CLICKS AND CLUNKS -
The truth about manipulation!

Dr Gordon Cameron dispels some common myths.

Manipulation of the spine has been used to treat back pain for many centuries. It goes back at least as far as the ancient Greeks and perhaps farther.

If manipulation is going to help your back then it makes little difference who does it – provided they are properly trained. The techniques of manipulation may vary a little but there are only so many ways the back can move and I don’t think it matters if the movement is produced by a chiropractor, an osteopath, a physiotherapist, doctor or whoever. The end result is likely to be much the same. For that reason it’s seldom worth pursuing a variety of different manipulation treatments if one type hasn’t worked for you. Try to avoid getting stuck in an endless round of visits to different types of manipulative therapist in an attempt to find the elusive magic cure. You’re likely to end up a lot poorer financially and not much better medically.

As someone who often treats people by manipulation I feel a strong need to strip away all the mysticism and mumbo jumbo that surrounds it. Manipulation treatment does have a basis in science and it will only become more widely available if it is seen to be properly researched and based on our knowledge of how the body works.

WHAT DOES MANIPULATION DO TO THE SPINE?

No one really knows what happens during manipulation but there are many theories put forward. It’s easier to tell you what it doesn’t do. It definitely doesn’t “put discs back” or “bones back into place”. Putting a slipped disc back in would be like putting toothpaste back into the tube and no X-ray has ever shown bones moving around under the influence of manipulation. I’m not saying manipulation doesn’t work – simply that science hasn’t yet figured out how it does what it does.

Luckily we do have some clues. The joints of the spine contain little flaps of tissue called meniscoids – which poke into the space between the bones. One explanation for the success of manipulation is that it releases trapped meniscoid folds.

Recent research has also shown how the middle of a disc can fill up with toxic fluid that will irritate nerves if it touches them. It may be possible to move that fluid around within the disc during manipulation and so make a change in the sufferer’s symptoms.

These are both just theories but they do seem to make sense based on what we know about discs and joints.

CAN MANIPULATION TREAT CONDITIONS OTHER THAN BACK PAIN?

This is an interesting question. D. D. Palmer – the founder of chiropractic treatment – is reported to have cured a factory worker of deafness by manipulating his neck and there are other similar stories throughout the textbooks of manipulation.

Science-wise it could be possible that treating the spine will affect another bit of the body by changing what is happening in the nerves going to that area. Many manipulative therapists could give examples of this type of “cure.” Cynics would say that the wrong diagnosis had been made in the first place. In other words it had been the spine at fault all along and the doctor had been mistaken in blaming the gall bladder or whatever. This may be true. In any case, the jury remains out on whether manipulation can treat anything except spinal problems.

If you feel you would like to try manipulation as a treatment for a non-spinal ailment then ask your doctor first. It is very unlikely that manipulation could make any internal condition worse but a misguided reliance on it as a treatment could delay proper treatment being given, possibly with dangerous consequences.

MYTHS ABOUT MANIPULATION

Treatment with manipulation is nowadays very common. Despite this there are still a lot of mistaken beliefs about it.

MYTH NUMBER ONE: SOMETHING SHOULD GO POP OR CRACK

The noise that is sometimes heard during manipulation has a very simple cause. It’s due to a small bubble of gas in the joint – and nothing to do with discs going back or bones being altered. If a noise is heard it can mean the treatment is going to work well but plenty of people have heard lots of cracking and popping without getting any benefit. Even if no noise is heard the manipulation may work very well. Try not to feel too disappointed or cheated if your therapist does not make your back go crack – it really isn’t important.

MYTH NUMBER TWO: MANIPULATION SHOULD BE PAINFUL

It shouldn’t be – not under any circumstances. You may experience brief discomfort but if the treatment is hurting you either at the time or afterwards then it’s either the wrong treatment, or it’s being given at the wrong time or in the wrong way. Don’t let anyone tell you otherwise.

MYTH NUMBER THREE: IT WILL TAKE SEVERAL TREATMENTS BEFORE YOU KNOW IF IT IS WORKING

This again is false. If manipulation is going to be the right treatment for you then you’ll know it very quickly. There should be an obvious change for the better after every session of treatment. You might not be cured but you should notice an improvement either straight away or within a day or so at most. As a rule of thumb if three treatment sessions have not produced a noticeable benefit then manipulation is not going to be the answer for you.

IS MANIPULATION SAFE?

When the lower back is treated by manipulation, complications are very rare but the treatment needs to be tailored to the person – there are some types of manipulation, which are too vigorous to be used on an older person or someone with hip problems. Make sure your therapist is well trained and experienced and follow the guidelines below.

Do not have manipulation done if:

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• you are taking medicines such as warfarin which thin the blood.
• you have thin or brittle bones.
• there is a chance that your pain could be due to a serious illness.
• you should also be careful in the later stages of pregnancy although more gentle versions of manipulation can be very helpful for pregnancy back pain.

Manipulation is not likely to be a great help if:

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• you have pain in the leg which goes right down to the foot, especially if you have had it for more than a few months. This doesn’t mean it’s not worth a try but take care that it does not make your pain worse either at the time or afterwards.

Manipulation will probably help a lot if:

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• your pain is of recent onset, particularly if it came on suddenly.
• the pain is staying in the back or the buttock and not really going down the leg.
• your pain seems to vary depending on your posture.

In general, providing you have none of the things which rule out manipulation as a treatment, then it is always worth a try but do remember my “three treatment rule”. You should be able to see or feel a real difference after no more than three treatments. If you can’t then think twice about continuing.

SO WHAT’S THE DIFFERENCE BETWEEN THE KINDS OF MANIPULATION TREATMENT AVAILABLE?

I don’t think there is any difference in what happens to the spine whether your treatment is done by a physiotherapist, a doctor, a chiropractor or an osteopath. Manipulation is manipulation. There are more similarities than differences between the techniques these people use although they would sometimes lead you to think otherwise.

Chiropractors often use special couches to help them perform the techniques and it is likely that you will be X-rayed the first time you visit them. Physiotherapists and most osteopaths are not able to perform X-rays without arranging it through your doctor but these two groups place less emphasis on X-ray appearances in any case.

Most physiotherapists work within the NHS although a few are available for private consultation. Most doctors who perform manipulation techniques make them available both privately and through the NHS.

Chiropractors and osteopaths work privately although some GPs nowadays are making arrangements so that their own patients can see such therapists without paying.

If you need more information about manipulation treatment then make an appointment with a qualified practitioner who can discuss it with you. Don’t be afraid to question what’s being done to you. If you are unsure then perhaps attend for one session of treatment before committing yourself to a longer programme and keep in mind that if it’s working for you, then you yourself will know it without needing to be told.

The last few years have seen a sea change in how back pain is viewed by the medical profession. I would like to see manipulation being more widely available but a balanced approach to what it can and can’t do is important. Less mystique and more evidence will be the key to better acceptance.

Dr Gordon Cameron is a specialist in musculoskeletal medicine

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