MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Spinal manipulation is an umbrella term for numerous manoeuvres chiropractors, osteopaths, physiotherapists and other clinicians apply to their patients’ vertebral columns.  Spinal manipulations are said to be effective for a wide range of conditions. But how do they work? What is their mode of action? A new article tries to address these questions. here is its abstract:

Spinal manipulation has been an effective intervention for the management of various musculoskeletal disorders. However, the mechanisms underlying the pain modulatory effects of spinal manipulation remain elusive. Although both biomechanical and neurophysiological phenomena have been thought to play a role in the observed clinical effects of spinal manipulation, a growing number of recent studies have indicated peripheral, spinal and supraspinal mechanisms of manipulation and suggested that the improved clinical outcomes are largely of neurophysiological origin. In this article, we reviewed the relevance of various neurophysiological theories with respect to the findings of mechanistic studies that demonstrated neural responses following spinal manipulation. This article also discussed whether these neural responses are associated with the possible neurophysiological mechanisms of spinal manipulation. The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more. However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.

I have to admit, this made me laugh. Any article that starts with the claim spinal manipulation is an effective intervention and speaks about its observed clinical effects without critically assessing the evidence for it must be ridiculous. The truth is that, so far, it is unclear whether spinal manipulations cause any therapeutic effects at all. To take them as a given, therefore discloses a bias that can only be a hindrance to any objective evaluation.

Yet, perhaps unwittingly, the paper raises an important question: do we need to search for a mode of action of treatments that are unproven? It is a question, of course, that is relevant to all or at least much of SCAM.

Do we need to research the mode of action of acupuncture?

Do we need to research the mode of action of energy healing?

Do we need to research the mode of action of reflexology?

Do we need to research the mode of action of homeopathy?

Do we need to research the mode of action of Bach flower remedies?

Do we need to research the mode of action of cupping?

Do we need to research the mode of action of qigong?

In the absence of compelling evidence that a mode of action (other than the placebo response) exists, I would say: no, we don’t. Such research might turn out to be wasteful and carries the risk of attributing credibility to treatments that do not deserve it.

What do you think?

 

67 Responses to The mode of action of spinal manipulation

  • Claiming SMT is not effective is becoming a very rare and uninformed position to take. Looking at Oliviera review from 2018 shows that 81% of clinical guidelines published worldwide by medical associations and governmental offices supports the use of spinal manipulation in cases of “non-specific” LBP… so EVERYONE is wrong, all these working teams are biased, they all fail to read the literature… only you know best…

    https://www.ncbi.nlm.nih.gov/pubmed/29971708

    Also a few blogs ago your main argument was … if we cannot prove mechanism of action than we should not use alternative techniques even if they show effectiveness… now you claim the opposite… you need to decide what “scientific” claim you make to push your political agenda.

  • For all these scam treatments, I reckon it is up to their supporters to at least come up with the science of how they might work first. Homeopathy is a case in point but so are a number in the list. Until they do that they should be confined to the history books whilst real medicine carries on working.

    • Real medicine is the number 3 cause of death in this country. So…maybe let’s continue to search. There are so many things we still don’t know about the body, so to just sick with one that has only been around a couple hundred years is just not intelligent. Remember real medicine used to recommend smoking cigarettes, cocaine, heroin etc..

      • yes, remember real medicine learnt from mistakes and changed; SCAM does neither.

        • You are so astute. You must not have heard about the Opiod epidemic that was the direct result of who? That’s right…”Real Medicine”

          • the direct result of criminal promotion by manufacturers wanting to make a profit.
            the story is a good example for what can go wrong, if we deviate from evidence-based medicine/practice.

