic or whether the congruence between the chiropractor and the patient is closer than with other providers, these results can only be suggestive. This congruence of beliefs may in part explain why some people seek chiropractic care. Other studies have shown that postmodernist values are the most predictive of attitudes toward complementary and alternative health care. Earlier research on chiropractic patients also suggested that compatibility of belief systems was a powerful element in the chiropractic health encounter.

[nari]

Interesting thoughts here, jon.

In the study of expectations and the placebo-controlled RCTs, I think it clearly points out, as we suspected, that control/measurement of expectations would be almost impossible. Like blood pressure, they will change from minute to minute, pre-, peri- and post-trial. At best, an RCT would show a sort of trend.

In the patient/chiro survey, no surprises. The general public does not know what PTs do, apart from exercises, modalities and what they call 'massage'; whereas they know chiros "put spines and hips back into place" and that they manipulate. It all sounds much more dramatic. Even a chiro who does not support the subluxation meme would find his/her patients do.

nari

[bernard]

Hi all,
Here is the paper.
Neurophysiological effects of spinal manipulation

[Luke Rickards]

I can only presume that if a high velocity thrust is performed after taking up slack of a composite ROM that "a manipulation" has occurred, whatever that means. As far as I know, no one who actually uses this technique has chimed in.

Both Matt and I were quite highly trained in HVLA at uni (3 years of classes). According to our training, a manipulation has been performed if there is a cavitation. The 'pop' is seen as the goal, and if you can't get it then you "can't adjust". As the papers Jon posted point out, this definition of a manipulation has little to do with outcomes. I remember an old osteopath once rapidly pulling his finger backwards twice in exactly the same motion each time. Only the first produced a 'pop'. He asked, "Which one did the most good?"

In the October issue of the (now International) Journal of Osteopathic Medicine, the same issue containing Barrett's Analgesia of Movement, there is an article titled "Intervertebral dysfunction: a discussion of the manipulable spinal lesion". This article reviews theories for an essential diagnosis that might lead one to consider manipulation (not necessarily high-velocity) as a logical intervention. Some of these address acute spinal pain and others chronic pain. These include neurological models (inlcuding muscles contraction), meniscoid entrapment/extrapment, z-joint sprain, caspular inflammation, peri-articluar adhesion, nucleus pulposis displacement, fat pad dysfunction. Perhaps we should dissect these as well (eg I don't know why you would want to manipulate someone with a joint sprain).

I sometimes have patients with very localised spinal pain who say that their pain feels like something is "locked" or "stuck" or "jammed" etc (Bogduk suggests a plausible explanation for this symptom is meniscoid entrapment). I know that if I give them a gentle manipulation (in these cases, now the only ones I use HVLA for, you don't seem to need much force) then the relief is instant and I don't see them again for the same problem. Interestingly, quite often immediately after the 'pop' they start to giggle like a naughty school kid and will chuckle uncontrollably few for several minutes. I have actually had this myself, and I know Matt has too. Any ideas? I would have thought endorphin release but there doesn't seem to be evidence that manipulation results in increased endorphine secretion.

Luke

[junglelord]

sorry double post.

[junglelord]

primary is the cause
secondary is an effect.
if you use a therapy modality with instant success, then the technique matched the cause.

same theapy different patient, but no results, the lesion you are addressing this time in this patient is an effect...not the cause.
simple enough?

chiros by and large are not handymen because they only tend to rely on hammers (HVLAT).
if your subluxation is the primary or the cause of all your problems then all you need is a hammer.
if you have a subluxation secondary (effect) from another primary (cause) be it fascial, muscle, scar, etc, then put the hammer down...
how do you know it is not a primary?
the patient has no relief!
is that simple enough Dorko?

so how full is your toolbox?
are you a handyman, or a toolman?
are you treating cause or effect....is everything one cause?
therefore correct tool (therapy) for correct primary.

i spend an hour with a patient, i do not do things over and over, I have lots of tools, and i have yet to see a cause without effects.
so i treat all the systems within that hour, so by trial or circumstance i will treat the primary.
again since primarys always have secondaries, i tend to know what the primary is due to experince and i think it important to smooth out the secondaries...that fills in an hour of Integrative Systems Therapy.
those with less experience in determining the primary will still be successful, because they treat each system anyway.
so they treat cause and effect...which in itself must be successful.
since a one hour treatment is average in our proffesion, it only makes sense, keeps you from getting board, and the patient is addressed at every level of dysfunction.
after all how many times do you want to do the same thing for an hour?
I treat joints, fascia, muscle, bones, skin, ANS.
there are great therapies out there for each system.

