CHIROPRACTIC SPINAL ADJUSTMENT / MANIPULATION
Manipulation vs. Mobilization
Part 1 of 2
Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature
Kinetically,spinal manipulation is defined as a high-velocity low amplitude (HVLA) thrust maneuver. According to Ernst and Harkness (2001), “SM (spinal manipulation) involves high velocity thrusts with either a long or short lever-arm, usually aimed at reducing pain and improving range of motion (p. 879).
Kinetics and kinematics of motion (sub-areas of biomechanics) were described by Evans and Breen (2006). “Kinetics is the branch of mechanics that deals with motion (of an object) under the action of given forces. This includes static (equilibrium) states in which no movement is occurring and dynamic states in which forces may vary as movement occurs” (p. 72). “Kinematics is the branch of mechanics that deals with motion (of an object) without reference to force or mass. With a few notable exceptions, most biomechanical studies of spinal manipulation have given scant attention to kinematics” (p. 73). Thus, kinetics is the study of the type of force used with spinal manipulation while kinematics is the study of the motion geometry of the thrust.
Respectfully, spinal manipulation performed by a doctor of chiropractic is a specific chiropractic spinal adjustment (CSA). From an insurance coding a billing perspective, a CSA is also called a chiropractic manipulative treatment (CMT). In part 2 of this series, we will detail the necessity for that language. In this paper (part 1 of 2), we will focus on the definition of spinal manipulation and the different outcomes desired by disparate professions. However, the terminology of a specific chiropractic spinal adjustment needs to be considered at all times when referencing spinal manipulation in this article.
Zinovy and Funiciello (2018, Sept. 17, para. 2) regarding spinal manipulation reported, “This high-velocity, low-amplitude (HVLA) thrusts, also called chiropractic adjustments or osteopathic manipulative treatments (OMT), are carefully performed by applying enough force to push the spinal joint beyond the restricted range of motion with the goal of improving the joint’s function, increasing range of motion, and reducing pain. When a high-velocity manipulation is performed on the spine, it typically involves a cracking or popping sound that can be heard. Some people report feeling relief or enjoying the cracking sound, whereas others do not” (https://www.spine-health.com/conditions/neck-pain/manual-manipulation-and-mobilization-chronic-stiff-neck).
Conversely, spinal mobilization is kinetically defined as a low-velocity, low-amplitude force (LVLA) non-thrust maneuver used to help relieve pain, improve motion and restore function. Zinovy and Funiciello (2018, Sept. 17) regarding spinal mobilization wrote, “These low-velocity, low amplitude (LVLA) manipulations gradually work the spinal joints through their well-tolerable ranges of motion rather than forcing them beyond the normal limit. The practitioner’s hands gently move the vertebra and stretch each spinal level being worked. Spinal mobilization usually does not involve a neck-cracking sound” (para. 3).
Differentiating Spinal Manipulation Amongst Providers
In a United States-based review (which derived from an analysis of 67 articles and 9 books or textbooks) by Shekelle, Adams, Chassin, Hurwitz, Phillips and Brook (1991, P. 3), the authors stated “A recent analysis of a community-based sample of patients showed that chiropractors delivered 94% of all the manipulative care for which reimbursement was sought, with osteopaths delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder” (https://www.rand.org/pubs/reports/R4025z1.html).
In other words, DCs perform 94% of All spinal manipulations in the United States while Doctors of Osteopathy (DOs) perform 4% and subsequently, the remaining 2% of spinal manipulations are performed by Physical Therapists (PTs) and Medical Doctors (MDs).
Further, although Zinovy and Funiciello (2018, Sept. 17) reported the general goal of spinal manipulation is “improving the joint’s function, increasing range of motion, and reducing pain” (para. 2), beyond that, the intention of spinal manipulation amongst DCs, DOs and PTs is different. So, what is the difference?
Spinal Manipulation (CSA) According to DCs
In addition to improving joint function, increasing range of motion and reducing pain, spinal manipulation for DCs is about normalizing neuro-biomechanical biomechanical function and reducing neurological irritation to maintain optimal function of the nervous system. Petterman (2007) explained this is known as the Law of the Nerve (p. 168). DC’s more precisely regard spinal manipulation as a specific chiropractic spinal adjustment or chiropractic manipulative treatment (CMT). Andersson, Lucente, Davis, Kappler, Lipton and Leurgans (1999) reported in the New England Journal of Medicine, “The chiropractic approach is focused more on the nervous system and advocates adjustments of the spinal vertebrae to improve neurotransmission” (p. 1426).
Evans (2002), referring to the above images, described the cause of neuro-biomechanical dysfunction due to meniscoid entrapment as follows:
Meniscoid entrapment. 1) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. 2) On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule. Pain occurs as a result of capsular tension, and extension is inhibited. 3) Manipulation of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space (4) [Realignment of the joint.] (p. 253)
Evans (2002) continued:
Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoid have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoid causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue (p. 252). A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent the impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…
Evans (2002) further added, “An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain” (p. 252-253).
When considering the neuro-biomechanical lesion, (or vertebral subluxation complex [VSC] as traditionally coined) in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define the lesion beyond the inter-articulation entrapments.
