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  • The manipulation solution

    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.
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

  • #2
    the manipulation solution
    Please clarify. To me, manipulators ARE like
    Someone who pounds on the Pepsi machine
    ...
    Diane
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    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

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    • #3
      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.
      Last edited by Jon Newman; 02-02-2006, 04:41 AM.
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        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
        Eric Matheson, PT

        Comment


        • #5
          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.
          "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

          Comment


          • #6
            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

            Comment


            • #7
              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
              Eric Matheson, PT

              Comment


              • #8
                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?
                Last edited by Jon Newman; 02-02-2006, 05:35 AM.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #9
                  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

                  Comment


                  • #10
                    Neurophysiological effects of spinal manipulation: Review Article

                    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.

                    Comment


                    • #11
                      Neurophysiological effects of spinal manipulation
                      Joel G. Pickar, DC, PhD*
                      Palmer Center for Chiropractic Research
                      Simplicity is the ultimate sophistication. L VINCI
                      We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                      Everything should be made as simple as possible, but not a bit simpler.
                      If you can't explain it simply, you don't understand it well enough. Albert Einstein
                      bernard

                      Comment


                      • #12
                        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
                        Last edited by Luke Rickards; 02-02-2006, 02:09 PM.
                        Luke Rickards
                        Osteopath

                        Comment


                        • #13
                          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. :angel:
                          Simplicity is the ultimate sophistication. L VINCI
                          We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                          Everything should be made as simple as possible, but not a bit simpler.
                          If you can't explain it simply, you don't understand it well enough. Albert Einstein
                          bernard

                          Comment


                          • #14
                            Matt,
                            Do you have access the pdf or reference list of that paper?
                            Luke Rickards
                            Osteopath

                            Comment


                            • #15
                              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
                              Simplicity is the ultimate sophistication. L VINCI
                              We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                              Everything should be made as simple as possible, but not a bit simpler.
                              If you can't explain it simply, you don't understand it well enough. Albert Einstein
                              bernard

                              Comment

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