  • Yes exactly! A fundamental issue I have always had regarding “joint cracking” is the do-it-yourselfer. Excepting some joints do require excessive force to crack, MOST joints can be cracked by oneself. Innumerable people crack their spines everyday (and like burping or going to a chiroquacker give themselves 13 minutes of “relief”). Over time however you typically feel worse…or get poorer.
    BUT somehow DCs MUST perpetuate the ill-conceived notion that THEIR bone-cracking is both better AND fundamental to improving human-health….where me cracking my own spine ain’t.
    It is anathema to reason to NOT suspect “subluxation” “fixation” “improper motion” yada, yada, yada…. is the BS necessary to shake cash out of the gullible. The DC has “tests” that tell EXACTLY WHERE TO CRACK! But as McGill and others have pointed out, IF your joints don’t crack it’s probably because they are stable or arthritic. Joints that crack may not be.
    Of course that’s only looking at SMT. What about the 70% of DCs using utterly un-researched “drop tables” and Activators? They have ONLY “subluxation-detection-&-correction” to base their treatments. Quite a professional foundation either way.

    • I always find in comical when other people think they can tell me what i think and what I believe.

      • @DC on Thursday 06 June 2019 at 19:46
        [QUOTE]
        I always find in comical when other people think they can tell me what i think and what I believe.
        [/QUOTE}

        He isn’t referring to you personally, bonehead, rather the generic (non)DC. As much as you think you are clever, you aren’t, as evidence betrays.

    • You are sadly misinformed and uneducated. Research is showing adjustments effect your vestibular system, the vestibulospinal and spinovistibular. Heidi Haavik of Austraila has a lot of research showing this. Joints are not getting cracked.
      Of course, keep taking your drugs and getting cut open or spouting things you clearly have no understanding of.

      • I think you are absolutely correct, if by “you’re an idiot” you mean you are an idiot. Perhaps you should link us to all of this exciting research….and then explain the difference between “adjustments”, joints being “cracked” (or not cracked, as research seems to suggest with or without a “crack” the same non-outcome results…) and “drop-tables” or “Activator-adjusting”. And of course the copious research showing the validated-“testing” proving both “EXACTLY where and when” to “adjust”, AND which of the myriad gizmos, tables and techniques to use. THAT is Chiroquackery science at its BEST: pseudo-doctors claiming to know where, when and how to apply the life-changing “adjustment”….and then expertly bill up-the-wazoo for it.
        “Chiropractic: pretending to be healthcare since 1895”.

    • @MK
      “They have ONLY “subluxation-detection-&-correction” to base their treatments.”
      So certain Michael.
      “IF your joints don’t crack it’s probably because they are stable or arthritic. Joints that crack may not be.”
      Recent paper in JMPT:
      Are Stability and Instability Relevant Concepts for Back Pain?
      https://www.ncbi.nlm.nih.gov/pubmed/31021689

  • It is an unfortunate trait of the ego that we too quickly discount that which we don’t yet understand.

    I used to call BS on a wide variety of so called alternative treatments until I actually listened to some of their professionals and quit making assumptions about what others know or don’t know. The arrogance of some medical practitioners is astounding and quite frankly, shows a good deal of ignorance.

    Arrogance does a great disservice to our patients.

    • Personally, all I’ve ever asked for is evidence.

      I don’t want to “listen to the professionals.” An anecdote from a “professional” is still just an anecdote. And it holds about as much credibility as if came from my three-year-old son. Come to think of it, I don’t have a three-year-old son. It’s made up. Kind of like so-called complementary and alternative medicine.

      What I’d really like is for those professionals to, get ready for it, SHOW ME THE EVIDENCE!

  • Yes, the authors should have referenced their statement of benefit in the paper. They could have used this more recent review.

    “Among patients with acute low back pain, spinal manipulation therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.” https://jamanetwork.com/journals/jama/fullarticle/2616395

    Or this one…

    “The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy.” https://www.cochrane.org/CD008112/BACK_spinal-manipulative-therapy-for-chronic-low-back-pain

  • But still Chiroquackery colleges continue to solicit students with obfuscation, hyperbole and 125 year old rhetoric regarding “it” as a stand-alone “science”, a healthcare modality with distinct and foundational scientific principals (though never delineating what “it” actually is).
    IF “it” was honestly promoted as: “a $200,000, 4 year “education” where you (might) learn to be adept at joint-manipulation, and other arcane nonsense shrouded in pseudoscience mumbo-jumbo…and all of which are no better than any other mode of therapy, garnering only transient, superficial relief….and after 125 years of promulgating “it” as important for human-health we can offer ZERO validation of that”……I suspect the doors would be shuttered in no time. As it should be.

