Spinal Manipulations - All it’s cracked up to be?
Spinal manipulations (Back cracking) has long been part of the landscape in treatment of lower back and neck pain. It has also been promoted as a way to maintain a well-aligned and healthy spine.
While it does not make up part of my array of treatment techniques, as a physiotherapist, I get asked questions about back cracking all the time.
Does it help?
Is it safe?
Is my back “out” and can you put it “back in place”?
To answer the questions, we must look at exactly what a spinal manipulation is.
a type of passive (not requiring muscular control of recipient) movement of a skeletal joint
involves application of force to point where there is tension (thought to be created by the cohesive effect of fluid within the joint). From this point, a further, more rapid force is applied to break this resistance.
creates an audible “pop” or “crack” thought to be due to distortion of the joint resulting in pressure changes within the joint that cause gases to escape quickly.
So to answer…
Does it help?
The evidence says spinal manipulations provide:
temporary relief of pain or tension (1)
temporary small increase in passive range of motion (2)
affects on central nervous system to modulate pain (3)
Is it safe?
Considered safe and legal by most worldwide health governing bodies
Risks generally considered small and tolerable
common side effects may include post treatment soreness, radiation of pain, tireness or headache (4)
more serious but less common side affects include stroke, vertebrobasilar accidents, disc herniation, fractures or damage to parts of the spinal cord (cauda equina syndrome) (4)
Can you put my back “back in place”?
The spine is designed to be constantly changing position. To have a perfectly aligned spine all the time would be extremely uncomfortable!
A joint manipulation may very temporarily change the position of a joint. You may feel looser or have reduced tension or pain but it won’t make you feel that way forever. (5)
If you are unable to move in a certain direction, it is not generally because something is out of place, but more its your bodies way of guarding an underlying process. This may be injury, sensitivity, inflammation or bony blocking. Thorough assessment and diagnosis is important to determine this cause.
To summarise:
Acute back pain can be addressed with a good assessment, reassurance that you can move, use of pain medications. Passive treatments such as manipulations, but also massage, heat, ice or joint mobilisations, may assist in speeding up this process but have limited evidence to support them.
A recipient of any treatment is more likely to respond with what they believe in. Those with positive experiences with certain treatments may continue to have positive experiences in the future.
Movement and exercise are the important part of managing back pain and your physiotherapist can guide you through the process to ensure you can take control over your own back rather than let someone have control over it!
The following is an excerpt from NPS (National Prescribing Services) Guidelines on management of back pain.
Exercise
Exercise should probably be the first choice of treatment because it complements the principle that people with persistent back pain should be physically active and involved in their management. In contrast, treatments such as acupuncture, massage and spinal manipulative therapy are passive and the patient plays no role in therapy. Another argument in favour of exercise is that it is likely to provide health benefits beyond managing back pain, for example, in terms of cardiovascular and bone health.
Simply advising patients to exercise is unlikely to be effective. Exercise programs are more likely to be effective if they are supervised, individually designed, high dose and include strengthening and stretching components. There are many different forms of exercise and there is no reason to expect that one approach would be superior to another. It is best to ask the patient which form they would prefer. The best exercise for a patient is the one they continue with.
https://www.nps.org.au/australian-prescriber/articles/managing-low-back-pain-in-primary-care
References and further reading
1) Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. Paige NM, et al. JAMA. 2017.
2) The effect of spinal manipulative therapy on spinal range of motion: a systematic literature review. Millan M, et al. Chiropr Man Therap. 2012.
3) Neurophysiological effects of spinal manipulation Pickar JG. Spine J. 2002 Sep-Oct.
4) Adverse effects of spinal manipulation: a systematic review E Ernst J R Soc Med. 2007 Jul; 100(7): 330–338
5) Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis