View Full Version : Re: Spinal Manipulation

Stephen Levin
12-10-1998, 05:01 AM
To those who are at all interested,
Just to add to the  confusion:
There are some of us who believe that the 'maniputable lesion' has
little to do with Vercovian pathology but it is an abnormality of the rhythms
of the system, much like irritable bowel syndrome, benign cardiac arrhythmias,
asthma, hives, urinary urgency, etc.. See: "Perspectives in Biological
Dynamics and Theoretical Medicine", Koslow SH, Mandel AJ, Shelesinger MF
Eds., Annals of the NY Academy of Sciences, Vol. 504, 1987. This makes
it even more of a biomechanics problem. It is a movement problem not a
disease in the classic sense. There is no pathology to 'fix', just movement
imbalances, sort of like a stuck drawer. Whatever pathology found is not
altered by manipulation. Healing is linear, response to manipulation is
nonlinear therefore, two different problems.
Stephen M. Levin, MD
"Stephen M. Perle, DC" wrote:
I will ignore those comments that Dr. Swanepoel directed
to Neil Tuttle
as I believe I have already dealt with those issues.
M Swanepoel wrote:
> Come on, all
> you chiropracters out there, does spinal manipulation:
In case your spell checker does not know, there are only two acceptable
forms of the name of the professional or profession: chiropractor and
chiropractic, respectively. Neither chiropracter nor chiropractice
> 1  Cure muscular inflammation?
No but I have a question for you.  What condition that one typically
present to our offices would you describe as muscular inflammation? 
am only aware of inflammation in a muscle as a typical patient
presentation as a *normal* sequella to a muscular strain or as part
delayed onset muscle soreness (DOMS).  Since inflammation is a
part of healing from a injury I am curious to know:
1. Why should one want to "cure" it?
2. What condition typically causes muscular inflammation and is a cause
for common patient presentations? And how does it manifest itself
> 2  Cure torn paraspinal musles?
> 3  Cure torn spinal ligaments?
> 4  Cure torn facet joint capsules?
> 5  Cure a tear in the annulus fibrosus and IV disk prolapse?
> 6  Remove osteophytes impinging on nerve roots?
> 7  Cure marginal fractures of the facet joints?
> 8  Cure vertebral endplate fractures?
> 9  Permanently cure intervertebral subluxation by arresting
age-related fibrosis
>     of the nucleus pulposus and the concomitant
> 10  Cure congential malformations of the spine?
> 11  Cure facet joint osteoarthrosis and subsequent arthrodesis?
> 12  Cure metastases of malignant cancers?
> 13  Cure primary spinal cancers?
> 14  Permanently cure L5/S1 spondylolisthesis?
> 15  Cure bacterial spinal infections, such as tuberculous spines?
> 16  Cure HLA 27-related disorders, ankylosing spondylitis and
>       scoliosis?
> 17  Cure spinal vascular restrictions?
To your remaining conditions I would submit to you that the chiropractic
profession has not claimed that we have significant impact on these
many many years and in fact consider a few of these to be
contraindications to manipulation in general or to the effected motion
I would submit that manipulation may be effective in a total treatment
program for the following conditions.
> 2  Cure torn paraspinal musles?
> 3  Cure torn spinal ligaments?
> 4  Cure torn facet joint capsules?
The rationale is that loss of joint motion in supr and subjacent motion
segments should increase loads on the injured motion segments. Thereby
exacerbating the injury.   As noted in my previous posting,
a member of
this list Dr. Greg Kawchuk, has published preliminary evidence that
manipulation produces dramatic increases in segmental flexibility.(1)
This was done with a device that he has shown is both valid and
In a motion segment that has a restriction of its range of motion as
result of injury, manipulation by restoring motion to that spinal
segment could accelerate healing of that motion segment. Support for
this concept is found in the literature that shows the benefits of
motion on the healing of ligaments.(3-5) (I know there are more
references but I am only using ones where I have read the actual paper.)
I am well aware that these are purely deductive theoretical concepts
that do need to be tested in an appropriate animal model.  I would
to produce the literature that supports this concept but the lack of
substantial government funding for chiropractic research in the past
significantly retarded the growth of our science. The newly created
National Center for Complementary and Alternative Medicine we hope
help accelerate that growth.
> 5  Cure a tear in the annulus fibrosus and IV disk prolapse?
There is literature to document that manipulation may be effective in
treating patients with the symptoms of and the imaging to document
herniation. Although the manipulation may not actually have any impact
on the disk prolapse.(6-28)  Further it should be kept in mind
that a
large percentage of people who demonstrate discal abnormalities on
are asymptomatic.(29-33) As such, those annular tears or disk prolapses
may in reality be clinically insignificant incidental findings in
patients with symptoms from mechanical causes that are amenable to
chiropractic manipulation and not people who suffer with clinically
significant disk problems.  Although within the population of
treated in the studies cited above there may actually be patients with
clinically significant disk problems.
> 11  Cure facet joint osteoarthrosis and subsequent arthrodesis?
Osteoarthrosis is an interesting case. One experimental animal model
immobilization and since Kawchuk has found that manipulation improves
the flexibility of a motion segment it is conceivable that manipulation
might be an effective treatment for osteoarthosis and might then prevent
subsequent arthrodesis.  Again this is a construct that awaits
validation.  A documented case of arthrodesis secondary to
osteoarthrosis or any other cause is, of course, a contraindication
manipulation of the effected motion segment.
> I beg chiropracters to answer these questions, to prove that their
> manipulations do not exacerbate matters in most, and to
> provide the supporting references.
There is no literature that I know of that shows that manipulation is
deleterious to joints.  Watson (34-37)  has suggested that
(cracking) of joints is harmful.  Watson notes that the energy
during joint cavitation is 0.07 mJ/mm3 and that threshold of energy
hyaline cartilage can before injury results is 1.0 mJ/mm3.  Therefore
the energy involved in cavitation of a joint is below the threshold
injury and thus should be safe. Watson hypothesizes that the damage
the cartilage is due to the additive effects of repeated caviation.(35)
However, studies by Castellanos (38) and  Swezey, (39) have found
habitual knuckle crackers do not have a higher risk for joint
degeneration. The importance of this, in the current discussion is
studies have shown that the noise generated by knuckle cracking and
spinal manipulation are similar, suggesting that these are similar
processes mechanically.(40, 41)
I have previously discussed the fact that the literature shows us that
catastrophic complications to manipulation are exceedingly rare. 
review and assessment can be found in Dabbs and Lauretti.(42)
> The only condition that I know of that may be "cured" by chiropractic
> manipulation, and this is unproven, is nipping of facet joint villi
> between the articulating surfaces.
I am interested in seeing a reference for this.  For I was unaware
this existed.
> Spinal traction provides temporary
> relief of compressive spinal conditions, and provides temporary
> stabilization of most spinal fractures  - your local paramedics
> know and apply this from day to day.
Although many chiropractors use traction (I for one do not) but it is
not the core therapeutic method used by the profession. Manipulation
> It is a pointless waste of time to list all the papers which have
> spinal motion, although I have already sent lists of references to
> few people who actually wished to see the scientific evidence.
> Having examined the facet joints, I believe (no, I am certain!) that
> vigorous rotational movements of vertebrae seriously damage the
> articular cartilage, which is usually soft and in a state of "bad
> repair" anyway.  (Swanepoel MW, Adams LM, and Smeathers JE,
> lumbar apophyseal joint damage and intervertebral disc degeneration,
> Ann Rheum Dis, 1995, 54, 182-188).
What literature do you have to support the knowledge, of which you are
certain, that "vigorous rotational moments of vertebrae seriously damage
the articular cartilage.?"   I do realize that Watson's literature
search which produced the absorbed energy injury threshold may be in
healthy cartilage and thus Dr. Swanepoel's assertion that manipulation
will injure cartilage that is already in "bad repair" may be correct.
But this requires evidence from appropriately constructed studies.  
hold you to the same high standard you would like to hold me to.
However, I do accept that this is as reasonable a theoretical construct
as those I have proposed.  It should be tested.  (See below)
Further, I would like to get a reprint of your paper but having access
at this time to just your abstract, I quote:
"The predominantly peripheral location of fibrillation of both superior
and inferior surfaces may be associated with inadequate mechanical
conditioning of marginal joint areas. Disc degeneration cannot be the
initial cause of apophyseal fibrillation in most specimens. The study
indicates a need for regular spinal exercise, starting at a young age."
Given your findings and those of Kawchuk it would appear that you should
be supporting the regular manipulation of joints to improve their
mobility and thus improve their "mechanical conditioning."  Maybe
decrease in segmental flexibility is the precipitating event for the
degeneration of the apophyseal joint.
