Spinal Manipulation – Is it safe?

Spinal Manipulation – What is it and is it safe?

What is it?

Spinal manipulation is a specific manual technique that is shared by multiple healthcare professions including physical therapists, medical doctors, osteopathic physicians and chiropractors. Despite being committed to all things physical therapy, in regards to a definition, I must in this instance give my Chiropractic colleagues the nod. In 1999, the Virginia Chiropractic Association defined spinal manipulation as, “a passive movement of short amplitude and high velocity which moves the joint into paraphysiological range. This is accompanied by gaping or cavitation of the joints.”

To put that in layman’s terms the technique should be a “small quick movement” that takes the joint into a range that the patient cannot do themselves and that this creates audible “pops”. Although, each profession has specific nuances to this shared technique, these few key components seem be crucial to consider the technique a manipulation.

Many more studies have been performed over the years to specifically define exactly how much movement is required and how fast it needs to be. Kawchuck et al (1992), showed that mean peak force for a cervical (neck) manipulation was 118 N and that the mean duration of this force lasted just 102 milliseconds. Hence, it’s more speed than power.

So is it safe?

Klein et al (2003), were able to show that in neck manipulation techniques a mean of 30 degrees of rotation, 46 degrees of lateral bending and 2 degrees of either flexion or extension are required to achieve successful cavitation. Individually, these ranges all fall within your normal physiological range i.e. you could move your own neck that way. The reason it becomes paraphysiological i.e. a movement you cannot create yourself, is because during a manipulation they are all combined at the same time along with a lateral shift.

This is important because the act of combining them all at the same time with a lateral shift manufactures an artificial barrier within a safe range of neck movement. No one direction exceeds normal range. This makes the technique very safe for you, the patient.

Every patient comes with their own story. Some patients even report having terrible past experiences of manipulations being done either without their prior consent or with poor technique which caused unnecessary pain. Sometimes the speed of the technique along with the creation of multiple audible pops can surprise and even concern patients.

So when a patient has concerns about the safety of the technique, I get it. I understand where they are coming from. That being said estimates of a serious complication from cervical manipulation ranges between 5 and 10 per 10 million manipulations (Hurwitz, Aker, Adams, Meeker, & Shekelle, 1996).

While manipulation is an amazing technique that can produce excellent results in a short period of time it is not for all patients nor all problems. Screening out patients for whom it is inappropriate is of paramount importance. Severe vascular, bony and neurological pathology along with extreme pain, lack of clinical diagnosis and lack of consent are absolute contraindications to receiving the technique.

For anyone else though, it’s my recommendation that we keep it on the table as a possible intervention.

How does it work?

The effects or benefits of spinal manipulation are numerous and can be categorized as short term or long term. Obviously, the longer the effect lasts the more meaningful it is to the patient. Because of the inter-relationship between joint dysfunction and myofascial tripper points (where one can lead to the other) spinal manipulation can represent a first line of intervention allowing us to break into the harmful cyclic relationship simultaneously reducing the dysfunction in both joint and soft tissue through the one intervention (C. Fernández-de-las-Peñas, 2007).

Other benefits of spinal manipulation include increasing range of motion, relieving pain and increasing circulation. These effects can start immediately after the manipulation and extend for hours to days. Along with additional treatments performed during the session and guidance on home exercises these benefits can soon become permanent.

Phil Chamberlain, MSPT, Cert DN

References
C. Fernández-de-las-Peñas, C. A.-B. (2007). Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study. Manual Therapy, 29-33.

Hurwitz, E. L., Aker, P. D., Adams, A. H., Meeker, W. C., & Shekelle, P. G. (1996). Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature. Spine, 1746-1759.

Kawchuk GN, H. W. (1992). Forces generated during spinal manipulative therapy of the cervical spine: a pilot study. Journal of Manipulative and Physiological Therapeutics, 275-278.

P Kleina, C. B. (2003). Global 3D head–trunk kinematics during cervical spine manipulation at different levels. Clinical Biomechanics, Pages 827–831.