CT Spinal Manipulative Therapy: The Great Conversation

[Diane]

OK, I'm going to start a new thread on spinal manipulative therapy. EB posted this article on Eric's tenderness palpation thread. I think it's time we got down on this, and EB seems willing to play.

I just read the article, and honestly, what I got was that 90% of people who see chiros get manipulated, that a chiropractor got together with a researcher and a bunch of cats got their muscle spindles examined after being manipulated. (As a cat lover, I had to look past that.. )
But anyway, I'm still left with this sense that chiros will turn not only themselves but now cats inside out to "prove" that spinal manip does something.. anything. So yes, now we know that cats' spindles fire abnormally for awhile after, before returning to normal. So, the spindles are shocked into abnormal behavior for a time. The bit about the "novel stimulus" to the cortex was interesting given that the cats were "deeply anesthetized".. My question is, and always will be, so what? Why am I supposed to be impressed by this?

Really, one wonders why go to this extreme to try to save manip from oblivion. It's done on people mostly, not cats, and wide awake people at that, and futhermore, people whose skin has been left intact. There will certainly be a whole whack of other neural factors coming into play at many many levels, long before any effect on any spindles, in real life on real people.

[nari]

Diane, speaking of anaesthetised cats....

Unconscious monkeys were presented with novel visual stimuli, and imaging demonstrated high activity in the primary visual cortex, medial temporal cortex and the lateral geniculate nuclei. If the same could be done in unconscious patients (eg passive movements) who knows what bits of cortex light up??

(This is from Nikos Logthetis, director of the cognitive processes dept at the Max Planck Institute. The full article plus other goodies, including phantom limb pain by Melzack, can be read in the Scientific American Special Ed. on the Senses. Vol 16, #3, 2006.)


Nari

PS ....by the way, I think your thread is a good idea!!

[Diane]

I the same could be done in unconscious patients (eg passive movements) who knows what bits of cortex light up?

Good question. If the passive movment were delivered with SMT, I would expect to see the areas involved with alarm, defence, and threat light up. I can sorta see why the immune system (see EB's SMT and immune system thread) might kick up a bit. It's probably being stimulated via neurohormonal pathways, by that phylogenetically ancient part of the CNS mostly housed by vertebrae, to try to defend its organism.

Which begs the question, why would anyone ever in their right minds choose to do this to any patient's nervous system?

Wait a minute, most manipulative practitioners are not usually in their right minds.. that must be the answer.

[Luke Rickards]

There is great discussion on this topic in The manipulation solution thread also.

[Diane]

Good idea Luke, here's the rehab edge thread, posted earlier by Eric. Might as well get all these threads linked up in this one.

[Evidencebased]

Diane

My question is, and always will be, so what? Why am I supposed to be impressed by this?

Not a good way to start a level headed "conversation". Also, please quit it with the anti-chiro propaganda:

I'm still left with this sense that chiros will turn not only themselves but now cats inside out to "prove" that spinal manip does something.. anything.

SMT research is not exclusive to chiropractic by any means. PT's, DO's MD's do it too. Your inference that chiro's are try anything to prove SMT does anything shows narrowed mindedness on your part.

Really, one wonders why go to this extreme to try to save manip from oblivion.

SMT research is not exclusive to chiropractic by any means. PT's, DO's MD's do it too. Are all manipulators wrong Diane? Some, DC's in particular, seem more wrong than others, right? How can we have a debate when you SMT discussions always turns into an anti-chiropractic statement? Speaking of which, you wouldn't happen to be a moderator at an anti-chiropractic website would you? Just curious.

Anyways onto a few points of clarification:

1) You are calling this the great conversation. Conversations are usually respectful, and ideas are exchanged back and forth. Seeing the other "great conversation" threads, they've all turned into flame wars. I'm not going to be the white knight defending SMT. Many professions use it. Many patients benefit from it. It's being increasingly researched, with the research appearing in many peer reviewed journals. It's a difficult topic to study since it's almost impossible to find a good "sham" to compare it to. Furthermore, you're attitude is disrepectful and unbecoming of a mod, IMHO

Wait a minute, most manipulative practitioners are not usually in their right minds.. that must be the answer

2) How can I seriously expect a level-headed and fair debate here? It's myself "against" a forum moderator that even has her own following "Dianesians". Asking this forum about the merits of SMT is like asking a hockey player if his favourite sport is football!

3) I find it completely intellectually dishonest how you began this thread using that paraspinal spindle study. You had asked in a previous thread how SMT could have an effect a relaxing effect on muscles so I provided you with a study. Next thing I know you are dedicating an entire thread to SMT topic and using this study as the centre piece or a lightning rod.

Also

It's probably being stimulated via neurohormonal pathways, by that phylogenetically ancient part of the CNS mostly housed by vertebrae, to try to defend its organism.

Which begs the question, why would anyone ever in their right minds choose to do this to any patient's nervous system?

You are speculating here and basing using a rhetorical question to further your point. Besides your own extremely biased opinion, do you have any progressive comments besides calling manipulators names and questioning their intellect?

Also, what do you do besides DNM? Is that the solution to all NMSK issues? By reading many of your posts, it seems like its a one trick pony solution. I also don't understand why you are constantly pacifying the nervous system like a baby. You make it sound so weak and fragile. It can handle a lot. Do you have any background with sports or sports performance? Training for sports, especially high level sport, is extremely intensive for the nervous system. It's essentially gets maxed out at certain points. Would you consider this bad the nervous system? I'm looking forward to your insight on this point.

I don't think I can take you seriously as your extremely big anti-chiropractic bias is influencing your opinions to the point where all SMT talk degenerates into an anti-chiropractic rant. I choose to use many tools at my disposal, Diane, SMT being one of them. You don't think its a valid treatment. Research, anectodal and otherwise and millions of patients have benefited from modern SMT for over 100 years. SMT didn't begin and end with DD Palmer. You might recall a certain important practitioner, Hippocrates, also practiced "bone setting" in addition to more allopathic forms of medicine.

Anyways, I'm all up for a "conversation" I'm just waiting for us to talk about the issues instead of your repeated jabs to myself and my entire profession.

[Jon Newman]

Hi Marc,

I think Diane's question is reasonable. What is it about that study that leads chiropractors to use it on 90% of their patients? For sure other professionals use SMT but not on 90% of their patients. It seems excessive.

[Diane]

Just so it's clear for you, I'm anti-manip. If chiros are mixed up in there, so be it.

Please be big enough to stand apart from the issue of spinal manipulation and debate that, and do not take this so personally. It's not about you as a human, it's about manipulation and its use/abuse. Stop identifying so strongly with manipulation and maybe we'll get somewhere. Get over yourself. This isn't about you. Unless you'd like it to be.

You may have noted that we've had more than one "great conversation" on this board. It's the constructs I am interested in discussing. Are the constructs valid, given what we know about the nervous system, how it evolved, what it's doing here in bodies, how to handle it, how to get IT to do all the work of changing its output, without banging it around or falling prey to ideas that we can actually change mesoderm.

Are you up for this? If not, so be it.

[BB]

Hi EB,

One issue that I've always had with manipulation is the resulting explanation that the patient is left with. "They popped my back and that helped my pain. Therefore when I have pain I need popped."

This alone doesn't sound so bad. However, when the patient thinks the popping is reducing a disolcation or restoring alignment, pain= something out of place, or out of alignment.

Even when this is not the explanation that is provided to them, that cultural expectation exists to a degree that they come to the conclusion on thier own.

In my experience, people become afraid of thier bodies, afraid that every time they have pain something is out of alignment, effectively that they are broken.

So, although SMT undeniably works to reduce pain, the resulting explanation of the patient creates a new threat. Since pain is built on real or potential threat this is significant.

[nari]

Another point about SMT is the likelihood of creating a dependency on a health professional to perform the HVLA; in other words, it is a manouevre which most patients can't perform easily themselves.
Some try, with scary results: I have come across several patients who self-manipulate their necks, one of them every half hour throughout the day. (They were not manipulated by chiros, just to keep the field even).

No-one denies the effectiveness of SMT; it is the message it sends.
If you have pain, come in and I'll fix it for you.
This is not restricted to HVLAs - it applies equally to spinal mobilisations, too.

We can't fully explain why SMT works - yet - so the patient can be left with the idea of misalignment, weak joints, weak muscles leading irrevocably to pain.

Traction used to be done for 90% of patients with LBP and/or sciatica. We got over that, fortunately; no one technique or modality is appropriate for almost everyone; physiology doesn't work that way.

Nari

[Diane]

Note: A few posts have been moved so the discussion can stick to topic.
I've reattached EB's article he posted earlier in one of the moved posts.

About the content, we've already been up one side and down the other of the TrA issue, and I doubt adding SMT to the mix of what the deep model is this case of ab recruitment will help much.

[Diane]

Here is something to think about for those who perform SMT on the neck:
Painonline Nov.5 blog.

For more about how people in chronic central pain live, visit Kevin McHenry's great blogsite, http://www.painonline.com

[BB]

Great post Eric!

Please see these editorials by International Journal of Osteopathic Medicine editor, Nicholas Lucas. OMT in the title stands for "osteopathic manipulative therapy." These are great editorials that are very relevant to this discussion.

As for the Maigne article, this passage makes my point for me a bit:

As with all treatments, a placebo effect occurs with SMT.
A feeling that the vertebra has been returned to its normal
position, a perception that the cracking sound indicates effectiveness,
and the manual contact preceding the manipulation
all contribute to the placebo effect. In addition to this psychological
effect, many spinal pain syndromes improve spontaneously.
Finally, patients may perceive the explanations supplied
by SMT practitioners as more satisfactory than those
given by physicians [44].

See the above linked editorials for a more accurate description on what placebo actually is, as well. This passage, like most, still regards placebo as simply a psychological effect.

As for this article providing mechanisms of SMT, this is just one such passage from the article:

According to the lesion felt to be
responsible for the pain, SMT seeks either to return a vertebra
to its normal position or restore lost mobility.

There were also many passages of the "this is thought to occur, but has yet to be found" variety. And even "this is thought to occur, but the current evidence suggests otherwise. So, we'll keep looking" variety. Not great science in my opinion.

EB,
Even if you make the attempt to educate the patient that "putting bones in place is not what we are doing," my feeling is that they will still come to that conclusion anyway. The cultural meme is just too deeply entrenched. This will be even more likely to occur if you follow the Childs study reasoning of "who cares why, we can just tell them it decreases pain in 98% of patients of a certain presentation."

I've expressed my feeling and evidence about this topic previously in this post.