The misunderstood practice of chiropractic manipulation

Posted Jan. 03, 2013, at 1:50 p.m.

Manipulation is thought to be one of the oldest forms of treating pain and disability. The ancient Egyptians and Chinese used manipulation, as did Hippocrates, the father of modern medicine, who is thought to have said, “For many illnesses, look to the spine.” Traditional “bone setting” techniques are common in many native cultures.

Unfortunately, manipulation is still widely misunderstood; its benefits are minimized and its risks overstated, especially by those who do not practice it or have never had the treatment. For example, some medical providers still warn patients away from manipulation for back or neck pain, saying it is too risky.

Instead, they often recommend a prescription for an anti-inflammatory medication, such as ibuprofen, Celebrex or Toradol. (This class of drugs is commonly called NSAIDs, short for Non-Steroidal Anti-Inflammatory Drug.) However, the risks of serious complications from spinal manipulation are very small, estimated at one per 400,000 to one per 10 million treatments. This compares very favorably to the risks from NSAIDs, which have been estimated to be about 400 times higher. One study found that one out of every 1,200 patients who took NSAIDs for at least two months died from gastrointestinal bleeding caused by the drug.

While aggressive manual manipulation may not be appropriate for older adults, chiropractors are trained in, and frequently use, alternative styles of manipulation that are gentle and will not harm even the most elderly patient.

Certainly some of the reason for the misunderstandings about manipulation is the fact that we still don’t completely know how it works. What goes wrong inside the joint? What does manipulation do that fixes the problem?

There are two main schools of thought on this. The first is that the bones that make up the joint literally go out of place slightly and get stuck there; they are then put back in place by manipulation. If you have ever had your back or neck “go out,” you can understand this idea. It certainly feels like that is exactly what is happening. A manipulation often makes a “pop,” gives immediate relief, and restores motion, giving the feeling that something has been put back into place.

In chiropractic school, we had classes on different ways to evaluate patients for this type of problem, especially with the use of standing X-rays to evaluate for joint alignment, and “leg length checks” that showed pelvic torque. One patient, I recall, had a typical “bone out of place” type of problem. In his case, the problem had a recent onset, caused by a stumble and fall a few days earlier. His right lower back was in a lot of pain and he had a pronounced limp. When I had him lie face down on the table, his right leg appeared about an inch short. It wasn’t due to a birth defect; it was due to the bone of the pelvis on the right being rotated, pulling the leg up with it.

I did one simple manipulation to the right side of the pelvis, with him lying on his left side. There was a loud “pop” and immediately upon standing he no longer had pain or a limp, and his leg length was even.

The other theory is that a joint can lose some of its normal function, called joint play, and it does not move properly as a result. This is called the joint dysfunction theory. If the problem develops due to chronic stress on the body, at first the joint dysfunction will be minor, and the joint seems to move normally to the patient. However, if the joint is not moving properly, it is irritating to use. Eventually, the joint will become inflamed with use, and once it is chronically inflamed, it can even be aggravated by prolonged rest. The manipulation is done to restore motion without actually changing the alignment of the bones.

We were trained in school to evaluate patients for joint dysfunction. For one semester, we examined all the joints of the body, beginning at the top of the neck and ending with the ankles, even the toe and jaw joints. Every joint has its own “feel,” and with proper training and practice, joint problems can be detected and corrected.

I recently had a patient whose condition was a typical joint dysfunction type. She had fallen and sprained both ankles. One side was healing as expected and getting better. The other side had a more severe sprain and was not improving. When I examined the poorly healing ankle, I found the usual swelling, inflammation and tenderness; however, most importantly, the “joint play” was completely absent. A quick check of the other joint’s function showed it to be fine. The loss of this “joint play” was what prevented the ankle from healing. With some painless ankle manipulation, we restored the play to the joint. There was immediate relief, and the ankle was then able to start healing.

According to a recent article in the British medical journal The Lancet, musculoskeletal problems are the most common “chronic disease burden” in many countries. Despite the controversy, manipulation, which chiropractors specialize in, has been shown to be one of the safest, most effective, and most cost-effective treatments for this problem.

In my next online column, I’ll cover another controversial aspect of manipulation: treatment of internal organ disorders.

Dr. Michael Noonan practices chiropractic, acupuncture and other wellness therapies in Old Town.

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