Manipulation: Should Osteopaths Perform it on The Intervertebral Discs?

What is Spinal Manipulation?

The definition of spinal manipulation is quite broad and does have many descriptive elements as shown a paper by Evans and Lucas (2010) which provides a reappraisal of what spinal manipulation is.

 A force is applied to the recipient

Manipulation involves a force being applied to the recipient. Most commonly, this force is externally generated and is usually applied to the recipient by physical contact at the skin surface. The force may include reaction forces from furniture,such as a plinth or chair and, in some circumstances, gravitational force may be utilised (Evans and Lucas, 2010).

The line of action of this force is perpendicular to the articular surface of the affected joint

Importantly the force has always been applied along a line of action perpendicular to the articular surfaces of the affected joint. Moreover, the motion produced by this force was joint surface separation, without any obvious ‘gliding’ motion. As synovial joint surfaces are designed to glide smoothly over one
another, the motion produced during this type of MCP joint manipulation is hence distinguished from that produced during typical ‘physiological’ motion. A complexity of this feature is that most synovial joints are curved rather than planar, and are not always congruent (Evans and Lucas, 2010).

Whereas the line of action of the applied force may be perpendicular to one point along the articular surface, this will not be the case with the
entire articular surface. Hence, the applied force may be more accurately described as acting perpendicular to a plane that is tangential to a point of contact between the articular surfaces of the joint (Evans and Lucas, 2010).

This joint motion always includes articular surface separation

The applied force induces motion between the articular surfaces of the affected joint, and when measured, articular surface separation (gapping) has always been observed (Evans and Lucas, 2010).

Cavitation occurs within the affected joint

Associated with joint surface separation is the elicitation of a high frequency vibration that manifests as an audible ‘click’ or ‘crack’ sound. .The most likely and widely accepted explanation for this audible sound during joint manipulation is a process known as cavitation, occurring within the synovial fluid of the affected joint. Cavitation is an engineering term used to describe the formation and activity of bubbles (or cavities) within fluid, which are formed when tension is applied to the fluid as a result of a local reduction in pressure (Evans and Lucas, 2010).

The UK Osteopath’s attitude towards Manipulation of Intervertebral Discs

You will find that Osteopaths in the UK have  quite varied opinions either in favour or against manipulation of the Intervertebral Joints. Though as a student Osteopath in the Osteopathic Colleges of the United Kingdom, it is kind of frowned upon to manipulate the intervertebral joints, Particularly when they are a final year osteopathic student are sitting their final clinical competency exam to register with the General Osteopathic Council. If the student has case during the exam where there is an opportunity to manipulate, the examiner would ask, “so would you manipulate a disc injury /Disc herniation?” The answer expected of the student should be “No!”

However with the research emerging at the moment, it makes it quite hard to justify whether this sort of treatment is appropriate for disc injuries /disc herniations.

In Favour of Manipulation of Intervertebral Discs

Reduction of radicular pain

The majority of patients in this study had either extruded or sequestered disc herniations. Patients with sequestered herniations treated with Spinal Manipulative Treatment to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points compared to patients with extruded disc herniations but this did not reach statistical significance. Further investigation is needed to determine mechanisms for this finding. This also calls into question the seriousness of disc sequestration in determining appropriate treatment (Ehrler et al. 2016).

Clinical Improvement with no serious adverse events

A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture SMT reported clinically relevant “improvement” with no serious adverse events (Leemann et al. 2014).

Against Manipulation of Intervertebral Discs

Surgical Treatment maybe required when Manipulation of Intervertebral Joints causes Dics

Patients with Lumbar Disc Hernation, who underwent surgical treatment due to exacerbation of presentation caused by SMT. Five risk factors have been identified regarding the treatment of LDH by SMT. The present data attempt to offer guidance to chiropractors for the appropriate management of patients. Chiropractors should assess patients with back pain before performing SMT and practice the manipulation particularly carefully if any of the risk factors exists. To the best of our knowledge, this is the first study to address the risk factors of SMT in the treatment of LDH (Huang et al. 2015).

Potential Paralysis

We presented an extremely rare case of cervical intervertebral disc hernation causing progressive quadriparesis after excessive spinal manipulation therapy (Yang et al. 2016).

Conclusion

Osteopaths should think careful about whether is it safe and appropriate to manipulate the intervertebral joints. As their are arguements in favour of manipulation as treatment to reduce the symptomology associated with a discal injury /disc hernations. But their arguements against performing manipulative techniques on the intervertebral joints from a safety aspect and possible associated adverse events that can occur. In which it is completely understandable for the osteopathic colleges in the UK to teach osteopathic students not to manipulate the intervertebral joints of the spine in the teaching clinics.

 

Reference List

Ehrler M, Peterson C, Leemann S, Schmid C, Anklin B, Humphreys BK.  Symptomatic (2016). MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal ManipulationManipulative Physiol Ther. Mar-Apr;39(3):192-9

Evans DW, Lucas N (2010).  What is ‘manipulation‘? A reappraisal. Man Ther. Jun;15(3):286-91

Huang SL, Liu YX, Yuan GL, Zhang J, Yan HW (2015). Characteristics of lumbar disc herniation with exacerbation of presentation due to spinal manipulative therapy. Medicine (Baltimore). Mar;94(12):e661.

Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulativetherapy: a prospective observational cohort study with one-year follow-up. Manipulative Physiol Ther.  Mar-Apr;37(3):155-63.

Yang HS, Oh YM, Eun JP (2016). Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal ManipulationTherapy: A Case Report and Literature Review. Medicine (Baltimore).  Feb;95(6):e2797.

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