While walking to work this morning, I passed the local chiropractor who had a sign up on the footpath “there is a crack, a crack in everything, that’s how the light gets in”. This is a Leonard Cohen quote from his song “Anthem”. I smiled at the humour and it resonated as I also used the quote to start my book “The Sensitive Nervous System” in 2001. In all that time I had never thought of the crack in the quote as relating to a joint, I was more reflecting on cracks in thinking at the time.
And as I wandered on, I thought, what has happened to manipulation these days? The high velocity thrusts (grade 5 techniques in some systems) often associated with joints popping and cracking and occasional spectacular relief.
Who is doing it?
Is it done as much as it was last century?
Is anyone researching the outcomes?
And are there others like me who have moved to more educational/mobilising strategies – but in the back of their minds they don’t want to give it up completely and so they keep “cracking” as an option?
Manipulation like many other techniques has its time and its place. Unfortunately some people miss the point and either think it is every time and every place, or never a time and never a place. Maybe someday our profession will get past the idea of “one size fits all”.
By cracky, there ain’t nothin’ like a good crack to impress the yourself, make you adorable to your fans, and empty someone’s wallet. Johnb
Working in a Pain Service in the UK NHS, I do no hands-on and think I’m definitely missing a trick. People, especially ones who are suffering, surely benefit from the touch of another empathic human. Right time, right place, definitely. All in the service of self efficacy though whether its a light touch, massage, mobilisation or a manip.
Touch is one thing – coercion another. I was trained in the ’70s by a famous cracker; Stan Paris. I stopped doing that in 1980 and don’t miss it.
Thanks for the comments – it makes me reflect on my manipulation career. I too was taught by experts – Geoff Maitland and colleagues nearly 30 years ago, I worked in clinics where manipulation was the treatment of choice and then I taught manipulation for many years at undergraduate and postgraduate level. I had “reasonable hands” as they say in the trade.
Back then, I was also influenced by a pain that I experienced during a long bushwalk. It was sudden anterior hip pain and I had to almost pull my leg forward to walk. It went on for hours. I got back to camp, lay on my back tried to twist and stretch with the help of a mate (can’t recall his exact training- he could have been an accountant!) and all of a sudden with a mighty “pop”, I was suddenly fixed! Instantly! Never to return! Hallelujah!
I guess it was the “golden click” that many still seek. If at that time I was less naïve about backs and I had visited a manipulator, the spectacular result would have sold the technique to me for years. All about timing I guess – maybe it was an upper lumbar joint stuck in some way but ready to let go, – kind of like how vets like to see an animal the moment just before an abscess bursts so they can lance it .
Like many of my colleagues I slowly stopped manipulating – the upper cervical spine first, then less and less in the rest of the spine. I came to realise that it was important that patients knew I could manipulate when I told them that I didn’t think it was necessary at that particular time and place for them. And of course we accumulated far more non manipulation techniques along the way.
I know it is an evocative topic for some – but I think manipulative techniques should be kept, though with a heap more research on who, when and why it is done. I can only guess what a skilful manipulation might do to the brain neurosignatures representing a sticky joint contributing to a pain construction.
But as has been suggested, it must be a clinically judicious act, not something for all – there is certainly not “a crack, a crack in everything” as Leonard Cohen insists in that pleasantly mournful voice.
To me, there’s a lot to be said about the SOUND made and what that may mean to us, reasonable or not. In the recent movie, Trouble With The Curve, Clint Eastwood is a nearly blind baseball scout who hears something when the bat hits the ball, and the sound alone tells him something important. What we’re talking about here is the auditory signal and its effect on our ancient brains – no small thing. After all, what happened when “The Rite of Spring” was first performed?
I agree Barrett – the pop for many must be is an auditory metaphor for verbal or nonverbal cognitions such as “it’s in”, “it’s over thank God” , “they have got it” etc., etc. Such a quickly constructed neurosignature could well lead to radical restructuring of motor, pain, autonomic, immune and other neurosignatures related to coping.
And for me there will always be a group, less in number than I once thought, where something is stuck, (not sure what!), warranting the cleverest of gentle but targeted coercion.
I have the sense that David and I have followed similar paths at times. In my daily blog today I wrote of how important sound can be. Another there called cavitation “therapeutic narcissism.” I also spoke of how we can know things when a bat hits a ball we can never sense otherwise. Sound – it’s powerful.
I think I have probably spent more time than most thinking about the question “what does manipulation do?” and have published several papers on it as a result.
