Spinal adjustment

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For the spinal manipulation procedure, see Joint manipulation.

Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe any of a number of specialized manual or mechanical procedures used in an effort to affect the alignment, motion and/or function of spinal joints and their relationship with the nervous system. The procedures make up the mainstay of chiropractic care that is directed toward reducing the effects of vertebral subluxation, the term given to the myriad of signs and symptoms that result from abnormal alignment or function of vertebrae. They may be supplemented with exercise, physiotherapy modalities and nutritional recommendations. Claims made for the benefits of spinal adjustments range from temporary palliative (pain relieving) effects to long term wellness and preventive care. Some claims are controversial, particularly with regard to indications and health benefits. There is debate concerning the safety of some of the procedures used in spinal adjustments, particularly those including upper cervical manipulations.

1 Adjustment vs. manipulation
2 Adjustment methods
- 2.1 Adjustment techniques
3 Mechanisms and effects
4 Safety issues
5 References
6 See also
7 External links

[edit] Adjustment vs. manipulation

The original spinal adjustment was a variation of a procedure known today as spinal manipulation. This form of treatment has documented use as far back as Hippocrates and the ancient Egyptians and was carried through the ages by families of bonesetters. It is generally described as a high velocity, low amplitude, (HVLA) thrust, that usually causes an audible "popping" sound. This sound is currently believed to be the result of the phenomenon of cavitation. When a manipulation is performed, the force applied separates the joint surfaces of the fully encapsulated joint cavity of a diartrodial joint creating a relative vacuum within the fluid filled joint space. In this low pressure environment, the naturally dissolved gases found in all bodily fluids turn into a gas bubble that rapidly collapses upon itself and a sound is created. The contents of this vacuum are thought to contain water vapor, nitrogen, oxygen, and carbon dioxide.<ref>Brodeur R. "The audible release associated with joint manipulation.". J Manipulative Physiol Ther 18 (3): 155-64. PMID 7790795.</ref><ref>Protopapas M, Cymet T, Protapapas M (2002). "Joint cracking and popping: understanding noises that accompany articular release.". J Am Osteopath Assoc 102 (5): 283-7. PMID 12033758. Available Online</ref> The effects of this process will remain for hours while it is slowly reabsorbed by the body. There is some evidence that ligament laxity may be associated with the tendency to cavitate.<ref name"Fryer">Fryer, Gary and Jacob, Mudge and McLaughlin, Patrick (2002) The Effect of Talocrural Joint Manipulation on Range of Motion at the Ankle. Journal of Manipulative and Physiological Therapeutics, 25. pp.384 to 390. PMID: 12183696</ref>

Today, chiropractors also use the term spinal adjustment to include hundreds of additional manual and mechanical methods that are used to affect their desired results. Some of these spinal adjustments include spinal manipulation, while others do not. Regardless, there is an essential philosophical difference between a spinal adjustment (only performed by chiropractors) and a spinal manipulation (as performed by non-chiropractors as well) concerning the intention. Chiropractic adjustments are intended to affect or correct vertebral subluxations, making the chiropractic adjustment a uniquely chiropractic technique. <ref name="ICA_adjust_manip"/> This intention forms the legal and philosophical foundation of the profession, and is even formulated in US Medicare law as "manual manipulation of the spine to correct a subluxation."<ref>Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis DHHS, June 2005 OEI-09-02-00530</ref>

While the terms "spinal adjustment" and "spinal manipulation" are often used interchangeably by chiropractors in their literature and research, <ref>To provide examples of interchangeable uses (as well as false positives), a search of the largest chiropractic website, Chiroweb.com, for "manipulation" yielded 1,610 hits, and for "adjustment" yielded 1,490 hits. A similar search of the oldest "straight" organization, International Chiropractors Association, for "manipulation" yielded 49 hits, and for "adjustment" yielded 86 hits. A similar search of the ultra-straight organization, World Chiropractic Alliance, for "manipulation" yielded 369 hits, and for "adjustment" yielded 74 hits. Retrieved on Nov. 06, 2006</ref> most straight (foundational) chiropractors prefer to use the word "adjustment" to describe the nature of their work. <ref name="ICA_adjust_manip">ICA Policy Statements: Spinal Adjustment and Spinal Manipulation. International Chiropractors Association.</ref>

The International Chiropractors Association (ICA), which tends to represent the majority of straight chiropractors, makes the distinction as:

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The word adjustment is also used by osteopaths trained at the European School of Osteopathy when referring to a technique called Specific Adjustment Technique, or SAT.<ref>Dummer Tom, D.O., M.R.O., A Textbook of Osteopathy, Vol. I and Vol. II, JoTom Publications, Hadlow Down, East Sussex, England, 1999.</ref> The technique was developed by UK osteopath Tom Dummer.<ref>Still Osteopathic Clinics</ref>

[edit] Adjustment methods

As the chiropractic profession engaged in the pursuit of improving health through adjustments to the nervous system, individual practitioners and institutions proposed and developed various proprietary techniques and methods. While many of these techniques did not endure, hundreds of different approaches remain in chiropractic practice today. Most cite case studies, anecdotal evidence, and patient testimonials as evidence for effectiveness. These techniques include:

Toggle Drop - this is when the chiropractor, using crossed hands, presses down firmly on a particular area of the spine. Then, with a quick and precise thrust, the chiropractor adjusts the spine. This is done to improve mobility in the vertebral joints.
Lumbar Roll (aka side posture) - the chiropractor positions the patient on his or her side, then applies a quick and precise manipulative thrust to the misaligned vertebra, returning it to its proper position.
Release Work - the chiropractor applies gentle pressure using his or her fingertips to separate the vertebrae.
Table adjustments - The patient lies on a special table with sections that drop down. The chiropractor applies a quick thrust at the same time the section drops. The dropping of the table allows for a lighter adjustment without the twisting positions that can accompany other techniques.
Instrument adjustments - often the gentlest methods of adjusting the spine. The patient lies on the table face down while the chiropractor uses a spring-loaded activator instrument to perform the adjustment. This technique is often used to perform adjustments on animals as well.
Manipulation under anesthesia (MUA) - this is performed by a chiropractor certified in this technique in a hospital outpatient setting when the patient is unresponsive to traditional adjustments.

[edit] Adjustment techniques

There are many techniques which chiropractors can specialize in and employ in spinal adjustments. Some of the most notable techniques include:

Activator Methods - uses the Activator Adjusting Instrument to give consistent low-force, high-speed chiropractic adjustments.
Active Release Therapy (Active Release Technique) - soft tissue system/movement based massage technique that treats problems with muscles, tendons, ligaments, fascia and nerves.
Cox Flexion-Distraction - a gentle, non-force adjusting procedure which mixes chiropractic principles with osteopathic principles and utilizes specialized adjusting tables with movable parts.
Directional Non-Force Technique - utilizes a diagnostic system for subluxation analysis consisting of gentle challenging and a unique leg check allowing the body to indicate the directions of misalignment of structures that are producing nerve interference. A gentle but directionally specific thumb impulse provides a long lasting correction to bony and soft tissue structures.
Diversified - the classic chiropractic technique, developed by D.D. Palmer, DC. Uses specific manual thrusts focused on restoring normal biomechanical function. Has been developed to adjust extremity joints as well.
Gonstead Technique - Developed by a mechanical engineer turned chiropractor, this technique uses a very specific method of analysis and precise adjusting techniques
Kale Technique (Specific Chiropractic) - gentle technique which utilizes a special adjusting table that helps adjust and stabilize the upper cervical region surrounding the brain stem.
Logan Basic Technique - a light touch technique that works to "level the foundation" or sacrum. Its concept employs the use of heel lifts and specific contacts.
NUCCA Technique - manual method of adjusting the atlas subluxation complex based on 3D x-ray studies which determine the correct line of drive or vector of force.
Thompson Terminal Point Technique (Thompson Drop-Table Technique) - uses a precision adjusting table with a weighing mechanism which adds only enough tension to hold the patient in the "up" position before the thrust is given.
Toggle Recoil Technique - a quick thrust and release to the upper cervical vertebra, the recoil is too allow the vertebra to oscillate into its proper postion.