    • And yet, patient satisfaction with chiropractic care routinely outperforms other approaches. Go figure.

      3 Cherkin DC, MacCornack FA (1989) Patient Evaluations of Low Back Pain
      Care from Family Physicians and Chiropractors. West J Med 150:351-355.
      4 Sawyer, CE, Kassak K (1993) Patient Satisfaction with Chiropractic Care,
      J Manipulative Physiol Ther 16:25-32.
      5 Carey TS, Garrett J. et al (1995) The Outcomes and Costs of Care for Acute
      Low Back Pain Among Patients seen by Primary Care Practitioners, Chiropractors and Orthopedic Surgeons, N Engl J Med, 333:913-917.
      6 Liciardone JC, Heron KM (2001) Characteristics, Satisfaction, and Perceptions of Patients Receiving Ambulatory Healthcare from Osteopathic Physicians: A Comparative National Survey. J Am Osteopath Assoc 101:374-385.
      7 Hertzman-Miller RP, Morgenstern H, Hurwitz EL et al. (2002) Comparing
      the Satisfaction of Low Back Pain Patients Randomized to Receive Medical
      or Chiropractic Care: Results from the UCLA Low-Back Pain Study, Am J
      Public Health 92:1628-1633.
      8 Verheof MJ, Page SA et al. (1997) The Chiropractic Outcome Study: Pain,
      Function Ability and Satisfaction with Care, J Manipulative Physiol Ther
      20:235-240.
      9 Meade TS, Dyer S et al. (1990) Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment, Br
      Med J 300:1431-1437.
      10 Nyiendo J, Haas M et al. (2001) Patient Characteristics and Physicians’
      Practice Activities for Patients with Chronic Low Back Pain: A Practicebased Study of Primary Care and Chiropractic Physicians, J Manipulative
      Physiol Ther, 24:92-100.
      11 Nyiendo J, Haas M et al. (2001) Patient Characteristics and Physicians’
      Practice Activities and One Month Outcomes for Chronic, Recurrent Low
      Back Pain Treated by Chiropractors and Family Medicine Physicians: A
      Practice Based Feasibility Study, J Manipulative Physiol Ther, 23:239-245.
      12 Cherkin DC, Deyo RA et al. (1998) A Comparison of Physical Therapy,
      Chiropractic Manipulation and Provision of an Educational Booklet for the
      Treatment of Patients with Low Back Pain, N Engl J Med 339:1021-1029.
      13 Gemmell HA, Hayes BM (2001) Patient Satisfaction with Chiropractic
      Physicians in an Independent Physicians’ Association, J Manipulative Physiol Ther, 24:556.559.

      • thanks for demonstrating that patient satisfaction is not a substitute for measuring efficacy.

        • EE…thanks for demonstrating that patient satisfaction is not a substitute for measuring efficacy.

          I never said it was.

        • Twenty-five years ago there was over 20 randomized control trials showing the efficacy of chiropractic adjustments. The only medical procedure put to the same rigor was knee surgery and the result was equivocal. So it is not that the science hasn’t been done, it just that the profession that makes it’s money from the sale of physiology altering toxic chemicals (PATCs) has no interest in acknowledging this science and all the work done since then. Poisons may have a very consistent result, but the result is purposeful interference with bodily responses. It’s not the same as health. Health comes from the body always. And anybody who aims to facilitate healthy function through other means will appear weak to people who will only accept the consistency of a poison in affecting the immense variety of bodies seeking relief from I’ll health.