Aussie osteopath/lecturer, Nic Lucas, and I spent a lot of toing and froing, with detailed reference to basic science papers, to come up with a ‘minimally sufficient’ list that defined what a manipulation is from a biomechanical viewpoint:
The proposed features are: 1) A force is applied to the recipient; 2) The line of action of this force is perpendicular to the articular surface of the affected joint; 3) The applied force creates motion at a joint; 4) This joint motion includes articular surface separation; 5) Cavitation occurs within the affected joint.
I could go on about the absence of ‘end range’ and ‘high velocity’, but suffice to say, once the mechanics are clearer, one can infer the likely mechanism(s) of action. IMO, the most plausible mechanism of action is still some intra-articular inclusion/meniscoid that has deformed or moved into part of the joint space where it ought not to be – this will plausibly cause the sudden-onset/acute ‘joint lock’ from a commonly innocuous (non-tissue damaging) event. This therefore limits the indications of joint manipulation to nociceptive pain for starters, and I would further limit it’s use to a non-traumatic onset (at least for a while).
Fascinating discussion; I don’t Grade V Cx because I’m scared of it. I will however manipulate Tx as an adjunct to mobs for shoulder, Tx and Lx restriction. I think it has its place but I don’t think it warrants being used routinely in clinical practice. Rachael.
Great intro to a necessary discussion, David. I suspect the need to manipulate and be manipulated is built upon beliefs, expectations and a bit of placebo. It’s also driven by the meaning of the “pop”. What would happen if we altered the meaning in someone who has never been manipulated? If we told them, “I’m going to twist you, but if you hear a pop, that is very, very bad”. I would imagine outcomes may change. And this leads to a problem when studying manipulation—it is very hard to reduce the dramatization that occurs when one goes to manipulate. Many of the current studies are performed by proponents of manipulation and the technique is compared against one, which the practitioner is less “excited ” about performing.
I have no doubt that patients can benefit from expert manipulation. The exact mechanisms whereby that benefit is conferred, however, are clearly up for debate.
Another problem is how one becomes expert without putting patients through discomfort or risk of serious adverse events.
But is the “expert” one who gets the technique “perfectly by the book” every time – with ‘reasonable hands’ – or is it the clinician who is able to set the stage and take greatest advantage of the therapeutic alliance established between the patient and the practitioner?
Would it not make the most sense to argue the latter over the former, especially considering our documented inability to isolate segments with manipulation?
Does anyone here have any specific expertise with manipulation including keeping up with the literature in manipulative therapy? There is evidence of benefit for mechanical spinal pain comparable to “standard medical care, physiotherapy and exercise therapy” according to the 2012 Cochrane review for LBP. Even so, most practitioners aren’t using SMT as the only intervention, routinely it is paired with exercise and education.
Lastly, the newest research is showing interesting effects on brain function. New research suggests that patients with mechanical neck pain and a high NDI score correlates with hypo-perfusion to the brain and C-SMT increases blood flow to the hypo-perfused areas. Thus, while the topic may be evocative for some practitioners of manual medicine, others see the daily benefit of this intervention, if it done skillfully and appropriately.
First off cavitation to my knowledge has been shown to be unimportant in predicting success from manipulation. As such the auditory element or the “crack” is unlikely to be a large part of the therapy- although clinical experience may differ.
Secondly depending on your education/background people have different ideas about the safety record of SMT as a therapy. As far as recent research goes many minor adverse events are likely a result of natural history http://www.ncbi.nlm.nih.gov/pubmed/23778372
In terms of more serious events, most prominent stroke, the risks seem fairly overstated.
Herzog found no undue stress on the artery during manipulation http://www.ncbi.nlm.nih.gov/pubmed/22483611
Cassidy found similar rates in GP’s suggesting that many strokes following care are likely either by chance or by missing the symptoms of the evolving CVA. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/
During my undergrad we had a presentation on strokes from a neurologist working at a local stroke ward. To paraphrase it was his opinion that the position/movement of the neck that initiated the event was just as likely to occur during a ROM assessment, brushing ones hair, surfing etc. Certainly I think a case can somewhat be built to put mobilisation/stretching of the cervical spine on a similar level of risk.
In terms of common day alternatives many of our patients wouldn’t think twice about NSAID use for their pain syndrome as such I think is a reasonable barometer of appropriate risk. http://www.ncbi.nlm.nih.gov/pubmed/8583176
Of course there are inherrant flaws with all articles/opinions I have expressed but in my opinion (Chiropractor) SMT has a pretty good track record compared to alternatives.