You have proposed a study (below) I propose one too.  In a small
model create a device that will reliably produce a loss of in a spinal
motion segment. Then see if this results in joint degeneration. 
If so,
then so prepare animals and then remove the devices after there is
degeneration.  Have one group undergo manipulation, one group
sham manipulation (control for the effect of touching) and one group
serve as controls.  Then determine if there is a different effect
on the
cartilage.  This should tell us if the manipulation is beneficial
to the
health of the cartilage (my belief) or detrimental (your belief). 
you want to collaborate on this?
> The role of the lumbar
> facet joints is to prevent significant intervertebral rotation, and
> to act against this by applying vigorous rotational impulses from
> without the body, is folly.  (I would support gentle twisting
> exercises with an extended spine, however, as a means of
> strengthening these joints and their cartilage.)
How would you define gentle? Triano (43) has measured the forces
generated by spinal manipulation in the lumbar spine.  Peak forces
495.5 N (142.5 95% CI) and peak moments 149.4 N (43.2  95% CI)
to the maxillary process were measured in vivo. In the cervical spine
peak forces of 99 to 140 N (mean 118 N) and in the thoracic spine 399
(sd=119 N) were measured by Herzog et al.(44) Gal et al (45) measured
mean peak force of 562N in the thoracic spine in an un-embalmed
post-rigor cadaver.
Concerning the fact that the lumbar facets function to restrict spinal
mobility, I understand that some patients present with segmental
instability and these subjects are probably not candidates for
manipulation of the effected joint.  Again I submit they may be
candidates for manipulation of adjacent motion segments to decrease
mechanical load on the unstable segment.  However, in my clinical
experience most of the patients I have treated have a loss of range
motion, both globally and segmentally.  The segmental range of
motion I
have assessed by motion palpation and by stress radiographs. 
Again, it
would appear that manipulation, that increases joint range of motion
would appear to be a reasonable treatment.
I have ignored the neurological discussion, this is the biomechanics
> I suggest a controlled experiment  is conducted in which about
200 patients
> suffering from non-specific (undiagnosed?) chronic back pain,
> (say one year after initial consultation),
> are divided into five groups.  One group receives no treatment
> bedrest, a second group is referred to orthopaedic consultants
> who apply placebo treatment, a third group is treated by qualified
> physiotherapists, a fourth group is treated by masseurs, and a fifth
> group is treated by chiropracters.  As part of this study I
> that the mental and pain states of each patient are assessed by psychiatrists
> before and after at least one treatment session, and that if possible
> physiological measures of well-being are also measured - (pulse rates
> and blood pressures before and after treatment?)
> Further I suggest that the therapists are blind to the fact that
> are participating in such a study.  (Are those howls of protest
I hear,
> carried by the wind?)
Ok this is a interesting idea. Of course you probably should start with
a literature search and read some of the hundreds of clinical studies
(of quite varied quality) that have already been conducted on
manipulation. (I can provide citations but shall not do so here.)  
suggestion is to take a look at the US Agency for Health Care Policy
Research's Clinical Practice Guideline Number 14  AHCPR Publication
95-0642: December 1994: Acute Low Back Problems in Adults.  You
can read
this on-line by going to:
http://text.nlm.nih.gov/ftrs/pick?dbK=&ftrsK=37547&t=913352021&collect=ahcpr&ad vOpt=
and in the drop down menu entitled Clinical Practice Guidelines choose:
#14 Acute Low Back Problems in Adults (Clinic...
Finally, there is funding available for your study from the National
Center for Complimentary and Alternative Medicine of the National
Institutes of Health:
Care to collaborate?
Finally, I present what I believe are some of the major areas in
biomechanics of manipulation that are drastically in need of research.
know that this is not an exhaustive list.  All we know regarding
items is theory and we desprately need and want to replace theory with
good scientific evidence.
1.      Biomechanical effects of manipulation
on tissues and what tissues are
2.      Effects of manipulation on IAR or
HAR of spinal motion segments
3.      Further research on the effects of
manipulation on the mechanical
properties of the motion segment.
4.      Biomechanical parameters of the manipulable
5.      Longevity of any mechanical effects
(and physiological and
neurophysiological effects, for that matter).
1.      Kawchuk G, Herzog W. Preliminary evidence
of changes in tissue
stiffness following spinal manipulation. In: International Conference
Spinal Manipulation; 1996: FCER; 1996. p. 18.
