Chapter 41 Manipulation
Therapeutic Keys
• Manipulation is a passive manual maneuver that introduces movement beyond the passive range of motion (ROM) through the elastic barrier, but does not exceed the anatomic barrier.1 Mobilizations are passive stretches with or without oscillations over which the patient can exert control.2 Chiropractic adjustments are techniques that range in force from a near imperceptible force to high-velocity thrusts causing joint cavitation (popping noise).
• As a prudent starting point, initial evaluation should determine if manipulation of the patient is appropriate, seeking out “red flags” that contraindicate manipulation, such as fracture, infection, neoplasm, progressive neurologic deficit, cord pressure, or cauda equina syndrome.3,4
• A correct differential diagnosis is key to selection of patients, and the functional assessment is key to the selection of appropriate manual medicine techniques.5
• If gross signs of inflammation are present in a joint (heat, swelling, redness, and pain), and repeated movement to end range (ER) worsens the signs, manipulation in that direction would most likely aggravate the condition.
• When bringing the joint complex to tension, if the pain peripheralizes, it is a relative contraindication to manipulation.
• The practitioner should be alerted that an adverse outcome is likely from manipulation when repetitive motion with progressive force in the direction of the manipulation peripheralizes pain and reduces function.
• Relaxation techniques (heat, muscle work, and calming environment) are helpful to patients complaining of anxiety, muscle tension, stiffness, and aching before manipulation.6
• If pain is the chief complaint, icing the area for 5 minutes causes surface anesthesia and 20 minutes causes sedation of the actions of the muscle spindle cells. Sedation of a muscle reflex arc before manipulation of a fixated painful joint may facilitate treatment.2
• If the patient reports an increase in pain or stiffness after manipulation, ice the area of treatment for 10 to 30 minutes to reduce spasm and pain.7,8 The patient should be placed into a position that centralizes pain when icing.
• “The goal of manipulation is to restore maximal pain-free movement of the musculoskeletal system and postural balance.”9
• Do not treat muscle spasm as a primary condition. Muscle spasm is almost always a response of the body to a noxious stimulus. Find the cause and treat it.10
• Trigger points are myofascial irritations that are frequently caused by underlying joint fixations. Manipulation can irritate a trigger point and can precipitate a muscle spasm later that day.11
Historical Perspective
Manipulations are depicted in prehistoric cave drawings and Chinese statues, circa 2700 BC,12 but Hippocrates is credited with the earliest recorded written physician’s prescription of manipulative treatment methods, which changed little until the sixth century. He advocated key principles of judicious use of force, direction of thrust, and proper levering of joints.13
During the Dark Ages, priests provided medical treatment at their monasteries. Kessler stated: “Friar Moultan, of the order of St. Augustine, wrote The Complete Bonesetter. The text, which was revised by John Turner in 1656, suggests that manipulation was practiced in medical settings throughout the Middle Ages and Renaissance.”14
Three main concepts developed during the 1700s still have a major influence on manipulation today. The first held that “vertebral luxation” (bone out of place) was responsible for spinal deformity. The second, the mainstream medical opinion, maintained that “caries of the spine” caused spinal deformity, which was treated with bloodletting and rest, while condemning extension and manipulation as both useless and dangerous and citing concerns about the potentially disastrous effects of manipulating tuberculous, neoplastic, rheumatic, or fractured joints. The third held that muscles were the main cause of problems, and treatment should be complete rest or active exercise, as the case warranted.13
It is interesting to note the following:
• Hippocrates railed against the abuse of manipulative therapy by physicians and others of his time.
• Physicians of the late 1700s assailed one another’s methods of treatment (e.g., in The Lancet, December 16, 1826, the banner on page 347 appropriately read “THE YELLOW JOURNAL”).
• Surgeons held “bonesetters” in great contempt “when they condescend[ed] to speak at all of bonesetters and their works.”12
• Bonesetters held their secrets and passed them from father to son.