      • A “profession” built on and promulgating pseudoscience and nonsense, whose purveyors MUST hoodwink, connive and ultimately bond with their marks in order to earn a living….and you see “satisfaction” as a noteworthy pillar on which to hoist validation? I would suggest you read about the centuries of humans’ loving and unending devotion and SATISFACTION with their chosen religious tradition….even in the midst of starvation, disease and destruction.

        • I didn’t claim patient satisfaction was a pillar of validation.

          Quit making stuff up.

          • learn to read!
            you demonstrated it by your comment.
            you did not claim it but your comment demonstrated it clearly, albeit inadvertently.

          • EE…you did not claim it but your comment demonstrated it clearly, albeit inadvertently.

            or maybe you have issues interpreting what was wrote.

            MK…and all of which are no better than any other mode of therapy, garnering only transient, superficial relief

            DC…And yet, patient satisfaction with chiropractic care routinely outperforms other approaches. Go figure.

          • or maybe you lack the intellectual capacity to follow?

          • well, yes it can be a challenge to follow MK ramblings. I shall go back to ignoring him.

  • DC: your ignorance (of me) is duly noted. But why not clench your buttocks, hold your nose and step over into the dark-side with the rest of us? It’s a lot of fun being an evil, close-minded nay-sayer. You’re soooo close.
    The pay is low but the high-class of people more than compensates. Unless you have already found your soul-mates in the likes of Greg, Dr. G, Critical_chiro, Dana etc etc. in which case may god have mercy on your soul and wallet.

      • I’m curious why this blog is here. Why are you guys concerned? The market had spoken for decades. people are getting better, Chiropractic is working. What is it that you guys need so bad? You want evidence..? Evidence these days are so scued.. Real science is drying. Research is bought and paid for. Focuson what you can do for your parents. Stop focusing on other fields. Make yours better. The market will determine what works, and market is speaking loudly right now. Holistic approach is growing faster than ever.

        • the market has spoken for decades: cocaine is good for you!

          • I see what you did there.. But you never answered the question.. Are you you not fulfilled in your work? Are you searching for something? Why not focus your attention and energy on your patients? Have you given up to. The point of questioning what is working for people? I’m just saying there are allot of things in this world that you (we) can’t explain in this world. Doesn’t mean it’s a scam.. You seem like an intelligent person. Focus Your gifts to help people my man.

          • before you write such nonsense, you could have looked me up. it would have prevented you to make a fool of yourself.

          • Wasn’t it Bayer that laced their aspirin with cocaine in the late 1800s?

        • @joe: you are damn tootin’ man! The days of them self righteous scientists and all their crazy calls for evidence, validation and proof are quickly going the way of public floggings. And I couldn’t agree more that “real science is drying”. That would make “real science” very similar to your brain.
          I am curious as to what you suggest those of us whose parents are dead should focus on?

        • Was that a typo or did you mean focus on your parents? Not sure what to make of that.

          I certainly know what to make of your other comments, though.

          “Chiropractic is working.” Quack, quack.

          Enjoy your day.

          • Lol gotcha.. yes I meant patients. when you start throwing insults intelligent debate is gone. I was wrong about you.. good luck to you and your indoctrination beliefs remember Focus your attention and energy on bettering yourself ,tools, and skill set to help your patients not what other specialists are doing.

  • And articles like this is why I do not practice anymore. The chiropractic profession is still dealing with effectiveness debates well after its 100th birthday. It is a one trick pony in a market disinterested on ponies.

  • Chiropractic mainly works by making biomechanical changes within a joint segment. We can take a patient and measure ranges of motion (flexion, extension, left lateral flexion, rotation) with instruments, such as, a goniometer before a chiropractic adjustment and then immediately after and see an immediate change (improvement) in ROM. Further more, a chiropractic patient can immediately feel an improvement (and often does) in their pain level immediately following a spinal manipulation. For example, I can take a patient that experiences pain in left lumbar rotation and immediately after the adjustment I can have them rotate to the left and there pain will be completely gone. Besides using a placebo argument, how else can you explain this as not being effective?