2.      Kawchuk G, Herzog W. The reliability
and accuracy of a standard
method of tissue compliance assessment. J Manipulative Physiol Ther
3.      Almekinders LC, Baynes AJ, Bracey
LW. An In Vitro Investigation Into
the Effects of Repetitive Motion and Nonsteroidal Antiinflammatory
Medication on Human Tendon Fibroblasts. Am J Sports Med
4.      Almekinders LC, Banes AJ, Ballenger
CA. Effects of Repetitive motion
on human fibroblasts. Med Sci Sports Exerc 1993;25(5):603-7.
5.      Reider B, Sathy M, Talkington J, Blyznak
N, Kollias S. Treatment of
isolated medial collateral ligament injuries in athletes with early
functional rehabilitation: A five-year follow-up study. Am J Sports
6.      Barrale R, Filson R, Wittmer M. Manipulative
management of lumbar
disc bulge. In: Chiropractic Technique; 1989. p. 79-87.
7.      BenEliyahu D. Infrared thermographic
assessment of chiropractic
treatment in patients with lumbar disc herniations: an observational
study. In: Chiropractic Technique; 1991. p. 126-33.
8.      BenEliyahu DJ. Magnetic resonance
imaging and clinical follow-up:
study of 27 patients receiving chiropractic care for cervical and lumbar
disc herniations. In: J Manipulative Physiol Ther; 1996. p. 597-606.
9.      Blomberg S, G. H, K. G, E. B, U. S.
Manual therapy with steroid
injections -- a new approach to treatment of low back pain: a controlled
multicenter trial with an evaluation by orthopedic surgeons. In: Spine;
1994. p. 569-77.
10.     Cassidy JD, Thiel HW, Kirkaldy Willis WH.
Side posture manipulation
for lumbar intervertebral disk herniation [see comments]. In: J
Manipulative Physiol Ther; 1993. p. 96-103.
11.     Cox J. The lumbar disc syndrome: a chiropractic
evaluation - Part
II. In: Digest of Chiropractic Economics; 1978. p. 21-4.
12.     Cox J. The lumbar disc syndrome: a chiropractic
evaluation. In:
Digest of Chiropractic Economics; 1978. p. 18--20, 99-100, 2.
13.     Cox JM. Low back pain: recent statistics
and data on its mechanism,
diagnosis and treatment from chiropractic manipulation. In: ACA Journal
of Chiropractic; 1979. p. S125-41.
14.     Cox JM, Hazen LJ, Mungovan M. Distraction
manipulation reduction of
an L5-S1 disk herniation [see comments]. In: J Manipulative Physiol
Ther; 1993. p. 342-6.
15.     Davis CG, Fernando CA, da Motta MA. Manipulation
of the low back
under general anesthesia: case studies and discussion. In: Journal
the Neuromusculoskeletal System; 1993. p. 126-34.
16.     Dreyer P, Lantz CA. Chiropractic management
of a herniated disc,
reduction of disc protrusion and maintenance of disc integrity as
substantiated by MRI. In: Proceedings of the 1991 International
Conference on Spinal Manipulation. Arlington, VA: FCER; 1991. p. 57-9.
17.     Haney P, Mootz R.  A case report on
nonresolving conservative care
of low back pain and sciatic radicular syndrome. In: Journal of
Manipulative & Physiological Therapeutics; 1985. p. 109-14.
18.     Hession EF, Donald GD. Treatment of multiple
lumbar disk herniations
in an adolescent athlete utilizing flexion distraction and rotational
manipulation. In: J Manipulative Physiol Ther; 1993. p. 185-92.
19.     Hubka MJ, Taylor JAM, Schultz GD, Traina
AD. Lumbar intervertebral
disc herniation: chiropractic management using flexion, extension,
rotational manipulative therapy. In: Chiropractic Technique; 1991.
20.     King L, Mior S, Devonshire-Zielonka K.
Adolescent lumbar disc
herniation: a case report. In: Journal of the Canadian Chiropractic
Association; 1996. p. 15-8.
21.     Mathews J, Yates D. Reduction of lumbar
disc prolapse by
manipulation. In: British Medical Journal; 1969. p. 696-7.
22.     Neault CC. Conservative management of an
L4-L5 left nuclear disk
prolapse with a sequestrated segment [see comments]. In: J Manipulative
Physiol Ther; 1992. p. 318-22.
23.     Nwuga V. Relative therapeutic efficacy
of vertebral manipulation and
conventional treatment in back pain management. In: American Journal
Physical Medicine; 1982. p. 273-8.
