Are Manipulations Safe?

There are at least 4 professions that can and do manipulate the spine. They are, in no particular order, Doctors of Osteopathy, Chiropractors, Physical Therapists and a fading group of practitioners called Mechano-therapists. Sometimes, even medical doctors will manipulate the body although they may have had little or no training with the techniques. Regardless of who is doing the treatment, there are some real issues with the field of Manipulative Therapies.

To begin with, manipulation of the spine starts with the assumption that something is stuck out of place, as if the problem or cause is actually in the joint.  Interestingly enough, no mysterious sticky glue has ever been found in our joints at autopsy. We know now that this theory is completely false.

How then do the spinal joints become “out”? Quite simply, the joints are being held out of place by muscles which have too much tone, are too short and are overly sensitive to stretch. With slips, falls, car accidents, over-use syndromes and too much stress, the muscles are “taught” or “programmed” to be too tight, too sensitive and too short. But how? There is a little computer chip (for lack of a better description) embedded within the muscles that is called a spindle. When a doctor taps your knee with a little rubber hammer, he or she is testing your reflexes and that reflex is mediated by the muscle spindle. This little computer chip sends information to the brain and spinal chord relaying what is going on in the muscles for any given time and task. The muscle spindle has the ability to modify itself through a sophisticated feedback loop to adjust to the task or demands that are being placed on it. Lift something heavy and it adjusts to help you to do the lift smoothly. Lift up an egg and it adjusts so you don’t use more force than needed and crack the egg.

But the system can become dysfunctional and the spindle may get programmed to be way too sensitive to stretch. This then tells the muscle(s) to do the same and, if it goes on long enough and with sufficient tension, the corresponding bones / joints may actually get pulled slightly out of position. This will cause pain – not only from the joints being stuck out of position, but also from the increased tone in the muscle.

We know this to be true. We have the body of research and evidence to show how, why, when and where this happens, and none of it happens with mysterious sticky glue. So you can see that the basic premise of the manipulation starts on some very shaky ground.

Secondly, the methods by which some manipulations are delivered can actually cause a number of serious complications (termed “undesirable events” by the defendant’s attorney). The professional literature is replete with documentation of “undesirable events” where people were maimed or even died from manipulations. There is a website, www.neck911.com, that lists the unfortunate victims of these “undesirable events.” Unfortunately, many of them actually died as a result of the manipulation. Those that did not die had strokes from a manipulation of the neck. You see, there is a delicate little artery in the neck called the vertebral artery and it can be pinched and severed with a manipulation, particularly if there are bone spurs present. A 60 second test can be done in advance of the manipulation to determine if there is a risk of injury from the manipulation, but few if any ever take the 60 seconds to find out if a vertebral artery problem is present. The manipulation tears or stretches the artery to the point that it begins to leak, and the patient dies or has a stroke within a few days.

How come you have never heard of this undesirable event before? Those people who have caused the event are not very likely to advertise that they killed someone. That kind of advertising is not good for business if all you know how to do is manipulate. Fortunately, this information is available if you are willing to dig for it. A good source is Grieve’s Modern Manual Therapy 3rd edition (on page 533, “Adverse effects of cervical manipulative therapy”). These undesirable events are discussed at length.

Now the cervical spine is not the only area that can be adversely affected by manipulative therapy. The lumbar spine is also another critical area that sees its fair share of manipulations. In many people, two defects in the spine that may be congenital or may have been caused by trauma are present. These two disorders, when present, are an absolute contraindication to manipulative therapy. They are called Spondylolisthesis (a complete break in one of the lumbar vertebrae) and Spondylolysis (a defect which can easily turn into a full blown break).

All professions who manipulate should be aware of these conditions, yet every year I see people in my clinic who have had manipulations and also have these defects. If present, they are a complete contra-indication to manipulations. This is taught on day one in schools of manipulation. That is why you are always (or at least should be) X-rayed prior to manipulative treatment. Note: they tell you they are X-raying you to check for alignment but this is a big fat lie. They are REALLY X-raying you to see if you have a pre-existing defect that would be disastrous if manipulated. If the X-ray shows either of the lesions, then no manipulations should be given. Why? Because the manipulation can break your back or cause severe damage to the spinal chord. Also, if a bulging or herniated disc is present or strongly suspected, manipulations are again contra-indicated as they will likely worsen the bulge and or herniate the disk.

There is yet one more down side to manipulations. Repeated manipulation of the spine can cause instability of the supporting ligaments which help to stabilize it. It does not take a rocket scientist to figure out that if you repeatedly stretch / beat up the structures that are designed to stabilize, after a while, the ligaments will not be able to do their job and the joint(s) become loose. Just ask any ageing skier or football player who has stretched or injured the ligaments of his or her knee several times before.

I was having a professional discussion with one of my colleagues and he was in favor of manipulations. He sited some research that said there was only a 2% incidence of “undesirable events” with manipulations when done by a Physical Therapist. To which I promptly responded, “Oh, well then how would you like to have your mother or wife as one of the lucky 2 %?” The phone went silent! “Ahhhh, errrr” he muttered. “Well, I suppose I don’t want it to happen to my mom or wife but…” Then I asked him how likely it is for a Physical Therapist (or any other professional, for that matter) to actually report one of these undesirable events for statistical purposes? “Well, who wants to bring on a lawsuit?” he fired back. So, I said, “What you have just admitted to is that your 2% may actually be a significantly higher percentage than reported, right?” Again, the phone went silent.

The point is this: 2% is just too much. It is unacceptable. I hear the stories from my patients who were manipulated once, twice and sometime 50 or more times, and it always makes me shudder. These “undesirable events” were 100% preventable. Herniated discs, broken bones, ruptured vertebral arteries and death were all preventable. But how is this possible?

Fortunately, there exists a subset of Manual Therapy that is non-manipulative. That’s right, no manipulations whatsoever. They are much more effective and never, ever put the patient at risk for an “undesirable event.” These non-manipulative techniques are called:

Muscle Energy Technique

Counter Strain Technique

They work by addressing those little computer chips in the muscles and putting the muscle back to “factory settings” so the bone just goes back where it belongs automatically. And, since you are actually addressing the real cause of the problem, you only need a few visits. Many times, I get it done in one visit. Once the bones are lined up, then stabilization exercises are taught to help hold everything in place. And you are on your way to not ever having to see anyone for a back problem again.

If it were just a case of manipulations doing no good and all you did was waste time and money, then that would be that. But when a technique has the potential to do severe harm, then it’s time to look for alternatives.

Now the bad news: There are very few practitioners who possess the skill and experience to get consistently reproducible results with these two techniques. I estimate that less than 2% who take a course in these techniques ever go on to master them and use them regularly. Why, you ask? Because they are much more difficult to learn than manipulations and take more time spent with the patient.

So, get on the phone and start calling clinics in your area and ask to speak to the “head honcho.” Ask if there is anyone on staff who is an EXPERT in Counter-Strain and Muscle Energy Techniques. If not, then keep calling until you find someone who is. Make sure they understand that you do not want any manipulations, nor do you wish to have your time wasted with hot pacs or ultrasound or electric stimulation to temporarily reduce the pain. Trust me, it is worth the effort on your part.
 

Internationally Recognized Physical Therapist, Teacher and Author Tom Ockler, P.T.

Tom Ockler, P.T. is a highly sought after international presenter who gives continuing education courses demonstrating his techniques to eliminate musculoskeletal pain and dysfunction.

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