PS hows my spelling, sentence structure, and grammer?

[Barrett Dorko]

In that last sentence you misspelled "How's" and "grammar."

[Jon Newman]

Jungle your random ecclectic approach is certainly simplistic enough. Since this thread is specific to those that respond positively to manipulation I'm exploring what is going on. Your vote that a subluxation was reuduced is duly noted.

[chiroortho]

We may be able to reach a consensus on one thing: manipulation of the lumbar spine provides quick relief of lower back pain in many individuals.

That said, there are many questions that should be addressed relative to the utility of manipulation. First, is it safe? Second, is the 'dysfunction' to which it is purportedly directed actually there? Third, how can we be sure that we have addressed the dysfunction by manipulation? Fourth, are there other, more effective ways to accomplish the desired change?

Since chiropractors are the (relatively) pre-eminent users of manipulative techniques, I wish that we were also the pre-eminent researchers of manipulative techniques. Unfortunately, this does not seem to be the case. However, that fact does not diminish the fact that manipulation seems to be very helpful to many sufferers of lower back pain.

My impression is that manipulation of the lumbar spinal joints is not specific, does not reposition anything for any significant length of time, and is generally very safe. Yes, even HVLA. In fact, as to safety, I would go so far as to assert that use of HVLA in the lumbar spine is safer than using hot packs. Yet when we use manipulation in the lumbar spine we must also acknowledge that some patients do not feel better, and some feel worse.

Thank you for this thread, and I appreciate the thoughtful responses of all that have posted. I hope that the 'tool' of manipulation isn't dismissed as useless simply because we chiropractors utilize it. By the way, I'm not asserting any relevance of manipulation as addressing the 'chiropractic subluxation'. I reject the subluxation theory for many reasons, not the least of which is on a practical basis that if it hasn't been proven to exist in the past 100 years, it is very unlikely to be proven any time soon.

[Luke Rickards]

if you use a therapy modality with instant success, then the technique matched the cause

Jungle,

Wrong. A positive response to treatment does not validate the treatment hypothesis.

[junglelord]

what does it validate then if not that the patient has that dysfunction as the primary (not hypothesis)?
theories will come and go, success will never disappear.
the body is a set of systems, we all that learned in school.
no one walks in missing one of those systems.
i treat a with a wholebody whole systems approach.
not simplistic....holistic.
no one system is the cause of every problem.
no one cause is without it's effects.
again there are lots of good therapies for each system.
the body being a complex synergy of those systems cannot be reduced to a one therapy approach.

And the chicken or egg question should pop into your mind at some point (cause vs effect).

since that is almost impossible to figure out every time, the first time....
then if you have a 60 min slot like i do, then you treat every dyfunction present with each system.
again, hit or miss, the cause and its effects will be treated.

If you see a chiro and you are instantly better, then yes that was the primary...but if it keeps going out of place, look else where.
if spend more then 5 mins with a patient, then you will have time to treat each system dysfunction.

and yes subluxations are real, but not always the main cause for their presence.

when it is the main cause, one adjustment, and you are better, and will not be back.

reductionism only reduces your success...
name me one patient that presents without any of the systems you learned in school...
and just why did you learn all those parts and sytems in the first place if one thing fixes everything?
because no one thing fixes everything...so put that schooling to good use.
so then tell me why joints, bones, fascia, skin, muscle, ANS, would not be involved in the cause and effect relationship.
manuel therapy is like martial arts, and a arguement over which is best...this mentality is so stupid.
chiro don't work, physio don't work, fascial therapy don't work, blah blah blah
along came Bruce Lee, and he said it is all important!
He was correct.
Be water my friend.
the only great debate is how anyone could have so much schooling, learn everything, then think only one thing matters.
Or that you can treat with so much prejudice and ego, that certain systems do not matter.
The service of the patient should be the focus of your practice, not your ego.
unless you have 100% results then maybe you should include therapy for each specific systems, then your ego has lost BUT your patient has won.
ARE YOU A REPEAT OFFENDER?
how many times does your patient repeat a treatment.
how long before you fill up that tool box?
am i making any sense to anyone out there?

[nari]

chiroortho,

I for one agree that a HVLA can be highly effective; its effect may be temporary (or not) and it would be a very useful thing to include in a Rx plan.

Can you say what you understand is the physiological rationale behind the rapid relief, for either pain or dysfunction or both, that a manip gives? There are so many hypotheses out there and always have been, yet no-one seems to be close to an explanation....yet.

Nari

Jungle:

Am I making any sense to anyone out there?

No.

[Jon Newman]

One of my favorite commercials on TV right now is for a cellular phone provider and centers on a fellow in a cubicle poking pins in a voodoo doll. His co-worker is quizzing him about the dolls and comes to find out that one of the dolls is for late fees and the other is for "overage" charges. This co-worker informs the voodoo practitioner that company x has done away with those charges. The voodoo practitioner looks at his dolls in astonishment and says "It works!"

Jungle,
Y following x does not mean x caused y.

[chiroortho]

Nari I've come to the conclusion that the simplest explanation is oftentimes the best, and in the case of pain, it would likely be the stimulation of mechanoreceptors that results in relief. As to improvement in segmental mobility, it would be improvement of discomfort => better movement/less spasm. Stretching of the articular capsule is an important factor in my opinion.

I realize that there are lots of fancy mechanisms postulated to be the essence of manipulations' effects. Perhaps they're right. But for me the simplest explanation is hard to beat.

Greg

[Jon Newman]

Hi Greg,

While I disagree that stimulation of the mechanoreceptor is the best explanation for pain relief with spinal manipulation it certainly could be one of the variables we add to our list. Please add any citations that help support this (I know there are some).

[Diane]

My question about mechanoreceptors would be, which ones/where exactly? And how do you know?

[Jon Newman]

Hi Bernard,

Thanks for that JG Pickar article. I'm doubtful I'll get as deeply into it as some other articles I read, but I could be wrong. One reason is that early on the author states "During spinal manipulation, the practitioner delivers a dynamic thrust (impulse) to a specific vertebra. The clinician controls the velocity, magnitude and direction of the impulse." However it would seem that we now know that a specific vertebra is not manipulated nor is anyone able to truly control those elements as it pertains to its specific effect on the vertebrae. In fact the author later states in the same section, "The large variability in the applied forces and durations should be recognized. the impact of this variability on the biological mechanisms that could contribute to the clinical effects of manipulation is unknown." It decreased my motivation to read the many pages of rational speculation that followed. Also the premise of this understandably lengthy examination is as follows

Spinal manipulation, then, theoretically alters the inflow of sensory signals from paraspinal tissues in a manner that improves physiological function. This explanation comprises one of the most rational neurophysiological bases for the mechanisms underlying the effects of spinal manipulation.

I can't disagree with that statement but isn't alteration of inflow of sensory signals the basic explanation of virtually all therapeutic treatments (minus those willing to talk about the alteration of outflow and processing)?

I haven't given up on it yet but unless someone points to this paper as containing the best summary of manipulation theory to date I don't feel compelled to go through it with a fine tooth comb. Has anyone else attempted a reading of it yet?

[nari]

I didn't read it fully, (getting distracted by geology again) but the conclusion, quoted in your post, jon, tells us nothing, really. There has to be something, I presume, that distinguishes a (passive) HVLA from a Gr4+ mob, for instance; or do they result in the same outcome consistently? (the latter is a lot tougher on the therapist's thumbs..) or PPIVMs, which I understand are shown to be nonspecific as well??

Nari

[chiroortho]

Good questions, great discussion.

Jon and Diane, it may be of interest to you that an RCT is in progress relative to SMT/NSAIDs for acute low back pain. Here is the reference:

Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617]
Mark J Hancock,1 Christopher G Maher,1 Jane Latimer,1 Andrew J McLachlan,2 Chris W Cooper,3 Richard O Day,4 Megan F Spindler,1 and James H McAuley1

1Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
2Faculty of Pharmacy, University of Sydney, NSW, 2006, Australia
3Discipline of General Practice, Balmain Hospital, 37A Booth St, Balmain, 2041, NSW, Australia
4Clinical Pharmacology, UNSW & St Vincent's Hospital, Darlinghurst 2010, NSW, Australia

As to the postulated role of mechanoreceptors in SMT/LBP, here is one study that may be of interest, as it addresses the issue from an interesting standpoint:

J Manipulative Physiol Ther. 2005 Nov-Dec;28(9):673-87. Related Articles, Links


High loading rate during spinal manipulation produces unique facet joint capsule strain patterns compared with axial rotations.