[edit] Mechanisms and effects

The effects of spinal adjustment vary depending on the method performed. All techniques claim effects similar to other manual therapies, ranging from decreased muscle tension to reduced stress. Most of these effects can be attributed to theoretical neurological pathways that modulate pain and proprioception and therefore affect muscle tone and postural balance. The mechanisms that are claimed to alter nervous system function and affect overall health are currently speculative in nature and range from mechanical pressure on nerve roots to autonomic reflexes altering Central Nervous System (CNS) function and therefore visceral function. Some techniques use adjustments in an effort to restore proper posture and curvatures; suggesting that posture is related to health. Whether these effects are placebo related is speculative as well. Regardless of the technique used, most emphasize the repetitive use of adjustments over time in an effort to retrain the body's nervous system.

The effects of spinal manipulation have been shown to include: temporary relief of musculoskeletal pain and shortened time to recover from acute back sprains (Rand). There is evidence that spinal manipulation is effective for the treatment of acute low back pain, tension headaches and some musculoskeletal issues.<ref name =Duke>McCrory DC, et al. Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-Based Practice Center, Durham, North Carolina, January 2001 available online (PDF format)</ref><ref name="Ernst E">Ernst E (2006) A systematic review of systematic reviews of spinal manipulation J R Soc Med 99:192-6 Available on-line</ref> Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort. <ref name="frequency">Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy. Outcomes of Treatment (Adverse) Spine. 22(4):435-440, February 15, 1997.</ref>

[edit] Safety issues

For safety issues related to spinal manipulation, see joint manipulation.

The World Health Organization states that when "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems."<ref name="WHO">WHO guidelines on basic training and safety in chiropractic, World Health Organization, Geneva, 2005. ISBN 92 4 159371 7. available online</ref> As with all interventions, there are risks associated with spinal manipulative therapy (SMT). Infrequent, but potentially serious side effects, include: vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral and rib fractures, and cauda equina syndrome. <ref name="frequency"/>

A study on the chiropractic spinal adjustment published in the February 2002 issue of the Annals of Internal Medicine reviewed more than 160 reports and studies on chiropractic. With regard to the safety of neck adjustment, it states: "The apparent rarity of these accidental events has made it difficult to assess the magnitude of the complication risk. No serious complication has been noted in more than 73 controlled clinical trials or in any prospectively evaluated case series to date." <ref name="meeker">Meeker WC, Haldeman S. Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine. Annals of Internal Medicine. February 5, 2002, Vol. 136, No. 3.</ref>

A New Zealand Commission report in 1979 said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe... By the end of the inquiry we found ourselves irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly based and valuable branch of the health care in a specialized area." <ref>Commission of Inquiry, Chiropractic in New Zealand. Report of the Commission of Inquiry (Wellington, New Zealand: P. D. Hasselberg, Government Printer, 1979):p 77)</ref>. However, the judge in the Wilk vs AMA case described this report as "unsatisfactory", and a review by the US Congress' Office of Technology Assessment (OTA) found 'serious problems' in its treatment of safety and efficacy issues.<ref name="Wilk">Wilk, et al vs. the AMA, et al, The Chiropractic Antitrust Suit, Multiple documents. [http://www.chiro.org/Wilk/ available online</ref>

In a 1993 study, J.D. Cassidy DC and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is "both safe and effective."<ref>Cassidy JD, Thiel H, Kirkaldy-Willis W (1993). "Side posture manipulation for lumbar intervertebral disk herniation.". J Manip Physiol Ther 16: 96-103. PMID 8445360.</ref>