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Osteopaths-Chiropractors: Cracking of the bones

This is a complicated subject since there is a lot of controversy surrounding manipulations. When we think of manipulation, we think of cracks, and those cracks to ¨us¨ means that our bone just went back into its place. I think we have all had someone in our life ¨crack¨, our back, and usually afterwards we all felt better. But, what is that cracking sound, is it really our bones? Or is it something else?

Well, it´s not the bone, sorry to tell you. When you manipulate a vertebrae (bones in your back) you forcefully separate the joint surfaces, the resultant vacuum pulls in nitrogen gas to fill the space, producing a ¨POP¨(1). Once the joint pops, it may take a few hours before the gas is absorbed and the joint surfaces settle back(1). So the popping sound is really just liquid and not the bone. Most people don´t know that the vertebrae are so fixed together that you coudn´t even separate them even with a crowbar(1)!! , and that´s a good thing. So why does it feel so good when they ¨crack¨ our back and is it really safe to let someone ¨manipulate¨ your back?

The scientific community has done different trials on manipulations and they have seen that manipulating is ineffective in treating different disorders as neck pain, headache, non-spinal  primary and secondary dysmenorrhea, infantile colic, asthma  allergy, cervicogenic dizziness, just to name a few(2). They only found out that spinal manipulation was considered superior to sham manipulation but not better than conventional treatments in dealing with acute low back pain.  So their conclusion, which was published in the ¨Journal of the Royal Society of Medicine¨, stated that ¨Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition(2). Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment¨. So, how come sometimes it feels so good when someone ¨cracks¨ your back? Well, it could be simply the placebo effect, the ¨pop¨ can do magical things to people´s head, (https://sports-diet-pain.com/2013/10/18/placebo/) or to the body´s production of endorphins. It is well known, for example, that spinal manipulation, acupuncture, massage, and other forms of physical treatment can stimulate the body´s production of endorphins to relieve pain.

It could also be that manipulation works, but not for the reason most people think it works. When you go to a chiropractic or osteopath they usually assess you through motion palpation test, positional faults assessments, clinical postural assessments or some other test, the funny thing is that these test usually have, at best, poor to fair reliability (5-13). What I mean by this is that, if you first go to one osteopath and then you go to another, they probably wouldn´t agree on what you have. One would say you have too much mobility, while they other one would say something else. The intertester reliability is horrible and if you don´t believe me look at the studies (5-13). So how come sometimes it works? Well, it could be because when someone manipulates you, he is in fact affecting the peripheral and central nervous system. Meaning, the novel stimulation (manipulation) may help the brain downregulate the perceived threat of current stimuli and thus decrease the pain.(https://sports-diet-pain.com/2013/10/18/pain-part-1/)

But what I can tell you for sure, and it has been demonstrated, is that your bone is not out of place, there is no such thing as a ¨subluxation¨(1-3). So next time you go to a physical therapist, chiropractic, osteopath or whatever, and that person tells you that you have a ¨subluxation¨and that he is going to put that bone in its place, get up and walk away. Manipulations can have some serious effects. In 2001, a systematic review of 5 studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches(3,4).  But the greatest risk comes from manipulating the cervical area (neck). This region is hugely vulnerable as it carries all the lifelines between the head and the body. In particular 2 vertebral arteries which are very close to the cervical vertebrae. Cervical manipulation has not been shown to be more effective than a massage in dealing with acute neck pain or chronic neckpain. But they are more dangerous. So my recommendation is not to let anyone manipulate your cervical area (neck).

To summarize, and not bore people to death, I will make a list of what the scientific community says with respect to when manipulation by a professional is in order and when they should NOT be manipulating you.

WHEN IT´S OK

  • A manipulation could  be beneficial in acute non specific lower back pain. In their own words ¨Manipulation is often more effective than physical therapy in relieving the symptoms of simple, uncomplicated back pain. But such treatment should be discontinued after one month if no improvement results¨.

WHEN THEY SHOULD NOT BE MANIPULATING YOU

  • Herniated disk, as suggested by sciatica (pain radiating dow on leg below the knee)
  • Spinal stenosis (narrowing of the spinal canal)
  • Ankylosing spondylitis
  • Cauda equina syndrome
  • Cancer or Infection, which might be suggested by history of cancer, unexplained weight loss, immunosuppression, urinary infection, fever, back pain not improved with rest, and age of patient over 50.
  • Spinal or compression fracture.

Hope you enjoyed it!!

References

  1. Homola S. Inside Chiropractic.Prometheus Books 1999. Amherst, New York.
  2. Ernst E, Canter P H. A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine 2006 April 99 (4): 192-96.
  3. Ernst E, Singh S. Trick or Treatment? Alternative Medicine on trial.Transworld Publishers 2009, London, UK.
  4. Hall H. Update: Chiropractic Neck Manipulation and Stroke. http://www.sciencebasedmedicine.org/update-chiropractic-neck-manipulation-and-stroke/
  5. Berneck J G, Kulig K, Landel F. R, Powers . The Relationship Between Lumbar Segmental Motion and Pain Response Produced by a Posterior-to Anterior Force in Persons With Nonspecific Low Back Pain, J Orthop Sports Phys Ther Vol 2005: 35;4.
  6. Cornwall J. Lubar Zygapophysial Joint Palpation. NZ Journal of Physiotherapy Nov 2004: 32;3.
  7. Zegarra-Parodi R, Rickards L, Renard E-O. Cranial Palpation Pressures Used by Osteopathy Student: Effect of Standardized Protocol Training. JAQA Vol 109 No 2 Feb 2009 79
  8. Simpson R, Gemmell H. Accuracy of spinal orthopaedic tests: a systematic review, Chiropractic & Osteopathy 2006, 14:26.
  9. Landel R, Kulig K, Fredericson M, Li B, Powers M C. Intertester Reliability and Validity of Motion Assessments During Lumbar Spine Accessory Motion Testing. Physical Therapy, Jan 2008. Vol 88 Number 1.
  10. Kmita A, Lucas N. Reliability of physical examination to assess asymmetry of anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain. Internationl Journal of Osteopathic Medicine in press(2208) 1 e10.
  11. Huijbregts P. Spinal Motion Palpation: A review of reliability Studies. The Journal of Manual & Manipulative Therapy Vol. 10 No. 1( 2002) 24-39.
  12. Hughes P, Taylor N, Green R. Most clinical test cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 2008 Vol 54.
  13. Tullberg T, Blomberg S, Branth B, Johnson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine 1998, 23(10):1124-29.
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