Ianuzzi A, Khalsa PS.

Department of Biomedical Engineering, Stony Brook University, HSC T18-030, Stony Brook, NY 11794-8181, USA

PURPOSE: Lumbar spinal manipulation (SM) is a popular, effective treatment for low back pain but the physiological mechanisms remain elusive. During SM, mechanoreceptors innervating the facet joint capsule (FJC) may receive a novel stimulus, contributing to the neurophysiological benefits of SM. The biomechanics of SM and physiological axial rotations were compared to determine whether speed or loading site affected FJC strain magnitudes or patterns. METHODS: Human lumbar spine specimens were tested during physiological rotations and simulated SM while measuring applied torque, vertebral motion, and FJC strain. During physiological rotations, specimens were actuated at T12 to 20 degrees left and right axial rotation at 2 degrees to 125 degrees per second. During SM simulations, a 7-mm impulse displacement was applied to L3, L4, or L5 at 5 to 50 mm per second. RESULTS: Physiological rotations. Increasing displacement rate resulted in significantly larger torque magnitudes (P < .001), whereas vertebral kinematics and FJC strain magnitudes were unchanged (P > .05). Physiological rotations vs SM. Applied torque and vertebral rotation magnitudes were similar across speed and vertebral level. Total vertebral translations were slightly larger during physiological rotations vs SM at a given loading rate (P < .05). Patterns of vertebral motions and FJC strain during SM and physiological rotations varied significantly with loading rate (P < .05) but not with actuation site (P > .15). CONCLUSIONS: The similar patterns observed in vertebral motion and FJC strain across actuation sites during SM and physiological rotations suggest that site specificity of SM may have minimal clinical relevance. High loading rates during lumbar SM resulted in unique patterns in FJC strain, which may result in unique patterns of FJC mechanoreceptor response.

PMID: 16326237 [PubMed - in process]

Both of these studies are very recent, and I hope that you find them useful. (The first article is available free in its entirety, but the second is not; if you don't have access to the full-text version, I would be happy to summarize the salient points for you).

Interesting discussion, thanks.

Greg

[Jon Newman]

Hi Greg,

Thanks for the references. We could add that to the list of variables but it may be premature at this point as there has been no study (that I know of) of the neurophysiological response of the facet joint receptors corresponding to the unique strain that HVLA produces. Also, I'm not certain how that relates to nociception except that it might act as a gating mechanism. It would have to be demonstrated that deformation of the same mechanoreceptors through some other movement (active or passive) is insufficient to produce a similar neurophysiological effect (in order to actually necessitate the HVLA, not just show it works).

Hi Nari,

The author does go on to demonstrate a variety of physiological responses to manipulation many of which may occur with other types of movement also. Few of the physiological responses explored had much to do with pain per se. This may be why he stated "improves physiologic function" (which isn't definitively demonstrated in my opinion) versus relieves pain.

I'll add one more variable to the list that is fairly popular in the literature right now, the hypomobile segment. I'll add a reference a bit later.

[Diane]

From the second abstract:

During SM, mechanoreceptors innervating the facet joint capsule (FJC) may receive a novel stimulus, contributing to the neurophysiological benefits of SM.

To me this word "may" jumps out... the authors can't be definitive about it for obvious reasons.. the fact the tests were done on "human lumbar spine specimens", means there was no active perceiving brain attached to these mechanoreceptors. Also missing were several stretchy layers of body, also containing mechanoreceptors, all surrounded by skin with not only lots of mechanoreception but also sensitivity of all sorts by virtue of being hardwired into the SM cortex. So it seems to me that this is still very much a postulate and not something I'd want to accept as being a real mechanism.

[Jon Newman]

Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52.
Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain.

Fritz JM, Whitman JM, Childs JD.