Panjabi (2006) reported, “Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into the diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes in the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury” (p.668-669).
In short, chiropractors primarily use a very specific high-velocity, low-amplitude spinal manipulation/ or a specific chiropractic spinal adjustment to correct the neuro-biomechanical dysfunction and reduce the neurological irritation/interference.
Spinal Manipulation According to DOs
The outcome for DOs is to improve overall blood flow throughout the body. As written by Petterman (2007), this is known as the Law of the Artery (p. 168). This is further supported by Andersson et al., (1999) who wrote, “The focus of osteopathic medicine has been the need to optimize the blood circulation to maintain or restore health” (p. 1426).
Further, DO’s perform non-specific spinal manipulation which they regard as osteopathic manipulative treatment (OMT). According to the American Osteopathic Association, “Through OMT, physicians manually apply a specific amount of pressure to different regions in the body. These techniques can help: Treat structural and tissue abnormalities, relieve joint restriction and misalignment, restore muscle and tissue balance and promote the overall movement of blood flow throughout the body (https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/).
Spinal Manipulation According to PTs
Like DOs, PTs perform non-specific spinal manipulation that is regarded as a unique form of manual therapy that they call thrust joint manipulation (TJM). According to Puentedura, Slaughter, Reilly, Venturan and Young (2017), “Thrust joint manipulation (TJM) is defined as a high-velocity low-amplitude thrust technique which can be distinguished from other joint mobilization techniques that do not utilize a final thrust maneuver” (p. 74).
Historically, in 1920, spinal manipulation was first introduced in Britain to physical therapists by the Osteopathic profession. Paris (2000) reported, “Osteopathic medicine and surgery was founded by Andrew Taylor Still in 1874” (p. 68). Pettman (2007) reported, in 1892, Andrew Still established the American Osteopathic College in Kirksville, Missouri. Conversely, in 1897, DD Palmer opened Palmer College of Cure which is now known as Palmer College of Chiropractic in Davenport Iowa (168).
Pettman (2007) further reported:
“Two of Still’s original students, William Smith and J. Martin Littlejohn, were medical physicians from Scotland. Smith struck a deal with Still that if Still taught him osteopathy, he would teach Still’s students anatomy, greatly enhancing the scientific validity of this emerging profession.
Littlejohn would become the first dean of the College of Osteopathy in Kirksville. He would then go on to found the Chicago College of Osteopathy before returning to Britain and becoming the founder of the British College of Osteopathy in London in 1917.
Despite many frustrating attempts, Littlejohn could never get the English legislature to give osteopathy the same parity with medicine that was enjoyed by his American colleagues. Ironically, instead of behaving antagonistically, he chose to begin educating his fellow physicians and physical therapists in the art and science of spinal manipulation as of 1920.” (p. 169).
Conversely, the development of manipulation to the physical therapy profession in the United States occurred 40 years after being introduced to PTs in Britain in 1920. In a document on the history of manipulative therapy in the United States, Paris (2000) wrote, “Since the 1960s, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function” (p. 66).
Farrell and Jensen (1992) added, “Physical therapy education has evolved considerably since 1970, when just a few programs included content and skills in "manipulative therapy"” (p. 845). Thus, physical therapists in the United States did not start developing knowledge of manipulation until the 1960s and few US PT programs taught manipulation in 1970.
PT’s Historical Confusion of Manipulation Vs. Mobilization
As already discussed, the development of spinal manipulation for PTs did not begin until the 1960s. Further, PTs did not have standardized terminology for manual therapy and often mobilization and manipulation were used interchangeably. Mintken, DeRosa, Little and Britt (2008) stated, “Seminal documents from noted professional associations and organizations, such as the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists, and the International Federation of Orthopaedic Manipulative Therapists, interchange such terms as manual therapy, mobilization, and manipulation with the implication often being that they are synonymous” (p. 51).
Mintken et al., (2008) added, “Physical therapists in particular are not immune to the consequences of this history. John Mennell, MD stated that physical therapists used a confusing array of terms that “cloud the issue by talking about degrees of manipulation using such terms as articulation and mobilization leading up to manipulation.” Such a woeful lack of language specificity ultimately precludes any ability to compare and contrast the intervention or the outcome and minimizes any opportunity to ultimately discern effective from ineffective” (p. 51).
Mintken et al., (2008) continued, “Furthermore, despite Mennell’s caution appearing many years ago, one could argue that the clarity of language concerning manipulation has not improved, but in fact has worsened” (p. 51).
To address this issue Mintken et al., (2008) published their article to standardize manipulation terminology. Mintken et al., (2008) stated, “In February 2007, the American Academy of Orthopaedic Manual Physical Therapists formed a task force to standardize manual therapy terminology, starting with the intervention of manipulation. The ultimate goal of this task force was to create a template that has the potential to be used internationally by the community of physical therapists in order to standardize manual therapy nomenclature” (pg. 50). Thus, you can see that as late as 2007, it was being reported that manipulation and mobilization in the physical therapy profession were still poorly differentiated and the terminology was not standardized.