Lastly from my experience clearly some people prefer a HVLA to what feels like poking/prodding to some of mobilization. Certainly some patients do better with the single thrust than perhaps the longer perturbations or a irritated joint.
I agree with what has been expressed above by others talking about SMT being only appropriate for a portion of patients (that percentile is up for discussion). I do however see a role in passive therapy to increase confidence in movement followed by active measures (return to work, pain education), if the therapy is somewhat safe and used appropriately (i.e not to promote dependance and scare the patient) it can be very valuable.
Although there is little else that has looked at the occurrence of cavitation and associated clinical outcomes, I would not invest too much into the several papers by Flynn and colleagues. This wasn’t a trial for starters, so causation cannot be inferred, and they used a very unusual manipulation technique, as against the more commonly utilised ‘lumbar roll’ technique. Also, it was a very heterogenous LBP sample, outcomes were taken only pre- and 48 hours post-manipulation, and numbers were small (50 of 71 experienced an audible crack… somewhere).
Accelerometry techniques used by Kim Ross with Stuart McGill, and more recently with Greg Cramer, allow for identification of the z-joint(s) in which cavitation occurs during SM. This approach needs to be paired up with clinical outcomes in an RCT, along with pre-manipulation z-joint/medial branch diagnostic blocks, to assess this question in a methodologically rigorous manner.
in case you missed it — chiro crack up http://www.youtube.com/watch?v=BJQfT9C5Adc
This is an anecdote I know, but I’ll use it anyhow.
Just seen a patient yesterday with 15 year history or on and off thoracic pain. Was sold the story of the meniscoid thingeey trapping whatever in the whatever space when he first got his pain.
Now his meniscoid gets stuck every few days. He manages it well by never moving much and bracing himself when he does something with load.
Was the explanation given to this bright, sensible chap at the time of his first pain useful? has it helped him? was it true? how accurate should we be with our explanation? does it really matter? if the pain goes away short term are there any other long term consequences with our explanations?
I have no particular answers to these questions but they do, on the very odd occasion, stop me from dozing off on time.
I’m sure he’s a one off story anyhow.
With a 15 year history, I don’t think that this would be a meniscoid-type presentation. He would have well established central senstization in this area, and innocuous afferent stimuli would be enough to trigger off a pain neurosignature.
If you want somewhere peripheral to target, given the location of the pain, I would be looking to the cervical spine, particularly those lower cervical nerve roots.
Joe, your point is very important to consider when discussing HVLA interventions. If one hears a click or pop let’s say with active lumbar rotation during a stressful task at work, the sound may be associated with something negative (e.g. something got damaged or out of place). The same sound in a manual therapy context will most likely be associated with something positive.
David E, regarding the deformed or misplaced meniscoid, can we assess for this in the clinic with good validity and reliability ?
I think we need to be a bit careful when we communicate with the patient a very specific structural “cause of pain” (less careful if it only stays in our head). Causation is much more complex and context dependent. We might be encouraging people to become fixated and even obsessed with their anatomy. Even though this might help maximize expectation analgesia during and after the intervention (“look we are fixing the problem”), we might be helping increasing instead of reducing the patient’s alarm system.
I still manipulate. I know it’s not a magic bullet but again sometimes it’s spectacular. I enjoy having it done to myself also. To me it feels good and relieves my neck – it seems a little faster than without. If nobody could do it anymore then I sure would miss it. If it scares patients then I don’t do it.
“It ain’t what you do but the way that you do it” that springs to mind. I have had my man drawer since the beginning of time and every now and then I rummage through it and find a use for that forgotten flat A3 battery!
Maybe it is the readers who follow us, but the term “right time and place” emerges. For me that is a healthy answer although the right time and place still needs identification. I suspect our posters are a long way from the self declared holistic manipulator in the clip linked by Reade Whitney.
But I will retire believing that much of the manipulation I used to do had a hoax element to it. I do wonder about attempts in some US states to legislate that manipulation should belong to one profession. Should processes with likely hoax elements be legislated?
There is a critical question too – what kind of pain would manipulation be relevant for? – As David Evans suggests, surely a person with significant nociceptive contributions. I hate to think of how many people with central sensitisation are being manipulated out there, for tempory but addictive relief in some or an increase in pain in others. It has been the new pain sciences, more than anything which has made me retreat from much manipulation.