    • I am sure you are bright enough to answer this question yourself; just try to think critically for a moment [or imagine a homeopaths makes an equivalent claim and you want to debunk it].

    • “However, it appears that SMT is a reasonable treatment op- tion for some patients with low back pain. The systematic re- view by Paige et al suggests a treatment effect similar in mag- nitude to nonsteroidal anti-inflammatory drugs. Further research will better identify which patients are most likely to benefit, and what manipulation techniques are most effec- tive. In the meantime, if manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for some patients with uncomplicated acute low back pain. This is an area in which a well-informed patient’s decisions should count as much as a practitioner’s preference.”

      “….renal and gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs are com- mon. For example, among patients taking nonsteroidal anti- inflammatory drugs, renal function abnormalities occur in approximately 1% of patients,10 and superficial gastric ero- sions or asymptomatic ulcers may occur in up to 5% to 20% of users.11 Furthermore, low back pain is among the most common reasons for prescribing opioids in the United States. Among patients initiating opioid therapy, about 5% become long-term opioid users, with associated risks of dependency, addiction, and overdose.12,13”

      The Role of Spinal Manipulation in the Treatment of Low Back Pain
      Richard A. Deyo, MD, MPH
      JAMA. 2017;317(14):1418-1419.

      • Chiroquackery has had 125 years to determine WHICH patients with LBP….OR any other pain….might benefit from SMT….and it’s still an echo of Paul Simons’ The Sound of Silence. Oh but wait, SMT doesn’t define chiroquackery, as innumerable DCs are quick to point out. And the American Chiroquacker magazine; Nov 2017 nat’l survey points out 70% use Activator (some 30% exclusively), 70% flexion-distraction, 80% drop-tables, 70% orthotics, 57% KT tape and 47% exercise-rehabilitation.
        Funny that the profession that has tried to usurp SMT still can’t figure out WHO, WHAT or HOW either. And clearly many of them really don’t think it works all that well in comparison to the other arcane, unresearched options.
        I’m sure Critical_choir will accuse me of carpet bombing for daring to quote figures. Since everyone knows you can’t get an accurate understanding of a profession or what they believe by examining what they DO.
        You need to investigate how they feel…in their hearts. AND investigate the motives of their detractors. Mine should be clear, I’m possessed by Satin.

        • “You need to investigate how they feel…in their hearts. AND investigate the motives of their detractors. Mine should be clear, I’m possessed by Satin.”

          I think your motives are pretty clear. You seem pretty bitter regarding your Ex (she’s a chiro, right?). Did she wear a lot of satin?

  • @JaM: Pardon my spelling….I meant ‘obsessed’ with Satin.
    It strikes me as odd that those with no logical counter arguments seek and dispense piffle and fallacy. The Genetic Fallacy is the most general fallacy-of-irrelevancy involving the origins or history of an idea.
    My “relationship” with an ex-wife, who to this day remains one of my closest friends and confidants and paid for law school has nothing-to-do with the insights, experiences and recognitions I have regarding Chiroquackery.
    As a matter of fact, in private conversation she readily admits her practice is a money-making scheme offering very little effect but oodles of perceived-effect….: it really is all about the money.

  • You are correct…there are NO representatives of the chiroquacker profession, excepting yourself. After all you are “DC”. And as the penultimate representative (behind DD) we can assume from your past comments a chiroquacker does NOT: practice for the money. Does not believe in misaligned, subluxed, fixated vertebral-segments, does not believe the ACA or ICA represents true-chiroquackery, does not use motion-palpation, AK, short-leg “analysis”, x-rays to find malalignments, thermography or “insight-subluxation-stations”. Doesn’t Set up long, elaborate treatment schedules, do “wellness “ care, treat organic illness, preach anti-medical rhetoric, sell shoe orthotics from Foot Levelers, adjust atlas with toggle recoil or atlas-orthogonality devices, restore lordosis, do the flying-seven, use an Activator or adjusting gun or waste time with a “drop-table”. Are you sure you are a chiroquacker??? I will hold to the contention my Ex IS far more representative of DCs than you. You should get the internet some day and google chiropractic.