OBJECTIVE: To examine the predictive validity of posterior-anterior (PA) mobility testing in a group of patients with low back pain (LBP). DESIGN: Randomized controlled trial. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Patients with LBP (N=131; mean age +/- standard deviation, 33.9+/-10.9 y; range, 19-59 y), and a median symptom duration of 27 days (range, 1-5941 d). Patients completed a baseline examination, including PA mobility testing, and were categorized with respect to both hypomobility and hypermobility (present or absent), and treated for 4 weeks. INTERVENTION: Seventy patients were randomized to an intervention involving manipulation and 61 to a stabilization exercise intervention. MAIN OUTCOME MEASURES: Oswestry Disability Questionnaire (ODQ) scores were collected at baseline and after 4 weeks. Three-way repeated measures analyses of variance (ANOVAs) were performed to assess the effect of mobility categorization and intervention group on the change on the ODQ with time. Number-needed-to-treat (NNT) statistics were calculated. RESULTS: Ninety-three (71.0%) patients were judged to have hypomobility present and 15 (11.5%) were judged with hypermobility present. The ANOVAs resulted in significant interaction effects. Pairwise comparisons showed greater improvements among patients receiving manipulation categorized with hypomobility present versus absent (mean difference, 23.7%; 95% confidence interval [CI], 5.1%-42.4%), and among patients receiving stabilization categorized with hypermobility present versus absent (mean difference, 36.4%; 95% CI, 10.3%-69.3%). For patients with hypomobility, failure rates were 26% with manipulation and 74.4% with stabilization (NNT=2.1; 95% CI, 1.6-3.5). For patients with hypermobility, failure rates were 83.3% and 22.2% for manipulation and stabilization, respectively (NNT=1.6; 95% CI, 1.2-10.2). CONCLUSIONS: Patients with LBP judged to have lumbar hypomobility experienced greater benefit from an intervention including manipulation; those judged to have hypermobility were more likely to benefit from a stabilization exercise program.

PMID: 16181937

[Jon Newman]

I just realized I had already included the hypomobile segment in an earlier post but the extra reference is pertinent anyway.

Anyone else with variables they feel are important to consider?

Greg, I appreciate your contributions. Let's keep that FJC strain thing on the list.

Luke notes that patients that state they feel like they need to be manipulated because of a feeling of a "locked joint" are people he is more likely to manipulate.

Luke, I've got a couple of questions. Is the locking sensation itself painful or does it seem to be in addition to the patient's of description of pain?

Would you be able to post a citation for the articles exploring the "manipulable lesion" in the October issue of IJOM?

Thanks.

[Luke Rickards]

Jon,

Apparently the locking/jamming is painful. The sensation is made more acute in a particular direction of movement.

Sorry, I can't post a citation becasue the journal wasn't listed on Medline in 2003.

Luke

[Jon Newman]

Thanks Luke,

Do you remember who the authors were?

[Jason Silvernail]

Great discussion.
I have long since abandoned the "joint" aspects of manipulation, and I think that the effects are almost entirely (if not 100%) neurophysiological. I'm not sure Pickar's paper covers the whole argument, but it's a good start.
After reading a lot of Barrett's work, I am beginning to think that the only reason manipulation ever works is that it provides a neurofacilitation stimulus that allows some ideomotor movement to occur.

Whether we agree or disagree with using manipulation as a tool, I agree that it is the effect we should be pursuing, and I think there are probably other ways to get that then cracking backs. Since I've no proof there is, I guess I'll continue the practice for now, but everytime I do it I kind of think "this is 21st century healthcare?". Great topic, Jon.

J

[Barrett Dorko]

Jason,

I'm very pleased to see you've returned. Do you think these issues are of any real interest to your fellow servicemen? Specifically AlexB. and Childs.

They don't exactly return my calls.

[Jason Silvernail]

Well, I can't really speak for them (though I'm sure you're not asking me to).

I believe the current push, at least to speak of my knowledge of the state of research in military PT, is to get outcomes reported from common interventions we use, to separate wheat from chaff. I believe the thrust is more clinically/outcome based research, "does treating someone with X lead to better outcomes than with Y?"
I believe many of us in the PT community are more concerned at this point with demonstrating outcomes to patients and payers than in constructing a defensible theory for why some of the things we use work. I don't believe that the theory is unimportant, just relatively less so given the pressure for outcomes from payers and other healthcare providers. Especially with our ongoing "competition" from the many other providers who treat similar problems as we do.

It is my opinion that the central difference between your position and theirs is one of research emphasis, nothing more. They don't deny these aren't pressing questions, I just think they see other questions as more integral to the survival and success of the profession in the short term.

I'm glad to be back, though a full work schedule and taking 8 credits at night for my tDPT program is keeping me busy...
J

[Jon Newman]

Jason,

Any idea when they're going to study MFR? There's apparently 50,000 therapists out there using it.