If posted under different circumstances, the title of this post would be: „Spinal manipulation – is it a precise science?“. Within a day of posting this, I was given two weeks notice. I’ve done my best to keep the tone and presentation as close to the Icelandic version as I can, even if the English suffers a bit. I’m not dressing this up any fancier, just because of the circumstances under which I post.
When I originally wrote this, I was very much political about it. I made a special effort to identify areas where manipulations may be useful, and make a point of not directly recommending that patients don’t receive them. The main purpose was to first point out some limitations to the methodology behind them in this article and follow through with the mechanisms of action, and ultimately their effectiveness as an only therapy in future articles.
I’ve made comments [in brackets] that are intended as a supplement or explanation to the english reader, and those were not included in the original article.
So without further ado:
Spinal manipulation – is it a precise science?
A memorable story I once heard involved a practitioner of some sort performing some sort of motion palpation when his wrist cracked. This prompted his client to say „ahhh… just what I needed!“. I don’t know if this story is true or not, but spinal manipulations are certainly very sought after treatments in Iceland – and unfortunately many confuse popularity for effectiveness.
Professionally I’ve met many individuals who have had a poor experience with spinal manipulations, be it from chiropractors, physios, bonesetters, or osteopaths. Many of them have booked countless treatment sessions and spent considerable money without getting any real improvements. Some are unsure if the treatment has been effective or not, others are certain that it was useful.
Still, the fact of the matter is, there are many myths around about the techniques associated with spinal manipulations. I’m going to take a look at some of the research that’s been done on spinal manipulation methods: how precise they are, if they can alter the position of joints in the spine, and if choosing the right manipulation technique is important.
Spinal manipulations aren’t precise
Many believe it’s possible to influence to a large degree which spinal joints to manipulate, for example to manipulate adjacent segments to a disc herniation. Studies have been performed to test this theory using sensitive vibration sensors placed on various segments to locate the source of the „pop“ sound. The results of these suggest that for the lumbar spine, only about half the manipulations hit the targeted joint, despite most of them manipulating more than 1 segment (1). If the target may be defined as either the upper or lower lumbar spine, accuracy improves up to 70% (2), and one is pretty certain to hit the correct half (left or right) most of the time. So, if one wishes to *not* manipulate a certain segment, the safest would be to at least have a 3 segment safety margin.
Spinal manipulations don’t alter joint position
Sometimes x-rays are used to support decision making for spinal manipulations where the therapist is looking for a misaligned segment to correct with a manipulation. It actually kind of amuses me that it’s no problem to take a diagnostic x-ray, but the second x-ray to verify the changed alignment is usually too much radiation…
Thankfully, not everyone has a problem with that second x-ray to confirm that at least sacroiliac joint manipulations don’t change sacroiliac joint alignments (3). The study used manual positional testing / motion palpation that diagnosed abnormal position of the joint before manipulation, and a correct alignment after the manipulation – but with no change in the actual position of the joints on x-rays. It remains an open question [this line included a link to another blog post I wrote about motion palpation, not translated at this time] what these motion palpation tests are actually testing.
I’m not aware of compatible studies on lumbar joint positions. The closest I could find was this study that used MRI’s to assess the height of the facet joint space before and after manipulations. The MRI was taken immediately after the manipulation, before the patient could get up from the therapy bench – so the significance of the change they found is uncertain. (4)
The giant’s bite [directly translated for amusement], when there’s a sudden onset of back pain with a restricted range of motion is very painful and can be quite scary. No one has yet confirmed the mechanism behind such sudden range of motion loss, although numerous theories exist. Further, there are no studies directly on the effects of manipulations of joints in this state or if they reverse whatever is causing the loss of range of motion. I don’t see any obstacles to trying out manipulations on this patient group.
You don’t need a detailed examination to select the proper manipulation technique
A meta analysis (5) examined if there was a difference in outcomes between studies where the practitioner can select the manipulation technique used, or when the technique is chosen beforehand by the researchers and found there was no difference at all. The results suggest that the method chosen, or the methods used to select the proper technique probably matter very little if at all. A study on cervical spines did not find a correlation between cervical range of motion as measured, and as palpated to be hypomobile by a therapist (6) [the link #6 in the Icelandic version links to a different article by mistake, I’m here linking the correct one] – so using such techniques to select joints to manipulate is likely meaningless anyway. I’ve previously discussed [link to Icelandic blog post] if motion palpation can be useful, and the short answer is no – long answer in link.
These three myths are a source of a number of theories about trying to find the right technique for the right person. There is no data to back any of that up, only hundreds of years of tradition and guesswork. Only recently has it been possible to adequately study these methods with sensitive measures like imaging, but the results so far all point in the same direction: if you are going to manipulate a spine, just go ahead and manipulate a spine. No real need for a complex examination scheme beforehand.
A second installment of this article series will discuss the effects of spinal manipulations on the body, and if there’s a reason to use those effects as part of treatments. A third article will discuss the long-term clinical effectiveness of spinal manipulations on low back pain. [I include this last paragraph about planned future articles only for completeness, the second one is already published and the third one nearly complete, but they are in Icelandic]
So that was it. I’m sure (or perhaps I hope?) that readers will find this less inflammatory than they had anticipated (or hoped?). It certainly could have been more direct in it’s message, and I think it would have made a better article that way as well since the parts about possible benefits of manipulations stray away from the direct topic at hand. But while I wrote this, I was very much mindful of those reading it.