24.     Pate DM, Hubka MJ, Eckard LJ, Vlasuk SL.
Disk herniations. In: Case
Studies in Clinical Radiology; 1990. p. 105-11.
25.     Stern PJ, Cote P, Cassidy JD. A series
of consecutive cases of low
back pain with radiating leg pain treated by chiropractors. In: J
Manipulative Physiol Ther; 1995. p. 335-42.
26.     Taylor DN. Treatment of disc herniation
and fragmentation by spinal
extension distraction. In: Chiropractic Technique; 1993. p. 111-8.
27.     Zachman ZJ, Traina AD, Bergmann TF. A comparison
of contained versus
non-contained disc lesions: a case report. In: Journal of the Australian
Chiropractors' Association; 1988. p. 57-9.
28.     Zhao P, Feng TY. The biomechanical significance
of herniated lumbar
intervertebral disk: a clinical comparison analysis of 22 multiple
39 single segments in patients with lumbar intervertebral disk
herniation. In: J Manipulative Physiol Ther; 1996. p. 391-7.
29.     Wiesel SW, Tsourmas N, Feffer HL, Citrin
CM, Patronas N. A Study of
Computer-Assisted Tomography: I. The Incidence of Positive CAT Scans
an Asymptomatic Group of Patients. Spine 1984;9(6):549-51.
30.     LaPrade R, Burnett Q, II, Veenstra M, Hodgman
C. The prevalence of
abnormal magnetic resonance imaging findings in asymptomatic knees:
correlation of magnetic resonance imaging to arthroscopic findings
symptomatic knees. Am J Sports Med 1994;22(6):739-45.
31.     Hitselberger WE, Witten RM. Abnormal Myelograms
in Asymptomatic
Patients. J Neurosurg 1968;28(3):204-6.
32.     Jensen MC, Brant-Zawadzki MN, Obuchowski
N, Modic MT, Malkasian D,
Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People
without Back Pain. N Engl J Med 1994;331(2):69-73.
33.     Boden SD, Davis DO, Dina TS, Patronas NJ,
Wiesel SW. Abnormal
Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects:
Prospective Investigation. J Bone Jt Surg 1990:403-8.
34.     Watson P, Kernohan WG, Mollan RAB. A study
of the cracking sounds
from the metacarpophalangeal joint. Proc Instn Mech Engrs [H]
35.     Watson P, Kernohan WG, Mollan RAB. The
effect of ultrasounically
induced cavitation on articular cartilage. Clin Ortho Rel Res
36.     Watson P, Hamilton A, Mollan B. Habitual
joint cracking and
radiological damage. Br Med J 1989;299:1566.
37.     Watson P, Mollan RAB. Cineradiography of
a cracking joint. Br J Rad
38.     Castellanos J, Axelrod D. Effect of habitual
knuckle cracking on
hand function. Ann Rheum Dis 1990;49:308-9.
39.     Swezey RL, Swezey SE. The consequences
of habitual knuckle cracking.
West J Med 1975;122(5):377-79.
40.     Herzog W, Zhang YT, Conway PJ, Kawchuk
GN. Cavitation sounds during
spinal manipulative treatments. J Manipulative Physiol Ther
41.     Méal GM, Scott RA. Analysis of the
joint crack by simultaneous
recording of sound and tension. J Manipulative Physiol Ther
42.     Dabbs V, Lauretti W. A risk assessment
of cervical manipulation vs.
NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther
43.     Triano J, Schultz AB. Loads transmitted
during lumbosacral spinal
manipulative therapy. Spine 1997;22(17):1955-64.
44.     Herzog W, Conway PJ, Kawchuk GN, Zhang
Y, Hasler EM. Forces exerted
during spinal manipulative therapy. Spine 1993;18(9):1206-12.
45.     Gál JM, Herzog W, Kawchuk GN, Conway
PJ, Zhang Y-T. Forces and
relative vertebral movements during SMT to unembalmed post-rigor human
cadavers: peculiarities associated with joint cavitation. J Manipulative
Physiol Ther 1995;18(1):4-9.
__________________________________________________ ___________________
Stephen M. Perle, D.C.                         
"A man who knows that
Assistant Professor of Clinical Sciences         
he is a fool is not
University of Bridgeport College of Chiropractic      
a great fool."
Bridgeport, CT 06601                                      
Chuang Tzu
E-mail: perle@bridgeport.edu
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n:Levin, MD;Stephen
fn:Potomac Back Center