Of course there is a place for active and passive good hard stretches and movement exploration and if something pops then so be it – interesting how a manipulation feels very different if you do it to yourself rather that have someone else do it.
Dave Nolan’s meniscus story is a horror. (Nothing wrong with appropriate anecdote from clinical scientists Dave!). On a slight tangent, how many patients have you seen with failed spinal surgery, yet could have benefitted by a bit of active and passive stretch , maybe a pop or two, some good knowledge and follow up.?
Right time , right place, and right patient needs more investigation.
Many thanks for the interest.
In the 2006 movie “The Prestige” with Christian Bale and Hugh Jackman playing viciously competing magicians, there is a brilliant quote:
“Every great magic trick consists of three parts or acts. The first part is called “The Pledge”. The magician shows you something ordinary: a deck of cards, a bird or a man. He shows you this object. Perhaps he asks you to inspect it to see if it is indeed real, unaltered, normal. But of course…it probably isn’t.
The second act is called “The Turn”. The magician takes the ordinary something and makes it do something extraordinary. Now you’re looking for the secret… but you won’t find it, because of course you’re not really looking. You don’t really want to know. You want to be fooled. But you wouldn’t clap yet. Because making something disappear isn’t enough; you have to bring it back.
That’s why every magic trick has a third act, the hardest part, the part we call “The Prestige”.
I think manipulation has these three components.
The Pledge is the person’s body and their pain.
The turn is the “wind up” or the seemingly special/magical positioning of the body ready for the thrust.
The thrust is not The Prestige, the thrust is part of The Turn.
The Prestige, is the audible pop…
At the end of the day though, maybe its still all just smoke and mirrors?
A post about magic and manual therapy reminds me of a letter to the editor in JOSPT in 2010 by Dorko and Silvernail: “Manual Magic: the method is not the trick” http://www.jospt.org/issues/id.2471/article_detail.asp
After returning to work from summer break I came across this interesting discussion. I must admit I have for quite some time wondered why so many manualtherapists, especially in english-speaking countries, have quit doing manip’s (hi-velocity thrusts). Is it because of legislation? Is it due to safety-reasons? Or is it lack of experience, knowledge, education and practice in techniques? My feeling is that education in manip’s has been less focused on for many years in these countries.
Norway has strong traditions in manipulations, and we maintain a big focus on this in our postgraduate education in manual therapy. It is a magnificent tool both to reduce pain as well as improve function. There is – in my opinion – no contradiction between using manip’s in one session, and follow this up with explain pain theory the next. Restoring function is in many cases a prerequisite in order to relieve pain.
By not offering manips to patients, manualtherapist effectively give chiropractors a monopoly on a treatment very many patients around the world for years have experienced as effective. Is that wise to do? As Dave points out, it is important to pick the right time and place for the right patient. We all know patients shop treatments, and chiropractors have little else to offer but manips…
Continous practice is necessary and important. By offering a great variety of treatment tools manualtherapist may stay attractive on the market, and thus over time have a bigger chance of implementing relevant explain pain theory to a steadily increasing audience of satisfied patients.
I am a UK osteopath and became interested in Noigroup as it helped explain my own impressions of manual therapy.Whilst I still use manipulation(no longer cervical) and dry needling, I am influenced very much by the patient.If they verbalise the “need for a crack” I will crack them . They may verbalise that they gained benefit from acupuncture when seeing me before (though I will have probably also rubbed,stertched and cracked) .The fact they felt the needles were the powerful tool will inform me that that will be the thing that helps them.
I would love to know the percentage of how much benefit is gained from what you say and what you do physically.Obviously it differs between patients but the longer I am in practice life the more I believe it has little to do with the actual physiological effects of the manual therapy.
I have thought recently that it might be an idea to ask patients what they want from me.If they are looking for a diagnosis I will spend a large chunk of time examining and explaining.If they want self help advice I will spend more time on this and if they want a “good crack” I would probably manipulate not just the area of complaint but certainly above and below.
I remember reading a biomechanics article suggesting that research into manipulation should look at what complaints respond best to it.For example does manipulation work better for pain in flexion or extension?.Or can it work well if there is a referral pattern etc?.
Part of me feels the patient chooses whether you are the right person to heal them,making that decision very soon after entering the room.
Maddeningly those therapists who wallow in their own brilliance probably get better results because of the confidence they exude.
Reblogged this on Triam Press.