• Financial competition was noted early in the literature. “It is known to most practitioners of surgery, and has been made known to many to their great cost and loss, that a large portion of the cases of impaired mobility or usefulness of limbs after injury fall into the hands of a class of men called ‘bonesetters’.”15
• Although there has been a great deal of animosity, and claims of superiority made by the various practitioners of manipulative treatment even to this day, “specific conclusions cannot be derived from the scientific literature for or against either the efficacy of spinal manipulative therapy or the pathophysiologic foundations from which it is derived.”16
Schools of Thought in Manipulation
Bonesetters of England
Bonesetters of England generally held that a bone was out of place and had a “feel” for what was wrong. Hutton described the information gained from a bonesetter as “bring[ing] some spoils out of the camp of the Philistines.”15
Chiropractic
D.D. performed the first chiropractic manipulation on a deaf janitor whose hearing had been lost when he stooped over and felt something give in his back. D.D. reasoned that if the deafness occurred from something slipping out, restoring the vertebra to its correct position should cure the condition: “With this new objective in view, a half-hour’s talk persuaded Mr. Lillard to allow me to replace it and his hearing was restored.’’17
Although there are multiple schools of thought in chiropractic, each with its own strengths and weaknesses, the literature supports the need to combine therapeutic exercise with manipulation. Rehabilitation of the Spine, A Practitioner’s Manual, 2nd ed. edited by Craig Liebenson,4 is considered a landmark publication by many in the field and addresses this topic at length.
Naturopathic
Several naturopathic schools in the past were associated with chiropractic and eclectic schools of medicine. The genesis of the naturopathic profession is well documented in Chapter 4, History of Naturopathic Medicine.
Osteopathic
Andrew Still left the practice of allopathic medicine and started a school of osteopathy in Kirksville, Missouri. It is highly probable that the first chiropractor, D.D. Palmer, went to this school and learned some of the techniques, but it is not well documented. The famed “equal but separate” movement of the osteopaths led to a 1921 resolution, submitted at the American Osteopathic Association convention, that allowed entrance of chiropractors with advanced standing into their schools. Still, before his death, saw the defection of his osteopathic profession into the ranks of medical orthodoxy.18–20 Interestingly, manipulation is now only an elective segment in some American osteopathic schools, whereas in England, where osteopathy is not part of the medical establishment, manipulation is still the mainstay of osteopathic practice.
Allopathic
James Cyriax, James Mennell, and John Mennell were brilliant physicians who worked to reintegrate manipulation into medical practice. They wrote valuable texts on manipulative therapy, although they did not totally agree on the effects they achieved with manipulation. Mennell held to the correction of lost joint play and denied the effect on the intervertebral disc,21 whereas Cyriax claimed reduction of a protruding disc.10
“Controversy and contention” best describe the higher levels of the respective schools of medical thought. The impression one gets in reading through the literature is intolerance of others’ ideas expressed in ad hominem attacks. The mistake “lay” manipulators and “nonphysicians” make is not ineffectiveness, but in their willingness to seek training outside the fraternal order of the “medical” brotherhood; to address the public directly rather than communicating exclusively within the order; and, worst of all, to openly compete, economically and politically, against the fraternal order.13,15
Donald B. Tower, in the chairman’s summary at the National Institute of Neurological and Communicative Diseases and Stroke conference in 1975,22 noted a physician who received little credit for his early contribution to the field: J. Evans Riadore, a London physician who wrote a treatise on the irritation of spinal nerves in 1843. He attributed many diseases to this condition, stating: “If any organ is deficiently supplied with nervous energy of blood, its functions immediately, and sooner or later its structure, become deranged.” This was a viewpoint subsequently echoed by osteopaths and chiropractors.22
The fifth edition of Spinal Manipulation by Bourdillion et al,23 the first authors who were medical manipulators, has been largely reworked from previous editions and heavily influenced by osteopathic methods.
Physical Therapy
James Cryiax influenced Robin McKenzie, a New Zealand physical therapist who subsequently developed a systematic approach called mechanical diagnosis and treatment (MDT) of musculoskeletal conditions. It is a process of evaluation and treatment of musculoskeletal disorders based on a mechanical history and the patient’s symptomatic and mechanical response to movement, positions, and loading.4 McKenzie’s approach is often prejudicially dismissed as “extension exercises for the low back.” He proposed a new tack in the approach to back pain that was found to be highly effective in populations with acute and chronic back pain as well as low in cost.24 MDT includes McKenzie’s observations that most conditions are self-resolving and that focus should be on prevention and recovery of function by teaching patients proper posture and self management. After years of studying, performing, and researching manipulation, he felt that only 20% of patients needed manipulative therapy, and 80% could self-treat using ER loading strategies learned from books or practitioners.25
Is Manual Medicine the Right Treatment?