    • DC says whatever comes to mind. I give him the benefit of the doubt when I say he is a troll, at best. His logic is, I don’t know, bizarre?

      Anyway, I wouldn’t pay too much mind. It’s like listening to a child. You know he’s saying something, you just can’t make sense of it.

    • MK…You should get the internet some day and google chiropractic.

      Ah, such a valid form of assessment.

    • “I will hold to the contention my Ex IS far more representative of DCs than you. You should get the internet some day and google chiropractic.”

      Based on reports from clients, friends, family, and my limited personal experience, DC is far more representative than what you’re claiming.

      But then again, I haven’t really googled it. I bet you could back up your claims (or any other claim, really) with some skillful googling.

      • “Based on reports from clients, friends, family, and my limited personal experience, DC is far more representative…”
        do you know what ‘representative’ means?
        clients, friends and friends cannot be representative; they are the opposite: unrepresentative!

        • Maybe you should brew up a strong cup of matcha, re-read, and try again. I hear that matcha promotes mental focus and supports healthy cognitive function. Just in case you don’t have any matcha, I’ll re-cap:

          DC asked Michael Kenny when his ex wife became the representative of the chiro community.

          Kenny responded that his ex is far more representative of DCs than DC.

          So I’ll re-word my comment for you. I’ll even pull out the thesaurus and avoid the trigger word ‘representative’.

          DC and Kenny paint very different pictures of chiropractics and chiropractors. Based on what I hear from people who get treatments from chiros, DC’s description is far more typical, characteristic, or illustrative than Kenny’s.

          Hope that helps. If not, maybe we can both just enjoy Kenny’s weird obsession with smooth, glossy fabric.

      • Hey, jm.

        With respect to your reports from clients, friends and family as well as your own, admittedly, limited experience, would you call that “evidence”? Just curious because it seems a lot of people mix up “evidence” with “anecdotes that mean nothing in the grand, or even tiny, scale of things.”

  • Oh dear JaM, I guess I’ll have to admit I am both an ineffectual joke-maker and spokesman for “people who see through the ruse of chiroquackery”. Firstly, the Satin was the joke. Notice the word was capitalized? Possessed by Satin not Satan? Sorry but I grew up on Monty Python and such non-sequiturs I think are funny. Being possessed by Statins was my original choice. See @Joe comment about “drying” and “parents”.
    As to being representative….DC has made the point that chiroquackery IS NOT to be assessed via its purveyors (practicing DCs) as seen on innumerable internet advertising and the professions nat’l magazines. And YOU believe assessments should be “based on what I hear from people…” very persuasive.
    So my point, albeit lost on those whose cognitive skills are overwhelmed by financial and dogmatic incentives, was that my Ex utilizes, advertises and has built her lucrative practice(s) with a large smattering of the BS Chiroquackery-stuff I included on my list….just like MOST DCs. (See American Chiroquacker; survey of chiropractic-techniques). Thus, I was contending my Ex is likely far more representative i .e. Typical to a class or group….of the way DCs practice. Ergo, It’s mostly gypsum tricks and pseudo-seance and always has been.

    • Yes, Kenny, I knew you were joking about the satin. I hope you didn’t think I was serious about satin being the fabric of the devil. Wear as much as you like. Just avoid Prada.

      Unlike Edzard, I knew what you were getting at with the whole representative thing, too. Regardless of your ex, surveys, and the great google machine – your list of BS Chiroquackery doesn’t really seem to play out in reality.

      A couple of weeks ago, DC made this comment:
      “Yes, often nonspecific back pain will self resolve. However, often the goal of receiving care, regardless of the practioneer is to increase comfort and function while this healing takes place.”

      Much more typical of the way chiros practice than the caricature you’re trying to sell. But again, that’s based on talking to patients – not feedback from the great googly machine.

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