The Mintken et al., (2008) reported, “The aim of the task force created in February 2007 by the American Academy of Orthopaedic Manual Physical Therapists was to propose a model for standardized terminology to describe manipulative techniques as simply and clearly as possible in language that is understandable to all clinicians, regardless of individual clinical practices or schools of thought” (p. 52-53).
DC’s perform 94% of All spinal manipulations in the United States. Although PTs began learning manipulation in Britain in 1920 through the osteopathic profession, the physical therapy profession did not begin developing spinal manipulation for PTs in the United States until the 1960s and in 1970 few schools included content and skills in manipulation. The purpose of this statement is not to diminish a PT trained to perform non-specific spinal manipulation, but rather to highlight the limited non-specific use and true infancy among PTs in performing spinal manipulation in the US.
Finally, spinal manipulation is kinematically regarded as HVLA and not synonymous with spinal mobilization which is regarded as LVLA. Further, while spinal manipulation acts to improve joint function, increase range of motion, and reduce pain, beyond this, it’s clinical intention is different amongst DCs (CSA: a specific form of spinal manipulation to normalize neuro-biomechanical biomechanical function and removing nerve interference), DOs (OMT: a non-specific form of spinal manipulation with intention on improving blood flow) and PTs (TJM: a non-specific form of spinal manipulation regarded as a unique form of manual therapy).
In part 2 of this series, we will further differentiate spinal manipulation amongst DCs, DOs and PTs and how it is a physician-based service for DCs and DO’s and a form of manual therapy for PTs. Moreover, we will explain in greater depth how spinal manipulation provided by DCs is regarded as specific while among DOs and PTs it is regarded as non-specific. Finally, we will discuss how a DCs intention in performing a specific CSA follow a salutogenic model (what keeps one healthy or well) while the intention of PTs and DOs in performing a non-specific spinal manipulation called TJM or OMT respectfully follows a pathogenic model(what causes disease or makes one ill).
Chiropractic vs. Physical Therapy
in Treating Low Back Pain
with Spinal Adjustments vs. Exercise Rehabilitation
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
In the United Kingdom, Field and Newell (2016) reported that back pain accounts for 4.8% of all social benefit claims with overall costs reaching $7 billion pounds or $9.35 billion US dollars. Boyles (2016) reported that “Researchers from the University of Washington, Seattle, found that the nation's dramatic rise in expenditures for the diagnosis and treatment of back and neck problems has not led to expected improvements in patient health. Their study appears in the Feb. 13 issue of The Journal of the American Medical Association. After adjustment for inflation, total estimated medical costs associated with back and neck pain increased by 65% between 1997 and 2005, to about $86 billion a year… Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations.
“We did not observe improvements in health outcomes commensurate with the increasing costs over time," lead researcher Brook I. Martin, MPH, and colleagues wrote. "Spine problems may offer opportunities to reduce expenditures without associated worsening of clinical outcomes." (http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain) Part of the explanation for the rise in cost of treatment of low back pain is the utilization of physical therapy by allopath’s (medical primary care providers and medical specialists) as the primary option for the treatment of low back pain vs. the literature verified better alternative of chiropractic based upon outcome studies.
Through the years, both chiropractors and physical therapists have concurrently utilized exercise rehabilitation as a modality to treat low back pain. As a rule, the chiropractic profession has utilized exercise rehabilitation as an adjunct to the spinal adjustment where in physical therapy, it has been the main focus of the treatment plan. In addition, other passive modalities to mitigate pain, such as electrical stimulation and/or hydro/cryotherapy has been utilized as an adjunct to each professions main treatment. As a rule, exercise rehabilitation is a crucial adjunct to the treatment of low back disorders as it adds necessary motion to the joint and helps balance muscle tone required to create a biomechanically stabilized joint over time.
However, Ianuzzi and Khalsa (2005) wrote (pg. 674)
Facet joint capsule strain magnitudes during simulated high velocity low amplitude spinal manipulations were within the range of motion occurred during maximum physiological motions, indicating that the procedure is biomechanically safe and provide a stimulus that is likely sufficient to stimulate facet joint capsule neurons. However, physiological motions of the lumbar spine by themselves (e.g. Exercise) are generally ineffective in treating low back pain, suggesting that facet joint capsule strain magnitude alone would be insufficient in providing a novel stimulus for facet joint capsule afferents.
The high strain rates that occurred during spinal manipulation could provide a novel “yet biomechanically safe” stimulus for afferents innervating given facet joint capsule. Alternatively, during spinal manipulation, the relative magnitudes (patterns) of facet joint capsule strain was in a region of the lumbar spine may be unique, which could result in a novel pattern of facet joint capsule mechanoreceptor firing in the spinal region and subsequently a novel stimulus to the central nervous system.
Simply put, the facet joint capsules are comprised of ligaments where the mechanoreceptors are located. A spinal manipulation (chiropractic spinal adjustment) stimulates the neurons in the capsule where exercise (physiological motion) does not. In addition, it has been shown that chiropractic spinal adjustments are safe to the joint capsule and ligaments that comprise the capsule.