Patients with somatic pain caused by psychosocial factors often seek a physical cause and treatment for their pain. If the presenting complaints do not seem to follow a mechanical pattern and the pain diagram is nonanatomic, consider the possibility of psychosocial factors. Psychosocial workplace factors associated with risk of spinal injury include job dissatisfaction, stressful working conditions as perceived by the employee, employer practices reported as being unfair, poor coping skills, lack of recognition at work, low supervisor support, a high frequency of job problems, and negative beliefs of or attitudes toward the consequences of having “low back trouble.”26,27 A major factor in identifying the incidence of future pain is the patient’s perception of being disabled.28 If the patient’s history and records include previous evaluation by multiple providers with conflicting and confusing reports from the patient, caution is advised in approaching the management of the patient. If in doubt, seek a consultation with an astute colleague, physiatrist, or appropriate specialist.
Is It Safe to Move?
A clinician must answer the question, “Is it safe to ‘move the patient’ using conservative therapies, exercise, mobilizations, and manipulations?” Red flags have been shown to have many false positives, resulting in unnecessary additional diagnostic testing. Recent studies showed less than 1% of patients presenting to general practitioners with conditions that warranted further diagnostic evaluation. Red flags are a source of unnecessary medical interventions. When the medical history and examination indicate a serious disease, neurologic compromise, or progressive neurologic deficit, further evaluation or consultation is warranted. Although the question of safety is usually answered by the provider’s clinical training, a general outline of triage is presented as a starting point to help determine if further evaluation is indicated before initiating or continuing care.29
Signs of Neoplasm
The combination of age over 50 years, a history of cancer, unexplained weight loss of more than 10 kg within 6 months, failure to improve after 1 month of conservative care, and an elevated erythrocyte sedimentation rate (ESR) have a sensitivity of 100% in identifying patients with a neoplasm. Night pain, especially pain that prevents the patient from getting sleep or “drives them from the bed” also generates a high degree of suspicion.30,31
Signs of Infection/Inflammation/Illness
Heat, swelling, pain, redness, and loss of function are the cardinal signs of inflammation. Acute inflammation lasts from 1 to 3 days and chronic inflammation usually is considered from 7 days to 7 weeks, but may last up to 12 months. The stages between acute and chronic inflammation overlap, and a continuum exists.32 The clinical picture may be confused by chronic pain.
Laboratory tests may show signs such as an elevated C-reactive protein, ESR, or other tests for inflammatory arthritides. Signs of infection may be as simple as a low grade fever, chills, a shift to the left in the white blood cell count, signs of a worsening chronic illness, or frank presentation of an acute illness.33 Clinical signs are pain that is constant 24 hours a day, described as aching, throbbing, or burning, and aggravated by movement with no position that gives relief.
Signs of Neurologic Disorder or Progressive Neurologic Deficit
A loss of sensation, decreased or absent deep tendon reflex, loss of muscle strength, and positive nerve root tension are signs of nerve root involvement. If only these neurologic findings are present and do not become progressively worse, appropriate conservative care may be effective.34 Dizziness, drop attacks, diplopia, dysarthria, dysphagia, numbness, nystagmus, and nausea are more concerning signs of central nervous system involvement. Loss of bladder or bowel control or saddle anesthesia requires urgent evaluation with magnetic resonance imaging of the lumbar spine. If progressive neurologic deficit of weakness, loss of sensation, and loss of function, or the previously mentioned signs and symptoms are present, a consultation with a competent colleague, physiatrist, or neurosurgeon is indicated.
Signs of Fracture
A fracture typically has an obvious traumatic cause when the patient is young or middle-aged. In older patients, pathologic fractures are a concern, especially if there is a history of prolonged or repeated steroid use. Be wary of occult fracture after motor vehicle accidents or athletic injuries and nontraumatic fractures in the elderly. The red flags suggesting vertebral fracture are age more than 50 years, female sex, major trauma, pain and tenderness, and a distracting painful injury. In particular, look above and below the site of injury, as the force of trauma may be transmitted and cause a fracture some distance from the site of impact.35 In a pelvic fracture, there is always a fracture in two places in the ring.36
